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Ankle Injuries
Ankle injuries fall into the same basic categories asdo all athletic injuries:
• Contusions•
Sprains• Strains• Fractures
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85% of all ankle sprains involve some plantar flexion of the ankle and
inversion of the foot
!he remaining "5% consist of eversion mechanisms #hich are often theresult of an outside force such as being fallen on from the outside
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Lateral aspect of the joints of the right ankle region
1- anterior inferior tibio bular ligament2- anterior oblique capsular reinforcement3- talonavicular ligament4- dorsal cuboideonavicular ligament5- t e t!o limbs of t e bifurcate ligament"- dorsal calcaneocuboid ligament#- e$tensor digitorum brevis
%- cervical ligament&- anterior talo bular ligament1'- lateral talocalcaneal ligament11- calcaneo bular ligament12- posterior intermalleolar ligament13- posterior talo bular ligament14- posterior talocalcaneal ligament
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!he s$ndesmosis ligament is often also injured#ith an eversion force f the tibia and fibula
spread on the talus& the ankle mortise isdisrupted and the ankle can become ver$unstable t is also not unusual to see anassociated fibula fracture #ith an eversionmechanism 'see x(ra$s belo#) Assessment of as$ndesmosis sprain #ill be difficult for theinitial *+ to +8 hours f the ankle is ,uites#ollen and edematous assessment of as$ndesmosis sprain ma$ be difficult until the
pain and s#elling have isolated to individualareas or x(ra$s sho# some spreading of theankle mortise
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-istal Fibula fracture #ithassociated medial deltoid ligamentdisruption !his injur$ is fre,uentl$the result of the foot being planted
#ith a valgus load applied to theleg
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.otice the disruption of the medialdeltoid ligament and the #idening
bet#een the medial malleolus andthe talus !his is indicative of aruptured deltoid ligament
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Ankle dislocation #ith no fractures !his takes ahigh degree of trauma and force n this case this#as generated as the result of a high flip off of a
trampoline and impact #ith the ground !he ankle#as in a plantar flexion and inverted position upon
impact !his #as an open dislocation
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Ankle Sprains
• *ost common at letic injur)+ 25, of allinjuries+
• e risk of ankle sprains varies !it t esport – 21-53, basketball. 1#-2&, soccer. 25, volle)ball+
• Ankle sprains account for 1', to 15, of alllost pla)ing time
• e medial malleolus is s orter t an t elateral mallelous so t ere is naturall) moreinversion t an eversion+
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Ankle Sprains• /reater inversion increases t e potential for over-
stretc ing of t e lateral ligaments+• *ost sprains involve t e lateral ligaments from
e$cessive inversion+• 0eltoid ligament is sprained less often 25, of
ankle sprains• f t e lateral ligments. t e A is sprained t e
most often follo!ed b) t e 6• 7prains ocur most often !it t e foot in plantar
8e$ion and inversion+
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Ankle 7prains
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Classification of Sprains
• 1st 0egree9 – Stretching of t e A – little or no edema – tenderness – maintain function+
• 2nd 0egree – Partial tear of t e
A and:or 6
– moderate edema – some function loss
• 3rd 0egree – Complete tear A .6 . and:or ;
– total loss of function – signi cant edema
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Ankle Sprains by Grade
Sign/symptom Grade I Grade II Grade III
Tendon
Loss of functional ability
Pain
Swelling
Ecchy osis
!ifficulty bearing weight
No tear
"ini al
"ini al
"ini al
#sually not
$o
Partial tear
So e
"oderate
"oderate
%re&uently
#sually
Complete tear
Great
Se'ere
Se'ere
(es
Al ost always
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tta!a rules
• nnecessar)=-ra)s9 costl).timeconsuming. and possible ealt risk
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• =-ra)s are onl) required if t ere is bon)pain in t e malleolar ?one A@0 an) oneof t e follo!ing9
• 1 B enderness along t e distal "cmof t e posterior edge of t e tibia
• 2 B enderness along t e distal "cm
of t e posterior edge of t e bula• 3 B Inabilit) to bear !eig t
immediatel) after injur) and in t e (C
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Treat ent
• AAFP (see table 3)• R.I.C.E.• Ice for 20 minutes on and 20 minutes off for the first
two hours.• After that, 20 min intervals over the next 48-72
hours,•
Compression wrap with donut or horse shoes to fillin gaps around malleolus from 24-36 hours; after48-72 hours contrasts baths with ROM exercises for4 minutes in warm and 1 min in ice water.
http://www.aafp.org/afp/980201ap/wexler.htmlhttp://www.aafp.org/afp/980201ap/wexler.htmlhttp://www.aafp.org/afp/980201ap/wexler.htmlhttp://www.aafp.org/afp/980201ap/wexler.html
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Achilles Tendonitists
• 6auses – Capidl) increasing training
eDort
– Adding ills or stair climbingto training – 7tarting too quickl) after a
la)oD – ;oor foot!ear
– ($cessive pronation – ig t posterior leg muscles
• If left untreated. it ma)progress to a completerupture+
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Ac illes endon Cupture
• *ost frequentl) ruptured tendon• 6omplete ruptures are due to
eccentric loading during abruptstopping. landing from a jump+
• >suall) a popping sound iseard !it a complete tear+
• ere ma) or ma) not be anobvious gap 2 to " cm from t ecalcaneus attac ment+
• reatment ma) or ma) notinclude surger) but bot requireimmobili?ed for 3 mont s+
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Plantar Fasciitis
• e plantar fascia runs from t e calcaneus to t emetatarsals+
• is tig t band acts like a bo! string to maintain t earc of t e foot+
• ;lantar fasciitis refers to an in8ammation of t eplantar fascia+
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;lantar asciitis
• In8ammation isusuall) due torepeated trauma to
! ere t e tissueattac es to t ecalcaneus+
• e trauma results inmicroscpic tears att e calcaneusattac ment site+
• is ma) produce ealspurs
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;lantar asciitis
• ;ain is !orse in t emorning or after a
period of inactivit)• 6auses
– Eig arc
– ($cessive pronation – oot!ear !orn out. stiD – Increase in intensit)
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Ankle Exercises
• 6alf stretc• 7oleus stretc• Cesisted dorsal
and plantar8e$ion
• Eeel raises
• 7tep-up• Fump rope
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A@G ( CA6 >C(
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(;I0(*I /H
• *ost ankle fractures are isolatedmalleolar fractures 2:3
•
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•
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CA0I /CA;EH
• tta!a Ankle rules 1'', sensitivit)for detecting ankle fractures
• ;ain near malleoli
• Age J 55 )ears• Inabilit) to bear !eig t•
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CA0I /CA;EH
• 7tandard A;. ateral vie!s• *ortise vie!9 = ra) beam parallel to
trans malleolar a$is;atient )s leg internal) rotated to 15
degrees
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CA0I /CA;EH
• = ra) measurements of alignmentand stabilit)9
• alo crural angle• Angle subtended b) line dra!n parallel to
articular surface of distal tibia and oneconnecting tip of bot malleoli
• 4 to 11 degrees• An) diDerence of 2-3 degrees to opposite
side is abnormal and indicates bulars ortening
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CA0I /CA;EH
• *edial clear space•
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CA0I /CA;EH
• ibio bular clearspace9
• 7)ndesmosis injur)•
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6 A77I I6A I @7
• ;ott )s9 Anatomical• *ono malleolar•
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A>/(- EA@7(@6 A77I I6A I @
• Associates speci c fracture patterns !itmec anism of injur)
• 7upination ($ternal rotation "',
• 7upination Adduction 2',• ;ronation ($ternal rotation and ;ronation
abduction 2',
• 1 st !ord- oot position at time of injur)• 2 nd !ord- 0irection of deforming force on
talus
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A>/(- EA@7(@6 A77I I6A I @
• it foot supinated. lateral supportstructures !ill fail rst
• it foot pronated medial supportstructures fail rst
• Injuries are graded 1 to 4 based onlevel of involvement and severit)+
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;A (C@ I A CA6 >C(
• 7-(C9 7piral oblique fracture runsfrom antero inferior margin upto
posterior superior corte$
• 7-A09 ransverse fracture distal tomortice or avulsion fracture of
tip
• ;-(C9 Above s)ndesmosis. fromsuperior anterior corte$ to posteroinferior corte$
• ;-A
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Supination E*ternal +otation Supination Adduction
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,igh fibula fracture with talar displace entPronation e*ternal rotation in-ury
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0A@I7 (
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!A$.S /E0E+ CLASS.%.CAT.1$
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• H;( 69• Abduction injur)• 61 9 oblique K pro$ to disrupted tibio bular
ligament• 62 9 Abduction L e$t+ rotation !it pro$ K ofbula and interosseous membrane
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A 6 A77I I6A I @
•
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7 A< (:>@7 A< (
• >@7 A< (9•
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.f %ibula is fractured and talus not shifted
Look for edial side swelling
"edial side swelling 2
!eltoid liga ent in-ury
#$STA0LE
"edial side swelling 3
Stress +adiography
Talus shifts#$STA0LE
Talus does not shiftSTA0LE
7 A< (:>@7 A< (
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7H@0(7* I6 I@F>CI(7
• *ost commonl) due to ;(C and ;A<• i$ation indicated if
• ;ro$imal bula K !it a medial injur)
• 7)ndesmotic injur) J 5 cm pro$imal toplafond
• Integrit) of s)ndesmosis can be judged intra operativel)9 i$ bula.pull laterall) !it a ook. if laterals ift J 3-4mm t en essential to $+
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• *aisonneuve )sfracture9
• 7piral K of t epro$imal bula
ssociated !itunstable ankle injur)
• ;ronation ($ternalrotation
• Cequires reductionand stabili?ation ofs)ndesmosis
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• < 7 C E )7 CA6 >C(9• e distal end of t e pro$imal fragment of
bula gets displaced posterior to t e tibiaand ma) be locked b) tibia )s postero lateralridge
• e bone cannot be released b)manupulation due to intact introsseousmembrane
• ibula is e$posed and considerable force isrequired to release t e bula. fracture t en
$ed operativel)
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C(A *(@
• Initial *anagement9 btain A;.lateral and mortice vie!s
• Ceduce talus immediatel)• ailure >rgent operative
intervention
CI 7panning e$ $6alcaneal
pin
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7 A< ( I@F>CH :
• K protected in a s ort leg cast orbrace for 4-" !eeks. allo! partial !t+bearing. < after 12 !eeks
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pen reatment
• @ot indicated in stable fractures. onl)if associated injuries like talar K orosteoc ondral K of talar dome
• Indicated in all unstable fractures
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CI
• ibula i$ation9• 1:3 rd tubular plate if
K above ankle• ag scre!s
• Cus rod9 if Ktransverse
• < 9 if fragmentsmall
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CI
• *edial *alleolus9• 2 parallel 4+' mm ; 67• < if fragment small and osteoporotic
• ;osterior *alleolus• i$ation important9 ot er!ise ma) lead to posterior
sublu$ation of talus• 7i?e of fragment important 6 scan• If J 25, - 3', of joint surface $ation done• i$ associated K rst and t en do an intra op
posterior dra!er test• Appl) 1:3 rd tubular plate posterior• Anterior to posterior intra fragmentar) scre!
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• 7)ndesmotic i$ation• Indication9 ;ro$ bula K associated !it medial injur)• en t e medial clear space !idens on intra op
stress vie!s after bula $ation• 7cre! $ed 2 -3 cm above ankle joint and parallel to
it and angled 3' degrees anteriorl)• 4+5 mm scre! used- purc ase 4 cortices• ig t scre! in ma$imal dorsi8e$ion of ankle• ime of scre! removal- controversialM++ *ost
surgeons prefer to remove t e scre! before !eig tbearing is allo!ed "B% !eeks
• >se s)ndesmotic scre! onl). !it out $ing t e bula! en K above mid bula
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; 7 ;(CA IN(
• Ankle immobili?ed in posteriorplaster splint
• 7plint removed after 3-4 da)s.replaced !it removable splint
• C * e$ercises are begun• @
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A=IA A0I@/ I@F>CI(79 IC(7
• Articular and metap )sealcomminution
• Foint impaction• ;ro$imal displacement of talus• Eig energ) trauma associated !it
soft tissue involvement• racture pattern depends upon
direction and position of foot
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AP and lateral 'iews of tibialPlafond showing articular and"etaphyseal co inution
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The position of the foot at the ti e1f a*ial load deter ines which part
1f the tibial plafond will fracture
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6 A77I I6A I @
• Cuedi- Allgo!erclassi cation9
• )pe 1 9@ondispaced
cleavage K• )pe 29 0isplaced
and minimall)comminuted K
• )pe 39 Eig l)
comminuted K
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6 A77I I6A I @
• A : A9• A9 @on- articular•
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C(A *(@
• Initial reatment9• Ceduce an) talar displacement• Articular reduction t roug eit er closed or open
met ods
• 7plint t e fracture ! ic ma) require temporar)skeletal traction
• reatment ptions9•
;late• 7panning e$ternal $ator• ($ternal $ator leaving t e anlke
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A0NA@ A/(7: 0I7A0NA@ A/(7Fixation Techniques
!echni,ue Advantages -isadvantages
/pen reduction and internal fixation nvolves #ide exposure for articularreductionAllo#s earl$ motion of ankle joint
-isrupts tenuous soft tissue envelopenvolves large subcutaneous implants
0as highest incidence of #ound healing problemsincluding: 1ound breakdo#n nfection /steom$elitis Amputation
2igid cross(ankle external fixation nvolves minimal disruption of 3one ofinjur$
2igidl$ immobili3es ankle
4xternal fixation of same side of joint Allo#s motion at the ankleAvoids large plates to stabili3e metaph$sis Cannot be used for all fractures-isrupts 3one of injur$s technicall$ demanding
Articulated cross(ankle externalfixation
Allo#s motion at the ankle 'limited)s technicall$ easier to appl$ fixator nvolves minimal disruption of 3one of
injur$
s difficult to align axis of hinge #ith axis of ankle joint2e,uires pins in hind(foot bones
alue of motion through an articulated hinge is not proven
0(6I7I @ *AGI@/ A@0 A6 C7
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0(6I7I @ *AGI@/ A@0 A6 C7C( A I@/ > 6 *(
• 6losed reatment9 >ndisplaced t)peA. )pe < and )pe 61 fractures
• pen reatment9• Immediate CI obsolete due to severe soft
tissue complications and ig rate of
implant failure• @ot favoured an) longer
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• >rgent stabili?ation done eit er b)• 7panning e$ternal $ator• ($ternal $ator sparing t e ankle joint• Illi?arov )s ring $ator
• 6alcaneal pin traction
• Adequate time is given for t e soft tissueto eal 4-" !eeks
• 0e native procedure is done after softtissue eals
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• 7panning e$ternal $ator andIlli?arov e$ternal $ator can be usedfor de nitive management
• Implants9• 7mall fragment 3+5 mm and 4+'' mm
scre!s for metap )seal stabili?ation
• 7mall plates- 1:3 rd tubular. 3+5 mm 06;.small clover leaf plates or s aped platesdesigned for distal radius. $ed anglelocking scre! plates
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C(7> 7
• Eig energ) trauma• Cesult not al!a)s good• 0epends on associated degree of soft
tissue trauma. !ound condition andinfections
• Average interval for fracture to eal 12!eeks
• Average time to return to normal activit)-1 )ear
• Cate of ;ost op art iritis and c:o pain and
disabilit) --- EI/EOO
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7>**ACH
• 6ommon fractures• Anatomical reduction. restoration of
bular lengt . s)ndesmotic repairlead to e$cellent outcomes for t epatient
• In plafond fractures management ofsoft tissue component and adequatestable $ation *A@0A CH
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!hank $ou66
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