TIBIA & ANKLE

FRACTURES
AND MANAGEMENT

DR. LIAU KAI MING

 Low Energy Trauma

Minimal soft-tissue injury

Lesscomplicated
fracture pattern and
management decisions

76.5% closed
 High Energy Trauma
Highincidence of
neurovascular energy and
open injury

Lowthreshold for
compartment syndrome

Complete soft-tissue
injury may not declare
itself for several days
 Radiographic Evaluation
Full length AP and
Lateral Views
Check joint above &
below

Oblique views may be

helpful in follow-up to
assess healing
 Injuries Associated
30% of patients will have
multiple injuries
Ipsilateral Fibula
Fracture
Foot & Ankle injury

Syndesmotic Injury

Ligamentous knee
injuries
 Injuries Associated
Ipsilateral Femur Fx
Floating Knee

Neurovascular Injury
More Common In:

High Energy

Proximal Fracture

Knee Dislocation
 Compartment Syndrome
Incidence - 5-15%
High-Energy
Crush
Exam
4 Compartments (Anterior,
Lateral, Superficial Posterior,
Deep Posterior)
6 Ps
Pain
Pain with passive
stretch
Parasthesias
Pulsless
Pallor
Paralysis
 Goals of Fasciotomy
Decompress the
compartment
Minimize further
soft-tissue damage
Two incisions
Go long
No increased
morbidity
No difference in
long-term
outcome
 Non-Operative Treatment of
tibia shaft fracture with long leg
cast: Indications
Minimal soft tissue damage
Non-intact fibula
Higher rate of nonunion & varus with intact fibula
Stable fracture pattern
< 5varus/valgus
< 10pro/recurvatum

< 1 cm shortening

Ability to bear weight in cast or fx brace

Requires frequent follow-up
 Surgical Indications
Patient Characteristics Fracture
Obesity Characteristics
Poor compliance with
non-operative Coronal
management Angulation > 5
Need for early mobility
Sagittal Angulation

Injury Characteristics
> 10
High Energy Rotation > 5
Moderate soft-tissue Shortening > 1cm
injury
Open Fracture
Comminution >
Compartment Syndrome 50% cortical
Ipsilateral Femur Fx circumference
Vascular Injury Intact fibula
 Surgical Options

Intramedullary Nail

ORIF with Plate

External Fixation

Combination of fixation
 Evaluation of Soft Tissues
Proximal and distal
tibia subcutaneous
Soft tissue remains
compromised for
at least 7 days
Early ORIF risks
wound breakdown
& compartment
syndrome
12
 Advantage of IM Nail

Less malunion
Early weight-bearing

Early motion

Early WB (load
sharing)
Patient satisfaction
TIBIA FRACTURE
TIBIA PLATEAU FRACTURE
 Intrarticular Fracture

ANATOMICAL STABLE FIXATION

AND EARLY ROM
 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
 Lateral ligament
Anterior- Talofibular

(ATFL)
Posterior- Talofibular

Calcaneofibular
SYNDESMOTIC LIGAMENTS
ACUTE LIGAMENTOUS
INJURY
Type I sprain- minor
Type II sprain - incomplete
Type III sprain - complete
 TREATMENT
Non-operative treatment
Achieved by RICE (Rest, Ice,
Immobilization ,Compression,
Elevation)

Operative treatment
Indicated when problems persist after 12
weeks of treatment including physiotherapy
Associated fracture
 The OTTAWA ANKLE Rules
Unable to weight bear immediately
Unable to walk four steps in medical facility
Bone tenderness medial or lateral malleolus

If YES to any, get ANKLE films

 The OTTAWA FOOT Rules
Bone tenderness base of fifth metatarsal
Bone tenderness navicular

If YES to either, get foot films

 AP VIEW
SYNDESMOSIS
Tibiofibular overlap-
10mm
TALAR CLEAR
SPACE
- superior, medial and
lateral clear space diff
<2mm
 MORTISE VIEW

Done with the leg internally rotated 15-20o

X-ray beam is perpendicular to the inter-malleolar line.
Permits examination of the articular space (clear space).
The width of the clear space between the talus and the articular surfaces
of the medial malleolus, the tibial plafond and the lateral malleolus should
be equal.
SYNDESMOTIC INJURY
TIBIAL PILON FRACTURES
Intraarticular fracture of distal tibia.
Fibula is fractured in 85% of these patients.
>20
FRACTURE 5TH METATARSAL
FRACTURE 5TH METATARSAL
THANKS