- 17-year-old Thai female presented to the hospital with right ankle pain and swelling after twisting her ankle 3 hours prior while playing football. - Physical examination revealed swelling and tenderness of the right ankle which was held in plantarflexion. X-rays showed a bimalleolar fracture of the right ankle. - Bimalleolar fractures involve fractures of both the medial and lateral malleoli. Non-displaced fractures are typically treated conservatively with immobilization while displaced or unstable fractures require open reduction and internal fixation surgery followed by non-weightbearing and rehabilitation.

1. Extern conference
Ext.Chaipat Khunphanichkij

2. CHIEF COMPLAINT
ข้อเท้าขวาพลิก 3 ชม.ก่อนมารพ.
Patient profile
ผู้ป่วยหญิงไทยโสดอายุ17ปี ภูมิลาเนา จ.นครราชสีมา

3. Primary Survey
A – patent airway, no midline spine tenderness
B – clear breath sound, equal both lungs, chest
compression test negative
C –BP 110/70 mmHg PR 82 bpm, no life-
threatening bleeding
D – GCS E4V5M6
E – no life threatening wound

4. Secondary survey
AMPLES
Allergy : NONE
Medication : NONE
Past history : no underlying disease
Last meal : 13.00 on the same day
Event : as present illness

5. Present illness
3 ชม.ก่อนมารพ. ขณะกาลังเล่นฟุตบอลสะดุดล้ม ข้อเท้าขวาพลิกลักษณะ
เข้าในจากนั้นลาตัวบิดก่อนล้มลง ไม่มีศีรษะกระแทก หลังล้มเจ็บข้อเท้า
ขวามาก ข้อเท้าขวาบวม ไม่มีแผลเลือดออก เดินลงน้าหนักที่ข้อเท้าขวา
ไม่ได้ กระดกข้อเท้าขวาไม่ได้ ยังขยับนิ้วเท้าได้ ไม่ชา จึงมารพ.

6. Physical examination
GA : alert Thai female, good consciousness, well cooperative
HEENT : no pale conjunctiva, anicteric sclera
Lungs : clear breath sound, equal both lungs, no adventitious
sound
CVS : regular pulse, normal s1,s2, no murmur
Abdomen : normoactive bowel sound, soft, not tender
Neuro : good conscious, motor grade V all except Rt.ankle cannot
evaluate due to pain, no sensory loss

7. Physical examination
Ext.
Rt.ankle : swelling, lie in plantarflexion posture, no wound, tender at
lateral and medial malleolus,
cap. refill <2s,
dorsalis pedis 2+
post. tibial 2+
normal pinprick sensation

8. Physical examination

9. Film Rt.ankle AP,Lat,Mortis

13. Diagnosis : Rt. bimalleolar fracture

14. Ankle fracture
Not only bone but also…

15. Epidemiology
• 187 per 100,000 people-year
–60-70% unimalleolar
–15-20% bimalleolar
–7-12% trimalleolar

16. Anatomy

17. ATFL : ant. talofibular lig.
PTFL : post. talofibular lig.
CFL : calcaneofibular lig.
Lateral Medial

19. Clinical presentation
• Pain
• Swelling
• Limit ROM of ankle
• Unable to stand on weightbearing

20. Mechanism of injury : Lauge-Hansen classification
Ant tib-fib sprain
Short oblique fx
of distal fibula
Post malleolus fx
Post tib-fib lig
Medial malleolus fx
Deltoid lig rupture
Transverse distal fibula fx
Talofibular lig sprain
Vertical medial malleolus fx

21. Mechanism of injury : Lauge-Hansen classification
Medial malleolus fx
Deltoid lig rupture
Ant tib-fib sprain
Chaput tubercle fx
High fibula fx
Post malleolus fx
Post tib-fib lig
Medial malleolus fx
Deltoid lig rupture
Ant tib-fib sprain
Chaput tubercle fx
Comminuted fx of
fibula

22. Ottawa ankle rules

23. Radiographic findings

24. Radiographic Feature
Accepted Normal
Parameter
Notes
Medial clear space
The joint spaces medial
and superior to the talus
should be equal. The
medial clear space should
be <5 mm, and no more
than 2 mm greater than
the tibiotalar clear space.
These measurements are
influenced by rotation,
individual patient
morphology, and the
presence of ankle
arthritis.
Tibiofibular clear space
(syndesmosis A) 10 mm
above joint line
>5 mm
Relatively constant with
rotation
Tibiofibular overlap
(syndesmosis B) 10 mm
above joint line
<5 mm on AP view and <1
mm on the mortise view
Highly variable dependent
on rotation
Fibular length
The articular margins of
the distal fibula and the
lateral process of the talus
on the mortise view
should be parallel, and
equal to the tibiotalar
joint space. The “ball sign”
(Fig. 59-15) is a
confirmatory visual cue.
Shortening of the fibula
results in lateral and
valgus subluxation of the
talus
Talocrural angle
Approximately 83 degrees,
and symmetrical with
contralateral ankle.
A further measurement of
fibular length.

26. Treatments
• Up to stability of injury
• Injury to ≥2 parts of ankle = unstable = need
surgery
• Immobilize : posterior short leg slab in 90 degree of
ankle
–Beware of compartment syndrome

27. Treatments
• Open reduction with internal fixation in
–Unstable injury
–Neurovascular involvement
Post-op care
leg elevation
pain control
observe compartment syndrome
ambulation with non-weightbearing with gait aid

28. Rehabilitation
• Goal
–Restore motion
–Strength
–Proprioception

29. References
• Uptodate.com : Overview of ankle fractures in adults
• ออร์โธปิดิกส์ ฉบับเรียบเรียงใหม่ ครั้งที่ 3.- - กรุงเทพฯ : ภาควิชา ออร์
โธปิดิกส์ คณะแพทยศาสตร์ โรงพยาบาลรามาธิบดี. 2554
• Rockwood and Green’s, Fractures in Adults, 8th edition Vol.1