Diagnostics, classification Diagnostics, classification and treatment of malleolar and treatment of malleolar fractures. Pilon fractures.fractures. Pilon fractures.

What are malleolar fracturesWhat are malleolar fractures??

Fractures of the ankle!!!Fractures of the ankle!!!

Anatomy???Anatomy???

What makes up the ankle joint?What makes up the ankle joint?• BonesBones• Soft tissues: ligaments and musclesSoft tissues: ligaments and muscles

BonesBones Distal tibia (plafond Distal tibia (plafond

and medial and medial malleolusmalleolus

Distal fibula (lateral Distal fibula (lateral malleolus)malleolus)

Talus (highly Talus (highly congruent congruent articulation with articulation with plafond)plafond)• Truncated coneTruncated cone

LigamentsLigaments Medial stabilizers: Medial stabilizers:

deltoid ligament (5 components)deltoid ligament (5 components) Lateral stabilizers: Lateral stabilizers:

anterior talofibular ligamentanterior talofibular ligamentposterior talofibular ligamentposterior talofibular ligamentcalcaneofibular ligament calcaneofibular ligament

LigamentLigamentss binding tibia and fibula together: binding tibia and fibula together: anterior and posterior inferior tibiofibular anterior and posterior inferior tibiofibular

ligaments ligaments inferior transverse ligament inferior transverse ligament interosseous ligament (strongest)interosseous ligament (strongest)

Medial stabilizersMedial stabilizers Deltoid Deltoid

ligamentligament• 5 components5 components• Resists Resists

abductionabduction

Lateral stabilizersLateral stabilizers

AAnterior nterior talofibular talofibular ligamentligament

Posterior Posterior talofibular talofibular ligamentligament

CCalcaneofibular alcaneofibular ligament ligament

SyndesmosisSyndesmosis

Anterior Anterior tibio-fibular tibio-fibular ligamentligament

Posterior Posterior tibio-fibular tibio-fibular ligamentligament

Interosseus Interosseus ligamentligament

Malleolar fractures: DiagnosticsMalleolar fractures: Diagnostics

HistoryHistory Clinical examinationClinical examination

• Observation: swelling, pain, deformity, Observation: swelling, pain, deformity, possible hematomapossible hematoma

• Physical examination: comparison of Physical examination: comparison of temperature of both sides (possible temperature of both sides (possible vessel injury)vessel injury)

Radiological examinationRadiological examination CT if necessaryCT if necessary

Malleolar fractures: DiagnosticsMalleolar fractures: Diagnostics Radiological Radiological

examinationexamination• AP and AP and

laterallateral views views• May also use May also use

a 30 degree a 30 degree internally internally rotated viewrotated view (mortise)(mortise)

Malleolar fractures: what to look for Malleolar fractures: what to look for on x-rayon x-ray

Position of lateral and medial anklePosition of lateral and medial ankle Dislocations Dislocations How parallel the surfaces of the tibia and How parallel the surfaces of the tibia and

talus are with regard to one anothertalus are with regard to one another Position of the Weber tip of the lateral anklePosition of the Weber tip of the lateral ankle Unevenness of the talar surface Unevenness of the talar surface

(osteochondral fractures)(osteochondral fractures) Distance between the medial ankle and talus Distance between the medial ankle and talus

(if >4mm and the Weber tip is displaced (if >4mm and the Weber tip is displaced proximally subluxation of the joint is proximally subluxation of the joint is probable)probable)

Classification: Why classify??Classification: Why classify??

Aim of classification is demonstration Aim of classification is demonstration of different types of fractures and of different types of fractures and their organizationtheir organization

Fracture classification aids in Fracture classification aids in determination of the best treatment determination of the best treatment and also gives an idea of fracture and also gives an idea of fracture prognosisprognosis

Should be simple and useableShould be simple and useable

Classification of malleolar fracturesClassification of malleolar fractures

Ankle fractures can be classified purely Ankle fractures can be classified purely along anatomical lines as monomalleolar, along anatomical lines as monomalleolar, bimalleolar, or trimalleolar.bimalleolar, or trimalleolar.

Lauge-Hansen classification takes into Lauge-Hansen classification takes into account the position of the forefoot account the position of the forefoot (pronation or supination) and the direction (pronation or supination) and the direction of the force which causes the fracture of the force which causes the fracture (abduction, adduction, outward rotation).(abduction, adduction, outward rotation).

Weber classification of lateral ankle Weber classification of lateral ankle fractures takes into account the level of the fractures takes into account the level of the fracture in a frontal view (AO classification is fracture in a frontal view (AO classification is similar to this).similar to this).

Lauge-Hansen classificationLauge-Hansen classification Supination-Supination-

adduction injury: adduction injury: with the forefoot in with the forefoot in supination, the force supination, the force acts in a varus acts in a varus direction thus direction thus adducting the foot.adducting the foot.• Transverse avulsion-Transverse avulsion-

type fracture of the type fracture of the fibula below the level fibula below the level of the joint or tear of of the joint or tear of lateral collateral lateral collateral ligamentsligaments

• Vertical fracture of Vertical fracture of medial malleolusmedial malleolus

Lauge-Hansen classificationLauge-Hansen classification Supination-external Supination-external

rotation injury: most rotation injury: most common. Forefoot in common. Forefoot in supination and force in supination and force in direction of external direction of external rotation further stresses rotation further stresses the forefoot.the forefoot.• Disruption of the anterior Disruption of the anterior

talofibular ligamenttalofibular ligament• Spiral oblique fracture of Spiral oblique fracture of

the distal tibiathe distal tibia• Disruption of the posterior Disruption of the posterior

tibiofibular ligament or tibiofibular ligament or fracture of the posterior fracture of the posterior malleolusmalleolus

• Fracture of the medial Fracture of the medial malleolus or rupture of the malleolus or rupture of the deltoid ligamentdeltoid ligament

33

Supination external rotationSupination external rotation

Lauge-Hansen classificationLauge-Hansen classification Pronation-abduction Pronation-abduction

injury: quite common, injury: quite common, besides forced abduction, besides forced abduction, the forefoot is in the forefoot is in pronation.pronation.• Transverse fracture of the Transverse fracture of the

medial malleolus or rupture medial malleolus or rupture of the deltoid ligamentof the deltoid ligament

• Rupture of the syndesmotic Rupture of the syndesmotic ligaments or avulsion ligaments or avulsion fracture of their insertionsfracture of their insertions

• Short, horizontal oblique Short, horizontal oblique fracture of the fibula above fracture of the fibula above the level of the jointthe level of the joint

Pronation-abductionPronation-abduction

Lauge-Hansen classificationLauge-Hansen classification Pronation-external rotation Pronation-external rotation

injury: more rare, forefoot injury: more rare, forefoot in pronation with a forced in pronation with a forced external rotationexternal rotation• Transverse fracture of the Transverse fracture of the

medial malleolus or disruption medial malleolus or disruption of the deltoid ligamentof the deltoid ligament

• Disruption of the anterior Disruption of the anterior tibiofibular ligamenttibiofibular ligament

• Short oblique fracture of the Short oblique fracture of the fibula above the level of the fibula above the level of the jointjoint

• Rupture of the posterior Rupture of the posterior tibiofibular ligament or tibiofibular ligament or avulsion fracture of the avulsion fracture of the posterolateral tibiaposterolateral tibia

Weber and AO classificationWeber and AO classification

Weber A: Fibula Weber A: Fibula fracture below fracture below syndesmosissyndesmosis

AO:AO:• A1: isolatedA1: isolated• A2: with fracture of A2: with fracture of

medial malleolusmedial malleolus• A3: with a A3: with a

posteromedial posteromedial fracturefracture

Weber and AO classificationWeber and AO classification Weber B: fracture Weber B: fracture

of the fibula at of the fibula at the level of the the level of the syndesmosissyndesmosis

AO:AO:• B1: isolatedB1: isolated• B2: with medial B2: with medial

lesion (malleolus lesion (malleolus or ligament)or ligament)

• B3: with a medial B3: with a medial lesion and lesion and fracture of fracture of posterolateral posterolateral tibiatibia

Weber and AO classificationWeber and AO classification Weber C: fracture Weber C: fracture

of the fibula above of the fibula above the level of the the level of the syndesmosis. syndesmosis.

AO:AO:• C1: diaphyseal C1: diaphyseal

fracture of the fracture of the fibula, simplefibula, simple

• C2: diaphyseal C2: diaphyseal fracture of the fracture of the fibula, complexfibula, complex

• C3: proximal C3: proximal fracture of the fracture of the fibulafibula

Treatment of malleolar fracturesTreatment of malleolar fractures With fractures of the ankle, only slight With fractures of the ankle, only slight

variation from normal is compatible with variation from normal is compatible with good joint function:good joint function:• The normal relationships of the ankle mortise The normal relationships of the ankle mortise

must be restoredmust be restored• The weight-bearing alignment of the ankle The weight-bearing alignment of the ankle

must be at a right angle to the longitudinal axis must be at a right angle to the longitudinal axis of the legof the leg

• The contours of the articular surface must be The contours of the articular surface must be as smooth as possibleas smooth as possible

The best results are obtained by The best results are obtained by anatomical joint restorationanatomical joint restoration

Anatomical joint restorationAnatomical joint restoration

Closed manipulation with plaster Closed manipulation with plaster casting (conservative treatment)casting (conservative treatment)

Open reduction and internal fixation Open reduction and internal fixation (operative treatment)(operative treatment)

Conservative treatmentConservative treatment Indications: non-Indications: non-

displaced fractures, displaced fractures, stable fractures (Weber stable fractures (Weber B, pronation-adduction B, pronation-adduction fractures)fractures)

Technique: reduction Technique: reduction using opposite to using opposite to mechanism of injurymechanism of injury

Time: 6-8 weeks cast, Time: 6-8 weeks cast, no weight-bearing for 3 no weight-bearing for 3 weeksweeks

Complications: when Complications: when swelling goes down, swelling goes down, cast becomes loose and cast becomes loose and fracture can re-fracture can re-dislocate. Frequent dislocate. Frequent follow-up is necessary!!follow-up is necessary!!

Operative treatmentOperative treatment Indications: all open Indications: all open

fractures, unstable fractures, unstable fractures, failure of fractures, failure of closed reduction closed reduction (retention?), displaced (retention?), displaced fracturesfractures

If possible, If possible, immediately. If not, immediately. If not, within 12 hours. After within 12 hours. After this, bullae or skin this, bullae or skin necrosis can develop necrosis can develop which further delay which further delay surgerysurgery

Operative treatmentOperative treatment

Osteosynthesis Osteosynthesis of lateral of lateral malleolusmalleolus• Plate and Plate and

screwsscrews• Interfragmental Interfragmental

screw in case of screw in case of diagonal diagonal fracturefracture

Operative treatmentOperative treatment

Osteosynthesis Osteosynthesis of medial of medial malleolusmalleolus• Isolated medial Isolated medial

malleolus malleolus fractures are fractures are rare, look for rare, look for proximal fibular proximal fibular fracture in fracture in these casesthese cases

• Tension band Tension band wiringwiring

• Cancellous Cancellous screwsscrews

Operative treatmentOperative treatment Osteosynthesis of Osteosynthesis of

the Posterior the Posterior malleolus (25-30% malleolus (25-30% of articular of articular surface)surface)• Can often be Can often be

reduced with reduced with closed reductionclosed reduction

• Cancellous screw Cancellous screw introduced from introduced from the ventral surfacethe ventral surface

Operative treatmentOperative treatment Injuries of the syndesmosis:Injuries of the syndesmosis:

• Anterior syndesmosis ligament injuries are Anterior syndesmosis ligament injuries are associated with both pronation and supination associated with both pronation and supination injuriesinjuries

• Instability occurs when the interosseous membrane Instability occurs when the interosseous membrane is lesioned to the level of the lateral malleolar is lesioned to the level of the lateral malleolar fracture (only in Weber C or pronation-external fracture (only in Weber C or pronation-external rotation injuries).rotation injuries).

• Reduction and stabilization of the membrane using Reduction and stabilization of the membrane using temporary pinning or reduction clamp and insertion temporary pinning or reduction clamp and insertion of syndesmotic screw (for anterior syndesmolysis)of syndesmotic screw (for anterior syndesmolysis)

• Reduction and stabilization of the Volkmann Reduction and stabilization of the Volkmann triangle (for posterior syndesmolysis)triangle (for posterior syndesmolysis)

Operative treatmentOperative treatment Syndesmosis lesionsSyndesmosis lesions

• Hard to assess Hard to assess radiographicallyradiographically

• May stabilize if lateral May stabilize if lateral and medial ankle are and medial ankle are fixedfixed

• Cotton test (pull with Cotton test (pull with bone hook bone hook intraoperatively)intraoperatively)

• External rotation External rotation under image under image intensifierintensifier

• Instability: Instability: >1.5->1.5-2.0mm widening or 2.0mm widening or medial clear space > medial clear space > 4mm4mm

Pilon fracturesPilon fractures Pilon fractures Pilon fractures = = Intraarticular Intraarticular

fractures of the distal tibiafractures of the distal tibia Pilon fractures Pilon fractures = =

Extraarticular fractures of Extraarticular fractures of distal tibia which are closer to distal tibia which are closer to joint than the diameter of the joint than the diameter of the tibiatibia

Can be caused by low energy Can be caused by low energy rotational forces or by high rotational forces or by high energy axial compressional energy axial compressional forces (car accidents or falling forces (car accidents or falling from height).from height).

Not frequent: make up about Not frequent: make up about 1% of fractures1% of fractures

Pilon fractures: Mechanism of injuryPilon fractures: Mechanism of injury Relatively less Relatively less malignant fracture if malignant fracture if the injury is indirect, the injury is indirect, small energy and small energy and usually rotational. usually rotational. Less connective Less connective tissue damage, and tissue damage, and dislocation of dislocation of articular surface is articular surface is minimal.minimal.

Fracture is worse if Fracture is worse if high energy, direct high energy, direct trauma with force trauma with force either in axial either in axial direction or as direction or as torsion force. More torsion force. More damage to bone, damage to bone, cartilage and cartilage and connective tissues.connective tissues.

Pilon fractures: DiagnosisPilon fractures: Diagnosis Clinical examination: pain, swelling, loss of Clinical examination: pain, swelling, loss of

function, determine amount of connective function, determine amount of connective tissue damage, circulation, innervationtissue damage, circulation, innervation

X-rayX-ray Doppler sonography (in cases where Doppler sonography (in cases where

circulation is suspect)circulation is suspect) Angiography Angiography Intraoperatively often find other injuries Intraoperatively often find other injuries

like impression fractures, ligament and like impression fractures, ligament and syndesmosissyndesmosis lesions. lesions.

Pay attention to compartment syndrome!!!Pay attention to compartment syndrome!!!

Pilon fractures: ClassificationPilon fractures: Classification

2 important classifications:2 important classifications:• AO classificationAO classification• Rüedi-Allgöwer classificationRüedi-Allgöwer classification

Pilon fractures: AO classificationPilon fractures: AO classification Type A: extraarticular distal Type A: extraarticular distal

tibial fractures subdivided tibial fractures subdivided into A1, A2, A3 depending on into A1, A2, A3 depending on amount of metaphyseal amount of metaphyseal comminutioncomminution

Type B: partial articular Type B: partial articular fractures in which a portion of fractures in which a portion of the articular surface remains the articular surface remains in continuity with the shaft; in continuity with the shaft; subdivided into B1, B2, B3 subdivided into B1, B2, B3 depending on the amount of depending on the amount of articular impaction and articular impaction and comminutioncomminution

Type C: complete Type C: complete metaphyseal fractures with metaphyseal fractures with articular involvement; articular involvement; subdivided into C1, C2, C3 subdivided into C1, C2, C3 depending on extent of depending on extent of metaphyseal and articular metaphyseal and articular comminutioncomminution

Pilon fractures: Rüedi-Allgöwer Pilon fractures: Rüedi-Allgöwer classificationclassification

Type I: non-displaced Type I: non-displaced cleavage fractures cleavage fractures that involve the joint that involve the joint surfacesurface

Type II: have Type II: have cleavage-type fracture cleavage-type fracture lines with lines with displacement of the displacement of the articular surface but articular surface but minimal comminutionminimal comminution

Type III: are Type III: are associated with associated with metaphyseal and metaphyseal and articular comminutionarticular comminution

Pilon fractures: tissue damagePilon fractures: tissue damage

At time of injury in pilon fractures, At time of injury in pilon fractures, often soft tissues are seriously often soft tissues are seriously damageddamaged

Pressure to skin, abrasions, bullae, Pressure to skin, abrasions, bullae, and variable degrees of open injuries and variable degrees of open injuries can occurcan occur

Pilon fractures: TreatmentPilon fractures: Treatment Treatment is usually difficult due to Treatment is usually difficult due to

the fact that the injury is usually the fact that the injury is usually caused by high energy forces that caused by high energy forces that lead to serious cartilage, bone and lead to serious cartilage, bone and soft tissue damagesoft tissue damage

The aim of treatment is painless, The aim of treatment is painless, complication-free, bony healingcomplication-free, bony healing

It should be pointed out that in It should be pointed out that in some cases injuries are so serious some cases injuries are so serious that treatment is limited to the that treatment is limited to the prevention of septic complications prevention of septic complications and the preparation of a situation and the preparation of a situation where arthrodesis is possible.where arthrodesis is possible.

Restoration of the articular surface, Restoration of the articular surface, stable osteosynthesis and early stable osteosynthesis and early mobilization decrease the risk of mobilization decrease the risk of post-traumatic arthrosispost-traumatic arthrosis

Pilon fractures: conservative Pilon fractures: conservative treatmenttreatment

The only time conservative The only time conservative treatment is utilized in pilon fractures treatment is utilized in pilon fractures is when operative treatment is is when operative treatment is absolutely contraindicatedabsolutely contraindicated

In theory, non-displaced or displaced In theory, non-displaced or displaced but reducable fractures can be but reducable fractures can be treated conservatively.treated conservatively.

Conservative treatmentConservative treatment

Plaster castingPlaster casting• Following reduction cast reaches the top Following reduction cast reaches the top

of the thighof the thigh• No weight-bearing for 6 weeksNo weight-bearing for 6 weeks• Cast remains for 12-16 weeks but in Cast remains for 12-16 weeks but in

some cases can change cast to PTB some cases can change cast to PTB (patella tendon bone) cast in the 6-8th (patella tendon bone) cast in the 6-8th week depending on the fracture.week depending on the fracture.

Conservative treatmentConservative treatment

TractionTraction• Following reduction we put a Steinman Following reduction we put a Steinman

nail into the calcaneus and pull the limb nail into the calcaneus and pull the limb with 3kgs weightwith 3kgs weight

• Traction uses ligamentotaxis to help Traction uses ligamentotaxis to help reductionreduction

• After 3 weeks the patient is put in a cast After 3 weeks the patient is put in a cast without weight-bearing and the cast is without weight-bearing and the cast is kept on for 8-16 weekskept on for 8-16 weeks

Pilon fractures: operative treatmentPilon fractures: operative treatment

Open reduction internal fixationOpen reduction internal fixation Closed indirect reduction and Closed indirect reduction and

external stabilizationexternal stabilization Minimal invasive osteosynthesisMinimal invasive osteosynthesis External fixatorExternal fixator

63 year old male patient63 year old male patient

Operative treatmentOperative treatment

49 year old male patient49 year old male patient

After treatmentAfter treatment

Thrombosis prophylaxisThrombosis prophylaxis Functional treatmentFunctional treatment

Thank you for your attentionThank you for your attention