Tag Archives: ankle fracture

Delayed Reconstruction of Post Traumatic Ankle Malunion: A case report

by Jeffrey Robertson DPM, Kirk Alexander DPM, FACFAS

The Foot and Ankle Online Journal 4 (9): 3

Treatment of acute ankle fractures is clear in the approach; however, questions about delayed repair of chronic malunited ankle fractures still remain. Illustrated here is a case report of a 49 year old female that presented with a bimalleolar malunion, with severe lateral talar displacement and valgus position. She presented to our clinic 8 months following the initial injury. In the presence of mild to moderate degenerative changes at the tibio-talar articulation open reduction internal fixation (ORIF) was performed without complication. Proper anatomic alignment was established and stable fixation achieved.

Key words: Ankle fracture, malunion, tibio-talar articulation, delayed reconstruction.

Accepted: August, 2011
Published: September, 2011

ISSN 1941-6806
doi: 10.3827/faoj.2011.0409.0003

It has been well documented that anatomic open reduction internal fixation (ORIF) of acute unstable ankle fractures decreases the rate and severity of post traumatic arthropathy compared to delayed intervention. [1,3,5-15] Ankle fractures occur frequently with an unfortunate propensity for malunion if not treated, or under corrected. Despite the ankle joint’s chondrocyte leniency toward increased demands, the ankle joint doesn’t tolerate mal-alignment well. [2,4,8]

Early contact studies of ankle joint congruency show that a deviation of the talus by 1mm may reduce tibiotalar contact surface area by as much as forty two percent. [10,11] These classic articles lower the threshold for intervention when we consider that a high percentage of malunions ultimately lead to debilitating post traumatic arthropathy.

Most commonly, Weber types B and C fractures result from external rotation and/or eversion forces shortening and externally rotating the fibula allowing the talus to shift laterally within the talocrural articulation. Untreated fractures or those with a medial malleolar fracture may allow for progressive rearfoot eversion and limited ankle joint dorsiflexion leading to further deformity and articular damage.

Therefore, should all fractures be fixated? Should consideration be given to the time from injury to surgical intervention? What are the outcomes? Are there factors that should be considered during evaluation to improve surgical decision making and prognosis of such injuries? Presented here is a case study of an untreated bi-malleolar malunion approximately 8 months after initial injury.

Case Report

We discuss a 49 year old female who sustained a right ankle fracture in July of 2010. Prior to injury she was a community ambulator. She was initially treated at an outside facility with immobilization and limited weight-bearing. After healing of the fractures, she began limited ambulation. Due to severe valgus position of the ankle and rearfoot, she walked on the medial foot. This was awkward and uncomfortable, so walking and standing was limited. Therefore, she often used a wheelchair as a substitute for ambulation. Past medical history includes a symptomatic cerebral aneurysm which occurred in 1986.

During the physical examination her neurological presentation illustrated a symmetrical reduction in strength (+4/5) to the anterior, lateral, and posterior compartments as well as to the intrinsic muscles of the legs and feet. However, no focal deficits were identified during the examination and protective sensation was intact bilateral and symmetrical.

Her vascular examination showed bilateral lower extremity pulses were palpable and symmetrical with+2 pitting edema. Doppler exam showed biphasic or triphasic pulses of the dorsalis pedis, perforating peroneal and posterior tibial arteries bilaterally. Dermatological exam demonstrates a superficial abrasion, 1 centimeter in diameter, over the medial malleolar malunion. Her contralateral leg had recently been injured in a fall secondary to the imbalance created from her malunion. The resulting wound over the left mid anterior tibia was large, with a mixed wound bed predominantly granular in nature. Neither wound showed signs of infection.

The musculoskeletal examination of the right lower extremity showed relative pain free passive ankle range of motion, with normal plantarflexion, but limited dorsiflexion. However, active range of motion showed increased sagittal plane motion illustrating greater midfoot and forefoot compensation. Mild to moderate crepitus of the ankle joint was appreciated.

The right foot in a maximal dorsiflexed position was 10 degrees plantarflexed with the knee extended and flexed. The subtalar joint, midtarsal joint, first ray and metatarsal phalangeal joints were flexible, and without crepitus or impingement. Radiographs demonstrated 30-35 degrees of ankle valgus with the talocalcaneal position maintained within anatomic alignment. Therefore, during ambulation axial load was translated medially in relation to the rearfoot. This deformity was fully compensated by the flexible degree of midfoot and forefoot supinatus and abduction.

Initial plain radiographs illustrate malunion of a right Weber B bi-malleolar ankle fracture. Medial and lateral malleolar fragments were translated and angulated laterally. No gross deformities were noted of the distal forefoot, midfoot, or rearfoot. (Figs. 1A-1C and 2A to 2B) To further investigate the degree of deformity a CT scan was performed. (Figs. 3A and 3B) The coronal and sagittal images illustrate the incomplete malunion at both malleoli as well as the presence of exostoses/calcification at the anterolateral aspect of the ankle joint and syndesmosis. (Fig. 4A and 4B) Tibio-talar joint space remained adequate. There was no significant subchondral sclerosis, or cystic changes.


Figure 1 Initial Weight bearing plain foot radiographs.  Lateral (A), dorsoplantar (B) and medial oblique (C) views of the foot at initial presentation.


Figure 2  Initial anteroposterior (A) and oblique (B) weightbearing plain ankle radiographs.


Figure 3  Computed tomography radiographs illustrating the  coronal image illustrating bi-malleolar ankle fracture with severe valgus deformity at the ankle joint. (A) The  sagittal image of the medial malleolus showing incomplete union of its distal aspect. (B)


Figure 4   Computed tomography adiographs illustrating the axial (A)  and sagittal (B) images showing exostosis vs possible Wagstaff avulsion fracture with ossification of the distal tibial fibular syndesmosis.

The position of the ankle did not allow normal function or stability therefore, we felt surgical intervention was appropriate considering severe ankle translation and angulation, pre-ulcerative lesion secondary to prominent medial malleolus, and minimal evidence of articular degeneration. Alternatives were discussed including but not limited to arthrodesis and bracing, but patient elected to forward with ORIF. Consent was obtained prior to procedure.


Preoperative antibiotics were administered (2g cefazolin) and general anesthesia with a popliteal block to the right lower extremity was performed. Saphenous coverage was provided by a separate local injection. A bump was placed under the ipsilateral hip. A right thigh tourniquet was applied. The right lower extremity was prepped and draped in the usual sterile fashion. Prior to incision the extremity was exsanguinated and the tourniquet was inflated to 275mmHg.

A percutaneous incision was made along the Achilles tendon where a percutaneous lengthening procedure was performed. At the distal third of the fibula a longitudinal incision was made slightly anterior to its midline as to provide adequate visualization of the fibula, the anterolateral ankle joint and syndesmosis.

The reactive bone formation was removed from the distal fibula and contoured with a ronguer and hand rasp. Removal of the calcifications from the anterior syndesmosis was also performed allowing for better tibio-fibular reduction.

The distal fibular fragment was liberated from its fibro-osseous union by re-creating the fracture-line. A 1.5 mm drill bit was utilized to perforate the length of the fracture followed by the use of a small straight osteotome to connect the drill holes, recreating the original fracture orientation. The fibrous tissue was removed from within the fracture site as well as off the most lateral aspect of the fibula. The lateral aspect of the tibiotalar articulation could now be inspected. Of note, was the lack of significant articular degeneration or presence of osteochondral lesions to the lateral talar shoulder. However, there were mild erosive changes to the lateral tibial plafond. Prior to fibular reduction and fixation, the medial malleolus was addressed to facilitate the correction of ankle translation and angulation.

A curvilinear incision was created anterior to the midline of the medial malleolus. This approach was performed to avoid placing the incision through the superficial abrasion at the medial malleolus. A transverse periosteal incision was created directly over the fracture line. A power saw was used to transect the malunion. A significant amount of fibrous tissue was found within the medial gutter and tightly adherent to the medial malleolar articular cartilage. All the fibrous tissue was removed by combination of sharp dissection and ronguer. Underlying the fibrous cap at the medial malleolus was healthy articular cartilage. Also noted was the isolated presence of mild to moderate erosive changes to the central talar dome as it was the focal point of weight bearing against the lateral tibial plafond.

After mobilizing the lateral and medial malleoli, the rearfoot was medialized. Intra-operative fluoroscopy guided medial malleolar reduction and fixation. Lag technique was utilized to provide interfragmentary compression that stabilized the medial malleolus and prevented lateralization secondary to soft-tissue contracture. The lateral malleolus was reduced and stabilized with temporary fixation. A large void at the fibular fracture was filled with morselized cancellous allograft. Fibular fixation was completed with a Zimmer’s Periarticular Distal Lateral Fibular Plate.

The fracture void and bone graft prevented placement of standard fibular interfragmentary screws, therefore, two syndesmosic [syndesmotic] screws were placed through the plate for increased stability to the fragments and rigidity of the construct. Final inspection and irrigations were performed followed by layered closure. The patient was placed in a well padded modified posterior Jones compression splint. The patient tolerated the procedure well and without complication. The patient was placed on a strict non-weight bearing status and discharged to a skilled nursing facility to aid in her post operative recovery period.

Stability achieved by the internal fixation and preservation of anatomic alignment in light of severe angular deformity four weeks post operatively. (Fig. 5A and 5B) Both the lateral and medial malleoli have maintained their positions well. Trabeculation with consolidation is appreciated at the medial and lateral malleoli. The fibula is near anatomic. The patient has progressed.


Figure 5A and 5B   General radiographs four weeks after surgery.  Lateral (A) and AP (B) views are shown.


Ankle fractures are common, and foot and ankle surgeons have developed and refined skills to successfully aid their patients in recovering their activities of daily living). Conceptually, we consider the ankle as a stable construct when all the ligaments and bony architecture remain intact creating the “stable ring”. [9] When a single break in the ring occurs, such as in a Weber A, B or C fracture, the ankle construct is still considered to be stable and surgical intervention may not be necessary. However, when there is additional damage such as additional ligamentous or osseous injury, resulting in a second “break” within the ring, the ankle joint is considered to be unstable warranting surgical stabilization for optimal prognosis. For best possible functional results it is widely accepted to reduce the articulations anatomically through direct surgical visualization and fixation. [6]

Complications come to mind when thinking about malunions of the ankle joint, such as degree of deformity, presence of degenerative arthropathy, patient level of activity, age, patient specific goals and overall surgical candidacy. Despite the obvious hesitation to perform delayed reconstruction early studies have illustrated that a patient’s age makes no difference and that the importance of maximizing talocrural articulation even in the presence of mild arthritic changes is suggested. [7,14] In fact, arthritic changes should not be considered a contraindication, and any presence of articular degeneration should be the very reason for intervention. [7,11] Reidsma’s and colleagues11 illustrate better long term prognosis for patients when there was less time between initial injury and reconstruction. Marti and his colleagues included one caveat to the above, that degree of deformity and age did not alter outcome as long as the patient’s functional status and meticulous pre-operative planning was performed. This allows full understanding of the nature of the deformity and requirements to recover fibular length, rotation and achieve anatomic tibio-talar congruency.

Many studies illustrate successful correction of ankle malunions. The transverse fibular osteotomy has been widely established to regain fibular length. [1,6,10,11-15] This is common in Weber C malunions. However, re-creation of the original fracture has only been mentioned in malunions with length and rotational components. This may be more attributable to the necessity of meticulous pre-operative planning so as to re-create the correct fracture pattern to allow proper lengthening and de-rotation of the distal fragment simultaneously. In this particular case of a Weber B malunion, correction of length and rotation was facilitated by recreating the original fractures. In addition to liberating each fragment, fixating the medial malleolar fragment first facilitated medialization of the talus within the mortise allowing for correct fibular fixation and overall anatomic alignment

This case study continues to support open correction of malunited ankle fractures. We agree with current literature that delayed repair is preferred, giving less regard to degree of deformity and articular degeneration.

We feel arthrodesis and arthroplasty should be reserved as salvage procedures for progressive deformity or failed delayed repair. The approach described in this case study may benefit delayed reconstruction of malunited ankle fractures by open liberation of the malleolar fracture fragments, recreation of a Weber B fracture, followed by fixation of the medial malleolus, and then lateral malleolus. This approach may allow for better medialization of the talus and allowing anatomic alignment of talocrural joint.


1. Davis JL, Giacopelli J. Transfibular osteotomy in the correction of ankle joint incongruity. J Foot Ankle Surg 1995 34 (4): 389-399.
2. Fetter NL, Leddy HA, Guilak F, Nunley JA. Composition and transport properties of human ankle and knee cartilage. J Orthop Res 2006 24: 211-219.
3. Henderson WB, Lau JT. Reconstruction of failed ankle fractures. Foot Ankle Clin 2006 11: 51-60.
4. Hendren L, Beeson P. A review of the differences between normal and osteoarthritis articular cartilage in human knee and ankle joints. Foot (Edinb) 2009 Sep;19(3):171-6.
5. Loder BG, Frascone ST, Wetheimer SJ. Tibiofibular arthrodesis for malunions of the talocrural joint. J Foot Ankle Surg 1995 34: 283-288.
6. Mann RA, Coughlin MJ, Saltzman CL. Surgery of the Foot and Ankle. 8th edition; Volume II, Mosby Elsevier 2007.
7. Marti RK, Raaymakers EL, Nolte PA. Malunited ankle fractures. The late results of reconstruction. JBJS 1990 72B: 709-713.
8. Miller SD. Late reconstruction after failed treatment for ankle fractures. Orthop Clin North Am 1995 26: 3363-3373.
9. Neer CS. Injuries of the ankle joint: Evaluation. Conn State Med J 1953 17: 580-583.
10. Perera A, Myerson M. Surgical techniques for the reconstruction of malunited ankle fractures. Foot Ankle Clin 2008 13:737-751.
11. Ramsey PL, Hamilton W. Changes in tibiotalar area of contact caused by lateral talar shift. JBJS 1976 58A: 356-357.
12. Reidsma II, Nolte PA, Marti RK, Raaymakers ELFB. Treatment of malunited fractures of the ankle. A long term follow up of reconstructive surgery. JBJS 2010 92B: 66-70.
13. Sinha A, Sirikonda S, Giotakis N, Walker C. Fibular lengthening for malunited ankle fractures. Foot Ankle Int 2008 29: 1136-1140.
14. Ward AJ, Ackroyd CE, Baker AS. Late lengthening of the fibula for malaligned ankle fractures. JBJS 1990 72B: 714-717.
15. Weber BG, Simpson LA. Corrective lengthening osteotomy of the fibula. Clin Orthop Relat Res 1985 199: 61-67.
16. Weber D, Freiderich NF, Muller W. Lengthening osteotomy of the fibula for post-traumatic malunion. Indications, technique and results. Int Orthop 1998 22: 149-152.

Address correspondence to: The Swedish Podiatric Surgical Residency, Seattle, Washington 98122.
Email: jeff.robertson@swedish.org, kirka@pacmed.org

1  Jeffrey Robertson DPM, PGY-2. 747 Broadway, Swedish Podiatric Surgical Residency, Seattle, WA 98122. 206-320-5301.
2  Kirk Alexander DPM, FACFAS. Surgical attending with Swedish Podiatric Surgical Residency, Seattle, WA 98122.

© The Foot and Ankle Online Journal, 2011

Hardware Related Pain and Hardware Removal after Open Reduction and Internal Fixation of Ankle Fractures

by Johan H. Pot1  , Remco J.A. van Wensen1, Jan G. Olsman1

The Foot and Ankle Online Journal 4 (5): 1

Objectives: To assess the incidence of hardware related pain after open reduction and internal fixation (ORIF) after ankle fractures through functional outcomes scores in patients with or without hardware related pain. Design: Retrospective study.
Setting: Regional trauma center.
Patients: One hundred and seventy six patients undergoing ORIF of an ankle fracture with a minimal follow up of 18 months were sent questionnaires. In total, 80 responding patients were available for analysis.
Main Outcome Measurements: Visual Analog Pain Score, Foot and Ankle Outcome Score (FAOS).
Results: In seventeen patients (21%), the hardware was removed because of pain. In another seventeen patients (21%), the hardware was not removed, but pain was reported. Patients with hardware related pain had significantly worse functional outcome scores than patients without hardware related pain. After elective hardware removal, pain reduction was achieved in 71 % of the patients. Mean Visual Analog Score was 7.0 before and 3.9 after elective hardware removal for pain.
Conclusions: Hardware related pain is a significant issue after ORIF of ankle fractures. Patients with hardware related pain have significantly worse functional outcome scores. Although pain reduction is achieved in 71% of the patients after elective hardware removal, a substantial number of patients have persistent complaints. Patients should be well informed about the expectations and risks of elective hardware removal.

Key words: Hardware, hardware removal, hardware related pain, ankle fracture, ORIF ankle, FAOS.

Accepted: April 2011
Published: May 2011

ISSN 1941-6806
doi: 10.3827/faoj.2011.0405.0001

Fractures of the distal tibia and fibula are one of the most common types of fractures in adults. [1] Whereas stable and non or minimally displaced fractures can be treated with cast immobilization, unstable dislocated ankle fractures require open reduction and internal fixation (ORIF) with plate and screws.

Long term functional outcome is satisfying in most patients, but a number of patients have persistent ‘hardware related’ complaints and tenderness that ‘require’ elective hardware removal. Aside from painful hardware, some asymptomatic patients also want their hardware removed for other reasons. Although hardware removal is frequently undertaken, it is not without risk and the results are often unpredictable. [2]

The more commonly reported risks of hardware removal are iatrogenic (nerve) injury, infections, delay in wound healing and re-fractures. In addition to medical considerations there is also an economic impact such as physician costs, hospital fees, patient loss of work and productivity. [2] Reports in literature are not consistent concerning the incidence of painful hardware and the outcome and pain relief after hardware removal. [3-5] This study was designed to document the incidence of late pain after ORIF of ankle fractures and to analyse the outcome, expectations and complications after hardware removal.

Patients and Methods

In October 2010, all patients with surgically treated unstable ankle (malleolar) fractures between April 2007 and April 2009 were reviewed. A total number of 176 patients were included with a minimum follow up of 18 months assuming the end stage of rehabilitation after the ankle fracture was achieved. Demographic data, patient’s age, sex and medical history, were obtained from the hospital database and clinical notes. All patients were sent a questionnaire. One part consisted of the Foot and Ankle Outcome Score (FAOS) which is designed to asses a number of foot and ankle related problems. It consists of 5 subscales; Pain, other Symptoms, Function in daily living (ADL), Function in sport and recreation (Sport) and foot and ankle-related Quality of Life (QOL). The second part of the questionnaire consisted of specific questions about pain at the site of the hardware material and specific questions about the removal of osteosynthesis material. Patients that underwent elective hardware removal were asked to indicate pain before and after hardware removal by a Visual Analog Scale (VAS) pain score. Surgical stabilization consisted of open reduction and internal fixation (ORIF).

All surgeries were performed in the Jeroen Bosch Hospital, a 600 bed teaching hospital, by or under direct supervision of one of the trauma surgeons. AO-fixation material was used including small-fragment plates and screws and sometimes K-wires on the fibula or tibia if necessary. Fixation of the posterior malleolus was performed if more than one-third of the joint surface on the lateral radiograph was affected. Syndesmotic fixation was performed in cases of widened mortises on stress-testing after ORIF. Most of the time, one hook test was performed.

Postoperative therapy was overall direct functional and non-weight bearing for a minimum of six weeks. Sometimes a below-the-knee plaster cast was applied for 1 week due to wound protection. After 6 weeks, patients were allowed to bear weight as tolerated and were referred for outpatient physical therapy if necessary. Patients that were treated with a syndesmotic screw remained non-weight bearing until the syndesmotic screw had been removed. According to one of the trauma-surgeons, weight bearing was allowed after 6 weeks without removal of the syndesmotic screw. Indications for hardware removal include infection, failure of osteosynthesis material, severe pain and tenderness on the location of hardware and specific demands in asymptomatic patients. Before the procedure was performed, fracture consolidation was assessed by a radiograph. Functional outcome scores for each FAOS subscale were correlated with the presence of local pain. Statistical analysis was performed by using the Student t test. Results were considered significant if p


The questionnaire was sent to 176 patients. The response rate was 46% (n=80 patients). In the response group there were 24% males and the mean age was 44 ±23 years. The mean follow up was 30 months and 29 patients (36%) reported hardware removal. (Table 1) The indication for removal was pain or discomfort in 60% (n=17).

Table 1 Patients with hardware removed and painful or painless hardware.

In one patient it was removed because of infection and syndesmotic screws were removed in 37% (n=11) as a standard procedure before weight bearing was allowed. In patients that did not have osteosynthesis material removed (n=51), 33 % had local pain or tenderness on the location of the osteosynthesis material. In total, 34 patients had pain at the hardware site after ORIF (42%). (Table 1)

FAOS score were compared between patients having local pain or tenderness overlying the hardware, patients who did not and patients that underwent hardware removal because of pain. Lower scores indicate a lower functional level and these scores are shown in Figure 1.  The FAOS scores of patients without hardware related pain was significantly higher in all the 5 subscores. (P<0.05) compared to patients with hardware related pain. Patients that underwent elective hardware removal however did not have significantly different scores than those with painful hardware.

Figure 1 FAOS scores of all patients with surgically treated ankle fractures. Patients without painful hardware have significantly higher FAOS score in all subscores compared to patients with hardware related pain (removed or not).

In 71% of the patients that underwent elective hardware removal because of pain, reported a decrease of their complaints after hardware removal.

These patients had a mean pain VAS (visual analog scale) of 7.0 (±2.1) before hardware removal and a mean VAS of 3.9 ±2.8 after hardware removal. This was a significant pain reduction. (p=<0.05)  However in 27% of the patients VAS scores did not change after elective hardware removal and only 24% became pain-free with a VAS of 0. (Table 2)

Table2   Change in pain after elective hardware removal (for painful hardware).

Recovery time from the secondary surgery was approximately 9 weeks (±10). Range of motion improved in 56% of the patients, whereas 6 % reported a decreased range of motion after hardware removal. 39% of the patients did not notice any change in range of motion. In 20% of the patients a superficial wound infection was reported that required additional treatment. No re-fractures or pseudoarthrosis were reported. Furthermore 25 % of the patients reported new complaints after hardware removal, such as other pain or instability.


After a mean follow up of 2.5 years 21% of the patients reported to have their hardware removed because of pain and 21% of the patients had significant and specific local pain at the site of the hardware. Obviously, hardware is not always the main contributor of this pain as scar tissue, post-traumatic changes and malalignment can also play a role. This should not be underestimated by (orthopedic) trauma surgeons. One study found similar results with 31% painful hardware and 17% removal. [4] However other studies report lower rates of painful hardware [6,7], especially among the elderly.8 Patients with painful hardware and also patients who had their hardware removed have significantly lower functional scores than patients without complaints.

In fact, all FAOS subscores were significantly worse in these patients suggesting a serious impact on quality of life and on daily activities. This is supported by Brown, et al., [4] who found significantly better outcome scores in patients that did not have hardware related pain. The results of hardware removal are comparable to Jacobsen, et al., [3] who found a 75% improvement after hardware removal. Brown on the other hand found a pain reduction in only 50% of the patients. A success rate of 71% in this study appears to be a promising statistic. However, in 76% of patients, they do not become pain free and have persistent pain. Patients should be informed correctly about the significant risk of persistent pain.

Range of motion is similar or better in most patients, but 25% of the patient had new or other complaints after removal of the hardware. Other studies that do not specifically investigate hardware removal of the ankle but hardware removal in general find other results. A prospective review about outcome of different types of hardware in different body parts found a significant pain relief, improved function and improved SMFA scores (Short Musculoskeletal Function Assessment Questionnaire). [5] Hardware in ankles, however can lead to location specific problems due to mechanical characteristics of the ankle and the lack of surrounding tissue in the ankle. Indications for elective hardware removal could be a pitfall. Local tenderness and pain can be due to the hardware, but can also be caused by posttraumatic changes in the ankle. Hence the surgeon and patient should also be well informed about specific complaints and a radiograph is mandatory to evaluate posttraumatic changes. If in doubt, an intra-articular injection with a local anaesthetic can help to differentiate between intra articular (post traumatic) and extra-articular (e.g. hardware) causes. Arthroscopic evaluation can be useful to assess degenerative changes, intra-articular malalignments or to remove loose bodies or adhesions.

Routine removal of hardware in patients with surgically treated ankle fractures is not recommended, because most patients do not have hardware related pain or may have minimal symptoms. Not only would routine hardware removal lead to more complications, increased health care costs, lost work and productivity, it can also lead to new complaints or increased pain. [2]

The type of implant or material may influence the amount of hardware related symptoms. Obviously bulky implants are more likely to cause symptoms, but smaller implants can lead to bony overgrowth which makes hard removal more difficult. Intramedullary nailing may be beneficial in some fractures, because soft tissue is less manipulated and also these implants can be easier to remove. [9]

Biodegradable osteosynthetic material have been proposed as a new method to avoid a secondary procedure to remove the material. [10] Although materials are improving, clinical results thus far are not encouraging. Petrisor, et al., concluded that patients with biodegradable osteosynthesis material had a higher risk (OR 2.63) for adverse events, such as osteosynthesis failure, compared to metal implants in patients with ankle fractures. [11] Ahl, et al., [10] found that patients treated with traditional titanium implants had better radiological measured stability, although clinical results did not differ. It is not clear whether these biodegradable materials result in less tenderness on palpation in short and long term.


Hardware related pain is a big issue in patients with a surgically treated ankle fracture that must not be underestimated. Functional outcome scores are significantly worse in patients with hardware related pain. Pain reduction can be achieved in 71% of the patients with hardware related pain but only 24% of the patients became pain-free after hardware removal. Similar results were found in literature. The most important conclusion that can be drawn is that the patient should be informed correctly about the risks and expectations of this second operation.


1.Daly PJ, Fitzgerald RH, Jr Melton LJ, Ilstrup DM. Epidemiology of ankle fractures in Rochester, Minnesota. Acta Orthop Scand 58: 539-544, 1987.
2.Busam ML,Esther RJand Obremskey WT. Hardware removal: indications and expectations. J Am Acad Orthop Surg 14: 113-120, 2006.
3.Jacobsen S,Honnens de Lichtenberg M,Jensen CM, Torholm C. Removal of internal fixation–the effect on patients’ complaints: a study of 66 cases of removal of internal fixation after malleolar fractures. Foot Ankle Int 15: 170-171, 1994.
4.Brown OL, Dirschl D, Rand Obremskey WT. Incidence of hardware-related pain and its effect on functional outcomes after open reduction and internal fixation of ankle fractures. J Orthop Trauma 15: 271-274, 2001.
5.Minkowitz RB,Bhadsavle S,Walsh M, Egol KA. Removal of painful orthopaedic implants after fracture union. JBJS 89A: 1906-1912, 2007.
6.Bostman O and Pihlajamaki H, Routine implant removal after fracture surgery: a potentially reducible consumer of hospital resources in trauma units. J Trauma 41: 846-849, 1996.
7.Michelson JD. Fractures about the ankle. JBJS 77A: 142-152, 1995.
8.Koval KJ,Zhou W,Sparks MJ, Cantu RV, Hecht P, Lurie J. Complications after ankle fracture in elderly patients. Foot Ankle Int 28: 1249-1255, 2007.
9.Guo JJ,Tang N,Yang HL, Tang TS. A prospective, randomised trial comparing closed intramedullary nailing with percutaneous plating in the treatment of distal metaphyseal fractures of the tibia. JBJS 92B: 984-988, 2010.
10. Ahl T, Dalen N, Lundberg A, Wykman A. Biodegradable fixation of ankle fractures. A roentgen stereophotogrammetric study of 32 cases. Acta Orthop Scand 65: 166-170, 1994.
11.Petrisor BA, Poolman R, Koval K, Tornetta P 3rd, Bhandari M; Evidence-Based Orthopaedic Trauma Working Group. Management of displaced ankle fractures. J Orthop Trauma 20: 515-518, 2006.

Address correspondence to: Johan Pot, Jeroen Bosch Hospital, Location Groot Ziekengasthuis, Postbus 90153, 5200 ME ’s-Hertogenbosch, The Netherlands. Email: johanhpot@gmail.com

1  Jeroen Bosch Hospital, ’s-Hertogenbosch, the Netherlands. Department of Surgery, Postbus 90153, 5200 ME ’s-Hertogenbosch The Netherlands. tel: (+31) 73-6992000; fax:(+31) 73-6992163.

© The Foot and Ankle Online Journal, 2011

Salter Harris Type II Physeal Ankle Fracture: A review of 10 cases

by J. Terrence Jose Jerome, MBBS, DNB (Ortho), MNAMS (Ortho)1, Mathew Varghese, M.S. (Ortho)2, Balu Sankaran, FRCS (C), FAMS3, K. Thirumagal, MD4

The Foot and Ankle Online Journal 3 (7): 2

Salter Harris Type II ankle injuries are reviewed in 10 cases. Potential premature physeal closure (PPC) is a real complication in most open reductions of this fracture. In the cases presented here, closed reduction offered the best clinical outcomes with no evidence of premature physeal closure. Restoring the congruency of the physeal plate is imperative in preventing long term complications such as talar tilts, post traumatic ankle stiffness and other angular and limb length discrepancies.

Key words: Salter Harris Fracture, ankle fracture.

Accepted: June, 2010
Published: July, 2010

ISSN 1941-6806
doi: 10.3827/faoj.2010.0307.0002

Injuries to the distal tibial and fibular physis are generally reported to account 25% to 38% of all physeal fractures, second in frequency only to distal radial physeal fractures. [1] In skeletally immature individuals, physeal ankle fractures are slightly more common than fractures of the tibial or fibular diaphysis. [2] Up to 58% of physeal ankle fractures occur during sports activities and account for 10 to 40% of all injuries to skeletal immature atheletes. [3] Physeal ankle fractures are more common in males than females. Tibial physeal fractures most commonly occur between the ages of 8 and 15 years, and fibular fractures between the ages of 8 and 14 years. [4] In 1898, Poland in his monograph, pointed out that in children, ligaments are stronger than physeal cartilage and forces that result in ligament damage in adults cause fractures of the physis in children. [5]

The various patterns of injury can be better understood if one is aware of the direct and indirect forces that act on the ankle, the ligamentous anatomy of the ankle, and the effects of trauma on the epiphysis before and during the time of epiphyseal fusion. A characteristic radiographic pattern of injury occurs as a result of each particular injuring force, which in turn requires a specific mode of fracture reduction. We present our cases with management protocol and review of the literature.

Materials and methods

This is retrospective study conducted from January 2003 to December 2005. A Salter-Harris Type II injury is an epiphyseal separation with a metaphyseal fragment attached to the epiphysis. Notation was made in each case as to the age of the patient, gender, mode of injury, mechanism of injury, methods of treatment, complications associated fractures of the fibula, and follow-up to 2 years duration.

The cases were also examined according to mechanism of injury using the system described by Crenshaw. [8] This system describes mechanisms of injury; plantarflexion, external rotation, abduction, adduction, and direct injury/axial compression. (Table 1)

Table 1  Ten case presentations of Salter-Harris Type II physeal fracture.  Four cases of stable closed reduction resulted in normal range of motion and no premature physeal closure (PPC*).  Four other cases of open reduction internal fixation (ORIF) resulted in premature physeal closure. (F – Female, M – Male, L – Left, R – Right, PER – Pronation, eversion, external rotation, SER – Supination, external rotation, SPF – Supination plantarflexion, DF – dorsiflexion, PF – plantarflexion).

Case Examples

Case 1

This 11 year-old girl sustained a fall from height and injured her right ankle. Diffuse swelling, tenderness, redness were the initial findings.

It was a severely displaced eversion, pronation-external rotation (PER) injury. Radiograph showed severe displacement of fracture fragments. (Figs. 1A and B) Closed reduction was unsuccessful and a valgus tilt of the ankle mortise was noted.


Figure 1A and B    Case 1 demonstrates a severe eversion, pronation-external rotation (PER) injury after falling from a height.

Open reduction and internal fixation (ORIF) was planned under spinal anesthesia. Soft tissue was interposed laterally between the metaphyseal fragments and the distal tibia. Reduction was completed and stabilized with two transmetaphyseal cancellous screws placed above the physis. (Fig. 2) At the end of 2 years, she had mild restriction of ankle range of motion and had valgus tilt which corrected spontaneously over time. She can do her normal activities.

Figure 2   Case 1 post ORIF with 2 transmetaphyseal screws in place above the physis.  She returned to normal activities despite a 12 degree valgus, talar tilt.

Case 2

A 10 year-old boy had sustained injury to his left ankle due to fall from stairs. He came to our out-patient department with swelling and pain to the left ankle. The left ankle was diffusely swollen, reddish discoloration of skin. (Figs. 3A and B)


Figure 3A and B   Case 2 shows typical ecchymosis and swelling to the foot and ankle following a Salter-Harris type II physeal ankle fracture.

Radiographs showed a large metaphyseal fracture fragment. (Figs. 4A and B) Closed reduction under spinal anesthesia was performed. Post-operative radiographs showed a well reduced metaphyseal fragment. (Figs.5A and B)

Figure 4A and B   Case 2 shows large metaphyseal fracture after a fall from the stairs.  This was a relatively stable supination-external rotation (SER) injury.


Figure 5A and B   Case 2 shows a stable ankle mortise after successful closed reduction.

An above-knee cast was applied for 4 weeks. It was then changed to below-knee for a period of 4 weeks. A follow-up radiograph was obtained every month for 2 years or until Park-Harris growth arrest line parallel to the physis is visible and there is no evidence of physeal deformity. The patient has full range of motion and is doing all of his daily activities. (Figs 6A, B and C)


Figures 6A, B and C   Case 2 shows a stable ankle mortise after successful closed reduction with full range of motion.


Our patients were between 8 and 14 years old. There were 6 males and 4 females examined. Equal number of sides was involved. The average age was 10.6 years. All had suffered the fracture following a severe type of injury. Forty percent of the patients on presentation had diffuse swelling where the vascular status could not be properly documented due to severe pain. The most common mechanism of injury pattern was supination-external rotation (SER) and pronation-eversion-external rotation (PER) (40% each). Supination-plantar flexion (pure posterior displacement and posterior metaphyseal fragment, Greenstick distal fibula fracture) accounted for 20% of the fracture pattern. All supination-external rotation was treated by closed reduction under spinal anesthesia and they remained very stable in the follow up. All pronation-eversion-external rotation and supination-plantar flexion were unstable after closed reduction. They were treated by open reduction and internal fixation with 2 transmetaphyseal cancellous screws (above the physis). Antero-posterior screws for supination plantar flexion pattern and medio-lateral for pronation-external rotation injuries were done. Soft tissue interposition, periosteum interposition were the most commonly interpreted structures found in the open reduction in PER and SPF fractures. Range of motion was severely restricted in 20 % of patients (one each of SPF and PER type). All PER type of injury had valgus tilt of an average of 11 degree in the initial post-operative period. There was no residual angulation in their long term follow up as this had spontaneously corrected. Premature physeal closure was seen in all cases of PER and SPF types. No premature physeal closure was seen in the supination and external rotation injury pattern.


In 1922, Ashhurst and Bromer published a thorough review of the literature and the results of their own extensive investigations and described a classification of ankle injuries based on the mechanism of injury. [6]

This classification did not differentiate between ankle injuries in adults and those of children. In 1955, Caruthers and Crenshaw reported 54 ankle physeal fractures, which were classified according to their modification of Asshurst. [8] They confirmed that growth-related deformities were frequent after Salter- Harris type III and IV injuries and infrequent after fractures caused by external rotation, abduction, and plantarflexion (Salter type II injuries). Spiegel and colleagues reviewed 237 physeal fractures and reported a high incidence of growth abnormalities after Salter-Harris III and IV injuries. Most of these patients had only mild shortening, but 6 had angular deformities that did not correct with growth. [4] Based on the results of 65 physeal ankle fractures, Kling and Co-workers concluded that frequency of growth related deformities could be reduced by open reduction and internal fixation of Salter-Harris III and IV fractures. [7]

Appropriate treatment of ankle fractures in children depends on the location of the fracture, the degree of displacement, and the age of the child. Non-displaced fractures may be appropriate for displaced fractures; if the closed fractures cannot be maintained with casting, skeletal fixation is necessary. If closed reduction is not possible, open reduction is indicated, provided there is significant physeal or articular displacement, followed by internal fixation or cast immobilization.

The anatomic type of the fracture (usually defined by the Salter-Harris classification), the mechanism of injury, and the amount of displacement of the fragments are the most important considerations of treatment.

When the articulation is disrupted, the amount of articular step-off or separation must be measured. The neurovascular status of the limb or the status of the skin may require emergency treatment of the fracture and associated problems. The general health of the patient and the time since injury also must be considered.

Type II Salter-Harris physeal fractures can be caused by four mechanisms. (Table 2) Patients with significant displaced fractures have severe pain and obvious deformity. The position of the foot relative to the leg may provide important information about the mechanism of injury and should be considered in reduction. The status of the skin, pulses, sensory and motor function should be determined and recorded. Tenderness, swelling, and deformity of the ipsilateral leg should be noted. Patients with non-displaced or minimally displaced ankle fractures often have no deformity, minimal swelling and moderate pain. Because of their benign clinical appearance, such fractures may be easily missed if radiographs are not obtained. On a standard antero-posterior view, the lateral portion of the distal physis is often partially obscured by the distal fibula.

A high quality mortise view of the ankle is essential in addition to the normal views. [9] Computerized tomography (CT) is useful in the evaluation of the intra-articular fractures, especially the Tillaux and triplane fractures. [10] Magnetic resonance imaging (MRI) is occasionally helpful in the identification of osteochondral injuries to the joint surfaces in children with ankle fractures. [11]

Table 2  The 4 mechanisms of injury in Type II Salter-Harris Physeal Fractures.

The location of Thurston-Holland fragment is helpful in determining the mechanism of injury in addition to the direction of displacement of the distal tibial epiphysis and associated fibular fracture:

1) A lateral fragment indicates pronation-eversion-external rotation. 2) a poster-medial fragment indicates supination-external rotation and 3) a posterior placed fragment indicates supination-plantar flexion injury.

Our results showed that the injury most commonly occurs between the age of 8 and 13 years because of direct and indirect forces that act on the ankle, the ligamentous anatomy of the ankle, and the effects of trauma on the epiphysis before and during the time of epiphyseal fusion. The mode of injury remained the high-energy type and severe displacement is always associated with diffuse swelling. This swelling prompted to check for the distal pulses and toe movements. The capillary circulation and sensation was intact in all of them. None of our patients had sustained neurovascular injury in this type of physeal fractures. Salter and Harris type II injury can be cause by any of the four mechanism described.14 PER and SER injury remained the most commonly involved mechanism in our pediatric ankle fractures.

Non-displaced fractures can be treated with cast immobilization usually with an above-knee cast for 3 to 4 weeks, followed by a below-knee walking cast for another 3 to 4 weeks. All supination and external rotation injuries in our study were stable after closed reduction and were treated with cast immobilization. One patient needed prolonged immobilization (12 weeks) because of poor compliance and he developed severe ankle stiffness. Although most researchers agree that closed reduction of significantly displaced Salter Harris type II ankle fracture should be attempted, opinions differ as to what degree of residual displacement or angulation is unacceptable and requires open reduction. Based on the follow-up of 33 cases, Caruthers concluded that ‘accurate reposition of the displaced epiphysis at the expense of forced or repeated manipulation or operative intervention is not indicated since spontaneous re-alignment of the ankle occurs even late in the growing period’.8 They found no residual angulation at follow up in patients who had up to 12 degrees of tilt after reduction, even in patients as old as 13 years at the time of injury.
An 11 degree valgus tilt was seen in pronation and external rotation type of injury in our study. The entire patient showed spontaneous realignment in their 2 years follow-up irrespective of the age of the patient.

Speigel and associates recommended from their series that ‘precise anatomic reduction’ is essential to prevent angular deformities. [4] Incomplete reduction is usually caused by interposition of soft tissue including the neurovascular bundle, resulting in circulatory embarrassment when closed reduction was attempted. A less definitive indication for open reduction is interposition of the periosteum, which causes physeal widening with no angulation or with minimal angulation. [15]

PER and supination-flexion injury in our cases reported here were invariably unstable after closed reduction because of the severity of injury, displacement and soft tissue and periosteum inter-position. Good results were obtained after open reduction and extraction of the periosteal flap. It is not clear that failure to extract the periosteum in such cases results in problems sufficient to warrant operation.

Due to the fear of iatrogenic damage to the distal tibial physis during closed reduction, many researchers recommend the use of general anesthesia with adequate muscle relaxation. However, no reports have compared the frequency of growth abnormalities in patients with after these fractures were reduced. We have reduced our SER injuries under spinal anesthesia and found the reduction stable and easy to perform. Hematoma block, intravenous sedation, intravenous regional anesthesia has been reported to be effective for pain relief in lower extremity injuries. [16,17] All fractures were reduced with a single manipulation.

Reflex sympathy dystrophy occasionally develops after these injuries and is treated initially with an intensive formal physical therapy regimen that encourages range of motion exercises and weight bearing. [12]

Delayed union, growth arrest, arthritis, avascular necrosis of the distal epiphysis and non-union are rare after this type II physeal fractures. Rotational malunion usually occur after triplane fractures that are either incompletely reduced or are initially immobilized in below-knee casts. Anterior angulation or plantar flexion deformity usually occurs after supination-plantar flexion injuries. Two of our patients developed severe restriction of dorsiflexion at the end of one year. Range of motion improved at the end of 2 years due to the remodeling with growth.

Theoretically, an equines deformity might occur if the angulation exceeds the range of ankle dorsiflexion before fracture, but this is rare, probably because the deformity is in the plane of joint motion and tends to remodel with growth. Valgus deformity is most common after external rotation type II injuries. [8]

For the Salter Harris type II fractures of the distal tibial physis 39.6% developed premature physeal closure. There is a difference in PPC based on injury mechanism. [13] The rate of Premature Physeal Closure (PPC) in patients with a supination-external-rotation-type injury was 35%, whereas patients with pronation-abduction-type injuries developed PPC in 54% of cases. [13] Type of treatment may prevent PPC in some fractures. Forty percent of our patients had pre-mature physeal closure. Twenty percent each of PER and supination plantar flexion injury showed premature closure. None of the supination and external rotation injury developed premature closure. The most important determinant of PPC is the fracture displacement following reduction.


Knowledge of common pediatric ankle fracture patterns and the pitfalls associated with their evaluation and treatment will aid the clinician in the effective management of these injuries. PPC is a common problem following Salter and Harris type II fractures of the distal tibia. Operative treatment may decrease the frequency of PPC in some fractures. Regardless of treatment method, we recommend anatomic reduction to decrease the risk of PPC.

The potential complications associated with pediatric ankle fractures include those seen with adult fractures (such as posttraumatic arthritis, stiffness, and reflex sympathetic dystrophy) as well as those that result from physeal damage (including leg-length discrepancy, angular deformity, or a combination thereof).

The goals of treatment are to achieve and maintain a satisfactory reduction and to avoid physeal arrest. In examining epiphyseal injuries of the ankle, the patterns of injury can easily be recognized and related to the mechanism of injury. Therefore, adequate therapeutic maneuvers can be instituted to restore the congruency of the epiphyseal plate. Adequate reduction of this fracture is necessary because it involves the joint surface. Being aware of the age incidence of these various fractures and recognizing the patterns of injury encountered and the subtle differences between various fractures, one can more accurately diagnose injuries of the distal tibia and direct the proper therapy.

Although most pediatric fractures do well, vigilance must be maintained because these injuries may have substantial long-term consequences. Angular deformity and joint incongruity can result in premature degenerative arthritis. Treatment strategies must be tailored to both the specific injury and the patient’s skeletal maturity. Follow-up of physeal injuries must extend at least 6 months after the injury to be sure that the growth of the physis is symmetric.


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Address correspondence to: Dr. J. Terrence Jose Jerome, MBBS.,DNB (Ortho), MNAMS (Ortho), FNB (Hand & Microsurgery). E-mail: terrencejose@gmail.com

Registrar in Orthopedics, Dept. of Orthopedics, St. Stephen’sHospital, Tiz Hazari, Delhi 54, India.
Registrar in Orthopedics, Department of Orthopedics, St. Stephens Hospital, Tiz Hazari, Delhi, India.
Head Professor, Department of Orthopedics, St. Stephens Hospital, Tiz Hazari, Delhi, India.
Professor Orthopedics, Tamilu,India.

© The Foot and Ankle Online Journal, 2010