Intramedullary nailing of lateral malleolus in ankle fractures - surgical technique and literature review

Our objective is to describe the technique of intramedullary (IM) nailing of lateral malleolus in the surgical management of ankle fractures. Fracture reduction is performed either percutaneously with a small pointed reduction clamp in simple oblique fractures or using longitudinal traction and rotation for comminuted fractures, thus reducing complications related to open reduction and internal fixation with a plate. The technique has been shown to be simple and reproducible. In addition, the technique allows early weight bearing, which accelerates rehabilitation and potentially fasten fracture healing. IM nailing is a viable option for the fixation of the of lateral malleolus in ankle fractures and should be considered in the surgeon’s armamentarium.

Keywords:
Ankle fracture; Fracture fixation, Intramedullary; Fracture fixation; Fibula

Authorship

Vincenzo Giordano Mailing address: Vincenzo Giordano. E-mail: v_giordano@me.com

Hospital Municipal Miguel Couto, Serviço de Ortopedia e Traumatologia Prof. Nova Monteiro - Rio de Janeiro - RJ - Brasil.Hospital Municipal Miguel Couto, Serviço de Ortopedia e Traumatologia Prof. Nova Monteiro - Rio de Janeiro - RJ - Brasil.Hospital Municipal Miguel Couto, Serviço de Ortopedia e Traumatologia Prof. Nova Monteiro - Rio de Janeiro - RJ - Brasil.

https://orcid.org/0000-0002-4429-312X

Peter V Giannoudis

School of Medicine, University of Leeds, Academic Department of Trauma & Orthopaedic Surgery - Leeds - Leeds - Reino Unido.School of Medicine, University of Leeds, Academic Department of Trauma & Orthopaedic Surgery - Leeds - Leeds - Reino Unido.School of Medicine, University of Leeds, Academic Department of Trauma & Orthopaedic Surgery - Leeds - Leeds - Reino Unido.

Guilherme Boni

UNIFESP - Escola Paulista de Medicina (EPM), Departmento de Ortopedia e Traumatologia - São Paulo - SP - Brasil.UNIFESP - Escola Paulista de Medicina (EPM), Departmento de Ortopedia e Traumatologia - São Paulo - SP - Brasil.UNIFESP - Escola Paulista de Medicina (EPM), Departmento de Ortopedia e Traumatologia - São Paulo - SP - Brasil.

Robinson Esteves Pires

Universidade Federal de Minas Gerais (UFMG), Departamento de Ortopedia - Belo Horizonte - MG - Brasil.Universidade Federal de Minas Gerais (UFMG), Departamento de Ortopedia - Belo Horizonte - MG - Brasil.Universidade Federal de Minas Gerais (UFMG), Departamento de Ortopedia - Belo Horizonte - MG - Brasil.

Junji Miller Fukuyama

Hospital Geral Vila Penteado, Serviço de Ortopedia e Traumatologia - São Paulo - SP - Brasil.Hospital Geral Vila Penteado, Serviço de Ortopedia e Traumatologia - São Paulo - SP - Brasil.Hospital Geral Vila Penteado, Serviço de Ortopedia e Traumatologia - São Paulo - SP - Brasil.

Alexandre Leme Godoy-Santos

Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (USP), Instituto de Ortopedia e Traumatologia (IOT) - São Paulo - SP - Brasil.Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (USP), Instituto de Ortopedia e Traumatologia (IOT) - São Paulo - SP - Brasil.Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo (USP), Instituto de Ortopedia e Traumatologia (IOT) - São Paulo - SP - Brasil.

Hilton Augusto Koch

Universidade Federal do Rio de Janeiro (UFRJ), Departamento de Radiologia - Rio de Janeiro - RJ - Brasil.Universidade Federal do Rio de Janeiro (UFRJ), Departamento de Radiologia - Rio de Janeiro - RJ - Brasil.Universidade Federal do Rio de Janeiro (UFRJ), Departamento de Radiologia - Rio de Janeiro - RJ - Brasil.

Mailing address: Vincenzo Giordano. E-mail: v_giordano@me.com

Conflict of interest: None

SCIMAGO INSTITUTIONS RANKINGS

Figures

Figures (6)

Thumbnail

Figure 1
Positioning of the patient is defined based on the necessity to approach or not the posterior malleolus fracture of the distal tibia. If fixation of the posterior malleolus is indicated, patient is positioned in lateral decubitus with uninjured leg resting on the operating table.

Thumbnail

Figure 2
In simple fracture patterns, the skin is marked, and a pointed reduction clamp applied to percutaneously reduce the fracture.

Thumbnail

Figure 3
A, Entry point is marked with a scalpel, then the bone is opened using a curved awl, which is advanced into the medullary canal. B, Slightly invert the subtalar joint to facilitate defining the correct entry point.

Thumbnail

Figure 4
A and B, IM canal is gradually reamed with sequential flexible reamers while holding the reduction. C, Then the nail is inserted using the targeting guide. D, The final position of the nail is confirmed with a 1.6-mm K-wire introduced through the targeting guide end nail hole using the C-arm. Nail should be completely inside the fibula, thus avoiding local soft tissue irritation.

Thumbnail

Figure 5
The targeting guide is rotated approximately 25º posteriorly and both distal locking screws and syndesmotic screws are inserted. A screw just proximal to the tip of the nail should be used in suprasyndesmotic (Weber type C) and some transyndesmotic fractures (Weber type B) to avoid proximal migration of the nail and consequent fracture collapse.

Thumbnail

Figure 6
A, Before closure, anatomical reduction / alignment of the distal fibula and correct position and size of the locking screws are checked with the C-arm. In addition, syndesmosis reduction and tibiotalar joint congruency are confirmed using the existing radiographic parameters. B, Final X-rays are done before patient leaves the OR.

Figure 1 Positioning of the patient is defined based on the necessity to approach or not the posterior malleolus fracture of the distal tibia. If fixation of the posterior malleolus is indicated, patient is positioned in lateral decubitus with uninjured leg resting on the operating table.

Figure 2 In simple fracture patterns, the skin is marked, and a pointed reduction clamp applied to percutaneously reduce the fracture.

Figure 3 A, Entry point is marked with a scalpel, then the bone is opened using a curved awl, which is advanced into the medullary canal. B, Slightly invert the subtalar joint to facilitate defining the correct entry point.

Figure 4 A and B, IM canal is gradually reamed with sequential flexible reamers while holding the reduction. C, Then the nail is inserted using the targeting guide. D, The final position of the nail is confirmed with a 1.6-mm K-wire introduced through the targeting guide end nail hole using the C-arm. Nail should be completely inside the fibula, thus avoiding local soft tissue irritation.

Figure 5 The targeting guide is rotated approximately 25º posteriorly and both distal locking screws and syndesmotic screws are inserted. A screw just proximal to the tip of the nail should be used in suprasyndesmotic (Weber type C) and some transyndesmotic fractures (Weber type B) to avoid proximal migration of the nail and consequent fracture collapse.

Figure 6 A, Before closure, anatomical reduction / alignment of the distal fibula and correct position and size of the locking screws are checked with the C-arm. In addition, syndesmosis reduction and tibiotalar joint congruency are confirmed using the existing radiographic parameters. B, Final X-rays are done before patient leaves the OR.

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Intramedullary nailing of lateral malleolus in ankle fractures - surgical technique and literature review

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[1] Mailing address: Vincenzo Giordano. E-mail: v_giordano@me.com