Management of acute ankle fractures

MANAGEMENT OF ACUTE ANKLE FRACTURES

Dr UDAY KUMAR MS(Orth) DNB(Orth)

SAGAR HOSPITALSSINDHI HOSPITALCHINMAYA HOSPITAL BANGALORE

Jan 9, 2015

- ankle fractures ----- between 107 and 187 per 100,000 persons per year

-Unimalleolar fractures-- most common -- 70%

-most common mechanism is---- supination injury foll by pronation

-more common in --- young men aged 15–24 yrs -- older women

INCIDENCE

Clinical features-H/O severe twisting, abduction or adduction injuries.

-Severe pain.-Inability to stand on the affected limb.-Swelling and deformity.-Tenderness on one or both malleoli.

Skin-soft tissue injury—closed/open

Nerves

Vasculature

Co-morbidities---diabetes smoking alcohol

Evaluate

Initial Management-Pain control

-RICE -Rest -Immobilise---splint -Compression bandage -Elevation

X rays

-Ankle Series AP mortise lateral

AP

Lateral

Mortise

- fractures of malleoli - distal tibia/fibula - talar dome - body and lateral process of

talus

Antero-posterior view

• Tibiofibular clear space: <5mm• Tibiofibular over lap: >10mm

• Talar Tilt: difference in width of med &lat aspect of joint–

<2mm

Measurements in AP view

-Foot in 15-20 degrees internal rotation

-Evaluate articular surface between talar dome and mortise

Mortise view

-Medial clear space: <4mm

•Posterior malleolar fractures

•AP talar subluxation

•Distal fibular translation &/or angulation

•Associated or occult injuries–Lateral process talus–Posterior process talus–Anterior process calcaneus

Lateral View

Evaluation: RadiographicOther Imaging Modalities

• Stress Views– Gravity – Manual

• CT– Articular involvement– Posterior malleolus

• MRI– Ligament and tendon

injury – Talar dome lesions– Syndesmosis injuries

Weber/AO classificationbased on level of fibula fracture

A – Below syndesmosis

B – At syndesmosis

C – Above syndesmosis

Classification: Lauge-Hansen meets Danis-Weber

Simple Classification Stable Unstable

• Stable fractures– Most commonly involve

medial or lateral side only

– Talus remains anatomic relative to tibia

Unstable fractures

– Disruption of 2 or more aspects of the mortise -- bone and/or ligament

– Talus may sublux or be dislocated from tibia

Stable Examples

Unstable Examples

Management

-Stable Ankle fracture --- short leg cast for 6 weeks

- Cast patients reduced hospital stay lower cost of treatment

Non-operative

Surgical Indications

• Bimalleolar / trimalleolar fractures

• Syndesmotic disruption

• Talar subluxation

• Open fractures

Soft tissue injury

• Debridement• External fixator and delayed ORIF

Basic Set-Up

• Supine position most common– Occasionally prone for direct approach to posterior

malleolus• Bump beneath ipsilateral buttocks (allows easier

approach to fibula)• Tourniquet• Prep / drape to above knee • Pre-op antibiotics• Fluoroscopy or X-ray

Instrumentation

• Small fragment set• Cannulated screws• K-wires• Cerclage wire • Power• Have mini-frag

available

Ankle Fracture

ORIF PLAN

Uni malleolar fracture

Fix with -- Two 4 mm cancellous screws --TB wire --plate

Bimalleolar fracture

Plate fibula

Two 4 mm cancellous screws in medial malleolus

Tri-malleolar fracture

Plate fibula Two 4 mm cancellous screws in med malleolus

fix posterior malleolus if >20 - 25% articular surface involved

Fixation techniques

Lateral Malleolus

• One-third tubular plate & 3.5 mm cortex screws

– Lateral– Posterior

• 3.5mm compression plate for unstable fractures

-avoid superficial peroneal nerve injury

Lateral Malleolus

• Locking plates -- lateral or posterolateral • Osteoporotic bone• Unstable fractures• Distal fractures

Lateral Malleolus in very distal fibula fractures

• Hook Plate• K wire with cerclage wire . Lag screw/Rush pin

Medial Malleolus

• Two partially threaded 4.0 mm cancellous screws

• K-wires with cerclage wire

• Buttress plate

Posterior Malleolus fixation

If involvement is > 25% of Articular surface > 2mm Displacement Persistent Posterior subluxation of talus

Anterior to posterior

Posterior to anterior

Posterior Malleolus

Syndesmosis Fixation

• Syndesmotic instability checked after fixation of malleolus

• Consider if fibula fracture > 4 cm above joint line

• Have bone hook on back table to check stability

Syndesmosis

• large or small fragment fully threaded screws, one or two

• Not inserted as lag screw, but as a positioning screw

• May be removed in 6 - 12 weeks

• Bioresorbable screws/Tight rope

Postoperative Care

• Well padded splint immobilization for a few days

• Ice and elevation• Non weight bearing for 6 weeks

• Early conversion to brace and ROM

Thank you