ANKLE FRACTURES

 The ankle is a complex joint consisting of functional articulations

between the tibia and fibula, tibia and talus, and the fibula and talus,
each supported by a group of ligaments.
 The tibia and fibula form a mortise, providing a constrained
articulation for the talus or tenon.
 The articular surface of the distal tibia (tibial plafond) and the
mortise is wider superiorly and anteriorly to accommodate the wedge-
shaped talus.
 The shape of the joint alone provides some intrinsic stability,
especially in weight bearing
Bony and ligaments structures of
the ankle joints
 Mechanism of ankle injury
 The pattern of injury to the ankle depends on many factors,
1) Age of the patient,
2) Quality of the bone,
3) Position of the foot at the time of injury,
4) The direction, magnitude, and rate of the loading forces.
of Lauge-Hansen. He emphasized the influence that the position of the
foot had on the injury pattern and correlated this position with the
direction of the deforming forces. In his system, the position of the
foot (pronation or supination) at the time of injury is described first
and the direction of the deforming force is described second.
 The common deforming forces acting on the ankle are (adduction,
abduction, external rotation, and vertical loading).
Basic mechanism of injury
Danis-Weber System of
classification AO
Weber-Danis classification is based
on location of the fibular
fracture
A. Weber A –Avulsion fracture
below the tibiofibular joint line.
B. Weber type B – Is an oblique
fracture arising from the joint
line.
C. Weber C- is more proximal
fracture of the fibula
associated with syndesmotic
injury
 Sings and symptoms
History
 Vertical loading from falls or high-speed deceleration
may result in axial compression injuries to the foot,
ankle, and spine, while twisting usually results in an
external rotation injury.
 A history of prior ankle problems or injury may be
important.
 Recurrent injuries, particularly ligament sprains, are
common, and preexisting laxity, instability, or
radiographic abnormalities can be misinterpreted as an
acute injury.
 The patient's medical history should be reviewed
because systemic problems such as diabetes, peripheral
vascular disease, or metabolic bone disease may affect
treatment planning.
 Physical Examination
 Careful examination is needed to determine the
status of the skin, soft tissues, and neurovascular
structures, as well as the bones and ligaments.
 The entire lower leg, including the fibula, should be
examined.
 Combinations of tenderness, swelling, or ecchymosis
over the bone, ligaments, or joint line suggest an
injury.
 The stability of the joint should be assessed,
especially when these findings are associated with
normal x-rays.
 Based on the physical findings, an anterior drawer,
inversion, eversion, or external rotation stress test
may be helpful.
Radiographic finding
 The standard radiographic evaluation of the ankle includes AP,
lateral, and mortise views.
1) The AP x-ray is taken in line with the long axis of the foot.
2) The lateral view is obtained with the limb perpendicular to the
long axis of the foot. The dome of the talus should be
centered under the tibia and congruous with the distal tibial
articular.
Radiographic finding
3) The mortise view is obtained with the leg internally rotated
15° to 20° so that the x-ray beam is nearly perpendicular to
the intermalleolar line.

Mortise view of the

ankle A-x-ray of the
normal ankle, B-
Parameters measured
from mortise view A-B
tibiofibular overlap
 Specialized Evaluation

 Stress X-Rays
Are used to confirm suspected ligamentous instability.
 Stress views of the opposite ankle must be obtained for
comparison.
 To evaluate the lateral ligaments, an AP and mortise view is
taken with an inversion (supination) stress on the ankle.
 Stress views with the foot in plantarflexion isolate the anterior
talofibular ligament, while views in neutral evaluate both the
anterior talofibular and calcaneofibular ligaments.
 There is normally less than 5° of talar tilt in the normal ankle.
 A difference in tilt of twice the uninjured ankle or a talar tilt
of more than 10° to 15° indicates a tear of the anterior
talofibular and calcaneofibular ligaments .
 The external rotation stress x-rays evaluate the syndesmosis,
and good views of the mortise are needed to make accurate
measurements of syndesmotic integrity.
 A lateral x-ray during an anterior or posterior drawer stress
may show subluxation of the talus.
 An anterior shift of greater than 8 to 10 mm compared with
the uninjured ankle indicates a tear of the anterior talofibular
ligament.
 The measurements obtained from the stress views may be
influenced by the degree of patient relaxation, the position of
the ankle, the amount of force used in testing, and the laxity
of the contralateral ankle.
 STRESS X-RAY

Anterior drawer stress

Inversion x-ray showing anterior
stress x-ray subluxation of the
showing talar talus
tilt
 Arthrography

 Arthrography has been used to evaluate the integrity of the

capsule and ligaments of the ankle.
 Tomography
 Computed Tomography
 Magnetic Resonance Imaging: Magnetic resonance imaging allows
multiplanar imaging without radiation. MRI is a useful diagnostic
tool in the assessment of acute and chronic tendon and ligament
injuries about the ankle.
 Bone Scan
 Arthroscopy
 TREATMENT
The goals of treatment are to obtain an anatomical reduction,
maintain this reduction until the fracture heals, and return
the patient to his or her preinjury level of function with a
painless, mobile ankle.
Nonoperative Treatment:
Closed reduction is indicated for
1) Nondisplaced or stable fractures.
2) Displaced fractures when an anatomical reduction
is obtained and maintained without repeated
manipulation.
3) When operative treatment is not indicated
because of the general condition of the patient or
the leg.
4) When operative treatment is planned but will be
 Operative Treatment
 The goals of operative treatment are to obtain an anatomical
reduction that is maintained by stable fixation, resulting in a
healed fracture and recovery of normal function.
 Indication for Operative treatment:
1) Failure of closed reduction
2) When closed reduction requires forced.
3) Abnormal positioning of the foot, such as forced plantarflexion
and inversion.
4) Displaced or unstable fractures of either or both malleoli that
result in displacement of the talus or widening of the mortise
greater than 1 to 2 mm.
5) Open fractures.
The current trend is toward recommending open reduction and
internal fixation for any displaced fracture that involves the
articular surface. However, each patient must be individualized
and the presence of systemic disease, such as diabetes
mellitus, physiologic age, activity level, and particularly
osteoporosis, must be evaluated before recommending operative
treatment.
Type of internal fixation
 Medial malleolar fracture
 Pt. present with medial ankle pain, swilling, ecchymosis and
decreased range of motion the may unable to bear weight.
Isolated fractures involving the medial articulation need
consultation with an orthopedic.
 When no evidence of joint instability should have short leg splint
and treated with RICE analgesics.
 Bi- and trimalleolar fracture:
1) Medial malleolar fractures often present one component of a bi
or trimalleolar fracture.
2) In trimalleolar fracture all malleoli (Lateral, medial, posterior)
are fractured.
Clinical picture:Sever pain, swilling, ecchymosis. If there is
dislocation with fracture joint deformity noted.
Should be reduced immediately in the ER prior to hospitalization for
ORIF .
 Closed injury are typically unaccompanied by vascular
compromise, and traction with appropriate manipulation to
correct deformity is usually successful.
 Open fractures are common and more likely to have
associated vascular compromise.
Reduction in emergency department after surgical
cleaning and copious irrigation is necessary unless
immediate orthopedic operative care is available.
 In both closed and open fracture and fracture dislocation,
a long leg posterior splint is placed followed by
postreduction x-ray and vascular checks and Ortho.
follow-up.
 Posterior marginal fracture:
Isolated posterior marginal tibial fractures are rare –nondisplaced
fractures involving less than 25% of articular surface cane be
treated closed and more than 25% displaced fracture need open
reduction and internal fixation.
 Plafond fracture :
Are also known an anterior marginal tibial fracture do to a high-
energy dorsiflexion force this fracture need Ortho consultation.
 Maisonneuve Fracture : is an oblique fracture of
proximal fibula with either disruption of the deltoid ligament or
fracture of the medial malleolus . Treatment depending on if the
medial malleolus displeased.
To need ORIF
Tillaux fracture

Is an avulsion fracture of
the bone element by ATFL
fracture of an anterior
aspect of the distal tibia.
The fracture line started
and the joint line and
extends vertically exiting
or distal to the fused
physis. If closed reduction
is unsuccessful,ORIF is
used.
 PILON FRACTURE
 Definition: it is distal tibial metaphyseal fracture with extension
in to the joint surface, usually with extensive comminution.
 The pilon fracture is among the most challenging problems faced
by the orthopaedic surgeon.
 This fracture involved the tibial plafond of the ankle joint. As
more experience with this fracture has been gained, the large
compressive forces with the resulting crush injury and the
significant disruption of the articular surface have been
recognized.
 Mechanism of Injury
The primary component of force is vertically directed
through the talus into the distal tibia.The severity of
bone, cartilage, and soft-tissue damage is directly
proportional to the amount of energy involved in the
traumatic event.
 Classification

1. Type I fractures are cleavage fractures of the articular

surface with minimal displacement of the intra-articular
fracture fragments.
2. Type II fractures involve significant displacement of the intra-
articular fractures without comminution but moderate intra-
articular incongruity.
3. Type III fractures are similar to type II fractures but have
significant comminution with impaction of the distal tibia and
gross incongruity of the articular surface.
 Signs and Symptoms
 Meticulous examination of the skin.
 Soft tissues.
 Neurovascular structures, including pulses, should be performed.
 The tibia is mostly subcutaneous in this area; fracture
displacement or excess pressure on the skin may convert a closed
fracture into an open one.
 Swelling is often rapid and massive, and the fracture should be
reduced and splinted as soon as the examination is complete.
 Subsequent edema, fracture blisters, and skin necrosis from the
original injury may still convert closed fractures to open injuries,
and continued soft-tissue monitoring is important.
 In addition, since many patients are victims of multitrauma,
associated injuries are common and must be treated appropriately.
 Diagnosis
 The standard three views of the ankle and a 45° external
rotation view to delineate the anteromedial and posterolateral
surfaces of the tibia should obtained.
 Computed tomography with coronal and sagittal reconstructions or
conventional tomography may be considered to better evaluate the
fracture pattern.
 A radiograph of the normal contralateral ankle may be used as a
template guide for preoperative planning.
 Conclusion
 Ankle injuries are commonplace in the ER.
 An understanding of ankle anatomy is
integral to the accurate assessment and
care of this injury.
 A systemic approach in the history and
phys. Exam. And selective use of x-ray
will prevent the clinician from overlooking
commonly missed injuries. Appropriate
splinting and timely consultation and
referral will help reduce the morbidity
associated with many ankle injuries
 The Foot
 Function of the foot includes weight bearing,
balance, and leverage for walking and
running.
I. Anatomy : the foot contain 28bons 57joints
II. Mechanism of injury
Foot injury are result of direct trauma indirect trauma and
overuse injury
A. Fall from height on the heel.
B. Axial compression on plantar flexed foot .
C. Sudden increase in training

III. Physical examination

Phys.exam it includes assessment for ligamentous and joint
stability, neurovascular compromise, soft tissue injury
exam and documentation should include the following
a) Inspection Inspect for swilling, ecchymosis,
deformity, color and skin integrity.
b) Palpation. Palpate for tenderness and Crepitus
at site remote from the injury
c) Range of motion
d) Neurovascular examination
IV. Radiography
Radiographic interpretation of the foot is difficult because of
overlapping shadows, secondary ossification centers, and
sesamoid bones.
a. Foot x-ray usually includes AP, Lt,Oblique view.
An oblique view is often necessary to sort out the
shadows of the overlapping small bones.
b. Calcaneous view are ordered when evaluating
calcaneal injury.
c. Toes x-ray suffice in injuries limited to the toes
d. Bone scan can aid in diagnosis of occult or stress
fractures that are not radiograhically apparent.
 Hand foot

1) TALUS FRACTURES
Associated with serious
complications,including:
a) Skin necrosis.
b) Infection.
c) Avascular necrosis.
d) Malunion,and nonunion.
e) Ankle and subtalar
Blood supply of the talus.The three
arthrofibrosis. main arterial contributions are
shown, in addition to the deltoid
f) Posttraumatic arthritis branch to the medial talar body .
 Talus fractures
I. Osteochondral fracture are common after inversion or
eversion injury of the ankle.
II. Body fractures are typically the result of high-impact
injuries causing compression of the talus between the tibia
and calcaneus.there is considerable displacement of fracture
fragments with dislocation of the ankle and subtalar joints.
This injuries should be evaluated by an orthopedic and often require
ORIF nondisplaced fracture cane be treated by cast for 6-
8weeks.
III. Neck fracture the most common mechanism of talar neck
fracture is hyperdorsiflexion of the foot on leg.
 RADIOGRAPHIC EVALUATION
 High-quality anteroposterior (AP).
 Lateral.
 Oblique radiographs of the ankle and foot.
 Pronated oblique view of the midfoot to better visualize the
talar neck and head.
 Tomograms or computed tomography (CT) scans are occasionally
required to assess the fracture configuration and displacement.

Pronated oblique view of

midfoot to better visualize
the talar neck. Ankle is in
maximal equinus, with foot
pronated 15°. Direct the
roentgen tube 75° from the
horizontal.
 Classification of talus fracture
 The progressive displacement of the body of the talus
produced one of three basic fracture configuration, with
correlate with the three fracture types by Hawkins type :
1. Nondisplaced vertical fracture of the talar neck.
2. Displaced fracture of the talar neck with subluxation or
dislocation of the subtalar joint (the ankle joint remains
aligned)
3. Displaced fracture of the talar neck with dislocation of the
body of the talus from both the subtalar and ankle joints.
 Treatment
 Should be designed to minimize these complications as
osteonecrosis which most common and depend on severity of
initial injury, all recent reviews of subject conclude that the best
results occur when prompt, perfectly anatomical reduction of the
neck fracture is achieved and maintained.
 Open dislocated fractures are orthopedic emergencies requiring:
1. Irrigation
2. Broad spectrum antibiotic
3. Operative debridement
4. Immobilization
Closed type I fracture require immobilization with cast for 8-12
weeks

Type II and III need prompt ORIF

 2) Calcaneus
 The calcaneous (os calcis) is the tarsal bone
most often fractured. Despite extensive
clinical experience with this injury. Its major
socioeconomic impact in regard to the time
lost from work and recreation, the attention
given it for many years by surgeons
throughout the world and recent advances in
imaging and operative treatment, often the
result of this fracture are poor.pointed out
that fracture of the calcaneous is one injury
that has not increased in frequency with the
advent of mechanized industry, automobile
travel, or war. It has been common, often
disabling injury since humans assumed the
erect posture and began to defy gravity.
 The calcaneous is the largest bone in the foot and
absorbs most of the body weight with walking.
 It the most commonly fractured tarsal bone.
 It articulate with cuboid anteriorly and the talus
superiorly.
 The medial and lateral processes on its plantar aspect
severe as insertion points for muscle and plantar fascia.
 The calcaneous has a thin cortex and contains
trabeculae that sometimes make radiographic
interpretation of the subtle fractures difficult.
 Calcaneal fracture occur with falls from height and
are associated with compression fractures of the
lumbar spine.
The treatment of calcaneal fracture is challenging
because often treatment result are not optimal.
 Symptoms and signs:
1) Pain
2) Swilling
3) Deformity
4) Skin blistering occur during first 36hour as result of
sever damage to surrounding of soft tissues.
 Imaging
X-ray AP and lateral view,axial calcaneal view .
Tomography, CT scanning will further delineated
fracture patterns and occult injury, bone scan may
be useful to diagnose a stress fracture.
 Classification
 The primary importance of classification is to separate those
fractures that tend to have a good prognosis from that do
poorly or require more aggressive treatment to ensure a
satisfactory outcome.
 Essex-Loprestiwas: One of the first to emphasize the
difference between extra-articular fractures, which tend to
do well, and fracture involving the subtalar joint, which
generally have a poorer prognosis. Various subtypes and
configuration exist within each group of fractures.
I. Extra-articular fractures occur infrequently (25% to30% of
all calcaneal fractures ) and are divided anatomically in to
the following:
1) Anterior process
2) Tuberosity (beak or avulsion)
3) Medial process, sustentaculum tali
4) Body
II. Intera-articular fractures (which comprise the remaining 70%
to 75% of calcaneal fractures )
 Type of intera-articular fractures
1) Nondisplaced fractures
2) Tongue type
3) Joint depression
4) Comminuted fracture

Treatment
 Displaced intera-articular fracture need orthopedic
consultation as a significant percentage of Pt have a poor
outcome with this injury.
 Extra –articular fractures all nondisplaced fracture
can be treated by RICE for 1-2weeks and
subsequent treatment with walking cast and partial
weight bearing for at lest 8weeks
 Displaced fracture need Ortho consultation
 Dislocation

 Subtalar dislocation also known as peritalar dislocation, involves

dislocation of the talocalcaneal and talonavicular joints with
intact tibiotalar and calcaneocuboid joints, medial dislocation
are the most common, than lateral dislocaation.
 Treatment of the dislocation is closed reduction and
immobilization. Open talar dislocation needs irrigation, broad-
spectrum antibiotic, and operative reduction
 Midfoot
 Fractures is rarely happened.
 Usually result from crush injury.
 Cuboid and cuneiform fractures usually occur in
combination and have associated subluxation or
dislocation .
Physical examination
1) Reveals tenderness and swilling over the fractured
bone.
Treatment : for most nondisplaced fractures is short leg
cast isolated fractures of the navicular, cuboid or
cuneiforms are best immobilization in short leg
posterior splint, with prompt orthopedic attention.
As in all foot fractures elevation and ice to prevent
excessive swilling are important. Multiple fractures
or open injury need hospitalization.
 Tarsometatarsal dislocation
 Lisfranc A fracture dislocation is rare but commonly missed
injury.the recessed base of second metatarsal is the locking
keystone of the joint and is held in place by an oblique
ligament between the medial cuneiform and the second
metatarsal .
 Transverse ligaments connect the bases of the second to
fifth metatarsals but not the first metatarsal.
 During injury there is dislocation at the site of lowest
resistance, usually the dorsal aspect of the Lisfrancs joint at
the base of the second metatarsal.
 The usual mechanism of action is an axial load. May result
from auto accidents when the foot is braced against the
floorboard in extreme plantarflexion. Direct crushing blows
can also cause this injury.
A. Physical examination
 Extreme swilling and tenderness over the Lisfrancs joint.
 Paresthesias may be described overlying the midfoot. Because
the extreme forces involved in these joints,open wound with
associated tissue damage and vascular impairment are typical.

B. Radiography :
X-ray diagnosis cane be difficult. The injury may be seen only on
an oblique view.

C. Treatment:
Hospitalization and immediate orthopedic consultation for reduction
and fixation under anesthesia. Complications such as acute
vascular compromise from artery compression or spasm as well
as residual pain and osteoarthritis can occur.
 Forefoot
A. Metatarsal: most metatarsal fracture are transverse
resulting from direct trauma. Nondisplaced neck and shaft
fractures should placed in short leg splint. Fracture with
neurovascular and skin injury need checks and orthopedic follow
up
The fracture best seen on the AP and lateral views.
1) Marsh fracture : the second and third metatarsal
fracture thy are susceptible to stress marsh fracture.
Diagnosis : by history and examination and bone scan that shows
increased activity in areas of stress may allow for an early
diagnosis.
Treatment cessation of activity 4-6 weeks is curative.
2. Base of the fifth metatarsal:
Peroneus brevis tendon avulses the tuberosity of the
base of the V metatarsal in longitudinal fashion.
3. Jones fracture :
Transverse fracture at the proximal diaphysis of the
fifth metatarsal
B. Phalangeal and sesamoid fracture&
dislocation:
Usually occur with direct trauma or forced
hyperextension, comminuted fractures of the great
toe may require a walking cast