1. INJURIES AROUND ANKLE JOINT AND IT’S MANAGEMENT

2. 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.

3. ANATOMY
Ankle joint is a synovial joint of hinge variety

4. Bony mortise- quadrilateral shape
Posterolateral position of fibula
Ligaments
3 groups
-Lateral
-Medial
-Syndesmotic

5. ANKLE JOINT IS SUPPORTED BY
Fibrous capsule
Deltoid ligament
A. Superficial
a. Anterior- Tibionavicular
b. Middle- Tibiocalcanean
c. Posterior- Posterior tibiotalar
B. Deep : Anterior- Tibiotalar

6. Lateral ligament Anterior- Talofibular Posterior- Talofibular
Calcaneofibular

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

8. ACUTE LIGAMENTOUS INJURY
Type I sprain- minor
Type II sprain - incomplete
Type III sprain - complete

9. TREATMENT LIGAMENT INJURY Non-operative treatment Operative treatment
Achieved by RICE
Operative treatment
Indicated when problems persist after 12 weeks of treatment including physiotherapy
Associated fracture

10. CLASSIFICATIONS
LAUGE HANSEN

11. LAUGE HANSEN Position of foot at injury- Pronation/Supination
Deforming force- Abduction/ adduction/ external rotation
Most Common mechanism of injury- SER
Most Common unstable ankle fracture variant- SER

12. LAUGE HANSEN SUPINATION ADDUCTION SUPINATION EXT ROT
PRONATION ABDUCTION
PRONATION EXT ROT
PRONATION DORSIFLEX

13. Maisonneuve’s fracture
High spiral oblique fracture of upper 3rd fibula with ankle PER injury

14. TYPES OF INJURIES Soft tissue injuries Fractures Ligament injuries
Lateral collateral ligament injury
Deltoid ligament injury
Syndesmotic injury
Fractures
Malleolar fractures
Pilon fractures
Physeal injuries

15. DIAGNOSIS

16. RADIOLOGICAL VIEWS
AP / LAT ANKLE
AP/OBLIQUE FOOT
AP MORTISE ANKLE

17. OTHER INVESTIGATIONS
ARTHROGRAPHY
ARTHROSCOPY
CT SCAN
MRI
BONE SCAN

18. AP VIEW SYNDESMOSIS MALLEOLAR LENGTH TALAR TILT
Tibiofibular overlap<10mm
MALLEOLAR LENGTH
Talocrural angle 83+_4 deg
TALAR TILT
- sup clear space- med clear space diff <2mm

19. MORTISE VIEW

20. What else to see in x-rays
LAT MALLEOLUS
Level of fracture
Orientation of fracture
Fracture comminution
MED/POST MALLEOLUS
Size
Assoc plafond #
Assoc syndesmotic injury

21. SYNDESMOTIC INJURY

25. Pott’s Fracture
Fracture involving the ankle joint loosely referred to as Pott’s Fracture
First degree single malleolus fractured.
In second degree two malleoli are fractured.
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)

26. 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)

27. 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.

28. TIBIAL PILON FRACTURES
Intraarticular fracture of distal tibia.
Fibula is fractured in 85% of these patients.

30. TIBIAL PILON FRACTURE Plaster immobilization Traction
Lag screw fixation
OR & IF with plates
External fixation with or without limited internal fixation
If articular incongruity <2 mm and reserved for low energy injuries

31. 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
Sudeck’s Osteodystrophy

32. TALUS FRACTURE

33. Anatomy-parts Head-articulate with navicular Neck-nonarticular
Body-articulate with tibia and calcaneus
No muscular or tendinous attachment

34. Blood supply Extraosseous supply Intraosseous supply
Posterior tibial a. tarsal canal a.
Anterior tibial a.  sinus tarsi a
Peroneal a. sinus tarsi a.
Intraosseous supply
Talar head
Talar body
-anastomosis between tarsal canal a. and tarsal sinus a.

35. Talar head fracture
5~10% of all talus fracture

36. Talar neck fracture Aviator’s 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
during the early days of aviation when crashes were more common

37. Classification-Hawkins classification
Displaced
Subtalar subluxation
nondisplaced
Ankle dislocation
(Talar body dislocation)
Talonavicular dislocation

38. Treatment Hawkins type I
4~6 weeks of no weightbearing in a short leg cast walking cast for 1~2 months
Percutaneous screw fixation

39. 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

40. Treatment Hawkins type III Hawkins type IV
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

41. Complication Skin necrosis and infection Delayed union or nonunion
Malunion
Posttraumatic arthritis
Osteonecrosis

42. Calcaneal fracture

43. 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

44. Calcaneal fracture Classification Essex-Lopresti
--Extraarticular(25%) v.s intraarticular(75%) fracture
Sanders
--CT classification of intraticular calcaneal fracture

45. Associated injuries A fall from a height or high–energy mechanisms
10% lumbar spine fracture(L1); 10% of calcaneal fracture are bilateral

46. ↓ ↑ varus position of the tuberosity
Pt supine, int. rot 45°, neutral DF, beam 10°-40°cephalad
varus position of the tuberosity
Broden’s view showing the depressed posterior facet

47. Intraarticular fracture (joint depression and tongue type)
Mechanism injury
Axial loading
Radiography
Loss of Bohler’s and Gissane’s angles

48. 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

49. 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

50. 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

51. Intraarticular fracture --complications
Soft tissue breakdown
Local infection
Subtalar arthritis

52. 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

53. 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

54. 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

55. Q4) Mechanism of injury of transverse fracture of medial
malleolus is
a. Abduction injury b. Adduction injury c. Rotation injury d. Direct injury

56. 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

57. Q6) Bimalleolar fracture is synonymous to
a. Cottons b. Potts c. Pirogoffs d. Dupuytrens

58. Q7) Avascular necrosis is a complication of
a. Fracture neck talus b. Fracture medial condyle femur c. Olecranon fracture d. Radial head fracture

59. Q8) POP cast in equinus position is indicated in
a. Distal fracture both bone leg b. Distal fracture fibula c. Bimalleolar d. Fracture Talus

60. Q9) Gissane’s angle in intra-articlar fracture calcaneum is
a. Reduced b. Increased c. Not changed d. Variable

61. Q10) Bohler’s angle is decreased in fracture of
a. Calcaneum b. Talus c. Navicular d. Cuboid

62. Q11) Stress fractures are most commonly seen in
Tibia
Fibula
Metatarsals
Neck of femur

63. Q12) Neutral triangle is seen radiologically in
a. Calcaneum b. Talus c. Naviuclar d. Tibia

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