Diagnostics, classification and treatment of malleolar fractures Diagnostics, classification and treatment of malleolar fractures. Pilon fractures.

What are malleolar fractures? Fractures of the ankle!!!

Anatomy??? What makes up the ankle joint? Bones Soft tissues: ligaments and muscles

Bones Distal tibia (plafond and medial malleolus Distal fibula (lateral malleolus) Talus (highly congruent articulation with plafond) Truncated cone

Ligaments Medial stabilizers: deltoid ligament (5 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 5 components Resists abduction

Lateral stabilizers Anterior talofibular ligament Posterior talofibular ligament Calcaneofibular ligament

Syndesmosis Anterior tibio-fibular ligament Posterior tibio-fibular ligament Interosseus ligament

Malleolar fractures: Diagnostics History Clinical examination Observation: swelling, pain, deformity, possible hematoma Physical examination: comparison of temperature of both sides (possible vessel injury) Radiological examination CT if necessary

Malleolar fractures: Diagnostics Radiological examination AP and lateral views May also use a 30 degree internally rotated view (mortise)

Malleolar fractures: what to look for on x-ray Position of lateral and medial ankle Dislocations How parallel the surfaces of the tibia and talus are with regard to one another Position of the Weber tip of the lateral ankle Unevenness of the talar surface (osteochondral fractures) Distance between the medial ankle and talus (if >4mm and the Weber tip is displaced proximally subluxation of the joint is probable)

Classification: Why classify?? Aim of classification is demonstration of different types of fractures and their organization Fracture classification aids in determination of the best treatment and also gives an idea of fracture prognosis Should be simple and useable

Classification of malleolar fractures Ankle fractures can be classified purely along anatomical lines as monomalleolar, bimalleolar, or trimalleolar. 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). Weber classification of lateral ankle fractures takes into account the level of the fracture in a frontal view (AO classification is similar to this).

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 further stresses the forefoot. Disruption of the anterior talofibular ligament Spiral oblique fracture of the distal tibia Disruption of the posterior tibiofibular ligament or fracture of the posterior malleolus Fracture of the medial malleolus or rupture of the deltoid ligament 3

Supination external rotation

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

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

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

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

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

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 (retention?), 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 are rare, look for proximal fibular fracture in these cases 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) Reduction and stabilization of the Volkmann triangle (for posterior 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) External rotation under image intensifier Instability: >1.5-2.0mm widening or medial clear space > 4mm

Pilon fractures Pilon fractures = Intraarticular fractures of the distal tibia Pilon fractures = Extraarticular fractures of distal tibia which are closer to joint than the diameter of the tibia Can be caused by low energy rotational forces or by high energy axial compressional forces (car accidents or falling from height). Not frequent: make up about 1% of fractures

Pilon fractures: Mechanism of injury Relatively less malignant fracture if the injury is indirect, small energy and usually rotational. Less connective tissue damage, and dislocation of articular surface is minimal. Fracture is worse if high energy, direct trauma with force either in axial direction or as torsion force. More damage to bone, cartilage and connective tissues.

Pilon fractures: Diagnosis Clinical examination: pain, swelling, loss of function, determine amount of connective tissue damage, circulation, innervation X-ray Doppler sonography (in cases where circulation is suspect) Angiography Intraoperatively often find other injuries like impression fractures, ligament and syndesmosis lesions. Pay attention to compartment syndrome!!!

Pilon fractures: Classification 2 important classifications: AO classification Rüedi-Allgöwer classification

Pilon fractures: AO classification Type A: extraarticular distal tibial fractures subdivided into A1, A2, A3 depending on amount of metaphyseal comminution Type B: partial articular fractures in which a portion of the articular surface remains in continuity with the shaft; subdivided into B1, B2, B3 depending on the amount of articular impaction and comminution Type C: complete metaphyseal fractures with articular involvement; subdivided into C1, C2, C3 depending on extent of metaphyseal and articular comminution

Pilon fractures: Rüedi-Allgöwer classification Type I: non-displaced cleavage fractures that involve the joint surface Type II: have cleavage-type fracture lines with displacement of the articular surface but minimal comminution Type III: are associated with metaphyseal and articular comminution

Pilon fractures: tissue damage At time of injury in pilon fractures, often soft tissues are seriously damaged Pressure to skin, abrasions, bullae, and variable degrees of open injuries can occur

Pilon fractures: Treatment Treatment is usually difficult due to the fact that the injury is usually caused by high energy forces that lead to serious cartilage, bone and soft tissue damage The aim of treatment is painless, complication-free, bony healing It should be pointed out that in some cases injuries are so serious that treatment is limited to the prevention of septic complications and the preparation of a situation where arthrodesis is possible. Restoration of the articular surface, stable osteosynthesis and early mobilization decrease the risk of post-traumatic arthrosis

Pilon fractures: conservative treatment The only time conservative treatment is utilized in pilon fractures is when operative treatment is absolutely contraindicated In theory, non-displaced or displaced but reducable fractures can be treated conservatively.

Conservative treatment Plaster casting Following reduction cast reaches the top of the thigh No weight-bearing for 6 weeks Cast remains for 12-16 weeks but in some cases can change cast to PTB (patella tendon bone) cast in the 6-8th week depending on the fracture.

Conservative treatment Traction Following reduction we put a Steinman nail into the calcaneus and pull the limb with 3kgs weight Traction uses ligamentotaxis to help reduction After 3 weeks the patient is put in a cast without weight-bearing and the cast is kept on for 8-16 weeks

Pilon fractures: operative treatment Open reduction internal fixation Closed indirect reduction and external stabilization Minimal invasive osteosynthesis External fixator

63 year old male patient

Operative treatment

49 year old male patient

After treatment Thrombosis prophylaxis Functional treatment

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