What is Blocking My Reduction?!

Jason R. Miller, DPM, FACFAS, FAPWCA Director- Pennsylvania Intensive Lower Extremity Fellowship Residency Director- Phoenixville Hospital PMSR/RRA Associate Professor- Adjunct Department of Surgery- Temple University School of Podiatric Medicine Premier Orthopaedics and Sports Medicine, Malvern PA Considerations

Ankle Anatomy Fracture Classifications Fracture management Reduction Techniques Irreducible fracture patterns Soft Tissue Blockade of Reduction Got An Issue, It’s Probably Soft Tissue! Ankle Anatomy

● Medial Malleoli ○ Anterior colliculus ■ Projects more inferior ■ Superficial attachments ○ Posterior colliculus ■ Deep deltoid ligament attachment ■ Posterior tibial tendon directly posterior ○ Intercollicular groove ■ Deep deltoid ligament attachment Ankle Anatomy

● Posterior Malleoli ○ 3rd in a ○ Sits more inferior than the anterior articular surface of the ○ Injured with severe ankle injury ○ Injury due to pull of PITFL Ankle Anatomy

• Ligaments of the ankle stabilize and secure the ankle through the various planes of motion. • Ankle Plantarflexion = Tout ATFL and relaxed CFL. • Ankle Dorsiflexed = Tout CFL and relaxed ATFL. • ATFL and PTFL stabilize talus in sagittal plane • CFL stabilizes talus and STJ in frontal plane • While lateral collateral ligaments are injured frequently in ankle sprains; they are the least injured in ligaments in an ankle fracture. Ankle Anatomy

• Syndesmotic ligaments stabilize the ankle mortise. • RUPTURE = DIASTASIS • Usually for this to occur there is a deltoid injury or medial malleolar fracture. • Allows talus to translate laterally • Deltoids prevent lateral talar excursion Overview of Ankle Fractures Classification Lauge-Hansen/Weber Classifications Classifications Supination - Adduction (I, II) • Medial ⇨ Lateral Pronation - Abduction (I, II, III) • Medial ⇨ Anterior ⇨ Lateral Supination - External rotation (I, II, III, IV) • Anterior lateral ⇨ Lateral ⇨ Post ⇨ Medial Pronation - External rotation (I, II, III, IV) • Medial ⇨ Anterior ⇨ Lateral ⇨ Posterior Muller Medial Malleolar Fractures

Type A: Avulsion of the tip of the medial malleoli Type B: Avulsion at the level of the ankle joint Type C: Oblique fracture Type D: Vertical fracture Maissoneuve

• Fibular neck fracture • Proximal fibular fracture due to external rotation • Energy of rotation transfers through the interosseous ligament and exits at proximal • Requires Syndesmotic fixation Volkmann Fracture

• Fracture of the posterior tibia (posterior malleoli) due to pull of posterior inferior tib-fib ligament. • Requires fixation if greater than 25% - 30% of articular surface involved.

An irreducible ankle- fracture dislocation characterized by the dislocation of the proximal fragment of the fibula posteriorly to the tibial tubercle

Bartoníček J, Rammelt S, Kostlivý K. Bosworth fracture: A report of two atypical cases and literature review of 108 cases. Fuss und Sprunggelenk . 2017;15(2):126-137. doi:10.1016/j.fuspru.2017.02.002. Tillaux Chaput Fractures

Fracture of the anterior lateral tibial epiphysis. Due to external force causing avulsion via the anterior tib-fib ligament. Mostly encountered in children. Wagstaffe (Le Fort) Fracture

Avulsion fracture of anterior margin of distal fibula at the Insertion of anterior Tib-fib ligament. Ankle Reduction Technique Ankle Reduction Technique

Closed Reduction Goals: • Prevent neurovascular compromise • Prevent skin tension/damage • Provide stability for preoperative versus conservative treatment • Pain Reduction Ankle Reduction Technique

Vassal’s Principle: Technique by which if the primary fracture (dominant fracture) is stabilized/reduced, then the secondary fractures reduce/maintain themselves in the reduced position due to the presence of ligamentous & other soft tissue attachments. Ligamentotaxis : Technique where ligaments are placed in sustained longitudinal traction so as to cause the realignment of the fractured fragments. Ankle Reduction Technique

AO Steps For Closed Reduction • Increase deformity • Distal distraction • Reverse mechanism of injury • Splintage

If talus is dislocated then first job is to relocate • Heel and forefoot grasped • Distal traction applied • Depending on Supinatory vs Pronatory injury, the may need to be ext/int rotated or inv/everted to recreate injury • Goal is to Bring talus back under Tib/Fib Ankle Reduction Technique

• Perform Hematoma Block (Rx ativan, flexeril, etc) • Apply 3-4 webrils from toes to tibial crest. • Ensure block/anesthesia is in effect • Apply posterior splint • Grasp toes with one lift and supinate foot • With other hand apply medial to lateral pressure against medial malleolus. If posterior fracture then apply posterior pressure as well. • Wait until fiberglass hardens • Order post reduction x-ray Ankle Reduction Technique

Quigley Maneuver • Apply gauze bandage role (2 inch) around 1st and 2nd toe as shown • Elevate leg 18 inches off the bed • IV ple placed on contralateral side of bed. • Pillow placed between legs to prevent adduction • Suspend for 2-3 mins. (No more than15min) • Can manually reduce more if necessary • Apply splint and apply same force as before Fracture Management Fracture Management

• Fracture fragments displaced greater than 2mm are generally said to require ORIF. • Ankle medial clear space greater than 4mm requires ORIF. • > 4mm indicates lateral subluxation of the talus • 42% decrease in tibiotalar contact occurs with just 1mm of lateral talar displacement (Ramsey et al.). • 2mm of fibular displacement allows 1-2mm of lateral talar subluxation. • A complete disruption of syndesmosis with a disruption of the deltoid ligament causes a 40% decrease in the tibiotalar contact area and a 36% increase in the tibiotalar contact pressures. Fracture Management

● On AP view the distal tibia should overlap the fibula by 10mm (Tib-fib overlap). ● Distance between medial fibula and lateral tibia should be less than 5mm. ● Talocrural angle – normal 83 degrees ± 4 ○ A line parallel to tibial articular surface and a line connecting the tips of the medial and lateral malleoli. Fracture Management

● Shenton’s Line ● Dime sign Fracture Management

• Talar tilt – Normal ≤ 2 mm Fracture Management

AO Principles • Reduce • Stabilize • Preserve blood supply • Early ROM Minor Complications:

• Skin (adhesion, superficial infection, etc) • Tendon (elongation, contracture) • Pain • Sural nerve disturbance Major Complications

• Re-rupture • Deep infection • Deep vein thrombosis [DVT] Irreducible Ankle Fractures Bosworth Fracture

Case report by Ellanti and colleagues from The journal of Emergency Medicine 2013

• 19 yr old M presented to the ED w/ L. sided pain and externally rotated foot subsequent to a fall. • Closed reduction was unsuccessful Radiographs • AP: Weber C lateral Mal fracture • Lateral: Posterior dislocation of the ankle Treatment

• Patient underwent ORIF • Lateral approach • Fibula was not easily visualized through incision • Proximal Fibula shaft firmly positioned behind Tibia. • Fibula levered out from behind Tibia with difficulty Fixation

• 3.5mm Lag screw and Locking compression plate with 2 screw syndesmotic fixation • Immobilized in below knee cast • NWB 6 wks followed by ROM exercise • Pain free at 3 months diastasis screws removed PTT, Retinaculum, Deltoid Ligament and Anteromedial joint capsule interposition Case Report by Stevens and colleagues from The Journal of Foot and Ankle Surgery 2017

• 36yr old M presented to the ED w/ R. sided pain subsequent to a fall. • Closed reduction was unsuccessful Radiographs • AP: PAB type fracture, Lateral subluxation of Talus, widening of the syndesmosis Treatment

• Patient underwent ORIF • Medial side addressed first • PTT noted to be dislocated inside the joint and was removed • PTT retinaculum was ruptured • Superficial and deep deltoid ligaments completely avulsed and their proximal aspect was inside of the joint. • Anteromedial joint capsule displaced inside of the joint. • No significant chondral damage was noted Medial Ankle PTT Entrapment Medial Ankle DL avulsion and Anteromedial Capsule Entrapment Fixation

• 3.5mm Lag screw and ⅓ tubular plate with 2 screw syndesmotic fixation • PTT reduced and retinaculum repaired • Immobilized in below knee cast • NWB 2 wks followed by ROM exercise for next 4 wks • F/U 6 months w/o complications PTT entrapment within Intact Ankle Mortise Case Report by Hunter and Bowlin in the JFAS 2015

● 56 yr old presented to the ED w/ L. ankle injury w/6cm oblique laceration originating 2cm superior to the LM and terminating posteriorly ● Closed reduction was unsuccessful

MRI

● 1.8cm Achilles rupture mid tendon ● 7cm superior to calc tuberosity ● Mildly comminuted intra-articular fracture of the MM. ● Entrapment of PTT Treatment

• Patient underwent ORIF • Incision at the medial Malleolus • MM displaced from posterior aspect • Apex of vertical fracture faced anteriorly with interposition of periosteum • PTT intact/ trapped tightly in fracture site • Achilles tendon ruptured PTT entrapment within MM fragment Fixation

• PTT removed from fracture site w/ tendon sheath reapproximated • MM reduced and fixated w/3 cannulated screws • (-) talar tilt and slight (+) anterior drawer sign. Conservative treatment. • Achilles tendon primary repair • Patient lost to f/u Dislocation due to Tibialis Anterior Subluxation Case report by Natoli and Summers from the JFAS 2015.

• 33 yr old M presented to the ED w/ L. ankle injury subsequent to a fall. • Closed reduction was unsuccessful • LOS to light touch distal plantar surface Radiographs • AP: Transverse fracture of the Proximal lateral Mal and medial malleolus w/ lateral dislocation of the Talus. • Lateral: posterior dislocation of the distal Fibula. Treatment

• Ankle irreducible in the medial direction before incision • Medial approach first to address TA tendon • Curvilinear incision • TA identified posteriorly and trapped around the MM fragment. Fixation

• TA tendon reduced • MM reduced • Fibula, MM and Chaput fragment reduced • Lateral plate w/syndesmotic screw • NWB 10 wks first 6wks in cast • 10.5 mo post op active dorsiflexion to 5 degrees, TA functioning • Normal shoe gear 4.5 mo • Return to work 6.5 mo Conclusion

• Although rare, the possibility of tendon or soft tissue interposition should be considered if the initial closed or open reduction attempts are not successful. • Awareness of these types of injuries can lead to more timely treatment with ORIF, increasing the likelihood of a favorable patient outcome. Citations

8) Lauge-Hansen N. Fractures of the ankle: combined experimental-surgical and experimental roentgenologic investigations. Arch Surg 1950;60:957- 985

12) Bartoníček J, Rammelt S, Kostlivý K. Bosworth fracture: A report of two atypical cases and literature review of 108 cases. Fuss und Sprunggelenk . 2017;15(2):126-137. doi:10.1016/j.fuspru.2017.02.002.

18) Lloyd, J, et al. Revisiting the concept of talar shift in ankle fractures. Foot and Ankle International; Oct 2006, 27 10, p793-p796, 4p.

24) Ellanti, P, Hammad, Y, Grieve, PP. Acutely irreducible ankle fracture dislocation: a report of a Bosworth fracture and its management. J Emerg Med. 2013 May;44(5):e349-52. doi: 10.1016/j.jemermed.2012.11.013. Epub 2013 Jan 26.https://doi.org/10.1016/j.jemermed.2012.11.013

27) Stevens, N, Wasterlain, A, Konda, S. Case Report: Irreducible Ankle Fracture With Posterior Tibialis Tendon and Retinaculum, Deltoid Ligament, and Anteromedial Joint Capsule Entrapment. Jfas. Volume 56, Issue 4, July–August 2017, Pages 889-893. https://doi.org/10.1053/j.jfas.2017.04.004

32) Hunter, Allison M., and Christopher Bowlin. “Posterior Tibial Tendon Entrapment Within an Intact Ankle Mortise: A Case Report.” The Journal of Foot and Ankle Surgery, vol. 54, no. 1, Jan-Feb 2015, pp. 116–119., doi:10.1053/j.jfas.2014.09.028.

36) Roman M.NatoliMD, PhD1Hobie D. Irreducible Ankle Fracture-Dislocation Due to Tibialis Anterior Subluxation: A Case Report. JFAS. Volume 54, Issue 2, March–April 2015, Pages 268-272. https://doi.org/10.1053/j.jfas.2014.11.012 Disclosures

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