Ankle fractures

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Ankle fractures

  1. 1. Ankle Anatomy andBiomechanicsThe ankle joint consists of the talus,which articulates withthe Malleoli medially and laterally and the tibial plafondsuperiorlyIn a neutral position, approximately 90% of the load istransmitted through the tibial plafond, with the remainingload borne by the lateral talofibular articulation
  2. 2. Any ankle injury that results in a stable mechanicalconfiguration can potentially be treated nonsurgicallybecause biomechanically normal function is notcompromised
  3. 3. Restoration of normal stability and motionin patients with unstable ankle fracturesthrough open anatomic reduction andinternal fixation yields better long-termoutcomes than does closed treatment,which may not adequately reconstituteeither the anatomic constraints or themotion
  4. 4. ClassificationsLauge- Hansen ClassificationDanis- Weber classificationAO classification of Malleolar Fractures
  5. 5. Lauge- Hansen ClassificationThe initial word of the classification (eg,supination, pronation) denotes the positionof the foot at the time of injury; thefollowing phrase (eg, external rotation)denotes the direction of the deformingforce.
  6. 6. Supination AdductionTransverse avulsion type fracture of the distal fibulabelow the level of the joint or tear of the lateralcollateral ligamentVertical fracture of the medial malleolus.
  7. 7. Supination External rotation injuryDisruption of the anterior tibiofibular ligamentSpiral oblique fracture of the distal fibulaDisruption of the posterior tibiofibular ligament orfracture of the posterior malleolusFracture of the medial malleolus or rupture of thedeltid ligament
  8. 8. Pronation AbductionTransverse fracture of the medial malleolus orrupture of the deltoid ligamentRupture of the syndesmotic ligaments or avulsionfracture of their insertions.Short horizontal oblique fracture of the fibula abovethe level of the joint
  9. 9. Pronation external rotationTransverse fracture of the medial mallleolus ordisruption of the deltoid ligament.Disruption of the anterior tibiofibular ligamentShort oblique fracture of the fibula above the level ofthe jointRupture of posterior tibiofibular ligament or avulsionfracture of the posterolateral tibia.
  10. 10. Pronation dorsiflexionFracture of the medial malleolusFracture of the anterior margin of the tibiaSupramalleolar fracture of the fibulaTransverse fracture of the posterior tibial surface.
  11. 11. Danis-weber classificationBased on location and appearance of the fibularfractureType A fracture is caused by internal rotation andadduction.Type A fracture produce transverse fracture of thelateral malleolus at or below plafond.
  12. 12. Type B fracture is caused by the external rotation thatresult in oblique fracture of the lateral malleolus.Beginning anteromedialy extending proximally toposterolateral aspect.
  13. 13. Type C fractures are divided into abduction injurieswith oblique fractures of the fibula proximal to thedisrupted tibiofibular ligaments
  14. 14. AO classification
  15. 15. RadiologyX ray measurements of Alignment and StabilityMeasuring the talocrural angle-4-11 degMedial clear space-should be equal to superior clearspace.(<4mm)Evaluation of syndesmosis -tibio fibular clear space should be less than 6mm onboth AP and mortice views.
  16. 16. TreatmentInitial evaluation-HistoryPhysical examination-Deformity,Color of the foot,PulsesCondition of the skinCarefully assessing the medial ankle over the deltoidligament for swelling and ecchymosis
  17. 17. Initial managementReduce the talus underneath the tibiaIf the joint is very unstable slab can be applied.The other options are spanning external fixator orcalcaneal pin traction.Rest Ice and elevationUse of continuous cryotherapy and intermittentpneumatic pedal compression pumps
  18. 18. Factors that affects theoutcomeMedial plafond impaction fractures with verticalmaeolus fracturesPosterior malleolar fracturesAnterolateral corner of the plafond fractures.Level and displacement of the fracture fibula.
  19. 19. Closed treatmentStable ankle fracturesUsually with only fibula fracturesImmobilization in cast for 4-6 weeks is the preferredtreatment.
  20. 20. ContraindicationsExact reduction and maintaince of the talus inmortice is not possibleShoulder fractures of the medial malleolusLarge posterior maleolar fracturesAnterolateral corner fractures.
  21. 21. Open treatmentStable fractures-Osteochondral fractures of the talardoneUnstable fractures.
  22. 22. General principlesTiming of the surgery-Type of the fracture,Skin condition,Other injuries andmedical condition.Antibiotics to reduce infections
  23. 23. Lateral Malleolar fracturesAvoid injuring the superficial peroneal nerveMake sure that distal fibula is fully out to lengthLaterally communited pronation abduction patternsare most difficult For maximum stability place plate posteriorly
  24. 24. Consider the location of the syndesmosis fixationwhen placing a fibular plate.Test the syndesmosis after lateral malleolar fixation.Beware of the short distal segments in elderlypatients with osteoporotic bone
  25. 25. Medial malleolar fixation4.0mm partially threaded screws work wellScrews should be perpendicular to the fracture lineand parallel for maximal compression.Spread two screws for good stabilityUse fluoroscopy to be sure screws are clear of thejoint
  26. 26. Deltoid ligament tearThe deltoid ligament, especially its deep branch isimportant to the stability of the ankle because itprevents lateral displacement and external rotation ofthe talusX ray will show displacement and tilting of the taluswith increased medial clear space
  27. 27. A 1mm lateral shift of the talus can reduce theeffective weight bearing area of the talotibialarticulation by 20% and 5mm shift can reduce by80%.It is repaired with nonabsorbable sutures.
  28. 28. Syndesmotic injuryIf the fibular fracture is above the level of the distaltibiofibular joint syndesmosis assumed to bedisrupted.
  29. 29. IndicationsSyndesmotic injuries associated with proximal fibularfractures for which fixation is not plannedSyndesmotic injuries extending more than 5 cmproximal to the plafond.
  30. 30. Use the syndesmosis fixation when the medial clearspace widens on intraoperative stress view after thefibula is fixedThe fibula must be accurately reduced to the tibia inall viewsUse 4.5 mm four cortex screw if the patient will bearweight postoperativelyDon’t remove syndesmotic screws 3-4 months postoperatively
  31. 31. Achieve perfectly symmetric tibiotalar clear spaceUse syndesmosis fixation only without fixing thefibula fracture when it is above the midfibula
  32. 32. Trimalleolar fracture50deg external rotation view is required for the mostaccurate assessment of the size and displacement of theposterior malleolar fragment.If the fragment of the posterior malleolus involves morethan 25 to 30% of the weigh bearing surface, it should beanatomically reduced and held with internal fixation
  33. 33. Irreducible fracture dislocationDeltoid ligament after being avulsed from the medialmalleolus and may be caught between malleolus and talusTrapping of the tibialis posterior tendon between medialmalleolus and talus.Bosworth fracture with entrapment of fibula behind tibia.
  34. 34. ComplicationsLoss of reductionMalunion-Fibula heals in short or external rotated position.Nonunion- extremely uncommonInfectionDecreased motion- Deficits in dorsiflexion is common.Ankle arthrosis-Quality of reduction

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