CLOSED ANKLE INJURIES

DR BASSEY A E

UATH, GWAGWALADA

OUTLINE• Introduction

• Definition• Statement of importance• Epidemiology

• Anatomy of the ankle joint• Components• Stability

• Types of ankle injuries• Soft tissue injuries – Ligament injuries, Peroneal tendon dislocation• Fractures – Malleolar, Pilon, Physeal injuries

• Treatment• Complications

• Early • Late

• Current trends• Conclusion• References

INTRODUCTION • Ankle injury refers to disruption of any

component or components of the ankle joint following trauma. When the site of such disruption has no communication with the external environment, it is described as closed.

• Ankle injuries occur frequently, and have high propensity for complications. Adequate knowledge of these injuries is therefore imperative in order to achieve satisfactory outcomes

INTRODUCTION

• In the USA,• Incidence – 628,000/year• Ankle injuries constitute 20% of joint injuries• They comprise 25% of sports injury

• In the UK• Accounts for 3 – 5% of ER visits

ANATOMY OF THE ANKLE JOINT• It is a synovial joint

with a mortise and tenon configuration

• It is a hinge joint

• Has bony and soft tissue components

ANATOMY OF THE ANKLE JOINT

• Bones – tibia, fibula & talus

• Soft tissue – lateral collateral ligament complex, medial collateral (deltoid) ligament, tibiofibular syndesmosis

ANATOMY OF THE ANKLE JOINT

• Stabilizing factors– Ligaments – deltoid ligament is the major

stabilizer– Peroneal tendons– Bony configuration

TYPES OF INJURIES• Soft tissue injuries– Ligament injuries • Lateral collateral ligament injury• Deltoid ligament injury

– Syndesmotic injury– Peroneal tendon dislocation

• Fractures – Malleolar fractures– Pilon fractures– Physeal injuries

SOFT TISSUE INJURIESINJURY REMARKS MECHANISM

OF INJURYCLINICAL FEATURES XRAY FINDINGS

LATERAL LIGAMENT INNJURY

Makes up 75% of ankle injury.

Isolated ATFL injury 60 – 70%, ATFL + CFL injury 20%

PTFL is the strongest and rarely injured

Forced inversion and plantarflexion

Pain and swelling ffl twisting of ankle after accidentally stepping into a pothole or kicking a kerb

Tenderness maximal inferior and slightly anterior to lat malleolus

Talar tilt (≥15o or 5o ≥ normal ankle), anterior drawer (≥10mm or 5mm ≥ normal ankle)

Assoc injuries – undisplaced fibular #/# 5th metatarsal

Soft tissue swelling

Chip avulsion fracture of tip of lat malleolus or talus

SOFT TISSUE INJURIES

SOFT TISSUE INJURIESINJURY REMARKS MECHANISM

OF INJURYCLINICAL FEATURES

XRAY FINDINGS

MEDIAL (DELTOID) LIGAMENT INJURY

Isolated injury is rare

Forced eversion and external rotation

Eversion test – for deloid ligament

External rotation stress test – for syndesmosis

Widening of medial joint space

Talar tilt

Syndesmotic diastasis

# distal fibula

SOFT TISSUE INJURIESINJURY REMARKS MECHANISM CLINICAL

FEATURESXRAY FINDINGS

SYNDESMOTIC INJURY

Partial – ant tibiofibular ligament injury

Complete – all ligaments

Partial – forced external rotation

Complete – severe abduction force

Pain in front of ankle

Marked tenderness directly over syndesmosis

Squeeze test +ve

May be isolated or assoc with medial ligament injury or fibular fracture

Widening of tibiofibular syndesmosis

SOFT TISSUE INJURIESINJURY REMARKS MECHANISM

OF INJURYCLINICAL FEATURES

XRAY FINDINGS

PERONEAL TENDON DISLOCATION

May be mistaken for lateral ligament injury

Injury to superior peroneal retinaculum or chip avulsion of its attachment to lat malleolus

Dislocation of peroneal tendons anteriorly over fibula on dorsiflexion and eversion

Oblique fracture of lateral malleolus

FRACTURESINJURY REMARKS MECHANISM

OF INJURYCLASSIFICATION

CLINICAL FEATURES

XRAY FINDINGS

MALLEOLAR FRACTURES

Most are low energy fractures of one or both malleoli

Never forget the often-present associated ligament injury

Forward fall with foot anchored to the ground

Talar tilt or rotation results in malleolar fracture

Danis-Weber

Lauge-Hansen

Hx of severe ankle twist followed by pain & inability to bear weight

Deformity may be obvious

Reveals fracture site as well as associated ligament or syndesmotic injury

DANIS-WEBER CLASSIFICATIONType A– below the level of the

talar dome– usually transverse– tibiofibular

syndesmosis intact– deltoid ligament intact– medial malleolus often

fractured– usually stable if medial

malleolus intact

• Type B– distal extent at the level of

the talar dome; may extend some distance proximally

– tibiofibular syndesmosis usually intact, but widening of the distal tibiofibular joint (especially on stressed views) indicates syndesmotic injury

– medial malleolus may be fractured

– deltoid ligament may be torn– Stability depends on status

of medial structures

• Type C– above the level of the

ankle joint– tibiofibular syndesmosis

disrupted – medial malleolus fracture

or deltoid ligament injury present

– fracture may arise as proximally as the level of fibular neck and not visualised on ankle films, requiring knee or full length tibia-fibula films (Maissonneuve fracture)

MALLEOLAR FRACTURES – DANIS-WEBER CLASSIFICATION

LAUGE-HANSEN CLASSIFICATION• Supination-adduction (Weber A)• Supination-external rotation (Weber B)

– stage 1: the anteroinferior tibiofibular ligament is torn or avulsed

– stage 2: the talus displaces and fractures the fibula in an oblique or spiral fracture, starting at the joint.

– stage 3: tear of the posteroinferior tibiofibular ligament or fracture posterior malleolus

– stage 4: tear of the deltoid ligament or transverse fracture medial malleolus

• Pronation-abduction (Weber C)• Pronation-external rotation (Weber C)• Pronation-dorsiflexion (Weber C

FRACTURESINJURY REMARK MECHANISM

OF INJURYCLASSIFICATION

CLINICAL FEATURES

XRAY FINDINGS

PILON FRACTURES

Intra-articular

High-energy fractures

Large compressive force drives talus upwards against tibial plafond

Articular cartilage and subchondral bone are damaged

Ruedi-Allgower

Pain, swelling, fracture blisters are common

Comminuted # distal tibia extending into ankle joint. # line may extend into tibial shaft

Fibula often fractured as well

CT better than Xrays

FRACTURESINJURY REMARKS MECHANISM

OF INJURYCLASSIFICATION

CLINICAL FEATURES

XRAY FINDINGS

PHYSEAL INJURY

A third of physeal injuries occur in the ankle

With foot fixed to the ground or trapped in a crevice the ankle is twisted

With severe twist fibular fracture may occur

Salter-Harris Pain, swelling, deformity

Fracture line usually obvious but undisplaced fractures can be easily missed

Repeat Xray in 1 week if physeal injury

TREATMENT• LATERAL LIGAMENT INJURY

• Non-operative treatment– Achieved by RICE

• Operative treatment– Indicated when problems persist after 12 weeks of treatment

including physiotherapy– Problems often due to cartilage damage or presence of scar

tissue in ankle joint– Surgical treatment may be open or arthroscopic

• MEDIAL LIGAMENT INJURY• Non-operative treatment

– Reduction of medial joint space and splintage

• Operative treatment– Indicated where medial joint space is cannot be reduced,

associated fibular fracture or diastasis

TREATMENT

• SYNDESMOTIC INJURY• Non-operative treatment

– Partial tear: strapping of ankle joint for 3 weeks

• Operative treatment– Complete tear: ORIF with a transverse screw

• PERONEAL TENDON DISLOCATION• Non-operative treatment

– Below-knee cast for 6 weeks

• Operative treatment– Indicated if it is recurrent– Reconstruction of the retinaculum using non-absorbable

sutures

TREATMENT

• MALLEOLAR FRACTURE• Non-operative treatment

– Isolated, undisplaced types A & B fractures– BK cast for 8 weeks

• Operative treatment– Indicated in

» Displaced Types A & B fractures that cannot be reduced closed

» Types A and B fractures with assoc ligament/syndesmotic injury

» Type C fractures

Weber B

TREATMENT• PILON FRACTURES

• Treatment is usually by operative means, however, even though bony union is achieved the fate of the joint is determined by severity of cartilage injury

• PHYSEAL INJURIES• SH 1 & 2 are treated non-operatively• Sh 3 & 4 if undisplaced are treated non-operatively as

well• If near-perfect reduction is not achievable by non-

operative means, then ORIF with interfragmentary screws is advocated

COMPLICATIONS

• EARLY– Vascular injury– Nerve injury

• LATE– Recurrent sprains– Joint stiffness– Joint instability– Osteoarthritis– Malunion

CURRENT TRENDS

• Ligament substitution with fascia lata graft in operative treatment of ankle sprain

• Arthroscopic joint debridement for impinged scar tissue

CONCLUSION

• As long as sports and recreational activities abound ankle injuries will remain a constant component of the orthopaedic surgeon’s caseload.

• Adequate knowledge and skill in managing this frequently-occurring problem are required to forestall complications and promote good quality of life

REFERENCES

• Apley’s system of Orthopaedics & fractures, D Warwick, S Nayagam, 9th Ed, pp 907 – 920

• http://www.medscape.com/viewarticle/826651_2

• http://www.boneschool.com/lower-limb/foot-and-ankle/trauma/ankle-injuries

• http://www.wheelessonline.com • http://radiopaedia.org/articles/weber-ankle-

fracture-classification