ANKLE INJURIES

(Xray discussion)

PRESENTOR: Dr.Nihal Gomes

MODERATOR: DR.A.K MATHUR
SIR
Contents
⚫ Normal xray presentaion
⚫ Ankle injuries-bones,ligaments,
syndesmosis
⚫ Malleolar fracture classifications
⚫ Treatment options of malleolar fractures

COMBINED CLASS DISCUSSION OF

⚫Affected Xray
⚫3D CT Films
 Bones
■ Distal tibia
(plafond and
medial malleolus
■ Distal fibula
(lateral malleolus)
■ Talus (highly
congruent
articulation with
plafond)
 Ligaments
Medial
stabilizers:
deltoid components-
Lateral stabilizers:
anterior talofibular ligament
posterior talofibular ligament
calcaneofibular ligament

Ligaments binding tibia and fibula together:

Anterior and Posterior inferior tibiofibular

ligaments
Inferior transverse ligament
Interosseous ligament (strongest)
 Medial stabilizers
■ Deltoid
ligament
• Deep
components
inserts into
the talus.
• Superficial
components
inserts into
the talus and
calcaneus
 Lateral stabilizers
Anterior
talofibular
ligament
Posterior
talofibular
ligament

Calcaneofibular
ligament
 Syndesmosis
■ Anterior
tibio-
fibular
ligament
■ Posterior
tibio-
fibular
ligament
■ Interosseus
ligament
 Classification of
malleolar fractures
1) Ankle fractures can be classified purely along
anatomical lines as monomalleolar, bimalleolar, or
trimalleolar.
2) Lauge-Hansen classification takes into account
the position of the forefoot (pronation or
supination) and the direction of the force which
causes the fracture (abduction, adduction,
outward rotation).
3) Danis Weber classification of lateral ankle
fractures takes into account the level of the
fracture in a frontal view (AO classification is
similar to this).
Reference:McRae’s Orthopaedic trauma 3rd edition Vol 1 page 486-491
 Lauge-Hansen classification
■ Supination-adduction
injury: with the forefoot in
supination, the force acts in a
varus direction thus adducting
the foot.

• Transverse avulsion-
type fracture of the
fibula below the level
of the joint or tear of
lateral collateral
ligaments
• Vertical fracture of
medial malleolus
 Lauge-Hansen classification
■ Supination-external rotation
injury: most common.
Forefoot in supination and
force in direction of external
rotation.

• Disruption of the anterior

talofibular ligament

• Spiral oblique fracture of the

distal tibia

• Disruption of the posterior 3

tibiofibular ligament or fracture
of the posterior malleolus

• Fracture of the medial

malleolus or rupture of the
deltoid ligament
 Supination external rotation

Fracture of
the medial
malleolus

Spiral oblique fracture of the distal tibia

fracture of the posterior malleolus
 Lauge-Hansen classification
■ Pronation-abduction injury:
quite common, besides
forced abduction, the
forefoot is in pronation.
• Transverse fracture of the
medial malleolus or rupture of
the deltoid ligament
• Rupture of the syndesmotic
ligaments or avulsion fracture
of their insertions
• Short, horizontal oblique
fracture of the fibula above the
level of the joint
 Pronation-abduction

avulsion
fracture

Short, horizontal oblique fracture of the fibula

Transverse fracture of the medial malleolus

 Lauge-Hansen classification
■ Pronation-external
rotation injury: more rare,
forefoot in pronation with
a forced external rotation
• Transverse fracture of the
medial malleolus or
disruption of the deltoid
ligament
• Disruption of the anterior
tibiofibular ligament
• Short oblique fracture of the
fibula above the level of the
joint
• Rupture of the posterior
tibiofibular ligament or
avulsion fracture of the
posterolateral tibia
Short oblique fracture of the fibula

avulsion fracture of the posterolateral tibia

Danis-Weber and AO classification
■ Weber A: Fibula
fracture below
syndesmosis
■ AO:
• A1: isolated
• A2: with fracture
of medial
malleolus
• A3: with a
posteromedial
fracture

Reference:Chapman’s 3rd edition (Michael W Chapman)Vol 1 page 814-816

Weber and AO classification
■ Weber B:
fracture of the
fibula at the
level of the
syndesmosis
■ AO:
• B1: isolated
• B2: with medial
lesion
(malleolus or
ligament)
• B3: with a
medial lesion
and fracture of
posterolateral
tibia
Reference:Chapman’s 3rd edition (Michael W Chapman)Vol 1 page 814-816
 Weber and AO classification
■ Weber C: fracture
of the fibula
above the level of
the syndesmosis.
■ AO:
• C1: diaphyseal
fracture of the
fibula, simple
• C2: diaphyseal
fracture of the
fibula, complex
• C3: proximal
fracture of the
fibula
Reference:Chapman’s 3rd edition (Michael W Chapman)Vol 1 page 814-816
Treatment of malleolar fractures

■ With fractures of the ankle, only slight

variation from normal is compatible with
good joint function:
• The normal relationships of the ankle mortise
must be restored
• The weight-bearing alignment of the ankle
must be at a right angle to the longitudinal
axis of the leg
• The contours of the articular surface must be
as smooth as possible

■ The best results are obtained by

anatomical joint restoration
 Anatomical joint restoration
■ Closed manipulation with plaster
casting (conservative treatment)
■ Open reduction and internal fixation
(operative treatment)
 Conservative treatment
■ Indications: non-
displaced fractures,
stable fractures
(Weber B, pronation-
adduction fractures)
■ Technique: reduction
using opposite to
mechanism of injury
■ Time: 6-8 weeks cast,
no weight-bearing for
3 weeks
■ Complications: when
swelling goes down,
cast becomes loose
and fracture can re-
dislocate. Frequent
follow-up is necessary.
 Operative treatment
■ Indications: all open
fractures, unstable
fractures, failure of
closed reduction,
displaced fractures
■ If possible,
immediately. If not,
within 12 hours. After
this, bullae or skin
necrosis can develop
which further delay
surgery
 Operative treatment
■ Osteosynthesis
of lateral
malleolus
• Plate and
screws
• Interfragmental
screw in case of
diagonal
fracture
 Operative treatment

■ Osteosynthesis
of medial
malleolus
• Isolated medial
malleolus
fractures.
• Tension band
wiring
• Cancellous
screws
 Operative treatment
■ Osteosynthesis of
the Posterior
malleolus
(25-30% of
articular surface)
• Can often be
reduced with
closed reduction
• Cancellous screw
introduced from
the ventral surface
 Operative treatment
■ Injuries of the syndesmosis:
• Anterior syndesmosis ligament injuries are
associated with both pronation and supination
injuries
• Instability occurs when the interosseous
membrane is lesioned to the level of the
lateral malleolar fracture (only in Weber C or
pronation-external rotation injuries).
• Reduction and stabilization of the membrane
using temporary pinning or reduction clamp
and insertion of syndesmotic screw (for
anterior syndesmolysis)
 Operative treatment
■ Syndesmosis lesions
• Hard to assess
radiographically
• May stabilize if lateral
and medial ankle are
fixed
• Cotton test (pull with
bone hook
intraoperatively)

Instability:
>1.5-2.0mm
widening or medial
clear space > 4mm
Affected xray
CT SCANS with 3D Reconstruction
 References:

1) Chapman’s 3rd edition (Michael W

Chapman)Vol 1 page 814-816

2) Campbell’s operative Orthopaedics 14th

edition ,vol 3 page 2812-2825

3) Rockwood and Green’s fractures in adults,

ed 4 Philadelphia,1996 Lippincott-Raven
Thank you
Post op xray