ankle fractures

ANKLE INJURIES

praveen reddy p

Surgical anatomy of ankle joint

Saddle shaped joint Three bone joint – tibia, fibula and

talus Tibia - tibial plafond and medial

malleolus Fibula – lateral malleolus Large surface of talar dome

anteriorly and laterally

Continued.. This configuration provides stability in

dorsi flexion and relative mobility in plantar flexion

# DORSI FLEXION - close packed position - stability by articular contact# PLANTAR FLEXION – stability principally by ligamentous structures

TIBIA Lower end formed by five surfaces,

# inferior,anterior,posterior,lateral,medial

` inferior surface is concave antero-posteriorly and convex transversely

` posterior border is lower than the lateral border

` lateral border is concave with two tubercles – anterior and posterior

TIBIA

Anterior tubercle over laps fibula - forms the basis for radiological tibio-fibular syndesmotic assessment

Posterior tubercle remains intact – forms the basis for indirect reduction of posterior malleolar fragment

MEDIAL MALLEOLUS Articular surface is comma shaped Posterior border includes groove for

tibialis posterior Composed of two colliculi seperated by

inter collicular groove Deep component of deltoid attaches to

inter collicular groove Superficial component attaches to

medial and anterior border of anterior colliculus

FIBULA Two major surfaces, medial and lateral which

widen to three surfaces at tibial plafond# anteriorly - ant tibio-fibular - ant talo-fibular

# inferiorly - calcaneo-fibular# posteriorly - post tibio-fibular - post talo-fibular

TALUS

Covered entirely by articular cartilage, no musculo-tendinous attachment

Trapezoidal – ant surface wider than the post surface

LIGAMENTS syndesmotic - ant tibio-fibular - post tibio-fibular – strongest - int-osseous ligament Lateral collateral - ant talo-fibular - calcaneo-fibular - post talo-fibular Deltoid - superficial - deep – primary medial stabiliser

SYNDESMOSIS

LATERAL LIGAMENTS

MEDIAL LIGAMENTS

Patient Evaluation History

Mechanism Time since injury Associated injuries Comorbidities

Diabetes Neuropathy Obesity Alcoholism / drug

abuse

Physical Exam Note obvious deformities Neurovascular exam Pain to palpation of malleoli and

ligaments Palpate along the entire fibula Pain at the ankle with compression

syndesmotic injury Examine the hindfoot and forefoot

for associated injuries

Ankle Injuries type I — Only a

few fibers are stretched or torn, so ankle is mildly tender and painful, but muscle strength is normal.

Ankle Injuries

Type II — A greater number of fibers are torn, so there is severe pain and tenderness, together with mild swelling, noticable loss of strength and sometimes bruising

Ankle Injuries

Type III — The ligaments tear all the way through, rip into two separate parts, there will be considerable pain, swelling, tenderness and discoloration.

Ankle Injuries Sprains / Strains –

80% of sprains are caused by ankle inversion.

Inversion sprains cause damage to the lateral ligaments

RADIOLOGY

OTTAWA ANKLE RULES# x-rays indicated only if ` pain near malleoli ` inability to bear weight ` bony tenderness at the tip of the malleolus or post edge# 100% sensitive, decreased cost and patient waiting time

X - RAYS

On plain x-rays – there is continous condensed sub chondral bone around the talus that extends from sub chondral bone of distal tibia to medial aspect of fibula

X - RAYS

AP and LATERAL MORTISE VIEW STRESS or OBLIQUE VIEW (cobb’s)

A-P VIEW

Tibio-fibular overlap <10mm implies

syndesmotic injury

Tibio-fibular clear space

>5mm implies syndesmotic injury

Talar tilt >2mm is considered

abnormal

MORTISE VIEW

AP view of ankle with foot internally rotated

Abnormal findings: medial joint space

widening tibia/fibula overlap

<1mm

LATERAL VIEW Posterior malleolus

fracture Subluxation of the talus Angulation of distal

fibula Talus fractures Calcaneus fractures

STRESS VIEWS

Demonstrate ligamentous or syndesmotic disruption

May require sedation or hematoma block Comparison with contralateral ankle

LAUGE HANSEN”S

Associates specific fracture patterns with mechanism of injury

Two-term scheme1. Position of foot

Supination (lateral)Pronation (medial)

2. Direction of forceAdduction / abductionExternal rotationDorsiflexion

LAUGE HANSEN”S Genetic classification Six groups of injuries # abduction injuries # adduction injuries # ext rotation injuries with diastasis of inferior tibio-fibular jt - pronation external rotation injuries # ext rotation injuries with out diastasis of inferior tibio-fibular jt - supination external rotation injuries # vertical compression injuries # uncommon unclassifiable injuries

LAUGE HANSEN”S

Continues to form the basis of our understanding of mehanism of injury

Provides good guide to prognosis after both operative and conservative methods

WEBER”S

Type A # below syndesmosis Type B # at the level of syndesmosis Type C # above the level of

syndesmosis

WEBER”S

WEBER”S

Attractive for its simplicity and its guided treatment

Level of fibular fracture exclusively to guide treatment isn’t accurate enough

Degree of syndesmotic injury not always accurately predicted

Ignores medial side of the injury

Surgical technique Standard AO fixation Inter-fragmentary screw and 1/3 tubular

neutralisation plate for fibula and lag screw fixation for medial malleolus

Syndesmosis screw is required if fibula is unstable at end of fixation (engage 3 cortices and ensure the ankle is at 90º when inserting screw, and that the screw is not lagged) Screw needs to be removed before weight bearing can be commenced

Alternative fixation for Type B fractures of the fibula is the anti-glide plate which has been shown to be biomechanically superior to a lateral plate

Posterior malleolus fractures need to be fixed if there is > 25% of the articular surface involved. This is often underestimated on lateral radiographs

ABDUCTION INJURY Talus forcibly abducted in ankle mortise producing traction

on medial structures -

# pull off fracture of medial malleolus or rupture of deltoid

ligament

# lateral compression force produces a lower fibular fracture

with characteristic lateral comminution

# doesnot produce seperation of tibio-fibular jt b’cos

combined strength of three ligaments is greater than lat malleolus

# rarely if associated with vertical compression can cause en-

bloc avulsion of incisura fibularis

DIAGNOSIS

Valgus deformity of foot Swelling over both medial and

lateral aspect

TREATMENT

Undisplaced isolated med malleolus fractures –

# b/k plaster cast for six weeks # rehabilitation

TREATMENT

Displaced / irreducible – due to soft tissue interposition,

# 4mm cancellous screw # T B W # inter-fragmentary

screw

TREATMENT

FIBULA – minimal comminution # b/k cast - severe comminution # 1/3rd tubular plate

ADDUCTION INJURY Traction on the lateral structures # forcible inversion of the plantar flexed foot > ant talo-fibular tear # forcible inversion at right angle > tear of all 3 lateral ligaments or lateral malleolus fracture > compression injury of the medial malleolus causing vertical fracture +/- depression of articular surface

ADDUCTION INJURY - TREATMENT

Isolated tear of ant talo-fibular ligament

# eversion stirrup and elastic bandaging # adhesion formation - pain, weakness, giving way - outer side heel raise - Inj hydrocortisone + hyaluronidase

ADDUCTION INJURY - TREATMENT Complete tear of lateral structures- # talus will move away from

malleolus and well defined sulcus appears between the two bones Marked talar tilt on stress x-rays Can lead to recurrent dislocation if

not treated

ADDUCTION INJURY - TREATMENT

Complete immobilisation in a plaster cast for 6-8 weeks and rehabilitation

Recurrent dislocation – # evan’s

procedure

EX ROTATION INJ WITH INF TIBIO-FIBULAR JT DIASTASIS Also known as PRONATION-EXTERNAL

ROTATION FRACTURE Three types – # isolated fracture of med malleolus # partial diastasis of the inf tibio-

fibular joint # complete diastasis of the inf tibio- fibular joint

EX ROTATION INJ WITH INF TIBIO-FIBULAR JT DIASTASIS

Isolated med malleolus fracture - # b/k plaster cast for 6-8

weeks # ORIF

EX ROTATION INJ WITH INF TIBIO-FIBULAR JT DIASTASIS Partial diastasis of the inf tibio-

fibular jt # reducible – a/k plaster cast in

slightly inverted and firmly int rotated position (fibula winds itself up on the intact post ligament which serves to locate it well in its groove in the tibia – incisura fibularis)

# irreducible – ORIF

EX ROTATION INJ WITH INF TIBIO-FIBULAR JT DIASTASIS

Complete diastasis of the inf tibio-fibular joint

ORIF - post op immobilisation - plaster cast for 6-8 weeks

EX-ROTATION INJ WITHOUT INF TIBIO-FIBULAR JT DIASTASIS

Also known as SUPINATION-EXTERNAL ROTATION FRACTURE

Oblique fracture of the lower fibula Fracture dislocation without inf

tibio-fibular joint diastasis

EX-ROTATION INJ WITHOUT INF TIBIO-FIBULAR JT DIASTASIS

Oblique fracture of the lower fibula # b/k plaster cast application

for 4 weeks

EX-ROTATION INJ WITHOUT INF TIBIO-FIBULAR JT DIASTASIS

Fracture dislocation without inf tibio-fibular joint diastasis

# reduction – cupping back the heel in one hand, gently pull forwards and inwards and at the same time with the other hand apply counter over the

medial side of tibial shaft # ORIF

Operative Tips Lateral Malleolus

Reduce first Proximal fragment (shaft) needs

reduction 3 bicortical screws into proximal fibula Unicortical screws into intra-articular

portion Be certain fibula is out to length

ISOLATED LATERAL MALLEOLAR #

` Reduce & internally fix lateral malleolar # first in case of a bimalleolar #.

` If the # is oblique, fix it with two lag screws 1cm apart.

` If the # is transverse, fix it with a rush rod / IL fibular rod.

` If the # is small & below the plafond and has good bone stock, it is fixed with a 4.5mm malleolar screw. In patients with poor bone stock tension band technique is used.

` If the # is above the syndesmotic level, a small fragment 1/3rd tubular plate or a 3.5mm DCP can be used, If the plate is placed posterolaterally it acts as a antiglide plate.

Operative Tips

Medial malleolus Open reduction Visualize the ‘shoulder’ of the

malleolus Remove interposed soft tissue and

intraarticular fragments Two points of fixation Anti-glide plate for vertical fractures

ISOLATED MED. MALLEOLAR #

` Non displaced #: cast immobilisation.` Avulsion # of the malleolar tip: no fixation required

unless displaced.` Fixation usually requires two 4mm cancellous lag

screws oriented perpendicular to the #.` Vertically oriented # requires horizontally placed

screws.` Smaller fragments require one lag screw & a k-wire to

prevent rotation.` Fragments too small or comminuted are fixed with

tension band technique.` Vertical # extending into metaphysis requires

semitubular buttress plate for fixation.

Medial Malleolus Fixation

Posterior Malleolus Repair if >25% of

articular surface Reduce by ankle

dorsiflexion Clamp through

fibular incision Anterior lag

screws

Maissoneuve Fracture Fracture of

proximal 1/3 of fibula

+/- medial malleolar fracture

Pronation-external rotation mechanism

Requires reduction and stabilization of syndesmosis

Maissoneuve Fracture Fracture of

proximal 1/3 of fibula

+/- medial malleolar fracture

Pronation-external rotation mechanism

Requires reduction and stabilization of syndesmosis

BIMALLEOLAR FRACTURE

` Non union reported in 10% of bimalleolar # treated with closed methods.

` Tile & AO group recommends ORIF of almost all bimalleolar #s.

` Most Weber type B & C lateral malleolar #s are stabilised with plate & screw fixation.

DELTOID LIG.TEAR & LATERAL MALLEOLAR #

` Supination- external rotation injury.` Associated with tear of the anterior capsule.` Stress x-ray with the supinated & externally rotated

shows talar tilting with a widened medial clear space.` 1mm lateral shift of talus reduces the effective wt.

bearing area of the talo-tibial articulation by 20-40%.` Optimal treatment of this injury provided skin condition, patient age & general condition permits, consists of ORIF of fibula with /without deltoid ligament repair.` Lateral malleolar # is fixed before the repair of deltoid ligament.

TRIMALLEOLAR FRACTURE

` Usually caused by abduction or external rotation injury

` Components - medial malleolar #/deltoid lig.rupture, fibular # & # of the posterior lip of the articular surface of tibia` 500 external rotation view - assessment of size &

displacement of posterior malleolar fragment.` Fragment size > 25-30% of the wt. bearing surface requires ORIF` Posterior lip # should be fixed before reduction of

either the medial or lateral malleolar #

SYNDESMOTIC INJURIES

Pronation- external rotation, pronation abduction and supination external rotation injuries.

Syndesmotic injuries extending > 4.5cm proximal to the ankle jt alter the joint mechanics, but that extending < 3cm proximal to the joint dont.INDICATIONS FOR FIXATION:

i. Associated proximal fibular #s for which fixation is not planned and involves a medial injury that cannot be stabilised.

ii. Injuries extending > 5cm proximal to the plafond.

SYNDESMOTIC INJURIES contd.

Normally intraoperative roentgenograms should demonstrate a clear space of < 5mm b/w medial wall of fibula & lateral wall of posterior tibial malleolus.

Fixation of syndesmosis is either with oblique pins or screws inserted trrough the lateral malleolus into the distal tibia.

The screws should be placed through both cortices of fibula & either one or both cortices of the tibia.

Screw position- 2cm proximal to plafond, parallel to the joint surface, 300 anterior, perpendicular to TF jt..

Fixation of Syndesmosis

Fix fibula anatomically

Make sure ankle mortise is reduced

Hold reduction with clamp

Do not lag! ? Large vs. small

fragment screw ? 3 vs. 4 cortices ? Screw removal

Postoperative Care Well padded splint

immobilization Ice and elevation Non weight bearing

for 6 weeks Early weight

bearing possible Early conversion to

brace and ROM

COMPLICATIONS

Mal union

# Can occur with lateral malleolus, medial malleolus or the posterior malleolus.

# Predisposes to late degenerative changes and pain.

COMPLICATIONS contd…

Treatment-

# Lat mall - osteotomy through the # site, fixation with plate

& screws and bone grafting.

# Medial mall - osteotomy through # site & fixation with

malleolar screw & k wire.

# Post mall - if >25% of articular surface involved, osteotomy

through # site, reduction& fixation with k wire & malleolar

screws.

COMPLICATIONS contd…

Non union

# > in conservatively treated patients. # Non union of lat. malleolus < med.malleolus. # Treatment- non union site exposed & ends are freshened , rigidly fixed with a malleolar screw & k wire.

COMPLICATIONS contd…

Sudecks atrophy-

# Characterised by pain, demineralisation,edema,

shiny skin with reduced ROM. # Prevented by early ROM exercises, elevation

of the affected limb. # once the condition has developed – intensive physiotherapy, prolonged elevation & use of sympathetic blocking agents.

COMPLICATIONS contd…

Wound healing

# Plate application over lateral malleolus interferes

with wound healing. # Prevented by meticulous closure of

subcutaneous layer to cover the implant & constant

elevation of the limb for first 5-7 days.

COMPLICATIONS contd…

Infection # Associated with poor closure ,failure to elevate the limb postoperatively # Treatment - leave the implant in situ, dressing to be done regularly. - when the repaired # has united, implant to be removed, debridement under antibiotic coverage & later SSG.

COMPLICATIONS contd…

Fixation failure

# Loosening or backing out of screws usually seen in distal fibula. # Treatment - if screw loosens prior to healing of syndesmotic ligament it should be replaced.

COMPLICATIONS contd…

Degenerative arthritis

# Due to imperfect reduction. # Treatment - if malunion is the cause correct it. - if advanced arthritis

present - arthrodesis.

PILON / PLAFOND FRACTURES (Pilon = Hammer / Plafond = Ceiling)  

Reudi & Allgower’s

Type Pathology

1 Undisplaced

2 Displaced with joint incongruity

3 Marked comminution with crushing of the subchondral cancellous bone

Reudi & Allgower’s

Initial treatment

Reduction of any dislocation and covering of exposed wounds if present

Assess neuro-vascular status Check for evidence of compartment

syndrome Splint fracture which may require

temporary skeletal traction

Investigations X-ray plus CT Timing of surgery Type II and III - goal is to keep

talus centred under the tibia, while soft tissue heal over 7 to 21 days

Surgical options1. ORIF Medial and anterior incisions with

full thickness flaps developed at level of the periosteum. These incisions must be at least 7 cm apart to protect the viability of the intervening skin bridge

Steps Fibula # brought out to length and fixed with

plate (DCP) Tibial # exposed and reduced, held with

temporary K-wires – usually 4 main fragments K-wires replaced with interfragmentary

screws and fixed with buttress plate Closure of wounds – tension must be avoided

and if present close deep layers and return later for delayed 1º closure of skin

2. Fine wire fixation with circular frames Using either the Ilizarov or hybrid

external fixators This can be combined with limited

internal fixation of the tibia using inter-fragmentary screws and fixation of the fibula

3. Trans-articular external fixation

Will align the tibia but will not address the central depression of the joint surface. 

Useful as first part of 2 -stage procedure (to allow soft tissue management & CT & planning)

Summary You WILL see ankle fractures Taken for granted Reduce the mortise anatomically

Fibular length Stable syndesmosis Anatomic reduction and debridement

medially Proper management leads to excellent

outcomes

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thanks for listenin..