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Radiographic Evaluation, Fixation Principles, and Post-Operative Management of Ankle Fractures

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Radiographic Evaluation, Fixation Principles, and Post-Operative Management of Ankle Fractures Central JSM Foot and Ankle Bringing Excellence in Open Access Review Article *Corresponding author Lisa Zhang, Department of Podiatry, University Hospital, G142. 150 Bergen St. Newark, NJ 07103, USA, Tel: 908- Radiographic Evaluation, 577-2543; Email: Submitted: 15 March 2018 Fixation Principles, and Post- Accepted: 23 June 2017 Published: 25 June 2017 ISSN: 2475-9112 Operative Management of Copyright © 2017 Zhang et al. Ankle Fractures OPEN ACCESS 1 2 Lisa Zhang * and Ritchard Rosen Keywords 1Department of Podiatry, University Hospital, Newark, USA • Fracture blisters 2Department of Podiatric Surgery, Holy Name Medical Center, USA • Neutralization plate • Posterior-antiglide plate • Tension banding Abstract • Direct approach Radiographically, ankle fractures can be evaluated on the anterior-posterior (AP) view • Early weight bearing with the talocrural angle, and on the mortise view, by Shenton’sline, the dime sign, and talar tilt. Displaced fractures > 2 mm, lateral malleolar fractures that are shortened, rotated, or angulated, and bimalleolar and trimalleolar fractures require fixation. Principles of fixation include a proper soft tissue envelope without fracture blisters present at incision sites. Due to the formation of soft callus, fractures should be fixated within the first two weeks of injury. The lateral malleolus is the dominant fracture, and must be pulled out to length, which will pull other ligamentous attachments to proper alignment. Lateral malleolar fixation may be accomplished by a neutralization plate or posterior anti-glide plate; a locking plate may also be used in osteoporotic bone. Medial malleolar fixation can be accomplished by two screw cancellous fixation or tension banding, the latter especially useful in smaller, comminuted fractures. Although 25% articular surface of the tibiotalar joint in posterior malleolar fractures has been traditionally used as a landmark, new literature suggests that proper anatomical alignment and fixation of fragments < 25% may aid in reducing the syndesmosis. Due to the large variability in posterior malleolar fractures on radiographs, CT may be beneficial in preoperative assessment. Posterior malleolar fragments may be fixated through the direct approach with a cancellous screw directed from posterior to anterior. Early weight bearing in a select population of post- operative patients increases ankle range of motion, as well as increases general mental and physical functioning scores. INTRODUCTION Ankle fractures account for 9% of all fractures and as such, [2]. According to Ramsey and Hamilton, 1 mm of talar shift are one of the most common lower extremity fractures [1]. The can result in a 42% decrease in tibiotalar contact. Tibiofibular annual incidence of ankle fractures is between 107 and 184 per overlap from the medial fibula to the lateral border of the 100,000 people [1]. The most common mechanisms of ankle onanterior the mortise tibia should view. It be is lessnoted than by the10 mm(1) talocrural on anterior-posterior angle. A line fractures are falls and inversion/eversion injuries, followed by is(AP) drawn view parallel of the ankle. to the Shorteningarticular surface of the offibula the distalcan be tibia, evaluated and a sports injuries. Ankle fractures are classified by both the Danis- cadaveric studies. The soft tissue should be not overlooked in medialline is drawnangle isperpendicular the talocrural to angle. the first. The Atalocrural second lineangle is shoulddrawn Weber system and Lauge-Hansen system, the latter based on connecting the most distal aspects of the malleoli. The superior- history, and level of activity should all be considered when clinical evaluation. The patient’s age, co-morbidities, smoking Abe second83 +/- 4method degrees. of Two determining degrees of shortening shortening iswhen by evaluatingcompared to that of the contralateral is an indication of fibular shortening. consideringRADIOGRAPHIC surgical fixation EVALUATION of the fracture. (2) Shenton’s line. The contour of the subchondral bone of the A rigorous radiographic analysis should be performed of each ankle fracture. Widening of the medial clear space > 4 mm tibial plafond and tibial subchondral bone of the fibula should be indicates deltoid ligament injury and lateral talar transposition ofa curved, the curve unbroken is noted. line. Proximal With shortening disruption of ofthe this fibula, line aand broken any Shenton line is seen, and proximal migration of the fibular aspect Cite this article: Zhang L, Rosen R (2017) Radiographic Evaluation, Fixation Principles, and Post-Operative Management of Ankle Fractures. JSM Foot Ankle 2(3): 1029. Zhang et al. (2017) Email: Central Bringing Excellence in Open Access [3]. A third method of determining shortening is the (3) dime and by 16 days in hemorrhagic fracture blisters [7]. If an incision sign,divergence in which > 2 mman unbroken indicates rotationcurve connecting and shortening the recess of the infibula the isepithelization made into a isfracture expected blister, by 13 wound days inhealing serous complications fracture blisters, and measurementdistal tip of the of fibula ankle and instability the lateral on theprocess mortise of the view talus is theshould (4) infection may develop. A standard protocol of blister de-roofing talarbe seen tilt, [1].measured If broken, by lines fibular drawn shortening along the is domepresent. of theA fourth talus week.and application In a prospective of Silver study, Sulfadiazine in 47 patients cream with can lower promote extremity re- and tibial plafond. The degree of lateral opening is measured. epithelization allowing surgery to precede with a delay of one These lines should be parallel, or within three degrees of parallel [3]. On the lateral view, a line in the center of the tibia should fractures in which serous and hemorrhagic blisters were de- intersect with the lateral process of the talus. If not seen, this roofed with subsequent application of Silver Sulfadiazine cream, indicates either anterior of posterior displacement of the tibia. with a mean follow-up for 27 weeks, 82.3% (37 of 45) of patients ofhad soft an uncomplicatedtissue injury is post-operative often greater thancourse the and blister healed itself, without and FRACTURES REQUIRING FIXATION incisionskin or woundplacement complications should be made[7]. In with diabetic caution, patients, especially the zonewith hemorrhagic blisters [7]. displacedIsolated < 2non-displaced mm lateral malleolar fibular fractures fractures without with no angulation, talar shift GOALS OF REDUCTION areshortening stable orinjuries rotation can do be not managed require conservatively.fixation. Isolated Isolated mildly length and restoration of the ankle mortise. In a bimalleolar Two goals of reduction are restoration of the fibular displacedfibular fractures or mildly with displaced displacement < 2 mm greater medial thanmalleolar 2 mm fractures or with due to the Vassal Principle. Proper anatomical alignment of doangulation, not require shortening, operative and management. rotation require Bimalleolar fixation. fractures Non- or trimalleolar ankle fracture, the fibula should be fixated first only one break in the ring, such as with an isolated lateral asthe a fibulabuttress, allows keeping the other the talus fractures in the to mortise. align into On placelateral due view, to often require fixation, especially if displaced. When there is evaluationsoft tissue ofand reduction ligamentous of the attachments. posterior spike The is fixed evidence fibula of acts the potentialmalleolar foror isolateddisplacement, medial and malleolar thus, less fracture indication - especially for open if non-displaced, non-shortened, or non-angulated - there is less talusfibula from out toresuming length. itsAccording anatomical to Yablon,position. impingement In 53 patients of with the in the ring as seen with bimalleolar fractures, the potential for lateral malleolus on the proximal fibular fragment prevented the displacementreduction internal exists, fixation thus making (ORIF). surgical However, management with two abreaks more attractive option [4]. If greater than 25% of the articular surface ina bimalleolar which soft tissueankle fracture,interposition anatomic prevented fixation replacement was achieved of the by of the tibiotalar articular surface or a > 2 mm step off is noted, medialplate fixation malleolus of the when lateral the malleolus, lateral malleolus and there was was reduced no instance [8]. Assessment of restoration of the ankle mortise can be assessed then ORIF is traditionally indicated for posterior malleolar byIn pullingradiographic the fibula measurements out to length, of thethe medialankle mortise clear space is restored. <4 mm thatfractures absolute [5]. articularHowever, congruity recent studiesis established. in the Anliterature often missed have advocated for fixing smaller posterior malleolar fractures so posterior (AP) view 1 cm superior to the ankle joint, and talar tiltafter < reduction,10 degrees. tibia-fibula As with all (tib fractures, fib) overlap> the goal 10 mmof rigid, on anterior- internal spacefracture or is syndesmoticthe Maisonneuve diastasis. fracture, Clinical a proximal exam fibular is warranted fracture. Initial ankle films may only show a widening of the medial clear Maisonneuve fracture was not diagnosed in 11.32% (12) of fixationPRINCIPLES and anatomic IN LATERAL reduction should MALLEOLAR be achieved. FIXATION 106with casesexamination [6]. It isof importantthe proximal to obtainfibula. andIn
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