Ankle fractures

Question 1

What role does the deltoid ligament have?

Answer 1

Primary stabiliser to anterolateral talar displacement

Question 2

What role does the fibula have?

Answer 2

Acts as a butress to prevent lateral displacement of the talus

Question 3

What xrays and measurements are useful to assess the injured ankle?

Answer 3

AP and Lateral - WB f possible
EXTERNAL ROTATION STRESS - assess deltoid log- MEDIAL CLEAR SPACE >4MM= DELTOID DISRUPTION
TIBIOFIB OVERLAP normal >10MM
TIBIOFIB SPACE Normal <5MM
TALAR SUBLUXATION
TALAR TILT

Question 4

Name some classifications systems of ankle fractures ?

Answer 4

AO- 44 A- INFRASYNDESMTOIC
       44B - TRANSSYDESMOTIC
       44C - SUPRASYNDESMOTIC
WEBER- A -NFRASYNDESMTOIC
              B- TRANSSYDESMOTIC
              C-SUPRASYNDESMOTIC
LAUGE- HANSEN

Question 5

Describe the LAUGE- HANSEN classification in more detail

Answer 5

SUPINATION ADDUCTION- Distal to FIB avulsion, Vertical med mall fracture, Impaction of anteromed distal tibia
SUPINATION EXTERNAL ROTATION- ant tibiofib lig, lat oblique short fib (POST-INF to SUP-ANT), Post tib lig rupture/ Post mall fracture, Transverse med mall fracture= WEBER B
PRONATION ABDUCTION- med mall transv frac, ant tibfib lig sprain, transve comminuted fib frac= weber C
PRONATION EXT ROTATION- MED mall small AS TO POST-INF, Ant tibiofib lig, Lat oblique spiral fib frac, POst Mall/ post tibiofib lig

Question 6

What is the criteria for non op tx?

Answer 6

non displaced Medial malleolus

<25% joint involved of POST mall

Question 7

What is non op tx?

Answer 7

Short walking cast 4-6 weeks

Question 8

What is the criteria for op tx?

Answer 8

Displaced >3mm Lat mall fracture
Displaced Medial mall fracture
Talar shift
Displaced bilateral mall fracture

Question 9

What is the aim for op tx?

Answer 9

Stable anatomical reduction ti improve functional outcome

A 1mm shift of talus-> 42% reduction in tibiotalar contact area

Question 10

In which pt is outcome worse ?

Answer 10

Smokers
Reduced education
Excess ETOH
Increased Age
Presence of medial mall fracture

Question 11

What surgical methods could you use to fix fibular?

Answer 11

Lateral neutralisation plate and AP lag screw
Fibular nail
Postlat plate has greater stability but greater risk of soft tissue irritation- esp peroneal tendons

Question 12

What surgical methods could you use to fix med mall ?

Answer 12

medial lag screws
TBW
medial buttress for vertical fracture

Question 13

What methods could you use to fix post mall? Which approach would you use?

Answer 13

AP lag screw
Post butress plate
Posterior or posteriolateral - depends on fracture configuration and whether the fibula needs fixing.

Question 14

What xray changes are suggestive of syndesmotic injury?

Answer 14

Increase in medial clear space
tibiofib clear space >5mm
tibiofib overlap reduces
Common with fibular fracture over 6mm from ankle joint

Question 15

Briefly describe how you would fix a syndesmotic injury

Answer 15

restore fibular length and orientation
1-2 cortical screws (3.5mm women,4.5mm men)
2-4 cm above the joint angle post to ant

Question 16

What is your post op regime post surgical fixation of syndesmotic injury?

Answer 16

Post op NWB 8-12 weeks

No ev to suggest ant diff between screw removal, loosening or breakage effects outcome at 1 year