Ankle FracturesAnkle Fractures

Dr. Anshu Sharma,Dr. Anshu Sharma,Orthopaedic Resident,Orthopaedic Resident,

MGMC&H, Jaipur.MGMC&H, Jaipur.

Ankle is a complex hinge joint Ankle is a complex hinge joint composed of the tibia, fibula, composed of the tibia, fibula, talus and complex ligamentous talus and complex ligamentous system. system.

Distal tibial surface is referred Distal tibial surface is referred to as the “plafond” which, to as the “plafond” which, together with the medial and together with the medial and lateral malleoli, forms the lateral malleoli, forms the mortise.mortise.

Talus articulates with the tibial Talus articulates with the tibial plafond superiorly , posterior plafond superiorly , posterior malleolus of the tibia posteriorly malleolus of the tibia posteriorly and medial malleolus medially.and medial malleolus medially.

Lateral articulation is with Lateral articulation is with malleolus of fibula.malleolus of fibula.

-The talar dome is trapezoidal, with the anterior aspect 2.5mm wider than the posterior talus.

-The body of talus is almost entirely covered by articular cartilage.

- The medial malleolus articulates with the medial facet of the talus and divide into an anterior colliculus and a posterior colliculus, which provides attachment to superficial and deep deltoid ligaments respectively.

-The tibiotalar articulation is considered to be highly congruent such that 1 mm talar shift within the mortise decreases the contact area by 42 %.

ANKLE JOINT IS SUPPORTED BYANKLE JOINT IS SUPPORTED BY

Fibrous capsuleFibrous capsule Deltoid ligamentDeltoid ligament A. Superficial A. Superficial

a. Anterior- a. Anterior- Tibionavicular, Tibionavicular,

b. Middle- b. Middle- Tibiocalcaneal,Tibiocalcaneal,

c. Posterior- c. Posterior- Supreficial Supreficial Tibiotalar.Tibiotalar.

B. Deep : Deep B. Deep : Deep Tibiotalar.Tibiotalar.

Lateral ligamentLateral ligament• Anterior- Anterior-

Talofibular,Talofibular,• Posterior- Posterior-

Talofibular,Talofibular,• Calcaneofibular. Calcaneofibular.

SYNDESMOTIC LIGAMENTSSYNDESMOTIC LIGAMENTS

Anterior inferior Anterior inferior tibiofibular ligament,tibiofibular ligament,

Posterior inferior Posterior inferior tibiofibular ligament,tibiofibular ligament,

Transverse Transverse tibiofibular ligament,tibiofibular ligament,

Interosseous Interosseous ligament.ligament.

BiomechanicsBiomechanics The normal ROM of Ankle:The normal ROM of Ankle: -Dorsiflexion: 30*,-Dorsiflexion: 30*, -Planter flexion: 45*.-Planter flexion: 45*. Motion analysis studies reveal that a Motion analysis studies reveal that a

minimum of 10* of dorsiflexion and 20* of minimum of 10* of dorsiflexion and 20* of planter flexion are required for normal planter flexion are required for normal gait.gait.

The axis of flexion of the ankle runs The axis of flexion of the ankle runs between the distal aspect of two malleoli, between the distal aspect of two malleoli, which is externally rotated 20* compared which is externally rotated 20* compared with knee axis.with knee axis.

INTRODUCTION

Ankle fractures are among the most common injuries and management of these fractures depends upon careful identification of the extent of bony injury as well as soft tissue and ligamentous damage.

The key to successful outcome following ankle fractures is anatomic restoration and healing of ankle mortise.

Mechanism of InjuryMechanism of Injury Pattern of ankle fracture depends on Pattern of ankle fracture depends on

many factors:many factors: -Position of foot and direction of -Position of foot and direction of

force,force, -Chronicity or recurrent trauma -Chronicity or recurrent trauma

leading to ligament injury or laxity leading to ligament injury or laxity and distorted ankle biomechanics.and distorted ankle biomechanics.

-Patients age,-Patients age, -Bone quality.-Bone quality.

Clinical EvalutionClinical Evalution Variable presentation (limp to Variable presentation (limp to

nonambulatory with severe pain, swelling nonambulatory with severe pain, swelling and deformity)and deformity)

Extent of soft tissue injury must be Extent of soft tissue injury must be evaluated.evaluated.

Neurovascular status should be carefully Neurovascular status should be carefully documented.documented.

Entire length of fibula should be palpated Entire length of fibula should be palpated for tenderness.for tenderness.

A dislocated ankle should be reduced and A dislocated ankle should be reduced and splinted immediately.splinted immediately.

Radiographic EvaluationRadiographic EvaluationPlain X-ray FilmsPlain X-ray Films::

•Anterio-posterior view of ankle, Anterio-posterior view of ankle, •Lateral view of ankle,Lateral view of ankle,•Mortise view of ankle,Mortise view of ankle,•Stress views when required,Stress views when required,•Image the entire tibia, ankle to knee Image the entire tibia, ankle to knee joint,joint,•Foot films when tender to palpation.Foot films when tender to palpation.

On the anteroposterior view:-

-The distal tibia and fibula, including the medial and lateral malleoli, are well demonstrated.-Important note is that the fibular (lateral) malleolus is longer than the tibial (medial) malleolus.

-This anatomic feature, important for maintaining ankle stability, is crucial for reconstruction of the fractured ankle joint.-Even minimal displacement or shortening of the lateral malleolus allows lateral talar shift to occur and may cause incongruity in the ankle joint, possibly leading to posttraumatic arthritis.

•Tibiofibular overlapTibiofibular overlap <10mm<10mm is abnormal – is abnormal – implies syndesmotic injury.implies syndesmotic injury.

•Tibiofibular clear spaceTibiofibular clear space >5mm>5mm is abnormal – is abnormal – implies syndesmotic injury.implies syndesmotic injury.

•Talar tiltTalar tilt >2mm>2mm is is considered abnormal.considered abnormal.

Consider a comparison with radiographs of the normal side if there are unresolved concerns of injury.

•Posterior mallelolar Posterior mallelolar fractures can be fractures can be identified.identified.

•AP Talar subluxation:AP Talar subluxation: Dome of the talus should Dome of the talus should be centered under the tibia be centered under the tibia and congruous with the and congruous with the tibial plafond.tibial plafond.

•Associated injuries Associated injuries to:to:

–Talus,Talus,–Calcaneum.Calcaneum.

AP view taken with AP view taken with ankle in 15-ankle in 15-20degrees of 20degrees of internal rotation.internal rotation.

Useful in Useful in evaluation of evaluation of articular surface articular surface between talar between talar dome and mortise.dome and mortise.

10 degrees internal rotation of 5th MT with respect to a vertical line

Medial clear spaceMedial clear space• Between lateral Between lateral

border of medial border of medial malleous and medial malleous and medial talus.talus.

<= 4mm is normal,<= 4mm is normal, >4mm suggests >4mm suggests

lateral shift of talus.lateral shift of talus.

Consider a comparison with radiographs of the normal side if there are unresolved concerns of injury.

Shenton’s Line of the Ankle.

• Stress ViewsStress Views– Gravity stress view Gravity stress view – Manual stress viewsManual stress views

• CTCT– Joint involvement,Joint involvement,– Posterior malleolar Posterior malleolar

fracture pattern,fracture pattern,– Pre-operative Pre-operative

planning,planning,– Evaluate hindfoot and Evaluate hindfoot and

midfoot if needed.midfoot if needed.• MRIMRI

– Ligament and tendon Ligament and tendon injury,injury,

– Syndesmosis injuries.Syndesmosis injuries.

The ankle is a ringThe ankle is a ring• Tibial plafondTibial plafond• Medial malleolusMedial malleolus• Deltoid ligamentsDeltoid ligaments• calcaneouscalcaneous• Lateral collateral ligamentsLateral collateral ligaments• Lateral malleolusLateral malleolus• SyndesmosisSyndesmosis

Fracture of single part Fracture of single part usually stableusually stable

Fracture > 1 part = Fracture > 1 part = unstableunstable

Classification SystemClassification System Classification systems:Classification systems:

•Lauge-Hansen,Lauge-Hansen,•Weber,Weber,•OTA.OTA.

Additional Anatomic Evaluation:Additional Anatomic Evaluation:•Posterior Malleolar Fractures,Posterior Malleolar Fractures,•Syndesmotic Injuries,Syndesmotic Injuries,•Common Eponyms.Common Eponyms.

Lauge-Hansen Lauge-Hansen ClassificationClassification

Four Patterns are recognized, based on PURE injury Four Patterns are recognized, based on PURE injury sequences, each subdivided into stages of increasing severity.sequences, each subdivided into stages of increasing severity.

Based on Cadaveric studies.Based on Cadaveric studies. First word: Position of foot at time of injuryFirst word: Position of foot at time of injury Second word: Force applied to foot relative to tibia at time of Second word: Force applied to foot relative to tibia at time of

injury.injury.

Types: SER SAd PER PAb

Several stages per type with increasing severity.Several stages per type with increasing severity.

Imperfect system:Imperfect system:• Not every fracture fits exactly into one categoryNot every fracture fits exactly into one category

• Even mechanismEven mechanismspecific pattern has been specific pattern has been questionedquestioned

• Inter and intraobserver variation not idealInter and intraobserver variation not ideal

• Still useful and widely usedStill useful and widely used

Remember the injury starts on the tight side of the ankle.! The lateral side is tight in supination, while the medial side is tight in pronation.

Supination-External Supination-External RotationRotation

Accounts for 40 to 75% of Malleolar fractures.Stage 1- AITFL disruption,Stage 2- Spiral # of Fibula,Stage 3- PITFL disruption or PM #,Stage 4-Deltoid Ligament disruption or transverse # of MM

Standard: Closed management

Lateral Injury: classic posterosuperioranteroinferior fibula fracture

Medial Injury: Stability maintained

Lateral Injury: classic posterosuperioranteroinferior fibula fracture

Medial Injury: medial malleolar fracture &*/or deltoid ligament injury

Standard: Surgical management

GOAL: TO EVALUATE DEEP DELTOID [i.e. INSTABILITY]

METHOD: MEDIAL TENDERNESS

MEDIAL SWELLING

MEDIAL ECCHYMOSIS

STRESS VIEWS- GRAVITY OR MANUAL

+ Stress View

Widened Medial Clear Space

SE-4SE-4

Supination AdductionSupination Adduction

Accounts for 10-20% of Accounts for 10-20% of Malleolar fractures.Malleolar fractures.

Stage 1: Transverse # Stage 1: Transverse # of Fibula (Weber A or B),of Fibula (Weber A or B),

Stage 2: Vertical medial Stage 2: Vertical medial malleolus #.malleolus #.

Supination Supination Adduction: Stage 2Adduction: Stage 2

Lateral Injury: transverse fibular fracture at/below level of mortise

Medial injury: vertical shear type medial malleolar fracture

Pronation-External Pronation-External RotationRotation

Accounts for 5 to 20% Accounts for 5 to 20% of malleolar fractures.of malleolar fractures.

Stage 1 – Deltoid Stage 1 – Deltoid disruption or transverse disruption or transverse # medial malleolus.# medial malleolus.

Stage 2- AITFL Stage 2- AITFL disruption.disruption.

Stage 3 –Spiral # of Stage 3 –Spiral # of fibula (Weber C).fibula (Weber C).

Stage 4 – PITFL Stage 4 – PITFL disruption or posterior disruption or posterior malleolus #.malleolus #.

Pronation External Pronation External Rotation: Stage 4Rotation: Stage 4

Medial injury: deltoid ligament tear &/or transverse medial malleolar fracture

Lateral Injury: spiral proximal lateral malleolar fracture

HIGHLY UNSTABLE…SYNDESMOTIC INJURY COMMON

• Must x-ray knee to ankle to Must x-ray knee to ankle to assess injury.assess injury.

• Syndesmosis is disrupted in Syndesmosis is disrupted in most cases.most cases.-Eponym: Maissoneuve -Eponym: Maissoneuve

FractureFracture• Restore:Restore:

– Fibular length and Fibular length and rotation,rotation,

– Ankle mortise,Ankle mortise,– Syndesmotic stability.Syndesmotic stability.

Pronation-AbductionPronation-Abduction

Accounts for 5 to 20% of Accounts for 5 to 20% of malleolar fractures.malleolar fractures.

Stage 1 – Transverse # of Stage 1 – Transverse # of MM or deltoid ligament MM or deltoid ligament disruption,disruption,

Stage 2 – PITFL Stage 2 – PITFL disruption or PM fracture.disruption or PM fracture.

Stage 3 – Compression Stage 3 – Compression bending of fibula leads to bending of fibula leads to transverse or short transverse or short oblique communited oblique communited fracture.fracture.

Pronation-AbductionPronation-Abduction

Medial injury: tranverse to short oblique medial malleolar fracture

Lateral Injury: comminuted impaction type lateral malleolar fracture

Based on location of Based on location of fibula fracture relative to fibula fracture relative to mortise and appearance.mortise and appearance.

Weber A fibula below Weber A fibula below to mortise.(SAD)to mortise.(SAD) Weber B fibula at level Weber B fibula at level of mortise.(SER)of mortise.(SER) Weber C fibula above Weber C fibula above to mortise.(PER)to mortise.(PER)Concept - The higher the Concept - The higher the fibula # the more severe fibula # the more severe the injury in terms of the injury in terms of syndesmosis disruption.syndesmosis disruption.

Alpha-Numeric Alpha-Numeric CodeCode

Tibia =4

Malleolar segment =4

Infrasyndesmotic=44A

Suprasyndesmotic=44C

Transsyndesmotic=44B

+

AO classification divides the three Danis Weber types further for associated medial injuries.

Alpha-Numeric Alpha-Numeric CodeCode

Infrasyndesmotic=44A

Alpha-Numeric Alpha-Numeric CodeCode

Transsyndesmotic=44B

Alpha-Numeric Alpha-Numeric CodeCode

Suprasyndesmotic=44C

Function: Stability- Prevents posterior translation of talus &

enhances syndesmotic stability,Weight bearing- increases surface area of ankle joint.

• Fracture pattern:Fracture pattern:– VariableVariable– Difficult to assess on standard lateral Difficult to assess on standard lateral

radiograph, so require:radiograph, so require:• External rotation lateral view External rotation lateral view • CT scan CT scan

Type I- posterolateral oblique type Type II- medial extension type

Type III- small shell type

67% 19%

14%

FUNCTION:

Stability- Resists external rotation, axial, & lateral displacement of talus

Weight bearing- Allows for equal loading of weight.

• Maisonneuve Fracture– Fracture of proximal fibula

with syndesmotic disruption.• Volkmann Fracture

– Fracture of tibial attachment of PITFL.

– Posterior malleolar fracture.• Tillaux-Chaput Fracture

– Fracture of tibial attachment of AITFL

Pott fracture:In the Pott fracture, the fibula is fractured above the intact distal tibiofibular syndesmosis, the deltoid ligament is ruptured, and the talus is subluxed laterally.

Dupuytren fracture:(A) This fracture usually occurs 2 to 7 cm above the distal tibiofibular syndesmosis, with disruption of the medial collateral ligament and, typically, tear of the syndesmosis leading to ankle instability.(B) In the low variant, the fracture occurs more distally and the tibiofibular ligament remains intact.

Wagstaffe-LeFort fracture:In the Wagstaffe-LeFort fracture,on the anteroposterior view, the medial portion of the fibula is avulsed at the insertion of the anterior tibiofibular ligament. The ligament, however, remains intact.

•Collicular FracturesCollicular Fractures–Avulsion fracture of Avulsion fracture of distal portion of medial distal portion of medial malleolusmalleolus–Injury may continue Injury may continue and rupture the deep and rupture the deep deltoid ligamentdeltoid ligament

•Bosworth fracture Bosworth fracture dislocationdislocation

–Fibular fracture with Fibular fracture with posterior dislocation of posterior dislocation of proximal fibular proximal fibular segment behind tibia.segment behind tibia.

POSTERIOR COLLICULUS ANTERIOR COLLICULUS

INTERCOLLICULAR GROOVE

Tibial Pilon Fractures

The terms tibial plafond fracture, pilon fracture, and distal tibial explosion fracture all have been used to describe intraarticular fractures of the distal tibia.

Accounts for 7 to 10% of all tibia fractures.

Most common in men of 30-40 years.

These terms encompass a spectrum of skeletal injury ranging from fractures caused by low-energy rotational forces to fractures caused by high-energy axial compression forces arising from motor vehicle accidents or falls from a height.

Source:Rosen

Rotational variants typically have a more favorable prognosis, whereas high-energy fractures frequently are associated with open wounds or severe, closed, soft-tissue trauma.

-Because of their high energy nature, these fractures can be expected to have specific associated injuries to calcaneum, tibial plateau, pelvis and vertebral fractures.

-Swelling is often massive and rapid, required serial assessment of skin integrity, necrosis and fracture blisters.

-Meticulous assessment of soft tissue damage is of paramount importance.

-Some advise waiting 7 to 10 days for soft tissue healing to occur before planning surgery.

Ruedi and Allgower Ruedi and Allgower classification:classification:

-Based on the severity of -Based on the severity of comminuation and displacement of comminuation and displacement of the articular surface.the articular surface.

-Poor prognosis with increasing grade.-Poor prognosis with increasing grade.

Type I- Nondisplaced cleavage Type I- Nondisplaced cleavage fracture of ankle joint.fracture of ankle joint.

Type II- Displaced fracture with Type II- Displaced fracture with minimal impaction or comminution.minimal impaction or comminution.

Type III- Displaced fracture with Type III- Displaced fracture with significant articular comminution significant articular comminution and metaphyseal impaction. and metaphyseal impaction.

CLASSIFICATION OF ANKLE FRACTURES IN CHILDREN

Salter-Harris anatomic classification as applied to injuries of the distal tibial epiphysis.

Ankle Fracture in Children (Dias-Tachdjian classification)

TreatmentTreatment In Emergency Room Rx:In Emergency Room Rx:-Closed reduction for displaced #,-Closed reduction for displaced #,-Dislocated ankle should be reduced,-Dislocated ankle should be reduced,-Open wounds and abrasions should be -Open wounds and abrasions should be

cleansed and dressed,cleansed and dressed,-Following fracture reduction a well padded -Following fracture reduction a well padded

posterior slab should be applied,posterior slab should be applied,-Postreduction radiographs should be -Postreduction radiographs should be

obtained for fracture asessment.obtained for fracture asessment.-Limb must be elevated for reducing -Limb must be elevated for reducing

swelling.swelling.

Non- operative RxNon- operative Rx Indications:Indications: -Nondisplaced, stable fractures,-Nondisplaced, stable fractures, -Displaced fracture for stable anatomic reduction -Displaced fracture for stable anatomic reduction

of ankle mortise is achieved.of ankle mortise is achieved. -Patient not fit for surgery.-Patient not fit for surgery. Apply well padded posterior splint for first few Apply well padded posterior splint for first few

days while swelling subsides with limb elevation.days while swelling subsides with limb elevation. Then apply cast with good padding for 4 to 6 Then apply cast with good padding for 4 to 6

weeks with serial radiographic evaluation to weeks with serial radiographic evaluation to ensure maintenance of reduction and fracture ensure maintenance of reduction and fracture healing.healing.

If adequate fracture healing is present patient If adequate fracture healing is present patient can be placed in a short leg cast.can be placed in a short leg cast.

Weight bearing is restricted until fracture healing Weight bearing is restricted until fracture healing is adequate. is adequate.

Operative RxOperative Rx Majority of unstable fracture are best Majority of unstable fracture are best

treated operatively.treated operatively. ORIF is indicated for:ORIF is indicated for: -Failure to achieve or maintain closed -Failure to achieve or maintain closed

reduction (may be due to soft tissue inter reduction (may be due to soft tissue inter position), position),

-Unstable fracture,-Unstable fracture, -Fractures that require abnormal fot -Fractures that require abnormal fot

positioning to maintain reduction( extreme positioning to maintain reduction( extreme planter flexion),planter flexion),

-Open fractures.-Open fractures.

ORIF should be performed when patients ORIF should be performed when patients general medical condition, swelling around general medical condition, swelling around ankle and soft tissue status allow.ankle and soft tissue status allow.

Usually swelling, blisters and soft tissue Usually swelling, blisters and soft tissue issues stabilize within 7 to 10 days.issues stabilize within 7 to 10 days.

Occasionally , a closed fracture with Occasionally , a closed fracture with severe soft tissue trauma and swellin may severe soft tissue trauma and swellin may require reduction and stabilization with require reduction and stabilization with external fixation to allow soft tissue external fixation to allow soft tissue management before definitive fixation.management before definitive fixation.

Lateral malleolar fractures Lateral malleolar fractures distal to syndesmosis: lag distal to syndesmosis: lag screw or k- wire with screw or k- wire with tension banding.tension banding.

Lat. Malleolar fractures at Lat. Malleolar fractures at or above syndesmosis or above syndesmosis require accurate reduction require accurate reduction and restoration of fibular and restoration of fibular length: combination of lag length: combination of lag screws and plate.screws and plate.

For Medial malleolar fractures For Medial malleolar fractures ORIF indications are:ORIF indications are:

-Fracture with syndesmotic -Fracture with syndesmotic injury,injury,

-Persistent widening of medial -Persistent widening of medial clear space following fibula clear space following fibula reduction,reduction,

-Inability to obtain adequate -Inability to obtain adequate fibular reduction,fibular reduction,

-Persistent medial fracture -Persistent medial fracture displacement after fibular displacement after fibular fixation.fixation.

Usually stabilized with Usually stabilized with cancellous screw or a figure cancellous screw or a figure of 8 tension band. of 8 tension band.

Indication for fixation of posterior Indication for fixation of posterior malleolar fracture are:malleolar fracture are:

-Involvement of >25% of articular surface,-Involvement of >25% of articular surface, -> 2mm displacement,-> 2mm displacement, -Persistent posterior subluxation of talus.-Persistent posterior subluxation of talus.

Fixation is achieved by indirect reduction Fixation is achieved by indirect reduction and placement of an anterior to posterior and placement of an anterior to posterior lag screw or a posteriorly placed plate.lag screw or a posteriorly placed plate.

Posterior Malleolus Posterior Malleolus Fracture: FixationFracture: Fixation

Screws Screws

PlatesPlates

Syndesmotic Injury RxSyndesmotic Injury Rx Fibular fractures above the plafond may Fibular fractures above the plafond may

require syndesmotic stabilization.require syndesmotic stabilization. After fixation of the medial and lateral After fixation of the medial and lateral

malleoli, the syndesmosis should be malleoli, the syndesmosis should be stressed intra-operatively by lateral pull on stressed intra-operatively by lateral pull on the fibula with a bone hook or by stressing the fibula with a bone hook or by stressing the ankle in external rotation.the ankle in external rotation.

Syndesmotic instability can then be Syndesmotic instability can then be recognised clinically and under C-arm.recognised clinically and under C-arm.

Distal tibia-fibula Distal tibia-fibula joint reduction is joint reduction is held with a large held with a large pointed pointed reduction clamp.reduction clamp.

Now a Now a syndesmotic syndesmotic screw is placed screw is placed 1.5 to 2.0 cm 1.5 to 2.0 cm above the above the plafond from the plafond from the fibula to the fibula to the tibia.tibia.

Syndesmotic Screw Controversy Syndesmotic Screw Controversy

3.5 mm vs 4.5 mm 3.5 mm vs 4.5 mm screw(s)screw(s)

3 cortices vs 4 cortices3 cortices vs 4 cortices

Retain vs RemovalRetain vs Removal

Metallic vs BioabsorbableMetallic vs Bioabsorbable

TIBIAL PILON FRACTURE RxTIBIAL PILON FRACTURE Rx

1.1. Plaster immobilization Plaster immobilization 2.2. TractionTraction3.3. Lag screw fixationLag screw fixation4.4. OR & IF with platesOR & IF with plates5.5. External fixation with or External fixation with or

without limited internal without limited internal fixation.fixation.

Wait for 7 to 10 days for soft tissue healing to occur before planning surgery.

If articular If articular incongruity <2 incongruity <2 mm and reserved mm and reserved for low energy for low energy injuries .injuries .

ComplicationComplicationss PerioperativePerioperative

• MalreductionMalreduction• Inadequate fixationInadequate fixation• Intra-articular hardware penetrationIntra-articular hardware penetration

Early PostoperativeEarly Postoperative• Wound edge dehiscence/necrosis,Wound edge dehiscence/necrosis,• Infection,Infection,

LateLate• Stiffness,Stiffness,• Persistent oedema,Persistent oedema,• Malunion,Malunion,• Nonunion,Nonunion,• Post-traumatic arthritis,Post-traumatic arthritis,• Hardware related complications.Hardware related complications.

COMPLICATIONSCOMPLICATIONS