orthopaedic aspect of ankle

1. Ankle fractures
SRI SIDDHARTHA MEDICAL COLLEGE
TUMKUR
Subject seminar
CHAIRPERSON: PROF. & HOD Dr. Kiran Kalaiah
MODERATOR: PROF. & HOD Dr. Kiran Kalaiah
SPEAKER: Dr. G. ARUN SIVA RAM

2. Epidemiology
• road traffic accidents
• a slip while walking or getting down from stairs
• a twisting injury in sports
• fall from a height.
• ankle injuries when one attempts to turn violently over a fixed foot or
the foot being used as lever to produce twist at the ankle .

3. • Great majority indirect violence.
• If not treated  disability in the form of pain, instability and early
degenerative arthritis of the ankle.
• cause destruction of not only the bony architecture but also often the
ligamentous and soft tissue components

4. Aim
• Restoration of ankle mortise
• weight-bearing alignment of the ankle must be at a right angle
to the longitudinal axis of the leg.
• The contours of the articular surface must be satisfactorily reduced

5. anatomy
Structurally, the joint is very strong. The stability of the joint is ensured
by:
(i) Close interlocking of the articular surfaces;
(ii) strong collateral ligaments on the sides; and
(iii) the tendons that cross the joint, four in front,
and five behind

7. Ligaments
The joint is supported by:
(i) Fibrous capsule,
(ii) the deltoid or medial ligament, and
(iii) a lateral ligament

8. Fibrous capsule
It surrounds the joint and is attached all around the articular margins
with exceptions.
(1) Poster-superiorly, it is attached to the inferior transverse tibiofibular
ligament; and
2) anteroinferiorly, it is attached to the dorsum of the neck of the talus
at some distance from the trochlear surface.

9. Deltoid or medial ligament
This is a very strong triangular ligament present on the medial side of the
ankle.
superficial layer
tibiocalcaneal ligament
tibionavicular ligament
posterior superficial tibiotalar ligament
tibiospring ligament
deep layer:
this layer is intra-articular and is covered by synovium
anterior tibiotalar ligament (ATTL)
posterior deep tibiotalar ligament (PDTL)

12. Lateral ligament
This ligament consists of three bands as follows.
• 1. The anterior talofibular ligament is a flat band which passes from
the anterior margin of the lateral malleolus to the neck of the talus,
just in front of the fibular facet.
• 2. The posterior talofibular ligament passes from the lower part of the
malleolar fossa of the fibula to the lateral tubercle of the talus.
• 3. The calcaneofibular ligament is a long rounded cord which passes
from the notch on lower border of the lateral malleolus to the
tubercle on the lateral surface of the calcaneum.

16. Blood supply

18. Nerve supply
• The talocrural joint is innervated by branches from the deep
peroneal,sural and tibial nerves (or medial and lateral plantar nerves,
depending on the level of division of the tibial nerve). Occasionally,
the superficial peroneal nerve also supplies the ankle joint

19. Syndesmotic joint

21. Biomechanics
• ROM 30* dorsiflex, 45* plantarflex
• Normal gait  10* dorsiflex, 20* plantar flex
• Axis of flexion ankle EXT rotated 20* compared with knee axis
• Lateral talar shift of 1mm  decrease surface contact by 40%
• 3mm shift  60% decrease
• Syndesmotic disruption  tibiofibular overlap
• Syndesmotic disruption with fibula#  2-3mm lateral talar shift even
with intact deltoid ligament.

22. Injuries around ankle
• A. Ligament injuries.
• B. Bony injuries.

23. Ligament injuries
• The common injuries are the lateral ligament injury, the medial or the
deltoid ligament injury and
• the syndesmotic ligament injury (the ligament binding the inferior tibio-
fibular syndesmosis).
• • Grade 1—Stretching of the ligaments.
• • Grade 2—Partial tear of the ligaments.
• • Grade 3—Complete tear of the ligaments.
• Management
• Complete and severe tears require surgical repair. Less severe strains and
sprains heal well with adequate immobilization. Physiotherapy and gradual
mobilization is always essential for a good recover

24. classification
Lauge-Hansen,
Weber,
OTA.
Additional Anatomic Evaluation:
Posterior Malleolar Fractures,
Syndesmotic Injuries,
Common Eponyms.

25. Lauge-Hansen Classification
• Four Patterns are recognized, based on PURE injury sequences, each
subdivided into stages of increasing severity.
• Based on Cadaveric studies.
First word: Position of foot at time of injury
Second word: Force applied to foot relative to tibia at time of injury.
Types:
1. SER
2. SAd
3. PER
4. PAb

41. Weber classification
Type A-
• # fibula below tibial plafond
• Associated with oblique / vertical # of medial malleoli
• Lauge – Hansensupination adduction
Type B:
• # fibula at syndesmosis
• 50% associated with ant syndesmotic ligament injury
• Lauge – Hansensupination external rotation

42. Type-c
• # fibula above syndesmosis
• Lauge-Hansen pronation abduction
Concept - The higher the fibula # the
more severe the injury in terms of
syndesmosis disruption.

48. # pattern
• Variable
• Difficult to assess on standard lateral radiograph
• So. Require EXT rotation LAT view, CT scan

50. Ruedi-Allgower classification
• Type 1: No significant articular incongruity; cleavage fractures without
displacement of bony fragments.
• Type 2: Significant articular incongruity with minimal impaction or
comminution.
• Type 3: Significant articular comminution with metaphysical
Impaction

52. Common eponyms
Maisonneuve fracture:
#proximal fibula with syndesmotic disruption

53. Volksmann fracture
• # tibial attachment of PITFL
• Posterior malleolar type

54. Tillaux chaput fracture
• # tibial attachment of AITFL

58. Bowsworth fracture
• Distal end of proximal fragment of fibuladisplaced posterior to tibia
• Locked by tibia’s posterolateral ridge
• Bone cannot be released  pull of intact interosseous membrane

59. Collicular #
• –Avulsion fracture of distal portion of medial malleolus
• –Injury may continue and rupture the deep deltoid ligament

60. Tibial pilon fractures
• The terms tibial plafond fracture, pilon fracture, and distal tibial
explosion fracture all have been used to describe intraarticular
fractures of the distal tibia.
• Accounts for 7 to 10% of all tibia fractures. Most common in men of
30-40 years.
• These terms encompass a spectrum of skeletal injury ranging from
fractures caused by low-energy rotational forces to fractures caused
by high-energy axial compression forces arising from motor vehicle
accidents or falls from a height.

62. • because of their high energy nature, these fractures can be expected
to have specific associated injuries to calcaneum, tibial plateau, pelvis
and vertebral fractures.
• -Swelling is often massive and rapid, required serial assessment of
skin integrity, necrosis and fracture blisters.
• -Meticulous assessment of soft tissue damage is of paramount
importance.
• -Some advise waiting 7 to 10 days for soft tissue healing to occur
before planning surgery

66. Clinical examination

73. Investigations
• Xray AP / Mortice

75. Ottawa rules:when to image
• 98% sensitivity
• Decrease radiographs
DO NOY APPLY IF:
Age < 18 yo
Pregnancy
Multiple painful injuries
Compromised sensation

78. Mortice view
• 10-15* INT rotation  offset intermalleolar axis
• Medial clear space > 4 to 5mm  lateral talar shift
• Talocrural angle  8-15*
• Talofibular overlap <1cm  syndesmotic disruption
• Talar shift >1mm abnormal

80. 10* internal rotation of 5th MT with respect to
vertical line

81. Shenton’s line of the ankle

85. Lateral view

86. •Posterior mallelolar fractures can be fractures can be identified.
AP Talar subluxation:
Dome of the talus should be centered under the tibia and congruous
with the tibial plafond.
Associated injuries to:
–Talus,
–Calcaneum

87. Stress projection for subluxation
• AP STRESS

88. • LATERAL STRESS

89. Management
definitive
Aim- restoration of complete normal anatomical alignment of ankle.
Patients if needs operation should be operated within 24hrs of injury
or after one week once the swelling subsides.
Undisplaced fracture medial malleolus :
Below knee POP cast for 6 weeks.
Reduction fails (may be due to soft tissue (periosteal) inter position)

90. Non operative
• nondisplaced, stable fractures,
• -Displaced fracture for stable anatomic reduction of ankle mortise is
achieved.
• -Patient not fit for surgery

91. Operative indications:
• Failure to achieve closed reduction
• Unstable #  talar displacement
• Widening of ankle mortise
• Open #

92. • Displaced:
• Open reduction and internal fixation by Cancellous screws group
• Tension band wiring Fracture lateral malleolus:
• Lateral Malleolus helps in length maintenance & maintenance of
ankle mortice.
• Hence, lateral malleolus has to be fixed internally

94. Ankle fracture fixation techniques

95. GATELLIER AND CHASTANG for LATERAL
MALLEOLUS
• Begin the incision about 12 cm proximal to the tip of the lateral
malleolus and extend it distally along the posterior margin of the
fibula to the tip of the malleolus. Curve the incision anteriorly for 2.5
to 4 cm in the line of the peroneal tendons
• Expose the fibula, including the lateral malleolus subperiosteally, and
incise the sheaths of the peroneal retinacula and tendons, permitting
the tendons to be displaced anteriorly.
• if the fibula is not fractured, divide it 10 cm proximal to the tip of the
lateral malleolus and free the distal fragment by dividing the
interosseous membrane and the anterior and posterior tibiofibular
ligament

97. • carefully preserve the calcaneofibular and talofibular ligaments to
serve as a hinge and to maintain the integrity of the ankle after
operation.
• Turn the fibula laterally on this hinge and expose the lateral and
posterior aspects of the distal tibia and the lateral aspect of the ankle
joint. Great care should be used in children to avoid creating a
fracture through the distal fibular physis when reflecting the fibula.
• When closing the incision, replace the fibula and secure it with a
screw extending transversely from the proximal part of the lateral
malleolus through the tibiofibular syndesmosis into the tibia just
proximal and parallel to the ankle joint

99. Approches to medial malleolus

100. Koenig and schaefer
• Curve the incision just proximal to the medial malleolus and divide the
malleolus with an osteotome or small power saw; preserve the attachment
of the deltoid ligament.
• Subluxate the talus and malleolus laterally to reach the joint surfaces.
• Later replace the malleolus and fix it with one or two cancellous screws. To
make replacement easier, drill the holes for the screws before the
osteotomy, insert the screw, and then remove it. At the end of the
operation, reinsert the screws and close the wound.
• The surfaces of the osteotomized bone are smooth, and the malleolus can
rotate on a single screw. Two screws are used to prevent rotation of the
osteotomized medial malleolus Interfragmentary technique should be used
for screw fixation of the medial malleolus to provide compression across
the osteotomy site

101. Colonna and ralston
• Begin the incision at a point about 10 cm proximal and 2.5 cm
posterior to the medial malleolus and curve it anteriorly and inferiorly
across the center of the medial malleolus and inferiorly and
posteriorly 4 cm toward the heel (Fig. 1-38C).
• Expose the medial malleolus by reflecting the periosteum, but
preserve the deltoid ligament.
• Divide the flexor retinaculum and retract the flexor halluces longus
tendon and the neurovascular bundle posteriorly and laterally.
• Retract the tibial posterior and flexor digitorum longus tendons
medially and anteriorly to expose the posterior tibial fracture

103. Lateral malleolar fixation
Lateral malleolar fractures
distal to syndesmosis: lag
screw or k- wire with
tension banding.
Lat. Malleolar fractures at
or above syndesmosis
require accurate reduction
and restoration of fibular
length: combination of lag
length

107. Posterior malleolor # indication
• Involvement of >25% of articular surface,
• -> 2mm displacement,
• -Persistent posterior subluxation of talus.
Fixation is achieved by indirect reduction and placement of an anterior
to posterior lag screw or a posteriorly placed plate.

116. Complications
Perioperative:
• Malreduction
• Inadequate fixation
• Intra-articular hardware penetration.

117. Early postoperative
• Wound edge dehiscence/ necrosis
• Infection

118. late
• Stiffness
• Persistent edema
• Malunion
• Nonunion
• Post traumatic arthritis
• Hardware related complications

119. Thank you