Tag Archives: ankle fracture

Intramedullary fixation of distal fibular fractures in a geriatric patient: A case report

by Amanda Kamery DPM1*, Craig Clifford DPM MHA FACFAS FACFAOM2

The Foot and Ankle Online Journal 11 (3): 1

Intramedullary rod fixation is presented as a viable treatment option for distal fibular fractures in the geriatric population. This technique leads to a reduction in wound complications, hardware irritation, procedure time and need for subsequent surgeries as seen with traditional open reduction internal fixation for distal fibular fractures in higher-risk patients.

Keywords: ankle fracture, trauma, geriatric, open reduction

ISSN 1941-6806
doi: 10.3827/faoj.2018.1103.0001

1 – Franciscan Foot and Ankle Institute- St Francis Hospital, Federal Way, WA PGY-3
2 – Residency Director, Franciscan Foot and Ankle Institute- St Francis Hospital, Federal Way, WA
* – Corresponding author: akamery@kent.edu

Geriatric patients are at an increased risk for sustaining ankle fractures due to increased fall rate and decreased bone density. Surgical repair for such injuries is often complex, due to the standard large incision and relatively bulky fixation which is necessary in the geriatric patient due to their generally poor bone stock [1]. This traditional form of fixation carries a complication rate of up to 30% [2]. Additionally, wound healing complications and hardware irritation is more common in this population due to a poor soft tissue envelope, with wound infection rates ranging from 26-40% [3]. Commonly, subsequent surgeries are necessary to remove hardware or to perform wound debridements [4]. As it is well documented that surgical morbidity increases in this population, it is important to utilize techniques and fixation methods that limit subsequent encounters. In this case report, we present intramedullary fixation for distal fibular fractures as a viable option for the geriatric population.

Case  Report

The patient is a 94-year-old male who presented 5 days after a fall with a Weber B, slightly comminuted, left distal fibular fracture (Figure 1a). Due to the unstable nature and slight displacement of the fracture, surgical intervention with an intramedullary fibular rod was chosen. Intra-operatively under general anesthesia, excellent anatomic reduction was noted after placement of the rod and one syndesmotic screw (Figure 1b).

At 2 weeks postoperatively, the posterior splint and skin staples were removed. The patient transitioned to protected heel touch weight-bearing for 4 weeks. He resumed regular activity and normal shoe wear at 6 weeks postoperatively. There were no wound healing complications or hardware irritation noted throughout the postoperative course. At 12 months follow up, patient reported no ankle pain or limitations in activities of daily living (Figures 2a-b).


Figure 1 AP ankle radiograph showing Weber B fracture with slight comminution and displacement (a). Two weeks postoperative AP radiograph showing excellent anatomic reduction with fibular rod and syndesmotic screw (b).


Figure 2 Twelve months post operative AP (a) and lateral (b) radiographs showing excellent bony consolidation of fracture fragments and adequate anatomic reduction.


Treatment of distal fibular fractures in geriatric patients have an increased risk for postoperative complications which can lead to wound healing issues and subsequent surgeries. It is important to utilize techniques and fixation methods that limit subsequent encounters in order to decrease surgical morbidity in this cohort. The intramedullary fibular rod is an excellent alternative to traditional ORIF in the geriatric population. Our case example demonstrates an ideal patient for this technique, including successful anatomic realignment and uneventful postoperative course.


  1. Mitchell JJ, Bailey JR, Bozzio AE, Fader RR, Mauffrey C. Fixation of distal fibula fractures: an update. Foot Ankle Int. 2014;35(12):1367-1375.
  2. Lamontagne J, Blachut PA, Broekhuyse HM, O’Brien PJ, Meek RN. Surgical treatment of a displaced lateral malleolus fracture: the antiglide technique versus lateral plate fixation. J Orthop Trauma. 2002;16(7):498-502)
  3. Höiness P, Engebretsen L, Stromsoe K. The influence of perioperative soft tissue complications on the clinical outcome in surgically treated ankle fractures. Foot Ankle Int. 2001;22(8):642-648.
  4. Lee YS, Huang HL, Lo TY, Huang CR. Lateral fixation of AO type-B2 ankle fractures in the elderly: the Knowles pin versus the plate. Int Orthop 2007;31:817–821.


Novel ankle cast designs with non-toxic material

by Hirsimäki J¹, Lindfors NC², Salo J³pdflrg

The Foot and Ankle Online Journal 7 (4): 5

Foot and ankle immobilization is usually based on circular support, either using casts or boot-like orthoses. Basic requirements for immobilization of the ankle region include reliable support and possibility of full weight bearing during healing. Woodcast® is a novel, freely 3D moldable cast material based on non-toxic components. The material is strong but light weight and can be used as a split or a cast. Our hypothesis was to test in a proof-of-concept type study, whether a new open cast design, leaving the calf area free can be clinically used in ankle immobilization. Thirty patients with an acute ankle fracture or a recently performed ankle arthrodesis were recruited.  Two different types of cast designs were used, one semi-rigid cast and one rigid cast. All fractures and arthrodesis healed well, with no major postoperative complications. Patient satisfaction was high in both groups and slightly higher in the semi-rigid group. This study shows that the ankle area can be immobilized using a novel type of a very light weight Woodcast® material.  By combining soft and hard wood composite materials, an optimal open cast design leaving the calf area free can be performed, allowing full weight bearing and reliable immobilizing of the ankle.

Key words: Ankle, fracture, immobilization, cast, orthosis, wood, orthopaedic equipment, orthopaedic fixation devices

ISSN 1941-6806
doi: 10.3827/faoj.2014.0704.0005

Address correspondence to: ¹Hirsimäki J, University of Eastern Finland, Yliopistonranta 1, 70211 Kuopio, Finland; Tel: +358 40 753 4415; E-mail: jhirsima@student.uef.fi

² Helsinki University Central Hospital, Department of Orthopaedic and Hand Surgery, Helsinki University, Helsinki, Finland
³ Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland

Immobilisation in fracture treatment has a long history. Fractures have been treated millennia with natural materials such as wood sticks, but it was only until 1852 that Plaster-of-Paris (POP) was first used in fracture treatment. Inorganic calcium based component had been traditionally used in building walls, but it required additional binding material to be used in limb immobilization. Cotton offered this possibility, and it was utilized almost simultaneously by two army doctors, Dutch Antonius Mathysen and Russian Nikolay Pirogov.

It took a long time to get the first commercially available POP on the market (Cellona, Germany 1932). Typically, POP offered sufficient rigidity with relatively thick and heavy layers, allowing at least partial weight bearing. But it was also brittle and did not tolerate water. As a first improvement to POP, fiberglass was introduced to fracture treatment in the 1950s. It is lightweight, rigid or semi-rigid, and tolerates both water and continuous mechanical loading during walking. It is partially moldable with a strong net like support structure as a limiting factor [1-3]. Modern orthopedic plaster casts are commonly based on synthetic plastic that contains up to 25% methylene diphenyl diisocyanate (MDI). Severe issues have been raised in occupational health sector related to use of isocyanates used in modern paints, moldable glues and orthopaedic casting materials like fiberglass and polyurethane [4].

Ankle fractures can be treated in a conservative way when certain criteria are fulfilled. Some centers prefer cast immobilization also after plate fixation, others rely more on ORIF stability and accept functional orthosis or free mobilization. If cast is to be used, it is however of one basic design regardless of material used. The leg and calf area are covered with a circular cast having different additional layers for sufficient stability [5-9]. Different kind of pre-shaped orthosis have come to the market, initially for functional treatment of ankle sprains, and in some studies also for treatment of ankle fractures [10-14].

In 2010, an innovative wood-composite material was introduced for fracture treatment by Onbone Oy, Helsinki, Finland. The Woodcast® material is an ecologically friendly, biodegradable, wood-plastic composite material, with absolutely free three-dimensional (3D) molding properties. Because of its extreme strength and exceptional molding properties, we hypothesized that it could be possible to treat common ankle fractures and postoperative immobilization in ankle arthrodesis with a novel, open cast design. The goal for the cast was to leave the calf area free, and to allow cast removal and reinserting without tools. Absolute requirements were that the new cast design has to be stiff enough to allow full weight bearing.

This proof-of-concept type multicenter trial was conducted in accordance with the ethics principle originating in the latest version of the Declaration of Helsinki, applicable regulatory requirements, including the standards of the International Organization, and Finnish law and regulations. The study protocol was approved by the Ethics Committee of the Helsinki University Central Hospital (HUCH) and informed consent was obtained of the patients. The study was registered at www.clinicaltrials.gov.

Major hypothesis were that novel light weight cast designs could be successful in treatment of ankle fractures and as postoperative supporting device after ankle arthrodesis.


Casting materials

Woodcast® is a composite of thermoplastic polymer and a woody material approved for clinical use in limb immobilization (European approval in 2010). The material is hard in room and body temperature, but becomes moldable when heated up to +62 oC.  During cooling, it retains moldable down to 45 oC offering extended working time.  When ready, casting hardening can be enhanced with external cooling.  The material is non-toxic, does not release irritant aerosols, and can be handled without protective gloves. It is strongly self-adhesive and slightly adhesive toward padding and bandage materials, but does not attach to skin. It can be composted after use. The Woodcast® materials can be reheated repeatedly without affecting their mechanical properties, and they can be stretched and bent freely in 3D.


Thirty patients were enrolled in the study. The inclusion criteria were: Finnish or Swedish speaking patient, age between 0-90 years, a non-complicated ankle fracture or a performed elective foot arthrodesis normally requiring cast immobilization. The exclusion criteria were compromised co-operation for any reason, a complicated fracture, other simultaneous or earlier fractures, nerve, vessel or tendon injuries on the index extremity, malignancy and other severe diseases.

Postoperatively the patients were treated with other casting materials for two weeks. After two weeks the postoperative cast was changed either to a Woodcast® semi-rigid ankle cast model (Group 1) or a rigid model (Group 2). The cast technicians were educated for both models and the choice of design depended on the hospital they were working in.

Figure 1. A removable semi-rigid orthosis

Figure 1 A removable semi-rigid orthosis.

The semi-rigid model was made of 80 cm long Woodcast® 2 mm Soft, 40 cm long Woodcast® 4 mm and of a 15 cm peace of Woodcast® 2mm. The Woodcast® 4 mm offers mechanical stability and the Soft product is used to achieve flexibility. The cast material was applied on the anterior part of the extremity leaving the posterior side of the extremity free and then allowed to cool. The cast was then removed and finalized with soft tape around the edges (Figure 1). Padding and Velcro tape were used. During the immobilization period the patients were allowed to remove the cast temporarily.

The rigid cast was made of two 80 cm long Woodcast® 2mm pieces with paddings protecting the skin. A U-shaped casting material was applied from the lateral side, around the heel area and extending to medial side. The other 80 cm piece was cut oblique in two parts and applied anteriorly to stabilize the TC-joint and protect the plantar area during walking (Figure 2).


Figure 2 A non-removable rigid cast.


All patients completed the study. Thirteen (13/30) patients with ankle fractures were treated with the semi-rigid orthosis (Group 1). In 17/30 cases the rigid cast was used (Group 2) including 10 ankle arthrodesis patients and 7 trauma cases. In Group 1 the average age was 47.5 (the youngest patient being 24, and oldest 66 years old) and in group 2 the average age was 50.1 (the youngest patient being 24, and oldest 76 years old). Applying time was not depended on cast type rather skills of the technician. There were no major difference in immobilization time between Groups 1 and 2 (Table 1).

The orthopedic technicians reported that no primary complications occurred in Group 1, although in one case orthosis soft material broke from the metatarsus area during the last week of immobilization, but didn’t cause complications for the patient. Twelve (12/13) of the patients in Group 1 reported that they removed the orthosis themselves during the immobilization at least once.

Primary complications were reported by technicians in Group 2. Molding the cast was not easy in one case and in six of the cases there were issues applying the cast in correct position because of the multilayer composition. In two of the cases preheating the casting material didn’t occur fast enough.


Table 1 Results of removable semi-rigid orthosis versus non-removable rigid cast.

Patient satisfaction was high in both groups yet superficial skin complications were seen in Group 2. Superficial maceration reported in 6/17 cases, focal compression in the cast 3/17 and 3/17 both simultaneously (Table 1). One rigid cast was changed to the semi-rigid orthosis because of the increased level of moisture in the cast with good results.  There were no skin complications in Group 1. There were no post-operative infections in either of the reported groups.


Cast designs used in this study concentrate especially in immobilization of ankle joint and subtalar joint lines. Shortening the distal dimension in the cast gives more freedom to the toes, to the Lisfranc area, and finally to midtarsal Chopart joint line. This more targeted immobilization is possible with the specific material properties, but whether this has an effect on functional recovery remains to be seen in future studies. In acute ankle sprains (grades II & III), functional brace seems to give better outcome than total immobilization of the lower extremity [12,14]. It can be at least assumed that this kind of new material offers possibilities to design functional braces in the near future.

The anteromedial margin of tibia is the area where soft tissue layers are thinnest. This offers a good contact area for bone immobilization, but requires good fitting of cast material. Cast designs used in this study utilize this area as an anchor site for ankle immobilization. Although no direct force measures were included in this study, our emphasis is that this is far more stable than padded circular cast around the whole calf area with soft tissues on the posterior area. No patient had discomfort on this anteromedial area, even with the use of hard material only. The hard version of Woodcast®, 4 mm and 2 mm are extremely stiff and durable materials.  Hard material can be used as an internal support in elastic constructions, but if it is used as the only material attention must be paid on breathability and edges of cast design. Based on our experience in this relative small patient population, skin maceration and compression discomfort can occur in closed cast design. In Group 1, no patients with combined soft and hard material had cast related discomfort. This emphasizes the role of careful cast design, and use of appropriate padding.

The immobilization or the cast itself can cause several complications. Pressure sores are common complications if improper techniques are used. The risk receiving pressure sores increases in patients who suffer from peripheral nerve or vessel disorders. Compartment syndrome may develop due to a too tight cast [15]. Immobilization may also lead to problems such as joint stiffness, muscle atrophy, cartilage degradation, ligament weakening and osteoporosis [9]. Deep venous thrombosis (DVT) is perhaps the most common complication in lower extremity immobilization, with an incidence of 1.1% to 20% in various type of lower limb injuries treated with a circular cast [16]. In this study, no DVT occurred although no prophylactic agents were used. The number of patients in this proof-of-concept study is too low to draw any solid conclusions on this, but it can be assumed that this type of novel cast design leaving the calf muscle area free could even decrease the risk of DVT. If a DVT is suspected, a circular cast has to be removed, but this open design allows ultrasound diagnostics directly with cast on.

Achilles tendon ruptures are prone to wound complications [18]. Although these ruptures were not in the scope of this study, it is evident that this kind of easily removable cast will fit well in treatment of these injuries. One advantage would be to monitor and treat wound complications even with the cast on. It also gives a direct access to healing tendon, either to monitor tendon healing with ultrasound, or possibly to stimulate tendon healing with external pulsating equipment.


This study challenges the long-time circular cast design in ankle immobilization. It seems that even a semi-rigid open wood composite cast is safe and strong enough to stabilize common ankle fractures, and to successfully protect postoperative period after ankle arthrodesis.  Taken together current data is very promising for an open type cast technology, further and larger studies are highly warranted.


  1. Colditz J. Plaster of Paris: The Forgotten Hand Splinting Material. J Hand Ther 2002 Apr-Jun;15(2):144-57.(Pubmed)
  2. Lindfors NC, Salo J. A Novel Nontoxic Wood-Plastic Composite Cast. Open Med Dev J 2012; 4:1-5. (Link)
  3. Runumi G, Utpal KN. Study of Effect of NCO/OH Molar Ratio and Molecular Weight of Polyol on the Physico-Mechanical Properties of Polyurethane Plaster Cast. World Appl Sci J 2013; 21(2):276-283. (Link)
  4. Suojalehto H, Linström I, Henriks-Eckerman M-L, Jungwelter S, Suuronen K. Occupational asthma related to low levels of airborne methylene diphenyl diisocyanate (MDI) in orthopedic casting work. Am J Ind Med 2011 Dec;54(12):906-10. (Pubmed)
  5. Lee YS, Chen SW. Lateral fixation of open AO type-B2 ankle fractures: the Knowles pin versus plate. Int Orthop 2009 Aug;33(4):1135–1139. (Pubmed)
  6. Herscovici D, Scaduto JM, Infante A. Conservative treatment of isolated fractures of the medial malleolus. J Bone Joint Surg 2007 Jan;89(1):89-93. (Pubmed)
  7. Van Laarhoven CJHM, Meeuwis JD, Van Der Werken C. Postoperative treatment of internally fixed ankle fractures. J Bone Joint Surg 1996 May;78(3):395-9. (Pubmed)
  8. Egol KA, Dolan R, Koval KJ. Functional outcome of surgery for fractures of the ankle. J Bone Joint Surg 2000 Mar;82(2):246-9. (Pubmed)
  9. Halanski M., Noonan KJ. Cast and Splint Immobilization: Complications. J Am Acad Orthop Surg 2008 Jan;16(1):30-40. (Pubmed)
  10. Dietrich A, Lill H, Engel T, SchönfelderM, Josten C. Conservative functional treatment of ankle fractures. Orthop Trauma Surg 2002 Apr;122(3):165-168. (Pubmed)
  11. Cooke MW, Marsh JL, Clark M, Nakash R, Jarvis RM, Hutton JL, Szczepura A, Wilson S, Lamb SE. Treatment of severe ankle sprain: a pragmatic randomised controlled trial comparing the clinical effectiveness and cost-effectiveness of three types of mechanical ankle support with tubular bandage. Health Technol Assess 2009 Feb;13(13). (Pubmed)
  12. Petersen W, Rembitzki IV, Koppenburg AG, Ellermann A, Liebau C, Brüggemann GP, Best R. Treatment of acute ankle ligament injuries: a systematic review. Orthop Trauma Surg 2013 Aug;133(8):1129–1141. (Pubmed) FORUM
  13. Wykes PR, Eccles B, Thennavan B; Barries JL. Improvement in the treatment of stable ankle fractures: an audit based approach. Injury 2004 Aug;35(8):799-804. (Pubmed)
  14. Polzer H, Kanz KG, Prall WC. Diagnosis and treatment of acute ankle injuries: development of an evidence-based algorithm. Orthop Rev 2012 Jan;4(2):22-32. (Pubmed)
  15. Pifer G. Casting and splinting: Prevention of complications. Top Emerg Med 2000;22:48-54. (Link)
  16. Patil S, Gandhi J, Curzon I, Hui ACW. Incidence of deep-vein thrombosis in patients with fractures of the ankle treated in a plaster cast. J Bone Joint Surg 2007; 89:1340-3. (Link)
  17. Kesieme E, Kesieme C, Jebbin N, Irekpita E, Dongo A. Deep vein thrombosis: a clinical review. J Blood Med 2011 Apr;2:59–69. (Pubmed)
  18. Roderik Metz R, Kerkhoffs G, Verleisdonk EJ, Van der Heijden GJ. Acute Achilles tendon rupture: minimally invasive surgery versus non operative treatment, with immediate full weight bearing. Design of a randomized controlled trial. BMC Musculoskeletal Disorders 2007 Nov;8:108. (Link)

Natural History of Diabetic Foot and Ankle Fractures: A Retrospective Review of 40 Patients

by Brian T. Dix, DPM1, Alan R. Catanzariti, DPM, FACFAS, Robert W. Mendicino, DPM, FACFASpdflrg

The Foot and Ankle Online Journal 6 (11): 1

Background: Ankle fractures in diabetics with secondary complications are more prone to postoperative complications than ankle fractures in diabetics without secondary complications. This study retrospectively compared the post injury complications of foot and ankle fractures in diabetics with and without secondary complications. Secondary complications of diabetes mellitus include peripheral arterial disease, nephropathy, and/or peripheral neuropathy. Uncomplicated diabetics did not have any of these end organ diseases associated with diabetes. Our hypothesis was that foot and ankle fractures in complicated diabetics would incur more post injury complications than uncomplicated diabetics.
Materials and Methods: We contrasted the post injury complications of foot and ankle fractures in 25 complicated diabetics with15 uncomplicated diabetics.
Results: At an average follow-up of 33.8 weeks we established that foot fractures in complicated diabetics had a non significant trend of a 2.8 times increase in overall post injury complications versus foot fractures in uncomplicated diabetics. Furthermore, with an average follow up of 28.8 weeks we demonstrated a non significant tendency of a 1.4 times increase in overall post injury complications of ankle fractures in complicated diabetics compared to ankle fractures in uncomplicated diabetics. Lastly, with a mean follow up of 33.7 weeks we found insignificant trends of a 1.7 times increase in overall post injury complications and a 2.8 times increase in noninfectious complications (malunion, delayed union, nonunion or Charcot neuroarthropathy) in complicated diabetic foot and ankle fractures contrasted to uncomplicated diabetic foot and ankle fractures.
Conclusion: Foot and ankle fractures in complicated diabetics are presumably at an increased risk of developing a post injury complication compared to uncomplicated diabetics. Specifically, foot fractures should be treated similar to ankle fractures in complicated diabetics with an extended period of non-weight-bearing in a total contact cast. Mandatory post injury clinical evaluation for peripheral arterial disease, peripheral neuropathy and nephropathy should be implemented. This analysis will be used as a template for a future prospective comparative study evaluating foot and ankle fractures in complicated and uncomplicated diabetics with a power analysis to achieve statistical significance.

Key words: Diabetes mellitus, ankle fracture, Charcot arthropathy

Accepted: October, 2013
Published: November, 2013

ISSN 1941-6806
doi: 10.3827/faoj.2013.0611.001

Address correspondence to:1Resident, Department of Foot and Ankle Surgery, Western Pennsylvania Hospital, Pittsburgh, PA

In 2010 it was projected that 25.8 million people in the United States had diabetes mellitus representing 8.3% of the population with another 7 million undiagnosed.[1]

The first report of diabetes mellitus affecting bone healing was an animal study in 1968 by Herbsman, et al.[2] They found that rats with uncontrolled diabetes mellitus had reduced fracture healing compared to the healthy controls.

Other animal studies have confirmed these results and have found that fractures in diabetic rats treated with insulin improved bone healing.[3-6] In the earliest human case report, Cozen reviewed 9 diabetics with lower extremity fractures and contrasted them with 9 matched controls. He verified a delayed time to union in the diabetic patients.[7]

Several studies have demonstrated increased complications in diabetic ankle fractures compared to the healthy controls.[8-12] However, several recent studies have shown that ankle fractures in diabetics without comorbidities (uncomplicated diabetics) had complication rates similar to the controls. Conversely, complicated diabetics (peripheral neuropathy, nephropathy and peripheral arterial disease) had significantly increased complications.[13-15] However, to the best of our knowledge, in the English literature, there have been no studies examining the natural history of diabetic foot and ankle fractures concomitantly. Thus, a retrospective review of 40 patients with diabetes mellitus who sustained a foot and/or ankle fracture was performed.

Methods and Patients

On July 26, 2012, the Western Pennsylvania Allegheny Health System Institutional Review Board accepted this as an exempt study. A retrospective review of patient charts, radiographs, and operative reports with diagnosis codes for “diabetes mellitus” and “fracture” to the foot and/or ankle was assembled. Complicated diabetics were diagnosed with peripheral neuropathy (PN), peripheral arterial disease (PAD) and/or nephropathy. Uncomplicated diabetics did not have any of these end organ diseases.[16,17] PN was diagnosed when the patient could not detect the 5.07 Semmes Weinstein monofilament. PAD was diagnosed if the patient had been revascularized in the past or when the patient had non palpable dorsalis pedis or posterior tibial pulses.

Nephropathy was diagnosed when the patient had a serum creatinine of > 1.5.[11] Charcot neuroarthropathy was defined as bone fragmentation, bone absorption and boney consolidation.[18]

Superficial infections were categorized based on the need for only oral antibiotics and local wound care. Deep infections were delineated when the wound required intravenous antibiotics and surgical debridment.[11]

A nonunion was defined when a minimum of 9 months has passed and there are no interval changes consistent with a union on serial radiographs. A delayed union had decreased bone healing on serial radiographs.

Data was collected for patients treated between 1/1/2002 – 7/1/2012. Patients less than 18 years old and with incomplete medical records were excluded. The information gathered included age, sex, body mass index (BMI), fracture type, fracture location, fracture treatment, time to union, malunion, nonunion, infection, ulceration, Charcot neuroarthropathy, amputation, PN, nephropathy, and PAD.

The type of treatment was at the judgment of the attending foot and ankle surgeon. All patients with an ankle fracture underwent open reduction and internal fixation (ORIF) with plates and screw fixation of the fibula. Also, the medial malleolar fixation was accomplished with screws or tension banding. Syndesmotic fixation was accomplished with tri-cortical or quad-cortical screws when appropriate. All ankle fractures received preoperative antibiotics with continuation of antibiotics through the hospital course for open fractures. Non-weight-bearing (NWB) was generally instituted for a minimum of 7 weeks in a total contact cast (TCC) with transitioning to weight-bearing (WB) for a minimum of 4 weeks in a fracture walker for postoperative ankle fractures.

Forefoot fractures (toe and metatarsal) were commonly allowed WB in a surgical shoe or fracture walker for at least 2 weeks before transitioning to a sneaker. Patients were usually followed up at 2 week and subsequently 1 month intervals until fracture union. At most visits, medial oblique, anteroposterior and lateral radiographs were obtained to assess fracture healing.


Table 1: Frequency by diabetic group (complicated vs. uncomplicated).


Table 2: Time-based measures in weeks (complicated vs. uncomplicated).*


There were a total of 40 diabetic foot and ankle fractures with an average follow up of 31.7 (4-137) weeks. Patient ages ranged from 43 to 85, with a mean of 62.00±10.34 (standard deviation). There were a total of 22 females (55%) and 18 males (45%). Patient BMI ranged from 21.81 to 56.35 with a mean of 34.11±5.91. Thirty seven (93%) experienced closed injuries while three (7%) experienced open injuries. Nineteen patients (48%) were treated non-operatively (toe, metatarsal and cuboid fractures) and 21 (52%) were treated operatively (ankle and a calcaneal avulsion fracture).

Twenty five patients possessed a previous diagnosis of complicated diabetes (63%) while fifteen patients had uncomplicated diabetes (37%).

Regarding type of injury, 17 patients experienced an ankle fracture (43%), 12 patients a metatarsal fracture (30%), nine patients a phalanx (toe) fracture (22%), one patient a calcaneal avulsion fracture (2.5%), and one patient a cuboid fracture (2.5%).

When evaluating BMI there was no difference between complicated diabetics (mean=32.64±5.10) and uncomplicated diabetics (mean=36.55±6.51), t (38) = 2.12, p = .25. There was no difference in age between complicated diabetics (mean = 62.32±10.65) and uncomplicated diabetics (mean=61.93±10.15), t (38) = .11, p = .91.


Table 3: Complications among foot fractures.


Table 4: Complications among ankle fractures.


Table 5: Diabetes complications by post injury complications.

Also, there was no statistical difference between uncomplicated and complicated diabetes with regards to the frequency of sex and treatment (Table 1).

There was no statistical difference between complicated and uncomplicated diabetics regarding the number of weeks WB (8.56±5.64, 7.40±6.70, p = .56) and non-weight-bearing (7.93±4.17, 7.75±3.25, p = .90). Along with no statistical significance among complicated and uncomplicated diabetics (table 2) in weeks to clinical union (10.12±6.35, 9.27±3.44, p=.64) and radiographic union (14.76±7.20, 12.87±5.87, p = .40).

Twenty three foot fractures were included in the retrospective review with an average follow up of 33.8 weeks. (Table 3). Eighteen (78%) were complicated diabetics while five (22%) were uncomplicated diabetics. Ten (56%) of the complicated diabetics experienced a post injury complication.
Conversely, only 1 (20%) uncomplicated diabetic experienced a post injury complication. A two sided Fisher’s Exact test indicated no significant difference in proportion of patients experiencing post injury complications between complicated and uncomplicated diabetic groups (p = .32).

Moreover, there were a total of seventeen ankle fractures with a mean follow up of 28.8 weeks. (Table 4). Seven (41%) had complicated diabetes while 10 (59%) had uncomplicated diabetes. Among complicated diabetics, 4 (57%) experienced a post injury complication, whereas 4 (40%) of uncomplicated diabetics experienced a post injury complication. A two sided Fisher’s Exact test indicated no significant difference in proportion of patients who experienced a post injury complication between complicated and uncomplicated diabetic groups (p = .64).


Table 6: Complications among diabetes type.


Table 7: Complications among foot and ankle fractures.

Further analyses evaluated the relationship between severity of complicated diabetes (PN+ PAD + nephropathy) and the number of post injury complications sustained by each patient. Eighteen diabetics (72%) were diagnosed with one complicating factor, six (24%) were diagnosed with two complicating factors, and one (4%) was diagnosed with all three complicating factors.

Among all complicated diabetics, 11 (44%) patients experienced no post injury complications, 8 (32%) patients experienced one complication, five (20%) patients experienced two complications, and one (4%) patient experienced three complications (Table 5). A Pearson’s Chi-squared test was conducted indicating no relationship between number of diabetes complicating factors and number of post injury complications, χ2 (2, N = 25) = 3.96, p = .14.


Table 8: Non-infectious complications by diabetes type and total fractures.

The relationship between diabetes type and the presence of a post injury complication when collapsing across all types of injuries was conducted (Table 6).Fourteen (56%) complicated diabetics experienced one or more post injury complications. Among uncomplicated diabetics, 5 (33%) experienced one or more post injury complications. A two-sided Fisher’s Exact test indicated no relationship between diabetics type and the presence of injury complications (p = .20). All diabetic foot and ankle fracture complications are described in Table 7. There were no amputations performed in any of the complicated or uncomplicated diabetic foot or ankle fractures.

A non-infectious complication includes any complication involving a malunion, delayed union, nonunion or Charcot neuroarthropathy.13 A total of 9 (47%) complicated diabetic foot and ankle fractures experienced a non-infectious complication and 4 (19%) uncomplicated diabetics experienced a non-infectious complication (Table 8.) A series of Chi-Square analyses were conducted and found no statistical significant relationship between diabetes-type and number of non-infectious complications for foot fractures [χ2 (2, N = 23) = .66, p = .72.], ankle fractures [χ2 (2, N = 17) = 1.54, p = .46] and overall fractures [χ2 (2, N = 40) = 1.95, p = .38].


This retrospective review of the natural history of 40 diabetic fractures is the first to evaluate foot and ankle fractures together. In regards to foot fractures (Figure 1), 56% (10/18) of foot fractures in the complicated group experienced a post injury complication while only 20% (1/5) of the uncomplicated group sustained a post injury complication (p = .32). Although not statistically significant, there was a 36% (2.8 times) increase in complications with complicated diabetics who sustained a foot fracture (Table 3). Kristiansen described a diabetic second metatarsal shaft fracture that was allowed to weight bear immediately with a bandage. Three months later the metatarsal fracture developed Charcot neuroarthropathy. He concluded that even metatarsal fractures should be immobilized and weight-bearing must be deferred until fracture healing is complete.[20] The foot fractures (metatarsal, phalanx, and cuboid) in this study were allowed to WB immediately in a surgical shoe or fracture walker. The authors hypothesize that a more aggressive immobilization regimen such as non-weight-bearing or total contact casting should be considered to decrease adverse outcomes in the complicated diabetic group.


Figure 1: Radiographs demonstrating a distal phalanx fracture in a complicated diabetic.


Figure 2: Initial and 12 week radiographs of a bimalleolar ankle fracture in a complicated diabetic.

In evaluating 17 operatively treated ankle fractures (Figure 2), the complicated diabetic group had a 57% (4/7) post injury complication rate while the uncomplicated diabetic group had 40% (4/10) post injury complication rate (p = .64). Many studies, including a meta-analysis of 356 ankle fractures, have established an overall increase in complications in diabetic ankle fractures compared to non diabetics.[21-27] Additionally, Wukich, et al., retrospectively confirmed that complicated diabetics had a 3.8 (p = .003) times amplified risk of a post injury complication.[11] In our study, there was a non significant trend of a 17% (1.4 times) increased complication rate for ankle fractures in the complicated diabetic group compared to the uncomplicated diabetic group. However, in the Wukich, et al., study there was total of 59 uncomplicated diabetics and 46 complicated diabetics which achieved statistical significance.[11] To attain statistical significance in our study, approximately 90 additional ankle fractures would need to be evaluated.

Compiling all diabetic foot and ankle fractures there were a total of 25 complicated and 15 uncomplicated fractures. Post injury complications occurred in 56% (14/25) of the complicated diabetics and in 33% (5/15) of the uncomplicated diabetics (p = .20). Also, 47% (9/19) of the complicated diabetics experienced a non-infectious complication compared to only 19% (4/21) of the uncomplicated diabetics (p = .38). Thus, there was a non significant tendency of a 23% (1.7 times) elevated risk of developing a post injury complication in the complicated diabetics with a 28% (2.4 times) increased risk of having a non-infectious complication. This increase is on par with Wukich, et al., who found a 3.4 times increased risk of developing a non-infectious complication ankle fractures in complicated diabetics. Also, the complicated diabetic group took almost 2 weeks longer for radiographic union compared to the uncomplicated diabetic group (14.76±7.20, 12.87±5.87, p = .40). While there was no statistical difference between the groups, the overall increase in healing time for all diabetic fractures is consistent with other studies.[2-7,12,22]

On the other hand, in our study no diabetic fractures resulted in an amputation. The literature has demonstrated amputation rates of diabetic ankle fractures ranging from 4 -17%.[9,23,28] Our 0% amputation rate is most likely due to the fact that we are not located at a level 1 trauma center and only had 3 (7%) open ankle fractures with no open foot fractures. Open diabetic ankle fractures traditionally have very poor outcomes with a 38% amputation rate in a case study by White, et al., in 2003.

A novel analysis evaluated the relationship between the severity of complicated diabetes and the number of post injury complications sustained by each patient. Eighteen diabetics (72%) were diagnosed with one complicating factor and seven (28%) were diagnosed with two or more complicating factors. Six (78%) of the diabetics with 2 or more complicating factors experienced at least one post injury complication compared to 8 (44%) of the diabetics with only 1 complicating factor (p = .14). This also showed a non significant propensity as the number of diabetic complicating factors increases, the amount of complications increases as well (1.7 times higher).

The most obvious weakness of our evaluation was the study being underpowered. This was because of the relatively small number of diabetic patients reviewed. Over 30 patients had to be excluded from the study due incomplete medical records including no height or weight being recorded, complications described too broad for interpretation, and radiographs/charts missing. These patients may have helped influence the data to become significant.

The other main weakness was the retrospective nature of the study. Retrospective studies are based on the correctness of patient charts/radiographs and thus information collected is only as accurate as the medical information documented. Also, this study also did not evaluate other complications such as deep vein thrombosis, thromboembolism, stroke, or myocardial infarction.

Furthermore, there could have been measurement bias as there was not a standard protocol initiated. However, all diabetic ankle fractures did receive ORIF with treatment based on standard fixation principles. Also, all diabetic foot fractures except one calcaneal avulsion fracture, were treated non-operatively in a surgical shoe or fracture walker.

Non-responder bias is also a part of this study since some patients were followed longer than others. If some patients were observed longer more complications could have been discovered. Most foot fractures were followed until fracture union and were not followed up thereafter. Moreover, there also could have been interview bias as the treating foot and ankle surgeon determined if there was a complication and recorded this in the patient’s clinical chart.


Although not statistically significant, the trend of increased complication rate for foot fractures in complicated diabetics leads us to believe that foot fractures should be treated in the same manner as ankle fractures in complicated diabetics. Post injury clinical evaluation for PAD, PN and nephropathy should be considered. This analysis will be used as a template for a future prospective study comparing complicated and uncomplicated diabetic foot and ankle fractures.

1. Centers for Disease Control and Prevention. National diabetes fact sheet: national estimates and general information on diabetes and prediabetes in the United States, 2011. Atlanta, GA: US. Department of Health and Human Services, Centers for Disease Control and Prevention, 2011. [Website]
2. Herbsman H, Powers JC, Hirschman A, Shaftan GW. Retardation of fracture healing in experimental diabetes. Journal of Surgical Research 1968 8: 424-431. [PubMed]
3. Dixit PK, Ekstrom RA. Retardation of fracture healing in experimental diabetes. Indian J Med Res 1987 85: 426-435. [PubMed]
4. Macey LR, Kana SM, Jingushi S, Terek RM, Borretos J, Bolander ME. Defects of early fracture-healing in experimental diabetes. JBJS 1989  71A: 722-733. [PubMed]
5. Funk JR, Hale JE, Carmines D, Gooch HL, Hurwitz SR. Biomechanical evaluation of early fracture healing in normal and diabetic rats. J Orthop Res 2000 8: 126-132.
6.  Gooch HL, Hale JE, Fujioka H, Balian G, Hurwitz SR. Alterations of cartilage and collagen expression during fracture healing in experimental diabetes. Connect Tissue Res 2000 41: 81-91. [PubMed]
7. Cozen L. Does diabetes delay fracture healing? Clin Orthop Relat Res 1972 82: 134-140. [PubMed]
8. Chaudhary SB, Liporace FA, Gandhi A, Donley BG, Pinzur MS, Lin SS. Complications of ankle fracture in patients with diabetes. J Am Acad Orthop Surg 2008 16: 159-170. [PubMed]
9. Flynn JM, Rodriguez-del Rio F, Piza PA. Closed ankle fractures in the diabetic patient. Foot Ankle Int 2000 21: 311-319. [PubMed]
10. SooHoo NF, Krenek L, Eagan MJ,  Complication rates following open reduction and internal fixation of ankle fractures. JBJS 2009 91A: 1042-1049. [PubMed]
11. Prisk VR, Wukich DK. Ankle fractures in diabetics. Foot Ankle Clin 2006 11: 849-863. [PubMed]
12. Wukich DK, Kline AJ. The management of ankle fractures in patients with diabetes. JBJS 2008 90A: 1570-1578. [PubMed]
13. Jones KB, Maiers-Yelden KA, Marsh JL, Zimmerman MB, Estin M, Saltzman CL. Ankle fractures in patients with diabetes mellitus. JBJS  2005 87B: 489-495. [PubMed]
14. Costigan W, Thordarson DB, Debnath UK. Operative management of ankle fractures in patients with diabetes mellitus. Foot Ankle Int 2007 28: 32-37. [PubMed]
15. Wukich DK, Joseph A, Ryan M, Ramirez C, Irrgang JJ. Outcomes of ankle fractures in patients with uncomplicated versus complicated diabetes. Foot Ankle Int 2011 32: 120-30. [PubMed]
16. Deyo RA, Cherkin DC, Ciol MA. Adapting a clinical comorbidity index for use with ICD-9-CM administrative databases. J Clin Epidemiol 1992 45: 613-619. [PubMed]
17. Quan H, Parsons GA, Ghali WA. Validity of information on comorbidity derived rom ICD-9-CCM administrative data. Med Care 2002 40: 675-685. [PubMed]
18. Eichenholtz S. Charcot Joints. Springfield, IL: Charles C. Thomas; 1966.
19. Holm S. A simple sequentially rejective multiple test procedure. Scand J Statistics 1979 6: 65-70.
20. Kristiansen B. Ankle and foot fractures in diabetics provoking neuropathic joint changes. Acta Orthop Scand 1980 51: 975-979. [PubMed]
21. Loder RT. The influence of diabetes mellitus on the healing of closed fractures. Clin Orthop Relat Res 1988 232: 210-216. [PubMed]
22. Low CK, Tan SK. Infection in diabetic patients with ankle fractures. Ann Acad Med Singapore 1995 24: 353-355. [PubMed]
23. Blotter RH, Connolly E, Wasan A, Chapman MW. Acute complications in the operative treatment of isolated ankle fractures in patients with diabetes mellitus. Foot Ankle Int 1999 20: 687-694. [PubMed]
24. Flynn JM, Rodriguez-del Rio F, Pizá PA. Closed ankle fractures in the diabetic patient. Foot Ankle Int 2000 21: 311-319. [PubMed]
25. Lillmars SA, Meister BR. Acute trauma to the diabetic foot and ankle. Current Opinion in Orthopedics 2001 (2): 100-105.
26.Ganesh SP, Pietrobon R, Cecílio WA, Pan D, Lightdale N, Nunley JA. The impact of diabetes on patient outcomes after ankle fracture. JBJS  2005 87A: 1712-1718. [PubMed]
27. Kline AJ, Gruen GS, Pape HC, Tarkin IS, Irrgang JJ, Wukich DK. Early complications following the operative treatment of pilon fractures with and without diabetes. Foot Ankle Int 2009 30(11):1042-1047. [PubMed]
28.  White CB, Turner NS, Lee GC, Haidukewych GJ. Open ankle fractures in patients with diabetes mellitus. Clin Orthop Relat Res 2003 (414): 37-44. [PubMed]

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