Editor’s note: The following article is a review of a video available via the AAOS Orthopaedic Video Theater (OVT). AAOS Now routinely reviews OVT Plus videos, which are vetted by topic experts and offer CME. For more information, visit aaos.org/OVT.

Ankle fractures are among the most common operations performed by orthopaedic surgeons. In the Lauge-Hansen classification, the most commonly encountered injuries in the emergency department are supination–external rotation types of injuries. In the OVT video titled “Variant SE4 Ankle Fracture: Recognizing the Pattern and Implications for Open Reduction and Internal Fixation,” Maxwell C. Alley, MD, and Paul Tornetta III, MD, PhD, FAAOS, concisely describe a variant supination–external rotation type, which has implications for internal fixation.

The video presents the case of a man, aged 53 years, who fell down a flight of stairs, sustaining a supination–external rotation type of ankle fracture. External rotation stress views demonstrated mortise and syndesmotic instability (Fig. 1). Radiographs demonstrated an unusual fracture variant with the proximal shaft lateral to the distal fracture segment. This pattern makes internal fixation using a posterior antiglide plate difficult.

The video then outlines the surgical procedure. After the surgeons exposes the fibula fracture through a lateral incision, they elevate the periosteum posterolaterally to demonstrate positioning of an antiglide plate. Use of reduction force clarifies why this technique should not be used for this fracture pattern, as the fracture segment displaces medially rather than being reduced into the axilla of the plate. Instead, the authors use a more traditional technique. The fracture site is debrided of interposing hematoma and periosteum, reduced, and fixated with an anterior to posterior 2.4 mm lag screw.

Lateral plating is performed to neutralize the lag screw. Two 3.5 mm tricortical syndesmotic screws are placed. The patient is kept non–weight bearing for 10 weeks.

Orthopaedic surgeons operating on ankle fractures are likely to encounter this variant. This video nicely demonstrates that although a posterolateral antiglide plate can be effective for many lateral malleolus fractures, it should not be used blindly. Each fracture must be assessed individually with preoperative planning and intraoperative assessment.

Michael DeRogatis, MD, MS, is an orthopaedic surgery resident at St. Luke’s University Health Network in Bethlehem, Pennsylvania.

Paul S. Issack, MD, PhD, FAAOS, FACS, is a clinical associate professor in the Department of Orthopaedic Surgery, Weill Cornell Medical College, and a trauma and adult reconstruction orthopaedic surgeon at New York–Presbyterian/Lower Manhattan Hospital. He is also a member of the AAOS Now Editorial Board.

Video details

Title: Variant SE4 Ankle Fracture: Recognizing the Pattern and Implications for Open Reduction and Internal Fixation
Authors: Maxwell C. Alley, MD, and Paul Tornetta III, MD, PhD, FAAOS
Published: March 15, 2022
Time: 5:30
Tags: Trauma, Foot and Ankle, ORIF

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