Ankle

Question 1

Ankle special tests

Answer 1

Anterior drawer - displace foot anteirorly against fixed tibia

Talar tilt: foot stressed in inversion and angle of talar rotation is evaluated by xray

Question 2

Mortise view definition and benefit

Answer 2

Ankle at 15o of internal rotation

Gives true view of ankle joint

Joint space should be symmetric with no talar tilt

Question 3

Ankle fracture complications

Answer 3

high incidence of post-traumatic arthritis

■ ipsilateral ligamentous tears or transverse bony avulsion

■ contralateral shear fractures (oblique or spiral)

Question 4

Ankle fracture treatment

Answer 4

• non-operative
■ indication: non-displaced, no history of dislocation
■ below knee cast, NWB

• operative
■ indications
◆ any fracture-dislocation: restore vascularity, minimize articular injury, reduce pain and skin pressure
◆ most of type B, and all of type C
◆ trmalleolar (medial, posterior, lateral) fractures
◆ talar tilt >10°
◆ medial clear space on X-ray greater than superior clear space
◆ open fracture/open joint injury
■ ORIF

Question 5

Danis-Weber classification of ankle fractures

Answer 5

• based on level of fibular fracture relative to syndesmosis

Type A (infra-syndesmotic)
• pure inversion injury
• avulsion of lateral malleolus below plafond or torn calcaneofibular ligament
• ± shear fracture of medial malleolus

Type B (trans-syndesmotic) 
• external rotation and eversion (most common) 
• ± avulsion of medial malleolus or rupture of deltoid ligament 
• spiral fracture of lateral malleolus starting at plafond 

Type C (supra-syndesmotic)
• pure exte nal rotation
• avulsion of medial malleolus or torn deltoid ligament
• ± posterior malleolus avulsion with posterior tibio-fibular ligament
• fibular fracture is above plafond (called Maisonneuve fracture if at proximal fibula)
• frequently tears syndesmosis

Question 6

With a history of significant trauma from axial loading of the lower limb what fractures need to be considered

Answer 6

Spinal injuries

Femoral neck

Tibial plateau

Talar/calcaneal fractures

Question 7

Complication of medial ligament complex (deltoid ligament)

Answer 7

Avulsion of medial or posterior malleolus and strains syndesmosis

Question 8

What composes the lateral ligament complex

Answer 8

Anterior talofibular

Posterior talofibular

Calcaneofibular

Question 9

If the ankle is plantar flexed what is the ligament most commonly and severely injured

Answer 9

Anterior talofibular ligament

Question 10

What will you see on clinical exam for lateral ligament complex injury

Answer 10

Positive ankle anterior drawer

Question 11

What will you see on imaging for lateral ligament complex injury

Answer 11

May have significant medial talar tilt on inversion stress xray

Question 12

Ankle ligamentous injuries treatment

Answer 12

• non-operative

■ microscopic tear (Grade I)
◆ rest, ice, compression, elevation

■ macroscopic tear (Grade II)
◆ strap ankle in dorsiflexion and eversion x 4-6 wk
◆ physiotherapy: strengthening and proprioceptive retraining

■ complete tear (Grade III) ◆ below knee walking cast x 4-6 wk
◆ physiotherapy: strengthening and proprioceptive retraining
◆ surgical intervention may be required if chronic symptomatic instability develops