Ankle fractures

$Page 1: Ankle fractures$
ANKLE FRACTURESANKLE FRACTURES

John W Cory MDJohn W Cory MDOrthoArizonaOrthoArizona

The Foot & Ankle CenterThe Foot & Ankle Center

ADULT ANKLE FRACTURESADULT ANKLE FRACTURES AO/WEBER AO/WEBER

CLASSIFICATIONCLASSIFICATION Based on level of Based on level of

fibular fracture fibular fracture Medial malleolar Medial malleolar

fracturefracture Posterior racturePosterior racture

AO/WEBER AO/WEBER A~(sup/add)A~(sup/add)

A1A1isolated fibular isolated fibular fracture below fracture below syndesmosissyndesmosis

A2A2 A1+ medial A1+ medial malleolus fracturemalleolus fracture

A3A3A1 or A2+ A1 or A2+ posterior medial posterior medial fracturefracture

ADULT ANKLE FRACTURESADULT ANKLE FRACTURESAO/WEBER A

ADULT ANKLE FRACTURESADULT ANKLE FRACTURES AO/WEBER B~(SER)AO/WEBER B~(SER) B1B1isolated fibula isolated fibula

fracture @ syndesmosisfracture @ syndesmosis B2B2B1 + medial B1 + medial

lesion(frx or lig)lesion(frx or lig) B3B3B2 + posterior lateral B2 + posterior lateral

fracturefracture– VolkmannVolkmann’s fragment’s fragment

AO/WEBER C~(PER)AO/WEBER C~(PER) C1C1isolated simple isolated simple

diaphyseal fracture of diaphyseal fracture of fibulafibula

C2C2complex diaphyseal complex diaphyseal fracture of fibulafracture of fibula

C3C3proximal fibula proximal fibula fracture,w/medial &/or fracture,w/medial &/or syndesmosis injurysyndesmosis injury

ADULT ANKLE FRACTURESADULT ANKLE FRACTURES

AO/WEBER B AO/WEBER C


ADULT ANKLE FRACTURESADULT ANKLE FRACTURES LAUGE-HANSEN CLASSIFICATIONLAUGE-HANSEN CLASSIFICATION Position of footPosition of foot Force appliedForce applied Better descriptor of injuryBetter descriptor of injury Helps catalog injury patternHelps catalog injury pattern Allows for understanding of injured Allows for understanding of injured

structures & guide treatmentstructures & guide treatment

ADULT ANKLE FRACTURESADULT ANKLE FRACTURES LAUGE-HANSEN-SALAUGE-HANSEN-SA Supination of footSupination of foot Inward rotation at Inward rotation at

ankle ankle Adduction of the Adduction of the

hindfoot hindfoot Inversion of the Inversion of the

forefootforefoot

LAUGE-HANSEN-SALAUGE-HANSEN-SA ~Weber A~Weber A SA ISA I

– Transverse or short Transverse or short oblique fibula fractureoblique fibula fracture

SA IISA II– Vertical fracture of Vertical fracture of

medial malleolusmedial malleolus

ADULT ANKLE FRACTURESADULT ANKLE FRACTURESLAUGE-HANSEN SA

ADULT ANKLE FRACTURESADULT ANKLE FRACTURESLAUGE-HANSEN SA

ADULT ANKLE FRACTURESADULT ANKLE FRACTURES LAUGE-HANSEN-SERLAUGE-HANSEN-SER Oblique frx at the level of Oblique frx at the level of

sydesmosis sydesmosis Supination of foot w/ Supination of foot w/

internal rotation of ankleinternal rotation of ankle Supinated foot externally Supinated foot externally

rotates rotates SER I-IV SER I-IV ~Weber B~Weber B

LAUGE-HANSEN-SERLAUGE-HANSEN-SER SER ISER I

– AITFL rupture or Wagstaff AITFL rupture or Wagstaff tub. frxtub. frx

SER IISER II– Spiral oblique fibular Spiral oblique fibular

fracture @ syndesmosisfracture @ syndesmosis SER IIISER III

– Posterior injury Posterior injury SER IVSER IV

– Medial injury Medial injury

ADULT ANKLE FRACTURESADULT ANKLE FRACTURESLAUGE-HANSEN SER

ADULT ANKLE FRACTURESADULT ANKLE FRACTURESLAUGE-HANSEN SER

ADULT ANKLE FRACTURESADULT ANKLE FRACTURES LAUGE-HANSEN-PER LAUGE-HANSEN-PER Pronated forefoot w/ ER Pronated forefoot w/ ER

of ankleof ankle Abduction of hindfootAbduction of hindfoot Eversion of forefootEversion of forefoot Avulsion frx of medial Avulsion frx of medial

malleolusmalleolus Syndesmosis ruptureSyndesmosis rupture Transverse(butterfly)Transverse(butterfly) fibula frxfibula frx

LAUGE-HANSEN-PERLAUGE-HANSEN-PER PER IPER I

– deltoid rupture or medial deltoid rupture or medial malleolus avulsion frxmalleolus avulsion frx

PER IIPER II– Sydysmosis ruptureSydysmosis rupture

PER IIIPER III– Transverse fibula fracture Transverse fibula fracture

@ syndesmosis w/ butterfly@ syndesmosis w/ butterfly– UnstableUnstable– Maisonneuve FractureMaisonneuve Fracture


LAUGE-HANSEN PA

ADULT ANKLE FRACTURESADULT ANKLE FRACTURESLAUGE-HANSEN PA

ADULT ANKLE FRACTURESADULT ANKLE FRACTURES LAUGE-HANSEN-PERLAUGE-HANSEN-PER Eversion injuryEversion injury Medial side injury is firstMedial side injury is first ~Weber C~Weber C

LAUGE-HANSEN-PERLAUGE-HANSEN-PER PER 1PER 1

– Deltoid rupture or Deltoid rupture or transverse frx of medial transverse frx of medial malleolusmalleolus

PER 2PER 2– ATFL or Wagstaff tub. frxATFL or Wagstaff tub. frx

PER 3PER 3– Short oblique fibula frx Short oblique fibula frx

above syndesmosisabove syndesmosis PER 4PER 4

– PITFL or post malleolus frxPITFL or post malleolus frx

ADULT ANKLE FRACTURESADULT ANKLE FRACTURESLAUGE-HANSEN PER

ADULT ANKLE FRACTURESADULT ANKLE FRACTURESLAUGE-HANSEN PER

ADULT ANKLE FRACTURESADULT ANKLE FRACTURES PILON PILON

FRACTURESFRACTURES– ““Hammer”Hammer”– Compression injuryCompression injury– Axial loadingAxial loading– Low & High energy Low & High energy

injuriesinjuries– Posterior injury-ankle Posterior injury-ankle

plantar flexionplantar flexion– Anterior injury-ankle Anterior injury-ankle

dorsiflexiondorsiflexion– Cleavage-neutralCleavage-neutral


ADULT ANKLE FRACTURESADULT ANKLE FRACTURES PILON FRACTURESPILON FRACTURES

– High association of secondary injuryHigh association of secondary injury– Fibula fractured in 75-85%Fibula fractured in 75-85%– If fibula intact-massive medial plafond injury, If fibula intact-massive medial plafond injury,

ankle varusankle varus– 30% ipsilateral LE injury30% ipsilateral LE injury– 15% contralateral LE injury15% contralateral LE injury

ADULT ANKLE FRACTURESADULT ANKLE FRACTURES PILON FRACTURESPILON FRACTURES L1 compression fracturesL1 compression fractures High rate of compartment syndromeHigh rate of compartment syndrome Hip fractureHip fracture Knee injuryKnee injury Tibial shaft fractureTibial shaft fracture Calcaneus fractureCalcaneus fracture


FRACTURESFRACTURES RUEDI-ALLGOWERRUEDI-ALLGOWER

– I: cleavage w/o severe I: cleavage w/o severe joint surface injuryjoint surface injury

– II: cleavage w/ joint II: cleavage w/ joint injury, not comminutedinjury, not comminuted

– III: comminution & III: comminution & impactionimpaction


FRACTURESFRACTURES AO AO

CLASSIFICATIONCLASSIFICATION A1-3A1-3

– extraarticular (w/ extraarticular (w/ increasing injury)increasing injury)

B1-3B1-3– Partial articular Partial articular

C1-3C1-3– articular + articular +

metaphysealmetaphyseal

ADULT ANKLE FRACTURESADULT ANKLE FRACTURES PILON FRACTURE TREATMENT PILON FRACTURE TREATMENT

GOALSGOALS Restoration of lengthRestoration of length Reconstruct metaphyseal shellReconstruct metaphyseal shell Bone graftingBone grafting Reattachment of metaphysis to diaphysisReattachment of metaphysis to diaphysis *Restoration of articular surface*Restoration of articular surface *Early mobilization*Early mobilization

ADULT ANKLE FRACTURESADULT ANKLE FRACTURES PILON TREATMENT OPTIONSPILON TREATMENT OPTIONS Splinting/ CastingSplinting/ Casting External FixationExternal Fixation ORIFORIF External fixation + limited ORIFExternal fixation + limited ORIF Compartment syndromeCompartment syndrome Associated injuriesAssociated injuries

ADULT ANKLE FRACTURESADULT ANKLE FRACTURES CASTINGCASTING Rarely treatment Rarely treatment

choicechoice Only with most Only with most

univolved univolved Ruedi-Allgower IRuedi-Allgower I AO A1AO A1

EXTERNAL EXTERNAL FIXATIONFIXATION

Indirect reductionIndirect reduction ““Skeletal traction”Skeletal traction” TemporizingTemporizing Maintain length & Maintain length &

alignmentalignment Preserves biologyPreserves biology

ADULT ANKLE FRACTURESADULT ANKLE FRACTURES ORIFORIF Timing is keyTiming is key

– ““6 hours/ 6 days-swelling peaks b/w 24hr-3 6 hours/ 6 days-swelling peaks b/w 24hr-3 daysdays

– Usually delayed 7-10 days w/ severe swellingUsually delayed 7-10 days w/ severe swelling– >21 days-granulation, hematoma >21 days-granulation, hematoma

organization, bone resorption, cartilage organization, bone resorption, cartilage malnutritionmalnutrition

29% fracture blisters w/ pilon fracture29% fracture blisters w/ pilon fracture

ADULT ANKLE FRACTURESADULT ANKLE FRACTURES ORIFORIF Soft tissue handling is KEYSoft tissue handling is KEY

– Full thickness flapsFull thickness flaps– Avoid compromised skinAvoid compromised skin

Surgical approachSurgical approach– 2 incision technique is workhorse2 incision technique is workhorse– Posterior lateral incision for fibulaPosterior lateral incision for fibula– Extended anterior arthrotomyExtended anterior arthrotomy

ADULT ANKLE FRACTURESADULT ANKLE FRACTURES ORIFORIF Restoration of lengthRestoration of length Reconstruct Reconstruct

metaphyseal shellmetaphyseal shell Bone graftingBone grafting Reattachment of Reattachment of

metaphysis to metaphysis to diaphysisdiaphysis

ORIFORIF 2X rate of delayed 2X rate of delayed

wound healingwound healing High complication High complication

raterate Reports of excellent Reports of excellent

results skewedresults skewed Best results with low Best results with low

energy injuriesenergy injuries

ADULT ANKLE FRACTURESADULT ANKLE FRACTURES EXTERNAL EXTERNAL

FIXATION + ORIFFIXATION + ORIF Massive soft tissue injuryMassive soft tissue injury Severe comminutionSevere comminution Utilizes inderect reductionUtilizes inderect reduction Restore/maintain length Restore/maintain length Maintain aligmentMaintain aligment

EXTERNAL EXTERNAL FIXATION + ORIFFIXATION + ORIF

Limited ORIFLimited ORIF– Fibular plateFibular plate– Interfrag screwsInterfrag screws

Increased rate of:Increased rate of:– Delayed/nonunionDelayed/nonunion– malunionmalunion

Decrease rate of:Decrease rate of:– Skin sloughSkin slough– InfectionInfection– Secondary closureSecondary closure


FIXATION + ORIFFIXATION + ORIF Half-pin fixatorHalf-pin fixator Skinny wire fixatorSkinny wire fixator Hybrid frameHybrid frame


Half-pin fixatorHalf-pin fixator– TibiotalarTibiotalar– TibiocalcanealTibiocalcaneal– Triangular frameTriangular frame

– *No early mobilization*No early mobilization


FIXATION + ORIFFIXATION + ORIF Skinny wire fixatorSkinny wire fixator

– Does not span ankleDoes not span ankle– Excellent for C1 & C2Excellent for C1 & C2– Diaphyseal Diaphyseal

comminutioncomminution– Highly comminutedHighly comminuted


Hybrid fixatorHybrid fixator– Does not span ankleDoes not span ankle– half pins diaphysealhalf pins diaphyseal– Skinny wire ring Skinny wire ring

metaphysealmetaphyseal

ADULT ANKLE FRACTURESADULT ANKLE FRACTURES PILON FRACTURES OUTCOMESPILON FRACTURES OUTCOMES Initial injuryInitial injury Soft tissue envelopeSoft tissue envelope TreatmentTreatment

– Delayed wound healing w/ traditional ORIF & Delayed wound healing w/ traditional ORIF & soft tissue injurysoft tissue injury

– Malunion/Nonunion w/ fixatorsMalunion/Nonunion w/ fixators


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Ankle fractures