Semmelweis UniversityDepartment of Traumatology

Dr. Gál Tamás

Anatomy

Ankle injuries

DIRECT INDIRECT

VerticalCompression(Tibia plafond–Pilon)

AO 43-A,B,C

Suppination (adduction + inversion)AO 44-A

Pronation (abduction + eversion)AO 44-B,C

Ankle injuries

DIRECT

VerticalCompression

(Tibia plafond–Pilon)AO 43-A,B,C

Pilon fractures

AO classification according to the fracture of the tibia

43�A: Extraarticular

�B: Partial articular surface

injury

�C: Total articular surface injury

Tibia pilon fracture treatment 1.

Non-operative treatment:• Non-dislocated fracture – apply cast

• If operation is contraindicated –traction + cast

• No weight bearing for 8-10 weeks

Tibia pilon fracture treatment 2.

Surgical treatment in one session:1.Reconstruction of the fibula2.Reconstruction of the tibia articular

surface3.Autologous bone grafting4.Anteromedial plate fixation

Tibia pilon fracture treatment 3.

Two step surgical treatment� First session

1. Temporary fixation with External Fixation (bridging)2. Plate synthesis of fibula + Tibia External Fixation3. Tibia plafond reconstruction + External fixation4. Shortening (in case of major soft tissue damage or

bone defect)

� Second session7-10 days later autologous bone graft + definitive

surgical stabilization

Tibia pilon fracture treatment 4.

Timing of operation – depends on soft tissue damage

�Open fracture, major soft tissue damage –primary operation within 6-8 hours

�Uncomplicated fracture, no major soft tissue damage – primary, one-step surgery

� In all other cases – postponed definitive reconstruction in multiple sessions or calcaneal traction “Consultant” operation

Pilon AO 43 C2 (no fracture of the fibula)

Screw fixation – articular surface reconstructionno weight bearing for 12-16 weeks

Pilon C3

Plate synthesis of fibula on lateral side –lengthExternal fixation for support on the medial

•Significant soft tissue injury

•High risk of soft tissue loss and infection

•Posttraumatic arthritis

•May require late arthrodesis

Ankle injuries

INDIRECT

Supination (adduction + inversion)AO 44-A

Pronation (abduction + eversion)AO 44-B,C

Supination injuries�Weber A Fracture�Distorsion/strain�Talofibular ligament

rupture/sprainTalocrural sub/luxation

�Chopart joint distorsion�Avulsion fracture of navicular

bone�V. metatarsus base fracture

Ligament injuries

Anterior

Distorsions-sprains

�Physical examination

�RadiographyDiagnosis:

�Arthrography�Stress radiographs

1. Adduction2. Anterior drawer

Talus tilt•Less than 10°= distorsion/strain•10-15°= partial sprain or rupture (usually anterior talofibular lig.)•More than 15°= total rupture

Stress radiography

Painful

Rarely needed for acute injury (no therapeutic consequence)

Still used for to diagnose chronic instability

Treatment of ligament injuries

Strain or sprain?Doesn’t matter, treatment is the same for a

distorsion and talofibular ligament rupture

Can the patient bear weight?

YesEarly rehabilitationNSAID + brace

NoCast splint + thrombosis profilaxis (8-10 days)

Rehabilitation time: 5-6 weeks

Distal joint distorsions/sprains

Chopart, Lisfranc•Physical exam•Radiography (AP and lateral foot, not ankle)Small ligament sprains, sometimes with bone abruptionsTreatment is the same, can the patient bear weightCould be painful for a long time (6-12 weeks)

Fifth metatarsal base avulsion fracture

Insertion of the peroneus brevis tendon Tension band wiring

Ankle fracturesDanis-Weber classification

Supination Pronation

Classification: level of fibula fracture in relation to the syndesmosis

A: below B: at the level of the syndesmosis C: above

(Lauge Hansen is another type of classification based on mechanism of fracture)

Weber A (AO 44-A1, A2, A3)supination

~5%

Level of syndesmosi

s

Weber B (AO 44 – B1, B2, B3)

Pronation•~85%•Pronation mechanism, fibula is fractured AT the level of the syndesmosis•B1: isolated lateral malleolus•B2: lateral malleolar + avulsion medial malleolus or (rupture of deltoid ligament)•B3: lateral and medial and Volkmann triangle (sometimes tuber Chaput)

Weber B

Rupture of the deltoid ligament

Syndesmotic screw

Weber B

Fibula fracture at level of syndesmosis

Avulsion fracture of medial malleolus

Lateral malleolus plate osteosynthesisMedial malleolus tension ban wiring

Weber B with Volkmann triangle fracture

Anterior compression screw

Avulsed posterior edge of tibia

Weber C fractures

�AO type 44 C�Pronation

mechanism�Fractures are

above the syndesmosis

Weber C

Supramalleolar fracture, where the syndesmosis and the interosseus membrane are ruptured

�C 1: Lateral injury only�C 2: Fibula + syndesmosis + medial

malleolus/deltoid ligament�C 3: Subcapital fibula (Maissoneuve),

syndesmosis + interosseus membrane + medial malleolus + Volkmann triangle

Maissoneuve fracture

� Subcapital fracture of the fibula

� Tibia x-ray (below knee)

� The syndesmotic screw is removed after 6-8 weeks

Open fracture Grade III, Weber C

•Open fracture on the medial side•Urgent operation, obtain bacterial culture, antibiotic profylaxis,tetanus toxoid, stable osteosynthesis

Soft tissue injury

Soft tissue swelling, blister formation, skin necrosis…Therefore ORIF is urgent even if the fracture is closed

Late complications

Weber B fracture ORIFposttraumatic arthritis

ankle arthrodesis

Tarsal and metatarsal injuries

� Calcaneus� Talus� …and the rest

(Navicular,Cuboid,

Cuneiform bones)

Calcaneal fractures•High energy, direct trauma. Usually caused by fall from height.•Also called Lover's fracture and Don Juan fracture becausea lover may jump from great heights while trying to escape from the lover's spouse•Look for associated spine injuries•Symptoms:

�Hematoma on sole of foot�Soft tissue swelling

•X-rays – Broden, Zadravecz(AP, lateral, axial directions)

•Calcaneus is a cancellous boneDepressed frx of articular surface

•Goal: reconstruction of articular surface and bone axis, no weight bearing

Böhler’s angle

ORIF

Closed reductionReduction with distracter

Closed reduction and screw fixation

Extra-articular Tongue-type fracture

Achilles tendon

Talar fracturesAvascular necrosisTitanium implants! MRI

Classification:

Hawkins I. NondisplacedHawkins II. Subtalar displacmentHawkins III. Ankle joint displacm.Hawkins IV. Ankle + subtalar +

talonavic. displacm.

AVN

10%

30%90%100%

Titanium screws

MRI follow up

Midfoot and metatarsal injuries

�Direct or Indirect trauma� If direct – associated soft tissue damage�March fracture (stress fracture of

metatarsals) – soldiers, runners, organists, doctors

�Usually non-operative treatment� Immobilization for 6 weeks�Transverse and longitudinal arches!

Special considerations for foot injuries

�Foot skin quality is different than elsewhere

�The skin is potentially contaminated�26 small bones compose the structure and

function of the foot�Direct, high energy trauma is more

common�Foot compartment syndrome

Amputations – only at determined levels

Levels of amputation

1. Toe amputation2. Transmetatarsal?3. Lisfranc, Chopart4. Pirogov / Symes5. BKA – at the proximal-middle third of calf6. AKA – depends on circulation7. Hip exarticulation

Pirogov

Thank you for your attention