Ankle Fractures I - Podiatry Course

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Questions and Answers

What are the main functions of the ankle joint?

Allows only for upward and downward movement.

Functions as a hinge joint allowing for triplane motion. (correct)

Acts only as a stabilizing structure.

Functions solely as a pivot point.

Which ligaments are classified as medial ligaments of the ankle?

Posterior tibiofibular ligament, Inferior transverse ligament.

Lateral collateral ligament, AITFL.

Anterior talofibular ligament, Calcaneofibular ligament.

Superficial deltoid, Deep deltoid. (correct)

What does the Lauge-Hansen classification system primarily consider?

The type of treatment required for ankle fractures.

The radiographic features of the fibular fracture.

The involvement of soft tissue injuries.

The foot position and direction of talar motion. (correct)

In the context of ankle fractures, what does the Danis-Weber classification relate to?

The radiographic appearance of fibular fractures concerning the syndesmosis. Signup and view all the answers

Which of the following is NOT a ligamentous structure associated with the medial aspect of the ankle?

Anterior talofibular ligament. Signup and view all the answers

Which of the following best describes the purpose of the syndesmotic ligaments in the ankle?

To connect the tibia and fibula, maintaining joint stability. Signup and view all the answers

Which term refers to the first word in the Lauge-Hansen classification, describing the foot position?

Supination. Signup and view all the answers

What anatomical structure is primarily responsible for the hinge motion at the ankle joint?

All of the above. Signup and view all the answers

What characterizes a Stage 1 injury in Supination-Adduction according to the Lauge-Hansen classification?

Transverse avulsion type fracture of the distal fibula below joint level Signup and view all the answers

In the Danis-Weber classification, a Type C fracture is defined as:

Fracture of the lateral malleolus above the syndesmosis Signup and view all the answers

Which stage in the Lauge-Hansen Supination External Rotation classification involves injury to the posterior inferior tibiotalar ligament?

Stage 3 Signup and view all the answers

The injury characterized by a transverse fracture of the medial malleolus or deltoid ligament injury corresponds to which classification?

Pronation External Rotation Stage 1 Signup and view all the answers

What type of fracture is identified in Danis-Weber Type B classification?

Fracture of the lateral malleolus at the level of the syndesmosis Signup and view all the answers

Which of the following describes the injury at Stage 2 of Pronation-Abduction classification?

Posterior malleolar fracture or avulsion of AITFL/PITFL ligaments Signup and view all the answers

Which named fracture is specifically an AITFL avulsion from the anterolateral tibia?

Tillaux-Chaput Signup and view all the answers

A fracture of the lateral malleolus distal to the syndesmosis is classified as:

Danis-Weber Type A Signup and view all the answers

In the Lauge-Hansen classification, which stage corresponds to a vertical medial malleolar fracture?

Pronation-Adduction Stage 2 Signup and view all the answers

Which statement is true regarding the overlaps between Lauge-Hansen and Danis-Weber classifications?

Danis-Weber B overlaps with Supination-Adduction Stage 2 Signup and view all the answers

Which ligament serves as the main stabilization structure for the medial aspect of the ankle joint?

Posterior tibiotalar ligament Signup and view all the answers

What is the correct order of foot position and talar motion in the Lauge-Hansen classification for Supination-External Rotation?

Supination-External Rotation Signup and view all the answers

According to the Danis-Weber classification, which type of fracture is associated with a fibular fracture that is above the level of the syndesmosis?

Type C Signup and view all the answers

Which of the following best defines the relationship of the Inferior transverse tibiofibular ligament within the ankle anatomy?

Connects the distal ends of the tibia and fibula posteriorly Signup and view all the answers

In the context of syndesmotic ligament injuries, which ligament is primarily a contributor to horizontal stability across the ankle?

Anterior inferior tibiofibular ligament Signup and view all the answers

What is a key characteristic of a Pronation-Abduction injury in the Lauge-Hansen classification?

Involves a fracture of the lateral malleolus Signup and view all the answers

Which phrase best describes the Lauge-Hansen classification’s method of categorizing ankle fractures?

Depending on foot position and direction of talar motion Signup and view all the answers

Which of the following is NOT a component of the syndesmotic ligaments in the ankle?

Calcaneofibular ligament Signup and view all the answers

What type of fibular fracture is classified as Type A in the Danis-Weber classification?

Fracture distal to the syndesmosis Signup and view all the answers

Which stage of the Lauge-Hansen Supination External Rotation classification involves a spiral fracture of the fibula?

Stage 2 Signup and view all the answers

In the context of Lauge-Hansen classification, what does Stage 1 of Pronation-Abduction describe?

Transverse fracture of medial malleolus Signup and view all the answers

What is the injury characterized by a posterior malleolar fracture in the Pronation-Abduction classification?

Stage 2 Signup and view all the answers

Which named fracture corresponds to an AITFL avulsion from the anteromedial fibula?

Wagstaff Signup and view all the answers

What characterizes Danis-Weber Type C classification?

Fracture of the lateral malleolus above the syndesmosis Signup and view all the answers

Which stage in Lauge-Hansen classifications describes a transverse avulsion type fracture of the distal fibula?

Stage 1 of Supination-Adduction Signup and view all the answers

Which statement accurately reflects an overlap between the Danis-Weber and Lauge-Hansen classifications?

Danis-Weber A corresponds with Lauge-Hansen Stage 1 Signup and view all the answers

What type of injury is identified in Stage 3 of Supination-Adduction?

Short, oblique fibular fracture Signup and view all the answers

Which clinical evaluation aspect assesses the possibility of active bleeding in an ankle fracture case?

Capillary refill time Signup and view all the answers

What is the primary goal of open reduction internal fixation (ORIF) in the management of ankle fractures?

To restore normal alignment and stability of the fracture Signup and view all the answers

Which factor is NOT considered when evaluating the stability of an ankle fracture?

Neurological integrity Signup and view all the answers

In the context of fracture healing processes, which phase primarily focuses on the re-establishment of structural integrity?

Remodeling phase Signup and view all the answers

What classification scheme primarily helps in understanding the pattern of fracture based on external forces?

Lauge-Hansen classification Signup and view all the answers

What is the significance of evaluating tibio-fibular overlap in ankle injuries?

A positive overlap indicates potential syndesmotic injuries. Signup and view all the answers

What does a widening of the medial clear space greater than 4 mm suggest?

Possible deltoid ligament injury and lateral translation of the talus. Signup and view all the answers

Which measurement indicates lateral ankle instability in a talar tilt evaluation?

A distance between lines greater than 2 mm. Signup and view all the answers

In evaluating syndesmotic injuries, which sign would indicate fibular shortening?

A clear 'dime sign' observed on radiographs. Signup and view all the answers

What does a normal measurement on the Shenton line suggest in ankle evaluations?

Integrity of the ankle joint. Signup and view all the answers

What is a primary purpose of performing a thorough neurovascular evaluation in ankle fractures?

To evaluate potential nerve or blood vessel compromise. Signup and view all the answers

Which of the following is a possible outcome of insufficient treatment for a syndesmotic injury?

Chronic pain and instability in the ankle. Signup and view all the answers

In the context of radiographic evaluation, what does a decrease in tibiotalar contact as reported by Ramsey and Hamilton indicate?

A significant lateral talar shift affecting joint integrity. Signup and view all the answers

What defines an unstable ankle fracture?

Presence of bone fragments that are not aligned Signup and view all the answers

Which of the following is a disadvantage of closed reduction?

Potential loss of correction over time Signup and view all the answers

In the Charnley Maneuver, which step is performed last?

Immobilize with splint or cast Signup and view all the answers

What is a key advantage of open reduction internal fixation (ORIF)?

Immediate anatomical reduction and stability Signup and view all the answers

What does primary bone healing require?

Rigid fixation and anatomic reduction Signup and view all the answers

Which fracture pattern would be classified as spiral?

Fracture that wraps around the shaft of the bone Signup and view all the answers

What is the primary role of a neutralization plate in ORIF?

Protects lag screws from deforming forces Signup and view all the answers

When is an interfragmentary screw primarily employed?

In spiral fibular fractures Signup and view all the answers

Which technique involves applying tension to compress the fracture line?

Tension band wire technique Signup and view all the answers

Which situation necessitates the fixation of a posterior malleolar fracture?

If it cannot be reduced after fibular stabilization Signup and view all the answers

Which complication is commonly associated with open reduction internal fixation?

Soft tissue complications from hardware Signup and view all the answers

What is necessary for successful fracture pattern treatment?

Consideration of both fracture patterns and classifications Signup and view all the answers

What is considered a disadvantage of using interfragmentary screws?

Requires careful Drilling technique to prevent fractures Signup and view all the answers

For a trimalleolar ankle fracture, what is the typical first method of stabilization?

Open reduction and internal fixation Signup and view all the answers

What is the primary advantage of minimally invasive fracture fixation using an intramedullary nail for elderly patients?

It allows for quicker recovery with minimal soft tissue disruption. Signup and view all the answers

What challenge is most associated with managing diabetic ankle fractures?

Increased risk of malunion due to potential soft tissue complications. Signup and view all the answers

In evaluating syndesmotic injuries, what imaging finding indicates fibular shortening?

Increased distance between the fibula and the tibia. Signup and view all the answers

Which management strategy is crucial for addressing fracture blisters in ankle fractures?

Delaying surgery until blisters resolve completely. Signup and view all the answers

What factor limits the use of open reduction internal fixation (ORIF) in younger patients with ankle fractures?

Higher activity demands leading to implant failure. Signup and view all the answers

What is the main advantage of suture button fixation over screw fixation in syndesmotic injuries?

Allows for greater dynamic motion Signup and view all the answers

Which of the following best describes the purpose of a delta frame in unstable ankle fractures?

To stabilize soft tissue structures and maintain reduction Signup and view all the answers

What is a common complication faced by diabetic patients with ankle fractures?

Increased risk of Charcot neuroarthropathy Signup and view all the answers

Which technique is emphasized to avoid blister formation during surgery?

Using incisions strategically Signup and view all the answers

What is a significant consideration when evaluating syndesmotic injuries on X-rays?

Evaluation of tibio-fibular overlap Signup and view all the answers

Which of the following is NOT a characteristic of minimally invasive plate osteosynthesis (MIPO)?

It involves large incisions to improve visibility Signup and view all the answers

How does hemorrhoid-filled blister treatment differ from clear fluid-filled blister treatment?

Hemorrhagic blisters typically take longer to heal Signup and view all the answers

What is a primary risk associated with performing surgery after the formation of fracture blisters?

Higher likelihood of wound infections Signup and view all the answers

What defines a stable ankle fracture during evaluation?

Minimal displacement of bone fragments Signup and view all the answers

Which method is commonly used to evaluate the success of syndesmotic fixation post-operatively?

Cotton hook test Signup and view all the answers

In diabetic ankle fracture management, which method helps to enhance healing in the absence of traditional fixation?

Super construct hardware designs Signup and view all the answers

Which of the following is a hallmark of syndesmotic fixation with screws?

Screws should be placed parallel to the ankle joint Signup and view all the answers

What is a key disadvantage of using intramedullary nail fixation in active young patients?

Increased physical demands on hardware Signup and view all the answers

What is a typical goal of non-operative treatment for pilon fractures?

Promotion of early weight-bearing and functional recovery Signup and view all the answers

Which operative technique is most commonly employed for managing pilon fractures?

Open reduction internal fixation (ORIF) Signup and view all the answers

In the management of pilon fractures, what role does soft tissue play?

Soft tissue assessment is crucial for determining fracture severity and treatment strategy Signup and view all the answers

Which imaging technique is preferred for initial assessment of pilon fractures?

CT scan due to its superior ability to detail complex fractures Signup and view all the answers

What classification scheme is most commonly used to categorize pilon fractures?

AO/OTA classification Signup and view all the answers

What is the primary limitation of non-operative treatment for displaced intra-articular fractures of the tibial plafond?

It is generally insufficient for managing severe fractures. Signup and view all the answers

Which operative treatment technique is specifically designed for stabilizing fractures with minimal soft tissue disruption?

Minimally invasive plate fixation Signup and view all the answers

What is the main goal of stable fixation in pilon fracture management?

To achieve anatomical restoration of the distal tibial articular surface. Signup and view all the answers

Which imaging technique is primarily used to assess the extent of bone fragments in pilon fractures?

CT scan Signup and view all the answers

Type III fractures in the Ruedi and Allgower classification are characterized by which feature?

Severely comminuted and displaced fractures. Signup and view all the answers

Which treatment approach is indicated for managing significant metaphyseal defects in pilon fractures?

Bone grafting Signup and view all the answers

Which classification describes the degree of comminution associated with a fracture?

AO Classification Signup and view all the answers

What is the role of axial compression in the evaluation of fracture fragments?

It helps in identifying the nature and alignment of fractures. Signup and view all the answers

What is the primary objective during the application of an external fixator for ankle fractures?

Providing stability while soft tissue calms down Signup and view all the answers

Which component is crucial for the reduction of pilon fractures associated with fibula fractures?

Anatomical reduction of the fibula Signup and view all the answers

During which stage of surgical management is meticulous planning most critical?

Preoperative stage prior to intervention Signup and view all the answers

What is the typical duration before weight-bearing is encouraged after surgery for ankle fractures?

12 weeks Signup and view all the answers

What is the significance of approaching the posterior aspect of the medial malleolar fragment during reduction?

To accurately align the Volkmann fragment Signup and view all the answers

Which of the following best describes the outcome of high-energy pilon fractures?

Generally poor compared to functional outcome scores Signup and view all the answers

What is the focus of the initial treatment phase for soft tissue management in fractures?

Allowing for swelling to subside Signup and view all the answers

In the context of pilon fracture classifications, which fragment is typically addressed first during reduction?

Posterolateral fragment Signup and view all the answers

What characterizes the postoperative management plan after ankle fracture surgery?

Continued splinting with a gradual introduction of movement Signup and view all the answers

What is the primary aim of restoring the articular surface during surgery for ankle fractures?

To enable early motion and improve function Signup and view all the answers

What is a significant impact of soft tissue trauma in the management of pilon fractures?

It complicates surgical fixation and may lead to infections. Signup and view all the answers

Which operative treatment approach is most appropriate for pilon fractures involving substantial displacement?

Open reduction and internal fixation (ORIF) to restore alignment. Signup and view all the answers

Which non-operative treatment option is typically suitable for non-displaced pilon fractures?

Conservative management with immobilization in a cast. Signup and view all the answers

Which imaging technique is crucial for the detailed assessment of a pilon fracture?

CT scans to evaluate both bone and soft tissue disruption. Signup and view all the answers

Which classification best describes pilon fractures that involve the tibial plafond?

A specific classification for intra-articular fractures of the tibial plafond. Signup and view all the answers

What role does accurate fibular length play in treating tibial deformity?

It indirectly reduces the majority of tibial deformity. Signup and view all the answers

Which surgical technique is primarily focused on the reduction of the articular surface in pilon fractures?

Anatomic reduction of the fibula Signup and view all the answers

What is the primary goal of applying an external fixator in the management of fractures?

To stabilize the fracture while soft tissues heal. Signup and view all the answers

What is the recommended approach for soft tissue handling during surgical management of fractures?

Meticulous attention and planning Signup and view all the answers

In the context of post-operative care, which recommendation is generally advised for early rehabilitation?

Partial progressive weight-bearing in a removable boot Signup and view all the answers

Which of the following surgical approaches is NOT mentioned in managing pilon fractures?

Medial-Lateral Signup and view all the answers

What is indicated to achieve the desired alignment of the talus during fracture treatment?

Distraction alignment Signup and view all the answers

What is a significant outcome after poorly managed high-energy pilon fractures?

Worse functional outcome scores Signup and view all the answers

Which factor is most critical to address in the reduction and fixation of fractures?

Restoration of the articular surface Signup and view all the answers

What is the appropriate timing for intervention in the surgical management of fractures?

Dependent on the stability of fracture patterns Signup and view all the answers

What is the primary focus of non-operative treatment for displaced intra-articular fractures of the tibial plafond?

To manage only those fractures that are truly nondisplaced Signup and view all the answers

Which of the following operative treatment methods is NOT typically used in the management of Pilon fractures?

Conservative casting Signup and view all the answers

What does the AO classification for fractures include?

Extra-articular, partial intra-articular, and completely intra-articular descriptions Signup and view all the answers

Which type of imaging technique is primarily used for assessing fracture fragments in tibial plateau injuries?

CT scan for detailed fracture fragment evaluation Signup and view all the answers

In the Ruedi and Allgower classification of fractures, which type indicates severely comminuted fractures with impaction?

Type III Signup and view all the answers

What is a critical principle when performing fixation for a Pilon fracture?

Achieving stable fixation with buttress plating Signup and view all the answers

What is a fundamental limitation of non-operative treatment in managing intra-articular fractures?

Lack of adequate reduction and fixation Signup and view all the answers

Which imaging technique is most suitable for detecting signs of axial compression injuries?

CT evaluations for fracture detail Signup and view all the answers

What aspect of morphology is primarily assessed for deformity correction?

Varus Signup and view all the answers

Which technique is emphasized for effectively managing morphological deformities?

Joint Depression-Sinus tarsi Approach Signup and view all the answers

What is the recommended post-operative protocol in the initial weeks following surgery?

Non-weight bearing (NWB) in a splint for 2-3 weeks Signup and view all the answers

What role do compression socks play in the management of post-operative recovery?

They decrease swelling and promote circulation. Signup and view all the answers

In the context of surgical approaches, which joint is notably involved in articular incongruity requiring attention?

Calcaneocuboid Joint Signup and view all the answers

What is the primary goal in achieving anatomical reduction of the calcaneus during surgery?

To protect the articular surfaces from weight-bearing stresses Signup and view all the answers

What is crucial for correcting a varus deformity during the Joint Depression-Sinus tarsi approach?

Achieving a valgus alignment Signup and view all the answers

In the context of percutaneous reduction with ring fixation, which of the following is given less consideration?

Weight-bearing status Signup and view all the answers

What surgical approach uses skeletal traction followed by fracture reduction?

Frame application with external fixation Signup and view all the answers

What impact does a minimally invasive approach have on post-operative protocols?

Reduces soft tissue damage Signup and view all the answers

Which of the following ROWE classifications describes a fracture involving the sustentaculum tali?

I b Signup and view all the answers

Which type of morphology needs to be addressed to ensure optimal joint function following correction?

Articular incongruities in impacting joints Signup and view all the answers

Regarding post-operative protocols, what is a critical factor for ensuring successful outcomes after calcaneal surgery?

Immediate full weight-bearing Signup and view all the answers

Which incision length characterization relates to the sinus tarsi approach originally used?

1 cm incisions increased for better access Signup and view all the answers

Which statement accurately reflects the soft tissue considerations during the anterior process fracture treatment?

Soft tissue injuries often necessitate surgical intervention Signup and view all the answers

In the Joint Depression-Sinus tarsi Approach, what is vital to ensure after the anatomical correction?

Correct all identified deformities Signup and view all the answers

What type of calcaneal fracture is most commonly associated with a fall from height and results in intra-articular damage?

IV Signup and view all the answers

What is a primary consideration regarding soft tissue during the Joint Depression-Sinus tarsi approach?

Minimizing disruption to surrounding tissues Signup and view all the answers

In addressing shortening of the tuberosity fragment, which aspect is prioritized?

Reestablishing height and length Signup and view all the answers

In the context of deformity correction techniques, which procedure prioritizes sparing soft tissue integrity?

Percutaneous reduction Signup and view all the answers

What is a key goal of the sinus tarsi approach in terms of deformity correction?

Restore specific joint morphologies Signup and view all the answers

What is the primary focus of the Joint Depression-Sinus tarsi approach in surgical treatment?

Correcting morphological deformities Signup and view all the answers

In the context of percutaneous fixation, which of the following classifications is specifically referenced?

Sanders 2C Signup and view all the answers

What is the recommended non-weightbearing (NWB) duration in a splint for a patient post-Joint Depression-Sinus tarsi surgery?

2-3 weeks Signup and view all the answers

What aspect of imaging is crucial for evaluating articular incongruity in surgeries related to the subtalar joint?

CT scans to assess joint congruence Signup and view all the answers

What is one of the key postoperative treatments following a Joint Depression-Sinus tarsi approach?

Therapeutic exercises and compression socks Signup and view all the answers

What is the primary indication for using the Joint Depression-Sinus Tarsi Approach?

Sanders Type 2 fractures Signup and view all the answers

Which outcome is NOT associated with the use of the Joint Depression-Sinus Tarsi Approach?

Longer hospital stay Signup and view all the answers

What does the morphology correction in the Joint Depression-Sinus Tarsi Approach specifically target?

All deformities including width and shortening Signup and view all the answers

Which of the following accurately describes the surgeon's role in the Joint Depression-Sinus Tarsi Approach?

Need to follow reduction to correct all deformities Signup and view all the answers

What is the initial length of the incision used in the Joint Depression-Sinus Tarsi Approach?

1 cm Signup and view all the answers

In the context of the Joint Depression-Sinus Tarsi Approach, which aspect of healing is highlighted as being generally quicker?

Healing time Signup and view all the answers

Which of the following describes a key factor in patient selection for the Joint Depression-Sinus Tarsi Approach?

Poor soft tissue condition Signup and view all the answers

What is a critical aspect of imaging in the management of fractures treated via the Joint Depression-Sinus Tarsi Approach?

Assessment of articular incongruity Signup and view all the answers

What does a decrease in Böhler’s angle suggest about a calcaneal fracture?

There is displacement of the weightbearing posterior facet. Signup and view all the answers

Which of the following correctly describes the Critical angle of Gissane?

An angle that increases with the presence of a fracture. Signup and view all the answers

In the Sanders classification, which Roman numeral indicates a fracture without displacement?

Type I Signup and view all the answers

What is the purpose of the Essex-Lopresti classification?

To classify displaced intra-articular fractures. Signup and view all the answers

What do Broden’s Views in imaging allow for?

Visualization of the posterior facet from an anterior to posterior perspective. Signup and view all the answers

Which feature is indicative of the medial wall reduction procedure during surgery?

Correct placement of screws to stabilize fractures. Signup and view all the answers

What anatomical aspect is primarily evaluated using the Harris Beath axial view?

Disruption of the articular surface of the calcaneus. Signup and view all the answers

What is the characteristic angle for Böhler’s angle in a healthy calcaneus?

20 to 40 degrees Signup and view all the answers

Which type of fracture characterizes a fall from height with the foot dorsiflexed, leading to joint depression and comminution?

Essex-Lopresti tongue type fracture Signup and view all the answers

What occurs in Sanders Type II fractures that distinguishes it from Type I fractures?

Involves two part fractures of the posterior facet Signup and view all the answers

In the Hawkins Classification, what is the prognosis associated with a Hawkins Type 3 fracture?

AVN 83 – 100 % Signup and view all the answers

What is indicated by the presence of a shear fracture that divides the calcaneus into two parts, according to the Essex-Lopresti classification?

Calcaneal joint depression fracture Signup and view all the answers

Which classification system provides a predictive value for avascular necrosis in talar neck fractures?

Hawkins Classification Signup and view all the answers

Which statement describes a characteristic feature of Sanders IV fractures?

Three fracture lines separating all columns Signup and view all the answers

What type of fracture occurs at the metaphyseal-diaphyseal junction, according to the Stewart Classification?

Type 1 Signup and view all the answers

Under the Sneppen classification, which type pertains to a crush injury in the talar bone?

Type V Signup and view all the answers

What is the primary difference between Sanders Type I and Type II fractures?

Number of fracture lines Signup and view all the answers

What feature is common to Sanders IIIAB fractures?

Two fracture lines giving three columns Signup and view all the answers

In Watson-Jones classification, which type involves an avulsion fracture of the tuberosity?

Type I Signup and view all the answers

A 'total incongruity of the TMT joint' is classified under which type in Hardcastle classification?

Type A Signup and view all the answers

What common characteristic is shared by Type I and Type II fractures in the Berndt & Harty classification?

Both relate to osteochondral lesions Signup and view all the answers

What is the primary distinction of Sanders Type IIIC fractures?

Features two fracture lines separating the medial and sustentaculum columns Signup and view all the answers

What characterizes a Stage II Pilon fracture according to the Ruedi/Allgower classification?

Some displacement but not comminution or impaction Signup and view all the answers

In the Danis-Weber classification, Type A fractures are associated with which of the following?

Fracture below the level of the ankle Signup and view all the answers

Which statement accurately describes a Growth Plate Injury of type SH III?

Disrupts the joint surface and exits through the epiphysis Signup and view all the answers

In Pilon fractures classified as Stage I, what is the condition of the joint fragments?

No comminution or displacement Signup and view all the answers

For calcaneal fractures, which Rowe classification type represents an avulsion fracture of the tuberosity?

Rowe II b Signup and view all the answers

Which statement describes a consequence of a Type C fracture in the Danis-Weber classification?

Involves fibular fractures above the level of the ankle and often requires surgical intervention Signup and view all the answers

What is the primary characteristic of a SH II growth plate injury?

Partially splits through physis and extends into the metaphysis Signup and view all the answers

Stage 3 of Supination-External Rotation injury classification involves what specific fracture?

Spiral fracture of the fibula at the ankle joint Signup and view all the answers

Which type of calcaneal fracture is classified as Rowe IV?

Body fracture involving the subtalar joint Signup and view all the answers

What condition does a Stage V growth plate injury represent?

Compression or crush injuries with no visible fracture lines Signup and view all the answers

Which Rowe classification type describes a fracture of the calcaneal tubercle?

Rowe I a Signup and view all the answers

The Ruedi/Allgower classification refers to which aspect of Pilon fractures?

Comminution and displacement of joint fragments Signup and view all the answers

Which type of fracture occurs in the distal fibula classified as Type A in Danis-Weber?

Fracture below the level of the ankle joint Signup and view all the answers

What does a Stage 1 injury in Supination-Adduction classification entail?

Rupture of lateral collateral ligaments or transverse fracture of fibula Signup and view all the answers

What is the recommended treatment for Stage III lateral lesions?

Surgical treatment Signup and view all the answers

Which surgical treatment option is specifically designed to facilitate ingrowth of fibrocartilage?

Microfracture (marrow stimulation) Signup and view all the answers

What is NOT one of the criteria to evaluate avascular necrosis (AVN)?

Presence of joint effusion Signup and view all the answers

Which imaging technique is essential for the assessment of osteochondral lesions?

MRI Signup and view all the answers

What is a common post-operative complication following ankle arthroscopy?

Infection Signup and view all the answers

What is the purpose of osteochondral autologous transplantation in the treatment of ankle lesions?

To restore the joint surface with the patient's own cartilage Signup and view all the answers

Which surgical procedure involves both debridement and microfracture techniques?

Ankle arthrotomy Signup and view all the answers

What is a key factor influencing the choice between surgical and conservative treatment for ACL injuries?

Grade of injury Signup and view all the answers

Which method is an example of a conservative pre-collapse treatment for avascular necrosis of the talus?

Patellar Tendon Bearing Brace Signup and view all the answers

What is the primary goal of core decompression in the treatment of avascular necrosis of the talus?

Revascularization of the talus Signup and view all the answers

Which of the following is a characteristic of fresh en bloc talar allograft in the treatment of AVN?

Involves transplantation of both cartilage and bone Signup and view all the answers

What is a potential complication when using hyperbaric oxygen therapy for AVN treatment?

Compliance issues among patients Signup and view all the answers

Which imaging technique is most appropriate for evaluating the extent of avascular necrosis in the talus?

MRI Signup and view all the answers

What should be monitored as a possible post-operative complication after surgical treatment for AVN?

Infection at the surgical site Signup and view all the answers

Which aspect of treatment is critical for the management of post-operative complications in the context of AVN?

Regular imaging follow-ups Signup and view all the answers

What is a primary consideration when evaluating candidates for surgical intervention for AVN?

Extent of cartilage involvement Signup and view all the answers

Which surgical procedure is specifically indicated for post-collapse treatment of the talus in cases of Avascular Necrosis?

Tibiotalocalcaneal (TTC) fusion Signup and view all the answers

What is a common clinical manifestation of a Talar Dome lesion after an ankle injury?

Initial pain improvement followed by delayed symptoms Signup and view all the answers

In assessing post-operative complications from surgical treatment of talar injuries, which factor is least likely to influence recovery?

The patient's diet during recovery Signup and view all the answers

Which imaging technique is most effective in the early detection of Talar Dome lesions post-injury?

MRI (Magnetic Resonance Imaging) Signup and view all the answers

Which statement correctly describes the criteria for evaluating Avascular Necrosis (AVN) of the talus?

Collapse of the talar dome leading to surface incongruity Signup and view all the answers

Which of the following is NOT a recognized surgical option for treating Avascular Necrosis of the Talus?

Total Ankle Replacement Signup and view all the answers

What is the first step in managing a patient with Talar Dome lesions post-collapsed treatment?

Initial conservative management including rest and ice Signup and view all the answers

Which post-operative condition is a significant concern in the management of Avascular Necrosis after surgical treatments?

Secondary osteoarthritis development Signup and view all the answers

What is the main arterial source responsible for supplying the talar body?

Artery of the tarsal canal Signup and view all the answers

Which of the following arteries is NOT involved in providing vascularity to the talus?

Radial artery Signup and view all the answers

What condition results from disruption of the vascular sling supplying the talar body?

Avascular necrosis Signup and view all the answers

Which artery contributes the least to the blood supply of the talus?

Anterior tibial artery Signup and view all the answers

What anatomical feature limits the blood supply to the talus?

Lack of soft tissue attachments Signup and view all the answers

Which artery is considered to provide the most vital blood supply to the medial part of the talus?

Posterior tibial artery Signup and view all the answers

What happens if the blood supply to the talus is disrupted?

Potential for avascular necrosis Signup and view all the answers

Which artery's branches have a significant role in supplying vascularity to the talus?

Posterior tibial artery Signup and view all the answers

What is the primary mechanism of injury associated with talar head fractures?

Violent dorsiflexion of a fully plantarflexed foot Signup and view all the answers

What percentage of talar head fractures is likely to develop avascular necrosis (AVN)?

10% Signup and view all the answers

In cases of displaced talar head fractures, which treatment is typically required?

Open reduction internal fixation (ORIF) Signup and view all the answers

How long is immobilization typically required for non-displaced talar head fractures?

6-8 weeks Signup and view all the answers

What is a typical characteristic of a talar head fracture regarding its structure?

It usually divides the head into medial and lateral fragments Signup and view all the answers

What factor plays a crucial role in determining the treatment for talar head fractures?

Degree of joint involvement and comminution Signup and view all the answers

What is a common outcome if a talar head fracture is left untreated?

Permanent instability of the ankle joint Signup and view all the answers

Which joint is usually invaded in displaced talar head fractures?

The talonavicular (T-N) joint Signup and view all the answers

Which type of fracture is classified as Group I according to Sneppen?

Osteochondral dome fracture Signup and view all the answers

What is the primary goal of immediate reduction for dislocated joints in talar body management?

To minimize the risk of avascular necrosis (AVN) Signup and view all the answers

Which type of fracture is classified under Group IV in Sneppen's classification system?

Lateral process fracture Signup and view all the answers

What imaging techniques are primarily used to evaluate injuries of the talar body?

Radiographs and CT scan Signup and view all the answers

In Sneppen's classification, which group consists of shearing fractures?

Group II Signup and view all the answers

What is a crucial aspect of post-operative care to decrease complications in talar body fractures?

Monitoring for infection Signup and view all the answers

What characterizes a Group III fracture according to Sneppen's classification?

Posterior process fracture Signup and view all the answers

What is an immediate step in the management of a dislocated talar body joint?

Closed reduction in the emergency room Signup and view all the answers

What type of fracture accounts for 20% of talar fractures?

Fractures of the lateral process Signup and view all the answers

What is the typical treatment duration for non-displaced or small comminuted fractures?

4-6 weeks Signup and view all the answers

What mechanism of injury is associated with fractures of the lateral process?

Compression during inversion and dorsiflexion Signup and view all the answers

Which phrase best describes the relationship between snowboarding and talar fractures?

The injury commonly referred to as 'snowboarder’s fracture' Signup and view all the answers

In cases of large, displaced, intra-articular fragments, what surgical intervention is recommended?

Open reduction internal fixation (ORIF) Signup and view all the answers

What is a primary indicator for the treatment method chosen in talar fractures?

Presence of joint involvement and displacement Signup and view all the answers

What factor has led to an increased incidence of lateral process fractures?

Popularity of snowboarding Signup and view all the answers

What is the main focus when treating small comminuted fractures?

Non-weight bearing status Signup and view all the answers

What is the most common cause of talar neck fractures?

Motor vehicle accidents and falls from height Signup and view all the answers

How does the Hawkins classification correlate with talar neck fractures?

It correlates well with prognosis and risk of avascular necrosis (AVN) Signup and view all the answers

What is the AVN rate associated with a Hawkins I talar neck fracture?

0-13% Signup and view all the answers

Which treatment method is typically advised for a Hawkins I talar neck fracture?

Conservative treatment with non-weight bearing and splinting Signup and view all the answers

What mechanism of injury is primarily responsible for leading to a talar neck fracture?

Forced axial load of the tibia through the talus Signup and view all the answers

What is the proper non-weight bearing status duration for treating a Hawkins I fracture?

6-8 weeks Signup and view all the answers

Which factor does NOT influence the treatment of a talar neck fracture?

Patient’s nutritional status Signup and view all the answers

What happens to the talar body as a result of continued force following the shear of the anterior tibia?

It rotates around the deltoid ligament Signup and view all the answers

What is a key factor that necessitates operative management of a fracture?

Displacement greater than 3-4 mm Signup and view all the answers

Which of the following is NOT a recommended approach for non-operative management of non-displaced metatarsal fractures?

Immediate weight bearing with regular shoes Signup and view all the answers

What imaging technique is most commonly used to identify stress fractures in the bones?

Bone scans using Tech-99 Signup and view all the answers

What is the typical healing rate for non-displaced first metatarsal fractures managed non-operatively?

4-6 weeks Signup and view all the answers

What long-term functional outcome is expected after appropriate management of a non-displaced metatarsal fracture?

Full restoration of weight-bearing ability Signup and view all the answers

What is the primary goal of non-operative management for a distal diaphyseal fracture?

Weight-bearing to tolerance within a stiff-soled shoe or boot Signup and view all the answers

Which imaging technique is often considered for complications like nonunion in metatarsal fractures?

CT and MRI Signup and view all the answers

Which operative technique is indicated for a nonunion associated with an avulsion fracture?

Excision of fragment with peroneus brevis repair Signup and view all the answers

What is the average time for healing of Jones fractures managed with open reduction internal fixation (ORIF)?

10 weeks Signup and view all the answers

What does a high nonunion rate of approximately 25% in metaphyseal-diaphyseal fractures indicate?

Increased likelihood of surgical intervention Signup and view all the answers

In non-operative management of an avulsion fracture, what is the recommended duration for weight-bearing in a cast shoe?

4-8 weeks Signup and view all the answers

What is highlighted regarding long-term functional outcomes for nonoperatively managed distal fifth metatarsal fractures?

Excellent outcomes after limited follow-up Signup and view all the answers

What is the primary choice for successful fixation of a distal diaphyseal (Dancer’s) fracture when indicated?

Plating and screw constructs Signup and view all the answers

What is a complication often associated with neglected avulsion fractures?

Failure to achieve bony union Signup and view all the answers

What factor is crucial in determining the approach to manage a dancer's fracture?

Stability and displacement of the fracture Signup and view all the answers

What is the recommended approach for managing a Jones fracture in an athlete?

Surgical treatment with a focus on accelerated rehabilitation Signup and view all the answers

Which factor predominantly influences the healing process of metatarsal fractures?

Degree of displacement and angulation Signup and view all the answers

What imaging technique is useful in differentiating between an open epiphysis and a fracture in skeletally immature patients?

X-ray assessment Signup and view all the answers

What is the average time for athletes to return to play after surgical treatment of a Jones fracture?

8.7 weeks Signup and view all the answers

What complications may arise from poor management of a recurrent cavovarus foot structure in the context of stress fractures?

Higher likelihood of re-injury Signup and view all the answers

Which statement best reflects the healing outcomes for the majority of metatarsal fractures?

They typically heal uneventfully. Signup and view all the answers

Which operative approach has been observed in a study of NFL players with Jones fractures?

Operative treatment by the same surgeon over years Signup and view all the answers

In managing stress fractures, what is one critical consideration regarding patient education?

Understanding the risks of recurrent injury Signup and view all the answers

Study Notes

Ankle Anatomy

Ankle joint consists of three osseous structures: Tibia, Fibula, and Talus.
Functions as a hinge-type synovial joint allowing triplane motion.

Ligamentous Structures

Medial Ligaments:
- Superficial Deltoid (including posterior tibiotalar, tibionavicular, and tibiocalcaneal ligaments)
- Deep Deltoid (anterior tibiotalar ligament)
Lateral Ligaments:
- Anterior talofibular ligament
- Posterior talofibular ligament
- Calcaneofibular ligament

Syndesmotic Ligaments

Four main components:
- Anterior inferior tibiofibular ligament (AITFL)
- Posterior inferior tibiofibular ligament (PITFL)
- Inferior transverse tibiofibular ligament
- Interosseous ligament

Ankle Fracture Classification Systems

Lauge-Hansen Classification:
- Based on foot position (supination/pronation) and talar motion direction (adduction/abduction/eversion).
- Four main groups: Supination-Adduction, Pronation-Abduction, Supination-External Rotation, Pronation-External Rotation.
Danis-Weber Classification:
- Based on the relationship of fibular fracture location to the syndesmosis.
- Three main types: Type A, Type B, Type C.

Lauge-Hansen Classification Details

Supination-Adduction:
- Stage 1: Transverse avulsion fracture of the distal fibula.
- Stage 2: Vertical medial malleolar fracture.
Pronation-Abduction:
- Stage 1: Transverse fracture of medial malleolus or deltoid ligament tear.
- Stage 2: Posterior malleolar fracture.
- Stage 3: Short, oblique fibular fracture.
Supination External Rotation:
- Stage 1: AITFL injury or avulsion.
- Stage 2: Spiral fibular fracture.
- Stage 3: Posterior inferior tibiotalar ligament injury.
- Stage 4: Transverse fracture of medial malleolus.
Pronation External Rotation:
- Stage 1: Transverse medial malleolar fracture or deltoid ligament injury.
- Stage 2: Anterior inferior tibiofibular ligament rupture.
- Stage 3: Oblique or spiral fibular fracture above syndesmosis.
- Stage 4: Posterior inferior tibiofibular ligament injury.

Danis-Weber Classification Types

Type A: Fracture of lateral malleolus distal to the syndesmosis.
Type B: Fracture of lateral malleolus at the level of the syndesmosis.
Type C: Fracture of lateral malleolus above the syndesmosis.

Overlap Between Classifications

Danis-Weber A corresponds to Lauge-Hansen SAD Stage 1.
Danis-Weber B aligns with Lauge-Hansen SER Stage 2 or PAB Stage 3.
Danis-Weber C relates to Lauge-Hansen PER Stage 3.

Named Ankle Fractures

Tillaux-Chaput: AITFL avulsion fracture from anterolateral tibia.
Wagstaff: AITFL avulsion fracture of anteromedial fibula.
Volkmann: PITFL avulsion fracture from posterior lateral tibia.
Bosworth: PITFL avulsion fracture from posterior medial fibula.
Maisonneuve: Proximal fibular fracture near fibular neck.

Ankle Anatomy

Ankle joint consists of three osseous structures: Tibia, Fibula, and Talus.
Functions as a hinge-type synovial joint allowing triplane motion.

Ligamentous Structures

Medial Ligaments:
- Superficial Deltoid (including posterior tibiotalar, tibionavicular, and tibiocalcaneal ligaments)
- Deep Deltoid (anterior tibiotalar ligament)
Lateral Ligaments:
- Anterior talofibular ligament
- Posterior talofibular ligament
- Calcaneofibular ligament

Syndesmotic Ligaments

Four main components:
- Anterior inferior tibiofibular ligament (AITFL)
- Posterior inferior tibiofibular ligament (PITFL)
- Inferior transverse tibiofibular ligament
- Interosseous ligament

Ankle Fracture Classification Systems

Lauge-Hansen Classification:
- Based on foot position (supination/pronation) and talar motion direction (adduction/abduction/eversion).
- Four main groups: Supination-Adduction, Pronation-Abduction, Supination-External Rotation, Pronation-External Rotation.
Danis-Weber Classification:
- Based on the relationship of fibular fracture location to the syndesmosis.
- Three main types: Type A, Type B, Type C.

Lauge-Hansen Classification Details

Supination-Adduction:
- Stage 1: Transverse avulsion fracture of the distal fibula.
- Stage 2: Vertical medial malleolar fracture.
Pronation-Abduction:
- Stage 1: Transverse fracture of medial malleolus or deltoid ligament tear.
- Stage 2: Posterior malleolar fracture.
- Stage 3: Short, oblique fibular fracture.
Supination External Rotation:
- Stage 1: AITFL injury or avulsion.
- Stage 2: Spiral fibular fracture.
- Stage 3: Posterior inferior tibiotalar ligament injury.
- Stage 4: Transverse fracture of medial malleolus.
Pronation External Rotation:
- Stage 1: Transverse medial malleolar fracture or deltoid ligament injury.
- Stage 2: Anterior inferior tibiofibular ligament rupture.
- Stage 3: Oblique or spiral fibular fracture above syndesmosis.
- Stage 4: Posterior inferior tibiofibular ligament injury.

Danis-Weber Classification Types

Type A: Fracture of lateral malleolus distal to the syndesmosis.
Type B: Fracture of lateral malleolus at the level of the syndesmosis.
Type C: Fracture of lateral malleolus above the syndesmosis.

Overlap Between Classifications

Danis-Weber A corresponds to Lauge-Hansen SAD Stage 1.
Danis-Weber B aligns with Lauge-Hansen SER Stage 2 or PAB Stage 3.
Danis-Weber C relates to Lauge-Hansen PER Stage 3.

Named Ankle Fractures

Tillaux-Chaput: AITFL avulsion fracture from anterolateral tibia.
Wagstaff: AITFL avulsion fracture of anteromedial fibula.
Volkmann: PITFL avulsion fracture from posterior lateral tibia.
Bosworth: PITFL avulsion fracture from posterior medial fibula.
Maisonneuve: Proximal fibular fracture near fibular neck.

Objectives

Understand mechanisms of ankle fracture injury and classification schemes.
Learn management principles for open reduction internal fixation (ORIF) of ankle fractures.
Identify concepts and details associated with fixation devices for ankle fractures.
Evaluate internal fixation devices based on established criteria.

Clinical Evaluation

Assess patient's overall appearance: looks of distress and pain levels.
Examine gross appearance of the limb: check for deformity, open wounds, and swelling.
Assess vascular status: check dorsalis pedis and posterior tibial arteries, skin temperature, capillary refill, and active bleeding.

Neurological Status

Evaluate sensation and compare to patient’s baseline.
Assess active movement capabilities and perform a musculoskeletal exam to determine stability.

Radiographic Evaluation

Initial evaluation requires three standard views: Anteroposterior (AP), Mortise, and Lateral.
Medial clear space: widening greater than 4 mm indicates deltoid ligament injury and lateral talar translation.
Tibio-fibular overlap should be less than 10 mm and indicates syndesmotic integrity.

Talar Tilt Assessment

Mortise view used to measure distance between tibial articular surface and talar surface.
Normal distance is approximately 2 mm or less; greater indicates lateral ankle instability.

Fibular Shortening Assessment

Evaluated using Shenton line and Dime sign to observe joint line integrity and curvature of the fibula.

Ankle Fracture Evaluation

Assess for additional injuries and determine if fracture is stable or unstable.
Determine whether the injury is open or closed, and consider urgency of treatment.

Closed Reduction vs Open Reduction with Internal Fixation

Closed Reduction Advantages: lower infection risk, less anesthesia complication, potentially shorter recovery time.
Closed Reduction Disadvantages: imperfect anatomical reduction, possibility of loss of correction, complications from casting.

Closed Reduction Techniques

Charnley Maneuver: involves exaggerating the deformity, distracting the limb, reducing the deformity, and immobilizing with a splint/cast.
Quigly Maneuver: requires lifting the foot by the hallux and externally rotating the leg, ensuring medial malleolus integrity.

Open Reduction Internal Fixation

Advantages include anatomical reduction, earlier weight-bearing, and increased stability.
Disadvantages can involve soft tissue incision, hardware complications, distress of correction, and infection risks.

Vassal Principle

Major fracture correction (typically fibula) aids in correcting lesser fractures due to shared soft tissue structures.

Bone Healing Types

Primary Bone Healing: requires rigid fixation and leads to no callus formation.
Secondary Bone Healing: involves significant callus formation and stabilization through endochondral healing.

Fracture Pattern Types

Focus on treating the specific fracture pattern, which can be transverse, vertical, spiral (short/long), or oblique.

Open Reduction Internal Fixation Hardware

Use various clamp options for anatomical reduction and temporary fixation before final fixation.
Interfragmentary screws are important for spiral fibular fractures, utilizing lag techniques for insertion.

Plating Techniques

Neutralization Plates: protect lag screws and can be either locking or non-locking.
Buttress Plates: used for intraarticular fractures, particularly around metaphyseal fractures.
Anti-glide Plates: placed posteriorly to prevent proximal movement of fracture fragments.

Management of Specific Fractures

Medial malleolar fractures often require two cancellous screws or wires.
Tension Band Wire Technique applies compression for medial malleolar fractures but is not first line.
Posterior Malleolar fractures require fixation if it involves more than 25% of joint surface.

Post-Operative Care

Immobilization with posterior splint or short leg cast; non-weight bearing for 6-8 weeks.
Possible progression to weight bearing in a CAM boot; may include physical therapy.
Routine post-operative pain management and DVT prophylaxis for 2-3 weeks.

Objectives of Ankle Fractures

Understand injury mechanisms and classification for ankle fractures.
Learn management principles for open reduction internal fixation (ORIF) of ankle fractures.
Familiarize with concepts and details of ankle fracture fixation devices.
Identify criteria for evaluating ankle fracture internal fixation devices.

Fracture Blisters

Develop within 24-48 hours post-injury; more common in high-energy trauma.
Two types: clear fluid-filled and hemorrhagic-filled, which can coexist.
Not indicators of injury severity; hemorrhagic blisters signify more serious soft tissue injury.
Treatment for clear fluid blisters typically sees healing in about 12 days, while hemorrhagic takes about 16 days.
Surgery can be attempted before blister formation; incisions can help avoid or address blisters.

Syndesmotic Injuries

Syndesmosis assessed on AP X-ray; instability requires fixation of the syndesmosis ligament.
The “Cotton hook test” evaluates syndesmosis post-fracture fixation.
Important to anatomically reduce syndesmosis due to its role in joint stability.

Syndesmotic Fixation Devices

Screw Fixation:
- Fully threaded cortical screws should not compress the syndesmosis.
- Inserted in a posterior to anterior orientation at a 30-degree angle; placed 1.5-2 cm proximal to the ankle joint.
Suture Button Fixation:
- Involves a synthetic suture with metallic buttons, allowing dynamic motion similar to natural ligaments.

Diabetic Ankle Fractures

Present challenges due to comorbid conditions and peripheral neuropathy affecting weight-bearing ability.
High risk of wound healing complications and Charcot neuroarthropathy.
New fixation techniques include:
- Minimally invasive plate osteosynthesis (MIPO) to preserve periosteum.
- Super construct hardware designs for stronger fixation.
- Intramedullary nailing as a minimally invasive option.

External Fixation with Delta Frames

Utilized for unstable or open ankle fractures for soft tissue stabilization.
Delta frames help maintain reduction and prevent equinus deformity.
Left in place until swelling resolves, then replaced with traditional internal fixation.

Intramedullary Nail Fixation

Indicated for elderly patients, acute trauma in active individuals, and poly-trauma patients.
Contraindicated in young, active patients with high physical demands, not primary fixative choice for most.
Benefits include reduced wound complications, decreased symptomatic reactions, faster recovery, and earlier weight-bearing.

Case Study: 53-Year-Old Male

Presents with a closed tri-malleolar ankle fracture complicated by non-verbal status.
Physical exam indicates instability with mild edema and no significant deformity.
Initial conservative treatment includes casting and non-weight bearing (NWB).
Treatment plan evolves to open reduction with internal fixation; later considered hardware removal and TTC fusion with intramedullary nail.

IM Nail Fixation Summary

Intramedullary nail fixation offers a minimally invasive stabilization method following traumatic injury.
Optimal for elderly with lower physical demands; selected for revision or reconstruction in younger patients on a case-by-case basis.

Overview of Pilon Fractures

Pilon fractures refer to intra-articular fractures of the tibial plafond, often described as tibial plafond fractures.
The term "pilon" originated from the French word for pestle, symbolizing the talus's impact on the tibial plafond.

Classification of Pilon Fractures

Ruedi and Allgower classify pilon fractures into three types:
- Type I: Non-displaced fractures
- Type II: Displaced fractures with loss of articular congruency
- Type III: Displaced and severely comminuted fractures with impaction
AO Classification adds more detail:
- Extra-articular: 43A
- Partial intra-articular: 43B
- Completely intra-articular: 43C
- Fractures further categorized by degree of comminution: 1, 2, 3.

Mechanisms of Injury and Anatomy

Pilon fractures typically result from axial loading or high-energy trauma, leading to complex fracture patterns.
Key anatomical features include soft tissues, which play a crucial role in fracture stability and healing.

Imaging

Diagnostic imaging includes X-rays and CT scans to evaluate fracture patterns and severity.

Non-Operative Treatment

Nonoperative management is limited to truly nondisplaced fractures or patients unable to undergo surgery.

Operative Treatment Options

Surgery options include:
- External fixation
- Open reduction and internal fixation (ORIF)
- Minimally invasive plate fixation
- Medullary nailing
- Arthrodesis
- Combination of techniques.

Principles of Fracture Fixation

Essential to restore anatomical alignment of the fibula and tibial articular surface.
Requires stable fixation, often using buttress plating and possible bone grafting for defects.

Surgical Techniques

Soft tissue management is crucial for successful outcomes.
Anterior-medial and posterior-lateral approaches are common surgical maneuvers.
Reduction sequences focus on re-establishing fractured fragments in anatomical position.

Post-Operative Care

Splinting is required in a neutral position until suture removal (2-3 weeks post-surgery).
Gradual physical therapy begins, aiming for active range of motion.
Weight-bearing is typically restricted for about 12 weeks, with progressive transitions into a removable boot.

Patient Outcomes

High-energy pilon fractures often yield poor functional outcomes.
Midterm results show similar effectiveness between ORIF and external fixation methods.

Overview of Pilon Fractures

Pilon fractures refer to intra-articular fractures of the tibial plafond, often described as tibial plafond fractures.
The term "pilon" originated from the French word for pestle, symbolizing the talus's impact on the tibial plafond.

Classification of Pilon Fractures

Ruedi and Allgower classify pilon fractures into three types:
- Type I: Non-displaced fractures
- Type II: Displaced fractures with loss of articular congruency
- Type III: Displaced and severely comminuted fractures with impaction
AO Classification adds more detail:
- Extra-articular: 43A
- Partial intra-articular: 43B
- Completely intra-articular: 43C
- Fractures further categorized by degree of comminution: 1, 2, 3.

Mechanisms of Injury and Anatomy

Pilon fractures typically result from axial loading or high-energy trauma, leading to complex fracture patterns.
Key anatomical features include soft tissues, which play a crucial role in fracture stability and healing.

Imaging

Diagnostic imaging includes X-rays and CT scans to evaluate fracture patterns and severity.

Non-Operative Treatment

Nonoperative management is limited to truly nondisplaced fractures or patients unable to undergo surgery.

Operative Treatment Options

Surgery options include:
- External fixation
- Open reduction and internal fixation (ORIF)
- Minimally invasive plate fixation
- Medullary nailing
- Arthrodesis
- Combination of techniques.

Principles of Fracture Fixation

Essential to restore anatomical alignment of the fibula and tibial articular surface.
Requires stable fixation, often using buttress plating and possible bone grafting for defects.

Surgical Techniques

Soft tissue management is crucial for successful outcomes.
Anterior-medial and posterior-lateral approaches are common surgical maneuvers.
Reduction sequences focus on re-establishing fractured fragments in anatomical position.

Post-Operative Care

Splinting is required in a neutral position until suture removal (2-3 weeks post-surgery).
Gradual physical therapy begins, aiming for active range of motion.
Weight-bearing is typically restricted for about 12 weeks, with progressive transitions into a removable boot.

Patient Outcomes

High-energy pilon fractures often yield poor functional outcomes.
Midterm results show similar effectiveness between ORIF and external fixation methods.

Minimally Invasive Approaches

Preference for minimally invasive techniques among patients to enhance recovery.
Benefits include reduced stiffness, shorter hospital stays, and faster healing times.
Minimally invasive methods also promote less soft tissue damage.

Joint Depression-Sinus Tarsi Approach

Particularly indicated for Sanders Type 2 fractures.
Minimal involvement required with anterior process or calcaneocuboid.
Optimal outcomes depend on the skill of the surgeon and monitoring of deformities.
Historical incision length began at 1 cm but has since increased.

Corrective Focus

Emphasis on addressing various deformities:
- Morphological aspects: Width and Varus alignment.
- Shortening conditions: Restoring height and length.
- Articular incongruity concerning subtalar and calcaneocuboid joints.

Tuberosity Fragment Management

Addressing shortening involves restoring height and length.
Correcting varus malalignment to achieve valgus orientation.
Managing widening by medially shifting the structure.

External Fixation & Percutaneous Reduction

Percutaneous reduction beneficial when soft tissue and bone fragmentation concerns are absent.
Joint distraction protects the subtalar joint surfaces from bearing stresses, preserving the reduced posterior facet.

Surgical Goals

Prioritize soft tissue respect and anatomic reduction of the calcaneus.
Aim for full weight-bearing capability immediately post-surgery.
Focus on restoring patient functionality.

Surgical Technique Overview

Initial skeletal traction applied to achieve proper alignment.
Followed by fracture reduction and application of the external frame.

Advantages of the Technique

Short operating time of less than 45 minutes.
Maintains soft tissue integrity leading to reproducible results.
Weight-bearing capability is enhanced through effective fixation strategies.

Rowe Classification of Calcaneal Fractures

Classification ranges from extra-articular fractures (Type I) to more complex intra-articular fractures (Type IV).
Each type has specific traumatic mechanisms and treatment considerations based on displacement.

Post-Operative Considerations

Non-weight bearing (NWB) advised for 2-3 weeks in a splint, followed by an NWB boot for about 8 weeks.
Transitioning to a weight-bearing boot around week 4, integrated with therapy and the use of compression socks.

Percutaneous Fixation Strategy

Tongue-type fixation indicated for Sanders Type 2C fractures.
Timing of surgery is crucial for optimal healing and functional recovery.

Imaging – Lateral Findings

Double Density Sign: Indicative of certain fractures.
Loss of Height in Posterior Facet: Suggests significant injury to the calcaneal structure.
Shortening of the Calcaneus: A radiologic finding indicating possible fracture or injury.
Böhler’s Angle:
- Measured between the highest point of the anterior process and posterior facet, with a tangent to the tuberosity's superior edge.
- Normal range: 20° to 40°.
- A decrease in this angle indicates displacement of the posterior facet.
Neutral Triangle: Important in assessing calcaneal alignment.
Critical Angle of Gissane:
- Formed by two strong cortical columns beneath the lateral talus.
- Normal range: 95° to 105°.
- Increased angle is associated with fractures.

Special Imaging Techniques

Harris Beath Axial View:
- Identifies disruption and displacement of the articular surface and the lateral wall.
- Evaluates heel width translation and tuberosity angulation.
Broden’s Views:
- Allows visualization of the entire posterior facet using angled X-rays.
- Now commonly replaced by CT scans for pre-op evaluations.

CT Imaging – Sanders Classification

Utilizes coronal CT imaging to classify posterior facet joint depression fractures.
Types I to IV indicate the number of fragments:
- Type I: No displacement.
- Type IV: Highly comminuted with four or more fragments.
Locations described by letters A, B, and C:
- Type A: Lateral fracture line.
- Type B: Central fracture line.
- Type C: Medial fracture line near the sustenaculum tali.

Joint Depression – Sinus Tarsi Approach

Indications: Sanders Type 2 fractures with minimal anterior process/calcaneocuboid involvement.
Incision: Originally 1cm, now longer for better access.
Goals:
- Correct deformities in morphology (width, varus/valgus alignment).
- Restore height and length.
- Address articular incongruity in subtalar and calcaneocuboid joints.

Post-Operative Care

Non-Weight Bearing (NWB): Initial 2-3 weeks in a splint followed by NWB boot for around 8 weeks.
Weightbearing Boot: Used for 4 weeks post-surgery.
Rehabilitation: Therapy and compression socks recommended.

Percutaneous Fixation

Tongue Type (Sanders 2C): A specific fixation technique for fractures.
Timing of Surgery: Critical to address fractures effectively.
Goals: Like other procedures, focus on correcting all deformities related to morphology and articular congruity.

Fracture Classifications

Essex-Lopresti tongue type fracture features a primary intra-articular shear fracture that separates the sustentaculum tali from the lateral body, accompanied by a secondary fracture through the tuberosity resembling an avulsion.
Rowe V fracture occurs from a fall with the foot dorsiflexed, leading to an intra-articular fracture with joint depression and comminution, similar to Essex-Lopresti joint depression fractures.

Essex-Lopresti Joint Depression Type Fracture

Characterized by a shear fracture that splits the calcaneus into two fragments: the sustentaculum and the tuberosity.
Lateral portion of the posterior facet gets isolated and impacted into the body, often resulting in a blow-out fracture of the lateral wall.
The foot's position during injury influences the specific blow-out fracture type.
Significant decrease in both height and width of the calcaneus can occur.

Sanders Classification

Constructs a CT classification based on coronal and axial imaging, examining the widest posterior facet section.
Divides the calcaneus into four columns using three fracture lines labeled A, B, and C from lateral to medial.
Features four main types of fractures with various subclassifications focused on the complexity of injury.

Sanders Types

Type I: All nondisplaced intra-articular fractures, irrespective of fracture lines.
Type II: Two-part fractures of the posterior facet subdivided into IIA (lateral), IIB (central), and IIC (medial).
Type III: Three-part fractures featuring a centrally depressed fragment, subclassified into IIIAB, IIIAC, and IIIBC based on the positioning of fracture lines.
Type IV: Comminuted four-part fractures with joint depression and a high fragmentation count.

Talar Fractures

Sneppen Classification

Classifies based on anatomical location:
- I: Transchondral dome fractures
- II: Shear fractures
- III: Posterior tubercle fractures
- IV: Lateral process fractures
- V: Crush injuries

Hawkins Classification

Excellent correlation with prognosis, indicating AVN (avascular necrosis) risk associated with talar neck fractures:
- Type 1: Non-displaced, AVN risk 0-13%
- Type 2: Displaced with subtalar subluxation, AVN risk 20-50%
- Type 3: Dislocated subtalar and ankle joints, AVN risk 83-100%
- Type 4: Complex fractures including talonavicular subluxation, rare variant.

Navicular Fractures

Watson-Jones Classification

Classification includes:
- I: Avulsion of the tuberosity
- II: Dorsal chip fracture
- III: Body fracture
- IV: Stress fracture

Tarsal-Metatarsal Fractures

Quenu and Kuss Classification

Hardcastle Classification

Type A: Total incongruity of TMT joint
Type B1: Partial incongruity affecting the first ray
Type B2: Partial incongruity affecting one or more lateral metatarsals
Type C1 and C2: Divergent patterns with partial or total displacement.

Fifth Metatarsal Fractures

Stewart Classification

Type 1: Fractures at the metaphyseal-diaphyseal junction.

Ankle Fractures

Lauge-Hansen Classification

Describes injuries based on foot positioning and talus movement:
- Supination-adduction, Pronation-abduction, Supination-external rotation, Pronation-external rotation.
Specific stages outline ligament ruptures and various fractures associated with each type of motion.

Pilon Fractures

Ruedi/Allgower Classification

Stage I: No comminution or joint displacement.
Stage II: Some displacement without comminution.
Stage III: Comminution and/or impact of the joint surface.

Growth Plate Injuries

Salter-Harris Classification

SH I: Through hypertrophic zone, requires high suspicion for diagnosis; excellent prognosis after closed reduction.
SH II: Partially through physis and into metaphysis, known as Thurston-Holland sign; good prognosis.
SH III: Extends through physis into the joint, requiring ORIF.
SH IV: Involves the metaphysis, physis, and epiphysis; ORIF needed.
SH V: Compression injuries, challenging to diagnose but possible to treat if growth potential remains.
Additional classifications SH VI to IX exist for various injury complexities and impact on growth.

Calcaneal Fractures

Classified into extra-articular and intra-articular fractures.
Rowe classification specifies different fracture types, including:
- I (tubercle fracture), II (beak and avulsion fractures), III (oblique fractures), IV (body fractures with STJ involvement), and V (joint depression with comminution).

Osteochondroses Treatment Approaches

Stage I & II lesions and Stage III medial lesions typically managed with conservative treatment using weight-bearing solutions (WB SLC).
Stage III lateral lesions and Stage IV lesions generally require surgical intervention.

Surgical Treatment Options for Talar Dome

Ankle Arthroscopy
- Debridement of osteochondral defects (OCD) to promote fibrocartilage growth.
- Micro-fracture technique (marrow stimulation) employed.
- Chondrocyte implantation considered for recovery.
Ankle Arthrotomy
- Similar to arthroscopy, this allows for direct access to debride OCD.
- Microfracture technique may be used here as well.
- Osteochondral Autologous Transplantation provides options like:
  - Mosaicplasty to patch lesions with healthy cartilage.
  - En bloc talar shoulder transplantation for extensive damage.

Avascular Necrosis (AVN) of the Talus

Pre-collapse Conservative Treatments
- Patellar Tendon Bearing (PTB) Braces aim to offload pressure but may face compliance issues.
- Hyperbaric Oxygen Therapy (HBOT) has anecdotal support and high costs.
Pre-collapse Surgical Treatments
- Core decompression targets intact cartilage; reduces internal pressure and enhances revascularization.
- Fresh en bloc talar allograft replaces both necrotic cartilage and bone for comprehensive healing.
Post-collapse Surgical Treatments
- Tibiotalocalcaneal (TTC) and Tibiocalcaneal (Blair) fusions are options for severe cases.
- Total Ankle Replacement (TAR) is traditionally contraindicated with AVN but may have evolving standards.

Fractures and Lesions of the Talar Dome

Talar dome lesions constitute 1% of talar fractures, originating from localized injuries to articular cartilage and subchondral bone.
Commonly linked with previous ankle fractures or inversion sprains.
Symptoms may include persistent pain, swelling, joint locking, instability, and restricted range of motion, often presenting after an initial period of improvement post-injury.

Anatomy of the Talar Fractures

Blood supply to the talus is limited due to minimal soft tissue attachments and extensive cartilaginous surfaces.
The three main distal leg arteries contribute to the vascularity of the talus:
- Posterior tibial artery provides key blood supply via deltoid branches and the artery of the tarsal canal (supplying 2/3 of talar body).
- Anterior tibial artery, through dorsalis pedis, supplies the talar head and neck.
- Peroneal artery, via the artery of the tarsal sinus, also contributes.

Talar Head Fractures

Comprise less than 10% of all talar fractures.
Often result from violent dorsiflexion of a fully plantarflexed foot, creating medial and lateral fragments.
Treatment varies depending on:
- Displacement
- Joint involvement
- Comminution
Non-displaced fractures typically require immobilization for 6-8 weeks.
Displaced fractures necessitate open reduction and internal fixation (ORIF) and usually involve the talonavicular (T-N) joint.
Approximately 10% of talar head fractures lead to avascular necrosis (AVN).

Fractures of the Lateral Process

Account for around 20% of talar fractures.
Known as “snowboarder’s fracture” due to increased incidence in snowboarding.
Caused by compression during inversion and dorsiflexion.
Treatment is determined by the extent of displacement and joint involvement.
Non-displaced and small comminuted fractures are managed with non-weight bearing (NWB) short leg cast (SLC) for 4-6 weeks.
Large, displaced intra-articular fragments may require ORIF.

Fractures of the Talar Body

Categorized into three types: compression, shearing, and crush fractures.
Sneppen classification divides fractures based on location into groups:
- Group I: Compression fracture (osteochondral dome fracture).
- Group II: Shearing fractures (coronal, sagittal, transverse).
- Group III: Posterior process fracture.
- Group IV: Lateral process fracture.
- Group V: Crush injury.
Goals for managing fractures include:
- Evaluating injury extent via radiographs and CT scans.
- Immediate closed reduction of dislocated joints.
- Anatomic reduction and stable fixation of fractures.
- Facilitating union and reducing risk of AVN with proper post-operative care.

Talar Neck Fractures

Recognized as the second most common talar fracture.
Caused by forced axial loading of the tibia through the talus, often during motor vehicle accidents or falls.
Displacement and joint involvement dictate treatment strategies.
Classified by Hawkins, correlating with prognosis and predicting AVN occurrence.

Hawkins Classification

Grouped into categories that assess the risk of AVN and treatment needs:
- Hawkins I: Nondisplaced talar neck fracture; AVN rate of 0-13%, best prognosis, typically treated conservatively.
- Treatment for Hawkins I often involves NWB SLC for 6-8 weeks.

Bone Scan

Tech-99 is a radiopharmaceutical commonly used for bone scanning.
Useful for detecting stress fractures.
Its application has limitations.

Management Overview

Two primary management strategies: Non-Operative and Operative.

Management: Non-Operative

Nondisplaced or minimally displaced metatarsal fractures are generally treated non-operatively.
Goals include maintaining the metatarsal heads' parabola, sagittal plane position, and congruent metatophalangeal joints.

Non-Operative Management Protocols

Non-displaced first metatarsal fractures require 4-6 weeks of non-weight bearing (NWB) in a cast or boot, followed by 6-8 weeks of protected weight-bearing as tolerated (WBAT).
For a single non-displaced central metatarsal fracture, 6-8 weeks of WBAT in a surgical shoe or boot is standard; transition to regular footwear occurs once bone callus is visible and tenderness resolves.
Multiple non-displaced central metatarsal fractures: 4-6 weeks NWB in cast or boot, followed by 6-8 weeks WBAT in boot.

Closed Reduction Techniques

Closed reduction may be performed if necessary, employing local/hematoma block, sedation, and finger traps.

Management: Operative

Indications for surgery include fractures with over 3-4 mm displacement or angulation greater than 10 degrees, as these can complicate healing.

Fracture Classifications

Common classification systems include Lawrence & Botte, Stewart, and Torg.

Distal Diaphyseal Fractures

Known as "Dancer’s fractures," these occur due to forced dorsiflexion of a plantarflexed and inverted forefoot.

Avulsion Fractures

Commonly associated with peroneus brevis or plantar fascia injuries.
Nondisplaced and mildly displaced avulsion fractures can be managed non-operatively with weight-bearing as tolerated in a stiff-soled shoe or boot for 4-8 weeks.

Imaging Techniques

Standard imaging is similar to other metatarsal fractures, with CT and MRI considered for cases of delayed healing, non-union, or suspected stress fractures.

Management: Non-Operative for Specific Fractures

Majority of distal diaphyseal fractures are treated non-operatively; studies show excellent long-term functional outcomes.
For Jones fractures, nonunion rates can be as high as 25%. Healing averages 10 weeks with open reduction and internal fixation (ORIF), compared to 24 weeks for non-operative management.

Management: Operative for Avulsion and Distal Diaphyseal Fractures

Surgical methods include bicortical screw, intramedullary screw, tension band, and plate fixation for avulsion fractures.
For distal diaphyseal fractures, small plate and screw construct is commonly employed.

Jones Fracture Surgical Considerations

Operative treatment results in faster healing rates and lower re-fracture rates, with intramedullary fixation preferred.
Lateral decubitus position is used during surgery; correct guidewire placement is crucial.

Special Considerations

Metatarsus adductus and cavovarus foot structure can influence fracture risk and management strategies.
Athletes are often recommended for operative treatment to ensure quick return to play, shown to be effective in NFL players.
Skeletally immature patients require special attention to avoid misdiagnosing open epiphysis as fractures.

Summary

Treatment for metatarsal fractures primarily depends on displacement and angulation.
Special circumstances, like Jones fractures, warrant close patient education.
Most metatarsal fractures heal without complications.

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This quiz focuses on the mechanisms, classifications, and management principles of ankle fractures. Participants will learn about open reduction internal fixation techniques and the evaluation criteria for fixation devices. The quiz aims to enhance understanding of ankle fracture treatment in a podiatric context.

Ankle Fractures I - Podiatry Course

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Questions and Answers

What are the main functions of the ankle joint?

Which ligaments are classified as medial ligaments of the ankle?

What does the Lauge-Hansen classification system primarily consider?

In the context of ankle fractures, what does the Danis-Weber classification relate to?

Which of the following is NOT a ligamentous structure associated with the medial aspect of the ankle?

Which of the following best describes the purpose of the syndesmotic ligaments in the ankle?

Which term refers to the first word in the Lauge-Hansen classification, describing the foot position?

What anatomical structure is primarily responsible for the hinge motion at the ankle joint?

What characterizes a Stage 1 injury in Supination-Adduction according to the Lauge-Hansen classification?

In the Danis-Weber classification, a Type C fracture is defined as:

Which stage in the Lauge-Hansen Supination External Rotation classification involves injury to the posterior inferior tibiotalar ligament?

The injury characterized by a transverse fracture of the medial malleolus or deltoid ligament injury corresponds to which classification?

What type of fracture is identified in Danis-Weber Type B classification?

Which of the following describes the injury at Stage 2 of Pronation-Abduction classification?

Which named fracture is specifically an AITFL avulsion from the anterolateral tibia?

A fracture of the lateral malleolus distal to the syndesmosis is classified as:

In the Lauge-Hansen classification, which stage corresponds to a vertical medial malleolar fracture?

Which statement is true regarding the overlaps between Lauge-Hansen and Danis-Weber classifications?

Which ligament serves as the main stabilization structure for the medial aspect of the ankle joint?

What is the correct order of foot position and talar motion in the Lauge-Hansen classification for Supination-External Rotation?

According to the Danis-Weber classification, which type of fracture is associated with a fibular fracture that is above the level of the syndesmosis?

Which of the following best defines the relationship of the Inferior transverse tibiofibular ligament within the ankle anatomy?

In the context of syndesmotic ligament injuries, which ligament is primarily a contributor to horizontal stability across the ankle?

What is a key characteristic of a Pronation-Abduction injury in the Lauge-Hansen classification?

Which phrase best describes the Lauge-Hansen classification’s method of categorizing ankle fractures?

Which of the following is NOT a component of the syndesmotic ligaments in the ankle?

What type of fibular fracture is classified as Type A in the Danis-Weber classification?

Which stage of the Lauge-Hansen Supination External Rotation classification involves a spiral fracture of the fibula?

In the context of Lauge-Hansen classification, what does Stage 1 of Pronation-Abduction describe?

What is the injury characterized by a posterior malleolar fracture in the Pronation-Abduction classification?

Which named fracture corresponds to an AITFL avulsion from the anteromedial fibula?

What characterizes Danis-Weber Type C classification?

Which stage in Lauge-Hansen classifications describes a transverse avulsion type fracture of the distal fibula?

Which statement accurately reflects an overlap between the Danis-Weber and Lauge-Hansen classifications?

What type of injury is identified in Stage 3 of Supination-Adduction?

Which clinical evaluation aspect assesses the possibility of active bleeding in an ankle fracture case?

What is the primary goal of open reduction internal fixation (ORIF) in the management of ankle fractures?

Which factor is NOT considered when evaluating the stability of an ankle fracture?

In the context of fracture healing processes, which phase primarily focuses on the re-establishment of structural integrity?

What classification scheme primarily helps in understanding the pattern of fracture based on external forces?

What is the significance of evaluating tibio-fibular overlap in ankle injuries?

What does a widening of the medial clear space greater than 4 mm suggest?

Which measurement indicates lateral ankle instability in a talar tilt evaluation?

In evaluating syndesmotic injuries, which sign would indicate fibular shortening?

What does a normal measurement on the Shenton line suggest in ankle evaluations?

What is a primary purpose of performing a thorough neurovascular evaluation in ankle fractures?

Which of the following is a possible outcome of insufficient treatment for a syndesmotic injury?

In the context of radiographic evaluation, what does a decrease in tibiotalar contact as reported by Ramsey and Hamilton indicate?

What defines an unstable ankle fracture?

Which of the following is a disadvantage of closed reduction?

In the Charnley Maneuver, which step is performed last?

What is a key advantage of open reduction internal fixation (ORIF)?

What does primary bone healing require?

Which fracture pattern would be classified as spiral?

What is the primary role of a neutralization plate in ORIF?

When is an interfragmentary screw primarily employed?

Which technique involves applying tension to compress the fracture line?

Which situation necessitates the fixation of a posterior malleolar fracture?

Which complication is commonly associated with open reduction internal fixation?

What is necessary for successful fracture pattern treatment?

What is considered a disadvantage of using interfragmentary screws?

For a trimalleolar ankle fracture, what is the typical first method of stabilization?

What is the primary advantage of minimally invasive fracture fixation using an intramedullary nail for elderly patients?

What challenge is most associated with managing diabetic ankle fractures?

In evaluating syndesmotic injuries, what imaging finding indicates fibular shortening?

Which management strategy is crucial for addressing fracture blisters in ankle fractures?

What factor limits the use of open reduction internal fixation (ORIF) in younger patients with ankle fractures?

What is the main advantage of suture button fixation over screw fixation in syndesmotic injuries?

Which of the following best describes the purpose of a delta frame in unstable ankle fractures?

What is a common complication faced by diabetic patients with ankle fractures?

Which technique is emphasized to avoid blister formation during surgery?

What is a significant consideration when evaluating syndesmotic injuries on X-rays?

Which of the following is NOT a characteristic of minimally invasive plate osteosynthesis (MIPO)?

How does hemorrhoid-filled blister treatment differ from clear fluid-filled blister treatment?

What is a primary risk associated with performing surgery after the formation of fracture blisters?

What defines a stable ankle fracture during evaluation?