7-Ankle Fractures
if there is a syndesmotic injury what two things will be fractured first in the classification?
1. deltoids 2. medial malleolus
which two ligaments stabilize in the sagittal plane?
ATLF and PTFL
What is the fracture of the medial mall caused by?
extreme adduction
what is the criteria for "required fixation"?
if the articular surface is 25-30% involved with the fracture
why are the three components so important?
important for surgical planning - we need to know if the fx went as far as to fx the posterior colliculis
what is it's relationship in terms of the ant. articular surface of the tibia?
it sits *more inferior* than the ant. surface
IF you have a supination injury where does the fracture begin?
laterally
if the force continues in a SAD I what else can fracture?(1)
medial malleolus
what determines the level of the fracture?
wherever the fracture line begins is where the type is labeled
*If the fibula displaces 2mm how much lateral talar subluxation can occur? *
*2mm of fibular displacement allows 1-2mm of lateral talar subluxation. *
*With just 1mm of lateral talar displacement means what for the articulation? *
*42% decrease in tibiotalar contact occurs with just 1mm of lateral talar displacement (Ramsey et al.)*
*greater than 4mm of medial clear space means what about the position of the talus ? *
*> 4mm indicates lateral subluxation of the talus *
*what is a tell tale sign of the medial gutter that says we will need to do ORIF? *
*Ankle medial clear space greater than 4mm requires ORIF. *
*What happens when there is a rupture of the syndesmosis?*
*Diastasis*
*Why does the post. malleolus injures?*
*Pull of the PITFL*
*again, what is the most common clinical finding of the foot on the ankle?*
*most commonly posterior and lateral and with foot externally rotated*
Lateral ligaments are injured frequently in ankle sprains- what does this say about ankle fractures?
-they are the least injured in ligaments in an ankle fx
What are the three components of the syndesmosis?
1. AITFL 2. PITFL 3. Interosseous ligament
Again what are the orders for the SER i-IV
1. AITFL 2. Post. Spike fracture 3. Post. Malleoli fracture 4. Medial mall.
what three components is the medial malleolus made up of?
1. Anterior colliculus 2. Posterior colliculus 3. intercollicular groove
what are the treatment parameters for closed fractures? what should we not do with fracture blisters?
1. Closed fractures should be treated within 3 weeks. 2. Should not cut through fracture blisters Reports of up to 60% infection rate
what attaches to the post. colliculus and what is located directly posterior to it?
1. Deep deltoid ligament attachments 2. posterior tibial tendon directly posterior
PAB/Danis weber B: it is numbered 1-3 and what are the structures that are damaged
1. Deltoid ligament rupture or medial malleolar fracture 2. AITFL rupture 3. Bending fracture of the fibula 1cm proximal to the plafond
what is the mechanism or traveling or the energy through the leg?
1. Energy of rotation transfers through the interosseous ligament and exits at proximal fibula
which ones classifies greater than 95% of all ankle fractures? what does the first word denote? and what does the second word indicate?
1. L-H 2. first word denotes the position of the foot at time of injury 3. second word indicates the force of injury
what fracture should we look for that is proximal on the fibula? and what force causes this?
1. Maissoneuve fracture 2. proximal fibular fracture due to external rotation
What is the Tx for SAD/Danis Weber A? under non-displaced? minimally displaced? and displaced?
1. Non displaced -WBAT in a short leg walking boot. -Repeat x-rays at 10-14 days 2. Minimally Displaced -NWB in a short leg cast 3. Displaced -ORIF
treatment parameter of non displaced fractures: what are the parameters? is a bimalleolar fracture displaced usually? what is the healing time?
1. Non displaced fractures can be casted or placed in a boot non weight bearing. 2. Rarely is a bimalleolar fracture non displaced, but if it is a long leg cast may be utilized to prevent rotation. 3. Healing time is usually 6-8 weeks
what are the two most common ankle fractures?
1. PER 2. SER
PER: what is the percentage of ankle fractures? what does it often time require? where does it begin? where is the fibular fracture located?
1. Represent 7-19% of all ankle fractures 2. Often times require surgical intervention 3. Begin medially 4. Fibular fracture above the level of the syndesmosis
which ankle fracture has a posterior spike fracture and what is the weber?
1. SERII 2. Weber B
WE may be concerned with a DVT- what are *Virchow's triad? *
1. Stasis 2. endothelial damage 3. hypercoagulability state
Lauge-Hansen SERII: waht is the direction or MAO, weber? , the commonality? where does the level of injury begin for this one?
1. Supination External Rotation 2. Lauge - Hansen SER II 3. Danis - Weber B 4. Most common ankle fractures encountered 40-70% of the time. *5. This injury begins at the level of the ankle joint*
what are the three osseous components of the ankle joint? what are the five ligamentous compontents of the ankle?
1. Tibia 2. fibula 3. Talus 1. ATFL 2, CFL 3. PTFL 4. Deltoids 5. Syndesmosis
What are three Diagnostic studies used for diagnosis? and a fourth that is not indicated for acute ankle fx?
1. X-rays 3 views 2. stress external rotation vies 3. CT for epiphyseal or pilon fractures 4. MRI is not indicated in acute ankle fx
so what LH are above at and below the level of the ankle?
1. above = PER 2. below = SAD 3. at = SER
So shows a picture of SAD I there are two results what are they?
1. can get a CFL rupture/or transverse fibular fracture at or below level of joint 2. will get above plus transverse fracture of med. mall.
in order for the rupture of the syndesmosis what two things occur first?
1. deltoid injury 2. or medial. malleolar fracture
what direction does the ant. colliculus project and what attachments are here?
1. inferiorly projects 2. superficial deltoids attach here
when is it injured? and how does it get injured?
1. inured with severe ankle injury 2. injury due to pull of PITFL
in kids are bones or ligaments stronger? in adults are bones or ligaments stronger?
1. ligaments 2. bone
What are the four important steps to reducing a fracture?
1. reproduce the injury 2. Distract 3. reverse injury/reduce 4. stabilize with splint
what ligaments is taut and which is relaxed in ankle DF?
1. taut- CFL 2. ATFL relaxed
What are 8 clinical findings?
1.History of trauma 2.Pain 3.Ecchymosis 4.Edema 5.Fracture blisters 6.Pain on ambulation 7.Inability to bear weight 8.Visible deformity
again what should we not do with fracture blisters? and why?
2. Should not cut through fracture blisters Reports of up to 60% infection rate
Weber vs. Lauge Hansen: what laugh hansen matches up with Weber A, B, and C
A: Supination Adduction B: Supination External rotation C: Pronation external rotation
What is the Wagstaffe (Le Fort) Fracture?
Avulsion fracture of anterior margin of distal fibula at insertion of anterior tib-fib ligament.
Where does the fracture begin?
Begins lateral with rupture of anterior syndesmotic ligament and proceeds medially.
What are both classification systems based on?
Both are based on fibular injury pattern
a PER fracture will have what hallmark sign?
Butterfly fracture
what ligament stabilizes the talus and STJ in the frontal plane?
CFL
what does a PER equate to?
Danis Weber C
What prevents the lateral talar exclusion?
Deltoids
what causes the tillaux Chaput fracture?
Due to external force causing avulsion via the anterior tib-fib ligament
what department will you see these most? ask them if they had an injury or trauma...
ER
What does Weber classification not allow?
Easy to learn, but not specific to sequential injury and ligamentous damage
of the fibula and tibia what is the dominant fracture if both are fractured?
Fibula
what is the specific location of this fracture?
Fracture of the anterior lateral tibial epiphysis.
What is a Volkmann Fracture?
Fracture of the posterior tibia (posterior malleoli) due to pull of posterior inferior tib-fib ligament.
How do we reduce a dislocated ankle fracture: IF we have a fracture that has a hematoma - what can we do with the anesthesia?
Hematoma block- can inject local into the blodo that is sitting from the fracture -aspirate back and see blood in the syringe- push anesthetic into the hematoma - this hematoma is filled with local allowing for that whole area to be anesthetized
What is the Order for a SER Fracture I-IV- name each structure
I - AITFL II- Spiral fibular fracture(Post. spike) III- posterior malleolar fracture IV- medal malleoli fracture
what structure is disrupted in each stage? I-IV
I- Deltoid rupture/medial malleolar fracture. II- Rupture of anterior inferior tib-fib ligament, intra-osseous ligament, intra-osseous membrane. III- Spiral, transverse or comminuted fibular fracture above the level of the syndesmosis. IV- Posterior inferior tib-fib ligament rupture
what is the ligament and fracture for the SER III and IV?
III- posteior inferior tib-fib ligament rupture or posterior malleolar fracture IV- Deltoid rupture/medial malleoli fracture
how does a SAD I fracture?
Injury begins laterally with a CFL rupture or transverse fibular fracture below the level of the syndesmosis.
again where does the injury begin for SERII?
LVL of the ankle joint
What are the two classification systems we will use?
Lauge- Hansen Danis-Weber
if you have a pronated ankle fracture what will be injured first?
Medial structures
technically what LH will cause a Maissoneuve fracture?
PER
What is an example of LH?
PER- Pronation with external rotation
What are the three types of Danis weber with their descriptions?
Type A: Fracture below the level of the syndesmosis. Type B: Fracture at the level of the syndesmosis. Type C: Fracture above the level of the syndesmosis.
What is the most common dislocation of the foot on to the leg of a trauma?
Post. Lateral Externally rotated
what is the most common ankle fracture that we will see and what is the hallmark on radiograph?
SER II Posterior spike on the lateral view
*Posteiror spike*
SER II/Danis Weber B
Lauge-Hansen SAD I what is the weber type? what is the direction? what is the percentage of all ankle fx?
Supination Adduction Danis - Weber Type A Lauge - Hansen SAD I 10-20% of all ankle fractures
What ligaments stabilize the ankle mortise?
Syndesmotic ligaments
Treatment parameters: Vassal's Principle:
Technique by which if the primary fracture (dominant fracture) is stabilized/reduced, then the secondary fractures reduce/maintain themselves in the reduced position due to the presence of ligamentous & other soft tissue attachments.
explain what the technique of *Ligamentotaxis* does?
Technique where ligaments are placed in sustained longitudinal traction so as to cause the realignment of the fractured fragments.
SAD/Danis-Weber A: what is the surgical treatment? 5 options?
Tension banding of fibula Plating fibula Intermedullary screw/pin of fibula Screws fixation to tibia Butress plate to fibula
what is a type of fracture that occurs in children on the lateral aspect of the tibia?
Tillaux Chaput fracture
which Danis - Weber does SER correlate with?
Weber B - at the level of the ankle joint
what is often associated with a Weber C fracture?
a higher butterfly fracture/communited
This is considered a syndesmotic injury so what is it?
an unstable ankle mortise
what is the first ligament to be ruptured in the SER II?
ant. syndesmotic ligament
CT scan is enough. Why do you use stress external rotation views?
assesses stability of deltoids and diastasis
He is not focusing on PAB/Danis Weber B
bc we don't see one prob
what attaches to the intermolecular groove?
deep deltoid ligament attachment
do we fix these fractures?
no- bc of the common peroneal nerve
what is the 3rd malleolus in a trimalleolar fracture?
posterior malleoli
what is a rare ankle injury ? how does it progress? where does it begin in regards to the ankle?
pronation abduction -progresses from medial to lateral -at the level of the ankle **It does not have external rotation
what does this type of fracture require for surgical repair?
requires syndesmotic fixation
what will most bimalleolar fractures go onto?
surgical intervention
what does this allow for the talus to do?
talus will translate laterally
what ligaments is taut and which is relaxed in ankle PF?
taut- ATFL relaxed CFL
When a fx occurs what is the dislocation labeled as?
the foot is posterior and lateral dislocated on the leg with external rotation
what structure is injured that causes this fracture?
the syndesmosis - fix the syndesmosis
what is the general rule if fracture fragments are displaced greater than 2 mm?
they will require ORIF
