injuries around ankle joint and it’s management. introduction ankle injury refers to disruption...
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INJURIES AROUND ANKLE JOINT AND IT’S MANAGEMENT
INTRODUCTION
Ankle injury refers to disruption of any component or components of the ankle joint following trauma.
Ankle injuries occur frequently, and have high propensity for complications.
ANATOMY
Ankle joint is a synovial joint of hinge variety
Bony mortise- quadrilateral shape
Posterolateral position of fibula
Ligaments
3 groups
-Lateral
-Medial
-Syndesmotic
ANKLE JOINT IS SUPPORTED BY
Fibrous capsule
Deltoid ligament
A. Superficial
a. Anterior- Tibionavicular
b. Middle- Tibiocalcanean
c. Posterior- Posterior tibiotalar
B. Deep : Anterior-Tibiotalar
Lateral ligament Anterior- Talofibular
Posterior- Talofibular
Calcaneofibular
SYNDESMOTIC LIGAMENTS
Ant inf tibio fib
Supf post tibio fib
Deep post tibio fib
Interosseous lig
ACUTE LIGAMENTOUS INJURY
Type I sprain- minor
Type II sprain - incomplete
Type III sprain - complete
TREATMENT LIGAMENT INJURY
Non-operative treatment
Achieved by RICE
Operative treatment
Indicated when problems persist after 12 weeks of treatment including physiotherapy
Associated fracture
CLASSIFICATIONS
LAUGE HANSEN
LAUGE HANSEN
1. Position of foot at injury- Pronation/Supination
2. Deforming force- Abduction/ adduction/ external rotation
Most Common mechanism of injury- SER
Most Common unstable ankle fracture variant- SER
LAUGE HANSEN
SUPINATION ADDUCTION
SUPINATION EXT ROT
PRONATION ABDUCTION
PRONATION EXT ROT
PRONATION DORSIFLEX
Maisonneuve’s fracture
High spiral oblique fracture of upper 3rd fibula with ankle PER injury
TYPES OF INJURIES
Soft tissue injuries
Ligament injuries
Lateral collateral ligament injury
Deltoid ligament injury
Syndesmotic injury
Fractures
Malleolar fractures
Pilon fractures
Physeal injuries
DIAGNOSIS
RADIOLOGICAL VIEWS
AP / LAT ANKLE
AP/OBLIQUE FOOT
AP MORTISE ANKLE
OTHER INVESTIGATIONS
ARTHROGRAPHY
ARTHROSCOPY
CT SCAN
MRI
BONE SCAN
AP VIEW
SYNDESMOSIS Tibiofibular
overlap<10mm
MALLEOLAR LENGTH Talocrural angle 83+_4
deg
TALAR TILT
- sup clear space- med clear space diff <2mm
MORTISE VIEW
What else to see in x-rays
LAT MALLEOLUS
Level of fracture
Orientation of fracture
Fracture comminution
MED/POST MALLEOLUS
Size
Assoc plafond #
Assoc syndesmotic injury
SYNDESMOTIC INJURY
Pott’s Fracture
Fracture involving the ankle joint loosely referred to as Pott’s Fracture
1. First degree single malleolus fractured.
2. In second degree two malleoli are fractured.
3. In third degree there is bimalleolar fracture with a fracture of posterior part of inferior articular surface of the tibia referred to as third malleolus. (Tri Malleolar fracture)
MANAGEMENT
RICE
Definitive
Aim- restoration of complete normal anatomical alignment of ankle.
Patients if needs operation should be operated within 24hrs of injury or after one week once the swelling subsides.
Undisplaced fracture medial malleolus :
Below knee POP cast for 6 weeks.
Reduction fails (may be due to soft tissue (periosteal) inter position)
Displaced: Open reduction and internal fixation by
Cancellous screws group Tension band wiring
Fracture lateral malleolus: Lateral Malleolus helps in length maintenance &
maintenance of ankle mortice. Hence, lateral malleolus has to be fixed
internally.
TIBIAL PILON FRACTURES
Intraarticular fracture of distal tibia.
Fibula is fractured in 85% of these patients.
TIBIAL PILON FRACTURE
1. Plaster immobilization
2. Traction
3. Lag screw fixation
4. OR & IF with plates
5. External fixation with or without limited internal fixation
If articular incongruity <2 mm and reserved for low energy injuries
COMPLICATIONS
Malunion- may result in posttraumatic arthritis and painful movements.
Nonunion of medial malleolus- commonly due to interposition of fractured periosteum between two fragments.
Repeated edema Sudeck’s Osteodystrophy
TALUS FRACTURE
Anatomy-parts
Head-articulate with navicular
Neck-nonarticular
Body-articulate with tibia and calcaneus
No muscular or tendinous attachment
Blood supply
Extraosseous supply Posterior tibial a. tarsal
canal a.
Anterior tibial a. sinus tarsi a
Peroneal a. sinus tarsi a.
Intraosseous supply Talar head
Talar body
-anastomosis between tarsal canal a. and tarsal sinus a.
Talar head fracture
5~10% of all talus fracture
Talar neck fracture
Aviator’s astragalus
High energy injury, hyperdorsiflexion
15~20% open fracture
Associated with malleloar fracture(25% of cases), medial malleolus is more common
High risk of soft tissue injury and compartment syndrome
Classification-Hawkins classification
nondisplaced
Displaced
Subtalar subluxation
Ankle dislocation
(Talar body dislocation)
Talonavicular dislocation
Treatment
Hawkins type I
4~6 weeks of no weightbearing in a short leg cast walking cast for 1~2 months
Percutaneous screw fixation
Treatment
Hawkins type II
Orthopaedic emergency: traction and plantar flexion by manipulation anatomic reduction(50%) treated as type I
Open reduction: screw placed across the neck fracture
Treatment
Hawkins type III
ORIF and Skeletal traction through the calcaenus
Open fracture (> type III)
:talar body excision followed
By primary tibiocalcaneal or Blair-type arthrodesis
Hawkins type IV
Rare injury
As type II
Complication
Skin necrosis and infection
Delayed union or nonunion
Malunion
Posttraumatic arthritis
Osteonecrosis
Calcaneal fracture
Anatomy
Largest, most irregularly shaped bone in foot Large calcellous bone and multiple processes Achilles tendon posteriorly and plantar fascia inferiorly :
tuberosity Posterior facet: talar lateral process and body Middle facet: Sustentacular fragment (flexor hallucis longus pass) Anterior process: cuboid
Calcaneal fracture
Classification
Essex-Lopresti
--Extraarticular(25%) v.s intraarticular(75%) fracture
Sanders
--CT classification of intraticular calcaneal fracture
Associated injuries
A fall from a height or high–energy mechanisms
10% lumbar spine fracture(L1); 10% of calcaneal fracture are bilateral
Broden’s view showing the depressed posterior facet
varus position of the tuberosity
↓ ↑
Intraarticular fracture(joint depression and tongue type)
Mechanism injury Axial loading
Radiography Loss of Bohler’s and Gissane’s angles
Intraarticular fracture
Joint-depression type, in which the primary fracture line exited the bone close to the subtalar joint
tongue-type, in which the primary
fracture line exited the bone posteriorly
Intraarticular fracture--Treatment
Nondisplaced articular fractures Bulky (Robert-jones) dressing: active subtalar ROM,
prohibit weightbearing walking 8~12 wks later
Displaced intraarticular fracture with large fragment ORIF
Intraarticular fracture--Treatment
Displaced intraarticular fracture with severe comminution
Increasing intraarticualr comminution leads to less satisfactory results
ORIF primary arthrodesis
Restoring the heel width and height
Intraarticular fracture --complications
Soft tissue breakdown
Local infection
Subtalar arthritis
ANKLE AND FOOT INJURIES
Q1) The stability of the ankle joint is maintained by all of
the following except
a. Spring ligament
b. Deltoid ligament c. Lateral ligament d. Shape of the superior talar articular surface
Q2) The most commonly affected component of lateral
collateral ligament complex in an ankle sprain
a. Anterior talo fibular ligamentb. Posterior talo fibular ligamentc. Calcaneofibular Ligamentd. None
Q3) Ankle sprain is due to
a. Rupture of anterior talo-fibular ligamentb. Rupture of posterior talo-fibular ligamentc. Rupture of deltoid ligamentd. Rupture of calcaneo-fibular ligament
Q4) Mechanism of injury of transverse fracture of medial
malleolus is
a. Abduction injuryb. Adduction injuryc. Rotation injuryd. Direct injury
Q5) Cottons fracture is
a. Avulsion fracture of C7b. Bimalleolar fracturec. Trimalleolar fractured. Burst fracture of the Atlase. None of the above
Q6) Bimalleolar fracture is synonymous to
a. Cottonsb. Pottsc. Pirogoffsd. Dupuytrens
Q7) Avascular necrosis is a complication of
a. Fracture neck talusb. Fracture medial condyle femurc. Olecranon fractured. Radial head fracture
Q8) POP cast in equinus position is indicated in
a. Distal fracture both bone legb. Distal fracture fibulac. Bimalleolard. Fracture Talus
Q9) Gissane’s angle in intra-articlar fracture calcaneum is
a. Reducedb. Increasedc. Not changedd. Variable
Q10) Bohler’s angle is decreased in fracture of
a. Calcaneumb. Talusc. Naviculard. Cuboid
Q11) Stress fractures are most commonly seen in
a.Tibia
b.Fibula
c.Metatarsals
d.Neck of femur
Q12) Neutral triangle is seen radiologically in
a. Calcaneumb. Talusc. Naviuclard. Tibia