Bimalleolar fracture.pptx

Bimalleolar fractures

1. Acute Ankle Fracture Dislocation Fracture Closed Complete Transverse Displaced Medial and Lateral Malleolus Left secondary to Motor Vehicular Accident Weber B Lauge - Hansen SER Stage IV Dias- Tachdjian Stage SI AO 44A2.3

2. TALOCRURAL ANGLE Assess for fibular shortening Measurement Mortise view Line along the distal tibial plafond articular surface Line joining the tips of both malleoli Interpretation Normal: 83° ± 4° 2 or 8-15° 3 Fibular shortening: >2° difference to the contralateral side

3. TALAR TILT MORTISE VIEW Measurement of the angle between the talus and the distal tibia, used in the assessment of: 1. Ankle instability 2. Ankle osteoarthritis Measurement Talar tilt is measured on either AP or mortise view radiographs of the ankle. Talar tilt is the angle between the articular surface of the talar dome and the articular surface of the tibial plafond. Interpretation Normal values <2° on non-stress radiographs <5° on inversion stress radiographs Talar tilt ≥2° upgrades Kellgren and Lawrence ankle OA from grade 3a to 3b, which is associated with worse clinical outcomes

4. MORTISE VIEW Mortise joint space should uniformly: < 4mm Lateral Clear Space: <3-6mm Distal tibiofibular overlap >1mm Fibular fossa: Visible AP VIEW Distal tibio -fibular joint: < 5.5mm Distal tibofibular overlap: >6mm Equal Horizontal and Medial CS: 3mm

5. MORTISE VIEW Mortise joint space should uniformly: < 4mm Lateral Clear Space: <3-6mm Distal tibiofibular overlap >1mm Fibular fossa: Visible AP VIEW Distal tibio -fibular joint: < 5.5mm Distal tibofibular overlap: >6mm Equal Horizontal and Medial CS: 3mm

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7. PLAN PLAN: Debridement ankle left, Closed vs Open reduction multiple pinning lateral and medial malleolus left Lined up as STAT CASE LABORATORIES: HEM: 12.8 WBC: 22.2 PLAT : 310 ESR: 120 CRP:140 Covid 19 PT-PCR negative (+) Covid positive exposure 11-10-22

8. PHYSIS Distal tibial physis C ontributes 45% of the growth of the tibia O ssifies between 6 and 12 months of Age medial malleolus appears at 7 years in girls and 8 years in boys. The medial malleolus usually ossifies as a down ward extension of the distal tibial ossific nucleus The distal aspect of the tibia is completely ossified by 14 to 15 years of age and fuses with the diaphysis at 18 years Distal fibula O ssifies during the second year of life, generally between the ages of 18 and 20 months. This physis usually closes 12 to 24 months later than the distal tibial physis CHAPTER 30 Lower Extremity Injuries, pg1379 Tachdjian’s Pediatric Orthopaedics 6 th ED

9. ANATOMY Ankle Syndesmosis Interosseous Ligament Anterior and Posterior Inferior Tibiofibular Ligaments Inferior Transverse Ligament Posteriorly

10. Medial Ligamentous Structure Deltoid ligament Superficial Anterior Talotibial Ligament Posterior Talotibial Ligament Tibionavicular Ligament Calcaneotibial Ligament Deep Primary restraint to lateral displacement of talus

11. LATERAL LIGAMENTOUS STRUCTURE Anterior Talofibular Ligament (ATFL) Calcaneofibular Ligament (CFL) Posterior Talofibular Ligament (PTFL)

12. Type I and II : Often amenable to closed tx Lower risk of physeal arrest Type III and IV: More likely to require operative tx H igher risk of physeal arrest Classification (Anatomic) Salter-Harris Classification High interobserver correlation Correlated with outcomes

13. CLASSIFICATION (MECHANISTIC) DIAS-TACHDJIAN (1978) 4 Types Supination-inversion Pronation-eversion external rotation (PEER) Supination-external rotation Supination-plantarflexion

14. SUPINATION INVERSION Grade 1: Adduction or inversion force avulses fibula • SH type I or II, rarely can be an epiphyseal fracture Grade 2: Further inversion tibia fracture Compressive force to medial malleolus SH type III or IV

15. VARIANTS OF GRADE II SUPINATION–INVERSION INJURIES A: SH type I fracture of the distal tibia and fibula. B : SH type I fracture of the fibula, type II tibial fracture. C : SH type I fibular fracture, type III tibial fracture D : SH type I fibular fracture, type IV tibial fracture

16. SUPINATION INVERSION McFarland Fracture Higher likelihood of nonunion Intra-articular fracture Delayed union not uncommon Late displacement can occur Growth arrest most common in this pattern Up to 40-50 % Adequacy of reduction is only predictive factor of physeal arrest

17. PRONATION-EVERSION, EXTERNAL-ROTATION This injury results when an eversion and lateral rotation force is applied to a fully pronated foot Tibial SH I/II fracture pattern Thurston-Holland fragment posterolateral Transverse fibula fracture Can be a greenstick fracture Premature physeal closure is common

18. Supination-External Rotation Grade 1: External rotational force SH type II tibia fracture Thurston Holland fragment visible on AP Xray Differentiates from Supination-plantarflexion Tibial epiphysis displaces posterolaterally Similar to Supination-plantarflexion Grade 2: Spiral fx distal fibula metaphysis Anteroinferior to posterosuperior Complications : External rotation deformity can occur due to incomplete reduction

19. WEBER CLASSIFICATION

20. COTTON FRACTURE Cotton fracture is a three-part fracture of the ankle involving the lateral malleolus, medial malleolus and distal posterior aspect of the tibial plafond (posterior malleolus)

21. TREATMENT Location of fracture Amount of displacement Age of child (how much growth remains) Distal tibia physis contributes: 3-4 mm growth per year 35-45% of overall tibia length Follow up X-rays for 6-12 months to evaluate for physeal closure

22. NON-OPERATIVE SLCC for 4 weeks Weight bearing is restricted for initial 2 weeks Additional immobilization is based on amount of healing present

23. OPERATIVE INDICATIONS O pen fractures or injuries with severe soft tissue injury Displacement of the articular surface (>2mm) Unable to obtain or maintain acceptable reduction

24. TREATMENT