Lecture trauma ankle_fracture
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Ankle Fracture
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Lecture trauma ankle_fracture
- 1. AAnnkkllee FFrraaccttuurreess UUCCMMCC OOrrtthhooppaaeeddiicc TTrraauummaa CCoonnffeerreennccee AApprriill 22001122
- 3. • MMeecchhaanniissmm • TTiimmiinngg • SSoofftt--ttiissssuuee iinnjjuurryy • BBoonnee qquuaalliittyy • CCoommoorrbbiiddiittiieess • AAssssoocciiaatteedd IInnjjuurriieess
- 4. • SSkkiinn • NNeerrvveess • VVaassccuullaattuurree • PPaaiinn • DDeeffoorrmmiittyy
- 5. AAnnaattoommyy:: MMeeddiiaall SSiiddee Anterior Colliculus Intercollicular Groove Posterior Colliculus Origin: anterior colliculus Origin: posterior colliculus & intercollicular groove Pankovich 1979
- 8. AAPP – TTiibbiiooffiibbuullaarr oovveerrllaapp – <<1100mmmm – TTiibbiiooffiibbuullaarr cclleeaarr ssppaaccee – >>55mmmm – TTaallaarr ttiilltt – >>22mmmm Consider a comparison view
- 9. MMoorrttiissee VViieeww –TTaallooccrruurraall aannggllee:: <<88 oorr >>1155 ddeeggrreeeess
- 10. MMoorrttiissee VViieeww Weber SICOT 1981 FIBULAR LENGTH: 1. Shenton’s Line of the ankle 2. The dime test
- 13. SSuuppiinnaattiioonn--EExxtteerrnnaall RRoottaattiioonn Stage 1 Anterior tibio- fibular ligament 3 Stage 2 Fibula fx Stage 3 Posterior malleolus fx or posterior tibio-fibular ligament Stage 4 Deltoid ligament tear or medial malleolus fx
- 15. Ext Supination-Exteerrnnaall RRoottaattiioonn SSttaaggee 44:: UUnnssttaabbllee Lateral Injury: classic posterosuperioranteroinferior fibula fracture Medial Injury: medial malleolar fracture &*/or deltoid ligament injury Standard: Surgical management *Tornetta JBJS 2000
- 16. SSuuppiinnaattiioonn AAdddduuccttiioonn:: SSttaaggee 22 Lateral Injury: transverse fibular fracture at/below level of mortise Medial injury: vertical shear type medial malleolar fracture BEWARE OF IMPACTION McConnell J Orthop Trauma 2001
- 17. PPrroonnaattiioonn--EExxtteerrnnaall RRoottaattiioonn • SSttaaggee 11 DDeellttooiidd lliiggaammeenntt tteeaarr oorr mmeeddiiaall mmaalllleeoolluuss ffxx • SSttaaggee 22 AAnntteerriioorr ttiibbiioo--ffiibbuullaarr lliiggaammeenntt aanndd iinntteerroosssseeoouuss mmeemmbbrraannee • SSttaaggee 33 SSppiirraall,, pprrooxxiimmaall ffiibbuullaa ffrraaccttuurree • SSttaaggee 44 PPoosstteerriioorr mmaalllleeoolluuss ffxx oorr ppoosstteerriioorr ttiibbiioo--ffiibbuullaarr lliiggaammeenntt • 1 2 3 4
- 18. Pronation EExxtteerrnnaall RRoottaattiioonn:: SSttaaggee 44 Medial injury: deltoid ligament tear &/or transverse medial malleolar fracture Lateral Injury: spiral proximal lateral malleolar fracture HIGHLY UNSTABLE…SYNDESMOTIC INJURY COMMON
- 19. PPrroonnaattiioonn--AAbbdduuccttiioonn • SSttaaggee 11 TTrraannssvveerrssee mmeeddiiaall mmaalllleeoolluuss ffxx ddiissttaall ttoo mmoorrttiissee • SSttaaggee 22 PPoosstteerriioorr mmaalllleeoolluuss ffxx oorr ppoosstteerriioorr ttiibbiioo--ffiibbuullaarr lliiggaammeenntt • SSttaaggee 33 FFiibbuullaa ffrraaccttuurree,, ttyyppiiccaallllyy pprrooxxiimmaall ttoo mmoorrttiissee,, oofftteenn wwiitthh aa bbuutttteerrffllyy ffrraaggmmeenntt 1 2 3
- 20. PPrroonnaattiioonn--AAbbdduuccttiioonn Medial injury: tranverse to short oblique medial malleolar fracture Lateral Injury: comminuted impaction type distal lateral malleolar fracture
- 21. Classification: LLaauuggee--HHaannsseenn mmeeeettss DDaanniiss-- WWeebbeerr SKELETAL TRAUMA
- 22. PPoosstteerriioorr MMaalllleeoolluuss FFrraaccttuurreess Function:Stability- prevents posterior translation of talus & enhances syndesmotic stability Weight bearing- increases surface area of ankle joint
- 23. Haraguchi et al. JBJS 2006 Type I- posterolateral oblique type Type II- medial extension type Type III- small shell type 67% 19% 14% PPoosstteerriioorr MMaalllleeoolluuss FFrraaccttuurree
- 24. SSyynnddeessmmoottiicc IInnjjuurryy FUNCTION: Stability- resists external rotation, axial, & lateral displacement of talus
- 25. Leeds JBJS 1984 Weening JOT 2005
- 26. Common NNaammeess ooff FFrraaccttuurree VVaarriiaannttss • Maisonneuve Fracture – Fracture of proximal fibula with syndesmotic disruption • Volkmann Fracture – Fracture of tibial attachment of PITFL – Posterior malleolar fracture type • Wagstaffe-Le Fort Fracture – Fracture of fibular attachment of AITFL • Tillaux-Chaput Fracture – Fracture of tibial attachment of AITFL
- 27. CCoommmmoonn NNaammeess ooff FFrraaccttuurree VVaarriiaannttss • CCoolllliiccuullaarr FFrraaccttuurreess – AAvvuullssiioonn ffrraaccttuurree ooff ddiissttaall ppoorrttiioonn ooff mmeeddiiaall mmaalllleeoolluuss – IInnjjuurryy mmaayy ccoonnttiinnuuee aanndd rruuppttuurree tthhee ddeeeepp ddeellttooiidd lliiggaammeenntt • BBoosswwoorrtthh ffrraaccttuurree ddiissllooccaattiioonn – FFiibbuullaarr ffrraaccttuurree wwiitthh ppoosstteerriioorr ddiissllooccaattiioonn ooff pprrooxxiimmaall ffiibbuullaarr sseeggmmeenntt bbeehhiinndd ttiibbiiaa INTERCOLLICULAR GROOVE POSTERIOR COLLICULUS ANTERIOR COLLICULUS
- 28. Operative Treatment: Approaches Medial
- 29. Operative Treatment: ANTERIOR Approaches LATERAL Anteromedial Anterolateral Lateral
- 30. OOppeerraattiivvee TTrreeaattmmeenntt:: LLaatteerraall AApppprrooaacchh • BEWARE: SSUUPPEERRFFIICCIIAALL PPEERROONNEEAALL NNEERRVVEE Blair CORR 1994 72% 16% 12%
- 32. Standard Fixation CCoonnssttrruuccttss:: LLaatteerraall SSiiddee SCREWS ONLY LATERAL PLATING POSTEROLATERAL PLATING POSTERIOR PLATING
- 33. Standard Fixation CCoonnssttrruuccttss:: MMeeddiiaall SSiiddee Tension Band Wires Screws Plate/Screw Combination
- 34. Standard Fixation CCoonnssttrruuccttss:: PPoosstteerriioorr MMaalllleeoolluuss Screws Plating
- 35. Standard Fixation CCoonnssttrruuccttss:: SSyynnddeessmmoossiiss Single Screw 3 cortices Single Screw 4 cortices 2 Screws 6 cortices 2 Screws 8 cortices
- 36. CCaassee EExxaammppllee ##11 20 yo male falls while running - sustains ankle injury
- 40. WWeebbeerr CC // PPEERR 44 Short!
- 62. TTHHAANNKKSS
Editor's Notes
- 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.
- 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.
- 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
- A medial injury is thought to be required for a syndesmotic injury to alter loading [Boden JBJS 1989]
- Plain radiographic reduction parameters may be inadequate for assessing the quality of reduction [when MRI is used as gold standard rather than stress views]. Gardner FAI 2006 Instability should be assessed after osseous injuries have been stabilized.
- Note difference in level of syndesmotic screw placement. There is evidence that placing screws closer to the syndesmosis leads to less widening [McBryde FAI 1997]. General recommendation is approximately 2 cm above the tibiotalar joint but not directly into the cartilage of the syndesmosis.