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Summary & ConclusionFractures and fracture dislocations of the ankle are among the most common injuries treated by orthopedic surgeons. One such injury was described by Percival Pott in 1768, and the group as a whole was for a long time referred to as Pott’s fracture. The most obvious injury is a fracture of one or both malleoli (Solomon et al., 2001).One commonly used classification, the Lauge-Hansen classification (Lauge-Hansen,1949; Lauge-Hansen,1950; Lauge-Hansen,1952; Lauge-Hansen, 1953; Lauge-Hansen,1954; Bonnin,1950; Dabezies et al.,1978; Danis,1947; Handerson,1952; Weber,1966 and Weber,1972), uses radiographic features to determine the mechanism of injury, but then it classifies the fractures based on the mechanism of injury rather than directly on the radiographic appearance. When this classification was first developed, it was a valuable clinical tool that assisted surgeons in determining which forces to apply to obtain and maintain closed reduction of an ankle fracture sublaxation or dislocation. Reversing the deforming forces achieves reduction. Most unstable fractures are now treated surgically, and this decreases the impact of classification on treatment.(Marsh & Saltzman,2001)The other commonly used classification, the Danis-Weber System, is based on the level of the fracture of the fibula. (Weber, 1966; Weber, 1972 and Müller et al., 1979) This simple classification provided the initial guidelines for surgical treatment because A fractures frequently do not require surgical treatment, B fractures are treated by stabilization of lateral malleolus, and C fractures are treated by syndesmosis fixation in addition to lateral malleolus stabilization.(Marsh & Saltzman,2001) Unfortunately, using the level of the fibula fracture exclusively to determine the need for and type of surgical treatment was simplistic and was often not accurate enough to be truly clinically useful. (Bauer et al.,1987 and Broos & Bisschop,1991)As the goals of treatment are to obtain an anatomical reduction, maintain this reduction until the fracture heals, and return the patient to his or her preinjury level of function with a painless, mobile ankle. Many studies have attempted to compare the results of nonoperative and operative treatment.(Bauer et al,1985a; Bauer et al,1985b; Kristensen & Hansen,1985 and Ryd & Bengtsson,1992)Similar results are reported when these goals of treatment are achieved by either method of treatment. The outcome correlates directly with how well the anatomy of the ankle has been restored. In some fracture patterns a closed reduction may be difficult to achieve or maintain. Loss of reduction and repeated manipulations have been associated with unsatisfactory results.(Burwell & Charnley,1965 and Eventov et al.,1978)Prolonged immobilization may also lead to disuse osteoporosis and joint stiffness. All displaced malleolar fractures should be treated by ORIF as it is the best way to regain normal anatomy, smooth articular surface as possible and stability of the ankle (Whittle & Wood, 2003).There are different methods of internal fixation of lateral malleolus including one third semitubular 3.5 mm plate & screws, 3.5 mm lag screws (interfragmentery), Kirschner wires & tension band and intramedullary fixation (Whittle & Wood, 2003). Intramedullary fixation can be done with Steinmann pins, Rush rods, axial screw 4.5 mm or Inyo nail (Ray et al., 1994).The most common method of fixation is one third semitubular 3.5 mm plate &screws which provides stable fixation and maintains the length of the fibula especially in comminuted fractures. It has disadvantages of extensive dissection, periosteal stripping, postoperative wound breakdown especially in swollen ankles, infection, unacceptable scarring, painful prominent hardware and penetration of ankle joint and talus by distal screws. However, these risks are eliminated by intramedullary fixation (Ray et al., 1994).With intramedullary fixation the surgical time is reduced compared with any method of internal fixation, also, the fracture haematoma is not violated, which improves healing and shortens the rehabilitation time. Intramedullary fixation has disadvantages of migration and slipping of intramedullary nail or Kirschner wire, which is prevented by inserting an axial screw 4.5 mm, but it fails to solve the problem of rotation and shortening which may lead to malunion and secondary osteoarthritis (Ray et al., 1994).There are different methods of internal fixation of medial malleolus including two 4 mm cancellous lag screws, one 4 mm lag screw & Kirschner wire and two Kirschner wires & tension band (Whittle & Wood, 2003).
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