INJURIES AROUND ANKLE JOINT AND ITS MANAGEMENT INTRODUCTION

INJURIES AROUND ANKLE JOINT AND IT’S MANAGEMENT

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.

ANATOMY Ankle joint is a synovial joint of hinge variety

Bony mortise- quadrilateral shape Posterolateral position of fibula Ligaments 3 groups -Lateral -Medial -Syndesmotic

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

Lateral ligament Anterior- Talofibular Posterior- Talofibular Calcaneofibular

SYNDESMOTIC LIGAMENTS Ant inf tibio fib Supf post tibio fib Deep post tibio fib Interosseous lig

ACUTE LIGAMENTOUS INJURY Type I sprain- minor Type II sprain - incomplete Type III sprain - complete

TREATMENT LIGAMENT INJURY Non-operative treatment Achieved by RICE Operative treatment Indicated when problems persist after 12 weeks of treatment including physiotherapy Associated fracture

CLASSIFICATIONS LAUGE HANSEN

LAUGE HANSEN 1. 2. Position of foot at injury. Pronation/Supination Deforming force. Abduction/ adduction/ external rotation Most Common mechanism of injury- SER Most Common unstable ankle fracture variant. SER

LAUGE HANSEN SUPINATION ADDUCTION SUPINATION EXT ROT PRONATION ABDUCTION PRONATION EXT ROT PRONATION DORSIFLEX

Maisonneuve’s fracture High spiral oblique fracture of upper 3 rd fibula with ankle PER injury

TYPES OF INJURIES Soft tissue injuries Ligament injuries Lateral collateral ligament injury Deltoid ligament injury Syndesmotic injury Fractures Malleolar fractures Pilon fractures Physeal injuries

DIAGNOSIS

RADIOLOGICAL VIEWS AP / LAT ANKLE AP/OBLIQUE FOOT AP MORTISE ANKLE

OTHER INVESTIGATIONS ARTHROGRAPHY ARTHROSCOPY CT SCAN MRI BONE SCAN

AP VIEW SYNDESMOSIS Tibiofibular overlap<10 mm MALLEOLAR LENGTH Talocrural angle 83+_4 deg TALAR TILT - sup clear space- med clear space diff <2 mm

MORTISE VIEW

What else to see in x-rays LAT MALLEOLUS MED/POST MALLEOLUS Level of fracture Size Orientation of fracture Assoc plafond # Fracture comminution Assoc syndesmotic injury

SYNDESMOTIC INJURY

Pott’s 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)

MANAGEMENT RICE Definitive Aim- restoration of complete normal anatomical alignment of ankle. Patients if needs operation should be operated within 24 hrs 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)

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.

TIBIAL PILON FRACTURES Intraarticular fracture of distal tibia. Fibula is fractured in 85% of these patients.

TIBIAL PILON FRACTURE 1. Plaster immobilization 2. Traction If articular incongruity <2 mm and reserved for low energy injuries 3. Lag screw fixation 4. OR & IF with plates 5. External fixation with or without limited internal fixation

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

TALUS FRACTURE

Anatomy-parts Head-articulate with navicular Neck-nonarticular Body-articulate with tibia and calcaneus No muscular or tendinous attachment

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.

Talar head fracture 5~10% of all talus fracture

Talar neck fracture Aviator’s astragalus High energy injury, hyperdorsiflexion 15~20% open fracture Associated with malleloar fracture(25% of cases), malleolus is more common medial High risk of soft tissue injury and compartment syndrome

Classification-Hawkins classification Displaced nondisplaced Ankle dislocation (Talar body dislocation) Subtalar subluxation Talonavicular dislocation

Treatment Hawkins type I 4~6 weeks of no weightbearing in a short leg cast walking cast for 1~2 months Percutaneous screw fixation

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

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

Complication Skin necrosis and infection Delayed union or nonunion Malunion Posttraumatic arthritis Osteonecrosis

Calcaneal fracture

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

Calcaneal fracture Classification Essex-Lopresti --Extraarticular(25%) v. s intraarticular(75%) fracture Sanders --CT classification of intraticular calcaneal fracture

Associated injuries A fall from a height or high–energy mechanisms 10% lumbar spine fracture(L 1); 10% of calcaneal fracture are bilateral

↓ Broden’s view showing the depressed posterior facet ↑ varus position of the tuberosity

Intraarticular fracture (joint depression and tongue type) Mechanism injury Axial loading Radiography Loss of Bohler’s and Gissane’s angles

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

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

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

Intraarticular fracture --complications Soft tissue breakdown Local infection Subtalar arthritis

ANKLE AND FOOT INJURIES Q 1) 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

Q 2) The most commonly affected component of lateral collateral ligament complex in an ankle sprain a. Anterior talo fibular ligament b. Posterior talo fibular ligament c. Calcaneofibular Ligament d. None

Q 3) Ankle sprain is due to a. Rupture of anterior talo-fibular ligament b. Rupture of posterior talo-fibular ligament c. Rupture of deltoid ligament d. Rupture of calcaneo-fibular ligament

Q 4) Mechanism of injury of transverse fracture of medial malleolus is a. Abduction injury b. Adduction injury c. Rotation injury d. Direct injury

Q 5) Cottons fracture is a. Avulsion fracture of C 7 b. Bimalleolar fracture c. Trimalleolar fracture d. Burst fracture of the Atlas e. None of the above

Q 6) Bimalleolar fracture is synonymous to a. Cottons b. Potts c. Pirogoffs d. Dupuytrens

Q 7) Avascular necrosis is a complication of a. Fracture neck talus b. Fracture medial condyle femur c. Olecranon fracture d. Radial head fracture

Q 8) POP cast in equinus position is indicated in a. Distal fracture both bone leg b. Distal fracture fibula c. Bimalleolar d. Fracture Talus

Q 9) Gissane’s angle in intra-articlar fracture calcaneum is a. Reduced b. Increased c. Not changed d. Variable

Q 10) Bohler’s angle is decreased in fracture of a. Calcaneum b. Talus c. Navicular d. Cuboid

Q 11) Stress fractures are most commonly seen in a. Tibia b. Fibula c. Metatarsals d. Neck of femur

Q 12) Neutral triangle is seen radiologically in a. Calcaneum b. Talus c. Naviuclar d. Tibia