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Toronto Notes 2019 Ankle Ankle Fracture
Mechanism
• patternoffracturedependsonthepositionoftheanklewhentraumaoccurs • generallyinvolves
■ ipsilateral ligamentous tears or transverse bony avulsion
■ contralateral shear fractures (oblique or spiral) • classificationsystems
■ Danis-Weber
■ Lauge-Hansen: based on foot’s position and motion relative to leg
Treatment
• non-operative
■ indication: non-displaced, no history of dislocation ■ below knee cast, NWB
• operative
■ indications
◆ any fracture-dislocation: restore vascularity, minimize articular injury, reduce pain and skin pressure
◆ most of type B, and all of type C
◆ trimalleolar (medial, posterior, lateral) fractures
◆ talar tilt >10°
◆ medial clear space on X-ray greater than superior clear space ◆ open fracture/open joint injury
■ ORIF
Complications
• highincidenceofpost-traumaticarthritis
Ankle Ligamentous Injuries
• seeFigure47forankleligaments
Medial Ligament Complex (deltoid ligament)
• eversioninjury
• usuallyavulsesmedialorposteriormalleolusandstrainssyndesmosis
Lateral Ligament Complex
(Anterior Talofibular, Calcaneofibular, Posterior Talofibular) • inversioninjury,>90%ofallanklesprains
• ATFmostcommonlyandseverelyinjuredifankleisplantarflexed
• swellingandtendernessanteriortolateralmalleolus
• ++ecchymosis
• positiveankleanteriordrawer
• mayhavesignificantmedialtalartiltoninversionstressX-ray
Treatment
• non-operative
■ microscopic tear (Grade I)
◆ rest, ice, compression, elevation ■ macroscopic tear (Grade II)
◆ strap ankle in dorsiflexion and eversion x 4-6 wk
◆ physiotherapy: strengthening and proprioceptive retraining ■ complete tear (Grade III)
◆ below knee walking cast x 4-6 wk
◆ physiotherapy: strengthening and proprioceptive retraining
◆ surgical intervention may be required if chronic symptomatic instability develops
Orthopedics OR39
1 24
3
5 6
Legend
1. Posterior malleolus
2. Medial malleolus
3. Deltoid ligament
4. Syndesmosis
5. Lateral malleolus
6. Calcaneofibular
ligament
Normal ankle
Type A
Type C
Type B
Figure 46. Ring principle of the ankle and Danis-Weber classification
PTF CF ATF
PTF: Posterior talofibular CF: Calcaneofibular ATF: Anterior talofibular PTT: Posterior tibiotalar TC: Tibiocalcaneal ATT: Anterior tibiotalar TN: Tibionavicular
Figure 47. Ankle ligament complexes
With a history of significant trauma from axial loading of lower limb, always consider spinal injuries, femoral neck, tibial plateau, and talar/ calcaneal fractures
Legend
PTT TC ATT
TN