Lecture trauma ankle_fracture
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Transcript of Lecture trauma ankle_fracture
Ankle FracturesAnkle Fractures
UCMC Orthopaedic Trauma ConferenceUCMC Orthopaedic Trauma ConferenceApril 2012April 2012
• MechanismMechanism
• TimingTiming
• Soft-tissue injurySoft-tissue injury
• Bone qualityBone quality
• ComorbiditiesComorbidities
• Associated InjuriesAssociated Injuries
• SkinSkin
• NervesNerves
• VasculatureVasculature
• PainPain
• DeformityDeformity
Anatomy: Medial SideAnatomy: Medial Side
Anterior Colliculus
Posterior Colliculus
Intercollicular Groove
Origin: anterior colliculus
Origin: posterior colliculus& intercollicular groove
Pankovich 1979
Osseous AnatomyOsseous AnatomyMcMinn 1996
APAP
– Tibiofibular overlapTibiofibular overlap– <10mm<10mm
– Tibiofibular clear space Tibiofibular clear space – >5mm>5mm
– Talar tiltTalar tilt– >2mm>2mm
Consider a comparison view
Mortise ViewMortise View
– Talocrural Talocrural angle: <8 angle: <8 or >15 or >15 degreesdegrees
Mortise ViewMortise View
Weber SICOT 1981
FIBULAR LENGTH: 1. Shenton’s Line of the ankle2. The dime test
Supination-External RotationSupination-External Rotation
3Stage 1 Anterior tibio- fibular ligament
Stage 2 Fibula fx
Stage 3 Posterior malleolus fx or posterior tibio-fibular ligament
Stage 4 Deltoid ligament tear or medial malleolus fx
Supination-External Rotation Supination-External Rotation Stage 4: UnstableStage 4: Unstable
Lateral Injury: classic posterosuperioranteroinferior fibula fracture
Medial Injury: medial malleolar fracture &*/or deltoid ligament injury
Standard: Surgical management *Tornetta JBJS 2000
Supination Adduction: Supination Adduction: Stage 2Stage 2
Lateral Injury: transverse fibular fracture at/below level of mortise
Medial injury: vertical shear type medial malleolar fractureBEWARE OF IMPACTION
McConnell J Orthop Trauma 2001
Pronation-External RotationPronation-External Rotation
• Stage 1 Deltoid ligament tear or Stage 1 Deltoid ligament tear or medial malleolus fxmedial malleolus fx
• Stage 2 Anterior tibio-fibular Stage 2 Anterior tibio-fibular ligament and interosseous ligament and interosseous membranemembrane
• Stage 3 Spiral, proximal fibula Stage 3 Spiral, proximal fibula fracturefracture
• Stage 4 Posterior malleolus fx Stage 4 Posterior malleolus fx or posterior tibio-fibular or posterior tibio-fibular ligament ligament
•
34
1 2
Pronation External Rotation: Pronation External Rotation: Stage 4Stage 4
Medial injury: deltoid ligament tear &/or transverse medial malleolar fracture
Lateral Injury: spiral proximal lateral malleolar fracture
HIGHLY UNSTABLE…SYNDESMOTIC INJURY COMMON
Pronation-AbductionPronation-Abduction• Stage 1 Transverse medial Stage 1 Transverse medial
malleolus fx distal to mortisemalleolus fx distal to mortise
• Stage 2 Posterior malleolus fx or Stage 2 Posterior malleolus fx or posterior tibio-fibular ligament posterior tibio-fibular ligament
• Stage 3 Fibula fracture, typically Stage 3 Fibula fracture, typically proximal to mortise, often with a proximal to mortise, often with a butterfly fragmentbutterfly fragment
1 2
3
Pronation-AbductionPronation-Abduction
Medial injury: tranverse to short oblique medial malleolar fracture
Lateral Injury: comminuted impaction type distal lateral malleolar fracture
Classification: Lauge-Hansen meets Danis-Classification: Lauge-Hansen meets Danis-WeberWeber
SKELETAL TRAUMA
Posterior Malleolus FracturesPosterior Malleolus Fractures
Function:Stability- prevents posterior translation of talus & enhances syndesmotic stability
Weight bearing- increases surface area of ankle joint
Haraguchi et al. JBJS 2006
Type I- posterolateral oblique type
Type II- medial extension type
Type III- small shell type
67%19%
14%
Posterior Malleolus Posterior Malleolus FractureFracture
Syndesmotic InjurySyndesmotic Injury
FUNCTION:
Stability- resists external rotation, axial, & lateral displacement of talus
Weening JOT 2005
Leeds JBJS 1984
Common Names of Fracture VariantsCommon Names of Fracture Variants• Maisonneuve Fracture
– Fracture of proximal fibula with syndesmotic disruption
• Volkmann Fracture– Fracture of tibial attachment of PITFL– Posterior malleolar fracture type
• Wagstaffe-Le Fort Fracture– Fracture of fibular attachment of AITFL
• Tillaux-Chaput Fracture– Fracture of tibial attachment of AITFL
• Coll icular FracturesColl icular Fractures– Avulsion fracture of distal Avulsion fracture of distal
portion of medial malleolusportion of medial malleolus– Injury may continue and Injury may continue and
rupture the deep deltoid rupture the deep deltoid ligamentligament
• Bosworth fracture Bosworth fracture dislocationdislocation– Fibular fracture with posterior Fibular fracture with posterior
dislocation of proximal fibular dislocation of proximal fibular segment behind tibiasegment behind tibia
Common Names of Fracture VariantsCommon Names of Fracture Variants
POSTERIOR COLLICULUS ANTERIOR COLLICULUS
INTERCOLLICULAR GROOVE
Operative Treatment: ApproachesMedial
LATERAL
ANTERIOR
AnteromedialAnterolateral
Lateral
Operative Treatment: Approaches
• BEWARE: SUPERFICIAL PERONEAL BEWARE: SUPERFICIAL PERONEAL NERVENERVE
Operative Treatment: Lateral Operative Treatment: Lateral ApproachApproach
Blair CORR 1994
72% 16% 12%
Standard Fixation Constructs: Lateral Standard Fixation Constructs: Lateral SideSide
SCREWS ONLY LATERAL PLATING POSTEROLATERAL PLATING POSTERIOR PLATING
Standard Fixation Constructs: Medial Standard Fixation Constructs: Medial SideSide
Tension Band Wires Screws Plate/Screw Combination
Standard Fixation Constructs: Posterior Standard Fixation Constructs: Posterior MalleolusMalleolus
Screws Plating
Standard Fixation Constructs: SyndesmosisStandard Fixation Constructs: Syndesmosis
Single Screw3 cortices
Single Screw4 cortices
2 Screws6 cortices
2 Screws8 cortices
Case Example #1Case Example #1
20 yo male falls while running - sustains ankle injury
Antiglide PlatingAntiglide Plating
Weber C / PER 4Weber C / PER 4
Short!
Postop & F/UPostop & F/U
THANKSTHANKS