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ANKLEFRACTURE

Incidenceofanklefractures Incidencehasbeenincreasingthelast20years,nowapproximately187per100,000 Typesofanklefractures: Isolatedmalleolarfracture67% Bimalleolarfracture25% Trimalleolarfracture8% Openfracture2%

RADIOLOGYOFANKLE
OttawaAnkleRules(JAMA1993;269(9):112732) Ankleradiographrequiredifpainnearthemalleoliandifoneormoreofthe followingconditionsispresent: Age55yearsorolder Inabilitytobearweight Bonetendernessattheposterioredgeortipofeithermalleolus. NormalAnatomy Talocruralangle Aanglecreatedbyalinedrawnperpendiculartothetibialplafondintersectingaline drawnfromthetipsofthemedialandlateralmalleoli;thenormalanglerangesfrom 79to87 TheShentonline DrawnfromtheWagstaffetubercleonthebulatowardthemedialmalleolus.Ifthe bulaisofadequate,anatomiclength,thelineshouldpassthroughthetibialplafond Thecirclesign Seenonthemortiseradiograph,andshouldbeanunbrokencurveconnectingthe recessinthedistaltipofthebulaandthelateralprocessofthetaluswhenthe bulaisofadequate,anatomiclength. Tibiofibularoverlap OnanAPradiograph,tibiobularoverlapshouldbemeasuredfromthemedialedge ofthebulatothelateralborderofthetibia,anditshouldexceed6mm.Anterior tubercleoftibiashouldoverlapfibulabyatleast10mm. Tibiofibularclearspace

Thetibiobularclearspaceisoneofthemostsensitiveindicatorsofsyndesmotic injuriesandismeasuredontheAPviewfromthemedialborderofthebulatothe lateralborderofthetibialincisura.Tibiofibulardistanceshouldbe3.7mm=/ 0.5mm,1cmabovethejoint. Medialclearspace Onthemortiseview,thedistancebetweenthelateralborderofthemedial malleolusandthemedialborderofthetalus(themedialclearspace)shouldbe equaltothesuperiorclearspacebetweenthetalusandthedistaltibia.Aspace greaterthan4mmisconsideredabnormalandindicatesalateralshiftofthetalus. Stressradiograph Legstabilizedin10degreesIRtoobtainmortiseview.Withankleinneutral dorsiflexionan810lbERforceisappliedtotheankle.Positivefindingismedialclear spaceof>4mmand>1mmgreaterthanthesuperiorjointspaceoranylateraltibial subluxation.Gravitystressradiographsmaybeequallyassensitivewithlesspain.

BIOMECHANICS
Theempiricaxisoftheanklejointpassesapproximately5mmdistaltothetipofthe medialmalleolusand3mmdistaland8mmanteriortothelateralmalleolus, althoughtheanklejointinrealityhasacontinuouslychangingaxisofrotation. Duringdorsiflexionoftheankle,theintermalleolardistanceincreasesapproximately 1.5mmasthefibularotatesexternallyanddisplaceslaterally.Thismotioniscoupled withthelateralrotationofthetalusandiscontrolledbythematchingwedge contourofthetalusinthemortise.

CLASSIFICATION
Pottsfracture(Pott,P.(1769).SomeFewGeneralRemarksonFracturesand Dislocations.London,Howes.Clarke.Collins) Describedfracturepatternsoftheankleinregardstomalleolar(i.e.uni,biandtri). ThebimalleolarfracturewastermedaPottsfracturefollowingthedescriptionofa fracturehehimselfsustained. Cottonsfracture(CottonFJ:Anewtypeofanklefracture.JAMA64:318321,1915) Thetypicaltrimalleolarfracture. Dupuytrenfracture(Dupuytren,G.(1819).Mmoiresurlafracturedelextremit inferieureduperon,lesluxationsetlesaccidentsquiensontlasuite.Annmed.chir Hp.Paris,1:2212.) Dupuytrenusedcadaverexperimentstoproduceanklefracturesbyabductionor "outwardmovement"ofthefoot.Subsequently,Frenchauthorshavereferredtoa lowDupuytrenfracture,ashortobliquefractureofthefibulajustabovearuptured anteriorinferiortibiofibularligamentorbelowanintactone;andahighDupuytren

lesion,whichreferstoatransverseorshortobliquefractureatthejunctionofthe middleanddistalthirdsofthefibulaaccompaniedbydisruptionofthesyndesmosis. LaugeHansenclassification(ArchSurg1950;60:95785) Thetypeofanklefracturethatoccursdependsontwofactors: thepositionofthefootatinjury,eithersupinationorpronation thedeformingforce,whichisexternalrotation,abduction,oradduction. Whenthefootispronated,thedeltoidligamentistense,andtheinitialinjuryis medial,eitheramedialmalleolusfractureoradeltoidligamentdisruption.Inall thesetypes,theinitialinjurymaybeisolatedormaybefollowedinapredictable sequenceoffurtherinjurytootherstructuresaroundtheankle. Supinationadduction Transversefractureoffibula/tearofcollateralligamentsverticalfracture medialmalleolus Supination/eversion(externalrotation)mostcommoninjury 1. 1.Disruptionoftheanteriortibiofibularligament 2. 2.Spiralobliquefractureofthedistalfibula 3. 3.Disruptionoftheposteriortibiofibularligamentorfractureoftheposterior malleolus 4. 4.Fractureofthemedialmalleolusorruptureofthedeltoidligament Pronation/abduction 1. Transversefractureofthemedialmalleolusorruptureofthedeltoid ligament 2. Ruptureofthesyndesmoticligamentsoravulsionfractureoftheir insertion(s) 3. Short,horizontal,obliquefractureofthefibulaabovethelevelofthejoint Pronation/eversion 1. Transversefractureofthemedialmalleolusordisruptionofthedeltoid ligament 2. Disruptionoftheanteriortibiofibularligament 3. Shortobliquefractureofthefibulaabovethelevelofthejoint 4. Ruptureofposteriortibiofibularligamentoravulsionfractureofthe posterolateraltibia DanisWeberclassification(InitiallyproducedbyDanis(DanisR.Lesfractures malleolaires.In:DanisR,ed.TheorieetPractiquedel'Osteosynthese,1949:13365) andmodifiedbyWeber(WeberBG.DieVerletzungendesoberenSprungelenkes, 2nded.Bern:HansHuber,1972.)) A. Avulsionfracturefibulashearfractureofmedialmalleolus B. Fibulafractureatlevelofsyndesmosisfracturemedialmalleolus/tear ofdeltoidligament

AshurstandBromerclassification(ArchSurg1922;4:51129) Externalrotation60% Abduction20% Adduction15% Verticalloading3% Directviolence2% Theyfurthersuggestedthat3ofseverityexistedwithineachcategory:firstdegree injuriesinvolvedonlyonemalleolus,seconddegreeinjurieswerebimalleolar,and thirddegreeinjuriesweresupramalleolarfractures LeFort'sfracture(BullGenTher1886,110:193199) Verticalfractureoftheanteromedialpartofthedistalfibulawithavulsionofthe anteriortibiofibularligament. Maissoneuvesfracture(Maisonneuve,J.G.(1840).Recherchessurlafracturedu pron.Paris.France:Loquin&Cie) Generallyattributedtothespiralfractureofproximalfibulaassociatedwith disruptionoftheinterosseousmembraneandthedistaltibiafibularsyndesmosis calledbysomethehighDuputrenfracture.However,Maisonneuve,apupilof Dupuytren,wasthefirstandalmostonlysurgeonbeforethe20thcenturyto emphasizetheroleofexternalrotationintheproductionofanklefractures,showing howexternalrotationofthetalusintheanklemortisecouldproducethehigh fractureofthefibulathatbearshisname.Hisoriginalillustration,however,failedto showthenecessaryinterosseousdisruption,andtheobliquityofthefibularfracture wasdepictedinthecoronalratherthanthecharacteristicsagittalplane. Maisonneuve'smostsignificantcontributionwashisdescriptionofamuchmore commonfracture,thelowexternalrotationfractureofthefibula,which,becauseit beginsanteriorlybelowandendsposteriorlyabovetheattachmentsofthe respectivetibiofibularligaments,hasbeenlabeledthe"mixedoblique"fracture. Bosworthfracture(JBJSAm1947,29:1305) AlesiondescribedbyBosworthmaybethecauseoffailuretoreduceaposterior fracturedislocationoftheankle.Thedistalendoftheproximalfragmentofthe fibulamaybedisplacedposteriortothetibiaandlockedbythetibiasposterolateral ridge;thebonecannotbereleasedbymanipulationbecauseofthepulloftheintact interosseousmembrane. HerscoviciJrclassificationofisolatedmedialmalleolusfractures(JBJSBr 2007,89(1):8993) A. Tipavulsions(anteriorcolliculus) B. Intermediate C. Levelofplafond

C. Fibulafractureabovelevelofsyndesmosismedialinjury+tearof inferiortibiofibularligamentandinterosseousmembrane

Haraguchiclassification(JBJSAm2006,88(5):108592) Categorizedposteriormalleolarfracturesintothreetypes: 1. Theposterolateralobliquetype(AttachedtoPITFL)(67%) 2. Themedialextensiontype(19%) 3. Thesmallshelltype(14%). Theaverageareaofthefragmentcomprised11.7%ofthecrosssectionalareaofthe tibialplafondforposterolateralobliquefracturesand29.8%formedialextension fractures.Inthecasesthatcomprised>25%ofthetibialplafond,thefractureline extendedtothemedialmalleolus. Tillauxfracture(TillauxP.Recherchescliniquesetexperimentalessurlesfractures malleolaires.RapportparGosselin.BullAcadMed,Paris,Ser.1872;21:817) Afractureoftheanterolateraltibialepiphysisthatiscommonlyseeninadolescents. Thefragmentisavulsedduetothestronganteriortibiofibularligamentinan externalrotationinjuryofthefootinrelationtotheleg.SirAstleyCooperfirst describedafractureofthelateralaspectofthedistaltibiaintheadult.PaulJules Tillauxpartiallydescribedanavulsionfractureofthelateraltibiain1892,following hisexperimentoncadavers. Chaputfracture(HenriChaput(18571919)) Fractureofthephysisoftheposterolateralcornerofthetibiaduetothepullofthe PITFL. Wagstaffefracture(St.ThomasHospRep6:43,1875) AvulsionfracturefromtheanteriorfibularbythepulloftheAITFL(reverseofTillaux) similartoLeFortfracture. Wilsonfracture(ClinOrthop306:97102,1994) Malleolarfracturesproducedbyisolatedplantarflexion.Bothmalleolarfracture linesareinsagittalplane,butsuperoinferiordirectionisreversed. Volkmannsfracture(R.Volkmann,inCentralblattfrChirurgie,Leipzig,1875:358.) Fractureoftheposterolateralcornerofthetibia,knownasVolkmannstriangle. SimilartotheChaputfracture,attributedtoVolkmannalthoughhedidntdescribe thefracturejusttheareaofthetibia.

D. Aboveplafond(adductionfractures)

RATIONALBEHINDORIFANKLEFRACTURES
RamseyandHamilton(JBJS(B)1976)showedthata1mmlateralshiftofthe talusintheanklemorticereducesthecontactareaby42% DeSouza(JBJS(A)1985)showed90%satisfactoryresultscouldbeobtained evenifupto2mmoflateraldisplacement

IsolatedMedialMalleolarfracturehasa515%nonunionrateif>2mm displaced. Fixposteriormalleolusif>25%ofplafond(Scheidt,JTrauma1992;6:98)

ARTHRITISPOSTINJURY
Incidenceincreaseswithseverityofinjury Klossner(ActaChirScandSuppl.293:193,1962) Degenerativechangesin 10%ofanatomicallyfixed 85%ifnotadequatelyreducedchangesapparentwithin18months

PROGNOSIS
Thereisareductionintheincidenceofarthrosisinpatientswhereananatomical reductionhasbeenachieved(PhillipsetalJBJS67A:6778,1985) Prospectivetrialshowshighertotalanklescoresinthosethatareoperatively treatedespeciallysointhosepatientsmorethan50yrsold.