Posterolateral corner injuries of knee joint Samir Dwidmuthe
Missed posterolateral corner injuries of knee joint is a common cause for failure of ACL and PCL reconstruction only next to malpositioned tunnels.
Isolated PLC injuries are uncommon, making up <2% of all acute knee ligamentous injuries. Covey JBJS 2001
Incidence of PLC injuries associated with concomitant ACL and PCL disruptions are much more common (43% to 80%). Ranawat JAAOS 2008
A recent (MRI) analysis of surgical tibialplateau fractures demonstrated an incidence of PLC injuries in 68% of cases. Gardner JOT 2005
Take home message
PLC injuries to be ruled out in every case of ACL& PCL rupture.
Neurovascular integrity to be checked in every case.
Grade I & II can be managed conservatively.
Grade III Acute- Repair.
Grade III Chronic- Anatomic PLC recon.
Beware of varus knee alignment.
Posterolateral corner injuries of knee joint Samir Dwidmuthe
Missed posterolateral corner injuries of knee joint is a common cause for failure of ACL and PCL reconstruction only next to malpositioned tunnels.
Isolated PLC injuries are uncommon, making up <2% of all acute knee ligamentous injuries. Covey JBJS 2001
Incidence of PLC injuries associated with concomitant ACL and PCL disruptions are much more common (43% to 80%). Ranawat JAAOS 2008
A recent (MRI) analysis of surgical tibialplateau fractures demonstrated an incidence of PLC injuries in 68% of cases. Gardner JOT 2005
Take home message
PLC injuries to be ruled out in every case of ACL& PCL rupture.
Neurovascular integrity to be checked in every case.
Grade I & II can be managed conservatively.
Grade III Acute- Repair.
Grade III Chronic- Anatomic PLC recon.
Beware of varus knee alignment.
Medial patellofemoral ligament reconstruction ---- an update on techniques used. This lecture was taken by me at Trinity Arthroscopy Course, Chandigarh.
Arthroscopic ACL Reconstruction By Dr Shekhar ShrivastavDelhiArthroscopy
Arthroscopic Acl Reconstruction By Dr Shekhar Shrivastav.
HOW NORMAL KNEE WORKS ?
The knee is the largest joint in the body, and one of the most easily injured. It is made up of the lower end of the thigh bone(femur), the upper end of the shin bone (tibia), and the knee cap (patella), which slides in a groove on the end of the femur. Four bands of tissue, the anterior and posterior cruciate ligaments, and the medial and lateral collateral ligaments connect the femur and the tibia and provide joint stability. The surfaces where the femur, tibia and patella touch are covered with articular cartilage, a smooth substance that cushions the bones and enables them to glide freely. Semicircular rings of tough fibrous-cartilage tissue called the lateral and medial menisci act as shock absorbers and stabilizers.
WHAT IS THE ROLE OF ACL ?
ACL along with other ligaments of the knee joint and meniscus provides stability to the knee joint.
WHAT IS LIGAMENT RECONSTRUCTION ( ACL ) ?
Ligament reconstruction involves replacing the torn ligament with a tendon (graft) from your knee and fixing the graft in place with screws. This procedure is performed with the use of the arthroscope. The anterior cruciate ligament (ACL) is the most common ligament requiring reconstruction procedures. The torn ligament is excised arthroscopically and new ligament is prepared by ligament grafts taken from your own body. Bony tunnels are prepared in femur and tibia using specialized instruments through which the new ligament is passed and fixed with special screws. This procedure requires relative rest or leave from your work or studies for about 2-3 weeks after which you will be allowed normal day to day activities.
WHEN CAN THE PATIENT BE AMBULATED AFTER SURGERY ?
The patient can walk from the same evening of the surgery. Initially the patient is advised to walk with a brace and a walking cane. Strengthening and range of motion exercises for the knee are started from the next day. The patient is discharged from the hospital 2nd or 3rd day after surgery. The patient can walk without support by 10-14 days depending on muscle strengthening. Slow Jogging and other strenuous activities are permitted after 3 months and the patient can return to active sports only 8-9 months after surgery.
Torn ACL Reconstructed ACL
For Further Queries contact your Orthopedic Surgeon at
+ 91 9971192233
Assessent and radiology of distal end radius fractureSusanta85
distal end radius is a common fracture in elderly groups and also in young by high velocity trauma its assessment and radiology should know for its management
Hello ...im dr zamin abbas...i completed my residency from shifa international hospital islamabad...these are one of my presentations i want to share with other colleagues
Fracture shaft of tibia is a very common injury which we deal as a trauma surgeon
Medial patellofemoral ligament reconstruction ---- an update on techniques used. This lecture was taken by me at Trinity Arthroscopy Course, Chandigarh.
Arthroscopic ACL Reconstruction By Dr Shekhar ShrivastavDelhiArthroscopy
Arthroscopic Acl Reconstruction By Dr Shekhar Shrivastav.
HOW NORMAL KNEE WORKS ?
The knee is the largest joint in the body, and one of the most easily injured. It is made up of the lower end of the thigh bone(femur), the upper end of the shin bone (tibia), and the knee cap (patella), which slides in a groove on the end of the femur. Four bands of tissue, the anterior and posterior cruciate ligaments, and the medial and lateral collateral ligaments connect the femur and the tibia and provide joint stability. The surfaces where the femur, tibia and patella touch are covered with articular cartilage, a smooth substance that cushions the bones and enables them to glide freely. Semicircular rings of tough fibrous-cartilage tissue called the lateral and medial menisci act as shock absorbers and stabilizers.
WHAT IS THE ROLE OF ACL ?
ACL along with other ligaments of the knee joint and meniscus provides stability to the knee joint.
WHAT IS LIGAMENT RECONSTRUCTION ( ACL ) ?
Ligament reconstruction involves replacing the torn ligament with a tendon (graft) from your knee and fixing the graft in place with screws. This procedure is performed with the use of the arthroscope. The anterior cruciate ligament (ACL) is the most common ligament requiring reconstruction procedures. The torn ligament is excised arthroscopically and new ligament is prepared by ligament grafts taken from your own body. Bony tunnels are prepared in femur and tibia using specialized instruments through which the new ligament is passed and fixed with special screws. This procedure requires relative rest or leave from your work or studies for about 2-3 weeks after which you will be allowed normal day to day activities.
WHEN CAN THE PATIENT BE AMBULATED AFTER SURGERY ?
The patient can walk from the same evening of the surgery. Initially the patient is advised to walk with a brace and a walking cane. Strengthening and range of motion exercises for the knee are started from the next day. The patient is discharged from the hospital 2nd or 3rd day after surgery. The patient can walk without support by 10-14 days depending on muscle strengthening. Slow Jogging and other strenuous activities are permitted after 3 months and the patient can return to active sports only 8-9 months after surgery.
Torn ACL Reconstructed ACL
For Further Queries contact your Orthopedic Surgeon at
+ 91 9971192233
Assessent and radiology of distal end radius fractureSusanta85
distal end radius is a common fracture in elderly groups and also in young by high velocity trauma its assessment and radiology should know for its management
Hello ...im dr zamin abbas...i completed my residency from shifa international hospital islamabad...these are one of my presentations i want to share with other colleagues
Fracture shaft of tibia is a very common injury which we deal as a trauma surgeon
An Introduction, History, Diagnosis, Current Guidelines on Treatment of trochanteric fractures of femur. Presentation also contain an introduction of Dynamic Hip Screw and Surgical Techniques.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
3. Etiology
Usually the foot is
anchored to the ground while the body lunges
forward. The ankle is twisted and the talus
tilts and/or
rotates forcibly in the mortis
The precise fracture pattern is determined by:
(1) the position of the foot;
(2) the direction of force at the moment of
injury
4. Anatomy
Biomechanics
• deltoid ligament (deep portion)
• primary restraint to anterolateral talar
displacement
• fibula
• acts as buttress to prevent lateral
displacement of talus
6. Talocrural angle
•shortening of lateral malleoli
fractures can lead to
increased talocrural angle
•can also utilize the
realignment of the medial
fibular prominence with the
tibiotalar joint
12. Treatment Non-operative
• short-leg walking cast/boot
• isolated nondisplaced medial
malleolus fracture or tip avulsions
• isolated lateral malleolus fracture
with < 3mm displacement and no
talar shift
• bimalleolar fracture if elderly or
unable to undergo surgical
intervention
• posterior malleolar fracture with <
25% joint involvement or < 2mm
step-off
13. Treatment - Operative
• Indication - ORIF
• any talar displacement
• displaced isolated medial malleolar fracture
• displaced isolated lateral malleolar fracture
• bimalleolar fracture and bimalleolar-equivalent fracture
• posterior malleolar fracture with > 25% or > 2mm step-off
• Bosworth fracture-dislocations
• open fractures
• malleolar non-union
14. Treatment - Operative
• outcomes
• overall success rate of 90%
• prolonged recovery expected (2 years to obtain final functional result)
• significant functional impairment often noted
• anatomic reduction is considered the most important factor for a satisfactory outcome
• worse outcomes with: smoking, decreased education, alcohol use, presence of medial
malleolar fracture
• ORIF superior to closed treatment of bimalleolar fractures
• in Lauge-Hansen supination-adduction fractures, restoration of marginal impaction of the
anteromedial tibial plafond leads to optimal functional results after surgery
15. Treatment - Operative
• technique
• goal of treatment is stable anatomic reduction of talus in the ankle mortise
• 1 mm shift of talus leads to 42% decrease in tibiotalar contact area
• postoperative rehabilitation
• time for proper braking response time (driving) returns to baseline at nine weeks
for operatively treated ankle fractures
• braking travel time is significantly increased until 6 weeks after initiation of weight
bearing in both long bone and periarticular fractures of the lower extremity
16. Isolated medial malleolus fracture
•nondisplaced fracture and tip avulsions (conservative)
•deep deltoid inserts on posterior colliculus
ORIF
•any displacement or talar shift
•technique
•lag screw fixation
•antiglide plate with lag screw
•best for vertical shear fractures
•tension band fixation
•utilizing stainless steel wire
17. Isolated lateral malleolus fracture (conservative)
• if intact mortise, no talar shift, and < 3mm
displacement
• the deep deltoid may be intact with up to
8-10 mm of widening on stress
radiographs
• if the mortise is well reduced, results from
operative and non-operative treatment are
similar
18. Operative for Isolated Lateral Malleolus Fracture
Open reduction and internal
fixation (ORIF)
• if talar shift or > 3 mm of
displacement
• can be treated operatively if also
treating an ipsilateral syndesmosis
injury
• plate placement
• Lateral
• Posterior
19. Intramedullary retrograde screw
placement
•isolated lag screw fixation
•possible if fibula is a spiral pattern
and screws can be placed at least 1
cm apart
•post-operative care
•period of immobilization usually 4-6
weeks after ORIF
•duration of immobilization should be
doubled in diabetic patients
20. Posterior malleolar fracture (conservative)
• < 25% of articular surface involved
• evaluation of percentage should be
done with CT, as plain radiology is
unreliable
• < 2 mm articular stepoff
• syndesmotic stability
21. Posterior malleolar fracture (operative)
ORIF
• > 25% of articular surface involved
• > 2 mm articular stepoff
• syndesmosis injury
Approach
• posterolateral approach
• interval between FHL and the peroneals
• posteromedial approach
• fixation
a) anterior to posterior lag screws to
capture fragment (if nondisplaced)
b) posterior to anterior lag screw and
buttress plate
c) antiglide plate
22. Bosworth fracture-dislocation
• rare fracture-dislocation of the
ankle where the fibula becomes
entrapped behind the tibia and
becomes irreducible
• posterolateral ridge of the distal
tibia hinders reduction of the fibula
Operative - open reduction and
fixation of the fibula in the incisura
fibularis (indicated in most cases)
23. Hyperplantarflexion variant
• fracture-dislocation of the ankle due to
hyperplantarflexion
• main feature is a vertical shear fracture of
the posteromedial tibial rim
• "spur sign" is a double cortical density at
the inferomedial tibial metaphysis
Operative - fixation of posteromedial and
posterior fragments with antiglide plating
24. Associated syndesmotic injury
• suspect injury in all ankle fractures
• most common in Weber C fracture
patterns
• fixation usually not required when
fibula fracture within 4.5 cm of
plafond
• up to 25% of tibial shaft fractures
will have ankle injury (highest rate
with distal 1/3 spiral fractures)
25. Treatment – Syndesmosis Injury
• syndesmotic screw or suture
fixation
• widening of medial clear space
• tibiofibular clear space (AP)
greater than 5 mm
• tibiofibular overlap (mortise)
narrowed
• any postoperative malalignment or
widening should be treated with
open debridement, reduction, and
fixation
26. Techniques - Syndesmosis
• length and rotation of fibula must be accurately
restored
• outcomes are strongly correlated with anatomic
reduction
• placing reduction clamp on midmedial ridge and
the fibular ridge at the level of the syndesmosis
will achieve most reliable anatomic reduction
• "Dime sign"/Shentons line to determine length of
fibula
• one or two cortical screw(s) or suture devices 2-
4 cm above joint, angled posterior to anterior 20-
30 degrees
28. a proximal fibular fracture coexisting
with a medial malleolar fracture or
disruption of the deltoid ligament
associated with partial or complete
disruption of the syndesmosis
Maisonneuve Fracture
29. Dillemma in Syndesmotic Fixation
• number of screws
• 1 or 2 most commonly reported
• number of cortices
• 3 or 4 most commonly reported
• size of screws
• 3.5 mm or 4.5 mm screws
• implant material (stainless steel screws, titanium screws, suture,
bioabsorbable materials)
• suture devices are more forgiving on reduction
• need for hardware removal
• no difference in outcomes seen with hardware maintenance (breakage or
loosening) or removal at 1 year
• outcome may be worse with maintenance of intact screws
• malreduction of isolated syndesmotic injuries improves with screw removal
30. Open ankle fracture
• emergent operative debridement and ORIF
• indicated if soft tissue conditions allow
• primary closure at the index procedure can be performed in appropriately-
selected Gustilo-Anderson grade I, II, and IIIA open fractures in otherwise
healthy patients sustaining low-energy injuries without gross contamination
• external fixation - soft tissue conditions and overall patient characteristics
31. THANK YOU
References
• 10th Ed APLEY, A. G., & SOLOMON, L. (2001). Apley's system of
orthopaedics and fractures. London, Arnold.
• Shariff SS, Nathwani DK. Lauge-Hansen classification–a literature
review. Injury. 2006 Sep. 37(9):888-90.
• Dowdall H, Gee M, Brison RJ, Pickett W. Utilization of radiographs for
the diagnosis of ankle fractures in Kingston, Ontario, Canada. Acad
Emerg Med. 2011 May. 18(5):555-8.
• Gonzalez O, Fleming JJ, Meyr AJ. Radiographic Assessment of
Posterior Malleolar Ankle Fractures. J Foot Ankle Surg. 2014 Sep 25.
• Werner CM, Lorich DG, Gardner MJ, et al. Ankle fractures: it is not just a
“simple” ankle fracture. Am J Orthop. 2007 Sep. 36(9):466-9
• https://surgeryreference.aofoundation.org/
Editor's Notes
recommended views – AP, lateral, mortise
external rotation Stress - (most appropriate stress radiograph to assess competency of deltoid ligament, more sensitive to injury than medial tenderness, ecchymosis, or edema)
gravity stress radiograph is equivalent to manual stress radiograph
full-length tibia, or proximal tibia, to rule out Maisonneuve-type fracture
findings
syndesmotic injury
decreased tibiofibular overlap
measure at point of maximum overlap
normal >6 mm on AP view
normal >1 mm on mortise view
increased medial clear space
normal ≤ 4 mm on mortise or stress view
medial clear space of >5mm with external rotation stress applied to a dorsiflexed ankle is predictive of deep deltoid disruption
increased tibiofibular clear space
measure clear space 1 cm above joint
normal <6 mm on both AP and mortise views
measured by bisection of line through tibial anatomical axis and another line through the tips of the malleoli
talocrural angle is not 100% reliable for estimating restoration of fibular length
The ball or dime sign is described on the AP view as an unbroken curve connecting the recess in the distal tip of the fibula and the lateral process of the talus when the fibula is out to length.
Fibula malreduced in a shortened position, ball sign is absent.
• Type A – is a transverse fracture of the fibula below the tibiofibular syndesmosis, perhaps associated with an oblique or vertical fracture of the medial malleolus. This is almost certainly an adduction (or adduction and internal rotation) injury. • Type B – is an oblique fracture of the fibula in the sagittal plane (and therefore better seen in the lateral X-ray) at the level of the syndesmosis; often there is also an avulsion injury on the medial side (a torn deltoid ligament or fracture of the medial malleolus). This is probably an external rotation injury and it may be associated with a tear of the ATFL. • Type C – is a more severe injury, above the level of the syndesmosis, which means that the tibiofibular ligament and part of the interosseous membrane must have been torn. This is due to severe abduction or a combination of abduction and external rotation. Associated injuries are an avulsion fracture of the medial malleolus (or rupture of the medial collateral ligament), a posterior malleolar fracture and diastasis of the tibiofibular joint
The Lauge-Hansen classification system is based on a rotational mechanism of injury. It is perhaps the recognition that the fracture pattern is associated with a rotational injury, as opposed to an axial load type of injury, which must be ascertained before assigning the injury a classification system.
The first part of the name in the classification system describes the position of the foot at the time of injury, while the second part of the name describes the direction of force applied to the foot.
Four injury patterns are described: supination-adduction (SA), supinationexternal rotation (SER), pronation-abduction (PA), and pronationexternal rotation (PER).
Anatomic / Descriptive
isolated medial malleolar
isolated lateral malleolar
bimalleolar
trimalleolar
Bosworth fracture-dislocation (posterior dislocation of the fibula behind incisura fibularis)
Danis-Weber (location of fibular fracture)
A - infrasyndesmotic (generally not associated with ankle instability)
B - transsyndesmotic
C - suprasyndesmotic
AO / ATA
44A - infrasyndesmotic
44B - transsyndesmotic
44C - suprasyndesmotic
lag screw fixation stronger if placed perpendicular to fracture line
antiglide plate with lag screw
best for vertical shear fractures
fixation of medial malleolus fracture
for transverse pattern, lag by technique using 3.5 fully-threaded screw is biomechanically superior to lag by design using 4.0 partially-threaded screws
syndesmosis injury
stiffness of syndesmosis restored to 70% normal with isolated fixation of posterior malleolus (versus 40% with isolated syndesmosis fixation)
stress examination of syndesmosis still required after posterior malleolar fixation
posteroinferior tibiofibular ligament may remain attached to posterior malleolus and syndesmotic stability may be restored with isolated posterior malleolar fixation
Evaluation
measure clear space 1 cm above joint
lateral stress radiograph has more interobserver reliability than an AP/mortise stress film
best option is to assess stability intraoperatively with abduction/external rotation stress of dorsiflexed foot
instability of the syndesmosis is greatest in the anterior-posterior direction
maximum dorsiflexion of ankle not required during screw placement (can't overtighten a properly reduced syndesmosis)
screws should be maintained in place for at least 6 weeks
must remain non-weight bearing, as screws are not biomechanically strong enough to withstand forces of ambulation
After stabilization of all fractures as appropriate, the stability and reduction of the syndesmotic complex must be assessed.
Use a small bone hook to pull the fibula laterally to examine the syndesmotic complex. Remove any bony fragments from the distal tibiofibular joint.
Test for antero-posterior translation of the fibula by pushing and pulling the fibula with the fingers, or a bone hook.
Restoring length, axis and rotation of the fibula
If the fibula is displaced, make sure it is properly reduced.
Use a small bone hook to pull the lateral malleolus distally if necessary, until perfect congruence of the distal tibiofibular joint is achieved.
Check rotation, length and antero-posterior translation of the fibula, by intraoperative radiology and/or direct visual inspection of the syndesmosis. Fix the reduction with a K-wire, if necessary.
Preliminary fixation with a K-wire
Fix the reduction with a 2.0 mm K-wire, inserted from the lateral side, distal to the planned distal screw and 1-2 cm above the joint line. The position of the ankle joint during this maneuver should be in neutral.
Confirm reduction under image intensification in both planes. Reduction must be anatomical. Compare with the uninjured ankle.
Pitfall
If reduction in the anterior-posterior direction is not anatomical, the congruity of the tibio-talar joint in the lateral view is not perfect, ie, the joint lines are not perfectly aligned.
Drilling
Drill a 2.5 mm hole through the fibula and the lateral cortex of the tibia, just proximal to the inferior tibiofibular joint, 30 degrees from posterior to anterior, parallel to the tibial plafond, with the ankle joint in neutral position.
If the fibular fracture was treated with a plate at this level, the screw may be placed through a hole in the plate.
Screw insertion
Use a depth gauge to determine the length of the screw.
As this screw is not intended to act as a compressive lag screw, the thread must be tapped in both fibula and tibia.
Tap the thread and insert a 3.5 mm or 4.5 mm cortex screw.
The foot position during positioning screw placement should be in neutral.
Check position and reduction under image intensification and compare with corresponding images of the uninjured ankle.
Some surgeons prefer two small fragment screws as syndesmotic screws, especially in high fibular fractures, such as the Maisonneuve injury.
Prepare and insert the second positioning screw as described above, parallel to, and 1.5–2 cm proximal to, the first screw.
Once satisfactory reduction and hold with screws has been confirmed, the K-wire is removed.
Note
Intraoperative x-rays or image intensification are advised, to confirm the position of the screw and the distal tibiofibular joint.
Following plating of a multifragmentary fracture, or when a high fibular fracture has not been fixed, postoperative CT or MRI, to assess the rotation of the fibula at the level of the syndesmosis of both ankles, is strongly advised.
Pitfall - If the positioning screw does not follow the drill hole precisely, displacement of the fibula is possible. Carefully maintain the position of the fibula when inserting the screw.
Avulsion from the anterior tibial tubercle (Tillaux-Chaput)
Avulsion from the fibula (Le Fort lesion or Wagstaff fragment)
An occult injury of the ankle, mistaken for proximal fibular fracture alone & ankle injury is missed or sprain of ankle joint & prximal fibula # is missed
Requires high INDEX of suspicion (long Leg Film)
Unexplained widening of tibio-fibular clear space >5mm
Isolated proximal fibula #
If the fracture is not reduced and stabilized at an early stage, it may prove impossible to restore the anatomy. For this reason unstable injuries should be treated by internal fixation even in the presence of an open wound, provided the soft tissues are not too severely damaged and the wound is not contaminated. As with all open fractures, attention must be paid to the extent of damage to the soft-tissue envelope and the involvement of other structures, particularly neurovascular or tendinous injuries. If internal fixation seems inappropriate, an external fixator can be used, often as a temporary spanning option.
