INJURIES AROUND ANKLE JOINT

AND ITS MANAGEMENT

INTRODUCTION
Ankle injury refers to disruption of
any component or components of
the ankle joint following trauma.

Ankle injuries occur frequently, and

have high propensity for
complications.

ANATOMY

Ankle joint is a synovial joint of hinge variety

 Bony mortisequadrilateral shape

Posterolateral position of
fibula
Ligaments
3 groups
-Lateral
-Medial
-Syndesmotic

ANKLE JOINT IS SUPPORTED BY

Fibrous capsule

Deltoid ligament

A. Superficial
a. AnteriorTibionavicular
b. MiddleTibiocalcanean
c. Posterior- Posterior
tibiotalar

B. Deep : AnteriorTibiotalar

 Lateral ligament
Anterior- Talofibular
Posterior- Talofibular
Calcaneofibular

SYNDESMOTIC LIGAMENTS
Ant inf tibio fib
Supf post tibio fib
Deep post tibio fib
Interosseous lig

ACUTE LIGAMENTOUS
INJURY

Type I sprain- minor

Type II sprain - incomplete

Type III sprain - complete

TREATMENT

LIGAMENT INJURY
Non-operative treatment

Achieved by

RICE

Operative treatment

Indicated when problems persist after 12 weeks of

treatment including physiotherapy

Associated fracture

CLASSIFICATIONS

LAUGE HANSEN

LAUGE HANSEN
1.

Position of foot at
injuryPronation/Supination

Most Common
mechanism of injurySER

2.

Deforming forceAbduction/
adduction/ external
rotation

Most Common
unstable ankle fracture
variant- SER

LAUGE HANSEN

SUPINATION ADDUCTION

SUPINATION EXT ROT

PRONATION ABDUCTION

PRONATION EXT ROT

PRONATION DORSIFLEX

Maisonneuves fracture
High spiral oblique
fracture of upper 3rd fibula
with ankle PER injury

TYPES OF INJURIES

Soft tissue injuries

Ligament injuries
Lateral collateral ligament injury
Deltoid ligament injury

Syndesmotic injury

Fractures

Malleolar fractures

Pilon fractures

Physeal injuries

DIAGNOSIS

RADIOLOGICAL VIEWS

AP / LAT ANKLE

AP/OBLIQUE FOOT

AP MORTISE ANKLE

OTHER INVESTIGATIONS

ARTHROGRAPHY

ARTHROSCOPY

CT SCAN

MRI

BONE SCAN

AP VIEW
SYNDESMOSIS
Tibiofibular
overlap<10mm

MALLEOLAR LENGTH
Talocrural angle 83+_4
deg

TALAR TILT
- sup clear space- med clear
space diff <2mm

MORTISE VIEW

What else to see in x-rays

LAT MALLEOLUS

MED/POST MALLEOLUS

Level of fracture

Size

Orientation of fracture

Assoc plafond #

Fracture comminution

Assoc syndesmotic
injury

SYNDESMOTIC INJURY

Potts Fracture
Fracture involving the ankle joint
loosely referred to as Potts Fracture
1. First degree single malleolus
fractured.
2. In second degree two malleoli are
fractured.
3. In third degree there is bimalleolar
fracture with a fracture of posterior
part of inferior articular surface of
the tibia referred to as third
malleolus. (Tri Malleolar fracture)

MANAGEMENT

RICE

Definitive

Aim- restoration of complete normal anatomical alignment

of ankle.

Patients if needs operation should be operated within

24hrs of injury or after one week once the swelling
subsides.

Undisplaced fracture medial malleolus :

Below knee POP cast for 6 weeks.

Reduction fails (may be due to soft tissue (periosteal) inter

position)

Displaced:
Open reduction and internal fixation by
Cancellous screws group
Tension band wiring
Fracture lateral malleolus:
Lateral Malleolus helps in length maintenance &
maintenance of ankle mortice.
Hence, lateral malleolus has to be fixed internally.

TIBIAL PILON FRACTURES

Intraarticular fracture of distal tibia.

Fibula is fractured in 85% of these patients.

TIBIAL PILON FRACTURE

1. Plaster immobilization If articular incongruity <2 mm

2. Traction

and reserved for low energy

injuries

3. Lag screw fixation

4. OR & IF with plates
5. External fixation with or without limited
internal fixation

COMPLICATIONS

Malunion- may result in posttraumatic arthritis

and painful movements.
Nonunion of medial malleolus- commonly due to
interposition of fractured periosteum between
two fragments.
Repeated edema
Sudecks Osteodystrophy

TALUS FRACTURE

Anatomy-parts

Head-articulate with
navicular

Neck-nonarticular

Body-articulate with
tibia and calcaneus

No muscular or
tendinous
attachment

Blood supply

Extraosseous supply

Posterior tibial a.

tarsal

Anterior tibial a.

sinus

canal a.

tarsi a

Peroneal a.

sinus tarsi a.

Intraosseous supply

Talar head

Talar body

-anastomosis between tarsal canal

a. and tarsal sinus a.

Talar head fracture

5~10% of all talus fracture

Talar neck fracture

Aviators astragalus

High energy injury, hyperdorsiflexion

15~20% open fracture

Associated with malleloar fracture(25% of cases),

medial malleolus is more common

High risk of soft tissue injury and compartment

syndrome

Classification-Hawkins
classification
Displaced
nondisplaced

Ankle dislocation
(Talar body dislocation)

Subtalar subluxation

Talonavicular
dislocation

Treatment

Hawkins type I

4~6 weeks of no weightbearing in a short leg cast

walking cast for 1~2 months

Percutaneous screw fixation

Treatment

Hawkins type II

Orthopaedic emergency: traction and plantar flexion

by
manipulation anatomic reduction(50%)
treated as type I

Open reduction: screw placed across the neck

fracture

Treatment

Hawkins type III

ORIF and Skeletal

traction
through
the calcaenus
Open fracture (> type
III)

:talar body excision

followed
By primary tibiocalcaneal
or Blair-type
arthrodesis

Hawkins type IV

Rare injury

As type II

Complication

Skin necrosis and infection

Delayed union or nonunion

Malunion

Posttraumatic arthritis

Osteonecrosis

Calcaneal fracture

Anatomy

Largest, most irregularly shaped bone in foot

Large calcellous bone and multiple processes

Achilles tendon posteriorly and plantar fascia inferiorly : tuberosity

Posterior facet: talar lateral process and body

Middle facet: Sustentacular fragment (flexor hallucis longus pass)

Anterior process: cuboid

Calcaneal fracture

Classification

Essex-Lopresti

--Extraarticular(25%) v.s intraarticular(75%) fracture

Sanders

--CT classification of intraticular calcaneal fracture

Associated injuries

A fall from a height or highenergy mechanisms

10% lumbar spine fracture(L1); 10% of calcaneal fracture are bilateral

Brodens view showing the depressed

posterior facet

varus position of the tuberosity

Intraarticular fracture
(joint depression and tongue
type)

Mechanism injury

Axial loading

Radiography

Loss of Bohlers and Gissanes angles

Intraarticular fracture

Joint-depression type, in which the

primary fracture line exited the bone
close to the subtalar joint

tongue-type, in which the primary

fracture line exited the bone posteriorly

Intraarticular fracture
--Treatment

Nondisplaced articular fractures

Bulky (Robert-jones) dressing: active subtalar ROM,

prohibit weightbearing walking 8~12 wks later

Displaced intraarticular fracture with large

fragment

ORIF

Intraarticular fracture
--Treatment

Displaced intraarticular fracture with severe

comminution

Increasing intraarticualr comminution leads to less

satisfactory results

ORIF primary arthrodesis

Restoring the heel width and height

Intraarticular fracture
--complications

Soft tissue breakdown

Local infection

Subtalar arthritis

ANKLE AND FOOT INJURIES

Q1) The stability of the ankle joint is maintained by all
of
the following except
a. Spring ligament
b. Deltoid ligament
c. Lateral ligament
d. Shape of the superior talar articular surface

Q2) The most commonly affected component of lateral

collateral ligament complex in an ankle sprain
a. Anterior talo fibular ligament
b. Posterior talo fibular ligament
c. Calcaneofibular Ligament
d. None

Q3) Ankle sprain is due to

a. Rupture of anterior talo-fibular ligament
b. Rupture of posterior talo-fibular ligament
c. Rupture of deltoid ligament
d. Rupture of calcaneo-fibular ligament

Q4) Mechanism of injury of transverse fracture of

medial
malleolus is
a. Abduction injury
b. Adduction injury
c. Rotation injury
d. Direct injury

Q5) Cottons fracture is

a. Avulsion fracture of C7
b. Bimalleolar fracture
c. Trimalleolar fracture
d. Burst fracture of the Atlas
e. None of the above

Q6) Bimalleolar fracture is synonymous to

a. Cottons
b. Potts
c. Pirogoffs
d. Dupuytrens

Q7) Avascular necrosis is a complication of

a. Fracture neck talus
b. Fracture medial condyle femur
c. Olecranon fracture
d. Radial head fracture

Q8) POP cast in equinus position is indicated in

a. Distal fracture both bone leg
b. Distal fracture fibula
c. Bimalleolar
d. Fracture Talus

Q9) Gissanes angle in intra-articlar fracture calcaneum

is
a. Reduced
b. Increased
c. Not changed
d. Variable

Q10) Bohlers angle is decreased in fracture of

a. Calcaneum
b. Talus
c. Navicular
d. Cuboid

Q11) Stress fractures are most commonly seen in

a.Tibia
b.Fibula
c.Metatarsals
d.Neck of femur

Q12) Neutral triangle is seen radiologically in

a. Calcaneum
b. Talus
c. Naviuclar
d. Tibia