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Ortho > R&G Chapter 59 - Ankle Fx > Flashcards

R&G Chapter 59 - Ankle Fx Flashcards

1
Q

Ottawa Ankle Rules

A

Pain near one or both malleoli AND one or more:

Age >55
Inability to bear weight
Bone tenderness over posterior edge or tip of either malleolus

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2
Q

Standard Radiographs of Ankle

A

AP
Lateral
Mortise

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3
Q

What additional imaging should you get for proximal fibular tenderness?

A

AP/LAT TIB/FIB with view of full leg

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4
Q

What is the geometric shape of the talus?

A

Frustrum

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5
Q

What is Potts classification based on?

A

Number of fracture malleoli

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6
Q

What is Weber classification based on?

A

Location of lateral malleolar fracture

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7
Q

What is Lauge-Hansen classification based on?

A

Position of the foot at time of fracture and the deforming force

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8
Q

What is a Weber A?

A

Infrasyndesmotic lateral malleolar fracture

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9
Q

What is a Weber B?

A

Lateral malleolar fracture at the level of the syndesmosis

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10
Q

What is a Weber C?

A

Suprasyndesmotic lateral malleolar fracture

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11
Q

What is a SER1?

A

Supination External Rotation injury resulting in rupture of the AITFL.
Stable ankle injury

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12
Q

What is a SER2?

A

Supination External Rotation injury with syndesmotic fibular fracture resulting in oblique fracture line with classic long posterior spike.
Typically treated non-operatively

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13
Q

What is a SER3?

A

SER injury where posterior tibiofibular ligament ruptures or a posterior malleolar fracture occurs.
Treat operatively

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14
Q

What is a SER4?

A

SER injury where the medial aspect of the ankle in injured and the joint becomes unstable.
Typically rupture of medial deltoid ligament or oblique fracture of the medial malleolus.

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15
Q

What is a SAD1?

A

Supination adduction injury with either talofibular ligament disruption or a transverse lateral malleolar avulsion fracture.
Stable injury

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16
Q

What is a SAD2?

A

SAD injury where medial mall is sheared off in addition to SAD1 radiographic findings giving a characteristic vertical fracture line.
Unstable injury
Medial plafond may suffer impaction

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17
Q

What is a PAB1?

A

Abducting talus avulses the medial malleolus resulting in transverse fracture line or causes medial deltoid ligament rupture

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18
Q

What is PAB2?

A

PAB injury where in addition to characteristic medial malleolar findings the fibular is pushed laterally resulting in AITFL rupture or avulsion of tubercle of chaput.

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19
Q

What is a PAB3?

A

PAB injury where in addition to medial and lateral findings the fibula fractures due to compression and bending resulting in comminuted fracture above the syndesmosis.

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20
Q

What is a PER1?

A

PER injury where isolated medial malleolar fracture or deltoid rupture is produced

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21
Q

What is a PER2?

A

In addition to medial findings AITFL rupture or fracture of tubercle of chaput occurs

22
Q

What is a PER3?

A

In addition to medial and lateral findings a fracture of the fibula occurs through torsion resulting in an oblique or spiral fracture above the syndesmosis

23
Q

What is a Volkmann’s fracture?

A

Fracture of the posterior malleolus

24
Q

What is a maisonneuve fracture?

A

Fracture of the proximal fibula associated with a medial malleolar fracture or deltoid ligament injury.
5% of all ankle fractures

25
Q

Radiographic measurements to make on mortise view of the ankle?

A 
5 things:
Medial clear space
Tibiofibular overlap
Tibiofibular clear space
Ball sign
Talocrural angle
26
Q

What is the ball sign?

A

Unbroken curve connecting the recess in the distal tip of the fibula and the lateral process of the talus when the fibula is out to length

27
Q

What does it mean if the ball sign is absent?

A

The fibula is short and malreduced

28
Q

What is the normal parameter for medial clear space?

A

Spaces medial and superior to the talus should be equal
Medial clear space <5mm
Medial clear space no more than 2mm greater than tibiotalar clear space

29
Q

What is the normal parameter for tibiofibular clear space?

A

> 5mm at 10mm above the joint line

30
Q

What is the normal parameter for tibiofibular overlap?

A

<5mm on AP

<1mm on Mortise

31
Q

What is the normal parameter for talocrural angle?

A

Approximately 83 degrees

Symmetric with contralateral ankle

32
Q

What is the accepted normal parameter for the medial malleolus?

A

<2mm of displacement

33
Q

What is the accepted normal parameter for the lateral malleolus?

A

<2mm of displacement or shortening

34
Q

What is the accepted normal parameter for posterior malleolus displacement?

A

<25% of the ankle joint seen on lateral
AND
<2mm displaced

35
Q

When is CT of the ankle useful?

A

Characterizing displacement of pilon fractures
Assessing size of posterior malleolar fragments
Assessing accuracy of syndesmosis reduction postop

36
Q

How are isolated lateral malleolar fractures best managed?

A

No difference in outcome beyond 3 months with below knee weight bearing casts, ACE bandage, air stirrups, ankle braces, and stabilizing shoes.
Use whichever is most pragmatic for surgeon and patient

37
Q

How are lateral malleolar fractures associated with instability managed?

A

These are SER4 injuries and are treated operatively

Repair of the medial deltoid is not necessary

38
Q

How are isolated medial malleolar fractures managed?

A

Unidisplaced or minimally displaced fractures can be managed nonop with plaster or functional bracing for 6wks, WBAT
Significant displacement or fractures through plafond should be treated with ORIF, typically with orthaganol cancellous screws.

39
Q

How are bimalleolar fractures best managed?

A

By definition unstable injuries and should be treated by ORIF of both medial and lateral malleolus
In elderly or infirm, stable reduced fractures can be treated non-op if under close clinical and radiographic review

40
Q

How are posterior malleolar fractures best managed?

A

Fx involving >25% or the posterior mal should be managed operatively with perc anterior and posterior screws
Large or irreducible fragments should be posteriorly plated

41
Q

How are syndesmotic injuries best managed?

A

Clear widening of the syndesmosis - surgical fixation is recommended
Distal third fibular fractures - fix fracture to reduce syndesmosis (fibular nail preferred)
Middle/proximal third fractures - ORIF

42
Q

Describe generally the medial surgical approach to ankle fractures

A

Exploits internervous interval between dorsiflexors and inverters/plantarflexors
Straignt longitudinal incision directly over the malleolus or a curvilinear incision anteriorly over the malleolar border curving posteriorly to the tip
The great saphenous vein and nerve are at risk in the sub-q just anterior to the medial mal

43
Q

Describe generally the posteromedial surgical approach to ankle fractures

A

Useful for posteromedial distal fragment
Incision made longitudinally halfway between medial malleolus and Achilles tendon
Blunt dissection to expose fascia overlying flexor tendons
Fascia incised longitudinally away from back of medial mal (safest interval between FHL tendon and peroneal tendons retracting FHL medially

44
Q

Describe generally the lateral surgical approach to ankle fracture

A

Incision directly over the border of the fibula
Principle structure at risk is superficial peroneal nerve
More vulnerable proximally from fibular tip
Blunt dissection recommended through sub-q fat

45
Q

Describe generally the posterolateral surgical approach to ankle fracture

A

Allows access to posterior malleolar fractures and posterior fibula
Patient in prone
Incision midway between posterior border of lateral mal and lateral border of Achilles tendon
Blunt dissect through fat to avoid injuring sural nerve
Elevate FHL and retract medially

46
Q

What is the epidemiology of ankle fractures?

A 
10% of all fractures
Bimodal distribution
Mean age 45
Typically low energy injury
Most common in obese or those with hx of multiple falls (elderly)
47
Q

What are the ligaments of the syndesmosis?

A

AITFL, PITFL, Interosseus

48
Q

What are the attachments of the AITFL?

A

Tubercle of chaput (tibia) to tubercle of wagstaff (fibula)

49
Q

What are the attachments of the PITFL?

A

Volkmanss tubercle of posterior mal to fibula

50
Q

What are the components of the superficial deltoid ligament?

A

Talotibial, calcaneotibial, naviculotibial

51
Q

What is the purpose of the deep deltoid ligament?

A

Restrains talus against lateral displacement and rotation

52
Q

What are the lateral collateral ligaments?

A

ATFL, PTFL, Fibulocalcaneal ligament

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