ankle mortice

ANKLE FRACTURES : 

ANKLE FRACTURES Dr.Ankit Gujarathi Ortho Resident DMH,PUNE

Introduction : 

Introduction Most malleolar injuries are due to indirect forces-rotational,translational,axial. Articular fractures. Patients factor-age,osteoporosis,diabetes need to consider before fixation.

Anatomy of ankle joint : 

Anatomy of ankle joint Modified hinge joint Inferior tibiofibular and subtalar joint also take part in its function.

Lateral structures-ligaments : 

Lateral structures-ligaments Anterior inferior tibiofibular ligament Anterior talofibular ligament Calcanofibular ligament Posterior talofibular ligament Lateral talocalcaneal ligament

Lateral structures-muscles : 

Lateral structures-muscles Peroneus longus Peroneus brevis Extensor digitorum brevis Extensor digitorum longus

Medial structure-ligaments : 

Medial structure-ligaments Superficial deltoid ligament Deep deltoid ligament Spring ligament

Medial structure-muscles : 

Medial structure-muscles Tibialis posterior Flexor digitorom longus Flexor hallucis longus

Posterior structure : 

Posterior structure Tibialis posterior Flexor digitorum longus Neurovascular bundle Flexor hallusis longus

Biomechanics-movement : 

Biomechanics-movement Only movement is dorsiflexion-planter flexion Axis is not quite parallel to either the ground or the coronal plane. Talus is wider anteriorly than posteriorly, so the lateral malleolus has to rotate externally by about 11°.

Biomechanics-stability : 

Biomechanics-stability

Biomechanics-stability : 

Biomechanics-stability Intact deep deltoid check-rein keeps the talus in place. Contact area is more on lateral surface,but after # shifted more medially. (1 mm of talus shift laterally reduces contact area by 40%).

Classifications for ankle #- : 

Classifications for ankle #- 1.Lauge Hansen classification 2.Weber classification 3.AO classification

Position of foot : 

Position of foot

Lauge Hansen classification : 

Lauge Hansen classification

Lauge Hansen classification : 

Lauge Hansen classification Supination-Adduction (SA) Transverse avulsion-type fracture of the fibula below the level of the joint or tear of the lateral collateral ligaments   Vertical fracture of the medial malleolus Supination-Eversion (External Rotation) (SER) Disruption of the anterior tibiofibular ligament   Spiral oblique fracture of the distal fibula   Disruption of the posterior tibiofibular ligament or fracture of the posterior malleolus   Fracture of the medial malleolus or rupture of the deltoid ligament Pronation-Abduction (PA) Transverse fracture of the medial malleolus or rupture of the deltoid ligament   Rupture of the syndesmotic ligaments or avulsion fracture of their insertions   Short, horizontal, oblique fracture of the fibula above the level of the joint Pronation-Eversion (External Rotation) (PER) Transverse fracture of the medial malleolus or disruption of the deltoid ligament   Disruption of the anterior tibiofibular ligament   Short oblique fracture of the fibula above the level of the joint   Rupture of posterior tibiofibular ligament or avulsion fracture of the posterolateral tibia Pronation-Dorsiflexion (PD) Fracture of the medial malleolus   Fracture of the anterior margin of the tibia   Supramalleolar fracture of the fibula   Transverse fracture of the posterior tibial surface

Weber classification : 

Weber classification

A O classification : 

A O classification (based on the relationship of lateral malleolar lesion to syndesmotic ligament) 44 A-INFRASYNDESMOTIC LESIONS 1-isolated lateral malleolus 2-with fracture medial malleolus 3-with posteromedial fractures 44B-TRANCESYNDESMOTIC LESIONS 1-isolated lateral malleolus 2-with medial lesion 3-with medial lesion and volkmann 44C-SUPRASYNDESMOTIC LESIONS 1-fibular diaphyseal,simple 2-fibular diaphyseal,multyfragmentary 3-proximal fibular lesion(Maisonneuve fracture)

How good are the classifications? : 

How good are the classifications? Lauge Hansen classification-the relationship between forces exerted on the ankle and fracture patterns is not exact. Weber classification-omits isolated fractures of the medial and posterior malleoli. A O classification-based on radiographic findings rather than hypothetical fracture mechanisms, probably more reproducible.

Towards a stability-based fracture classification? : 

Towards a stability-based fracture classification? key treatment decisions are based more on the stability of the fracture than any other factor. stability/instability gives an indication of prognosis. unstable fractures did better with fixation and stable fractures with non-surgical treatment. Stable-the talus is congruent in the mortise -there is a trans- or infra-syndesmotic fibular # -there is no medial injury -there is no clinical evidence of high energy #

Clinical features : 

Clinical features Normally give a history of a fall or other injury mechanism Inspect the skin and subcutaneous tissues for open fractures, fracture blisters and swelling. Palpation of the acutely injured ankle should begin at the proximal fibula.

Imaging : 

Imaging X rays-AP view mortise view lateral view CT SCAN-(for unusual configuration or major plafond fragments )

AP view vs Mortise view : 

AP view vs Mortise view

Importance of mortise view : 

Importance of mortise view Ankle internally rotated(15°) so that the malleoli are in the same horizontal plane and the joint space is seen evenly on both sides of the ankle. In mortise view, the ankle joint “clear space” should be even on both sides of, and above, the talus. Some evidence favours 4mm as the maximum medial clear space compatible with deep deltoid competence; other evidence suggests 5mm.

Management : 

Management Conservative-casting Operative- Preoperative planning Timing of surgery Surgical techniques Steps in surgery Role of posterior “anti-glide” plate Role of syndesmotic screw Posterior malleolus fixation

Conservative-casting/bracing : 

Conservative-casting/bracing Stable fractures means talus is congruent in the mortise can be manage conservatively. They need-the use of casts -avoidance of weight bearing -follow-up radiography Treat patients with significant clinical suspicion with operative.

Preoperative planning : 

Preoperative planning Implants-2.5mm,3mm k wires -tension band wires -cancellous screws -recon/semitubular/locking plate Study x ray and decide implant template preoperatively.

Timing of surgery : 

Timing of surgery Timing of surgery is dictated by the state of soft tissue. In case of intradermal edema, subcutaneous edema,fracture blisters surgery should be avoided. Compound injuries should manage meticulously.

Surgical techniques : 

Surgical techniques Position-supine with sand bag underneath buttocks to avoid external rotation of feet. Incisions- medialy-anteromedial,posteromedial lateraly-anterolateral,posterolateral

Steps in surgery : 

Steps in surgery Step 1-fixation of fibula should be done first. Step 2-fix posterior malleolus ( if # ≥ 25% ) step 3-fix medial malleolus Step 4-do hook test Step 5-if required put syndesmotic screw.

Role of posterior “anti-glide”plate : 

Role of posterior “anti-glide”plate The main deformity with Type B # is of external rotation, posterior displacement, proximal shift. Therefore posterior “anti-glide” plate gives buttressing effect for such #. Incision should be kept more posteriorly to access posterior margin of fibula.

Posterior malleolar fixation : 

Posterior malleolar fixation Accurate reduction of lateral malleolus will generally take care of posterior malleolus reduction. Fragment >25% of the articular surface on lateral view need fixation. Lag screw can be fix anteriorly or posteriorly. Posterior screw gives more accurate placement.

Role of syndesmotic screw : 

Role of syndesmotic screw Do intraoperative stress x rays or hook test(gently pull fibula laterally) Widening of medial joint space >2mm indicates syndesmotic instability. Position of screw-foot in dorsiflexion -from fibula to tibia -obliquely from posterior to anterior at an angle of 20-25° -parallel to tibial plateau -fully tapped tibia-fibula All 4 cortices should be pierced? When to remove? One screw/two screw?

Post operative management : 

Post operative management (AO recommendations) Suction drain for lateral malleolus. Plaster of paris slab posteriorly with foot in neutral Weight bearing with slab from day 2 If syndesmotic screw –avoid weight bearing till 6 postop weeks Do serial x –rays 2 wk,4 wk,6 wk.

Complications : 

Complications Tendon subluxation or disruption, wound infection, injury to the nerve and vessels in the area, non-union or delayed union of the fracture, ankle joint instability, degenerative arthritis, complex regional pain syndrome (CRPS), permanent loss of range of motion, and calcification of the ligaments. Diabetic patients are more prone to wound gaping , skin brake down(40-50%).

Cases in DMH : 

Cases in DMH Case 1 -44 B 1

Cases in DMH : 

Cases in DMH Case 2 - 44 C 1

Cases in DMH : 

Cases in DMH Case 3 - ?

TAKE HOME MESSAGE : 

TAKE HOME MESSAGE Every ankle # needs special attention. Operative time is crucial. Diabetic patient needs proper wound follow up.

Slide 39: 

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