Ankle FracturesAnkle Fractures

UCMC Orthopaedic Trauma ConferenceUCMC Orthopaedic Trauma ConferenceApril 2012April 2012

• MechanismMechanism

• TimingTiming

• Soft-tissue injurySoft-tissue injury

• Bone qualityBone quality

• ComorbiditiesComorbidities

• Associated InjuriesAssociated Injuries

• SkinSkin

• NervesNerves

• VasculatureVasculature

• PainPain

• DeformityDeformity

Anatomy: Medial SideAnatomy: Medial Side

Anterior Colliculus

Posterior Colliculus

Intercollicular Groove

Origin: anterior colliculus

Origin: posterior colliculus& intercollicular groove

Pankovich 1979

Osseous AnatomyOsseous AnatomyMcMinn 1996

APAP

– Tibiofibular overlapTibiofibular overlap– <10mm<10mm

– Tibiofibular clear space Tibiofibular clear space – >5mm>5mm

– Talar tiltTalar tilt– >2mm>2mm

Consider a comparison view

Mortise ViewMortise View

– Talocrural Talocrural angle: <8 angle: <8 or >15 or >15 degreesdegrees

Mortise ViewMortise View

Weber SICOT 1981

FIBULAR LENGTH: 1. Shenton’s Line of the ankle2. The dime test

Supination-External RotationSupination-External Rotation

3Stage 1 Anterior tibio- fibular ligament

Stage 2 Fibula fx

Stage 3 Posterior malleolus fx or posterior tibio-fibular ligament

Stage 4 Deltoid ligament tear or medial malleolus fx

Supination-External Rotation Supination-External Rotation Stage 4: UnstableStage 4: Unstable

Lateral Injury: classic posterosuperioranteroinferior fibula fracture

Medial Injury: medial malleolar fracture &*/or deltoid ligament injury

Standard: Surgical management *Tornetta JBJS 2000

Supination Adduction: Supination Adduction: Stage 2Stage 2

Lateral Injury: transverse fibular fracture at/below level of mortise

Medial injury: vertical shear type medial malleolar fractureBEWARE OF IMPACTION

McConnell J Orthop Trauma 2001

Pronation-External RotationPronation-External Rotation

• Stage 1 Deltoid ligament tear or Stage 1 Deltoid ligament tear or medial malleolus fxmedial malleolus fx

• Stage 2 Anterior tibio-fibular Stage 2 Anterior tibio-fibular ligament and interosseous ligament and interosseous membranemembrane

• Stage 3 Spiral, proximal fibula Stage 3 Spiral, proximal fibula fracturefracture

• Stage 4 Posterior malleolus fx Stage 4 Posterior malleolus fx or posterior tibio-fibular or posterior tibio-fibular ligament ligament

•

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1 2

Pronation External Rotation: Pronation External Rotation: Stage 4Stage 4

Medial injury: deltoid ligament tear &/or transverse medial malleolar fracture

Lateral Injury: spiral proximal lateral malleolar fracture

HIGHLY UNSTABLE…SYNDESMOTIC INJURY COMMON

Pronation-AbductionPronation-Abduction• Stage 1 Transverse medial Stage 1 Transverse medial

malleolus fx distal to mortisemalleolus fx distal to mortise

• Stage 2 Posterior malleolus fx or Stage 2 Posterior malleolus fx or posterior tibio-fibular ligament posterior tibio-fibular ligament

• Stage 3 Fibula fracture, typically Stage 3 Fibula fracture, typically proximal to mortise, often with a proximal to mortise, often with a butterfly fragmentbutterfly fragment

1 2

3

Pronation-AbductionPronation-Abduction

Medial injury: tranverse to short oblique medial malleolar fracture

Lateral Injury: comminuted impaction type distal lateral malleolar fracture

Classification: Lauge-Hansen meets Danis-Classification: Lauge-Hansen meets Danis-WeberWeber

SKELETAL TRAUMA

Posterior Malleolus FracturesPosterior Malleolus Fractures

Function:Stability- prevents posterior translation of talus & enhances syndesmotic stability

Weight bearing- increases surface area of ankle joint

Haraguchi et al. JBJS 2006

Type I- posterolateral oblique type

Type II- medial extension type

Type III- small shell type

67%19%

14%

Posterior Malleolus Posterior Malleolus FractureFracture

Syndesmotic InjurySyndesmotic Injury

FUNCTION:

Stability- resists external rotation, axial, & lateral displacement of talus

Weening JOT 2005

Leeds JBJS 1984

Common Names of Fracture VariantsCommon Names of Fracture Variants• Maisonneuve Fracture

– Fracture of proximal fibula with syndesmotic disruption

• Volkmann Fracture– Fracture of tibial attachment of PITFL– Posterior malleolar fracture type

• Wagstaffe-Le Fort Fracture– Fracture of fibular attachment of AITFL

• Tillaux-Chaput Fracture– Fracture of tibial attachment of AITFL

• Coll icular FracturesColl icular Fractures– Avulsion fracture of distal Avulsion fracture of distal

portion of medial malleolusportion of medial malleolus– Injury may continue and Injury may continue and

rupture the deep deltoid rupture the deep deltoid ligamentligament

• Bosworth fracture Bosworth fracture dislocationdislocation– Fibular fracture with posterior Fibular fracture with posterior

dislocation of proximal fibular dislocation of proximal fibular segment behind tibiasegment behind tibia

Common Names of Fracture VariantsCommon Names of Fracture Variants

POSTERIOR COLLICULUS ANTERIOR COLLICULUS

INTERCOLLICULAR GROOVE

Operative Treatment: ApproachesMedial

LATERAL

ANTERIOR

AnteromedialAnterolateral

Lateral

Operative Treatment: Approaches

• BEWARE: SUPERFICIAL PERONEAL BEWARE: SUPERFICIAL PERONEAL NERVENERVE

Operative Treatment: Lateral Operative Treatment: Lateral ApproachApproach

Blair CORR 1994

72% 16% 12%

Standard Fixation Constructs: Lateral Standard Fixation Constructs: Lateral SideSide

SCREWS ONLY LATERAL PLATING POSTEROLATERAL PLATING POSTERIOR PLATING

Standard Fixation Constructs: Medial Standard Fixation Constructs: Medial SideSide

Tension Band Wires Screws Plate/Screw Combination

Standard Fixation Constructs: Posterior Standard Fixation Constructs: Posterior MalleolusMalleolus

Screws Plating

Standard Fixation Constructs: SyndesmosisStandard Fixation Constructs: Syndesmosis

Single Screw3 cortices

Single Screw4 cortices

2 Screws6 cortices

2 Screws8 cortices

Case Example #1Case Example #1

20 yo male falls while running - sustains ankle injury

Antiglide PlatingAntiglide Plating

Weber C / PER 4Weber C / PER 4

Short!

Postop & F/UPostop & F/U

THANKSTHANKS