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Ankle Fractures Classification and Management
- 1. Presenter: Dr. Ravi Moderator – Dr. H.S. Selhi 5/12/2018
- 2. Ankle fractures – 10 % of all fractures 2nd most common lower limb fractures after hip fractures Mean age of injury 45 years Low energy injury- simple fall/sports 5/12/2018
- 3. Ankle is a three bone joint composed of the tibia , fibula and talus Talus articulates with the tibial plafond superiorly , posterior malleolus of the tibia posteriorly and medial malleolus medially Lateral articulation is with malleolus of fibula 5/12/2018
- 4. Ankle joint - saddle-shaped Dome - wider anterior than posterior Ankle dorsiflexes- external roatation fibula to accommodate this widened anterior surface of the talar dome The tibiotalar articulation is considered to be highly congruent such that 1 mm talar shift within the mortise decreases the contact area by 42 % 5/12/2018
- 5. 5/12/2018 3 groups of stabilizing ligament complexes • MEDIAL • LATERAL • SYNDESMOTIC 2 OUT OF 3 COMPLEXES SHOULD BE INTACT FOR THEANKLE TO BE STABLE
- 6. 1) LATERAL anterior talofibular ligament (ATFL)-WEAKEST calcaneofibular ligament (CFL) posterior talofibular ligament (PTFL).-STRONGEST -limit ankleinversionand prevent anterior and lateral subluxationof the talus 5/12/2018
- 7. 2. MEDIAL LIGAMENT COMPLEX SUPERFICIAL(little contribution to stability) >Tibionavicular ligament >Tibiocalcaneal ligament >Superficial tibiotalar ligament DEEP( primary medial stabilizer) >Intraarticular >Deep tibiotalar lig. -stabilize the joint during eversion and prevent talar subluxation -20-50% stronger than lateral ligaments 5/12/2018
- 8. Medial talar tubercle Navicular tuberosity Anterior colliculus Sustentacular tali 5/12/2018
- 10. • Axial, rotational & translational stability. 1- ANTERIORTIBIOFIBULARLIG. 2- POSTERIOR TIBIOFIBULARLIG. 3- TRANSVERSETIBIOFIBULARLIG. 4- INTEROSSEUS LIG. 3.SYNDESMOTIC LIGAMENT COMPLEX 5/12/2018
- 12. Swelling, echymosis, deformity management of these fractures depends upon careful identification of the extent of bony injury as well as soft tissue and ligamentous damage. the key to successful outcome following rotational ankle fractures is anatomic restoration and healing of ankle mortise. 5/12/2018
- 13. Otawa ankle rules X-raysare required if there is bony painin the malleolar zone AND anyone of the following: • Age > 55 yrs • Inability to bear weight • Bone tenderness over the posterior edge or tip of either malleolus. validated and found to be both cost effective and reliable (up to 100% sensitivity) 5/12/2018
- 14. • Plain Films AP & Lateral views of the ankle Mortise view - 15 degree internal rotation Full length radiograph of leg when tenderness of proximal fibula Foot films when tender to palpation 5/12/2018
- 15. An initial evaluation of the radiograph should 1st focus on •Tibiotalar articulation and access for fibular shortening •Widening of joint space •Malrotation of fibula •Talar tilt 5/12/2018
- 16. Identifies fractures of ◦ malleoli ◦ distal tibia/fibula ◦ plafond ◦ talar dome ◦ body and lateral process of talus ◦ calcaneous Ap view 5/12/2018
- 17. Tibiofibular clear space Tibiofibular overlap 5/12/2018
- 18. 5/12/2018
- 19. On the anteroposterior view, Important note fibular (lateral) malleolus is longer than the tibial (medial) malleolus. Even minimal displacement or shortening of the lateral malleolus allows lateral talar shift to occur and may cause incongruity in the ankle joint, possibly leading to posttraumatic arthritis. 5/12/2018
- 20. Quantitative analysis ◦Tibiofibular overlap ◦< 1 0 m m is abnormal - implies syndesmotic injury ◦Tibiofibular clear space ◦> 5 m m is abnormal - implies syndesmotic injury ◦Talar tilt ◦> 2 m m is considered abnormal Comparison with radiographs of the normal side if there are unresolved concerns of injury 5/12/2018
- 21. Taken with ankle in 15 degrees of internal rotation Useful in evaluation of articular surface between talar dome and mortise 5/12/2018
- 22. Medial clear space ◦ Between lateral border of medial malleous and medial talus ◦ <5mm is normal ◦ >5mm suggests lateral shift of talus ◦ The joint spaces medial and superior to talus should be equal5/12/2018
- 23. Recess in distal fibula lateral process of talus FIBULAR LENGTH: 1.Shenton’s Line of the ankle 2.The dime test5/12/2018
- 24. 5/12/2018 TALOCRURAL ANGLE : - Approximately 83 degrees and symetrical with contalateral ankle Assesment of fibular length
- 25. •Posterior mallelolar fractures •AP talar subluxation •Distal fibular translation &/or angulation •Associated or occult injuries –Lateral process talus –Posterior process talus –Anterior process calcaneus 5/12/2018
- 26. The ankle is a ring ◦ Tibial plafond ◦ Medial malleolus ◦ Deltoid ligaments ◦ calcaneous ◦ Lateral collateral ligaments ◦ Lateral malleolus ◦ Syndesmosis Fracture of single part usually stable Fracture > 1 part = unstable 5/12/2018
- 27. • Stress Views – Gravity stress view – Manual stress views 5/12/2018 When radiographs of the ankle are normal, stress views are extremely important in evaluating ligament injuries .
- 28. Inversion stress view. (A) For inversion (adduction)-stress examination of the ankle, the foot is fixed in the device while the patient is supine. The pressure plate, positioned approximately 2 cm above the ankle joint, applies varus stress adducting the heel. (If the examination is painful, 5 to 10 mL of 1% Xylocaine or a similar local anesthetic is injected at the site of maximum pain.) (B) On the anteroposterior film, the degree of talar tilt is measured by the angle formed by lines drawn along the tibial plafond and the dome of the talus. The contralateral ankle is subjected to the same procedure for comparison. This angle helps diagnose tears of the lateral collateral ligament5/12/2018
- 29. The anterior-draw stress film for determining injury to the anterior talofibular ligament Values of up to 5 mm of separation between the talus and the distal tibia are considered normal between 5 and 10 mm may be normal or abnormal, and the opposite ankle should be stressed for comparison. Values above 10 mm always indicate abnormality. 5/12/2018
- 30. 5/12/2018 CT- Posterior malleolar fracture pattern Joint invovement Pre operative planning MRI – ligament and tendon injuries syndesmosis injury
- 31. • Classification of ankle fractures • Pott classification – Unimalleolar • bimalleolar • timalleolar. • Dennis-weber and AO/OTA classifications • Lauge-hansen classification 5/12/2018
- 32. 5/12/2018 Dennis –weber classification describes the injury based on the location of lateral malleolar fracture A- below the level of syndesmosis B- at the level of syndesmosis C- above the level of syndesmosis Does not predict the level or presence of syndesmotic injury Does not address the presence of injury to medial side of ankle Does not provide robust prognostic information Good interobserver reliability
- 33. 5/12/2018 AOclassification divides the three Danis Weber types further for associated medial injuries Infrasyndesmotic=44A Transsyndesmotic=44B Suprasyndesmotic=44C v
- 37. Based on cadaveric study it employs 2 words and a number • First word: position of foot at time of injury • Second word: force applied to foot relative to tibia at time of injury Number refers to the progression through stages of bony and soft tissue injury 5/12/2018
- 38. 5/12/2018 Types: Supination External Rotation Supination Adduction Pronation External Rotation Pronation Abduction
- 39. In each type there are several stages of injury • Imperfect system: – Not every fracture fits exactly into one category – Even mechanismspecific pattern has been – questioned – Inter and intraobserver variation not ideal Still useful and widely used 5/12/2018
- 40. Advantage • useful for reconstructing the mechanism of injury a guide for the closed reduction • Sequential pattern –inference of ligament injuries complicated, variable inter observer reliability doesn’t signify prognosis doesn’t indicate stability 5/12/2018 Disadvantage
- 41. 5/12/2018
- 42. 1 3 2 4 Stage 1 Anterior tibio- fibular ligament Stage 2 Fibula fx Stage 3 Posterior malleolus fx or posterior tibio- fibular ligament Stage 4 Deltoid ligament tear or medial malleolus fx5/12/2018
- 43. Lateral Injury: classic posterosuperioranteroinferior fibula fracture Medial: Stability maintained Standard: Closed management5/12/2018
- 44. Lateral Injury: classic posterosuperioranteroinferior fibula fracture Medial Injury: medial malleolar fracture &*/or deltoid ligament injury Standard: Surgical management 5/12/2018
- 45. GOAL: TO EVALUATE DEEP DELTOID [i.e. INSTABILITY] Medial tenderness, swelling, echymosis STRESS VIEWS- GRAVITY OR MANUAL 5/12/2018
- 46. SER-2 Negative Stress view External rotation of foot with ankle in neutral flexion (00) + Stress View Widened Medial Clear Space SE-4 5/12/2018
- 47. • Stage 1: fibula fracture is transverse below mortise. • Stage 2: medial malleolus fracture is classic vertical pattern. 1 2 5/12/2018
- 48. Lateral Injury: transverse fibular fracture at/below level of mortise Medial injury: vertical shear type medial malleolar fracture BEWARE OF IMPACTION 5/12/2018
- 49. • Important to restore: – Ankle stability – Articular congruity- including medial impaction 5/12/2018
- 50. 5/12/2018
- 51. Stage 1 Deltoid ligament tear or medial malleolus fx Stage 2 Anterior tibio-fibular ligament and interosseous membrane Stage 3 Spiral, proximal fibula fracture Stage 4 Posterior malleolus fx or posterior tibio- fibular ligament34 1 2 5/12/2018
- 52. Medial injury: deltoid ligament tear &/or transverse medial malleolar fracture Lateral Injury: spiral proximal lateral malleolar fracture HIGHLY UNSTABLE…SYNDESMOTIC INJURY COMMON 5/12/2018
- 53. • Must x-ray knee to ankle to assess injury • Syndesmosis is disrupted in most cases – Eponym: Maissoneuve Fracture • Restore: – Fibular length and rotation – Ankle mortise – Syndesmotic stability 5/12/2018
- 54. Stage 1 Transverse medial malleolus fx distal to mortise Stage 2 avulsion fx of tubercle of chaput or tibio-fibular ligament Stage 3 Fibula fracture, typically proximal to mortise, often with a butterfly fragment 1 2 3 5/12/2018
- 55. Medial injury: tranverse to short oblique medial malleolar fracture Lateral Injury: comminuted impaction type distal lateral malleolar fracture 5/12/2018
- 56. Function: Stability- prevents posterior translation of talus & enhances syndesmotic stability Weight bearing- increases surface area of ankle joint 5/12/2018
- 57. • Fracture pattern: – Variable – Difficult to assess on standard lateral radiograph • External rotation lateral view • CT scan 5/12/2018
- 58. Type I- posterolateral oblique type Type II- medial extension type Type III- small shell 67 % 19 % 14 % 5/12/2018
- 59. FUNCTION: Stability- resists external rotation, axial, & lateral displacement of talus Weight bearing- allows for standard loading 5/12/2018
- 60. • Maisonneuve Fracture – Fracture of proximal fibula with syndesmotic disruption 5/12/2018
- 61. 5/12/2018 • Volkmann Fracture – Fracture of tibial attachment of PITFL – Posterior malleolar fracture type
- 62. 5/12/2018 • Tillaux-Chaput Fracture – Fracture of tibial attachment of AITFL
- 63. In the Pott fracture, the fibula is fractured above the intact distal tibiofibular syndesmosis, the deltoid ligament is ruptured, and the talus is subluxed laterally 5/12/2018 Pott fracture
- 64. Dupuytren fracture. (A) This fracture usually occurs 2 to 7 cm above the distal tibiofibular syndesmosis, with disruption of the medial collateral ligament and, typically, tear of the syndesmosis leading to ankle instability. (B) In the low variant, the fracture occurs more distally and the tibiofibular ligament remains intact. 5/12/2018
- 65. Wagstaffe-LeFort fracture. In the Wagstaffe-LeFort fracture, the medial portion of the fibula is avulsed at the insertion of the anterior tibiofibular ligament. The ligament, however, remains intact. 5/12/2018
- 66. •Collicular Fractures –Avulsion fracture of distal portion of medial malleolus –Injury may continue and rupture the deep deltoid ligament I POSTERIOR COLLICULUS NTERCOLLICULAR GROOVE ANTERIOR COLLICULUS 5/12/2018
- 67. 5/12/2018 •Bosworth fracture dislocation –Fibular fracture with posterior dislocation of proximal fibular segment behind tibia
- 68. 5/12/2018 Initialmanagement • Reducethe talus • If joint unstable - slab • other options -spanning external fixator , calcaneal pin traction. • Rest,Ice, elevation
- 69. 5/12/2018 Closed reduction and immobilization • Stableankle fractures • Usually with only fibulafractures • Immobilization in castfor 4-6weeksis the preferred treatment.
- 70. 5/12/2018 Indications of surgery Inability to obtain or maintain an anatomic mortise (unstable fracture pattern) Open fractures
- 71. LateralMalleolarfractures 5/12/2018 • Avoidinjuring the superficial peronealnerve • Makesurethat distal fibula isfully out to length • Laterallycomminuted pronation abduction patterns aremostdifficult • Formaximum stability placeplateposteriorly
- 72. Medialmalleolarfixation 5/12/2018 • 4.0mmpartially threaded screws • Screwsshouldbe perpendicular to the fracture line andparallel for maximal compression. • Spreadtwo screwsfor goodstability • Usefluoroscopy to besurescrewsare clearof the joint
- 73. Deltoidligamenttear 5/12/2018 • Thedeltoid ligament, especially its deep branch isimportant to the stability of the ankle becauseit prevents lateral displacement and external rotation of thetalus • Xray will show displacement and tilting ofthe talus with increased medial clearspace • It isrepaired with nonabsorbablesutures.
- 74. 5/12/2018 SyndesmosisFixation • Syndesmotic instability after fixation of malleolus • Consider if fibula fracture >4 cm above joint line & Maisonneuve’s fracture • Havebone hook on back table to checkstability
- 75. Complications following ankle fractures 5/12/2018 EARLY :- wound infection/ dehiscence loss of reduction thromboembolism LATE: - symptomatic hardware osteoarthritis nonunion compartment syndrome neuroma
- 76. 5/12/2018