Tib and fib Flashcards
Describe TIb shaft fracture
Most common long bone fracture- also the commonest open fracture
They are largely unstable fractures with marked vascular and interosseous injury. THere is a High risk of compartment syndrome
Peroneal nerve is the msot commonly affected
Describe the AO classification
Type A (simple)
- 1 Spiral
- 2 oblique (angle >30 degrees)
- 3 transverse (angle <30 degrees)
Type B (multi frag wedge)
1) spiral wedge
2) bending wedge
3) fragmented wedge
Type C (complex)
1) spiral wedge
2) segmental
3) irregular
Discuss lateral mal fractures
Most common ankle fractures
Stability of the joint depends on the location of the fracture
Weber classifecation
A: below the tibiotalar joint - rarely disrupt other bony or ligamentous structures and in the absence of injury to medial structures are unlilkely to cause joint instability.
B: at the level of the syndesmosis - syndesmosis usually intact but widening of the distal tib-fib joint indicates injury
C: Above the level of the syndesmosis
-syndesmosis integrity disrupted.
-medial mal and deltoid ligament injury often present
W
Discuss management of lateral mal
Weber A
- uncomplicated isolated lateral mal fractures involves casting for 6-8 week with nil weight bearing for 3 and other followup
Weber B
-Less clear than other clases as 50% will have syndesmosis injuryeis that may require opreative management.
Weber C
- Almost always disrupt syndesmosis and require ortho input
Discuss Medial Mal fracture
Usually the result of eversion or external rotation. These two forces exert tension on the deltoid ligament causing an avulsion of the tip of the medial malleolus or a rupture of the deltoid ligament
Although they can occur in isolated more commonly are associated with posterior or lateral mal fractures and warrant investigation for the same
Isolated can be treated with cast andfor 6-8 weeks with non weight bearing for 3
Discuss Bimalleolar and trimalleolar fractures
Involve the disruption of at least two elements of the ankle ring and are therefore unstbale.
Associated damage to soft tissue structures surrounding is common including syndesmosis injury
Trimalleoar fractures involve all the elements of the ring and always require surgical fixation
Describe pilon fractures
Involve the distal tibial metaphysis and usually are the result of high energy mechanisms with axial loading of the ankle joint such as falls from a significant height
These injuries are often comminuted and associated with significant soft tissue trauma and devastation of joint architecture with joint shortening
25% are open - are due to a the talus driving itself into the tibial plafond
MANAGMENT AND IX
- XR should include the entire tib and fib + ankle
- Needs ORIF however if siginficant soft tissue injury will need EXFIX first
Describe achilles tendon rupture and its risk factors
Most common in middle aged men and its causes are multifactorial
-Usually occur in the setting of trauma or forced dorsiflexion of a plantar flexed foot
Risk factores
- RA
- SLE
- GOUT
- Steroid use
- Fluroquinolone
- hyperparathyroisms
Discuss ix of achilles rupture
Primarily clinical.
- Sudden onset of pain at the back of the ankle with associated audible pop or snap.
- Pain may resolve rapidly but will have reduced power in plantar flexion.
- Exam may reveal a visible and palable tendon defect 2-6cm proximal to the calcanela insertion.
- Thompson test - patient is prone and the knee flexed at 90 degrees or the feet hanging over the end of a stretcher. Squeeing the calf should cause posive plantar flexion of the foot.
XR - Kagers triangle - opacification of the fatty tissue filled space anteiror to the achilles tendon
US and MRI are standard
Surgical vs conservative
-young active or athletes should have repair
Describe Ankle dislocation
Described based on the direction of the displacement of the talus and foot in relation to the tibia.
Medial dislocation is the most common
Describe talar fractures
The talus is divided into three regions
1) head: which articulates with the navicular and calcaneus
2) body: which articulates with the tibia, fibular and the calcaneus
3) neck: which connects the head and the body
MINOR FRACUTES
- Avulsions fractures of the superior neck and head and lateral medial and posterior aspects of the body
MAJOR
- Tala neck fractures account for 50% of major talar injuries
- The Hawkins classification grade talar neck fractures by displacement and associated subluxation
Describe the Hawking classifications
Grade talar neck fractures
- Grade 1 - non displaced
- Grade 2 - fractures are displaced vertical fractures with subtalar joint subluxation
- Grade 3 - 50% are open invovle a vertical talar neck fracture with subluxation of the subtalar and tibiotalr joint
- Grade 4 - involve distraction of the subtalar, tibiotalar and tibionavicular jiont
Above guides treatment and correlates with risk for AVN which can approach 50% for grade 3
Discuss management of talar fractures
Nondipslaced minor require casting.
Talar neck fractures carry significant risk of long term morbidity and require precise reduction.
- Type 1 are the only fracture amenable to non op treatment
- Hawkins type 2-4 require surgical management
Briefly describe osteochondral lesions of the talar dome
Defect of the articular cartilage and often include subchondral bone. SHould be considered in any patient with acute ligamentous ankle injury
Can progress to chronic ankle discomfort and OA- all should be referred to ortho for ongoing management
Describe subtalar dislocation
Disruption of both the talocalcaneal and talonavicular joints wihout disruption of the tibiotalr. This occurs whne the talonavicular and talocalcaneal ligaments rupture while the stronger calcanoenavicular ligament remains intact
Obvious deformity typically is present often with skin tension on the side opposite the dierction of the dislocation. Neurovascular status should be carefully assessed.
Closed reduction in the ED and casting
Complciations
- AVN is rare
- long term limitation of subtalar motion a sequela that can affect gait
