ankle fractures lecture · ankle fractures posterolateral approach 4/19/2016 34 maissoneuve...
TRANSCRIPT
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Orthopaedic Trauma Association
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Ankle Fractures
Resident Comprehensive Fracture Course
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Introduction
Ankle fractures are extremely commonTreated by a wide
variety of surgeonsComplex injuryNot just “intern’s case”
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Introduction
Ankle Fractures
High-Energy Pilon Fractures
Low-Energy Pilon Fractures
Atypical Ankle
Fractures
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Physical Examination
Swelling/ecchymosis
Pain over syndesmosis
Neurovascular exam pulses
neuropathy
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Anatomy
Bony Structures
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Anatomy
Ligamentous structures Lateral ligaments ATFL
PTFL
CFL
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Anatomy
Ligamentous structures Medial ligaments Deltoid
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Imaging – What’s Normal
• Symmetric mortise
• Fibular length
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Imaging – What’s Normal
• Tibiofibular clear space (AP & mortise)– <6mm
• Tibiofibular overlap– > 6mm or ~40%
fibular width (AP)
– > 1mm (mortise)
• Medial clear space
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Classifcation
Weber
Lauge-Hansen
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Imaging
Radiographs
Ankle 3 views
Need Tib-fib films
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Imaging
Stress radiographs?
Tornetta JBJS 2004
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ImagingWeight Bearing radiographs
Is the fracture unstable under physiologic loads?
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Initial Treatment
Need to reduce dislocations!
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Advanced Imaging CT
Good for posterior malleolar fractures
MRI?
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Instability
Loss of normal anatomical relationships at rest or under physiologic loading
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Decision Making
Stable
Conservative Tx4/19/2016 18
Medial Malleolar Fractures
Nondisplaced fractures may be treated nonoperatively
Displaced fractures Isolated ?? ORIF
Part of bimalleolar pattern ORIF Horizontal (tension) compression
Vertical (shear) antiglide plate
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Medial Malleolus
Screw Fixation Standard 2 screws Solid
Cannulated
Fully threaded
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Other compression options for medial side
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Medial Malleolus Plate Fixation Vertical fracture patterns
Additional stability
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Lateral Malleolus Fractures Nonoperative management
2-3 mm displacement NO medial widening or
syndesmotic injury Cast or boot
immobilization 6 wks WBAT Follow closely!
Stress view to ensure no medial injury ???
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Lateral Malleolus Traditional Lateral Approach Relatively safe (sup. peroneal n.)
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Implant ConsiderationsLateral Side
One-third tubular “neutralization” plate
laterally “antiglide” plate posteriorly
3.5 LCDCP on shaft
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Other options forlateral side
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Posterior Malleolar Fractures
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Posterior Malleolus
> 25% rule
Based on nothing Fix if ANY posterior
subluxation
A P or P A
Prone position very helpful
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Posterior Malleolus Controversial topic
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Methods of Fixation
Screws Antegrade
Retrograde
Plate
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Ankle Fractures Posteromedial approach Through floor of PT, FDL
Supine or prone
Symptomatic HWR
Allows for fixation of medial malleolus
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Ankle Fractures Posteromedial approach
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Ankle Fractures Posterolateral approach Prone Also allows for ORIF medial
malleolus
Larger fragments
ORIF fibula through same approach
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Ankle Fractures Posterolateral approach
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Maissoneuve Fracture
Fracture of proximal fibula
+/- medial malleolar fracture
Pronation-external rotation
Requires reduction and stabilization of syndesmosis
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Maissoneuve Fracture
Fracture of proximal fibula
+/- medial malleolarfracture
Pronation-external rotation
Requires reduction and stabilization of syndesmosis
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Anatomy Fibula relation to tibia
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Anatomy
Ligamentous structures Syndesmotic ligament AITFL
PITFL
ITL
IOM
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Syndesmosis Fixation
MUST test for Syndesmoticinstability after fixation of lateral malleolus
Have bone hook on table to check stability, Cotton Test
Syndesmosis Controversies
1 vs. 2 screws
3.5 vs. 4.5 screws
4 cortices vs. 3
Two hole plate
Tightrope
No Difference!
The key is the REDUCTION !!
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Special Considerations
Diabetics/Neuropathy Need more & bigger fixation
Prolonged NWB
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Diabetics/Neuropathy
Diabetics/Neuropathy Alternative Treatments
Increased risk of complications
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Aftercare
Splint x 2weeks
Boot at 2wks to allow ROM
Weightbearing a 6-8 wks in Boot May consider brace for simpler patterns
Brace and therapy at 10 weeks May consider therapy sooner for stiffness
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Summary
Mutliple factors play into determining ORIF
Select best technique/incision for fixation on an individual basis
Goal is to provide stability and articular reduction
Be respectful and humble