ANKLE FRACTURES

POTT’S FRACTURE

Introduction-• Ankle joint is a modified hinge joint. The

socket is formed by the distal articular surface of tibia and fibula, tibio-fibular lig and articular surfaces of the malleoli(mortise). Which articulates with the superior surface of talus.

• Ankle fractures include fractures of the medial and lateral malleoli as well as the distal articular surface of the tibia and fibula.

Anatomy-

Definition-• A Pott’s fracture is a type of ankle fracture that is

characterized by a break in one or more bony prominences on the sides of the ankle known as the malleoli.

• Also known as Broken Ankle, Ankle Fracture and malleolar fracture.

• Pott’s fracture often occurs in combination with other injuries such as a sprained ankle or other fractures of the foot, ankle or lower leg.

Mechanism of Injury-• Twisting injury while

walking,running.• During certain activities such as

landing from a jump,stress is placed on the tibia and fibula.

• Abduction, adduction or external rotation forces

• Sports involving sudden change of direction such as football, soccer, rugby, basketball and netball.

Classification-

1)Ankle fractures can be classsified as unimalleolar(70%) bimalleolar(23%) and trimalleolar fractures(7%)

2)Danis -Weber classification location and appearance of the fibular fracture

3)AO-OTA classification location of fracture lines & degree of comminution also describes the severity and degree of instability associated with fracture pattern

4)Lauge-Hansen classsification mechanism of injury

1)Uni,bi and tri malleolar #’s

2)Danis -Weber classification• Type A- caused by internal rotation and

adduction that produce a transverse fracture of the fibula at or below the plafond, with or without an oblique fracture of the medial malleolus

• Type B- caused by external rotation that results in an oblique fracture of the fibula.

• The injury may include rupture or avulsion of the anteroinferior tibiofibular ligament, fracture of the medial malleolus, or rupture of the deltoid ligament.

• Type C-fractures are abduction injuries with oblique fracture of the fibula proximal to the ankle joint, medial malleolar fracture or a deltoid ligament rupture.

3)AO-OTA classification

4)Lauge-Hansen classsification

Clinical features-

• Pain(sudden onset,sharp intense pain over lower leg/ankle)

• Swelling,bruising• Crepitus• Reduced ROM• Inability to stand/wt.bear• Deformity

Diagnosis- H/O Twisting injury RTA Clinical features Radiological examination- Fracture line of med/lat malleolus Tibio-fibular syndesmosis-lateral subluxation of talus Posterior subluxation of talus

Orthopaedic Treatment-• Basic principal of T/t is to achieve anatomical

reconstruction of ankle-mortise so as to regain good function and minimise possibility of OA developing later.

• Expected time for bone healing- Extraarticular malleolar-6-10wks Itraarticular malleolar-8-12wks

• For stable injuries(undisplaced#)-below knee plaster cast is applied for 3-6weeks

• For unstable injuries(displaced#)-anatomical(closed) reduction and ORIF

ORIFDepending upon the type of fracture-Medial malleolus# • Transverse#- compression screws,tension band wiring• Oblique- compression screws• Avulsion- tension band wiringLateral malleolus#• Transverse-TBW• Spiral-Comp.screws• Comminuted-buttress plating• #lower end of fiblua- 4 hole plate

Post malleolus#• Comp.screwsTibio-fibular Syndesmosis disruption- long

screw from fibula into tibia.

Conservative Method-Reduction by manipulation under GA-Once reduced below knee plaster cast 8-10wks(no wt bear)

Physiotherapy management-• PT for conservatively managed fractures- First week- active MTP ROM’s Second week-MTP ROM’s with quadriceps strengthening exs By 4-6 weeks-cast may be changed to PTB cast-isometrics for

quads, ankle strengthening exs(PF/DF) After 6-8 weeks, cast is removed,active/active assisted ROM’s

for knee,ankle,subtalar and MTP, heel slides calf stretching, static quads and hams Isotonic and Isokinetic Exs for ankle also can be started.After 8-12 weeks self assisted passive ankle movts

• Weight bearing- NWB with 2 pt. crutches By 6-8 weeks- PWB By 8 weeks-full wt bearing

• Post-OP PT management-Phase 1 (upto 6 weeks)Goals: PWB DF to neutral Control edema1. AROMs for ankle,subtalar and MT jts within pain tol. -Ankle pumps -Inv/Evn -toe crunches2. Calf stretching,heel slides3. Elevation for edema4. Static quads and hams5. 2-4 weeks- initiate wt.bearing as tolerated with crutches followed

by PWB

• Phase2(6-8 weeks) Goals: FWB of involed LE >50%AROM all planes Control edema Minimize complications Maintain optimal bone and soft tissue healing1. AROMs2. PROMs in restricted range3. Heel slides4. Calf stretching5. Ankle isometrics6. grade 1-2 mobilization for ankle and subtalar jts.7. Leg curls,leg press8. Wall stretch with KF and KE9. FWB walking- minisquats, standing heel raise,one leg balance on floor,

wobble board exs

• Phase3(>8weeks) Goals: Full AROMs Restore gait on level surfaces,hills,stairs Full return to function1. Cont.Phase2 exs2. Prog.to theraband exs3. Squats and lunges also wobble board exs4. One leg standing with eyes open & eyes closed5. Stair climbing exs6. Agility training

REFERENCES

• Ebneizar• Hoppenfield• Maheshwari