Ankle fracture case presentation

1. Ankle Fracture
Shubhanshu Ranjan Singh
PG Student

2. Case 1
• A 30-year-old married female named Tanushree
from Jalpaiguri West Bengal had an injury to her
left ankle while playing badminton and position
of foot at the time of injury was in Pronation and
proximal part in adduction on 17 March 2022.
• She was complaining of Pain and swelling in left
ankle region and unable to walk since 5 days.

3. Case 1
Examination
• On general examination patient conscious and
vitals are stable.
• On local examination(Left Ankle)
Inspection
Attitude – Planter flexion
Swelling – Present in medial and lateral side
Lesion – 2*2cm abrasion present
over lateral malleolus

4. Case 1
Examination
Palpation
Local temp was raised,
Tenderness +
Swelling +
ROM was painful and restricted
TM +
Dorsalis pedis artery and posterior tibial artey
papable bilaterally

5. Case 1- Diagnosis
• She had Left Ankle Bimalleolar fracture -
Medial Malleolus (vertical #) and Lateral
Malleolus(transverse#)
• No k/c/o endocrine disease, cardiac disease

6. Injury Date 17/3/2022

7. Xray- 21/03/2022

8. Spanning on 22/03/2022

9. Scanning
Coronal
AXIAL
Saggital

10. Post Op Day 1
Lateral malleolus Intramedullary cancellous screw
Medial malleolus Plate Fixation with horizontal screw fixation

11. Case 1
Two stage procedure
• First Stage: Spanning with Delta External
Fixator for reduction applied on 22/03/2022
to immobilize the left ankle joint
• Interval period taken for to decrease the
swelling @ surgical site of 6 days
• 2nd Stage : On 28/03/2022- ORIF with 2cc
Screw and one third tubular plate for medial
malleolus and cancellous screw for lateral
malleolus

12. Case 1
2nd day Post op
• Patient vitally stable
• No soakage
• TM +
• Dorsalis pedis artery palpable billateraly

13. Case 2
• 19/F named Muskan from Patna had an injury
to her left ankle and position of foot at the
time of injury on staircase was in Pronation
and proximal part in Eversion on 25 March
2022.
• She was complaining of Pain and swelling in
left ankle region and unable to walk since
same day

14. Case 2
Examination
• On general examination patient conscious and
vitals are stable
• On local examination(Left Ankle)
Inspection
Attitude – Planter flexion
Swelling – Present in medial and lateral side

15. Case 2
Examination
Palpation
Local temp was raised,
Tenderness +
Swelling +
ROM was painful and restricted
TM +
Dorsalis pedis artery palpable bilaterally

16. Case 2- Diagnosis
• She was diagnosed as fracture on 25 March
2022 of Left Ankle Bimalleolar fracture –
Medial Malleolus (Transverse), Posterior
Malleolus of tibia(transverse)

17. Injury Date 25/03/2022

18. CT Scan

19. On C ARM Post Op

20. Case 2
Management
• In causality Below left knee slab applied
• On 28/03/2022 Left ORIF with Tension Band
wiring for medial malleolus(small fragment)
and percutaneous cannulated screw for
posterior malleolus(AP)

21. Case 2
2nd day Post op
• Patient vitally stable
• No soakage
• Ankle movement painful
• Toe movement present
• Dorsalis pedis artery palpable bilateraly

22. Case 3
• A 43-year-old female married named from
Patna had an injury to her right ankle and
position of foot at the time of injury on
RTA(fell from bike) was in Planter Flexion on
11 March 2022.
• She was complaining of Pain and swelling in
Right ankle region and unable to walk since 10
days

23. Case 3
Examination
• On general examination patient conscious and
vitals are stable
• On local examination(Right Ankle)
Inspection
Attitude – Planter flexion
Swelling – + & Bruising marks present around
right ankle region

24. Case 3
Examination
Palpation
Local temp was raised,
Tenderness +
Swelling +
ROM was painful and restricted
TM +
Dorsalis pedis artery palpable bilaterally

25. Case 3- Diagnosis
• She had Trimalleolar Fracture of right ankle-
Medial malleolar(small fragment), Lateral
malleolar(), Posterior malleolar(Comminuted)

26. X-ray: 21/03/2022

27. CT scan

28. Post Op Day 1

29. Case 3
Management
• On 29/03/2022
ORIF with one third tubular plate &
interfragmentory screw for lateral malleolus
ORIF with 2 Malleolus screw for Medial
Malleolus and ORIF with T plate for Posterior
Malleolus

30. Case 3
1st day Post op
• Patient vitally stable
• No soakage
• Ankle movement painful
• Toe movement present
• Capillary Refilling time normal

31. Preoperative Management
• Pre-operative Assessment
• Pre-operative Preparation
• Premedication

32. Preoperative assessment
• Taking history
• Physical examination
• Investigations
• Assess risk of Anesthesia

33. Preoperative preparation
• Preoperative Nil per oral
• Information to patient and taking written
consent
• Collect or prepare of blood product

34. Pre-Medication
• Reduce Secretion
• Foleys catheter
• Secure Cannula
• Antibiotics (up to a 4-hour interval before
bacterial growth becomes established enough to
cause an infection after a breach in the tissues-
decisive period)
• Temperature control
• Part preparation

35. Ankle Fracture Classification

36. Abduction

37. Danis Weber Classification
• Based on the level of the fibular fracture
• More proximal more syndesmotic disruption and
associated instability
• Type A: equivalent to the Lauge–Hansen
supination–adduction injury.
• Type B: equivalent to the Lauge–Hansen
supination– external rotation injury.
• Type C: Maisonneuve-type injuries and
corresponds to Lauge–Hansen pronation–
external rotation or pronation–abduction stage III
injuries.

39. Jan Bartonicek Classification
• Type 1 : Extraincisural fragment with intact
fibularnotch
• Type 2 : Posterolateral fragment extending into
fibular notch.
• Type 3 : Posteromedial 2 part fragment involving
Medial malleolus
• Type 4 : Large posterolateral triangular fragment
(involve >1/3 notch)
• Type 5 : Nonclassified, irregular, osteoporotic
fragments.

40. Rüedi and Allgöwer Classification for
Tibial plafond
• Based on the severity of comminution and the
displacement of the articular surface.
• Type I: Nondisplaced cleavage fracture of the
ankle joint
• Type II: Displaced fracture with minimal
impaction or comminution
• Type III: Displaced fracture with significant
articular comminution and metaphyseal
impaction

42. Edwards and DeLee Classification
• For Diastases of the distal tibiofibular
syndesmosis
1. Type I diastasis involves lateral subluxation
without fracture.
2. Type II involved lateral subluxation with plastic
deformation of the fibula.
3. Type III involves posterior
subluxation/dislocation of the fibula.
4. Type IV involves superior
subluxation/dislocation of the talus within the
mortise.

43. OT
• Pneumatic tourniquet applied Association of
surgical technologists (upper extremity, 50
mm Hg above SBP; lower extremity, 100 mm
Hg above SBP)
• Local preparation of the patient done (7.5%
povidone-iodine solution that is diluted
approx 50% with sterile saline solution)
• Draping done

44. OT
• Incisions for medial approaches to ankle joint:
1. Koenig and Schaefer (A),
2. Broomhead (B),
3. Colonna and Ralston (C).

47. OT