Transcript ankle injuries

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. AnteriorTibionavicular
b. MiddleTibiocalcanean
c. Posterior- Posterior
tibiotalar
B. Deep : AnteriorTibiotalar
 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.
Position of foot at
injuryPronation/Supination
 Most Common
mechanism of injurySER
2.
Deforming forceAbduction/
adduction/ external
rotation
 Most Common unstable
ankle fracture variantSER
LAUGE HANSEN
 SUPINATION ADDUCTION
 SUPINATION EXT ROT
 PRONATION ABDUCTION
 PRONATION EXT ROT
 PRONATION DORSIFLEX
Maisonneuve’s fracture
 High spiral oblique fracture
of upper 3rd 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<10mm
 MALLEOLAR LENGTH
 Talocrural angle 83+_4 deg
 TALAR TILT
- sup clear space- med clear
space diff <2mm
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
 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 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)
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),
medial malleolus is more common
 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(L1); 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
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
Q2) 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
Q3) 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
Q4) Mechanism of injury of transverse fracture of medial
malleolus is
a. Abduction injury
b. Adduction injury
c. Rotation injury
d. Direct injury
Q5) Cottons fracture is
a. Avulsion fracture of C7
b. Bimalleolar fracture
c. Trimalleolar fracture
d. Burst fracture of the Atlas
e. None of the above
Q6) Bimalleolar fracture is synonymous to
a. Cottons
b. Potts
c. Pirogoffs
d. Dupuytrens
Q7) Avascular necrosis is a complication of
a. Fracture neck talus
b. Fracture medial condyle femur
c. Olecranon fracture
d. Radial head fracture
Q8) POP cast in equinus position is indicated in
a. Distal fracture both bone leg
b. Distal fracture fibula
c. Bimalleolar
d. Fracture Talus
Q9) Gissane’s angle in intra-articlar fracture calcaneum is
a. Reduced
b. Increased
c. Not changed
d. Variable
Q10) Bohler’s angle is decreased in fracture of
a. Calcaneum
b. Talus
c. Navicular
d. Cuboid
Q11) Stress fractures are most commonly seen in
a. Tibia
b. Fibula
c. Metatarsals
d. Neck of femur
Q12) Neutral triangle is seen radiologically in
a. Calcaneum
b. Talus
c. Naviuclar
d. Tibia