ANKLE FRACTUREHighly susceptible to injury because they are relatively mobile and weight bearing (support more weight per unit area than any other joint)

Incidence: USA 15% of ankle injuries

AnatomyBone

Tibia distalFibula distalTalus

AnatomyThree groups of stabilizing ligaments :

Syndesmotic ligamentsLateral collateral ligamentsMedial collateral ligaments

AnatomySyndesmotic ligamentsAnteroinferior tibiofibular (AITFL), posteroinferior tibiofibular (PITFL), inferior transverse ligament (ITL), interosseus ligament (IOL)Maintains the integrity of the distal tibia and the fibula and resist the axial, rotational, and translational forces

Anatomy2. Lateral ligament

anterior talofibular ligament (ATFL)calcaneofibular ligament (CFL)posterior talofibular ligament (PTFL). limit ankle inversion and prevent anterior and lateral subluxation of the talus

Anatomy3. Medial (deltoid)Superficial. Talotibial, naviculotibial, calcaneotibialDeep.run transversly from post colliculus of tibia to the talus

stabilize the joint during eversion and prevent talar subluxation

Classification Lauge-HansenPosition of the foot and the forces acting at the time of injuryFoot position : supination, pronationDeforming force : external rotation, abduction, or adductio

Classification SUPINATION-EVERSiON(EXTERNAL ROTATION) (SER)

Disruption of the anterior tibiofibular ligament Spiral oblique fracture of the distal fibula Disruption of the posterior tibiofibular ligament or fracture of the posterior malleolus Fracture of the medial malleolus or rupture of the deltoid ligament

Classification SUPINATION-ADDUCTION (SA)

Transverse avulsion-type fracture of the fibula below the level of the joint or tear of the lateral collateral ligaments Vertical fracture of the medial malleolus

Classification PRONATION-EVERSON (EXTERNAL ROTATION) (PER)

Transverse fracture of the medial malleolus or disruption of the deltoid ligament Disruption of the anterior tibiofibular ligament Short oblique fracture of the fibula above the level of the joint Rupture of posterior tibiofibular ligament or avulsion fracture of the posterolateral tibia

Classification PRONATION-ABDUCTION (PA)

Transverse fracture of the medial malleolus or rupture of the deltoid ligament Rupture of the syndesmotic ligaments or avulsion fracture of their insertion(s) Short, horizontal, oblique fracture of the fibula above the level of the joint

Classification Danis-WeberBased on the location and appearance of the fibular fracture Emphasizes the importance of the lateral side of the ankleUseful in planning surgical treatment

Classification Weber type Acaused by internal rotation and adductiontransverse fracture of the lateral malleolus at or below the plafond, with or without an oblique fracture of the medial malleolus.

Classification Weber type B caused by external rotation oblique fracture of the lateral malleolus,. Theinjury may include rupture or avulsion of the anteroinferior tibiofibular ligament, fracture of the medial malleolus, or rupture of the deltoid ligament.

Classification Weber Type C C-1 : Abduction injuries, oblique fracture of the fibula proximal to the disrupted tibiofibular ligaments C-2 : Abductionexternal rotation injuries interosseous membrane, medial malleolar fracture or a deltoid ligament rupture.

Diagnosis History

mechanism of injuryankle and foot position during the injuryany sounds heard at the time injuryprevious history of ankle injury, any knee or foot paindegree of function after the event.

Diagnosis

Physical Examination

Inspectiondeformity, ecchymosis, swelling

ROM (normal)30 to 50 degrees plantar flexion20 degrees dorsiflexion25 degrees inversion and eversion 15 degrees of adduction 30 degrees of abduction

Palpation-individual ligaments (MCL,LCL, syndesmotic) and tendons -the joints above and below the ankle

Diagnosis Special TestsAnterior Drawer integrity of the ATFLgrasp the heel with one hand and apply a posterior force to the tibia with the other hand, while drawing the heel forward.laxity is compared with the opposite (uninjured) ankle. positive test: a difference of 2 mm subluxation compared with the opposite side or a visible dimpling of the anterior skin of the affected ankle (suction sign) Squeeze Test tests the integrity of the syndesmotic ligaments examiner places his hand 6 to 8 inches below the knee and squeezes the tibia and fibula togetherpositive test: results in pain in the ankle, which indicates injury of the syndesmotic ligament

Diagnosis X-rays

Indications :Bony tenderness at the posterior edge or tip of the medial / lateral malleolus.

ViewsAP, lateral, mortise view (15-20 degrees of internal rotation)AP : malleoli, plafond, talar dome, lateral process of the talusLateral : ant/post tibial margins, talar neck, post, talar process and calcaneusMortise : most important view, medial clear space should not exceed 4mm

DiagnosisCT-Scan and MRITo asses the complexity of the fracture and any associated ligamentous and intraarticular injuries

X-ray measurements

Treatment Goal : restore function to the level before the insultRestoring the original anatomyClosed treatment not recommended except displacement is within acceptable limits.Open treatment restore the anatomy to its original condition without forced manipulations

TreatmentNon-operative Extra articular fracture of the tibia and fibulaNon displaced fractureShort leg cast for 4 6 weeks

Treatment OperativeUnstable fracture Internal fixation all fracture of the articular surface with displacement greater than 2mm lateral or posterior at the lateral or medial malleolus

Post-operative CarePrevent the foot from dropping into equinusElevate the limb until swelling subsideGentle ROM exercise can begin as tolerated limited weight bearing for at least 6 weeks

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Pilon Fractures (Bad!)axial compressiontalus driven into the plafondusually comminuted and displaced with extensive soft tissue swellinglook for associated injuries calcaneus, femoral neck, acetabulum, lumbar vertebraeClassification (AO/OTA) : type A non-articular fracture, type B articular partial, type C total articular fractureSurgical treatment

*Bone *Medial clear space not >4mm if so disruption of integratyA-B clear space if >5mm disruption of the syndesmotic ligaments