Ankle fractures

1. ANKLE INJURIES

2.  Frequent site of injuries
 A large variety of bending and twisting force result
in a number of fractures and fracture-dislocation -
'Pott's fracture’

3. ANATOMY
 A modified hinge-joint
 The 'socket’ is formed by...
 Distal articular surfaces of the tibia and fibula
 The intervening tibio-fibular ligament
 The articular surfaces of the malleoli
 Ankle-mortice
 The superior articular surface of the talus
articulates with this socket

4.  The strong tibio-fibular syndesmosis,
along with the medial and lateral
malleoli make the ankle a strong and
stable articulation
 Therefore, pure dislocation of the ankle
is rare
 Commonly, dislocation occurs only with
fractures of the malleoli
 The elongated posterior part of the
distal articular surface of the tibia often
gets chipped-off in ankle injuries, and is
termed a posterior malleolus

5.  Ligaments of the ankle:
 Two main ligaments
 Medial collateral ligament (deltoid ligament):
 Strong ligament on the medial side
 Superficial - tibio-calcaneal
 Deep - tibio-talar
 Lateral collateral ligament:
 Weak ligament and is often injured
 Three parts:
 Anterior talo-fibular
 Calcaneo-fibular in the middle
 Posterior talo-fibular

7. SOME TERMS USED IN RELATION TO ANKLE
INJURIES
 Inversion (adduction): Inward twisting of the ankle
 Eversion (abduction): Outward twisting of ankle
 Supination: Inversion plus adduction of the foot so that the
sole faces medially
 Pronation: Eversion and abduction of the foot so that the sole
faces laterally
 Rotation (external or internal): A rotatory movement of the
foot so that the talus is subjected to a rotatory force along its
vertical axis
 Vertical compression: A force along the long axis of the tibia

8. THE LAUGE-HANSEN CLASSIFICATION
 It is believed that a specific pattern of bending and
twisting forces results in specific fracture pattern
 Five basic mechanisms
 Adduction injuries
 Abduction injuries
 Pronation-external rotation injuries
 Supination external rotation injuries
 Vertical compression injuries
 When a foot is subjected to these forces, different
parts of the ankle-mortice are subjected to distraction
and compression stress. The specific fracture-pattern
depends on the type of stress and its severity

9. ADDUCTION INJURIES (INVERSION)
 An inversion force with the foot in plantar-flexion
results in a sprain of the lateral ligament of the
ankle
 Partial or complete rupture
 A partial rupture - limited to the anterior
fasciculus of the lateral ligament (talo-fibular
component)
 A complete rupture - tear extends backwards to
involve the whole of the lateral ligament
complex
 The talus tends to subluxate out of the ankle-
mortice

10.  The inversion force on an ankle in neutral or
dorsiflexed position results in…
 A fracture of the medial malleolus - typically
fracture-line running obliquely upwards from the
medial angle of the ankle-mortice
 On the lateral side - may be associated with a
low-transverse (below the ankle-mortice)
fracture of the lateral malleolus, or a lateral
ligament rupture(avulsion injury)

11. ABDUCTION INJURIES (EVERSION)
 The medial structures - subjected to a
distracting force and the lateral structures to
compressive force
 Results in rupture of the deltoid ligament or
a low-lying transverse fracture of the medial
malleolus (avulsion fracture on the medial
side)
 On the lateral side - a fracture of the lateral
malleolus at the level of the ankle-mortice
with comminution of the outer cortex occurs
 The talus, with two fractured malleoli
subluxates laterally

12. PRONATION – EXTERNAL ROTATION INJURIES
 When a pronated foot rotates externally,
the talus also rotates outwards along its
vertical axis
 The first structures to give way are those
on the medial side
 There may occur a transverse fracture
of the medial malleolus at the level of the
ankle-mortice, or a rupture of the medial-
collateral ligament

13.  With further rotation of the talus, the anterior tibio-fibular
ligament is torn
 This is followed by a spiral fracture of the lower end of the
fibula as the rotating talus hits the lateral malleolus
 In the case where the tibio-fibular syndesmosis is completely
disrupted, the fracture occurs above the syndesmosis i.e.,
in the lower-third of the fibula
 At times the fracture may occur as high as the neck of the
fibula – Massonaie’s fracture
 Thus a fracture of the fibula above the ankle-mortice, in an
ankle injury, is an indication of disruption of the tibio-
fibular syndesmosis

14. SUPINATION – EXTERNAL ROTATION INJURIES
 With the foot supinated, the talus twists
externally within the mortice
 As the medial structures are lax, the
first structure to give way are those on
the lateral side, the head of the talus
striking against the lateral malleolus,
producing a spiral fracture at the level
of the ankle-mortice
 The next structure to break is the
posterior malleolus

15.  As the talus rotates further, it hits against the medial
malleolus resulting in a transverse fracture
 The tibio-fibular syndesmosis remains intact
 In extreme cases, the whole foot along with the
three malleoli, is displaced

16. VERTICAL COMPRESSION INJURIES
 All the above injuries may become
complex due to a component of vertical
compression force
 It may be primarily a vertical
compression injury resulting in either an
anterior marginal fracture of the tibia or
a comminuted fracture of the
tibial articular surface with a fracture
of the fibula - Pilon fracture

17. CLINICAL FEATURES
 H/o twisting ankle injury followed by pain and swelling
 Often the patient is able to express exactly
the way the ankle got twisted
 On examination:
 The ankle is found to be swollen
 The swelling and tenderness may be localised to the
area of injury (bone or ligament)
 Crepitus may be noticed if there is a fracture
 The ankle may be lying deformed (adducted or abducted, with
or without rotation)

18. RADIOLOGICAL EXAMINATION
 X- ray AP and lateral view
 The fracture line of the medial and lateral malleoli should
be studied in order to evaluate the type of ankle injury
(Lauge-Hansen classification).
 Small avulsion fractures from the malleoli are sometimes
missed. These often have attached to them the whole
ligament
 Tibio-fibular syndesmosis:
 All ankle injuries where the fibular fracture is above the
mortice, the syndesmosis is bound to have been
disrupted
 In injuries where the fibular fracture is at the level of the
syndesmosis, one must carefully look for any lateral
subluxation of the talus; if it is so, width of the joint space
between the medial malleolus and the talus will be more
than that between the weight-bearing surfaces of tibia
and talus

19.  A posterior subluxation of the talus
should be looked for on the lateral X-
ray
 A soft-tissue swelling on the medial or
lateral side in the absence of a fracture,
must arouse suspicion of a ligament
injury
 This should be confirmed or ruled out after
thorough clinical examination and stress
X-rays

20. TREATMENT
 Principles of Treatment:
 The basic principle of treatment is to achieve
anatomical reconstruction of the ankle-mortice so as to
regain good function and minimise the possibility of
osteoarthritis developing later
 In some cases, it is possible to do so by conservative
methods
 In most an operative reduction and internal fixation is
required

21. FRACTURES WITHOUT DISPLACEMENT
 Sufficient to protect the ankle in a below-knee
plaster for 3-6 weeks, followed by physiotherapy

22. FRACTURES WITH DISPLACEMENT
 The aim of treatment:
 To ensure anatomical reduction of the ankle-mortice
 This means ensuring anatomical reduction of medial
and lateral malleoli, and that the talus is placed normally
within the mortice
 Operative methods
 Conservative methods

23. OPERATIVE METHODS
 Internal fixation for all displaced fractures of ankle with
or without attempting closed reduction
 By operative reduction it is possible to achieve perfect
alignment as well as stable fixation of fragments
 Allows early motion of the ankle joint, thereby
improving overall results
 In general, operative reduction and internal fixation may
be used in cases…
 Where closed reduction has not been successful
 The reduction has slipped during the course of conservative
treatment

24.  Medial malleolus fracture:
 Transverse fracture - compression screw
tension-band wiring
 Oblique fracture - compression screws
 Avulsion fracture - tension-band wiring
 Lateral malleolus fracture:
 Transverse fracture - tension-band wiring
 Spiral fracture - compression screws
 Comminuted fracture - buttress plating
 Fracture of the lower-third of fibula - 4-hole
plate

25.  Posterior malleolus:
 Involving less than one-third of the articulating surface
of the tibia - no additional treatment
 Involving more than one-third of the articulating surface
of the tibia - internal fixation with compression screws
 Tibio-fibular syndesmosis disruption: needs to be
treated by inserting a long screw from the fibula into the
tibia
 All major ligament injuries e.g., that of deltoid
ligament, lateral ligament should be repaired

26. CONSERVATIVE TREATMENT
 It is often possible to achieve a good reduction by
manipulation under general anaesthesia
 The essential feature of the reduction is to
concentrate on restoring the alignment of the foot to
the leg
 By doing so the fragments automatically fall into
place
 Once reduced, a below knee plaster cast is applied

27.  If the check X-ray shows a satisfactory position, the
plaster cast is continued for 8-10 weeks
 The patient is not allowed to bear any weight on the
leg during this period
 Check X-rays are taken frequently to make sure
that the fracture does not get displaced
 If everything goes well, the plaster is removed after
8-10 weeks and the patient taught physiotherapy to
regain movement at the ankle.

28.  External fixation:
 Required in cases where closed methods cannot be
used e.g. open fractures with bad crushing of the
muscles and tendons, with skin loss around the ankle

29. COMPLICATIONS
 More serious fracture-dislocation may
be complicated because of improper treatment
 Sometimes, the nature of injury is such that perfect
functions cannot be restored

30.  Stiffness of the ankle:
 Following immobilisation in plaster, stiffness occurs
 In ankle injuries, the recovery takes a long time because
of the tendency for gravitational oedema
 Most common in elderly persons
 With persistent treatment, using limb elevation, crepe-
bandage and active toe movements, the oedema
subsides
 It may be necessary to continue ankle exercises for a
long period (6-8months)

31.  Osteoarthritis:
 Since most ankle fractures involve the articular surfaces,
anything short of a perfect anatomical reduction with smooth
and congruous joint surfaces will lead to wear and tear
of the articular cartilage
 This will start the process of degenerative osteoarthritis
 The greater the irregularity of the articular surfaces, the more
rapidly will the degenerative changes occur
 The patient will complain of persistent pain, swelling
and joint stiffness
 In severe cases – ankle arthrodesis

32. DUPUYTREN'S FRACTURE
 An eponyms for a bi-malleolar ankle fracture
accompanied by a rupture of tibio-fibular ligament
and talar subluxation or dislocation that may follow
diastasis