injuries of the ankle, talus, calcaneus and the...
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Semmelweis UniversityDepartment of Traumatology
Dr. Gál Tamás
Anatomy
Ankle injuries
DIRECT INDIRECT
VerticalCompression(Tibia plafond–Pilon)
AO 43-A,B,C
Suppination (adduction + inversion)AO 44-A
Pronation (abduction + eversion)AO 44-B,C
Ankle injuries
DIRECT
VerticalCompression
(Tibia plafond–Pilon)AO 43-A,B,C
Pilon fractures
AO classification according to the fracture of the tibia
43�A: Extraarticular
�B: Partial articular surface
injury
�C: Total articular surface injury
Tibia pilon fracture treatment 1.
Non-operative treatment:• Non-dislocated fracture – apply cast
• If operation is contraindicated –traction + cast
• No weight bearing for 8-10 weeks
Tibia pilon fracture treatment 2.
Surgical treatment in one session:1.Reconstruction of the fibula2.Reconstruction of the tibia articular
surface3.Autologous bone grafting4.Anteromedial plate fixation
Tibia pilon fracture treatment 3.
Two step surgical treatment� First session
1. Temporary fixation with External Fixation (bridging)2. Plate synthesis of fibula + Tibia External Fixation3. Tibia plafond reconstruction + External fixation4. Shortening (in case of major soft tissue damage or
bone defect)
� Second session7-10 days later autologous bone graft + definitive
surgical stabilization
Tibia pilon fracture treatment 4.
Timing of operation – depends on soft tissue damage
�Open fracture, major soft tissue damage –primary operation within 6-8 hours
�Uncomplicated fracture, no major soft tissue damage – primary, one-step surgery
� In all other cases – postponed definitive reconstruction in multiple sessions or calcaneal traction “Consultant” operation
Pilon AO 43 C2 (no fracture of the fibula)
Screw fixation – articular surface reconstructionno weight bearing for 12-16 weeks
Pilon C3
Plate synthesis of fibula on lateral side –lengthExternal fixation for support on the medial
•Significant soft tissue injury
•High risk of soft tissue loss and infection
•Posttraumatic arthritis
•May require late arthrodesis
Ankle injuries
INDIRECT
Supination (adduction + inversion)AO 44-A
Pronation (abduction + eversion)AO 44-B,C
Supination injuries�Weber A Fracture�Distorsion/strain�Talofibular ligament
rupture/sprainTalocrural sub/luxation
�Chopart joint distorsion�Avulsion fracture of navicular
bone�V. metatarsus base fracture
Ligament injuries
Anterior
Distorsions-sprains
�Physical examination
�RadiographyDiagnosis:
�Arthrography�Stress radiographs
1. Adduction2. Anterior drawer
Talus tilt•Less than 10°= distorsion/strain•10-15°= partial sprain or rupture (usually anterior talofibular lig.)•More than 15°= total rupture
Stress radiography
Painful
Rarely needed for acute injury (no therapeutic consequence)
Still used for to diagnose chronic instability
Treatment of ligament injuries
Strain or sprain?Doesn’t matter, treatment is the same for a
distorsion and talofibular ligament rupture
Can the patient bear weight?
YesEarly rehabilitationNSAID + brace
NoCast splint + thrombosis profilaxis (8-10 days)
Rehabilitation time: 5-6 weeks
Distal joint distorsions/sprains
Chopart, Lisfranc•Physical exam•Radiography (AP and lateral foot, not ankle)Small ligament sprains, sometimes with bone abruptionsTreatment is the same, can the patient bear weightCould be painful for a long time (6-12 weeks)
Fifth metatarsal base avulsion fracture
Insertion of the peroneus brevis tendon Tension band wiring
Ankle fracturesDanis-Weber classification
Supination Pronation
Classification: level of fibula fracture in relation to the syndesmosis
A: below B: at the level of the syndesmosis C: above
(Lauge Hansen is another type of classification based on mechanism of fracture)
Weber A (AO 44-A1, A2, A3)supination
~5%
Level of syndesmosi
s
Weber B (AO 44 – B1, B2, B3)
Pronation•~85%•Pronation mechanism, fibula is fractured AT the level of the syndesmosis•B1: isolated lateral malleolus•B2: lateral malleolar + avulsion medial malleolus or (rupture of deltoid ligament)•B3: lateral and medial and Volkmann triangle (sometimes tuber Chaput)
Weber B
Rupture of the deltoid ligament
Syndesmotic screw
Weber B
Fibula fracture at level of syndesmosis
Avulsion fracture of medial malleolus
Lateral malleolus plate osteosynthesisMedial malleolus tension ban wiring
Weber B with Volkmann triangle fracture
Anterior compression screw
Avulsed posterior edge of tibia
Weber C fractures
�AO type 44 C�Pronation
mechanism�Fractures are
above the syndesmosis
Weber C
Supramalleolar fracture, where the syndesmosis and the interosseus membrane are ruptured
�C 1: Lateral injury only�C 2: Fibula + syndesmosis + medial
malleolus/deltoid ligament�C 3: Subcapital fibula (Maissoneuve),
syndesmosis + interosseus membrane + medial malleolus + Volkmann triangle
Maissoneuve fracture
� Subcapital fracture of the fibula
� Tibia x-ray (below knee)
� The syndesmotic screw is removed after 6-8 weeks
Open fracture Grade III, Weber C
•Open fracture on the medial side•Urgent operation, obtain bacterial culture, antibiotic profylaxis,tetanus toxoid, stable osteosynthesis
Soft tissue injury
Soft tissue swelling, blister formation, skin necrosis…Therefore ORIF is urgent even if the fracture is closed
Late complications
Weber B fracture ORIFposttraumatic arthritis
ankle arthrodesis
Tarsal and metatarsal injuries
� Calcaneus� Talus� …and the rest
(Navicular,Cuboid,
Cuneiform bones)
Calcaneal fractures•High energy, direct trauma. Usually caused by fall from height.•Also called Lover's fracture and Don Juan fracture becausea lover may jump from great heights while trying to escape from the lover's spouse•Look for associated spine injuries•Symptoms:
�Hematoma on sole of foot�Soft tissue swelling
•X-rays – Broden, Zadravecz(AP, lateral, axial directions)
•Calcaneus is a cancellous boneDepressed frx of articular surface
•Goal: reconstruction of articular surface and bone axis, no weight bearing
Böhler’s angle
ORIF
Closed reductionReduction with distracter
Closed reduction and screw fixation
Extra-articular Tongue-type fracture
Achilles tendon
Talar fracturesAvascular necrosisTitanium implants! MRI
Classification:
Hawkins I. NondisplacedHawkins II. Subtalar displacmentHawkins III. Ankle joint displacm.Hawkins IV. Ankle + subtalar +
talonavic. displacm.
AVN
10%
30%90%100%
Titanium screws
MRI follow up
Midfoot and metatarsal injuries
�Direct or Indirect trauma� If direct – associated soft tissue damage�March fracture (stress fracture of
metatarsals) – soldiers, runners, organists, doctors
�Usually non-operative treatment� Immobilization for 6 weeks�Transverse and longitudinal arches!
Special considerations for foot injuries
�Foot skin quality is different than elsewhere
�The skin is potentially contaminated�26 small bones compose the structure and
function of the foot�Direct, high energy trauma is more
common�Foot compartment syndrome
Amputations – only at determined levels
Levels of amputation
1. Toe amputation2. Transmetatarsal?3. Lisfranc, Chopart4. Pirogov / Symes5. BKA – at the proximal-middle third of calf6. AKA – depends on circulation7. Hip exarticulation
Pirogov
Thank you for your attention
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