INJURIES AROUND ANKLE JOINT AND IT’S MANAGEMENT

1. INJURIES AROUND ANKLE JOINT AND IT’S MANAGEMENT

2. 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.

3. ANATOMY • Ankle joint is a synovial joint of hinge variety

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

5. 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

6. Lateral ligament • Anterior- Talofibular • Posterior- Talofibular • Calcaneofibular

7. SYNDESMOTIC LIGAMENTS • Ant inf tibio fib • Supf post tibio fib • Deep post tibio fib • Interosseous lig

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

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

10. CLASSIFICATIONS • LAUGE HANSEN

11. LAUGE HANSEN • 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

12. LAUGE HANSEN • SUPINATION ADDUCTION • SUPINATION EXT ROT • PRONATION ABDUCTION • PRONATION EXT ROT • PRONATION DORSIFLEX

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

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

15. DIAGNOSIS

16. RADIOLOGICAL VIEWS • AP / LAT ANKLE • AP/OBLIQUE FOOT • AP MORTISE ANKLE

17. OTHER INVESTIGATIONS • ARTHROGRAPHY • ARTHROSCOPY • CT SCAN • MRI • BONE SCAN

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

19. MORTISE VIEW

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

21. SYNDESMOTIC INJURY

25. Pott’s Fracture • Fracture involving the ankle joint loosely referred to as Pott’s Fracture • First degree single malleolus fractured. • In second degree two malleoli are fractured. • 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)

26. 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)

27. 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.

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

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

31. 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

32. TALUS FRACTURE

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

34. 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.

35. Talar head fracture • 5~10% of all talus fracture

36. 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

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

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

39. 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

40. 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

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

42. Calcaneal fracture

43. 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 hallucislongus pass) • Anterior process: cuboid

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

45. Associated injuries • A fall from a height or high–energy mechanisms • 10% lumbar spine fracture(L1); 10% of calcaneal fracture are bilateral

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

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

48. 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

49. 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

50. 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