ANKLE FRACTURES: CLASSIFICATION AND TREATMENT

Dr. Sandeep Shaina

EPIDEMIOLOGY
Most ankle fractures are isolated malleolar fractures (2/3) Bimalleolar(25%) Trimalleolar(7%) Open Fracture(2%) Most common weight bearing fracture(70% of all fractures)

Bimodal Distribution
Men 15-65 years 15Women >60 years Not related to osteoporosis Related to obesity

RADIOGRAPHY
Ottawa Ankle rules( 100% sensitivity for detecting ankle fractures)
Pain near malleoli Age > 55 years Inability to bear weight Bone tenderness at posterior edge or tip of either malleolus

RADIOGRAPHY
Standard AP, Lateral views Mortise view: X ray beam parallel to trans malleolar axis Patients leg internaly rotated to 15 degrees

RADIOGRAPHY
X ray measurements of alignment and stability: Talo crural angle
Angle subtended by line drawn parallel to articular surface of distal tibia and one connecting tip of both malleoli 4 to 11 degrees Any difference of 2-3 degrees to opposite side is 2abnormal and indicates fibular shortening

RADIOGRAPHY
Medial clear space
Between lateral border of medial malleolus and lateral border of talus Should be equal to superior clear space > 4mm abnormal

RADIOGRAPHY
Tibio fibular clear space:
Syndesmosis injury Between medial surface of fibula and incisural surface of tibia > 5mm implies syndesmotic injury

CLASSIFICATIONS
Potts: Anatomical
Mono malleolar Bimalleolar Trimalleolar

LAUGELAUGE- HANSEN CLASSIFICATION

Associates specific fracture patterns with mechanism of injury Supination External rotation (60%) Supination Adduction(20%) Pronation External rotation and Pronation abduction(20%) 1st word- Foot position at time of injury word2nd word- Direction of deforming force on talus word-

LAUGELAUGE- HANSEN CLASSIFICATION

With foot supinated, lateral support structures will fail first With foot pronated medial support structures fail first Injuries are graded 1 to 4 based on level of involvement and severity.

PATTERN OF FIBULA FRACTURE

S-ER: Spiral oblique fracture runs from antero inferior margin upto posterior superior cortex S-AD: Transverse fracture distal to mortice or avulsion fracture of tip P-ER: Above syndesmosis, from superior anterior cortex to postero inferior cortex P-AB: low transverse or slightly oblique

Supination External Rotation

Supination Adduction

High fibula fracture with talar displacement Pronation external rotation injury

DANIS WEBER CLASSIFICATION

Based on location and appearance of fibula fracture TYPE A:
Transverse # lat. Malleolus at or below plafond with or without oblique fracture of medial malleolus Internal rotation and adduction

TYPE B:
Oblique # with rupture of ant. Tibio fibular lig. With # medial malleolus or ruptured deltoid

DANIS WEBER CLASSIFICATION

TYPE C:
Abduction injury C1 : oblique # prox to disrupted tibio fibular ligament C2 : Abduction + ext. rotation with prox # of fibula and interosseous membrane

AO CLASSIFICATION
Based on Weber
A: Infra syndesmotic B: Trans syndesmotic C: Supra syndesmotic

Type A and B based on presence or absence of medial lesion and Type C on characters of fibula fractures

STABLE/UNSTABLE
UNSTABLE: Bimalleolar/ Trimalleolar When talus subluxated or tilted

STABLE/UNSTABLE

If Fibula is fractured and talus not shifted Look for medial side swelling Medial side swelling + Deltoid ligament injury Medial side swelling Stress Radiography Talus shifts UNSTABLE Talus does not shift STABLE

UNSTABLE

SYNDESMOTIC INJURIES
Most commonly due to PER and PAB Fixation indicated if
Proximal fibula # with a medial injury Syndesmotic injury > 5 cm proximal to plafond

Integrity of syndesmosis can be judged intra operatively: Fix fibula, pull laterally with a hook, if lateral shift > 3-4mm then 3essential to fix.

Maisonneuves fracture:
Spiral # of the proximal fibula ssociated with unstable ankle injury Pronation External rotation Requires reduction and stabilization of syndesmosis

BOSWORTHS FRACTURE:
The distal end of the proximal fragment of fibula gets displaced posterior to the tibia and may be locked by tibias postero lateral ridge The bone cannot be released by manupulation due to intact introsseous membrane Fibula is exposed and considerable force is required to release the fibula, fracture then fixed operatively

TREATMENT
Initial Management: Obtain AP, lateral and mortice views Reduce talus immediately Failure Urgent operative intervention ORIF Spanning ex fix Calcaneal pin

Biomechanical Studies
Displacement of talus follows displacement of fibula(Yablon) 1mm of lateral talar shift increases contact loading of tibio talar joint by 42% Recent studies have shown that ankle function is normal after ISOLATED fibula fractures Without a deltoid ligament injury or a displaced medial malleolus fracture, talus is stable and CLOSED treatment may be advocated However, some surgeons still prefer ORIF for isolated fibula #

STABLE INJURY T/T

# protected in a short leg cast or brace for 4-6 weeks, allow partial wt. bearing, FWB after 12 weeks

Open Treatment
Not indicated in stable fractures, only if associated injuries like talar # or osteochondral # of talar dome Indicated in all unstable fractures

ORIF
Fibula Fixation:
1/3rd tubular plate( if # above ankle) Lag screws Rush rod: if # transverse TBW: if fragment small

ORIF
Medial Malleolus:
2 parallel 4.0 mm PTCS TBW if fragment small and osteoporotic

Posterior Malleolus
Fixation important: otherwise may lead to posterior subluxation of talus Size of fragment important(CT scan) If > 25% - 30% of joint surface fixation done Fix associated # first and then do an intra op posterior drawer test Apply 1/3rd tubular plate posterior Anterior to posterior intra fragmentary screw

Syndesmotic Fixation
Indication: Prox fibula # associated with medial injury When the medial clear space widens on intra op stress views after fibula fixation Screw fixed 2 -3 cm above ankle joint and parallel to it and angled 30 degrees anteriorly 4.5 mm screw used- purchase 4 cortices usedTight screw in maximal dorsiflexion of ankle Time of screw removal- controversial.. Most surgeons removalprefer to remove the screw before weight bearing is allowed (68 weeks) (6 Use syndesmotic screw only, without fixing the fibula when # above mid fibula

POST OPERATIVE
Ankle immobilized in posterior plaster splint Splint removed after 3-4 days, replaced 3with removable splint ROM exercises are begun NWBNWB- 6 weeks Partial wt. bearing allowed Full wt. bearing after 12 weeks

AXIAL LOADING INJURIES: TIBIAL PLAFOND FRACTURES

Articular and metaphyseal comminution Joint impaction Proximal displacement of talus High energy trauma associated with soft tissue involvement Fracture pattern depends upon direction and position of foot

AP and lateral views of tibial Plafond showing articular and Metaphyseal comminution

The position of the foot at the time Of axial load determines which part Of the tibial plafond will fracture

CLASSIFICATION
RuediRuedi- Allgower classification:
Type 1 : Nondispaced cleavage # Type 2: Displaced and minimally comminuted # Type 3: Highly comminuted #

CLASSIFICATION
AO/ OTA:
A: Non- articular NonB: Partial- articular PartialC: Total- articular Total-

Divided into 3 sub groups based on degree of comminution

TREATMENT
Initial Treatment:
Reduce any talar displacement Articular reduction through either closed or open methods Splint the fracture which may require temporary skeletal traction

Treatment Options:
Plate Spanning external fixator External fixator leaving the anlke

ADVANTAGES/ DISADVANTAGES
Technique Open reduction and internal fixation Advantages Fixation Techniques Disadvantages Disrupts tenuous soft tissue envelope Involves large subcutaneous implants Has highest incidence of wound healing problems including: Wound breakdown Infection Osteomyelitis Amputation Involves wide exposure for articular reduction Allows early motion of ankle joint

Rigid cross-ankle external fixation

Involves minimal disruption of zone of injury Allows motion at the ankle Avoids large plates to stabilize metaphysis

Rigidly immobilizes ankle

External fixation of same side of joint

Cannot be used for all fractures Disrupts zone of injury Is technically demanding

Articulated cross-ankle external fixation

Allows motion at the ankle (limited) Is technically easier to apply fixator Involves minimal disruption of zone of injury

Is difficult to align axis of hinge with axis of ankle joint Requires pins in hind-foot bones Value of motion through an articulated hinge is not proven

DECISION MAKING AND FACTORS RELATING TO OUTCOME

Closed Treatment: Undisplaced type A, Type B and Type C1 fractures Open Treatment:
Immediate ORIF obsolete due to severe soft tissue complications and high rate of implant failure Not favoured any longer

Urgent stabilization done either by

Spanning external fixator External fixator sparing the ankle joint Illizarovs ring fixator Calcaneal pin traction

Adequate time is given for the soft tissue to heal(4heal(4-6 weeks) Definative procedure is done after soft tissue heals

Spanning external fixator and Illizarov external fixator can be used for definitive management Implants:
Small fragment 3.5 mm and 4.00 mm screws for metaphyseal stabilization Small plates- 1/3rd tubular, 3.5 mm DCP, small platesclover leaf plates or T shaped plates designed for distal radius, fixed angle locking screw plates

RESULTS
High energy trauma Result not always good Depends on associated degree of soft tissue trauma, wound condition and infections Average interval for fracture to heal 12 weeks Average time to return to normal activity- 1 year activityRate of Post op arthiritis and c/o pain and disability --- HIGH!!

SUMMARY
Common fractures Anatomical reduction, restoration of fibular length, syndesmotic repair lead to excellent outcomes for the patient In plafond fractures management of soft tissue component and adequate stable fixation MANDATORY