Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.
Philosophy of Malleolar  Fractures AO North America Podiatric Advanced Course Orlando, FL <ul><li>Shannon M. Rush,  DPM, F...
AO Philosophy <ul><li>Atraumatic technique </li></ul><ul><ul><li>Biologic dissection </li></ul></ul><ul><li>Anatomic reduc...
Philosophy of Malleolar Fractures <ul><li>Relevant preoperative factors  </li></ul><ul><ul><li>Patient’s age & health stat...
Philosophy of Malleolar Fractures <ul><li>Relevant surgical issues </li></ul><ul><ul><li>Fracture pattern </li></ul></ul><...
Ankle Biomechanics <ul><li>Subtalar Joint </li></ul><ul><ul><li>Torque converter </li></ul></ul><ul><ul><li>Influences tal...
Classification <ul><li>Lauge Hansen  </li></ul><ul><ul><li>Rotational injuries I-IV </li></ul></ul><ul><ul><li>Translation...
Muller AO Classification Infra-syndesmotic Trans-syndesmotic Supra-syndesmotic 44-A2 bifocal 44-A3 circumferential 44-B1 i...
Radiographic Evaluation <ul><li>AP View </li></ul><ul><ul><li>6 mm overlap </li></ul></ul><ul><ul><li>6 mm clear space </l...
Radiographic Evaluation <ul><li>Orthogonal views </li></ul><ul><li>Evaluate all views </li></ul><ul><li>Advanced imaging <...
Soft Tissue Injury Attention not just to the x-ray…. But to the leg as a functional organ.  -Tscherne <ul><li>Intuition ba...
Grading Soft Tissues <ul><li>Tscherne – 1984 </li></ul><ul><ul><li>Closed injuries </li></ul></ul><ul><ul><li>4 stages (0-...
Fracture Stability <ul><li>Ring of stabilty </li></ul><ul><ul><li>Malleoli (med, lat, post) </li></ul></ul><ul><ul><li>Del...
Closed Reduction <ul><li>Critical first step </li></ul><ul><li>Must eliminate medial tension! </li></ul><ul><ul><li>Evolvi...
Deltoid Complex <ul><li>Deltoid complex </li></ul><ul><ul><li>Superficial sleeve </li></ul></ul><ul><ul><li>Deep  </li></u...
<ul><li>Inversion mechanism (SAD) </li></ul><ul><ul><li>I – Transverse fibular fracture </li></ul></ul><ul><ul><ul><li>Lig...
44-B  Trans-Syndesmotic <ul><li>Rotational injury </li></ul><ul><ul><li>Most common – 70%+ </li></ul></ul><ul><li>Inversio...
43-C  Supra-Syndesmotic <ul><li>Eversion/External Rotation </li></ul><ul><ul><li>I – Medial fracture or deltoid  </li></ul...
Weber C Fracture <ul><li>Importance of plating </li></ul><ul><li>Length and Rotation </li></ul><ul><li>Reduction of deltoi...
Controversy Which is most important to stability? <ul><li>Historically important </li></ul><ul><li>Lateral buttress </li><...
Medial Stability  <ul><li>Medial fracture </li></ul><ul><ul><li>Antreior colliculus </li></ul></ul><ul><ul><li>Entire mall...
Deltoid Evaluation <ul><li>Clinical exam </li></ul><ul><ul><li>Tenderness, ecchymosis, edema? </li></ul></ul><ul><li>Manua...
Stress Evaluation Without anesthesia General anesthesia
Fibular Plating <ul><li>Lateral or Posterior </li></ul><ul><ul><li>Arguments for both </li></ul></ul><ul><ul><li>No absolu...
Medial Malleolar Fixation <ul><li>Open vs. PC techniques </li></ul><ul><ul><li>ST interposition </li></ul></ul><ul><li>Scr...
Age Related Issues <ul><li>Increasing prevalence </li></ul><ul><li>Higher degree injuries </li></ul><ul><li>Need for early...
Weight Bearing After ORIF  <ul><li>Control rotational forces </li></ul><ul><li>Considerations </li></ul><ul><ul><li>Deltoi...
Weight Bearing After ORIF Pitfalls <ul><li>PER </li></ul><ul><ul><li>Diastasis, deltoid, valgus hindfoot </li></ul></ul><u...
Philosophy of Malleolar Fractures <ul><li>Understand all components of the injury </li></ul><ul><li>Plan and execute prope...
Thank You [email_address]
ROM After ORIF <ul><li>Always appropriate </li></ul><ul><li>Compliance </li></ul><ul><li>Wound healing </li></ul><ul><li>E...
Upcoming SlideShare
Loading in …5
×

Philosophy Of Malleolar1

1,931 views

Published on

AO Talk

Published in: Health & Medicine, Business
  • Be the first to comment

Philosophy Of Malleolar1

  1. 1. Philosophy of Malleolar Fractures AO North America Podiatric Advanced Course Orlando, FL <ul><li>Shannon M. Rush, DPM, FACFAS </li></ul><ul><li>Department Of Orthopedics and Podiatric Surgery </li></ul><ul><li>Palo Alto Medical Foundation -Camino Division </li></ul><ul><li>Mountain View, CA </li></ul>
  2. 2. AO Philosophy <ul><li>Atraumatic technique </li></ul><ul><ul><li>Biologic dissection </li></ul></ul><ul><li>Anatomic reduction </li></ul><ul><ul><li>Articular vs extra-articular </li></ul></ul><ul><li>Stable internal fixation </li></ul><ul><ul><li>Early joint motion and WB </li></ul></ul><ul><li>Early functional rehabilitation </li></ul><ul><ul><li>Dependant on first three goals </li></ul></ul>
  3. 3. Philosophy of Malleolar Fractures <ul><li>Relevant preoperative factors </li></ul><ul><ul><li>Patient’s age & health status </li></ul></ul><ul><ul><li>Co-morbidities (DM, PVD, BMI) </li></ul></ul><ul><ul><li>Associated injuries </li></ul></ul><ul><ul><ul><li>Mobility </li></ul></ul></ul><ul><ul><li>Has the patient ambulated on the ankle? </li></ul></ul><ul><ul><ul><li>Compliance and stability </li></ul></ul></ul>
  4. 4. Philosophy of Malleolar Fractures <ul><li>Relevant surgical issues </li></ul><ul><ul><li>Fracture pattern </li></ul></ul><ul><ul><li>Soft tissue injury </li></ul></ul><ul><ul><li>Imaging </li></ul></ul><ul><ul><ul><li>Stress views </li></ul></ul></ul><ul><ul><ul><ul><li>Syndesmosis </li></ul></ul></ul></ul><ul><ul><li>Surgical planning </li></ul></ul><ul><ul><ul><li>Incision approach </li></ul></ul></ul><ul><ul><li>Fixation </li></ul></ul><ul><ul><ul><li>Fracture mechanics </li></ul></ul></ul>
  5. 5. Ankle Biomechanics <ul><li>Subtalar Joint </li></ul><ul><ul><li>Torque converter </li></ul></ul><ul><ul><li>Influences talar rotation </li></ul></ul><ul><li>Trochlear surface of talus </li></ul><ul><ul><li>Frustrum </li></ul></ul><ul><li>Rotational/translational forces </li></ul><ul><ul><li>Fracture patterns </li></ul></ul><ul><ul><ul><li>Shear, compression, avulsion </li></ul></ul></ul>
  6. 6. Classification <ul><li>Lauge Hansen </li></ul><ul><ul><li>Rotational injuries I-IV </li></ul></ul><ul><ul><li>Translational injuries I, II, III </li></ul></ul><ul><li>Reliability? </li></ul><ul><li>No absolute criteria </li></ul><ul><ul><li>20% variants </li></ul></ul><ul><li>Recognize skeletal and soft tissue component to injury </li></ul><ul><li>Determine degree of stability </li></ul><ul><li>Make appropriate surgical decisions </li></ul>
  7. 7. Muller AO Classification Infra-syndesmotic Trans-syndesmotic Supra-syndesmotic 44-A2 bifocal 44-A3 circumferential 44-B1 isolated lateral 44-B2 lateral and medial 44-B3 lateral, medial and posterior 44-C1 simple diaphyseal 44-C2 multifragmentary 44-C3 proximal 44-A1 unifocal
  8. 8. Radiographic Evaluation <ul><li>AP View </li></ul><ul><ul><li>6 mm overlap </li></ul></ul><ul><ul><li>6 mm clear space </li></ul></ul><ul><li>Mortise </li></ul><ul><ul><li>>1mm </li></ul></ul><ul><li>Dymanic exam! </li></ul><ul><li>No Lateral view criteria </li></ul>
  9. 9. Radiographic Evaluation <ul><li>Orthogonal views </li></ul><ul><li>Evaluate all views </li></ul><ul><li>Advanced imaging </li></ul><ul><li>Surgical decision making </li></ul>
  10. 10. Soft Tissue Injury Attention not just to the x-ray…. But to the leg as a functional organ. -Tscherne <ul><li>Intuition based on mechanism </li></ul><ul><li>Blisters </li></ul><ul><ul><li>60% infection rate (incision through blister) </li></ul></ul><ul><ul><ul><li>Prospective, n=1400 </li></ul></ul></ul><ul><ul><li>Early stabilization reduced blister formation </li></ul></ul><ul><ul><ul><ul><li>Varella et al: JOT, 1993 </li></ul></ul></ul></ul><ul><li>Surgical timing </li></ul><ul><li>Edema evolves for 36 hours </li></ul>
  11. 11. Grading Soft Tissues <ul><li>Tscherne – 1984 </li></ul><ul><ul><li>Closed injuries </li></ul></ul><ul><ul><li>4 stages (0-3) </li></ul></ul><ul><ul><ul><li>Contusion Internal degloving, necrosis of tissue </li></ul></ul></ul>
  12. 12. Fracture Stability <ul><li>Ring of stabilty </li></ul><ul><ul><li>Malleoli (med, lat, post) </li></ul></ul><ul><ul><li>Deltoid complex </li></ul></ul><ul><ul><li>Syndesmosis </li></ul></ul><ul><li>Single isolated injury </li></ul><ul><ul><li>Stable </li></ul></ul><ul><li>Combined injury </li></ul><ul><ul><li>Unstable </li></ul></ul><ul><li>A stability based ankle fracture classification system is prognostic. Better </li></ul><ul><li>radiographic results when decision for surgery is based on stability. </li></ul><ul><li>Michaelson et al. JOT 2007. </li></ul>
  13. 13. Closed Reduction <ul><li>Critical first step </li></ul><ul><li>Must eliminate medial tension! </li></ul><ul><ul><li>Evolving open fracture </li></ul></ul><ul><li>Fibula? </li></ul><ul><li>Quigley maneuver </li></ul><ul><ul><li>Internal rotation of foot </li></ul></ul>
  14. 14. Deltoid Complex <ul><li>Deltoid complex </li></ul><ul><ul><li>Superficial sleeve </li></ul></ul><ul><ul><li>Deep </li></ul></ul><ul><ul><li>Direct repair? </li></ul></ul><ul><li>Critical to motion </li></ul><ul><ul><li>Uncoupled talar rotation </li></ul></ul><ul><li>Fibular reduction </li></ul><ul><ul><li>Indirect repair </li></ul></ul>
  15. 15. <ul><li>Inversion mechanism (SAD) </li></ul><ul><ul><li>I – Transverse fibular fracture </li></ul></ul><ul><ul><ul><li>Ligament disruption </li></ul></ul></ul><ul><ul><li>II – Vertical medial fracture </li></ul></ul><ul><ul><ul><li>Articular impaction </li></ul></ul></ul><ul><li>Fixation techniques </li></ul><ul><li>Variant patterns </li></ul>44-A Infra-Syndesmotic
  16. 16. 44-B Trans-Syndesmotic <ul><li>Rotational injury </li></ul><ul><ul><li>Most common – 70%+ </li></ul></ul><ul><li>Inversion/External Rotation </li></ul><ul><ul><li>I – Anterior syndesmosis </li></ul></ul><ul><ul><li>II – Oblique fib. Frx </li></ul></ul><ul><ul><li>III – Posterolateral avulsion </li></ul></ul><ul><ul><li>IV – Deltoid rupture or medial avulsion fracture </li></ul></ul><ul><ul><li>“ V – Open medial” </li></ul></ul><ul><li>Syndesmosis instability? </li></ul><ul><ul><li>External rotation stress! </li></ul></ul><ul><li>Level of fibular fracture does not necessarily </li></ul><ul><li>correlate to the level of syndesmotic rupture. </li></ul><ul><li>Nielson et al. JOT 2004 </li></ul>
  17. 17. 43-C Supra-Syndesmotic <ul><li>Eversion/External Rotation </li></ul><ul><ul><li>I – Medial fracture or deltoid </li></ul></ul><ul><ul><li>II – Syndesmosis disruption </li></ul></ul><ul><ul><li>III – Fibular fracture </li></ul></ul><ul><ul><ul><li>Above syndesmosis </li></ul></ul></ul><ul><ul><li>IV – Posterior malleolar fracture </li></ul></ul><ul><li>Translational mechanism </li></ul><ul><ul><li>I – Medial fracture or deltoid </li></ul></ul><ul><ul><li>II – Fibular fracture </li></ul></ul><ul><ul><ul><li>Lateral spike or butterfly </li></ul></ul></ul>
  18. 18. Weber C Fracture <ul><li>Importance of plating </li></ul><ul><li>Length and Rotation </li></ul><ul><li>Reduction of deltoid </li></ul>
  19. 19. Controversy Which is most important to stability? <ul><li>Historically important </li></ul><ul><li>Lateral buttress </li></ul><ul><li>Restoring mortise </li></ul><ul><li>Primary stabilizer under physiologic loading </li></ul><ul><li>No abnormal motion without deltoid rupture </li></ul>Normal Talar rotation and translation depends on an intact deltoid complex. Uncoupled motion most obvious in plantarflexion. Michelsen et al. JBJS(A) 1996 An intact deltoid has the most influence on tibiotalar loading patterns. Earll et al. FAI 1996 Fibula Deltoid Complex
  20. 20. Medial Stability <ul><li>Medial fracture </li></ul><ul><ul><li>Antreior colliculus </li></ul></ul><ul><ul><li>Entire malleolus </li></ul></ul><ul><li>Stability with reduction? </li></ul>
  21. 21. Deltoid Evaluation <ul><li>Clinical exam </li></ul><ul><ul><li>Tenderness, ecchymosis, edema? </li></ul></ul><ul><li>Manual stress or gravity? </li></ul><ul><li>Radiographic evaluation </li></ul><ul><ul><li>Medial clear space? </li></ul></ul><ul><li>Manual and gravity stress are equivalent techniques. </li></ul><ul><li>Gill et al. JBJS(A) 2007 . (I) </li></ul><ul><li>Medial clear space is not an absolute indicator for deltoid rupture in the </li></ul><ul><li>4-6 mm range. Schuberth et al, JFAS 2004. (IV) </li></ul>
  22. 22. Stress Evaluation Without anesthesia General anesthesia
  23. 23. Fibular Plating <ul><li>Lateral or Posterior </li></ul><ul><ul><li>Arguments for both </li></ul></ul><ul><ul><li>No absolute rules </li></ul></ul><ul><li>Posterior plating </li></ul><ul><ul><li>Post. malleolar fracture </li></ul></ul><ul><ul><li>Post subluxation </li></ul></ul><ul><li>Fracture dictate? </li></ul><ul><li>Fibular reduction and fixation is critical with medial instability </li></ul><ul><li>Posterior plating best employed for bi or trimalleolar equivalent </li></ul><ul><li>fractures with posterior subluxation. </li></ul>
  24. 24. Medial Malleolar Fixation <ul><li>Open vs. PC techniques </li></ul><ul><ul><li>ST interposition </li></ul></ul><ul><li>Screws vs. tension band </li></ul><ul><li>Plating </li></ul><ul><ul><li>Anti-glide </li></ul></ul><ul><ul><li>Buttress </li></ul></ul>
  25. 25. Age Related Issues <ul><li>Increasing prevalence </li></ul><ul><li>Higher degree injuries </li></ul><ul><li>Need for early mobilization </li></ul>
  26. 26. Weight Bearing After ORIF <ul><li>Control rotational forces </li></ul><ul><li>Considerations </li></ul><ul><ul><li>Deltoid rupture/dislocation </li></ul></ul><ul><ul><li>Syndesmosis </li></ul></ul><ul><ul><li>Large PM fracture </li></ul></ul><ul><li>Wound complications </li></ul><ul><li>Early WB facilitates recovery and return to earlier RTW. Cuts time to FWB in half. </li></ul><ul><li>Simanski et al. JOT 2006 (II) </li></ul><ul><li>Functional brace has a higher risk of wound complications than SLC after ORIF. </li></ul><ul><li>Lehtonen et al. JBJS(A) 2003 (I) </li></ul><ul><li>Early ROM and WB facilitates recovery as well as improved subjective and </li></ul><ul><li>objective clinical outcomes. </li></ul><ul><li>Functional bracing should be used when the incision is healed, stable fixation, </li></ul><ul><li>and a motivated compliant patient. </li></ul>
  27. 27. Weight Bearing After ORIF Pitfalls <ul><li>PER </li></ul><ul><ul><li>Diastasis, deltoid, valgus hindfoot </li></ul></ul><ul><li>SAD </li></ul><ul><li>Vertical medial fracture with varus hindfoot </li></ul>
  28. 28. Philosophy of Malleolar Fractures <ul><li>Understand all components of the injury </li></ul><ul><li>Plan and execute proper techniques </li></ul><ul><li>Pay close attention to fixation </li></ul><ul><li>Plan post operative care prior to surgery </li></ul><ul><li>Encourage early WB when safe </li></ul><ul><li>Encourage ROM when incisions allow </li></ul>
  29. 29. Thank You [email_address]
  30. 30. ROM After ORIF <ul><li>Always appropriate </li></ul><ul><li>Compliance </li></ul><ul><li>Wound healing </li></ul><ul><li>Exact formula? </li></ul>

×