Ankle Xrays.ppt

8/10/2019 Ankle Xrays.ppt

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An approach toankle x-rays

Aric Storck PGY2(acknowledgement to Dr. Dave Dyck for several slides)

September 11, 2003


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Objectives Review basic ankle fracture classification

Review x-rays of common anklefractures

Discuss management of common anklefractures


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Case 1: 25 year old female

Jumped off roof

Right ankle pain Inability to weight bear on right foot

What else do you want to know on

history and physical examination?

Does she need x-rays ?


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Ottawa Ankle Rules:

Order ankle x-rays if acute trauma to ankleand one or more of Age 55 or older

Inability to weight bear both immediately and in ER (4steps)

Bony tenderness over posterior distal 6 cm of lateralor medial malleoli

Sensitivity ~100%

Specificity ~40%


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You have decided to order an

ankle x-ray. The nurse entering

your orders asks which views youwant


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Ankle X-rays: 3 views

AP Identifies fractures of malleoli, distal tibia/fibula,

plafond, talar dome, body and lateral process of talus,

calcaneous Mortise

Ankle 15-25 degrees internal rotation Evaluate articular surface between talar dome and

mortise

Lateral Identifies fractures of anterior/posterior tibial margins,

talar neck, displacement of talus


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AP x-ray:

Identifies fractures of

malleoli

distal tibia/fibula

plafond

talar dome

body and lateralprocess of talus

calcaneous


8/43Tib/fib clear space Tib/fib overlap


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AP xray


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Now apply what

youve learned

Lateral malleolar fracture

Tib/fib clear space 10 mm

No evidence of

syndesmotic injury


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Mortise x-ray:

Talar tilt

Normal = -1.5 to +1.5degrees (ie. Parallel)

Can go up to 5degrees in stress

views


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Lateral x-ray:

Identifies fractures of

Anterior/posterior tibialmargins

Talus

Displacement of talus

Os trigonum


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Stable vs Unstable

The ankle is a ring Tibial plafond Medial malleolus

Deltoid ligaments calcaneous Lateral collateral ligaments Lateral malleolus

Syndesmosis Fracture of single part usually

stable

Fracture > 1 part = unstable

Source: Rosen


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Walking the walk .

Talking the talk

Ortho is on the phone. They

ask you to describe thefracture.


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Lauge-Hansen:

15 basic types of injury in 5 major

categories

Described by two words

1.Position of foot at time of injury2.Direction of talus within mortise causing fracture

Eg: supination-external rotation

Further subdivided into worsening areas of injury

Impossible to remember and clinically

useless in the ED


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Danis-Weber

Defines injury based on level of fibular fracture A=below tibiotalar joint

No disruption of syndesmosis

Usually stable B=at level of tibiotalar joint

Partial disruption of syndesmosis

C=above tibiotalar joint

Disrupts syndesmosis to level of fracture unstable

THE MORE PROXIMAL THE FIBULAR # THEMORE SEVERE THE INJURY


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AO classification:

Similar to Danis-Weber scheme

Takes into account damage to otherstructures (usually medial malleolous)

~2 pages of classifications

Remember them all for your exam!


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AO classification


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Case 2


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Lateral Malleolar Fracture

Danis-Weber A

Mechanism

Suppination/adduction (inversion)

Mortise intact Stable fracture

Treatment

Below knee cast


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Case 3


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Bimalleolar (lat & post malleoli)

Mechanism Inversion Avulsion of posterior

malleolus (posttibiofibular ligament)

Medial mortise wide Suggests instability

Management Posterior slab Orthopedic consult

Source: McRaes Practical Fracture Treatment


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Case 4


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Unstable Multiple ligamentous injuries Usually involves syndesmosis

Treatment Posterior slab

Urgent orthopedic consultation ORIF

Trimalleolar Fractures

CASE 5


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Source:Rosen

CASE 5


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Fracture of distal tibialmetaphysis Often comminuted

Often significant other injuries Mechanism

Axial load Position of foot determines injury

Treatment Unstable X-ray tib/fib & ankle Orthopedic consultation

Pilon (tibial plafond) fractures

Source:Rosen


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Case 6


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Tillaux Fracture

Occurs in 12-14 year olds

18 month period when epiphysis is closing

Salter-Harris 3 injury

Runs through anterolateral physis until reaches fused part,then extends inferiorly through epiphysis into joint

Visible if x-ray parallel to plane of fracture (may requireoblique)

Mechanism External rotation

Strenth of tibiofibular ligament > unfused epiphysis


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Tillaux Fracture

Management Inadequate reduction of articular surface can lead

to early OA

Gap >2mm in articular surface is unacceptable Advanced imaging techniques may be necessary Early orthopedic consultation Non-displaced

NWB below knee cast Displaced

surgery


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Case 7

Source: Rosen


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Maisonneuve Fracture

Mechanism

Eversion + lateral rotation

May cause medial malleolar fracture or deltoidligament disruption

Injury proceeds along syndesmosis andinvolves proximal fibula

Always rule out Maisonneuve fracture inmedial malleolar/ligamentous injury


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Maisonneuve Fracture

Mechanism

Eversion + lateral rotation

Causes medial malleolar fracture ordeltoid ligament disruption


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As talus continues to rotate

Posterior tib-fib ligament ruptures

Interosseous membrane rips

Gross diastasis

Dupuytren fracture dislocation of the ankle


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Case 8


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the end

Ankle Xrays.ppt

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