Page 972 - TNFlipTest

OR38 Orthopedics
Ankle Toronto Notes 2019
Treatment
Approach #1 (based on amount of depression seen on x-ray)
Approach #2 (based on varus/ valgus instability)
Non-operative indication (if depression on x-ray is <3 mm): straight leg immobilization x 4-6 wk with progressive ROM weight bearing
Operative indication (if depression is >3 mm): ORIF often requiring bone grafting to elevate depressed fragment
Non-operative indication (if minimal varus/valgus instability [<15°]): straight leg immobilization x 4-6 wk with progressive ROM weight bearing
Operative indication (if significant varus/valgus instability [>15°]): ORIF often requiring bone grafting to elevate depressed fragment
Figure 45. Tibial shaft fracture treated with IM nail and screws
Tibial shaft fractures have high incidence of compartment syndrome and are often associated with soft tissue injuries
Danis-Weber Classification
• Based on level of fibular fracture relative to syndesmosis
Type A (infra-syndesmotic)
• Pure inversion injury
• Avulsion of lateral malleolus below plafond
or torn calcaneofibular ligament
• ± shear fracture of medial malleolus Type B (trans-syndesmotic)
• External rotation and eversion (most
common)
• ± avulsion of medial malleolus or rupture
of deltoid ligament
• Spiral fracture of lateral malleolus starting
at plafond
Type C (supra-syndesmotic)
• Pure external rotation
• Avulsion of medial malleolus or torn deltoid
ligament
• ± posterior malleolus avulsion with
posterior tibio-fibular ligament
• Fibular fracture is above plafond (called
Maisonneuve fracture if at proximal fibula)
• frequently tears syndesmosis
Ottawa Ankle Rules (see Emergency Medicine, ER17)
X-rays are only required if:
Pain in the malleolar zone AND bony tenderness over the distal 6 cm of the posterior aspect of the tibia or tip of the medial or lateral malleolus OR inability to weight bear both immediately after injury and in the ER
Specific Complications (see General Fracture Complications, OR7) • ligamentousinjuries
• meniscallesions
• AVN
• infection • OA
Tibial Shaft Fracture
• mostcommonlongbonefractureandopenfracture
Mechanism
• lowenergypattern:torsionalinjury
• highenergy:includingMVC,falls,sportinginjuries
Clinical Features
• pain,inabilitytoweightbear • openvs.closed
• neurovascularcompromise
Investigations
• X-ray: AP, lateral
■ full length, plus knee and ankle
Treatment
• non-operative
■ indication: closed and minimally displaced or adequate closed reduction
◆ long leg cast x 8-12 wk, functional brace after • operative
■ indication: displaced or open
◆ if displaced and closed: ORIF with IM nail, plate and screws, or external fixator
◆ if open: antibiotics, I&D, external fixation or IM nail, and vascularized coverage of soft tissue
defects
Specific Complications (see General Fracture Complications, OR7) • highincidenceofneurovascularinjuryandcompartmentsyndrome • poorsofttissuecoverage(criticaltooutcome)
Ankle
Evaluation of Ankle and Foot Complaints
Special Tests
• anteriordrawer:examinerattemptstodisplacethefootanteriorlyagainstafixedtibia • talartilt:footisstressedininversionandangleoftalarrotationisevaluatedbyX-ray
X-Ray
• AP, lateral
• mortiseview:ankleat15°ofinternalrotation
■ gives true view of ankle joint
■ joint space should be symmetric with no talar tilt
• OttawaAnkleRulesshouldguideX-rayuse(seeEmergencyMedicine,ER17);nearly100%sensitivity • ±CTtobettercharacterizefractures