Ankle Injury Orto ICO 2

8/19/2019 Ankle Injury Orto ICO 2

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Ankle Injuries

Ankle injuries fall into the same basic categories asdo all athletic injuries:

• Contusions•

Sprains• Strains• Fractures


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85% of all ankle sprains involve some plantar flexion of the ankle and

inversion of the foot

!he remaining "5% consist of eversion mechanisms #hich are often theresult of an outside force such as being fallen on from the outside


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Lateral aspect of the joints of the right ankle region

1- anterior inferior tibio bular ligament2- anterior oblique capsular reinforcement3- talonavicular ligament4- dorsal cuboideonavicular ligament5- t e t!o limbs of t e bifurcate ligament"- dorsal calcaneocuboid ligament#- e$tensor digitorum brevis

%- cervical ligament&- anterior talo bular ligament1'- lateral talocalcaneal ligament11- calcaneo bular ligament12- posterior intermalleolar ligament13- posterior talo bular ligament14- posterior talocalcaneal ligament


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!he s$ndesmosis ligament is often also injured#ith an eversion force f the tibia and fibula

spread on the talus& the ankle mortise isdisrupted and the ankle can become ver$unstable t is also not unusual to see anassociated fibula fracture #ith an eversionmechanism 'see x(ra$s belo#) Assessment of as$ndesmosis sprain #ill be difficult for theinitial *+ to +8 hours f the ankle is ,uites#ollen and edematous assessment of as$ndesmosis sprain ma$ be difficult until the

pain and s#elling have isolated to individualareas or x(ra$s sho# some spreading of theankle mortise


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9/76Ankle (cc )mosis


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-istal Fibula fracture #ithassociated medial deltoid ligamentdisruption !his injur$ is fre,uentl$the result of the foot being planted

#ith a valgus load applied to theleg


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.otice the disruption of the medialdeltoid ligament and the #idening

bet#een the medial malleolus andthe talus !his is indicative of aruptured deltoid ligament


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Ankle dislocation #ith no fractures !his takes ahigh degree of trauma and force n this case this#as generated as the result of a high flip off of a

trampoline and impact #ith the ground !he ankle#as in a plantar flexion and inverted position upon

impact !his #as an open dislocation


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Ankle Sprains

• *ost common at letic injur)+ 25, of allinjuries+

• e risk of ankle sprains varies !it t esport – 21-53, basketball. 1#-2&, soccer. 25, volle)ball+

• Ankle sprains account for 1', to 15, of alllost pla)ing time

• e medial malleolus is s orter t an t elateral mallelous so t ere is naturall) moreinversion t an eversion+


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Ankle Sprains• /reater inversion increases t e potential for over-

stretc ing of t e lateral ligaments+• *ost sprains involve t e lateral ligaments from

e$cessive inversion+• 0eltoid ligament is sprained less often 25, of

ankle sprains• f t e lateral ligments. t e A is sprained t e

most often follo!ed b) t e 6• 7prains ocur most often !it t e foot in plantar

8e$ion and inversion+


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Ankle 7prains


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Classification of Sprains

• 1st 0egree9 – Stretching of t e A – little or no edema – tenderness – maintain function+

• 2nd 0egree – Partial tear of t e

A and:or 6

– moderate edema – some function loss

• 3rd 0egree – Complete tear A .6 . and:or ;

– total loss of function – signi cant edema


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Ankle Sprains by Grade

Sign/symptom Grade I Grade II Grade III

Tendon

Loss of functional ability

Pain

Swelling

Ecchy osis

!ifficulty bearing weight

No tear

"ini al

"ini al

"ini al

#sually not

$o

Partial tear

So e

"oderate

"oderate

%re&uently

#sually

Complete tear

Great

Se'ere

Se'ere

(es

Al ost always


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tta!a rules

• nnecessar)=-ra)s9 costl).timeconsuming. and possible ealt risk


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• =-ra)s are onl) required if t ere is bon)pain in t e malleolar ?one A@0 an) oneof t e follo!ing9

• 1 B enderness along t e distal "cmof t e posterior edge of t e tibia

• 2 B enderness along t e distal "cm

of t e posterior edge of t e bula• 3 B Inabilit) to bear !eig t

immediatel) after injur) and in t e (C


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Treat ent

• AAFP (see table 3)• R.I.C.E.• Ice for 20 minutes on and 20 minutes off for the first

two hours.• After that, 20 min intervals over the next 48-72

hours,•

Compression wrap with donut or horse shoes to fillin gaps around malleolus from 24-36 hours; after48-72 hours contrasts baths with ROM exercises for4 minutes in warm and 1 min in ice water.

http://www.aafp.org/afp/980201ap/wexler.htmlhttp://www.aafp.org/afp/980201ap/wexler.htmlhttp://www.aafp.org/afp/980201ap/wexler.htmlhttp://www.aafp.org/afp/980201ap/wexler.html


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Achilles Tendonitists

• 6auses – Capidl) increasing training

eDort

– Adding ills or stair climbingto training – 7tarting too quickl) after a

la)oD – ;oor foot!ear

– ($cessive pronation – ig t posterior leg muscles

• If left untreated. it ma)progress to a completerupture+


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Ac illes endon Cupture

• *ost frequentl) ruptured tendon• 6omplete ruptures are due to

eccentric loading during abruptstopping. landing from a jump+

• >suall) a popping sound iseard !it a complete tear+

• ere ma) or ma) not be anobvious gap 2 to " cm from t ecalcaneus attac ment+

• reatment ma) or ma) notinclude surger) but bot requireimmobili?ed for 3 mont s+


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Plantar Fasciitis

• e plantar fascia runs from t e calcaneus to t emetatarsals+

• is tig t band acts like a bo! string to maintain t earc of t e foot+

• ;lantar fasciitis refers to an in8ammation of t eplantar fascia+


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;lantar asciitis

• In8ammation isusuall) due torepeated trauma to

! ere t e tissueattac es to t ecalcaneus+

• e trauma results inmicroscpic tears att e calcaneusattac ment site+

• is ma) produce ealspurs


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;lantar asciitis

• ;ain is !orse in t emorning or after a

period of inactivit)• 6auses

– Eig arc

– ($cessive pronation – oot!ear !orn out. stiD – Increase in intensit)


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Ankle Exercises

• 6alf stretc• 7oleus stretc• Cesisted dorsal

and plantar8e$ion

• Eeel raises

• 7tep-up• Fump rope


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A@G ( CA6 >C(


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(;I0(*I /H

• *ost ankle fractures are isolatedmalleolar fractures 2:3

•


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•


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CA0I /CA;EH

• tta!a Ankle rules 1'', sensitivit)for detecting ankle fractures

• ;ain near malleoli

• Age J 55 )ears• Inabilit) to bear !eig t•


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CA0I /CA;EH

• 7tandard A;. ateral vie!s• *ortise vie!9 = ra) beam parallel to

trans malleolar a$is;atient )s leg internal) rotated to 15

degrees


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CA0I /CA;EH

• = ra) measurements of alignmentand stabilit)9

• alo crural angle• Angle subtended b) line dra!n parallel to

articular surface of distal tibia and oneconnecting tip of bot malleoli

• 4 to 11 degrees• An) diDerence of 2-3 degrees to opposite

side is abnormal and indicates bulars ortening


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CA0I /CA;EH

• *edial clear space•


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CA0I /CA;EH

• ibio bular clearspace9

• 7)ndesmosis injur)•


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6 A77I I6A I @7

• ;ott )s9 Anatomical• *ono malleolar•


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A>/(- EA@7(@6 A77I I6A I @

• Associates speci c fracture patterns !itmec anism of injur)

• 7upination ($ternal rotation "',

• 7upination Adduction 2',• ;ronation ($ternal rotation and ;ronation

abduction 2',

• 1 st !ord- oot position at time of injur)• 2 nd !ord- 0irection of deforming force on

talus


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A>/(- EA@7(@6 A77I I6A I @

• it foot supinated. lateral supportstructures !ill fail rst

• it foot pronated medial supportstructures fail rst

• Injuries are graded 1 to 4 based onlevel of involvement and severit)+


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;A (C@ I A CA6 >C(

• 7-(C9 7piral oblique fracture runsfrom antero inferior margin upto

posterior superior corte$

• 7-A09 ransverse fracture distal tomortice or avulsion fracture of

tip

• ;-(C9 Above s)ndesmosis. fromsuperior anterior corte$ to posteroinferior corte$

• ;-A


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Supination E*ternal +otation Supination Adduction


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,igh fibula fracture with talar displace entPronation e*ternal rotation in-ury


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0A@I7 (


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!A$.S /E0E+ CLASS.%.CAT.1$


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• H;( 69• Abduction injur)• 61 9 oblique K pro$ to disrupted tibio bular

ligament• 62 9 Abduction L e$t+ rotation !it pro$ K ofbula and interosseous membrane


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A 6 A77I I6A I @

•


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7 A< (:>@7 A< (

• >@7 A< (9•


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.f %ibula is fractured and talus not shifted

Look for edial side swelling

"edial side swelling 2

!eltoid liga ent in-ury

#$STA0LE

"edial side swelling 3

Stress +adiography

Talus shifts#$STA0LE

Talus does not shiftSTA0LE

7 A< (:>@7 A< (


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7H@0(7* I6 I@F>CI(7

• *ost commonl) due to ;(C and ;A<• i$ation indicated if

• ;ro$imal bula K !it a medial injur)

• 7)ndesmotic injur) J 5 cm pro$imal toplafond

• Integrit) of s)ndesmosis can be judged intra operativel)9 i$ bula.pull laterall) !it a ook. if laterals ift J 3-4mm t en essential to $+


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• *aisonneuve )sfracture9

• 7piral K of t epro$imal bula

ssociated !itunstable ankle injur)

• ;ronation ($ternalrotation

• Cequires reductionand stabili?ation ofs)ndesmosis


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• < 7 C E )7 CA6 >C(9• e distal end of t e pro$imal fragment of

bula gets displaced posterior to t e tibiaand ma) be locked b) tibia )s postero lateralridge

• e bone cannot be released b)manupulation due to intact introsseousmembrane

• ibula is e$posed and considerable force isrequired to release t e bula. fracture t en

$ed operativel)


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C(A *(@

• Initial *anagement9 btain A;.lateral and mortice vie!s

• Ceduce talus immediatel)• ailure >rgent operative

intervention

CI 7panning e$ $6alcaneal

pin


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7 A< ( I@F>CH :

• K protected in a s ort leg cast orbrace for 4-" !eeks. allo! partial !t+bearing. < after 12 !eeks


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pen reatment

• @ot indicated in stable fractures. onl)if associated injuries like talar K orosteoc ondral K of talar dome

• Indicated in all unstable fractures


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CI

• ibula i$ation9• 1:3 rd tubular plate if

K above ankle• ag scre!s

• Cus rod9 if Ktransverse

• < 9 if fragmentsmall


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CI

• *edial *alleolus9• 2 parallel 4+' mm ; 67• < if fragment small and osteoporotic

• ;osterior *alleolus• i$ation important9 ot er!ise ma) lead to posterior

sublu$ation of talus• 7i?e of fragment important 6 scan• If J 25, - 3', of joint surface $ation done• i$ associated K rst and t en do an intra op

posterior dra!er test• Appl) 1:3 rd tubular plate posterior• Anterior to posterior intra fragmentar) scre!


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• 7)ndesmotic i$ation• Indication9 ;ro$ bula K associated !it medial injur)• en t e medial clear space !idens on intra op

stress vie!s after bula $ation• 7cre! $ed 2 -3 cm above ankle joint and parallel to

it and angled 3' degrees anteriorl)• 4+5 mm scre! used- purc ase 4 cortices• ig t scre! in ma$imal dorsi8e$ion of ankle• ime of scre! removal- controversialM++ *ost

surgeons prefer to remove t e scre! before !eig tbearing is allo!ed "B% !eeks

• >se s)ndesmotic scre! onl). !it out $ing t e bula! en K above mid bula


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; 7 ;(CA IN(

• Ankle immobili?ed in posteriorplaster splint

• 7plint removed after 3-4 da)s.replaced !it removable splint

• C * e$ercises are begun• @


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A=IA A0I@/ I@F>CI(79 IC(7

• Articular and metap )sealcomminution

• Foint impaction• ;ro$imal displacement of talus• Eig energ) trauma associated !it

soft tissue involvement• racture pattern depends upon

direction and position of foot


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AP and lateral 'iews of tibialPlafond showing articular and"etaphyseal co inution


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The position of the foot at the ti e1f a*ial load deter ines which part

1f the tibial plafond will fracture


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6 A77I I6A I @

• Cuedi- Allgo!erclassi cation9

• )pe 1 9@ondispaced

cleavage K• )pe 29 0isplaced

and minimall)comminuted K

• )pe 39 Eig l)

comminuted K


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6 A77I I6A I @

• A : A9• A9 @on- articular•


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C(A *(@

• Initial reatment9• Ceduce an) talar displacement• Articular reduction t roug eit er closed or open

met ods

• 7plint t e fracture ! ic ma) require temporar)skeletal traction

• reatment ptions9•

;late• 7panning e$ternal $ator• ($ternal $ator leaving t e anlke


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A0NA@ A/(7: 0I7A0NA@ A/(7Fixation Techniques

!echni,ue Advantages -isadvantages

/pen reduction and internal fixation nvolves #ide exposure for articularreductionAllo#s earl$ motion of ankle joint

-isrupts tenuous soft tissue envelopenvolves large subcutaneous implants

0as highest incidence of #ound healing problemsincluding: 1ound breakdo#n nfection /steom$elitis Amputation

2igid cross(ankle external fixation nvolves minimal disruption of 3one ofinjur$

2igidl$ immobili3es ankle

4xternal fixation of same side of joint Allo#s motion at the ankleAvoids large plates to stabili3e metaph$sis Cannot be used for all fractures-isrupts 3one of injur$s technicall$ demanding

Articulated cross(ankle externalfixation

Allo#s motion at the ankle 'limited)s technicall$ easier to appl$ fixator nvolves minimal disruption of 3one of

injur$

s difficult to align axis of hinge #ith axis of ankle joint2e,uires pins in hind(foot bones

alue of motion through an articulated hinge is not proven

0(6I7I @ *AGI@/ A@0 A6 C7


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0(6I7I @ *AGI@/ A@0 A6 C7C( A I@/ > 6 *(

• 6losed reatment9 >ndisplaced t)peA. )pe < and )pe 61 fractures

• pen reatment9• Immediate CI obsolete due to severe soft

tissue complications and ig rate of

implant failure• @ot favoured an) longer


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• >rgent stabili?ation done eit er b)• 7panning e$ternal $ator• ($ternal $ator sparing t e ankle joint• Illi?arov )s ring $ator

• 6alcaneal pin traction

• Adequate time is given for t e soft tissueto eal 4-" !eeks

• 0e native procedure is done after softtissue eals


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• 7panning e$ternal $ator andIlli?arov e$ternal $ator can be usedfor de nitive management

• Implants9• 7mall fragment 3+5 mm and 4+'' mm

scre!s for metap )seal stabili?ation

• 7mall plates- 1:3 rd tubular. 3+5 mm 06;.small clover leaf plates or s aped platesdesigned for distal radius. $ed anglelocking scre! plates


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C(7> 7

• Eig energ) trauma• Cesult not al!a)s good• 0epends on associated degree of soft

tissue trauma. !ound condition andinfections

• Average interval for fracture to eal 12!eeks

• Average time to return to normal activit)-1 )ear

• Cate of ;ost op art iritis and c:o pain and

disabilit) --- EI/EOO


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7>**ACH

• 6ommon fractures• Anatomical reduction. restoration of

bular lengt . s)ndesmotic repairlead to e$cellent outcomes for t epatient

• In plafond fractures management ofsoft tissue component and adequatestable $ation *A@0A CH


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!hank $ou66


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Ankle Injury Orto ICO 2