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Department of Orthopaedics

Seminar on: ANKLE INJURIES.

Chairperson: Prof. & HOD: Dr.Kiran Kalaiah

Moderator: Professor Dr.J K Reddy

Presenter : Dr. Yashavardhan.T.M

Introduction:

Ankle injuries apart from road traffic accidents can also result from a slip while walking or getting down from stairs or a twisting injury in sports and fall from a height.

All these tend to produce ankle injuries when one attempts to turn violently over a fixed foot or the foot being used as lever to produce twist at the ankle .

Great majority of ankle injuries are caused by indirect violence.

If not treated properly the ankle injuries are a source of disability in the form of pain, instability and early degenerative arthritis of the ankle.

Injuries around the ankle joint cause destruction of not only the bony architecture but also often the ligamentous and soft tissue components.

Aims:

(1) The normal relationships of the ankle mortise must be restored

(2) The weight-bearing alignment of the ankle must be at a right angle to the longitudinal axis of the leg.

(3) The contours of the articular surface must be satisfactorily reduced. The best results are obtained by anatomic joint restoration, and the method used to accomplish this may be either closed manipulation or open reduction and internal fixation (ORIF). For most fractures, the latter method most often ensures anatomic joint restoration and union.

Anatomy:

Articular surfaces ?1. Structurally, the joint is very strong. The stability of the joint is ensured by:

2. (i) Close interlocking of the articular surfaces;

3. (ii) strong collateral ligaments on the sides; and

4. (iii) the tendons that cross the joint, four in front,

and five behind

LigamentsThe joint is supported by:

(i) Fibrous capsule,

(ii) the deltoid or medial ligament, and

(iii) a lateral ligament.

Fibrous CapsuleIt surrounds the joint and is attached all around the articular margins with exceptions.

(1) Poster-superiorly, it is attached to the inferior transverse tibiofibularligament; and

2) anteroinferiorly, it is attached to the dorsum of the neck of the talus at some distance from the trochlear surface.

Deltoid or Medial Ligament This is a very strong triangular ligament present on the medial side of the ankle.

superficial layer

tibiocalcaneal ligament

tibionavicular ligament

posterior superficial tibiotalar ligament

tibiospring ligament

deep layer: this layer is intra-articular and is covered by synovium

anterior tibiotalar ligament (ATTL)

posterior deep tibiotalar ligament (PDTL)

Deltoid or Medial Ligament This is a very strong triangular ligament present on the medial side of the ankle.

superficial layer

tibiocalcaneal ligament

tibionavicular ligament

posterior superficial tibiotalar ligament

tibiospring ligament

deep layer: this layer is intra-articular and is covered by synovium

anterior tibiotalar ligament (ATTL)

posterior deep tibiotalar ligament (PDTL)

Deltoid or Medial Ligament This is a very strong triangular ligament present on the medial side of the ankle.

superficial layer

tibiocalcaneal ligament

tibionavicular ligament

posterior superficial tibiotalar ligament

tibiospring ligament

deep layer: this layer is intra-articular and is covered by synovium

anterior tibiotalar ligament (ATTL)

posterior deep tibiotalar ligament (PDTL)

Lateral Ligament

This ligament consists of three bands as follows.

1. The anterior talofibular ligament is a flat band which passes from the anterior margin of the lateral malleolus to the neck of the talus, just in front of the fibular facet.

2. The posterior talofibular ligament passes from the lower part of the malleolar fossa of the fibula to the lateral tubercle of the talus.

3. The calcaneofibular ligament is a long rounded cord which passes from the notch on lower border of the lateral malleolus to the tubercle on the lateral surface of the calcaneum.

Lateral Ligament

This ligament consists of three bands as follows.

1. The anterior talofibular ligament is a flat band which passes from the anterior margin of the malleolus to the neck of the talus, just in front of the fibular facet.

2. The posterior talofibular ligament passes from the lower part of the malleolar fossa of the fibula the lateral tubercle of the talus.

3. The calcaneofibular ligament is a long rounded cord which passes from the notch on the lower border of the lateral malleolus to the tubercle on the lateral surface of the calcaneum.

Movementsmovements are dorsiflexion and plantar-flexion

(a) dorsiflexion

(b) plantar flexion

Muscles producing movements

Movement Principal muscles Accessory muscles

A. Dorsiflexion Tibialis anterior 1. Extensor digitorum anterior longus

2. Extensor hallucis longus

3. Peroneus tertius

B. Plantar 1. Gastrocnemius 1. Plantaris flexion

2. Soleus 2. Tibialis posterior

3. Flexor hallucis longus

4. Flexor digitorum longus

BLOOD SUPPLY

The arteries crossing the ankle sends branches which form arterial anastomosis

around the ankle, tarsus and metatarsus

BLOOD SUPPLY

The arteries crossing the ankle sends branches which form arterial anastomosis

around the ankle, tarsus and metatarsus

BLOOD SUPPLY

The arteries crossing the ankle sends branches which form arterial anastomosis

around the ankle, tarsus and metatarsus

NERVE SUPPLY

The talocrural joint is innervated by branches from the deep peroneal, sural and tibial nerves (or medial and lateral plantar nerves, depending on the level of division of the tibial nerve). Occasionally, the superficial peroneal nerve also supplies the ankle joint.

SYNDESMOTIC JOINT

SYNDESMOTIC JOINT

Injuries around the Ankle

A. Ligament injuries.

B. Bony injuries.

Ligament Injuries

The common injuries are the lateral ligament injury, the medial or the deltoid ligament injury and the syndesmotic ligament injury (the ligament binding the inferior tibio-fibular syndesmosis).

• Grade 1—Stretching of the ligaments.

• Grade 2—Partial tear of the ligaments.

• Grade 3—Complete tear of the ligaments.

Management

Complete and severe tears require surgical repair. Less severe strains and sprains heal well with adequate immobilization. Physiotherapy and gradual mobilization is always essential for a good recovery.

COMMON EPONYMS

Bowsworth Fracture

The distal end of the proximal fragment of the fibula may be displaced posterior to the

tibia and locked by the tibia's posterolateral ridge; the bone cannot be released

by manipulation because of the pull of the intact interosseous membrane

Classification.

1. Lauge-Hansen Classification*1. 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

2. 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.

1. Lauge-Hansen Classification*1. 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

2. 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

3. 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 insertions Short, horizontal, oblique fracture of the fibula above the level of the joint

4. Pronation-Eversion (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

3. 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 insertions Short, horizontal, oblique fracture of the fibula above the level of the joint

4. Pronation-Eversion (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

5. Pronation-Dorsiflexion (PD)

Fracture of the medial malleolus. Fracture of the anterior margin of the tibia. Supramalleolar fracture of the fibula. Transverse fracture of the posterior tibialsurface.

5. Pronation-Dorsiflexion (PD)

Fracture of the medial malleolus. Fracture of the anterior margin of the tibia. Supramalleolar fracture of the fibula. Transverse fracture of the posterior tibialsurface.

2.Danis-Weber classification

Danis-Weber classification of ankle fractures based on mechanism of injury and location and appearance of fibular fracture.

2.Danis-Weber classification

Danis-Weber classification of ankle fractures based on mechanism of injury and location and appearance of fibular fracture.

3. AO CLASSIFICATION:

AO Classification of fractures has further divided each of these three types into three groups - to quantify the spectrum of injury within each type.

Ruedi-Allgower Classification

Type 1: No significant articular incongruity; cleavage fractures without displacement of bony fragments.

Type 2: Significant articular incongruity with minimal impaction or comminution.

Type 3: Significant articular comminutionwith metaphysical Impaction

Clinical examination:

Investigations:

X-ray :

Antero-posterior – basic (Mortice projection)

Ottawa Rules: When to Image

Ottawa Ankle Rules: 98% sensitivity for fracture, decrease radiographs

Validated in ED and PCP Office

Do not apply rules if:

Age < 18 yo

Pregnancy

Multiple painful

injuries

Compromised

sensation

Investigations:

X-ray :

Antero-posterior – basic (Mortice projection)

Investigations:

X-ray :

Antero-posterior – basic (Mortice projection)

Lateral (basic) – medio-lateral

Stress projections for subluxation

Antero-posterior – stress

Lateral – stress

MANAGEMENT

Definitive

Aim- restoration of complete normal anatomical alignment of ankle.

Patients if needs operation should be operated within 24hrs of injury or after one week once the swelling subsides.

Undisplaced fracture medial malleolus :

Below knee POP cast for 6 weeks.

Reduction fails (may be due to soft tissue (periosteal) inter position)

Displaced: Open reduction and internal fixation by

Cancellous screws group

Tension band wiring

Fracture lateral malleolus: Lateral Malleolus helps in length maintenance & maintenance of ankle mortice.

Hence, lateral malleolus has to be fixed internally

ANKLE FRACTURE FIXATION TECHNIQUES

GATELLIER AND CHASTANG for LATERAL MALLEOLUS

■ Begin the incision about 12 cm proximal to the tip of the lateral malleolus and extend it distally along the posterior margin of the fibula to the tip of the malleolus. Curve the incision anteriorly for 2.5 to 4 cm in the line of the

peroneal tendons ■ Expose the fibula, including the lateral malleolus subperiosteally, and incise the sheaths of the peroneal retinacula and tendons, permitting the tendons to be displaced anteriorly.

■ if the fibula is not fractured, divide it 10 cm proximal to the tip of the lateral malleolus and free the distal fragment by dividing the interosseousmembrane and the anterior and posterior tibiofibular ligaments.

GATELLIER AND CHASTANG for LATERAL MALLEOLUS

■ Begin the incision about 12 cm proximal to the tip of the lateral malleolus and extend it distally along the posterior margin of the fibula to the tip of the malleolus. Curve the incision anteriorly for 2.5 to 4 cm in the line of the

peroneal tendons ■ Expose the fibula, including the lateral malleolus subperiosteally, and incise the sheaths of the peroneal retinacula and tendons, permitting the tendons to be displaced anteriorly.

■ if the fibula is not fractured, divide it 10 cm proximal to the tip of the lateral malleolus and free the distal fragment by dividing the interosseousmembrane and the anterior and posterior tibiofibular ligaments.

■ carefully preserve the calcaneofibular and talofibular ligaments to serve as a hinge and to maintain the integrity of the ankle after operation. Turn the fibula laterally on this hinge and expose the lateral and posterior aspects of the distal tibia and the lateral aspect of the ankle joint. Great care should be used in children to avoid creating a fracture through the distal fibular physis when reflecting the fibula.

■ When closing the incision, replace the fibula and secure it with a screw extending transversely from the proximal part of the lateral malleolus through the tibiofibular syndesmosis into the tibia just proximal and parallel to the ankle joint.

■ carefully preserve the calcaneofibular and talofibular ligaments to serve as a hinge and to maintain the integrity of the ankle after operation. Turn the fibula laterally on this hinge and expose the lateral and posterior aspects of the distal tibia and the lateral aspect of the ankle joint. Great care should be used in children to avoid creating a fracture through the distal fibular physis when reflecting the fibula.

■ When closing the incision, replace the fibula and secure it with a screw extending transversely from the proximal part of the lateral malleolus through the tibiofibular syndesmosis into the tibia just proximal and parallel to the ankle joint.

■ Overdrill the hole made in the fibula to allow for compression across the syndesmosis. Dorsiflex the ankle joint as the screw is tightened because the talar dome is wider at its anterior half than its posterior half. Failure to overdrillthe fibula can result in widening of the syndesmosis and ankle mortise, with resulting arthritic degeneration of the

tibiotalar joint. Add additional fixation with a small plate and screws if desired.

■ Replace the tendons, repair the tendon sheaths and retinacula, and close the incision.

After the osteotomy or fracture has healed, remove the screw to prevent its becoming loose or breaking

APPROCHES TO MEDIAL MALLEOLUS

KOENIG AND SCHAEFER

■ Curve the incision just proximal to the medial malleolus and divide the malleolus with an osteotome or small power saw; preserve the attachment of the deltoid ligament.

■ Subluxate the talus and malleolus laterally to reach the joint surfaces.

■ Later replace the malleolus and fix it with one or two cancellous screws. To make replacement easier, drill the holes for the screws before the osteotomy, insert the screw, and then remove it. At the end of the operation, reinsert the screws and close the wound.

■ The surfaces of the osteotomized bone are smooth, and the malleolus can rotate on a single screw. Two screws are used to prevent rotation of the osteotomized medial malleolus Interfragmentary technique should be used for screw fixation of the medial malleolus to provide compression across the osteotomy site

COLONNA AND RALSTON

■ Begin the incision at a point about 10 cm proximal and 2.5 cm posterior to the medial malleolus and curve it anteriorly and inferiorly across the center of the medial malleolus and inferiorly and posteriorly 4 cm toward the heel (Fig. 1-38C).

■ Expose the medial malleolus by reflecting the periosteum, but preserve the deltoid ligament.

■ Divide the flexor retinaculum and retract the flexor halluces longus tendon and the neurovascular bundle posteriorly and laterally.

■ Retract the tibial posterior and flexor digitorum longus tendons medially and anteriorly to expose the posterior tibial fracture.

COLONNA AND RALSTON

■ Begin the incision at a point about 10 cm proximal and 2.5 cm posterior to the medial malleolus and curve it anteriorly and inferiorly across the center of the medial malleolus and inferiorly and posteriorly 4 cm toward the heel (Fig. 1-38C).

■ Expose the medial malleolus by reflecting the periosteum, but preserve the deltoid ligament.

■ Divide the flexor retinaculum and retract the flexor halluces longus tendon and the neurovascular bundle posteriorly and laterally.

■ Retract the tibial posterior and flexor digitorum longus tendons medially and anteriorly to expose the posterior tibial fracture.

Lateral Malleolar Fixation

FOR LATERAL MALLEOLUS

Plating

Intramedullary Nailing

Medial Malleolar Fixation

Tension Band wiring

POSTERIOR APPROACH TO THE ANKLE

Posterior Malleolar Fixation

COMPLICATIONS

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