Extraperiosteal Plating of Pronation-Abduction Ankle Fractures

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Extraperiosteal Plating of Pronation-Abduction Ankle Fractures. 

Surgical Technique 

Jodi Siegel and Paul Tornetta, III 

J Bone Joint Surg Am. 2008;90:135-144. doi:10.2106/JBJS.G.01138 

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135 

COPYRIGHT © 2008 BY THE JOURNAL OF BONE AND JOINT SURGERY, INCORPORATED 

Extraperiosteal Plating of Pronation- 

Abduction Ankle Fractures 

Surgical Technique 

By Jodi Siegel, MD, and Paul Tornetta III, MD 

Investigation performed at the Department of Orthopaedic Surgery, Boston University Medical Center, Boston, Massachusetts 

The original scientific article in which the surgical technique was presented was published in JBJS Vol. 89-A, pp. 276-81, February 2007 

ABSTRACT FROM THE ORIGINAL ARTICLE 

BACKGROUND: Pronation-abduction ankle fractures frequently are associated with substantial lateral comminution and 

have been reported to be associated with the highest rates of nonunion among indirect ankle fractures. The purpose of 

the present study was to report the technique for and outcomes of extraperiosteal plating in a series of patients with 

pronation-abduction ankle fractures. 

METHODS: Thirty-one consecutive patients with an unstable comminuted pronation-abduction ankle fracture were managed 

with extraperiosteal plating of the fibular fracture. The average age of the patients was forty-four years. There were nineteen 

bimalleolar and twelve lateral malleolar fractures with an associated deltoid ligament injury. No attempt to reduce 

the comminuted fragments was made as this area was spanned by the plate. The patients were evaluated functionally 

(with use of the American Orthopaedic Foot and Ankle Society score), radiographically, and clinically (with range-of-motion 

testing). 

RESULTS: Immediate postoperative and final follow-up radiographs showed that all patients had a well-aligned ankle mortise 

on the fractured side as compared with the normal side on the basis of standardized measurements. All fractures 

healed without displacement. At a minimum of two years after the injury, the average American Orthopaedic Foot and Ankle 

Society score (available for twenty-one patients) was 82. The range of motion averaged 13° of dorsiflexion and 31° of 

plantar flexion, with one patient not achieving dorsiflexion to neutral. There were no deep infections, and one patient had 

an area of superficial skin breakdown that healed without operative intervention. 

CONCLUSIONS: Extraperiosteal plating of pronation-abduction ankle fractures is an effective method of stabilization that 

leads to predictable union of the fibular fracture. The results of this procedure are at least as good as those of other 

techniques of open reduction and internal fixation of the ankle, although specific results for pronation-abduction injuries 

have not been previously reported, to our knowledge. 

LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence. 

ORIGINAL ABSTRACT CITATION:“Extraperiosteal Plating of Pronation-Abduction Ankle Fractures” (2007;89:276-81). 

DISCLOSURE: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of 

their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial 

entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit 

organization with which the authors, or a member of their immediate families, are affiliated or associated. 

A video supplement to this article developed by the American Academy of Orthopaedic Surgeons and JBJS is available at the JBJS web site, www.jbjs.org. 

To obtain a copy of the video, contact the AAOS at 800-626-6726 or go to their web site, www.aaos.org, and click on Educational Resources Catalog 

J Bone Joint Surg Am. 2008;90 Suppl 2 (Part 1):135-44 • doi:10.2106/JBJS.G.01138

136 

T HE JOURNAL OF BONE & JOINT SURGERY · SURGICAL TECHNIQUES MARCH 2008 · VOLUME 90-A · SUPPLEMENT 2, PART 1 · JBJS.ORG 

INTRODUCTION 

The Lauge-Hansen ankle fracture 

classification system correlates 

the radiographic features of 

a fracture with the mechanism 

of injury, defining which forces 

to counter in order to reduce 

and surgically stabilize a 

fracture 1 . The deforming force 

in pronation-abduction fractures 

is translational rather than 

rotational, with the medial 

structures failing first, under 

tension, and the fibula fracturing 

last. This typically results in 

FIG. 1 

a transverse fracture line approximately 

5 cm proximal to 

the joint with lateral comminution, 

consistent with bending 

failure (Fig. 1). With the use of 

an extraperiosteal approach, the 

soft-tissue attachments to the 

fracture fragments are preserved, 

which maintains blood 

flow to promote healing and aids 

in obtaining the reduction. 

SURGICAL TECHNIQUE 

The patient is placed supine on a 

standard operating-room table, 

with a small bump under the ipsilateral 

hip so the knee is 

straight up and down. No tourniquet 

is utilized. If the ankle 

fracture is bimalleolar and the 

medial malleolar fracture pattern 

is supracollicular, it is reduced 

and fixed as the first step 

in the procedure. This aids in 

the reduction because the deep 

deltoid ligament, the strongest 

portion of the ligament, which 

attaches to the posterior colliculus 

and the intercollicular 

groove, is attached to the dis- 

A bimalleolar stage-3 pronation-abduction ankle fracture showing lateral comminution with bending failure of the fibula after an abduction 

stress.

137 


placed medial malleolar 

fragment 2 . Thus, an anatomic reduction 

of a supracollicular medial 

malleolar fracture restores 

medial support, gains talar congruence, 

and assists with reduction 

of the lateral malleolus 2,3 

(Fig. 2-A). The incision used on 

the medial side is slightly concave 

anteriorly and is centered over 

the medial malleolus, as this allows 

both visualization of the reduction 

and placement of the 

screws (Fig. 2-B). Bicortical lagscrew 

fixation, perpendicular to 

the fracture line, is preferred to 

increase the stability of the fixation 

and to compress across the 

fracture site (Fig. 3). 

Attention is then turned to 

the lateral side. The ankle should 

be positioned with bolsters under 

the ankle joint and not under 

the heel. Bolsters under the heel 

can cause anterior subluxation of 

the talus and a malreduction. 

The foot is adducted and medially 

translated to center the talus 

in the mortise, which aids in fibular 

alignment. Because the lateral 

ankle ligaments are intact in 

this injury pattern, reducing the 

talus under the plafond usually 

aligns the distal fibular fragment 

and restores fibular length. Fluoroscopic 

imaging at this point allows 

an assessment of fibular 

length. The lateral cortex of the 

fibula is comminuted, but the 

medial cortex typically starts as a 

transverse fracture line, so one 

can evaluate the reduction at this 

location to assess length (Fig. 4). 

Finally the talocrural angle on 

the affected side is compared 

with the contralateral, normal 

ankle to confirm fibular length 4 . 

As the talocrural angle is not related 

to the size of an image, fluoroscopic 

evaluation is not 

affected by magnification, as are 

other measures of fibular length. 

After determining the necessary 

manipulation of the foot that 

recreates fibular length, one can 

proceed. (For additional techniques 

to gain fibular length, see 

separate section below.) 

Once the general reduction 

of the fibula can be obtained, the 

incision is made. The incision is 

centered over the posterior onehalf 

of the fibula. When the incision 

has been made through the 

skin, care is taken not to incise 

the periosteum. It is found immediately 

subcutaneously and 

often has small rents in it as part 

of the injury, which can make it 

difficult to recognize. Sharp 

Weitlaner retractors can aid by 

applying tension to the skin, 

helping to peel the subcutaneous 

tissues from the periosteum. The 

periosteum is left entirely intact; 

individual fracture fragments are 

not identified, stripped, or further 

handled. Once the dissection 

is at the level of the 

periosteum (Fig. 5), all retractors 

are removed from the 

wound as they can shorten the 

fibula because of the tension 

placed on the surrounding soft 

tissues. Reduction is obtained by 

manipulating the foot, and then 

a lateral fluoroscopic image is 

made to confirm that there is no 

angulation or translation of the 

fibula. This is the last time that 

an unobstructed lateral radiograph 

can be made so it is imper- 

ative that any sagittal plane 

displacement of the fibula is corrected 

now. Once this is completed, 

the anteroposterior 

radiograph is made again to confirm 

the coronal plane reduction. 

Residual lateral translation or 

angulation is often seen; this is 

normal and is corrected later 

with the undercontoured plate. 

Next, a precontoured 

direct lateral fibular plate, or a 

straight one-third tubular smallfragment 

plate that the surgeon 

contours to the shape of the distal 

aspect of the fibula, is placed 

into the wound. It is vital that the 

plate be slightly undercontoured 

in relation to the lateral surface 

of the fibula as this ultimately 

corrects the lateral translation of 

the fibula. The plate is placed 

onto the fibula, with the surgeon 

ensuring that it is centered between 

the anterior and posterior 

borders of the bone. This is done 

initially by feel as one cannot 

strip the soft tissue from the fibula 

to visualize the bone directly, 

but a Kirschner wire can be used 

as a probe to assist in identifying 

the anterior and posterior borders 

of the fibula. Fluoroscopic 

lateral imaging is required to 

confirm that the plate is centered 

on the bone before fixation 

is placed (Fig. 6-A). This is paramount 

for the reduction as the 

direction of the force provided 

by the plate must be directly medially 

to reduce the laterally 

translated fibula. Additionally, 

the fibula must be evaluated for 

angulation. Any anterior or posterior 

angulation must be corrected 

prior to fixation by

138 


FIG. 2-A 

The medial malleolus is composed of the anterior and posterior colliculi. A supracollicular fracture (left) extends from the anterior tibial cortex 

to the posterior tibial cortex; an anterior collicular fracture (right) exits inferiorly between the colliculi, creating an anterior fracture fragment. 

The broad superficial deltoid ligament, which is the weaker of the two portions of the ligament, takes its origin from the anterior 

colliculus and acts to prevent external rotation of the ankle when the foot is in plantar flexion. The stronger deep deltoid ligament originates 

from the posterior colliculus and the intercollicular groove, and prevents external rotation of the ankle with the foot in dorsiflexion. Fixation of 

a supracollicular medial malleolar fracture, with the deltoid ligament (most importantly, the deep portion) intact on it, restores medial 

stability 3 . The incision is concave anteriorly, which allows visualization of the joint and placement of lag screws perpendicular to the fracture. 

moving the bolster to an appropriate 

position. Once appropriate 

plate position is confirmed, 

the plate is provisionally fixed to 

the bone with Kirschner wires or 

provisional fixation pins (Fig. 6- 

B). After temporary fixation, the 

centered location of the plate on 

the fibula is again confirmed. 

Screws can then be placed, from 

proximal to distal, which will 

push the fibula (and therefore 

the talus) medially, under the 

plafond (Figs. 7-A and 7-B). The 

reduction is confirmed on the 

anteroposterior radiograph. If 

the talus does not reduce, one of 

two problems exists. Either the 

syndesmosis is unreduced or the 

plate is incorrectly contoured to 

effect a reduction and the fibula

139 


FIG. 2-B 

Incision and dissection for medial malleolar fixation. The fracture is now reduced and 

clamped with a bone tenaculum. Note the visualization of the joint while the surgeon is 

still able to place lag screws perpendicular to the fracture. 

is not anatomic. If the fibula is 

not accurately reduced, then the 

plate must be removed, recon- 

FIG. 3 

Medial malleolar fixation with bicortical lag screws 

ideally placed parallel to each other and perpendicular 

to the fracture site. Since the tibia is a curved 

bone, the screws may appear as though they are 

not bicortical when in fact they are penetrating the 

posterior cortex. Bicortical screws increase stability 

and allow compression across the fracture site. 

toured, and replaced, with attention 

to fibular length. If the 

fibula is anatomically aligned, 

then the syndesmosis is unstable 

and needs to be reduced and stabilized 

as described below. 

With both medial and lateral 

stability restored, the syndesmosis 

must be tested for stability. 

If the medial injury is ligamentous, 

the syndesmosis is tested by 

applying an abduction stress on 

the foot and evaluating the medial 

clear space, the syndesmotic 

space, and residual talar subluxation 

(Fig. 8-A). If the medial injury 

is osseous and fixation is in 

place, then a clamp is placed on 

the fibula and an abduction stress 

is applied. If >2 mm of lateral 

translation occurs at the syndesmotic 

notch, syndesmotic fixation 

is indicated. The reduction 

of the syndesmosis can be accomplished 

in several ways. Most 

commonly, we use a large balltipped 

reduction clamp, which 

engages a plate hole or screw

140 


FIG. 4 

Intraoperative fluoroscopic image made after preliminary closed reduction. The fibula is 

out to length as determined by the alignment of the fracture line at the medial cortex. 

head on the fibula and the anteromedial 

distal aspect of the tibia. 

It does not require much force to 

accurately reduce the syndesmosis, 

but tightening the clamp too 

hard can translate the fibula posteriorly. 

A perfect lateral radiograph 

to confirm the fibular 

location and compare it with the 

normal ankle prevents malreduction 

as there is no direct visualization 

of this region. Alternately, 

direct digital pressure by the surgeon 

can be used to hold the reduction. 

In rare cases, the 

syndesmotic screw can be placed 

as a lag screw to obtain the reduction, 

but it must be placed 

through the plate exactly in the 

plane perpendicular to the tibiofibular 

axis and care must be 

taken not to overtighten it as this 

will overcontour the plate 

through the area of fibular comminution. 

Once the reduction is 

achieved and is confirmed on the 

anteroposterior and lateral radiographs, 

the syndesmotic screws 

are placed through the plate, 

which acts as a substitute for the 

lateral cortex (Fig. 8-B). Typically, 

syndesmotic fixation is 

FIG. 5 

achieved with one or two fully 

threaded 3.5-mm cortical position 

screws (non-lag), placed just 

proximal to the subchondral 

bone of the plafond, through the 

plate, and through three cortices. 

When there is substantial comminution 

in the fibula, screws can 

be placed through the plate and 

into the tibia to gain additional 

fixation even if the syndesmosis is 

stable with a stress examination. 

This is recommended if more 

than two screw holes in the plate 

are not usable because of fibular 

comminution. 

Fibular Length 

Restoring fibular length is one of 

the most important aspects of 

this technique. In general, it is 

not difficult to restore length because 

of the pure bending mechanism 

of the injury. Occasionally, 

however, restoring and confirming 

fibular length with use of the 

Intraoperative example of extraperiosteal dissection. The peroneal tendons are visible. 

The outline of the fibula has been drawn in. There is a rent in the periosteum caused by 

the initial fracture displacement (red arrow). Weitlaner retractors help to identify the 

plane between the subcutaneous tissues and the periosteum.

141 


FIG. 6-A 

The lateral fluoroscopic image demonstrating that there is no translation and no angulation and that the plate is centered over the fibula. 

FIG. 6-B 

Anteroposterior fluoroscopic image after provisional fixation of the plate, showing reduction. 

previously described methods 

can be challenging. Close attention 

to the reduction of the uncomminuted 

medial cortex of 

the fibula and use of the talocrural 

angle 4 are the best ways to 

judge length (Fig. 9). If length is 

not restored with the previously 

described technique, one can try 

grasping the distal end of the fibula 

with a bone tenaculum and 

applying straight distal traction. 

Sometimes, the restored length 

can be held with a Kirschner wire 

driven into the tibia; alternatively, 

one must maintain the 

length manually while inserting 

the proximal screws into the

142 


FIG. 7-A FIG. 7-B 

Fig. 7-A There is mild residual lateral fracture displacement and joint subluxation. Fig. 7-B With the plate used as a reduction tool, both the 

fracture and the talus have been reduced to their anatomic position. 

FIG. 8-A FIG. 8-B 

Fig. 8-A After lateral fixation is complete, the syndesmosis is stressed. Note that the medial clear space and syndesmotic space are widened 

while the fibula remains anatomically aligned, indicating syndesmotic instability. Medial clear space widening (arrow) can be appreciated. 

Fig. 8-B The syndesmosis is reduced, and a syndesmotic screw is placed. Additionally, with this fixation, the plate is acting as a 

substitute lateral cortex.

143 


FIG. 9 

The talocrural angle after indirect reduction of the affected side (left) is within 1° of the normal side (right), providing an objective measure 

of fibular length and congruence of the mortise 4 . 

plate. If fibular length is restored 

with this technique, screws must 

be placed into the distal fragment 

or length will be lost once the 

Kirschner wire (or manual traction) 

is removed. 

If fibular length cannot be 

restored with use of this method, 

then the last option is to fix the 

plate to the distal fragment of the 

fibula and use an articulated 

compression-distraction device 

proximally to push the fibula out 

to length. When this is done, a 

clamp must be used to hold the 

plate to the bone proximally or 

the tensioning device will lift it 

off the bone. Once length is restored 

in this way, the proximal 

screws can be inserted in the 

plate. The downside to this technique 

is the additional exposure 

required to use the articulated 

compression-distraction device. 

However, without restoration of 

fibular length, proper ankle mechanics 

will not be reestablished. 

Care should be taken to maintain 

as much soft-tissue integrity of 

the fracture fragments as possible 

to preserve healing potential. 

This outrigger method is simple 

and predictable but is rarely 

needed. 

POSTOPERATIVE MANAGEMENT 

Postoperatively, patients who 

have a stable syndesmosis are 

kept non-weight-bearing for six 

weeks, but, in compliant pa- 

tients, active and passive motion 

is permitted as soon as the 

wounds are healed. If syndesmotic 

screws are required, 

weight-bearing is deferred for 

twelve weeks. Active and passive 

motion is begun at four weeks in 

compliant patients. After twelve 

weeks, patients are offered syndesmotic 

screw removal. If the 

patient chooses to have the hardware 

removed, it is removed 

prior to the commencement of 

any weight-bearing. If the patient 

elects not to have the screw removed, 

he or she is told that the 

screw(s) will either loosen or 

break at some point in the future 

and the patient is unlikely to 

know when that happens.

144 


CRITICAL CONCEPTS 

INDICATIONS: 

Ankle fractures caused by a lateral bending force (Lauge-Hansen pronation-abduction ankle fractures) 

CONTRAINDICATIONS: 

Ankle fractures caused by rotational or medial bending forces (Lauge-Hansen supination-external rotation, pronation-external 

rotation, or supination-adduction ankle fractures) 

Substantial lateral soft-tissue injury causing blisters, unresolved swelling, or other open wounds 

PITFALLS: 

Not correctly evaluating or restoring fibular length 

Not placing the plate directly laterally, thereby creating an inappropriate vector with the plate, which will not counter the 

deforming forces on the ankle 

Placing the bolster under the heel, which can cause anterior talar subluxation and ankle malreduction 

Aggressive dissection, thereby stripping the periosteum. This violates the blood supply, increases the risk for nonunion, 

and destroys the ability to use soft-tissue tension to generally align the fragments. 

Not obtaining a perfect reduction on the lateral radiograph 

AUTHOR UPDATE: 

No changes have occurred in the surgical technique since the original article was published. 

Jodi Siegel, MD 

Paul Tornetta III, MD 

Department of Orthopaedic Surgery, Boston University 

Medical Center, 850 Harrison Avenue, 

D2N, Boston, MA 02118. E-mail address for 

P. Tornetta III: ptornetta@pol.net 

The line drawings in this article are the work of 

Emily G. Shaw of Illustrating Medicine 

(illustratingmedicine.com). 

REFERENCES 

1. Lauge-Hansen N. Fractures of the ankle. II. 

Combined experimental-surgical and experimental-roentgenologic 

investigations. Arch 

Surg. 1950;60:957-85. 

2. Pankovich AM, Shivaram MS. Anatomical 

basis of variability in injuries of the medial 

malleolus and the deltoid ligament. II. Clinical 

studies. Acta Orthop Scand. 1979;50: 

225-36. 

3. Tornetta P 3rd. Competence of the deltoid 

ligament in bimalleolar ankle fractures after 

medial malleolar fixation. J Bone Joint Surg 

Am. 2000;82:843-8. 

4. Phillips WA, Schwartz HS, Keller CS, 

Woodward HR, Rudd WS, Spiegel PG, 

Laros GS. A prospective, randomized study 

of the management of severe ankle fractures. 

J Bone Joint Surg Am. 1985;67: 

67-78.

Extraperiosteal Plating of Pronation-Abduction Ankle Fractures

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