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Pronation-External Rotation Fractures

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Pronation-External Rotation Fractures CHAPTER 24 PRONATION-EXTERNAL ROTATION FRACTURES George S. Gumann, DPM INTRODUCTION needs to be addressed, or reduction of the fibular fracture fails to reduce the ankle mortise. Pronation-external rotation injuries represent the second If the medial malleolus is fractured, it is exposed and the most common pattern associated with ankle fractures. They medial joint space inspected for osteochondral fractures. It is are consistent with the Danis-Weber Type C fracture. 1,2 then anatomically reduced, and can be fixated employing The stages 2,3 of pronation-external rotation fractures are: several techniques. 6-8 If the fracture is large, then two 4.0 Stage I (rupture of the deltoid ligament or fracture of the mm partially-threaded cancellous screws are placed. They medial malleolus); stage II (rupture of the anterior inferior can be either cannulated or non-cannulated. Another tibiofibular [anterior syndesmotic] ligament and the fixation technique if the fracture is osteoporotic, smaller in interosseous membrane); stage III (spiral fracture of the size, comminuted, or if the screws fail to purchase is tension fibula above the level of the syndesmosis); and stage IV band wire. The wire may be placed through a drill hole in (rupture of the posterior inferior tibiofibular [posterior the tibial metaphysis but is more commonly placed over a syndesmotic] ligament or fracture of the posterior malleolus). unicortical hanging screw. If the tibia is osteoporotic, then make sure the hanging screw engages both the medial and STAGE I lateral cortex for increased stability. Two other options for fixation of a smaller sized medial malleolus fracture are Stage I represents injury to the medial structures of the utilizing 1 cancellous screw with adjacent Kirschner-wire or ankle. The foot is in a pronated position at the time of injury employing 2 smaller size cancellous screws. The location of with the leg internally rotating, which produces a relative the incision is changed to the posteromedial aspect of the external rotation of the talus in the ankle mortise. The ankle tibia if there is a fracture involving the posterior aspect of the fracture rotates through a fibular axis. 2-4 Theoretically, this tibia. This allows excellent exposure to the posterior aspect produces either a rupture of the deltoid ligament or a of the tibia. transverse fracture of the medial malleolus. However, an isolated complete rupture of the deltoid ligament probably STAGE II does not occur clinically. If the deltoid is ruptured it is associated with other injured structures involving the Stage II represents injury to the anterior syndesmosis and syndesmosis (diastasis) and fibula (fracture). The transverse interosseous ligament/membrane. 2-4 This is a rare injury and fracture of the medial malleolus represents a pull-off fracture sometimes may only be uncovered by stress external and is usually large. If the medial malleolus fracture is rotation radiographs. In a strictly ligamentous injury, it nondisplaced, then management involves a short-leg cast represents an unstable diastasis. The anterior syndesmotic for 7-8 weeks. An initial period of nonweight bearing injury usually presents as a mid-substance ligamentous for 2-4 weeks may be considered but normally the fracture disruption of the anterior inferior tibiofibular ligament. is relatively stable. However, there can be an osseous avulsion off either the If the fracture is displaced, then operative intervention anterolateral aspect of the tibia (Chaput fracture) or the is considered. The medial injury is easily approached through distal fibula (Wagstaffe fracture). This injury requires a curved incision, which may be placed anteromedially, transydesmotic stabilization (see discussion later). Stage II medially, or posteromedially. Under normal circumstances, can also present with a fracture of the medial malleolus preference is given to a hockey-stick shaped incision placed and a diastasis. along the anterior and inferior aspect of the medial malleolus. This is used to approach both a ruptured deltoid STAGE III ligament or a medial malleolus fracture. It should be noted that not all deltoid ligament ruptures are surgically repaired. 5 Stage III represents a fracture of the fibula above the In the presence of a deltoid ligament rupture, the medial syndesmosis. 2-4 The fracture can occur anywhere from just side is opened when there has been a dislocation of the ankle, above the syndesmosis to the neck of the fibula there is osteochondral damage on the medial talar dome that (Maisonneuve fracture). The fracture configuration is 124 CHAPTER 24 classically described as spiral. It is uncommon for this fracture Should the screw be a positional or a lag screw? What pattern to be non-displaced and usually requires open size screw to use? How many screws should be placed? How reduction and internal fixation (ORIF). The approach and many cortices should be engaged? At what level should they internal fixation varies depending on the location of the be placed? What position should the foot be in when placing fracture. 6-8 If the fracture is in the distal one-third of the the screw? Should the patient be weight bearing or non - fibula, it is approached through a direct incision over weight bearing? Should the screws be removed or left in? the fracture site. The fibular fracture can be spiral or The author’s preference for transyndesmotic fixation is to oblique-spiral in configuration. This fracture pattern employ a 4.5 mm cortical screw without lag technique. On sometimes produces a butterfly fragment. It can also be occasion, a 3.5 mm cortical screw may be used. It is rare that significantly comminuted. a lag screw is employed. The syndesmosis is provisionally held After anatomic reduction, stabilization is performed reduced with a large pointed reduction forceps prior to screw with 1 or more cortical lag screws from anterior to posterior placement. If the fibular fracture has been fixated with a plate, for a spiral fracture followed by application of a one-third then the transyndesmotic screw is placed either through tubular plate for neutralization. The plate can be locking (more commonly) or below the plate depending on the level or non-locking. If the fracture is more oblique in of the fracture. If the fibula was plated, then normally one configuration, then the cortical lag screw is placed through transyndesmotic screw is placed. But if significant instability the plate from lateral to medial. Sometimes, lag screws are is present, 2 screws will be utilized. If the fibula fracture was employed both outside as well as through the plate at the addressed indirectly, then 2 transyndesmotic screws are same time. If there is comminution involving several large always employed. In very osteoporotoic bone or patients with fragments, then these can be incorporated into the diabetes, multiple transyndesmotic screws may be placed in a reduction and stabilized with individual lag screws or held tibia-profibula configuration. The screws are placed in a reduced by the plate. If the comminution is extensive and posterolateral to anteromedial direction and engage 4 the fragments small, then they are left in place and stabilized cortices. The screws are placed with the foot in close to with a plate that bridges the fracture. The only question that neutral position but not dorsiflexed. The weight bearing remains is the stability of the syndesmosis. status is determined by the patient’s circumstances but Theoretically, since the posterior syndesmosis is intact, usually is for 4-6 weeks. The transyndesmotic screws are then anatomic reduction rigid internal fixation of the fibula removed no sooner than 3 months. along with suturing the anterior syndesmotic ligament should produce a stable ankle mortise. There is literature STAGE IV that indicates if the fracture is within 3.5 cm of the syndesmosis, transyndesmotic fixation is not required. 9 The Stage IV presents as a ruptured posterior syndesmotic best advice to give is that every fracture needs to have stress ligament or a fractured posterior malleolus. 2-4 Obviously, the external rotation radiographs performed after reduction and posterior syndesmotic ligament is not repaired. The posterior placement of internal fixation. If there is any indication of malleollar fracture is anatomically reduced and fixated if it instability demonstrated by an increased medial joint space represents 25-30% of the tibial articular surface on the lateral (lateral talar subluxation) or increased syndesmotic interval, radiograph. 6-8,13-15 If the posterior malleolar fracture is large then transyndesmotic fixation needs to be placed. enough to fix, it usually exits near the posterior aspect of Traditionally, this has been accomplished with a positional the medial malleolus. If there is some concern about the screw. 10 Recently, there has been interest in using a button size of the posterior malleolar fracture, then a computed suture technique. 11 tomography scan can be ordered. If the fibular fracture is in the upper one-half of the As indicated previously, if the posterior malleolus needs fibula, the surgical approach is different. The fracture site is reduction, it is usually approached through a posteromedial not exposed because of the muscular coverage or the danger incision. This incision allows good visualization along the of iatrogenic damage to the common peroneal nerve. Here, posterior aspect of the tibia. The fracture can be aligned an indirect approach is performed. An incision is made over employing the cortical margins. If there is an associated the lateral aspect of the ankle. The fibula is pulled distally medial malleolar fracture, it can be retracted inferiorly while internally rotating to gain the proper length and allowing aligment of the articular margins along the rotation. The fracture is provisionally stabilized with a large posterior tibia. The fixation screw is placed from anterior to pointed reduction forceps about the ankle. Transyndesmotic posterior utilizing a cortical lag screw that can be placed stabilization is performed with one or more screws.
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