ankle fractures management
DESCRIPTION
Ankle # managementTRANSCRIPT
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ANKLE FRACTURES - MANAGEMENT
Presenter : Dr.sunil santhosh .gModerator :Dr.Y.Sivaprasad
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Radiography CT MRI
Investigations :
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Assists in ordering X-rays in pt.’s with ankle injury.
Ankle X-rays needed only if there is pain near the malleoli with one or more of following,
a) age >55 b) inability to bear wt c) bone tenderness at posterior edge or tip of either
malleolus.
Nearly 100% sensitivity.
Useful in reducing no. of x-rays in trauma setting.
Ottawa Ankle Rules:
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Antero-posterior
Mortise
Lateral
Ankle X-rays: 3 views
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Identifies fractures of malleoli, distal tibia/fibula, talar dome, body and lateral process of talus,
Antero-posterior view
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Tibiofibular clear space: <5mm Tibiofibular over lap: >10mm
Talar Tilt: difference in width of med &lat aspect of joint–
<2mm
Measurements in AP view
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Foot in 15-20 degrees internal rotation
Evaluate articular surface between talar dome and mortise
Mortise view :
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Medial clear space: <4mm
Tibiofibular overlap: >1mm
Measurements in mortise view
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•Posterior mallelolar fractures
•AP talar subluxation
•Distal fibular translation &/or angulation
•Associated or occult injuries–Lateral process talus–Posterior process talus–Anterior process calcaneus
Lateral View
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Talocrural angle : Btn 8-15 degrees & within 2-3 deg of opp
ankle
Talar tilt: angle formed b/n line Drawn parallel
to articular surface & Talar surface – they should be parallel to each other
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CT Articular involvement Joint involvement Posterior malleolar fracture pattern Pre-operative planning Evaluate hindfoot and midfoot if needed
MRI◦ Ligament and tendon injury ◦ Talar dome lesions◦ Syndesmosis injuries
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Stability may be defined as the combination of insufficient fracture displacement to compromise long-term function and the ability of the injured ankle to withstand routine physiologic forces without further displacement
In stable ankle # Talus is centered Does not shift with stress
Presence or absence of Medial injury is key to the stability of Lateral malleolar #
Stable Versus Unstable Fractures
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Biomechanical studies in an axially loaded ankle model indicate that
despite fracture of the fibula and complete disruption of the anterior and posterior syndesmosis, in the absence of a medial side injury, the talus remains stable and centered in the mortise .
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Non-operative : Indications
Non displaced Stable # & intact Syndesmosis Displaced # if stable Anatomic mortise is
achieved Those not Surgically fit
TREATMENT
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Patients with Stable # Pattern can be maintained in short leg cast &allowed to weight bear as tolerated
Those with un-stable # pattern are placed in long leg cast for 4-6 weeks to maintain rotational control Once adequate healing is demonstrable can be shifted to short leg cast but they are best treated opreratively.
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Open reduction & Internal fixation is indicated in :
Failure to achieve or maintain Closed reduction Unstable # with talar displacement or Widened Ankle mortise # that require abnormal foot position for
reduction Open fractures
Operative Rx
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Indications :
If Fibular displacement is >3mm # Within 5cms of Ankle joint Talar displacement Complete deltoid ligament rupture Associated with Bi or trimalleolar #
Lateral malleoli Fixation
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Fibula # is fixed first If associated with medial or posterior malleolar # except when it is severely communited.
It is exposed by either Lateral longitudinal or postero-lateral
approach
Care to be taken to avoid superficial peroneal nerve injury
Technique
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IF # is below the syndesmosis it is stabilised by using a lag screw or k-wires with tension banding
If # above syndesmosis is fixed with 1/3 semitubular plate & screw fixation
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If # is a long oblique - fixed with two lag screws in a-p direction to achieve compression & must be engaged to post cortex .
If # is Transverse Intramedullary device like rush nail, Intramedullary screw can be used.
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Indications :
Associated syndesmotic injury Widening of medial clearspace after Fibular
fixation. Inability to attain fibular reduction Persistent Medial # displacement after
fibular fixation
Medial malleoli fixation
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Approached through Antero-medial incision
Usually fixed using Two 4 mm cancellous lag screws perpendicular to # line
Technique :
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Alternatively Fixation can be done by using Tension Band wiring if # fragment is small
If associated with Proximalcommunition then Butress plate is used to maintain reduction
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In this both Medial & Lateral stabilizing Structures of the ankle joint are lost .
Usually Treated with ORIF of Both malleoli as there is more chance of non-union with Closed reduction .
Bi-MALLEOLAR #
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In this Bimalleolar # is associated with # of Posterior tibial lip
Results are usually poor Compared to bi-malleolar #
TRI-MALLEOLAR #
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Indications :
If Involment is> 25% of Articular surface
> 2mm Displacement
Persistent Posterior subluxation of talus
Reduction is achieved in this by using either by direct or indirect technique
Posterior malleolar Fixation :
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In Indirect Approach , Screw is passed Anterior to posterior & inter fragmentary compression is achieved .
In Direct approach Screw or Plate fixation is done posterior to anterior direction through postero lateral incision .
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Syndesmotic injuries are most commonly caused by prn–ext rotation, prn-abdc and infrequently,supn–ext rotation mechanisms (Danis-Weber type C and type B injuries).
These forces cause talus to abduct or rotate externally in the mortise, leading to disruption of the syndesmotic ligaments.
SYNDESMOTIC INJURY
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Indications : syndesmotic injuries associated with
proximalfibular and that involve a medial injury that cannot be stabilized and
syndesmotic injuries extending more than 5 cm proximal to the plafond.
Integrity of syndesmosis is confirmed by Extrernal rotation stress test & Cotton test
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screws or oblique pins inserted through the lateral malleolus and into the distal tibia.
The screw should be positioned 2 to 3 cm proximal to the tibial plafond,
Directed parallel to the joint surface, and
angled 30 degrees anteriorly so that it is perpendicular to the tibiofibular joint.
Technique :
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Two screws have been found to provide more stability than fixation with one screw
Screws should engage both cortex of fibula & one or two cortex of fibula
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Occurs supination -external rotation of the foot.
X-ray AP view shows tilting of talus & Increased medial clear space Under stress
Accepted RX is ORIF of Fibula with ligament repair to maintain ankle mortise.
Deltoid ligament Tear :
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Through Ant-medial approach
Deltoid ligament identified
Deep part Identified by opening tibialis post sheath
Ligament repaired by suturing it to neck & body of Talus Diagonally
Technique
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Open Ankle Fractures
◦ Treat with appropriate antibiotics pre-op and 48 hr post-op
◦ I & D with immediate ORIF if clean wound
◦ ORIF and Ex Fix if severe soft tissue damage present to allow for wound care
◦ Low grade open # results similar to closed fractures
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Complications
• Perioperative– Malreduction– Inadequate fixation– Intra-articular hardware penetration
• Early Postoperative– Wound edge dehiscence/necrosis– Infection– Compartment syndrome
• Late– Stiffness– Distal tibiofibular synostosis– Malunion– Nonunion– Post-traumatic arthritis– Hardware related complications– Complex regional pain syndrome type 1
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Complications
Malunion
◦Usually associated with shortened or malrotated distal fibula ◦Failure to reduce the syndesmotic injury◦Treated with fibular lengthening and/or derotational osteotomy +/- syndesmotic fixation◦Ankle fusion for advanced arthrosis or osteotomy failure
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Complications
Non-union
◦ Usually involving the medial malleolus due to soft tissue (i.e. posterior tibial tendon) interposition
◦ Treated with electrical stimulation, ORIF, bone graft, or excision of fragment
◦ Patient may have co-morbidities such as diabetes, peripheral vascular disease or smoking
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Complications
Wound problems
◦ Edge necrosis (3%)
◦ Dehiscence
Risk is decreased by minimizing swelling, not using a tourniquet, and careful atraumatic soft tissue handling
ORIF in the presence of fracture blisters and larger abrasions have more than twice the average wound complication rate.
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Complications
Infection
◦ Occurs in less than 2% of closed fractures
◦ Increased incidence in Diabetics, Age > 50, and Alcoholics
◦ Treated with antibiotics
◦ Implants usually left in place to maintain stability for optimal soft tissue perfusion
◦ May require serial debridements +/- VAC dressing
◦ Arthrodesis used as a salvage procedure
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Complications
Post traumatic arthrosis secondary either to articular damage at the time of injury or inadequate reduction resulting in abnormal mechanics.
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Complications
Tibiofibular synostosis◦ associated with syndesmotic screw use
and is usually asymptomatic
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THANK YOU
Reference:Campbell,Rockwood,Hand book of #,Net.