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ANKLE INJURIES
praveen reddy p
Surgical anatomy of ankle joint
Saddle shaped joint Three bone joint – tibia, fibula and
talus Tibia - tibial plafond and medial
malleolus Fibula – lateral malleolus Large surface of talar dome
anteriorly and laterally
Continued.. This configuration provides stability in
dorsi flexion and relative mobility in plantar flexion
# DORSI FLEXION - close packed position - stability by articular contact# PLANTAR FLEXION – stability principally by ligamentous structures
TIBIA Lower end formed by five surfaces,
# inferior,anterior,posterior,lateral,medial
` inferior surface is concave antero-posteriorly and convex transversely
` posterior border is lower than the lateral border
` lateral border is concave with two tubercles – anterior and posterior
TIBIA
Anterior tubercle over laps fibula - forms the basis for radiological tibio-fibular syndesmotic assessment
Posterior tubercle remains intact – forms the basis for indirect reduction of posterior malleolar fragment
MEDIAL MALLEOLUS Articular surface is comma shaped Posterior border includes groove for
tibialis posterior Composed of two colliculi seperated by
inter collicular groove Deep component of deltoid attaches to
inter collicular groove Superficial component attaches to
medial and anterior border of anterior colliculus
FIBULA Two major surfaces, medial and lateral which
widen to three surfaces at tibial plafond# anteriorly - ant tibio-fibular - ant talo-fibular
# inferiorly - calcaneo-fibular# posteriorly - post tibio-fibular - post talo-fibular
TALUS
Covered entirely by articular cartilage, no musculo-tendinous attachment
Trapezoidal – ant surface wider than the post surface
LIGAMENTS syndesmotic - ant tibio-fibular - post tibio-fibular – strongest - int-osseous ligament Lateral collateral - ant talo-fibular - calcaneo-fibular - post talo-fibular Deltoid - superficial - deep – primary medial stabiliser
SYNDESMOSIS
LATERAL LIGAMENTS
MEDIAL LIGAMENTS
Patient Evaluation History
Mechanism Time since injury Associated injuries Comorbidities
Diabetes Neuropathy Obesity Alcoholism / drug
abuse
Physical Exam Note obvious deformities Neurovascular exam Pain to palpation of malleoli and
ligaments Palpate along the entire fibula Pain at the ankle with compression
syndesmotic injury Examine the hindfoot and forefoot
for associated injuries
Ankle Injuries type I — Only a
few fibers are stretched or torn, so ankle is mildly tender and painful, but muscle strength is normal.
Ankle Injuries
Type II — A greater number of fibers are torn, so there is severe pain and tenderness, together with mild swelling, noticable loss of strength and sometimes bruising
Ankle Injuries
Type III — The ligaments tear all the way through, rip into two separate parts, there will be considerable pain, swelling, tenderness and discoloration.
Ankle Injuries Sprains / Strains –
80% of sprains are caused by ankle inversion.
Inversion sprains cause damage to the lateral ligaments
RADIOLOGY
OTTAWA ANKLE RULES# x-rays indicated only if ` pain near malleoli ` inability to bear weight ` bony tenderness at the tip of the malleolus or post edge# 100% sensitive, decreased cost and patient waiting time
X - RAYS
On plain x-rays – there is continous condensed sub chondral bone around the talus that extends from sub chondral bone of distal tibia to medial aspect of fibula
X - RAYS
AP and LATERAL MORTISE VIEW STRESS or OBLIQUE VIEW (cobb’s)
A-P VIEW
Tibio-fibular overlap <10mm implies
syndesmotic injury
Tibio-fibular clear space
>5mm implies syndesmotic injury
Talar tilt >2mm is considered
abnormal
MORTISE VIEW
AP view of ankle with foot internally rotated
Abnormal findings: medial joint space
widening tibia/fibula overlap
<1mm
LATERAL VIEW Posterior malleolus
fracture Subluxation of the talus Angulation of distal
fibula Talus fractures Calcaneus fractures
STRESS VIEWS
Demonstrate ligamentous or syndesmotic disruption
May require sedation or hematoma block Comparison with contralateral ankle
LAUGE HANSEN”S
Associates specific fracture patterns with mechanism of injury
Two-term scheme1. Position of foot
Supination (lateral)Pronation (medial)
2. Direction of forceAdduction / abductionExternal rotationDorsiflexion
LAUGE HANSEN”S Genetic classification Six groups of injuries # abduction injuries # adduction injuries # ext rotation injuries with diastasis of inferior tibio-fibular jt - pronation external rotation injuries # ext rotation injuries with out diastasis of inferior tibio-fibular jt - supination external rotation injuries # vertical compression injuries # uncommon unclassifiable injuries
LAUGE HANSEN”S
Continues to form the basis of our understanding of mehanism of injury
Provides good guide to prognosis after both operative and conservative methods
WEBER”S
Type A # below syndesmosis Type B # at the level of syndesmosis Type C # above the level of
syndesmosis
WEBER”S
WEBER”S
Attractive for its simplicity and its guided treatment
Level of fibular fracture exclusively to guide treatment isn’t accurate enough
Degree of syndesmotic injury not always accurately predicted
Ignores medial side of the injury
Surgical technique Standard AO fixation Inter-fragmentary 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 90º 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
ABDUCTION INJURY Talus forcibly abducted in ankle mortise producing traction
on medial structures -
# pull off fracture of medial malleolus or rupture of deltoid
ligament
# lateral compression force produces a lower fibular fracture
with characteristic lateral comminution
# doesnot produce seperation of tibio-fibular jt b’cos
combined strength of three ligaments is greater than lat malleolus
# rarely if associated with vertical compression can cause en-
bloc avulsion of incisura fibularis
DIAGNOSIS
Valgus deformity of foot Swelling over both medial and
lateral aspect
TREATMENT
Undisplaced isolated med malleolus fractures –
# b/k plaster cast for six weeks # rehabilitation
TREATMENT
Displaced / irreducible – due to soft tissue interposition,
# 4mm cancellous screw # T B W # inter-fragmentary
screw
TREATMENT
FIBULA – minimal comminution # b/k cast - severe comminution # 1/3rd tubular plate
ADDUCTION INJURY Traction on the lateral structures # forcible inversion of the plantar flexed foot > ant talo-fibular tear # forcible inversion at right angle > tear of all 3 lateral ligaments or lateral malleolus fracture > compression injury of the medial malleolus causing vertical fracture +/- depression of articular surface
ADDUCTION INJURY - TREATMENT
Isolated tear of ant talo-fibular ligament
# eversion stirrup and elastic bandaging # adhesion formation - pain, weakness, giving way - outer side heel raise - Inj hydrocortisone + hyaluronidase
ADDUCTION INJURY - TREATMENT Complete tear of lateral structures- # talus will move away from
malleolus and well defined sulcus appears between the two bones Marked talar tilt on stress x-rays Can lead to recurrent dislocation if
not treated
ADDUCTION INJURY - TREATMENT
Complete immobilisation in a plaster cast for 6-8 weeks and rehabilitation
Recurrent dislocation – # evan’s
procedure
EX ROTATION INJ WITH INF TIBIO-FIBULAR JT DIASTASIS Also known as PRONATION-EXTERNAL
ROTATION FRACTURE Three types – # isolated fracture of med malleolus # partial diastasis of the inf tibio-
fibular joint # complete diastasis of the inf tibio- fibular joint
EX ROTATION INJ WITH INF TIBIO-FIBULAR JT DIASTASIS
Isolated med malleolus fracture - # b/k plaster cast for 6-8
weeks # ORIF
EX ROTATION INJ WITH INF TIBIO-FIBULAR JT DIASTASIS Partial diastasis of the inf tibio-
fibular jt # reducible – a/k plaster cast in
slightly inverted and firmly int rotated position (fibula winds itself up on the intact post ligament which serves to locate it well in its groove in the tibia – incisura fibularis)
# irreducible – ORIF
EX ROTATION INJ WITH INF TIBIO-FIBULAR JT DIASTASIS
Complete diastasis of the inf tibio-fibular joint
ORIF - post op immobilisation - plaster cast for 6-8 weeks
EX-ROTATION INJ WITHOUT INF TIBIO-FIBULAR JT DIASTASIS
Also known as SUPINATION-EXTERNAL ROTATION FRACTURE
Oblique fracture of the lower fibula Fracture dislocation without inf
tibio-fibular joint diastasis
EX-ROTATION INJ WITHOUT INF TIBIO-FIBULAR JT DIASTASIS
Oblique fracture of the lower fibula # b/k plaster cast application
for 4 weeks
EX-ROTATION INJ WITHOUT INF TIBIO-FIBULAR JT DIASTASIS
Fracture dislocation without inf tibio-fibular joint diastasis
# reduction – cupping back the heel in one hand, gently pull forwards and inwards and at the same time with the other hand apply counter over the
medial side of tibial shaft # ORIF
Operative Tips Lateral Malleolus
Reduce first Proximal fragment (shaft) needs
reduction 3 bicortical screws into proximal fibula Unicortical screws into intra-articular
portion Be certain fibula is out to length
ISOLATED LATERAL MALLEOLAR #
` Reduce & internally fix lateral malleolar # first in case of a bimalleolar #.
` If the # is oblique, fix it with two lag screws 1cm apart.
` If the # is transverse, fix it with a rush rod / IL fibular rod.
` If the # is small & below the plafond and has good bone stock, it is fixed with a 4.5mm malleolar screw. In patients with poor bone stock tension band technique is used.
` If the # is above the syndesmotic level, a small fragment 1/3rd tubular plate or a 3.5mm DCP can be used, If the plate is placed posterolaterally it acts as a antiglide plate.
Operative Tips
Medial malleolus Open reduction Visualize the ‘shoulder’ of the
malleolus Remove interposed soft tissue and
intraarticular fragments Two points of fixation Anti-glide plate for vertical fractures
ISOLATED MED. MALLEOLAR #
` Non displaced #: cast immobilisation.` Avulsion # of the malleolar tip: no fixation required
unless displaced.` Fixation usually requires two 4mm cancellous lag
screws oriented perpendicular to the #.` Vertically oriented # requires horizontally placed
screws.` Smaller fragments require one lag screw & a k-wire to
prevent rotation.` Fragments too small or comminuted are fixed with
tension band technique.` Vertical # extending into metaphysis requires
semitubular buttress plate for fixation.
Medial Malleolus Fixation
Posterior Malleolus Repair if >25% of
articular surface Reduce by ankle
dorsiflexion Clamp through
fibular incision Anterior lag
screws
Maissoneuve Fracture Fracture of
proximal 1/3 of fibula
+/- medial malleolar fracture
Pronation-external rotation mechanism
Requires reduction and stabilization of syndesmosis
Maissoneuve Fracture Fracture of
proximal 1/3 of fibula
+/- medial malleolar fracture
Pronation-external rotation mechanism
Requires reduction and stabilization of syndesmosis
BIMALLEOLAR FRACTURE
` Non union reported in 10% of bimalleolar # treated with closed methods.
` Tile & AO group recommends ORIF of almost all bimalleolar #s.
` Most Weber type B & C lateral malleolar #s are stabilised with plate & screw fixation.
DELTOID LIG.TEAR & LATERAL MALLEOLAR #
` Supination- external rotation injury.` Associated with tear of the anterior capsule.` Stress x-ray with the supinated & externally rotated
shows talar tilting with a widened medial clear space.` 1mm lateral shift of talus reduces the effective wt.
bearing area of the talo-tibial articulation by 20-40%.` Optimal treatment of this injury provided skin condition, patient age & general condition permits, consists of ORIF of fibula with /without deltoid ligament repair.` Lateral malleolar # is fixed before the repair of deltoid ligament.
TRIMALLEOLAR FRACTURE
` Usually caused by abduction or external rotation injury
` Components - medial malleolar #/deltoid lig.rupture, fibular # & # of the posterior lip of the articular surface of tibia` 500 external rotation view - assessment of size &
displacement of posterior malleolar fragment.` Fragment size > 25-30% of the wt. bearing surface requires ORIF` Posterior lip # should be fixed before reduction of
either the medial or lateral malleolar #
SYNDESMOTIC INJURIES
Pronation- external rotation, pronation abduction and supination external rotation injuries.
Syndesmotic injuries extending > 4.5cm proximal to the ankle jt alter the joint mechanics, but that extending < 3cm proximal to the joint dont.INDICATIONS FOR FIXATION:
i. Associated proximal fibular #s for which fixation is not planned and involves a medial injury that cannot be stabilised.
ii. Injuries extending > 5cm proximal to the plafond.
SYNDESMOTIC INJURIES contd.
Normally intraoperative roentgenograms should demonstrate a clear space of < 5mm b/w medial wall of fibula & lateral wall of posterior tibial malleolus.
Fixation of syndesmosis is either with oblique pins or screws inserted trrough the lateral malleolus into the distal tibia.
The screws should be placed through both cortices of fibula & either one or both cortices of the tibia.
Screw position- 2cm proximal to plafond, parallel to the joint surface, 300 anterior, perpendicular to TF jt..
Fixation of Syndesmosis
Fix fibula anatomically
Make sure ankle mortise is reduced
Hold reduction with clamp
Do not lag! ? Large vs. small
fragment screw ? 3 vs. 4 cortices ? Screw removal
Postoperative Care Well padded splint
immobilization Ice and elevation Non weight bearing
for 6 weeks Early weight
bearing possible Early conversion to
brace and ROM
COMPLICATIONS
Mal union
# Can occur with lateral malleolus, medial malleolus or the posterior malleolus.
# Predisposes to late degenerative changes and pain.
COMPLICATIONS contd…
Treatment-
# Lat mall - osteotomy through the # site, fixation with plate
& screws and bone grafting.
# Medial mall - osteotomy through # site & fixation with
malleolar screw & k wire.
# Post mall - if >25% of articular surface involved, osteotomy
through # site, reduction& fixation with k wire & malleolar
screws.
COMPLICATIONS contd…
Non union
# > in conservatively treated patients. # Non union of lat. malleolus < med.malleolus. # Treatment- non union site exposed & ends are freshened , rigidly fixed with a malleolar screw & k wire.
COMPLICATIONS contd…
Sudecks atrophy-
# Characterised by pain, demineralisation,edema,
shiny skin with reduced ROM. # Prevented by early ROM exercises, elevation
of the affected limb. # once the condition has developed – intensive physiotherapy, prolonged elevation & use of sympathetic blocking agents.
COMPLICATIONS contd…
Wound healing
# Plate application over lateral malleolus interferes
with wound healing. # Prevented by meticulous closure of
subcutaneous layer to cover the implant & constant
elevation of the limb for first 5-7 days.
COMPLICATIONS contd…
Infection # Associated with poor closure ,failure to elevate the limb postoperatively # Treatment - leave the implant in situ, dressing to be done regularly. - when the repaired # has united, implant to be removed, debridement under antibiotic coverage & later SSG.
COMPLICATIONS contd…
Fixation failure
# Loosening or backing out of screws usually seen in distal fibula. # Treatment - if screw loosens prior to healing of syndesmotic ligament it should be replaced.
COMPLICATIONS contd…
Degenerative arthritis
# Due to imperfect reduction. # Treatment - if malunion is the cause correct it. - if advanced arthritis
present - arthrodesis.
PILON / PLAFOND FRACTURES (Pilon = Hammer / Plafond = Ceiling)
Reudi & Allgower’s
Type Pathology
1 Undisplaced
2 Displaced with joint incongruity
3 Marked comminution with crushing of the subchondral cancellous bone
Reudi & Allgower’s
Initial treatment
Reduction of any dislocation and covering of exposed wounds if present
Assess neuro-vascular 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
Surgical options1. 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 Fibula # brought out to length and fixed with
plate (DCP) Tibial # exposed and reduced, held with
temporary K-wires – usually 4 main fragments K-wires replaced with interfragmentary
screws and fixed with buttress plate Closure of wounds – tension must be avoided
and if present close deep layers and return later for delayed 1º 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 inter-fragmentary 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)
Summary You WILL see ankle fractures Taken for granted Reduce the mortise anatomically
Fibular length Stable syndesmosis Anatomic reduction and debridement
medially Proper management leads to excellent
outcomes
Thanks for listenin!!!!
thanks for listenin..