Operation for fracture of the lateral malleolus
In unstable or displaced fractures of the Weber B and C types, in which the ligamentous apparatus of the ankle has very probably or certainly also been injured, as well as in so-called open fractures, in which one or more of the fragments protrude through the skin to the outside, surgical treatment of the external ankle fracture is absolutely necessary. Fractures that are associated with vascular or nerve injuries or that cannot be straightened out by hand are also good reasons for surgical intervention. The same applies to external ankle injuries with considerable soft tissue damage, i.e. bruising or tearing of the muscles and/or subcutaneous fatty tissue in the affected area.
The surgical treatment of an external ankle fracture can be carried out under general anaesthesia, but regional anaesthesia procedures or so-called nerve blocks or spinal anaesthesia are also possible in principle. The individual decision for or against a certain procedure is made by the patient together with an anaesthetist, according to his personal risk profile and preference. The operation should then serve to reposition and fix the fragments.
The ligamentous apparatus and surrounding structures can also be precisely restored. The anatomically correct reconstruction of the bone is achieved with the help of so-called screw and/or plate osteosyntheses. This is understood to mean the bringing together and fixing of different fragments with the aid of screws or small metal plates.
The main purpose of these plates is to permanently fix the bone or bone fragments in a certain position. The screws fix the plate to the bone or two pieces of bone together. A precise fit of the fragments and firm compression are crucial for a good and rapid healing process.
For more complex external ankle fractures or patients suffering from osteoporosis, so-called stable-angle plates are recommended. The special interlocking of the fixing screws within the plate prevents the fixation from tilting after the surgical procedure. During the course of the operation, the surgeon also examines and checks the ligamentous apparatus of the entire ankle – especially the so-called syndesmosis, in order to be able to safely exclude a possible joint injury.
If necessary, sutures or other fixation may also be necessary here. In any case, the surgical team will of course also treat other injuries in the area of the fracture. Damaged nerves are sutured as well as blood vessels that may have been torn.
In the case of large crush injuries or large skin wounds, this area must also be reconstructed in order to guarantee the patient an appropriate visual result. Once all structures are aligned and fixed, the surgeon checks the stability of the ankle once again. This is done on the one hand by manual examination, because the treating physician usually has a lot of experience with corresponding injuries and can assess displacements well, and on the other hand with the help of special tests under X-ray control.
If the ankle is still unstable despite fixation of the fracture, a so-called set screw is inserted in the last step of the operation. This screw connects the two bones of the lower leg (tibia and fibula) just above the ankle and keeps them at an optimal distance. Through this additional screw connection, the fractured outer ankle is additionally stabilized.
However, this does not have to be necessary in every case. Under special circumstances, the operation described above may not be possible temporarily or even permanently. In these exceptional cases, the attending physician will suggest an alternative procedure and discuss this in detail with the patient.
You can read more about surgery for an external ankle fracture here. Surgical treatment of an external ankle fracture is performed immediately as part of emergency surgery in the case of open fractures that pierce the skin, or severe soft tissue damage that puts the skin and surrounding tissue under tension. All other fractures to be operated on should be treated within 6-8 hours after the actual injury, if the swelling permits.
In the case of very severe swelling of the tissue, the reduction of the swelling must first be awaited with decongestant measures as well as so-called thrombosis prophylaxis and antibiotic therapy as required. Afterwards, the treatment described above can follow as a planned operation. This operation is of course not completely free of risks and possible complications.
Often a haematoma, i.e. a bruise, occurs in the area of the operation wound. Sometimes a death of some skin and tissue parts can be observed, a so-called wound necrosis. As infections of the ankle or leg occur in about 2% of cases after the operation, regular check-ups by a doctor are necessary.
By observing and feeling the area of the operation, swelling and possible inflammation are assessed. In addition, several x-ray checks are carried out to verify the correct fit of the osteosyntheses and to detect any subsequent slippage at an early stage. According to the surgeon’s instructions, a dosed loading of the operated ankle can be started relatively early.
The load is slowly built up with the help of a physiotherapist. As a rule, full weight-bearing is possible after about 6 weeks. However, if an adjusting screw has been inserted, it must be removed before the start of weight-bearing.
In most cases this happens after about 6 – 8 weeks. Only after this time are training, gait training and other physiotherapeutic measures possible. Other screws and/or plates that have been placed for fixation can also be removed after the final bone healing is complete, if the patient so desires.
This may be the case, for example, if older osteosyntheses are painful or restrict the range of motion. However, there is of course also the risk of a new operation and the risk of another fracture due to the removal of the implants.