ANKLE FRACTURES - MANAGEMENT

Presenter : Dr.sunil santhosh .gModerator :Dr.Y.Sivaprasad

Radiography CT MRI

Investigations :

Assists in ordering X-rays in pt.’s with ankle injury.

Ankle X-rays needed only if there is pain near the malleoli with one or more of following,

a) age >55 b) inability to bear wt c) bone tenderness at posterior edge or tip of either

malleolus.

Nearly 100% sensitivity.

Useful in reducing no. of x-rays in trauma setting.

Ottawa Ankle Rules:

Antero-posterior

Mortise

Lateral

Ankle X-rays: 3 views

Identifies fractures of malleoli, distal tibia/fibula, talar dome, body and lateral process of talus,

Antero-posterior view

Tibiofibular clear space: <5mm Tibiofibular over lap: >10mm

Talar Tilt: difference in width of med &lat aspect of joint–

<2mm

Measurements in AP view

Foot in 15-20 degrees internal rotation

Evaluate articular surface between talar dome and mortise

Mortise view :

Medial clear space: <4mm

Tibiofibular overlap: >1mm

Measurements in mortise view

•Posterior mallelolar fractures

•AP talar subluxation

•Distal fibular translation &/or angulation

•Associated or occult injuries–Lateral process talus–Posterior process talus–Anterior process calcaneus

Lateral View

Talocrural angle : Btn 8-15 degrees & within 2-3 deg of opp

ankle

Talar tilt: angle formed b/n line Drawn parallel

to articular surface & Talar surface – they should be parallel to each other

CT Articular involvement Joint involvement Posterior malleolar fracture pattern Pre-operative planning Evaluate hindfoot and midfoot if needed

MRI◦ Ligament and tendon injury ◦ Talar dome lesions◦ Syndesmosis injuries

Stability may be defined as the combination of insufficient fracture displacement to compromise long-term function and the ability of the injured ankle to withstand routine physiologic forces without further displacement

In stable ankle # Talus is centered Does not shift with stress

Presence or absence of Medial injury is key to the stability of Lateral malleolar #

Stable Versus Unstable Fractures

Biomechanical studies in an axially loaded ankle model indicate that

despite fracture of the fibula and complete disruption of the anterior and posterior syndesmosis, in the absence of a medial side injury, the talus remains stable and centered in the mortise .

Non-operative : Indications

Non displaced Stable # & intact Syndesmosis Displaced # if stable Anatomic mortise is

achieved Those not Surgically fit

TREATMENT

Patients with Stable # Pattern can be maintained in short leg cast &allowed to weight bear as tolerated

Those with un-stable # pattern are placed in long leg cast for 4-6 weeks to maintain rotational control Once adequate healing is demonstrable can be shifted to short leg cast but they are best treated opreratively.

Open reduction & Internal fixation is indicated in :

Failure to achieve or maintain Closed reduction Unstable # with talar displacement or Widened Ankle mortise # that require abnormal foot position for

reduction Open fractures

Operative Rx

Indications :

If Fibular displacement is >3mm # Within 5cms of Ankle joint Talar displacement Complete deltoid ligament rupture Associated with Bi or trimalleolar #

Lateral malleoli Fixation

Fibula # is fixed first If associated with medial or posterior malleolar # except when it is severely communited.

It is exposed by either Lateral longitudinal or postero-lateral

approach

Care to be taken to avoid superficial peroneal nerve injury

Technique

IF # is below the syndesmosis it is stabilised by using a lag screw or k-wires with tension banding

If # above syndesmosis is fixed with 1/3 semitubular plate & screw fixation

If # is a long oblique - fixed with two lag screws in a-p direction to achieve compression & must be engaged to post cortex .

If # is Transverse Intramedullary device like rush nail, Intramedullary screw can be used.

Indications :

Associated syndesmotic injury Widening of medial clearspace after Fibular

fixation. Inability to attain fibular reduction Persistent Medial # displacement after

fibular fixation

Medial malleoli fixation

Approached through Antero-medial incision

Usually fixed using Two 4 mm cancellous lag screws perpendicular to # line

Technique :

Alternatively Fixation can be done by using Tension Band wiring if # fragment is small

If associated with Proximalcommunition then Butress plate is used to maintain reduction

In this both Medial & Lateral stabilizing Structures of the ankle joint are lost .

Usually Treated with ORIF of Both malleoli as there is more chance of non-union with Closed reduction .

Bi-MALLEOLAR #

In this Bimalleolar # is associated with # of Posterior tibial lip

Results are usually poor Compared to bi-malleolar #

TRI-MALLEOLAR #

Indications :

If Involment is> 25% of Articular surface

> 2mm Displacement

Persistent Posterior subluxation of talus

Reduction is achieved in this by using either by direct or indirect technique

Posterior malleolar Fixation :

In Indirect Approach , Screw is passed Anterior to posterior & inter fragmentary compression is achieved .

In Direct approach Screw or Plate fixation is done posterior to anterior direction through postero lateral incision .

Syndesmotic injuries are most commonly caused by prn–ext rotation, prn-abdc and infrequently,supn–ext rotation mechanisms (Danis-Weber type C and type B injuries).

These forces cause talus to abduct or rotate externally in the mortise, leading to disruption of the syndesmotic ligaments.

SYNDESMOTIC INJURY

Indications : syndesmotic injuries associated with

proximalfibular and that involve a medial injury that cannot be stabilized and

syndesmotic injuries extending more than 5 cm proximal to the plafond.

Integrity of syndesmosis is confirmed by Extrernal rotation stress test & Cotton test

screws or oblique pins inserted through the lateral malleolus and into the distal tibia.

The screw should be positioned 2 to 3 cm proximal to the tibial plafond,

Directed parallel to the joint surface, and

angled 30 degrees anteriorly so that it is perpendicular to the tibiofibular joint.

Technique :

Two screws have been found to provide more stability than fixation with one screw

Screws should engage both cortex of fibula & one or two cortex of fibula

Occurs supination -external rotation of the foot.

X-ray AP view shows tilting of talus & Increased medial clear space Under stress

Accepted RX is ORIF of Fibula with ligament repair to maintain ankle mortise.

Deltoid ligament Tear :

Through Ant-medial approach

Deltoid ligament identified

Deep part Identified by opening tibialis post sheath

Ligament repaired by suturing it to neck & body of Talus Diagonally

Technique

Open Ankle Fractures

◦ Treat with appropriate antibiotics pre-op and 48 hr post-op

◦ I & D with immediate ORIF if clean wound

◦ ORIF and Ex Fix if severe soft tissue damage present to allow for wound care

◦ Low grade open # results similar to closed fractures

Complications

• Perioperative– Malreduction– Inadequate fixation– Intra-articular hardware penetration

• Early Postoperative– Wound edge dehiscence/necrosis– Infection– Compartment syndrome

• Late– Stiffness– Distal tibiofibular synostosis– Malunion– Nonunion– Post-traumatic arthritis– Hardware related complications– Complex regional pain syndrome type 1

Complications

Malunion

◦Usually associated with shortened or malrotated distal fibula ◦Failure to reduce the syndesmotic injury◦Treated with fibular lengthening and/or derotational osteotomy +/- syndesmotic fixation◦Ankle fusion for advanced arthrosis or osteotomy failure

Complications

Non-union

◦ Usually involving the medial malleolus due to soft tissue (i.e. posterior tibial tendon) interposition

◦ Treated with electrical stimulation, ORIF, bone graft, or excision of fragment

◦ Patient may have co-morbidities such as diabetes, peripheral vascular disease or smoking

Complications

Wound problems

◦ Edge necrosis (3%)

◦ Dehiscence

Risk is decreased by minimizing swelling, not using a tourniquet, and careful atraumatic soft tissue handling

ORIF in the presence of fracture blisters and larger abrasions have more than twice the average wound complication rate.

Complications

Infection

◦ Occurs in less than 2% of closed fractures

◦ Increased incidence in Diabetics, Age > 50, and Alcoholics

◦ Treated with antibiotics

◦ Implants usually left in place to maintain stability for optimal soft tissue perfusion

◦ May require serial debridements +/- VAC dressing

◦ Arthrodesis used as a salvage procedure

Complications

Post traumatic arthrosis secondary either to articular damage at the time of injury or inadequate reduction resulting in abnormal mechanics.

Complications

Tibiofibular synostosis◦ associated with syndesmotic screw use

and is usually asymptomatic

THANK YOU

Reference:Campbell,Rockwood,Hand book of #,Net.