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Sequalae of Ankle Sprains: Peri Articular Fractures of the Ankle in Sports Medicine A. Amendola MD Professor, Dept of Orthopaedic Surgery Director, Sports.

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Presentation on theme: "Sequalae of Ankle Sprains: Peri Articular Fractures of the Ankle in Sports Medicine A. Amendola MD Professor, Dept of Orthopaedic Surgery Director, Sports."— Presentation transcript:

1 Sequalae of Ankle Sprains: Peri Articular Fractures of the Ankle in Sports Medicine A. Amendola MD Professor, Dept of Orthopaedic Surgery Director, Sports Medicine Center University of Iowa

2 Chronic Ankle Pain The most common cause The most common cause of chronic pain following an ankle sprain is a missed or associated injury From Alexander, Foot and Ankle Examination

3 Chronic Ankle Pain Extra-articular Bone ( avulsions ) Bone ( avulsions ) Soft tissue Soft tissue Neural Neural Venous stasis Venous stasisIntra-articular OLT / tibia OLT / tibia Impingement Impingement OA / chondromalacia OA / chondromalacia Synovitis Synovitis Differential Diagnosis

4 Bone Injuries ( peri –articular avulsions ) medial malleollus medial malleollus Lateral malleolus Lateral malleolus Posterior malleollus Posterior malleollus Talus Talus Posteromedial ( Cedell #) Posteromedial ( Cedell #) Posterior ( os trigonum ) Posterior ( os trigonum ) Lateral wall Lateral wall Anterior process calcaneus Anterior process calcaneus Differential Diagnosis

5 Chronic Ankle Pain Approach Detailed clinical exam Detailed clinical exam Correlate symptoms with exam and imaging Correlate symptoms with exam and imaging Most of these injuries are palpable ( tenderness ) Most of these injuries are palpable ( tenderness ) Operative approach : open vs arthroscopic Operative approach : open vs arthroscopic

6 Ankle pain ; history of recurrent sprains

7 Ankle pain ; recurrent sprains Anterior impingement and medial malleollar avulsion

8 Lateral malleollar avulsions Usually associated with avulsion of CFL Usually associated with avulsion of CFL Usually not signifcant and CFL scars in or can be repaired to remaining fibula Usually not signifcant and CFL scars in or can be repaired to remaining fibula Rx if symptomatic Rx if symptomatic Excise if stable, pain only (arthroscopic) Excise if stable, pain only (arthroscopic) Excise if unstable, repair CFL to fibula ( open )( video ) Excise if unstable, repair CFL to fibula ( open )( video )

9 Lateral Ligaments : fibular avulsion ( CFL ) ATF CFL ATF Leg Foot

10 Lateral malleollar avulsions

11 Calcaneus : Anterior process avulsion fracture Pain post sprain Pain post sprain Easily missed on X-rays Easily missed on X-rays High index of suspicion High index of suspicion Scrutinize X-rays Scrutinize X-rays Bone tenderness always present Bone tenderness always present Rx : Open excision if problematic Rx : Open excision if problematic

12 Talus Fractures Osteochondral Osteochondral Shear / sagittal / coronal Shear / sagittal / coronal Posterior process Posterior process Os trigonum Os trigonum Posteromedial ( Cedell ) / posterolateral process Posteromedial ( Cedell ) / posterolateral process Lateral process Lateral process

13 Video Os trigonum fracture, 17yoM

14 Lateral Talar process fx Snowboarders fracture Snowboarders fracture Diagnosis delayed & associated with ankle sprains Diagnosis delayed & associated with ankle sprains Need a high degree of suspicion Need a high degree of suspicion

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16 Treatment : lateral process # Acute - nondisplaced: cast treatment NWB Acute - nondisplaced: cast treatment NWB Acute - displaced: ORIF or excise Acute - displaced: ORIF or excise Late: excise or ORIF based on size ( usually chronic subfibular pain ) Late: excise or ORIF based on size ( usually chronic subfibular pain ) Excise open or arthroscopic Excise open or arthroscopic

17 Lateral talar process avulsion Rx : excision Rx : excision

18 Excision lat talar process : chronic

19 Post Talar Body fracture

20 Post talar body fracture ( video )

21 Post talar body fracture fixation ARIF ( video )

22 Summary: Common cause of Chronic dysfunction / pain Common cause of Chronic dysfunction / pain Ankle arthroscopy is an excellent procedure for evaluation and treatment Ankle arthroscopy is an excellent procedure for evaluation and treatment minimal morbidity with careful technique minimal morbidity with careful technique Excision is the common treatment, unless fixation warranted Excision is the common treatment, unless fixation warranted Periarticular ( avulsion ) Fractures Sports Trauma

23 Ankle Arthroscopy Acute Ankle Fractures: Advantages avoids extensive exposure improves visualization of articular surface maintains existing blood supply Disadvantages time consuming technically more challenging swelling of soft tissues

24 Ankle Arthroscopy Acute Ankle Fractures: Indications Mild to moderate pilon fractures/ impaction To ensure articular surface reduction Remove loose fragments/ hematoma/ chondral injury

25 50 yo M, impacted pilon #

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27 Post op 1 year post op

28 Case : fibular # ;medial dome talus

29 Case :; fibular # ;medial dome talus

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31 Case : fibular # ;medial dome talus

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33 Literature Review Hintermann B, Regazzoni P, Lampert C, Stutz G, Gachter A. Bone Joint Surg Br Apr;82(3): Arthroscopic findings in acute fractures of the ankle. Prospective study Ankle # in 288 consecutive patients (148 men and 140 women) AO-Danis-Weber, 14 type-A,198 type B and 76 type C. Chondral lesions in 228 ankles (79.2%), the talus (69.4%) ;distal tibia (45.8%), the fibula (45.1%), medial malleolus (41.3%). worse in patients under 30 years and in those over 60 years of age. The frequency and severity of the lesions increased from type-B to type-C fractures (p < 0.05).

34 Literature Review : ARIF Ankle # Ono A, Nishikawa S, Nagao A, Irie T, Sasaki M, Kouno T. Arthroscopy Jul;20(6): Arthroscopically assisted treatment of ankle fractures: arthroscopic findings and surgical outcomes. 105 patients (105 joints) ; malleolar fractures Cartilaginous damage was noted in 21 patients distal tibiofibular joint diastasis + fixation in 8 patients. good result in 100 cases and a fair outcome in 5 (no control group).

35 Use of Ankle Arthroscopy with Fractures Summary Useful adjunct in diagnosis and treatment Useful adjunct in diagnosis and treatment Biologic exposure Biologic exposure Needs further experience and investigation Needs further experience and investigation


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