1. Ankle Fractures
Justin Mullner – 8/27/09

2. Outline Anatomy and common ankle views Ottawa Ankle Rules
Classifications (Weber, Lauge-Hansen)
Biomechanics
Named fractures
The tibia and fibula have specific parts that make up the ankle:
Medial malleolus: Inside part of the tibia
Posterior malleolus: Back part of the tibia
Lateral malleolus: End of the fibula
Two joints are involved in ankle fractures:
Ankle joint
Syndesmosis: The joint between the tibia and fibula, which is held together by ligaments
Multiple ligaments help make the ankle joint stable

3. LATERAL VIEW
Standard radiographic examination of the ankle includes AP, lateral, and mortise views of the joint.
Mortise view requires oblique examination at 20 to 30 degrees internal rotation and results in alignment of medial and lateral malleoli in the same plane.
Talus: Also called the ankle bone, the talus sits directly behind the navicular (medially)

4. AP VIEW
MORTISE VIEW

5. Lateral Ankle Ligaments Medial Ankle Ligaments
CFL = Calcaneofibular ligament
PTFL = Posterior talofibular ligament
ATFL = Anterior talofibular ligament
Deltoid ligament covers the medial ankle and is comprised of:
posterior tibiotalar ligament
tibiocalcaneal ligament
tibionavicular ligament
anterior tibiotalar ligament
Peroneus Longus and Brevis Tendons run over the PTFL
CFL = Calcaneofibular ligament
PTFL = Posterior talofibular ligament
ATFL = Anterior talofibular ligament
Deltoid Ligament

6. Ottawa Ankle Rules
Before introduction of the rules, all injured ankles were X-rayed but only 15% were positive for fracture
The ankle is the most commonly injured weight bearing joint
Unnecessary X-rays: costly, time consuming, and possible health risk
Unnecessary X-rays: costly, time consuming, and health risk

7. Ottawa Ankle Rules
X-rays are only required if there is bony pain in the malleolar zone AND any one of the following:
1 – Tenderness along the distal 6cm of the posterior edge of the tibia
2 – Tenderness along the distal 6cm of the posterior edge of the fibula
3 – Inability to bear weight immediately after injury and in the ER

8. Ottawa Ankle Rules

9. Classification Schemes
Danis-Weber system
Level of the fibular fracture in relationship to the ankle joint (A, B, C)
Ideal for the primary care setting – allows you to classify the injury easily and guides treatment
Lauge-Hansen system
2-word descriptors detailing position and motion of the foot each with 2-4 stages specifying exact locations of fractures
More descriptive but very complicated
i.e. pronation-abduction-stage 2
Supination-adduction
supination-external rotation (eversion)
Pronation-abduction
pronation-eversion
Pronation-dorsiflexion

10. Biomechanics Dorsiflexion Eversion Adduction Plantarflexion Inversion
Abduction
Supination = Abduction + inversion + plantarflexion
triplanar
Pronation = Adduction + eversion + dorsiflexion

11. Biomechanics
Simple unidirectional forces can be involved in an ankle injury resulting in ligamentous damage and isolated fractures
Multidirectional forces are usually involved making diagnosis a challenge

12. Biomechanics Lateral Complex
Distal fibula
Lateral facet of the talus
Lateral ligaments of the ankle
Subtalar joints
Lateral complex injuries typically occur with inversion and supination
The most common ankle injury
Inversion ligamentous injuries of the ankle are the most commonly observed soft-tissue trauma in sports.

13. Biomechanics
Anteroposterior (AP) radiograph (left) of ankle in 23-year-old woman shows medial displacement of talus relative to tibia: horizontal avulsion fracture
through lateral malleolus and vertically oriented compression fracture through medial malleolus. Model on right shows mechanism of Weber type A ankle fracture: As talus undergoes inversion rotational injury, it applies avulsive pulling forces on lateral side of mortise and compressive pushing forces on medial side.
Type A fractures are horizontal avulsion fractures found below the mortise. They are stable and amenable to treatment with closed reduction and casting unless accompanied by a displaced medial malleolus fracture.
Inversion force avulses the lateral malleolus and continued force causes oblique fracture of the distal tibia

14. Biomechanics Medial Complex
Medial malleolus
Medial facet of the talus
Superficial/deep deltoid ligament
Medial complex injuries typically occur from eversion and abduction
Most unstable ankle fractures are the result of excessive external rotation of the talus with respect to the tibia. If the foot is supinated at the time of external rotation, an oblique fracture of the fibula ensues. If the foot is pronated at the time of external rotation, a mid- or high-fibular fracture results.

15. Biomechanics
Anteroposterior (AP) radiograph (left) of ankle in 79-year-old woman shows lateral displacement of talus relative to tibia, horizontal avulsion fracture through
medial malleolus, and obliquely vertically oriented compression fracture through distal fibula, below level of syndesmosis. Model on right shows mechanism of Weber type B ankle fracture. As talus undergoes eversion rotational injury, it applies avulsive pulling forces on medial malleolus and compressive pushing forces on fibula.
Type B fracture is a spiral fibular fracture that starts at the level of the mortise. This type of fracture occurs secondary to external rotational forces. These fractures may be stable or unstable depending on ligamentous injury or associated fractures on the medial side.
Eversion force avulses the distal medial malleolus (young/elderly) and continued force results in rupture of the syndesmosis or transverse fracture of the distal fibula

16. Biomechanics
AP radiograph (left) of ankle in 30-year-old woman shows horizontal avulsion fracture through medial malleolus and obliquely vertically oriented compression
fracture through distal fibula, above level of syndesmosis. Syndesmosis is disrupted and abnormally widened, with no overlap between tibia and fibula. Model on right shows mechanism of Weber type C ankle fracture. Mechanism of injury is same as Weber type B except compressive force extends through syndesmosis, tearing tibial fibular ligaments and distal IOM, with oblique fracture higher up on fibula. If compressive force extends proximally up length of IOM, fracturing through proximal fibula up near knee, then this is referred to as “Maisonneuve fracture” (next slide).
Type C fracture is above the level of the mortise and disrupts the ligamentous attachment between the fibula and the tibia distal to the fracture. These fractures are unstable and require open reduction and internal fixation.
Horizontal avulsion fracture through the medial malleolus and oblique-vertically oriented compression fracture through the distal fibula. The syndesmosis is disrupted and abnormally widened, with no overlap between tibia and fibula

17. MAISONNEUVE FRACTURE -Proximal half of fibula -Strong eversion
-The more proximal the
fracture, the more
unstable the joint
Fracture of the proximal half of the fibula.
Results from strong eversion at the ankle joint.
Disruption of the tibiofibular syndesmosis occurs as well as fracture of the medial malleolus or tearing of the tibiofibular ligament. A greater extent of damage is done to the interosseous membrane when the fracture is more proximal.

18. TILLAUX FRACTURE Lateral margin avulsion of the distal tibia Abduction+
External Rotation
Typically occurs in
adolescents
after medial epiphyseal
plate closes but
before the lateral
(18 month window)
Tillaux Fracture external rotation force w/ stress placed on anterior tibiofibular ligament, causing avulsion of distal tibial epiphyseal plate anterolaterally;           - further lateral rotation causes displacement of fracture;    
Look for a vertical fracture line extending from the distal articular surface upward to the lateral cortex of the tibia.
Careful radiologic exam is critical for determining the neccesity of surgery. If there is greater than 2 mm lateral displacement of the fracture fragment or step-off of the distal articular surface, surgery is often required. Otherwise, conservative treatment is indicated. CT is most commonly the method of choice for this evaluation.

19. TRIPLANE FRACTURE Twisting Injuries - adolescents
1 = vertical frxr thru the epiphysis
TRIPLANE FRACTURE
2 = horizontal frxr thru the physis
3 = oblique frxr thru the metaphysis
frx tends to occur in older children and young adolescents during an 18 month window, prior to physeal closure;           - lateral portion of epiphysis is the last to close leaving it vulnerable to injury;
the fracture exists in the frontal, lateral, and transverse planes
AKA = Marmor-Lynn occurs due to external rotation forces;
Twisting Injuries - adolescents

20. PILON FRACTURE
Fractures of the tibial pilon are injuries than involve the ceiling or top of the ankle joint. These are distinguished from “ankle fractures” which involve the sides or malleoli at the ankle joint. Tibial pilon fractures are usually the result of high energy trauma. Typical mechanisms of injury are falls from height (for example, falls from a ladder, roof, or building), motor vehicle crashes, or motorcycle crashes. Sometimes they occur from other activities such as snow skiing.
Pilon fractures refer to any tibial fracture that involves the distal articular plafond and are typically the result of an axial loading force
TRAUMA!!

21. TRIMALLEOLAR FRACTURE
This fracture may be caused by talar eversion and posterior displacement. The fracture is also known as a Henderson fracture.
Can be caused by talar eversion and posterior displacement
Also known as a Henderson fracture

22. Questions?