lower extremity trauma m4 student clerkship unmc orthopaedic surgery department of orthopaedic...
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Lower Extremity Lower Extremity TraumaTrauma
M4 Student ClerkshipM4 Student Clerkship
UNMC Orthopaedic SurgeryUNMC Orthopaedic Surgery
Department of Orthopaedic Surgeryand Rehabilitation
Lower Extremity TraumaLower Extremity Trauma
Hip Fractures / DislocationsHip Fractures / Dislocations Femur FracturesFemur Fractures Patella FracturesPatella Fractures Knee DislocationsKnee Dislocations Tibia FracturesTibia Fractures Ankle FracturesAnkle Fractures
Hip FracturesHip Fractures
Hip DislocationsHip Dislocations Femoral Head FracturesFemoral Head Fractures Femoral Neck FracturesFemoral Neck Fractures Intertrochanteric FracturesIntertrochanteric Fractures Subtrochanteric FracturesSubtrochanteric Fractures
250,000 Hip fractures annually250,000 Hip fractures annually– Expected to double by 2050Expected to double by 2050
At risk populationsAt risk populations– Elderly: poor balance & vision, Elderly: poor balance & vision,
osteoporosis, inactivity, medications, osteoporosis, inactivity, medications, malnutritionmalnutrition
– Young: high energy traumaYoung: high energy trauma
EpidemiologyEpidemiology
Hip DislocationsHip Dislocations
Significant trauma, usually Significant trauma, usually MVAMVA
Posterior: Hip flexion, IR, AddPosterior: Hip flexion, IR, Add Anterior: Extreme ER, Anterior: Extreme ER,
Abd/FlexAbd/Flex
Hip DislocationsHip Dislocations
Emergent Treatment: Closed ReductionEmergent Treatment: Closed Reduction– Dislocated hip is an emergencyDislocated hip is an emergency– Goal is to reduce risk of AVN and DJDGoal is to reduce risk of AVN and DJD– Allows restoration of flow through occluded Allows restoration of flow through occluded
or compressed vesselsor compressed vessels– Literature supports decreased AVN with Literature supports decreased AVN with
earlier reductionearlier reduction– Requires proper anesthesiaRequires proper anesthesia– Requires “team” (i.e. more than one person)Requires “team” (i.e. more than one person)
Hip DislocationsHip Dislocations
Emergent Treatment: Closed ReductionEmergent Treatment: Closed Reduction– General anesthesia with muscle relaxation General anesthesia with muscle relaxation
facilitates reduction, but is not necessaryfacilitates reduction, but is not necessary– Conscious sedation is acceptableConscious sedation is acceptable– Attempts at reduction with inadequate Attempts at reduction with inadequate
analgesia/ sedation will cause unnecessary analgesia/ sedation will cause unnecessary pain, cause muscle spasm, and make pain, cause muscle spasm, and make subsequent attempts at reduction more subsequent attempts at reduction more difficultdifficult
Hip DislocationsHip Dislocations Emergent Treatment: Emergent Treatment:
Closed Reduction Closed Reduction Allis ManeuverAllis Maneuver
– Assistant stabilizes pelvis Assistant stabilizes pelvis with pressure on ASISwith pressure on ASIS
– Surgeon stands on Surgeon stands on stretcher and gently stretcher and gently flexes hip to 90deg, flexes hip to 90deg, applies progressively applies progressively increasing traction to the increasing traction to the extremity with gentle extremity with gentle adduction and internal adduction and internal rotationrotation
– Reduction can often be Reduction can often be seen and feltseen and felt
Insert hip ReductionPicture
Hip DislocationsHip Dislocations
Following Closed ReductionFollowing Closed Reduction– Check stability of hip to 90deg flexionCheck stability of hip to 90deg flexion– Repeat AP pelvisRepeat AP pelvis– Judet views of pelvis (if acetabulum fx)Judet views of pelvis (if acetabulum fx)– CT scan with thin cuts through acetabulumCT scan with thin cuts through acetabulum– R/O bony fragments within hip joint R/O bony fragments within hip joint
(indication for emergent OR trip to remove (indication for emergent OR trip to remove incarcerated fragment of bone)incarcerated fragment of bone)
Hip DislocationsHip Dislocations
Following Closed ReductionFollowing Closed Reduction– No flexion > 60deg (Hip Precautions)No flexion > 60deg (Hip Precautions)– Early mobilization with PT/OTEarly mobilization with PT/OT– TTWB for 4-6 weeksTTWB for 4-6 weeks– MRI at 3 months (follow risk of AVN)MRI at 3 months (follow risk of AVN)
Femoral Head FracturesFemoral Head Fractures
Concurrent with hip dislocation due Concurrent with hip dislocation due to shear injuryto shear injury
Femoral Head FracturesFemoral Head Fractures
Pipkin ClassificationPipkin Classification– I: Fracture inferior to foveaI: Fracture inferior to fovea– II: Fracture superior to foveaII: Fracture superior to fovea– III: Femoral head + acetabulum fractureIII: Femoral head + acetabulum fracture– IV: Femoral head + femoral neck fractureIV: Femoral head + femoral neck fracture
Treatment OptionsTreatment Options– Type IType I
Nonoperative: non-displacedNonoperative: non-displaced ORIF if displacedORIF if displaced
– Type II: ORIFType II: ORIF– Type III: ORIF of both fracturesType III: ORIF of both fractures– Type IV: ORIF vs. hemiarthroplastyType IV: ORIF vs. hemiarthroplasty
Femoral Head FracturesFemoral Head Fractures
Femoral Neck FracturesFemoral Neck Fractures
Garden ClassificationGarden Classification– I Valgus impacted I Valgus impacted – II Non-displacedII Non-displaced– III Complete: III Complete:
Partially DisplacedPartially Displaced– IV Complete: Fully IV Complete: Fully
DisplacedDisplaced Functional Functional
ClassificationClassification– Stable (I/II)Stable (I/II)– Unstable (III/IV)Unstable (III/IV)
I II
III IV
Treatment OptionsTreatment Options– Non-operativeNon-operative
Very limited roleVery limited role Activity modificationActivity modification Skeletal tractionSkeletal traction
– OperativeOperative ORIFORIF Hemiarthroplasty (Endoprosthesis)Hemiarthroplasty (Endoprosthesis) Total Hip ReplacementTotal Hip Replacement
Femoral Neck FracturesFemoral Neck Fractures
ORIF
Hemi
THR
Femoral Neck FracturesFemoral Neck Fractures
Young PatientsYoung Patients– Urgent ORIF (<6hrs)Urgent ORIF (<6hrs)
Elderly PatientsElderly Patients– ORIF possible (higher risk AVN, non-ORIF possible (higher risk AVN, non-
union, and failure of fixation)union, and failure of fixation)– HemiarthroplastyHemiarthroplasty– Total Hip ReplacementTotal Hip Replacement
Intertrochanteric Hip FxIntertrochanteric Hip Fx
Intertrochanteric Intertrochanteric Femur FractureFemur Fracture– Extra-capsular Extra-capsular
femoral neck femoral neck – To inferior border To inferior border
of the lesser of the lesser trochantertrochanter
Intertrochanteric Hip FxIntertrochanteric Hip Fx
Intertrochanteric Intertrochanteric Femur FractureFemur Fracture– Physical Findings: Physical Findings:
Shortened / ER PostureShortened / ER Posture– Obtain Xrays: AP Pelvis, Obtain Xrays: AP Pelvis,
Cross table lateralCross table lateral
ClassificationClassification– # of parts: Head/Neck, GT, LT, Shaft# of parts: Head/Neck, GT, LT, Shaft– StableStable
Resists medial & compressive Loads after fixationResists medial & compressive Loads after fixation
– UnstableUnstable Collapses into varus or shaft medializes despite Collapses into varus or shaft medializes despite
anatomic reduction with fixationanatomic reduction with fixation
– Reverse ObliquityReverse Obliquity
Intertrochanteric Hip FxIntertrochanteric Hip Fx
Stable ReverseObliquity
Unstable
Intertrochanteric Hip FxIntertrochanteric Hip Fx
Intertrochanteric Hip FxIntertrochanteric Hip Fx
Treatment OptionsTreatment Options– Stable: Dynamic Hip Screw (2-hole)Stable: Dynamic Hip Screw (2-hole)– Unstable/Reverse: IM Recon NailUnstable/Reverse: IM Recon Nail
Subtrochanteric Femur FxSubtrochanteric Femur Fx
ClassificationClassification– Located from LT to 5cm Located from LT to 5cm
distal into shaftdistal into shaft– Intact Piriformis Fossa?Intact Piriformis Fossa?
TreatmentTreatment– IM Nail IM Nail – Cephalomedullary IM Cephalomedullary IM
NailNail– ORIFORIF
Femoral Shaft FxFemoral Shaft Fx Type 0 - No comminutionType 0 - No comminution Type 1 - Insignificant butterfly Type 1 - Insignificant butterfly
fragment with transverse or fragment with transverse or short oblique fractureshort oblique fracture
Type 2 - Large butterfly of less Type 2 - Large butterfly of less than 50% of the bony width, > than 50% of the bony width, > 50% of cortex intact50% of cortex intact
Type 3 - Larger butterfly leaving Type 3 - Larger butterfly leaving less than 50% of the cortex in less than 50% of the cortex in contactcontact
Type 4 - Segmental Type 4 - Segmental comminutioncomminution
Winquist and Hansen Winquist and Hansen 66A, 198466A, 1984
Treatment OptionsTreatment Options– IM Nail with locking screwsIM Nail with locking screws– ORIF with plate/screw constructORIF with plate/screw construct– External fixationExternal fixation– Consider traction pin if prolonged delay Consider traction pin if prolonged delay
to surgeryto surgery
Femoral Shaft FxFemoral Shaft Fx
Distal Femur FracturesDistal Femur Fractures
Distal Metaphyseal Distal Metaphyseal FracturesFractures
Look for intra-articular Look for intra-articular involvementinvolvement
Plain filmsPlain films CTCT
Distal Femur FracturesDistal Femur Fractures
Treatment:Treatment:– Retrograde IM NailRetrograde IM Nail– ORIF open vs. ORIF open vs.
MIPOMIPO– Above depends on Above depends on
fracture type, fracture type, bone quality, and bone quality, and fracture locationfracture location
High association of injuriesHigh association of injuries– Ligamentous InjuryLigamentous Injury
ACL, PCL, Posterolateral CornerACL, PCL, Posterolateral Corner LCL, MCLLCL, MCL
– Vascular InjuryVascular Injury Intimal tear vs. DisruptionIntimal tear vs. Disruption Obtain ABI’s Obtain ABI’s (+) (+) Arteriogram Arteriogram Vascular surgery consult with Vascular surgery consult with
repair within 8hrsrepair within 8hrs
– Peroneal >> Tibial N. injuryPeroneal >> Tibial N. injury
Knee DislocationsKnee Dislocations
Patella FracturesPatella Fractures HistoryHistory
– MVA, fall onto knee, MVA, fall onto knee, eccentric loadingeccentric loading
Physical ExamPhysical Exam– Ability to perform straight Ability to perform straight
leg raise against gravity (ie, leg raise against gravity (ie, extensor mechanism still extensor mechanism still intact?)intact?)
– Pain, swelling, contusions, Pain, swelling, contusions, lacerations and/or abrasions lacerations and/or abrasions at the site of injuryat the site of injury
– Palpable defectPalpable defect
Patella FracturesPatella Fractures
RadiographsRadiographs– AP/Lateral/Sunrise viewsAP/Lateral/Sunrise views
TreatmentTreatment– ORIF if ext mechanism ORIF if ext mechanism
is incompetentis incompetent– Non-operative Non-operative
treatment with brace if treatment with brace if ext mechanism remains ext mechanism remains intactintact
Tibia FracturesTibia Fractures
Proximal Tibia Fractures (Tibial Proximal Tibia Fractures (Tibial Plateau)Plateau)
Tibial Shaft FracturesTibial Shaft Fractures Distal Tibia Fractures (Tibial Distal Tibia Fractures (Tibial
Pilon/Plafond)Pilon/Plafond)
Tibial Plateau FracturesTibial Plateau Fractures
MVA, fall from height, sporting injuriesMVA, fall from height, sporting injuries Mechanism and energy of injury plays a Mechanism and energy of injury plays a
major role in determining orthopedic major role in determining orthopedic carecare
Examine soft tissues, neurologic exam Examine soft tissues, neurologic exam (peroneal N.), vascular exam (esp with (peroneal N.), vascular exam (esp with medial plateau injuries)medial plateau injuries)
Be aware for compartment syndromeBe aware for compartment syndrome Check for knee ligamentous instabilityCheck for knee ligamentous instability
Tibial Plateau FracturesTibial Plateau Fractures
Xrays: AP/Lateral +/- traction filmsXrays: AP/Lateral +/- traction films CT scan (after ex-fix if appropriate)CT scan (after ex-fix if appropriate)
Schatzker Classification of Plateau Schatzker Classification of Plateau FxsFxs
Lower Energy
Higher Energy
Tibial Plateau FracturesTibial Plateau Fractures
TreatmentTreatment– Spanning External Spanning External
Fixator may be Fixator may be appropriate for appropriate for temporary temporary stabilization and to stabilization and to allow for resolution allow for resolution of soft tissue of soft tissue injuriesinjuries
Insert blisterPics of ex-fix here
Tibial Plateau FracturesTibial Plateau Fractures
TreatmentTreatment– Definitive ORIF for Definitive ORIF for
patients with patients with varus/valgus varus/valgus instability, >5mm instability, >5mm articular stepoff articular stepoff
– Non-operative in Non-operative in non-displaced stable non-displaced stable fractures or patients fractures or patients with poor surgical with poor surgical risksrisks
Tibial Shaft FracturesTibial Shaft Fractures
Mechanism of InjuryMechanism of Injury– Can occur in lower energy, torsion type Can occur in lower energy, torsion type
injury (e.g., skiing)injury (e.g., skiing)– More common with higher energy More common with higher energy
direct force (e.g., car bumper)direct force (e.g., car bumper)– Open fractures of the tibia are more Open fractures of the tibia are more
common than in any other long bonecommon than in any other long bone
Tibial Shaft FracturesTibial Shaft Fractures
Open Tibia FxOpen Tibia Fx PrioritiesPriorities
– ABC’SABC’S– Associated InjuriesAssociated Injuries– TetanusTetanus– AntibioticsAntibiotics– FixationFixation
Johner and Wruh’s ClassificationJohner and Wruh’s Classification
Tibial Shaft FracturesTibial Shaft Fractures Gustilo and Anderson Classification of Gustilo and Anderson Classification of
Open FxOpen Fx– Grade 1Grade 1
<1cm, minimal muscle contusion, usually <1cm, minimal muscle contusion, usually inside out mechanisminside out mechanism
– Grade 2Grade 2 1-10cm, extensive soft tissue damage1-10cm, extensive soft tissue damage
– Grade 3Grade 3 3a: >10cm, adequate bone coverage3a: >10cm, adequate bone coverage 3b: >10cm, periosteal stripping requiring 3b: >10cm, periosteal stripping requiring
flap advancement or free flapflap advancement or free flap 3c: vascular injury requiring repair3c: vascular injury requiring repair
Tibial Shaft FracturesTibial Shaft Fractures Tscherne Classification of Soft Tissue Tscherne Classification of Soft Tissue
InjuryInjury– Grade 0- negligible soft tissue injuryGrade 0- negligible soft tissue injury– Grade 1- superficial abrasion or contusionGrade 1- superficial abrasion or contusion– Grade 2- deep contusion from direct traumaGrade 2- deep contusion from direct trauma– Grade 3- Extensive contusion and crush injury Grade 3- Extensive contusion and crush injury
with possible severe muscle injurywith possible severe muscle injury
Management of Open Fx Management of Open Fx Soft TissuesSoft Tissues– ERER: initial evaluation : initial evaluation
wound covered with wound covered with sterile dressing and leg sterile dressing and leg splinted, tetanus splinted, tetanus prophylaxis and prophylaxis and appropriate antibioticsappropriate antibiotics
– OROR: Thorough I&D : Thorough I&D undertaken within 6 hours undertaken within 6 hours with serial debridements with serial debridements as warranted followed by as warranted followed by definitive soft tissue definitive soft tissue covercover
Tibial Shaft FracturesTibial Shaft Fractures
Tibial Shaft FracturesTibial Shaft Fractures Definitive Soft Tissue CoverageDefinitive Soft Tissue Coverage
– Proximal third tibia fractures can be covered Proximal third tibia fractures can be covered with gastrocnemius rotation flapwith gastrocnemius rotation flap
– Middle third tibia fractures can be covered Middle third tibia fractures can be covered with soleus rotation flapwith soleus rotation flap
– Distal third fractures usually require free flap Distal third fractures usually require free flap for coveragefor coverage
Tibial Shaft FracturesTibial Shaft Fractures Treatment OptionsTreatment Options
– IM NailIM Nail– ORIF with PlatesORIF with Plates– External FixationExternal Fixation– Cast or Cast-BraceCast or Cast-Brace
Advantages of IM nailingAdvantages of IM nailing– Lower non-union rateLower non-union rate– Smaller incisionsSmaller incisions– Earlier weightbearing and Earlier weightbearing and
functionfunction– Single surgerySingle surgery
Tibial Shaft FracturesTibial Shaft Fractures
IM nailing of IM nailing of distal and distal and proximal fxproximal fx– Can be done but Can be done but
requires requires additional additional planning, special planning, special nails, and nails, and advanced advanced techniquestechniques
Tibial Shaft FracturesTibial Shaft Fractures
Fractures involving distal tibia Fractures involving distal tibia metaphysis and into the ankle jointmetaphysis and into the ankle joint
Soft tissue management is key!Soft tissue management is key! Often occurs from fall from height or Often occurs from fall from height or
high energy injuries in MVAhigh energy injuries in MVA ““Excellent” results are rare, “Fair to Excellent” results are rare, “Fair to
Good” is the norm outcomeGood” is the norm outcome Multiple potential complicationsMultiple potential complications
Tibial Pilon FracturesTibial Pilon Fractures
Initial EvaluationInitial Evaluation– Plain films, CT scanPlain films, CT scan– Spanning External FixatorSpanning External Fixator– Delayed Definitive Care to protect soft Delayed Definitive Care to protect soft
tissues and allow for soft tissue swelling tissues and allow for soft tissue swelling to resolveto resolve
Tibial Pilon FracturesTibial Pilon Fractures
Tibial Pilon FracturesTibial Pilon Fractures
Treatment GoalsTreatment Goals– Restore Articular SurfaceRestore Articular Surface– Minimize Soft Tissue InjuryMinimize Soft Tissue Injury– Establish LengthEstablish Length– Avoid Varus CollapseAvoid Varus Collapse
Treatment OptionsTreatment Options– IM nail with limited ORIFIM nail with limited ORIF– ORIFORIF– External FixatorExternal Fixator
Tibial Pilon FracturesTibial Pilon Fractures
ComplicationsComplications– Mal or Non-union (Varus)Mal or Non-union (Varus)– Soft Tissue ComplicationsSoft Tissue Complications– InfectionInfection– Potential AmputationPotential Amputation
Ankle FracturesAnkle Fractures Most common weight-Most common weight-
bearing skeletal injurybearing skeletal injury Incidence of ankle fractures Incidence of ankle fractures
has doubled since the has doubled since the 1960’s1960’s
Highest incidence in elderly Highest incidence in elderly womenwomen– Unimalleolar Unimalleolar 68%68%– Bimalleolar Bimalleolar 25%25%– TrimalleolarTrimalleolar 7% 7%– OpenOpen 2% 2%
Osseous AnatomyOsseous Anatomy
Lateral Ligamentous Lateral Ligamentous AnatomyAnatomy
Medial Ligamentous AnatomyMedial Ligamentous Anatomy
Syndesmosis AnatomySyndesmosis Anatomy
Ankle FracturesAnkle Fractures HistoryHistory
– Mechanism of injuryMechanism of injury– Time elapsed since the injuryTime elapsed since the injury– Soft-tissue injurySoft-tissue injury– Has the patient ambulated on Has the patient ambulated on
the ankle?the ankle?– Patient’s age / bone qualityPatient’s age / bone quality– Associated injuriesAssociated injuries– Comorbidities (DM, smoking)Comorbidities (DM, smoking)
Ankle FracturesAnkle Fractures Physical ExamPhysical Exam
– Neurovascular exam Neurovascular exam – Note obvious deformitiesNote obvious deformities– Pain over the medial or lateral Pain over the medial or lateral
malleolimalleoli– Palpation of ligaments about the Palpation of ligaments about the
ankleankle– Palpation of proximal fibula, Palpation of proximal fibula,
lateral process of talus, base of lateral process of talus, base of 55thth MT MT
– Examine the hindfoot and Examine the hindfoot and forefootforefoot
Ankle FracturesAnkle Fractures
Radiographic StudiesRadiographic Studies– AP, Lateral, Mortise of Ankle (Weight AP, Lateral, Mortise of Ankle (Weight
Bearing if possible)Bearing if possible)– AP, Lateral of Knee (Maissaneve injury)AP, Lateral of Knee (Maissaneve injury)– AP, Lateral, Oblique of Foot (if painful)AP, Lateral, Oblique of Foot (if painful)
AP AnkleAP Ankle– Tibiofibular overlapTibiofibular overlap
<10mm is abnormal <10mm is abnormal and implies and implies syndesmotic injurysyndesmotic injury
– Tibiofibular clear Tibiofibular clear space space >5mm is abnormal - >5mm is abnormal -
implies syndesmotic implies syndesmotic injuryinjury
– Talar tiltTalar tilt >2mm is considered >2mm is considered
abnormalabnormal
Ankle FracturesAnkle Fractures
Ankle Mortise ViewAnkle Mortise View– Foot is internally Foot is internally
rotated and AP rotated and AP projection is performed projection is performed
– Abnormal findings:Abnormal findings: Medial joint space Medial joint space
wideningwidening Talocural angle Talocural angle <8<8 or or
>15>15 degrees ( degrees (compare to compare to normal sidenormal side))
Tibia/fibula overlap Tibia/fibula overlap <1mm<1mm
Ankle FracturesAnkle Fractures
Lateral ViewLateral View– Posterior malleolar Posterior malleolar
fracturesfractures– Anterior/posterior Anterior/posterior
subluxation of the subluxation of the talus under the tibiatalus under the tibia
– Displacement/Displacement/Shortening of distal Shortening of distal fibulafibula
– Associated injuriesAssociated injuries
Ankle FracturesAnkle Fractures
Ankle FracturesAnkle Fractures Classification Systems (Lauge-Hansen)Classification Systems (Lauge-Hansen)
– Based on cadaveric studyBased on cadaveric study– First word refers to position of foot at time of First word refers to position of foot at time of
injuryinjury– Second word refers to force applied to foot Second word refers to force applied to foot
relative to tibia at time of injuryrelative to tibia at time of injury
Ankle FracturesAnkle Fractures Classification Systems (Weber-Danis)Classification Systems (Weber-Danis)
– A: Fibula Fracture distal to mortiseA: Fibula Fracture distal to mortise– B: Fibula Fracture at the level of the B: Fibula Fracture at the level of the
mortisemortise– C: Fibula Fracture proximal to mortiseC: Fibula Fracture proximal to mortise
Ankle FracturesAnkle Fractures
Initial ManagementInitial Management– Closed reduction (conscious Closed reduction (conscious
sedation may be necessary)sedation may be necessary)– AO splintAO splint– Delayed fixation until soft Delayed fixation until soft
tissues stabletissues stable– Pain controlPain control– Monitor for possible Monitor for possible
compartment syndrome in high compartment syndrome in high energy injuriesenergy injuries
Ankle FracturesAnkle Fractures Indications for non-operative care:Indications for non-operative care:
– Nondisplaced fracture with intact syndesmosis Nondisplaced fracture with intact syndesmosis and stable mortiseand stable mortise
– Less than 3 mm displacement of the isolated Less than 3 mm displacement of the isolated fibula fracture with no medial injuryfibula fracture with no medial injury
– Patient whose overall condition is unstable and Patient whose overall condition is unstable and would not tolerate an operative procedurewould not tolerate an operative procedure
ManagementManagement::– WBAT in short leg cast or CAM boot for 4-6 weeksWBAT in short leg cast or CAM boot for 4-6 weeks– Repeat x-ray at 7–10 days to r/o interval Repeat x-ray at 7–10 days to r/o interval
displacementdisplacement
Ankle FracturesAnkle Fractures Indications for operative Indications for operative
care:care:– Bimalleolar fracturesBimalleolar fractures– Trimalleolar fracturesTrimalleolar fractures– Talar subluxationTalar subluxation– Articular impaction injuryArticular impaction injury– Syndesmotic injurySyndesmotic injury
Beware the painful ankle with Beware the painful ankle with no ankle fracture but a no ankle fracture but a widened mortise… check widened mortise… check knee films to rule out knee films to rule out Maissoneuve Syndesmosis Maissoneuve Syndesmosis injury.injury.
Ankle FracturesAnkle Fractures
ORIF:ORIF:– FibulaFibula
Lag Screw if possible + PlateLag Screw if possible + Plate Confirm length/rotationConfirm length/rotation
– Medial MalleolusMedial Malleolus Open reduceOpen reduce 4-0 cancellous screws vs. tension 4-0 cancellous screws vs. tension
bandband
– Posterior MalleolusPosterior Malleolus Fix if >30% of articular surface Fix if >30% of articular surface
– SyndesmosisSyndesmosis Stress after fixationStress after fixation Fix with 3 or 4 cortex screwsFix with 3 or 4 cortex screws
Ankle FracturesAnkle Fractures Most common weight-Most common weight-
bearing skeletal injurybearing skeletal injury Incidence of ankle fractures Incidence of ankle fractures
has doubled since the has doubled since the 1960’s1960’s
Highest incidence in elderly Highest incidence in elderly womenwomen– Unimalleolar Unimalleolar 68%68%– Bimalleolar Bimalleolar 25%25%– TrimalleolarTrimalleolar 7% 7%– OpenOpen 2% 2%
Osseous AnatomyOsseous Anatomy
Lateral Ligamentous Lateral Ligamentous AnatomyAnatomy
Medial Ligamentous AnatomyMedial Ligamentous Anatomy
Syndesmosis AnatomySyndesmosis Anatomy
Ankle FracturesAnkle Fractures HistoryHistory
– Mechanism of injuryMechanism of injury– Time elapsed since the injuryTime elapsed since the injury– Soft-tissue injurySoft-tissue injury– Has the patient ambulated on Has the patient ambulated on
the ankle?the ankle?– Patient’s age / bone qualityPatient’s age / bone quality– Associated injuriesAssociated injuries– Comorbidities (DM, smoking)Comorbidities (DM, smoking)
Ankle FracturesAnkle Fractures Physical ExamPhysical Exam
– Neurovascular exam Neurovascular exam – Note obvious deformitiesNote obvious deformities– Pain over the medial or lateral Pain over the medial or lateral
malleolimalleoli– Palpation of ligaments about the Palpation of ligaments about the
ankleankle– Palpation of proximal fibula, Palpation of proximal fibula,
lateral process of talus, base of lateral process of talus, base of 55thth MT MT
– Examine the hindfoot and Examine the hindfoot and forefootforefoot
Ankle FracturesAnkle Fractures
Radiographic StudiesRadiographic Studies– AP, Lateral, Mortise of Ankle (Weight AP, Lateral, Mortise of Ankle (Weight
Bearing if possible)Bearing if possible)– AP, Lateral of Knee (Maissaneve injury)AP, Lateral of Knee (Maissaneve injury)– AP, Lateral, Oblique of Foot (if painful)AP, Lateral, Oblique of Foot (if painful)
AP AnkleAP Ankle– Tibiofibular overlapTibiofibular overlap
<10mm is abnormal <10mm is abnormal and implies and implies syndesmotic injurysyndesmotic injury
– Tibiofibular clear Tibiofibular clear space space >5mm is abnormal - >5mm is abnormal -
implies syndesmotic implies syndesmotic injuryinjury
– Talar tiltTalar tilt >2mm is considered >2mm is considered
abnormalabnormal
Ankle FracturesAnkle Fractures
Ankle Mortise ViewAnkle Mortise View– Foot is internally Foot is internally
rotated and AP rotated and AP projection is performed projection is performed
– Abnormal findings:Abnormal findings: Medial joint space Medial joint space
wideningwidening Talocural angle Talocural angle <8<8 or or
>15>15 degrees ( degrees (compare to compare to normal sidenormal side))
Tibia/fibula overlap Tibia/fibula overlap <1mm<1mm
Ankle FracturesAnkle Fractures
Lateral ViewLateral View– Posterior malleolar Posterior malleolar
fracturesfractures– Anterior/posterior Anterior/posterior
subluxation of the subluxation of the talus under the tibiatalus under the tibia
– Displacement/Displacement/Shortening of distal Shortening of distal fibulafibula
– Associated injuriesAssociated injuries
Ankle FracturesAnkle Fractures
Ankle FracturesAnkle Fractures Classification Systems (Lauge-Hansen)Classification Systems (Lauge-Hansen)
– Based on cadaveric studyBased on cadaveric study– First word refers to position of foot at time of First word refers to position of foot at time of
injuryinjury– Second word refers to force applied to foot Second word refers to force applied to foot
relative to tibia at time of injuryrelative to tibia at time of injury
Ankle FracturesAnkle Fractures Classification Systems (Weber-Danis)Classification Systems (Weber-Danis)
– A: Fibula Fracture distal to mortiseA: Fibula Fracture distal to mortise– B: Fibula Fracture at the level of the B: Fibula Fracture at the level of the
mortisemortise– C: Fibula Fracture proximal to mortiseC: Fibula Fracture proximal to mortise
Ankle FracturesAnkle Fractures
Initial ManagementInitial Management– Closed reduction (conscious Closed reduction (conscious
sedation may be necessary)sedation may be necessary)– AO splintAO splint– Delayed fixation until soft Delayed fixation until soft
tissues stabletissues stable– Pain controlPain control– Monitor for possible Monitor for possible
compartment syndrome in high compartment syndrome in high energy injuriesenergy injuries
Ankle FracturesAnkle Fractures Indications for non-operative care:Indications for non-operative care:
– Nondisplaced fracture with intact syndesmosis Nondisplaced fracture with intact syndesmosis and stable mortiseand stable mortise
– Less than 3 mm displacement of the isolated Less than 3 mm displacement of the isolated fibula fracture with no medial injuryfibula fracture with no medial injury
– Patient whose overall condition is unstable and Patient whose overall condition is unstable and would not tolerate an operative procedurewould not tolerate an operative procedure
ManagementManagement::– WBAT in short leg cast or CAM boot for 4-6 weeksWBAT in short leg cast or CAM boot for 4-6 weeks– Repeat x-ray at 7–10 days to r/o interval Repeat x-ray at 7–10 days to r/o interval
displacementdisplacement
Ankle FracturesAnkle Fractures Indications for operative Indications for operative
care:care:– Bimalleolar fracturesBimalleolar fractures– Trimalleolar fracturesTrimalleolar fractures– Talar subluxationTalar subluxation– Articular impaction injuryArticular impaction injury– Syndesmotic injurySyndesmotic injury
Beware the painful ankle with Beware the painful ankle with no ankle fracture but a no ankle fracture but a widened mortise… check widened mortise… check knee films to rule out knee films to rule out Maissoneuve Syndesmosis Maissoneuve Syndesmosis injury.injury.
Ankle FracturesAnkle Fractures
ORIF:ORIF:– FibulaFibula
Lag Screw if possible + PlateLag Screw if possible + Plate Confirm length/rotationConfirm length/rotation
– Medial MalleolusMedial Malleolus Open reduceOpen reduce 4-0 cancellous screws vs. tension 4-0 cancellous screws vs. tension
bandband
– Posterior MalleolusPosterior Malleolus Fix if >30% of articular surface Fix if >30% of articular surface
– SyndesmosisSyndesmosis Stress after fixationStress after fixation Fix with 3 or 4 cortex screwsFix with 3 or 4 cortex screws