Fractures of the Ankle: Pathogenesis and Treatment

J South Orthop Assoc. 2000;9(2) 

In This Article

Historical Landmarks

Because of the absence of radiography and the inchoate state of biomechanics, knowledge of ankle injuries before 1900 was based on clinical observations and cadaver experiments; but the significance of these early observations is clouded by ambiguous terminology and by the failure of authors to distinguish experimental findings from clinical impressions.

Among the earliest observations on the pathomechanics of ankle injuries were those by Sir Percival Pott,[1] who, in an article entitled "Some Few General Remarks on Fractures and Dislocations," published in 1768, attempted to relate the clinical findings in a given case to the injuries that caused them. He described a fracture of the fibula 2 to 3 inches above its tip associated with a tear of the deltoid ligament and lateral subluxation of the talus. By failing to include the syndesmotic injury that accompanies this fibular fracture, Pott described a nonexistent lesion. Since his description, the term "Pott's fracture" has often been applied to bimalleolar fractures; however, in Pott's original description, neither malleolus was broken, which makes the eponym doubly unfortunate.

During the next 150 years, most experimental studies on the production of ankle injuries were done by the French. In 1816, Dupuytren[2] used cadaver experiments to produce ankle fractures by abduction or "outward movement" of the foot. Subsequently, French authors have referred to a low Dupuytren fracture, a short oblique fracture of the fibula just above a ruptured anterior inferior tibiofibular ligament or below an intact one; and a high Dupuytren lesion, which refers to a transverse or short oblique fracture at the junction of the middle and distal thirds of the fibula accompanied by disruption of the syndesmosis -- though this latter injury undoubtedly includes an element of external rotation (Fig 1). Nélaton[3,4] suggested out that it was the high Dupuytren fracture, with or without intercrural dislocation of the talus, that most deserved designation as the Dupuytren fracture, though because of the confusion it engenders, it is perhaps best to avoid the eponym altogether.

Figure 1.

Abduction fractures according to Dupuytren.[2]

Maisonneuve,[5] a pupil of Dupuytren, was the first and almost only surgeon before the 20th century to emphasize the role of external rotation in the production of ankle fractures, showing how external rotation of the talus in the ankle mortise could produce the high fracture of the fibula that bears his name. His original illustration, however, failed to show the necessary interosseous disruption, and the obliquity of the fibular fracture was depicted in the coronal rather than the characteristic sagittal plane. Maisonneuve's most significant contribution was his description of a much more common fracture, the low external rotation fracture of the fibula, which, because it begins anteriorly below and ends posteriorly above the attachments of the respective tibiofibular ligaments, has been labeled the "mixed oblique" fracture (Fig 2).

Figure 2.

Low "mixed oblique" fibular fracture of Maisonneuve.[5]

In 1848, Tillaux[6] described an external rotation fracture in which the anterolateral corner of the lower tibia was avulsed by the tibiofibular ligament, a fracture that had been depicted without comment in Sir Astley Cooper's[7] 1822 treatise on fractures. The rarely encountered fibular counterpart of the Tillaux fracture was described by Wagstaffe[8] in 1875.

Although Cooper had called attention to articular fractures of the posterior tibia in his 1822 treatise by including an illustration of one that had healed with posterior talar subluxation, Earle[9] was the first, in 1828, to report a fresh posterior lip fracture encountered at autopsy, a finding confirmed shortly thereafter by other European authors. With some dismay, those familiar with this earlier literature encountered an article in 1915 by Cotton,[10] in which he described this injury as a "new type of ankle fracture," modestly suggesting that, when the injury occurred in association with fractures of the medial and lateral malleoli, it be called "Cotton's fracture."

Almost 50 years after Earles's report on posterior lip fractures, Nélaton[3,4] described fracture of the anterior lip of the tibia. In 1911, Destot[11] described the comminuted fracture of the tibial plafond that has since been referred to as a pilon or "pestle" fracture.

Bosworth,[12] in 1947, provided the first description of a low, external rotation fracture of the fibula in which the displaced proximal fragment became locked behind the posterior tibia, where it was held by an intact interosseous membrane.

In 1994, Wilson et al[13] described the malle-olar fractures resulting from isolated plantar flexion injuries. Both malleoli are fractured obliquely in the sagittal plane, though the lateral malleolar fracture runs posteriorly and upward, whereas the medial malleolar fracture courses posteriorly and downward -- a truly mixed oblique pattern (Fig 3).

Figure 3.

Malleolar fractures produced by isolated plantar flexion. Both malleolar fracture lines are in sagittal plane, but superoinferior direction is reversed.