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Emergency Med - Exam 2 > 25, 26, 28 - Ankle Fractures > Flashcards

25, 26, 28 - Ankle Fractures Flashcards

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1
Q

Lecture objectives

A
  • Mechanisms of injury, classification schemes and management principles for ankle fractures.
  • Principles of open reduction internal fixation of ankle fractures.
  • Specific concepts and details of ankle fracture fixation devices.
  • Criteria used to evaluate ankle fracture internal fixation devices.
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2
Q

Lauge-Hansen classification system

A
  • First word = Position of foot at time of injury
  • Second word = Motion of talus through the injury
  • Four Main Patterns of Injury
  • Most fractures fit into system
  • 95% of ankle fractures are said to fit into this classification system
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3
Q

Four main patterns of injury

A

o Supination-adduction
o Pronation-abduction
o Supination-external rotation (SER) 75% of all L-H fractures*** = MOST COMMON
o Pronation-external rotation (PER)

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4
Q

Supination-adduction

A

Has 2 stages

  • ONLY class where talus moves MEDIALLY
  • ONLY class where a talus MEDIAL dislocation is possible
  • NOTE: STARTS LATERALLY***
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5
Q

Supination-adduction stage 1 (SAdd 1)

A

o Rupture of lateral collateral ligaments (or…)

o Transverse fracture of fibula BELOW ankle joint

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6
Q

Supination-adduction stage 2 (SAdd 2)

A

o Vertical fracture of medial malleolus

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7
Q

Pronation abduction

A

Has 3 stages

- NOTE: when talus moves laterally, the injury begins medially – STARTS MEDIALLY***

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8
Q

Pronation-abduction stage 1 (PAb 1)

A

o Rupture of deltoid ligament (talus is moving laterally) (or…)
o Transverse fracture of medial malleolus (evulsion fracture of medial malleolus)

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9
Q

Pronation-abduction stage 2 (PAb 2)

A

o Disruption of AITFL (tib-fib) and PITFL (tib-fib)

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10
Q

Pronation-abduction stage 3 (PAb 3)

A

o Short oblique fracture of the fibula at ankle joint

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11
Q

Supination-external rotation (SER)

A

Has 4 stages

- NOTE: START ANTERIORLY***

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12
Q

Supination-external rotation stage 1 (SER 1)

A

o Disruption of AITFL

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13
Q

Supination-external rotation stage 2 (SER 2)

A

o Spiral fracture of fibula AT the level of ankle joint***

o “Posterior spike” is patho-pneumonic for SER***

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14
Q

Supination-external rotation stage 3 (SER 3)

A

o Disruption of PITFL (tib-fib)

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15
Q

Supination-external rotation stage 4 (SER 4)

A

o Rupture of deltoid ligament (or…)

o Transverse fracture of medial malleolus

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16
Q

Pronation-external rotation (PER)

A

Has 4 stages

- NOTE: START MEDIALLY***

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17
Q

Pronation-external rotation stage 1 (PER 1)

A

o Rupture of deltoid ligament (or…)

o Transverse fracture of medial malleolus

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18
Q

Pronation-external rotation stage 2 (PER 2)

A

o Disruption of AITFL (or…)

o Rupture of interosseous membrane

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19
Q

Pronation-external rotation stage 3 (PER 3)

A

o Fibular fracture proximal to syndesmosis (ABOVE ANKLE)

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20
Q

Pronation-external rotation stage 4 (PER 4)

A

o Disruption of PITFL (tib-fib)

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21
Q

NOTE on images in powerpoint

A

There are more pictures in the powerpoint that you need to review before the exam
- He said there could be radiographs or illustrations on the exam, so BE FAMILIAR with them***

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22
Q

NOTE on fracture location

A
  • When classifying the ankle fractures, ALWAYS pay attention to WHERE it is in relation to the ANKLE***
23
Q

Danis-Weber classification system

A
  • Three main patterns of injury

- Based on fibular fracture and its relationship to the ankle joint*****

24
Q

Types of Danis-Weber fractures

A
  • A: Fibular fracture below level of the ankle
  • B: Fibular fracture at level of the ankle
  • C: Fibular fracture above level of the ankle
25
Q

Types of Danis-Weber fractures – Trick to determining LH from DW

A
  • A: Fibular fracture below level of the ankle –> LH = Supination-adduction
  • B: Fibular fracture at level of the ankle (look at lateral radiograph to distinguish) –> LH = Supination-external rotation (posterior spike will be present) OR LH = Pronation abduction (will appear to be a transverse fracture)
  • C: Fibular fracture above level of the ankle –> LH = Pronation external rotation, then need to figure out stage

NOTE: if there is a fibular fracture, use the DW trick to figure out what LH it is by looking at the level of the ankle fracture, then look to figure out what stage it is

26
Q

Internal fixation

A

Treat Fracture Patterns NOT Fracture Classifications

27
Q

Fracture patterns

A
  • Transverse fracture
  • Vertical fracture
  • Short oblique fractures
  • Long oblique fractures
  • Spiral fractures
  • Evulsion fractures
28
Q

Avulsion fracture fixation methods

A
  • Tension Band Wire
  • Cross K-Wires
  • Lag Screws (which are partially threaded cancellous screw – lag design)
29
Q

Tension band wiring

A
  • Great technique to get compression in osteoporotic or osteopenic bone which is harder to get screws to purchase into bone
  • Involves running two k wires across fracture site then drilling a hole in bone proximal to fracture then run thin wire (monofilament) through the hole and crisscross it in a figure 8 pattern and twist it down on itself, creating compression on the fracture site
  • You can utilize it for any evulsion fracture – this works for evulsion fractures of the elbow or the ankle
30
Q

Vertical medial malleolus fracture

A

Lag Screw
o Two or Three Partially Threaded Cancellous Screws
o Washer can be used

31
Q

Example of lag screw use

A

Example: Vertical fracture of the medial malleolus that is seen in LH supination-adduction
o SAD stage 2

32
Q

Spiral fibula fracture (ANY spiral fracture) fixation

A

Inter-fragmentary Compression Screw
o “Inter-frag. screw”
o Lag Screw that goes across the fracture site
o Can either be a 3.5mm cortical screw (which would need to be inserted by lag by TECHNIQUE) or a 4.0mm partially threaded cancellous screw (which would need to be inserted by lag by DESIGN)
o “Lag” just means “compression” – so either compression by design or compression by technique

33
Q

Placement of inter-fragmentary screw

A

When more than one screw is used
o One perpendicular to bone
o One perpendicular to fracture

When one screw is used
o Placed in the middle (“split the difference”)
o This is the compromise when the fracture line is not long enough to use two screws across it

34
Q

Insertion of lag screw by technique (NOT GOING TO TEST THIS)

A 
Cortical Screw (threads are closer together)
o	2.5mm Guide Hole
o	3.5mm Glide Hole
o	Countersink
o	Depth Gauge
o	3.5mm Tap
o	Insert Screw
35
Q

Insertion of lag screw by design (NOT GOING TO TEST THIS)

A 
Partially Threaded Cancellous Screw (threads are farther apart) 
o	2.5mm Guide Hole
o	Countersink
o	Depth Gauge
o	4.0mm Tap
o	Insert Screw
36
Q

Cortical and cancellous screws

A
  • Top arrows = cortical screw (needs to go through both cortices) – threads are closer together
  • Bottom arrows = cancellous screw (does not go through both cortices and there is more cancellous bone here) – threads are farther apart
37
Q

Spiral fibular fracture

A

Neutralization Plate
o 1/3 tubular plate
o Cortical Screws Proximally
o Cancellous Screws Distally

38
Q

Insertion of cortical screws through a plate

A
  • 2.5mm Guide Hole
  • Depth Gauge
  • 3.5mm Tap
  • Insert Screw
39
Q

Insertion of cancellous screws through a plate

A
  • 2.5mm Guide Hole - DO NOT VIOLATE THE ANKLE MORTISE WITH THESE CANCELLOUS SCREWS (Angle Drill Proximally)
  • Depth Gauge, 4.0mm Tap
  • Insert Screw
40
Q

Oblique fibula fracture or high fibula fracture

A
  • Usually fracture is TOO SHORT to insert an inter-fragmentary screw across it
  • Need to apply plate instead
41
Q

Fixation of posterior malleolus fracture

A
  • Only have to fixate when it does not reduce after fixation of the fibular fracture or it is >25% of the joint surface
  • Direct Fixation
  • Indirect Fixation
42
Q

Direct fixation

A

o Partially Threaded Cannulated Screw directed from Posterior to Anterior

43
Q

Indirect fixation

A

o Partially Threaded Cannulated Screw directed from Anterior to Posterior

44
Q

Syndesmotic screw

A
  • First evaluate syndesmosis on X-ray (LH PER is ONLY class that involves a syndesmotic rupture)
  • After fractures are fixated, test the syndesmosis with a bone hook
  • If you can separate the syndesmosis with the bone hook, you will need a syndesmotic screw
  • Insert screw 4cm proximal to ankle and angle screw 25-30 degrees ANTERIORLY (because fibular sits more posteriorly on the tibia, so if you drill straight across, you would miss it)
  • DORSIFLEX foot during insertion - DO NOT WANT COMPRESSION AT SYNDESMOSIS***
45
Q

Syndesmotic cortical screw

A

o No Lag Technique

o Engage All Four Cortices

46
Q

Syndesmotic fully threaded cancellous screw

A

o Engage Only Three Cortices

47
Q

Note on what to NOT use for a syndesmotic screw

A
  • NEVER USE A PARTIALLY THREADED SCREW – don’t want compression
  • NEVER DO LAG TECHNIQUE – don’t want compression
  • If you have compression, you will crush the talus
48
Q

What do you need to remember about a syndesmotic screw?

A
  • NEED TO REMOVE SCREW PRIOR TO WEIGHTBEARING
49
Q

Case study 1

A

o A 41-year-old male with past medical history of hypertension presented to the emergency department after sustaining a left ankle injury while mowing his lawn. He reported slipping on wet grass and his ankle gave out. Pt. was unable to walk on left foot, ankle is swollen and painful. Pt. states that injury happened less than an hour ago. His pain is 10/10.

50
Q

Physical exam

A

o At presentation, he was in moderate distress due to pain, found to be alert and oriented to person, place and time. Vital signs were stable. Examination of the left foot and ankle revealed neurovascular status intact. Pain on palpation of lateral fibular and anterior left ankle. No angular deformities noted. Edema lateral left ankle. No open lesions or lacerations. No ecchymosis. No pain on palpation to medial side.
- X-rays

51
Q

X-rays

A

o Can see posterior spike sign – DW B, LH SER stage 2

o Another fracture – evulsion of anterior tibia

52
Q

Case study 2

A

o A 48-year-old male with past medical history of asthma presented to the emergency department after sustaining a right ankle injury while playing basketball last night. He reported landing on his right ankle wrong, but is unable to describe position of foot at time of injury. He rates his pain as 7/10. He noticed swelling on inside of the ankle and has pain with movement and walking, tried to ice last night without improvement so came to ED this AM. At presentation, he was in moderate distress due to pain, found to be alert and oriented to person, place and time. Vital signs were stable.

53
Q

Physical exam

A

o Examination of the right foot and ankle neurovascular status intact. Swelling, ecchymosis and pain on palpation of medial ankle around medial malleolus. Pain with passive ROM of right ankle. Muscle strength deferred. No pain on palpation of lateral malleolus. No edema lateral malleolus.

54
Q

X-rays

A

o There is a medial malleolar injury
o No fracture of the fibula at ankle
o Fracture of fibula at knee joint
o DW C, LH PER stage 4

Emergency Med - Exam 2 (11 decks)

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