Ankle Fractures

Four patterns are recognized, based on “pure” injury sequences, each subdivided into stages of increasing severity.

This system is based on cadaveric studies.

Patterns may not always reflect clinical reality.

The system takes into account (1) the position of the foot at the time of injury and (2) the direction of the deforming force.

Maisonneuve fracture

Curbstone fracture

LeForte-Wagstaffe fracture

Tillaux-Chaput fracture

Collicular fractures

Chip avulsion

Pronation-dorsiflexion fracture

Closed reduction should be performed for
displaced fractures. Fracture reduction helps to minimize postinjury
swelling, reduces pressure on the articular cartilage, lessens the risk
of skin breakdown, and minimizes pressure on the neurovascular
structures.

Dislocated ankles should be reduced before radiographic evaluation.

Open wounds and abrasions should be
cleansed and dressed in a sterile fashion as dictated by the degree of
injury. Fracture blisters should be left intact and dressed with a
well-padded sterile dressing.

Following fracture reduction, a
well-padded posterior splint with a U-shaped component should be placed
to provide fracture stability and patient comfort.

Postreduction radiographs should be
obtained for fracture reassessment. The limb should be aggressively
elevated with or without the use of ice.

Indications for nonoperative treatment include:

Patients with stable fracture patterns
can be placed in a short leg cast or a removable boot or stirrup and
allowed to bear weight as tolerated.

For displaced fractures, if anatomic
reduction is achieved with closed manipulation, a bulky dressing and a
posterior splint with a U-shaped component may be used for the first
few days while swelling subsides. The patient is then placed in a long
leg cast to maintain rotational control for 4 to 6 weeks with serial
radiographic evaluation to ensure maintenance of reduction and healing.
If adequate healing is demonstrated, the patient can be placed in a
short leg cast or fracture brace. Weight bearing is restricted until
fracture healing is demonstrated.

Open reduction and internal fixation (ORIF) is indicated for:

ORIF should be performed once the
patient’s general medical condition, swelling about the ankle, and soft
tissue status allow. Swelling, blisters, and soft tissue issues usually
stabilize within 5 to 10 days after injury with elevation, ice, and
compressive dressings. Occasionally, a closed fracture with severe soft
tissue injury or massive swelling may require reduction and
stabilization with use of external fixation to allow soft tissue
management before definitive fixation.

Lateral malleolar fractures distal to the
syndesmosis may be stabilized using a lag screw or Kirschner wires with
tension banding. With fractures at or above the syndesmosis,
restoration of fibular length and rotation is essential to obtain an
accurate reduction. This is most often accomplished using a combination
of lag screws and plate.

Management of medial malleolar fractures
is controversial. In general, with a deltoid rupture the talus follows
the fibula. Indications for operative fixation of the medial malleolus
include concomitant syndesmotic injury, persistent widening of the
medial clear space following fibula reduction, inability to obtain
adequate fibular reduction, or persistent medial fracture displacement
after fibular fixation. Medial malleolar fractures can usually be
stabilized with cancellous screws or a figure-of-eight tension band.

Indications for fixation of posterior
malleolus fractures include involvement of >25% of the articular
surface, >2 mm displacement, or persistent posterior subluxation of
the talus. Fixation may be achieved by indirect reduction and placement
of an anterior to posterior lag screw, or a posterior to anterior lag
screw through a separate incision.

Fibula fractures above the plafond may
require syndesmotic stabilization. After fixation of the medial and
lateral malleoli is achieved, the syndesmosis should be stressed
intraoperatively by lateral pull on the fibula with a bone hook or by
stressing the ankle in external rotation. Syndesmotic instability can
then be recognized clinically and under image intensification. Distal
tibia-fibula joint reduction is held with a large-pointed reduction
clamp A syndesmotic screw is placed 1.5 to 2.0 cm above the plafond
from the fibula to the tibia. Controversy exists as to the number of
purchased cortices (three or four) and the size of the screw (3.5 or
4.5 mm). The need for ankle dorsiflexion during syndesmotic screw
placement is also controversial.

Very proximal fibula fractures with
syndesmosis disruption can usually be treated with syndesmosis fixation
without direct fibula reduction and stabilization. One must however,
ascertain correct fibula length and rotation before placing syndesmotic
fixation.

Following fracture fixation, the limb is
placed in a bulky dressing incorporating a plaster splint. Progression
to weight bearing is based on the fracture pattern, stability of
fixation, patient compliance, and philosophy of the surgeon.

Pilon fractures account for 7% to 10% of all tibia fractures.

Most pilon fractures are a result of high-energy mechanisms; thus, concomitant injuries are common and should be ruled out.

Most common in men 30 to 40 years old.

Axial compression: fall from a height

Shear: skiing accident

Combined compression and shear

Because of their high-energy nature,
these fractures can be expected to have specific associated injuries:
Calcaneus, tibial plateau, pelvis, and vertebral fractures.

Most pilon fractures are associated with high-energy trauma; full trauma evaluation and survey may be necessary.

Patients typically present nonambulatory with variable gross deformity of the involved distal leg.

Evaluation includes assessment of neurovascular status and evaluation of any associated injuries.

The tibia is nearly subcutaneous in this
region; therefore, fracture displacement or excess skin pressure may
convert a closed injury into an open one.

Swelling is often massive and rapid,
necessitating serial neurovascular examinations as well as assessment
of skin integrity, necrosis, and fracture blisters.

Meticulous assessment of soft tissue
damage is of paramount importance. Significant damage occurs to the
thin soft tissue envelope surrounding the distal tibia as the forces of
impact are dissipated. This may result in inadequate healing of
surgical incisions with wound necrosis and skin slough if not treated
appropriately. Some advise waiting 7 to 10 days for soft tissue healing
to occur before planning surgery.

AP, lateral, and mortise radiographs should be obtained.

CT with coronal and sagittal reconstruction is helpful to evaluate the fracture pattern and articular surface.

Careful preoperative planning is
essential with a strategically planned sequence of reconstruction;
radiographs of the contralateral side may be useful as a template for
preoperative planning.

Even when accurate reduction is obtained,
predictably excellent outcomes are not always achieved, and less than
anatomic reduction can lead to satisfactory outcomes.

Soft tissue slough, necrosis, and
hematoma: These result from initial trauma combined with improper
handling of soft tissues. One must avoid excessive stripping and skin
closure under tension. Secondary closure, skin grafts, or muscle flaps
may be required for adequate closure.

Nonunion: Results from significant
comminution and bone loss, as well as hypovascularity and infection. It
has a reported incidence of 5% regardless of treatment method.

Malunion: Common with nonanatomic
reduction, inadequate buttressing followed by collapse, or premature
weight bearing. The reported incidence is up to 25% with use of
external fixation.

Infection: Associated with open injuries
and soft tissue devitalization. It has a high incidence with early
surgery under unfavorable soft tissue conditions. Late infectious
complications may manifest as osteomyelitis, malunion, or nonunion.

Posttraumatic arthritis: More frequent
with increasing severity of intraarticular comminution; it emphasizes
the need for anatomic restoration of the articular surface.

Tibial shortening: Caused by fracture
comminution, metaphyseal impaction, or initial failure to restore
length by fibula fixation.

Decreased ankle ROM: Patients usually average <10 degrees of dorsiflexion and <30 degrees of plantar flexion.

Most ankle sprains are caused by a
twisting or turning event to the ankle. This can result from either
internal or external rotation.

Mechanism of injury and the exact ligaments injured depend on the position of the foot and the direction of the stress.

Mild ankle sprain: Patients have minimal
functional loss, no limp, minimal or no swelling, point tenderness, and
pain with reproduction of mechanism of injury.

Moderate sprain: Patients have moderate
functional loss, inability to hop or toe-rise on the injured ankle, a
limp with walking, and localized swelling with point tenderness.

Severe sprain: This is indicated by diffuse tenderness, swelling, and a preference for non–weight bearing.

This system does not delineate the specific ligaments involved.

Patients often describe a popping or tearing sensation in the ankle, and they remember the immediate onset of pain.

Some patients have an acute onset of
swelling around the lateral ankle ligaments and difficulty with weight
bearing secondary to pain.

Significant physical examination findings
may include swelling, ecchymosis, tenderness, instability, crepitus,
sensory changes, vascular status, muscle dysfunction, and deformity.

The location of the pain helps to
delineate the involved ligaments, and it can include the lateral aspect
of the ankle, the anterior aspect of the fibula, the medial aspect of
the ankle, and the syndesmotic region.

The value of stress testing of the lateral collateral ankle ligaments in the acute setting is controversial.

Injury to the lateral collateral ankle
ligaments should be differentiated from other periarticular ligamentous
injuries on examination. Significant initial ecchymosis along the heel

indicates
possible subtalar ligamentous sprain. To evaluate potential syndesmotic
injury, the squeeze test and stress external rotation tests are
performed (see later).

Most patients should probably undergo
radiographic examination to rule out occult foot and ankle injuries
with an x-ray series of the foot and ankle.

In the acute setting, there probably is little role for performing radiographic stress testing.

Nonsurgical approaches are preferred for initial treatment for acute ankle sprains.

Initial treatment involves the use of rest, ice, compression (elastic wrap), elevation (RICE) and protected weight bearing.

Once the initial inflammatory phase has
resolved, for the less severe ankle sprains (mild to moderate), one can
initiate a home rehabilitation program consisting of eversion muscle
group strengthening, proprioceptive retraining, and protective bracing
while the patient gradually returns to sports and functional
activities. Bracing or taping is usually discontinued 3 to 4 weeks
after resuming sports. For more severe sprains, taping or bracing
programs are continued during sports activities for 6 months, and a
supervised rehabilitation program used.

Patients who continue to have pain in the
ankle that does not decrease with time should be reevaluated for an
occult osseous or chondral injury.

Patients with a history of recurrent
ankle sprains who sustain an acute ankle sprain are treated in a manner
similar to that described earlier.

Type I diastasis involves lateral subluxation without fracture.

Type II involved lateral subluxation with plastic deformation of the fibula.

Type III involves posterior subluxation/dislocation of the fibula.

Type IV involves superior subluxation/dislocation of the talus within the mortise.

Immediately after a syndesmotic ankle
sprain, the patient will have well-localized tenderness in the area of
the sprain, but soon thereafter, with ensuing swelling and ecchymosis,
the precise location of the sprain often becomes obscured.

Patients ordinarily present to physicians
several hours, if not days, after these injuries, with difficulty in
weight bearing, ecchymosis extending up the leg, and marked swelling.
The clue to chronic, subclinical syndesmotic sprains is the history of
vague ankle pain with push-off and normal imaging studies.

The clinical examination involves
palpating the involved ligaments and bones. The fibula should be
palpated in a proximal to distal direction. The proximal tibiofibular
joint should be assessed for tenderness or associated injury.

Two clinical tests can be used to isolate syndesmotic ligament injury.

The radiographic evaluation of a
syndesmotic injury, in an acute setting, involves an attempt at
weight-bearing radiographs of the ankle (AP, mortise, lateral) and, if
negative, an external rotation stress view.

Without injury, a weight-bearing mortise view should show:

With acute sprains, on lateral radiographs, a small avulsion fragment may be apparent. Similarly, with more chronic

problems, calcification of the syndesmosis or posterior tibia may suggest syndesmotic injury.

When routine x-rays are negative, and the
patient is still suspected of having a syndesmotic injury, stress
radiographs can be considered. The examiner should inspect stress
radiographs for widening of the medial joint space and tibiofibular
clear space on the mortise view and for posterior displacement of the
fibula relative to the tibia on the lateral view.

In difficult-to-diagnose acute cases or
latent presentations, an MRI evaluation of the syndesmosis may
delineate injury to the syndesmotic ligaments.

Tibiofibular syndesmotic ligamentous
injuries are slower to recover than other ankle ligamentous injuries
and may benefit from a more restrictive approach to initial management.

Patients are immobilized in a
non-weight-bearing cast for 2 to 3 weeks after injury. This is followed
by use of a protective, modified, articulated ankle-foot orthosis that
eliminates external rotation stress on the ankle for a variable period,
depending on the functional needs and sports activities of the patient.

Operative treatment is considered for
patients with irreducible diastasis. To hold the syndesmotic ligaments
while healing, two screws usually placed at the superior margin of the
syndesmosis in a nonlagged fashion, from the fibula into the tibia. The
patients are maintained non-weight bearing for 6 weeks, and the screws
are removed approximately 12 to 16 weeks after fixation.

Most Achilles tendon problems are related to overuse injuries and are multifactorial.

The principal factors include host susceptibility and mechanical overload.

The spectrum of injury ranges from paratenonitis to tendinosis to acute rupture.

In a trauma setting, a true rupture is the most common presentation.

Delayed or missed diagnosis of Achilles tendon rupture by primary treating physicians is relatively common (up to 25%).

The Achilles tendon is the largest tendon in the body.

It lacks a true synovial sheath and
instead has a paratenon with visceral and parietal layers permitting
approximately 1.5 cm of tendon glide.

It receives its blood supply from three sources:

With either partial or complete Achilles
tendon rupture, patients typically experience sharp pain, often
described as feeling like being kicked in the leg.

With a partial rupture, physical examination may only reveal a localized, tender area of swelling.

With complete rupture, examination normally reveals a palpable defect in the tendon.

Goals are to restore normal
musculotendinous length and tension and thereby to optimize ultimate
strength and function of the gastrocnemius-soleus complex.

Whether operative or nonoperative treatment best achieves these goals remains a matter of controversy.

Nonoperative treatment begins with a period of immobilization.

Surgical treatment is often preferred when treating younger and more athletic patients.

Patients with peroneal tendon subluxation or dislocation demonstrate tenderness posterior to the lateral malleolus.

The anterior drawer test is negative, and the patient has discomfort and apprehension with resisted eversion of the foot.

Radiographic evaluation of a patient with
peroneal tendon subluxation or dislocation may reveal a small fleck of
bone off the posterior aspect of the lateral malleolus, which is best
seen on the internal oblique or mortise view.

If the diagnosis is unclear, as a result
of swelling and diffuse ecchymosis, an MRI evaluation may help to
delineate this soft tissue injury.

When the initial reduction of dislocated tendons is stable, nonoperative techniques can be successful.

When the diagnosis is made on a delayed
basis or the patient presents with recurrent dislocations, operative
treatment is considered because nonoperative measures are unlikely to
work.