50 year old male diabetic Tripped and fell from a single stair

injuring right ankle Locally treated initially with below

knee cast for 3 weeks Patient told he had “minor” fracture

in ankle Immediate post injury x rays not with

the patient

Swollen, warm, erythematous distal leg, ankle and foot

No pain...patient came walking to the OPD....No stick, no cast

On IV antibiotics for 10 days post cast removal : Meropenem and dalacin

Blood cell counts normal Blood sugar Random 345 HbA1C : 11.5 Peripheral doppler normal Neuropathy

CT report:

• Fracture head, neck and body of talus, displaced fracture fragments extruded medially

• Comminuted fracture around posterior subtalar joint involving both talus and calcaneus with lateral dislocation of the fragments

• Fracture distal medial tibia, superiorly displaced

At 14 weeksAt 10 months: trivial fallAfter surgery

4 days post a closed fracture

Eventually after 3 surgeries

It is good to compare with the normal side

Trivial trauma in a diabetic

In 6 weeks!!

Diabetic fractures

Dr.Rajiv ShahFoot & Ankle OrthopaedicsFoot & Ankle SurgeonPresident, Indian Foot & Ankle Society

Fractures in diabetics: facts ‘Literature’Diabetes affects fracture healing at cellular level 1) deficient production of

growth factors leading to impaired bone formation

2) Deficient osteoclastogenesis

Impaired bone quality rather than impaired bone density leads to higher fracture risk in diabetics at subtle trauma

A history of any previous fracture increasesthe risk of further fracture by at least twofold

Fractures in diabetics took 163% longer time to heal!!

Fractures in diabetics: facts Literature69 years old diabeticX-rays at five months

X-rays at Nine months

8

What is special about diabetic fractures?Whether you operate on them or you conserve them results are universally bad with many complications!

Complications following diabetic ankle fracturesComplication at 90 days

Uncomplicated diabetes

Complicated Diabetes

Infections 2.46 3.85

Revision Surgery 1.84 5.09

Below knee Amputation

6.41 27.6

Ankle fractures in diabetics: ‘Literature’Complication rate in ankle fractures with uncomplicated diabetes is same as control(10%)

Complication rate in ankle fractures with complicated diabetes (neuropathy, nephropathy or vaculopathy)is very high(56%)!!

Surgical treatment of diabetic ankle fractures have shown major complication rate of 43% & infection rate up to 30%

Fractures in diabetics: facts

Diabetic fractures behave differently especially in presence of neuropathy

Bone destruction can be rapid Charcot process may start even

with “chip” fracture

Fractures in diabetics: facts

Many charcot are misdiagnosed as cellulitis / infection and are treated with antibiotics

‘Elevation test’ Rule out un displaced fracture

extensions not seen on the x ray with CT scan

Fractures in diabetics: facts

Diabetic patients need MORE of everything ▪ More investigations : Neuropathy, CT,

Doppler▪ Longer duration of immobilization▪ Longer duration of NWB▪ More fixation : stronger implants▪ May require primary fusions more often

than non neuropathic cases

Adelaide Diabetic Ankle Fracture Algorithm

Ankle Redness / Swelling and/or Pain

DIABETIC?NoRisk Factors?

Yes

Screen for DM

Diabetic RADIOLOGY

FRACTURE / DISLOCATION / CHARCOT

No

Other causes

Non DM

No

Two points each One point each

1. Peripheral Neuropathy / loss of protective proprioceptive sensation

2. Vasculopathy3. Previous history of

charcot at any joint4. IDDM5. Poor control HbA1c more

than 7.5

1.Diabetic more than 20 years

2.Nephropathy / Retinopathy

3.Obesity4.Non Compliant

patient

AFDA Scoring

Adelaide Diabetic Fracture Management Algorithm

Fractures in diabetics‘High Index of Suspicion’

Fractures in diabeticsWhat to ask ? History Mode & severity of traumaCould you walk after trauma?Presentation(delayed) after traumaPrior fractureTingling, numbness, burning, lack of sensibility, feeling of cushioned feet, night painsRenal or visual problems

Fractures in diabeticsWhat to look?

NeuropathySensory element

NeuropathyAutonomic element

NeuropathyMotor element

Fractures in diabeticsWhat to look? VasculopathyPeripheral pulses

VasculopathyToe hair growth

VasculopathyDoplerABI

HBA1C < 7Total lymphocyte >1500Total albumin > 3.0Pinzur criteria( CORR, 1993)

Fractures in diabeticsHow to treat?

Uncomplicated diabetic

fracture

Conservative care

Same as routine

Surgical care Same as routine

Fractures in diabeticsHow to treat?

Complicated diabetic fracture:

Conservative care

Watch for infection,Pressure sores,Frequent visits,

Periodic check X-raysLonger immobilization

Delayed weight bearingProtection if needed

Ankle fractures in diabeticsHow to treat? Complicated diabetic ankle fractures: Surgical guidelineTwo ways

Fractures in diabetics with neuropathyHow to treat? Longer

fixations Stronger

fixation Combination

fixations Crossing &

spanning of joints

Longer protection

Delayed weight bearing

Long time bracing

Do inform patient & relatives

Diabetic male aged 65 years

Fall Injury to

right ankle

Exploration of medial side & suture anchors for deltoid?

Syndesmotic screw?

Follow up

Infection – sinuses – implant failure

what

next?

Stage 1: Debridement, anchor removalStage 2: Ankle fusion with hind foot nail

42 years old male

Plate fixation

4 months –ex-fix removal

Associated with IHD Atherosclerosis Lower limb ischemia Infection Finally required Below Knee Amputation!!

Diabetic female aged 58 years

Fall in bathroom

Injury to left ankle

This is what was done

Comments?What next?

Position after mobilization

Revision fixation Comments?What next?

Mobilization with wound issues Comments?

Was it deemed?

What next?

Non unionInfectionCharcotLower third tibia fracture

Stage 1: Debridement, implant removalStage 2: Ankle fusion with hind foot nail Fracture stabilization with ilizarov fixator

Just 3 weeks post –surgery patient died!!

That’s all…Thank you all..