The seminar discussed ankle injuries, focusing on anatomy, classification systems, and common injuries. The ankle is supported by strong ligaments and tendons and permits dorsiflexion and plantar flexion. Common injuries include ligament sprains and fractures of the medial and lateral malleoli. Injury patterns are classified using systems like Lauge-Hansen which consider the mechanism of force and resulting bone and soft tissue injuries. Proper treatment aims to restore normal ankle alignment and joint surfaces.

1. .
Department of Orthopaedics
Seminar on: ANKLE INJURIES.
Chairperson: Prof. & HOD: Dr.Kiran Kalaiah
Moderator: Professor Dr.J K Reddy
Presenter : Dr. Yashavardhan.T.M

2. Introduction:
 Ankle injuries apart from road traffic accidents can also result from a slip while
walking or getting down from stairs or a twisting injury in sports and fall from a
height.
 All these tend to produce 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 .
 Great majority of ankle injuries are caused by indirect violence.
 If not treated properly the ankle injuries are a source of disability in the form of
pain, instability and early degenerative arthritis of the ankle.
 Injuries around the ankle joint cause destruction of not only the bony
architecture but also often the ligamentous and soft tissue components.

3. Aims:
 (1) The normal relationships of the ankle mortise must be restored
 (2) The weight-bearing alignment of the ankle must be at a right angle
to the longitudinal axis of the leg.
 (3) The contours of the articular surface must be satisfactorily reduced.
The best results are obtained by anatomic joint restoration, and the
method used to accomplish this may be either closed manipulation or
open reduction and internal fixation (ORIF). For most fractures, the
latter method most often ensures anatomic joint restoration and union.

4. Anatomy:
 Articular surfaces ?
1. Structurally, the joint is very strong. The stability of the joint is ensured by:
2. (i) Close interlocking of the articular surfaces;
3. (ii) strong collateral ligaments on the sides; and
4. (iii) the tendons that cross the joint, four in front,
and five behind

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

6.  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.

7.  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)

8.  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)

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)

10.  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.

11.  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
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
the lateral tubercle of the talus.
 3. The calcaneofibular ligament is a long rounded cord which passes from the notch on the lower
border of the lateral malleolus to the tubercle on the lateral surface of the calcaneum.

12.  Movements
movements are dorsiflexion and plantar-flexion
 (a) dorsiflexion
(b) plantar flexion
Muscles producing movements
Movement Principal muscles Accessory muscles
A. Dorsiflexion Tibialis anterior 1. Extensor digitorum anterior longus
2. Extensor hallucis longus
3. Peroneus tertius
B. Plantar 1. Gastrocnemius 1. Plantaris flexion
2. Soleus 2. Tibialis posterior
3. Flexor hallucis longus
4. Flexor digitorum longus

13.  BLOOD SUPPLY
 The arteries crossing the ankle sends branches which form arterial anastomosis
around the ankle, tarsus and metatarsus

14.  BLOOD SUPPLY
 The arteries crossing the ankle sends branches which form arterial anastomosis
around the ankle, tarsus and metatarsus

15.  BLOOD SUPPLY
 The arteries crossing the ankle sends branches which form arterial anastomosis
around the ankle, tarsus and metatarsus

16.  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.

17. SYNDESMOTIC JOINT

18. SYNDESMOTIC JOINT

19. Injuries around the Ankle
A. Ligament injuries.
B. Bony injuries.

20.  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
recovery.

21. COMMON EPONYMS

25. Bowsworth Fracture
 The distal end of the proximal fragment of the fibula may be displaced posterior to the
tibia and locked by the tibia's posterolateral ridge; the bone cannot be released
by manipulation because of the pull of the intact interosseous membrane

26. Classification.
1. Lauge-Hansen Classification*
1. Supination-Adduction (SA)
 Transverse avulsion-type fracture of the fibula below the level of the joint or tear of the lateral collateral
ligaments Vertical fracture of the medial malleolus
2. Supination-Eversion (External) Rotation (SER)
 Disruption of the anterior tibiofibular ligament Spiral oblique fracture of the distal fibula. Disruption of the
posterior tibiofibular ligament or fracture of the posterior malleolus. Fracture of the medial malleolus or
rupture of the deltoid ligament

27. Classification.
1. Lauge-Hansen Classification*
1. Supination-Adduction (SA)
 Transverse avulsion-type fracture of the fibula below the level of the joint or tear of the lateral collateral
ligaments Vertical fracture of the medial malleolus
2. Supination-Eversion (External) Rotation (SER)
 Disruption of the anterior tibiofibular ligament Spiral oblique fracture of the distal fibula. Disruption of the
posterior tibiofibular ligament or fracture of the posterior malleolus. Fracture of the medial malleolus or
rupture of the deltoid ligament

28. 3. Pronation-Abduction (PA)
 Transverse fracture of the medial malleolus or rupture of the deltoid ligament. Rupture of the
syndesmotic ligaments or avulsion fracture of their insertions Short, horizontal, oblique fracture of
the fibula above the level of the joint
4. Pronation-Eversion (External) Rotation (PER)
 Transverse fracture of the medial malleolus or disruption of the deltoid ligament. Disruption of the
anterior tibiofibular ligament Short oblique fracture of the fibula above the level of the joint.
Rupture of posterior tibiofibular ligament or avulsion fracture of the posterolateral tibia

29. 3. Pronation-Abduction (PA)
 Transverse fracture of the medial malleolus or rupture of the deltoid ligament. Rupture of the
syndesmotic ligaments or avulsion fracture of their insertions Short, horizontal, oblique fracture of
the fibula above the level of the joint
4. Pronation-Eversion (External) Rotation (PER)
 Transverse fracture of the medial malleolus or disruption of the deltoid ligament. Disruption of the
anterior tibiofibular ligament Short oblique fracture of the fibula above the level of the joint.
Rupture of posterior tibiofibular ligament or avulsion fracture of the posterolateral tibia

30.  5. Pronation-Dorsiflexion (PD)
 Fracture of the medial malleolus. Fracture of the anterior margin of the tibia.
Supramalleolar fracture of the fibula. Transverse fracture of the posterior tibial
surface.

31.  5. Pronation-Dorsiflexion (PD)
 Fracture of the medial malleolus. Fracture of the anterior margin of the tibia.
Supramalleolar fracture of the fibula. Transverse fracture of the posterior tibial
surface.

32. 2.Danis-Weber classification
 Danis-Weber classification of ankle fractures based on mechanism of injury and
location and appearance of fibular fracture.

33. 2.Danis-Weber classification
 Danis-Weber classification of ankle fractures based on mechanism of injury and
location and appearance of fibular fracture.

34. 3. AO CLASSIFICATION:
 AO Classification of fractures has further divided each of these three types into
three groups - to quantify the spectrum of injury within each type.

35. 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

36. Clinical examination:

43. Investigations:
 X-ray :
 Antero-posterior – basic (Mortice projection)

44. Ottawa Rules: When to Image
 Ottawa Ankle Rules: 98% sensitivity for fracture, decrease
radiographs
 Validated in ED and PCP Office
 Do not apply rules if:
 Age < 18 yo
 Pregnancy
 Multiple painful
injuries
 Compromised
sensation

46. Investigations:
 X-ray :
 Antero-posterior – basic (Mortice projection)

47. Investigations:
 X-ray :
 Antero-posterior – basic (Mortice projection)

50. Lateral (basic) – medio-lateral

51. Stress projections for subluxation
 Antero-posterior – stress

52.  Lateral – stress

53. 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)

54. 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

56. ANKLE FRACTURE FIXATION TECHNIQUES

57. 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 ligaments.

58. 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 ligaments.

59.  ■ 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.

60.  ■ 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.

61.  ■ Overdrill the hole made in the fibula to allow for compression across the
syndesmosis. Dorsiflex the ankle joint as the screw is tightened because the
talar dome is wider at its anterior half than its posterior half. Failure to overdrill
the fibula can result in widening of the syndesmosis and ankle mortise, with
resulting arthritic degeneration of the
 tibiotalar joint. Add additional fixation with a small plate and screws if desired.
 ■ Replace the tendons, repair the tendon sheaths and retinacula, and close the
incision.
 After the osteotomy or fracture has healed, remove the screw to prevent its
becoming loose or breaking

62. APPROCHES TO MEDIAL MALLEOLUS

63. 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

64. 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.

65. 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.

66. Lateral Malleolar Fixation
 FOR LATERAL MALLEOLUS
 Plating

67.  Intramedullary Nailing

69. Medial Malleolar Fixation
 Tension Band wiring

71. POSTERIOR APPROACH TO THE ANKLE

72. Posterior Malleolar Fixation

75. COMPLICATIONS

76. THANK YOU 