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An approach to ankle x-rays. Aric Storck PGY2 (acknowledgement to Dr. Dave Dyck for several slides) September 11, 2003. Objectives. Review basic ankle fracture classification Review x-rays of common ankle fractures Discuss management of common ankle fractures. Case 1:. 25 year old female

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an approach to ankle x rays

An approach to ankle x-rays

Aric Storck PGY2

(acknowledgement to Dr. Dave Dyck for several slides)

September 11, 2003

objectives
Objectives
  • Review basic ankle fracture classification
  • Review x-rays of common ankle fractures
  • Discuss management of common ankle fractures
case 1
Case 1:
  • 25 year old female
    • Jumped off roof
    • Right ankle pain
    • Inability to weight bear on right foot
  • What else do you want to know on history and physical examination?
  • Does she need x-rays ?
ottawa ankle rules
Ottawa Ankle Rules:
  • Order ankle x-rays if acute trauma to ankle and one or more of
    • Age 55 or older
    • Inability to weight bear both immediately and in ER (4 steps)
    • Bony tenderness over posterior distal 6 cm of lateral or medial malleoli
  • Sensitivity ~100%
  • Specificity ~40%
you have decided to order an ankle x ray the nurse entering your orders asks which views you want
You have decided to order an “ankle x-ray.” The nurse entering your orders asks which views you want …
ankle x rays 3 views
Ankle X-rays: 3 views
  • AP
    • Identifies fractures of malleoli, distal tibia/fibula, plafond, talar dome, body and lateral process of talus, calcaneous
  • Mortise
    • Ankle 15-25 degrees internal rotation
    • Evaluate articular surface between talar dome and mortise
  • Lateral
    • Identifies fractures of anterior/posterior tibial margins, talar neck, displacement of talus
ap x ray
Identifies fractures of

malleoli

distal tibia/fibula

plafond

talar dome

body and lateral process of talus

calcaneous

AP x-ray:
slide8

Tib/fib clear space

Tib/fib overlap

now apply what you ve learned
Now apply what you’ve learned …
  • Lateral malleolar fracture
  • Tib/fib clear space <5mm
  • Tib/fib overlap >10 mm
  • No evidence of syndesmotic injury
mortise x ray
Mortise X-Ray
  • Taken with ankle in 15-25 degrees of internal rotation
  • Useful in evaluation of articular surface between talar dome and mortise
mortise x ray1
Mortise x-ray:
  • Medial clear space
    • Between lateral border of medial malleous and medial talus
    • <4mm is normal
    • >4mm suggests lateral shift of talus
mortise x ray2
Mortise x-ray:
  • Talar tilt
    • Normal = -1.5 to +1.5 degrees (ie. Parallel)
    • Can go up to 5 degrees in stress views
    • <2mm difference between medial and lateral talar/plafond distances
lateral x ray
Lateral x-ray:
  • Identifies fractures of
    • Anterior/posterior tibial margins
    • Talus
    • Displacement of talus
    • Os trigonum
stable vs unstable
Stable vs Unstable
  • The ankle is a ring
    • Tibial plafond
    • Medial malleolus
    • Deltoid ligaments
    • calcaneous
    • Lateral collateral ligaments
    • Lateral malleolus
    • Syndesmosis
  • Fracture of single part usually stable
  • Fracture > 1 part = unstable

Source: Rosen

walking the walk talking the talk
Walking the walk …. Talking the talk

Ortho is on the phone. They ask you to describe the fracture….

lauge hansen
Lauge-Hansen:
  • 15 basic types of injury in 5 major categories
    • Described by two words
      • Position of foot at time of injury
      • Direction of talus within mortise causing fracture
    • Eg: supination-external rotation
    • Further subdivided into worsening areas of injury
  • Impossible to remember and clinically useless in the ED
danis weber
Danis-Weber
  • Defines injury based on level of fibular fracture
    • A=below tibiotalar joint
      • No disruption of syndesmosis
      • Usually stable
    • B=at level of tibiotalar joint
      • Partial disruption of syndesmosis
    • C=above tibiotalar joint
      • Disrupts syndesmosis to level of fracture
      • unstable
  • THE MORE PROXIMAL THE FIBULAR # THE MORE SEVERE THE INJURY
ao classification
AO classification:
  • Similar to Danis-Weber scheme
  • Takes into account damage to other structures (usually medial malleolous)
  • ~2 pages of classifications
    • Remember them all for your exam!
pott s classification
Pott’s classification:
  • Easy to remember
  • First degree
    • unimalleolar
  • Second degree
    • bimalleolar
  • Third degree
    • trimalleolar
lateral malleolar fracture danis weber a
Lateral Malleolar FractureDanis-Weber A
  • Mechanism
    • Suppination/adduction (inversion)
  • Mortise intact
  • Stable fracture
  • Treatment
    • Below knee cast
bimalleolar lat post malleoli
Bimalleolar (lat & post malleoli)
  • Mechanism
    • Inversion
    • Avulsion of posterior malleolus (post tibiofibular ligament)
  • Medial mortise wide
    • Suggests instability
  • Management
    • Posterior slab
    • Orthopedic consult

Source: McRae’s Practical Fracture Treatment

trimalleolar fractures
Trimalleolar Fractures
  • Unstable
    • Multiple ligamentous injuries
    • Usually involves syndesmosis
  • Treatment
    • Posterior slab
    • Urgent orthopedic consultation
    • ORIF
slide31

CASE 5

Source:Rosen

pilon tibial plafond fractures
Pilon (tibial plafond) fractures
  • Fracture of distal tibial metaphysis
    • Often comminuted
    • Often significant other injuries
  • Mechanism
    • Axial load
    • Position of foot determines injury
  • Treatment
    • Unstable
    • X-ray tib/fib & ankle
    • Orthopedic consultation

Source:Rosen

tillaux fracture
Tillaux Fracture
  • Occurs in 12-14 year olds
    • 18 month period when epiphysis is closing
  • Salter-Harris 3 injury
    • Runs through anterolateral physis until reaches fused part, then extends inferiorly through epiphysis into joint
    • Visible if x-ray parallel to plane of fracture (may require oblique)
  • Mechanism
    • External rotation
    • Strenth of tibiofibular ligament > unfused epiphysis
tillaux fracture1
Tillaux Fracture
  • Management
    • Inadequate reduction of articular surface can lead to early OA
    • Gap >2mm in articular surface is unacceptable
    • Advanced imaging techniques may be necessary
    • Early orthopedic consultation
    • Non-displaced
      • NWB below knee cast
    • Displaced
      • surgery
case 7
Case 7

Source: Rosen

maisonneuve fracture
Maisonneuve Fracture
  • Mechanism
    • Eversion + lateral rotation
    • May cause medial malleolar fracture or deltoid ligament disruption
    • Injury proceeds along syndesmosis and involves proximal fibula
  • Always rule out Maisonneuve fracture in medial malleolar/ligamentous injury
maisonneuve fracture1
Maisonneuve Fracture
  • Mechanism
    • Eversion + lateral rotation
    • Causes medial malleolar fracture or deltoid ligament disruption
slide40
If injury proceeds along syndesmosis it involves proximal fibula = Maisonneuve Fracture
  • Always rule out Maisonneuve fracture in medial malleolar/ligamentous injury
slide41
As talus continues to rotate
    • Posterior tib-fib ligament ruptures
    • Interosseous membrane rips
    • Gross diastasis
    • Dupuytren fracture – dislocation of the ankle