Ankle fractures


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Ankle fractures

  1. 1. ANKLE INJURIES praveen reddy p
  2. 2. Surgical anatomy of anklejoint Saddle shaped joint Three bone joint – tibia, fibula and talus Tibia - tibial plafond and medial malleolus Fibula – lateral malleolus Large surface of talar dome anteriorly and laterally
  3. 3. Continued.. This configuration provides stability in dorsi flexion and relative mobility in plantar flexion# DORSI FLEXION - close packed position - stability by articular contact# PLANTAR FLEXION – stability principally by ligamentous structures
  4. 4. TIBIA Lower end formed by five surfaces, # inferior,anterior,posterior,lateral,medial` inferior surface is concave antero-posteriorly and convex transversely` posterior border is lower than the lateral border` lateral border is concave with two tubercles – anterior and posterior
  5. 5. TIBIA Anterior tubercle over laps fibula - forms the basis for radiological tibio-fibular syndesmotic assessment Posterior tubercle remains intact – forms the basis for indirect reduction of posterior malleolar fragment
  6. 6. MEDIAL MALLEOLUS Articular surface is comma shaped Posterior border includes groove for tibialis posterior Composed of two colliculi seperated by inter collicular groove Deep component of deltoid attaches to inter collicular groove Superficial component attaches to medial and anterior border of anterior colliculus
  7. 7. FIBULA Two major surfaces, medial and lateral which widen to three surfaces at tibial plafond# anteriorly - ant tibio-fibular - ant talo-fibular# inferiorly - calcaneo-fibular# posteriorly - post tibio-fibular
  8. 8. TALUS Covered entirely by articular cartilage, no musculo-tendinous attachment Trapezoidal – ant surface wider than the post surface
  9. 9. LIGAMENTS syndesmotic - ant tibio-fibular - post tibio-fibular – strongest - int-osseous ligament Lateral collateral - ant talo-fibular - calcaneo-fibular - post talo-fibular Deltoid - superficial - deep – primary medial stabiliser
  13. 13. Patient Evaluation History  Mechanism  Time since injury  Associated injuries  Comorbidities  Diabetes  Neuropathy  Obesity  Alcoholism / drug abuse
  14. 14. Physical Exam Note obvious deformities Neurovascular exam Pain to palpation of malleoli and ligaments Palpate along the entire fibula Pain at the ankle with compression  syndesmotic injury Examine the hindfoot and forefoot for associated injuries
  15. 15. Ankle Injuries type I — Only a few fibers are stretched or torn, so ankle is mildly tender and painful, but muscle strength is normal.
  16. 16. Ankle Injuries Type II — A greater number of fibers are torn, so there is severe pain and tenderness, together with mild swelling, noticable loss of strength and sometimes bruising
  17. 17. Ankle Injuries Type III — The ligaments tear all the way through, rip into two separate parts, there will be considerable pain, swelling, tenderness and discoloration.
  18. 18. Ankle Injuries Sprains / Strains – 80% of sprains are caused by ankle inversion. Inversion sprains cause damage to the lateral ligaments
  19. 19. RADIOLOGYOTTAWA ANKLE RULES# x-rays indicated only if ` pain near malleoli ` inability to bear weight ` bony tenderness at the tip of the malleolus or post edge# 100% sensitive, decreased cost and patient waiting time
  20. 20. X - RAYS On plain x-rays – there is continous condensed sub chondral bone around the talus that extends from sub chondral bone of distal tibia to medial aspect of fibula
  22. 22. A-P VIEW Tibio-fibular overlap  <10mm implies syndesmotic injury Tibio-fibular clear space  >5mm implies syndesmotic injury Talar tilt  >2mm is considered abnormal
  23. 23. MORTISE VIEWAP view of ankle with foot internally rotatedAbnormal findings:  medial joint space widening  tibia/fibula overlap <1mm
  24. 24. LATERALVIEW Posterior malleolus fracture Subluxation of the talus Angulation of distal fibula Talus fractures Calcaneus fractures
  25. 25. STRESS VIEWS Demonstrate ligamentous or syndesmotic disruption May require sedation or hematoma block Comparison with contralateral ankle
  26. 26. LAUGE HANSEN”S Associates specific fracture patterns with mechanism of injury Two-term scheme 1. Position of foot Supination (lateral) Pronation (medial) 1. Direction of force Adduction / abduction External rotation Dorsiflexion
  27. 27. LAUGE HANSEN”S Genetic classification Six groups of injuries # abduction injuries # adduction injuries # ext rotation injuries with diastasis of inferior tibio-fibular jt - pronation external rotation injuries # ext rotation injuries with out diastasis of inferior tibio-fibular jt - supination external rotation injuries # vertical compression injuries # uncommon unclassifiable injuries
  28. 28. LAUGE HANSEN”S Continues to form the basis of our understanding of mehanism of injury Provides good guide to prognosis after both operative and conservative methods
  29. 29. WEBER”S Type A # below syndesmosis Type B # at the level of syndesmosis Type C # above the level of syndesmosis
  30. 30. WEBER”S
  31. 31. WEBER”S Attractive for its simplicity and its guided treatment Level of fibular fracture exclusively to guide treatment isn’t accurate enough Degree of syndesmotic injury not always accurately predicted Ignores medial side of the injury
  32. 32. Surgical technique Standard AO fixation Inter-fragmentary screw and 1/3 tubular neutralisation plate for fibula and lag screw fixation for medial malleolus Syndesmosis screw is required if fibula is unstable at end of fixation (engage 3 cortices and ensure the ankle is at 90º when inserting screw, and that the screw is not lagged) Screw needs to be removed before weight bearing can be commenced Alternative fixation for Type B fractures of the fibula is the anti-glide plate which has been shown to be biomechanically superior to a lateral plate Posterior malleolus fractures need to be fixed if there is > 25% of the articular surface involved. This is often underestimated on lateral radiographs
  33. 33. ABDUCTION INJURY Talus forcibly abducted in ankle mortise producing traction on medial structures - # pull off fracture of medial malleolus or rupture of deltoid ligament # lateral compression force produces a lower fibular fracture with characteristic lateral comminution # doesnot produce seperation of tibio-fibular jt b’cos combined strength of three ligaments is greater than lat malleolus # rarely if associated with vertical compression can cause en- bloc avulsion of incisura fibularis
  34. 34. DIAGNOSIS Valgus deformity of foot Swelling over both medial and lateral aspect
  35. 35. TREATMENT Undisplaced isolated med malleolus fractures – # b/k plaster cast for six weeks # rehabilitation
  36. 36. TREATMENT Displaced / irreducible – due to soft tissue interposition, # 4mm cancellous screw #TBW # inter-fragmentary screw
  37. 37. TREATMENT FIBULA – minimal comminution # b/k cast - severe comminution # 1/3rd tubular plate
  38. 38. ADDUCTION INJURY Traction on the lateral structures # forcible inversion of the plantar flexed foot > ant talo-fibular tear # forcible inversion at right angle > tear of all 3 lateral ligaments or lateral malleolus fracture > compression injury of the medial malleolus causing vertical fracture +/- depression of articular surface
  39. 39. ADDUCTION INJURY -TREATMENT Isolated tear of ant talo-fibular ligament # eversion stirrup and elastic bandaging # adhesion formation - pain, weakness, giving way - outer side heel raise - Inj hydrocortisone + hyaluronidase
  40. 40. ADDUCTION INJURY -TREATMENT Complete tear of lateral structures- # talus will move away from malleolus and well defined sulcus appears between the two bones Marked talar tilt on stress x-rays Can lead to recurrent dislocation if not treated
  41. 41. ADDUCTION INJURY -TREATMENT Complete immobilisation in a plaster cast for 6-8 weeks and rehabilitation Recurrent dislocation – # evan’s procedure
  42. 42. EX ROTATION INJ WITH INFTIBIO-FIBULAR JTDIASTASIS Also known as PRONATION-EXTERNAL ROTATION FRACTURE Three types – # isolated fracture of med malleolus # partial diastasis of the inf tibio-fibular joint # complete diastasis of the inf tibio- fibular joint
  43. 43. EX ROTATION INJ WITH INFTIBIO-FIBULAR JTDIASTASIS Isolated med malleolus fracture - # b/k plaster cast for 6-8 weeks # ORIF
  44. 44. EX ROTATION INJ WITH INFTIBIO-FIBULAR JTDIASTASISPartial diastasis of the inf tibio-fibular jt# reducible – a/k plaster cast in slightly inverted and firmly int rotated position (fibula winds itself up on the intact post ligament which serves to locate it well in its groove in the tibia – incisura fibularis)# irreducible – ORIF
  45. 45. EX ROTATION INJ WITH INFTIBIO-FIBULAR JTDIASTASIS Complete diastasis of the inf tibio-fibular joint ORIF - post op immobilisation - plaster cast for 6-8 weeks
  46. 46. EX-ROTATION INJ WITHOUTINF TIBIO-FIBULAR JTDIASTASIS Also known as SUPINATION- EXTERNAL ROTATION FRACTURE Oblique fracture of the lower fibula Fracture dislocation without inf tibio- fibular joint diastasis
  47. 47. EX-ROTATION INJ WITHOUTINF TIBIO-FIBULAR JTDIASTASIS Oblique fracture of the lower fibula # b/k plaster cast application for 4 weeks
  48. 48. EX-ROTATION INJ WITHOUTINF TIBIO-FIBULAR JTDIASTASIS Fracture dislocation without inf tibio-fibular joint diastasis # reduction – cupping back the heel in one hand, gently pull forwards and inwards and at the same time with the other hand apply counter over the medial side of tibial shaft # ORIF
  49. 49. Operative Tips Lateral Malleolus  Reduce first  Proximal fragment (shaft) needs reduction  3 bicortical screws into proximal fibula  Unicortical screws into intra-articular portion  Be certain fibula is out to length
  50. 50. ISOLATED LATERAL MALLEOLAR #` Reduce & internally fix lateral malleolar # first in case of a bimalleolar #.` If the # is oblique, fix it with two lag screws 1cm apart.` If the # is transverse, fix it with a rush rod / IL fibular rod.` If the # is small & below the plafond and has good bone stock, it is fixed with a 4.5mm malleolar screw. In patients with poor bone stock tension band technique is used.` If the # is above the syndesmotic level, a small fragment 1/3rd tubular plate or a 3.5mm DCP can be used, If the plate is placed posterolaterally it acts as a antiglide plate.
  51. 51. Operative Tips Medial malleolus  Open reduction  Visualize the ‘shoulder’ of the malleolus  Remove interposed soft tissue and intraarticular fragments  Two points of fixation  Anti-glide plate for vertical fractures
  52. 52. ISOLATED MED. MALLEOLAR #` Non displaced #: cast immobilisation.` Avulsion # of the malleolar tip: no fixation required unless displaced.` Fixation usually requires two 4mm cancellous lag screws oriented perpendicular to the #.` Vertically oriented # requires horizontally placed screws.` Smaller fragments require one lag screw & a k-wire to prevent rotation.` Fragments too small or comminuted are fixed with tension band technique.` Vertical # extending into metaphysis requires semitubular buttress plate for fixation.
  53. 53. Medial MalleolusFixation
  54. 54. Posterior Malleolus Repair if >25% of articular surface Reduce by ankle dorsiflexion Clamp through fibular incision Anterior lag screws
  55. 55. Maissoneuve Fracture Fracture of proximal 1/3 of fibula +/- medial malleolar fracture Pronation-external rotation mechanism Requires reduction and stabilization of syndesmosis
  56. 56. Maissoneuve Fracture Fracture of proximal 1/3 of fibula +/- medial malleolar fracture Pronation-external rotation mechanism Requires reduction and stabilization of syndesmosis
  57. 57. BIMALLEOLAR FRACTURE` Non union reported in 10% of bimalleolar # treated with closed methods.` Tile & AO group recommends ORIF of almost all bimalleolar #s.` Most Weber type B & C lateral malleolar #s are stabilised with plate & screw fixation.
  58. 58. DELTOID LIG.TEAR & LATERAL MALLEOLAR#` Supination- external rotation injury.` Associated with tear of the anterior capsule.` Stress x-ray with the supinated & externally rotated shows talar tilting with a widened medial clear space.` 1mm lateral shift of talus reduces the effective wt. bearing area of the talo-tibial articulation by 20-40%.` Optimal treatment of this injury provided skin condition, patient age & general condition permits, consists of ORIF of fibula with /without deltoid ligament repair.` Lateral malleolar # is fixed before the repair of deltoid ligament.
  59. 59. TRIMALLEOLAR FRACTURE` Usually caused by abduction or external rotation injury` Components - medial malleolar #/deltoid lig.rupture, fibular # & # of the posterior lip of the articular surface of tibia` 500 external rotation view - assessment of size & displacement of posterior malleolar fragment.` Fragment size > 25-30% of the wt. bearing surface requires ORIF` Posterior lip # should be fixed before reduction of either the medial or lateral malleolar #
  60. 60. SYNDESMOTIC INJURIES Pronation- external rotation, pronation abduction and supination external rotation injuries. Syndesmotic injuries extending > 4.5cm proximal to the ankle jt alter the joint mechanics, but that extending < 3cm proximal to the joint dont. INDICATIONS FOR FIXATION:i. Associated proximal fibular #s for which fixation is not planned and involves a medial injury that cannot be stabilised.ii. Injuries extending > 5cm proximal to the plafond.
  61. 61. SYNDESMOTIC INJURIES contd . Normally intraoperative roentgenograms should demonstrate a clear space of < 5mm b/w medial wall of fibula & lateral wall of posterior tibial malleolus. Fixation of syndesmosis is either with oblique pins or screws inserted trrough the lateral malleolus into the distal tibia. The screws should be placed through both cortices of fibula & either one or both cortices of the tibia. Screw position- 2cm proximal to plafond, parallel to the joint surface, 300 anterior, perpendicular to TF jt..
  62. 62. Fixation of Syndesmosis Fix fibula anatomically Make sure ankle mortise is reduced Hold reduction with clamp Do not lag!  ? Large vs. small fragment screw  ? 3 vs. 4 cortices  ? Screw removal
  63. 63. Postoperative Care Well padded splint immobilization Ice and elevation Non weight bearing for 6 weeks  Early weight bearing possible Early conversion to brace and ROM
  64. 64. COMPLICATIONSMal union # Can occur with lateral malleolus, medial malleolus or the posterior malleolus. # Predisposes to late degenerative changes and pain.
  65. 65. COMPLICATIONS contd…Treatment- # Lat mall - osteotomy through the # site, fixation with plate & screws and bone grafting. # Medial mall - osteotomy through # site & fixation with malleolar screw & k wire. # Post mall - if >25% of articular surface involved, osteotomy through # site, reduction& fixation with k wire & malleolar screws.
  66. 66. COMPLICATIONS contd…Non union # > in conservatively treated patients. # Non union of lat. malleolus < med.malleolus. # Treatment- non union site exposed & ends are freshened , rigidly fixed with a malleolar screw & k wire.
  67. 67. COMPLICATIONS contd…Sudecks atrophy- # Characterised by pain, demineralisation,edema, shiny skin with reduced ROM. # Prevented by early ROM exercises, elevation of the affected limb. # once the condition has developed – intensive physiotherapy, prolonged elevation & use of sympathetic blocking agents.
  68. 68. COMPLICATIONS contd…Wound healing # Plate application over lateral malleolus interferes with wound healing. # Prevented by meticulous closure of subcutaneous layer to cover the implant & constant elevation of the limb for first 5-7 days.
  69. 69. COMPLICATIONS contd…Infection # Associated with poor closure ,failure to elevate the limb postoperatively # Treatment - leave the implant in situ, dressing to be done regularly. - when the repaired # has united, implant to be removed, debridement under antibiotic coverage & later SSG.
  70. 70. COMPLICATIONS contd…Fixation failure # Loosening or backing out of screws usually seen in distal fibula. # Treatment - if screw loosens prior to healing of syndesmotic ligament it should be replaced.
  71. 71. COMPLICATIONS contd…Degenerative arthritis # Due to imperfect reduction. # Treatment - if malunion is the cause correct it. - if advanced arthritis present - arthrodesis.
  72. 72. PILON /  PLAFOND FRACTURES (Pilon = Hammer / Plafond = Ceiling)  
  73. 73. Reudi & Allgower’sType Pathology1 Undisplaced2 Displaced with joint incongruity3 Marked comminution with crushing of the subchondral cancellous bone
  74. 74. Reudi & Allgower’s
  75. 75. Initial treatment Reduction of any dislocation and covering of exposed wounds if present Assess neuro-vascular status Check for evidence of compartment syndrome Splint fracture which may require temporary skeletal traction
  76. 76.  Investigations X-ray plus CT Timing of surgery Type II and III - goal is to keep talus centred under the tibia, while soft tissue heal over 7 to 21 days
  77. 77. Surgical options1. ORIF Medial and anterior incisions with full thickness flaps developed at level of the periosteum. These incisions must be at least 7 cm apart to protect the viability of the intervening skin bridge
  78. 78.  Steps  Fibula # brought out to length and fixed with plate (DCP)  Tibial # exposed and reduced, held with temporary K-wires – usually 4 main fragments  K-wires replaced with interfragmentary screws and fixed with buttress plate  Closure of wounds – tension must be avoided and if present close deep layers and return later for delayed 1º closure of skin
  79. 79. 2. Fine wire fixation with circular frames Using either the Ilizarov or hybrid external fixators This can be combined with limited internal fixation of the tibia using inter- fragmentary screws and fixation of the fibula
  80. 80. 3. Trans-articular external fixation Will align the tibia but will not address the central depression of the joint surface.  Useful as first part of 2 -stage procedure (to allow soft tissue management & CT & planning)
  81. 81. Summary You WILL see ankle fractures Taken for granted Reduce the mortise anatomically  Fibular length  Stable syndesmosis  Anatomic reduction and debridement medially Proper management leads to excellent outcomes
  82. 82. Thanks for listenin!!!! thanks for listenin..