Related Ankle Fractures: Case Series Radiographic Imaging ...
Management of acute ankle fractures
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MANAGEMENT OF ACUTE ANKLE FRACTURES
Dr UDAY KUMAR MS(Orth) DNB(Orth)
SAGAR HOSPITALSSINDHI HOSPITALCHINMAYA HOSPITAL BANGALORE
Jan 9, 2015
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- ankle fractures ----- between 107 and 187 per 100,000 persons per year
-Unimalleolar fractures-- most common -- 70%
-most common mechanism is---- supination injury foll by pronation
-more common in --- young men aged 15–24 yrs -- older women
INCIDENCE
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Clinical features-H/O severe twisting, abduction or adduction injuries.
-Severe pain.-Inability to stand on the affected limb.-Swelling and deformity.-Tenderness on one or both malleoli.
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Skin-soft tissue injury—closed/open
Nerves
Vasculature
Co-morbidities---diabetes smoking alcohol
Evaluate
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Initial Management-Pain control
-RICE -Rest -Immobilise---splint -Compression bandage -Elevation
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X rays
-Ankle Series AP mortise lateral
AP
Lateral
Mortise
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- fractures of malleoli - distal tibia/fibula - talar dome - body and lateral process of
talus
Antero-posterior view
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• Tibiofibular clear space: <5mm• Tibiofibular over lap: >10mm
• Talar Tilt: difference in width of med &lat aspect of joint–
<2mm
Measurements in AP view
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-Foot in 15-20 degrees internal rotation
-Evaluate articular surface between talar dome and mortise
Mortise view
-Medial clear space: <4mm
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•Posterior malleolar fractures
•AP talar subluxation
•Distal fibular translation &/or angulation
•Associated or occult injuries–Lateral process talus–Posterior process talus–Anterior process calcaneus
Lateral View
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Evaluation: RadiographicOther Imaging Modalities
• Stress Views– Gravity – Manual
• CT– Articular involvement– Posterior malleolus
• MRI– Ligament and tendon
injury – Talar dome lesions– Syndesmosis injuries
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Weber/AO classificationbased on level of fibula fracture
A – Below syndesmosis
B – At syndesmosis
C – Above syndesmosis
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Classification: Lauge-Hansen meets Danis-Weber
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Simple Classification Stable Unstable
• Stable fractures– Most commonly involve
medial or lateral side only
– Talus remains anatomic relative to tibia
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Unstable fractures
– Disruption of 2 or more aspects of the mortise -- bone and/or ligament
– Talus may sublux or be dislocated from tibia
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Stable Examples
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Unstable Examples
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Management
-Stable Ankle fracture --- short leg cast for 6 weeks
- Cast patients reduced hospital stay lower cost of treatment
Non-operative
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Surgical Indications
• Bimalleolar / trimalleolar fractures
• Syndesmotic disruption
• Talar subluxation
• Open fractures
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Soft tissue injury
• Debridement• External fixator and delayed ORIF
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Basic Set-Up
• Supine position most common– Occasionally prone for direct approach to posterior
malleolus• Bump beneath ipsilateral buttocks (allows easier
approach to fibula)• Tourniquet• Prep / drape to above knee • Pre-op antibiotics• Fluoroscopy or X-ray
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Instrumentation
• Small fragment set• Cannulated screws• K-wires• Cerclage wire • Power• Have mini-frag
available
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Ankle Fracture
ORIF PLAN
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Uni malleolar fracture
Fix with -- Two 4 mm cancellous screws --TB wire --plate
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Bimalleolar fracture
Plate fibula
Two 4 mm cancellous screws in medial malleolus
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Tri-malleolar fracture
Plate fibula Two 4 mm cancellous screws in med malleolus
fix posterior malleolus if >20 - 25% articular surface involved
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Fixation techniques
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Lateral Malleolus
• One-third tubular plate & 3.5 mm cortex screws
– Lateral– Posterior
• 3.5mm compression plate for unstable fractures
-avoid superficial peroneal nerve injury
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Lateral Malleolus
• Locking plates -- lateral or posterolateral • Osteoporotic bone• Unstable fractures• Distal fractures
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Lateral Malleolus in very distal fibula fractures
• Hook Plate• K wire with cerclage wire . Lag screw/Rush pin
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Medial Malleolus
• Two partially threaded 4.0 mm cancellous screws
• K-wires with cerclage wire
• Buttress plate
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Posterior Malleolus fixation
If involvement is > 25% of Articular surface > 2mm Displacement Persistent Posterior subluxation of talus
Anterior to posterior
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Posterior to anterior
Posterior Malleolus
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Syndesmosis Fixation
• Syndesmotic instability checked after fixation of malleolus
• Consider if fibula fracture > 4 cm above joint line
• Have bone hook on back table to check stability
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Syndesmosis
• large or small fragment fully threaded screws, one or two
• Not inserted as lag screw, but as a positioning screw
• May be removed in 6 - 12 weeks
• Bioresorbable screws/Tight rope
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Postoperative Care
• Well padded splint immobilization for a few days
• Ice and elevation• Non weight bearing for 6 weeks
• Early conversion to brace and ROM
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Thank you