Orthopedic RSUD Panembahan Senopati Bantul
Ankle Fractures
Winda Alviranisa/20204010293
Pembimbing : dr. Muhammad Pandu Nugraha, [Link]
What is Fracture of the Ankle?
A broken ankle is a fracture or multiple fractures of one or more of three bones
in the ankle joint: the tibia (shinbone), the fibula (outer bone of the lower leg),
and the talus.
1. Ankle fractures are very common injuries to the ankle which generally
occur due to a twisting mechanism.
2. Diagnosis is made with orthogonal radiographs of the ankle.
3. Treatment can be nonoperative or operative depending on fracture
displacement, ankle stability, syndesmosis injury, and patient activity
demands.
Anatomy
Three bones make up the ankle joint:
● Tibia - shinbone
● Fibula - smaller bone of the lower leg
● Talus - a small bone that sits between
the heel bone (calcaneus) and the tibia
and fibula
The tibia and fibula have specific parts
that make up the ankle:
● Medial malleolus - inside part of the
tibia
● Posterior malleolus - back part of the
tibia
● Lateral malleolus - end of the fibula
Anatomy of the Ankle Joint
Anatomy of the Ankle Joint
Different Type of Ankle Fractures
Because the ankle joint comprises three bones, there are numerous
types of ankle fractures. Doctors think of the ankle as having three sides
and a "roof," and fractures can occur in each of these areas or in
combination.
The lower portion of the tibia forms the roof and medial (inside) of the
ankle, while the lower portion of the fibula forms the lateral (outside)
and posterior (back) of the ankle
Most Common Ankle Fractures
1. Lateral malleolus fracture: This is the most common type of ankle
fracture. It is a break of the lateral malleolus, the knobby bump on the
outside of the ankle (in the lower portion of the fibula).
2. Bimalleolar ankle fracture: This second-most common type involves
breaks of both the lateral malleolus and of the medial malleolus, the
knobby bump on the inside of the ankle (in the lower portion of the tibia).
3. Trimalleolar ankle fracture: This type involves breaks in three sides of the
ankle: the medial malleolus, the lateral malleolus and distal (lower portion)
of the posterior malleolus of the tibia.
4. Pilon fracture (also called a plafond fracture): This is a fracture through
the weightbearing “roof” of the ankle (the central portion of the lower tibia).
This is usually a higher energy traumatic injury resulting from a fall from a
height.
Classification
of Ankle Fractures
There are two other commonly used
classifications systems: Danis-Weber
and Lauge Hansen Classification
Danis-Weber
Classification
● Characterized by a transverse fibula
fracture at or below the ankle joint and
no syndesmotic injury;
● Involves a spiral fibula fracture
beginning at the level of the joint and a
partial syndesmotic injury;
● The fracture is proximal to the ankle
joint with associated disruption of the
syndesmosis to this level
Lauge-Hansen Classification
SAD
PAB
SER PER
How to Diagnosed?
Ankle fractures usually result from torsional forces and present typically with tenderness,
swelling, deformity and inability to weight-bear.
LOOK
Looks at any open wounds, the condition of the skin, neurovascular status
FEEL
Soft tissue palpation of all the ligamentous structures should be performed. These
include the anterior talofibular ligament, the posterior talofibular ligament, the
calcaneofibular ligament, the deltoid ligament complex and the anterior tibiofibularsyn-
desmosis.
MOVE
Range of motion should be assessed actively and passively: dorsiflexion, plantarflexion,
inversion and eversion. These should be compared bilaterally. Normal passive
dorsiflexion is 10-15 degrees, plantarflexion 50-70 degrees, inversion 40 degrees and
eversion is 10 degrees.
Special Test
Kleiger Test
Imaging-Radiographic
RECOMMENDED VIEWS
• AP
• lateral
• mortise
• external rotation stress
Most appropriate stress radiograph to assess competency of deltoid ligament
more sensitive to injury than medial tenderness, ecchymosis, or edema
gravity stress radiograph is equivalent to manual stress radiograph
• full-length tibia, or proximal tibia radiographs
Important to rule out maisonneuve-type fracture
Radiograph Findings
Syndesmotic Injury
Decreased tibiofibular Increased medial clear Increased tibiofibular
overlap space clear space
Lateral Malleolus Fractures
Talocrural angle
Posterior Malleolus Fractures
Double Contour sign Misty Mountains sign
Differential Diagnosis
Deltoid Ligament Sprain
Examination usually shows tenderness and swelling over the medial malleolus. Weight-bearing ankle X-
rays may show a talar shift. MRI scan could be useful but for the diagnosis of the deltoid ligament sprain.
Lateral Collateral Complex Sprain
Examination usually shows tenderness and swelling over the medial malleolus. Weight-bearing ankle X-
rays may show a talar shift. MRI scan could be useful but for the diagnosis of the lateral ligament
complex sprain.
Tendon Achilles Rupture
There is usually a history of sharp pain or a feeling of a snap in the back of the affected ankle. Clinical
assessment may reveal a palpable gap over the tendon Achilles and positive Simmonds test. Simmonds
test should be performed in a prone position. Squeezing of the calf muscles by the examiner should
move the foot to a plantarflexion position (negative Simmonds test). In tendon Achilles rupture, no foot
plantar flexion will occur on squeezing the calf (positive Simmonds test). X-rays are usually negative in
case of tendon Achilles rupture. Ultrasound scan is useful in the tendon Achilles rupture setting to assess
the degree of rupture and length of tendon gap.
Treatment
Non-Operative
Treatment
SHORT-LEG WALKING CAST/BOOT
Indications
● isolated nondisplaced medial malleolus
fracture or tip avulsions
● isolated lateral malleolus fracture with
< 3mm displacement and no talar shift
● bimalleolar fracture if elderly or unable
to undergo surgical intervention
● posterior malleolar fracture with <
25% joint involvement or < 2mm step-
off
Operative Treatment
ORIF
Indications
• Any talar displacement
• Displaced isolated medial malleolar fracture
• Displaced isolated lateral malleolar fracture
• Bimalleolar fracture and bimalleolar-equivalent fracture
• Posterior malleolar fracture with > 25% or > 2mm step-off
• Bosworth fracture-dislocations
• Open fractures
• Malleolar nonunions
Complications
1. Wound problems (4-5%)
2. Deep infections (1-2%)
up to 20% in diabetic patients
larrgest risk factor for diabetic patients is presence of peripheral neuropathy
3. Malunion
high suspicion for articular impaction of the tibial plafond in supination-adduction
injuries, which should be addressed at the time of surgery
corrective osteotomy requires obtaining anatomic fibular length and mortise
correction for optimal outcomes
4. Post-operative stiffness
5. Loss of dorsiflexion with posterior fixation
6. Post-traumatic arthritis
rare with anatomic reduction and fixation
REFERENCES
1. Taylor, B. 2021. Ankle Fractures. Grand Medical Center, Ohio. Orthobullets. https://
[Link]/trauma/1047/ankle-fractures
2. Singh, et al. 2014. Ankle Fractures : A Literature Review of Current Treatment Method. Open Journal
of Orthopedic. https://
[Link]/publication/268816462_Ankle_Fractures_A_Literature_Review_of_Current_Tre
atment_Methods#pfa
3. Wire, J., et al. 2021. Ankle Fractures. Pubmed. [Link]
4. Apley, G.A. ad Solomon, L. 2010. Apley’s System of Orthopaedics and Fractures. 9th Ed. Jakarta:
Widya Medika
5. [Link]
Thanks!
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