management of acute ankle fractures
TRANSCRIPT
MANAGEMENT OF ACUTE ANKLE FRACTURES
Dr UDAY KUMAR MS(Orth) DNB(Orth)
SAGAR HOSPITALSSINDHI HOSPITALCHINMAYA HOSPITAL BANGALORE
Jan 9, 2015
- ankle fractures ----- between 107 and 187 per 100,000 persons per year
-Unimalleolar fractures-- most common -- 70%
-most common mechanism is---- supination injury foll by pronation
-more common in --- young men aged 15–24 yrs -- older women
INCIDENCE
Clinical features-H/O severe twisting, abduction or adduction injuries.
-Severe pain.-Inability to stand on the affected limb.-Swelling and deformity.-Tenderness on one or both malleoli.
Skin-soft tissue injury—closed/open
Nerves
Vasculature
Co-morbidities---diabetes smoking alcohol
Evaluate
Initial Management-Pain control
-RICE -Rest -Immobilise---splint -Compression bandage -Elevation
X rays
-Ankle Series AP mortise lateral
AP
Lateral
Mortise
- fractures of malleoli - distal tibia/fibula - talar dome - body and lateral process of
talus
Antero-posterior view
• Tibiofibular clear space: <5mm• Tibiofibular over lap: >10mm
• Talar Tilt: difference in width of med &lat aspect of joint–
<2mm
Measurements in AP view
-Foot in 15-20 degrees internal rotation
-Evaluate articular surface between talar dome and mortise
Mortise view
-Medial clear space: <4mm
•Posterior malleolar fractures
•AP talar subluxation
•Distal fibular translation &/or angulation
•Associated or occult injuries–Lateral process talus–Posterior process talus–Anterior process calcaneus
Lateral View
Evaluation: RadiographicOther Imaging Modalities
• Stress Views– Gravity – Manual
• CT– Articular involvement– Posterior malleolus
• MRI– Ligament and tendon
injury – Talar dome lesions– Syndesmosis injuries
Weber/AO classificationbased on level of fibula fracture
A – Below syndesmosis
B – At syndesmosis
C – Above syndesmosis
Classification: Lauge-Hansen meets Danis-Weber
Simple Classification Stable Unstable
• Stable fractures– Most commonly involve
medial or lateral side only
– Talus remains anatomic relative to tibia
Unstable fractures
– Disruption of 2 or more aspects of the mortise -- bone and/or ligament
– Talus may sublux or be dislocated from tibia
Stable Examples
Unstable Examples
Management
-Stable Ankle fracture --- short leg cast for 6 weeks
- Cast patients reduced hospital stay lower cost of treatment
Non-operative
Surgical Indications
• Bimalleolar / trimalleolar fractures
• Syndesmotic disruption
• Talar subluxation
• Open fractures
Soft tissue injury
• Debridement• External fixator and delayed ORIF
Basic Set-Up
• Supine position most common– Occasionally prone for direct approach to posterior
malleolus• Bump beneath ipsilateral buttocks (allows easier
approach to fibula)• Tourniquet• Prep / drape to above knee • Pre-op antibiotics• Fluoroscopy or X-ray
Instrumentation
• Small fragment set• Cannulated screws• K-wires• Cerclage wire • Power• Have mini-frag
available
Ankle Fracture
ORIF PLAN
Uni malleolar fracture
Fix with -- Two 4 mm cancellous screws --TB wire --plate
Bimalleolar fracture
Plate fibula
Two 4 mm cancellous screws in medial malleolus
Tri-malleolar fracture
Plate fibula Two 4 mm cancellous screws in med malleolus
fix posterior malleolus if >20 - 25% articular surface involved
Fixation techniques
Lateral Malleolus
• One-third tubular plate & 3.5 mm cortex screws
– Lateral– Posterior
• 3.5mm compression plate for unstable fractures
-avoid superficial peroneal nerve injury
Lateral Malleolus
• Locking plates -- lateral or posterolateral • Osteoporotic bone• Unstable fractures• Distal fractures
Lateral Malleolus in very distal fibula fractures
• Hook Plate• K wire with cerclage wire . Lag screw/Rush pin
Medial Malleolus
• Two partially threaded 4.0 mm cancellous screws
• K-wires with cerclage wire
• Buttress plate
Posterior Malleolus fixation
If involvement is > 25% of Articular surface > 2mm Displacement Persistent Posterior subluxation of talus
Anterior to posterior
Posterior to anterior
Posterior Malleolus
Syndesmosis Fixation
• Syndesmotic instability checked after fixation of malleolus
• Consider if fibula fracture > 4 cm above joint line
• Have bone hook on back table to check stability
Syndesmosis
• large or small fragment fully threaded screws, one or two
• Not inserted as lag screw, but as a positioning screw
• May be removed in 6 - 12 weeks
• Bioresorbable screws/Tight rope
Postoperative Care
• Well padded splint immobilization for a few days
• Ice and elevation• Non weight bearing for 6 weeks
• Early conversion to brace and ROM
Thank you