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![GOAL: TO EVALUATE DEEP DELTOID [i.e. INSTABILITY]
METHOD: MEDIAL TENDERNESS
MEDIAL SWELLING
MEDIAL ECCHYMOSIS
STRESS VIEWS- GRAVITY OR MANUAL](https://image.slidesharecdn.com/anklefracturesfinal-120314092959-phpapp01-150806181221-lva1-app6892/85/Anklefracturesfinal-120314092959-phpapp01-44-320.jpg)
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Anklefracturesfinal 120314092959-phpapp01
- 1. PRESENTER: Dr. ANKURMITTAL
- 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
- 3. The joint isconsidered 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 The tibiotalar articulation is considered to be highly congruent such that 1 mm talar shift within the mortise decreases the contact area by 42 %
- 4. Anterior Colliculus Posterior Colliculus IntercollicularGroove Medial malleolus consists of: -Anterior Colliculus -Intercollicular Groove -Posterior Colliculus Origin: anterior colliculus
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- 7. Medial view offibula Articular surface Malleolar fossa Lateral Ridge McMinn 1996 Lateral Ligamentous Complex
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- 9. MEDIAL SIDE LATERALSIDE LACINATE LIG. TARSAL TUNNEL
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- 11. 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.
- 12. 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 .
- 13. •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
- 14. An initial evaluationof the radiograph should 1st focus on •Tibiotalar articulation and access for fibular shortening •Widening of joint space •Malrotation of fibula •Talar tilt
- 15. Identifies fracturesof ◦ malleoli ◦ distal tibia/fibula ◦ plafond ◦ talar dome ◦ body and lateral process of talus ◦ calcaneous
- 18. On the anteroposteriorview, the distal tibia and fibula, including the medial and lateral malleoli, are well demonstrated . important note is that the fibular (lateral) malleolus is longer than the tibial (medial) malleolus. This anatomic feature, important for maintaining ankle stability, is crucial for reconstruction of the fractured ankle joint. Even minimal displacement or shortening of the lateral malleolus allows lateral talar shift to occur and may cause incongruity in the ankle joint, possibly leading to posttraumatic arthritis.
- 19. Quantitative analysis ◦Tibiofibular overlap ◦<10mmis abnormal - implies syndesmotic injury ◦Tibiofibular clear space ◦>5mm is abnormal - implies syndesmotic injury ◦Talar tiltTalar tilt ◦>2mm is considered abnormal Consider a comparison with radiographs of the normal side if there are unresolved concerns of injury
- 20. Lateral malleolarfracture Tib/fib clear space <5mm Tib/fib overlap >10 mm No evidence of syndesmotic injury
- 21. Taken withankle in 15-25 degrees of internal rotation Useful in evaluation of articular surface between talar dome and mortise
- 22. 10 degrees internalrotation of 5th MT with respect to a vertical line
- 24. Medial clearspace ◦ Between lateral border of medial malleous and medial talus ◦ <4mm is normal ◦ >4mm suggests lateral shift of talus
- 25. •Abnormal findings: –Medial jointspace widening –Talocrural angle: <8 or >15 degrees –Tibia/fibula overlap:<1mm Consider a comparison with radiographs of the normal side if there are unresolved concerns of injury
- 26. FIBULAR LENGTH: 1.Shenton’s Line of the ankle 2. The dime test
- 27. •Posterior mallelolar fractures •APtalar subluxation •Distal fibular translation &/or angulation •Syndesmotic relationship •Associated or occult injuries –Lateral process talus –Posterior process talus –Anterior process calcaneus
- 28. The ankleis a ring ◦ Tibial plafond ◦ Medial malleolus ◦ Deltoid ligaments ◦ calcaneous ◦ Lateral collateral ligaments ◦ Lateral malleolus ◦ Syndesmosis Fracture of single part usually stable Fracture > 1 part = unstable Source: Rosen
- 29. • 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
- 30. Some ligament injuriesmay be diagnosed on the basis of disruption of the ankle mortise and displacement of the talus; others can be deduced from the appearance of fractured bones. For example, fibular fracture above the level of the ankle joint indicates that the distal anterior tibiofibular ligament is torn. Fracture of the fibula above its anterior tubercle strongly suggests that the tibiofibular syndesmosis is completely disrupted. Fracture of the fibula above the level of the ankle joint without accompanying fracture of the medial malleolus indicates rupture of the deltoid ligament.
- 31. Transverse fracture ofthe medial malleolus indicates that the deltoid ligament is intact. High fracture of the fibula associated with a fracture of the medial malleolus or tear of the tibiofibular ligament, the so-called Maisonneuve fracture (see later), indicates rupture of the interosseous membrane up to the level of the fibular fracture
- 32. When radiographs ofthe ankle are normal, however, stress views are extremely important in evaluating ligament injuries . Inversion (adduction) and anterior-draw stress films are most frequently obtained; only rarely is an eversion (abduction)-stress examination required.
- 33. Inversion stress view.(A) For inversion (adduction)-stress examination of the ankle, the foot is fixed in the device while the patient is supine. The pressure plate, positioned approximately 2 cm above the ankle joint, applies varus stress adducting the heel. (If the examination is painful, 5 to 10 mL of 1% Xylocaine or a similar local anesthetic is injected at the site of maximum pain.) (B) On the anteroposterior film, the degree of talar tilt is measured by the angle formed by lines drawn along the tibial plafond and the dome of the talus. The contralateral ankle is subjected to the same procedure for comparison. This angle helps diagnose tears of the lateral collateral ligament
- 34. The anterior-draw stressfilm, obtained in the lateral projection, provides a useful measurement for determining injury to the anterior talofibular ligament Values of up to 5 mm of separation between the talus and the distal tibia are considered normal; values between 5 and 10 mm may be normal or abnormal, and the opposite ankle should be stressed for comparison. Values above 10 mm always indicate abnormality.
- 35. 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
- 36. • Classification systems –Lauge-Hansen – Weber – OTA • Additional Anatomic Evaluation – Posterior Malleolar Fractures – Syndesmotic Injuries – Common Eponyms
- 37. 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
- 38. • In eachtype there are several stages of injury • Imperfect system: – Not every fracture fits exactly into one category – Even mechanismspecific pattern has been questioned – Inter and intraobserver variation not ideal – Still useful and widely used Remember the injury starts on the tight side of the ankle! The lateral side is tight in supination, while the medial side is tight in pronation.
- 39. Primary advantage : Characteristic fibular # pattern useful for reconstructing the mechanism of injury a guide for the closed reduction Sequential pattern – inference of ligament injuries Disadvantages: complicated, variable inter observer reliability doesn’t signify prognosis internal rotation injuries (Weber A3) missed doesn’t indicate stability
- 41. 1 23 4 Stage 1 Anterior 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
- 42. Standard: Closed management LateralInjury: classic posterosuperioranteroinferior fibula fracture Medial Injury: Stability maintained
- 43. Lateral Injury: classicposterosuperioranteroinferior fibula fracture Medial Injury: medial malleolar fracture &*/or deltoid ligament injury Standard: Surgical management
- 44. GOAL: TO EVALUATEDEEP DELTOID [i.e. INSTABILITY] METHOD: MEDIAL TENDERNESS MEDIAL SWELLING MEDIAL ECCHYMOSIS STRESS VIEWS- GRAVITY OR MANUAL
- 45. SER-2 NegativeStress view External rotation of foot with ankle in neutral flexion (00 ) + Stress View Widened Medial Clear Space SE-4SE-4
- 46. • Stage 1:fibula fracture is transverse below mortise. • Stage 2: medial malleolus fracture is classic vertical pattern. 1 2
- 47. Lateral Injury: transversefibular fracture at/below level of mortise Medial injury: vertical shear type medial malleolar fracture BEWARE OF IMPACTION
- 48. • Important torestore: – Ankle stability – Articular congruity- including medial impaction
- 50. 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
- 51. Medial injury: deltoidligament tear &/or transverse medial malleolar fracture Lateral Injury: spiral proximal lateral malleolar fracture HIGHLY UNSTABLE…SYNDESMOTIC INJURY COMMON
- 52. • 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
- 53. Stage 1Transverse medial malleolus fx distal to mortise Stage 2 Posterior malleolus fx or posterior tibio-fibular ligament Stage 3 Fibula fracture, typically proximal to mortise, often with a butterfly fragment 1 2 3
- 54. Medial injury: tranverseto short oblique medial malleolar fracture Lateral Injury: comminuted impaction type distal lateral malleolar fracture
- 55. • Classification systems –Lauge-Hansen – Weber – OTA • Additional Anatomic Evaluation – Posterior Malleolar Fractures – Syndesmotic Injuries – Common Eponyms
- 56. Based on locationof fibula fracture relative to mortise and appearance Weber A fibula distal to mortise Weber B fibula at level of mortise Weber C fibula proximal to mortise Concept - the higher the fibula the more severe the injury
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- 58. • Classification systems –Lauge-Hansen – Weber – OTA • Additional Anatomic Evaluation – Posterior Malleolar Fractures – Syndesmotic Injuries – Common Eponyms
- 59. Alpha-Numeric Code Tibia=4 Malleolar segment =4 Infrasyndesmotic=44A Suprasyndesmotic=44C Transsyndesmotic=44B + AO classification divides the three Danis Weber types further for associated medial injuries.
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- 63. • Classification systems –Lauge-Hansen – Weber – OTA • Additional Anatomic Evaluation – Posterior Malleolar Fractures – Syndesmotic Injuries – Common Eponyms
- 64. Function: Stability- prevents posteriortranslation of talus & enhances syndesmotic stability Weight bearing- increases surface area of ankle joint
- 65. • Fracture pattern: –Variable – Difficult to assess on standard lateral radiograph • External rotation lateral view • CT scan
- 66. Type I- posterolateraloblique type Type II- medial extension type Type III- small shell type 67% 19% 14%
- 67. • Classification systems –Lauge-Hansen – Weber – OTA • Additional Anatomic Evaluation – Posterior Malleolar Fractures – Syndesmotic Injuries – Common Eponyms
- 68. FUNCTION: Stability- resists externalrotation, axial, & lateral displacement of talus Weight bearing- allows for standard loading
- 69. • Classification systems –Lauge-Hansen – Weber – OTA • Additional Anatomic Evaluation – Posterior Malleolar Fractures – Syndesmotic Injuries – Common Eponyms
- 70. • Maisonneuve Fracture –Fracture of 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
- 71. Pott fracture. In thePott fracture, the fibula is fractured above the intact distal tibiofibular syndesmosis, the deltoid ligament is ruptured, and the talus is subluxed laterally
- 72. Dupuytren fracture. (A) Thisfracture usually occurs 2 to 7 cm above the distal tibiofibular syndesmosis, with disruption of the medial collateral ligament and, typically, tear of the syndesmosis leading to ankle instability. (B) In the low variant, the fracture occurs more distally and the tibiofibular ligament remains intact.
- 73. 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.
- 74. •Collicular Fractures –Avulsion fractureof distal portion of medial malleolus –Injury may continue and rupture the deep deltoid ligament •Bosworth fracture dislocation –Fibular fracture with posterior dislocation of proximal fibular segment behind tibia POSTERIOR COLLICULUS ANTERIOR COLLICULUS INTERCOLLICULAR GROOVE
- 75. Tibial Pilon Fractures Theterms tibial plafond fracture, pilon fracture, and distal tibial explosion fracture all have been used to describe intraarticular fractures of the distal tibia. These terms encompass a spectrum of skeletal injury ranging from fractures caused by low-energy rotational forces to fractures caused by high-energy axial compression forces arising from motor vehicle accidents or falls from a height. Rotational variants typically have a more favorable prognosis, whereas high-energy fractures frequently are associated with open wounds or severe, closed, soft-tissue trauma.
- 76.
- 77. Rotational fracture ofthe ankle can be viewed as a continuum, progressing from single malleolar fractures to bimalleolar fractures to fractures involving the distal tibial articular surface. Lauge-Hansen described a pronation-dorsiflexion injury that produces an oblique medial malleolar fracture, a large anterior lip fracture, a supraarticular fibular fracture, and a posterior tibial fracture. Giachino and Hammond described a fracture caused by a combination of external rotation, dorsiflexion, and abduction that consisted of an oblique fracture of the medial malleolus and an anterolateral tibial plafond fracture..
- 78. These fractures generallyhave little comminution, no significant metaphyseal involvement, and minimal soft-tissue injury. They can be treated similarly to other ankle fractures with internal fixation of the fibula and lag screw fixation of the distal tibial articular surface through limited surgical approaches
- 79. CLASSIFICATION OF ANKLEFRACTURES IN CHILDREN Salter-Harris anatomic classification as applied to injuries of the distal tibial epiphysis.
- 80. Classification of AnkleFracture in Children (Dias-Tachdjian)
- 81. Supination Inversion grade Iadduction or inversion force avulses the distal fibular epiphysis (Salter-Harris type I or II fracture). Occasionally, the fracture is transepiphyseal; rarely, the lateral ligaments fail. grade II further inversion produces a tibial fracture, usually a Salter-Harris type III or IV and, rarely, a Salter-Harris type I or II injury, or the fracture passes through the medial malleolus below the physis
- 82. A.Salter-Harris I fractureof the distal tibia and fibula. B. B. Salter-Harris I fracture of the fibula, Salter-Harris II tibial fracture. C.C. Salter-Harris I fibular fracture, Salter- Harris III tibial fracture. D.D. Salter-Harris I fibular fracture, Salter- Harris IV tibial fracture. Variants of grade II supination inversion injuries (Dias-Tachdjian classification).
- 83. Supination Plantarflexion The plantarflexionforce displaces the epiphysis directly posteriorly, resulting in a Salter-Harris type I or II fracture. Fibular fractures were not reported with this mechanism. The tibial fracture usually is difficult to see on anteroposterior x-rays
- 84. Supination External Rotation Ingrade I the external rotation force results in a Salter-Harris type II fracture of the distal tibia The distal fragment is displaced posteriorly, as in a supination plantarflexion injury, but the Thurston-Holland fragment is visible on an anteroposterior x-ray, with the fracture line extending proximally and medially. Occasionally, the distal tibial epiphysis is rotated but not displaced.
- 85. In grade II,with further external rotation, a spiral fracture of the fibula is produced, running from anteroinferior to posterosuperior (
- 86. Pronation Eversion ExternalRotation A Salter-Harris type I or II fracture of the distal tibia occurs simultaneously with a transverse fibular fracture. The distal tibial fragment is displaced laterally, and the Thurston-Holland fragment, when present, is lateral or posterolateral . Less frequently, a transepiphyseal fracture occurs through the medial malleolus (Salter type II).
Editor's Notes
- #16 How do you tell AP from mortise?
- #20 AP defined as long axis of foot in true vertical position. Tib fib overlap defined by Pettrone in classic article [JBJS 1983] Tibiofibular clear space defined in the same article. It has subsequently been reevaluated multiple times [Harper Foot Ankle 1993; Park et al JOT 2006…] Talar tilt originated ??? One early reference is Joy et al JBJS 1974. In this it was defined by measuring the distance between the articular surfaces of the tibia and talus in the medial and lateral parts of the joint as seen on the AP.
- #23 “In the adult, the coronal plane of the ankle is oriented in about 15 – 20 degrees of ER with reference to the coronal plane of the knee, and therefore the lateral malleolus is slightly posterior to the medial malleolus. To obtain a true AP of the tibiotalar articulation [i.e. a mortise view], the ankle must be positioned with the medial and lateral malleoli parallel to the tabletop; that is, in about 15-20 degrees of internal rotation.” This was best achieved by internally rotating the foot so that the lateral border of the fifth metatarsal was 10 degrees internally rotated with respect to a vertical line.
- #26 The medial clear space has been defined as the distance between the lateral border of the medial malleolus and the medial border of the talus at the level of the talar dome [Joy et al JBJS 1974]. The idea dates back at least to the 1940s [Burns 1943]. It is considered to be representative of the status of the deep deltoid ligament. It varies depending on the position of the radiograph, the stress on the ankle, and the injury to the ankle. Historically a space wider than 4mm was considered to be abnormal. More recently, a medial clear space of greater than or equal to 5mm on radiographs taken in dorsiflexion with an external rotation stress was found to be most predictive of deep deltoid ligament transection after distal fibular fracture [Park et al. JOT 2006]. The talocrural angle is the superomedial angle formed by the intersection of a line joining the tips of both malleoli and of a line perpendicular to the distal tibial articular surface. This originated in 1976 [Sarkisian , Cody, J Trauma]. Note tib fib overlap is measured on both the AP and the mortise view. [Pettrone et al. JBJS 1983]. The number revealing likely instability is different by a factor of ten.
- #27 Fibular length can be defined by: Shenton’s line of the ankle The dime test Other measurements [eg bimalleolar angular measurements [Rolfe et al Foot and Ankle 1989] Comparison radiographs always useful
- #28 Widened anterior joint space on true lateral radiograph should increase suspicion for external rotation/posterior translation of talus which can occur with syndesmotic widening
- #45 Recently even this has been questioned [Koval Presentation OTA 2006]. It is plausible that the degree of instability makes a difference in functional outcome. That is, incomplete deep deltoid injuries could lead to a widened medial joint space with stress…but still heal with nonoperative treatment in a stable position, with no apparent functional problems in the short term [average 18 months].
- #69 A medial injury is thought to be required for a syndesmotic injury to alter loading [Boden JBJS 1989]