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ANKUR MITTAL
Anterior Colliculus
Posterior Colliculus
Anterior colliculus
Medial talar
tubercle
Navicular
tuberosity
Sustantaculm tali
Intercollicular groove
Posterior colliculus
Medial talus
Lateral Ridge
Articular surface
Malleolar fossa
Medial view of fibula
McMinn 1996
Volkman
tubercle
Chaput tubercle
Wagstaffe
tubercle
MEDIAL SIDE
LATERAL SIDE
LACINATE LIG.
TARSAL TUNNEL
ANTERIOR
SIDE
INTRODUCTION
Ankle fractures are among the most common injuries and
management of these fractures depends upon careful
identification of the extent of bony injury as well as soft tissue
and ligamentous damage.
Once defined, the key to successful outcome following
rotational ankle fractures is anatomic restoration and healing of
ankle mortise.
Although the OTTAWA RULES have been validated and found to be both cost
effective and reliable (up to 100% sensitivity their implementation has been
inconsistent in general clinical practice
Plain
Films
AP, Mortise, Lateral
views of the ankle
Image the entire
tibia to knee joint
Foot films when
tender to palpation
Common
associated fractures
are:
5th metatarsal
base fracture
Calcaneal fracture
Identifies fractures
of
malleoli
distal tibia/fibula
plafond
talar dome
body and lateral
process of talus
calcaneous
Quantitative analysis
Tibiofibular overlap
Talar tilt
No evidence of
syndesmotic injury
Abnormal
findings:
FIBULAR LENGTH:
Posterior
mallelolar
fractures
AP talar subluxation
Distal fibular translation
&/or angulation
Syndesmotic relationship
Associated or occult
injuries
Tibial plafond
Medial malleolus
Deltoid ligaments
calcaneous
Lateral collateral ligaments
Lateral malleolus
Syndesmosis
Source: Rosen
Stress Views
Joint involvement
Posterior malleolar
fracture pattern
Pre-operative planning
Evaluate hindfoot and
midfoot if needed
CT
MRI
Some ligament injuries may be diagnosed on the basis of disruption of the ankle
mortise and displacement of the talus; others can be deduced from the
appearance of fractured bones.
For example,
fibular fracture above the level of the ankle joint indicates that the distal anterior
tibiofibular ligament is torn.
Fracture of the fibula above its anterior tubercle strongly suggests that the
tibiofibular syndesmosis is completely disrupted.
Fracture of the fibula above the level of the ankle joint without accompanying
fracture of the medial malleolus indicates rupture of the deltoid ligament.
Classification systems
Lauge-Hansen
Weber
OTA
Additional Anatomic Evaluation
Posterior Malleolar Fractures
Syndesmotic Injuries
Common Eponyms
Types:
Supination External Rotation
Supination Adduction
Pronation External Rotation
Pronation Abduction
Primary advantage :
Stage 1 Anterior
tibio- fibular
ligament
Stage 2 Fibula fx
Stage 3 Posterior
malleolus fx or
posterior tibiofibular ligament
4
1
3
Stage 4 Deltoid
ligament tear or
medial malleolus
fx
MEDIAL TENDERNESS
MEDIAL SWELLING
MEDIAL ECCHYMOSIS
STRESS VIEWS- GRAVITY OR MANUAL
SER-2
+StressView
Negative Stress view
WidenedMedialClearSpace
External rotation of
foot with ankle in
neutral flexion (00)
SE4
Stage 1: fibula
fracture is
transverse below
mortise.
Stage 2: medial
malleolus fracture is
classic vertical
pattern.
Important to restore:
Ankle stability
Articular congruity- including medial
impaction
1
4
Stage 1 Deltoid
ligament tear or
medial malleolus
fx
Stage 2 Anterior
tibio-fibular
ligament and
interosseous
membrane
Stage 3 Spiral,
proximal fibula
fracture
Stage 4 Posterior
malleolus fx or
posterior tibiofibular ligament
Medial injury: deltoid ligament tear &/or transverse medial malleolar fracture
Lateral Injury: spiral proximal lateral malleolar fracture
HIGHLY UNSTABLESYNDESMOTIC INJURY COMMON
Restore:
Fibular length and rotation
Ankle mortise
Syndesmotic stability
1
2
Stage 1 Transverse
medial malleolus fx
distal to mortise
Stage 2 Posterior
malleolus fx or
posterior tibio-fibular
ligament
Classification systems
Lauge-Hansen
Weber
OTA
Additional Anatomic Evaluation
Posterior Malleolar Fractures
Syndesmotic Injuries
Common Eponyms
Based
on location of fibula
fracture relative to mortise
and appearance
Weber A fibula distal to
mortise
Weber C fibula
proximal to
mortise
Concept
SKELETAL TRAUMA
Classification systems
Lauge-Hansen
Weber
OTA
Additional Anatomic Evaluation
Posterior Malleolar Fractures
Syndesmotic Injuries
Common Eponyms
Alpha-Numeric
Code
Infrasyndesmotic=44A
+
Malleolar segment =4
Tibia =4
Transsyndesmotic=44B
Suprasyndesmotic=44C
Infrasyndesmotic=44A
Alpha-Numeric
Code
Transsyndesmotic=44B
Alpha-Numeric
Code
Suprasyndesmotic=44C
Alpha-Numeric
Code
Classification systems
Lauge-Hansen
Weber
OTA
Additional Anatomic Evaluation
Posterior Malleolar Fractures
Syndesmotic Injuries
Common Eponyms
Function:
Stability- prevents posterior translation of talus &
enhances syndesmotic stability
Weight bearing- increases surface area of ankle joint
Fracture pattern:
Variable
Difficult to assess on standard lateral
radiograph
External rotation lateral view
CT scan
67%
19%
14%
Classification systems
Lauge-Hansen
Weber
OTA
Additional Anatomic Evaluation
Posterior Malleolar Fractures
Syndesmotic Injuries
Common Eponyms
FUNCTION:
Stability- resists external rotation, axial, & lateral
displacement of talus
Weight bearing- allows for standard loading
Classification systems
Lauge-Hansen
Weber
OTA
Additional Anatomic Evaluation
Posterior Malleolar Fractures
Syndesmotic Injuries
Common Eponyms
Maisonneuve Fracture
Fracture of proximal fibula with
syndesmotic disruption
Volkmann Fracture
Fracture of tibial attachment of
PITFL
Posterior malleolar fracture type
Tillaux-Chaput Fracture
Fracture of tibial attachment of
AITFL
Pott fracture.
In the Pott fracture, the fibula is
fractured above the intact distal
tibiofibular syndesmosis, the deltoid
ligament is ruptured, and the talus is
subluxed laterally
Dupuytren fracture.
(A) This fracture usually
occurs 2 to 7 cm above
the distal tibiofibular
syndesmosis, with
disruption of the medial
collateral ligament and,
typically, tear of the
syndesmosis leading to
ankle instability. (B) In
the low variant, the
fracture occurs more
distally and the
tibiofibular ligament
remains intact.
Wagstaffe-LeFort fracture.
In the Wagstaffe-LeFort
fracture, seen here
schematically on the
anteroposterior view, the
medial portion of the fibula is
avulsed at the insertion of the
anterior tibiofibular ligament.
The ligament, however, remains
intact.
Collicular
Fractures
Avulsion fracture of distal
portion of medial malleolus
Injury may continue and
rupture the deep deltoid
ligament
Bosworth fracture
dislocation
Fibular fracture with posterior
dislocation of proximal fibular
segment behind tibia
INTERCOLLICULAR GROOVE
POSTERIOR COLLICULUS
ANTERIOR COLLICULUS
Source:Rosen
Supination Inversion
Supination Plantarflexion
The plantarflexion force displaces the epiphysis directly posteriorly,
resulting in a Salter-Harris type I or II fracture. Fibular fractures were not
reported with this mechanism. The tibial fracture usually is difficult to see
on anteroposterior x-rays
In grade II, with further external rotation, a spiral fracture of the fibula is
produced, running from anteroinferior to posterosuperior (