24 Ankle Fractures II 2024.pdf

Ankle Fractures II 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...

Ankle Fractures II 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. Clinical Evaluation Generalized patient appearance Do they look in distress? How much pain? ABC’s Gross appearance of the limb Is the foot under the leg? Is there significant deformity? Are there open wounds? Swelling? How much? Vascular status Dorsalis pedis & posterior tibial arteries Skin temperature Capillary refill time Active bleeding https://medizzy.com/feed/9879793 Clinical Evaluation Neurological status Is sensation intact? What is patient’s baseline? Active movement possible? Musculoskeletal exam Stable vs unstable Pain on palpation? Where? Ankle ligament exam Syndesmosis evaluation https://medizzy.com/feed/9879793 Radiographic Evaluation Begin with 3 standard views Anteroposterior (AP) Mortise Lateral Evaluate obvious fractures Classify injury Plan for treatment Radiographic Evaluation Medial clear space: Widening > 4 mm Deltoid ligament injury and lateral translation of talus Ramsey and Hamilton - 1 mm lateral talar shift results in 42% decrease in tibiotalar contact Widening of medial clear space can indicate syndesmotic injury https://www.uptodate.com/contents/image?imageKey=RHEUM%2F74769&topicKey=SM%2F214&source=see_link Radiographic Evaluation Tibio-fibular overlap Medial fibula to lateral border of tibia Should be < 10 mm Should always be positive Good evaluation of syndesmotic integrity https://link.springer.com/article/10.1007/s12178-013-9184-9  Radiographic Evaluation Talar tilt: Mortise view Line over tibial articular surface Line parallel to talar surface Distance between lines should be less than 2 mm Indicates abnormal ankle, lateral ankle instability Normal should be approximately 2 degrees or less than 2 mm https://www.researchgate.net/figure/Standard-stress-talar-tilt-angle-of-the-right-ankle-at-the-preoperative-radiograph-and_fig4_325716701  Radiographic Evaluation Fibular shortening evaluated by: Shenton line: Broken joint line at lateral aspect of ankle joint Dime sign: Unbroken curve of distal aspect of fibula and lateral process of the talus https://www.sciencedirect.com/science/article/pii/S1877056820303698  Radiographic Evaluation Shenton Line Dime Sign https://www.jfas.org/article/S1067-2516%2817%2930501-X/fulltext h ttp s :/ / w w w.r e s e a r c h g a te.n e t/ f i g u r e / A b b - 1 - 8 - D i e - F i b u l a - i s t- v e r k u e r z t- m i t- U n te r b r u c h - i n - d e r - S h e n to n - L i n i e - g e l b e - L i n i e - D e r _ f i g 1 _ 2 6 1 2 5 6 4 7 7 Ankle Fracture Evaluation Evaluate patient for additional injuries Neurovascular compromise present? Must determine if ankle fracture is stable or unstable Open or closed injury Urgent/emergent vs delayed https://radiologyassistant.nl/musculoskeletal/ankle/fracture-mechanism-and-radiography Closed Reduction vs Open Reduction with Internal Fixation  Closed Reduction vs Open Reduction with Internal Fixation Closed Reduction: Advantages: Lower infection risk Lower anesthesia complication risk Potentially less down time Disadvantages: Imperfect anatomical reduction Loss of correction Cast complications Closed Reduction Techniques Charnley Maneuver Quigly Maneuver  Closed Reduction Techniques Charnley Maneuver: 1.) Exaggerate the deformity 2.) Distally distract the limb 3.) Reduce the deformity 4.) Immobilize with splint/cast Closed Reduction Techniques Quigly Maneuver: 1.) Lift foot by hallux 2.) Leg externally rotates 3.) Will cause foot to invert 4.) Medial malleolus must be intact https://journals.lww.com/em-news/blog/theproceduralpause/pages/post.aspx?PostID=107  Closed Reduction History and Physical exam Closed reduction Splinting Verify on radiograph appropriate correction Check for skin tinting Can lead to necrosis/open fracture Non-surgical vs surgical correction Appropriate fracture care https://www.researchgate.net/figure/a-Pre-reduction-antero-posterior-AP-X-ray-of-a-trimalleolar-ankle-fracture-b_fig5_349313483 Open Reduction Internal Fixation Advantages: Anatomic reduction Earlier weight bearing Increased stability Disadvantages: Soft tissue incision Hardware complications Loss of correction Infection Vassal Principle Correction of the dominant/major fracture will result in correction of the lesser fractures by principle that they share common soft tissue structures Fibula is commonly considered the dominant fracture in ankle fracture injuries Bone Healing Primary Bone Healing Secondary Bone Healing Anatomic reduction Close reduction Rigid fixation Endochondral healing Stability Significant callus formation Haversian canals No callus formation Fracture Pattern Types Treat the fracture pattern, not the classification Fracture types: Transverse Vertical Spiral Short Long Oblique Open Reduction Internal Fixation Hardware and Techniques Fracture Reduction Must reduce the fracture Goal: anatomical reduction Use variety of clamp options to do this Lobster Point-to-point Temporary fixation before final fixation options Interfragmentary Screws Used in spiral fibular fractures Utilize lag screws Can be inserted by lag by technique or design Interfragmentary Screw: Lag Screw By technique: Full threaded cortical screw Over drill near cortex Outer diameter of screw head Under drill far cortex Inner diameter of screw Countersink Measure Tap Insert screw https://www.indiamart.com/proddetail/cortical-screw-3-5mm-20-t-p-i-2053174988.html Interfragmentary Screw: Lag Screw By Design: Partially threaded screw Under drill Countersink Measure Tap Insert screw https://www.indiamart.com/avishkar-international/orthopedic-screw.html Interfragmentary Screw Position One screw (yellow line): Place in center of fracture Perpendicular to fracture line Two Screws (blue lines): First screw perpendicular to bone Second screw perpendicular to fracture Plating Techniques  Open Reduction Internal Fixation Plating Techniques: Neutralization plate Neutralization plate protects lag screw from deforming forces Can use locking or non-locking construct https://www.wheelessonline.com/bones/lateral-plating-of-ser-weber-b-frx/ High Fibular Fractures (Weber C) Bridge Plating: Ensure adequate fibular length is achieved Commonly use bridge plating technique to span fracture site Bridge plates span fracture and allow for mostly secondary bone healing Ensure syndesmosis is stable  Open Reduction Internal Fixation Plating Techniques: Buttress Plates Buttress plates are utilized to protect intraarticular fractures Commonly used around metaphyseal fractures h ttp s :/ / w w w.r e s e a r c h g a te.n e t/ f i g u r e / M e d i a l - m a l l e o l u s - a n ti s h e a r - p l a te - w i th - 2 - l a g - s c r e w s - a c r o s s - f r a c tu r e - th e s e - c a n - g o _ f i g 1 _ 5 8 9 7 8 0 8 Anti-glide plate: In ankle fractures, placed posteriorly to prevent proximal movement of fracture fragment Medial Malleolar Fractures Commonly use 2 partially or fully threaded cancellous screws Can use wires May need washers to hold fixation https://www.jfas.org/article/S1067-2516%2817%2930699-3/fulltext Tension Band Wire Technique Used in medial malleolar fractures Figure of 8 application Uses tension to apply compression to fracture line Not common first line of fixation Posterior Malleolar Fractures Fixate when it does not reduce after fixation of the fibular fracture or it is >25% of the joint surface is involved Direct Fixation Partially Threaded Cannulated Screw directed from Posterior to Anterior Indirect Fixation Partially Threaded Cannulated Screw directed from Anterior to Posterior https://www.wheelessonline.com/bones/posterior-malleolar-fractures/ Post-Operative Course Posterior splint Short leg cast Non-weight bearing for minimum of 6-8 weeks Progress to protected weight bearing in CAM boot May need physical therapy Possible removal of hardware depending on fixation type Post operative pain management DVT prophylaxis 2-3 weeks Resources 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