Closed ankle injuries
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Transcript of Closed ankle injuries
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CLOSED ANKLE INJURIES
DR BASSEY A E
UATH, GWAGWALADA
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OUTLINE• Introduction
• Definition• Statement of importance• Epidemiology
• Anatomy of the ankle joint• Components• Stability
• Types of ankle injuries• Soft tissue injuries – Ligament injuries, Peroneal tendon dislocation• Fractures – Malleolar, Pilon, Physeal injuries
• Treatment• Complications
• Early • Late
• Current trends• Conclusion• References
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INTRODUCTION • Ankle injury refers to disruption of any
component or components of the ankle joint following trauma. When the site of such disruption has no communication with the external environment, it is described as closed.
• Ankle injuries occur frequently, and have high propensity for complications. Adequate knowledge of these injuries is therefore imperative in order to achieve satisfactory outcomes
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INTRODUCTION
• In the USA,• Incidence – 628,000/year• Ankle injuries constitute 20% of joint injuries• They comprise 25% of sports injury
• In the UK• Accounts for 3 – 5% of ER visits
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ANATOMY OF THE ANKLE JOINT• It is a synovial joint
with a mortise and tenon configuration
• It is a hinge joint
• Has bony and soft tissue components
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ANATOMY OF THE ANKLE JOINT
• Bones – tibia, fibula & talus
• Soft tissue – lateral collateral ligament complex, medial collateral (deltoid) ligament, tibiofibular syndesmosis
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ANATOMY OF THE ANKLE JOINT
• Stabilizing factors– Ligaments – deltoid ligament is the major
stabilizer– Peroneal tendons– Bony configuration
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TYPES OF INJURIES• Soft tissue injuries– Ligament injuries • Lateral collateral ligament injury• Deltoid ligament injury
– Syndesmotic injury– Peroneal tendon dislocation
• Fractures – Malleolar fractures– Pilon fractures– Physeal injuries
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SOFT TISSUE INJURIESINJURY REMARKS MECHANISM
OF INJURYCLINICAL FEATURES XRAY FINDINGS
LATERAL LIGAMENT INNJURY
Makes up 75% of ankle injury.
Isolated ATFL injury 60 – 70%, ATFL + CFL injury 20%
PTFL is the strongest and rarely injured
Forced inversion and plantarflexion
Pain and swelling ffl twisting of ankle after accidentally stepping into a pothole or kicking a kerb
Tenderness maximal inferior and slightly anterior to lat malleolus
Talar tilt (≥15o or 5o ≥ normal ankle), anterior drawer (≥10mm or 5mm ≥ normal ankle)
Assoc injuries – undisplaced fibular #/# 5th metatarsal
Soft tissue swelling
Chip avulsion fracture of tip of lat malleolus or talus
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SOFT TISSUE INJURIES
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SOFT TISSUE INJURIESINJURY REMARKS MECHANISM
OF INJURYCLINICAL FEATURES
XRAY FINDINGS
MEDIAL (DELTOID) LIGAMENT INJURY
Isolated injury is rare
Forced eversion and external rotation
Eversion test – for deloid ligament
External rotation stress test – for syndesmosis
Widening of medial joint space
Talar tilt
Syndesmotic diastasis
# distal fibula
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SOFT TISSUE INJURIESINJURY REMARKS MECHANISM CLINICAL
FEATURESXRAY FINDINGS
SYNDESMOTIC INJURY
Partial – ant tibiofibular ligament injury
Complete – all ligaments
Partial – forced external rotation
Complete – severe abduction force
Pain in front of ankle
Marked tenderness directly over syndesmosis
Squeeze test +ve
May be isolated or assoc with medial ligament injury or fibular fracture
Widening of tibiofibular syndesmosis
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SOFT TISSUE INJURIESINJURY REMARKS MECHANISM
OF INJURYCLINICAL FEATURES
XRAY FINDINGS
PERONEAL TENDON DISLOCATION
May be mistaken for lateral ligament injury
Injury to superior peroneal retinaculum or chip avulsion of its attachment to lat malleolus
Dislocation of peroneal tendons anteriorly over fibula on dorsiflexion and eversion
Oblique fracture of lateral malleolus
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FRACTURESINJURY REMARKS MECHANISM
OF INJURYCLASSIFICATION
CLINICAL FEATURES
XRAY FINDINGS
MALLEOLAR FRACTURES
Most are low energy fractures of one or both malleoli
Never forget the often-present associated ligament injury
Forward fall with foot anchored to the ground
Talar tilt or rotation results in malleolar fracture
Danis-Weber
Lauge-Hansen
Hx of severe ankle twist followed by pain & inability to bear weight
Deformity may be obvious
Reveals fracture site as well as associated ligament or syndesmotic injury
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DANIS-WEBER CLASSIFICATIONType A– below the level of the
talar dome– usually transverse– tibiofibular
syndesmosis intact– deltoid ligament intact– medial malleolus often
fractured– usually stable if medial
malleolus intact
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• Type B– distal extent at the level of
the talar dome; may extend some distance proximally
– tibiofibular syndesmosis usually intact, but widening of the distal tibiofibular joint (especially on stressed views) indicates syndesmotic injury
– medial malleolus may be fractured
– deltoid ligament may be torn– Stability depends on status
of medial structures
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• Type C– above the level of the
ankle joint– tibiofibular syndesmosis
disrupted – medial malleolus fracture
or deltoid ligament injury present
– fracture may arise as proximally as the level of fibular neck and not visualised on ankle films, requiring knee or full length tibia-fibula films (Maissonneuve fracture)
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MALLEOLAR FRACTURES – DANIS-WEBER CLASSIFICATION
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LAUGE-HANSEN CLASSIFICATION• Supination-adduction (Weber A)• Supination-external rotation (Weber B)
– stage 1: the anteroinferior tibiofibular ligament is torn or avulsed
– stage 2: the talus displaces and fractures the fibula in an oblique or spiral fracture, starting at the joint.
– stage 3: tear of the posteroinferior tibiofibular ligament or fracture posterior malleolus
– stage 4: tear of the deltoid ligament or transverse fracture medial malleolus
• Pronation-abduction (Weber C)• Pronation-external rotation (Weber C)• Pronation-dorsiflexion (Weber C
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FRACTURESINJURY REMARK MECHANISM
OF INJURYCLASSIFICATION
CLINICAL FEATURES
XRAY FINDINGS
PILON FRACTURES
Intra-articular
High-energy fractures
Large compressive force drives talus upwards against tibial plafond
Articular cartilage and subchondral bone are damaged
Ruedi-Allgower
Pain, swelling, fracture blisters are common
Comminuted # distal tibia extending into ankle joint. # line may extend into tibial shaft
Fibula often fractured as well
CT better than Xrays
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FRACTURESINJURY REMARKS MECHANISM
OF INJURYCLASSIFICATION
CLINICAL FEATURES
XRAY FINDINGS
PHYSEAL INJURY
A third of physeal injuries occur in the ankle
With foot fixed to the ground or trapped in a crevice the ankle is twisted
With severe twist fibular fracture may occur
Salter-Harris Pain, swelling, deformity
Fracture line usually obvious but undisplaced fractures can be easily missed
Repeat Xray in 1 week if physeal injury
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TREATMENT• LATERAL LIGAMENT INJURY
• Non-operative treatment– Achieved by RICE
• Operative treatment– Indicated when problems persist after 12 weeks of treatment
including physiotherapy– Problems often due to cartilage damage or presence of scar
tissue in ankle joint– Surgical treatment may be open or arthroscopic
• MEDIAL LIGAMENT INJURY• Non-operative treatment
– Reduction of medial joint space and splintage
• Operative treatment– Indicated where medial joint space is cannot be reduced,
associated fibular fracture or diastasis
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TREATMENT
• SYNDESMOTIC INJURY• Non-operative treatment
– Partial tear: strapping of ankle joint for 3 weeks
• Operative treatment– Complete tear: ORIF with a transverse screw
• PERONEAL TENDON DISLOCATION• Non-operative treatment
– Below-knee cast for 6 weeks
• Operative treatment– Indicated if it is recurrent– Reconstruction of the retinaculum using non-absorbable
sutures
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TREATMENT
• MALLEOLAR FRACTURE• Non-operative treatment
– Isolated, undisplaced types A & B fractures– BK cast for 8 weeks
• Operative treatment– Indicated in
» Displaced Types A & B fractures that cannot be reduced closed
» Types A and B fractures with assoc ligament/syndesmotic injury
» Type C fractures
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Weber B
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TREATMENT• PILON FRACTURES
• Treatment is usually by operative means, however, even though bony union is achieved the fate of the joint is determined by severity of cartilage injury
• PHYSEAL INJURIES• SH 1 & 2 are treated non-operatively• Sh 3 & 4 if undisplaced are treated non-operatively as
well• If near-perfect reduction is not achievable by non-
operative means, then ORIF with interfragmentary screws is advocated
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COMPLICATIONS
• EARLY– Vascular injury– Nerve injury
• LATE– Recurrent sprains– Joint stiffness– Joint instability– Osteoarthritis– Malunion
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CURRENT TRENDS
• Ligament substitution with fascia lata graft in operative treatment of ankle sprain
• Arthroscopic joint debridement for impinged scar tissue
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CONCLUSION
• As long as sports and recreational activities abound ankle injuries will remain a constant component of the orthopaedic surgeon’s caseload.
• Adequate knowledge and skill in managing this frequently-occurring problem are required to forestall complications and promote good quality of life
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REFERENCES
• Apley’s system of Orthopaedics & fractures, D Warwick, S Nayagam, 9th Ed, pp 907 – 920
• http://www.medscape.com/viewarticle/826651_2
• http://www.boneschool.com/lower-limb/foot-and-ankle/trauma/ankle-injuries
• http://www.wheelessonline.com • http://radiopaedia.org/articles/weber-ankle-
fracture-classification