We're going to talk about ankle fractures today. I have no relevant disclosures. We will start with the anatomy and then talk about diagnosis, both looking at stable versus unstable fractures because that really changes your treatment. We'll talk about treatment and reasons to refer and then finish up with some pediatric considerations. The ankle joint, pretty basic, but we have the distal tibia, the distal fibula, and the talus, which forms the talocrural joint. On the inside, we have the deltoid ligaments. On the outside, we have the ATFL, the PTFL, and CFL. Then the ligamentous complex that we're most not concerned about but becomes important in ankle fractures is the syndesmosis. That's a complex made up of the anterior and posterior inferior tib-fib ligaments. Here's your anterior and here's your posterior. Then the interosseous membrane, so in here. That complex keeps the tib-fib together and becomes really important when we talk about instability. Other anatomy pieces that you should be aware of, there's something called the tibial plafond. That's the inferior distal tibia. It's this shelf that sits over the talar dome. One reason that I bring this up and that it's important to think about is that's actually broader in the front than the back, as is the talus. Here's the, from a bird's eye view, here's your talus and the talar dome is broader in the front than the back. When the ankle comes up into dorsiflexion, it locks in. When the ankle then is in plantarflexion, it's looser and more vulnerable. That's when a lot of your injuries occur, both sprains as well as fractures. Just keep that in mind when you're evaluating folks. Another anatomy concept to think about is the ring of the ankle mortis. If you think about all the ligaments that stabilize and keep things together, and then the bones, if you have a single break, so you break one side, it tends to be stable. But as soon as you have a double break, you're at risk of having instability and then that can lead to more long-term consequences if not treated appropriately. You can have a ligament on one side and a bone fracture on the other, two bone fractures, two ligament injuries, but keep that in mind in terms of stability. So to sort of illustrate our history and physical exam, I just wanted to bring up a case, which is always good to go through. So we have a 34-year-old female who presents with ankle pain. Surprise, surprise, let's talk about ankle fractures. Two days prior, she was hiking in muck boots up here in Maine and slipped on a rock. She had immediate pain. It was hard for her to walk. She limped home and she had swelling and pain. She used some home care of elevation, ice, and rest. She said it was bruised all over and she really can't walk on it anymore. She had to get some friend's crutches, so that's why she came in to see you. So this just illustrates some key points, right, on your history. You want to talk about the location, what makes it better, what makes it worse. Are there any other injuries? Was it high impact or low impact? If you can ask, and a lot of times patients don't really know, but you can inquire about the ankle position at the time of injury, and are they able to bear weight? On physical exam, you always want to examine the uninjured side, so what's normal, right, so is it swollen, is it not? You want to be sure, excuse me, to examine the full length of the tip fib, right, that proximal fibula you don't want to miss, and the joint above, joint below, so the knee and foot as well. On inspection, look for swelling, any deformities, any open wounds, that's going to change your management. Palpation wise, a lot of times ankles just hurt all over, but if you can really find the point of maximal tenderness, that can sometimes help guide your diagnosis. You look at passive range of motion, active range of motion, and weight bearing status all play a role. Do a good neurovascular exam, and don't forget to, you know, think out of the box a little bit and make sure you monitor for signs of compartment syndrome if you have higher level trauma. Some special tests you can do, similar, you know, we're always sort of trying to figure out is it a sprain or a fracture, where do we go from here? So the squeeze test is when you squeeze the tip fib together more proximally, and then you look for pain that radiates distally to that lower syndesmosis, towards the ankle joint. The intra-jaw test, illustrated here, but you grasp the tibia, then your hand under the calcaneus, and pull forward, and you look again for laxity, and comparing both sides. The dorsiflexion external rotation test, things come by other names, but basically you dorsiflex, you externally rotate the foot. And again, that stresses that syndesmosis, and you want to look for pain and symptoms there as well. That can also be used for stress x-rays, so we'll talk about that in a minute as well. So moving right into radiology, there are something called the Ottawa ankle rules and foot rules that you should all be familiar with if you're not already. And just in brief, the Ottawa ankle rules require that you have tenderness in the posterior aspect of the lateral malleolus, or the medial malleolus, up to 6 centimeters, and the inability to bear weight. So those are keys, and if you have a positive rule, then it's sort of indicated to get an x-ray. If those are negative, it's less likely. And then the foot rules, just to review, if you have tenderness at the navicular and the fifth metatarsal, that's a positive. So if you've decided to move on with radiology, and we're talking fractures, so we always get x-rays, the three major views you want to get are the AP lateral and mortis view. And then you want to also consider stress views, and that can be with gravity, so having the patient bear weight, and they really need to bear weight, because you want to have that pressure down to stress the mortis. And then if you have tenderness at the proximal fibula, you want to get a full-length tib-fib view. So some examples of that, here's your AP view. This is the lateral, and some of these have findings, but we'll get to those as we move through the talk. And then here is your mortis. And you can see here, the difference between the mortis view and the AP, the mortis is an AP, but the foot is then internally rotated, or adducted a bit, so you really want to get those equal joint spaces, that's what you're looking for. So both sides, as well as the top, the superior, medial, and lateral aspects should be equal. And whenever we get x-rays, I'd just like to point out that one view is no view. If you just had this x-ray, you'd say, that looks pretty normal. But you want to look at your lateral view, and you can see this nice posterior malleolar fracture line here, which could be missed if you were too focused on the AP or the mortis view. So just remember, look at your own x-rays, and examine all your views. And this is just to give you some quick follow-up on this patient. Here's a fracture, nine weeks later with conservative treatment, you have some great callus formation and complete resolution of that fracture line. So x-rays are really our gold standard. I just wanted to make a quick point, MRI is usually not indicated in an acute injury. They are better to evaluate ligamentous integrity, OCD lesions, more in a chronic ankle situation. Ultrasound can be used to detect x-rays, so that's a great new tool that we have that can even use on the sideline, because that can show soft tissue as well as bony abnormalities. CT scans are sometimes used for surgical planning, so if you have a really complex fracture and you're worried about joint step-off, a CT is going to better delineate that. So it could come into consideration for some things, but mostly your x-ray is going to be your gold standard modality. So fracture patterns, some other things to know about and help you evaluate your patient. An avulsion fracture usually is transverse. So these are nice schematics, I think. So an avulsion, so if that ligament pulls down on the bone, it usually creates a transverse fracture. Sometimes you can get an impaction on the other side, which is actually shown here. So if you get an impaction, you get more of an oblique pattern. But this also, again, shows you the importance of always examining the opposite side, so you can have a ligamentous injury and then a bony injury, but you may only obviously see one on x-ray. These are some x-rays just showing that difference. Here's your transverse fracture. This is a nice x-ray that illustrates that transverse, that's the avulsion. And you can picture how that tail is shifted and caused an oblique fracture from an impaction on the other side. Classification systems, there are a bunch out there. I think the most common used in our specialty is the Dennis-Weber, so more commonly known as the Weber classification. It's based on the fibula fracture and the location of the fracture in relation to the mortis. Just so that you're aware, there is something called Lange-Hansen, as well as AO, but due to the nature of this talk, we're just going to move right through and try to cover what we can here. So the Dennis-Weber system, a Weber A is a fracture below the mortis, and the syndesmosis is often intact. A Weber B is right at the mortis, and usually you have this oblique pattern. And the syndesmosis, again, is usually intact, but those are the ones you want to sort of take a good look at and get those stress views if indicated. And then a Weber C is above the mortis, and usually the syndesmosis is also impacted in those. Some x-ray examples here, here's a pretty classic Weber A. You've got a transverse fracture through the distal fibula. This is actually also an A. So this is an accessory ossicle, but our real fracture is just this tiny little avulsion on the tip of the fibula. I think I have a bigger picture here. So this is also considered an A, right? So it's a distal fibula fracture below the level of the mortis. This fracture here, this is actually our hiker, this is our case. And we have this oblique fracture, which you can see, here's the fracture line through here, it comes up through here, but really where the bone meets that tib-fib articulation is right at the mortis. So this is considered a Weber B. And then you can see it also on this lateral view as well. But this one is really what helps you characterize it the best, because you can see where that fracture line comes out. So let's move on to treatment. So this is our Weber A sort of isolated malleolar fractures. And again, so we have a transverse fracture, a little avulsion fracture. This one's a little bit more chronic. So small non-displaced fractures, you can treat with early immobilization similar to an ankle sprain. So these are very similar to, let's say, a grade three ankle sprain, right? So there is complete disruption, but in general, they're very stable. So you can use a brace or a functional stirrup, splint, and really rehab as tolerated. I do find that patients often are still very uncomfortable, maybe very swollen, and they do benefit occasionally from wearing a walking boot for about a week or so just to get them ambulating comfortably. And then, but it can be a very quick transition to a brace and functional rehab. And then moving on to these more oblique fractures, you really want to check for stability. So you want to get those weight-bearing views. You want to check for that medial joint space widening, right, on your mortis view. But if you determine they are stable, these can be treated in a short-leg walking caster fracture boot for about four to six weeks. You want to maintain about 90 degrees of dorsiflexion, right, so pretty neutral there to minimize your Achilles shortening. And compliance is really key, right? A fracture boot only works if you wear it. So for our younger patients and even some of our older patients, sometimes you need to put them in a cast because, you know, if they're not going to comply, then there is a risk either for delayed union or obviously if there's a little question of stability, you want to just make sure that this heals up and they don't have long-term complications. So in about seven to ten days, you want to follow up for that x-ray check, make sure there's been no shifting of your fragments. At four weeks, if they're non-tender and things are stable, they can move on to gradual weight-bearing and range of motion. If there's no sign of healing, as in this patient, so this again is our hiker. She had some callus, but she was still really tender, and you can still see those fracture lines. So we actually kept her in for another couple weeks. She did very well in the end, but she just needed a little bit more immobilization. So reasons to refer open fractures, and depending on your sports medicine practice, you may manage some of these things in conjunction with your orthopedic colleagues, but just in general, I would say if it's unstable, like a bimalleolar, trimalleolar fracture, those should be referred. If you have a displaced medial malleolar fracture more than two millimeters, again, you want to think about getting that reduced, any syndesmotic disruption, proximal fibular fractures, again, those just tend to be a little bit more unstable. A posterior malleolar fracture, if it's non-displaced, you can treat that as well, but if it gets displaced or more than two millimeters or involves 25% of the articular surface, those again, you really want to get those into position as much as possible. The ankle takes a lot of weight over time, and any slight variation in its biomechanics can really lead to earlier onset of post-traumatic arthritis and obviously complications. So the goal really of stabilization is less than one millimeter of displacement in any view. Some examples of things you probably want a little help with managing, this is obviously significant medial joint space widening. This is a, well, it could be a bimalleolar, but as soon as you get that lateral view, you see that now you have a trimalleolar fracture, so that needs a little bit of reduction. An example here, and this is your mesonew fracture. So you have some medial joint space widening, and then on this view, I'll just point it out there, there's your medial joint space widening, and then we have our proximal fibula fracture, and sort of that's the mechanism. So you get the energy goes up through the ligaments, tears your ligaments, goes up and then comes out through the proximal fibula. So this is your classic mesonew fracture. This one is unstable given the widening. If it's stable, that's something you can treat, but really, again, get those stress views and watch this closely.

2nd Edition, CASE 10

2nd Edition

Foot and Ankle

ankle fractures

diagnostic techniques

treatment strategies

syndesmosis stability

Ottawa ankle rules