4/3/2012

1

Ankle Anatomy and Radiology

Mark C. Reilly

Chief, Orthopaedic Trauma Service

New Jersey Medical School

Anatomic Pictures c/o Primal Pictures

Speakers

• David Stephen

– U Toronto, Sunnybrook Hospital

• David Barei

– U Washington, Harborview Medical Center

• Michael Sirkin

– New Jersey Medical School

• Hobie Summers

– Loyola University Medical School

Stability

• Bony anatomy

• Ligamentous anatomy

• Joint capsule

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Ligaments • Important component of ankle fractures and

injuries

• Syndesmotic

• Lateral collateral

• Medial collateral

Syndesmotic

• Interosseous membrane

• Interosseous ligament

• Anterior tibiofibular l.

• Posterior tibiofibular l.

• Transverse tibiofibular l.

Medial Collateral

• Superficial Deltoid

– Anterior colliculus

– Posterior Tibiotalar

– Tibiocalcaneal

– Tibionavicular

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Medial Collateral

• Deep Deltoid

– Posterior colliculus

– Prevents lateral subluxation

Fibular collateral

• Three bands

–Anterior talofibular

• plantarflexion

– Calcaneofibular

• dorsiflexion

– Posterior talofibular • Posterior subluxation

• Rotatory

Radiographs

• AP

• Lateral

• Mortise • 10-15º internal rotation of tibia

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AP

• Medial and lateral gutters not equally visible

• Fibula overlaps talus and tibia

AP

Medial border fibula

Incisural border

≤ 5mm

Tib-fib overlap

AP radiograph

Medial border fibula

Lateral border of Chaput tubercle

≥ 10mm

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Talocrural Angle

Mortise

About 83º • 75-87º

Measure of fibular length

Mortise

Medial and lateral clear space should be equal to superior clear space

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Mortise

Medial clear space ≤ 4mm

Compare to tibio-talar joint

Mortise

Lateral border of talus aligned with medial border incisura

Mortise

Fibular Articular surface congruent to Lateral Talus

Shenton’s Line

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Talar Dome Lateral

• Fibula/Tibia Relationship

• Anterior and Posterior Colliculi of Medial Malleolus

Talar Dome Lateral

• Fibula/Tibia Relationship

• Anterior and Posterior Colliculi of Medial Malleolus

Need for CT

• Suspicion of/ evaluate:

– impaction

– posterior malleolus

– anterolateral fragment

– associated fractures

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Don’t Forget Tibial Films

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Conclusion

• Understand the relevant osseous and ligamentous anatomy

• Understand the normal radiographic relationships

• Both osseous and ligamentous structures make significant contribution to ankle stability after injury

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Syndesmosis injuries

David Stephen Sunnybrook HSC

University of Toronto

Toronto, Canada

Disclosures

• Research support: Synthes Canada

• Speaker: Synthes USA / Canada

Objectives:

• Challenges

• Management strategies

• Take home points

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Syndesmosis disruptions

Controversies:

• screw only vs plate & screw

• 1 vs 2 screws

• 3 vs 4 cortices

• remove vs leave screw(s)

• 3.5mm vs 4.0mm vs 4.5mm screws

• Suture anchors??

“Challenges”

• Diagnosis

• Accurate reduction

• Stable fixation

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“I read that you can just pull the fibula down and

perc it”

Syndesmosis screws removed @10 weeks

4 months postop 6 weeks post screw removal

fibular length

syndesmosis widening

medial malleolar malreduction

Problems:

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Biomechanics

• Fibular shortening peak pressures

• External rotation fibula TT contact

• Lateral talar shift shear stress

instability

Ankle Fractures: Malunion

OA

Management: Fibular osteotomy Debride syndesmosis/medial jt Orif syndesmosis

4 months postop 6 weeks post screw removal

2 year follow-up

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KEYS: lateral side

• fibula: – length

– rotation

• Syndesmosis – low threshold for

open reduction

32 yo fall down stairs: seen at local hospital – “reduction / cast”

CT to assess syndesmosis/ posterior malleolus

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Surgical tactic

• Lateral position

• Posterolateral approach

• Debridement chondral debris

• Fixation posterior malleolus

• Direct open reduction/ fixation syndesmosis (4.0mm cortical screws)

3 months postoperative

Syndesmosis: “Challenges”

• Diagnosis

• Accurate reduction

• Stable fixation

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Take Home points

• Understand the injury

– Preoperative CT

• KEYS to reconstruction

– Open reduction

– Stable fixation (screws)

– Consider postoperative CT if concern

Thank You

3/30/2012

1

AO Trauma NA Complex Ankle Fractures Webinar

David P. Barei MD, FRCSC Harborview Medical Center

University of Washington Seattle

Posterior Malleolus Fracture Management

Disclosure

• Teaching Honoraria (AO, Synthes)

• Synthes Consultant (implant design)

• Journal Reviewer

– JBJS-A, J Orthop Trauma, CORR, J Knee Surgery

• AO Fellowship Committee

Institutional-UW Orthop-Research

• AO Spine North America

• AO-Stiftung-ASIF Foundation

• Bank of America Foundation

• The Center, Orthopaedics and Neurological Surgeons

• Fidelity Investments

• Helena Orthopaedics Clinic

• Illinois Orthopaedics & Hand Center

• Inland Orthopaedics of Spokane

• JMS Hand Associates

• Northwest Biomet, Inc.

• Pacific Rim Orthopaedics

• Proliance Surgeons, Inc.

• Proliance Orthopeadics & Sports Medicine

• The Seattle Foundation

• Seattle Christian Foundation

• Silicon Valley Community Foundation

• Simonian Sports Medicine Clinic

• SKS Plastic Surgery

• Spectrum Research

• Synthes U.S.A.

• Synthes Spine Co.

• Washington Research Foundation

• Washington State Orthopaedics Association

• Webber Lawn & Yard Care

• National Institutes of Health (NIH)

• National Science Foundation (NSF)

• Veterans Affairs Rehabilitation Research and

• Development Service

• Orthopaedic Research and Education Foundation (OREF)

• A.O. North America

• Amgen, Inc.

• Bayer AG

• BioAxone Therapeutique, Inc.

• CeraPedics, LLC

• Christopher Reeve Paralysis Foundation

• Depuy (Johnson & Johnson, Inc. )

• Foundation for Orthopedic Trauma

• Integra Lifesciences Corporation

• National Science Foundation

• Ostex International, Inc.

• Orthopaedic Trauma Association

• Paradigm Spine

• Smith & Nephew

• Synthes Spine Co.

• The Boeing Company

• US Army Research Office

• US Department of Education

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Anatomy

• Evolution of understanding

– Conceptually simple

– Focus on articular surface

McDaniel CORR, 1977

Treatment Evidence

• Poorly described • “Large fragments”

– 20-30% of the articular surface • Talar subluxation, arthrosis, worse outcomes

• Smaller fragments didn’t seem to be associated with

problems

• Trimalleolar fractures seem to have worse outcomes than bimalleolar

• Thought to be secondary to chondral injury and disrupted tibiotalar congruity

Anatomy

• Evolution of understanding…Soft tissue attachments

– Syndesmosis

• PITFL

• Osseous incisura

– Tibiotalar

• Capsular attachments

• Articular congruity

Hermans J. Anat, 2010

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Posterior Malleolus Fractures • Contributes to syndesmotic stability (PITFL)

• Indications for fixation controversial

• >25% versus larger versus smaller versus all?

• Posterior subluxation?

Pathoanatomy

• 19%

67% 19% 14%

12% 30% N/A

Frequency

Cross-Section Area

Haraguchi JBJSA, 2006

Reduction and Fixation Choices Indirect Reduction

Ankle dorsiflexion

Rarely adequate for an accurate reduction

Direct Reduction

Visualize the cortical exit

Fixation

Anterior to posterior screws

Posterior to anterior screws

Posterior anti-glide plate

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What we do know • Tibiotalar incongruity & subluxation = arthrosis

• Large fragments result in syndesmosis disruption:

– Incisura deformity – PITFL “disruption”

• We are bad at reducing a syndesmosis closed,

• Posterior malleolar ORIF provides more stability to the

syndesmosis than trans-syndesmotic fixation – PITFL stays attached to the posterior malleolus

• Good ankle fracture outcomes seem to be increasingly

related to anatomic and stable syndesmosis

Surgeon Practices

• Gardner Foot Ankle Int, 2011

– Wide variation in practices

– Noted that fragment size wasn’t the sole indication

– Other considerations:

• Joint stability,

• Syndesmosis reduction,

• Syndesmosis stability

The Problem

Posterior talar subluxation Point contact loading on the plafond and talus Chondral destruction Syndesmotic dislocation and dysfunction

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The Other Problem

• If you are considering that a given posterior malleolus requires reduction and fixation, strongly consider a CT scan….

Case 1

Large fragment articular incongruity no gross tibiotalar displacement/dislocation Antiglide plate and screw fixations tibiotalar subluxation and arthrosis

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Case 2

Small fragment with gross tibiotalar instability and fibular syndesmotic comminution Posterior anterior screw with a small modified plate as a washer for syndesmosis reduction and stability

Posterolateral

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Case 3

Case 3 Approach?

1. Anteromedial

2. Anterolateral

3. Posterolateral

4. Posteromedial

5. Combined posterior and anterior

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Radiologic medial double density

Large posteromedial fragment Posteromedial osteochondral fragments

Smaller posterolateral fragment

Posterolateral

Posterolateral

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Posterolateral

Posterolateral

Posteromedial

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Posteromedial

Posteromedial

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Case 4

Main concern with last 2 cases: Tibiotalar arthrosis

Posteromedial talar subluxation

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Posteromedial

Summary

• Relative anatomic importance:

– Syndesmotic stability via PITFL

– Osseous incisura

– Tibiotalar congruity/stability

• Varying morphologies

– Consider CT scan in those that you deem operative

• Fixation strategies

– Posterolateral/posteromedial approaches

– Antiglide fixation for large fragments

1

Ankle

Fractures

Michael Sirkin, MD Vice Chairman, Department of Orthopaedics

New Jersey Medical School

Fixation in the elderly:

Avoiding problems:

Disclosures

•Consultant for Biomet

•Editorial Board

–JAAOS

–JOT

–Journal of Trauma

Today • Define the problem

• Basics to understand

• Fixation strategies

–Examples

• Avoiding problems

2

• 95 year

old

• Fell on

ice

• Closed

fracture

The problem

Loss of

reduction

Backing out

of screws

The problem

• Follow up

Stability • Bony anatomy

–Poor bone quality

–Fixation techniques need

modification

• Ligamentous anatomy

• Joint capsule

3

Standard

Fixation

Techniques

Common medial fixation

Cancellous

screws

Screw and

wire Tension Bands

Medial

Lag Screws

Neutralize

Antiglide

Common Techniques

Lateral

4

Standard Fixations

Elderly Fixation

• Special techniques may be need in osteoporotic bone

• Hardware not as well held in place

• Prevent displacement

• Preserve reduction

Special fixation

• Cancellous screw position

• Cortical lag screws

–Long

• Plates

• Supplemental k-wires

Medial

5

Cancellous screws • If using partially threaded

screws-use right size

• Just long enough for thread

to cross fracture

• Have threads in

metaphyseal bone—not

intramedullary canal

Medial

• Cortical screws-

lag technique

• Lag by technique

• Allows maximal

purchase

• May use very

long screws

• Can be bicortical

if necessary

Cortical screws Medial

• Cortical screws-

lag technique

• Lag by technique

• Allows maximal

purchase

• May use very

long screws

• Can be bicortical

if necessary

Cortical screws Medial

6

•Good for comminution

–No bony stability

Plates Medial

•Good for comminution

–No bony stability

• Small fragments

• Vertical fractures

• Act as a buttress

Plates Medial

K-wires • Can be used with

screws/plates

–Small fragment

–Bad screw purchase

–Multiple points of fixation

–Can be bicortical

Medial

7

Elderly Fixation

• Special techniques may be need in osteoporotic bone

• Hardware not as well held in place

• Prevent displacement

• Preserve reduction

–Techniques

Fibula

Reduction

8

Special Fixation

• Distal cross screws

• Intramedullary k-wires

• Longer plates

• Use tibia for fixation

• Locked plates

Lateral

• 1/3rd Tubular plate

• Flatten plate

• Cross Screws distally

–Creates bony triangle

–Longer screws

–Metal on metal

–Longer screws

• 20mm

Distal screw Lateral

Intramedullary K-wires

• Used with plates

and screws

• K-wire placed prior

to screws

• Increases purchase

of screws

• Metal on metal

interdigitates

Lateral

9

Longer plate • Distal fixation less

important

• Buttress to distal fragment

• Rely on proximal fixation

to hold distally

Lateral

Tibial fixation • Tetra cortical screws

–Use tibia for lateral

fixation

• Increased bony

purchase

• Function not as

syndesmotic screws

• Use as many as

needed

Lateral

80 yof fall in grocery store

10

3 months postop

11

Locked plates

• Small screws in

distal fragment

–Questionable

benefit

• Fixation held

proximally

Locked plates

• Multiple small

screws probably

better

Locked plates

• Small screws in distal

fragment

• Fixation held

proximally

• Can also gain fixation

in tibia

12

External Fixation

• Can use ex-fix to

protect fixation

• Typically 6

weeks

• Frequently more than one

technique is needed

• Use both medial and lateral

techniques

• Longer lateral

plate

• Longer

medial

cortical lag

screws

13

• 85 year old

• Twist and fall

• Over last 2 years

–Fractures Wrist

–Compression of L5

Multiple Techniques • Medial

–Longer screws

• Bicortical screws

• Lateral

–Longer plate

–Add intramedullary K-

wire

–Cross screws distally

Conclusions

• Care must be taken when

treating the osteopenic

• Special techniques may be

needed

• Can be done

14

• Frequently more than one

technique is needed

• Use both medial and lateral

techniques

• All techniques can be used

• 65 year old

• Diabetic

• Dialysis

dependent

• Walking to

bathroom

twisted ankle

• Lateral

– Intramedullary wires

–Longer plate

–Tetracortical screws

–Crossed distal

screws

• Medial

–Plate

–K-wires

–Long screws

15

6 weeks, no loss of

reduction

Thank

You

4/3/2012

1

Medial and Lateral Impaction in Ankle Fractures

Hobie Summers, MD

VuMedi Event

April 3, 2012

Disclosures

• Institutional grant from Synthes for research coordinator

• Synthes – consultant for representative education

Common Issues

• Easily unrecognized on initial imaging

• Must keep a high index of suspicion

• Adduction and Abduction type patterns

– Supination/Adduction

– Pronation/Abduction

• Still look for impaction in rotational injuries, especially with dislocation

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Where to look

• Supination/Adduction

– Medial impaction

• Pronation/Abduction

– Lateral impaction vs Chaput fragment

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15 months

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Summary

• Beware of adduction/abduction injuries

• Disimpact the articular surface

• Bone graft

• Buttress plating works well

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4/3/2012

1

32 y/o homeless female

Falls while intoxicated

Splinted in ER and referred to clinic

By report, minimal pain medially, not particularly swollen either

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Stress

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Stress

43 year old firefighter

Fall onto Lower Extremity

Closed, Isolated Injury

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Anterior Posterior Medial

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48 y/o male s/p motorcycle crash

10cm transverse medial open wound

Isolated injury

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46 year old male seen and splinted after twisting injury to ankle

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