INJURIES AROUND ANKLE JOINT AND IT’S MANAGEMENT

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.

ANATOMY

Ankle joint is a synovial joint of hinge variety

Bony mortise- quadrilateral shape

Posterolateral position of fibula

Ligaments

3 groups

-Lateral

-Medial

-Syndesmotic

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

Lateral ligament Anterior- Talofibular

Posterior- Talofibular

Calcaneofibular

SYNDESMOTIC LIGAMENTS

Ant inf tibio fib

Supf post tibio fib

Deep post tibio fib

Interosseous lig

ACUTE LIGAMENTOUS INJURY

Type I sprain- minor

Type II sprain - incomplete

Type III sprain - complete

TREATMENT LIGAMENT INJURY

Non-operative treatment

Achieved by RICE

Operative treatment

Indicated when problems persist after 12 weeks of treatment including physiotherapy

Associated fracture

CLASSIFICATIONS

LAUGE HANSEN

LAUGE HANSEN

1. Position of foot at injury- Pronation/Supination

2. Deforming force- Abduction/ adduction/ external rotation

Most Common mechanism of injury- SER

Most Common unstable ankle fracture variant- SER

LAUGE HANSEN

SUPINATION ADDUCTION

SUPINATION EXT ROT

PRONATION ABDUCTION

PRONATION EXT ROT

PRONATION DORSIFLEX

Maisonneuve’s fracture

High spiral oblique fracture of upper 3rd fibula with ankle PER injury

TYPES OF INJURIES

Soft tissue injuries

Ligament injuries

Lateral collateral ligament injury

Deltoid ligament injury

Syndesmotic injury

Fractures

Malleolar fractures

Pilon fractures

Physeal injuries

DIAGNOSIS

RADIOLOGICAL VIEWS

AP / LAT ANKLE

AP/OBLIQUE FOOT

AP MORTISE ANKLE

OTHER INVESTIGATIONS

ARTHROGRAPHY

ARTHROSCOPY

CT SCAN

MRI

BONE SCAN

AP VIEW

SYNDESMOSIS Tibiofibular

overlap<10mm

MALLEOLAR LENGTH Talocrural angle 83+_4

deg

TALAR TILT

- sup clear space- med clear space diff <2mm

MORTISE VIEW

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

SYNDESMOTIC INJURY

Pott’s Fracture

Fracture involving the ankle joint loosely referred to as Pott’s Fracture

1. First degree single malleolus fractured.

2. In second degree two malleoli are fractured.

3. 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)

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)

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.

TIBIAL PILON FRACTURES

Intraarticular fracture of distal tibia.

Fibula is fractured in 85% of these patients.

TIBIAL PILON FRACTURE

1. Plaster immobilization

2. Traction

3. Lag screw fixation

4. OR & IF with plates

5. External fixation with or without limited internal fixation

If articular incongruity <2 mm and reserved for low energy injuries

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

TALUS FRACTURE

Anatomy-parts

Head-articulate with navicular

Neck-nonarticular

Body-articulate with tibia and calcaneus

No muscular or tendinous attachment

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.

Talar head fracture

5~10% of all talus fracture

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

Classification-Hawkins classification

nondisplaced

Displaced

Subtalar subluxation

Ankle dislocation

(Talar body dislocation)

Talonavicular dislocation

Treatment

Hawkins type I

4~6 weeks of no weightbearing in a short leg cast walking cast for 1~2 months

Percutaneous screw fixation

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

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

Complication

Skin necrosis and infection

Delayed union or nonunion

Malunion

Posttraumatic arthritis

Osteonecrosis

Calcaneal fracture

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 hallucis longus pass) Anterior process: cuboid

Calcaneal fracture

Classification

Essex-Lopresti

--Extraarticular(25%) v.s intraarticular(75%) fracture

Sanders

--CT classification of intraticular calcaneal fracture

Associated injuries

A fall from a height or high–energy mechanisms

10% lumbar spine fracture(L1); 10% of calcaneal fracture are bilateral

Broden’s view showing the depressed posterior facet

varus position of the tuberosity

↓ ↑

Intraarticular fracture(joint depression and tongue type)

Mechanism injury Axial loading

Radiography Loss of Bohler’s and Gissane’s angles

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

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

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

Intraarticular fracture --complications

Soft tissue breakdown

Local infection

Subtalar arthritis

ANKLE AND FOOT INJURIES

Q1) The stability of the ankle joint is maintained by all of

the following except

a. Spring ligament

b. Deltoid ligament c. Lateral ligament d. Shape of the superior talar articular surface

Q2) The most commonly affected component of lateral

collateral ligament complex in an ankle sprain

a. Anterior talo fibular ligamentb. Posterior talo fibular ligamentc. Calcaneofibular Ligamentd. None

Q3) Ankle sprain is due to

a. Rupture of anterior talo-fibular ligamentb. Rupture of posterior talo-fibular ligamentc. Rupture of deltoid ligamentd. Rupture of calcaneo-fibular ligament

Q4) Mechanism of injury of transverse fracture of medial

malleolus is

a. Abduction injuryb. Adduction injuryc. Rotation injuryd. Direct injury

Q5) Cottons fracture is

a. Avulsion fracture of C7b. Bimalleolar fracturec. Trimalleolar fractured. Burst fracture of the Atlase. None of the above

Q6) Bimalleolar fracture is synonymous to

a. Cottonsb. Pottsc. Pirogoffsd. Dupuytrens

Q7) Avascular necrosis is a complication of

a. Fracture neck talusb. Fracture medial condyle femurc. Olecranon fractured. Radial head fracture

Q8) POP cast in equinus position is indicated in

a. Distal fracture both bone legb. Distal fracture fibulac. Bimalleolard. Fracture Talus

Q9) Gissane’s angle in intra-articlar fracture calcaneum is

a. Reducedb. Increasedc. Not changedd. Variable

Q10) Bohler’s angle is decreased in fracture of

a. Calcaneumb. Talusc. Naviculard. Cuboid

Q11) Stress fractures are most commonly seen in

a.Tibia

b.Fibula

c.Metatarsals

d.Neck of femur

Q12) Neutral triangle is seen radiologically in

a. Calcaneumb. Talusc. Naviuclard. Tibia