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Ankle fracture
- 1. DR MRUDEV GANDHI Resident Deptof Orthopedics Pramukh Swami Medical College, Karamsad
- 2. Ankle isa three bone joint composed of the tibia , fibula an talus. Talus articulates with the tibial plafond superiorly , posterior malleolus of the tibia posteriorly and medial malleolus medially Lateral articulation is with malleolus of fibula Medial malleolus is shorter and anterior and thus axis of the joint is 15 degrees of external rotation.
- 3. Stability of ankle: (1)Static stabilizers (a) Medial osteoligamentus complex: Superficial deltoid ligament – Posterior tibio talar, Tibiocalcaneal and Tibio navicular ligament Deep deltoid ligament – Anterior tibio talar ligamnet (b) Lateral Osteoligamentus complex: Anterior talo fibular ligament (ATFL- weakest – most commen to injury in ankle sprain) Posterior talo fibular ligament Calcaneo fibular ligament (c) Syndesmosis: Anterior inferior tibio fibular ligamnet Posterior inferior tibio fibular ligamnet Interosseous ligament
- 5. Anterior Colliculus Posterior Colliculus IntercollicularGroove Medial malleolus consists of: -Anterior Colliculus -Intercollicular Groove -Posterior Colliculus Origi
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- 7. (2) Dynamic stabilizers (a)Axial loading: The joint is considered saddle-shaped with the dome itself is wider anteriorly than posteriorly, and as the ankle dorsiflexes, the fibula rotates externally through the tibiofibular syndesmosis, to accommodate this widened anterior surface of the talar dome. It forms a closed pack position which provides stability to ankle (b) Muscles around ankle joint
- 8. INTRODUCTION Ankle fractures areamong the most common injuries and management of these fractures depends upon careful identification of the extent of bony injury as well as soft tissue and ligamentous damage. Once defined, the key to successful outcome following rotational ankle fractures is anatomic restoration and healing of ankle mortise. Low velocity injuries a/w rotational component
- 9. Clinical Evaluation: Detailed History DetailedExamination a/w soft tiuuse injuries Compartment syndrome
- 10. IMAGING AND DIAGNOSTICMODALITIES OTTAWA ANKLE RULES To manage the large volume of ankle injuries of patients who presented to emergency certain criteria has been established for requiring ankle radiographs. Pain exists near one or both of the malleoli PLUS one or more of the following: •Age > 55 yrs old •Inability to bear weight •Bone tenderness over the posterior edge or tip of either malleolus .
- 11. •Plain Films –AP, Mortise,Lateral views of the ankle –Image the entire tibia to knee joint –Foot films when tender to palpation – Common associated fractures are: •5th metatarsal base fracture •Calcaneal fracture Although the OTTAWA RULES have been validated and found to be both cost effective and reliable (up to 100% sensitivity their implementation has been inconsistent in general clinical practice
- 12. Quaitative analysis◦Tibiofibular overlap <10mm is abnormal - implies syndesmotic injury ◦Tibiofibular clear space ◦> 5mm is abnormal - implies syndesmotic injury ◦Talar tilt ◦> 2mm is considered abnormal Consider a comparison with radiographs of the normal side if there are unresolved concerns of injury
- 13. Taken withankle in 15-25 degrees of internal rotation Useful in evaluation of articular surface between talar dome and mortise
- 14. 10 degrees internalrotation of 5th MT with respect to a verticalline
- 15. Medial clearspace ◦ Between lateral border of medial malleous and medial talus ◦ <4mm is normal ◦ >4mm suggests lateral shift of talus
- 17. FIBULAR LENGTH: 1.Shenton’s Line of the ankle 2. The dime test
- 18. •Posterior mallelolar fractures •AP talarsubluxation •Distal fibular translation &/or angulation •Syndesmotic relationship •Associated or occult injuries –Lateral process talus –Posterior process talus –Anterior process calcaneus
- 19. • Stress Views –Gravity stress view – Manual stress views • CT Joint involvement Posterior malleolar fracture pattern Pre-operative planning – – – – Evaluate hindfoot and midfoot if needed • MRI Ligament and tendon– – – injury Talar dome lesions Syndesmosis injuries
- 21. Radiography after reductionshould be studied with following requirements in mind: •Normal relationship of ankle mortise must be restored. •Weight bearing alignment of ankle must be at right angle to the longitudinal axis of leg •Counters of the articular surface must be as smooth as possible
- 22. • Classification systems –Lauge-Hansen – Weber – OTA • Additional Anatomic Evaluation – Posterior Malleolar Fractures – Syndesmotic Injuries – Common Eponyms
- 23. Based oncadaveric study • First word: position of foot at time of injury • Second word: force applied to foot relative to tibia at time of injury Types: Supination External Rotation Supination Adduction Pronation External Rotation Pronation Abduction
- 25. 1 3 2 4 Stage 1Anterior tibio- fibular ligament Stage 2 Fibula fx Stage 3 Posterior malleolus fx or posterior tibio- fibular ligament Stage 4 Deltoid ligament tear or medial malleolus fx
- 26. Standard: Closed management LateralInjury: classic posterosuperioranteroinferior fibula fracture Medial Injury: Stability maintained
- 27. Lateral Injury: classicposterosuperioranteroinferior fibula fracture Medial Injury: medial malleolar fracture &*/or deltoid ligament injury Standard: Surgical management
- 28. • Stage 1:fibula fracture is transverse below mortise. • Stage 2: medial malleolus fracture is classic vertical pattern. 1 2
- 29. Lateral Injury: transversefibular fracture at/below level of mortise Medial injury: vertical shear type medial malleolar fracture BEWARE OF IMPACTION
- 30. • Important torestore: – Ankle stability – Articular congruity- including medial impaction
- 32. Stage 1Deltoid ligament tear or medial malleolus fx Stage 2 Anterior tibio-fibular ligament and interosseous membrane Stage 3 Spiral, proximal fibula fracture Stage 4 Posterior malleolus fx or posterior tibio- fibular ligament 34 1 2
- 33. Medial injury: deltoidligament tear &/or transverse medial malleolar fracture Lateral Injury: spiral proximal lateral malleolar fracture HIGHLY UNSTABLE…SYNDESMOTIC INJURY COMMON
- 34. • Must x-rayknee to ankle to assess injury • Syndesmosis is disrupted in most cases – Eponym: Maissoneuve Fracture • Restore: – Fibular length and rotation – Ankle mortise – Syndesmotic stability
- 35. Stage 1Transverse medial malleolus fx distal to mortise Stage 2 Anterior tib- fib ligament/ Chaput’s fracture Stage 3 Fibula fracture, typically proximal to mortise, often with a butterfly fragment 1 2 3
- 36. Medial injury: tranverseto short oblique medial malleolar fracture Lateral Injury: comminuted impaction type distal lateral malleolar fracture
- 37. Based on locationof fibula fracture relative to mortise and appearance Weber A - fibula distal to Syndesmosis Weber B - fibula at the level of Syndesmosis Weber C - fibula above the level of Syndesmosis Concept - the higher the fibula the more severe the injury
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- 39. Function: Stability- prevents posteriortranslation of talus & enhances syndesmotic stability Weight bearing- increases surface area of ankle joint
- 40. • Fracture pattern: –Variable – Difficult to assess on standard lateral radiograph •External rotation lateral view (50 degrees) •CT scan
- 41. Type I- posterolateraloblique type Type II- medial extension type Type III- small shell type 67% 19% 14%
- 42. FUNCTION: Stability- resists externalrotation, axial, & lateral displacement of talus Weight bearing- allows for standard loading
- 43. • Diastasis requiresrupture of three strong ligaments and iterosseous membrane, hence suggesting a very substantial insult to ankle. • Severe abduction forces causes torsional movement of talus which forces the tibia and fibula causing syndesmosis injury. • Pronation type is frequently associated with syndesmosis injury than Supination injuries. • PER with deltoid rupture is particularly at high risk.
- 44. • Radiographic evaluationof Syndesmosis injury • On AP view – Tibio fibular clear space > 5mm (synd-A) – Tibio fibular overlap <5mm (synd-B) • On Mortise view - Tibio fibular overlap <1mm (synd-B) Comparison radiograph of opposite normal ankle is more accurate.
- 45. • Intra operativestress testing: (1)Lateral force to heel to displace the fibula laterally (cotton’s test) (2)Pulling the fibula laterally with a hook (hook test) – most popular by the surgeons (3)External rotation stress test
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- 48. • • • Maisonneuve Fracture – Fractureof proximal fibula with syndesmotic disruption Volkmann Fracture – Fracture of tibial attachment of PITFL – Posterior malleolar fracture type Tillaux-Chaput Fracture – Fracture of tibial attachment of AITFL
- 49. Wagstaffe-LeFort fracture. In theWagstaffe-LeFort fracture, seen here schematically on the anteroposterior view, the medial portion of the fibula is avulsed at the insertion of the anterior tibiofibular ligament. The ligament, however, remains intact.
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- 51. Isolated lateral malleolusfracture: (with no instability) - Truly isolated lateral malleolus #- stable - SER 2 and SAD 1 type - No tibiotalar incongruence - Can be managed conservatively with weight bearing cast, ankle brace, elastic bandaging, stabilizing shoes, air stirrup devices.
- 52. Lateral malleolus fracturewith associated instability - A/w deltoid ligament failure (SER 4 ) - It may be Frank instability or Occult instability Frank instability is diagnosed by - obvious deformity at time of presentation - clear displacement of talus on trauma radiographs Surgical treatment is required for lateral malleolus in such cases.
- 53. • Occult ankleinstability is checked by, (a) Clinically – swelling , tenderness, bruising over posterior aspect of medial malleolus (b) Stress view radiographs – mortise views medial clear space >5mm Surgical fixation of lateral malleolus is required in such cases. * In many centers pragmatic approach of walking plaster is taken. If no talar shift is noticed on one week follow up xray the ankle has proved its stability.
- 54. SER-2 NegativeStress view External rotation of foot with ankle in neutral flexion (00) + Stress View Widened Medial Clear Space SE-4
- 55. Isolated medial malleolusfracture: • This includes - anterior colliculus # with/without deep deltoid injuty - posterio colliculus # - supracollicular # - chip avulsion fractures Undisplaced fractures can be treated conservatively but fractures with below knee cast for 6 weeks f/b progressive ewight bearing and phyiotherapy Fractures with significant displacement require fixation.
- 56. Bimalleolar fractures: • Bylarge bimalleolar fractures are unstable and should be managed operatively. • Only undisplaced bimalleolar fractures can be treated conservatively. Posterior malleolus fractures: • Fractures involving >25% of joint surface should be managed operatively ( McDaniel and Wilson et al.) • pre operative ct scan is required
- 57. Simple algorithm forankle fractures:
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- 59. Fixation of lateral malleolus Simpleoblique fracture (SER 3,4) Inter frag screw +/- neutralization plate Or Malleolar screw Simple transverse fracture (PER 3,4) Compression plate Comminuted fracture (PAB 3) Bridge platting Or IM nailing
- 63. Fixation of medial malleolus Verticalfracture (SAD 2) 2 transverse screws Or Antiglide plate Oblique fracture Two 4.5 mm partially threaded cancellous screws perpendicular to the fracture line Transverse fracture Tension bend wire
- 66. Fixation of posterior malleolus <25 %of plafond Can be conserved >25% of plafond Cancellous screws AP or Antiglide plate
- 67.
- 68. Early • Wound infection/dehiscence 1–10%Superficial infections can be treated with antibiotics and dressings. Deep infections may respond to suppression antibiotics until the fracture has united but then usually require surgery to debride the wound and obtain bacteriologic specimens. Exposed hardware may require removal and the use of a spanning external fixator until the infection is eradicated • Loss of reduction 0–2%. -Most common in conservatively treated, unstable fractures. -In surgically treated fractures this may be related to inadequate initial reduction, inadequate fixation, poor bone stock, peripheral neuropathy or psychiatric illness. • Malunion • Osteoarthritis • Thromboembolism
- 69. Late • Osteoarthritis Rare inlow-energy fractures but up to 30% of unstable patterns. May take several decades to become evident. Higher when anatomical reduction of the mortise is not achieved, other cases probably related to chondral injury at time of injury. May require functional bracing or an arthrodesis • Nonunion Most commonly encountered after nonoperative treatment. Often asymptomatic, but if painful may require (revision) fixation and possibly bone grafting
- 70. • Symptomatic hardware •Compartment syndrome Rare, associated with high-energy fractures • Neuroma The superficial peroneal, sural, and saphenous nerves are all at risk in the subcutaneous layer and injurymay result in a patch of anesthetic, or worse, dysesthetic skin.
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