Open reduction of fractures and dislocations of the ankle

If anatomical reduction of closed fractures and dislocations of the ankle region of the adult cannot be achieved and maintained by closed technics, open reduction and fixation by a combination of internal and external means may delay the onset of disabling symptoms of post-traumatic arthritis. A concise and practicable classification of these osseoligamentous injuries is difficult because of the variety of combinations. A basic understanding of the functional anatomy of the ankle region coupled with careful physical and roentgenographic examinations permit correlation of the direction and magnitude of maximal spatial displacement of the astragalus in reference to the tibia with the extent and type of osseoligamentous injury. Accurate preoperative diagnosis is essential in order to plan surgical approaches and methods of fixation. Five basic paramelleolar approaches provide access to all aspects of the ankle joint and serve adequately for open reduction and internal fixation of the major proportion of closed fractures and dislocations. Attention to anatomical details prevents injury to major vessels and nerves. A thorough knowledge of the general principles of internal fixation of fractures and meticulous attention to details of technic are of greater importance in rendering successful treatment than the use of elaborate fixation apparatus. Technics of internal fixation of common fractures and repair of ligamentous lesions are discussed and illustrated. Some complications can be avoided by awaiting restoration of bony continuity and sound ligamentous healing before unsupported weight bearing is initiated. Factors other than anatomical restoration have significant influence in the prevention of certain sequelae, such as symptomatic postraumatic arthritis. Open reduction is hazardous and should be reserved for those patients in whom more conservative measures are likely to fail.