Ankle fractures
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Transcript of Ankle fractures
ANKLE FRACTURESANKLE FRACTURES
John W Cory MDJohn W Cory MDOrthoArizonaOrthoArizona
The Foot & Ankle CenterThe Foot & Ankle Center
ADULT ANKLE FRACTURESADULT ANKLE FRACTURES AO/WEBER AO/WEBER
CLASSIFICATIONCLASSIFICATION Based on level of Based on level of
fibular fracture fibular fracture Medial malleolar Medial malleolar
fracturefracture Posterior racturePosterior racture
AO/WEBER AO/WEBER A~(sup/add)A~(sup/add)
A1A1isolated fibular isolated fibular fracture below fracture below syndesmosissyndesmosis
A2A2 A1+ medial A1+ medial malleolus fracturemalleolus fracture
A3A3A1 or A2+ A1 or A2+ posterior medial posterior medial fracturefracture
ADULT ANKLE FRACTURESADULT ANKLE FRACTURESAO/WEBER A
ADULT ANKLE FRACTURESADULT ANKLE FRACTURES AO/WEBER B~(SER)AO/WEBER B~(SER) B1B1isolated fibula isolated fibula
fracture @ syndesmosisfracture @ syndesmosis B2B2B1 + medial B1 + medial
lesion(frx or lig)lesion(frx or lig) B3B3B2 + posterior lateral B2 + posterior lateral
fracturefracture– VolkmannVolkmann’s fragment’s fragment
AO/WEBER C~(PER)AO/WEBER C~(PER) C1C1isolated simple isolated simple
diaphyseal fracture of diaphyseal fracture of fibulafibula
C2C2complex diaphyseal complex diaphyseal fracture of fibulafracture of fibula
C3C3proximal fibula proximal fibula fracture,w/medial &/or fracture,w/medial &/or syndesmosis injurysyndesmosis injury
ADULT ANKLE FRACTURESADULT ANKLE FRACTURES
AO/WEBER B AO/WEBER C
ADULT ANKLE FRACTURESADULT ANKLE FRACTURES
ADULT ANKLE FRACTURESADULT ANKLE FRACTURES LAUGE-HANSEN CLASSIFICATIONLAUGE-HANSEN CLASSIFICATION Position of footPosition of foot Force appliedForce applied Better descriptor of injuryBetter descriptor of injury Helps catalog injury patternHelps catalog injury pattern Allows for understanding of injured Allows for understanding of injured
structures & guide treatmentstructures & guide treatment
ADULT ANKLE FRACTURESADULT ANKLE FRACTURES LAUGE-HANSEN-SALAUGE-HANSEN-SA Supination of footSupination of foot Inward rotation at Inward rotation at
ankle ankle Adduction of the Adduction of the
hindfoot hindfoot Inversion of the Inversion of the
forefootforefoot
LAUGE-HANSEN-SALAUGE-HANSEN-SA ~Weber A~Weber A SA ISA I
– Transverse or short Transverse or short oblique fibula fractureoblique fibula fracture
SA IISA II– Vertical fracture of Vertical fracture of
medial malleolusmedial malleolus
ADULT ANKLE FRACTURESADULT ANKLE FRACTURESLAUGE-HANSEN SA
ADULT ANKLE FRACTURESADULT ANKLE FRACTURESLAUGE-HANSEN SA
ADULT ANKLE FRACTURESADULT ANKLE FRACTURES LAUGE-HANSEN-SERLAUGE-HANSEN-SER Oblique frx at the level of Oblique frx at the level of
sydesmosis sydesmosis Supination of foot w/ Supination of foot w/
internal rotation of ankleinternal rotation of ankle Supinated foot externally Supinated foot externally
rotates rotates SER I-IV SER I-IV ~Weber B~Weber B
LAUGE-HANSEN-SERLAUGE-HANSEN-SER SER ISER I
– AITFL rupture or Wagstaff AITFL rupture or Wagstaff tub. frxtub. frx
SER IISER II– Spiral oblique fibular Spiral oblique fibular
fracture @ syndesmosisfracture @ syndesmosis SER IIISER III
– Posterior injury Posterior injury SER IVSER IV
– Medial injury Medial injury
ADULT ANKLE FRACTURESADULT ANKLE FRACTURESLAUGE-HANSEN SER
ADULT ANKLE FRACTURESADULT ANKLE FRACTURESLAUGE-HANSEN SER
ADULT ANKLE FRACTURESADULT ANKLE FRACTURES LAUGE-HANSEN-PER LAUGE-HANSEN-PER Pronated forefoot w/ ER Pronated forefoot w/ ER
of ankleof ankle Abduction of hindfootAbduction of hindfoot Eversion of forefootEversion of forefoot Avulsion frx of medial Avulsion frx of medial
malleolusmalleolus Syndesmosis ruptureSyndesmosis rupture Transverse(butterfly)Transverse(butterfly) fibula frxfibula frx
LAUGE-HANSEN-PERLAUGE-HANSEN-PER PER IPER I
– deltoid rupture or medial deltoid rupture or medial malleolus avulsion frxmalleolus avulsion frx
PER IIPER II– Sydysmosis ruptureSydysmosis rupture
PER IIIPER III– Transverse fibula fracture Transverse fibula fracture
@ syndesmosis w/ butterfly@ syndesmosis w/ butterfly– UnstableUnstable– Maisonneuve FractureMaisonneuve Fracture
ADULT ANKLE FRACTURESADULT ANKLE FRACTURES
LAUGE-HANSEN PA
ADULT ANKLE FRACTURESADULT ANKLE FRACTURESLAUGE-HANSEN PA
ADULT ANKLE FRACTURESADULT ANKLE FRACTURES LAUGE-HANSEN-PERLAUGE-HANSEN-PER Eversion injuryEversion injury Medial side injury is firstMedial side injury is first ~Weber C~Weber C
LAUGE-HANSEN-PERLAUGE-HANSEN-PER PER 1PER 1
– Deltoid rupture or Deltoid rupture or transverse frx of medial transverse frx of medial malleolusmalleolus
PER 2PER 2– ATFL or Wagstaff tub. frxATFL or Wagstaff tub. frx
PER 3PER 3– Short oblique fibula frx Short oblique fibula frx
above syndesmosisabove syndesmosis PER 4PER 4
– PITFL or post malleolus frxPITFL or post malleolus frx
ADULT ANKLE FRACTURESADULT ANKLE FRACTURESLAUGE-HANSEN PER
ADULT ANKLE FRACTURESADULT ANKLE FRACTURESLAUGE-HANSEN PER
ADULT ANKLE FRACTURESADULT ANKLE FRACTURES PILON PILON
FRACTURESFRACTURES– ““Hammer”Hammer”– Compression injuryCompression injury– Axial loadingAxial loading– Low & High energy Low & High energy
injuriesinjuries– Posterior injury-ankle Posterior injury-ankle
plantar flexionplantar flexion– Anterior injury-ankle Anterior injury-ankle
dorsiflexiondorsiflexion– Cleavage-neutralCleavage-neutral
ADULT ANKLE FRACTURESADULT ANKLE FRACTURES
ADULT ANKLE FRACTURESADULT ANKLE FRACTURES PILON FRACTURESPILON FRACTURES
– High association of secondary injuryHigh association of secondary injury– Fibula fractured in 75-85%Fibula fractured in 75-85%– If fibula intact-massive medial plafond injury, If fibula intact-massive medial plafond injury,
ankle varusankle varus– 30% ipsilateral LE injury30% ipsilateral LE injury– 15% contralateral LE injury15% contralateral LE injury
ADULT ANKLE FRACTURESADULT ANKLE FRACTURES PILON FRACTURESPILON FRACTURES L1 compression fracturesL1 compression fractures High rate of compartment syndromeHigh rate of compartment syndrome Hip fractureHip fracture Knee injuryKnee injury Tibial shaft fractureTibial shaft fracture Calcaneus fractureCalcaneus fracture
ADULT ANKLE FRACTURESADULT ANKLE FRACTURES PILON PILON
FRACTURESFRACTURES RUEDI-ALLGOWERRUEDI-ALLGOWER
– I: cleavage w/o severe I: cleavage w/o severe joint surface injuryjoint surface injury
– II: cleavage w/ joint II: cleavage w/ joint injury, not comminutedinjury, not comminuted
– III: comminution & III: comminution & impactionimpaction
ADULT ANKLE FRACTURESADULT ANKLE FRACTURES PILON PILON
FRACTURESFRACTURES AO AO
CLASSIFICATIONCLASSIFICATION A1-3A1-3
– extraarticular (w/ extraarticular (w/ increasing injury)increasing injury)
B1-3B1-3– Partial articular Partial articular
C1-3C1-3– articular + articular +
metaphysealmetaphyseal
ADULT ANKLE FRACTURESADULT ANKLE FRACTURES PILON FRACTURE TREATMENT PILON FRACTURE TREATMENT
GOALSGOALS Restoration of lengthRestoration of length Reconstruct metaphyseal shellReconstruct metaphyseal shell Bone graftingBone grafting Reattachment of metaphysis to diaphysisReattachment of metaphysis to diaphysis *Restoration of articular surface*Restoration of articular surface *Early mobilization*Early mobilization
ADULT ANKLE FRACTURESADULT ANKLE FRACTURES PILON TREATMENT OPTIONSPILON TREATMENT OPTIONS Splinting/ CastingSplinting/ Casting External FixationExternal Fixation ORIFORIF External fixation + limited ORIFExternal fixation + limited ORIF Compartment syndromeCompartment syndrome Associated injuriesAssociated injuries
ADULT ANKLE FRACTURESADULT ANKLE FRACTURES CASTINGCASTING Rarely treatment Rarely treatment
choicechoice Only with most Only with most
univolved univolved Ruedi-Allgower IRuedi-Allgower I AO A1AO A1
EXTERNAL EXTERNAL FIXATIONFIXATION
Indirect reductionIndirect reduction ““Skeletal traction”Skeletal traction” TemporizingTemporizing Maintain length & Maintain length &
alignmentalignment Preserves biologyPreserves biology
ADULT ANKLE FRACTURESADULT ANKLE FRACTURES ORIFORIF Timing is keyTiming is key
– ““6 hours/ 6 days-swelling peaks b/w 24hr-3 6 hours/ 6 days-swelling peaks b/w 24hr-3 daysdays
– Usually delayed 7-10 days w/ severe swellingUsually delayed 7-10 days w/ severe swelling– >21 days-granulation, hematoma >21 days-granulation, hematoma
organization, bone resorption, cartilage organization, bone resorption, cartilage malnutritionmalnutrition
29% fracture blisters w/ pilon fracture29% fracture blisters w/ pilon fracture
ADULT ANKLE FRACTURESADULT ANKLE FRACTURES ORIFORIF Soft tissue handling is KEYSoft tissue handling is KEY
– Full thickness flapsFull thickness flaps– Avoid compromised skinAvoid compromised skin
Surgical approachSurgical approach– 2 incision technique is workhorse2 incision technique is workhorse– Posterior lateral incision for fibulaPosterior lateral incision for fibula– Extended anterior arthrotomyExtended anterior arthrotomy
ADULT ANKLE FRACTURESADULT ANKLE FRACTURES ORIFORIF Restoration of lengthRestoration of length Reconstruct Reconstruct
metaphyseal shellmetaphyseal shell Bone graftingBone grafting Reattachment of Reattachment of
metaphysis to metaphysis to diaphysisdiaphysis
ORIFORIF 2X rate of delayed 2X rate of delayed
wound healingwound healing High complication High complication
raterate Reports of excellent Reports of excellent
results skewedresults skewed Best results with low Best results with low
energy injuriesenergy injuries
ADULT ANKLE FRACTURESADULT ANKLE FRACTURES EXTERNAL EXTERNAL
FIXATION + ORIFFIXATION + ORIF Massive soft tissue injuryMassive soft tissue injury Severe comminutionSevere comminution Utilizes inderect reductionUtilizes inderect reduction Restore/maintain length Restore/maintain length Maintain aligmentMaintain aligment
EXTERNAL EXTERNAL FIXATION + ORIFFIXATION + ORIF
Limited ORIFLimited ORIF– Fibular plateFibular plate– Interfrag screwsInterfrag screws
Increased rate of:Increased rate of:– Delayed/nonunionDelayed/nonunion– malunionmalunion
Decrease rate of:Decrease rate of:– Skin sloughSkin slough– InfectionInfection– Secondary closureSecondary closure
ADULT ANKLE FRACTURESADULT ANKLE FRACTURES EXTERNAL EXTERNAL
FIXATION + ORIFFIXATION + ORIF Half-pin fixatorHalf-pin fixator Skinny wire fixatorSkinny wire fixator Hybrid frameHybrid frame
EXTERNAL EXTERNAL FIXATION + ORIFFIXATION + ORIF
Half-pin fixatorHalf-pin fixator– TibiotalarTibiotalar– TibiocalcanealTibiocalcaneal– Triangular frameTriangular frame
– *No early mobilization*No early mobilization
ADULT ANKLE FRACTURESADULT ANKLE FRACTURES EXTERNAL EXTERNAL
FIXATION + ORIFFIXATION + ORIF Skinny wire fixatorSkinny wire fixator
– Does not span ankleDoes not span ankle– Excellent for C1 & C2Excellent for C1 & C2– Diaphyseal Diaphyseal
comminutioncomminution– Highly comminutedHighly comminuted
EXTERNAL EXTERNAL FIXATION + ORIFFIXATION + ORIF
Hybrid fixatorHybrid fixator– Does not span ankleDoes not span ankle– half pins diaphysealhalf pins diaphyseal– Skinny wire ring Skinny wire ring
metaphysealmetaphyseal
ADULT ANKLE FRACTURESADULT ANKLE FRACTURES PILON FRACTURES OUTCOMESPILON FRACTURES OUTCOMES Initial injuryInitial injury Soft tissue envelopeSoft tissue envelope TreatmentTreatment
– Delayed wound healing w/ traditional ORIF & Delayed wound healing w/ traditional ORIF & soft tissue injurysoft tissue injury
– Malunion/Nonunion w/ fixatorsMalunion/Nonunion w/ fixators