Tibia and fibula diaphysis, ankle and foot injuries

Injuries to the tibia & fibula diaphysis, ankle and foot

1. TIBIA & FIBULA DIAPHYSIS AND ANKLE INJURIES Presenter; Joyce F. Mwatonoka MD5 November 2016

2. TIBIA AND FIBULA ANATOMY

3. Cont…

4. Because of its subcutaneous position, the tibia is more commonly fractured, and more often sustains an open fracture, than any other long bone

5. Twisting force-spiral fracure Angulatory force-transverse/short oblique Indirect injury is usually low energy ; with a spiral or long oblique fracture one of the bone fragments may pierce the skin from within Direct injury crushes or splits the skin over the fracture; this is usually a high-energy injury and the most common cause is a motorcycle accident MECHANISM OF INJURY

6. The behaviour of these injuries – and therefore the choice of treatment –depends on the following factors; 1. The state of the soft tissues; direct proportion to risk of complications and # healing. Closed fractures are best described using Tscherne’s ( Oestern and Tscherne , 1984) method; for open injuries, Gustilo’s grading. Risk of infection 1% in Gustilo 1 - 30% in Gustilo 3c. Pathological Anatomy

7. 2. The severity of the bone injury; High-energy fractures are more damaging and take longer to heal than low-energy fractures; this is regardless of whether the fracture is open or closed. Lowenergy breaks are typically closed or Gustilo I or II, and spiral. High-energy fractures are usually caused by direct trauma and tend to be open ( Gustilo III A–C), transverse or comminuted Cont…

8. 3. Stability of the fracture Consider whether it will displace if weight bearing is allowed. Long oblique fractures tend to shorten; those with a butterfly fragment tend to angulate towards the butterfly . Severely comminuted fractures are the least stable of all, and the most likely to need mechanical fixation Cont…

9. 4. Degree of contamination In open fractures this is an important additional variable Cont…

10. IC1 No skin lesion IC2 No skin laceration but contusion IC3 Circumscribed degloving IC4 Extensive, closed degloving IC5 Necrosis from contusion TSCHERNE’S CLASSIFICATION OF SKIN LESIONS IN CLOSED FRACTURES

11. The limb should be carefully examined for signs of soft-tissue damage: bruising, severe swelling, crushing or tenting of the skin, an open wound, circulatory changes, weak or absent pulses, diminution or loss of sensation and inability to move the toes. Any deformity should be noted before splinting the limb. Always be on the alert for signs of an impending compartment syndrome Clinical features

12. X-ray The entire length of the tibia and fibula , as well as the knee and ankle joints, must be seen. The type of fracture, its level and the degree of angulation and displacement are recorded Spiral fractures without comminution are low energy injuries Transverse , short oblique and comminuted fractures, especially if displaced or associated with a fibula # at a similar level, are high energy injuries Cont…

13. (1) To limit soft-tissue damage and preserve (or restore, in the case of open fractures) skin cover; (2) To prevent – or at least recognize – a compartment syndrome; (3) To obtain and hold fracture alignment; (4) To start early weightbearing (loading promotes healing); (5) To start joint movements as soon as possible. MANAGEMENT; Objectives

14. Most can be treated by non-operative methods U ndisplaced or minimally displaced #; a full-length cast from upper thigh to metatarsal necks is applied with the knee slightly flexed and the ankle at a right angle Displacement of the fibular fracture, unless it involves the ankle joint, is unimportant and can be ignored. LOW-ENERGY FRACTURES

15. If the fracture is displaced, it is reduced under GA with x-ray control Apposition need not be complete but alignment must be near-perfect (no more than 7 degrees of angulation ) and rotation absolutely perfect. A full-length cast is applied as for undisplaced fractures (note, however, that if placing the ankle at 0 degrees causes the fracture to displace, a few degrees of equinus are acceptable) Cont…

16. The position is checked by x-ray; minor degrees of angulation can still be corrected by making a transverse cut in the plaster and wedging it into a better position Then observation for 48-72 hrs If there is excessive swelling , the cast is split T hen discharged and allowed to bear minimal weight with the aid of crutches Cont…

17. The immediate application of plaster may be unwise if skin viability is doubtful, in which case a few days on skeletal traction is useful as a preliminary measure A change from an above- to a below-the-knee cast is possible around 4–6 weeks, when the fracture becomes ‘ sticky ’. The cast is retained (or renewed if it becomes loose) until the fracture unites, which is around 8 weeks in children but seldom under 12 weeks in adults Cont…

18. If follow-up x-rays show unsatisfactory fracture alignment U nstable # s Open #s Indications for skeletal fixation

19. Closed intra medullary nailing method of choice for internal fixation a guide-wire, a nail, transverse locking screws For diaphyseal fractures, union can be expected in over 95% of cases. However, the method is less suitable for fractures near the bone ends Cont…

20. Plate fixation B est for metaphyseal fractures that are unsuitable for nailing A lso sometimes used for unstable tibial shaft fractures in children F ull weightbearing will need to be deferred until some callus formation is evident on xray , usually at 6–8 weeks. Cont…

21. External fixation A n alternative to closed nailing Partial weightbearing is permitted from the start and the external fixator can be replaced by a functional brace once there are signs of union Cont…

22. First check for surrounding soft tissue and bone viability Transverse fractures are usually stable after reduction; they can be treated ‘closed’ Comminuted and segmental fractures, those associated with bone loss, and indeed any high-energy fracture that is inherently unstable, require early surgical stabilization HIGH-ENERGY FRACTURES

23. For closed #s, external fixation and closed nailing are equally suitable For open #s, the use of internal fixation has to be accompanied by debridement and prompt cover of the exposed bone and implant; alternatively, external fixation can be used Cont…

24. Each of your feet has 26 bones, 33 joints, and more than 100 tendons, muscles, and ligaments INJURIES OF ANKLE AND FOOT

25. Anatomy

26. M ost common of all sports related injuries, accounting for over 25% of cases In more than 75% of cases it is the lateral ligament complex that is injured, in particular the anterior talofibular and calcaneofibular ligaments Medial ligament injuries are usually associated with a fracture or joint injury. ANKLE LIGAMENT INJURIES/SPRAINS

27. They are 3 ligaments that resist inversion of the ankle joint They run from the lateral malleolus of the fibula   to the talus and  calcaneus Anterior talofibular ligament (ATFL) anterior component arises from distal fibula; inserts on the lateral talus Calcaneofibular ligament middle component arises from distal fibula; inserts on the lateral calcaneus Posterior talofibular ligament (PTFL) posterior component arises from distal fibular; inserts on the posterior talus Lateral collateral ligaments of the ankle

28. Attaches the medial malleolus to multiple tarsal bones The ligament is composed of two layers;  The superficial layer has variable attachments and crosses two joints while. Has 4 ligaments The deep layer has talar attachments and crosses one joint. It is intra- articular and has 2 ligaments Deltoid ligament  / medial collateral ligament of the ankle

29. It occurs due to eversion and/or pronation injury, or can be associated with lateral ankle fractures About 15% are ass/c ankle # Mechanism of injury

30. (1) Pain around the malleolus ; (2) Inability to take weight on the ankle immediately after the injury; (3) Inability to take four steps in the Emergency Department; (4) Bone tenderness at the posterior edge or tip of the medial or lateral malleolus or the base of the fifth metatarsal bone Anteroposterior , lateral and ‘mortise’ (30-degree oblique) views are done The Ottawa Ankle Rules for X-ray

31. P – protection; crutches, splint or brace R – rest; I – ice; for 20min every 2hours and after any activity C - compression E – elevation R – rehabilitation; supported return to function Continued for 1–3 weeks depending on the severity of the injury and the response to treatment Use of NSAIDs oral/topical for pain management Management (PRICER)

32. If no impovement after 2weeks, further review and investigation are called for Persistent problems at 12 weeks after injury, despite physiotherapy, may signal the need for operative treatment ( ORIF ) Postoperatively the ankle is immobilized in eversion for 2 weeks ; a below-knee cast is then applied for another 4 weeks, during which time the patient can bear weight Thereafter, a removable brace is worn (for 3 months ) and exercises are encouraged. The brace can be used from time to time for sports activities Operative Rx

33. Fractures and fracture dislocations of the ankle are common Most are low-energy fractures of one or both malleoli , usually caused by a twisting mechanism Less common are the more severe fractures involving the tibial plafond , the pilon fractures, which are high-energy injuries often caused by a fall from a height MALLEOLAR FRACTURES OF THE ANKLE

34. The patient stumbles and falls Usually the foot is anchored to the ground while the body lunges forward The ankle is twisted and the talus tilts and/or rotates forcibly in the mortise , causing a low-energy fracture of one or both malleoli , with or without associated injuries of the ligaments Mechanism of injury

35. Mortise

36. The precise fracture pattern is determined by: 1) The position of the foot; 2) The direction of force at the moment of injury Classification Lauge -Hansen (1950) Danis and Weber ( Müller et al., 1991), which focuses on the fibular fracture Cont…

37. A transverse fracture of the fibula below the tibiofibular syndesmosis Perhaps associated with an oblique or vertical fracture of the medial malleolus ; this is almost certainly an adduction (or adduction and internal rotation) injury Type A (infra- syndesmotic )

38. An oblique fracture of the fibula in the sagittal plane (better seen in the lateral xray ) at the level of the syndesmosis ; Often there is also an avulsion injury on the medial side (a torn deltoid ligament or # of the medial malleolus ) This is probably an external rotation injury and it may be associated with a tear of the anterior tibiofibular ligament Type B (trans- syndesmotic )

39. Above the level of the syndesmosis , the tibiofibular ligament and part of the interosseous membrane must have been torn This is due to severe abduction or a combination of abduction and external rotation Associated injuries are an avulsion # of the medial malleolus (or rupture of the medial collateral ligament), a posterior malleolar fracture and diastasis of the tibiofibular joint Type C (supra- syndesmotic )

40. The patient usually presents with a history of a twisting injury , usually with the ankle going into inversion , followed by immediate pain, swelling and difficulty weightbearing Bruising often comes out soon after injury The site of tenderness is important; if both the medial and lateral sides are tender, a double injury (bony or ligamentous ) must be suspected Clinical presentation

41. At least 3 views are needed: AP , lateral and a 30-degree oblique ‘ mortise ’ view The level of the fibula # is often best seen in the lateral view Diastasis may not be appreciated without the mortise view Further x-rays may be needed to exclude a proximal fibular fracture MANAGEMENT; X-Ray

42. Swelling is usually rapid and severe Ankle fractures are often unstable Look for clues to the invisible ligament injury Widening of the tibiofibular space Asymmetry of the talotibial space Widening of the medial joint space, or Tilting of the talus Treatment

43. The fibula must be restored to its full length The talus must sit squarely in the mortise, with the talar and tibial articular surfaces parallel; The medial joint space must be restored to its normal width, i.e. the same width as the tibio-talar space (about 4mm); Oblique x-rays must show that there is no tibiofibular diastasis Assessment of accuracy of reduction

44. An isolated, undisplaced Danis –Weber type A fracture is stable and will need minimal splintage , a firm bandage or stirrup brace is applied Undisplaced type B fractures; a below-knee cast is applied with the ankle in the anatomical position (+/- an overboot ). Pretty unstable, x-ray after 2 weeks to confirm that the # remains undisplaced . The cast can usually be discarded after 6–8 weeks, then physio For undisplaced #s

45. Reduction ASAP Indications for ORIF; All fracture-dislocations All type C #s Trimalleolar #s Talar shift or tilt Failure to achieve or maintain closed reduction Displaced #s

46. NB ; A  trimalleolar fracture  is a  #  of the ankle that involves the lateral malleolus , the medial malleolus , and the distal posterior aspect of the tibia , which can be termed the posterior malleolus Cont…

47. Internal fixation ; plate and screws or tension-band wiring can be used. After ORIF movements should be regained before applying a below-knee plaster cast Postoperatively a ‘ walking cast ’ or removable splintage boot is applied for 6 weeks Prognosis depend upon anatomic reduction High incidence of post-traumatic arthritis Cont…

48. EARLY Vascular injury Wound breakdown and infection LATE Incomplete reduction Non-union Joint stiffness (when the plaster is removed, he or she must, until circulatory control is regained, wear a crepe bandage and elevate the leg whenever it is not being used actively) COMPLICATIONS

49. Algodystrophy Osteoarthritis ( Malunion and/or incomplete reduction may lead to secondary osteoarthritis in later years) Cont…

50. Is a  fracture  of the distal part of the tibia , involving its articular surface at the ankle joint Occurs when a large force drives the talus upwards against the tibial plafond, like a pestle ( pilon ) being struck into a mortar Damage to the articular cartilage and the subchondral bone may be broken into several pieces; in severe cases, the comminution extends some way up the shaft of the tibia PILON/PLAFOND FRACTURES

51. Control of soft tissue swelling is a priority; this is best achieved either by elevation and applying an external fixator across the ankle joint It may take 2– 3 weeks before the soft tissues improve Once the skin has recovered, an open reduction and fixation with plates and screws (usually with bone grafting) may be possible Management

52. The bones in the foot may be broken in many ways including direct blows, crush injuries, falls and overuse or stress Initial treatment may include RICE (rest, ice, compression, elevation). Rest may include the use of crutches to limit weight bearing X-rays often help make the dx but bone scan or CT may be needed to help visualize the injury Rx of foot #s depend upon which bone is broken but many #s are treated with a compression dressing, a stiff- soled shoe, and weight bearing as tolerated Some foot fractures require surgery to repair the damage Complications of foot fractures include non-union at the fracture site, arthritis if a joint is involved, and infection if the skin is broken Bones of Foot injuries