Ankle Fractures http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a... Printout from Orthoteers.com website, member id 1969. © 2007 All rights reserved. Please refer to the site policies for rules on diseminating site content. Ankle Fractures Classifications 1. Lauge-Hansen Cadaveric study which relates the fracture pattern to an injury mechanism The first word in the designation refers to the foot's position at the time of injury; the second word refers to the direction of the deforming force. "eversion" is a misnomer; it more correctly should be "external" or "lateral" rotation Type of injury (foot position/direction Pathology of force) Supination/adduction Transverse # of fibula/tear of collateral ligaments - vertical # medial malleolus Supination/eversion (external 1.Disruption of the anterior tibiofibular ligament rotation) 2.Spiral oblique fracture of the distal fibula 3.Disruption of the posterior tibiofibular ligament or fracture of the posterior malleolus 4.Fracture of the medial malleolus or rupture of the deltoid ligament Pronation/abduction 1.Transverse fracture of the medial malleolus or rupture of the deltoid ligament 2.Rupture of the syndesmotic ligaments or avulsion fracture of their insertion(s) 3.Short, horizontal, oblique fracture of the fibula above the level of the joint Pronation/eversion 1.Transverse fracture of the medial malleolus or disruption of the deltoid ligament 2.Disruption of the anterior tibiofibular ligament 3.Short oblique fracture of the fibula above the level of the joint 4.Rupture of posterior tibiofibular ligament or avulsion fracture of the posterolateral tibia Pronation/Dorsiflexion (Pilon) 1.Fracture of the medial malleolus 2.Fracture of the anterior margin of the tibia 3.Supramalleolar fracture of the fibula 4.Transverse fracture of the posterior tibial surface 1 of 5 10/6/2007 10:49 AM Ankle Fractures http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a... 2. AO/ Danis-Weber [Click for Image ] Type Pathology A Avulsion # fibula - shear # of med malleolus B Fibula # at level of syndesmosis - # med malleolus/ tear of deltoid ligament C Fibula # above level of syndesmosis - medial injury + tear of ITFL and interosseous membrane Maissoneuve's fracture Spiral fracture of proximal fibula associated with very unstable ankle injury Bosworth Fracture A lesion described by Bosworth may be the cause of failure to reduce a posterior fracture-dislocation of the ankle. The distal end of the proximal fragment of the fibula may be displaced posterior to the tibia and locked by the tibia's posterolateral ridge; the bone cannot be released by manipulation because of the pull of the intact interosseous membrane. In these cases the fibula is exposed, and a periosteal elevator is used to release the bone; considerable force may be necessary. The fibular fracture then is fixed. 2 of 5 10/6/2007 10:49 AM Ankle Fractures http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a... Bosworth fracture with entrapment of fibular behind tibia. A, Anteroposterior view. B and C, Lateral views. Rationale behind ORIF of ankle fractures Tibiotalar congruency Ramsey and Hamilton (JBJS (B) 1976) showed that a 1mm lateral shift of the talus in the ankle mortice reduces the contact area by 42% Posterior malleolus fracture >33% leads to a significant loss of tibiotalar contact DeSouza (JBJS (A) 1985) showed 90% satisfactory results could be obtained even if up to 2mm of lateral displacement was present Generally Young ORIF if >1mm displacement or >2 o talar tilt Old can accept up to 2mm of displacement Always take into account the ambulatory needs of the patient and judge treatment accordingly Surgical technique Standard AO fixation Interfragmentary screw and 1/3 tubular neutralisation plate for fibula and lag screw fixation for medial malleolus Syndesmosis screw is required if fibula is unstable at end of fixation (engage 3 cortices and ensure the ankle is at 90 o when inserting screw, and that the screw is not lagged) Screw needs to be removed before weight bearing can be commenced Alternative fixation for Type B fractures of the fibula is the anti-glide plate which has been shown to be biomechanically superior to a lateral plate Posterior malleolus fractures need to be fixed if there is > 25% of the articular surface involved. This is often underestimated on lateral radiographs. Post-operative management In studies comparing the effect of early movement vs immobilisation and weight bearing vs non-weight bearing, the conclusion is that there is no difference in the final result whichever regime is used. 3 of 5 10/6/2007 10:49 AM Ankle Fractures http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a... Arthritis Incidence increases with severity of injury Degenerative changes in 10% of anatomically fixed 85% if not adequately reduced - changes apparent within 18 months Klossner "Late results of operative and non-operative treatment of severe ankle fractures" Acta Chir Scand Suppl. 293: 1-93, 1962 Prognosis There is a reduction in the incidence of arthrosis in patients where an anatomical reduction has been achieved (Phillips et al JBJS 67A: 67-78, 1985) Prospective trial shows higher total ankle scores in those that are operatively treated- especially so in those pts more than 50 yrs old PILON / PLAFOND FRACTURES (Pilon = Hammer / Plafond = Ceiling) Reudi & Allgower Classification (Ruedi TP, Allgower M: Clin Orthop 1979;138:105-110) Type Pathology I Undisplaced II Displaced with joint incongruity III Marked comminution with crushing of the subchondral cancellous bone Reudi 4 of 5 10/6/2007 10:49 AM Ankle Fractures http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a... & Allgower classification. (Clin Orthop 1979;138:105-110) Initial treatment Reduction of any dislocation and covering of exposed wounds if present Assess neurovascular status Check for evidence of compartment syndrome Splint fracture which may require temporary skeletal traction Investigations X-ray plus CT Timing of surgery Type II and III - goal is to keep talus centred under the tibia while soft tissue heal over 7 to 21 days Study by M.Sirkin et al 1999, a series of pilon fractures underwent immediate external fixation and ORIF of the fibula, and formal ORIF of the tibial articular surface was performed on a delayed basis (avg. delay 12-13 days); - using this protocol, no patient that presented with a closed injury developed a full thickness skin necrosis and none required secondary soft tissue coverage The historically high rate of infection and skin necrosis following ORIF of these injuries is most related to operative timing - in the study by MJ Patterson and JD Cole (JTO 1999), all patients underwent a two staged technique for the treatment of complex pilon fracture - initially all patients underwent immediate fibular fixation and placement of a medial fixator Surgical options 1. ORIF Medial and anterior incisions with full thickness flaps developed at level of the periosteum. These incisions must be at least 7 cm apart to protect the viability of the intervening skin bridge Steps 1. Fibula # brought out to length and fixed with plate (DCP) 2. Tibial # exposed and reduced, held with temporary K-wires - usually 4 main fragments 3. K-wires replaced with interfragmentary screws and fixed with buttress plate 4. Closure of wounds - tension must be avoided and if present close deep layers and return later for delayed 1 o closure of skin 2. Fine wire fixation with circular frames Using either the Ilizarov or hybrid external fixators This can be combined with limited internal fixation of the tibia using interfragmentary screws and fixation of the fibula 3. Trans-articular external fixation Will align the tibia but will not address the central depression of the joint surface. Useful as first part of 2 -stage procedure (to allow soft tissue management & CT & planning) Outcomes Operative treatment of high-energy pilon fractures will take an average of 4 months to heal 75% of patients that do not develop wound complications may expect a good result Subsequent arthrodesis rate ~ 10% Bourne et al " Pilon fractures of the distal tibia" CORR 240:42-46, 1989 36% satisfactory results in intra artic fracture treated with closed means 76% satisfactory for operative treatment 32% at 4.5 yrs had undergone ankle arthrodesis for failed result Sponsored Links www.biometeurope.com [ Close Window ] 5 of 5 10/6/2007 10:49 AM Ankle Instability http://orthoteers.com/(S(o30paf45azn4qf452py0pc45))/printPage.aspx?a... Printout from Orthoteers.com website, member id 1969. © 2007 All rights reserved. Please refer to the site policies for rules on diseminating site content. Ankle Instability INVESTIGATIONS NON-OPERATIVE TREATMENT OPERATIVE TREATMENT Non-Augmented Augmented Preferred Method Ankle Instability - Q&A - Click to view INVESTIGATIONS [Back To Top] 1. Plain radiography: AP standing, lateral 2. EUA - Stress x-rays under anaesthesia (GA or peroneal block) 3. Arthroscopy - Cook et al found that 25% of patients arthroscoped for instability symptoms had another intra-articular pathology, usually treatable arthroscopically NON-OPERATIVE TREATMENT [Back To Top] Most patients with ankle instability will improve with non-operative rehabilitation. Programme [ Orth Clin N Am.- Jan '94 ] Phase 1: RICE (immobilze in POP for 2-3wks) Phase 2: Strengthening of peroneal & dorsiflexor muscles, stretching of TA. Isometric exercises using furniture or rubber bands. Phase 3: Proprioceptive training. W hen pain & swelling gone. = wobble board exercises. Progress thro functional activities- walking, running, figure-of-eight running, hopping, jumping & cutting. In severe strains protect ankle with pneumatic brace or taping for sports for 3-6mnths. OPERATIVE TREATMENT [Back To Top] Prior to considerations for surgery, ensure that subtalar instability is not present Indications: Failed non-operative management +ve anterior drawer & talar tilt tests clinically stress x-rays tibiotalar tilt > 20 deg. anterior translation > 5mm. Aims: Restore functional stability. Results: A wide variety of reconstructive techniques have had a high degree of success. Most authors report a good or excellent result in 80% to 85% of patients.