Ankle Fractures III 2024 PDF

Ankle Fractures III Allen J Kempf, DPM, MS, FACFAS, DABPM Assistant Professor College of Podiatric Medicine and Surgery Des Moines University Objectives Identify the mechanisms of injury, classification schemes for ankle fractures. Identify the management principles of open reduction interna...

Ankle Fractures III Allen J Kempf, DPM, MS, FACFAS, DABPM Assistant Professor College of Podiatric Medicine and Surgery Des Moines University Objectives Identify the mechanisms of injury, classification schemes for ankle fractures. Identify the management principles of open reduction internal fixation of ankle fractures. Identify the specific concepts and details of ankle fracture fixation devices. Identify the criteria used to evaluate ankle fracture internal fixation devices. Fracture Blisters Typically arise within 24-48 hours after injury More common in high energy traumatic injuries 2 main types: Clear fluid-filled Hemorrhagic-filled Can both occur in the same injury Not predictor of severity of injury, but blood-filled are more serious soft tissue injury Fracture Blisters Regular blister treatment is effective Clear fluid filled heal in 12 days on average Hemorrhagic filled heal in 16 days on average No clear distinction in literature on surgical timing for either Can attempt to perform surgery prior to blister formation Can attempt to avoid blisters with incision, specifically with hemorrhagic blisters Can cut through blister with incision if necessary Fracture Blisters Clear-Fluid Blisters Hemorrhagic Blisters https://www.sciencedirect.com/science/article/pii/S0020138320309840 Syndesmotic Injuries Evaluate syndesmosis On AP X-Ray After fractures are fixated test the syndesmosis with a bone hook “Cotton hook test” If instability exists, must fixate syndesmotic ligament Dorsiflex foot during insertion- classic recommendation DO NOT WANT COMPRESSION AT SYNDESMOSIS 6 Syndesmotic Injuries Syndesmotic injury leads to instability in the ankle joint Important to anatomically reduce syndesmosis Several types of fixation devices utilized Screw Suture button https://www.orthobullets.com/foot-and-ankle/7029/high-ankle-sprain-and-syndesmosis-injury Syndesmotic Fixation Screw Fixation: Fully threaded cortical screw can be utilized Do not want to compress syndesmotic screws Screw is inserted in posterior to anterior orientation at approximately 30 degrees from fibula to tibia Can be inserted within or outside of fibular plate Screw inserted 1.5-2 cm proximal to ankle joint Should be placed parallel to the ankle joint Additional screws inserted 1.5-2 cm proximal to first screw https://www.hmpgloballearningnetwork.com/site/podiatry/current-insights-fixation-options-ankle-syndesmosis-injuries Syndesmotic Fixation Suture button fixation Synthetic suture between 2 metallic buttons Stable fixation similar to screw fixation, but allows for more dynamic motion of the syndesmosis More similar to natural ligament state https://www.mdpi.com/2077-0383/11/9/2524/htm Diabetic Ankle Fractures Diabetic Ankle Fractures Challenging fractures to address Patients often have comorbid conditions Peripheral neuropathy can make pain or weight bearing difficult Unable to tell how much weight they are putting on extremity Wound healing complications High risk for developing Charcot neuroarthropathy with and without fixation Diabetic Ankle Fracture: Hardware Selection Early on, traditional plates and screw fixation were utilized Altered bone and skin healing secondary to metabolic disorder made this approach challenging New approaches including: Minimally invasive plate osteosynthesis (MIPO) Avoids large incisions Preserves periosteum Super construct hardware designs More, sturdier hardware Intramedullary nailing Minimally invasive Diabetic Ankle Fractures: Super Constructs Technique which was derived from Charcot reconstruction constructs Contain the following characteristics: Extends hardware beyond the immediate injury site Planning incisions allow for insertion of hardware in lower risk surgical dissection intervals Utilizing strongest available fixation Applying fixation in mechanically strongest fashion Commonly involves increasing the amount of hardware Diabetic Ankle Fractures External Fixation: Delta Frames  Unstable or Open Ankle Fractures: External Fixation External fixation can be utilized for a variety of pathology in the foot and ankle Type of device used depends on pathology involved and length of time the frame will be on the patient Ring vs static fixators Delta frames are commonly utilized in the acute trauma setting Delta Frames in Ankle Fractures Delta frame commonly utilized to stabilize soft tissue structures Allows for maintenance of reduction in neutral position Helps prevent equinus from developing Follow principles of external fixation Delta Frames in Ankle Fractures Utilized to temporarily stabilize osseous and soft tissues Left in place until swelling is improved or resolved Typically not used for definitive treatment Delta frame is removed and traditional internal fixation is applied Screws and plates https://www.orthoracle.com/library/application-of-a-hoffmann-3-ankle-spanning-external-fixator-delta-frame/ Intramedullary Nail Fixation in Ankle Fractures  Indications for IM Nail Fixation in Ankle Fractures Elderly patients Acute trauma in younger, more active individuals Poly-trauma patients Comorbidities Diabetes PVD Contraindications for IM Nail Fixation Young patients who live active lifestyles without meeting additional criteria Patients with high physical demands Not primary choice for fixation in most patients  Benefits of IM Nailing May reduce wound complications – Minimal dissection required for insertion Decreased incidence of symptomatic metal reactions Improve recovery times Load-sharing rather than load- bearing = less stress shielding Decreased risk of peri-implant fractures Earlier time to weight bearing Case Study  53 y/o M CC: Right ankle fracture  53 y/o M CC: Right ankle fracture Patient initially presented to outpatient Orthopedic urgent care center – Noted to have closed, tri-malleolar ankle fracture of the right lower extremity – Patient complicated as non-verbal at baseline, lives in assisted living facility – Unwitnessed fall at the facility – Outpatient provider determined conservative treatment preferred secondary to patient’s ability to comply with treatment, fracture was reduced, casted and instructed to remain NWB to the RLE 53 y/o M PMH: Intellectual disability, seizure disorder, CHF, HTN, HLD PSH: ORIF left ankle fracture w/ wound healing complications 2/2 non-compliance with NWB FH: Unable to obtain SH: Unable to obtain Meds: atorvastatin, vit D-3, midodrine, promethazine, levetiracetam, escitalopram, albuterol-ipratropium, diazepam, gabapentin, meloxicam, lorazepam, promethazine, depakote, fenofibrate Allergies: NKDA  53 y/o M Physical Exam: Vascular: DP/PT pulses intact, moderate edema to right foot/ankle Neuro: Deferred secondary to AMS Derm: Mild ecchymosis noted to right foot/ankle. Not open, no tenting Ortho: Instability of right ankle with crepitus on palpation, no gross deformity of right ankle. LLE unremarkable 53 y/o M Plan?  Plan Open reduction with internal fixation 53 y/o M Plan?  Plan? CT Scan  Plan Removal of hardware TTC fusion with intramedullary nail 53 y/o M  IM Nail in Ankle Fractures Summary IM nail is a MIS option for achieving stability of the hindfoot following traumatic injury Not primary choice for most patients Optimally utilized on elderly patients with minimal physical demand Can be used for revision or reconstruction Utilization in younger patient population based on case-by- case basis References AO Surgery Reference Center 2022 https://surgeryreference.aofoundation.org/ McGlamry ED, Southerland JT. Mcglamry's Comprehensive Textbook of Foot and Ankle Surgery. 4Th ed. / ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2013. Modified from Dr. Smith Lecture Ankle Fractures 2021