Ankle xrays
-
Upload
krishna-mohan-reddy -
Category
Documents
-
view
1.404 -
download
7
Transcript of Ankle xrays
![Page 1: Ankle xrays](https://reader034.fdocuments.net/reader034/viewer/2022050801/554b2a7cb4c905d3088b4a77/html5/thumbnails/1.jpg)
An approach An approach to to
ankle x-raysankle x-raysAric Storck PGY2
(acknowledgement to Dr. Dave Dyck for several slides)
September 11, 2003
![Page 2: Ankle xrays](https://reader034.fdocuments.net/reader034/viewer/2022050801/554b2a7cb4c905d3088b4a77/html5/thumbnails/2.jpg)
ObjectivesObjectives• Review basic ankle fracture classification
• Review x-rays of common ankle fractures
• Discuss management of common ankle fractures
![Page 3: Ankle xrays](https://reader034.fdocuments.net/reader034/viewer/2022050801/554b2a7cb4c905d3088b4a77/html5/thumbnails/3.jpg)
Case 1:Case 1:• 25 year old female
o Jumped off roofo Right ankle paino Inability to weight bear on right foot
• What else do you want to know on history and physical examination?
• Does she need x-rays ?
![Page 4: Ankle xrays](https://reader034.fdocuments.net/reader034/viewer/2022050801/554b2a7cb4c905d3088b4a77/html5/thumbnails/4.jpg)
Ottawa Ankle Rules:Ottawa Ankle Rules:• Order ankle x-rays if acute trauma to ankle
and one or more ofo Age 55 or oldero Inability to weight bear both immediately and in ER
(4 steps)o Bony tenderness over posterior distal 6 cm of
lateral or medial malleoli
• Sensitivity ~100%• Specificity ~40%
![Page 5: Ankle xrays](https://reader034.fdocuments.net/reader034/viewer/2022050801/554b2a7cb4c905d3088b4a77/html5/thumbnails/5.jpg)
You have decided to You have decided to order an “ankle x-ray.” order an “ankle x-ray.”
The nurse entering The nurse entering your orders asks your orders asks
which views you want which views you want ……
![Page 6: Ankle xrays](https://reader034.fdocuments.net/reader034/viewer/2022050801/554b2a7cb4c905d3088b4a77/html5/thumbnails/6.jpg)
Ankle X-rays: 3 viewsAnkle X-rays: 3 views• AP
o Identifies fractures of malleoli, distal tibia/fibula, plafond, talar dome, body and lateral process of talus, calcaneous
• Mortiseo Ankle 15-25 degrees internal rotationo Evaluate articular surface between talar dome and
mortise
• Lateral o Identifies fractures of anterior/posterior tibial
margins, talar neck, displacement of talus
![Page 7: Ankle xrays](https://reader034.fdocuments.net/reader034/viewer/2022050801/554b2a7cb4c905d3088b4a77/html5/thumbnails/7.jpg)
AP x-ray:AP x-ray:• Identifies fractures
of o malleolio distal tibia/fibulao plafondo talar domeo body and lateral
process of taluso calcaneous
![Page 8: Ankle xrays](https://reader034.fdocuments.net/reader034/viewer/2022050801/554b2a7cb4c905d3088b4a77/html5/thumbnails/8.jpg)
Tib/fib clear space Tib/fib overlap
![Page 9: Ankle xrays](https://reader034.fdocuments.net/reader034/viewer/2022050801/554b2a7cb4c905d3088b4a77/html5/thumbnails/9.jpg)
AP xrayAP xray
![Page 10: Ankle xrays](https://reader034.fdocuments.net/reader034/viewer/2022050801/554b2a7cb4c905d3088b4a77/html5/thumbnails/10.jpg)
Now apply Now apply what what
you’ve you’ve learned …learned …
• Lateral malleolar fracture
• Tib/fib clear space <5mm
• Tib/fib overlap >10 mm
• No evidence of syndesmotic injury
![Page 11: Ankle xrays](https://reader034.fdocuments.net/reader034/viewer/2022050801/554b2a7cb4c905d3088b4a77/html5/thumbnails/11.jpg)
Mortise X-RayMortise X-Ray• Taken with ankle
in 15-25 degrees of internal rotation
• Useful in evaluation of articular surface between talar dome and mortise
![Page 12: Ankle xrays](https://reader034.fdocuments.net/reader034/viewer/2022050801/554b2a7cb4c905d3088b4a77/html5/thumbnails/12.jpg)
![Page 13: Ankle xrays](https://reader034.fdocuments.net/reader034/viewer/2022050801/554b2a7cb4c905d3088b4a77/html5/thumbnails/13.jpg)
Mortise x-ray:Mortise x-ray:• Medial clear space
o Between lateral border of medial malleous and medial talus
o <4mm is normalo >4mm suggests lateral
shift of talus
![Page 14: Ankle xrays](https://reader034.fdocuments.net/reader034/viewer/2022050801/554b2a7cb4c905d3088b4a77/html5/thumbnails/14.jpg)
Mortise x-ray:Mortise x-ray:• Talar tilt
o Normal = -1.5 to +1.5 degrees (ie. Parallel)
o Can go up to 5 degrees in stress views
o <2mm difference between medial and lateral talar/plafond distances
![Page 15: Ankle xrays](https://reader034.fdocuments.net/reader034/viewer/2022050801/554b2a7cb4c905d3088b4a77/html5/thumbnails/15.jpg)
Lateral x-ray:Lateral x-ray:• Identifies fractures
of o Anterior/posterior
tibial marginso Taluso Displacement of
taluso Os trigonum
![Page 16: Ankle xrays](https://reader034.fdocuments.net/reader034/viewer/2022050801/554b2a7cb4c905d3088b4a77/html5/thumbnails/16.jpg)
Stable vs UnstableStable vs Unstable• The ankle is a ring
o Tibial plafondo Medial malleoluso Deltoid ligamentso calcaneouso Lateral collateral ligamentso Lateral malleoluso Syndesmosis
• Fracture of single part usually stable
• Fracture > 1 part = unstable
Source: Rosen
![Page 17: Ankle xrays](https://reader034.fdocuments.net/reader034/viewer/2022050801/554b2a7cb4c905d3088b4a77/html5/thumbnails/17.jpg)
Walking the Walking the walk ….walk ….Talking the Talking the
talktalk
Ortho is on the phone. They ask you to describe the fracture….
![Page 18: Ankle xrays](https://reader034.fdocuments.net/reader034/viewer/2022050801/554b2a7cb4c905d3088b4a77/html5/thumbnails/18.jpg)
Lauge-Hansen:Lauge-Hansen:• 15 basic types of injury in 5 major
categorieso Described by two words
1.Position of foot at time of injury2.Direction of talus within mortise
causing fractureo Eg: supination-external rotationo Further subdivided into worsening
areas of injury
![Page 19: Ankle xrays](https://reader034.fdocuments.net/reader034/viewer/2022050801/554b2a7cb4c905d3088b4a77/html5/thumbnails/19.jpg)
Danis-WeberDanis-Webero Defines injury based on level of fibular
fracture• A=below tibiotalar joint
o No disruption of syndesmosiso Usually stable
• B=at level of tibiotalar jointo Partial disruption of syndesmosis
• C=above tibiotalar jointo Disrupts syndesmosis to level of fractureo unstable
o THE MORE PROXIMAL THE FIBULAR # THE MORE SEVERE THE INJURY
![Page 20: Ankle xrays](https://reader034.fdocuments.net/reader034/viewer/2022050801/554b2a7cb4c905d3088b4a77/html5/thumbnails/20.jpg)
AO classification:AO classification:• Similar to Danis-Weber scheme
• Takes into account damage to other structures (usually medial malleolous)
• ~2 pages of classificationso Remember them all for your exam!
![Page 21: Ankle xrays](https://reader034.fdocuments.net/reader034/viewer/2022050801/554b2a7cb4c905d3088b4a77/html5/thumbnails/21.jpg)
AO AO classificationclassification
![Page 22: Ankle xrays](https://reader034.fdocuments.net/reader034/viewer/2022050801/554b2a7cb4c905d3088b4a77/html5/thumbnails/22.jpg)
Pott’s classification:Pott’s classification:• Easy to remember
• First degreeo unimalleolar
• Second degreeo bimalleolar
• Third degreeo trimalleolar
![Page 23: Ankle xrays](https://reader034.fdocuments.net/reader034/viewer/2022050801/554b2a7cb4c905d3088b4a77/html5/thumbnails/23.jpg)
Case 2Case 2
![Page 24: Ankle xrays](https://reader034.fdocuments.net/reader034/viewer/2022050801/554b2a7cb4c905d3088b4a77/html5/thumbnails/24.jpg)
![Page 25: Ankle xrays](https://reader034.fdocuments.net/reader034/viewer/2022050801/554b2a7cb4c905d3088b4a77/html5/thumbnails/25.jpg)
Lateral Malleolar Lateral Malleolar FractureFracture
Danis-Weber ADanis-Weber A• Mechanism
o Suppination/adduction (inversion)
• Mortise intact• Stable fracture• Treatment
o Below knee cast
![Page 26: Ankle xrays](https://reader034.fdocuments.net/reader034/viewer/2022050801/554b2a7cb4c905d3088b4a77/html5/thumbnails/26.jpg)
Case 3Case 3
![Page 27: Ankle xrays](https://reader034.fdocuments.net/reader034/viewer/2022050801/554b2a7cb4c905d3088b4a77/html5/thumbnails/27.jpg)
Bimalleolar (lat & Bimalleolar (lat & post malleoli)post malleoli)
• Mechanismo Inversiono Avulsion of
posterior malleolus (post tibiofibular ligament)
• Medial mortise wideo Suggests instability
• Managemento Posterior slabo Orthopedic consult
Source: McRae’s Practical Fracture Treatment
![Page 28: Ankle xrays](https://reader034.fdocuments.net/reader034/viewer/2022050801/554b2a7cb4c905d3088b4a77/html5/thumbnails/28.jpg)
Case 4Case 4
![Page 29: Ankle xrays](https://reader034.fdocuments.net/reader034/viewer/2022050801/554b2a7cb4c905d3088b4a77/html5/thumbnails/29.jpg)
![Page 30: Ankle xrays](https://reader034.fdocuments.net/reader034/viewer/2022050801/554b2a7cb4c905d3088b4a77/html5/thumbnails/30.jpg)
Trimalleolar FracturesTrimalleolar Fractures• Unstable
o Multiple ligamentous injurieso Usually involves syndesmosis
• Treatmento Posterior slabo Urgent orthopedic consultationo ORIF
![Page 31: Ankle xrays](https://reader034.fdocuments.net/reader034/viewer/2022050801/554b2a7cb4c905d3088b4a77/html5/thumbnails/31.jpg)
Source:Rosen
CASE 5
![Page 32: Ankle xrays](https://reader034.fdocuments.net/reader034/viewer/2022050801/554b2a7cb4c905d3088b4a77/html5/thumbnails/32.jpg)
Pilon (tibial plafond) fracturesPilon (tibial plafond) fractures
• Fracture of distal tibial metaphysiso Often comminutedo Often significant other injuries
• Mechanismo Axial loado Position of foot determines
injury
• Treatmento Unstableo X-ray tib/fib & ankleo Orthopedic consultation
Source:Rosen
![Page 33: Ankle xrays](https://reader034.fdocuments.net/reader034/viewer/2022050801/554b2a7cb4c905d3088b4a77/html5/thumbnails/33.jpg)
Case 6Case 6
![Page 34: Ankle xrays](https://reader034.fdocuments.net/reader034/viewer/2022050801/554b2a7cb4c905d3088b4a77/html5/thumbnails/34.jpg)
Tillaux FractureTillaux Fracture• Occurs in 12-14 year olds
o 18 month period when epiphysis is closing
• Salter-Harris 3 injuryo Runs through anterolateral physis until reaches fused
part, then extends inferiorly through epiphysis into jointo Visible if x-ray parallel to plane of fracture (may require
oblique)
• Mechanismo External rotationo Strenth of tibiofibular ligament > unfused epiphysis
![Page 35: Ankle xrays](https://reader034.fdocuments.net/reader034/viewer/2022050801/554b2a7cb4c905d3088b4a77/html5/thumbnails/35.jpg)
Tillaux FractureTillaux Fracture• Management
o Inadequate reduction of articular surface can lead to early OA
o Gap >2mm in articular surface is unacceptableo Advanced imaging techniques may be
necessaryo Early orthopedic consultationo Non-displaced
• NWB below knee casto Displaced
• surgery
![Page 36: Ankle xrays](https://reader034.fdocuments.net/reader034/viewer/2022050801/554b2a7cb4c905d3088b4a77/html5/thumbnails/36.jpg)
Case 7Case 7
Source: Rosen
![Page 37: Ankle xrays](https://reader034.fdocuments.net/reader034/viewer/2022050801/554b2a7cb4c905d3088b4a77/html5/thumbnails/37.jpg)
![Page 38: Ankle xrays](https://reader034.fdocuments.net/reader034/viewer/2022050801/554b2a7cb4c905d3088b4a77/html5/thumbnails/38.jpg)
Maisonneuve FractureMaisonneuve Fracture• Mechanism
o Eversion + lateral rotationo May cause medial malleolar fracture or deltoid ligament disruptiono Injury proceeds along syndesmosis and involves proximal fibula
• Always rule out Maisonneuve fracture in medial malleolar/ligamentous injury
![Page 39: Ankle xrays](https://reader034.fdocuments.net/reader034/viewer/2022050801/554b2a7cb4c905d3088b4a77/html5/thumbnails/39.jpg)
Maisonneuve Maisonneuve FractureFracture
• Mechanismo Eversion + lateral rotationo Causes medial malleolar
fracture or deltoid ligament disruption
![Page 40: Ankle xrays](https://reader034.fdocuments.net/reader034/viewer/2022050801/554b2a7cb4c905d3088b4a77/html5/thumbnails/40.jpg)
• If injury proceeds along syndesmosis it involves proximal fibula = Maisonneuve Fracture
• Always rule out Maisonneuve fracture in medial malleolar/ligamentous injury
![Page 41: Ankle xrays](https://reader034.fdocuments.net/reader034/viewer/2022050801/554b2a7cb4c905d3088b4a77/html5/thumbnails/41.jpg)
• As talus continues to rotateo Posterior tib-fib ligament
ruptureso Interosseous membrane ripso Gross diastasis
o Dupuytren fracture – dislocation of the ankle
![Page 42: Ankle xrays](https://reader034.fdocuments.net/reader034/viewer/2022050801/554b2a7cb4c905d3088b4a77/html5/thumbnails/42.jpg)
Case 8Case 8
![Page 43: Ankle xrays](https://reader034.fdocuments.net/reader034/viewer/2022050801/554b2a7cb4c905d3088b4a77/html5/thumbnails/43.jpg)
the endthe end
![Page 44: Ankle xrays](https://reader034.fdocuments.net/reader034/viewer/2022050801/554b2a7cb4c905d3088b4a77/html5/thumbnails/44.jpg)
![Page 45: Ankle xrays](https://reader034.fdocuments.net/reader034/viewer/2022050801/554b2a7cb4c905d3088b4a77/html5/thumbnails/45.jpg)
![Page 46: Ankle xrays](https://reader034.fdocuments.net/reader034/viewer/2022050801/554b2a7cb4c905d3088b4a77/html5/thumbnails/46.jpg)
![Page 47: Ankle xrays](https://reader034.fdocuments.net/reader034/viewer/2022050801/554b2a7cb4c905d3088b4a77/html5/thumbnails/47.jpg)
![Page 48: Ankle xrays](https://reader034.fdocuments.net/reader034/viewer/2022050801/554b2a7cb4c905d3088b4a77/html5/thumbnails/48.jpg)
![Page 49: Ankle xrays](https://reader034.fdocuments.net/reader034/viewer/2022050801/554b2a7cb4c905d3088b4a77/html5/thumbnails/49.jpg)
![Page 50: Ankle xrays](https://reader034.fdocuments.net/reader034/viewer/2022050801/554b2a7cb4c905d3088b4a77/html5/thumbnails/50.jpg)
![Page 51: Ankle xrays](https://reader034.fdocuments.net/reader034/viewer/2022050801/554b2a7cb4c905d3088b4a77/html5/thumbnails/51.jpg)
![Page 52: Ankle xrays](https://reader034.fdocuments.net/reader034/viewer/2022050801/554b2a7cb4c905d3088b4a77/html5/thumbnails/52.jpg)