lower extremity trauma m4 student clerkship unmc orthopaedic surgery department of orthopaedic...

Lower Extremity Lower Extremity TraumaTrauma

M4 Student ClerkshipM4 Student Clerkship

UNMC Orthopaedic SurgeryUNMC Orthopaedic Surgery

Department of Orthopaedic Surgeryand Rehabilitation

Lower Extremity TraumaLower Extremity Trauma

Hip Fractures / DislocationsHip Fractures / Dislocations Femur FracturesFemur Fractures Patella FracturesPatella Fractures Knee DislocationsKnee Dislocations Tibia FracturesTibia Fractures Ankle FracturesAnkle Fractures

Hip FracturesHip Fractures

Hip DislocationsHip Dislocations Femoral Head FracturesFemoral Head Fractures Femoral Neck FracturesFemoral Neck Fractures Intertrochanteric FracturesIntertrochanteric Fractures Subtrochanteric FracturesSubtrochanteric Fractures

250,000 Hip fractures annually250,000 Hip fractures annually– Expected to double by 2050Expected to double by 2050

At risk populationsAt risk populations– Elderly: poor balance & vision, Elderly: poor balance & vision,

osteoporosis, inactivity, medications, osteoporosis, inactivity, medications, malnutritionmalnutrition

– Young: high energy traumaYoung: high energy trauma

EpidemiologyEpidemiology

Hip DislocationsHip Dislocations

Significant trauma, usually Significant trauma, usually MVAMVA

Posterior: Hip flexion, IR, AddPosterior: Hip flexion, IR, Add Anterior: Extreme ER, Anterior: Extreme ER,

Abd/FlexAbd/Flex


Emergent Treatment: Closed ReductionEmergent Treatment: Closed Reduction– Dislocated hip is an emergencyDislocated hip is an emergency– Goal is to reduce risk of AVN and DJDGoal is to reduce risk of AVN and DJD– Allows restoration of flow through occluded Allows restoration of flow through occluded

or compressed vesselsor compressed vessels– Literature supports decreased AVN with Literature supports decreased AVN with

earlier reductionearlier reduction– Requires proper anesthesiaRequires proper anesthesia– Requires “team” (i.e. more than one person)Requires “team” (i.e. more than one person)


Emergent Treatment: Closed ReductionEmergent Treatment: Closed Reduction– General anesthesia with muscle relaxation General anesthesia with muscle relaxation

facilitates reduction, but is not necessaryfacilitates reduction, but is not necessary– Conscious sedation is acceptableConscious sedation is acceptable– Attempts at reduction with inadequate Attempts at reduction with inadequate

analgesia/ sedation will cause unnecessary analgesia/ sedation will cause unnecessary pain, cause muscle spasm, and make pain, cause muscle spasm, and make subsequent attempts at reduction more subsequent attempts at reduction more difficultdifficult

Hip DislocationsHip Dislocations Emergent Treatment: Emergent Treatment:

Closed Reduction Closed Reduction Allis ManeuverAllis Maneuver

– Assistant stabilizes pelvis Assistant stabilizes pelvis with pressure on ASISwith pressure on ASIS

– Surgeon stands on Surgeon stands on stretcher and gently stretcher and gently flexes hip to 90deg, flexes hip to 90deg, applies progressively applies progressively increasing traction to the increasing traction to the extremity with gentle extremity with gentle adduction and internal adduction and internal rotationrotation

– Reduction can often be Reduction can often be seen and feltseen and felt

Insert hip ReductionPicture


Following Closed ReductionFollowing Closed Reduction– Check stability of hip to 90deg flexionCheck stability of hip to 90deg flexion– Repeat AP pelvisRepeat AP pelvis– Judet views of pelvis (if acetabulum fx)Judet views of pelvis (if acetabulum fx)– CT scan with thin cuts through acetabulumCT scan with thin cuts through acetabulum– R/O bony fragments within hip joint R/O bony fragments within hip joint

(indication for emergent OR trip to remove (indication for emergent OR trip to remove incarcerated fragment of bone)incarcerated fragment of bone)


Following Closed ReductionFollowing Closed Reduction– No flexion > 60deg (Hip Precautions)No flexion > 60deg (Hip Precautions)– Early mobilization with PT/OTEarly mobilization with PT/OT– TTWB for 4-6 weeksTTWB for 4-6 weeks– MRI at 3 months (follow risk of AVN)MRI at 3 months (follow risk of AVN)

Femoral Head FracturesFemoral Head Fractures

Concurrent with hip dislocation due Concurrent with hip dislocation due to shear injuryto shear injury


Pipkin ClassificationPipkin Classification– I: Fracture inferior to foveaI: Fracture inferior to fovea– II: Fracture superior to foveaII: Fracture superior to fovea– III: Femoral head + acetabulum fractureIII: Femoral head + acetabulum fracture– IV: Femoral head + femoral neck fractureIV: Femoral head + femoral neck fracture

Treatment OptionsTreatment Options– Type IType I

Nonoperative: non-displacedNonoperative: non-displaced ORIF if displacedORIF if displaced

– Type II: ORIFType II: ORIF– Type III: ORIF of both fracturesType III: ORIF of both fractures– Type IV: ORIF vs. hemiarthroplastyType IV: ORIF vs. hemiarthroplasty


Femoral Neck FracturesFemoral Neck Fractures

Garden ClassificationGarden Classification– I Valgus impacted I Valgus impacted – II Non-displacedII Non-displaced– III Complete: III Complete:

Partially DisplacedPartially Displaced– IV Complete: Fully IV Complete: Fully

DisplacedDisplaced Functional Functional

ClassificationClassification– Stable (I/II)Stable (I/II)– Unstable (III/IV)Unstable (III/IV)

I II

III IV

Treatment OptionsTreatment Options– Non-operativeNon-operative

Very limited roleVery limited role Activity modificationActivity modification Skeletal tractionSkeletal traction

– OperativeOperative ORIFORIF Hemiarthroplasty (Endoprosthesis)Hemiarthroplasty (Endoprosthesis) Total Hip ReplacementTotal Hip Replacement


ORIF

Hemi

THR


Young PatientsYoung Patients– Urgent ORIF (<6hrs)Urgent ORIF (<6hrs)

Elderly PatientsElderly Patients– ORIF possible (higher risk AVN, non-ORIF possible (higher risk AVN, non-

union, and failure of fixation)union, and failure of fixation)– HemiarthroplastyHemiarthroplasty– Total Hip ReplacementTotal Hip Replacement

Intertrochanteric Hip FxIntertrochanteric Hip Fx

Intertrochanteric Intertrochanteric Femur FractureFemur Fracture– Extra-capsular Extra-capsular

femoral neck femoral neck – To inferior border To inferior border

of the lesser of the lesser trochantertrochanter


Intertrochanteric Intertrochanteric Femur FractureFemur Fracture– Physical Findings: Physical Findings:

Shortened / ER PostureShortened / ER Posture– Obtain Xrays: AP Pelvis, Obtain Xrays: AP Pelvis,

Cross table lateralCross table lateral

ClassificationClassification– # of parts: Head/Neck, GT, LT, Shaft# of parts: Head/Neck, GT, LT, Shaft– StableStable

Resists medial & compressive Loads after fixationResists medial & compressive Loads after fixation

– UnstableUnstable Collapses into varus or shaft medializes despite Collapses into varus or shaft medializes despite

anatomic reduction with fixationanatomic reduction with fixation

– Reverse ObliquityReverse Obliquity


Stable ReverseObliquity

Unstable



Treatment OptionsTreatment Options– Stable: Dynamic Hip Screw (2-hole)Stable: Dynamic Hip Screw (2-hole)– Unstable/Reverse: IM Recon NailUnstable/Reverse: IM Recon Nail

Subtrochanteric Femur FxSubtrochanteric Femur Fx

ClassificationClassification– Located from LT to 5cm Located from LT to 5cm

distal into shaftdistal into shaft– Intact Piriformis Fossa?Intact Piriformis Fossa?

TreatmentTreatment– IM Nail IM Nail – Cephalomedullary IM Cephalomedullary IM

NailNail– ORIFORIF

Femoral Shaft FxFemoral Shaft Fx Type 0 - No comminutionType 0 - No comminution Type 1 - Insignificant butterfly Type 1 - Insignificant butterfly

fragment with transverse or fragment with transverse or short oblique fractureshort oblique fracture

Type 2 - Large butterfly of less Type 2 - Large butterfly of less than 50% of the bony width, > than 50% of the bony width, > 50% of cortex intact50% of cortex intact

Type 3 - Larger butterfly leaving Type 3 - Larger butterfly leaving less than 50% of the cortex in less than 50% of the cortex in contactcontact

Type 4 - Segmental Type 4 - Segmental comminutioncomminution

Winquist and Hansen Winquist and Hansen 66A, 198466A, 1984

Treatment OptionsTreatment Options– IM Nail with locking screwsIM Nail with locking screws– ORIF with plate/screw constructORIF with plate/screw construct– External fixationExternal fixation– Consider traction pin if prolonged delay Consider traction pin if prolonged delay

to surgeryto surgery

Femoral Shaft FxFemoral Shaft Fx

Distal Femur FracturesDistal Femur Fractures

Distal Metaphyseal Distal Metaphyseal FracturesFractures

Look for intra-articular Look for intra-articular involvementinvolvement

Plain filmsPlain films CTCT

Distal Femur FracturesDistal Femur Fractures

Treatment:Treatment:– Retrograde IM NailRetrograde IM Nail– ORIF open vs. ORIF open vs.

MIPOMIPO– Above depends on Above depends on

fracture type, fracture type, bone quality, and bone quality, and fracture locationfracture location

High association of injuriesHigh association of injuries– Ligamentous InjuryLigamentous Injury

ACL, PCL, Posterolateral CornerACL, PCL, Posterolateral Corner LCL, MCLLCL, MCL

– Vascular InjuryVascular Injury Intimal tear vs. DisruptionIntimal tear vs. Disruption Obtain ABI’s Obtain ABI’s (+) (+) Arteriogram Arteriogram Vascular surgery consult with Vascular surgery consult with

repair within 8hrsrepair within 8hrs

– Peroneal >> Tibial N. injuryPeroneal >> Tibial N. injury

Knee DislocationsKnee Dislocations

Patella FracturesPatella Fractures HistoryHistory

– MVA, fall onto knee, MVA, fall onto knee, eccentric loadingeccentric loading

Physical ExamPhysical Exam– Ability to perform straight Ability to perform straight

leg raise against gravity (ie, leg raise against gravity (ie, extensor mechanism still extensor mechanism still intact?)intact?)

– Pain, swelling, contusions, Pain, swelling, contusions, lacerations and/or abrasions lacerations and/or abrasions at the site of injuryat the site of injury

– Palpable defectPalpable defect

Patella FracturesPatella Fractures

RadiographsRadiographs– AP/Lateral/Sunrise viewsAP/Lateral/Sunrise views

TreatmentTreatment– ORIF if ext mechanism ORIF if ext mechanism

is incompetentis incompetent– Non-operative Non-operative

treatment with brace if treatment with brace if ext mechanism remains ext mechanism remains intactintact

Tibia FracturesTibia Fractures

Proximal Tibia Fractures (Tibial Proximal Tibia Fractures (Tibial Plateau)Plateau)

Tibial Shaft FracturesTibial Shaft Fractures Distal Tibia Fractures (Tibial Distal Tibia Fractures (Tibial

Pilon/Plafond)Pilon/Plafond)

Tibial Plateau FracturesTibial Plateau Fractures

MVA, fall from height, sporting injuriesMVA, fall from height, sporting injuries Mechanism and energy of injury plays a Mechanism and energy of injury plays a

major role in determining orthopedic major role in determining orthopedic carecare

Examine soft tissues, neurologic exam Examine soft tissues, neurologic exam (peroneal N.), vascular exam (esp with (peroneal N.), vascular exam (esp with medial plateau injuries)medial plateau injuries)

Be aware for compartment syndromeBe aware for compartment syndrome Check for knee ligamentous instabilityCheck for knee ligamentous instability


Xrays: AP/Lateral +/- traction filmsXrays: AP/Lateral +/- traction films CT scan (after ex-fix if appropriate)CT scan (after ex-fix if appropriate)

Schatzker Classification of Plateau Schatzker Classification of Plateau FxsFxs

Lower Energy

Higher Energy


TreatmentTreatment– Spanning External Spanning External

Fixator may be Fixator may be appropriate for appropriate for temporary temporary stabilization and to stabilization and to allow for resolution allow for resolution of soft tissue of soft tissue injuriesinjuries

Insert blisterPics of ex-fix here


TreatmentTreatment– Definitive ORIF for Definitive ORIF for

patients with patients with varus/valgus varus/valgus instability, >5mm instability, >5mm articular stepoff articular stepoff

– Non-operative in Non-operative in non-displaced stable non-displaced stable fractures or patients fractures or patients with poor surgical with poor surgical risksrisks

Tibial Shaft FracturesTibial Shaft Fractures

Mechanism of InjuryMechanism of Injury– Can occur in lower energy, torsion type Can occur in lower energy, torsion type

injury (e.g., skiing)injury (e.g., skiing)– More common with higher energy More common with higher energy

direct force (e.g., car bumper)direct force (e.g., car bumper)– Open fractures of the tibia are more Open fractures of the tibia are more

common than in any other long bonecommon than in any other long bone


Open Tibia FxOpen Tibia Fx PrioritiesPriorities

– ABC’SABC’S– Associated InjuriesAssociated Injuries– TetanusTetanus– AntibioticsAntibiotics– FixationFixation

Johner and Wruh’s ClassificationJohner and Wruh’s Classification

Tibial Shaft FracturesTibial Shaft Fractures Gustilo and Anderson Classification of Gustilo and Anderson Classification of

Open FxOpen Fx– Grade 1Grade 1

<1cm, minimal muscle contusion, usually <1cm, minimal muscle contusion, usually inside out mechanisminside out mechanism

– Grade 2Grade 2 1-10cm, extensive soft tissue damage1-10cm, extensive soft tissue damage

– Grade 3Grade 3 3a: >10cm, adequate bone coverage3a: >10cm, adequate bone coverage 3b: >10cm, periosteal stripping requiring 3b: >10cm, periosteal stripping requiring

flap advancement or free flapflap advancement or free flap 3c: vascular injury requiring repair3c: vascular injury requiring repair

Tibial Shaft FracturesTibial Shaft Fractures Tscherne Classification of Soft Tissue Tscherne Classification of Soft Tissue

InjuryInjury– Grade 0- negligible soft tissue injuryGrade 0- negligible soft tissue injury– Grade 1- superficial abrasion or contusionGrade 1- superficial abrasion or contusion– Grade 2- deep contusion from direct traumaGrade 2- deep contusion from direct trauma– Grade 3- Extensive contusion and crush injury Grade 3- Extensive contusion and crush injury

with possible severe muscle injurywith possible severe muscle injury

Management of Open Fx Management of Open Fx Soft TissuesSoft Tissues– ERER: initial evaluation : initial evaluation

wound covered with wound covered with sterile dressing and leg sterile dressing and leg splinted, tetanus splinted, tetanus prophylaxis and prophylaxis and appropriate antibioticsappropriate antibiotics

– OROR: Thorough I&D : Thorough I&D undertaken within 6 hours undertaken within 6 hours with serial debridements with serial debridements as warranted followed by as warranted followed by definitive soft tissue definitive soft tissue covercover


Tibial Shaft FracturesTibial Shaft Fractures Definitive Soft Tissue CoverageDefinitive Soft Tissue Coverage

– Proximal third tibia fractures can be covered Proximal third tibia fractures can be covered with gastrocnemius rotation flapwith gastrocnemius rotation flap

– Middle third tibia fractures can be covered Middle third tibia fractures can be covered with soleus rotation flapwith soleus rotation flap

– Distal third fractures usually require free flap Distal third fractures usually require free flap for coveragefor coverage

Tibial Shaft FracturesTibial Shaft Fractures Treatment OptionsTreatment Options

– IM NailIM Nail– ORIF with PlatesORIF with Plates– External FixationExternal Fixation– Cast or Cast-BraceCast or Cast-Brace

Advantages of IM nailingAdvantages of IM nailing– Lower non-union rateLower non-union rate– Smaller incisionsSmaller incisions– Earlier weightbearing and Earlier weightbearing and

functionfunction– Single surgerySingle surgery


IM nailing of IM nailing of distal and distal and proximal fxproximal fx– Can be done but Can be done but

requires requires additional additional planning, special planning, special nails, and nails, and advanced advanced techniquestechniques


Fractures involving distal tibia Fractures involving distal tibia metaphysis and into the ankle jointmetaphysis and into the ankle joint

Soft tissue management is key!Soft tissue management is key! Often occurs from fall from height or Often occurs from fall from height or

high energy injuries in MVAhigh energy injuries in MVA ““Excellent” results are rare, “Fair to Excellent” results are rare, “Fair to

Good” is the norm outcomeGood” is the norm outcome Multiple potential complicationsMultiple potential complications

Tibial Pilon FracturesTibial Pilon Fractures

Initial EvaluationInitial Evaluation– Plain films, CT scanPlain films, CT scan– Spanning External FixatorSpanning External Fixator– Delayed Definitive Care to protect soft Delayed Definitive Care to protect soft

tissues and allow for soft tissue swelling tissues and allow for soft tissue swelling to resolveto resolve



Treatment GoalsTreatment Goals– Restore Articular SurfaceRestore Articular Surface– Minimize Soft Tissue InjuryMinimize Soft Tissue Injury– Establish LengthEstablish Length– Avoid Varus CollapseAvoid Varus Collapse

Treatment OptionsTreatment Options– IM nail with limited ORIFIM nail with limited ORIF– ORIFORIF– External FixatorExternal Fixator


ComplicationsComplications– Mal or Non-union (Varus)Mal or Non-union (Varus)– Soft Tissue ComplicationsSoft Tissue Complications– InfectionInfection– Potential AmputationPotential Amputation

Ankle FracturesAnkle Fractures Most common weight-Most common weight-

bearing skeletal injurybearing skeletal injury Incidence of ankle fractures Incidence of ankle fractures

has doubled since the has doubled since the 1960’s1960’s

Highest incidence in elderly Highest incidence in elderly womenwomen– Unimalleolar Unimalleolar 68%68%– Bimalleolar Bimalleolar 25%25%– TrimalleolarTrimalleolar 7% 7%– OpenOpen 2% 2%

Osseous AnatomyOsseous Anatomy

Lateral Ligamentous Lateral Ligamentous AnatomyAnatomy

Medial Ligamentous AnatomyMedial Ligamentous Anatomy

Syndesmosis AnatomySyndesmosis Anatomy

Ankle FracturesAnkle Fractures HistoryHistory

– Mechanism of injuryMechanism of injury– Time elapsed since the injuryTime elapsed since the injury– Soft-tissue injurySoft-tissue injury– Has the patient ambulated on Has the patient ambulated on

the ankle?the ankle?– Patient’s age / bone qualityPatient’s age / bone quality– Associated injuriesAssociated injuries– Comorbidities (DM, smoking)Comorbidities (DM, smoking)

Ankle FracturesAnkle Fractures Physical ExamPhysical Exam

– Neurovascular exam Neurovascular exam – Note obvious deformitiesNote obvious deformities– Pain over the medial or lateral Pain over the medial or lateral

malleolimalleoli– Palpation of ligaments about the Palpation of ligaments about the

ankleankle– Palpation of proximal fibula, Palpation of proximal fibula,

lateral process of talus, base of lateral process of talus, base of 55thth MT MT

– Examine the hindfoot and Examine the hindfoot and forefootforefoot

Ankle FracturesAnkle Fractures

Radiographic StudiesRadiographic Studies– AP, Lateral, Mortise of Ankle (Weight AP, Lateral, Mortise of Ankle (Weight

Bearing if possible)Bearing if possible)– AP, Lateral of Knee (Maissaneve injury)AP, Lateral of Knee (Maissaneve injury)– AP, Lateral, Oblique of Foot (if painful)AP, Lateral, Oblique of Foot (if painful)

AP AnkleAP Ankle– Tibiofibular overlapTibiofibular overlap

<10mm is abnormal <10mm is abnormal and implies and implies syndesmotic injurysyndesmotic injury

– Tibiofibular clear Tibiofibular clear space space >5mm is abnormal - >5mm is abnormal -

implies syndesmotic implies syndesmotic injuryinjury

– Talar tiltTalar tilt >2mm is considered >2mm is considered

abnormalabnormal


Ankle Mortise ViewAnkle Mortise View– Foot is internally Foot is internally

rotated and AP rotated and AP projection is performed projection is performed

– Abnormal findings:Abnormal findings: Medial joint space Medial joint space

wideningwidening Talocural angle Talocural angle <8<8 or or

>15>15 degrees ( degrees (compare to compare to normal sidenormal side))

Tibia/fibula overlap Tibia/fibula overlap <1mm<1mm


Lateral ViewLateral View– Posterior malleolar Posterior malleolar

fracturesfractures– Anterior/posterior Anterior/posterior

subluxation of the subluxation of the talus under the tibiatalus under the tibia

– Displacement/Displacement/Shortening of distal Shortening of distal fibulafibula

– Associated injuriesAssociated injuries


Ankle FracturesAnkle Fractures Classification Systems (Lauge-Hansen)Classification Systems (Lauge-Hansen)

– Based on cadaveric studyBased on cadaveric study– First word refers to position of foot at time of First word refers to position of foot at time of

injuryinjury– Second word refers to force applied to foot Second word refers to force applied to foot

relative to tibia at time of injuryrelative to tibia at time of injury

Ankle FracturesAnkle Fractures Classification Systems (Weber-Danis)Classification Systems (Weber-Danis)

– A: Fibula Fracture distal to mortiseA: Fibula Fracture distal to mortise– B: Fibula Fracture at the level of the B: Fibula Fracture at the level of the

mortisemortise– C: Fibula Fracture proximal to mortiseC: Fibula Fracture proximal to mortise


Initial ManagementInitial Management– Closed reduction (conscious Closed reduction (conscious

sedation may be necessary)sedation may be necessary)– AO splintAO splint– Delayed fixation until soft Delayed fixation until soft

tissues stabletissues stable– Pain controlPain control– Monitor for possible Monitor for possible

compartment syndrome in high compartment syndrome in high energy injuriesenergy injuries

Ankle FracturesAnkle Fractures Indications for non-operative care:Indications for non-operative care:

– Nondisplaced fracture with intact syndesmosis Nondisplaced fracture with intact syndesmosis and stable mortiseand stable mortise

– Less than 3 mm displacement of the isolated Less than 3 mm displacement of the isolated fibula fracture with no medial injuryfibula fracture with no medial injury

– Patient whose overall condition is unstable and Patient whose overall condition is unstable and would not tolerate an operative procedurewould not tolerate an operative procedure

ManagementManagement::– WBAT in short leg cast or CAM boot for 4-6 weeksWBAT in short leg cast or CAM boot for 4-6 weeks– Repeat x-ray at 7–10 days to r/o interval Repeat x-ray at 7–10 days to r/o interval

displacementdisplacement

Ankle FracturesAnkle Fractures Indications for operative Indications for operative

care:care:– Bimalleolar fracturesBimalleolar fractures– Trimalleolar fracturesTrimalleolar fractures– Talar subluxationTalar subluxation– Articular impaction injuryArticular impaction injury– Syndesmotic injurySyndesmotic injury

Beware the painful ankle with Beware the painful ankle with no ankle fracture but a no ankle fracture but a widened mortise… check widened mortise… check knee films to rule out knee films to rule out Maissoneuve Syndesmosis Maissoneuve Syndesmosis injury.injury.


ORIF:ORIF:– FibulaFibula

Lag Screw if possible + PlateLag Screw if possible + Plate Confirm length/rotationConfirm length/rotation

– Medial MalleolusMedial Malleolus Open reduceOpen reduce 4-0 cancellous screws vs. tension 4-0 cancellous screws vs. tension

bandband

– Posterior MalleolusPosterior Malleolus Fix if >30% of articular surface Fix if >30% of articular surface

– SyndesmosisSyndesmosis Stress after fixationStress after fixation Fix with 3 or 4 cortex screwsFix with 3 or 4 cortex screws

Ankle FracturesAnkle Fractures Most common weight-Most common weight-

bearing skeletal injurybearing skeletal injury Incidence of ankle fractures Incidence of ankle fractures

has doubled since the has doubled since the 1960’s1960’s

Highest incidence in elderly Highest incidence in elderly womenwomen– Unimalleolar Unimalleolar 68%68%– Bimalleolar Bimalleolar 25%25%– TrimalleolarTrimalleolar 7% 7%– OpenOpen 2% 2%

Osseous AnatomyOsseous Anatomy

Lateral Ligamentous Lateral Ligamentous AnatomyAnatomy

Medial Ligamentous AnatomyMedial Ligamentous Anatomy

Syndesmosis AnatomySyndesmosis Anatomy

Ankle FracturesAnkle Fractures HistoryHistory

– Mechanism of injuryMechanism of injury– Time elapsed since the injuryTime elapsed since the injury– Soft-tissue injurySoft-tissue injury– Has the patient ambulated on Has the patient ambulated on

the ankle?the ankle?– Patient’s age / bone qualityPatient’s age / bone quality– Associated injuriesAssociated injuries– Comorbidities (DM, smoking)Comorbidities (DM, smoking)

Ankle FracturesAnkle Fractures Physical ExamPhysical Exam

– Neurovascular exam Neurovascular exam – Note obvious deformitiesNote obvious deformities– Pain over the medial or lateral Pain over the medial or lateral

malleolimalleoli– Palpation of ligaments about the Palpation of ligaments about the

ankleankle– Palpation of proximal fibula, Palpation of proximal fibula,

lateral process of talus, base of lateral process of talus, base of 55thth MT MT

– Examine the hindfoot and Examine the hindfoot and forefootforefoot


Radiographic StudiesRadiographic Studies– AP, Lateral, Mortise of Ankle (Weight AP, Lateral, Mortise of Ankle (Weight

Bearing if possible)Bearing if possible)– AP, Lateral of Knee (Maissaneve injury)AP, Lateral of Knee (Maissaneve injury)– AP, Lateral, Oblique of Foot (if painful)AP, Lateral, Oblique of Foot (if painful)