Extern conference-ankle 2 Nov.17

2. CC- ANKLE PAIN 2 HOURS PTA
PATIENT PROFILE –
THAI WOMAN 39 YO , FISH DEALER ,
UNIVERSAL COVERAGE

3. PRESENT ILLNESS -
Last 2 hr jogging and slip down.
Her lt.ankle and hip knock on floor , pain on her
lt.ankle can’t stand with that side,
no lt.Hip and lt. knee pain ,no head injury
,no unconciousness ,can remember all of that event

4. PRIMARY SURVEY
A- able to talk, active neck motion without pain
B- spontaneous breathing, RR16 ,satO2 100%
C- BP 143/95 Pulse 95 bpm
D- full conciousness ,E4V5M6
E- no wound , no active bleeding, swelling lt.ankle

5. SECONDARY SURVEY
A- no hx of allergy , no u/d
M- no medication use
P- no previous sx , no steroid use no IVDU
L- meal 6 hr water 3 hr PTA
E- slip down while jogging ,Lt.ankle pain
no head injury ,no other tender point

6. PHYSICAL EXAMINATION
v/s – Temp 37.1 BP 143/95
Pulse 95 bpm RR16
GA- thai woman ,good concious well cooperative
HEENT – no subconjunctivae hemorrhage
Lung – normal breath sound ,no adventitious sound
Heart –normal s1s2, no murmur
Abdomen – soft not tender

7. Extrimities – lt. ankle swelling , marked pain at
lateral malleolus ,no pain on medial side,limit ROM
due to pain , cap. refil <2sec , PTA DPA 2+,
intact sensory, squeeze test -
PHYSICAL EXAMINATION

8. X-RAY AP VIEW

9. X-RAY MORTISE VIEW

10. X-RAY LATERAL VIEW

11. DIAGNOSIS
Ankle fracture LAUGE-HANSEN CLASSIFICATION SAD1
MANAGEMENT
Posterior short leg slab + NWB with axillary crutches

12. ANATOMY

13. SYNDESMOTIC STRUCTURE
1. Antrior inferior tibiofibular ligament
2. Posterior inferior tibiofibular ligament
3. Interoseous membrane

14. DELTOID LIGAMENT

15. LATERAL LIGAMENT COMPLEX

16. SPECIFIC TEST
Anterior drawer test – subluxation or dislocation
Talar tilt – check laxity of lat. compartment
Squeeze test – check syndesmotic inj.
Ex. rotation stress test – check tibiofibular &
interosseous memb.

17. FILM OR NOT FILM?

18. AP VIEW
▸ Medial clear space < 5mm
▸ Tibiofibular clear space < 5 mm
▸ Tibiofibular overlaps > 5 mm
▸ dime sign /Ball sign

19. MORTISE VIEW

20. LATERAL VIEW
Syndesmosis disruption
Anterior or posterior ankle subluxation
Posterior malleolus fracture
Subluxation of ankle associated with posterior lip

21. NO FX SEEN >> SPRAIN

22. IF FRACTURE ARE SEEN
CLASSIFICATION
▸ Pott classification>>Base on number of malleolar
▸ Danis-Weber >>Base on location of fracture line &
comminution
▸ Lauge-Hansen Classification>>Base on causative
mechanism of injury

23. DANIS-WEBER CLASSIFICATION

24. LAUGE-HANSEN CLASSIFICATION
• Divide ankle fracture into 4 patterns by mechanism
• Four injury patterns :
Supination : adduction (SAD) 20% / external rotation
(SER). 60%
Pronation : abduction (PAB) 8% / external rotation
(PER). 12%

27. TRICK NOTE
Weber A => SA – avulsion of lat. Wall +
*malleolus compression*
Weber B => SER – start ant.>>lateral>>Post.>>medial
*oblique fx fibular*
Weber C => PER – start medial>>ant.>>lat.>>post.
*high fibular fx * *syndesmotic inj.*
Moreover, PAB are rarely to seen *comminuted fibular*
Ex. If see high fib. Fx don’t forget to check medial side
,although there are no fx seen lig. probably involved.

28. HOW CAN WE KNOW IF IT ISOLATED FIBULAR
FRACTURE NOT FRACTURE FIBULAR
FRACTURE + TORN DELTOID LIGAMENT ?

29. HISTORY
- MANNER OF INJURY
PHYSICAL EXAMINATION
- PAIN AT DELTOID LIGAMENT AREA
X-RAY
- SHOW LAXATION OF LIGAMENT
- TRY RETROSPECTIVE MECHANISM FROM X-RAY

30. MANAGEMENT
If no fx seen >> sprain
Grade1. RICE +early mobilization
Grade 2 RICE +splint
GRADE3 RICE+ rigid splint/cast

31. CONSERVATIVE
If seen fracture
Try conservative if
▸ Stable
▸ Anatomical reduction with joint congruent
▸ Non-displace fracture
Stable fractures
Supportive brace with weight bearing allowed as tolerated
Unstable fracture with anatomical reduction
Long-leg cast for 6 weeks
Then advanced to either a short-leg cast or walking boot

32. OPERATIVE
▸ Unstability
▸ Syndesmotic injury
▸ Intra-articular fracture
▸ Failed conservative

33. HOW CAN WE KNOW IF IT ANKLE INJ. FROM
INDIRECT FORCE FROM TWIST OF ANKLE OR
OR DIRECT FORCE (LIKE HAMMER HIT)?
*IN FIBULAR FRACTURE*

34. DIRECT INJURY
.- USUALLY MORE THAN 2 PIECES /
COMMINUTION
INDIRECT INJURY
-USUALLY SPIRAL /OBLIQUE/ TRANSVERSE
TYPES OF FRACTURE ARE DIFFERENT

36. REFERENCES
• Campbell 13th edition
• Rockwood and Green's Fractures in Adults, 8th
Edition, 2009
• เวชปฏิบัติทางออโธปิดิกส์ โรงพยาบาลมหาราช นครราชสีมา