ANKLE FRACTURE

DR. Rahmatullah

EPIDEMIOLOGY :

Highest incidence in elderly women Incidence – 187 per 1 lakh people per

year Isolated malleolar fractures – 66 % Bi malleolar fractures – 25% Tri malleolar fractures – 5 to 10% Open fractures – 2% Incresed BMI is a risk factor.

ANATOMY Complex hinge joint with complex ligamentous system• The plafond is concave in AP plane & convex in Lateral plane• Plafond is wider anteriorly to allow for congruency with the wedge

shaped talus• Talar dome is trapezoidal, with anterior aspect 2.5 cm wider than

posterior talus Chaput's tubercle: insertion site of anterior tibiofibular ligament

on the anterolateral tibia Wagstaffe's tubercle: insertion site of anterior tibiofibular

ligament on the anterior fibula Volkmann's tubercle: tibial insertion of posterior tibiofibular

ligament at the posterolateral aspect of tibia Anterior colliculus: located at anterior, inner aspect of medial

malleolus distally, Insertion site of deltoid ligament. Larger than posterior colliculus Posterior colliculs: located at posterior, inner aspect of medial

malleolus distally, Insertion site of deltoid ligament.

LIGAMENTS

SYNDESMOTIC LIGAMENT COMPLEX : Exists between distal tibia & fibula Composed of 1) Anterior Inferior TibioFibular Ligament 2) Posterior Inferior TibioFibular Ligament

– thicker & stonger 3) Transverse TibioFibular Ligament 4) Interosseous Ligament

LIGAMENTS SYNDESMOTIC LIGAMENT COMPLEX

DELTOID LIGAMENT

SUPERFICIAL PORTION : 3 ligaments originates from anterior colliculus1) Tibionavicular Ligament2) Tibiocalcaneal Ligament3) Tibiotalar Ligament – most prominent DEEP PORTION : Originates on inter collicular groove and

posterior colliculus1. Deep ant talotibial Ligamen2. Deep post talotibial Ligament

DELTOID LIGAMENT

FIBULAR COLLATERAL LIGAMENT

Not as strong as medial complex

1)Ant Talofibular Ligament-weakest of lat ligaments2) Post Talofibular Ligament-strongest of lat ligaments3)Calcaneofibular Ligament- Stabilises subtalar joint &

limits inversion- Rupture of this ligament

causes POSITIVE TALAR TEST

Ottawa ankle rules These rules are used to determine

the need for radiographs in patients with an ankle injury.

Ankle X-ray series are only required in case of:

Bone tenderness along the distal 6 cm of the posterior edge of the fibula or tip of the lateral malleolus.

Bone tenderness along the distal 6 cm of the posterior edge of the tibia or tip of the medial malleolus.

Inability to bear weight for 4 steps both immediately and in the emergency department

RADIOGRPHYAP VIEW

Tibiofibular overlap should be>10mm

Tibiofibular clear space <5mm

Talar tilt : difference in width of medial & lateral aspect of the superior joint space should be <2mm .

LATERAL VIEW

The dome of talus should be centered under the tibia & congruous with tibial plafond

Posterior tuberocity # & avulsion # of talus can be identified

MORTISE VIEW Taken with foot in 15-20 degrees of

internal rotation that is perpendicular to intermalleolar axis

Medial clear space should be equal to superior clear space, should be <4mm, >4mm is abnormal & indicates lateral talar shift

Talocrural angle : angle subtended between the inter malleolar line and a line parallel to the distal tibial articular surface - 8 to 15 degrees.

- should be within 2 to 3 degrees of un injured ankle.

Tibiofibular overlap should be > 1mm, <1mm is syndesmotic injury

Talar shift >1mm is abnormal Tibiofibular clear space should

< 6mm

BIOMECHANICS

Normal ROM – dorsiflexion : 30 & plantar flexion – 45 degrees

Minimum of 10 degree of dorsiflexion & 20 degree of plantar flexion are required for normal gait

Axis of ankle flexion runs between 2 malleoli, which is externally rotated 20 degrees

Lateral talar shift of 1mm will decrease surface contact by 40%, & 3mm shift results in >60% decrease

Disruption of syndesmotic ligaments results in decreased tibiofibular overlap & lateral talar shift

CLINICAL EVALUATION

Swelling, tenderness, variable deformity from a limp to non ambulatory.

Check for Neurovascular status & extent of soft tissue injury

Squeeze test – positive in high ankle sprains, syndesmotic injuries

Dislocated ankle should be reduced & splinted immediately

CT scan- specially for plafond #s MRI –for ligament, cartilage, tendon injuries BONE SCAN – for occult #, continued pain after

injury

LAUGE-HANSEN (ROTATIONAL ANKLE FRACTURE) CLASSIFICATION

Takes into account 1) the position of the foot at the time of

injury 2) the direction of deforming force Based on cadaveric studies Patterns may not always reflect clinical

reality

SUPINATION-ADDUCTION DEFORMITY

10-20% of malleolar # Only type asso with

medial displacement of talus

STAGE-I : Transverse avulsion # fibula (or) Rupture of talofibular ligament

STAGE-II : - Vertical medial malleolus #

-Transverse distal fibula # -Medial plafond impaction

SUPINATION-EXTERNAL ROTATION

40-70% of malleolar # occurs with this mech.

STAGE-I : Disruption of ant tibiofibular lig +/- avulsion #

STAGE- II: Spiral # of distal fibula

STAGE- III: Disruption of post tibiofibular lig (or) # of post malleolus

STAGE- IV: Transverse avulsion # of medial malleolus (or) rupture of deltoid ligament

PRONATION-EXTERNAL ROTATION

5-20% of malleolar # STAGE- I : Transverse

medial malleolus # (or) rupture of deltoid ligament

STAGE- II : Disruption of ant tibiofibular lig +/- avulsion #

STAGE- III : Spiral # distal fibula at/above the level of syndesmosis

STAGE- IV : Disruption of post tibiofibular lig (or) avulsion # of posterolateral tibia

PRONATION-ABDUCTION

5-20% of malleolar # STAEGE- I : Transverse

fracture of medial malleolus (or) rupture of deltoid lig

STAGE- II : Rupture of syndesmotic lig (or) avulsion # with medial injury

STAGE- III : Transverse/laterally comminuted # fibula with medial injury

DENNIS-WEBER CLASSIFICATION Based on the level of fibular # The more proximal, the greater risk of

syndesmotic disruption & instability type A

below level of the ankle joint Tibio fibular syndesmosis intact Deltoid ligament intact Medial malleolus often fractured usually stable : occasionally requires ORIF

type B at the level of the ankle joint, extending superiorly

and laterally up the fibula tibiofibular syndesmosis intact or only partially

torn, but no widening of the distal tibiofibular articulation

medial malleolus may be fractured or deltoid ligament may be torn

variable stability type C

above the level of the ankle joint tibiofibular syndesmosis disrupted with widening

of the distal tibiofibular articulation medial malleolus fracture or deltoid ligament

injury present unstable : requires ORIF

Maisonneuve fracture - Ankle AP

1 - Disruption of the medial ankle joint with small bone avulsion

2 - Disruption of the distal tibio-fibular syndesmosis

No fibular fracture is visible at the ankle raising the suspicion of a proximal fibular fracture

Spiral fracture of the proximal fibula

It is a pronation & external rotation injury

CURBSTONE # : Avusion fracture of posterior tibia is produced by a trippling mechanism

LEFORTE – WAGSTAFFE # : -Anterior fibular tubercle avulsion fracture by anterior tibiofibular

ligament -Associated with Lauge-Hansen SER type # THILLAUX – CHAPUT # : - Anterior tibial tubercle avulsion fracture by anterior tibiofibular

ligament - Counter part of Leforte-Wagstaffe # VOLKMANNS TRIANGLE: -Bony avulsion of posterior tibiofibular ligament from the tibia HERSCOVICI CLASSIFICATION of medial malleolar fractures. A - tip avulsions (anterior colliculus) B - intermediate C - level of plafond D - above plafond (adduction fractures) Posterior colliculus fracture : - the fragment is nondisplaced because of stabilisation by posterior tibial & flexor digitorum longus tendons - supra malleolar spike clearly seen on external rotation views .

TREATMENT Emergency room : -Dislocated ankles should be reduced immediately. If reduction fails , go for

urgent surgical reduction - open wounds, abrasions cleansed & dressed - fracture reduction for displaced fractures - splint application STABLE FRACTURES Ankles with perfect position of the talus and with no medial swelling and

tenderness are considered to be stable, follow-up x-ray 1 week after injury to ensure there is no displacement.

if talus is perfectly centered but medial swelling and tenderness, take stress x-rays.

- If there is no sign of talar shift, the ankle is considered to be stable. removable walking boot or short-leg cast for 6 wks with crutches but bear

weight as tolerated Sport activity limitation for 3 months

Nonoperative short-leg walking cast/boot

indications - isolated nondisplaced medial malleolus fx or tip avulsions- isolated lateral malleolus fx with < 3mm displacement and no talar shift- posterior malleolar fx with < 25% joint involvement or < 2mm step-off

OPERATIVE : open reduction internal fixation

indications- any talar displacement - displaced isolated medial malleolar fx- displaced isolated lateral malleolar fx

bimalleolar fx and functional bimalleolar fracture- posterior malleolar fx with > 25% or > 2mm step-off- Bosworth fracture-dislocations (distal fibula # with posterior

dislocation of proximal fibular fragment behind posterior tibial tubercle )open fracturesTECHNIQUE :

- goal of treatment is stable anatomic reduction of talus in the ankle mortise

- 1 mm shift of talus leads to 42% decrease in tibiotalar contact area- OUTCOMES :- overall success rate of 90%

prolonged recovery expected (2 yrs to obtain final functional result) - worse outcomes with: smoking, decreased education, alcohol use,

increased age, presence of medial malleolar fracture- ORIF superior to closed treatment of bimalleolar fxs- in Lauge-Hansen supination-adduction fractures restoration of

marginal impaction of the anteromedial tibial plafond leads to optimal functional results after surgery

Isolated Medial Malleolus Fx Nonoperative short leg cast

indications - nondisplaced fracture - tip avulsion fractures

Operative ORIF If they are displaced, thick periosteum usually folds into the

fracture site leading to nonunion. indications

- any displacement or talar shift technique

- lag screw fixation lag screw fixation stronger if placed perpendicular to fracture line

- antiglide plate with lag screw best for vertical shear fractures

- tension band fixation utilizing stainless steel wire Used when fragment is small & in osteroporotic fragments Adverse effect - posterior tibial tendon irritation

Pearls and Pitfalls of Medial Malleolar Fixation

4.0 mm partially threaded screws work well for most patterns

Screws should be perpendicular to the fracture line and parallel for maximal compression

Spread two screws for good stability Ignore or excise small anterior colliculus fractures Use fluoroscopy to be sure screws are clear of the joint Beware supination adduction patterns with vertical

fracture lines and impacted medial dome fragments Oblique fractures of posterior colliculus involve posterior

lip of the tibia. - On the AP x-ray- double profile of the medial malleolus. - better visualized on a slightly externally rotated AP x-ray

Isolated Lateral Malleolus Fx Nonoperative short leg cast

indications - intact mortise,- no talar shift, - < 3mm displacement

Operative ORIF

indications - if talar shift or > 3 mm of displacment- can be treated operatively if also treating an ipsilateral

syndesmosis injury Techniques :

- open reduction and plating - intramedullary retrograde screw placement- isolated lag screw fixation

ORIF LATERAL MALLEOLUS Most commonly fixed with one third tubular plate 3 types of plate orientations : lateral, posterolateral, posterior Avoid screw impingement on talofibular articular surface in lateral

plating Posterior fibuar plating conditions : when # is more distal, dislocation is

posterior, osteopenic bone - distal part of plate provides buttress & stabilise # even without

distal screws - provides maximum stability - m/c disadvantage of posterior antiglide plating – peroneal irritation if

the plate is too distal when # is long, oblique, non comminuted - isolated lag screw fixation Intra medullary screw or rod fixation : - more limited approach - particularly difficult in SER type #s Severly comminuted fibula #s : seen in Pronation-Abduction injuries - if asso with MM #, first fix MM that stabilises talus which reduces

fibula - Bone grafting is not necessary - the position of the talus in the mortise should be used as the ultimate

guide to accurate position of the distal fibula.

Pearls and Pitfalls in lateral malleolus fixation

Avoid injuring the superficial peroneal nerve with anterolateral incisions

Make sure the distal fibula is fully out to length Laterally comminuted pronation abduction patterns

are most difficult For maximal stability place a plate posterior Consider the location of syndesmosis fixation when

placing a fibular plate Test the syndesmosis after lateral malleolar fixation Beware in short distal segments, elderly patients

with osteopenic bone, diabetics

COMBINED PROCEDURES

For bimalleolar or trimalleolar fractures Fix the fibula fracture before reducing

and fixing the medial malleolus. When the fibula is laterally comminuted

and the medial malleolus fracture is large, we reduce and fix the medial malleolus fracture first.

posterior malleolar evaluation and possible reduction and fixation as the last step in ankle fixation.

AVOID RISKS

The superficial peroneal nerve is at risk during the lateral approach to the fibula.

The sural nerve lies posterior to the fibula, and during a posterolateral approach to the fibula, it should be identified and protected

The deep peroneal nerve, the anterior tibial artery and branches of the superficial peroneal nerve are at risk when small incisions are made for front-to-back posterior malleolar fixation

Functional Bimalleolar Fx (deltoid tear with fibular fracture)

- small increase in the medial clear space and valgus sag of the talus might be apparent

- The talus is narrowest posteriorly leading to increased space in the mortise in plantar flexion.

- absence of the deltoid allows the talus to rotate externally, technique

- not necessary to repair medial deltoid ligament- only need to explore it if you are unable to reduce the mortise- Interposition of the deltoid ligament is one potential cause of

residual talar shift , but very unusual.- The clinical outcome of these ankle fractures is not improved

by suturing the deltoid ligament

POSTERIOR MALLEOLUS #

External rotation lateral x ray view & CT scan are choice Increased rotation and posterior subluxation of the talus with

positive posterior drawer test but have little effect on stability in inversion or eversion

Trimalleolar fractures are known to have a worse prognosis than bimalleolar fractures (23).

Large posterior malleolar fractures lead to poorer outcomes Approach : direct ( posterior to anterior) indirect (anterior to posterior) most important factor in reducing and stabilizing the

posterior malleolus is accurate stable fixation of the associated fibular #

In trimalleolar #, first fix MM, LM & then fix post malleolus When the fibula is reduced, the posterior malleolus is often

nearly reduced, and the talus is centered After fibular fixation check posterior drawer test for posterior

stability

Rx of posterior malleolus Non operative : short leg cast

indications - < 25% of articular surface involved

evaluation of percentage should be done with CT, as plain radiology is unreliable

- < 2 mm articular stepoff OPERATIVE : ORIF

indications- > 25% of articular surface involved

> 2 mm articular stepoff- ipsilateral syndesmosis injury

technique use posterolateral or posteromedial approach to the ankle joint to reduce

and place fixation decision of approach will depend on fracture lines and need for fibular

fixation can use anterior to posterior lag screws to capture fragment (if

nondisplaced)- syndesmosis injury

stiffness of syndesmosis restored to 70% normal with isolated fixation of posterior malleolus (versus 40% with isolated syndesmosis fixation)

stress examination of syndesmosis still required after posterior malleolar fixation

posteroinferior tibiofibular ligament may remain attached to posterior malleolus and syndesmotic stability may be restored with isolated posterior malleolar fixation

Bosworth Fracture-DislocationOverview rare fracture-dislocation of the ankle where the

proximal fibula fragment becomes entrapped behind the posterior tibial tubercle and becomes irreducible

posterolateral ridge of the distal tibia hinders reduction of the fibula

Operative open reduction and fixation of the fibula

indicated in most cases Open Ankle Fx Operative

emergent operative debridement and ORIF external fixation

SYNDESMOTIC INJURY Associated Syndesmotic Injury Overview

suspect injury in all ankle fractures most common in Weber C fracture , L-H pronation type & AO

type C pattern. fixation usually not required when fibula fracture within 4.5 cm

of plafond Higher fibula fractures >4.5cm result in syndesmotic widening

despite internal fixation of the fibula fracture and require syndesmotic fixation

When there is a proximal fibula fracture and the talus is shifted or when the talus is shifted without a fibula fracture, there is always a syndesmosis injury with instability

Radiographically, syndesmosis instability should always be suspected when fibula fractures are above the level of the ankle mortise

Stress x-rays : ankle in the mortise position with external rotation force

Pronation-abduction injuries completely tear the entire syndesmosis and lead to greater instability than external rotation injuries

Evaluation : measure clear space 1 cm above joint

it has also been reported that there is no actual correlation between syndesmotic injury and tibiofibular clear space or overlap measurements

lateral stress radiograph has more reliability than an AP/mortise stress film

best option is to assess stability intra operatively with abduction /external rotation stress of dorsiflexed foot

the decision to fix or not to fix the syndesmosis must be individualized in each case and preferably should be based on direct stress testing of syndesmosis integrity after internal fixation of other structures.

instability of the syndesmosis is most in the anterior-posterior direction

in the absence of a deltoid injury, fixing the syndesmosis is unnecessary, and if a medial malleolar fracture is securely fixed restoring the deltoid ligament, despite complete disruption of the syndesmosis, tibial fibular fixation is not needed (Boden SD, Labropoulos PA, McCowin P, et al.)

OPERATIVE Rx OF SYNDESMOSIS syndesmosis screw fixation

- indications widening of medial clear space tibiofibular clear space (AP) greater than 5 mm tibiofibular overlap (mortise) narrowed any postoperative malalignment or widening should be treated with

open debridement, reduction, and fixation - technique

length and rotation of fibula must be accurately restored open reduction required if closed reduction unsuccessful or

questionable one or two cortical screw(s) 2-4 cm above joint, angled posterior to

anterior 20-30 degrees lag technique not desired maximum dorsiflexion of ankle not required during screw placement

(can't overtighten a properly reduced syndesmosis) SER injury that shows mild syndesmosis diastasis, a single three-

cortex 3.5-mm screw is sufficient, In Maisonneuve's proximal fibula fracture with complete disruption

of the syndesmosis without a medial malleolus fracture, fixing the syndesmosis will provide the entire stability of the ankle

- postoperative screws should be maintained in place for at least 8-

12 weeks must remain non-weight bearing, as screws are not

biomechanically strong enough to withstand forces of ambulation

- controversies 3 or 4 cortices (3 – motion between tibia, fibula & 4-

stable fixation) 3.5 mm or 4.5 mm screws implant material (stainless steel screws, titanium

screws, suture, bioabsorbable materials) need for hardware removal no differences seen in hardware breakage,

loosening, or removal at 1 year

Pearls and Pitfalls of Syndesmosis

Use syndesmosis fixation when the medial clear space widens on intraoperative stress views after the fibula is fixed

The fibula must be accurately reduced to the tibia in all views including the lateral

Use a 4.5-mm four cortex screw if the patient will weight bear postoperatively

Do not remove syndesmosis screws before 3-4 months postinjury

Achieve a perfectly symmetric tibiotalar clear space Use syndesmosis fixation only without fixing the fibula

fracture when it is above the midfibula Overcompressing the syndesmosis by applying a screw with

the ankle in plantar flexion or using a compression technique should be avoided

BIO ABSORBABLE IMPLANTS Polyglycolide or polylactide implants have been used most

commonly Advantages : eliminating the need for hardware removal,

decreasing irritation over prominent screws and plates, and allowing for gradual stress transfer from the implant to bone.

used as screws for the fibula, syndesmosis, and the medial malleolus

Polylactide implants have excellent MRI compatibility wound infection rate has been reported to be similar to that

seen with metallic implants Chance of redisplacement – 0.9% with simple ankle # - 8.2% with complex unstable ankle fractures A local inflammatory granulomatous reaction to polyglycolide

has been reported in 4% to 50% of malleolar fractures, in the 3rd or 4th postoperative month, is culture negative, that contains polyglycolide debris

Polylactide implants degrade at a much slower rate than polyglycolide implants

longer time to degrade significantly decreases the rate of reaction to these implants

COMPLICATIONS

NONUNION – m/c in medial malleolus MALUNION – due to lateral malleolus shortening & external

rotation WOUND PROBLEMS INFECTIONS POST TRAUMATIC ARTHRITIS REFLEX SYMPATHETIC DYSTROPHY – rare, minimised by

anatomical restoration of ankle & early return of function COMPARTMENT SYNDROME OF LEG, FOOT TIBIOFIBULAR SYNOSTOSIS – asso with use of syndesmotic

screw, usually asymptomatic LOSS OF REDUCTION – in 25% of unstable # treated non

operatively LOSS OF ANKLE ROM

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