ANKLE FRACTURES AND

INJURIES
INTRODUCTION

 Ankle injury refers to disruption of any

component or components of the ankle joint
following trauma.

 Ankle injuries occur frequently, and have high

propensity for complications.
ANATOMY
 Ankle joint is a synovial joint of hinge variety
• Bony mortise- quadrilateral
shape
• Posterolateral position of fibula
• Ligaments
3 groups
-Lateral
-Medial
-Syndesmotic
ANKLE JOINT IS SUPPORTED BY

 Fibrous capsule
 Deltoid ligament
A. Superficial
a. Anterior-
Tibionavicular
b. Middle- Tibiocalcanean
c. Posterior- Posterior
tibiotalar
B. Deep : Anterior-
Tibiotalar
• Lateral ligament
• Anterior- Talofibular
• Posterior- Talofibular
• Calcaneofibular
SYNDESMOTIC LIGAMENTS
• Ant inf tibio fib
• Supf post tibio fib
• Deep post tibio fib
• Interosseous lig
ACUTE LIGAMENTOUS
INJURY
• Type I sprain- minor
• Type II sprain - incomplete
• Type III sprain - complete
TREATMENT
 LIGAMENT INJURY

 Non-operative treatment
 Achieved by RICE

 Operative treatment
 Indicated when problems persist after 12
weeks of treatment including
physiotherapy
 Associated fracture
LAUGE HANSEN
CLASSIFICATION
• Most Common
1. Position of foot mechanism of injury-
at injury- SER
Pronation/Supin
ation • Most Common unstable
ankle fracture variant-
2. Deforming force- SER
Abduction/
adduction/
external rotation
LAUGE HANSEN
• SUPINATION ADDUCTION
• SUPINATION EXT ROT
• PRONATION ABDUCTION
• PRONATION EXT ROT
• PRONATION DORSIFLEX
Pott’s Fracture
 Fracture involving the ankle joint
loosely referred to as Pott’s Fracture
1. First degree single malleolus fractured.
2. In second degree two malleoli are
fractured.
3. In third degree there is bimalleolar
fracture with a fracture of posterior
part of inferior articular surface of the
tibia referred to as third malleolus. (Tri
Malleolar fracture-AKA- Cotton’s
fracture)
MANAGEMENT
• RICE
Definitive
• Aim- restoration of complete normal anatomical alignment of ankle.
• Patients if needs operation should be operated within 24hrs of injury or
after one week once the swelling subsides.
Undisplaced fracture medial malleolus :
• Below knee POP cast for 6 weeks.
• Reduction fails (may be due to soft tissue (periosteal) inter position)
Displaced:
 Open reduction and internal fixation by
 Cancellous screws group
 Tension band wiring
Fracture lateral malleolus:
 Lateral Malleolus helps in length maintenance & maintenance
of ankle mortice.
 Hence, lateral malleolus has to be fixed internally.
Maisonneuve’s fracture
• High spiral oblique fracture of
upper 3rd fibula with ankle PER
injury
TYPES OF INJURIES
• Soft tissue injuries
• Ligament injuries
• Lateral collateral ligament injury
• Deltoid ligament injury
• Syndesmotic injury
• Fractures
• Malleolar fractures
• Pilon fractures
• Physeal injuries
DIAGNOSIS-
RADIOLOGICAL VIEWS
• AP / LAT ANKLE
• AP/OBLIQUE FOOT
• MORTISE ANKLE
OTHER INVESTIGATIONS
• ARTHROGRAPHY
• ARTHROSCOPY
• CT SCAN
• MRI
• BONE SCAN
AP VIEW
• SYNDESMOSIS
• Tibiofibular overlap<10mm
• MALLEOLAR LENGTH
• Talocrural angle 83+_4 deg
• TALAR TILT
- sup clear space- med clear
space diff <2mm
MORTISE VIEW
What else to see in x-rays
LAT MALLEOLUS MED/POST MALLEOLUS
 Level of fracture • Size
 Orientation of fracture • Assoc plafond #
 Fracture comminution • Assoc syndesmotic
injury
SYNDESMOTIC INJURY
• High Ankle Sprain & Syndesmosis Injuries are
traumatic injuries that affect the distal tibiofibular
ligaments
• Most commonly occur due to sudden external
rotation of the ankle.
• Diagnosis is suspected clinically with tenderness
over the syndesmosis which worsens with
squeezing of the tibia and fibula together at the
midcalf. Plain stress radiographs of the ankle are
required to diagnosis complete syndesmosis
injuries with tibiofibular diastasis.
Provocative tests

• Squeeze test (Hopkin's) - Compression of tibia and

fibula at midcalf level causes pain at syndesmosis
• External rotation stress test - Pain over syndesmosis
is elicited with external rotation/dorsiflexion of the
foot with knee and hip flexed to 90 degrees
• Cotton test - Widening of the syndesmosis with
lateral pull on the fibula
• Fibular translation- Anterior and posterior drawer
force to the fibula with the tibia stabilized causes
increased translation of the fibula and pain
TREATMENT
• Nonoperative
• non-weight-bearing
CAM boot or cast for 2
to 3 weeks
• indications
• syndesmotic sprain
without diastasis or
ankle instability
Operative
syndesmosis screw fixation
•indications
•syndesmotic sprain (without
fracture) with instability on
stress radiographs
•syndesmotic sprain
refractory to conservative
treatment
•syndesmotic injury with
associated fracture
that remains unstable after
fixation of fracture
TIBIAL PILON FRACTURES
• Intraarticular fracture of distal tibia.
• Fibula is fractured in 85% of these patients.
TIBIAL PILON FRACTURE

1. Plaster immobilization If articular incongruity <2 mm

and reserved for low energy
2. Traction injuries

3. Lag screw fixation

4. Open Reduction Internal fixation with plates
5. External fixation with or without limited internal fixation
COMPLICATIONS
 Malunion- may result in posttraumatic arthritis
and painful movements.
 Nonunion of medial malleolus- commonly due to
interposition of fractured periosteum between
two fragments.
 Repeated edema
 Sudeck’s Osteodystrophy
TALUS FRACTURE
Anatomy-parts

• Head-articulate with
navicular
• Neck-nonarticular
• Body-articulate with
tibia and calcaneus
• No muscular or
tendinous
attachment
Blood supply
 Extraosseous supply
 Posterior tibial a. tarsal canal
a.
 Anterior tibial a.  sinus tarsi
a
 Peroneal a. sinus tarsi a.

 Intraosseous supply
 Talar head
 Talar body
-anastomosis between tarsal
canal a. and tarsal sinus a.
Talar head fracture
• 5~10% of all talus fracture
Talar neck fracture
• Aviator’s astragalus
• High energy injury, hyperdorsiflexion
• 15~20% open fracture
• Associated with malleloar fracture(25% of cases),
medial malleolus is more common
• High risk of soft tissue injury and compartment
syndrome
Classification-Hawkins
classification
Displaced
Subtalar subluxation
nondisplaced

Ankle dislocation Talonavicular

(Talar body dislocation)
dislocation
Treatment

• Hawkins type I
• 4~6 weeks of no weight bearing in a short
leg cast walking cast for 1~2 months
• Percutaneous screw fixation
Treatment

• Hawkins type II
• Orthopaedic emergency: traction and
plantar flexion by manipulation anatomic
reduction(50%)  treated as type I

• Open reduction: screw placed across the

neck fracture
Treatment
• Hawkins type IV
• Hawkins type III • Rare injury
• ORIF and Skeletal
traction through
• As type II
the calcaenus
• Open fracture (> type
III) :talar body
excision followed By
primary tibiocalcaneal
or Blair-type
arthrodesis
Complication

• Skin necrosis and infection

• Delayed union or nonunion
• Malunion
• Posttraumatic arthritis
• Osteonecrosis
Calcaneal fracture
Anatomy

 Largest, most irregularly shaped bone in foot

 Large calcellous bone and multiple processes
 Achilles tendon posteriorly and plantar fascia inferiorly : tuberosity
 Posterior facet: talar lateral process and body
 Middle facet: Sustentacular fragment (flexor hallucis longus pass)
 Anterior process: cuboid
Calcaneal fracture
• Classification
• Essex-Lopresti
--Extraarticular(25%) v.s intraarticular(75%)
fracture
• Sanders
--CT classification of intraticular calcaneal
fracture
• Associated injuries
• A fall from a height or high–energy mechanisms
• 10% lumbar spine fracture(L1); 10% of calcaneal fracture
are bilateral
 ↓ ↑

Broden’s view showing the depressed varus position of the tuberosity

posterior facet
Intraarticular fracture
(joint depression and
tongue type)
• Mechanism injury
• Axial loading
• Radiography
• Loss of Bohler’s and Gissane’s angles
Intraarticular fracture

Joint-depression type, in which the tongue-type, in which the primary

primary fracture line exited the bone fracture line exited the bone posteriorly
close to the subtalar joint
Intraarticular fracture
--Treatment

• Nondisplaced articular fractures

• Bulky (Robert-jones) dressing: active
subtalar ROM, prohibit weightbearing
walking 8~12 wks later
• Displaced intraarticular fracture with
large fragment
• ORIF
Intraarticular fracture
--Treatment

• Displaced intraarticular fracture with severe

comminution
• Increasing intraarticualr comminution leads to less
satisfactory results
• ORIF  primary arthrodesis
• Restoring the heel width and height
Intraarticular fracture
--complications
 Soft tissue breakdown
 Local infection
 Subtalar arthritis