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Surgical Planning for SER Ankle Frx (Weber B)

- Preoperative Considerations:
    - radiographs
    - open ankle fractures
    - fracture dislocations of the ankle
    - trimalleolar frx:
         - in these fractures, consider a posterior approach using an antiglide plate which allows for direct fixation of the posterior mallleolar frx (w/ screws inserted from posterior to anterior thru the same incision);
    - timing of surgery;
         - excessive swelling, may cause the surgeon to delay surgery;
         - in one study, there was no significant difference in complications w/early vs. delayed treatment;
                - Early versus delayed treatment of severe ankle fractures: a comparison of results.
    - in absence of a medial malleolar frx, routine exploration of medial side of the ankle  is not necessary unless there is evidence that portion of the deltoid ligament or the tibialis posterior has entered the joint and is blocking reduction of the talus;

- Associated Injuries:
    - osteochondral lesions of the talus
    - proximal fibular frx:
           - it is unusual to have a classic SER fracture along with a proximal fibular frx, but these injuries can occur together when there are 2 sequential traumatic injuries (as might happen when falling down stairs);
    - syndesmotic injury:
           - its important to not to confuse sydesmotic widening from medial clear space widening;
           - if frx begins at or just above level of anterior tubercle, then anterior syndesmosis is disrupted, however the interosseous membrane and posterior  syndesmosis remains intact, and syndesmosis repair is not necessary;
           - in this example, there is lateral talar shift (increased clear space) but there is no syndesmotic widening;


           - rarely, the supination-external rotation pattern may begin above the syndesmotic ligaments and inerosseous membrane;
                  - when the fracture occurs above the syndesmosis along w/ a deltoid ligament injury then placement of a syndesmotic screw is indicated

Use of a tourniquet in the internal fixation of fractures of the distal part of the fibula. A prospective, randomized trial.