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Ankle xrays
The document discusses common ankle fractures, including: - Lateral malleolar fractures (Danis-Weber type A), which are stable and treated with casting. - Bimalleolar fractures involving the lateral and posterior malleoli, which can be unstable and require orthopedic consultation. - Trimalleolar fractures, which are highly unstable with multiple ligament injuries and usually involve the syndesmosis, requiring orthopedic surgery. - Pilon fractures of the distal tibia are often comminuted with significant injuries requiring orthopedic consultation. - Tillaux fractures in adolescents involve the anterolateral physis and epiphysis and require orthopedic consultation to ensure proper
Ankle xrays
- 1. An approach to ankle x-rays Aric Storck PGY2 (acknowledgement to Dr. Dave Dyck for several slides) September 11, 2003
- 2. Objectives Review basicankle fracture classification Review x-rays of common ankle fractures Discuss management of common ankle fractures
- 3. Case 1: 25year old female • Jumped off roof • Right ankle pain • Inability to weight bear on right foot What else do you want to know on history and physical examination? Does she need x-rays ?
- 4. Ottawa Ankle Rules: Order ankle x-rays if acute trauma to ankle and one or more of • Age 55 or older • Inability to weight bear both immediately and in ER (4 steps) • Bony tenderness over posterior distal 6 cm of lateral or medial malleoli Sensitivity ~100% Specificity ~40%
- 5. You have decidedto order an “ankle x-ray.” The nurse entering your orders asks which views you want …
- 6. Ankle X-rays: 3views AP • Identifies fractures of malleoli, distal tibia/fibula, plafond, talar dome, body and lateral process of talus, calcaneous Mortise • Ankle 15-25 degrees internal rotation • Evaluate articular surface between talar dome and mortise Lateral • Identifies fractures of anterior/posterior tibial margins, talar neck, displacement of talus
- 7. AP x-ray: Identifies fractures of • malleoli • distal tibia/fibula • plafond • talar dome • body and lateral process of talus • calcaneous
- 8. Tib/fib clear spaceTib /fib overlap
- 9.
- 10. Now apply what you’ve learned … Lateral malleolar fracture Tib/fib clear space <5mm Tib/fib overlap >10 mm No evidence of syndesmotic injury
- 11. Mortise X-Ray Taken with ankle in 15-25 degrees of internal rotation Useful in evaluation of articular surface between talar dome and mortise
- 13. Mortise x-ray: Medial clear space • Between lateral border of medial malleous and medial talus • <4mm is normal • >4mm suggests lateral shift of talus
- 14. Mortise x-ray: Talar tilt • Normal = -1.5 to +1.5 degrees (ie. Parallel) • Can go up to 5 degrees in stress views • <2mm difference between medial and lateral talar/plafond distances
- 15. Lateral x-ray: Identifies fractures of • Anterior/posterior tibial margins • Talus • Displacement of talus • Os trigonum
- 16. Stable vs Unstable The ankle is 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
- 17. Walking the walk…. Talking the talk Ortho is on the phone. They ask you to describe the fracture….
- 18. Lauge-Hansen: 15basic types of injury in 5 major categories • Described by two words 1.Position of foot at time of injury 2.Direction of talus within mortise causing fracture • Eg: supination-external rotation • Further subdivided into worsening areas of injury Impossible to remember and clinically useless in the ED
- 19. Danis-Weber • Definesinjury based on level of fibular fracture • A=below tibiotalar joint • No disruption of syndesmosis • Usually stable • B=at level of tibiotalar joint • Partial disruption of syndesmosis • C=above tibiotalar joint • Disrupts syndesmosis to level of fracture • unstable • THE MORE PROXIMAL THE FIBULAR # THE MORE SEVERE THE INJURY
- 20. AO classification: Similar to Danis-Weber scheme Takes into account damage to other structures (usually medial malleolous) ~2 pages of classifications • Remember them all for your exam!
- 21.
- 22. Pott’s classification: Easyto remember First degree • unimalleolar Second degree • bimalleolar Third degree • trimalleolar
- 23.
- 25. Lateral Malleolar Fracture Danis-Weber A Mechanism • Suppination/adduction (inversion) Mortise intact Stable fracture Treatment • Below knee cast
- 26.
- 27. Bimalleolar (lat &post malleoli) Mechanism • Inversion • Avulsion of posterior malleolus (post tibiofibular ligament) Medial mortise wide • Suggests instability Management • Posterior slab • Orthopedic consult Source: McRae’s Practical Fracture Treatment
- 28.
- 30. Trimalleolar Fractures Unstable • Multiple ligamentous injuries • Usually involves syndesmosis Treatment • Posterior slab • Urgent orthopedic consultation • ORIF
- 31.
- 32. Pilon (tibial plafond)fractures Fracture of distal tibial metaphysis • Often comminuted • Often significant other injuries Mechanism • Axial load • Position of foot determines injury Treatment • Unstable • X-ray tib/fib & ankle • Orthopedic consultation Source:Rosen
- 33.
- 34. Tillaux Fracture Occurs in 12-14 year olds • 18 month period when epiphysis is closing Salter-Harris 3 injury • Runs through anterolateral physis until reaches fused part, then extends inferiorly through epiphysis into joint • Visible if x-ray parallel to plane of fracture (may require oblique) Mechanism • External rotation • Strenth of tibiofibular ligament > unfused epiphysis
- 35. Tillaux Fracture Management • Inadequate reduction of articular surface can lead to early OA • Gap >2mm in articular surface is unacceptable • Advanced imaging techniques may be necessary • Early orthopedic consultation • Non-displaced • NWB below knee cast • Displaced • surgery
- 36. Case 7 Source:Rosen
- 38. Maisonneuve Fracture Mechanism • Eversion + lateral rotation • May cause medial malleolar fracture or deltoid ligament disruption • Injury proceeds along syndesmosis and involves proximal fibula Always rule out Maisonneuve fracture in medial malleolar/ligamentous injury
- 39. Maisonneuve Fracture Mechanism • Eversion + lateral rotation • Causes medial malleolar fracture or deltoid ligament disruption
- 40. If injuryproceeds along syndesmosis it involves proximal fibula = Maisonneuve Fracture Always rule out Maisonneuve fracture in medial malleolar/ligamentous injury
- 41. As taluscontinues to rotate • Posterior tib-fib ligament ruptures • Interosseous membrane rips • Gross diastasis • Dupuytren fracture – dislocation of the ankle
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- 43.
Editor's Notes
- #8 How do you tell AP from mortise?
- #9 What criteria do you use to evaluate AP views?
- #18 Danis-Weber A
- #29 Comminuted impacted fracture of the distal tibia and fibula. Trimalleolar fracture with dislocation. Largest fragment from posterior medial malleolus – displaced 1.5 cm posteriorly.
- #43 Fracture dislocation at level of ankle. Talus displaced laterally for three quarters of its width. Large bony fragment situated anterior to the joint space on lateral view. Comminuted fracture of distal fibula.