Managing acute ankle injuries

A recent presentation that was available at the EFORT meeting in Barcelona highlighted the importance of the medial and posteromedial structures in the ankle. Dr. Minatore has always been a proponent of appropriate management of acute ankle injuries. Unfortunately, many ankle injuries are either over treated or more significantly undertreated. The significance of the medial structures in particularly the posteromedial complex has escaped the attention of many observers leading to poor non-surgical outcomes in a number of patients. In addition, it is becoming increasingly apparent that management of acute ankle fractures requires specialists undertaking.

The presentation in the EFORT meeting in Barcelona passed particular attention upon the importance of the syndesmotic ligaments and in particular of the posterior malleolar fragments. This fragment often contains the insertion of the posterior syndesmotic ligament and, thus, is a particularly important stabilizing structure. I have, for many years, emphasized the importance of an internal fixed solution of these types of fractures.

In the study that was presented and in the very professional dissertation that was provided by the speaker, attention was turned to the fact that all complex fractures should undergo CT scanning, that the posterior malleolar fragments should be internally fixed, and that particular attention should be given to syndesmotic injuries. Whilst we have in the past been concerned in relation to lateral malleolar fractures and their instability, the real question seems to hover in relation to the medial structures and posteromedial corner.

Thus, ankle fractures require specialists internal fixation and management. Management such as arthroscopic evaluation of the join has proven, in my hands, to be very successful.

It is not sufficient for the junior staff members to internally fix these fractures without supervision. Unfortunately, many of these fractures are managed in the public hospital system some without supervision and some in particular without follow up by a specialist orthopaedic surgeon. I see many patients who come to see me for a second opinion after a failure of treatment. Quite commonly this relates to poor surgical management, but in some cases, it also relates to poor post operative supervision.