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Introduction:A Pott's fracture, is an archaic term loosely applied to a variety of bimalleolar anklefractures. The injury is caused by a combined abduction external rotation from aneversion force. This action pulls on the extremely strong medial (deltoid) ligament, oftentearing off the medial malleolus. The talus then moves laterally, shearing off the lateralmalleolus or, more commonly, breaking the fibula superior to the tibiofibularsyndesmosis. A bIntroBimallelolar fracture with syndesmosis disruption is not a common injury that you seeevery day. Out of all the ankle injuries evaluated only 15% end up being anklefractures. In the past 20 yrs the frequency of ankle fractures has increased to about 187in 100,000 person/ year. The ratio for ankle fractures from male to female is 2:1, butpeople who get ankle fractures that are older than 50 usually are female and youngerthan 50 are usually male. Bimalleolar fractures are called Pott’s fractures, which meansthat at least 2 elements of the ankle ring are involved. Pott’s fractures require urgent
orthopedic attention because the ankle is unstable.
AnatomyThe articulation between the distal ends of the fibula and tibia form the distal tibiofibular joint. This is a
syndesmotic type joint allowing only a limited amount of motion. This joint is supported by the anterior-
inferior tibiofibular ligament, interosseous ligament, and posterior- inferior fibular ligaments (Figure 1)
The pertinentThe bony anatomy of the ankle for (talocrural) joint, also known as the ankle
consistincludes s of the fibula, tibiula, calcaneous and talus bones. The rounded malleolar prominences
on each side of the joint form a mortise for the upper surface of the talus. (Figure 2) The joint and bones
are stabilized via ligaments some of which include the anterior talofibular ligament, calcaneofibular
ligament, tibionavicular ligament, and the anterior tibiotalar ligament. A few of the musculature of the
ankle and lower leg are anterior and posterior tibialis, peroneus tertius, longus and brevis and externsor
hallucis longus and brevis.
The anterior-inferior tibiofibular ligament, interosseous ligament, and posterior- inferior fibular
ligaments. make up the syndesmosis.
Common MOI
Common mechanism of injury for a bimalleolar fracture include blunt force trauma or in
the case of this athlete, a team tackle. The syndesmosis injury usually occurs when the
foot is forced upward and outward.
Signs and Symptoms
The chief complaint following a The signs and symptoms of a bimalleolar fracture are is
severe pain throughout the whole ankle. Other signs and symptoms include a
significant amountThere will also be lots of swelling present in the foot, ankle and lower
leg. There will be a majorand deformity seen from the dislocation and you will possibly
be able to see the fx’s. One of the main things is that the athleteFunctionally the patient
Comment [MSOffice1]: Citation?
Comment [MSOffice2]: Citation?
Formatted: Font: (Default) Arial, 12 pt
Formatted: Font: (Default) Arial, 12 pt
Comment [MSOffice3]: Citation
Comment [MSOffice4]: Pott’s fractures are
named after the individual that described them
originally… see
http://www.whonamedit.com/synd.cfm/1126.html
Formatted: Strikethrough
Comment [MSOffice5]: Probably don’t need to
mention the muscles involved.
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will be unable to bear weight on their ankle. Mild to moderate syndesmosis sprains may
at first feel like a routine sprained ankle. The signs and symptoms of syndesmosis
disruption include pain and swelling on the outside lateral side of the ankle. The patient
may also reportMay get pain in the ankle joint if they try to turn or twist their ankle . The
pain can also radiating paine upward along the lower part of the leg.
Sugrical Intervention?
Rehabilitation
Post-op: bulky jones dressing, NWB, elevation
7-10 Days: Wound check, functional Air-Stirrup ankle brace (Aircast). Partial weight bearing as tolerated.
Encourage daily active and passive range-of-motion exercises of the ankle and subtalar joints without
the brace.
6 Weeks: Assess xrays for union. Progress with activity / PT. Driving: may drive after 9 weeks for right
leg. (Egol KA, JBJS 2003;85A:1185). Swelling is common after ankle sprain or fx. Rx=compression stocking
(sigvaris, Jobst) 20-30mmHg
3 Months: Begin sport specific rehab. Running, stair-climbing, and participation in sports are allowed
only after a full range of motion of the ankle has been achieved
6 Months: Return to sport / full activities.
1Yr: Assess outcomes, F/U xrays.
Manual Therapy
Therapeutic exercises
Modalities
Neuromuscular Re-education
Patient Education
Return to playAthletes who fracture both malleoli can return to play once their fractures are completely healed. They
also need to have full and pain free range of motion. When testing their muscle strength they need to
have at least 90% back when compared to their uninvolved extremity. To completely clear and athlete
to return to play they need to be ran through a functional tests and pass them.
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Case Study
On April 11, 2009, a 20 yr old intercollegiate football athlete at a Division I-AA institution was
involved in a team tackle where his ankle was “caught under the pile at practice.” He was evaluated on
the field by Brian Norton, MS, ATC. The athletes’ ankle was noticeably dislocateddeformed, so thus he
was splinted and sent to the ER. There Dr. James Dunlaphe patient was diagnosed the athletes injury
aswith a closed bimalleolar fracture with a / syndesmosticis disruption after x-rays. On April 12, 2009 the
athlete was scheduled for surgery, which was performed by Dr. James Dunlap at Providence Orthopedic
Specialists. The surgery wasthe patient underwent an open reduction internal fixation. The athlete was
able to start physical therapy on May 21st
at U District PT “Institute of Sports Performance”one month
later. He went twice a week for 8- 10 weeks. After returning to play and starting out the fall season, the
athlete was injured again while playing in a game. On September 28, 2009 during the football game
against Sacramento State the athlete tore his ACL. He was evaluated on the field side lines by Brian
Norton, MS, ATC and Dr. Dan Dami. Dr. Dan Dami stated that the ACL had been injured in the spring
when his other injury had occurred. After returning to Eastern Washington University the athlete wasseen by team physician, Dr. Halverson, who also confirmed that the ACL had been injured in the spring
season prior to that game, but during the Sacramento State game he ended up completely tearing it.
For the athlete ACL he had an MRI on September 30, 2009. The results of that MRI were that the athlete
had a grade 3 ACL and a partially torn meniscus. The athlete and head athletic trainer Brian Norton, MS,
ATC decided that it would be better to have surgery after season but would continue playing with a
brace. The athlete had a scheduled surgery for January 4, 2010. After his surgery the athlete is now
currently doing rehab with EWU Athletic Training and is making good progress.
I would only mention the ACL tear in passing (see status section below)
Rehabilitation (Can you put this into the narrative format? …and be specific to
your patient)
Post-op: bulky jones dressing, NWB, elevation
7-10 Days: Wound check, functional Air-Stirrup ankle brace (Aircast). Partial weight bearing as tolerated.
Encourage daily active and passive range-of-motion exercises of the ankle and subtalar joints without
the brace.
6 Weeks: Assess xrays for union. Progress with activity / PT. Driving: may drive after 9 weeks for right
leg. (Egol KA, JBJS 2003;85A:1185). Swelling is common after ankle sprain or fx. Rx=compression stocking
(sigvaris, Jobst) 20-30mmHg
3 Months: Begin sport specific rehab. Running, stair-climbing, and participation in sports are allowed
only after a full range of motion of the ankle has been achieved
6 Months: Return to sport / full activities.
1Yr: Assess outcomes, F/U xrays.
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Manual Therapy
Therapeutic exercises
Modalities
Neuromuscular Re-education
Patient Education
Return to playAthletes who fracture both malleoli can return to play once their fractures are completely healed. They
also need to have full and pain free range of motion. When testing their muscle strength they need to
have at least 90% back when compared to their uninvolved extremity. To completely clear and athlete
to return to play they need to be ran through a functional tests and pass them.
Status: I would mention that the patient’s return to play has been complicated by another injury…
References (personal communications are not listed in the reference listing)
Anderson M., Hall S., & Martin M. (2004). Foundations of athletic training. Philadelphia: Lippincott
Williams and Wilkins.
Pudda, G., Giombini, A., & Selvanetti, A. (2001). Rehabilitation of sS ports iInjuries: Current cC oncepts .
Berlin/Heidelberg: Springer.
Norton, Brian MS ATC, initial evaluation
http://emedicine.medscape.com/article/824224-overview
Author: Kara Iskyan, MD, Staff Physician, Departments of Internal Medicine and Emergency Medicine, Allegheny General
Hospital
Coauthor(s): Andrew A Aronson, MD, FACEP, Vice President, Physician Practices, Bravo Health Advanced Care Center;
Consulting Staff, Department of Emergency Medicine, Taylor Hospital, Ridley Park, Pennsylvania
http://eorif.com/AnkleFoot/Ankle%20Fx%20ORIF.html
Figure 1
Comment [MSOffice6]: Fix this citation.
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I didn’t see an abstract attached… Here is my suggestion…
A Pott's fracture, is an archaic term loosely applied to a variety of bimalleolar anklefractures - which means that at least 2 elements of the ankle ring are involved. Abimallelolar fracture with syndesmosis disruption is not a common injury that you seeevery day. Out of all the ankle injuries evaluated only 15% end up being anklefractures. This case study describes the history and rehab of a 20 yr old intercollegiate
football athlete at a Division I-AA institution that was diagnosed with a closed bimalleolar
fracture with a syndesmostic disruption.
Comment [MSOffice7]: Citation?