Malleolar fractures of the ankle
Fractures and fracture dislocation of
the ankle are common.
Clinical features
•
Intense pain, inability to stand on one leg
•
Ankle is swollen and deformity may be
obvious
•
Tenderness and brusing
X-ray
•
AP,lateral and mortise view are needed
treatment
•
If the injury is not dealt within a few hours,
definititive treatment may have to bedeferred
•
for several days till swelling can subside
Clues to invisible ligament injury
•
Widening of the tibiofibular space, asymmetry
of the talotibial space, widening of the medial
joint space
•
Good reduction need four objectives must be
met
•
1.the fibula must be restrored to its full length
•
Most are low energy fractures of one or both
malleoli , usually caused by a twisting
mechanism.The most obvious injury is a
fracture of one or both malleoli ; often though
, the invisible part of the injury –rupture of
one or more ligaments.
Mechanism
•
The patient stumble and fall.Usually the foot is
anchored to the ground while the body lunges
foreward.The ankle is twisted and talus tilts
and or rotates in the mortise , causing a low
energy fracture of one or both malleoli, with
or without injuries of the ligaments.The
precise fracture pattern is determined by
:1.the position of foot 2.the direction of force
at the moment of injury.
Classification
•
A simpler classification is that of Danis and
Weber, which focus es on the fibular fracture
•
Type A is a transverse fracture of the fibula below
tibiofibular syndesmosis, perhaps associated with
oblique or vertical fracture of the medial
malleolus, this is adduction or adduction and
internal rotation injury
•
Type B is an oblique fracture of the fibula in the
sagital plane at the level of the syndesmosis;
often there is avulsion injury of the medial side,
this is an external rotation
•
Type B fracture may be associated wiyh a tear
of the anterior tibiofibular ligament.
•
Type C is amore severe injury , above the level
of the syndesmosis, which means that the
tibiofibular ligament and part of the
interosseos membrane must have been torn,
this is abduction or abduction and externan
rotation injury.
Clinical features
•
Intense pain , inability to stand on the
leg,ankle is swollen. Tenderness and brusing
X-ray
•
AP ,lateral and mortise view is needed
treatment
•
If the injury is not dealt with a few hours,
definitive treatment may have to be deferred
for several days till swelling subside.
•
Clues to invisible ligament injury include –
widening of tibiofibular space,asymmetry of
the talotibial space,widening of the medial
joint space.
•
Type A undisplaced fracture is stable and firm
bandage or brace is applied mainly for
comfort until the fracture heals.
•
Displaces type A fracture , the medial
malleolar fracture is vertical and remain
unstable after closed reduction; internal
fixation is done and fibular fracture must also
reduced by closed method if failed , internal
fixation must be done
•
Undisplaced type B fracture can be treated with a
below –knee cast with ankle in the neutral
position.X ray is taken at 2 weeks to confirm that
fracture remain undisplaced.The cast can usually
be discarded after 6-8 weeks.
•
Displaced type B fracture ; if there is spiral
fracture of the fibula and an oblique fracture of
the medial malleolus, closed reduction by
traction and then internal rotationof the foot if
failed internal fixation is needed
•
Type C fracture displaced or not need open
reduction and internal fixation.
complications
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Early : vascular injury , wound breakdown and
infection
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Late: incomplete reduction , non-union, joint
stiffness, algodystrophy and osteoarthritis.