Ankle injury

1. INJURIES AROUND ANKLE JOINT
AND IT’S MANAGEMENT

2. INTRODUCTION
 Ankle injury refers to disruption of any
component or components of the ankle
joint following trauma.
 Ankle injuries occur frequently, and have
high propensity for complications.

3. ANATOMY
 Ankle joint is a synovial joint of hinge variety

4.  Bony mortise- quadrilateral
shape
 Posterolateral position of
fibula
 Ligaments
3 groups
-Lateral
-Medial
-Syndesmotic

5. ANKLE JOINT IS SUPPORTED BY
 Fibrous capsule
 Deltoid ligament
A. Superficial
a. Anterior-
Tibionavicular
b. Middle-
Tibiocalcanean
c. Posterior- Posterior
tibiotalar
B. Deep : Anterior-
Tibiotalar

6.  Lateral ligament
 Anterior- Talofibular
 Posterior- Talofibular
 Calcaneofibular

7. SYNDESMOTIC LIGAMENTS
 Ant inf tibio fib
 Supf post tibio fib
 Deep post tibio fib
 Interosseous lig

8. ACUTE LIGAMENTOUS INJURY
 Type I sprain- minor
 Type II sprain - incomplete
 Type III sprain - complete

9. TREATMENT
 LIGAMENT INJURY
 Non-operative treatment
 Achieved by RICE
 Operative treatment
 Indicated when problems persist after 12 weeks of treatment
including physiotherapy
 Associated fracture

10. CLASSIFICATIONS
 LAUGE HANSEN

11. LAUGE HANSEN
1. Position of foot at
injury-
Pronation/Supination
2. Deforming force-
Abduction/ adduction/
external rotation
 Most Common
mechanism of injury- SER
 Most Common unstable
ankle fracture variant- SER

12. LAUGE HANSEN
 SUPINATION ADDUCTION
 SUPINATION EXT ROT
 PRONATION ABDUCTION
 PRONATION EXT ROT
 PRONATION DORSIFLEX

13. Maisonneuve’s fracture
 High spiral oblique fracture
of upper 3rd fibula with ankle
PER injury

14. TYPES OF INJURIES
 Soft tissue injuries
 Ligament injuries
 Lateral collateral ligament injury
 Deltoid ligament injury
 Syndesmotic injury
 Fractures
 Malleolar fractures
 Pilon fractures
 Physeal injuries

15. DIAGNOSIS

16. RADIOLOGICAL VIEWS
 AP / LAT ANKLE
 AP/OBLIQUE FOOT
 AP MORTISE ANKLE

17. OTHER INVESTIGATIONS
 ARTHROGRAPHY
 ARTHROSCOPY
 CT SCAN
 MRI
 BONE SCAN

18. AP VIEW
 SYNDESMOSIS
 Tibiofibular overlap<10mm
 MALLEOLAR LENGTH
 Talocrural angle 83+_4 deg
 TALAR TILT
- sup clear space- med clear space
diff <2mm

19. MORTISE VIEW

20. What else to see in x-rays
LAT MALLEOLUS
 Level of fracture
 Orientation of fracture
 Fracture comminution
MED/POST MALLEOLUS
 Size
 Assoc plafond #
 Assoc syndesmotic injury

21. SYNDESMOTIC INJURY

25. Pott’s Fracture
 Fracture involving the ankle joint
loosely referred to as Pott’s Fracture
1. First degree single malleolus fractured.
2. In second degree two malleoli are
fractured.
3. In third degree there is bimalleolar
fracture with a fracture of posterior part
of inferior articular surface of the tibia
referred to as third malleolus. (Tri
Malleolar fracture)

26. MANAGEMENT
 RICE
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)

27. 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.

28. TIBIAL PILON FRACTURES
 Intraarticular fracture of distal tibia.
 Fibula is fractured in 85% of these patients.

30. TIBIAL PILON FRACTURE
1. Plaster immobilization
2. Traction
3. Lag screw fixation
4. OR & IF with plates
5. External fixation with or without limited
internal fixation
If articular incongruity <2 mm
and reserved for low energy
injuries

31. COMPLICATIONS
 Malunion- may result in posttraumatic arthritis and
painful movements.
 Nonunion of medial malleolus- commonly due to
interposition of fractured periosteum between two
fragments.
 Repeated edema
 Sudeck’s Osteodystrophy

32. TALUS FRACTURE

33. Anatomy-parts
 Head-articulate with
navicular
 Neck-nonarticular
 Body-articulate with tibia
and calcaneus
 No muscular or tendinous
attachment

34. Blood supply
 Extraosseous supply
 Posterior tibial a. tarsal canal a.
 Anterior tibial a.  sinus tarsi a
 Peroneal a. sinus tarsi a.
 Intraosseous supply
 Talar head
 Talar body
-anastomosis between tarsal canal a. and
tarsal sinus a.

35. Talar head fracture
 5~10% of all talus fracture

36. Talar neck fracture
 Aviator’s astragalus
 High energy injury, hyperdorsiflexion
 15~20% open fracture
 Associated with malleloar fracture(25% of cases), medial
malleolus is more common
 High risk of soft tissue injury and compartment syndrome

37. Classification-Hawkins
classification
nondisplaced
Displaced
Subtalar subluxation
Ankle dislocation
(Talar body dislocation)
Talonavicular
dislocation

38. Treatment
 Hawkins type I
 4~6 weeks of no weightbearing in a short leg cast
walking cast for 1~2 months
 Percutaneous screw fixation

39. Treatment
 Hawkins type II
 Orthopaedic emergency: traction and plantar flexion by
manipulation anatomic reduction(50%)  treated as type
I
 Open reduction: screw placed across the neck fracture

40. Treatment
 Hawkins type III
 ORIF and Skeletal traction
through the calcaenus
 Open fracture (> type III)
:talar body excision followed
By primary tibiocalcaneal or
Blair-type arthrodesis
 Hawkins type IV
 Rare injury
 As type II

41. Complication
 Skin necrosis and infection
 Delayed union or nonunion
 Malunion
 Posttraumatic arthritis
 Osteonecrosis

42. Calcaneal fracture

43. Anatomy
 Largest, most irregularly shaped bone in foot
 Large calcellous bone and multiple processes
 Achilles tendon posteriorly and plantar fascia inferiorly : tuberosity
 Posterior facet: talar lateral process and body
 Middle facet: Sustentacular fragment (flexor hallucis longus pass)
 Anterior process: cuboid

44. Calcaneal fracture
 Classification
 Essex-Lopresti
--Extraarticular(25%) v.s intraarticular(75%) fracture
 Sanders
--CT classification of intraticular calcaneal fracture

45.  Associated injuries
 A fall from a height or high–energy mechanisms
 10% lumbar spine fracture(L1); 10% of calcaneal fracture are bilateral

46. Broden’s view showing the depressed
posterior facet
varus position of the tuberosity
↓ ↑

47. Intraarticular fracture
(joint depression and tongue type)
 Mechanism injury
 Axial loading
 Radiography
 Loss of Bohler’s and Gissane’s angles

48. Intraarticular fracture
Joint-depression type, in which the
primary fracture line exited the bone
close to the subtalar joint
tongue-type, in which the primary
fracture line exited the bone posteriorly

49. Intraarticular fracture
--Treatment
 Nondisplaced articular fractures
 Bulky (Robert-jones) dressing: active subtalar ROM, prohibit
weightbearing walking 8~12 wks later
 Displaced intraarticular fracture with large fragment
 ORIF

50. Intraarticular fracture
--Treatment
 Displaced intraarticular fracture with severe comminution
 Increasing intraarticualr comminution leads to less satisfactory
results
 ORIF  primary arthrodesis
 Restoring the heel width and height

51. Intraarticular fracture
--complications
 Soft tissue breakdown
 Local infection
 Subtalar arthritis

52. ANKLE AND FOOT INJURIES
Q1) The stability of the ankle joint is maintained by all of
the following except
a. Spring ligament
b. Deltoid ligament
c. Lateral ligament
d. Shape of the superior talar articular surface

53. Q2) The most commonly affected component of lateral
collateral ligament complex in an ankle sprain
a. Anterior talo fibular ligament
b. Posterior talo fibular ligament
c. Calcaneofibular Ligament
d. None

54. Q3) Ankle sprain is due to
a. Rupture of anterior talo-fibular ligament
b. Rupture of posterior talo-fibular ligament
c. Rupture of deltoid ligament
d. Rupture of calcaneo-fibular ligament

55. Q4) Mechanism of injury of transverse fracture of medial
malleolus is
a. Abduction injury
b. Adduction injury
c. Rotation injury
d. Direct injury

56. Q5) Cottons fracture is
a. Avulsion fracture of C7
b. Bimalleolar fracture
c. Trimalleolar fracture
d. Burst fracture of the Atlas
e. None of the above

57. Q6) Bimalleolar fracture is synonymous to
a. Cottons
b. Potts
c. Pirogoffs
d. Dupuytrens

58. Q7) Avascular necrosis is a complication of
a. Fracture neck talus
b. Fracture medial condyle femur
c. Olecranon fracture
d. Radial head fracture

59. Q8) POP cast in equinus position is indicated in
a. Distal fracture both bone leg
b. Distal fracture fibula
c. Bimalleolar
d. Fracture Talus

60. Q9) Gissane’s angle in intra-articlar fracture calcaneum is
a. Reduced
b. Increased
c. Not changed
d. Variable

61. Q10) Bohler’s angle is decreased in fracture of
a. Calcaneum
b. Talus
c. Navicular
d. Cuboid

62. Q11) Stress fractures are most commonly seen in
a. Tibia
b. Fibula
c. Metatarsals
d. Neck of femur

63. Q12) Neutral triangle is seen radiologically in
a. Calcaneum
b. Talus
c. Naviuclar
d. Tibia