for the treatment part consult

1. ANKLE INJURIES
praveen reddy p

2. Surgical anatomy of ankle
joint
 Saddle shaped joint
 Three bone joint – tibia, fibula and talus
 Tibia - tibial plafond and medial
malleolus
 Fibula – lateral malleolus
 Large surface of talar dome anteriorly
and laterally

3. Continued..
 This configuration provides stability in dorsi
flexion and relative mobility in plantar flexion
# DORSI FLEXION - close packed position
- stability by articular
contact
# PLANTAR FLEXION – stability principally
by ligamentous
structures

4. TIBIA
 Lower end formed by five surfaces,
# inferior,anterior,posterior,lateral,medial
` inferior surface is concave antero-posteriorly
and convex transversely
` posterior border is lower than the lateral
border
` lateral border is concave with two tubercles – anterior
and posterior

6. TIBIA
 Anterior tubercle over laps fibula - forms
the basis for radiological tibio-fibular
syndesmotic assessment
 Posterior tubercle remains intact –
forms the basis for indirect reduction of
posterior malleolar fragment

7. MEDIAL MALLEOLUS
 Articular surface is comma shaped
 Posterior border includes groove for tibialis
posterior
 Composed of two colliculi seperated by inter
collicular groove
 Deep component of deltoid attaches to inter
collicular groove
 Superficial component attaches to medial and
anterior border of anterior colliculus

8. FIBULA
 Two major surfaces, medial and lateral
which widen to three surfaces at tibial
plafond
# anteriorly - ant tibio-fibular
- ant talo-fibular
# inferiorly - calcaneo-fibular
# posteriorly - post tibio-fibular

9. TALUS
 Covered entirely by articular cartilage,
no musculo-tendinous attachment
 Trapezoidal – ant surface wider than
the post surface

10. LIGAMENTS
 syndesmotic - ant tibio-fibular
- post tibio-fibular – strongest
- int-osseous ligament
 Lateral collateral - ant talo-fibular
- calcaneo-fibular
- post talo-fibular
 Deltoid - superficial
- deep – primary medial stabiliser

11. SYNDESMOSIS

12. LATERAL LIGAMENTS

13. MEDIAL LIGAMENTS

14. Patient Evaluation
 History
 Mechanism
 Time since injury
 Associated injuries
 Comorbidities

Diabetes

Neuropathy

Obesity

Alcoholism / drug
abuse

15. Physical Exam
 Note obvious deformities
 Neurovascular exam
 Pain to palpation of malleoli and
ligaments
 Palpate along the entire fibula
 Pain at the ankle with compression
 syndesmotic injury
 Examine the hindfoot and forefoot for
associated injuries

16. Ankle Injuries
 type I — Only a few
fibers are stretched
or torn, so ankle is
mildly tender and
painful, but muscle
strength is normal.

17. Ankle Injuries
Type II — A greater
number of fibers are
torn, so there is
severe pain and
tenderness, together
with mild swelling,
noticable loss of
strength and
sometimes bruising

18. Ankle Injuries
 Type III — The
ligaments tear all the
way through, rip
into two separate
parts, there will be
considerable pain,
swelling, tenderness
and discoloration.

19. Ankle Injuries
 Sprains / Strains –
80% of sprains are
caused by ankle
inversion.
 Inversion sprains
cause damage to
the lateral ligaments

20. RADIOLOGY
OTTAWA ANKLE RULES
# x-rays indicated only if
` pain near malleoli
` inability to bear weight
` bony tenderness at the tip of the
malleolus or post edge
# 100% sensitive, decreased cost and
patient waiting time

21. X - RAYS
 On plain x-rays – there is continous
condensed sub chondral bone around
the talus that extends from sub
chondral bone of distal tibia to medial
aspect of fibula

22. X - RAYS
 AP and LATERAL
 MORTISE VIEW
 STRESS or OBLIQUE VIEW (cobb’s)

23. A-P VIEW
 Tibio-fibular overlap
 <10mm implies
syndesmotic injury
 Tibio-fibular clear
space
 >5mm implies
syndesmotic injury
 Talar tilt
 >2mm is considered
abnormal

24. MORTISE VIEW
AP view of ankle with
foot internally
rotated
Abnormal findings:
 medial joint space
widening
 tibia/fibula overlap
<1mm

25. LATERAL
VIEW
 Posterior malleolus
fracture
 Subluxation of the talus
 Angulation of distal fibula
 Talus fractures
 Calcaneus fractures

26. STRESS VIEWS
 Demonstrate ligamentous or syndesmotic
disruption
 May require sedation or hematoma block
 Comparison with contralateral ankle

27. LAUGE HANSEN”S
 Associates specific fracture patterns with
mechanism of injury
 Two-term scheme
1. Position of foot
Supination (lateral)
Pronation (medial)
1. Direction of force
Adduction / abduction
External rotation
Dorsiflexion

28. LAUGE HANSEN”S
 Genetic classification
 Six groups of injuries
# abduction injuries
# adduction injuries
# ext rotation injuries with diastasis of
inferior tibio-fibular jt
- pronation external rotation injuries
# ext rotation injuries with out diastasis of
inferior tibio-fibular jt
- supination external rotation injuries
# vertical compression injuries
# uncommon unclassifiable injuries

29. LAUGE HANSEN”S
 Continues to form the basis of our
understanding of mehanism of injury
 Provides good guide to prognosis after
both operative and conservative
methods

30. WEBER”S
 Type A
# below syndesmosis
 Type B
# at the level of syndesmosis
 Type C
# above the level of syndesmosis

31. WEBER”S

32. WEBER”S
 Attractive for its simplicity and its guided
treatment
 Level of fibular fracture exclusively to
guide treatment isn’t accurate enough
 Degree of syndesmotic injury not
always accurately predicted
 Ignores medial side of the injury

33. Surgical technique
 Standard AO fixation
 Inter-fragmentary screw and 1/3 tubular neutralisation
plate for fibula and lag screw fixation for medial
malleolus
 Syndesmosis screw is required if fibula is unstable at
end of fixation (engage 3 cortices and ensure the
ankle is at 90º when inserting screw, and that the
screw is not lagged) Screw needs to be removed
before weight bearing can be commenced
 Alternative fixation for Type B fractures of the fibula is
the anti-glide plate which has been shown to be
biomechanically superior to a lateral plate
 Posterior malleolus fractures need to be fixed if there
is > 25% of the articular surface involved. This is
often underestimated on lateral radiographs

34. ABDUCTION INJURY
 Talus forcibly abducted in ankle mortise producing traction on
medial structures -
# pull off fracture of medial malleolus or rupture of deltoid
ligament
# lateral compression force produces a lower fibular fracture
with characteristic lateral comminution
# doesnot produce seperation of tibio-fibular jt b’cos
combined strength of three ligaments is greater than lat
malleolus
# rarely if associated with vertical compression can cause en-
bloc avulsion of incisura fibularis

35. DIAGNOSIS
 Valgus deformity of foot
 Swelling over both medial and lateral
aspect

36. TREATMENT
 Undisplaced isolated med malleolus
fractures –
# b/k plaster cast for six
weeks
# rehabilitation

37. TREATMENT
 Displaced / irreducible – due to soft
tissue interposition,
# 4mm cancellous screw
#TBW
# inter-fragmentary screw

38. TREATMENT
FIBULA – minimal comminution
# b/k cast
- severe comminution
# 1/3rd tubular plate

39. ADDUCTION INJURY
 Traction on the lateral structures
# forcible inversion of the plantar flexed foot
> ant talo-fibular tear
# forcible inversion at right angle
> tear of all 3 lateral ligaments or
lateral malleolus fracture
> compression injury of the medial
malleolus causing vertical fracture +/-
depression of articular surface

40. ADDUCTION INJURY -
TREATMENT
 Isolated tear of ant talo-fibular ligament
# eversion stirrup and elastic
bandaging
# adhesion formation
- pain, weakness, giving way
- outer side heel raise
- Inj hydrocortisone + hyaluronidase

41. ADDUCTION INJURY -
TREATMENT
 Complete tear of lateral structures-
# talus will move away from malleolus
and well defined sulcus appears
between the two bones
 Marked talar tilt on stress x-rays
 Can lead to recurrent dislocation if not
treated

42. ADDUCTION INJURY -
TREATMENT
 Complete immobilisation in a plaster
cast for 6-8 weeks and rehabilitation
 Recurrent dislocation –
# evan’s procedure

43. EX ROTATION INJ WITH INF
TIBIO-FIBULAR JT
DIASTASIS
 Also known as PRONATION-EXTERNAL
ROTATION FRACTURE
 Three types –
# isolated fracture of med malleolus
# partial diastasis of the inf tibio-fibular
joint
# complete diastasis of the inf tibio-
fibular joint

44. EX ROTATION INJ WITH INF
TIBIO-FIBULAR JT
DIASTASIS
 Isolated med malleolus fracture -
# b/k plaster cast for 6-8 weeks
# ORIF

45. EX ROTATION INJ WITH INF
TIBIO-FIBULAR JT
DIASTASIS
Partial diastasis of the inf tibio-fibular jt
# reducible – a/k plaster cast in slightly
inverted and firmly int rotated position
(fibula winds itself up on the intact post
ligament which serves to locate it well in
its groove in the tibia – incisura fibularis)
# irreducible – ORIF

46. EX ROTATION INJ WITH INF
TIBIO-FIBULAR JT
DIASTASIS
 Complete diastasis of the inf tibio-fibular
joint
 ORIF - post op immobilisation
- plaster cast for 6-8 weeks

47. EX-ROTATION INJ WITHOUT
INF TIBIO-FIBULAR JT
DIASTASIS
 Also known as SUPINATION-
EXTERNAL ROTATION FRACTURE
 Oblique fracture of the lower fibula
 Fracture dislocation without inf tibio-
fibular joint diastasis

48. EX-ROTATION INJ WITHOUT
INF TIBIO-FIBULAR JT
DIASTASIS
 Oblique fracture of the lower fibula
# b/k plaster cast application for 4
weeks

49. EX-ROTATION INJ WITHOUT
INF TIBIO-FIBULAR JT
DIASTASIS
 Fracture dislocation without inf tibio-fibular
joint diastasis
# reduction – cupping back the heel
in one hand, gently pull forwards and
inwards and at the same time with the
other hand apply counter over the medial
side of tibial shaft
# ORIF

56. Operative Tips
 Lateral Malleolus
 Reduce first
 Proximal fragment (shaft) needs reduction
 3 bicortical screws into proximal fibula
 Unicortical screws into intra-articular
portion
 Be certain fibula is out to length

57. ISOLATED LATERAL MALLEOLAR #
` Reduce & internally fix lateral malleolar # first in case of
a bimalleolar #.
` If the # is oblique, fix it with two lag screws 1cm apart.
` If the # is transverse, fix it with a rush rod / IL fibular
rod.
` If the # is small & below the plafond and has good bone
stock, it is fixed with a 4.5mm malleolar screw. In
patients with poor bone stock tension band technique
is used.
` If the # is above the syndesmotic level, a small
fragment 1/3rd tubular plate or a 3.5mm DCP can be
used, If the plate is placed posterolaterally it acts as a
antiglide plate.

58. Operative Tips
 Medial malleolus
 Open reduction
 Visualize the ‘shoulder’ of the malleolus
 Remove interposed soft tissue and
intraarticular fragments
 Two points of fixation
 Anti-glide plate for vertical fractures

59. ISOLATED MED. MALLEOLAR #
` Non displaced #: cast immobilisation.
` Avulsion # of the malleolar tip: no fixation required
unless displaced.
` Fixation usually requires two 4mm cancellous lag
screws oriented perpendicular to the #.
` Vertically oriented # requires horizontally placed
screws.
` Smaller fragments require one lag screw & a k-wire to
prevent rotation.
` Fragments too small or comminuted are fixed with
tension band technique.
` Vertical # extending into metaphysis requires
semitubular buttress plate for fixation.

60. Medial Malleolus
Fixation

61. Posterior Malleolus
 Repair if >25% of
articular surface
 Reduce by ankle
dorsiflexion
 Clamp through
fibular incision
 Anterior lag screws

62. Maissoneuve Fracture
 Fracture of proximal
1/3 of fibula
 +/- medial malleolar
fracture
 Pronation-external
rotation mechanism
 Requires reduction
and stabilization of
syndesmosis

63. Maissoneuve Fracture
 Fracture of proximal
1/3 of fibula
 +/- medial malleolar
fracture
 Pronation-external
rotation mechanism
 Requires reduction
and stabilization of
syndesmosis

64. BIMALLEOLAR FRACTURE
` Non union reported in 10% of bimalleolar # treated
with closed methods.
` Tile & AO group recommends ORIF of almost all
bimalleolar #s.
` Most Weber type B & C lateral malleolar #s are
stabilised with plate & screw fixation.

65. DELTOID LIG.TEAR & LATERAL MALLEOLAR
#
` Supination- external rotation injury.
` Associated with tear of the anterior capsule.
` Stress x-ray with the supinated & externally rotated
shows talar tilting with a widened medial clear space.
` 1mm lateral shift of talus reduces the effective wt.
bearing area of the talo-tibial articulation by 20-40%.
` Optimal treatment of this injury provided skin
condition, patient age & general condition permits,
consists of ORIF of fibula with /without deltoid ligament
repair.
` Lateral malleolar # is fixed before the repair of deltoid
ligament.

66. TRIMALLEOLAR FRACTURE
` Usually caused by abduction or external rotation injury
` Components - medial malleolar #/deltoid
lig.rupture, fibular # & # of the
posterior lip of the articular surface of
tibia
` 500 external rotation view - assessment of size &
displacement of posterior malleolar fragment.
` Fragment size > 25-30% of the wt. bearing surface
requires ORIF
` Posterior lip # should be fixed before reduction of either
the medial or lateral malleolar #

67. SYNDESMOTIC INJURIES
 Pronation- external rotation, pronation abduction
and supination external rotation injuries.
 Syndesmotic injuries extending > 4.5cm proximal
to the ankle jt alter the joint mechanics, but that
extending < 3cm proximal to the joint dont.
INDICATIONS FOR FIXATION:
i. Associated proximal fibular #s for which fixation is
not planned and involves a medial injury that
cannot be stabilised.
ii. Injuries extending > 5cm proximal to the plafond.

68. SYNDESMOTIC INJURIES contd .
 Normally intraoperative roentgenograms should
demonstrate a clear space of < 5mm b/w medial wall
of fibula & lateral wall of posterior tibial malleolus.
 Fixation of syndesmosis is either with oblique pins or
screws inserted trrough the lateral malleolus into the
distal tibia.
 The screws should be placed through both cortices of
fibula & either one or both cortices of the tibia.
 Screw position- 2cm proximal to plafond, parallel to
the joint surface, 300 anterior, perpendicular to TF jt..

69. Fixation of Syndesmosis
 Fix fibula
anatomically
 Make sure ankle
mortise is reduced
 Hold reduction with
clamp
 Do not lag!
 ? Large vs. small
fragment screw
 ? 3 vs. 4 cortices
 ? Screw removal

70. Postoperative Care
 Well padded splint
immobilization
 Ice and elevation
 Non weight bearing
for 6 weeks
 Early weight bearing
possible
 Early conversion to
brace and ROM

71. COMPLICATIONS
Mal union
# Can occur with lateral malleolus,
medial malleolus or the
posterior malleolus.
# Predisposes to late degenerative
changes and pain.

72. COMPLICATIONS contd…
Treatment-
# Lat mall - osteotomy through the # site, fixation with plate
& screws and bone grafting.
# Medial mall - osteotomy through # site & fixation with
malleolar screw & k wire.
# Post mall - if >25% of articular surface involved, osteotomy
through # site, reduction& fixation with k wire & malleolar
screws.

73. COMPLICATIONS contd…
Non union
# > in conservatively treated patients.
# Non union of lat. malleolus <
med.malleolus.
# Treatment- non union site exposed &
ends are freshened , rigidly fixed with a
malleolar screw & k wire.

74. COMPLICATIONS contd…
Sudecks atrophy-
# Characterised by pain, demineralisation,edema,
shiny skin with reduced ROM.
# Prevented by early ROM exercises, elevation of
the affected limb.
# once the condition has developed – intensive
physiotherapy, prolonged elevation & use of
sympathetic blocking agents.

75. COMPLICATIONS contd…
Wound healing
# Plate application over lateral malleolus interferes
with wound healing.
# Prevented by meticulous closure of subcutaneous
layer to cover the implant & constant elevation of
the limb for first 5-7 days.

76. COMPLICATIONS contd…
Infection
# Associated with poor closure ,failure to elevate the
limb postoperatively
# Treatment - leave the implant in situ, dressing to
be done regularly.
- when the repaired # has united,
implant to be removed, debridement
under antibiotic coverage & later
SSG.

77. COMPLICATIONS contd…
Fixation failure
# Loosening or backing out of screws
usually seen in distal fibula.
# Treatment - if screw loosens prior to
healing of syndesmotic
ligament it should be
replaced.

78. COMPLICATIONS contd…
Degenerative arthritis
# Due to imperfect reduction.
# Treatment - if malunion is the cause
correct it.
- if advanced arthritis present -
arthrodesis.

79. PILON /
PLAFOND
FRACTURES
(Pilon = Hammer /
Plafond = Ceiling)

80. Reudi & Allgower’s
Type Pathology
1 Undisplaced
2 Displaced with joint incongruity
3 Marked comminution with
crushing of the subchondral
cancellous bone

81. Reudi & Allgower’s

82. Initial treatment
 Reduction of any dislocation and
covering of exposed wounds if present
 Assess neuro-vascular status
 Check for evidence of compartment
syndrome
 Splint fracture which may require
temporary skeletal traction

83.  Investigations
 X-ray plus CT
 Timing of surgery
 Type II and III - goal is to keep talus
centred under the tibia, while soft tissue
heal over 7 to 21 days

84. Surgical options
1. ORIF
 Medial and anterior incisions with full
thickness flaps developed at level of the
periosteum. These incisions must be at
least 7 cm apart to protect the viability
of the intervening skin bridge

85.  Steps
 Fibula # brought out to length and fixed with plate
(DCP)
 Tibial # exposed and reduced, held with temporary
K-wires – usually 4 main fragments
 K-wires replaced with interfragmentary screws and
fixed with buttress plate
 Closure of wounds – tension must be avoided and
if present close deep layers and return later for
delayed 1º closure of skin

86. 2. Fine wire fixation with circular
frames
 Using either the Ilizarov or hybrid
external fixators
 This can be combined with limited
internal fixation of the tibia using inter-
fragmentary screws and fixation of the
fibula

87. 3. Trans-articular external fixation
 Will align the tibia but will not address
the central depression of the joint
surface.
 Useful as first part of 2 -stage
procedure (to allow soft tissue
management & CT & planning)

88. Summary
 You WILL see ankle fractures
 Taken for granted
 Reduce the mortise anatomically
 Fibular length
 Stable syndesmosis
 Anatomic reduction and debridement
medially
 Proper management leads to excellent
outcomes

89. Thanks for listenin!!!!
thanks for
listenin..