Introduction - cme.uthscsa.edu

Ankle Fractures

Ronald Belczyk, DPM

Fellowship Director: Thomas Zgonis, DPM

Introduction

• Incidence– 250,000 per year– Among most

common fractures treated by foot/ ankle surgeons

– Increase due to better reporting, MVA’s, stronger athletes

4th Annual International External Fixation Symposium

December 11-14, 2008

Mortise Anatomy• Mortise is a tight socket for the foot• Lateral Ligaments: ATFL, CFL, PTFL,• Deltoid lig: Superficial and deep fibers.

– Disruption leads to increased talar eversion and increased internal rotation

• Syndesmosis: Connnects the distal tibia and fibula

• Fibula :Triangular shape. Cortex thicker t l t ll thi t l t llanterolaterally, thinner posterolaterally

• Incisura: articulation between tibia and fibula

Mortise Anatomy• Not a simple hinge joint

Axis of motion– Axis of motion• line between tips of

malleoli – Saddle-shaped joint

• ankle mortise provides constrained articulation

– Tibia bears 5/6 of weight, fibula bears 1/6fibula bears 1/6

– The weight-bearing contact area of the ankle is large

• high congruence of the articular surfaces



Mortise Anatomy

• Displacement of talus leads to incongruence– 1 mm lateral shift of the talus

decreased contact area 42%– 3 mm shift decreased area >

60% (Ramsey & Hamilton, JBJS, 1976)

• Shortened or malrotated fibula allows talus to shift

• Experimental models show results on lateral translation only but talus rotates ant lat.

• Pressure = Force/ Area• Predisposes to arthritis

History • Mechanism of injury

V ti l l di– Vertical loading -axial compression

– Twisting -rotation injury

• Associated injuriesAssociated injuries• Medical co-

morbidities– i.e. Neuropathy



Physical Exam• Inspection - Swelling, open

wounds fracture blisterswounds, fracture blisters• Palpation• Anterior drawer test - ATF

stability• Talar tilt test - CF stability• Eversion stress test -

superficial deltoid ligament2 weeks later s/p closed

reduction

• External rotation stress test -syndesmotic ligaments

Radiographic Evaluation

• Intra/ Interobserver variabilityIntra/ Interobserver variability • Vary depending weight-bearing vs.

nonweight- bearing• Degree of magnification • What’s normal vs. abnormal?• How to correlate small amounts of

displacement clinically?



Radiographic Evaluation

• Mortise view: requires a neutral foot and 15Mortise view: requires a neutral foot and 15 degrees internal rotation of leg. Can see medial and lateral clear spaces

• Clear spaces should be same thickness• > 4-5mm medial clear space suggest deltoid

ligament disruptionI t t t bt i tib fib i t• Important to obtain tib-fib views to assess proximal fibular fracture

Radiographic Evaluation•Shenton’s line

•Tib-fib overlap

• Anteroposterior view

• Mortise view• Lateral view• (+/-) Stress views

•Tibiofibular line

•Talocrural Angle

•Medial clear space

•Tib- fib overlap

Tib fib overlap

•Tib-fib clear space

•Syndesmosis stress testing

•Anterior drawer

•Talar tilt

•Fibular displacement



Tibiofibular Line– On the mortise view,

a line formed by thea line formed by the subchondral bone of the distal tibia and the medial aspect of the fibula should be continuous

– Disruption of this line indicates shorteningindicates shortening, rotation, or lateral displacement of the fibula

Shenton’s Line of the AnkleShenton’s line• UnbrokenUnbroken

subchondral semi-circle of bone at distal fibula and talus

• When broken suggest a shortened fibula. Talocruralfibula. Talocrural angle correspondingly decreases



Talocrural Angle

• Mortise view, line drawn parallel to the articular psurface of the distal tibia and one connecting the tips of both malleoli (intermalleolar line)

• Normally between 8°and 15°and 15

• Within 2° to 3° of the contra lateral side

Medial Clear Space• Mortise view

Di t b t• Distance between lateral border of medial malleolus and medial border of talar dome

• Should be equal to the superior clear space, < 4mm

• Widening indicates talar shift / deltoid injury



Syndesmotic Integrity• Tibiofibular Overlap

– A-P view• overlap >10 mm at 1 cm above

joint– Mortise View

• overlap should be 1 mm or more

• Tibiofibular clear space p– A-P view

• space < 6mm, widening indicates syndesmotic injury

• Stress Testing with external rotation

Stress Views

Talar tilt of more than 5 degrees Anterior Drawer more than 4-5mm



• Rarely necessary for

CT Scany y

evaluating routine ankle fractures

• Valuable to assess complex fracture patterns– articular depression or

step-off– assess comminution or

intra-articular fragmentsintra articular fragments– locate fracture lines for

preop planning

MRI

• Rarely necessary forRarely necessary for evaluating routine ankle fractures

• Best for evaluating ligamentous or tendon injury

• Useful for• Useful for demonstrating stress fractures or osteochondral lesions



• arthroscopy of acute ankle

Arthroscopy

pyfractures demonstrates high rate of associated articular injuries - unclear clinical significance

• possible role for evaluating adequacy of articular reduction

• role of arthroscopy in acute ankle fractures remains controversial and continues to evolve

Classification

• Danis-Weber• Danis-Weber• AO• Lauge-Hansen• No prognostic significance• 80-90% are Weber B• Most are Supination/Ext Rot



Danis-Weber Classification• Based on the level of theBased on the level of the

fracture of the fibula– A= fracture distal to the

level of the sydesmosis– B= fracture at the level of

the syndesmosis– C= fracture above the

level of the syndesmosis• The more proximal the

fracture the greater the incidence of syndesmotic injury

AO Classification

• Modification of Danis-Weber system • Type A (infrasyndesmotic)• Type A (infrasyndesmotic)

– A1-isolated– A2-with fracture of medial malleolus– A3-with posteromedial fracture

• Type B (transyndesmotic)– B1-isolated– B2-with medial lesion (malleolar fx or

ligament disruption)– B3-with medial lesion and fracture of 3 t ed a es o a d actu e o

posterolateral tibia• Type C (suprasyndesmotic)

– C1-diaphyseal fracture of the fibula, simple

– C2-diaphyseal fracture of the fibula, complex

– C3-proximal fracture of the fibula



Lauge-Hansen system

• Based on the position of Understanding the MOI canBased on the position of the foot at the time of injury and the direction of the deforming force

• 90% of ankle fractures can be placed in one of the four groups

help you plan your reductionby reversing the deformity

the four groups

Distal fibula:shifts laterally, externally rotates, and displaces superior and posteriorly



Supination-External Rotation (SER)

Most common mechanism Most common mechanism • Stage I: AITFL tear • Stage II: fibula fracture at

the level of the mortise progressing anteroinferior to posterosuperior.

• Stage III: PITFL tear or a f t f th t ifracture of the posterior malleolus

• Stage IV: Deltoid ligament tear or transverse medial malleolus fracture

Pronation-External Rotation (PER)

• Pronated footPronated foot• Stresses medial tissues

and progresses laterally• Stages I-IV• Fibula fracture

– proximal to the level of the ankle jointthe ankle joint

– Posteroinferior to anterosuperior

– Syndesmotic injury• Maisonnueve fx



Supination-Adduction (SA)

• Stage I:• Stage I:– transverse fibula

fracture at or below the level of the mortise

• Stage II:– vertical medial

malleolar fracture• ORIF fibula: tension

band, Lag screws with K-wires, hook plate

• Ligament disruption, small and large transverse fibular fx., vertical medial fx with/out medial plafond injury

Pronation-Abduction• Stage I:

t di l– transverse medial malleolar fracture or deltoid injury

• Stage II:– Rupture of the

syndesmosis or avulsion fxs of theiravulsion fxs of their attachments

• Stage III:– transverse fibula

fracture at or above the ankle mortise

• Lateral comminution with lateral plafond injury. Fibular fx requires distraction to restore length.



Which Classification System is Best?

• Each has merits and shortcomings• Each has merits and shortcomings• Original Danis-Weber system

– ignored medial injury– not prognostic for outcome of surgical

treatment– simpler, emphasis on level of fibula fracture

helps determine need for surgical treatmenthelps determine need for surgical treatment• Lauge-Hansen system is complex but

prognostic especially for SER patterns– Aids in planning reduction maneuvers

• Restore complete function with the least risk to the

General Treatment

Restore complete function with the least risk to the patient and the least anxiety for the surgeon

• Stable injuries: intact deep deltoid and medial malleolus, talus reduced under the plafonds

• Unstable injuries: mortise disrupted, fracture/ ligament disruption medially and laterally. Treat with ORIF. Non operative treatment increases risks of

li ticomplications.



• Ankle mortise incongruity is poorly tolerated and

General Treatment

Ankle mortise incongruity is poorly tolerated and causes abnormal loads on cartilage

• Restore complete function with the least risk to the patient and the least anxiety for the surgeon

• Stable injuries: intact deep deltoid and medial malleolus, talus reduced under the plafond

• Unstable injuries: mortise disrupted, fracture/ ligament disruption medially and laterally. Treat with ORIF. Non operative treatment increases risks of complications.

Stable Injuries

• SLWC can be used• SLWC can be used• Radiographic healing lags clinical healing• Good results noted in 94-98% in Stage II SER

even with up to 3 mm of displacement of the fibula as long as talus is reducedOth t di h t d t t d• Other studies have not demonstrated any advantage to ORIF for Stage II injuries



Nonsurgical Management• Nondisplaced or stable fractures• Displaced fractures when an

anatomical reduction is obtainedanatomical reduction is obtained and maintained

• Contraindications for surgery – Local or systemic

• Stable Fractures– Cast, Prefabricated Boot– Protect until radiographic union

• Unstable fracture with anatomic• Unstable fracture with anatomic reduction– Bulky Jones dressing until

swelling has subsided– Long leg cast for up to 6 weeks– Weekly radiographs for first

month

• Failure of closed reduction

Indications for Surgical Management

– loss of reduction – abnormal positioning of

the foot required to maintain reduction

• Displaced fractures • Bimalleolar or trimalleolar

fractures• Bimalleolar or trimalleolar• Bimalleolar or trimalleolar

equivalent pattern (deltoid ligament ruptured)

• Open fractures• Current trend toward ORIF for

displaced fracture that involves articular surface



Surgical Pearls for the Unstable distal fibula fractures

• Anatomic reduction preferred• Anatomic reduction preferred• Stabilize the fibula with a neutralization plate such 1/3

tubular, reconstruction plate, antiglide plate, or double technique

• If the reduction is anatomic after fibular fixation, deltoid ligament exploration and repair is not necessary

• If there is a medial block then medial exploration is necessary

• Once ankle is stable, postop routine is the same as nonoperative treatment in Normosensate patients

Surgical PrinciplesPreoperative planning• The Patient• The Patient• Timing of surgery• Good xrays• Choice of incision• Selection of implants

– Small frag. , tension band wiring, • Use of templates

– Correct length, rotation, and alignment of bone– Length of fibular plate and number of screws– Function of screws

• i.e lag screw positioning Intraoperative tacticsIntraoperative• Type of anesthesia• ? need for tourniquet• positioning/ approach, implants/ instrumentation,

radiolucent table special equipment for reduction, bone grafting, blood products

• Supportive services: C-arm, arthroscopyPostoperative Care• Splinting



Surgical Principles• Preoperative managementp g

– Reduce fracture/dislocation and if very unstable use a long leg cast or long leg splint

– Immobilize in bulky splint to prevent further soft-tissue injury and decrease swelling

– Ice, elevation of the extremity, compression +/-pneumatic foot pump to reduce swelling

– Pre-operative antibioticsPre operative antibiotics– First generation cephalosporin x 24 - 48 hours

perioperatively– Surgery can be done electively



Incision planning

L lLateral

Posterolateral

Anterolateral

Medial

AnteromedialAnteromedial

Advice: •Know the anatomy!

•Don’t cut any more nerves/ tendons/ vessels than are absolutely necessary

L S

• Early Development:– Founders (1958)

Müller,Allgöwer,Willnegger, Schneider

Load Bearing ConstructImplant completely removes stress from bone

Basic AO Techniques

Lag Screw•Lag by technique

•by design

•Interfragmentary compression

– First AO book (1962)– First AO manual (1969)

• Arbeitgemeinschaft fur Osteosynthesisfragen

• Association for the Study of Internal Fixation

• Instituted specific methods to increase the effectiveness of

3.5 cortical

Lateral plateneutralize or absorb any disruptive forces: torsional, shear, or bending to which the bone and osteosynthesis may be subjected.

internal fixation• Principles: Atraumatic soft tissue

technique, Anatomic reduction, Rigid internal fixation, Early active ROM

4.0 cancellous



• Small frag – (3.5, 4.0 mm, 1/3 tubular plate)

Basic AO Techniques

• 3.5 mm Cortical ScrewScrew specification– Head diameter 6.0 mm– Core diameter 2 4 mm

• 4.0 Partially Threaded Cancellous

Screw specification– Head diameter 6.0 mm

• 4.0 Fully Threaded Cancellous

Screw specification– Head diameter 6.0 mmCore diameter 2.4 mm

– Thread diameter 3.5 mm– Pitch 1.25– Hexagonal socket 2.5

mm

Head diameter 6.0 mm– Shank diameter 2.3 mm– Pitch 1.75 mm– Core diameter 1.9 mm– Thread diameter 4.0mm– Hexagonal socket 2.5 mm

Head diameter 6.0 mm– Core diameter 1.9 mm– Thread diameter 4.0 mm– Pitch 1.75– Hexagonal socket 2.5

mm

Bimalleolar Fractures

E if i iti l d ti iE if i iti l d ti i• Even if initial reduction is successful, maintaining reduction in cast is difficult secondary to edema– fragment displacement is

common as swelling subsides in castORIF is the treatment of

• Even if initial reduction is successful, maintaining reduction in cast is difficult secondary to edema– fragment displacement is

common as swelling subsides in castORIF is the treatment of– ORIF is the treatment of choice for displaced fractures

– ORIF is the treatment of choice for displaced fractures



Bimalleolar Ankle Fractures• Often unstable fracture

pattern and requires

SER IV with comminuted fibula

Fixated with 4.0 cancellous screw p qsurgical intervention

• 85 – 90% good results at 3 years after ORIF– Phillips WA, et al.

JBJS, 1985

and neutralization plate

Bimalleolar-equivalent Injuries

• Anatomic fixation of fibula with restoration of joint congruity

• 90% good results at 3 years after ORIF of SER IV fractures with deltoid tear



• Determination of medial ligamentous instability

Current Topics

• Determination of medial ligamentous instability• Lateral Fixation: Lateral vs. Posterior• Medial Malleolus Fixation• Posterior Malleolar Fixation• Syndesmotic Fixation Issues• Advanced Techniques• Postoperative Management• Factors that affect outcomes

Determination of Medial Ankle Instability

Cli i l fi di f di l id d t d• Clinical findings of medial sided tenderness• Radiographic evidence of medial space

widening• Inability to reduce the fracture



Determination of Medial Ankle Instability

Should the Deltoid be Repaired?• Indication for medial joint exploration = widened• Indication for medial joint exploration = widened

medial clear space intraoperatively after fibula fixation– Interposed tissue: posterior tibial tendon,

deltoid ligament, osteochondral fragments• Repair of deltoid may actually lead to poorer

results…controversial• Campbell’s says that some fibers of the deltoid

can block reduction and arthrotomy adds little morbidity to the procedure

• Recent literature suggests that medial malleolar fracture and deltoid ligament tear may coexist (Tornetta, JBJS, June 2000)

Antiglide plateLateral plate

Lateral vs. Antiglide Plating

• Advantages– Less exposure and bending need to

apply plate– Can be used to reduce fracture– Bicortical screws distal fragment– Avoids joint penetration

• Advantages– Can be used with syndesmotic screw– Avoid sural nerve with incision

• Disadvantages– Prominent lateral screws may cause

symptoms or wound necrosis– Possibility of distal intra-articular screw

insertion– Fibular cortex thicker ant lat– Less prominent hardware– Same incision for direct reduction of

Volkman’s fracture• Disadvantages

– Peroneal tendonitis– Potential sural nerve injury

– Inadequate fixation if distal screws are too short

– May not allow adequate fixation in osteoporotic bone

– May interfere w/ syndesmotic screw insertion



Isolated Undisplaced Medial Malleolar Fracture

Medial Malleolus Fixation

p• Treatment is controversial but consider ORIF in

high demand individuals• Isolated medial fractures are uncommon• R/O non-displaced or proximal fibular fracture• Non-displaced isolated medial malleolar fractures

– 4 - 6 weeks of cast immobilization5 15% i t ith ti– 5 - 15% nonunion rate with conservative management

• Inadequate reduction• Interposed soft tissue• Impaired blood flow?

• ORIF recommended if > 2mm


displacement (avoids varus)• Approximately 1% nonunion rate• Parallel 4mm lag screws

– Screw threads should gain purchase in distal metaphysis 2 - 4 cm above joint, where

SAD II

Fixated with 4.0 cancellous screw

j ,dense cancellous bone is present

– Not necessary to engage the opposite cortex unless osteoporosis is present





PEARLS:PEARLS:

• Screws posterior to Ant. Colliculus are at risk for injury and abutment of PTTD

• Use of the triple guide could allow for placement of 2 screws in anterior colliculus.

• In smaller specimens, the triple guide can place middle screw too far posteriorly- risking contact with the PTTD.

• If screw in posterior colliculus needed, then

• Zone 1: Anterior Colliculus• Zone 2: Intercollicular

groove• Zone 3: Posterior Colliculus

plan for hardware removal after fracture healing.



Medial Malleolar Fractures• Tension band wire technique

– Useful for very distal F t

SER IV

Fixated with 2 interfragmentary screws lag by h i 1/3 b l l i h 3 5– Fractures

– Provides dynamic compression

• Compression beyond the compression of the fracture achieved through static compression

• The implant is

technique, 1/3 tubular plate with 3.5 screws, tension band with cancellous screw

The implant is subjected to a physiological load which generates additional compression at the fracture plane

– Tension Band with screw provides greater strength

Competence of the Deltoid Ligament in Bimalleolar Ankle Fractures after

Medial Malleolar Fixation

The medial malleolar fracture is a supracollicular fragment,so both the anterior and posterior attachments of the deltoid are intact. No deltoid tear is present



Example of Deltoid ligament tear with a medial malleolus fracture

The fracture of the medial malleolus extends only throughthe anterior colliculus, so the injury occurs partly throughbone anteriorly and the deltoid posteriorly. Because the deepdeltoid is torn, anterior fixation does not restore stability

Posterior Malleolar Fixation

M di l & l t l i j i t t d• Medial & lateral injuries treated in same fashion as for bimalleolar fractures

• Posterior fragment is usually posterolateral

• Ligamentotaxis – Reduces the posterior

malleolar fragment with lateral malleolar fracture reduction

– Posterior inferior tibiofibular ligament

– Posterior ankle joint capsule (dorsiflex ankle)



• Indications for fixation of the posterior malleolar

Posterior Malleolar FixationIndications for fixation of the posterior malleolar fragment– Fractures involving > 25% of the articular surface

• Retrospective studies suggest that posterior subluxation of talus may occur with fractures involving > 25%

• Lateral plain x-ray often overestimates size of posterior fragment, CT more accurate

• CT scan is the optimal way to visualize the fracture and observe its extent

• Do not accept any posterior subluxation. Remember the lateral process of the talus

• Small avulsion fractures-


nonoperative• Large fragments (aka

posterior pilon fx)- ORIF– Stabilize the ankle,

restore contact area/ pressure

– What shape/ size of fracture

• CT




• Open reduction through a posterior-lateral incision– INDIRECT APPROACH

• Anterior to posterior screw fixation

– DIRECT APPOACH• Posterior to anterior

screw fixationscrew fixation

Syndesmotic Fixation Issues

Usually stable once medial malleolus is– Usually stable once medial malleolus is fixed and the fibula is anatomically aligned

– Recent study suggests that anterior colliculus medial malleolar fractures may occur with deltoid ligament injury, clinical syndesmotic instability may still exist after medial malleolar fixationmedial malleolar fixation

– The deep deltoid attaches to the posterior colliculus and the ligament tears



Stress Testing of SER Fibula FXMcConnell et al. JBJS 2004

• 97 patients had an isolated fibula fx with an intact kl ti hi h d t b SER IIankle mortise which appeared to be SER II

• 61 (63%) had a negative stress test• 36 (37%) had a positive stress test and were

reclassified as SER IV• Positive predictive value of severe medial

tenderness in predicting instability was only 56%• Negative predictive value of no or little g p

tenderness in predicting a stable injury was only69%

• Positive stress test was medial clear space of > 4mm and 1 mm > superior space

• ??? Should we be stressing undisplaced SER II


Why stabilize the syndesmosis?Why stabilize the syndesmosis?• Pronation injuries tear/ rupture/destabilizes syndesmosis• Allow ligaments to healWhy not?• Not needed

– Injuries involving the syndesmosis remain controversial– Some studies support the lateral malleolus as the key to stability

while others suggest medial malleolus is the keyI hibit l A kl j i t ROM– Inhibits normal Ankle joint ROM

– Danger with plating proximal fibula fractures (peroneal nerve)– Screws loosen and break after WB– Chronic pain over AITFL– Additional surgery for removal




When does syndesmosis need stability?When does syndesmosis need stability?• Disruption of the syndesmosis did not cause ankle

instability if no medial injury involved• If syndesmosis injured and fx of fibula was > 4.5 cm

above plafond coupled with medial injury then ankle instability resulted

• If fibula fracture < 3 cm above plafond no instability• If fibula fracture < 3 cm above plafond no instability resulted

Boden studied syndesmotic injury in cadavers (JBJS 1999)


When does syndesmosis need stability?When does syndesmosis need stability?

– Other cadaveric studies suggest that syndesmotic fixation is necessary when the fibula fracture is 7cm or more proximal to the ankle joint

– Intraoperative stress testing of syndesmosis after fibular fixation to determine if syndesmotic fixation isfibular fixation to determine if syndesmotic fixation is necessary

• Cotton test




How not to stabilizeHow not to stabilize the syndesmosis?


How to stabilize the syndesmosis?How to stabilize the syndesmosis?Many controversies• Material: Stainless steel vs. Titanium• One or two screws• 3.5 vs. 4.5 mm cortical screws• Three vs. Four cortices• Position of ankle when screw

placementp• Removal prior to weight bearing?




How to stabilize the syndesmosis?How to stabilize the syndesmosis?Many controversies• Role of New technology: absorbable ,

endobutton


PEARLSPEARLS• Check stability of syndesmosis after fibular length restored,

fixed, and medial side reconstructed– Hook test, Stress External rotation– Widening of > 2mm medial space suggest instability

• Anterior syndesmosis– Expose to fix Tillaux Chaput, Wagstaffe, or AITF

• Fibulotibial “syndesmotic” positioning screw– PA 25-30 degrees parallel with plafond, prox to tib fib

jointjoint– Not a lag screw– Fully tap and 3.5mm cortical screw– Maintain foot in dorsiflexion

• Trend for screw left in place longer (12 weeks)



Advanced TechniquesPreserve biology, Greater stability

Posterior Spoon technique with Double plating with hook plate

Circular Ex Fix•Load sharing device meaning implant shares stress with bone Closed ReductionTension Band plating with hook plate

Transarticular Pins•Maintains Ankle Mortise

Multiple Syndesmotic screws

Percutaneous Fixation with opposing olive wires and Ilizarov fixation

•Dynamic compression Antiglide plate•allows the distal screws to be longer and bi-corticalwithout risking joint penetrationLateral plate•greater screw placement and enhances torsionalStabilityDouble plate: forms a cage around distal fragment

Locking Plate Technology • Locking plate with 2 unicortical locking screws equivalent to standard plating with 3 screw

Advanced Techniques

• Functions as a Single Beam Construct• Whole construct has to fail• Load sharing like ex fix

p gunicortical screws

• May be beneficial in osteoporotic bone

oad s a g e e• AKA: An internal-external fixator• Better fixation in distal fibular

fragment• Less periosteal• stripping

• The torque to failure and construct stiffness were significantly greater on the side with the posterolateral antiglide plate than on the side with the the lateral locking plate



Postoperative Management• Trend toward earlier motion than in past• Stable fixation without ligamentous injuryStable fixation without ligamentous injury

– Begin motion once wound healed (2-3 weeks)– Protected weight bearing until radiographic

evidence of healing (~ 6 weeks)• Stable fixation with deltoid ligament injury

– 6 weeks immobilization - allows deltoid healing prior to instituting motionprior to instituting motion

• Syndesmotic fixation– Protected weightbearing while syndesmotic

fixation in place– Remove screw 12 weeks, advance to FWB

Postoperative Management• Motion and weight bearing both increase the forcesMotion and weight bearing both increase the forces

across the ankle joint and can lead to fracture displacement if fixation not stable

• A variety of randomized studies have been done comparing early motion versus immobilization, NWB versus protected WB

• No scientific data exists which supports the benefit of l ROM i ht b i i th h t l tearly ROM or weight bearing in the short or long term

• Early weight bearing in compliant patients is less restrictive and allows for increased mobility during the early phases of recovery.



Factors that affect outcome

Soft tissue problemsInfectionOpen fracturesOsteoporotic boneOsteochondral injuriesLigament InstabilityT d I jTendon InjuryNerve InjuryMalunion/ nonunionEquinus splinting

Open Fractures


• Similar approach as with other open fractures

• Usually a result of high energy injury– 60% MVA, 10% GSW

• Urgent surgical intervention mandatory– Adequate debridement of nonviable

tissue– Rigid anatomic fixation– 48 hrs of antibiotics– Second procedure 24 - 72 hrs

advocated with delayed primary closure

– Attempt early coverage of bone and implants

– Soft-tissue management of open wound = key to success



• Grade I and II fractures


• Grade I and II fractures– Internal fixation

acceptable• Grade III fractures

– External fixation with limited internal fixation

B f ili ith b l di hi

Summary

• Be familiar with abnormal radiographic findings

• Recognize different fracture/injury patterns• Indications for nonoperative vs. operative

intervention• Various Fixation Issues• Potential Complications



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