INJURIES AROUND ANKLE JOINT AND IT’S MANAGEMENT. INTRODUCTION Ankle injury refers to disruption...
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Transcript of INJURIES AROUND ANKLE JOINT AND IT’S MANAGEMENT. INTRODUCTION Ankle injury refers to disruption...
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INJURIES AROUND ANKLE JOINT AND IT’S MANAGEMENT
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INTRODUCTION
Ankle injury refers to disruption of any component or components of the ankle joint following trauma.
Ankle injuries occur frequently, and have high propensity for complications.
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ANATOMY
Ankle joint is a synovial joint of hinge variety
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Bony mortise- quadrilateral shape
Posterolateral position of fibula
Ligaments
3 groups
-Lateral
-Medial
-Syndesmotic
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ANKLE JOINT IS SUPPORTED BY
Fibrous capsule
Deltoid ligament
A. Superficial
a. Anterior- Tibionavicular
b. Middle- Tibiocalcanean
c. Posterior- Posterior tibiotalar
B. Deep : Anterior-Tibiotalar
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Lateral ligament Anterior- Talofibular
Posterior- Talofibular
Calcaneofibular
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SYNDESMOTIC LIGAMENTS
Ant inf tibio fib
Supf post tibio fib
Deep post tibio fib
Interosseous lig
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ACUTE LIGAMENTOUS INJURY
Type I sprain- minor
Type II sprain - incomplete
Type III sprain - complete
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TREATMENT LIGAMENT INJURY
Non-operative treatment
Achieved by RICE
Operative treatment
Indicated when problems persist after 12 weeks of treatment including physiotherapy
Associated fracture
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CLASSIFICATIONS
LAUGE HANSEN
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LAUGE HANSEN
1. Position of foot at injury- Pronation/Supination
2. Deforming force- Abduction/ adduction/ external rotation
Most Common mechanism of injury- SER
Most Common unstable ankle fracture variant- SER
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LAUGE HANSEN
SUPINATION ADDUCTION
SUPINATION EXT ROT
PRONATION ABDUCTION
PRONATION EXT ROT
PRONATION DORSIFLEX
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Maisonneuve’s fracture
High spiral oblique fracture of upper 3rd fibula with ankle PER injury
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TYPES OF INJURIES
Soft tissue injuries
Ligament injuries
Lateral collateral ligament injury
Deltoid ligament injury
Syndesmotic injury
Fractures
Malleolar fractures
Pilon fractures
Physeal injuries
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DIAGNOSIS
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RADIOLOGICAL VIEWS
AP / LAT ANKLE
AP/OBLIQUE FOOT
AP MORTISE ANKLE
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OTHER INVESTIGATIONS
ARTHROGRAPHY
ARTHROSCOPY
CT SCAN
MRI
BONE SCAN
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AP VIEW
SYNDESMOSIS Tibiofibular
overlap<10mm
MALLEOLAR LENGTH Talocrural angle 83+_4
deg
TALAR TILT
- sup clear space- med clear space diff <2mm
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MORTISE VIEW
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What else to see in x-rays
LAT MALLEOLUS
Level of fracture
Orientation of fracture
Fracture comminution
MED/POST MALLEOLUS
Size
Assoc plafond #
Assoc syndesmotic injury
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SYNDESMOTIC INJURY
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Pott’s Fracture
Fracture involving the ankle joint loosely referred to as Pott’s Fracture
1. First degree single malleolus fractured.
2. In second degree two malleoli are fractured.
3. In third degree there is bimalleolar fracture with a fracture of posterior part of inferior articular surface of the tibia referred to as third malleolus. (Tri Malleolar fracture)
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MANAGEMENT
RICE
Definitive
Aim- restoration of complete normal anatomical alignment of ankle.
Patients if needs operation should be operated within 24hrs of injury or after one week once the swelling subsides.
Undisplaced fracture medial malleolus :
Below knee POP cast for 6 weeks.
Reduction fails (may be due to soft tissue (periosteal) inter position)
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Displaced: Open reduction and internal fixation by
Cancellous screws group Tension band wiring
Fracture lateral malleolus: Lateral Malleolus helps in length maintenance &
maintenance of ankle mortice. Hence, lateral malleolus has to be fixed
internally.
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TIBIAL PILON FRACTURES
Intraarticular fracture of distal tibia.
Fibula is fractured in 85% of these patients.
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TIBIAL PILON FRACTURE
1. Plaster immobilization
2. Traction
3. Lag screw fixation
4. OR & IF with plates
5. External fixation with or without limited internal fixation
If articular incongruity <2 mm and reserved for low energy injuries
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COMPLICATIONS
Malunion- may result in posttraumatic arthritis and painful movements.
Nonunion of medial malleolus- commonly due to interposition of fractured periosteum between two fragments.
Repeated edema Sudeck’s Osteodystrophy
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TALUS FRACTURE
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Anatomy-parts
Head-articulate with navicular
Neck-nonarticular
Body-articulate with tibia and calcaneus
No muscular or tendinous attachment
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Blood supply
Extraosseous supply Posterior tibial a. tarsal
canal a.
Anterior tibial a. sinus tarsi a
Peroneal a. sinus tarsi a.
Intraosseous supply Talar head
Talar body
-anastomosis between tarsal canal a. and tarsal sinus a.
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Talar head fracture
5~10% of all talus fracture
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Talar neck fracture
Aviator’s astragalus
High energy injury, hyperdorsiflexion
15~20% open fracture
Associated with malleloar fracture(25% of cases), medial malleolus is more common
High risk of soft tissue injury and compartment syndrome
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Classification-Hawkins classification
nondisplaced
Displaced
Subtalar subluxation
Ankle dislocation
(Talar body dislocation)
Talonavicular dislocation
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Treatment
Hawkins type I
4~6 weeks of no weightbearing in a short leg cast walking cast for 1~2 months
Percutaneous screw fixation
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Treatment
Hawkins type II
Orthopaedic emergency: traction and plantar flexion by manipulation anatomic reduction(50%) treated as type I
Open reduction: screw placed across the neck fracture
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Treatment
Hawkins type III
ORIF and Skeletal traction through the calcaenus
Open fracture (> type III)
:talar body excision followed
By primary tibiocalcaneal or Blair-type arthrodesis
Hawkins type IV
Rare injury
As type II
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Complication
Skin necrosis and infection
Delayed union or nonunion
Malunion
Posttraumatic arthritis
Osteonecrosis
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Calcaneal fracture
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Anatomy
Largest, most irregularly shaped bone in foot Large calcellous bone and multiple processes Achilles tendon posteriorly and plantar fascia inferiorly :
tuberosity Posterior facet: talar lateral process and body Middle facet: Sustentacular fragment (flexor hallucis longus pass) Anterior process: cuboid
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Calcaneal fracture
Classification
Essex-Lopresti
--Extraarticular(25%) v.s intraarticular(75%) fracture
Sanders
--CT classification of intraticular calcaneal fracture
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Associated injuries
A fall from a height or high–energy mechanisms
10% lumbar spine fracture(L1); 10% of calcaneal fracture are bilateral
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Broden’s view showing the depressed posterior facet
varus position of the tuberosity
↓ ↑
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Intraarticular fracture(joint depression and tongue type)
Mechanism injury Axial loading
Radiography Loss of Bohler’s and Gissane’s angles
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Intraarticular fracture
Joint-depression type, in which the primary fracture line exited the bone close to the subtalar joint
tongue-type, in which the primary
fracture line exited the bone posteriorly
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Intraarticular fracture--Treatment
Nondisplaced articular fractures Bulky (Robert-jones) dressing: active subtalar ROM,
prohibit weightbearing walking 8~12 wks later
Displaced intraarticular fracture with large fragment ORIF
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Intraarticular fracture--Treatment
Displaced intraarticular fracture with severe comminution
Increasing intraarticualr comminution leads to less satisfactory results
ORIF primary arthrodesis
Restoring the heel width and height
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Intraarticular fracture --complications
Soft tissue breakdown
Local infection
Subtalar arthritis
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ANKLE AND FOOT INJURIES
Q1) The stability of the ankle joint is maintained by all of
the following except
a. Spring ligament
b. Deltoid ligament c. Lateral ligament d. Shape of the superior talar articular surface
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Q2) The most commonly affected component of lateral
collateral ligament complex in an ankle sprain
a. Anterior talo fibular ligamentb. Posterior talo fibular ligamentc. Calcaneofibular Ligamentd. None
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Q3) Ankle sprain is due to
a. Rupture of anterior talo-fibular ligamentb. Rupture of posterior talo-fibular ligamentc. Rupture of deltoid ligamentd. Rupture of calcaneo-fibular ligament
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Q4) Mechanism of injury of transverse fracture of medial
malleolus is
a. Abduction injuryb. Adduction injuryc. Rotation injuryd. Direct injury
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Q5) Cottons fracture is
a. Avulsion fracture of C7b. Bimalleolar fracturec. Trimalleolar fractured. Burst fracture of the Atlase. None of the above
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Q6) Bimalleolar fracture is synonymous to
a. Cottonsb. Pottsc. Pirogoffsd. Dupuytrens
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Q7) Avascular necrosis is a complication of
a. Fracture neck talusb. Fracture medial condyle femurc. Olecranon fractured. Radial head fracture
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Q8) POP cast in equinus position is indicated in
a. Distal fracture both bone legb. Distal fracture fibulac. Bimalleolard. Fracture Talus
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Q9) Gissane’s angle in intra-articlar fracture calcaneum is
a. Reducedb. Increasedc. Not changedd. Variable
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Q10) Bohler’s angle is decreased in fracture of
a. Calcaneumb. Talusc. Naviculard. Cuboid
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Q11) Stress fractures are most commonly seen in
a.Tibia
b.Fibula
c.Metatarsals
d.Neck of femur
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Q12) Neutral triangle is seen radiologically in
a. Calcaneumb. Talusc. Naviuclard. Tibia
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