Temporary Cast Application in Dislocated Ankle Fractures Leads to High Rates of Secondary Loss of Reduction: Does the Lauge-Hansen Injury Type Matter?

BACKGROUND: For the temporary treatment of ankle fracture dislocations (AFDs), previous studies indicate higher rates of secondary loss of reduction (LOR) with splint immobilization, prompting consideration for expanding indications for external fixation (ExFix). However, these studies did not investigate the influence of fracture morphology to further improve patient selection. The aim of this study was to investigate the influence of Lauge-Hansen injury type on the LOR rate in bimalleolar or trimalleolar AFDs for temporary cast vs ExFix immobilization. METHODS: In this retrospective cohort study, patients with isolated AFD cases treated at our institution from 2011 to 2020 were reviewed. Inclusion criteria required radiographs depicting initial dislocation and appropriate reduction after Cast or ExFix immobilization. Exclusion criteria encompassed concomitant injuries, open fractures, conservative management as well as surgery performed within 48 hours or at a different facility. Patients were grouped by temporary treatment (Cast or ExFix). The primary endpoint was LOR prior to definitive surgery across various Lauge-Hansen types. RESULTS: The LOR rate was significantly higher in the cast group (40/152, 26.3%) compared to the ExFix group (5/191, 2.6%; P < .0001). In the cast group, LOR was associated with an increase in time to definitive surgery by a mean of 3 days (P < .002). During cast treatment, LOR was significantly more likely for pronation abduction (P = .001) and supination external rotation injuries (P < .0001), whereas no significant differences were observed for pronation external rotation (P = .006), supination adduction (P > .99), and fractures not classifiable (P > .99). CONCLUSION: In cases of AFDs resulting from supination external rotation or pronation abduction trauma according to the Lauge-Hansen classification, especially in the setting of an additional posterior malleolar fracture, primary application of external fixation should be considered to reduce the risk for secondary loss of reduction. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Prevalence and associated factors of intra-articular lesions in acute ankle fractures evaluated by arthroscopy and clinical outcomes with minimum 24-month follow-up.

BACKGROUND: Acute ankle fractures can lead to high rate of concomitant intra-articular lesions which may compromise clinical results. The purpose of this study was to evaluate the incidence of concomitant intra-articular lesions in acute ankle fractures with arthroscopy. We also sought to analyze the relationship between intra-articular lesions and the fracture type, as well as the severity of the fracture. METHODS: It was a retrospective cohort study. From April 2014 to December 2015, we have chosen arthroscopy-assisted open reduction and internal fixation (AORIF) for the treatment of unstable acute ankle fractures. All concomitant intra-articular lesions were assessed and documented carefully and prospectively, such as ligament injuries, osteochondral lesions, and tibiofibular syndesmosis injuries. All fractures were classified according to the Lauge-Hansen classification system. The American Orthopedic Foot and Ankle Society's (AOFAS) ankle-hindfoot scale was used to assess post-operative function. Statistical comparisons between the intra-articular lesions, the fracture type, and the severity of the presenting fracture were performed using a Chi-squared analysis. RESULTS: Data of 36 patients were analyzed in the study, including 23 supination-type fractures and 13 pronation-type fractures. The incidence of tibiofibular syndesmosis injuries, chondral lesions, and loose bodies were 92%, 72%, and 39%, respectively. Avulsion fractures of the anterior tibiofibular syndesmosis were more commonly found in supination-type fractures than pronation-type fracture (45% vs. 15%, χ = 5.78, P = 0.02), which would cause mechanical blocking in the anterior portion of the ankle. On the contrary, chondral lesions were more commonly found in the more severe fractures than mild fractures (86% vs. 53%, χ = 4.57, P = 0.03). A mean 41.7 months (range, 33.0-51.0 months) of follow-up was achieved. A mean AOFAS's ankle-hindfoot scale was 96.9, and 97.2% of the patients were satisfied with the procedure. CONCLUSIONS: Acute ankle fractures have a high incidence of concomitant intra-articular lesions. Avulsion fractures of the anterior tibiofibular syndesmosis are more commonly found in supination-type fractures. Chondral lesions are related to the severity of the fractures, but not with the classification of the fractures. AORIF can be one reliable solution in dealing with the associated injuries seen with acute ankle fractures.

Reproducibility of the stability-based classification for ankle fractures.

BACKGROUND: Classification of ankle fracture is important when deciding for operative or conservative treatment. This study rates the reproducibility of ankle stability assessment and compares it with the classification by Lauge-Hansen and Arbeitsgemeinschaft für Osteosyntesefragen (AO) in adult patients with primary ankle fractures. METHODS: A total of 496 consecutive ankle fractures were included, and the X-ray images were reviewed 2 times by 2 medical students, 2 residents, and 1 consultant in orthopedic traumatology. The raters were blinded to each other and to their own results. Unweighted Kappa statistics were used to assess reproducibility. RESULTS: Overall mean (95% CI) interrater Kappa results were 0.65 (0.64; 0.68) for Lauge-Hansen, 0.62 (0.60; 0.63) for AO and 0.61 (0.57; 0.62) for the stability assessment. The intrarater results ranged from a mean Kappa of 0.64-0.80 for the medical students, 0.65-0.81 for the residents and 0.82-0.84 for the consultant. CONCLUSION: The stability assessment has substantial to almost-perfect agreement which is comparable to the Lauge-Hansen and AO classifications.

Routine Follow-Up Radiographs for Ankle Fractures Seldom Add Value to Clinical Decision-Making: A Retrospective, Observational Study.

Currently, the routine use of radiographs for uncomplicated ankle fractures represents good clinical practice. However, radiographs are associated with waiting time, radiation exposure, and costs. Studies have suggested that radiographs seldom alter the treatment strategy if no clinical indication for the imaging study was present. The objective of the present study was to evaluate the effect of routine radiographs on the treatment strategy during the follow-up period of ankle fractures. All patients aged ≥18 years, who had visited 1 of the participating clinics with an eligible ankle fracture in 2012 and with complete follow-up data were included. The data were retrospectively analyzed. The sociodemographic and clinical characteristics and the number of, and indications for, the radiographs taken were collected from the medical records of the participating clinics. We assessed the changes in treatment strategy according to the radiographic findings. In 528 patients with an ankle fracture, 1174 radiographs were performed during the follow-up period. Of these radiographs, 936 (79.7%) were considered routine. Of the routine radiographs taken during the follow-up period, only 11 (1.2 %) resulted in changes to the treatment strategy. Although it is common practice to take radiographs routinely during the follow-up period for ankle fractures, the results from the present study suggest that routine radiographs seldom alter the treatment strategy. This limited clinical relevance should be weighed against the health care costs and radiation exposure associated with the use of routine radiographs. For a definitive recommendation, however, the results of our study should be confirmed by a prospective trial, which we are currently conducting.

Nonoperative Versus Operative Treatment of Displaced Ankle Fractures in Diabetics.

BACKGROUND: Diabetes is a risk factor for complications related to displaced ankle fractures. Limited literature exists comparing complication rates in nonoperative versus operative treatment of displaced ankle fractures in diabetics. No study has highlighted the natural history of nonoperative treatment of displaced ankle fractures in diabetics. METHODS: We retrospectively reviewed all adult ankle fractures from September 2011 through December 2014. Inclusion was limited to ambulatory adults (>18 years) with closed, displaced (widened mortise) ankle fractures with diabetes mellitus. Nonoperative treatment consisted of closed reduction and casting. Fractures were classified according to the Lauge-Hansen and AO-Weber classification systems. All operative fractures underwent open reduction internal fixation (ORIF) within 3 weeks of injury. Functional outcomes and complication rates were compared. Of 28 displaced diabetic ankle fractures, 20 were treated nonoperatively (closed reduction and casting) and 8 operatively (ORIF within 3 weeks of injury). Mean follow-up was 7 months (range 3-18 months). RESULTS: Age, insulin-dependent diabetes, and AO type B fracture rate were similar in nonoperative and operative cohorts, but fracture dislocation rate was significantly higher among operative fractures (87.5% vs 40%; P = .04). Nonoperative treatment was associated with a 21-fold increased odds of complication compared with operative treatment (75% vs 12.5%, OR 21.0, P = .004). Complication rate following unintended ORIF for persistent nonunion or malunion in nonoperatively treated patients was significantly greater compared with immediate ORIF (100% vs 12.5%, P = .005). CONCLUSION: Nonoperative treatment of displaced diabetic ankle fractures was associated with unacceptably high complication rates when compared to operative treatment. LEVEL OF EVIDENCE: Level III, retrospective comparative series.

[Clinical outcomes Tight rope versus traditional screw fixation for the treatment of injury of distal tibiofibular syndesmosis in ankle fracture].

OBJECTIVE: To compare the clinical effectiveness for Tight rope fixation and traditional screw fixation in treating injury of distal tibiofibular syndesmosis in ankle fractures. METHODS: A retrospective study was carried out in patients with injury of distal syndesmosis in ankle fractures who received 2 surgical operations(observation group: 33 cases with Tight rope fixation; control group: 35 cases with traditional screw fixation) from May 2014 to February 2016. There were 18 males and 15 females, aged from 20 to 55 years old with an average of(32.4±5.2) years old in observation group; of them, 19 cases were caused by traffic accidents, 10 by sprain, and 4 by falling; according to Lauge-Hansen typing of ankle fractures, all of the 33 cases were pronation-extorsion fracture, 12 cases were III degree and 21 cases were IV degree. There were 19 males and 16 females, aged from 21 to 54 years old with an average of (32.8±5.5) years old in control group; of them, 20 cases were caused by traffic accidents, 11 by sprain, 4 by falling; according to Lauge-Hansen typing of ankle fractures, 1 case was with pronation-outreach, 34 cases with pronation-extorsion, 13 cases were III degree and 21 cases were IV degree. Fixation time and complication were compared between two groups and AOFAS scores were observed in two groups 3 and 6 months after the operation as well as final follow-up. RESULTS: All the patients were followed up from 8 to 24 months with an average of (16.3±3.8) months. Fixation time of observation group and control group were (10.1±2.8) min and (9.5±2.3) min(P>0.05) respectively. There were significant difference in complication and AOFAS of 3, 6 months postoperatively between two groups(P<0.05). In observation group, 23 case got excellent result, 9 good, 1 fair; and in control group, 18 cases got excellent results, 12 good, 5 fair; there was no significant difference between two groups(P>0.05). CONCLUSIONS: Tight rope for the treatment of injury of distal tibiofibular ligament union in ankle fractures has advantages such as easier techniques, earlier weight-bearing exercises without risk of screw breakage, thus is a new choice. However, it is still necessary to further study the angle, direction and tension of button steel plate.

Stability-based classification for ankle fracture management and the syndesmosis injury in ankle fractures due to a supination external rotation mechanism of injury.

The aim of this thesis was to confirm the utility of stability-based ankle fracture classification in choosing between non-operative and operative treatment of ankle fractures, to determine how many ankle fractures are amenable to non-operative treatment, to assess the roles of the exploration and anatomical repair of the AITFL in the outcome of patients with SER ankle fractures, to establish the sensitivities, specificities and interobserver reliabilities of the hook and intraoperative stress tests for diagnosing syndesmosis instability in SER ankle fractures, and to determine whether transfixation of unstable syndesmosis is necessary in SER ankle fractures. The utility of stability based fracture classification to choose between non-operative and operative treatment was assessed in a retrospective study (1) of 253 ankle fractures in skeletally mature patients, 160 of whom were included in the study to obtain an epidemiological profile in a population of 130,000. Outcome was assessed after a minimum follow-up of two years. The role of AITFL repairs was assessed in a retrospective study (2) of 288 patients with Lauge-Hansen SE4 ankle fractures; the AITFL was explored and repaired in one group (n=165), and a similar operative method was used but the AITFL was not explored in another group (n=123). Outcome was measured with a minimum follow-up of two years. Interobserver reliability of clinical syndesomosis tests (study 3) and the role of syndesmosis transfixation (study 4) were assessed in a prospective study of 140 patients with Lauge-Hansen SE4 ankle fractures. The stability of the distal tibiofibular joint was evaluated by the hook and ER stress tests. Clinical tests were carried out by the main surgeon and assistant, separately, after which a 7.5-Nm standardized ER stress test for both ankles was performed; if it was positive, the patient was randomized to either syndesmosis transfixation (13 patients) or no fixation (11 patients) treatment groups. The sensitivity and specificity of both clinical tests were calculated using the standard 7.5-Nm external rotation stress test as reference. Outcome was assessed after a minimum of one year of follow-up. Olerud-Molander (OM) scoring system, RAND 36-Item Health Survey, and VAS to measure pain and function were used as outcome measures in all studies. In study 1, 85 (53%) fractures were treated operatively using the stability based fracture classification. Non-operatively treated patients reported less pain and better OM (good or excellent 89% vs. 71%) and VAS functional scores compared to operatively treated patients although they experienced more displacement of the distal fibula (0 mm 30% vs. 69%; 0-2 mm 65% vs. 25%) after treatment. No non-operatively treated patients required operative fracture fixation during follow-up. In study 2, AITFL exploration and suture lead to equal functional outcome (OM mean, 77 vs. 73) to no exploration or fixation. In study 3, the hook test had a sensitivity of 0.25 and a specificity of 0.98. The external rotation stress test had a sensitivity of 0.58 and a specificity of 0.9. Both tests had excellent interobserver reliability; the agreement was 99% for the hook test and 98% for the stress test. There was no statistically significant difference in functional scores (OM mean, 79.6 vs. 83.6) or pain between syndesmosis transfixation and no fixation groups (Study 4). Our results suggest that a simple stability-based fracture classification is useful in choosing between non-operative and operative treatment of ankle fractures; approximately half of the ankle fractures can be treated non-operatively with success. Our observations also suggest that relevant syndesmosis injuries are rare in ankle fractures due to an SER mechanism of injury. According to our research, syndesmotic repair or fixation in SER ankle fracture has no influence on functional outcome or pain after minimum one year compared with no fixation.

Surgical versus nonsurgical treatment of the SE4-equivalent ankle fracture: a retrospective functional outcome study.

Treatment of Lauge-Hansen supination-eversion (SE)4-equivalent ankle fractures is controversial. This retrospective study conducted at a level-I trauma center compared the clinical outcome of nonsurgical vs open management of these fractures. One thousand eight ankle fractures treated between 1998 and 2003 were reviewed. Forty-three patients who met the criteria for a SE4-equivalent ankle fracture were identified. Average patient age of 23 men and 20 women was 42 years (range, 18-84 years). Olerud Molander ankle scores were recorded. Medical records and radiographs of all patients were reviewed. Average follow-up was 20 months.Twenty-six patients were treated nonsurgically, with an average ankle score of 84 ± 4. Seventeen patients treated surgically had an average ankle score of 63 ± 5. The difference is statistically significant (unpaired t test, P=.0035). There was no difference between open vs closed treatment in maintaining a reduction. To investigate the reason for poor results in the surgical group, we sought an association between functional ankle score and common covariables and found that age and preoperative radiographic grading were important variables for ankle score. Patients younger than 30 years had an average ankle score of 85, whereas those older than 50 years had an average score of 61 (P<.001). Type 1 fractures (medial clear space >5 mm in stress view only) had an average ankle score of 89, type 2 (medial clear space >5 mm but <10 mm) an average score of 76, and type 3 (medial clear space >10 mm or presented with fracture dislocation and/or syndesmosis injury) an average score of 61. Our data support that type 1 and 2 fractures can effectively be treated nonsurgically.

Managing type II and type IV Lauge-Hansen supination external rotation ankle fractures: current orthopaedic practice.

INTRODUCTION: Differentiating supination external rotation (SER) type II and IV ankle injuries is challenging in the absence of a medial malleolar fracture or talar shift on radiographs. The accurate differentiation between a stable SER-II from an unstable SER-IV injury would allow implementation of the appropriate management plan from diagnosis. The aim of this study was to ascertain the practice of orthopaedic surgeons in dealing with these injuries. MATERIALS AND METHODS: A postal survey was undertaken on 216 orthopaedic consultants from three regions. RESULTS: In the presence of medial-sided clinical signs (tenderness, swelling, ecchymosis), 22% of consultants would perform surgical fixation. 53% would choose non-operative treatment and the majority would monitor these fractures through serial radiographs. The remaining 25% of consultants would perform an examination under anaesthesia (EUA; 15%), request stress radiographs (9%) or an MRI scan (1%). Without medial-sided signs, 85% would advocate non-operative treatment and, of these, 74% would perform weekly radiographs. Interestingly, 6% would perform immediate surgical fixation. Stress radiographs (6%) and EUAs (2%) were advocated in the remaining group of consultants. Foot and ankle surgeons utilised stress radiographs more frequently and were more likely to proceed to surgical fixation should talar shift be demonstrated. CONCLUSIONS: Clinical practice is varied amongst the orthopaedic community. This may lead to unnecessary surgery in SER-II injuries and delay in diagnosis and operative management of SER-IV injuries. We have highlighted the various investigative modalities available that may be used in conjunction with clinical signs to make a more accurate diagnosis.

[Outcome of operative treatment for supination-external rotation Lauge-Hansen stage IV ankle fractures]. / Ocena wyników leczenia zlaman kostek goleni typu supinacyjno-rotacyjnego IV stopnia wedlug Lauge-Hansena.

INTRODUCTION: Ankle fractures are among the most common musculoskeletal injures. These fractures occur with an overall age- and sex-adjusted incidence rate around 180 per 100 000 person-years. The most frequent mechanism is considered to be supination-external rotation (60 to 80% of all ankle fractures) consisting of pathologic external rotation of the foot initially placed in some degree of supination. According to Lauge-Hansen classification, ankle joint structures are damaged in a sequence where the final, stage IV injuries, represents transverse fracture of the medial malleolus or its equivalent-rupture of the deltoid ligament. AIM OF THE WORK: The aim of this study is to compare the results of two subtypes of supination-external rotation stage IV fractures. MATERIAL AND METHODS: 43 patients treated surgically in 2006 to 2007 at Authors institution because of stage IV supination-external rotation ankle fracture were submitted to retrospective analysis. There were 25 patients with bimalleolar fracture (type 1) and in 18 patients with lateral malleolar fracture with accompanying rupture of the deltoid ligament (type 2). The mean age was 46 years (from 20 to 82 years). Average follow up period was 37 months (from 24 to 46 months). For the evaluation of treatment AOFAS hind-foot score (American Orthopedic Foot and Ankle Society) was used. RESULTS: The mean AOFAS score scale for Type 1 fractures was 85 points and for type 2 was significantly higher and amounted to 91 points (p < 0.05). CONCLUSIONS: Supination-external rotation stage IV ankle fractures with medial malleolar fracture, requires the implementation of additional diagnostic and therapeutic strategies and procedures in order to improve the outcome of results.

[Paresis of nervus peroneus after immobilization with range of motion walker]. / Parese af nervus peroneus efter bandagering med range of motion walker.

It is well known that cast immobilization can cause pressure on the common peroneal nerve. In this case a 64-year-old female patient had a fracture of the distal fibula (SU2, according to Lauge Hansens classification of angle fractures). This avulsion was conservatively treated and immobilized in a flexible cast. Unfortunately, the cast was too high, the metal plates inside it caused pressure on the common peroneal nerve and the patient sustained a peroneal palsy.

The treatment of unstable ankle fractures in patients over eighty years of age.

BACKGROUND: The current study examined the outcomes of operative treatment of unstable ankle fractures in patients at least 80 years old at the time of injury. METHODS: Of 2,682 patients who presented for treatment of ankle fractures, 17 patients met the study criteria. These patients had open reduction and internal fixation after sustaining 15 closed and two open unstable ankle fractures. There were 11 type B fractures and six type C fractures by the Danis-Weber classification, and 12 supination-external rotation and five pronation-external rotation fractures by the Laugen-Hansen classification systems. RESULTS: When noncompliant patients who developed complications were removed from analysis, the fixation failure and deep infection rates were 0% each. CONCLUSIONS: These results highlight the importance of patient compliance and non-weightbearing status in the treatment of ankle fractures in patients over 80 years.

Arthroscopic assessment of occult intra-articular injury in acute ankle fractures.

PURPOSE: To arthroscopically assess the pattern and extent of intra-articular damage associated with ankle fractures. TYPE OF STUDY: Prospective case series. METHODS: From 1989 to 1998, 48 consecutive patients with acute unstable ankle fractures underwent ankle arthroscopy followed by reduction and internal fixation. In addition, all injuries were categorized by specific osseous, ligamentous, and articular pathology, based on clinical and arthroscopic examination. Whenever possible, the fractures were classified according to Lauge-Hansen and Danis-Weber schemes. RESULTS: Traumatic articular surface lesions (TASLs), including chondral defects and osteochondral lesions measuring greater than 5 mm in diameter, were identified in 30 of the 48 ankles (63%), with 11 lesions localized to the tibia and 19 noted on the talus. The tibial lesions were at the posterior syndesmotic ligament insertion in 6 cases, at the anterior capsule origin in 3 cases, and at the central articular surface in 2 cases. Of the 19 talar lesions, 15 involved the medial dome and 4 involved the lateral articulation. TASLs of the talus in this series were uniformly unstable or displaced and virtually devoid of subchondral bone, precluding satisfactory internal fixation. Of the 10 pronation-external rotation fractures, 7 had articular surface defects with 5 involving the medial and 2 the lateral dome. Ten of the 24 supination-external rotation or Danis-Weber B fractures were found to have TASLs of the talus, 9 medial and 1 lateral. Nine of 12 fractures with syndesmosis disruptions sustained full-thickness damage to the talar chondral surface (P =.01). CONCLUSIONS: Ankle fractures have a high incidence of concomitant intra-articular pathology with syndesmosis disruption portending a particularly high risk of articular surface injury to the talar dome. Arthroscopy is a valuable tool in identifying and treating intra-articular damage that would otherwise remain unrecognized and may provide prognostic information regarding the functional outcome of these injuries.

[Injuries of the inferior tibiofibular syndesmosis]. / Verletzungen der unteren tibiofibularen Syndesmose.

The incidence of isolated distal tibiofibular syndesmotic ruptures in acute ankle sprains lies between 1% and 11%. These injuries are frequently overseen or misdiagnosed as anterolateral rotational instability of the ankle and often become apparent through protracted courses. Although the pathomechanics and extent of syndesmotic injuries have been systematically described by Lauge-Hansen and Weber, no generally accepted guidelines exist as to when these complex injuries are to be treated surgically to ensure sufficient and stable healing of the syndesmosis besides correct alignment of the distal fibula. So far, systematic follow-up regarding syndesmotic injuries in ankle fractures is missing, although it has long been recognized that tibiofibular diastasis secondary to chronic syndesmotic instability leads to external rotation of the talus. In combination with a valgus position of the talus, this instability leads to a decrease in the contact area which results in posttraumatic arthritic changes. This paper reviews the standard diagnostic and therapeutic procedures for acute syndesmotic ruptures in fracture dislocations of the ankle. Among the few corrective procedures advocated for chronic syndesmotic insufficiency are tibiofibular arthrodesis, synthetic ligament substitutes, and tenodesis with the peroneus brevis tendon. A sufficient reconstruction must restore the stability of the ankle mortise and alignment of the fibula in the tibiofibular incisura to ensure limitation of talar rotation. Therefore, a tenodesis was developed which substitutes the three important ligaments of the syndesmotic complex. The Casting procedure for chronic syndesmotic insufficiency was modified with reconstruction of the interosseous tibiofibular ligament in addition to the anterior and posterior tibiofibular ligaments. The resulting three-point fixation of the distal fibula appears more anatomically, physiologically, and biomechanically advantageous. The operative procedure is given in detail. Distal tibiofibular syndesmosis. Persistent instability of the distal syndesmosis. Ankle fractures. Syndesmotic screw.

[Irreducible fracture dislocation of the ankle: report of two cases].

The goal of operative treatment of ankle fracture are to obtain an anatomical reduction and rigid fixation to ensure a healed fracture and normally functioning recovery. Irreducible ankle fracture or fracture-dislocation is seldom encountered in clinical practice. Two cases of irreducible ankle fractures are presented. They are different from previous cases reported in the literature. During operation we recognized that the extensor tendons were entrapped in the distal tibiofibular joint under the extensor retinaculum. The reducible ankle fractures reported in the literature, together with the two cases in this report, are classified into three categories. Type I is a medial malleolar fracture with deltoid ligament or posterior tibialis tendon interposition. Type II is an irreducible fracture dislocation of the ankle due to posterior dislocation of the fibula. Type III is a diastatic ankle fracture with extensor tendons entrapped in the distal tibiofibular joint and restricted by extensor retinaculum. The mechanism of the irreducible ankle fracture is discussed and correlated with Lauge-Hansen classification and mechanism.

Closed treatment of ankle fractures. Stage II supination-eversion fractures followed for 20 years.

Ninety-four conservatively treated patients with Lauge Hansen Stage II supination-eversion fractures of the ankle were interviewed after 16-25 years. Patients with pain were examined clinically and radiographically. Eighty-nine patients had good and five medium results. Our observations compare well with published reports of open treatment. We conclude that this particular fracture type is so benign that it can be treated closed without reduction.

Evaluation and treatment of ankle fractures.

The ability to classify ankle fractures allows one to determine which fractures will probably do well with nonoperative treatment and which fractures will fare best with open reduction because of their inherent instability. An understanding of the Lauge-Hansen system also allows one to predict the degree of ligamentous injury on the basis of the osseous pattern of the injury. Operative management of ankle fractures requires a thorough understanding of ASIF technique. Open reduction is best performed with a fracture that is not anatomically reducible or with a fracture type that has been historically proven unstable with closed treatment. Restoration of anatomic alignment of articular surfaces should be the goal of treatment. When anatomic reduction has been achieved, ankle fractures generally do well whether they have been treated with operative or nonoperative techniques. Early motion is helpful if rigid fixation can be achieved, but one should not sacrifice stability in an attempt to begin early movement if rigid fixation has not been obtained. Decisions concerning length of immobilization and early movement should be based upon the principles of bone healing physiology.

Comminuted femoral-shaft fractures: treatment by roller traction, cerclage wires and an intramedullary nail, or an interlocking intramedullary nail.

In a retrospective study, we attempted to assess progress in the treatment of comminuted fractures of the femoral shaft at Parkland Memorial Hospital from 1978 to 1983. Seventy-nine comminuted femoral-shaft fractures were available for follow-up: thirty-two treated by roller traction, twenty-three treated by cerclage wires and an intramedullary nail, and twenty-four treated by an interlocking intramedullary nail. Using the classification of Winquist and Hansen, Grade-III and IV comminuted fractures accounted for 69 per cent of those treated by roller traction, 68 per cent of those treated by nailing and cerclage wires, and 96 per cent of those treated by an interlocking nail. The frequency of multiple injuries was 38 per cent in the patients treated by roller traction, 39 per cent in those treated by nailing and cerclage wires, and 58 per cent in those treated by an interlocking nail. The average hospitalization times were thirty-one days for roller traction, sixteen days for cerclage wires and an intramedullary nail, and 19.5 days for an interlocking nail. The average length of follow-up was 132 weeks after roller traction, 115 weeks after cerclage wiring and an intramedullary nail, and sixty weeks after insertion of an interlocking nail. All fractures were followed until after union; the average times to union were 18.4 weeks after roller traction, thirty-four weeks after open reduction and intramedullary nailing with cerclage wires, and 13.8 weeks after insertion of an interlocking nail. For the purposes of this study, treatment was assumed to have failed if a change in treatment was necessary, an unplanned reoperation was performed, femoral shortening exceeded 2.5 centimeters, angulation was more than 15 degrees, non-union or a deep infection developed, motion of the knee was less than 70 degrees of flexion, or a refracture occurred. By these criteria, the frequency of failure after roller traction was 66 per cent (secondary to malalignment and shortening); after insertion of an intramedullary nail with cerclage wires, 39 per cent (secondary to unplanned surgery, non-union, shortening, and infection); and after use of an interlocking nail, 4 per cent (secondary to shortening). Currently, at our institution, an interlocking intramedullary nail is the treatment of choice for comminuted femoral-shaft fractures because it encourages early union with maintenance of length and alignment and the results are predictable.