Ankle fracture

Simplifying fracture around the ankle. All information are collected from authentic source.

1. Ankle fracture Dr. Ashiqur Rahman Resident Orthopedics Dhaka Medical College & Hospital

2. Introduction Fracture dislocation of the ankle are common. Most are low energy fractures of one or both malleoli, usually caused by a twisting injury. More severe are involvement of tibial plafond, the pilon fracture, which are high energy injuries.

3. Lauge -Hansen classification: Supination-adduction type: ( i ) Stage – I: Transverse # lateral malleolus (ii) Stage – II: Vertical shear # @ base of the medial malleolus.

4. 2. Supination-external rotation type: stage-I: Rupture of the ATF ligament. Stage-II: Stage-I + Spiral oblique # fibula the level of ankle joint. Stage-III: Stage-II + # of the posterior malleolus. Stage-iv: Stage-III + # of the medial malleolus or rupture of DL.

5. 3. Pronation-abduction: Stage – I: Transverse # of medial malleolus or rupture of DL. Stage – II: Stage-I + Disruption of anterior & posterior TF ligament. Stage – III: Stage-II + short oblique # distal end of fibula.

6. 4. Pronation-external rotation: Stage-I: Transverse# MM or rupture of DL. Stage-II: Stage-I + Disruption of ATFL. Stege -III: Stage-II + #fibula proximal to syndesmosis. Stage-iv: Stage-III + Disruption of PTFL or # of Post. Malleolus.

7. 5. Pronation-Dorsiflexion type: Stage-I: A # of medial malleolus Stage-II: Stage-I + A # on the antero- inferior portion of tibia. Stage-III: Stage-II + A transverse # of fibula above the malleolus. Stage-IV: Stage-III + A # of distal tibia ( Pilon fracture).

8. Denis – Weber classification: Type – A : - Transverse avulsion # of the lateral malleolus between the layers of syndesmosis. - Associated shear # of medial malleolus. Type – B : - Spiral # fibula beginning @ the level of syndesmosis. - Avulsion # of MM or the DL may be ruptured.

9. Type – C : - # of the fibula above the syndesmosis & may be anywhere between the syndesmosis & head of the fibula. - A transverse avulsion # of MM or rupture of DL may be present

10. Syndesmosis is a fibrous joint held together by ligaments. It’s located near the ankle joint, between tibia, and the distal fibula. That’s why it’s also called distal tibio -fibular syndesmosis. It’s actually made up of several ligaments. The primary ones are : ( i ) Antero-inferior tibio -fibular ligament (ii) Postero -inferior tibio -fibular ligament (iii) Interosseous ligament (iv) Transverse tibio -fibular ligament

11. Q: Why malleolar fractures usually need operative treatment? 1 . It is an intraarticular fracture, so need anatomical reduction. 2 . Usually there is interposition of periosteum which may lead to nonunion . 3 . It is an avulsion fracture which is gradually separated and leads to nonunion.

12. Pilon fracture : Fracture of the lower end of tibia involving the distal articular surface & adjoining metaphysis. Tillaux fracture : Avulsion fracture of the anterolateral part of the tibia by the anterior tibiofibular ligament in growing child. Cotton fracture : Also known as trimalleolar #. In addition to the # of the medial malleolus & fibula, the posterior lip of the articular surface of the tibia is fractured. Tri-plane fracture : Fracture medial side of tibia & combination of salter-Harris type-II & III #. Fracture line passes in coronal, saggital & transverse plane.

13. Cotton fracture of ankle

14. Tillaux fracture

15. Tri-plane fracture

16. X-rays At least 03 views needed: Anteroposterior Lateral 30 degree oblique (mortise view): Will reveal entire extent of the ankle joint space.

17. X-ray findings: Widening of the tibiofibular space Asymmetry of the talotibial space Widening of the medial joint space Tilting of the talus

18. In assessing the accuracy of reduction 04 objects must be met: Fibula must be restored to it’s full length Talus sits squarely in the mortis, with the talar & tibial articular surfaces parallel. The medial joint space must be restored to it’s normal width, i.e , the same width as the tibiotalar space (about 4mm). Oblique view must show there is no tibiofibular diastasis.

19. Q: How the tibiofibular diastasis is assessed? The term diastasis is derived from a Greek word meaning “to separate”. Assessment of diastasis: Increase of ‘clear space’ between the posterior tubercle of fibular notch of tibia and medial margin of fibula. Normal ‘clear space’ is less than 6mm measured 1cm above the tibial plafond in both antero-posterior and mortise views. It is the most sensitive criterion. 2. Reduced tibiofibular overlap. Normal tibiofibular overlap is more than one-third of the fibular width in anteroposterior radiograph and more than 1 mm in the mortise view.

20. Q: What is talar shift and talar tilt? Is a radiological evaluation tool for joint displacement & is Seen in AP View. Talar shift: A vertical line is drawn along the midline of the tibia. It normally passes through the center of the talus. Distance of the vertical line from the center of the talus is measured in mm reflects talar displacement. >2mm displacement is unacceptable. Talar tilt: The talar tilt is measured as the difference in space between the articular surfaces of the tibia and the talus at the medial and lateral end of the is radiographic evaluation tool for joint displacement.

21. Approaches to the ankle joint for fixation of bimalleolar fracture: (A) Approaches to lateral malleolus: 1 . Anterolateral 2 . Midlateral 3 . Posterolateral/ posterior (B) Approaches to medial malleolus: A. Anteromedial / Oblique (Koenig & Schaefer) B. Posteromedial / Posterior convex (Broom head) C. Medial (Colona & Ralston) /Anterior convex (Colona & Ralston)

22. Rx of medial malleolus #

23. a. Non- displaced fracture of medial malleolus: by cast immobilization, patient with high functional demand internal fixation can be done. b . Displaced fracture : should be treated surgically as persistent displacement tilt the talus into varus . c . Avulsion fracture : with near normal ankle mortise do not required internal fixation. d . Fixation technique: by two 4 mm distal threaded cancellous screw given perpendicular to the fracture line. If fragments are small then screw will be replaced by k wires. e . Vertical fractures of the medial malleolus require horizontally directed screws or antiglide plating techniques.

24. Rx of lateral malleolus #

25. Q: How the malleoli are fixed? 1 . Lateral malleolus is fixed by either 1/3rd tubular plate or semitubular plates (1/2 circle of a tube) or small DCP . 2 . Medial malleolus is fixed with two 4mm cancellous (or 4.5mm cannulated malleolar) screws, or with one cancellous screw and another K-wire . 3. If the fragment is small & comminuted then TBW is needed.

26. Rx of lateral malleolus # Maximal acceptable displacement of the fibula reported literally from 0 to 05mm. In most pt. 02 to 03mm of displacement is accepted, depending of the functional demend .

27. Method to fix syndesmosis: Screw or oblique pin (insert through lateral malleolus & distal tibia) 2.5mm to 3.5mm tricortical neutralizing screw. Screw is inserted 2-3cm above & parallel to the ankle joint beginning postero -laterally to the fibula proceeding anteromedially to the tibia. 30 degree anteriorly angled. Three cortex fixation is ideal.

28. Pilon fractures Pilon injuries of the ankle joint occurs when a large force drives the talus upwards against the tibial plafond, like a pestle ( pilon ) being stuck into a mortar. There is considerable damage of the articular cartilage & subchondral bone may be broken into several pieces. In severe cases, the comminution may extends some way up the shaft of the tibia.

29. Posterior malleolus # fixation

30. Clinical features : Little swelling initially Fracture blister are common The ankle may be deformed & even dislocated Prompt appoximate reduction is mandatory

31. Imaging CT scanning (Preferably 3D reconstruction) Plain X-ray examination

32. Treatment Three point of early management of these injuries are : - Span - Scan - Plan 2. Staged treatment has reduced the complications rate in these injuries.

33. Treatment cont’d Control of soft tissue is the priority; this is best achieved by elevation & applying an external fixator across the ankle joint(the spanning external fixator). It may take 2-3weeks before the soft tissues improve, and fracture blisters can be actively managed rather than hidden under plaster. Surgery can be planned, based on CT scan.

34. Spanning external fixator