Ankle Fractures Phong Tran Orthopaedic Surgeon Western Health

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Ankle Fractures Phong Tran Orthopaedic Surgeon Western Health

Ankle Fractures Phong Tran Orthopaedic Surgeon Western Health

Ankle fractures • • • Most common fracture treated by orthopaedic surgeon Low energy

Ankle fractures • • • Most common fracture treated by orthopaedic surgeon Low energy injuries Twisting mechanism (similar to ankle sprains) 2

History and Examination • Mechanism of Injury – high vs low • PMHx •

History and Examination • Mechanism of Injury – high vs low • PMHx • • Diabetes, smoker, neuropathy Examination • Soft tissue • swelling, • blisters, • Bruising • Wounds • Special Tests • Areas of tenderness • Squeeze test • Ottawa 3

Maisonneuve Fracture 4

Maisonneuve Fracture 4

Ottawa Ankle Rules: Order ankle x-rays if acute trauma to ankle and one or

Ottawa Ankle Rules: Order ankle x-rays if acute trauma to ankle and one or more of • Age 55 or older • Inability to weight bear both immediately and in ER (4 steps) • Bony tenderness over posterior distal 6 cm of lateral or medial malleoli • Sensitivity ~100% • Specificity ~40% 5

Investigations AP Mortise Lateral 15° IR 6

Investigations AP Mortise Lateral 15° IR 6

Reading Xrays • Lateral malleolus • Medial malleolus • Syndesmosis • Mortice / Talar

Reading Xrays • Lateral malleolus • Medial malleolus • Syndesmosis • Mortice / Talar shift • Posterior malleolus 7

Reading Xrays • Lateral malleolus • Medial malleolus • Syndesmosis • Mortice / Talar

Reading Xrays • Lateral malleolus • Medial malleolus • Syndesmosis • Mortice / Talar shift • Posterior malleolus 8

Reading Xrays • Lateral malleolus • Medial malleolus • Syndesmosis • Mortice / Talar

Reading Xrays • Lateral malleolus • Medial malleolus • Syndesmosis • Mortice / Talar shift • Posterior malleolus 9

Mortise X-Ray • ankle in 15 -25° of IR

Mortise X-Ray • ankle in 15 -25° of IR

Mortise X-Ray • Medial clear space – Between lateral border of medial malleous and

Mortise X-Ray • Medial clear space – Between lateral border of medial malleous and medial talus – <4 mm is normal – >4 mm suggests lateral shift of talus

Mortise X-Ray

Mortise X-Ray

Mortise x-ray:

Mortise x-ray:

Mortise x-ray:

Mortise x-ray:

Classification • Lauge-Hansen (1949) • Weber (1972) - AO 15

Classification • Lauge-Hansen (1949) • Weber (1972) - AO 15

Lauge - Hansen classification • Mechanism of injury • • • Supination Adduction Supination

Lauge - Hansen classification • Mechanism of injury • • • Supination Adduction Supination External rotation Pronation Adduction Pronation External rotation Complicated / Hard to Remember 16

Supination External Rotation 17

Supination External Rotation 17

Weber classification Advantages: • easy to use • provides information about fibular Disadvantages: •

Weber classification Advantages: • easy to use • provides information about fibular Disadvantages: • ignores the medial injury The AO classification system • Modification of the Weber system • subdivided on the basis medial or posterior injury 18

Weber classification 19

Weber classification 19

Weber classification 20

Weber classification 20

Weber classification 21

Weber classification 21

Management priorities 1. Reduce 2. • Provisional reduction • Care of open fracture •

Management priorities 1. Reduce 2. • Provisional reduction • Care of open fracture • Soft tissues Hold 3. • Precise definitive reduction • Cast • ORIF Move • Rehabilitation 22

Goals of Treatment • Healed fracture • Ankle that moves and functions normally without

Goals of Treatment • Healed fracture • Ankle that moves and functions normally without pain 23

Cast vs Internal Fixation • • • What is broken? • Medial Malleolus •

Cast vs Internal Fixation • • • What is broken? • Medial Malleolus • Lateral Malleolus • Posterior Malleolus • Syndesmosis Does it need to be reduced? Stable vs Unstable 24

Stable vs Unstable • The ankle is a ring – – – – Source:

Stable vs Unstable • The ankle is a ring – – – – Source: Rosen Tibial plafond Medial malleolus Deltoid ligaments calcaneous Lateral collateral ligaments Lateral malleolus Syndesmosis

Stable vs Unstable • Fracture 1 part = usually stable • Fracture > 1

Stable vs Unstable • Fracture 1 part = usually stable • Fracture > 1 part = unstable

Unstable fractures • Lateral talar shift • Bimalleolar • Lateral fractures + medial tenderness

Unstable fractures • Lateral talar shift • Bimalleolar • Lateral fractures + medial tenderness • Syndemosis Injuries • Maisonneuve 27

Unstable fractures • Lateral talar shift • Bimalleolar • Lateral fractures + medial tenderness

Unstable fractures • Lateral talar shift • Bimalleolar • Lateral fractures + medial tenderness • Syndemosis Injuries • Maisonneuve 28

Unstable fractures • Lateral talar shift • Bimalleolar • Lateral fractures + medial tenderness

Unstable fractures • Lateral talar shift • Bimalleolar • Lateral fractures + medial tenderness • Syndemosis Injuries • Maisonneuve 29

Lateral Shift of Talus 1 -mm lateral shift = decreased contact area by 42%

Lateral Shift of Talus 1 -mm lateral shift = decreased contact area by 42% 3 mm of lateral shift, = decreased contact area by 60% 30

Lateral Shift of Talus 31

Lateral Shift of Talus 31

Pilon / Plafond fractures 32

Pilon / Plafond fractures 32

Pilon / Plafond fractures • Fracture of distal tibial metaphysis – Often comminuted –

Pilon / Plafond fractures • Fracture of distal tibial metaphysis – Often comminuted – Often significant other injuries • Mechanism – Axial load – Position of foot determines injury • Treatment – Unstable – X-ray tib/fib & ankle – Orthopedic consultation 33

Tillaux Fracture • Occurs in 12 -14 year olds 18 month period when epiphysis

Tillaux Fracture • Occurs in 12 -14 year olds 18 month period when epiphysis is closing • Salter-Harris 3 injury Runs through anterolateral physis until reaches fused part, then extends inferiorly through epiphysis into joint Visible if x-ray parallel to plane of fracture (may require oblique) • Mechanism External rotation Strenth of tibiofibular ligament > unfused epiphysis 34

Tillaux Fracture • Occurs in 12 -14 year olds 18 month period when epiphysis

Tillaux Fracture • Occurs in 12 -14 year olds 18 month period when epiphysis is closing • Salter-Harris 3 injury • Mechanism External rotation Strenth of tibiofibular ligament > unfused epiphysis 35

Tillaux Fracture • Management Articular injury Gap >2 mm in articular surface = ORIF

Tillaux Fracture • Management Articular injury Gap >2 mm in articular surface = ORIF Non-displaced • NWB below knee cast Displaced • surgery 36

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Thank you