Foot Ankle iSAWE 11

Question

A 45 year old man rolls his ankle on a step. The ankle is deformed with tented skin medially.

Foot Ankle iSAWE 11, AP radiograph of the ankle
AP radiograph of the ankle. Image by Nazzar Tellisi, I S Abdulkareem, P G Giannoudis, Wikimedia Commons, CC BY 4.0.
  1. Describe the radiograph and your immediate management.
  2. Classify the injury.
  3. What are the principles of fixation?

Answer

Radiograph and immediate care

  • Bimalleolar fracture dislocation of the ankle
  • Talar shift
  • Urgent reduction in the emergency department to protect the skin
  • Backslab, elevation and post reduction films
  • Check neurovascular status before and after

Classification

SystemCategory
WeberFibula at the level of the syndesmosis is Weber B
Lauge-HansenSupination external rotation IV is the commonest pattern
AO44 B

Fixation principles

  • Swelling may delay surgery, fix when skin wrinkles
  • Restore fibular length and rotation
  • Lag screw and neutralisation plate or posterior antiglide plate for the fibula
  • Medial malleolus with two partially threaded screws or tension band
  • Test the syndesmosis after fixation (Cotton or stress test)
  • Fix posterior malleolar fragments that involve the incisura or cause instability
  • Diabetic patients need more rigid fixation and longer protection

Evidence

  • AIM trial showed close contact casting was equivalent to surgery in patients over 60 with unstable fractures

Related pages

Author Contributions

Orthofracs team

Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 10 October 2026.