ANKLE FRACTURE

1. ANKLE FRACTURE DUNJA DELEVSKA PMS-4 New York College of Podiatric Medicine July 2012

2. OUTLINE • Presentation • Imaging • Classification • Management

3. PRESENTATION • 26 year-old female presents to ED unable to bear weight on the right foot. S/p slipped and fell on wet floor • No open fracture • Patient is AAO x3 • Denies LOC

4. PRESENTATION (CONT.) • PMH: denies • PSH: denies • Meds: none • Allergies: NKDA • FHx: non contributory • SHx: denies

5. PRESENTATION (CONT.) Swelling Echymoses

6. PRESENTATION (CONT.) • Fracture blisters? • Uebbinget al. Fracture blisters. West J Emerg Med. 2011 Feb;12(1):131-3. • early treatment prior to blister formation or delay until blister resolution before attempting surgical correction or stabilization. • Strauss et al. Blisters associated with lower-extremity fracture: results of a prospective treatment protocol. J Orthop Trauma. 2006 Oct;20(9):618-22. • three cases of minor soft-tissue breakdown, one superficial infection, and two major complications directly related to the presence of fracture blisters • average delay of surgery for ankle fractures was 6 days (range 0 to 18 days) • Treatment of fracture blisters with a silver sulfadiazine (Silvadene)

7. PRESENTATION (CONT.) Lateral and Deltoid lig. Syndesmoticlig.

8. IMAGING • Standard ragiographic evaluations of ankle fractures • Anteroposterior projection • Lateral projection • Mortise projection

9. IMAGING (CONT.) ANTEROPOSTERIOR PROJECTION

10. IMAGING (CONT.) ANTEROPOSTERIOR PROJECTION Midline axis of tibia passes through center of talar dome? ✗

11. IMAGING (CONT.) ANTEROPOSTERIOR PROJECTION Tibio-fibular overlap ≥ 10mm? ✗

12. IMAGING (CONT.) MORTISE PROJECTION

13. IMAGING (CONT.) MORTISE PROJECTION All joint spaces within 1mm? ✗

14. IMAGING (CONT.) MORTISE PROJECTION Medial clear space ≤ 4mm? ✗

15. IMAGING (CONT.) MORTISE PROJECTION Tibio-fibular clear space ≤ 5mm? ✗

16. IMAGING (CONT.) LATERAL PROJECTION

17. IMAGING (CONT.) LATERAL PROJECTION Midline axis of tibia passes through center of talar dome? ✗

18. IMAGING (CONT.) • NATURE AND LOCATION OF FRACTURES • Spiral fibular fracture at the level of the joint • Posteriorly displaced transverse (avulsion) fracture of the posterior colliculus of medial malleolus

19. CLASSIFICATION • LAUGE-HANSEN CLASS. • SUPINATION/EXTERNAL ROTATION? • Stage 1: Rupture of AITFL with possible Tillaux or Wagstaffe fracture • Stage 2: Hallmark – spiral fracture of the fibula • Stage 3: Rupture of PITFL with possible Volkmann’s fracture • Stage 4: Rupture of the deltoid ligament or a transverse avulsion fracture of the medial malleolus • ?

20. CLASSIFICATION (CONT.) • LAUGE-HANSEN CLASS. • PRONATION/EXTERNAL ROTATION • Stage 1: Transverse avulsion fracture of medial malleolus or rupture of deltoid ligament • Stage 2: Rupture of AITFL and interosseous membrane • Stage 3: High fibular fracture (Maisonneuve fracture) – oblique or spiral ? • Stage 4: Rupture of PITFL or Volkmann’s fracture

21. CLASSIFICATION (CONT.) Danis-Weber class. • Type B: trans syndesmotic • Type B2: with medial malleolar fracture

22. CLASSIFICATION (CONT.) • LAUGE-HANSEN CLASS. • PRONATION/EXTERNAL ROTATION

23. New proposed fracture mechanism CLASSIFICATION (CONT.) Haraguchiet al. A New Interpretation of the Mechanism of Ankle Fracture. J Bone Joint Surg Am. 2009 Apr;91(4):821-9.

24. CLASSIFICATION (CONT.) • In support of Pronation/External rotation • Talus is in a pronated position • Fracture of navicular

25. MANAGEMENT • Closed reduction– manipulation of the fracture fragment into normal alignment without the use of surgical incision under anesthesia. • Behrbalket al. Procedural Sedation with Propofol for PainfulOrthopaedic Manipulation in the EmergencyDepartment Expedites Patient ManagementCompared with a Midazolam/Ketamine Regimen. J Bone Joint Surg Am. 2011 Dec 21;93(24):2255-62. • INCREASE THE DEFORMITY • DISTRACT THE FRAGMENTS • REVERSE THE MECHANISM OF INJURY

26. MANAGEMENT (CONT.) • Open reduction with internal fixation (AO) • Anatomic reduction of fracture fragments • Rigid/stable internal fixation (biologic) • Atraumatic operative technique (preserve BS) • Early active pain-free mobilization

27. MANAGEMENT (CONT.) • Pakarinenet al. Intraoperative assessment of the stability of the distal tibiofibular joint in supination-external rotation injuries of the ankle: sensitivity, specificity, and reliability of two clinical tests. J Bone Joint Surg Am. 2011 Nov 16;93(22):2057-61. • Hook test: the tibia was stabilized with one hand, the lateral malleolus was grabbed with a bone hook, and a lateral force was applied with use of the bone hook. • positive if >2 mm of lateral movement of the fibula • External rotation stress test: the tibia was stabilized with one hand and an external rotation force was applied to the foot; the tibiotalar clear space was then assessed under fluoroscopy. • positive if the medial tibiotalar clear space was ≥ 5 mm under stress

28. MANAGEMENT (CONT.) Jenkinsonet al. Intraoperative diagnosis of syndesmosis injuries in external rotation ankle fractures. J Orthop Trauma. 2005 Oct;19(9):604-9. Demonstration of external rotation stress to F-tool and strain gauge

29. MANAGEMENT (CONT.)

30. MANAGEMENT (CONT.) Bottlanget al. Far cortical locking can reduce stiffness of locked plating constructs while retaining construct strength. J Bone Joint Surg Am. 2009 Aug;91(8):1985-94.

31. MANAGEMENT (CONT.) Vassal Principle: once the dominant (fibular) fracture is reduced, the vassal fracture (tibial) will reduce spontaneously or can be reduced easily

32. MANAGEMENT (CONT.) • COMPLICATIONS • Peletet al. The incidence of thromboembolic events in surgically treated ankle fracture. J Bone Joint Surg Am. 2012 Mar 21;94(6):502-6. • Clinically detectable thromboembolic events after surgical treatment of ankle fractures are uncommon and do not appear to be influenced by the use of thromboprophylaxis. • Kurmiset al. The effect of nonsteroidal anti-inflammatory drug administration on acute phase fracture-healing: a review. J Bone Joint Surg Am. 2012 May 2;94(9):815-23. • Short-duration NSAID regimen is a safe and effective supplement to other modes of post-fracture pain control, without a significantly increased risk of sequelae related to disrupted healing.

33. SUMMARY • Take note of soft tissue damage when assessing ankle fractures • Obtain appropriate imaging studies that allow evaluation of joint congruency, fracture nature and displacement • Understand the mechanism of injury and classify the fracture • Ensure anatomic reduction and use fixation with adequate stiffness and strength

34. REFERENCES • Uebbinget al. Fracture blisters. West J Emerg Med. 2011 Feb;12(1):131-3. • Strauss et al. Blisters associated with lower-extremity fracture: results of a prospective treatment protocol. J Orthop Trauma. 2006 Oct;20(9):618-22. • Haraguchiet al. A New Interpretation of the Mechanism of Ankle Fracture. J Bone Joint Surg Am. 2009 Apr;91(4):821-9. • Behrbalket al. Procedural Sedation with Propofol for PainfulOrthopaedic Manipulation in the EmergencyDepartment Expedites Patient ManagementCompared with a Midazolam/Ketamine Regimen. J Bone Joint Surg Am. 2011 Dec 21;93(24):2255-62. • Pakarinenet al. Intraoperative assessment of the stability of the distal tibiofibular joint in supination-external rotation injuries of the ankle: sensitivity, specificity, and reliability of two clinical tests. J Bone Joint Surg Am. 2011 Nov 16;93(22):2057-61. • Jenkinsonet al. Intraoperative diagnosis of syndesmosis injuries in external rotation ankle fractures. J Orthop Trauma. 2005 Oct;19(9):604-9. • Bottlanget al. Far cortical locking can reduce stiffness of locked plating constructs while retaining construct strength. J Bone Joint Surg Am. 2009 Aug;91(8):1985-94. • Peletet al. The incidence of thromboembolic events in surgically treated ankle fracture. J Bone Joint Surg Am. 2012 Mar 21;94(6):502-6. • Kurmiset al. The effect of nonsteroidal anti-inflammatory drug administration on acute phase fracture-healing: a review. J Bone Joint Surg Am. 2012 May 2;94(9):815-23.

35. THANK YOU QUESTIONS