2. Frequent site of injuries
A large variety of bending and twisting force result
in a number of fractures and fracture-dislocation -
'Pott's fracture’
3. ANATOMY
A modified hinge-joint
The 'socket’ is formed by...
Distal articular surfaces of the tibia and fibula
The intervening tibio-fibular ligament
The articular surfaces of the malleoli
Ankle-mortice
The superior articular surface of the talus
articulates with this socket
4. The strong tibio-fibular syndesmosis,
along with the medial and lateral
malleoli make the ankle a strong and
stable articulation
Therefore, pure dislocation of the ankle
is rare
Commonly, dislocation occurs only with
fractures of the malleoli
The elongated posterior part of the
distal articular surface of the tibia often
gets chipped-off in ankle injuries, and is
termed a posterior malleolus
5. Ligaments of the ankle:
Two main ligaments
Medial collateral ligament (deltoid ligament):
Strong ligament on the medial side
Superficial - tibio-calcaneal
Deep - tibio-talar
Lateral collateral ligament:
Weak ligament and is often injured
Three parts:
Anterior talo-fibular
Calcaneo-fibular in the middle
Posterior talo-fibular
6.
7. SOME TERMS USED IN RELATION TO ANKLE
INJURIES
Inversion (adduction): Inward twisting of the ankle
Eversion (abduction): Outward twisting of ankle
Supination: Inversion plus adduction of the foot so that the
sole faces medially
Pronation: Eversion and abduction of the foot so that the sole
faces laterally
Rotation (external or internal): A rotatory movement of the
foot so that the talus is subjected to a rotatory force along its
vertical axis
Vertical compression: A force along the long axis of the tibia
8. THE LAUGE-HANSEN CLASSIFICATION
It is believed that a specific pattern of bending and
twisting forces results in specific fracture pattern
Five basic mechanisms
Adduction injuries
Abduction injuries
Pronation-external rotation injuries
Supination external rotation injuries
Vertical compression injuries
When a foot is subjected to these forces, different
parts of the ankle-mortice are subjected to distraction
and compression stress. The specific fracture-pattern
depends on the type of stress and its severity
9. ADDUCTION INJURIES (INVERSION)
An inversion force with the foot in plantar-flexion
results in a sprain of the lateral ligament of the
ankle
Partial or complete rupture
A partial rupture - limited to the anterior
fasciculus of the lateral ligament (talo-fibular
component)
A complete rupture - tear extends backwards to
involve the whole of the lateral ligament
complex
The talus tends to subluxate out of the ankle-
mortice
10. The inversion force on an ankle in neutral or
dorsiflexed position results in…
A fracture of the medial malleolus - typically
fracture-line running obliquely upwards from the
medial angle of the ankle-mortice
On the lateral side - may be associated with a
low-transverse (below the ankle-mortice)
fracture of the lateral malleolus, or a lateral
ligament rupture(avulsion injury)
11. ABDUCTION INJURIES (EVERSION)
The medial structures - subjected to a
distracting force and the lateral structures to
compressive force
Results in rupture of the deltoid ligament or
a low-lying transverse fracture of the medial
malleolus (avulsion fracture on the medial
side)
On the lateral side - a fracture of the lateral
malleolus at the level of the ankle-mortice
with comminution of the outer cortex occurs
The talus, with two fractured malleoli
subluxates laterally
12. PRONATION – EXTERNAL ROTATION INJURIES
When a pronated foot rotates externally,
the talus also rotates outwards along its
vertical axis
The first structures to give way are those
on the medial side
There may occur a transverse fracture
of the medial malleolus at the level of the
ankle-mortice, or a rupture of the medial-
collateral ligament
13. With further rotation of the talus, the anterior tibio-fibular
ligament is torn
This is followed by a spiral fracture of the lower end of the
fibula as the rotating talus hits the lateral malleolus
In the case where the tibio-fibular syndesmosis is completely
disrupted, the fracture occurs above the syndesmosis i.e.,
in the lower-third of the fibula
At times the fracture may occur as high as the neck of the
fibula – Massonaie’s fracture
Thus a fracture of the fibula above the ankle-mortice, in an
ankle injury, is an indication of disruption of the tibio-
fibular syndesmosis
14. SUPINATION – EXTERNAL ROTATION INJURIES
With the foot supinated, the talus twists
externally within the mortice
As the medial structures are lax, the
first structure to give way are those on
the lateral side, the head of the talus
striking against the lateral malleolus,
producing a spiral fracture at the level
of the ankle-mortice
The next structure to break is the
posterior malleolus
15. As the talus rotates further, it hits against the medial
malleolus resulting in a transverse fracture
The tibio-fibular syndesmosis remains intact
In extreme cases, the whole foot along with the
three malleoli, is displaced
16. VERTICAL COMPRESSION INJURIES
All the above injuries may become
complex due to a component of vertical
compression force
It may be primarily a vertical
compression injury resulting in either an
anterior marginal fracture of the tibia or
a comminuted fracture of the
tibial articular surface with a fracture
of the fibula - Pilon fracture
17. CLINICAL FEATURES
H/o twisting ankle injury followed by pain and swelling
Often the patient is able to express exactly
the way the ankle got twisted
On examination:
The ankle is found to be swollen
The swelling and tenderness may be localised to the
area of injury (bone or ligament)
Crepitus may be noticed if there is a fracture
The ankle may be lying deformed (adducted or abducted, with
or without rotation)
18. RADIOLOGICAL EXAMINATION
X- ray AP and lateral view
The fracture line of the medial and lateral malleoli should
be studied in order to evaluate the type of ankle injury
(Lauge-Hansen classification).
Small avulsion fractures from the malleoli are sometimes
missed. These often have attached to them the whole
ligament
Tibio-fibular syndesmosis:
All ankle injuries where the fibular fracture is above the
mortice, the syndesmosis is bound to have been
disrupted
In injuries where the fibular fracture is at the level of the
syndesmosis, one must carefully look for any lateral
subluxation of the talus; if it is so, width of the joint space
between the medial malleolus and the talus will be more
than that between the weight-bearing surfaces of tibia
and talus
19. A posterior subluxation of the talus
should be looked for on the lateral X-
ray
A soft-tissue swelling on the medial or
lateral side in the absence of a fracture,
must arouse suspicion of a ligament
injury
This should be confirmed or ruled out after
thorough clinical examination and stress
X-rays
20. TREATMENT
Principles of Treatment:
The basic principle of treatment is to achieve
anatomical reconstruction of the ankle-mortice so as to
regain good function and minimise the possibility of
osteoarthritis developing later
In some cases, it is possible to do so by conservative
methods
In most an operative reduction and internal fixation is
required
21. FRACTURES WITHOUT DISPLACEMENT
Sufficient to protect the ankle in a below-knee
plaster for 3-6 weeks, followed by physiotherapy
22. FRACTURES WITH DISPLACEMENT
The aim of treatment:
To ensure anatomical reduction of the ankle-mortice
This means ensuring anatomical reduction of medial
and lateral malleoli, and that the talus is placed normally
within the mortice
Operative methods
Conservative methods
23. OPERATIVE METHODS
Internal fixation for all displaced fractures of ankle with
or without attempting closed reduction
By operative reduction it is possible to achieve perfect
alignment as well as stable fixation of fragments
Allows early motion of the ankle joint, thereby
improving overall results
In general, operative reduction and internal fixation may
be used in cases…
Where closed reduction has not been successful
The reduction has slipped during the course of conservative
treatment
25. Posterior malleolus:
Involving less than one-third of the articulating surface
of the tibia - no additional treatment
Involving more than one-third of the articulating surface
of the tibia - internal fixation with compression screws
Tibio-fibular syndesmosis disruption: needs to be
treated by inserting a long screw from the fibula into the
tibia
All major ligament injuries e.g., that of deltoid
ligament, lateral ligament should be repaired
26. CONSERVATIVE TREATMENT
It is often possible to achieve a good reduction by
manipulation under general anaesthesia
The essential feature of the reduction is to
concentrate on restoring the alignment of the foot to
the leg
By doing so the fragments automatically fall into
place
Once reduced, a below knee plaster cast is applied
27. If the check X-ray shows a satisfactory position, the
plaster cast is continued for 8-10 weeks
The patient is not allowed to bear any weight on the
leg during this period
Check X-rays are taken frequently to make sure
that the fracture does not get displaced
If everything goes well, the plaster is removed after
8-10 weeks and the patient taught physiotherapy to
regain movement at the ankle.
28. External fixation:
Required in cases where closed methods cannot be
used e.g. open fractures with bad crushing of the
muscles and tendons, with skin loss around the ankle
29. COMPLICATIONS
More serious fracture-dislocation may
be complicated because of improper treatment
Sometimes, the nature of injury is such that perfect
functions cannot be restored
30. Stiffness of the ankle:
Following immobilisation in plaster, stiffness occurs
In ankle injuries, the recovery takes a long time because
of the tendency for gravitational oedema
Most common in elderly persons
With persistent treatment, using limb elevation, crepe-
bandage and active toe movements, the oedema
subsides
It may be necessary to continue ankle exercises for a
long period (6-8months)
31. Osteoarthritis:
Since most ankle fractures involve the articular surfaces,
anything short of a perfect anatomical reduction with smooth
and congruous joint surfaces will lead to wear and tear
of the articular cartilage
This will start the process of degenerative osteoarthritis
The greater the irregularity of the articular surfaces, the more
rapidly will the degenerative changes occur
The patient will complain of persistent pain, swelling
and joint stiffness
In severe cases – ankle arthrodesis
32. DUPUYTREN'S FRACTURE
An eponyms for a bi-malleolar ankle fracture
accompanied by a rupture of tibio-fibular ligament
and talar subluxation or dislocation that may follow
diastasis
