Nicolae Testemi tanu [601409]

Ministerul Sa natatii al Republicii Moldova
Universitatea de Stat de Medicina si Farmacie
“Nicolae Testemi tanu”

FACULTATEA MEDICIN A
Catedra de Ortopedie si Traumatologie

TEZA DE DIPLOM A
“FUNCTIONAL OUTCOME OF TREATMENT OF
BIMALLEOLAR FRACTURES”

Numele si prenumele student: [anonimizat]: Fadila Faris
anul, grupa: an.VI, gr. 163 6
Numele si prenumele conduc atorului stiintific: Chiril a Vitalie

2

CONTENTS

INTRODUCTION 3
REVIEW OF LITERATURE 4
MATERIALS AND METHODS 13
OBSERVATIONS AND RESULTS 21
DISCUSSION 29
ANALYSIS 33
CONCLUSION 34
REFERENCES 36

2

INTRODUCTION

Ankle fractures are one of the most common injuries treated by orthopaedic
surgeons. A nkle fractures have been the subject of numerous studies and articles
regarding the mechanism of injury, classification and treatment modalities. The
ankle is a mortise joint formed by the lower end of the tibia and fibula articulating
with the talus. The anatomy of the joint makes it very unstable in cases of fractures
or ligamentous injuries of the ankle. As fractures of the ankle have been treated
with various modes of internal fixation devices, the best possible implant is
determined according to the an atomy of the fracture. In the postoperative period, the
protocol of mobilization of the ankle has been a topic of conflict. The final outcome
of a fractured ankle is of prime importance, as the treatment should benefit the
patient just not in short term bu t also in the long term. The treatment of fractures
has its challenges in cases where the fracture is complicated by co -morbid
conditions such as Diabetes mellitus, peripheral vascular diseases and neuropathic
conditions which complicates the treatment and influences the overall outcome
Considering all of the above, we have tried to analyse the results of bimalleolar
fractures treated at hospital.
Objectives : Evaluating the results of functional outcome of treatment of bimalleolar
fractures .
Methods : The study included 60 patients ages around 21 to 61 . a 42 (70%) male
patients with 18 (30%) female patients were included in this study .
The study show the incidence of males get affected more in young age then the
opposite way for female which there incid ence increased more in older age ,
With most common type of fracture showed as (Type B ) (53.7 %) of right leg side
as in generaly of (56.6%) incidence .

3

REVIEW OF LITERATURE
FRACTURE CLASSIFICATION
A classification system for fractures should be easy to use in daily practice. It
should be based on information easily obtained such as patient history, clinical
examination and results of radiological investigations. It should also define the
severity of the bone lesion and serve as a basis for treatment and for evaluation of
results.
The number of malleoli involved can describe ankle fractures: uni -, bi- and
trimalleolar. During the last century, a number of classification systems have been
developed. A shhurst and Bromer made the first classification in 192233. They
divided the fractures according to the vector of trauma in 300 patients: external
rotation, abduction and adduction included about 95% of all ankle fractures. The
rest were mainly caused by c ompression in the long axis of the limb33. The system
was further developed by Lauge -Hansen who developed a classification in 1942
after cadaver experiments34. He named each type by a double name, where the first
part defines the position of the foot at th e moment of trauma and the second part
specifies the direction of the dislocating force at the moment of trauma. Lauge –
Hansen identified four groups of fractures, each with a number of subgroups:
supination -eversion fractures, supination -adduction fracture s, pronation -eversion
fractures and pronation -abduction fractures
The most common fractures are in the group of supination -eversion fractures.

4

Lauge -Hansen also described pronation -dorsiflexion injuries. This injury was
combined with compression of the joint and is thus not a true ankle fracture. Lauge –
Hansen also described well how the classification could be used as a guide for
closed reduction 36. The Lauge -Hansen classification has been recommended by
several authors. However, studies have shown high interobserver variation and the
system has been described as difficult to apply .
In 1949, Danis described a classification which was more patholo gical -anatomical
and designed for application to operative treatment. This system has later been
further developed by Weber and the AO -group (Arbeitsgemeinschaft für
Osteosynthesefragen, English: Association for the Study of Internal Fixation/ASIF)
founded in 195839. The fractures are divided into three fracture types: A, B and C
with further subgroups. This division is based on the level of the lateral malleolar
fracture in relation to the level of the syndesmosis (Figure 4) .

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Fracture type A – injuries below the syndesmosis
A1 – isolated lateral lesion (ligament injury or fracture)
A2 – lateral les ion with a fracture of the medial malleolus
A3 – lateral lesion associated with a postero -medial fracture
Fracture type B – injuries at the level of the syndesmosis
B1 – isolated lateral malleolar fracture
B2 – lateral malleolar fracture associated wit h a medial lesion
B3 –lateral malleolar fracture associated with a medial lesion and a postero -lateral
fracture
Fracture type C – injuries above the syndesmosis
C1 – simple diaphyseal fracture of the fibula with a medial lesion and/or a postero –
lateral fracture
C2 – multifragmentary diaphyseal fracture of the fibula with a medial lesion and/or
a postero -lateral fracture
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C3 – proximal fracture of the fibula with a medial lesion and/or a postero -lateral
fracture
TREATMENT
The aim when treating ankle fractures is to re -establish the function of the injured
joint. This might include reduction of the fracture, retention of the obtained position
and rehabilitation. This can be achieved in several ways, both non -operatively and
operatively. When deciding which method to use, the fracture, the conditions of the
surrounding soft tissues as well as the patient characteristics have to be considered.
Also, the timing of the planned procedure is of importance: “a good closed
reduction followed by successful immobilization in a plaster cast is certainly likely
to give better outcome than is a poorly planned and executed open reduction and
internal fixation”42. When comparing studies of treatment, one must consider the
different inclusion criteria and outcome measurements that have been used.

NON -OPERATIVE TREATMENT
The most common method of non -operative treatment is immobilization in a plaster
cast and this is frequently used for ankle fractures (43 -73%)6,43 -45. It is, however,
essenti al to master the art of “plastercraft”. Charnley attributed failure of non –
operative treatment to inadequate plaster technique but admitted the difficulty in
retaining a good reduction46. Bauer et al. found in a randomized control study of
closed type B -fractures that even though the reduction was considered superior in
the operative group, the clinical outcome after an average of seven years was
comparable to non -operative treatment47. Neither could they reveal any significant
difference in late follow up (29 years)48. The favorable outcome of closed
treatment of ankle fractures with supination -eversion subgroup II (type B) has also
been supported by others49 -52. Pakarinen et al. applied a stability based criteria to
the AO classification, when deciding upo n treatment51. This criterion was similar
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to the recommendations from the AO -group which claims that isolated type A –
fractures with no medial lesion, as well as non -displaced type B -fractures with no
medial lesion can be treated non -operatively2

OPER ATIVE TREATMENT
That dislocated fractures and fractures with ankle mortise incongruity should be
treated with open reduction and internal fixation to restore the congruity of the joint,
has been advocated by several authors , The methods of internal fixati on have varied
though.
Palmer, Wiberg and Cedell described non -rigid, adaptive internal fixation
techniques with cerclage wiring, staples, pins and small -threaded screws, enough to
keep the malleolar fragments adapted, combined with a protective plaster c ast
during bone healing ,This method is still widely used in Sweden. Studies by Ahl et
al. have shown that it enables anatomical reconstruction and is sufficient for early
mobilization as well as full weight bearing58 -61. Other studies by Olerud et al.
have considered the non -rigid technique to be inadequate in retaining congruency in
bi- and trimalleolar fractures which also resulted in a poorer outcome as assessed by
the OMAS. Anatomical reduction and retention of the unstable fractures was only
achieved i n .
Danis developed the principle of absolute interfragmentary stability, where the
internal fixation should fulfill the following requirements. (1) Enablement of
immediate, active movement in the affected region and adjacent joints as soon as
wound heali ng is complete. (2) Complete restoration of the original shape of the
bone. (3) Direct union of the bone without visible callus formation55. With this
concept the fractures are treated with metal plates and screws (Figure 5). The
concept has further been d eveloped and spread worldwide by the AO -group2. The
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outcome of this method has shown good and excellent results , The rigid technique
has also been found to be superior to the non -rigid technique when comparing
degree of congruency on post -operative radi ographs65

Figure 5. Open reduction and internal fixation according to the AO -group.

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6

Initial management
• As with any trauma patient, carry out a primary survey following the
'ABCDE' principles of trauma care.
• Assess clinically for obvious deformity and for neurovascular status.
• If there is neurovascular compromise or dislocation (obvious deformity) of
the joint, the fracture should be reduced immediately – before X -ray – under
analgesia or sedation.
• Displaced fractures should be reduced as soon as possible after initial
assessment – this reduces pain/swelling and may prevent skin necrosis.
• Assessment o f neurovascular status is by testing sensation over the dorsal and
plantar surfaces of the foot, measuring capillary refill in all digits, and palpating the
distal pulses (although the dorsalis pedis artery is absent in 2 -3% of the population).
• Open frac tures should be covered with a wet, sterile dressing secured by
loosely wrapped dry sterile gauze. Check tetanus immunisation; consider antibiotic
prophylaxis.
• Provide analgesia if required.
• Full history, examination and X -rays (see separate Ankle Inju ries article).
• Once reduced, stabilise the fracture in a well fitted backslab cast.
• Elevate the limb.
• Re-assess neurovascular status to ensure there has been no compromise
during the reduction.
• Arrange post -reduction X -rays to confirm a dequate fracture reduction.

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Further management
Consider whether the fracture is stable or unstable. Unstable ankle fractures include:
• Fracture dislocation.
• Bimalleolar or trimalleolar fractures.
• Any lateral malleolar fracture with substantial talar shift.
As with all fractures, aim to reduce the fracture, maintain reduction, promote
healing and restore function. This can be achieved both conservatively and
operatively.
Conservative treatment
Conservative treatment (in a cast) can can be consi dered for:
• Non-displaced fractures or anatomically reduced fractures – although
functional outcome may be better if treated operatively.
• Patients with serious comorbidities who are not fit for surgery.
Conservative treatment comprises:
• A well moulded cast for 4 -6 weeks – following this, weight -bearing can be
resumed.
• Serial radiographs to ensure the reduction, joint congruity and healing are
maintained (eg repeat radiographs immediately after reduction, at 48 hours, at 7
days, and then at two -weekly intervals).
• Consider operative treatment if the fracture fails to heal or displaces.
• One audit found that some stable fractures may be more effectively treated in
a functional brace than a cast, and do not need further X -rays.

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Complications
 Infection.
 Compartment syndrome .
 Vascular compromise and foot ischaemia .
 Deep vein thrombosis (secondary to immobilisation).
 Fracture non -union and malunion.
 Poor wound healing.[7]
 Osteoarthritis (especially talus fractures).
 Reduced movement at the ankle (calcaneal fractures can compromise
inversion and eversion).
 Ankle fractures involving the growth plate in children can lead to deformity
and growth disturbance.

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MATERIALS AND METHODS

Sixty patients with fractures of the ankle treated hospital, were included in the
study. Patients admitted to the hospital were in the age group 20 yrs to 75 yrs and
the sex distribution was 42 males and 18 females.
Exclusion criteria:
1.Patients with open fracture dislocations of the ankle 2.Patients with epiphysis
ankle fractures
3.Patients with bilateral anklefractures 4.Cases with Pilon fractures
Patients operated at hospital, with a minimum period of 6 months follow up were
included in the study.
The patients were examined in the casualty and in the out patient department.
History was recorded and a thorough clinical evaluation was done. Patients were
stabilized haemodynamically and were administered adequate analgesia. Analgesics
administered were Inj Tramazac, Inj Diclofenac or Inj Pentazocine. Patients were
put on a below knee splintage either with a malleable splint or a plaster or Paris
posterior slab. Radiologic investigations were done with anteroposterior and lateral
views of the ankle.
The fractures were classified according to the Lauge -Hansen and Weber’s
classifications and graded as per Kristensons criteria. There were 12 cases of
Supination -Adduction injury, 24 cases of Supination – External rotation injury, 2
cases of Pronation – Abduct ion injury, 20 case of Pronation – External rotation
injury and 2 cases of Pronation – Dorsiflexion injury.
There were 6 cases of type A, 32 cases of type B and 22 cases of type C Weber
injury.
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Following the radiological evaluation, patients were brie fed regarding the need for
operative treatment and were investigated with routine investigations for the
surgical procedure. Patients with co -morbid medical illnesses were treated
appropriately with the help of general Physicians. Evaluation by anesthesiol ogists
was done. Consent for the surgical procedure was obtained. Antibiotics were
administered at the time of induction of anesthesia. The antibiotics used were either
a first or second generation Cephalosporin’s.

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Surgical procedure:

General anesthesia was administered to 35 patients and Spinal anesthesia for 25
patients. The patient was placed in supine position with a sand bag under the
ipsilateral buttock in cases of lateral malleolar fracture. Following exsanguinations,
tourniquet was inflated with time being noted. The affected limb was prepared with
a primary scrub with Betadine. The parts were then painted with Betadine and
Spirit. Surgical draping was done using the standard methods and the foot was
covered with a hand towel or a glove.
The operative approach for the fixation of the lateral malleolus was done as per the
standard approaches, depending on the mode of fixation planned. The lateral
malleolar fracture was exposed first. Lateral malleolar fixation was done in 60
cases.
Medial malleolus was approached according to the mode of fixation planned using
the standard approaches. Fixation was done in 60 patients. Posterior malleolar
fracture was noted in 11 cases. The posterior malleolar fracture was not fixed in any
of the cas es as there was anatomical reduction of the fragment.
48 patients were operated within first day of the injury. 11 patients were operated
between two and five days because of uncontrolled Diabetes and due to fracture
blisters. Two patient was operated 10 d ays later due to unsatisfactory skin condition
and fracture blisters.
All the patients were operated under tourniquet control. The duration of surgery
varied from 30 mins to 1 hour and 30 minutes averaging 1 hour
The implants used for the fixation of fract ures were as follows:
The medial malleolus was fixed with Malleolar screws in 54 cases of which six
were single screw. Tension band wiring was done in 6 cases.
The lateral malleolus was fixed with Semi tubular plate in 10,
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One third tubular plate in 26, Tension band wire in 6, Dynamic compression plate in
10, Rush pins in 2 and K -wire in 6 cases.

Syndesmotic screw was used in 16 cases:
The wound was washed with normal saline, drain tubes were placed and
subcutaneous sutures applied using 2 -0 Vicry l. Skin was closed with staples.
Dressing was done with adequate padding and a below knee plaster of Paris slab
was applied.
Patients were administered adequate analgesics. Antibiotics were administered for
72 hours postoperatively. The foot was kept eleva ted over pillows. Radiological
evaluation was done in the postoperative period which included both
Anteroposterior and Lateral views. These

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were graded as per the Kristensons criteria. Drain tube was removed on the second
post operative day. Patient was mobilized on the first post operative day, non
weight bearing on the affected leg with the help of walker or auxiliary crutches.
Patients were discharged on the fifth day on an average. Staples were removed at
follow up in the out patient clinic at the end of two weeks. Patients were advised to
continue non weight bearing ambulation with a walker or axillary crutches for a
period of six weeks. H owever in patients who had other associated injuries,
ambulation was delayed or mobilized on a wheelchair.
The Plaster slab or cast was removed at the end of 6 weeks. Check x rays were done
at six weeks. Presence of callus and status of the joint was noted . The patients were
started on active ankle mobilization. Patients with syndesmotic screw fixation were
admitted on a day care basis and the syndesmotic screw was removed. Partial
weight bearing was stared with support. Weight bearing was decided on the ba sis of
the X -ray picture. Patients were followed up at 3 months and 6 months.
The patients were evaluated as per the rating of the Weber’s criteria which included
objective criteria, subjective criteria and Radiological evaluation. These were
graded into g ood, fair and poor categories.
The objective criteria included the movements of the ankle joint and subtalar joint
function together which was deemed good when the rating was 0 -1, fair when the
rating was between 2 -4 and poor when it was 5 and above.
The s ubjective criteria involved the rating of pain, walking and return to activity.
Theses were graded as good when the rating was 0 -2, fair when it was between 3 -6
and poor when it was above 6.
The radiological rating was good when it was 0, fair when it was 1-2 and poor when
it was 3 and above.
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The removal of implants was done after the union of the fracture at patient’s
convenience at an average period of 1 year.

POST INJURY

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13

MEDIAL APPROACH AND FRACTURE SITE EXPOSED

LATERAL APPROACH AND FRACTURE SITE EXPOSED

19

14

IMAGE INTENSIFIER PICTURE

POST OPERATIVE SPLINTING IN SLAB

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15

OBSERVATIONS AND RESULTS

This study was done on patients admitted at hospital , who were surgically managed and internal
fixation was done for fracture fixation. This study was done on patients admitted between 2005
March and 2007 September.

Table 1: – Table depicting sex incidenc e in different age groups
Age in Years No of patients % Male % Female %

21-30 30 50% 28 66.6% 2 11.1%

31-40 10 16.6% 6 14.2% 4 22.2%

41-50 8 13.3% 6 14.2% 2 11.1%

51-60 6 10% 0 0 6 33.3%

61-more 6 10% 2 4.76% 4 22.2%

Total 60 42 18

Fig 1: – Bar diagram of age and sex incidence

70.00%

60.00%

50.00%

40.00%
Male

30.00%

Female

20.00%

10.00%

0.00%

21-30 31-40 41-50 51-60 >61

Maximum number of patients in our study ranged between 21 -30 years and males were
predominant.

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Mechanism of injury as per Lauge Hansen classification:
Table 2: – Depicting incidence of fractures depending on the mechanism of injury

Type No of Patients %

Supination Adduction 12 20%

Supination External rotation 24 40%

Pronation Abduction 2 3.3%

Pronation External rotation 20 33.3%

Pronation Dorsiflexion 2 3.3%

Fig 2: – Bar diagram of the mechanism of injury and incidence

50%

40%

30%

20%
NOP

10%

0%

SAD SER PAB PER PDF

Supination – External rotation injury was the most common mechanism of injury in our study as
per Lauge – Hansen’s classification comp rising upto 40% of the total number.

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Type of fracture as per Weber classification:
Table 3: – Depicts radiological types depending on Weber’s classification
Type of fracture No of Patients %

Type A 6 10%

Type B 32 53.7%

Type C 22 36.6%

Fig 3: – Pie diagram showing the types of fractures based on Weber’s classification

Type A
Type B
Type C

Weber type B fracture were the commonest type in our study comprising 36.6% of patients.

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Side of ankle fracture:

Table 4: – Shows the side of involvement of fractures
Side No of Patients %

Right 34 56.6%

Left 26 43.3%

Fig 4: – Bar diagram showing the side of involvement

60.00%

40.00%
NOP
20.00%

0.00%
Right Left

Right sided fractures were more predominant than the left side in our study comprising 56.6%

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Causes of injury:

Table 5: – Different causes of injury and their incidence

Causes of injury No of Patients %

Road traffice accident 32 53.3%

Domestic slipping & twisting 20 33.3%

Sports 8 13.3%

Others 0 0

Fig 5: – Bar diagram showing different causes of injury

100%
80%
60%
40%
20%

NOP

0%
RTA DNT SPORTS OTHERS

Road traffic accidents followed by domestic injuries were the most common cause of injury in our
study

Associated injuries and the co -morbidities noted were two cases each with fracture of the radius,
head injury, Two cases with fracture blisters, and one case fracture of humerus, fracture of shaft
of femur and fracture of 5th metatarsal.
Twelve cases were having diabetes mellitus and four with hypertension.

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Pre operative Kristenson’s radiological criteria:

Table 6: – Depicts pre operative radiological grading of fractures
Kristenson’s grade No of Patients %

Poor 22 36.6%

Fair 34 56.6%

Good 4 6.8%

Fig 6: – Bar diagram showing radiological grading of fractures

60.00%
40.00%
20.00%
0.00%

NOP
NOP
POOR
FAIR
GOOD

Radiologically 56.6% patients were in the fair group according to Kristensons’s radiological
criteria pre -operatively.

Post operative kristenson’ s radiological criteria:
Table 7: – Depicts post operative radiological grading

Kristenson’s Criteria No of Patients %

Poor 0 0%

Fair 20 33.4%

Good 40 66.6%

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21

80%

60%

40%

20%
NOP

0%

POOR
NOP

FAIR

GOOD

Kristenson’s grading

Post operatively all the patients were evaluated as per Kristenson’s criteria and the results were as
shown above 66.6% of patients had good results, 33.3% had fair results and none had poor results.

The cases after discharge were followed up at two weeks, six weeks, three months and six
months and at the end of one year regularly. The minimum period of follow up was six months
and maximum was thirty months. The average time for fracture union was six months.

The complications encountered were delayed wound healing and dehiscence in 6 patients. The
wounds of four patients healed at three weeks with regular dressings. 2 patients required split skin
grafting due to skin necrosis. Those who required SSG were the ones who had fracture
dislocation.

One patient with DCP fixation of the fibula was noted to have a long screw with intra-articular
extension. It was replaced at six weeks with a shorter screw before range of motion exercises of
the ankle was instituted.

One case had a discharge from the incision site over the medial malleolus after one month which
showed no evidence of deep infection. The wound healed over a time of 1 month without any
further complications.
No cases of degenerative arthritis and no cases of malunion were noted.

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Final outcome of the study as per Weber’s criteria:
Table 8: – Depicts the percentage of the results based on Weber’s criteria
GOOD GOOD FAIR FAIR POOR POOR

SUBJECTIVE 30 50% 24 40% 6 10%

OBJECTIVE 32 53.3% 26 43.3% 12 3.4%

RADIOLOGICAL 40 66.6% 16 26.6% 4 6.8%

100%
80%
60%
40%
20%

SUBJECTIVE
OBJECTIVE
RADIOLOGICAL

0%
GOOD FAIR POOR

Weber’s grades

All the patients who had good results returned to normal activity and had regained their full
ankle movements by the end of three months.

Those patients with fair results complained of swelling which was noticed towards the end of the
day and would respond to rest. Associated pain was related to activity.

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23

DISCUSSION

The fractures of the ankle are injuries se en in the young and middle aged patients
commonly. The mean age in our series was noted to be 36 yrs with a male predominance of
66.6%

Table 9: – Sex distribution in various studies

Study No of Patients Male:Female %males

Roberts SR 25 11:14 44

Beris et al 144 56:88 38.8

Present study 60 42:18 66.6

Sex distribution in our study showed a male preponderance compared to other studies.

Table 10: – Mean age distribution in various studies.

Study No of Patients Mean age

Roberts SR 25 40

Beris et al 144 30

Liestal 108 41

Present study 60 36

Mean age in our study was comparable to other studies.
Weber’s Type B fractures consisted of 53.7%

Table 11: – Weber’s type of injury:

Study No of Patients Type %

Liestal 108 Type B 64.8

Freibrug 100 Type B 60

St. Gallen 130 Type C 47.7

Present Study 60 Type B 53.7

The findings were similar to those of Leistal and Freibrug.

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The most common mechanism of injury was Supination -external rotation injury with 40%
incidence.
Table 12: – Mechanism of injury
Study No of Patients Most Common type Percentage

Roberts S R 25 Supination external rotation 34

Beris et al 144 Supination external rotation 45

Present Study 60 Supination external rotation 40

The findings were similar to observations of Roberts S R, Beris et al.

In this study, right ankle was more affected i.e., 34 Patients (56.6%)
Table 13: – Side affected
Study No of Patients Right Left

Roberts S R 25 14 (56%) 11 (44%)

Beris et al 144 73 (50.6%) 71(49.3%)

Present Study 60 34 (56.6%) 26 (43.3%)

The findings were similar to observations of Roberts S R, Beris et al.

Table 14: – Mode of injury
The commonest mode of injury was Road traffic accident. The findings were similar to
observations of Lee at el.

Study No of Patients Commonest mode

Baird et al 24 (15) Fall from height

Lee et al 168 (98) Road traffic accident

Present Study 60 (32) Road traffic accident

There was a wide spectrum of co -morbidities in these patients. 36.6% of the pa tients had
poor, 56.6% had fair and 6.8% had good Kristenson’s radiological criteria preoperatively. Post
operatively 66.6% of patients achieved good results and 33.4% achieved fair results.

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In the final score as per Weber’s 39,96 criteria, the objective signs and subjective symptoms
were noted and compared with the radiological criteria. All the comparisons were made once the
fractures united and at later follow ups. The results of the treatment is as shown in table 8.

The results of other studies were compared with our final outcome. This was divided into
2 groups of excellent and poor results in each of the fracture types. The results when compared
showed a comparable result as shown below

Study Excellent Poor

St Gallen84 A-78.2%, B-75.6%, A-21.8%, B-24.4%, 130 Cases with 67.5
C-77.4% C-22.6% months follow -up

Freibrug Series30 A-82.4%, B-83.4%, A-17.6%, B-16.6%, 105 Cases with 2 -7
C-85.3% C-14.7% years follow -up

Liestal Series56 A-82.7%, B-78.7%, A-17.3%, B-21.3%, 213 Cases with 4 -12
C-61.8% C-38.2% years follow -up

Our Study A-83.3%, B-87.5%, A-16.7%, B-12.5%, 60 Cases with 6 -30
C-86.5% C-13.6% months follow -up

Table 15: –

The number of complications noted were eleven in ten patients, the most common complication
being delayed wound healing in six cases. This was more common in the old aged and more often
in patients with diabetes mellitus. No major infections or malunion wa s noted.

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Comparison of complications with other studies:
Table 16: –
Study Eugene27 Beauchamp6 et al Our Study

Major infection 12% 8% 0%

Failed reduction 4.9% 0% 0%

Minor infection 9% 9% 10%

Failed reduction 4.2% 0% 0%

Miscellaneous 1% 4.5% 3.4%

Total 31.1% 21.4% 13.4%

The present study suggests anatomical reduction of the fracture and restoration of the joint
congruity of the ankle at the earliest.

The post operative immobilization in a plaster slab or a cast upto six weeks does not affect the
final outcome with respect to achieveing the ankle and subtalar range of movements as most of
the patients had achieved full range of motion at the end of 12 w eeks.

The factors that affected the final poor outcome were the presence of long standing and
uncontrolled Diabetes and old age, which was seen in four cases of which one had a neuropathic
foot.

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ANALYSIS
 60 patients were included in this study with closed ankle fractures that were
surgically treated by various surgeons with various 
techniques of internal fixation. 
 The classifications, review of literature, methods of investigations and
management have been enumerated. 
 The study had a male preponderance of 66.6% with road traffic accidents being
the major cause of injury.  
 Supination external rotation was the most common mechanism of injury and 
Weber’s type B fractures were the most common type of fracture. 
 The associated fractures and injuries noted and the co -morbidities seen in these
patients have been enumerated. 
 Open reduction and intern al fixation under image intensifier control was done in
all patients. Post operatively patients were immobilized with a plaster splint for a 
period of six weeks and were followed up with full weight bearing walking and
active range of movement of ankle e xercises. 
 The final outcome as per the Weber’s 39,96 radiological criteria was 66.6% good,
26.6% fair and 6.8% poor result which showed good correlation between the 
immediate pos t operative radiological score and the final radiological outcome.
Objective and subjective findings were also comparable. 

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CONCLUSION

1) The fractures of the ankle are commonly se en in the young adult male
population with

Road traffic accidents and twisting injuries being the common causes.

2) Right side ankles were commonly involved than the left side.

3) Weber type B was the commonest type of fracture. Supination externa l
rotation injury was the most common mechanism of injury.

4) During surgery, the soft tissues dissection was kept minimal to avoid further
vascular compromise in an already tense, swollen ankle.

5) In the post operative period, splintage of the ankle and precaution to prevent
swelling of the ankle is necessary. The swelling may lead to delayed wound
healing. Patients are ambulated with crutches or walker without bearing weight on
the injured limb from the first post operative day if there are no associ ated injuries
and can be discharged from the hospital by the first week.
34
6) Most of the fractures in the study were fixed within 24 hours which however
did not change the final outcome, though other studies have stressed upon fixation
within 8 hour s of injury. The complications that arose were in those where the
fractures were fixed after 24 hours which were delayed wound healing and

superficial infections of the wound which mostly healed with regular wound care.

7) The six week period of immobili zation did not affect the final range of ankle
function as most patients had achieved full range of motion by the end of 12 weeks
postoperatively with active exercise regimen.

8) The result of this study in comparison with other studies as enumerated
shows similar findings with respect to the functional outcome following surgical
stabilization of bimalleolar fractures. The rarity of complications in comparison to
other studies may be due to a small number of patients and a very short period of
follow up.
9) the study used Lauge Hansen’s classification for mechanism of injury and
Weber’S
classification for radiological classification. recommend use of Weber’S
classification for
management which is easier for classification and radiological assessment.

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