ANKLE FRACTURE

DUNJA DELEVSKA PMS-4New York College of Podiatric

MedicineJuly 2012

OUTLINE Presentation Imaging Classification Management

PRESENTATION 26 year-old female presents to

ED unable to bear weight on the right foot. S/p slipped and fell on wet floor

No open fracture Patient is AAO x3 Denies LOC

PRESENTATION (CONT.)

PMH: denies PSH: denies Meds: none Allergies: NKDA FHx: non

contributory SHx: denies

PRESENTATION (CONT.)

Swelling Echymoses

PRESENTATION (CONT.)

Fracture blisters? Uebbing et al. Fracture blisters. West J Emerg Med.

2011 Feb;12(1):131-3. early treatment prior to blister

formation or delay until blister resolution before attempting surgical correction or stabilization.

Strauss et al. Blisters associated with lower-extremity fracture: results of a prospective treatment protocol. J Orthop Trauma. 2006 Oct;20(9):618-22.

three cases of minor soft-tissue breakdown, one superficial infection, and two major complications directly related to the presence of fracture blisters

average delay of surgery for ankle fractures was 6 days (range 0 to 18 days)

Treatment of fracture blisters with a silver sulfadiazine (Silvadene)

PRESENTATION (CONT.)

Lateral and Deltoid lig. Syndesmotic lig.

IMAGING Standard ragiographic evaluations of

ankle fractures Anteroposterior projection Lateral projection Mortise projection

IMAGING (CONT.)

ANTEROPOSTERIOR PROJECTION

IMAGING (CONT.)ANTEROPOSTERIOR PROJECTIONMidline axis of tibia passes through center of talar dome? ✗

IMAGING (CONT.)

ANTEROPOSTERIOR PROJECTIONTibio-fibular overlap ≥ 10mm? ✗

IMAGING (CONT.)

MORTISE PROJECTION

IMAGING (CONT.)MORTISE PROJECTIONAll joint spaces within 1mm? ✗

IMAGING (CONT.)

MORTISE PROJECTIONMedial clear space ≤ 4mm? ✗

IMAGING (CONT.)

MORTISE PROJECTIONTibio-fibular clear space ≤ 5mm? ✗

IMAGING (CONT.)

LATERAL PROJECTION

IMAGING (CONT.)LATERAL PROJECTIONMidline axis of tibia passes through center of talar dome? ✗

IMAGING (CONT.)

NATURE AND LOCATION OF FRACTURES Spiral fibular fracture at the level of the joint Posteriorly displaced transverse (avulsion) fracture of the posterior

colliculus of medial malleolus

CLASSIFICATION

LAUGE-HANSEN CLASS. SUPINATION/EXTERNAL ROTATION?

Stage 1: Rupture of AITFL with possible Tillaux or Wagstaffe fracture

Stage 2: Hallmark – spiral fracture of the fibula Stage 3: Rupture of PITFL with possible Volkmann’s fracture Stage 4: Rupture of the deltoid ligament or a transverse

avulsion fracture of the medial malleolus

?

CLASSIFICATION (CONT.)

LAUGE-HANSEN CLASS. PRONATION/EXTERNAL ROTATION

Stage 1: Transverse avulsion fracture of medial malleolus or rupture of deltoid ligament

Stage 2: Rupture of AITFL and interosseous membrane Stage 3: High fibular fracture (Maisonneuve fracture) – oblique or

spiral ? Stage 4: Rupture of PITFL or Volkmann’s fracture

CLASSIFICATION (CONT.)

Danis-Weber class. Type B: trans

syndesmotic Type B2: with

medial malleolar fracture

CLASSIFICATION (CONT.)

LAUGE-HANSEN CLASS. PRONATION/EXTERNAL ROTATION

New proposed fracture mechanism

CLASSIFICATION (CONT.)

Haraguchi et al. A New Interpretation of the Mechanism of Ankle Fracture. J Bone Joint Surg Am. 2009 Apr;91(4):821-9.

CLASSIFICATION (CONT.)

In support of Pronation/External rotation Talus is in a pronated position Fracture of navicular

MANAGEMENT Closed reduction – manipulation of the

fracture fragment into normal alignment without the use of surgical incision under anesthesia.

Behrbalk et al. Procedural Sedation with Propofol for PainfulOrthopaedic Manipulation in the EmergencyDepartment Expedites Patient ManagementCompared with a Midazolam/Ketamine Regimen. J Bone Joint Surg Am. 2011 Dec 21;93(24):2255-62.

INCREASE THE DEFORMITYDISTRACT THE FRAGMENTSREVERSE THE MECHANISM OF

INJURY

MANAGEMENT (CONT.)

Open reduction with internal fixation (AO)

Anatomic reduction of fracture fragments

Rigid/stable internal fixation (biologic)Atraumatic operative technique (preserve

BS)Early active pain-free mobilization

MANAGEMENT (CONT.)

Pakarinen et al. Intraoperative assessment of the stability of the distal tibiofibular joint in supination-external rotation injuries of the ankle: sensitivity, specificity, and reliability of two clinical tests. J Bone Joint Surg Am. 2011 Nov 16;93(22):2057-61.

Hook test: the tibia was stabilized with one hand, the lateral malleolus was grabbed with a bone hook, and a lateral force was applied with use of the bone hook.

positive if >2 mm of lateral movement of the fibula

External rotation stress test: the tibia was stabilized with one hand and an external rotation force was applied to the foot; the tibiotalar clear space was then assessed under fluoroscopy.

positive if the medial tibiotalar clear space was ≥ 5 mm under stress

MANAGEMENT (CONT.)

Jenkinson et al. Intraoperative diagnosis of syndesmosis injuries in external rotation ankle fractures. J Orthop Trauma. 2005 Oct;19(9):604-9.

Demonstration of external rotationstress to F-tool and strain gauge

MANAGEMENT (CONT.)

MANAGEMENT (CONT.)

Bottlang et al. Far cortical locking can reduce stiffness of locked plating constructs while retaining construct strength. J Bone Joint Surg Am. 2009 Aug;91(8):1985-94.

MANAGEMENT (CONT.)

Vassal Principle: once the dominant (fibular) fracture is reduced, the vassal fracture (tibial) will reduce spontaneously or can be reduced easily

MANAGEMENT (CONT.)

COMPLICATIONS Pelet et al. The incidence of thromboembolic events in

surgically treated ankle fracture. J Bone Joint Surg Am. 2012 Mar 21;94(6):502-6.

Clinically detectable thromboembolic events after surgical treatment of ankle fractures are uncommon and do not appear to be influenced by the use of thromboprophylaxis.

Kurmis et al. The effect of nonsteroidal anti-inflammatory drug administration on acute phase fracture-healing: a review. J Bone Joint Surg Am. 2012 May 2;94(9):815-23.

Short-duration NSAID regimen is a safe and effective supplement to other modes of post-fracture pain control, without a significantly increased risk of sequelae related to disrupted healing.

SUMMARY

Take note of soft tissue damage when assessing ankle fractures

Obtain appropriate imaging studies that allow evaluation of joint congruency, fracture nature and displacement

Understand the mechanism of injury and classify the fracture

Ensure anatomic reduction and use fixation with adequate stiffness and strength

REFERENCES

Uebbing et al. Fracture blisters. West J Emerg Med. 2011 Feb;12(1):131-3. Strauss et al. Blisters associated with lower-extremity fracture: results of a

prospective treatment protocol. J Orthop Trauma. 2006 Oct;20(9):618-22. Haraguchi et al. A New Interpretation of the Mechanism of Ankle Fracture. J Bone Joint

Surg Am. 2009 Apr;91(4):821-9. Behrbalk et al. Procedural Sedation with Propofol for PainfulOrthopaedic

Manipulation in the EmergencyDepartment Expedites Patient ManagementCompared with a Midazolam/Ketamine Regimen. J Bone Joint Surg Am. 2011 Dec 21;93(24):2255-62.

Pakarinen et al. Intraoperative assessment of the stability of the distal tibiofibular joint in supination-external rotation injuries of the ankle: sensitivity, specificity, and reliability of two clinical tests. J Bone Joint Surg Am. 2011 Nov 16;93(22):2057-61.

Jenkinson et al. Intraoperative diagnosis of syndesmosis injuries in external rotation ankle fractures. J Orthop Trauma. 2005 Oct;19(9):604-9.

Bottlang et al. Far cortical locking can reduce stiffness of locked plating constructs while retaining construct strength. J Bone Joint Surg Am. 2009 Aug;91(8):1985-94.

Pelet et al. The incidence of thromboembolic events in surgically treated ankle fracture. J Bone Joint Surg Am. 2012 Mar 21;94(6):502-6.

Kurmis et al. The effect of nonsteroidal anti-inflammatory drug administration on acute phase fracture-healing: a review. J Bone Joint Surg Am. 2012 May 2;94(9):815-23.

THANK YOU

QUESTIONS