aotrauma na presents ankle fractures
DESCRIPTION
TraumatologíaTRANSCRIPT
4/3/2012
1
Ankle Anatomy and Radiology
Mark C. Reilly
Chief, Orthopaedic Trauma Service
New Jersey Medical School
Anatomic Pictures c/o Primal Pictures
Speakers
• David Stephen
– U Toronto, Sunnybrook Hospital
• David Barei
– U Washington, Harborview Medical Center
• Michael Sirkin
– New Jersey Medical School
• Hobie Summers
– Loyola University Medical School
Stability
• Bony anatomy
• Ligamentous anatomy
• Joint capsule
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Ligaments • Important component of ankle fractures and
injuries
• Syndesmotic
• Lateral collateral
• Medial collateral
Syndesmotic
• Interosseous membrane
• Interosseous ligament
• Anterior tibiofibular l.
• Posterior tibiofibular l.
• Transverse tibiofibular l.
Medial Collateral
• Superficial Deltoid
– Anterior colliculus
– Posterior Tibiotalar
– Tibiocalcaneal
– Tibionavicular
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Medial Collateral
• Deep Deltoid
– Posterior colliculus
– Prevents lateral subluxation
Fibular collateral
• Three bands
–Anterior talofibular
• plantarflexion
– Calcaneofibular
• dorsiflexion
– Posterior talofibular • Posterior subluxation
• Rotatory
Radiographs
• AP
• Lateral
• Mortise • 10-15º internal rotation of tibia
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AP
• Medial and lateral gutters not equally visible
• Fibula overlaps talus and tibia
AP
Medial border fibula
Incisural border
≤ 5mm
Tib-fib overlap
AP radiograph
Medial border fibula
Lateral border of Chaput tubercle
≥ 10mm
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Talocrural Angle
Mortise
About 83º • 75-87º
Measure of fibular length
Mortise
Medial and lateral clear space should be equal to superior clear space
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Mortise
Medial clear space ≤ 4mm
Compare to tibio-talar joint
Mortise
Lateral border of talus aligned with medial border incisura
Mortise
Fibular Articular surface congruent to Lateral Talus
Shenton’s Line
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Talar Dome Lateral
• Fibula/Tibia Relationship
• Anterior and Posterior Colliculi of Medial Malleolus
Talar Dome Lateral
• Fibula/Tibia Relationship
• Anterior and Posterior Colliculi of Medial Malleolus
Need for CT
• Suspicion of/ evaluate:
– impaction
– posterior malleolus
– anterolateral fragment
– associated fractures
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Don’t Forget Tibial Films
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Conclusion
• Understand the relevant osseous and ligamentous anatomy
• Understand the normal radiographic relationships
• Both osseous and ligamentous structures make significant contribution to ankle stability after injury
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Syndesmosis injuries
David Stephen Sunnybrook HSC
University of Toronto
Toronto, Canada
Disclosures
• Research support: Synthes Canada
• Speaker: Synthes USA / Canada
Objectives:
• Challenges
• Management strategies
• Take home points
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Syndesmosis disruptions
Controversies:
• screw only vs plate & screw
• 1 vs 2 screws
• 3 vs 4 cortices
• remove vs leave screw(s)
• 3.5mm vs 4.0mm vs 4.5mm screws
• Suture anchors??
“Challenges”
• Diagnosis
• Accurate reduction
• Stable fixation
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“I read that you can just pull the fibula down and
perc it”
Syndesmosis screws removed @10 weeks
4 months postop 6 weeks post screw removal
fibular length
syndesmosis widening
medial malleolar malreduction
Problems:
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Biomechanics
• Fibular shortening peak pressures
• External rotation fibula TT contact
• Lateral talar shift shear stress
instability
Ankle Fractures: Malunion
OA
Management: Fibular osteotomy Debride syndesmosis/medial jt Orif syndesmosis
4 months postop 6 weeks post screw removal
2 year follow-up
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KEYS: lateral side
• fibula: – length
– rotation
• Syndesmosis – low threshold for
open reduction
32 yo fall down stairs: seen at local hospital – “reduction / cast”
CT to assess syndesmosis/ posterior malleolus
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Surgical tactic
• Lateral position
• Posterolateral approach
• Debridement chondral debris
• Fixation posterior malleolus
• Direct open reduction/ fixation syndesmosis (4.0mm cortical screws)
3 months postoperative
Syndesmosis: “Challenges”
• Diagnosis
• Accurate reduction
• Stable fixation
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Take Home points
• Understand the injury
– Preoperative CT
• KEYS to reconstruction
– Open reduction
– Stable fixation (screws)
– Consider postoperative CT if concern
Thank You
3/30/2012
1
AO Trauma NA Complex Ankle Fractures Webinar
David P. Barei MD, FRCSC Harborview Medical Center
University of Washington Seattle
Posterior Malleolus Fracture Management
Disclosure
• Teaching Honoraria (AO, Synthes)
• Synthes Consultant (implant design)
• Journal Reviewer
– JBJS-A, J Orthop Trauma, CORR, J Knee Surgery
• AO Fellowship Committee
Institutional-UW Orthop-Research
• AO Spine North America
• AO-Stiftung-ASIF Foundation
• Bank of America Foundation
• The Center, Orthopaedics and Neurological Surgeons
• Fidelity Investments
• Helena Orthopaedics Clinic
• Illinois Orthopaedics & Hand Center
• Inland Orthopaedics of Spokane
• JMS Hand Associates
• Northwest Biomet, Inc.
• Pacific Rim Orthopaedics
• Proliance Surgeons, Inc.
• Proliance Orthopeadics & Sports Medicine
• The Seattle Foundation
• Seattle Christian Foundation
• Silicon Valley Community Foundation
• Simonian Sports Medicine Clinic
• SKS Plastic Surgery
• Spectrum Research
• Synthes U.S.A.
• Synthes Spine Co.
• Washington Research Foundation
• Washington State Orthopaedics Association
• Webber Lawn & Yard Care
• National Institutes of Health (NIH)
• National Science Foundation (NSF)
• Veterans Affairs Rehabilitation Research and
• Development Service
• Orthopaedic Research and Education Foundation (OREF)
• A.O. North America
• Amgen, Inc.
• Bayer AG
• BioAxone Therapeutique, Inc.
• CeraPedics, LLC
• Christopher Reeve Paralysis Foundation
• Depuy (Johnson & Johnson, Inc. )
• Foundation for Orthopedic Trauma
• Integra Lifesciences Corporation
• National Science Foundation
• Ostex International, Inc.
• Orthopaedic Trauma Association
• Paradigm Spine
• Smith & Nephew
• Synthes Spine Co.
• The Boeing Company
• US Army Research Office
• US Department of Education
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Anatomy
• Evolution of understanding
– Conceptually simple
– Focus on articular surface
McDaniel CORR, 1977
Treatment Evidence
• Poorly described • “Large fragments”
– 20-30% of the articular surface • Talar subluxation, arthrosis, worse outcomes
• Smaller fragments didn’t seem to be associated with
problems
• Trimalleolar fractures seem to have worse outcomes than bimalleolar
• Thought to be secondary to chondral injury and disrupted tibiotalar congruity
Anatomy
• Evolution of understanding…Soft tissue attachments
– Syndesmosis
• PITFL
• Osseous incisura
– Tibiotalar
• Capsular attachments
• Articular congruity
Hermans J. Anat, 2010
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Posterior Malleolus Fractures • Contributes to syndesmotic stability (PITFL)
• Indications for fixation controversial
• >25% versus larger versus smaller versus all?
• Posterior subluxation?
Pathoanatomy
• 19%
67% 19% 14%
12% 30% N/A
Frequency
Cross-Section Area
Haraguchi JBJSA, 2006
Reduction and Fixation Choices Indirect Reduction
Ankle dorsiflexion
Rarely adequate for an accurate reduction
Direct Reduction
Visualize the cortical exit
Fixation
Anterior to posterior screws
Posterior to anterior screws
Posterior anti-glide plate
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What we do know • Tibiotalar incongruity & subluxation = arthrosis
• Large fragments result in syndesmosis disruption:
– Incisura deformity – PITFL “disruption”
• We are bad at reducing a syndesmosis closed,
• Posterior malleolar ORIF provides more stability to the
syndesmosis than trans-syndesmotic fixation – PITFL stays attached to the posterior malleolus
• Good ankle fracture outcomes seem to be increasingly
related to anatomic and stable syndesmosis
Surgeon Practices
• Gardner Foot Ankle Int, 2011
– Wide variation in practices
– Noted that fragment size wasn’t the sole indication
– Other considerations:
• Joint stability,
• Syndesmosis reduction,
• Syndesmosis stability
The Problem
Posterior talar subluxation Point contact loading on the plafond and talus Chondral destruction Syndesmotic dislocation and dysfunction
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The Other Problem
• If you are considering that a given posterior malleolus requires reduction and fixation, strongly consider a CT scan….
Case 1
Large fragment articular incongruity no gross tibiotalar displacement/dislocation Antiglide plate and screw fixations tibiotalar subluxation and arthrosis
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Case 2
Small fragment with gross tibiotalar instability and fibular syndesmotic comminution Posterior anterior screw with a small modified plate as a washer for syndesmosis reduction and stability
Posterolateral
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Case 3
Case 3 Approach?
1. Anteromedial
2. Anterolateral
3. Posterolateral
4. Posteromedial
5. Combined posterior and anterior
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Radiologic medial double density
Large posteromedial fragment Posteromedial osteochondral fragments
Smaller posterolateral fragment
Posterolateral
Posterolateral
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Posterolateral
Posterolateral
Posteromedial
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Posteromedial
Posteromedial
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Case 4
Main concern with last 2 cases: Tibiotalar arthrosis
Posteromedial talar subluxation
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Posteromedial
Summary
• Relative anatomic importance:
– Syndesmotic stability via PITFL
– Osseous incisura
– Tibiotalar congruity/stability
• Varying morphologies
– Consider CT scan in those that you deem operative
• Fixation strategies
– Posterolateral/posteromedial approaches
– Antiglide fixation for large fragments
1
Ankle
Fractures
Michael Sirkin, MD Vice Chairman, Department of Orthopaedics
New Jersey Medical School
Fixation in the elderly:
Avoiding problems:
Disclosures
•Consultant for Biomet
•Editorial Board
–JAAOS
–JOT
–Journal of Trauma
Today • Define the problem
• Basics to understand
• Fixation strategies
–Examples
• Avoiding problems
2
• 95 year
old
• Fell on
ice
• Closed
fracture
The problem
Loss of
reduction
Backing out
of screws
The problem
• Follow up
Stability • Bony anatomy
–Poor bone quality
–Fixation techniques need
modification
• Ligamentous anatomy
• Joint capsule
3
Standard
Fixation
Techniques
Common medial fixation
Cancellous
screws
Screw and
wire Tension Bands
Medial
Lag Screws
Neutralize
Antiglide
Common Techniques
Lateral
4
Standard Fixations
Elderly Fixation
• Special techniques may be need in osteoporotic bone
• Hardware not as well held in place
• Prevent displacement
• Preserve reduction
Special fixation
• Cancellous screw position
• Cortical lag screws
–Long
• Plates
• Supplemental k-wires
Medial
5
Cancellous screws • If using partially threaded
screws-use right size
• Just long enough for thread
to cross fracture
• Have threads in
metaphyseal bone—not
intramedullary canal
Medial
• Cortical screws-
lag technique
• Lag by technique
• Allows maximal
purchase
• May use very
long screws
• Can be bicortical
if necessary
Cortical screws Medial
• Cortical screws-
lag technique
• Lag by technique
• Allows maximal
purchase
• May use very
long screws
• Can be bicortical
if necessary
Cortical screws Medial
6
•Good for comminution
–No bony stability
Plates Medial
•Good for comminution
–No bony stability
• Small fragments
• Vertical fractures
• Act as a buttress
Plates Medial
K-wires • Can be used with
screws/plates
–Small fragment
–Bad screw purchase
–Multiple points of fixation
–Can be bicortical
Medial
7
Elderly Fixation
• Special techniques may be need in osteoporotic bone
• Hardware not as well held in place
• Prevent displacement
• Preserve reduction
–Techniques
Fibula
Reduction
8
Special Fixation
• Distal cross screws
• Intramedullary k-wires
• Longer plates
• Use tibia for fixation
• Locked plates
Lateral
• 1/3rd Tubular plate
• Flatten plate
• Cross Screws distally
–Creates bony triangle
–Longer screws
–Metal on metal
–Longer screws
• 20mm
Distal screw Lateral
Intramedullary K-wires
• Used with plates
and screws
• K-wire placed prior
to screws
• Increases purchase
of screws
• Metal on metal
interdigitates
Lateral
9
Longer plate • Distal fixation less
important
• Buttress to distal fragment
• Rely on proximal fixation
to hold distally
Lateral
Tibial fixation • Tetra cortical screws
–Use tibia for lateral
fixation
• Increased bony
purchase
• Function not as
syndesmotic screws
• Use as many as
needed
Lateral
80 yof fall in grocery store
10
3 months postop
11
Locked plates
• Small screws in
distal fragment
–Questionable
benefit
• Fixation held
proximally
Locked plates
• Multiple small
screws probably
better
Locked plates
• Small screws in distal
fragment
• Fixation held
proximally
• Can also gain fixation
in tibia
12
External Fixation
• Can use ex-fix to
protect fixation
• Typically 6
weeks
• Frequently more than one
technique is needed
• Use both medial and lateral
techniques
• Longer lateral
plate
• Longer
medial
cortical lag
screws
13
• 85 year old
• Twist and fall
• Over last 2 years
–Fractures Wrist
–Compression of L5
Multiple Techniques • Medial
–Longer screws
• Bicortical screws
• Lateral
–Longer plate
–Add intramedullary K-
wire
–Cross screws distally
Conclusions
• Care must be taken when
treating the osteopenic
• Special techniques may be
needed
• Can be done
14
• Frequently more than one
technique is needed
• Use both medial and lateral
techniques
• All techniques can be used
• 65 year old
• Diabetic
• Dialysis
dependent
• Walking to
bathroom
twisted ankle
• Lateral
– Intramedullary wires
–Longer plate
–Tetracortical screws
–Crossed distal
screws
• Medial
–Plate
–K-wires
–Long screws
15
6 weeks, no loss of
reduction
Thank
You
4/3/2012
1
Medial and Lateral Impaction in Ankle Fractures
Hobie Summers, MD
VuMedi Event
April 3, 2012
Disclosures
• Institutional grant from Synthes for research coordinator
• Synthes – consultant for representative education
Common Issues
• Easily unrecognized on initial imaging
• Must keep a high index of suspicion
• Adduction and Abduction type patterns
– Supination/Adduction
– Pronation/Abduction
• Still look for impaction in rotational injuries, especially with dislocation
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Where to look
• Supination/Adduction
– Medial impaction
• Pronation/Abduction
– Lateral impaction vs Chaput fragment
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15 months
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Summary
• Beware of adduction/abduction injuries
• Disimpact the articular surface
• Bone graft
• Buttress plating works well
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32 y/o homeless female
Falls while intoxicated
Splinted in ER and referred to clinic
By report, minimal pain medially, not particularly swollen either
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Stress
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Stress
43 year old firefighter
Fall onto Lower Extremity
Closed, Isolated Injury
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Anterior Posterior Medial
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48 y/o male s/p motorcycle crash
10cm transverse medial open wound
Isolated injury
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46 year old male seen and splinted after twisting injury to ankle
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