This document provides information on various ankle injuries and their management. It begins with an introduction to ankle injuries and anatomy of the ankle joint. It then describes the classification systems for ankle injuries including Lauge-Hansen and Danis-Weber classifications. Specific injury mechanisms such as supination adduction, pronation abduction, and pronation external rotation injuries are explained. Evaluation, diagnosis and treatment approaches for different types of ankle injuries like sprains, lateral malleolus fractures, and bimalleolar fractures are covered. Radiographic tests and surgical fixation options are also summarized.
Please find the power point on Fracture of Talus with well diagrammatic explanation from very reliable sources. If you need such a power point on different topics related with MBBS then please write it on comment section. Thank you
Please find the power point on Fracture of Talus with well diagrammatic explanation from very reliable sources. If you need such a power point on different topics related with MBBS then please write it on comment section. Thank you
describing the decision making process in deciding which implant to use for trochanteric fractures and its complications - done for Basic AO course in Bengbu, China
describing the decision making process in deciding which implant to use for trochanteric fractures and its complications - done for Basic AO course in Bengbu, China
This presentation is about anatomy of ankle, classification of ankle injuries, the clinical features with which patient will present, the examination and treatment of them and the complications associated.
Research outcome measures related to ankle foot complex indications of de...Missions1
This presentation is about commonly used outcome measures of ankle foot complex. It also has information about delorme boot which a tool for progressive resisted exercise training
This is the Presentation on the topic "Pathomechanics of Knee Joint".
The presentation includes images and a clip for proper understanding. The sentences are framed in the way that you can learn it in a easy way.
Nutraceutical market, scope and growth: Herbal drug technologyLokesh Patil
As consumer awareness of health and wellness rises, the nutraceutical market—which includes goods like functional meals, drinks, and dietary supplements that provide health advantages beyond basic nutrition—is growing significantly. As healthcare expenses rise, the population ages, and people want natural and preventative health solutions more and more, this industry is increasing quickly. Further driving market expansion are product formulation innovations and the use of cutting-edge technology for customized nutrition. With its worldwide reach, the nutraceutical industry is expected to keep growing and provide significant chances for research and investment in a number of categories, including vitamins, minerals, probiotics, and herbal supplements.
Slide 1: Title Slide
Extrachromosomal Inheritance
Slide 2: Introduction to Extrachromosomal Inheritance
Definition: Extrachromosomal inheritance refers to the transmission of genetic material that is not found within the nucleus.
Key Components: Involves genes located in mitochondria, chloroplasts, and plasmids.
Slide 3: Mitochondrial Inheritance
Mitochondria: Organelles responsible for energy production.
Mitochondrial DNA (mtDNA): Circular DNA molecule found in mitochondria.
Inheritance Pattern: Maternally inherited, meaning it is passed from mothers to all their offspring.
Diseases: Examples include Leber’s hereditary optic neuropathy (LHON) and mitochondrial myopathy.
Slide 4: Chloroplast Inheritance
Chloroplasts: Organelles responsible for photosynthesis in plants.
Chloroplast DNA (cpDNA): Circular DNA molecule found in chloroplasts.
Inheritance Pattern: Often maternally inherited in most plants, but can vary in some species.
Examples: Variegation in plants, where leaf color patterns are determined by chloroplast DNA.
Slide 5: Plasmid Inheritance
Plasmids: Small, circular DNA molecules found in bacteria and some eukaryotes.
Features: Can carry antibiotic resistance genes and can be transferred between cells through processes like conjugation.
Significance: Important in biotechnology for gene cloning and genetic engineering.
Slide 6: Mechanisms of Extrachromosomal Inheritance
Non-Mendelian Patterns: Do not follow Mendel’s laws of inheritance.
Cytoplasmic Segregation: During cell division, organelles like mitochondria and chloroplasts are randomly distributed to daughter cells.
Heteroplasmy: Presence of more than one type of organellar genome within a cell, leading to variation in expression.
Slide 7: Examples of Extrachromosomal Inheritance
Four O’clock Plant (Mirabilis jalapa): Shows variegated leaves due to different cpDNA in leaf cells.
Petite Mutants in Yeast: Result from mutations in mitochondrial DNA affecting respiration.
Slide 8: Importance of Extrachromosomal Inheritance
Evolution: Provides insight into the evolution of eukaryotic cells.
Medicine: Understanding mitochondrial inheritance helps in diagnosing and treating mitochondrial diseases.
Agriculture: Chloroplast inheritance can be used in plant breeding and genetic modification.
Slide 9: Recent Research and Advances
Gene Editing: Techniques like CRISPR-Cas9 are being used to edit mitochondrial and chloroplast DNA.
Therapies: Development of mitochondrial replacement therapy (MRT) for preventing mitochondrial diseases.
Slide 10: Conclusion
Summary: Extrachromosomal inheritance involves the transmission of genetic material outside the nucleus and plays a crucial role in genetics, medicine, and biotechnology.
Future Directions: Continued research and technological advancements hold promise for new treatments and applications.
Slide 11: Questions and Discussion
Invite Audience: Open the floor for any questions or further discussion on the topic.
Cancer cell metabolism: special Reference to Lactate PathwayAADYARAJPANDEY1
Normal Cell Metabolism:
Cellular respiration describes the series of steps that cells use to break down sugar and other chemicals to get the energy we need to function.
Energy is stored in the bonds of glucose and when glucose is broken down, much of that energy is released.
Cell utilize energy in the form of ATP.
The first step of respiration is called glycolysis. In a series of steps, glycolysis breaks glucose into two smaller molecules - a chemical called pyruvate. A small amount of ATP is formed during this process.
Most healthy cells continue the breakdown in a second process, called the Kreb's cycle. The Kreb's cycle allows cells to “burn” the pyruvates made in glycolysis to get more ATP.
The last step in the breakdown of glucose is called oxidative phosphorylation (Ox-Phos).
It takes place in specialized cell structures called mitochondria. This process produces a large amount of ATP. Importantly, cells need oxygen to complete oxidative phosphorylation.
If a cell completes only glycolysis, only 2 molecules of ATP are made per glucose. However, if the cell completes the entire respiration process (glycolysis - Kreb's - oxidative phosphorylation), about 36 molecules of ATP are created, giving it much more energy to use.
IN CANCER CELL:
Unlike healthy cells that "burn" the entire molecule of sugar to capture a large amount of energy as ATP, cancer cells are wasteful.
Cancer cells only partially break down sugar molecules. They overuse the first step of respiration, glycolysis. They frequently do not complete the second step, oxidative phosphorylation.
This results in only 2 molecules of ATP per each glucose molecule instead of the 36 or so ATPs healthy cells gain. As a result, cancer cells need to use a lot more sugar molecules to get enough energy to survive.
Unlike healthy cells that "burn" the entire molecule of sugar to capture a large amount of energy as ATP, cancer cells are wasteful.
Cancer cells only partially break down sugar molecules. They overuse the first step of respiration, glycolysis. They frequently do not complete the second step, oxidative phosphorylation.
This results in only 2 molecules of ATP per each glucose molecule instead of the 36 or so ATPs healthy cells gain. As a result, cancer cells need to use a lot more sugar molecules to get enough energy to survive.
introduction to WARBERG PHENOMENA:
WARBURG EFFECT Usually, cancer cells are highly glycolytic (glucose addiction) and take up more glucose than do normal cells from outside.
Otto Heinrich Warburg (; 8 October 1883 – 1 August 1970) In 1931 was awarded the Nobel Prize in Physiology for his "discovery of the nature and mode of action of the respiratory enzyme.
WARNBURG EFFECT : cancer cells under aerobic (well-oxygenated) conditions to metabolize glucose to lactate (aerobic glycolysis) is known as the Warburg effect. Warburg made the observation that tumor slices consume glucose and secrete lactate at a higher rate than normal tissues.
Richard's entangled aventures in wonderlandRichard Gill
Since the loophole-free Bell experiments of 2020 and the Nobel prizes in physics of 2022, critics of Bell's work have retreated to the fortress of super-determinism. Now, super-determinism is a derogatory word - it just means "determinism". Palmer, Hance and Hossenfelder argue that quantum mechanics and determinism are not incompatible, using a sophisticated mathematical construction based on a subtle thinning of allowed states and measurements in quantum mechanics, such that what is left appears to make Bell's argument fail, without altering the empirical predictions of quantum mechanics. I think however that it is a smoke screen, and the slogan "lost in math" comes to my mind. I will discuss some other recent disproofs of Bell's theorem using the language of causality based on causal graphs. Causal thinking is also central to law and justice. I will mention surprising connections to my work on serial killer nurse cases, in particular the Dutch case of Lucia de Berk and the current UK case of Lucy Letby.
(May 29th, 2024) Advancements in Intravital Microscopy- Insights for Preclini...Scintica Instrumentation
Intravital microscopy (IVM) is a powerful tool utilized to study cellular behavior over time and space in vivo. Much of our understanding of cell biology has been accomplished using various in vitro and ex vivo methods; however, these studies do not necessarily reflect the natural dynamics of biological processes. Unlike traditional cell culture or fixed tissue imaging, IVM allows for the ultra-fast high-resolution imaging of cellular processes over time and space and were studied in its natural environment. Real-time visualization of biological processes in the context of an intact organism helps maintain physiological relevance and provide insights into the progression of disease, response to treatments or developmental processes.
In this webinar we give an overview of advanced applications of the IVM system in preclinical research. IVIM technology is a provider of all-in-one intravital microscopy systems and solutions optimized for in vivo imaging of live animal models at sub-micron resolution. The system’s unique features and user-friendly software enables researchers to probe fast dynamic biological processes such as immune cell tracking, cell-cell interaction as well as vascularization and tumor metastasis with exceptional detail. This webinar will also give an overview of IVM being utilized in drug development, offering a view into the intricate interaction between drugs/nanoparticles and tissues in vivo and allows for the evaluation of therapeutic intervention in a variety of tissues and organs. This interdisciplinary collaboration continues to drive the advancements of novel therapeutic strategies.
Earliest Galaxies in the JADES Origins Field: Luminosity Function and Cosmic ...Sérgio Sacani
We characterize the earliest galaxy population in the JADES Origins Field (JOF), the deepest
imaging field observed with JWST. We make use of the ancillary Hubble optical images (5 filters
spanning 0.4−0.9µm) and novel JWST images with 14 filters spanning 0.8−5µm, including 7 mediumband filters, and reaching total exposure times of up to 46 hours per filter. We combine all our data
at > 2.3µm to construct an ultradeep image, reaching as deep as ≈ 31.4 AB mag in the stack and
30.3-31.0 AB mag (5σ, r = 0.1” circular aperture) in individual filters. We measure photometric
redshifts and use robust selection criteria to identify a sample of eight galaxy candidates at redshifts
z = 11.5 − 15. These objects show compact half-light radii of R1/2 ∼ 50 − 200pc, stellar masses of
M⋆ ∼ 107−108M⊙, and star-formation rates of SFR ∼ 0.1−1 M⊙ yr−1
. Our search finds no candidates
at 15 < z < 20, placing upper limits at these redshifts. We develop a forward modeling approach to
infer the properties of the evolving luminosity function without binning in redshift or luminosity that
marginalizes over the photometric redshift uncertainty of our candidate galaxies and incorporates the
impact of non-detections. We find a z = 12 luminosity function in good agreement with prior results,
and that the luminosity function normalization and UV luminosity density decline by a factor of ∼ 2.5
from z = 12 to z = 14. We discuss the possible implications of our results in the context of theoretical
models for evolution of the dark matter halo mass function.
1. VARIOUS ANKLE
INJURIES AND
IT’S MANAGEMENT
PRESENTER:
DR. AMOL GAIKWAD
PG TRAINEE
DEPARTMENT OF ORTHOPAEDICS
MODERATOR:
DR. P. S. CHAKRABARTY
ASSOCIATE PROFESSOR
DEPARTMENT OF ORTHOPAEDICS
2. INTRODUCTION
Ankle injury refers to disruption of any component
or components of the ankle joint following trauma.
Ankle injuries occur frequently, and have high
propensity for complications.
3. ANATOMY
Ankle joint is a synovial joint of hinge variety
ARTICULAR SURFACES:
*Upper articular surface:
lower end of the tibia including the medial
malleolus
lateral malleolus of fibula
inferior transverse tibiofibular ligament
*Inferior articular surface:
upper medial and lateral aspects of Talus
4. ANATOMY
LIGAMENTS
* Fibrous capsule
surrounds the joint and it is attached all around
the articular margins.
* Deltoid or Medial ligament
very strong triangular ligament divided into
superficial and deep part
superficial part- anterior fibres/tibionavicular
middle fibres/tibiocalcaneal
posterior fibres/posterior tibiotalar
deep part or anterior tibiotalar
5. ANATOMY
LIGAMENTS
* Lateral ligament
- anterior talofibular ligament
flat band which passes from the
anterior margin of the lateral malleolus to the neck of the
talus.
- posterior talofibular ligament
passes from the lower part of the
malleolar fossa of the fibula to the lateral tubercle of the
talus
- calcaneofibular ligament
long rounded cord which passes from
the notch on the lower border of the lateral malleolus to
the tubercle on the lateral surface of the calcaneum
6. ANATOMY
SYNDESMOTIC LIGAMENT COMPLEX
resists the axial, rotational and translational forces to
maintain the structural integrity of the mortise
4 ligaments-
*Anterior inferior tibio fibular ligament
*Posterior inferior tibio fibular ligament
*Inferior Transverse tibio fibular ligament
*Interosseous ligament
8. CLINICAL EVALUATION
Variable presentation from a limp to nonambulatory in
significant pain and discomfort.
Neurovascular status should be carefully documented.
Extent of soft tissue injury should be evaluated.
Entire length of fibula should be palpated.
A dislocated ankle should be reduced and splinted
immediately.
9. RADIOGRAPHIC EVALUATION
Anteroposterior(AP), Lateral and Mortise views of the
ankle should be obtained.
AP view
*Tibiofibula overlap of <10 mm is abnormal and
implies syndesmotic injury
*Tibiofibula clear space of >5mm is abnormal and
implies syndesmotic injury
Lateral view
*dome of the talus should be centered under the tibia.
*posterior tibial tuberosity fractures can be identified
and direction of fibular injury
*avulsion fracture of talus.
10. RADIOGRAPHIC EVALUATION
MORTISE VIEW
* view taken with the foot in 15-20 degrees of
internal rotation to offset the intermalleolar axis
* medial clear space >4-5mm is abnormal and
indicates lateral talar shift
* Talocrural angle- is the angle subtended
between intermalleolar line and a line passing to the
distal tibial articular surface.
should be approx. 83degrees and should be within
2-3 degrees of the uninjured ankle.
11. RADIOGRAPHIC EVALUATION
The 3 important anatomical zones to be
considered in the decision making and
prognosis of ankle injuries:
Articular surface
Metaphysis
Fibula
12. RADIOGRAPHIC STRESS TESTS
TALAR TILT STRESS TEST:
X ray view is taken anteriorly by inverting the
plantar flexed heel.
Contralateral ankle is used for comparison.
Line is drawn across the talar dome and the
distal articulating surface of the tibia
Normal tilt is <5 degrees
Abnormal if tilt >10 degrees
Indicator of lateral ligament injury
13. RADIOGRAPHIC STRESS TESTS
STANDING TALAR TILT STRESS TEST:
More sensitive
Patient stands on inverted stress platform
Foot and ankle in 40 degrees of plantar flexion 50 degrees
of inversion
EXTERNAL ROTATION STRESS TEST:
Evaluates the syndesmotic and the deep deltoid ligaments
External rotation of the foot on a stabilised leg with ankle
in dorsiflexion
Difference in width of superior clear space between medial
and lateral side of the joint should be <2mm
14. RADIOGRAPHIC EVALUATION
Computed Tomography(CT) scans help to delineate bony
anatomy, especially in tibial plafond fractures.
Magnetic Resonance Imaging(MRI) may be used for assessing
occult cartilaginous, ligamentous or tendinous injuries
15. CLASSIFICATION OF ANKLE
INJURIES
LAUGE- HANSEN CLASSIFICATION
*end product of a sequence of bony and
ligamentous failures resulting from a deforming
force
* for a given deforming force the failure
sequence occurs in the same order to produce a
complex injury pattern which is pathognomonic
of that deforming force
16. INJURY MECHANISMS
SUPINATION ADDUCTION INJURY
* Talus is forcibly adducted in the mortise
* Compressive force- medial ankle structures
* Traction force- lateral ankle structures
* Partial or complete disruption of the
components of lateral ligaments of the ankle
17. SUPINATION ADDUCTION
INJURY
SPRAINED ANKLE
*Partial lateral ligament injury with a
tear of the Anterior Talofibular fasciculus only.
*forcible inversion of the plantar
flexed foot
* if the adduction force then stops, this
will be the only injury i.e. an isolated injury of
the Anterior Talofibular ligament.
18. GRADING OF SPRAIN
FIRST DEGREE SPRAIN:
Ligaments have been
stretched but not torn
SECOND DEGREE SPRAIN:
most common ankle injury
and partial tearing of the ligament
THIRD DEGREE SPRAIN:
most severe of ankle injuries
and there is complete tearing of the
ligament
19. SUPINATION ADDUCTION INJURY
If forcible inversion is exerted on a foot
which is at right angles to the tibia
all three fasciculi of the lateral
ligament are stressed simultaneously
producing complete tear of lateral ligament
But, If the combined resistance to traction of
the three ligamentous bands exceeds the
bony strength of the lateral malleolus
causing it to fracture.
20. SUPINATION ADDUCTION INJURY
the traction force on the lateral ankle structures
causes
-‘pull off fracture’ of the lateral malleolus.
Lateral malleolus fracture at the level of ankle joint.
Characteristic transverse fracture with a ‘clean’
break in the outer fibular cortex.
Deforming forces continue producing compression
injury of the medial malleolus
Near vertical fracture starting in the angle
between the medial malleolus and the horizontal
tibial articular surface
21. PRONATION ABDUCTION INJURY
Talus is forcibly abducted in the ankle mortise
Compression force- Lateral ankle structures
Traction force- medial ankle structures
22. PRONATION ABDUCTION INJURY
Medial traction force may cause either a complete
tear of the deltoid ligament or ‘pull off fracture’ of
the medial malleolus.
Lateral compression force produces a lower fibular
fracture angling slightly upwards from the level of
the ankle joint always with a communition of
lateral fibular cortex.
23. PRONATION EXTERNAL ROTATION
INJURY
With the foot pronated the deltoid ligament
is under tension.
The talus starts to rotate externally in the
ankle mortise- so the medial structures
which fail first.
Talus is then free of its medial tether and
swings forwards out of the inner side of the
ankle mortise about a lateral axis.
24. PRONATION EXTERNAL
ROTATION INJURY
This imparts a torsional force to the fibula which
first tears the anterior tibiofibular ligament
Followed by the rupture of the interosseous
ligament of the inferior tibiofibular joint
At this point only the posterior tibiofibular
ligament of the syndesmosis is intact
25. PRONATION EXTERNAL ROTATION
INJURY
If the deforming force continues to rotate the
fibula it will relax the posterior tibiofibular
ligament
Either resulting in the spiral fracture of the
fibula just above the level of the syndesmosis
or may be as high as the neck of fibula-
Partial diastasis of the inferior tibio fibular
joint which is known as Maisonneuve’s
injury.
26. PRONATION EXTERNAL ROTATION
INJURY
Or if the tibia is pushed medially off the top of the
rotating talus due to body weight and forward
thrust
Rupture of the posterior tibiofibular ligament
Oblique bending fracture of the fibular shaft and
complete diastasis of the inferior tibio fibular joint
known as Dupuytren’s fracture dislocation
27. SUPINATION EXTERNAL ROTATION
INJURY
Forcibly externally rotating a supinated foot.
As the foot is in a supinated position at the
moment when the talus starts to rotate- medial
structures are not in a state of tension.
Therefore they do not fail first.
Talus not free to rotate forwards on the medial
side so it starts to rotate backwards.
28. SUPINATION EXTERNAL ROTATION
INJURY
This backward rotation of talus causes the lateral
malleolus to be pushed posteriorly rupturing the
Anterior tibio-fibular ligament .
Low oblique fracture of the fibula passing downward
and forward to the level of ankle joint.
At this stage if the deforming arrests- only injury is
undisplaced fibula fracture.
29. SUPINATION EXTERNAL
ROTATION INJURY
The deforming forces does not cease-talus
will rotate backwards right out of the
mortise
Pushing off the restraining posterior
‘malleolus’ as a large fragment at the moment
of dislocation.
Medial structures fail producing a complete
‘trimalleolar’fracture dislocation of the
supination external rotation type.
42. DANIS-WEBER CLASSIFICATION
Based on the level of fibular fracture
The more proximal greater is the risk of syndesmotic
disruption an associated instability.
TYPE A: involves fracture of the fibula below the
level of the tibial plafond.
equivalent to LAUGE HANSEN supination
adduction injury
TYPE B:oblique or spiral fracture of the fibula caused
by external rotation at or near the level of
syndesmosis.
equivalent to LAUGE HANSEN supination
external rotation injury
TYPE C:involves fracture of the fibula above the level
of syndesmosis .
43. FRACTURE VARIANTS
LeFort-Wagstaffe fracture
Anterior fibular tubercle
avulsion fracture by the anterior
tibiofibular ligament.
Usually associate with LAUGE-
HANSEN Supination External Rotation
Type fracture patterns
44. Tillaux-Chaput Fracture
Avulsion of the anterior tibial
margin of the anterior
tibiofibular ligament.
Tibial counterpart of the
LeFort-Wagstaffe fracture
45. COLLICULAR FRACTURES
Avulsion fracture of distal portion of
medial malleolus.
Anterior colliculus fractures
deep portion of the deltoid may
remain intact.
Posterior colliculus fractures
fragment is usually non
displaced.
‘supramalleolar spike’
46. BOSWORTH FRACTURE
DISLOCATION
Fracture of the distal fibula with an
associated fixed posterior dislocation of
the proximal fragment which becomes
trapped behind the posterior tibial
tubercle.
Severe external rotation of the ankle
47. POTT’S FRACTURE
A common term for bimalleolar
fracture.
In the Pott fracture, the fibula is
fractured above the intact distal
tibiofibular syndesmosis, the
deltoid ligament is ruptured, and
the talus is subluxed laterally
48. DIAGNOSIS AND TREATMENT
ADDUCTION INJURIES
SPRAINED ANKLE: common injury caused by the inversion twist of
plantar flexed foot
DIAGNOSIS: characteristic swelling over the lateral aspect of ankle
joint.
* inverting the heel with foot at right angle produces little pain
* while in plantar flexed foot it produces severe pain in front of
lateral malleolus- pathognomonic of isolated anterior talofibular
ligament injury.
49. SPRAINED ANKLE
TREATMENT
RICE
Rest- stay off the Ankle, crutches may be needed
Ice- 15 minutes - 4 to 5 times a day
Compression- bandaging to keep swelling down
Elevation- keep ankle above heart level when
possible, allows gravity to pump out swelling
Use of EVERSION STIRRUP
50. ADDUCTION INJURIES
Complete tear of the lateral
ligament:
Suspected in every violent inversion
injury of the ankle joint.
Abnormal movement of talus on inversion
movement of the foot .
Anteroposterior radiographs are taken
with the heel forcibly held in fully inverted
position
In a complete tear well marked talar tilt is
evident.
51. ADDUCTION INJURIES
Complete tear of the lateral
ligament:
TREATMENT
A lightly padded below knee plaster cast
for 6-8 weeks is applied with the foot at right
angles to the leg with the heel being in neutral
position or slightly everted.
weight bearing is allowed.
Re-education of the propriceptive
function of the healed ligamentous structures
by ‘Wobble board ‘ exercises have been prove
useful
52. ADDUCTION FRACTURE OF THE
LATERAL MALLEOLUS
Pain and gross swelling over the outer aspect of ankle
Tenderness is present at the base of lateral malleolus and fracture
gap is felt to open up if gentle attempts are made to open up the
heel.
TREATMENT:
Conservative management usually gives excellent functional
results.
Lightly padded below knee cast is applied and the heel is
moulded into slight eversion
53. ADDUCTION FRACTURE OF THE
LATERAL MALLEOLUS
TREATMENT:
In case of failure to secure or hold anatomical
reduction of fracture, internal fixation becomes
essential
Intramedullary screw fixation can be one.
Screw should be inserted at the tip of the
lateral malleolus and angle as vertically as possible.
Malleolar fragment is over drilled to
produce a lag effect.
Screw should be long enough to engage the
medial cortex of the fibula well above the fracture
54. BIMALLEOLAR ADDUCTION
FRACTURES
Bimalleolar fractures when widely displaced are very
unstable injuries and reduction cannot be achieved by
conservative methods.
Internal fixation is the treatment of choice.
Lateral malleolus should be fixed by intramedullary
screw or TBW
Medial malleolar fragment is secure with one or two
almost horizontal screws.
Immobilisation for atleast 10 weeks and non weight
bearing for first 6 weeks
55. ABDUCTION INJURIES
Foot is in valgus deformity with swelling both
medially and laterally
Medial tenderness may be directly over the
medial malleolus and lateral swelling with
tenderness is at the base of lateral malleolus.
Radiographs reveal the typical fibular fracture
with varying degrees of comminution at the
lateral cortex and separation of the medial
malleolar fracture
56. ABDUCTION INJURIES
TREATMENT
Undisplaced isolated abduction fracture of the
medial malleolus unites if immobilised in a below knee
plaster cast.
If the original manipulation fails to achieve
anatomical reduction, there may be soft tissue
interposition between the fragments.
A flap, attached to the distal fragment and
consisting of superficial fibres of the deltoid ligament,
may tuck itself into the fracture gap.
Such a flap needs to be excise and the malleolus is
reduced and fixed with a screw to produce
interfragmentary compression.
57. TENSION BAND WIRING
A method of fixation, especially useful for smaller
fragments is the tension band wiring described by
Weber and Vasey
Reduced fragments are fixed using two parallel K-
wires at right angle to the fracture plane.
A horizontal through and through drill hole is then
made about 3cms proximal to the fracture and a
length of 20 G SS wire is passed through the hole.
The ends of the wire are crossed over and the two ends
of the loop tightened and twisted.
58. PRONATION EXTERNAL ROTATION
External rotation being applied to the pronated foot.
Medial structures fail first.
Sequential tearing of the anterior tibiofibular and
interosseous ligament.
Torsional force may continue causing spiral fibula
fracture leaving the posterior tibiofibular ligment
intact.
Torsional force may further continue tearing the
posterior tibiofibular ligment causing the oblique
comminuted bending fracture of the fibula.
59. ISOLATED FRACTURE OF THE
MEDIAL MALLEOLUS
These fractures are rarely grossly displaced an may
be accompanied only by a little swelling.
Radiologically ,these fractures can be easily missed.
Treated in a below knee plaster cast for 6-8 weeks
Possibility of soft tissue interposition and non
union many prefer to internally fix the medial
malleolus by a screw or TBW.
60. PRONATION EXTERNAL ROTATION
Partial diastasis of the inferior tibiofibular
joint.(Maissoneuve’s injury)
Medial pain and swelling with tenderness over the
fibula fracture above the syndesmosis.
There is rarely sufficient displacement to produce
clinical deformity
Palpation of the whole fibula is the integral part
of the clinical examination
External rotation stress films under general
anaesthesia
61. Partial diastasis of the inferior tibiofibular
joint.(Maissoneuve’s injury)
TREATMENT
Easily reduced if the rupture deltoid ligament is not interposed between
the fragments.
Immobilisation in above knee plaster cast with foot slightly inverted and
firmly internal rotated.
Where fixation is necessary, it is sound practice to fix the medial malleolar
fragment first.
Attention must be paid to the anatomical reduction and fixation of the
fibula.
62. SYNDESMOTIC SCREW
Then diastasis is secure by an oblique screw across the
syndesmosis inserted through the lateral fibular
cortex opposite the level of ankle joint angle 20
degrees upwards
Certain basic rules are to be followed
The screw should be inserted only after perfect
reduction and fixation of fibula fracture.
The foot should be held in dorsiflexion when
the screw is inserted.
The screw should not compress the inferior
tibiofibular joint-a lag screw should be tightened and
then backed off 90 degree
63. Complete diastasis of the inferior
tibiofibular joint(Dupuytren fracture
dislocation)
Major dislocation of the ankle joint and radiographs will confirm
the features of the injury complex.
Treatment of choice is ORIF and any medial malleolar fracture is
fixed first.
The fibular fracture is then explored and fixed after reduction
using a small plate or oblique screw across the fracture
Following fibular fixation the syndesmosis is stabilised with an
angled screw
64. SUPINATION EXTERNAL ROTATION
External rotation of the supinated foot where the talus
runs backwards out of the ankle mortise pushing the
fibula posteriorly.
First tearing the anterior tibiofibular ligament and then
producing undisplaced oblique fibular fracture.
Pain is felt mainly laterally with moderate swelling and
tenderness over the fibula just above the level of ankle.
Immobilisation in a plaster cast for 6 weeks and
mobilisation exercises should be encouraged after cast
removal.
65. Fracture dislocation without inferior
tibiofibular diastasis
Posterior malleolar fragment comprise a single
unit being united by the posterior tibiofibular
ligament.
History of considerable violence to the ankle
an it is clinically obvious that the ankle joint is
greatly deformed.
Prominence of the heel with shortening of the
forefoot –posterior dislocation.
66. Fracture dislocation without inferior
tibiofibular diastasis
TREATMENT:
The gross instability of this fracture dislocation makes it
difficult for reduction by conservative method.
ORIF is the treatment of choice.
Open reduction should start with reduction of the fibular
fracture
Best method is to insert one or two screws across the fracture
from in front backwards over drilling the anterior fragment
to produce interfragmentary compression
67. TIBIAL PILON FRACTURES
All the fractures of the tibia involving
distal articular surface are classified as
PILON fractures.
Pilon fractures account for 7-10% of all
tibia fractures and are a result of high
energy mechanisms .
68. MECHANISM OF INJURY
Fracture pattern is dictated by position of
foot and talus at the time of impact.
Plantar flexion injury: posterior lip
fragment
Neutral ankle: anterior and posterior
fragments
Dorsiflexion injury: anterior lip fragment
69. MECHANISM OF INJURY
AXIAL COMPRESSION: fall from height
The force is directed axially through the
talus into the tibial plafond
If the fibula remains intact, ankle is
forced into varus with impaction of the
tibial plafond
Plantar flexion or dorsiflexion at the
time of injury results in posterior or
anterior plafond injury
70. MECHANISM OF INJURY
ROTATIONAL(LOW ENERGY):Sporting accident
Mechanism is primarily torsion combined
with a varus or valgus stress
It produces two or more large fragments and
minimal articular comminution
Associated fibula fracture which is usually
transverse or short oblique
71. MECHANISM OF INJURY
COMBINED COMPRESSION AND SHEAR
These fracture patterns demonstrate
components of both compression and shear
The vector of these two forces determines the
fracture pattern
72. CLASSIFICATION
RUEDI- ALLGOWER CLASSIFICATION
TYPE I: Non displaced cleavage fracture of
the ankle joint
TYPE II: displaced fracture with minimal
impaction or comminution
TYPE III: displaced fracture with significant
articular comminution or metaphyseal
impaction
73. TREATMENT OPTIONS
Conservative treatment with cast
Open reduction and internal fixation
Combination of different types of external fixators with
or without internal fixation
74. TREATMENT
Non operative treatment:
Long leg cast for 6 weeks followed by fracture brace.
Indications:
Non displaced fracture patterns
Severely debilitated patient
Manipulation of displaced fractures is unlikely to result in
reduction of intra articular fragments
75. OPERATIVE TREATMENT
Displaced pilon fractures are usually treated surgically
TIMING OF SURGERY:
Surgery may be delayed for several days (7-10 days average) to
allow for optimization of soft tissue status, diminution of
swelling about the ankle, resolution of fracture blisters and
sloughing of compromise soft tissues
High energy injuries can be treated with spanning external
fixator
76. Goals of operative treatment
Maintenance of fibula length and stability
Restoration of tibial articular surface
Bone grafting of metaphyseal defects
Stabilisation of distal tibia
77. METHODS OF FIXATION
JOINT SPANNING EXTERNAL FIXATION
Used in patients with significant soft tissue
compromise or open fractures
Reduction is maintained via distraction and
ligamentotaxis
Non articulating (rigid) external fixation is commonly
used theoretically allowing no ankle motion
Articulating external fixation allows motion in the
sagittal plane, preventing varus and shortening
78. Hybrid external fixation
Non spanning external fixator
Fracture reduction is enhanced using
thin wires with or without olives to
restore the articular surface and
maintain bony stability.
Useful when internal fixation of any
kind is contra indicated
3% deep wound infection
79. INTERNAL FIXATION
Open reduction and plate fixation may be the best way to achieve a
precisely reduced articular surface
To minimise complications of plating, following techniques have been
recommended.
surgical delay until definitive surgical treatment
use of small, precontoured, low profile implants and mini
fragment screws
use of indirect reduction techniques to minimise soft tissue
stripping
percutaneous techniques for plate fixation
80. ORIF OF TIBIAL PLAFOND
FRACTURES
First step is to reduce and fix the fibular
fracture.
This locates a major lateral tibial fragment.
The tibial fragments are then exposed
Reconstruction of the joint surface is done and
fracture fragments are fixed with
interfragmentary screws and buttress plate.
Cancellous bone graft
81. OPEN FRACTURE DISLOCATIONS
Dislocations and fracture dislocations of ankle
joint are frequently compound because the
malleoli of tibia and fibula are just beneath the
skin.
If there is severe deformity with gross
displacement on one side the skin over the
opposite side of the ankle may be split.
The wound occurs because the tibia and fibula
bursts outwards.
The wound should be thoroughly cleansed and
excision of all devitalised tissues should be done
and fixation with internal or external fixation
should be done
82. RECENT ADVANCES
TAYLOR SPATIAL
FRAME(Smith & Nephew)
Aids surgeons in the
treatment of difficult crush injuries
to the distal tibia involving the
ankle.
SUTURE ANCHOR FIXATION
FOR SYNDESMOTIC INJURY
Stabilise an ankle after
injury and can be use in high ankle
sprains and fractures of the fibula
83. RECENT ADVANCES
ARTHROSCOPY:
Minimally invasive treatment of tibial pilon fractures through
arthroscopy and external fixator- assisted reduction
It produces less trauma and also protects soft tissues and blood
supply surrounding the fractures
External fixation could indirectly provide reduction and
effective operative space for arthroscopic implantation.
Fibrous capsule:except-posterosuperiorly, attached to inferior transverse tib fib lig and anteroinferiorly attached to the dorsum of the neck of talus
Deltoid- present on the medial side of the ankle
Both parts have a common attachment above to the apex and margins of med mal
Tibionavicular-attached to the tuberosity of the navicular bone
Tibiocalcaneal-attached to the whole length of sustentaculum tali
Posterior tibiotalar- medial tubercle of talus
Anterior tibiotalar- anterior part of the medial surface of the talus
Consists of 3 bands
EXISTS b/w distal tibia and fibula
Pitfl- thicker and stronger than the aitfl. Therefore the torsional or translational forces that rupture the aitfl may cause an avulsion # of the posterior tibial tubercle, leaving the pitfl intact.
Interosseous lig- distal continuation of the interosseous membrane
Patients may have a Variable presentation from a limp to a non ambulatory in significant pain and discomfort with swelling tenderness and variable deformity
Neurovascular status should be carefully documented and compared with the contralateral side
Extent of soft tissue injury should be evaluated with particular attention to open # and blistering
Entire length of fibula should be palpated for tenderness bcos associated fibular # may be found prox as high as the prox tib fib articulation
A dislocated ankle should be reduced and splinted immediately to prevent pressure or impaction injuries to the talar dome and preserve neurovascular integrity.
dome of the talus should be centered under the tibia and congruous with the tibial plafond
avulsion fracture of talus by the anterior capsule may be identified
Based upon cadaveric experiments and the careful study of a series of ankle injuries from both clinical and radiological points of view
it is based upon the concept that each of the patterns of fracture-dislocations of the ankle is the
If the force ceases to act at any point in the sequence a partial failure pattern will result.
Traction failure of the lateral structures precedes the medial injury in majority of cases
forcible inversion of the plantar flexed foot in which position the anterior band of the lateral ligament is under tension
Such a fracture may be presented by an avulsion fragment from the tip of the lateral malleolus at the insertion of the calcaneofibular lig
LAUGE HANSEN in his cadaveric experiments found that by pronating the foot and forcibly externally rotating it at the ankle joint he could produce this type of injury
Now this forward swing of the talus in the lateral axis
Now from this point where only posterior tibio fibular ligament is intact
From the point where the posterior tibiofibular ligament is intact
This injury can be consistently produced in a cadaver by
In consequence Talus not free to rotate forwards out of the mortise on the medial side so it starts to rotate backwards, pivoting the medial structures.
Commonest fracture around the ankle
If after the fibula fracture the deforming forces does not cease
In this injury the distal fibular and the posterior malleolar fragment displace together and simultaneously remaining firmly bound to eachother by the ptfl and moving as a single unit
TYPE A: involves fracture of the fibula below the level of the tibial plafond and avulsion injury thAT results from the supination of the foot and that may be associated with an oblique or vertical fracture of the medial mal.
TYPE B:oblique or spiral fracture of the fibula caused by external rotation at or near the level of syndesmosis associate disruption of the anterior syndesmotic lig whereas posterior syndesmotic lig remains intact and attached to the distal fibular fragment. Associated injury to the medial structures or the posterior mal.
Type c almost always associated with medial injury and is equivalent to pronation ER or pronation abduction injuries
fragment is usually non displaced because of stabilisation by the post tib & fdl tendons
. supramalleolar spike’on external rotation view.
Non elastic adhesive strapping applied on the inner aspect then the plantar surface of the heel an the outer aspect of the lower leg while the foot is held everted over this is applied a spiral of adhesive elastic bandaging from base of the toes to upper third of the calf.
In a normal foot the lateral surface if the boy of talus can just be felt in front of the lateral malleolus an even if the foot is inverted at the subtalar joint it remains in close contact of the malleolus but if the lateral lig is torn, inversion movement occurs at the ankle joint as well as subtalar joint an sometimes the talus moves away from the malleolus as a well defined sulcus b/w lat mal & tal
PULL off # of the whole lat mal at the level of ankle joint with a typical horizontal clean break of the lateral fibular cortex
Alternatively tbw can also be done
TRACTIO N failure of the lat structures f/b compression # of the medial mal.
Splitting off the med mal in a near vertical plane
Permitting the talus to rotate externally & forwards out of the mortise, twisting the fibula
Now according to these sequences and ceasing of the torsional forces at any point the first event in the sequence described is
In cases f doubt 45 degrees internal rotation view should be used.
Next in the sequence of injuries is the
Palpation of the whole fibula is the integral part of the clinical examination of the injure ankle & unexplained medial swelling & demands full length radiograph of fibula
External rotation stress films under general anaesthesia is very helpful in cases of ankle instability
This injury is usually easily reuce..
In cases of soft tissue interposition where fixation is necessary
continuing with the treatment of partial diastasis of tib fib joint
Then diastasis is secure by an oblique screw across the syndesmosis inserted through the lateral fibular cortex opposite the level of ankle joint angle 20 degrees upwards it will traverse approx at the centre of the inferior tibiofibular joint
Certain basic rules are to be followed to avoid synostosis of inferior tibio fibular joint
The foot should be held in dorsiflexion when the screw is inserted so that the widest portion of the talar body is engaged in the ankle thus avoiding pinching the mortise
Next in the sequence of pronation external rotation injuries is the rupture of the posterior tibiofibular ligament leading to
oblique fibular fracture probably the commonest ankle fracture.
If the injuring force continues after causing an oblique fibular fracture, talus then impinges against posterior lip of tibial articular surface causing posterior malleolar
the only acceptable result of treatment of fracture dislocations of ankle is union in anatomical position.
Nothing short of a perfect reduction should satisfy the surgeon. Even displacement of talus as small as 2mm can result in incongruity of joint leading to early degenerative arthritis.
If there is a medial malleolar fracture it should be fixed by screw or by TBW.
Non weight bearing below knee cast for 6 weeks post op followed by weight bearing cast further 2-4 weeks
the force is directed axially through the talus into the tibial plafond causing impaction of the articular surface & asso with significant comminution
High energy injuries can be treated with spanning external fixator to provide skeletal stabiisation, restoration of length and partial fracture reduction while awaiting definitive surgery.
Application is limited but theoretically it results in improve chondral lubrication and nutrition
surgical elay until efinitive surgical treatment using initial spanning external fixation for high energy injuries
Cancellous bone was crushed by impaction of tibial fragments a gap will now exist and an essential part of this operation is to fill this gap with cancellous bone chips from iliac crest
The wound occurs because the tibia and fibula bursts outwards an rarely by a reason of a direct crushing injury which devitalises tissues and drives in foreign bodies hence the prognosis is excellent
