ANKLE FRACTURE

DIBYENDUNARAYAN BID

ANKLE FRACTURE

• Definition: Ankle #s include #s of the medial and

lateral malleoli as well as the distal articular surfaces of the tibia and fibula.

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ANKLE FRACTURE

#s of the ankle are more specifically described as:

• Isolated lateral malleolar #s (extraarticular; Figures 30-1 and 30-2)

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ANKLE FRACTURE

• Fig. 30-1. Lateral Malleolar Fracture.

Avulsion of the distal portion of the lateral malleolus.

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ANKLE FRACTURE

• Fig. 30-2. Isolated lateral malleolar #.

Oblique # of the lateral malleolus at the level of the ankle mortise.

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ANKLE FRACTURE

• Bimalleolar #s (intraarticular; figures 30-3 & 30-4)

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ANKLE FRACTURE

• Fig. 30-3.

Bimalleolar # of the distal fibula with an oblique # of the medial malleolus.

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ANKLE FRACTURE

• Fig. 30-4. Bimalleolar #/dislocation of the ankle.

Extreme example of a supination / adduction type of ankle # with dislocation of the talus from the tibia. Note the distal transverse fibula # and the vertical shear type medial malleolar #.

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• Medial malleolar #s

(intraarticular; Figures 30-5 & 30-6)

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ANKLE FRACTURE

• Fig. 30-5. Medial Malleolar #.

Note that the medial malleolar # extends into the intraarticular surface of the tibial plafond.

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ANKLE FRACTURE

• Fig. 30-6. Minimally displaced medial malleolar #.

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• Bimalleolar equivalent #s (intraarticular), in which the lateral malleolus is fractured and the medial side of the ankle mortise is widened.

(Fig. 30-7 and 30-8).

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ANKLE FRACTURE

• Fig. 30-7. Bimalleolar equivalent # of the ankle.

Note the oblique # of the fibula at the level of the ankle mortise and the disruption of the deltoid ligament on the medial side of the ankle. (This is equivalent to a medial malleolar #.) Disruption of the medial side in association with a lateral malleolar # often produces a lateral subluxation of the talus under the tibia.

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ANKLE FRACTURE

• Fig. 30-8. Bimalleolar equivalent # of the ankle.

Note the oblique # of the fibula above the level of the ankle mortise and the disruption of the deltoid ligament on the medial side of the ankle, producing a subluxation of the talus laterally under the tibia. The disruption of the deltoid ligament is equivalent to a # of the medial malleolus.

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• Trimalleolar #s (intraarticular), involving the medial and lateral malleolus as well as the posterior aspect of the tibial plafond (posterior malleolus; Fig. 30-9).

• In addition ankle #s may disrupt the distal syndesmosis between the tibia and fibula. All ankle #s involve some ligamentous injury.

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ANKLE FRACTURE

• Fig. 30-9. Trimalleolar #.

Note the # of the lateral malleolus at the level of the ankle joint(1), oblique # of the medial malleolus (2), and # of the posterior malleolus (3), an avulsion # of the posterior tibia.

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Fig. 30-9A, B. Trimalleolar # involving the medial malleolus, lateral malleolus, and posterior malleolus.

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Mechanism of Injury

• Relatively low-energy forces, due to actions such as tripping on or twisting an ankle, are the most common cause of ankle fractures.

• Direct or indirect high energy forces , such as those incurred in motor vehicle accidents, can also cause ankle #s.

• Such #s are often associated with significant soft tissue injuries as well as dislocation of the ankle joint.

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• The pattern of ankle injury depends on the position of the foot at the time of injury, which can be either pronation and supination. The combination of foot position and deforming force provides a characteristic pattern of ankle #.

• The four most common deforming forces (in order of frequency) are:

supination/ external rotation, pronation / external rotation, supination /adduction, and pronation/ abduction (Figs. 30-20, 30-21, 30-22, 30-23, 30-24 and 30-25).

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ANKLE FRACTURE

Fig. 30-20 (far left) Bimalleolar # of the pronation/external rotation type. Note the oblique # of the lateral malleolus above the level of the ankle mortise and the transverse # of the medial malleolus. Also note the lateral subluxation of the talus under the tibia with the associated fibula# above the level of ankle joint, which indicates a rupture of the inferior tibio-fibular syndesmosis. This # requires fixation of the lateral malleolus and medial malleolus and restoration of the syndesmosis.

Fig. 30-21 (left) Bimalleolar # of the ankle with disruption of the inferior tibio-fibular syndesmosis. This is a pronation/external rotation injury. The fibular# is fixed with a lag screw and pin fixation ; the syndesmosis is restored with a syndesmotic screw through the fibular plate.dnbid 20

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ANKLE FRACTURE

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• The body moves on a planted foot , which propagates the injury.

• Twisting produces external rotation.

• Falling to one side produces adduction or abduction injury.

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TREATMENT GOALSORTHOPEDIC OBJECTIVES

• Alignment – The ankle mortise is the joint formed by the surfaces of the

lateral malleolus , tibial plafond, and medial malleolus, which articulates with the underlying dome of the talus.

– Restoration of ankle mortise is of critical importance for pain free weight-bearing across the ankle joint.

– Restoring the position of talus underneath the plafond is also crucial. (Figs. 30-10, 11, & 12)

– Loss of articular congruity by as little as 1 mm in the ankle joint may lead to posttraumatic arthritis and significant long term disability, pain, and limp.

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ANKLE FRACTURE

• Fig. 30-10. Normal ankle (A-P view).

Note the talus lying beneath the distal tibia (tibial plafond).

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ANKLE FRACTURE

• Fig. 30-11. Mortise view of the ankle.

A-P view with the ankle in 20 degrees of internal rotation (oblique view). This view is taken to visualize the ankle mortise, which is formed by the tibial plafond lying over the talus and lateral malleolus.

To confirm the intact joint, a space equivalent to that seen on the mortise view should be visualized between the medial malleolus and talus, tibial plafond and talus, and lateral malleolus and talus.

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ANKLE FRACTURE

• Fig. 30-12. Lateral view of the ankle.

This view is used to visualize #s of the lateral and posterior malleolus.

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ORTHOPEDIC OBJECTIVES

• Stability – Reconstruction of the medial, lateral, and posterior malleoli is

crucial to the static (standing still) and dynamic (walking) stability of ankle joint.

– Reconstitution or healing of ligamentous structures that may have been damaged by a # is also important for the dynamic stability of the ankle and proper distribution of forces during gait.

– This is especially important for a patient with recurrent instability, in which the ligaments may have to be surgically reconstructed. dnbid 28

RHABILITATION OBJECTIVES

• Range of Motion – Restore the full ROM of the ankle joint in all planes.

– Inadequate reduction or stabilization of the ankle joint can lead to significant loss of motion, specifically plantar flexion and dorsiflexion.

– Residual loss of ROM of the tibiotalar joint may increase stress on the subtalar articulation and the midtarsal joints because they compensate for motion lost at the tibiotalar joint.

– (Table 30-1)

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Table 30-1. Ankle Range of Motion

Motion Normal a Functional

Ankle Plantar Flexion

45 20

Ankle dorsiflexion 20 b 10

Foot Inversion 35 10

Foot Eversion 25 10

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RHABILITATION OBJECTIVES

• Muscle Strength – Improve the strength of muscles affected by the fracture or

subsequent immobilization:

• Plantar flexors of the ankle & foot

• Dorsiflexors of the ankle & foot

• Evertors of the foot

• Invertors of the foot

• Functional Goals– Restore gait to its preinjury level.

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• EXPECTED TIME OF BONE HEALING– Extraarticular malleolar (Isolated Lateral Malleolar)

#s; Six to 10 weeks.– Intra articular malleolar (bimalleolar, trimalleolar,

bimalleolar equivalent, and medial malleolar) #s; Eight to 12 weeks.

• EXPECTED DURATION OF REHABILITATION– After cast removal :

• Extraarticular malleolar #s: 12 to 16 weeks.

• Intra articular malleolar #s: 16 to24 weeks.dnbid 32

Methods of Treatment

• Cast

• Open Reduction and Internal Fixation

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• Cast– Biomechanics: Stress sharing device.

– Mode of bone healing: Secondary, with callous formation.

– Indications: – Nondisplaced or minimally displaced malleolar #s can usually be

treated satisfactorily in a non-wt-bearing long leg cast with the ankle in neutral position.

– Isolated #s of the distal fibula may also be treated in this manner or, more commonly, in a short leg cast with wt-bearing as tolerated if there is good pain control.

– Minimally to moderately displaced #s in patients who are not amenable to surgical intervention ay be treated with closed reduction and casting if a satisfactory reduction (maintenance of the ankle mortise) is obtained and the foot can be maintained in a relatively neutral position. The patient needs frequent radiographic monitoring of the reduction until the healing is secure with god callous formation at 3-4 week. If the reduction is lost and re-reduction can not be obtained, an ORIF is necessary (Figs. 30-13, 14).

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ANKLE FRACTURE

• Fig. 30-13. Bimalleolar # treated with cast mobilization.

Note the adequate bony alignment of the fibula and inadequate alignment of the medial malleolus with a gap seen at the # site.

Fracture reduction can not be

maintained in a cast; this patient required open reduction and internal fixation.

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ANKLE FRACTURE

• Fig. 30-14. Stirrup air cast used for the treatment of avulsion #s of the distal fibula to decrease post-injury pain and allow early mobilization.

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Open Reduction and Internal Fixation

Biomechanics: Stress shielding device with rigid fixation (compression); stress sharing system without rigid fixation.

Mode of bone healing: Secondary, with callous formation.

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• Indications:

– Displaced malleolar #s and any syndesmotic disruptions often involve significant subluxation or dislocation of the tibiotalar joint (ankle mortise).

– Anatomic reduction is often difficult to maintain without placing the foot in an extreme position.

– Fractures that are not amenable to close reduction or are inherently anatomically unstable require ORIF utilizing Kirschner wires, screws, or plates to fix the ankle joint rigidly while the bone and soft tissues heal.

– This also allows the patient to be mobilized in a short leg cast, which is markedly less cumbersome and debilitating than a long leg cast.

– It also allows earlier wt-bearing.

(Figs. 30-14, 15, 16, 17, 18, 19, 20, 21,22, 23, 24, 25, 26, 27, 28, and 29). dnbid 38

ANKLE FRACTURE

• Fig. 30-15. Lateral malleolar #s treated with pin fixation, an alternative to plate fixation, although less secure.

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ANKLE FRACTURE

• Fig. 30-16. Medial malleolar #.

Note the transverse # of the medial malleolus, with a displaced and rotated medial malleolar fragment.

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ANKLE FRACTURE

• Fig. 30-17. Medial malleolar # treated with parallel screw fixation.

This is preferred to achieve bony compression across the # site. The screw achieve a lag effect, with the threads at the distal end of the screw obtaining purchase at the proximal side of the #.

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ANKLE FRACTURE

• Fig. 30-18. Oblique medial malleolar # treated with two screws. This fixation is better performed with parallel screws inserted in a lag fashion.

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ANKLE FRACTURE

• Fig. 30-19. Oblique medial malleolar # treated with pin fixation.

Pin fixation is inferior to screw fixation because the lag effect is not achieved across the # site.

Early motion usually is not allowed with pin fixation.

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ANKLE FRACTURE

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ANKLE FRACTURE

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SPECIAL CONSIDERATIONS OF THE FRACTURE

• Age

• Systemic Disease

• Articular Involvement

• Fracture Pattern

• Open Fractures

• Compartment Syndrome

• Tendon and Ligamentous Injuries

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Associated Injury• The dorsalis pedis as well as posterior tibial pulses should be

monitored carefully, and all soft-tissues swelling should be measured and checked every two hours during the first 24 hours to screen for a foot compartment syndrome.

• Increased pain with passive ROM of the toes and decreased sensation are sign associated with compartment syndrome.

• Significant swelling of the foot or ankle can lead to necrosis and loss of soft tissue over the dorsum and particularly the dorsolateral aspect of the foot, potentially requiring soft-tissue skin grafting.

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• Loss of posterior tibial nerve is particularly disabling because that nerve provides sensation to the wt-bearing surface of the foot. ► plantar breakdown, pressure ulcers, etc.

• Injuries to other nerves that cross the ankle are also rare and seen only in high energy injuries. These can result in painful neuromas embedded in scar tissue.

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WEIGHT BEARING

• Gait– Stance Phase

• Heel Strike

• Foot Flat

• Mid-Stance

• Push-Off

– Swing Phase

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TREATMENT• Treatment: Early to Immediate (Day of Injury

to One Week).– Orthopedic & Rehabilitation Considerations

• Physical Examination

• Dangers

• Radiography

• Weight bearing

• ROM

• Muscle Strength

• Functional Activities

• Gait

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Bone Healing• Stability at # site: None

• Stage of Bone Healing: Inflammatory phase. The # hematoma is colonized by inflammatory cells, and debridement of the # begins.

• X-ray: No callus.dnbid 53

• Treatment: Early to Immediate (Day of Injury to One Week).– Methods of Treatment: Specific Aspects

• Cast

• Open Reduction & Internal Fixation

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Prescription

DAY ONE TO ONE WEEK– ROM

• For rigidly fixed #s, AROM at MTP joints and knee joint. No ankle ROM.

• For non-rigidly fixed #s, ROM at MTP joint. No ROM at ankle or knee.

– MUSCLE STRENGTH• No strengthening exercises to ankle or foot. Quadriceps

isometric exercises as tolerated.

– FUNCTIONAL ACTIVITIES• Non wt-bearing stand/pivot transfers and ambulation with

assistive devices.

– WEIGHT BEARING• None, except wt-bearing as tolerated for non displaced distal

fibula #s. dnbid 55

• Treatment: Two Weeks– Orthopedic & Rehabilitation Considerations

• Physical Examination

• Dangers

• Radiography

• Weight bearing

• ROM

• Muscle Strength

• Functional Activities

• Gait

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Bone Healing• Stability at # site: None to minimal.

• Stage of Bone Healing: Beginning of reparative phase. Osteoprogenitor cells differentiate into osteoblasts that lay down woven bone.

• X-ray: No changes noted. Fracture lines are visible; no callus present.

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• Treatment: Two Weeks.– Methods of Treatment: Specific Aspects

• Cast

• Open Reduction & Internal Fixation

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Prescription Two Weeks

• Precautions: Patients treated in long leg cast or external fixator do not have stable #s.

• Range of Motion: For rigidly fixed #s, AROM of the MTP joints & knee joint. No ROM to ankle.

• For non-rigidly fixed #s, AROM of the MTP joints. No ROM of the ankle or knee.

• Muscle Strength: For rigidly fixed #s, isometric exercises of dorsiflexors and plantar flexors of the toes and ankle. No resistive exercises.

• For non-rigidly fixed #s, no strengthening exercises.

• Functional Activities: Non-wt-bearing stand/pivot transfers. Ambulation with assistive devices.

• Weight Bearing: None, except for stable #s of the distal fibula. Toe-touch wt-bearing for rigidly fixed #s.

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Treatment: Four to Six Weeks.Bone Healing

• Stability at # site: Acute #s should be showing bridging callus, and the # is usually stable. However, the strength of this callus, especially with torsional load, is significantly lower than that of normal bone.

• Stage of Bone Healing: Reparative phase. Further organization of the callus and formation of lamellar bone begins.

• X-ray: Bridging callus is visible as a fluffy material on the periosteal surface of cortical bone. For #s rigidly fixed with screws and plates, callus may not be visible and there is a consolidation of # and filling in of lucent lines. Amount of callus deposition is less than that at a midshaft #.

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Prescription Four to Six Weeks

• Precautions: Keep unstable #s or those with limited fixation in a cast or cam walker. Stable #s are out of a cast.

• Range of Motion:

For rigidly fixed #s, AROM of the MTP joints, ankle & knee.

For non-rigidly fixed #s, AROM of the MTP joints. Range the ankle and knee as immobilization device allows.

• Muscle Strength: For rigidly fixed #s, isometric and isotonic exercises to dorsiflexors and plantar flexors of the ankle, evertors and invertors of the ankle and foot. No resistive exercises prescribed. Quadriceps strengthening continued.

For non-rigidly fixed #s, gentle isometric exercises to dorsiflexors and plantar flexors within the cast. No resistive exercises prescribed. Quadriceps strengthening continued.

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• Functional Activities: Non-wt-bearing stand/pivot transfers and ambulation with assistive devices for #s with little evidence of healing. Toe touch to partial wt- bearing with assistive devices for #s showing evidence of healing.

• Weight Bearing: None for #s showing little evidence of healing. Partial wt- bearing for #s that are non-tender to palpation and appear stable on radiography. Wt-bearing as tolerated for nondisplaced distal fibula #s.

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Treatment: Six to Eight WeeksBone Healing

• Stability at # site: With bridging callus, the # is usually stable. The strength of this callus, especially with torsional load, is significantly lower than that of normal bone . Confirm with physical examination.

• Stage of Bone Healing: Reparative phase. Further organization of the callus and formation of lamellar bone continues. This requires further protection to avoid re-fracture.

• X-ray: Bridging callus is visible and indicates increased rigidity. With rigid fixation, less callus is seen and # lines are less distinct. Healing with endosteal bone predominates.

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Prescription

SIX TO EIGHT WEEKS• Precautions: Keep unstable #s or those with limited fixation in

a cast or cam walker. Stable #s are out of a cast.

• Range of Motion:

For rigidly fixed #s, active, active-assistive, and passive ROM in all planes to the ankle and subtalar joint.

For non-rigidly fixed #s, begin active and active-assistive ROM to the ankle and subtalar joints. Patients still in a cast may actively range the MTP joints and try to actively range the ankle in their casts.

• Muscle Strength: For rigidly and non-rigidly fixed #s, begin resistive exercises to the dorsiflexors & plantar flexors as well as invertors & evertors of the ankle.

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Prescription

SIX TO EIGHT WEEKS

• Functional Activities: For rigidly fixed #s, partial to full wt-bearing with

assistive devices for #s showing evidence of healing. Use assistive devices as necessary.

For non-rigidly fixed #s, toe touch to partial wt-bearing using assistive devices for transfers and ambulation.

• Weight Bearing: Partial to full wt-bearing.

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Treatment: Eight to Twelve Weeks

Bone Healing• Stability at # site: Stable, except for the most

comminuted #s.

• Stage of bone healing: Remodeling phase. Woven bone is replaced with lamellar bone. The process of remodeling takes months to years for completion.

• X-ray: Rigidly fixed bones should show a disappearance of the # line. #s treated in a cast show a small amount of fluffy callus at the medial malleolus and along the shaft of the distal fibula.

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Prescription

Eight to Twelve Weeks• Precautions: Essentially none.

• ROM:

– For rigidly fixed #s, active, active-assistive, and passive ROM in all planes to the ankle and subtalar joint.

– For non-rigidly fixed #s, begin active and active-assistive ROM of the ankle and subtalar joints. Any patient still in a cast may actively range the MTP joints and try to actively range the ankle within the cast.

• Muscle Strength:

– For rigidly fixed #s, progress from partial to full wt-bearing as tolerated for transfers and ambulation, using assistive devices as necessary.

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Prescription

Eight to Twelve Weeks• Functional activities:

– For rigidly fixed #s, progress from partial to full wt-bearing as tolerated for transfers and ambulation, using assistive devices as necessary.

– For non-rigidly fixed #s, begin partial wt-bearing . Assistive devices required for transfers and ambulation.

• Weight Bearing: Partial to full wt-bearing.

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LONG TERM CONSIDERATIONS AND PROBLEMS

• Patients who have not had rigid fixation may still have limited ankle ROM. Active-assisted and passive ROM should be instituted.

• Progressive resistive exercises should be added to strengthen the ankle musculature.

• Plyometric exercises such as jumping and hopping are not necessary for functional ambulation for ADL.

• For athletes who want to improve their strength and performance, plyometric and high performance exercises are prescribed at a later stage of rehabilitation.

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LONG TERM CONSIDERATIONS AND PROBLEMS

• #s of the ankle usually involve some amount injury to the articular cartilage of the tibial plafond and the talar dome.

• This can result in traumatic arthritis, producing long term chronic disability that may permanently affect the patients ability to work & perform other activities of daily living.

• Early degenerative changes that progress to significant ankle pain may eventually require fusion or total joint replacement if the discomfort is great.

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LONG TERM CONSIDERATIONS AND PROBLEMS

• Appropriate reduction of both the ankle mortise and the distal tibiofibular syndesmosis is crucial for a patient to have normal function at the tibiotalar joint.

• Patients whose disruption is not recognized until after bony consolidation has begun and reduction is not possible, or if reduction and stabilization are inadequate, may have significant ankle pain because of the instability at the ankle joint.

• This affects the gait and causes ankle discomfort when the patient bears wt on that extremity because of the additional strains placed on the soft tissues, tendons, and articular surfaces.

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LONG TERM CONSIDERATIONS AND PROBLEMS

• Severe long term injuries to the ankle can also have long term sequelae.

• Particularly on the lateral side, recurrent instability of the lateral collateral ligament complex (which includes ATFL, CFL, & PTFL) and the turning of the ankle may cause repeated ankle sprains & damage to the articular cartilage of the tibiotalar articulation.

• Patients with lateral ankle ligamentous injury may need secondary repair to maintain the integrity of their ankle joint (Fig. 30-30).

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LONG TERM CONSIDERATIONS AND PROBLEMS

• Proprioception training must be instituted for all patients, especially athletes.

• Ankle taping, high top shoes, and mastering balance on one leg are important to aid in re-establishing the reflex response necessary to avoid further injury in high-performance sports.

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THE END

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