Ankle Fracture Flashcards
Epidemiology
Younger males and older females
Account for around 10% of all fractures seen in trauma setting.
What is the ankle comprised of?
Talus bone articulating within the mortise
Mortise is comprised of the tibial plafond and the medial malleolus + lateral malleolus.
Where do the tibia and fibula join?
At the syndesmosis
Explain the syndesmosis
A very strong fibrous structure comprised of anterior inferior tibiofibular ligament (AITFL) and the posterior inferior tibiofibular ligament (PITFL) and the intra-osseous membrane
Define ankle fracture
A fracture of any malleolus (lateral, medial or posterior) +/- disruption to the syndesmosis.
What is a fracture called where the tibial articular surface (the plafond) of joint is inovlved?
Pilon fracture
How can ankle fractures be described?
Isolated lateral malleolus fracture
Isolated medial malleolar fracture
Bimalleolar fracture
Trimalleolar fracture
What is the most common classification used?
Weber classification
Explain Weber classification
Classifies lateral malleolus fractures and used in Emergency setting
Type A - Below the syndesmosis
Type B - At the level of syndesmosis
Type C - Above the level of the syndesmosis
Explain degrees of severity related to Weber classification.
The more proximal injury => Higher likelihood of ankle instability
Type C fractures almost always need surgical fixation.
What classification is more common in orthopaedic practice?
Lauge-Hansen classification
Explain Lauge-Hansen classification
Based on ankle position at the time of injury and the deforming force involved
Much more detailed than Weber’s
Clinical features
Ankle pain following a traumatic injury
Associated deformity
Can have neurovascular compromise and be open (typically over the medial side)
Sometimes there is diagnostic uncertainty and the patient might be able to mobilise and have no visible deformity.
What can be used then?
Ottawa rules
Explain Ottawa ankle rules.
Bone tenderness at the posterior edge or tip of the lateral malleolus or…
Bone tenderness at the posterior edge or tip of the medial malleolus or…
An inability to bear weight both immediately and in the ED for four steps.
If any of the features above is present X-ray must be undertaken.
Ix
X-ray AP and lateral views
Check the joint space for uniformity ensuring there is no evidence of talar shift.
If there is complex ankle fractures, particularly where there is a displaced posterior malleolus fragment CT scan will be required for surgical planning.
What is important to consider in X-rays.
That the ankle is in full dorsiflexion.
This because the talus is narrower posteriorly and can appear translated within the mortise if it is done in plantarflexion.
Initial management
Immediate fracture reduction under sedation in ED to realign the fracture
Once reduced what management should be done?
Ankle should be placed in a below knee back slab.
Post-reduction neurovascular examination must be done.
Repeat X-ray should be done
If the reduction is not adequate repeat reduction attempts are required.
Indications of conservative management
Non-displaced medial malleolus fractures
Weber A or Weber B fractures without talar shift
Unfit for surgical intervention
Indications of surgical intervention.
Displaced bimalleolar fractures or trimalleolar fractures
Weber C fractures
Weber B fractures with talar shift
Open fractures
What surgical management is done?
ORIF to achieve stable anatomical reduction of the talus within the ankle mortise.
Complications
Post-traumatic OA but is rather rare with appropriate reduction and fixation
Surgical site infection
DVT or PE
Neurovascular injury
Non-union
Mal-union
