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Ankle Fractures

Ankle Fractures. OTA Fracture Course. Significance of Ankle Fractures. Most common weight bearing fracture we will treat Incidence is increasing Something we will all enc ounter. Lateral Ligaments. Medial Ligaments. Syndesmosis. Instability.

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Ankle Fractures

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  1. Ankle Fractures OTA Fracture Course

  2. Significance of Ankle Fractures Most common weight bearing fracture we will treat Incidence is increasing Something we will all encounter

  3. Lateral Ligaments

  4. Medial Ligaments

  5. Syndesmosis

  6. Instability • Inability to keep talus perfectly positioned under plafond • Usually lateral direction (external rotation) • Primary stabilizer is the deep deltoid JBJS 78, 1024

  7. How much is too much • 1 mm translation  decrease contact area by 42% JBJS 58,356

  8. Indications for surgery • Instability of talus • Dynamic incongruity • Plafond step-off • Static iincongruity

  9. X-ray • AP, Lateral and Mortise views of the ankle • AP and lateral of tibia • Consider stress views

  10. Overlap Tilt Anteroposterior View

  11. Mortise View Overlap Tilt Medial clear space

  12. Posterior malleolus fracture Subluxation of the talus Distal fibula fx Lateral View

  13. Classification • Lauge-Hansen • Danis-Weber (AO)

  14. Danis-Weber Classification Doesn’t address the medial injury

  15. (Over)simplified

  16. Weber A • Supination-Adduction

  17. Weber B • Supination-ER • With or without deltoid

  18. Weber C • Pronation-ER • Pronation-Abduction

  19. Maisonneuve Fx

  20. Treatment

  21. Medial Malleolar Fractures • Nondisplaced fractures may be treated nonoperatively • Displaced fractures • Isolated ?? ORIF • Part of bimalleolar pattern  ORIF • Horizontal (tension)  compression • Vertical (shear)  antiglide plate

  22. Other compression options for medial side

  23. Vertical (shear) medial fractures

  24. Vertical (shear) medial fractures

  25. Lateral Malleolus Fractures Nonoperative management • 2-3 mm displacement • NO medial widening or syndesmotic injury • Cast or boot immobilization 6 wks • WBAT • Follow closely! • Stress view to ensure no medial injury ???

  26. Surgical Indications • Bimalleolar / trimalleolar fractures • Bimalleolar equivalent • Syndesmotic disruption • Talarsubluxation

  27. Implant ConsiderationsLateral Side • One-third tubular • “neutralization” plate laterally • “antiglide” plate posteriorly • 3.5 LCDCP on shaft

  28. Other options forlateral side

  29. Other options forlateral side

  30. Posterior Malleolus • > 25% rule • Based on nothing • Fix if ANY posterior subluxation • A  P or P  A • Prone position very helpful

  31. Biomechanics - Syndesmosis • Gardner 2006 • Compared fixation of syndesmosisvs posterior malleolus ORIF • Syndesmosis fixed= 40% of normal • Posterior malleolus fixed = 70% of normal

  32. Maissoneuve Fracture • Fracture of proximal fibula • +/- medial malleolar fracture • Pronation-external rotation • Requires reduction and stabilization of syndesmosis

  33. Maissoneuve Fracture • Fracture of proximal fibula • +/- medial malleolar fracture • Pronation-external rotation • Requires reduction and stabilization of syndesmosis

  34. Syndesmosis Fixation • MUST test for Syndesmotic instability after fixation of lateral malleolus • Have bone hook on table to check stability, Cotton Test

  35. Syndesmosis Controversies No significant difference !! 1 vs. 2 screws 3.5 vs. 4.5 screws 4 cortices vs. 3 Two hole plate Tightrope The key is the REDUCTION !!

  36. THE END

  37. Biomechanics • Complex motion • 5x body weight in stance • At least 10 degrees of dorsiflexion is needed for normal gait • 1 mm of lateral talar shift decreases tibiotalar surface contact up to 40%

  38. (Over)simplified

  39. MM LM Talus INVERSION Weber A Tibia IOM Fibula Tib-Fib Lig Delt Lig Talo-Fib Lig

  40. MM LM Talus EVERSION Weber B Tibia IOM Fibula Tib-Fib Lig Delt Lig Talo-Fib Lig

  41. MM LM Talus EVERSION Weber C Tibia IOM Fibula Tib-Fib Lig Delt Lig Talo-Fib Lig

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