1. science
2. medicine
3. orthopedics

THE
TREATMENT
RIGID
INTERNAL
H. NEVILE
From
The
the
return
with
Method
of treatment-The
of
or
is to show
consistently
CHARNLEY,
Service
that
of the
accurate
exercises
fractures
in order
to
AT
JOINT
THE
ANKLE
MOVEMENT
DEWSBURY,
ENGLAND
Dewsburs’
Group
reduction
within
a few
were
treated
good results.
in this series
injuries
more
D.
Accident
by joint
FRACTURES
EARLY
AND
ARNOLD
and
study
followed
fixation
one
and
Orthopaedic
of this
ankle
of function
DISPLACED
FIXATION
BURWELL
the
purpose
involving
OF
the
stabilise
of Hospitals
and
days
firm
fixation
of operation
by open
ankle
reduction
period;
after
further
being
usually
unnecessary.
rapidly
regained,
internal
to permit
short
were
to rapid
and
sufficiently
of the ankle
was applied,
was retained
movements
of fractures
leads
exercise
of the joints
in bed without
delay.
When
full movements
been restored
and the swelling
had subsided,
a below-knee
plaster
weight
was taken and near normal
activity
encouraged.
The plaster
its removal
BY
active
and foot had
in which
full
for a relatively
remedial
treatment
CLASSIFICATION
Some
are
preliminary
discussion
is necessary
classified
in a manner
which
is not
The description
of ankle
fractures
(1922),
whose
accepted.
investigations
of an ankle
work,
with
modification
because
the
yet in general
was first put
(Bonnin
Further
development
has been
of Lauge-Hansen
(1948,
1950,
injury
in their correct
sequence
ankle
injuries
use.
on a sound
1950,
basis
reported
by Ashurst
Watson-Jones
1955),
This
“
to
have
writers
been
used
(Vasli
more
1957, Klossner
widely
although
1962, Cedell
and Wiberg
Jergesen
(1959),
Quigley
referred
to it. It is used in the description
Lauge-Hansen
divided
ankle
fractures
eversion
(PA).
moment
relation
Hansen
(SE),
In each
pronation-eversion
type the first
been
1962),
(1959)
injuries
presented
four
main
types
in this
referred
in
paper
Bromer
generally
and clinical
components
is represented
classification,
the mechanism
general
use
it does not
and
Rose
by
appear
(1962)
paper.
to as supination-
(SA) and pronation-abduction
to the posture
of the foot
at the
of injury,
while the second
word
indicates
the direction
of movement
of the talus in
to the leg in accordance
with the usual
convention.
It should
be noted
that Laugeused the term eversion
for lateral
rotation,
but we prefer
to use the latter in order to
avoid
ambiguity,
because
eversion
designated
pronation-dorsifiexion
marginal
of the
into
(PE),
supination-adduction
of the designation
refers
word
and
has
made
possible
by the experimental
1952, 1954) who placed
the individual
in time so that, when the end point
by a fracture,
the presence
ofintermediary
ligament
injuries
may be inferred.
described
by its author
as
genetic,”
is therefore
a valuable
aid to understanding
of ankle
fractures
and provides
a key to their
reduction.
Although
Scandinavian
in this
fractures
The sequence
radiographs
and
certain
is one
(PD)
fractures
of events
for each
of
showing
the characteristic
the
of the normal
movements
of the
includes
less common
injuries,
of the lower
tibial shaft which
also
four
injuries
main
types
is shown
of fracture
in Figure
foot.
A fifth type
namely
anterior
involve
the ankle.
together
1 and will
with
outline
be described
below.
Supination-lateral
rotation
(SL)-Produced
by lateral
talus
rotates
against
the lateral
malleolus,
rupturing
the
anterior
tibio-fibular
ligament
(stage
I) and then causing
a spiral
or oblique
fracture
of the
lateral
malleolus
(stage
2); further
lateral
rotation
of the talus
will rupture
the posterior
tibio-fibular
ligament
or fracture
the posterior
tibial
margin
(stage
3). The medial
ligament,
Eversion
(lateral
rotation
of the
initially
relaxed
fracture
of the
634
rotation)
supinated
because
medial
fractures.
foot;
the
of supination,
malleolus
(stage
now
comes
4) (Figs.
under
tension
and
may
rupture
or produce
2 to 5).
THE
JOURNAL
OF
BONE
AND
JOINT
SURGERY
THE
TREATMENT
Pronation-/ateral
rotation
ligament
already
in tension
rotating
anterior
talus
then
tibio-fIbular
rotation
force
tibio-fIbular
Adduction
near
level
will produce
to
of the
vertical
either
“
a fracture
of the posterior
ankle
fracture
joint,
or rupture
of the
medial
pronated
medial
tibial
margin
of the
talo-fibular
in stage
may
2 (Figs.
of the posterior
loss
malleolus
ligaments
occurs
10 and
the
is a
ankle joint
but
of the lateral
without
lateral
1); the
rupturing
next stage
or a rupture
of the
; the medial
(stage
above
the
application
designation
fracture
foot
malleolus
lateral
malleolus,
(stage
2): the
three
inches
continued
A traction
malleolus
the
of the
ligament
6 to 9).
(SA)-The
(5).
of the
away
at a level
3); finally,
635
AT THE ANKLE
rotation
or pulls
the anterior
border
and the interosseous
(stage
4) (Figs.
Supination-adduction
supination”
FRACTURES
by lateral
ruptures
of the fibula
typically
a higher
level (stage
ligament
fracture.
be shortened
the
(PL)-Produced
bears
upon
ligament
short
spiral
fracture
not infrequently
at
OF DISPLACED
of clarity
at or
in stage
below
I, and
a
11).
-3
2
i
LATERAL
SUPINATION
ROTATION
LATERAL
PRONATION
SUPINATION
PRONATION
1
FIG.
The
Abduction
fracture.
(P).
“pronation”
(stage
I);
a bending
next,
both
fracture
four
common
types
of fracture
Pronation-abduction
There
is fracture
anterior
of the
fibula
ROTATKDN
and
the Lauge-Hansen
(PA)-This
of the
posterior
occurs,
in
medial
associated
with displacement
of a triangular
(stage
3) (Figs.
12 and 13).
Compression
fracture.
Pronation-dorsflexion
may
malleolus
just
fragment
(PD)-These
similarly
or
tibio-fibular
generally
classification.
ligaments
above
from
be
the
rupture
level
the
fractures
abbreviated
to
medial
ligament
of the
rupture
(stage
2);
ankle
joint,
often
surface
of the
fibula
usually
caused
by
of the
lateral
are
finally,
fall from
a height,
the foot moving
into dorsiflexion
so that the wider
anterior
part of the
talus
engages
the ankle
mortise.
The medial
malleolus
is split off (stage
I); next, pressure
from the upper
surface
of the talus causes
fracture
of the anterior
part of the tibial articular
surface
(stage
2), and then fracture
of the fibula usually
in its lowest
third (stage
3). Finally,
the tibia may break
transversely
at the level of the proximal
margin
of the articular
fracture
described
VOL.
47 B,
above.
NO.
4, NOVEMBER
1965
a
636
H. N. BURWELL
This
classification
of the
P and
PL
nature
of the
fibular
injuries
moreover,
avulsion
has
the great
the
groups,
fracture
fractures
at
which
the
advantage
different
may
in all cases
be
in many
cases close
of
by
A. D. CHARNLEY
that
types
with
of injury
is characteristic
inferred
inspection
site
AND
for
the
exception
may
each
be
type.
a consideration
of the radiographs
ligamentous
of the
of the nature
will reveal
the
attachment.
stage
1 fractures
readily
distinguished
by the
The presence
of ligamentous
Not
of the
presence
infrequently
fractures;
of small
these
small
L
FIG.
Radiographs
showing
4 and 5-After
fragments
and
28);
reported
of
bone
Lauge-Hansen
an
incidence
Lauge-Hansen
of
ankle
employed
displacement.
because
are
best
4
FIG.
fracture.
Figures 2 and 3-Before
reduction;
note the fixation of the anterior
seen
in films
exposed
some
little
5
reduction.
Figures
tibial tubercle.
SL4
time
after
found
such fractures
in 55 per cent of his cases
of 74 per cent.
felt that the practical
value of his classification
was
It is also
it provides
of
information
importance
concerning
when
the
internal
associated
ThE
JOURNAL
the
and
in the
fixation
of
ligament
OF
BONE
injury
(Figs.
Magnusson
closed
the
reduction
fractures
injuries,
AND
26
(1944)
JOINT
and
SURGERY
is
so
THE TREATMENT
indicates
the ankle
the extent
stable.
The classification
readily
into one
and
as
excluded
injuries
(37
of the fractures
in practice-In
or other
of the
histograms
being
of fixation
per
cent
of the
total
in traffic
and
3 per
With
in that
of the
stage.
VOL.
he
and
been
Figures
be fitted
not
of unclassified
it is felt
maintained
injury
NO.
4,
NOVEMBER
the
this
1965
first
by falls
stage
with fracture
series
had
from
in order
to make
into
material,
that
sustained
medial
general
Lauge-Hansen’s
of
malleolus
a medial
the
or by direct
7-Before
for instance
is fracture
of the
the
a height
9
fracture.
Figures
6 and
8 and 9-After
reduction.
cent (Klossner
1962).
regard
to supination
fractures
that
caused
FIG.
PL4
could
incidence
talo-fibular
ligaments)
Three
patients
in
47 B,
to be necessary
8
showing
accidents
a similar
had
number)
reduction.
report
is likely
the present
series
four main groups.
FIG.
violence
which
637
AT THE ANKLE
“),
that
Radiographs
authors
FRACTURES
the injuries
to 126 ankles
(out of 135) fell
Of the remaining
nine (shown
in the tables
three
were
of the PD type,
and one resembled
a PL4 fracture,
group
only because
the fibular
fracture
was double.
Five of the
“other
from
OF DISPLACED
classification.
cent
(Vasli
views
may
be too
lateral
occurring
malleolar
Previous
1 6 per
malleolus
only
fracture
(or
1957)
rigid
rupture
in the
which
second
was
638
clearly
fibular
seems
H. N. BURWELL
of supination
or
adduction
AND
type,
the
A. D. CHARNLEY
fracture
fracture
or any clinical
sign of ligamentous
likely therefore
that either
the medial
or the
line
injury
lateral
being
vertical,
but
without
either
on the lateral
side of the joint.
malleolus
may fracture
in stage
It
I,
stage 2 being
represented
by a combination
of these injuries,
as noted
by Bonnin
(1950)
and
by Mitchell
and Fleming
(1959).
In addition,
there were two patients
whose
injuries
had clearly
been of the supination
type, but who in addition
to fractures
of the medial
and lateral
malleoli
FIG.
12
FIG.
Radiographs
had
fragments
such
instances
Isolated
were
who
noted
broken
off the
P3 fracture
posterior
margin
before
of the
13
and after reduction.
tibia.
Klossner
(1962)
reported
three
in his series.
of the
fractures
by Magnusson
considered
that they
Despite
the need for
classification
showing
is the
most
tibial
posterior
(34
might
slight
per
cent
be caused
modification
satisfactory
margin,
of his cases),
although
not described
by Kleiger
(1954)
by Lauge-Hansen,
and
by kicking
against
a solid object.
as indicated,
it seems
clear that
of those
by Bonnin
(1950)
Lauge-Hansen’s
available.
THE
JOURNAL
OF
BONE
AND
JOINT
SURGERY
THE
TREATMENT
OF DISPLACED
FRACTURES
AT THE
639
ANKLE
MATERIAL
This
fractures
1955-62.
of the
During
study
is based
on
a consecutive
at the ankle;
all of them
The unimalleolar
fractures
medial
malleolus
the same
period
severity,
mostly
series
of
were treated
which are
135 patients
who
or fractures
involving
the anterior
part of the
a total
of 721 patients
with ankle
fractures
of the lateral
malleolus,
were
had
sustained
by operation
at one hospital
during
included
in the series have been either
treated
without
operation.
tibial
articular
of a lesser
The
present
displaced
the years
fractures
surface.
degree
of
series
thus
30-
20-
10-
YEARS
14
FIG.
Distribution
of
patients
according
to
age
and
sex.
P
PL
SL
S
OTHER
-
15-1920-29
40-49
30-39
50-59
60-69
70-79
to age
of patient.
____
80-89
YEARS
FIG.
Distribution
of
fracture
types
15
according
forms
1 58 per cent of the total patients
available.
Two patients
died before adequate
assessment
of ankle
function
was possible
and one patient,
whose
fracture
was complicated
by severe
vascular
injury,
required
amputation;
these patients
appear
in the classification
but have been
excluded
from
for an average
the results.
All patients
have
period
of thirty-four
months,
Age and sex-The
Occupation-The
VOL.
47 B,
NO.
analysis
occupation
4,
NOVEMBER
of patients
of the
1965
been followed
up clinically
and
the limits
being
twelve
months
according
to age and sex is shown
patients
is shown
in Table
I.
radiographically
and eight years.
in Figures
14 and
15.
640
H. N. BURWELL
AND
A. D. CHARNLEY
TABLE
TypEs
OF
FaicruRE
Type
IN
I
RELATION
TO
OCCUPATION
of fracture
Occupation
Total
P
PLSL
19
16
25
Housewife
5
6
26
Clerical
4
Pensioner
2
2
Student
2
1
32
25
Manual
Total
S
-
6
OF INJURIES
75
56
37
28
-
5
-
-
9
67
5
-
-
9
67
5
3.5
-
2
61
8
135
100
II
ACCORDING
Type
9
T#{248}
ThE
NATURE
OF THE
Total
P
Slipping
PL
SL
S
8
11
42
1
6
2
-
-
3
4
13
-
.
5
1
1
or stumbling.
outer
side
ACCIDENT
of fracture
of accident
Nature
Blow
9
-
TABLE
DlsTIuBtrrioN
Percentage
Other
leg
.
Fallfromstoolorsteps
Falifromaheight
Percentage
Other
62
-
46
8
6
1
21
15
1
5
13
10
-
Direct
violence
.
.
3
1
2
3
1
10
7
Motor
accident
.
.
7
6
3
2
2
20
15
Blow inner side leg
.
-
-
-
1
1
-
Total
.
.
32
25
61
8
9
Percentage
.
.
24
18
45
6
7
TABLE
DEGREE
OF DISPLACEMENT
Type
of
1
100
135
111
TYPE
FOUND
IN EACH
Degree
of displacement
OF INJURY
fracture
Mild
Moderate
Severe
P
.
.
19
6
7
PL
.
.
10
9
6
SL
.
.
11
28
22
S
.
.
7
.
1
2
6
48
45
42
Other.
Total
.
-
THE
JOURNAL
OF
BONE
AND
JOINT
SURGERY
THE TREATMENT
Nature
forty-two
of
the accident-This
(69 per cent) of the
is shown
in
SL group
and
Classification-The
material
has
Lauge-Hansen,
according
to the
of malleoli
fractured.
Genetic
Class?fication-The
The distribution
1957,
Klossner
lower
than
than
fractures
the
four
5, PD
main
2, while
groups,
105 (83
EJ
in three
ways-by
of displacement,
shown
in Figure
with
form
the
because
and
cent)
had
results
largest
group,
present
irregular
the “genetic”
according
and
of
other
for
method
of
to the number
published
although
series
groups
were
of the patients
injuries
accounted
total.
16.
the
in the
twenty-one
per
641
AT THE ANKLE
Table
II.
Slipping
or stumbling
for sixty-two
(46 per cent) of the
classified
degree
are
work
in the
FRACTURES
conformity
SL fractures
published
Fractures
1 and
WOMEN
results
1962).
in
stages
been
initial
is in general
in other
men.
OF DISPLACED
in stages
the
there
proportion
are
not
found
entirely
(17 per cent)
3 and
(Vasli
series
is rather
more
women
in men;
of the
had injuries
in
4.
r
MEN
ACCU
RACY
OF
REDUCTION
6
2
ANATOMICAL
‘4
7
FAIR
6
2
POOR
GOOD
FAIR
POOR
OTHER
OBJECTIVE
7.’.
16
FIG.
Figure
16-Classification
FIG.
of the
by the genetic
material
Figure
method.
Classification
according
to
obtain
a general
indication
the talus have been recognised
17-Objective
initial
degree
of displacement-This
of the severity
of the injuries.
: 1) Mild-displacement
slight.
results
width
of the ankle
mortise.
3) Severe-displacement
or severe
displacement
was present
in 82 per
and
cent
in 64 per
Compound
of the
related
to accuracy
has been
Three
grades
2) Moderate-talar
up to half the
Moderate
Classification
the purpose
RESULT
17
cent
of reduction.
done
in order
of displacement
displacement
greater
than
of the SL
to
of
above.
type injuries
total.
according
to the number
of comparison
with some
fractures-Seven
patients
of ma/leo/i
fractured-This
earlier
series.
The analysis
had
compound
fractures
(52
information
is shown
is included
in Table
IV.
per
three
cent);
were
for
in
the PL group
and the remainder
were distributed
evenly
over the other
four groups.
Associated
injuries-Two
patients
had in addition
sustained
fractures
of the same tibia
that
were treated
by plate fixation
and two other
patients
had fractures
of the talus or calcaneus.
METHOD
Preliminary
undertaken
VOL.
47 B,
manipulation-A
in twenty-five
NO.
4.
NOVEMBER
manipulation
cases.
This
1965
OF
TREATMENT
followed
by the application
of a plaster
initial
treatment
was not a matter
of policy
had been
but had
642
H. N. BURWELL
been
used
in a number
temporary
protect
measure
the
Timing
skin
of patients
in
until
severely
operation
on
the
following
performed
during
the
the
could
remainder
was
undertaken
in twenty-four
first
forty-eight
other
other
under
on the
patients;
hours.
hundred
by three
from
fractures,
hospitals;
it was
morphine
sedation,
and
day
thus
In
no
twenty-three
of the
77 per
instance
accident
cent
was
patients
TABLE
Medial
OF MALLEOLI
.
.
.
.
.
.
of
.
.
.
Total
Anterior
tubercle
Medial
and lateral
.
.
.
.
60
Lateral
and medial
ligament
.
.
4
Medial
and posterior
.
.
.
1
Medial
and anterior
.
.
2
Medial,
lateral
Lateral,
posterior
and
posterior
.
and medial
indicates
a posterior
of internalfixation
anterior
on
67
49
43
32
37
.
ligament
two
large
enough
coarse
fragment
was
similarly
fixed
was
the
6
thread
to
involve
screws
the
and
articular
Burns
fixed
in
in two
of compound
exercises-The
in Table
that the
for a longer
period
immobilisation-After
plaster
was applied
place
with
patients:
a screw
screw
Secondary
operation
Removal
(74
per
was
not
operation-Five
was done and
of
cent).
the
internal
In two
or Sherman
plates
in
three
patients
fixation
of the
VIII.
more
fractures
duration
severely
injured
or where
the
skin
had
been
of
ankles
the
in
bed
following
(PL
exercises
and
in order
to restore
full movement.
restoration
of the ankle
and foot
in 114 (84 per cent)
of the patients
“other”
; the
syndesmosis
abraded,
groups)
movements
to reduce
incapacity
and to prevent
osteoporosis
by allowing
full weight
bearing.
of immobilisation
for the different
types of injuries
are shown
in Table
In twenty-one
patients,
mostly
young
subjects
in the
P and
immobilisation
surface.
occasions.
exception
were not used.
of post-operative
operation
is shown
It will be seen
exercises
Plaster
walking
18
fractures;
in a few instances
it was necessary
to use pins or hook
used in the three main fractures
is shown
in Tables
V, VI and VII.
marginal
tubercle
Antibiotics-With
fragment
used-Standard
were used for most of the
plates.
The type offixation
Duration
24
1
‘Posterior’
antibiotics
Percentage
23
UNCLASSIFIED
undertaken
on by the authors,
FRACTURED
TRIMALLEOLAR
was
were
beyond
IV
BY NUMBER
BIMALLEOLAR
tibial
to
patients
operations
delayed
operated
UNIMALLEOLAR
An
as a
order
in eighty
of the
operation
were
Number
ankles
anterior
used
in
surgeons.
CLASSIFICATION
Types
also
be undertaken.
day
the tenth
day.
Number
of surgeons-One
A. D. CHARNLEY
transferred
displaced
of operation-Operation
and
AND
The
IX.
PL
the
required
a below-knee
the degree
average
periods
groups,
plaster
of
used.
patients
in one case
fixation
patients
required
amputation.
secondary
appliances-Screws
screws
were
removed
procedures:
or
pins
were
as a possible
THE
JOURNAL
in four,
removed
source
OF
revision
in
of pain
BONE
AND
ten
and
JOINT
of the
patients
in one
SURGERY
THE TREATMENT
instance
joint
for
sepsis.
surfaces.
a few weeks
Complications.
all obtained
In
three
patients
In the remaining
after
operation.
Sepsis-Eight
good
results.
OF DISPLACED
FRACTURES
screws
four
were
instances,
patients
In one
OF
FIXATION
screw.
Pin.
FOR
MEDIAL
Hook
plate
Excised
S
25
20
42
2
5
3
2
3
3
3
3
2
31
No
1
.
fixation
-
-
-
-
OF FIXATION
USED
FOR
-
3
P
.
Antero-posterior
screw
Plate and screws
Pin.
.
Hook
plate
Cerclage
.
No fixation
.
-
-
.
.
-
-
.
.
-
I
.
.
-
9
One
screw
Two
screws.
.
Threescrews
removal
of the
internal
fixation
appliance.
47 B,
C.
NO.
4, NOVEMBER
1965
I1
-
S
Other
1
-
1
-
1
1
-
I
-
-
-
-
4
-
2
3
-
MALLEOLUS
of fracture
SL
I
S
-
-
One
FIBULA
5
P0smRI0R
-
I
-
fracture;
there was no infection
in the
Delayed
union-There
was no instance
the discussion,
union
was delayed.
VOL
-
AND
VII
FOR
Type
PL
P
I
-
9
.
USED
-
29
-
4
OF FIXATION
-
of fracture
2
TABLE
METHOD
-
PLSL
-
.
-
MALLEOLUS
2
.
-
VI
LATERAL
Type
Axial screw
no treatment;
resolved
after
Other
1
1
-
TABLE
METHOD
to
removed
of fracture
SL
-
proximity
were
MALLEOLUS
PL
.
pins
but required
serious
but
P
Twoscrews
of close
subjects,
V
USED
Type
One
because
young
superficial
infection
infection
was more
TABLE
METHOD
removed
all of them
developed
instance,
643
AT THE ANKLE
I
of the
Other
2
--
8
-
2
-
instances
remaining
six compound
of non-union;
in one
I
-
-
of sepsis
was
fractures.
of the fractures,
in a compound
referred
to
in
644
H. N. BURWELL
Amputation-One
patient,
impairment,
required
Deaths-Two
other
death
had
who
amputation
patients
died
at
: one
further
A. D. CHARNLEY
sustained
four
aged
aged
sixty-four
years
with
was pulmonary
embolism.
These
two patients
and the
AND
an
SL4
fracture
complicated
by
vascular
weeks.
eighty-five
a P fracture
patient
years
at five
whose
leg
with
a PL
months.
was
fracture
In each
amputated
at five
weeks,
instance
the
been
excluded
have
the
cause
of
from
consideration.
RESULTS
Radiographic
reduction
and
by Klossner
criteria
of
these
accord
(1962).
reduction-It
The
has
with
gradings
felt
necessary
those
employed
by
are shown
in Table
been
Magnusson
X.
TABLE
OF
DURATION
PERIOD
OF
observe
(1944),
strict
criteria
by Vasli
(1957)
of
and
VIII
EXERCISES
of fracture
Type
to
AFTER
Duration
OPERATION
of exercise
period
(weeks)
29
I
PL
3.7
SL
30
5
24
Other
4#{149}3
Average
30
IX
TABLE
DURATION
Type
OF
PLASTER
of fracture
IMMOBILISATION
Duration
of immobilisation
(weeks)
P
50
PL
53
SL
52
S
4#{149}5
Other
Accuracy
of
was
in
ofreduction
obtained
reduction
regularly
the PD
Table
of the
asjudged
for each
Vasli
(1962)
radiograph-Table
In the P and S groups
XI shows
the
anatomical
standard
reduction
; the PL and SL injuries
showed
a proportion
of less accurate
reduction;
irregular
groups
of injuries
the general
standard
obtained
was only fair.
shows
the standard
of reduction
according
to the initial degree
of displacement
fractures.
the whole
reduction
Clinical
by the post-operative
type of fracture.
achieved
and
XII
series
Over
the
63
was
results.
fair
Objective
(1957)
and
Klossner
and,
with
slight
anatomical
in 167
per
reduction
cent
criteria-The
(1962)
and
modification
and
are
was
poor
obtained
in 61
criteria
used
close
to those
of terminology,
per
are
of
those
THE
in 77#{149}2
per cent
of the
patients;
cent.
again
those
of
of Braunstein
JOURNAL
Magnusson
(1956),
Kristensen
OF
Jones
and
BONE
AND
Wade
JOINT
and
(1944),
Neal
(1959).
SURGERY
THE TREATMENT
The
objective
quarters
criteria
normal,
are
trivial
set
OF DISPLACED
out
below.
swelling,
normal,
small
amount
half normal,
swelling,
FRACTURES
Good-Ankle
normal
gait;
of swelling,
normal
any visible
deformity
and
Fair-Ankle
foot
and
gait; Poor-Ankle
of ankle
or foot,
TABLE
movements
foot
at least
movements
and
limp.
foot
at
movements
three-
least
half
less
than
X
Cumni
RADIOGRAPHIC
645
AT THE ANKLE
OF REDUCTION
ANATOMICAL
No
medial
No
angulation
Not
or
more
Not
than
more
No
lateral
displacement
1 millimetre
than
of the
longitudinal
2 millimetres
displacement
of
the
medial
and
lateral
displacement
proximal
malleoli
of the
displacement
medial
of
a
and
large
lateral
malleoli
posterior
fragment
talus
FAIR
or lateral
displacement
the medial
and
No
medial
No
angulation
2-5
millimetres
posterior
displacement
of the
2-5
millimetres
proximal
displacement
of a large
No
displacement
of the
of
lateral
lateral
malleoli
malleolus
posterior
fragment
talus
POOR
Any
medial
or lateral displacement
of the medial
5 millimetres
posterior
5 millimetres
displacement
of the
posterior
Any
displacement
of the
talus
More
than
residual
displacement
OF
REDUCTION
of the
-
of fracture
FOR
------
objective
------
27
4
-
PL
.
.
18
4
2
SL
.
.
47
9
4
8
-
-
5
2
Total.
.
102
22
8
Percentage
.
167
6l
of stiffness,
4,
Poor
.
NOVEMBER
are
772
shown
in relation
of reduction
(Fig. 17).
patients
were questioned
and
any
1965
disability.
The
than
-
Fair
.
results
more
FRACTURE
2
sensation
NO.
OF
.
to the accuracy
criteria-All
47 B,
TYPE
Other.
relation
Subjective
VOL.
EACH
P
S..
or
of reduction
--
Anatomical
The
malleolus
XI
OBTAINED
Standard
Type
lateral
malleolus
TABLE
STANDARD
lateral malleoli
and
to the
as to
grading
type
the
used
of fracture
(Table
presence
of
is given
below.
pain
XIII)
or
aching
Good-Complete
and
in
or
a
646
H. N. BURWELL
apart
slight
stiffness
(not
with work),
ability
to walk not seriously
impaired
; Poor-Any
of ability
to work
or walk,
pain.
results
agree
closely
with the objective
results
and it is not felt that they
serious
impairment
The
separate
Three
possible
slight
aching
A. D. CHARNLEY
recovery
enough
from
AND
after
use;
Fair-Aching
during
use,
to interfere
table.
patients
In 1 1 7 patients
whose
objective
(89 per cent) the objective
results
were fair had
objectively
good
were subjectively
result
in one instance
was good,
and
fair; of two ankles
in the other
fair.
TABLE
STANDARD
OF
and subjective
good
subjective
REDUCTION
RELATED
graded
INITIAL
DEGREE
OF
Anatomical
Fair
42
6
Moderate
.
33
6
4
27
10
4
102
22
8
167
6
Total
.
.
Percentage
77#{149}3
.
TABLE
OBJECTIVE
RESULTS
of fracture
-
XIII
RELATED
TO
TYPE
Objective
Type
OF
FRACTURE
results
Good
Fair
Poor
Percentage
Number
P
.
.
27
87
3
1
PL
.
.
19
71
5
-
SL
.
.
51
85
7
2
S
.
.
8
100
.
3
33
Other.
Total
subjective
Poor
.
.
the
DISPLACEMENT
Mild.
.
a
of reduction
StandMd
Severe
poor,
merit
were identical.
Nine
ankles
XII
TO
Initial
displacement
objectively
results
results.
.
.
Percentage
.
-
108
82
-
4
2
19
5
143
37
DISCUSSION
Diagnosis
out
that
injured
take
little
to the ankle-Bonnin
reliance
because
account
Correctly
posterior
medial
Special
the
of injuries
he
can
usually
only ofthe
centred
be
placed
has
little
information
radiographs
on
idea
the
(1950),
Kleiger
(1954)
patient’s
interpretation
of the
obtained
from
are essential,
forces
involved.
the radiographic
and of special
and
Rose
of how
It
is
more
(1962)
pointed
the ankle
was
satisfactory
and clinical
importance
to
examinations.
is the antero-
view with the limb in slight medial
rotation
(Bonnin
1950), which
by displaying
the
clear space exposes
any lack of congruity
between
the talar and tibial articular
surfaces.
radiographic
projections
in order to show the syndesmosis
have not been used, because
presence
of
diastasis
may
be
inferred
by
reference
to
THE
the
Lauge-Hansen
JOURNAL
OF
BONE
classification;
AND
JOINT
SURGERY
THE TREATMENT
in addition
(Magnusson
the difficulties
1944, Close
for careful
scrutiny
avulsed
fragments
areas
of tenderness
of the joint,
OF DISPLACED
FRACTURES
in the diagnosis
ofdiastasis
1956, Iselin
and de Vellis
by radiography
have been well discussed
1961, Rose
1962, Scott
1962).
The need
of radiographs
in order
to detect
the
indicating
ligamentous
injury
has already
over ligaments
will indicate
the need fcr
as shown
in Figures
18, 19 and
20.
In this
presence
of small
shell-shaped
been stressed.
Examination
for
strain
films to reveal
instability
connection
18
FIG.
647
AT THE ANKLE
an ankle
FIG.
injury
which
may
19
I
I
18
FIGS.
Radiographs
showing
rupture
strain
of
film
medial
20
TO
SL4
ligament
(Fig.
19).
after
axial
fracture
revealed
Figure
with
by
20-Stability
screwing.
rAi;.
FIG.
appear
in fact
to be of SL2 grade
(not involving
displacement
be of SL4 grade
in which
the dislocation
has
a radiographic
examination
is made;
if that
and the tenderness
over the ruptured
medial
serious
injury.
Injuries
to the calcaneo-fibular
fracture
of the ankle
have not been considered.
VOL.
47 B,
NO.
4, NOVEMBER
1965
is so,
of the
undergone
the
degree
20
talus in the
spontaneous
of general
ankle
mortise)
may
reduction
before
swelling
of the
ligament
will indicate
that there has been
ligament
which
are usually
unassociated
ankle
a more
with
648
H. N. BURWELL
The standard
bearing
and
required-Fractures
extremity
require
incidence
of arthritis
the
1940,
medial
of reduction
AND
accurate
A. D. CHARNLEY
at the
if residual
(Lambotte
reduction
is to be reduced
ankle
being
articular
pain and disability
1907, Lane
1914,
and in a weightare to be avoided
Lewis and Graham
de Marneffe
and lateral
1955, Jergesen
1959).
In particular,
residual
sideways
displacement
of the
malleoli,
by allowing
displacement
and lack of congruity
of the talus in the
ankle
mortise,
must
be avoided.
In fracture
of the medial
malleolus
displacement
or angulation
in any direction
may be expected
to impair
the result ; in the case of the lateral
malleolus
it is
held (Vasli
1957) that posterior
displacement
of up to two millimetres
is compatible
with a
good
result,
case
of the
exact
and
standards
involving
relating
less
Vasli
than
millimetres
outcome
compatible
with
a fair
varies
lateral
malleolus
apply
articular
surface
can
to the
In the
; the position
of posterior
fragments
be ignored
(Nelson
and Jensen
1940;
of the
in relation
result.
a third
of the articular
surface
is broken
off
and a quarter
of the articular
surface
is broken
Hultengren,
Lindholm
and Lindvall
1958 ; Klossner
of these authors
and also from the present
series that
from
clinical
to the
a quarter
1957 ; Bergkvist,
the results
clear
of up to five
malleolus,
if more
than
is essential
; if between
a third
reduction
the
off
displacement
posterior
accuracy
of the
The requirements
slightest
variations
reduction
1962).
It seems
the quality
of the
as shown
in Figure
17.
have been summarised
by Smith
(1956):
In fractures
of the ankle
only the
from normal
anatomy
are compatible
with good function
of the joint.”
The closed method.
Difficulty
in achieving
and maintaining
accurate
reduction-Accurate
reduction
by closed
manipulation
may be obtained
in a number
of low bimalleolar
fractures
of
the
SL
type
in which
of Iselin
posterior
tibial
the talus and the two malleoli
move
together-the
bloc astragaloand de Vellis
(1961).
However,
manipulation
offers
little control
fragments
and in addition,
solitary
displaced
fractures
of the medial
(stage
P and
bimalleolaire
over
“
“
“
large
malleolus
1 of the
PL
groups)
cause
difficulty,
the malleolus
must
usually
be accepted.
Difficulty
in
discussed
by many
authors
of whom
Cox and Laxson
and
Cedell
and Wiberg
(1962)
may be mentioned.
In
Wade
(1959)
of fifty-seven
patients
whose
ankle
injuries
twenty-eight
required
a
These
authors
during
the
first
Extent
obtained,
of
immobilisation
the patient
should
have
first
half
second
comment
the
of this
few
on
weeks
as the
who
injured
period
manipulation,
the
difficulty
and
in
oedema
limb
eight
maintaining
third
a
the
or
displacement
fourth
position
that
an adequate
a displaced
bimalleolar
immobilised
plaster
forward
of
manipulation.
by
plaster
splintage
subsides.
necessary-Assuming
has sustained
the
in that
maintaining
the initial
reduction
is
(1952),
Mitchell
and Fleming
(1959),
the series reported
by Braunstein
and
had been treated
by closed
reduction,
in a plaster
should
extend
for
above
the
ten
closed
reduction
or trimalleolar
to twelve
knee,
and
weeks.
weight
can be
fracture
During
bearing
the
should
be avoided.
Uninterrupted
immobilisation
for this period
after a severe
ankle
injury
results
in organisation
of the traumatic
exudate
so that ankle and foot movements
may be imperfectly
restored
; in addition,
this state
is achieved
only after
a long
period
of rehabilitation
and
incapacity.
A further
osteoporosis
particularly
Risk
ofmalunion
resulting
1950),
when
weight
bearing
andresidualsubluxation-Should
in malunion,
and
followed
risk
is avoided
by
disability
when
successful
early
degenerative
the congruity
is inevitable;
as
the
arthritis
result
attempts
described
of
operation
(MacKinnon
(1944),
by Muller
(1945)
as an aponeurotic
curtain.
half of the patients
in this series,
a similar
whereas
Meekison
(1945)
found
interposition
than
long
ofthe
is the
ankle
at correction
(Trethowan
1928, Speed
Risk
of non-union-Non-union
of the medial
malleolus
soft-tissue
interposition
is often
described
as periosteal
that the material
was usually
derived
from the transverse
more
for
development
which
may only resolve
after
many
months.
Resolution
may
in relatively
inactive
persons,
so that there is permanent
pain and
are
and
then
1926),
Boyd
of
be incomplete,
swelling.
not
be maintained,
difficult
are liable
1936).
(Bonnin
to
be
is also a definite
hazard.
Although
in origin,
in this series
it was found
retinacular
fibres which
have been
Material
of this nature
was
present
in
proportion
being reported
by Burgess
in all of his patients.
Interposition
of
THE
JOURNAL
OF
BONE
AND
JOINT
SURGERY
THE TREATMENT
OF DISPLACED
FRACTURES
AT THE
the posterior
tibial tendon
has been reported
as a reason
for failure
malleolus
(Coonrad
and Bugg 1954) but was not found
in this series.
malleolus
is one of the common
causes
of instability
of the ankle
liable
to give
pain
or
to cause
tenosynovitis
around
the
tibialis
649
ANKLE
of reduction
of the medial
Non-union
ofthe
medial
(Burgess
1944).
It is also
posterior
(Banks
1949).
If
non-union
is present
the outcome
may be satisfactory
if only the tip of the bone is involved;
rarely
is this so if the fracture
is at the level of the joint
line (Jones
and Neal
1962) unless
there is a very firm fibrous
union
(Klossner
1962).
Magnusson
(1944)
considered
the incidence
ofnon-union
ofthe
medial
malleolus
in conservatively
recent
series of conservatively
managed
7 per cent (Jones
and Neal 1962) and
may then be possible
and a satisfactory
although
plaster
inevitably
immobilisation
Limited
open
the
fractures
8 per cent
method
patient
has to
and rehabilitation
reduction
followed
treated
undergo
causing
a further
extended
by manipulation
commonly
malleolus
used
after
failure
of
followed
by manipulative
is thereby
improvement
used
to be 10 to
and
operation
incapacity.
the
application
closed
reduction
is that
reduction
of the other
as a fixed point
for realignment,
over the closed
method
since the
fractures
15 per
cent;
show incidences
of I 2 per cent (Bistr#{246}m I 952),
(Klossner
1962).
Treatment
by bone grafting
appears
to be that described
by Banks
(1949),
after
general
of
followed
by
periods
of a plaster-A
internal
fixation
fragments.
The
of
method
the
medial
which
plaster
is applied.
alignment
of the ankle
of
medial
malleolus
It is a definite
is usually
more
i:
21
FIG.
Radiographs
and
satisfactory
the
knee,
showing
non-union
which
would
immobilisation
FIG.
screw
of the
increase
is frequently
rehabilitation
has
fixation
of isolated
medial
the
continued
fracture
malleolus
temporary
for
of medial
is eliminated.
disability,
eight
22
malleolus.
A plaster
is usually
not
more
weeks,
so
is the
undisplaced,
method
are
or
P1
type.
extending
employed
that
the
above
although
period
of
to be prolonged.
Rigid internal
fixation
followed
by early exercises-This
Isolated
fractures
of the medial
malleolus,
unless
advocated
in this paper.
treated
by open reduction
and internal
fixation
(Figs.
21 and 22), followed
by earlyjoint
movement.
In the more severe
injuries,
if full reduction
is to be maintained
and early exercises
are to be encouraged,
more
than
one of the fractures
must
usually
be fixed in order
to make
the ankle
stable
without
external
in this
support.
series,
are
Secondly,
active
organisation
evacuation
When
VOL.
47 B,
exercises,
practised
of the traumatic
of the haemarthrosis
a full
applied
reduces
Fixation
malleolus,
The advantages
of this method
of treatment,
as follows.
Firstly,
accurate
reduction
is usually
range
of
ankle
and
which
has been employed
achieved
and maintained.
regularly
in bed during
the healing
of the wound,
prevent
exudate
which
otherwise
may cause
dense
adhesions.
The
at the time of the operation
is also of value in this connection.
foot
movements
has
been
restored,
a below-knee
in order
to permit
full weight
bearing
which
reduces
the disability
osteoporosis.
of medial
nialleolar
fractures-Accurate
fixation
of the fractures
which
always
involve
the articular
surface
of the joint,
is considered
NO.
4,
NOVEMBER
1965
plaster
and
is
materially
of the medial
essential,
and
650
in
H.
this
series
the
three-quarter
non-union,
the
operation.
(Muller
use
fragment
inches
N.
was
the
in length
fracture
BURWELL
first
being
line
not
to
screws
(fourteen
patients
in young
Fixation
subjects,
of lateral
frequently
in order
to
malleolar
being
has
series).
been
1959);
stressed
by a number
large fragments
may
Where
there
has
been
of authors
require
the
comminution
plate described
by Zuelzer
(1951)
may be used.
have been used on a few occasions
for small
avoid
growth
or fibular
arrest
at
the
epiphysial
fractures-Reduction
restores
the lateral
malleolus
1959) but it should
be emphasised
Wade
with,
a screw
of not less than
one and
is then
no danger
of redisplacement
or
invisible
on the radiograph
taken
after
length
Jergesen
in this
CHARNLEY
D.
dealt
There
infrequently
The need for a screw of adequate
1945, Mitchell
and Fleming
1959,
of two
A.
be
used.
one occasion
in this series)
the hook
steel pins two millimetres
in diameter
or
AND
line.
of the
to acceptable
position
that this is not always
(on
Stainless
fragments
medial
(Muller
achieved
side
of the
joint
1945, Braunstein
and
(Cedell
and Wiberg
1962).
Rotational
deformity
in particular
may persist,
impair
the function
of the joint
and
predispose
to arthritis.
There
is also the possibility
of residual
displacement
of the talus
if the
medial
ligament
has been damaged,
in addition
to fracture
of the medial
malleolus
(Close
1956)
(Figs.
23 and
24).
Nevertheless,
FIG.
Radiographs
on fixation
showing
of the
medial
fracture
is not
earlier
years
of this
series
there
FIG.
23
residual subluxation
after accurate
fixation
associated injury of the medial ligament.
malleolus
of the fibula
is necessary
the outer
side of the joint
fibular
in the
both
may
fixed
there
alone.
It is now
for the reasons
inhibit
by pain
may
felt
that
full
was
a tendency
or non-union
rely
24
of medial
malleolus-
reduction
and
given
and because
an unsupported
the rapid
return
of movement.
be delayed
to
(Cox
and
stabilisation
fracture
at
Finally,
if the
Laxson
1952).
Fixation
of fibular
low SL type of fracture
(1959),
and by Mitchell
fractures
may be achieved
in a number
of ways.
In this series
the
has usually
been stabilised
by an axial screw,
as also used by Jergesen
and Fleming
(1959) and Lamare
and Scheer
(1960).
This screw should
be three
in length
just
surgeons
alternative
posterior
the
with
or four
lateral
lower
the
an axial
a short
to
inches
the
ligamentous
is less satisfactory
method
which
screws
traversing
fibular
syndesmosis.
fragment
and
can
be quickly
attachment
(Figs.
and
easily
4 and
20).
inserted
The
at the
Rush
tip
pin
of the
used
by
bone
some
because
it provides
less firm fixation
and is liable to displace.
An
has been used
in this series
consists
of one or two short
anterothe fracture
(Figs.
25 to 28 and 29 to 32). An oblique
screw from
into the tibia
(Burgess
1944)
is considered
to interfere
unnecessarily
Fractures
of the
S and
P types
are also
usually
screw (Figs.
10 to 13), but fractures
of the fibular
shaft (PL
plate
and four screws
(Figs.
6 to 9). Wiring
of the fibula
THE
JOURNAL
suitable
type) are
(cerclage)
OF
BONE
for
fixation
with
best stabilised
by
was extensively
AND
JOINT
SURGERY
THE
employed
1957) and
TREATMENT
OF
DISPLACED
FRACTURES
AT
THE
651
ANKLE
in Vasli’s
series,
but the method
in general
has been strongly
criticised
(Charnley
in this series it was used only once:
a year after operation
the fracture
was ununited
because
of avascular
change,
but union
was observed
in radiographs
taken
four years later.
Fixation
of the posterior
malleolar
fracture-We
have adopted
the generally
accepted
view
(Vasli
1957, Klossner
1962) that fragments
involving
less than a third of the articular
surface
do
not
require
internal
fixation
than one screw is frequently
series)
(Figs.
29 to 32). The
and
found
unless
they
are
much
It has
displaced.
needed
to fix the fragments
securely
(nine
postero-lateral
incision
described
by Henry
been
found
that
more
out of thirteen
in this
(1945)
has been used
to be satisfactory.
FIG.
25
FIG.
FIG.
27
FIG.
26
.t
Radiographs
Conipression
extensive
fractures-In
and
comminution
not
possible,
can
be
the
position
achieved,
radiographs
discomfort
Diastasis-This
recently
of the
leg,
47 B,
so
as
are shown
or impairment
subject
Until
VOL.
showing
NO.
4,
fracture:
severe
injuries
displacement
may be much
to
give
the
fixation
has
been
benefits
in association
NOVEMBER
1965
held
with
of fibula
28
by antero-posterior
screw.
caused
by a fall from a height
there
is frequently
(Figs.
33 to 36).
Although
anatomical
reduction
is
improved
by a careful
operation
and sound
fixation
of
here was reviewed
six
of function.
has been widely
explored
diastasis
commonly
SL4
to
imply
a fracture
early
joint
movement.
The
patient
years
after
his
when
he
in medical
only
writings
actual
of the
accident
shaft
for more
separation
of the
of
fibula.
than
the
When
whose
had
little
a century.
two
the
bones
distal
652
H. N. BURWELL
part of the
to be absent
consequent
fibular
shaft
no matter
luxation
has
how
retained
great
of the talus)
AND
A. D. CHARNLEY
its connection
with
a degree
of displacement
may
(SL fractures)
which
form
the largest
concerning
the presence
or absence
be present.
In low
the
tibia,
diastasis
of the lateral
bimalleolar
and
group
in a series,
it is clearly
of displacement
of the fibular
has been
malleolus
trimalleolar
held
(and
fractures
unprofitable
shaft
(referred
to speculate
to in this
I
1
I
1.
1
FIG.
FIG.
Radiographs
showing
29
31
SL4
fracture:
firm
fixed by
antero-posterior
FIG.
32
fragment
by
two
screws;
of the fibula
(intraosseous
ankle
instability”
when
of an unstable
diastasis).
discussing
fibula
screws.
allows
uncontrolled
displacement
of the talus.
The importance
of instability
malleolus
in this type of fracture
has been discussed
most
recently
by iselin
(1961)
who introduced
the term “diastasis
intraperoni#{232}re “-that
is, diastasis
two fragments
term
“lateral
presence
posterior
as
“)
in the
a large
which
lateral
Vellis
the
the
diastasis
two
of
30
paper
“
classical
fixation
FIG.
fracture
of the
lateral
malleolus
of the
and de
between
Although
Kleiger
(1954)
introduced
fractures
of this type,
it is felt by the
THE
JOURNAL
OF
BONE
AND
JOINT
SURGERY
THE TREATMENT
present
writers
that
this
could
OF DISPLACED
with
advantage
FRACTURES
be used
AT THE
to embrace
653
ANKLE
both
types
of displacement
has
and consequently
been emphasised
(shown
in Figs. 37 and 38) because
it emphasises
what is important.
Classical
diastasis
has previously
been considered
of great
importance
diagnosis
of the displacement
by both clinical
and radiographic
methods
r
FIG.
Radiographs
because
it was
felt
showing
that
special
/
-
35
FIG.
comminuted
compression
measures
were
injury and method
frequently
required
(1956)
showed,
however,
that section
of
membrane
permitted
only a small
amount
the inferior
of separation
tibio-fibular
at this
malleolus
intact.
also
VOL.
47 B,
(or
NO.
medial
ligament)
4, NOVEMBER
1965
remained
He
showed
36
of internal fixation.
for
its correction.
ligaments
joint
if the
that
if
and
fibula
injuries
Close
interosseous
and medial
of the
latter
654
H. N. BURWELL
bones
were
was reduced
and
reduced
and
and maintained
in the
series
AND
A. D. CHARNLEY
stabilised
(either
by external
or
in position.
Classical
diastasis
presented
here
the
more
recent
internal
is found
fractures
were
fixation)
the diastasis
also
in the PL3 and 4 fractures
treated
by plating
of the
fibula
(nine
instances)
in association
with screw fixation
of the medial
malleolus
(Figs.
8 and 9).
Previously
many
writers
have regarded
internal
fixation
of the syndesmosis
as an essential
part of the treatment
in classical
diastasis
(Darrach
1942, Burgess
1944, Mayer
1956, Vasli
1957).
Most
writers
use a screw
although
the technique
differs.
Cox and Laxson
(1952),
Vasli
(1957)
although
and
Perkins
Vasli
(1958)
reported
advised
satisfactory
that
the
results,
screw
should
and
Laxson
Cox
be inserted
horizontally,
described
fibular
fragment.
Burgess
(1944),
Bonnin
(1950),
Mitchell
and Fleming
(1959),
and Scott
(1962)
recommended
that the screw
should
be oblique,
and Klossner
tilting
of the fibula if the screw were horizontal.
Mayer
(1956) used a boltacross
supplemented
by Zueltzer
Apart
the
from
the
is not
method
plates
doubt
embracing
the
as to whether
without
grave
and
angulation
of
Klossner
the
(1962)
referred
also
to
the syndesmosis
malleoli.
internal
fixation
disadvantages.
The
of the
fibula
is often
syndesmosis
must
be accurately
necessary
reduced
before
-
37
FIG.
fixation
Figure
37-Radiograph
and
it is difficult
38
FIG.
showing
showing
classical
intraosseous
to avoid
a little
diastasis
diastasis
rotation
(PL4
fracture).
(SL4
fracture).
or other
Figure
38-Radiograph
displacement
which
would
impair
the ankle
movements
and
predispose
to arthritis.
Charnley
(1957)
and
Klossner
(1962)
referred
to undue
tightening
of the screw,
and the degree
of tightening
may be difficult
to
assess.
Cox and Laxson
(1952),
Close (1956),
Braunstein
and Wade
(1959) and Jergesen
(1959)
referred
to the likelihood
of breakage
or loosening
of the screw
if it were not removed
at a
later
operation.
Bonnin
(1950)
also described
persisting
pain like a chronic
sprain
at the
syndesmosis
after removal
of the screw.
He also stated
that if the screw were left in position
it might
cause
a
wooden
feeling
in the ankle
or even limit dorsiflexion.
It seems,
therefore,
that internal
fixation
of the diastasis
should
not be undertaken
lightly.
“
In the present
series
as unnecessary.
The authors
plating
ruptured,
of
“
the
because
it was done
consider
fibula
the
and
in only
two
instances,
that
it is important
before
completing
ligament
may
be
turned
to
the
into
and
even
take
an
operation
the
in these
antero-posterior
if the
joint
THE
cases
and
JOURNAL
ligament
obstructing
OF
later
regarded
radiograph
medial
be
was
BONE
full
AND
after
has
JOINT
been
reduction
SURGERY
THE TREATMENT
(Figs.
39 and 40); in that case
The usual
r#{233}gimeis continued
Although
classical
diastasis
visible
of
the plain
Lauge-Hansen
on
the
fixation
of the
lntraosseous
although
classification,
fractures
achieved
and the fibula
state (Close
1956), and
diastasis
(“
to divaricate
in its long
and
interference
The timing
delayed
in order
to allow
the
“)
is present
fracture
to the
showing
classical
more
satisfactory,
Klossner
because
he did not find that
of the present
writers,
most
reduction
in this
series
is obtained.
it was
of the
the
syndesmosis
reaction
diastasis
caused
by
always
was
to settle,
and
in a PL4
fracture:
residual
inturned
deltoid
ligament.
then
normal
in all SL4
(40
fractures
that
wound
FIG.
40
subluxation
unnecessary
should
healing
after
per
should
be
by Burgess
to be contra-indicated
because
it involves
all the disadvantages
referred
to above.
Vasli
(1957)
considered
that
operation
soft-tissue
not
tibia, which
is the
by Grath
(1960).
of the lateral
malleolus
tibia,
as recommended
39
FIG.
Radiographs
Healing
slightly
from
axis as confirmed
intraperoni#{232}re
Close
(1956)
is considered
with the syndesmosis
with
of the operation-Although
spontaneous
patients
above.
cent of this series).
It is considered
that this spiral
stabilised
by an axial screw.
Fixation
of the fibula
(1944)
and
655
AT THE ANKLE
its presence
could
be deduced
from a consideration
and its reduction
was maintained
by internal
as described
remained
free
also to rotate
diastasis
FRACTURES
the ligament
is replaced
after operation.
occurred
in twenty-four
radiograph
genetic
associated
OF DISPLACED
was
be
then
plating
(1962)
recommended
operation
as soon as possible
after
injury
this caused
less satisfactory
wound
healing.
This is the experience
of the operations
in this series
having
been undertaken
without
delay.
The conditions
at the site of injury
are more
favourable
to operation
at this time
because
the fractures
are more
easily
reduced
before
there
has been
organisation
of the
traumatic
exudate.
This view was advocated
strongly
by Murray
(1944)
in relation
to the
open treatment
offractures,
and also by McLaughlin
and Ryder
(1949).
When
early operation
is undertaken,
any laceration
or abrasion
of the skin, which might become
septic if left without
thorough
treatment,
can be dealt
with at the time of the operation
so as to ensure
healing.
If open operation
to bandage
the
on ankle fractures
ankle
firmly
over
the bed should
contra-indicate
be elevated.
open operation,
VOL.
47 B,
NO.
4,
NOVEMBER
1965
is not possible
on the day of the accident,
then
wool and to apply
a plaster
splint;
in addition,
Under
may
these
conditions
be avoided.
blistering
of
the
skin,
it is essential
the foot of
which
would
656
H. N. BURWELL
AND
Technique
of operation-A
Medial
malleolus-Either
pneumatic
tourniquet
a curved
incision
just
over
the
found
after
tilting
bone
have
the
entered
near
fracture
surface
towel
clips.
bone
of
been
medial
the
of
the
The
the
drill
tibia.
The
distal
drill followed
by insertion
three-quarter
inches
long.
Lateral
malleolus
andfibular
The fracture
is then reduced.
and
in lateral
malleolar
The
fracture
firm pressure.
is advisable
anterior
Care
cortex,
firmly
after
The
two
patient
is then
of
an
held
to
to just
below
out
the
patient
far
as
and
the
the
the
gives
fragment
a small
an
knee
These
to
walk
as
patient
After
to walk
resume
as
most
ankle
re-form.
any
for
the
or
two
days,
or pins
In
one
arthritis-In
space,
any
margins.
ligaments
radiographic
follow-up.
screws
discomfort.
; sepsis,
joint
shown
returns
two
of joint
and
changes
by
Klossner,
Opinions
are
the
not
were
that
differ
one
and
is satisfactory.
and four screws,
a cr#{234}pebandage
is then
period
of wound
during
removed.
healing.
the
and
the
was
from
base
is dry,
the
of the
patient
On leaving
hospital
normal
activities
as
his
continue
duties
range
from
plaster
fractures
of movement
the
sticks.
period
the
range
series
the
each
because
and
two
to
tibia.
with
at this stage it
to engage
the
wounds
painful
when
normal
average
patients,
patients
with
light
semi-
period
of plaster
immobilisation
was five
mostly
with P1 and PL1 fractures
of the
to permit
unsupported
of the plaster
joint
which
are constantly
the
time
phase
after
to his
is rarely
this
inch
than
of
about
removal
of
normal
necessary
work
because
series
the
screws
pins,
four
cases
the
(of
reduction,
three
the
and
their
or
pins
weight
bearing
on the
movements
are quickly
present
at this stage
are
and
plaster,
are
by
do
not
frequently
activities.
presence
were
is rarely
removed
; incorrectly
avoided
weeks)
placed
associated
in ten
screws,
instances
three
cases;
case.
irregularity
These
fracture
plate
extending
using
and
healing
supervision,
two
cancellous
to the back of the
is carefully
replaced
(in this
a plaster
from
crucial
under
: temporary
cases
less
five minutes
bed)
in
and
of their
quickly
reasons
Post-traumatic
to
patient
is
possible
immobilised
the
following
aching,
the
the
of the
pain
been
exercises
and
Removal
with
has
during
Further
unnecessary
the
is changed
in the operation
is applied
without
padding.
The
not
restored
correctly
return
to work.
The
to eight weeks).
In fifteen
movements
are
been
removed
much
distal
by
tourniquet
the
for
exercises
has
is applied.
during
exercises
as the
are
is taught
Housewives
injured
into
not
of the
bandage
foot
malleolus
alone, fixation
was sufficientlyfirm
limb during
the fourth
week.
After removal
regained
without
pain since the dense
adhesions,
active
access
the
haemostasis,
crepe
and
long
stitches
is elevated
to achieve
movement
is then
the
a nine-sixty-fourths
screw
posterior
injured
the
of
stabilised
inches
using
of Henry
large
medial
when
and
to two
drill
centre
one
cleared
screw.
bed
day.
(so
full
and
is advised
possible.
of the
screws
of bed
sedentary
occupations
weeks
(range
three
the
to do ankle
When
days)
a half
is withdrawn.
After
closure
of turns
of plaster
wool and
operation
by the
reduced
and
twist
the
incision
centred
over the
it is fixed by a three-inch
axial
to be bulky
throughout
forty
is allowed
has
after
firmly
pin
foot
increases.
seven
the
encouraged
hour
gradually
toes
days
inch
in
over-drilled
incision
and
a number
which
and
or a straight
exposed
is maintained
by a temporary
transfixion
pin, and
position
radiographically.
Screws
are then inserted
and
over
dressing,
theatre
are
debris,
operation-The
first
half
of
Reduction
to check
the
tibial
is applied
an
are
emergence
of a coarse-threaded
straight
fractures
by
malleolus
surfaces
accurately
is then
postero-lateral
is cleared
one
tightening
fractures
Posteriorfragment-The
for
shaft-A
In shaft
its
is then
fragment
and
and
fracture
continued
medial
fracture
A seven-sixty-fourths
malleolus
; the
is then
The
outwards.
medial
is confirmed
is used.
behind
the
satisfactory.
malleolus
apex
A. D. CHARNLEY
diagnosis
of
the
ossifications,
caused
found
marginal
about
of arthritis
articular
at
by
in
the
site
37 per
significance
of
did
our
not
of
paid
also
attention
to
ligamentous
form
cent
have
and
of
a progressive
ossifications
the
we
surface
of
arthritis.
changes
JOURNAL
these
but
with
OF
diminution
ossification
at
indicate
On
material,
progress
ThE
of
attachment,
total
arthritic
to any
evidence
injury
strict
it was
criteria
noted,
as
increasing
length
of the
that
develop
after
BONE
may
AND
JOINT
SURGERY
THE TREATMENT
ankle
injuries.
found
found
arthritis
arthritis
definite
Thus
relationship
Of
the
between
twenty-two
aching
or
twenty-two
discomfort
had arthritis
Magnusson
(1944)
in 49 per cent,
in 43 per cent.
present
series
site of some
the
ankles
in
proved
to be so in the
cent)
of those
patients
(79
cent)
results
of those
graded
Walheim
after
which
severe
with
results
as
poor.”
(1937)
considered
of ankle
reduction
fractures
treated
conservatively
and
the
occurrence
of symptoms.
was
fair,”
“
seven
arthritic
changes
Thus
were
as
“
fair
were
In the
anatomical
radiographic
“
the
were
associated
were the
arthritis.
“
site
All eight ankles
in which
reduction
that symptoms
become
more marked
series.
results
graded
657
ANKLE
in which
reduction
was
of these
only nine had
arthritis.
It seems
present
whose
AT THE
in a series
of fractures
treated
by operation
of these writers
was able to demonstrate
any
of arthritis
104 ankles
although
and of arthritis
increases.
found
that more
severe
this has
(27 per
(1957)
neither
presence
of the
discomfort,
FRACTURES
in a series
and Vasli
However,
and all of these
had
and six were painful.
of malunion
Klossner
per
OF DISPLACED
of pain
or
was
poor”
as the degree
“
with
disability
and
arthritic
change
was found
in twenty-nine
objectively
graded
as
good,”
in fifteen
“
“
and
in five
had
no
(100
per
cent)
of those
with
“
fractures
and
both
that
young
Magnusson
people
(1944)
and
particular
Klossner
tendency
(1962)
referred
to
arthritis
to the
higher
100%
[__J
10%
MILD
MODERATE
INITIAL
D ISPLACEMENT
FIG.
Percentage
incidence
degree
AC C URACY
41
ofarthritis
ofdisplacement.
in relation
to initial
incidence
of arthritis
as age increased.
The
but this is because
of the increased
incidence
liable
to develop
arthritis
(43 per cent).
Effect
of initial
degree
of displacement-There
Percentage
accuracy
It seems clear that severe damage
corner
of the tibia
in supination
1950) would
to the articular
of
incidence
reduction.
Fair;
REDUCTION
42
of
arthritis
in
A=Anatomical;
P=Poor.
relation
to
F==
latter
finding
is borne
out in the present
series
in older
people
of SL fractures
which
are more
is a definite
of arthritis
and the initial
degree
of displacement
in the slightly
displaced
group
to 52 per cent in the
other
sites (Palmer
referred
to injury
OF
FIG.
relationship
between
of the fractures
ranging
more severely
displaced
from
fractures
to the articular
surfaces
such as has been found
fractures
(Klossner
1962) and in compression
be expected
to predispose
cartilage
and Cox and
to arthritis.
Laxson
(1952)
Jergesen
indicated
the
incidence
10 per
(Fig.
cent
41).
at the medial
fractures
at
(1959)
also
that damage
to the subchondral
bone
might
be expected
to interfere
with the nutrition
of the articular
cartilage.
In the present
series the highest
incidence
of arthritis
was found
in the displaced
SL fractures.
In these
it is common
for damage
to the articular
surface
in the region
of the
syndesmosis
to be seen on the initial
Effect
of accuracy
of reduction-The
after
VOL.
fractures
47 B,
NO.
of the ankle
4, NOVEMBER
is, however,
1965
radiograph.
most important
the accuracy
factor
determining
of the reduction.
the
Lewis
onset
of arthritis
and Graham
(1940)
658
H. N. BURWELL
who
described
arthritis
the patients
had
accurate
reduction
also that arthritis
“
in eighteen
AND
patients
A. D. CHARNLEY
after
ankle
fractures
reported
that
only
three
of
nearly
perfect
reduction.”
Jergesen
(1959)
emphasised
the importance
of
in preventing
arthritis,
and Klossner
(1962)
thought
the same but he stated
was not always
prevented
by this means
although
it was then usually
mild.
Cedell
and Wiberg
(1962)
stated
that the greater
the load
on a joint
the more
likely
it was that
irregularity
of the joint
would
give rise to symptoms
from
arthritis.
These
by the findings
in this series
views
(Fig.
was
found
in 25 per cent
of
reduction
graded
as
anatomical,”
are
42).
the
patients
with
in 73 per cent
“
of
those
with
100 per
reduction
cent
graded
of those
in whom
supported
Arthritis
as
fair
“
and
“
reduction
had
in
been
poor.
When
reduction
is really
is firm,
the onset
of arthritis
at least
deferred
for
many
paper
presents
accurate
can be
years
and fixation
prevented
or
(Fig.
43).
SUMMARY
1
This
.
displaced
ankle
fixation
followed
until
movements
ankle
after
5, six years
is virtually
shown
in Figures
2 to
operation.
Note
that
there
no degenerative
change.
of 1 35 patients
by full weight
bearing
in a plaster.
2. The advantages
obtained
are as follows
43
FIG.
The
a series
with
fractures
treated
by rigid
internal
by early
joint
exercises
in bed
were restored
and followed
then
.
: A high
.
standard
of reductlon
can be achleved
and maintamed.
The joint
movements
are established
before
of the traumatic
exudate.
Weight
bearing
in a plaster
reduces
the degree
of
and prevents
osteoporosis.
Further
remedial
treatment
after removal
of the plaster
organisation
disability
is usually
unnecessary.
3. All but five of the
fractures
(37
per
cent)
could
be classified
in the
manner
described
by
Lauge-Hansen.
4.
This
classification
general
use.
5. Anatomical
is the
reduction
clinical
results
6. The quality
was
in 108 patients
of the clinical
extent
on the degree
7. It is considered
that the term lateral
most
satisfactory
obtained
in
(82 per cent).
result depends
degree
of displacement
We wish to thank
102
those
available
patients
mostly
(77
and
per
on the accuracy
is recommended
cent),
with
good
is also
Mr J. D. Crossley
for
is to be avoided
to depend
mostly
except
upon
for
objective
of the reduction,
of initial
displacement,
and least on the type of fracture.
that the traditional
concept
of diastasis
requires
modification
ankle
instability,
which
includes
low fracture
of the fibula
diastasis)
is preferable.
8. Internal
fixation
of the syndesmosis
9. The incidence
of arthritis
is shown
initial
of
to a lesser
; it is felt
(intraosseous
in rare instances.
the accuracy
of reduction
; the
of importance.
the
prints
of the radiographs,
and
Mrs
Joan
Burwell
for secretarial
assistance.
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