OPEN REDUCTION AND INTERNAL FIXATION (ORIF) FOR BIMALLEOLAR ANKLE FRACTURES

Indications

• None of the existing classifications is adequate alone to dictate the treatment strategy.

• Fractures with talar displacement.

• Almost all bimalleolar fractures.

Pre-operative planning

Clinical assessment

• Mechanism of injury: direct or, more commonly, by indirect rotational, translational and axial forces.

• Soft tissue swelling, ecchymosis, tenderness.

• Look for associated injuries.

• Assess neurovascular integrity of the extremity.

• Obtain a careful patient history.

• Evaluate age, osteoporosis and systemic conditions.

Radiological assessment

• High-quality anteroposterior (AP) and lateral radiographs (Fig. 13.1a,b).

• Mortise view: AP in 20° internal rotation.

• CT scan: for evaluation of posterior malleolus.

• Assess: degree of fragment displacement, quality of bone.

Timing of surgery

• Dictated by the soft tissue condition.

• Before the development of soft tissue swelling or blisters.

• Delayed ORIF when soft tissue injury resolves.

Operative treatment

Anaesthesia

• Spinal or general anaesthesia.

• Prophylactic antibiotics as per local hospital protocol.

• Application of a pneumatic tourniquet to the upper thigh.

Table and equipment

• AO small fragment set.

• 3.5 mm cortical and 4.0 cancellous screws.

• Standard osteosynthesis set as per local hospital protocol.

• A radiolucent table.

• An image intensifier and a competent radiographer.

Table set up

• The instrumentation set is at the foot end of the table.

• Image intensifier is from the contralateral side.