1 / 35

ANKLE FRACTURE

ANKLE FRACTURE. DUNJA DELEVSKA PMS-4 New York College of Podiatric Medicine July 2012 . OUTLINE. Presentation Imaging Classification Management . PRESENTATION. 26 year-old female presents to ED unable to bear weight on the right foot. S/ p slipped and fell on wet floor

garret
Download Presentation

ANKLE FRACTURE

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. ANKLE FRACTURE DUNJA DELEVSKA PMS-4 New York College of Podiatric Medicine July 2012

  2. OUTLINE • Presentation • Imaging • Classification • Management

  3. PRESENTATION • 26 year-old female presents to ED unable to bear weight on the right foot. S/p slipped and fell on wet floor • No open fracture • Patient is AAO x3 • Denies LOC

  4. PRESENTATION (CONT.) • PMH: denies • PSH: denies • Meds: none • Allergies: NKDA • FHx: non contributory • SHx: denies

  5. PRESENTATION (CONT.) Swelling Echymoses

  6. PRESENTATION (CONT.) • Fracture blisters? • Uebbinget al. Fracture blisters. West J Emerg Med. 2011 Feb;12(1):131-3. • early treatment prior to blister formation or delay until blister resolution before attempting surgical correction or stabilization. • Strauss et al. Blisters associated with lower-extremity fracture: results of a prospective treatment protocol. J Orthop Trauma. 2006 Oct;20(9):618-22. • three cases of minor soft-tissue breakdown, one superficial infection, and two major complications directly related to the presence of fracture blisters • average delay of surgery for ankle fractures was 6 days (range 0 to 18 days) • Treatment of fracture blisters with a silver sulfadiazine (Silvadene)

  7. PRESENTATION (CONT.) Lateral and Deltoid lig. Syndesmoticlig.

  8. IMAGING • Standard ragiographic evaluations of ankle fractures • Anteroposterior projection • Lateral projection • Mortise projection

  9. IMAGING (CONT.) ANTEROPOSTERIOR PROJECTION

  10. IMAGING (CONT.) ANTEROPOSTERIOR PROJECTION Midline axis of tibia passes through center of talar dome? ✗

  11. IMAGING (CONT.) ANTEROPOSTERIOR PROJECTION Tibio-fibular overlap ≥ 10mm? ✗

  12. IMAGING (CONT.) MORTISE PROJECTION

  13. IMAGING (CONT.) MORTISE PROJECTION All joint spaces within 1mm? ✗

  14. IMAGING (CONT.) MORTISE PROJECTION Medial clear space ≤ 4mm? ✗

  15. IMAGING (CONT.) MORTISE PROJECTION Tibio-fibular clear space ≤ 5mm? ✗

  16. IMAGING (CONT.) LATERAL PROJECTION

  17. IMAGING (CONT.) LATERAL PROJECTION Midline axis of tibia passes through center of talar dome? ✗

  18. IMAGING (CONT.) • NATURE AND LOCATION OF FRACTURES • Spiral fibular fracture at the level of the joint • Posteriorly displaced transverse (avulsion) fracture of the posterior colliculus of medial malleolus

  19. CLASSIFICATION • LAUGE-HANSEN CLASS. • SUPINATION/EXTERNAL ROTATION? • Stage 1: Rupture of AITFL with possible Tillaux or Wagstaffe fracture • Stage 2: Hallmark – spiral fracture of the fibula • Stage 3: Rupture of PITFL with possible Volkmann’s fracture • Stage 4: Rupture of the deltoid ligament or a transverse avulsion fracture of the medial malleolus • ?

  20. CLASSIFICATION (CONT.) • LAUGE-HANSEN CLASS. • PRONATION/EXTERNAL ROTATION • Stage 1: Transverse avulsion fracture of medial malleolus or rupture of deltoid ligament • Stage 2: Rupture of AITFL and interosseous membrane • Stage 3: High fibular fracture (Maisonneuve fracture) – oblique or spiral ? • Stage 4: Rupture of PITFL or Volkmann’s fracture

  21. CLASSIFICATION (CONT.) Danis-Weber class. • Type B: trans syndesmotic • Type B2: with medial malleolar fracture

  22. CLASSIFICATION (CONT.) • LAUGE-HANSEN CLASS. • PRONATION/EXTERNAL ROTATION

  23. New proposed fracture mechanism CLASSIFICATION (CONT.) Haraguchiet al. A New Interpretation of the Mechanism of Ankle Fracture. J Bone Joint Surg Am. 2009 Apr;91(4):821-9.

  24. CLASSIFICATION (CONT.) • In support of Pronation/External rotation • Talus is in a pronated position • Fracture of navicular

  25. MANAGEMENT • Closed reduction– manipulation of the fracture fragment into normal alignment without the use of surgical incision under anesthesia. • Behrbalket al. Procedural Sedation with Propofol for PainfulOrthopaedic Manipulation in the EmergencyDepartment Expedites Patient ManagementCompared with a Midazolam/Ketamine Regimen. J Bone Joint Surg Am. 2011 Dec 21;93(24):2255-62. • INCREASE THE DEFORMITY • DISTRACT THE FRAGMENTS • REVERSE THE MECHANISM OF INJURY

  26. MANAGEMENT (CONT.) • Open reduction with internal fixation (AO) • Anatomic reduction of fracture fragments • Rigid/stable internal fixation (biologic) • Atraumatic operative technique (preserve BS) • Early active pain-free mobilization

  27. MANAGEMENT (CONT.) • Pakarinenet al. Intraoperative assessment of the stability of the distal tibiofibular joint in supination-external rotation injuries of the ankle: sensitivity, specificity, and reliability of two clinical tests. J Bone Joint Surg Am. 2011 Nov 16;93(22):2057-61. • Hook test: the tibia was stabilized with one hand, the lateral malleolus was grabbed with a bone hook, and a lateral force was applied with use of the bone hook. • positive if >2 mm of lateral movement of the fibula • External rotation stress test: the tibia was stabilized with one hand and an external rotation force was applied to the foot; the tibiotalar clear space was then assessed under fluoroscopy. • positive if the medial tibiotalar clear space was ≥ 5 mm under stress

  28. MANAGEMENT (CONT.) Jenkinsonet al. Intraoperative diagnosis of syndesmosis injuries in external rotation ankle fractures. J Orthop Trauma. 2005 Oct;19(9):604-9. Demonstration of external rotation stress to F-tool and strain gauge

  29. MANAGEMENT (CONT.)

  30. MANAGEMENT (CONT.) Bottlanget al. Far cortical locking can reduce stiffness of locked plating constructs while retaining construct strength. J Bone Joint Surg Am. 2009 Aug;91(8):1985-94.

  31. MANAGEMENT (CONT.) Vassal Principle: once the dominant (fibular) fracture is reduced, the vassal fracture (tibial) will reduce spontaneously or can be reduced easily

  32. MANAGEMENT (CONT.) • COMPLICATIONS • Peletet al. The incidence of thromboembolic events in surgically treated ankle fracture. J Bone Joint Surg Am. 2012 Mar 21;94(6):502-6. • Clinically detectable thromboembolic events after surgical treatment of ankle fractures are uncommon and do not appear to be influenced by the use of thromboprophylaxis. • Kurmiset al. The effect of nonsteroidal anti-inflammatory drug administration on acute phase fracture-healing: a review. J Bone Joint Surg Am. 2012 May 2;94(9):815-23. • Short-duration NSAID regimen is a safe and effective supplement to other modes of post-fracture pain control, without a significantly increased risk of sequelae related to disrupted healing.

  33. SUMMARY • Take note of soft tissue damage when assessing ankle fractures • Obtain appropriate imaging studies that allow evaluation of joint congruency, fracture nature and displacement • Understand the mechanism of injury and classify the fracture • Ensure anatomic reduction and use fixation with adequate stiffness and strength

  34. REFERENCES • Uebbinget al. Fracture blisters. West J Emerg Med. 2011 Feb;12(1):131-3. • Strauss et al. Blisters associated with lower-extremity fracture: results of a prospective treatment protocol. J Orthop Trauma. 2006 Oct;20(9):618-22. • Haraguchiet al. A New Interpretation of the Mechanism of Ankle Fracture. J Bone Joint Surg Am. 2009 Apr;91(4):821-9. • Behrbalket al. Procedural Sedation with Propofol for PainfulOrthopaedic Manipulation in the EmergencyDepartment Expedites Patient ManagementCompared with a Midazolam/Ketamine Regimen. J Bone Joint Surg Am. 2011 Dec 21;93(24):2255-62. • Pakarinenet al. Intraoperative assessment of the stability of the distal tibiofibular joint in supination-external rotation injuries of the ankle: sensitivity, specificity, and reliability of two clinical tests. J Bone Joint Surg Am. 2011 Nov 16;93(22):2057-61. • Jenkinsonet al. Intraoperative diagnosis of syndesmosis injuries in external rotation ankle fractures. J Orthop Trauma. 2005 Oct;19(9):604-9. • Bottlanget al. Far cortical locking can reduce stiffness of locked plating constructs while retaining construct strength. J Bone Joint Surg Am. 2009 Aug;91(8):1985-94. • Peletet al. The incidence of thromboembolic events in surgically treated ankle fracture. J Bone Joint Surg Am. 2012 Mar 21;94(6):502-6. • Kurmiset al. The effect of nonsteroidal anti-inflammatory drug administration on acute phase fracture-healing: a review. J Bone Joint Surg Am. 2012 May 2;94(9):815-23.

  35. THANK YOU QUESTIONS

More Related