Ankle fractures are common injuries, accounting for 10% of all fractures. The ankle is a three bone joint composed of the tibia, fibula, and talus. Stability of the ankle depends on intact medial and lateral ligament complexes. Classification systems help describe the pattern and severity of the injury. Treatment depends on restoring anatomy and stability through closed or open reduction and fixation.

1. Presenter: Dr. Ravi Moderator – Dr. H.S. Selhi
5/12/2018

2. Ankle fractures – 10 % of all fractures
2nd most common lower limb fractures after hip
fractures
Mean age of injury 45 years
Low energy injury- simple fall/sports
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3. Ankle is a three bone joint
composed of the tibia ,
fibula and talus
Talus articulates with the
tibial plafond superiorly ,
posterior malleolus of the
tibia posteriorly and
medial malleolus medially
Lateral articulation is with
malleolus of fibula
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4. Ankle joint - saddle-shaped
Dome - wider anterior than posterior
Ankle dorsiflexes- external roatation fibula
to accommodate this widened anterior surface of
the talar dome
The tibiotalar articulation is considered to be highly
congruent such that 1 mm talar shift within the mortise
decreases the contact area by 42 %
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5. 5/12/2018
3 groups of stabilizing
ligament complexes
• MEDIAL
• LATERAL
• SYNDESMOTIC
2 OUT OF 3 COMPLEXES SHOULD
BE INTACT FOR THEANKLE TO BE
STABLE

6. 1) LATERAL
 anterior talofibular ligament
(ATFL)-WEAKEST
 calcaneofibular ligament
(CFL)
 posterior talofibular ligament
(PTFL).-STRONGEST
-limit ankleinversionand
prevent anterior and
lateral subluxationof the
talus
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7. 2. MEDIAL LIGAMENT COMPLEX
SUPERFICIAL(little contribution to stability)
>Tibionavicular ligament
>Tibiocalcaneal ligament
>Superficial tibiotalar ligament
DEEP( primary medial stabilizer)
>Intraarticular
>Deep tibiotalar lig.
-stabilize the joint during eversion and
prevent talar subluxation
-20-50% stronger than lateral ligaments
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8. Medial talar tubercle
Navicular
tuberosity
Anterior colliculus
Sustentacular tali
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9. Medial
talusIntercollicular
groove
Posterior
colliculus
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10. • Axial, rotational & translational stability.
1- ANTERIORTIBIOFIBULARLIG.
2- POSTERIOR TIBIOFIBULARLIG.
3- TRANSVERSETIBIOFIBULARLIG.
4- INTEROSSEUS LIG.
3.SYNDESMOTIC LIGAMENT COMPLEX
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11. Chaput tubercle
Wagstaffe tubercle
Volkman
tubercle
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12. Swelling, echymosis, deformity
management of these fractures depends
upon careful identification of the extent of
bony injury as well as soft tissue and
ligamentous damage.
the key to successful outcome following
rotational ankle fractures is anatomic
restoration and healing of ankle mortise.
5/12/2018

13. Otawa ankle rules
X-raysare required
if there is bony painin the malleolar zone
AND anyone of the following:
• Age > 55 yrs
• Inability to bear weight
• Bone tenderness over the posterior edge or
tip of either malleolus.
validated and found to be both cost effective and reliable (up to
100% sensitivity)
5/12/2018

14. • Plain Films
AP & Lateral views
of the ankle
Mortise view - 15
degree internal rotation
Full length
radiograph of leg
when tenderness
of proximal fibula
Foot films when
tender to palpation
5/12/2018

15. An initial evaluation of the radiograph should
1st focus on
•Tibiotalar articulation and access for fibular
shortening
•Widening of joint space
•Malrotation of fibula
•Talar tilt
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16. Identifies
fractures of
◦ malleoli
◦ distal tibia/fibula
◦ plafond
◦ talar dome
◦ body and lateral
process of talus
◦ calcaneous
Ap view
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17. Tibiofibular clear space Tibiofibular overlap
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18. 5/12/2018

19. On the anteroposterior view,
Important note
fibular (lateral) malleolus is
longer than the tibial (medial)
malleolus.
Even minimal displacement or shortening of the lateral
malleolus allows lateral talar shift to occur and may cause
incongruity in the ankle joint, possibly leading to
posttraumatic arthritis.
5/12/2018

20. Quantitative analysis
◦Tibiofibular overlap
◦< 1 0 m m is abnormal - implies
syndesmotic injury
◦Tibiofibular clear space
◦> 5 m m is abnormal - implies
syndesmotic injury
◦Talar tilt
◦> 2 m m is considered abnormal
Comparison with radiographs of the
normal side if there are unresolved
concerns of injury
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21. Taken with ankle in
15 degrees of
internal rotation
Useful in
evaluation of
articular surface
between talar
dome and mortise
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22. Medial clear space
◦ Between lateral border of
medial malleous and
medial talus
◦ <5mm is normal
◦ >5mm suggests lateral
shift of talus
◦ The joint spaces
medial and superior to
talus should be equal5/12/2018

23. Recess in distal fibula
lateral process
of talus
FIBULAR
LENGTH:
1.Shenton’s Line of the ankle
2.The dime test5/12/2018

24. 5/12/2018
TALOCRURAL ANGLE : -
Approximately 83 degrees
and symetrical with
contalateral ankle
Assesment of fibular length

25. •Posterior mallelolar
fractures
•AP talar subluxation
•Distal fibular translation
&/or angulation
•Associated or occult
injuries
–Lateral process talus
–Posterior process talus
–Anterior process calcaneus
5/12/2018

26. The ankle is a ring
◦ Tibial plafond
◦ Medial malleolus
◦ Deltoid ligaments
◦ calcaneous
◦ Lateral collateral ligaments
◦ Lateral malleolus
◦ Syndesmosis
Fracture of single part
usually stable
Fracture > 1 part =
unstable
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27. • Stress Views
– Gravity stress view
– Manual stress views
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When radiographs of the ankle
are normal, stress views are
extremely important in evaluating
ligament injuries .

28. Inversion stress view. (A) For inversion
(adduction)-stress examination of the ankle, the
foot is fixed in the device while the patient is
supine. The pressure plate, positioned
approximately 2 cm above the ankle joint, applies
varus stress adducting the heel. (If the
examination is painful, 5 to 10 mL of 1%
Xylocaine or a similar local anesthetic is injected
at the site of maximum pain.) (B) On the
anteroposterior film, the degree of talar tilt is
measured by the angle formed by lines drawn
along the tibial plafond and the dome of the talus.
The contralateral ankle is subjected to the same
procedure for comparison.
This angle helps diagnose
tears of the lateral collateral
ligament5/12/2018

29. The anterior-draw stress film
for determining injury to the anterior talofibular
ligament
Values of up to 5 mm of
separation between the talus
and the distal tibia are
considered normal
between 5 and 10 mm may be
normal or abnormal, and the
opposite ankle should be
stressed for comparison.
Values above 10 mm always
indicate abnormality.
5/12/2018

30. 5/12/2018
CT- Posterior malleolar fracture pattern
Joint invovement
Pre operative planning
MRI – ligament and tendon injuries
syndesmosis injury

31. • Classification of
ankle fractures
• Pott classification –
Unimalleolar
• bimalleolar
• timalleolar.
• Dennis-weber and AO/OTA
classifications
• Lauge-hansen
classification
5/12/2018

32. 5/12/2018
Dennis –weber classification
describes the injury based on the
location of lateral malleolar fracture
A- below the level of syndesmosis
B- at the level of syndesmosis
C- above the level of syndesmosis
Does not predict the level or presence of syndesmotic injury
Does not address the presence of injury to medial side of ankle
Does not provide robust prognostic information
Good interobserver reliability

33. 5/12/2018
AOclassification divides the three Danis Weber types further for
associated medial injuries
Infrasyndesmotic=44A
Transsyndesmotic=44B
Suprasyndesmotic=44C
v

34. 5/12/2018
c
v
Infrasyndesmotic=44A

35. 5/12/2018
Transsyndesmotic=44B

36. 5/12/2018
Suprasyndesmotic=44C

37. Based on cadaveric study
it employs 2 words and a number
• First word: position of foot at time of injury
• Second word: force applied to foot relative to
tibia at time of injury
Number refers to the progression through
stages of bony and soft tissue injury
5/12/2018

38. 5/12/2018
Types:
Supination External Rotation
Supination Adduction
Pronation External Rotation
Pronation Abduction

39. In each type there are several stages of injury
• Imperfect system:
– Not every fracture fits exactly into one category
– Even mechanismspecific pattern has been
–
questioned
–
Inter and intraobserver variation not ideal
Still useful and widely used
5/12/2018

40. Advantage
• useful for reconstructing the mechanism of
injury a guide for the closed reduction
• Sequential pattern –inference of ligament
injuries
complicated, variable inter observer reliability
doesn’t signify prognosis
doesn’t indicate stability
5/12/2018
Disadvantage

41. 5/12/2018

42. 1
3 2
4
Stage 1 Anterior
tibio- fibular
ligament
Stage 2 Fibula fx
Stage 3 Posterior
malleolus fx or
posterior tibio-
fibular ligament
Stage 4 Deltoid
ligament tear or
medial malleolus
fx5/12/2018

43. Lateral Injury: classic posterosuperioranteroinferior
fibula fracture
Medial: Stability maintained
Standard: Closed management5/12/2018

44. Lateral Injury: classic posterosuperioranteroinferior
fibula fracture
Medial Injury: medial malleolar fracture &*/or deltoid
ligament injury
Standard: Surgical management
5/12/2018

45. GOAL: TO EVALUATE DEEP DELTOID [i.e.
INSTABILITY]
Medial tenderness,
swelling, echymosis
STRESS VIEWS- GRAVITY OR
MANUAL
5/12/2018

46. SER-2
Negative Stress view
External rotation of
foot with ankle in
neutral flexion (00)
+ Stress View
Widened Medial Clear Space
SE-4
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47. • Stage 1: fibula
fracture is transverse
below mortise.
• Stage 2: medial
malleolus fracture is
classic vertical
pattern.
1
2
5/12/2018

48. Lateral Injury: transverse fibular fracture at/below
level of mortise
Medial injury: vertical shear type medial
malleolar fracture BEWARE OF
IMPACTION
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49. • Important to restore:
– Ankle stability
– Articular congruity- including medial
impaction
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50. 5/12/2018

51. Stage 1 Deltoid
ligament tear or
medial malleolus
fx
Stage 2 Anterior
tibio-fibular
ligament and
interosseous
membrane
Stage 3 Spiral,
proximal fibula
fracture
Stage 4 Posterior
malleolus fx or
posterior tibio-
fibular ligament34
1 2
5/12/2018

52. Medial injury: deltoid ligament tear &/or transverse medial
malleolar fracture
Lateral Injury: spiral proximal lateral malleolar fracture
HIGHLY UNSTABLE…SYNDESMOTIC INJURY COMMON
5/12/2018

53. • Must x-ray knee to ankle to assess
injury
• Syndesmosis is disrupted in most cases
– Eponym: Maissoneuve Fracture
• Restore:
– Fibular length and rotation
– Ankle mortise
– Syndesmotic stability
5/12/2018

54. Stage 1 Transverse
medial malleolus fx
distal to mortise
Stage 2 avulsion fx of
tubercle of chaput
or tibio-fibular
ligament
Stage 3 Fibula fracture,
typically proximal to
mortise, often with a
butterfly fragment
1 2
3
5/12/2018

55. Medial injury: tranverse to short oblique medial malleolar
fracture
Lateral Injury: comminuted impaction type distal lateral
malleolar fracture
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56. Function:
Stability- prevents posterior
translation of talus & enhances
syndesmotic stability
Weight bearing- increases
surface area of ankle joint
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57. • Fracture pattern:
– Variable
– Difficult to assess on standard lateral
radiograph
• External rotation lateral view
• CT scan
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58. Type I- posterolateral
oblique type
Type II- medial extension
type
Type III- small shell
67
%
19
%
14
%
5/12/2018

59. FUNCTION:
Stability- resists external rotation, axial,
& lateral displacement of talus
Weight bearing- allows for standard
loading
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60. • Maisonneuve Fracture
– Fracture of proximal fibula
with syndesmotic disruption
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61. 5/12/2018
• Volkmann Fracture
– Fracture of tibial attachment of PITFL
– Posterior malleolar fracture type

62. 5/12/2018
• Tillaux-Chaput Fracture
– Fracture of tibial attachment of AITFL

63. In the Pott fracture, the fibula
is fractured above the intact
distal tibiofibular
syndesmosis, the deltoid
ligament is ruptured, and the
talus is subluxed laterally
5/12/2018
Pott fracture

64. Dupuytren
fracture.
(A) This fracture usually
occurs 2 to 7 cm above the
distal tibiofibular
syndesmosis, with disruption
of the medial collateral
ligament and, typically, tear
of the syndesmosis leading
to ankle instability.
(B) In the low variant, the
fracture occurs more distally
and the tibiofibular ligament
remains intact.
5/12/2018

65. Wagstaffe-LeFort
fracture.
In the Wagstaffe-LeFort
fracture, the medial portion
of the fibula is avulsed at the
insertion of the anterior
tibiofibular ligament. The
ligament, however, remains
intact.
5/12/2018

66. •Collicular
Fractures
–Avulsion fracture of distal
portion of medial malleolus
–Injury may continue and
rupture the deep deltoid
ligament
I
POSTERIOR
COLLICULUS
NTERCOLLICULAR GROOVE
ANTERIOR
COLLICULUS
5/12/2018

67. 5/12/2018
•Bosworth fracture dislocation
–Fibular fracture with posterior dislocation
of proximal fibular segment behind tibia

68. 5/12/2018
Initialmanagement
• Reducethe talus
• If joint unstable - slab
• other options -spanning
external fixator , calcaneal pin
traction.
• Rest,Ice, elevation

69. 5/12/2018
Closed reduction and immobilization
• Stableankle fractures
• Usually with only fibulafractures
• Immobilization in castfor 4-6weeksis the preferred
treatment.

70. 5/12/2018
Indications of surgery
 Inability to obtain or maintain an
anatomic mortise (unstable fracture
pattern)
 Open fractures

71. LateralMalleolarfractures
5/12/2018
• Avoidinjuring the superficial peronealnerve
• Makesurethat distal fibula isfully
out to length
• Laterallycomminuted pronation
abduction patterns aremostdifficult
• Formaximum stability placeplateposteriorly

72. Medialmalleolarfixation
5/12/2018
• 4.0mmpartially threaded screws
• Screwsshouldbe
perpendicular to the
fracture line andparallel
for maximal
compression.
• Spreadtwo screwsfor goodstability
• Usefluoroscopy to besurescrewsare
clearof the joint

73. Deltoidligamenttear
5/12/2018
• Thedeltoid ligament, especially
its deep branch isimportant to
the stability of the ankle
becauseit prevents lateral
displacement and external
rotation of thetalus
• Xray will show displacement and
tilting ofthe talus with
increased medial clearspace
• It isrepaired with
nonabsorbablesutures.

74. 5/12/2018
SyndesmosisFixation
• Syndesmotic instability
after fixation of
malleolus
• Consider if fibula fracture
>4 cm above joint
line &
Maisonneuve’s
fracture
• Havebone hook
on back table to
checkstability

75. Complications following ankle
fractures
5/12/2018
EARLY :- wound infection/ dehiscence
loss of reduction
thromboembolism
LATE: - symptomatic hardware
osteoarthritis
nonunion
compartment syndrome
neuroma

76. 5/12/2018