This document provides an overview of common ankle injuries. It begins with learning objectives and topics to be covered related to ankle anatomy, fractures, ligament injuries, and tendon injuries. It then describes the anatomy of the ankle joint and its ligaments in detail. It discusses the mechanisms, classifications, clinical evaluation, and treatment approaches for fractures, ligament sprains, tendon ruptures, and other ankle injuries. Surgical and non-surgical treatment options are presented, along with potential complications. The goal of treatment is described as anatomic restoration of the ankle joint and restoration of fibular length and rotation when necessary.

1. INJURIES AROUND THE
ANKLE
DR BIPUL BORTHAKUR
PROF & HOD
DEPT OF ORTHOPAEDICS,SMCH

2. LEARNING OBJECTIVES
ANATOMY
PATHOPHYSIOLOGY
CLINICAL SYMPTOMS
INVESTIGATIONS
TREATMENT
FOLLOW UP

3. TOPICS TO BE COVERED
ANATOMY OF ANKLE JOINT
BONY LESIONS(Fractures)
LIGAMENT INJURY
TENDON INJURY

4. ANATOMY OF ANKLE JOINT
Ankle is a complex hinge joint composed
of articulations among the fibula,tibia
and talus in close associations with a
complex ligamentous system.
Distal tibial articular surface is known as
–Plafond which together with medial
and lateral malleoli forms mortise.

5. ANKLE JOINT

6. CONTINUED
Plafond is concave in anteroposterior plane but
convex in lateral plane .
Talar dome is trapezoidal, with anterior aspect
2.5 mm wider than posterior talus.
Medial malleoli articulates with medial facet of
talus while lateral malleolus represent distal
aspect of fibula and provides support to ankle.

7. TIBIAL PLAFOND WITH TALUS

8. SYNDESMOTIC LIGAMENT
COMPLEX
Syndesmotic ligament complex exists
between distal tibia and fibula.
It is composed of four ligaments:
1. Anterior inferior tibiofibular ligament.
2.Posterior inferior tibiofibular ligament.
3.Inferior transverse tibio fibular ligament.
4. Interosseous ligament .

9. DELTOID LIGAMENT
It provides ligamentous support to medial aspect
of ankle.
Composed of superficial and deep components :
SUPERFICIAL PORTION
1.Naviculotibial ligament .
2.Tibiocalcaneal ligament.
3.Talotibial ligament.

10. DELTOID LIGAMENT

11. CONTINUED
DEEP PORTION :
ORIGIN-Intercollicular groove and posterior
colliculus of distal tibia.
INSERTION- Entire nonarticular medial
surface of talus.
It is the primary medial stabilizer against
lateral displacement of talus.

12. FIBULAR COLLATERAL
LIGAMENT
It provides lateral support to ankle.Made up
of 3 ligaments:
1.Anterior talofibular ligament(weakest ).
2.Posterior talofibular ligament(strongest).
3.Calcaneofibular ligament(stabilizes subtalar
joint and limits inversion).

13. LATERAL LIGAMENTOUS
COMPLEX

14. MECHANISM OF INJURY
Pattern of ankle injury depends on:
1.Mechanism(axial vs rotational loading).
2.Chronicity (recurrent ankle instability may result in
chronic ligamentous laxity and distorted
biomechanics).
3. Patient age.
4. Bone quality.
5. Position of foot at the time of injury.
6.Magnitude,direction and rate of loading.

15. CLINICAL EVALUATION
Patient may present with:
1.Limp
2.Swelling
3.Tenderness
4.Variable deformity
Dislocated ankle should be reduced and splinted
immediately.

16. ROTATIONALANKLE
FRACTURES
Lauge-Hansen classification:
Four patterns are recognised based on pure
injury sequence.
It takes into account :
1.Position of foot at the time of injury.
2.Direction of the deforming forces.

17. SUPINATION ADDUCTION (SA)
The only type associated with medial displacement of
talus,accounts for 10 to 20 % of malleolar fractures.
Stage 1- Produces either a transverse avulsion type
fracture of fibula distal to level of joint or a rupture of
lateral collateral ligament.
Stage 2- Results in a vertical medial malleolus fracture.

18. SUPINATION EXTERAL
ROTATION(SER)
Stage 1-Produces disruption of anterior tibiofibular
ligament.
Stage 2- Results in the typical spiral fracture of distal
fibula.
Stage 3- Produces either a disruption of the posterior
tibiofibular ligament or a fracture of posterior malleolus.
Stage 4- Produces either a transverse avulsion fracture
of medial malleolus or a rupture of deltoid ligament.

20. PRONATION ABDUCTION (PA)
Stage 1- Results in either a transverse fracture of
medial malleolus or rupture of deltoid ligament.
Stage 2- Produces either a rupture of the syndesmotic
ligaments or an avulsion fracture at their insertion
sites .
Stage 3- Produces a transverse or short oblique
fracture of distal fibula at or above level of
syndesmosis.

21. PRONATION EXTERNAL
ROTATION (PER)
 Stage 1- Produces either a transverse fracture of medial malleolus or a
rupture of deltoid ligament.
 Stage 2- Results in disruption of anterior tibiofibular ligament with or
without avulsion fracture at its insertion sites .
 Stage 3- Results in a spiral fracture of distal fibula at or above the level of
syndesmosis running from anterosuperior to postero inferior .
 Stage 4- Produces either a rupture of the posterior tibiofibular ligament or
avulsion fracture of posterolateral tibia.

23. DANIS- WEBER CLASSIFICATION
 It is based on level of fibular fracture.
 Type A- Fracture of fibula below the level of
tibial plafond,an avulsion injury that results
from supination of foot.
 Type B- This oblique or spiral fracture of the
fibula is caused by external rotation occurring
at or near the level of syndesmosis.
 Type C- This involves fracture of fibula above
the level of syndesmosis.

24. TREATMENT
GOAL-
1. Anatomic restoration of ankle joint.
2. Fibular length and rotation must be
restored.

25. EMERGENGY ROOM TREATMENT
Closed reduction should be performed for
displaced fractures.
Dislocated ankle should be reduced .
Following fracture reduction well padded
posterior splint should be kept.

26. NON OPERATIVE
Nondisplaced,stable fracture patterns with
intact syndesmosis .
Displaced fractures for which stable anatomic
reduction of ankle mortise is achieved.

27. OPERATIVE
 Orif should be performed when swelling,blisters and soft
tissue are usually stabilised.
 Lateral malleolar fractures distal to syndesmosis may be
stabilised by lag screw or K wire with tension band
wiring.
 With fractures at or above the syndesmosis,restoration of
fibular length and rotation is essential.

28. CONTINUED
Medial malleolar fractures can usually be stabilised with
cancellous screws or figure of eight tension band.
Fixation of posterior malleolus fractures may be
achieved by indirect reduction and placement of anterior
to posterior lag screw or posteriorly placed plate and or
through separate incision.

29. PRONATION ABDUCTION INJURY

30. A syndesmotic screw is placed 1.5 to 2 cm above the
plafond from the fibula to the tibia.
Fixation of posterior malleolar fracture fragment may
obviate the need for syndesmotic fixation.
Very proximal fibula fractures with syndesmotic
disruption can usually be treated with syndesmosis
fixation without direct fibula reduction.

31. COMPLICATIONS
NON UNION.
MALUNION
SKIN EDGE NECROSIS
INFECTIONS
POST TRAUMATIC ARTHRITIS
TIBIO FIBULAR SYNOSTOSIS
LOSS OF REDUCTION

32. PLAFOND (PILON) FRACTURES
It account for 7 to 10 % of all tibia fractures.
Mechanism of injury:
1. Axial compression(high energy): fall from
height,motor vehicle collision.
 Force is axially directed through the talus into
the tibial plafond, causing impaction of articular
surface.

33. Rotational (low energy): sporting accident.
Mechanism is primarily torsion combined with a
varus or valgus stress.
Combined compression and shear mechanism.
Ap,lateral and mortise radiograph along with
CT(coronal and sggittal) reconstruction are required.

34. RUEDI AND ALLGOWER
CLASSIFICATION
Based on severity of comminution and
displacement of articular surface.
Type 1- Non displaced cleavage fracture of
ankle joint .
Type 2- Displaced fracture with minimal
impaction or comminution.
Type 3-Displaced fracture with significant
articular comminution and metaphyseal
impaction.

35. TREATMENT
NON OPERATIVE
LONG LEG CAST
BRACE AND
ROM
EXERCISES
OPERATIVE
1. INTERNAL
FIXATION.
2.JOINT
SPANNING
EXTERNAL
FIXATOR.
3.ARTICULATING
VS
NONARTICULATIN
G SPANNING
EXTERNAL
FIXATION.
4.HYBRID
EX.FIXATION.

36. COMPLICATIONS
 SOFT TISSUE SLOUGH,NECROSIS AND
HAEMATOMA.
 NONUNION,MALUNION.
 POSTTRAUMATIC ARTHRITIS.
 TIBIAL SHORTENING.
 DECREASED ANKLE ROM.

37. LATERALANKLE LIGAMENT
INJURIES
 Mechanism of injury : Depends on
1.Position of foot .
2.Direction of stress.
 With ankle dorsiflexion and external rotation injury will
involve syndesmotic ligaments.
 Ankle dorsiflexion and inversion injury is usually to
calcaneofibular ligament.

38. CLASSIFICATION
MILD ANKLE SPRAIN,MODERATE ANKLE
SPRAIN AND SEVERE ANKLE SPRAIN .
Popping or tearing sensation followed by
immediate onset of pain with swelling around the
ankle .
Stress testing of lat. Collateral ligament can be
done.

39. MANAGEMENT
Most patients should undergo radiographic investigation
to rule out occult fractures.
Initial treatment involves RICE regimen.
 For moderate or severe strains we should immobilize
the ankle followed by isometric,proprioceptive
retraining.
Braces can be kept for sports and functional activities.

40. SYNDESMOSIS SPRAINS
 It accounts for approx. 1% of all ankle sprains.
 May occur without a fracture or frank diastases.
 Classification : Diastases of distal tibiofibular syndesmosis
classified into 4 types by Edwards and Delee.
Type 1- Diastases involves lateral subluxation without
fracture .
Type 2-lateral subluxation with plastic deformation of the
fibula.
Type 3-Posterior subluxation/dislocation of the fibula.
Type 4-Superior subluxation /dislocation of Talus within
mortise.

41. CLINICAL EVALUATION
 Localized tenderness in the area of the sprain with
ensuing ecchymosis and swelling.
 The clue to chronic ,subclinical syndesmotic sprains is
history of vague ankle pain with pushoff and normal
imaging.
 Squeeze test and external rotation stress test are
performed.
 In acute settings attempt at weight bearing radiographs of
ankle (AP,Mortise and lateral view) should be made.

42. TREATMENT
 Syndesmotic Ligamentous injuries are slower to
recover.
 Immobilisation in a non weight bearing cast for 2 to 3
weeks followed by use of protective,modified
articulated ankle foot orthosis.
 Operative treatment includes placing 2 screws at
superior margin of the syndesmosis from fibula to tibia.

43. ACHILLES TENDON RUPTURE
 Mostly associated with overuse injuries spectrum
ranges from paratenonitis to tendinosis to acute
rupture.
 It is the largest tendon in the body,lacks true
synovial sheath with visceral and parietal layers.

44. CLINICAL EVALUATION
 With either partial or complete rupture,patient
experiences sharp pain described as feeling like
being kicked in the leg.
 With complete rupture,examination reveals
palpable gap with Thomas test positive.

45. TREATMENT
 Keeping leg in splint for 2 weeks in plantar flexion
followed by a long leg cast for 6 to 8 weeks.
 Gradually plantar flexion is reduced and weight bearing
allowed after 6 weeks.
 Surgical treatment for younger and athletic patient by
percutaneous and open approaches can be done.
 Surgical technique uses medial longitudinal approach
to avoid injury to sural nerve,paratendon closed in
layers .

46. PERONEAL TENDON RUPTURE
 Uncommon injury resulting from forced dorsiflexion
or inversion especially in skiers.
 It demonstrate tenderness posterior to lateral
malleolus.Anterior drawer test is negative and patient
has discomfort with resisted eversion.
 Management includes immobilization in well
moulded cast in slight plantar flexion and mild
inversion.

47.  Surgical alternative includes transfer of lateral
Achilles tendon sheath,fibular osteotomy,rerouting
of peroneal tendons under fibulocalcaneal ligament .
 Post operatively leg is splinted for 1 or 2 weeks in
inversion and plantar flexion.

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