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FOOT ANKLE TRAUMA

VIEWS: 18 PAGES: 145

FOOT INJURIES EXPLAINED

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									FOOT AND ANKLE TRAUMA

       DR MANOJ R KANDOI
               M.S.,D’ORTH,DNB,FCPS,
            FRSM(LONDON),FICS(CHICAGO)
      FELLOWSHIP IN HAND AND FOOT SURGERIES
 USA,ITALY,FRANCE,GERMANY,UK,TAIWAN,REPUBLIC OF
                CHINA,NETHERLAND
       DR. MANOJ R. KANDOI
M.S.,D.N.B.,D’ORTH,F.C.P.S.,F.I.C.S.,F.R.S.M.,M.N
                     .O.F.
FELLOW:
• UNIVARSITY OF WASHINGTON
• MILANO UNIVARSITY
• HISSINGPARK CLINIC,AUGSBERG,GERMANY
• HARBORVIEW MEDICAL CENTRE,SEATTLE,U.S.A
• POLICLINICO MULTIMEDICA,MILAN,ITALY
• AITS – IRCAD, TAIWAN,R.O.CHINA
• INOR FELLOW,BRITISH ORTHOPEDIC SOCIETY
• INTERNATIONAL COLLEGE OF
  SURGEONS,CHICAGO
• IRCAD ,STRAUBERG, FRANCE
• AMC,AMSTERDAM,NETHERLAND
                        Foot       Tarsals (7)
                 Metatarsals (5)
    Digits (5)




                                     Talus
                                             Calcaneus


3
                  Ankle joint
Type:-
Synovial hinge.


Movements:-
Dorsiflexion
Planter flexion




4
5
          Foot Function

Hindfoot: Shock absorption, propulsion,
 deceleration

Midfoot: Controls relationship between
 hindfoot and forefoot

Forefoot: Platform for standing and lever
 for push off
                   Sesamoids
    Medial (tibial) & Lateral (fibular)
          Within FHB tendons
      Articulate with 1st MT head
   Weight bearing through sesamoids


Tibial Sesamoid:   Tibial FHB
                   Abductor Hallucis
Fibular Sesamoid: Fibular FHB
                   Adductor Hallucis
                   Deep Tverse MT ligament
                 Radiographs
Foot trauma series
  AP/lat/oblique

Don’t forget oblique

Sesamoid view
Tangential view (MT heads)

Contralateral foot films
  (comparison)
    Treatment Principles

Hindfoot: Protect subtalar, ankle and
 talonavicular joints

Midfoot: restore length and alignment of
 medial and lateral “columns”

Forefoot: Even weight distribution
               Treatment
Border Rays
 First metatarsal
 Fifth metatarsal

Dislocations

Multiple metatarsal
 shafts
        First MT Shaft Fractures
Nondisplaced
  Consider conservative
  treatment
  Immobilization with toe plate


Displaced
  Most require ORIF
  Strong muscle forces (TA,
  PL)
ORIF
  Deformity common
  Plate and screws
  Anatomically reduce
  Bears 2/6 body weight
  May cross first MTP joint (temp)
       First MT Base Fractures

Articular injuries

Frequently require ORIF

Fixation:
  Spans TMT
  Doesn’t span TMT
  Temporarily Spans TMT
       First MT Base Fractures

Articular injuries

Frequently require ORIF

Fixation:
  Spans TMT
  Doesn’t span TMT
  Temporarily Spans TMT
        43 year old male injured in a MVC
Observe the articular segment impaction of the
                 base of the first.
The first MT is shortened and dorsally displaced
 while the plantar ligaments remain attached.
   The patient underwent
ORIF of the base of the first
metatarsal with spanning of
  the first TMT, given the
    level of comminution
 observed. Additionally,
     temporary spanning
external fixation was used.
  Radiographic
appearance at 3
  months after
 removal of the
 external fixator
and metatarsal
   neck k-wire
    fixations.
      Non-displaced Metatarsal
           Fractures 2-4
Single metatarsal fractures
  Treatment usually nonoperative
  Symptomatic: hard shoe vs AFO vs cast
  vs elastic bandage

Multiple metatarsal fractures
 Usually symptomatic treatment (as above)
 May require ORIF if other associated
 injuries
     Displaced Metatarsal Shaft
             Fractures
    Sagittal plane displacement & angulation
                is most important.
    Reestablish length, rotation, & declination
  Dorsal deformity can produce transfer metatarsalgia
Plantar deformity can produce increased load at affected
                        metatarsal
                   Treatment Options

                      Closed Reduction
    Intramedullary pinning with k-wire (0.054” or 0.062”)
      Pinning of distal segment to adjacent metatarsal
               ORIF with dorsal plate fixation
This patient sustained an
open second metatarsal
fracture in a crush injury.
   Given the soft tissue
   injury and continued
  pressure on the dorsal
  skin, operative fixation
       was elected.
Fixation consisted of a dorsal
2.0 mm plate application after
 appropriate irrigation of the
        open fracture.
      multiple
    metatarsal
fractures (3,4,5)
     through a
       dorsal
     approach.
      Fixation
  consisted of a
2.7 mm DCP on
the fifth and 2.0
  mm plates on
   the third and
       fourth
   metatarsals.
   Medullary K-wires in Lesser
              MTs
Exit wire distally through
 the proximal phalanx



Plantar wire exit may
  produce a hyperextension
  deformity of the MTP

                             ST Hansen, Skeletal
                                  Trauma
This patient sustained multiple metatarsal neck fractures (2, 3,
 4) and a dislocation of the fifth MTP joint. Note the lateral
 translation, lateral angulation, and the displacement on the
                       lateral radiograph.




                                         Compliments: Daphne Beingessner, MD
 Stabilization consisted of closed reduction and percutaneous
  pin fixation of the multiple metatarsal fractures and closed
reduction of the fifth MTP dislocation. Note the location and
                    trajectory of the K-wires.
Following healing and removal of the pins, good alignment of
  the forefoot is demonstrated on the multiple radiographic
                            views.




                                       Compliments: Daphne Beingessner, MD
    Metatarsal Neck Fractures
Usually displace plantarly

May require reduction and
 fixation:

 Closed reduction and pinning
 Open reduction and pinning
 ORIF (dorsal plate)
 This patient sustained
multiple metatarsal neck
 fractures after an MVA.
Note additional fractures
   at the first and fifth
       metatarsals
Medullary wire fixation
 of metatarsal neck
   fractures 2, 3, 4
    Metatarsal Head Fractures
Unusual

Articular injuries

May require ORIF
                             Circular saw injury to the
 (especially if first   articular surface of the first MT head

 MT)
     Fifth Metatarsal Fractures

Mid diaphyseal fractures

Stress fractures (proximal
  diaphysis)

Jones fractures (metadiaphyseal
  jxn)

Tuberosity fractures
  Proximal Fifth Metatarsal Fractures
          Dameron, TB, JAAOS, 1995

Zone 1    cancellous tuberosity
          insertion of PB & plantar
 fascia
          involve metatarsocuboid
 joint


Zone 2    distal to tuberosity
          extend to 4/5 articulation


Zone 3    distal to proximal ligaments
          usually stress fractures
Zone 2 Fractures: Metadiaphyseal
           Operative Treatment
        Medullary Screw Stabilization
  (Delee, 1983; Kavanaugh, 1978; Dameron, 1975)


            Bone Graft Stabilization
     (Dameron, 1975; Hens, 1990; Torg, 1984)
          MTP Joint Injuries
Sprains
 “Turf Toe”: hyperextension with injury to thee
 plantar plate

 Hyperflexion sprains


Dislocations
           First MTP Dislocations
              Jahss, F&A, 1980
Type I:      Hallux dislocation without disrupting
  sesamoid
             Irreducible closed!
             MT incarcerated by conjoined tendons and
  intact                    sesamoid
             Open reduction required (dorsal, plantar, or
  medial                    approach)

Type II:     Disruption of intersesamoid ligament (type A)
             Transverse fracture of one of the sesamoids
  (type B)

             Usually stable after reduction
   Lesser MTP Dislocations
               Uncommon

            Dorsal vs Lateral

      Usually stable post reduction

      Rarely require open reduction

If unstable post reduction, consider k-wire
 Fractures of the Great
          Toe
Proximal Phalanx Fractures
 ORIF for transverse &
 displaced (?)
 ORIF intraarticular fractures (?)


Interphalangeal Joint
  Fractures
 Nonoperative treatment usually


Distal Phalanx Fractures
  Fractures of the LesserToes

   Correct alignment &
          rotation

Attempt taping to adjacent
             toe

    May require open
  reduction and pinning if
  adequate reduction not     ST Hansen, Skeletal
                                  Trauma
         obtained
  This patient was referred after temporary
stabilization of a comminuted first metatarsal
                  base fracture




                               Compliments: Steve Benirschke, MD
 Because of the significant intraarticular involvement of the
base of the first, fixation consisted of a direct reduction of the
 articular surface combined with spanning of the first TMT
  joint. A locking plate was used to ensure maintenance of
    length of the medial column given the limited fixation
              possibilities in the medial cuneiform




                                            Compliments: Steve Benirschke, MD
                The Crushed Foot
Soft Tissue Evaluation

Assess whether salvageable
   sensate, perfused, adequate plantar
     tissue


Wash open wounds

Reposition bone deformity that
  threatens the skin

Reduce dislocations

Release compartments as
This patient’s multiple and complex fractures of the midfoot
(and calcaneus; and pilon) were sequentiallly fixed. Because
  of the significant comminution of the fourth metatarsal, a
                     locking plate was used.
Fractures and Dislocations
 of the Mid-foot Including
      Lisfranc Injuries
                     Anatomy
• Lisfranc’s joint:
  articulation between the 3
  cuneifoms and cuboid
  (tarsus) and the bases of
  the 5 metatarsals
• Osseous stability is
  provided by the Roman
  arch of the metatarsals
  and the recessed
  keystone of the second
  metatarsal base
                  Anatomy
• Lisfranc’s ligament:
  large oblique ligament
  that extends from the
  plantar aspect of the
  medial cuneiform to
  the base of the
  second metatarsal
  (there is no
  transverse metatarsal
  ligament from 1 to 2)
            Clinical Findings
• Midfoot pain with
  difficulty in weight
  bearing
• Swelling across the
  dorsum of the foot
• Deformity variable
  due to possible
  spontaneous
  reduction
      Radiographic Evaluation
• AP, Lateral, and 30°
  Oblique X-Rays are
  mandatory
• AP: The medial
  margin of the 2nd
  metatarsal base and
  medial margin of the
  medial cuneifrom
  should be alligned
      Radiographic Evaluation
• Oblique: Medial base
  of the 4th metatarsal
  and medial margin of
  the cuboid should be
  alligned
      Radiographic Evaluation
• Lateral: The dorsal
  surface of the 1st and
  2nd metatarsals
  should be level to the
  corresponding
  cuneiforms
         Radiographic Evaluation
•    Standing views provide “stress” and may
     demonstrate subtle diastasis
•    Comparison views are very helpful
•    Associated fractures:
    1.   Base of 2nd metatarsal
    2.   Avulsion navicular
    3.   Isolated medial cuneiform
    4.   Cuboid
       Radiographic Evaluation
• Additional imaging:
  1. True stress views or
  fluroscopy
  2. CT Scans
  3. Bone scan – for
  persistent pain with no
  radiographic findings
  4. If suspicious: repeat x-
  rays and keep looking
                 Treatment
• Early recognition is the key to preventing long
  term disability
• Anatomic reduction is necessary for best results:
  displacement of >1mm. or gross instability of
  tarsometatarsal, intercuneiform, or
  naviculocuneiform joints is unacceptable
• Goal: obtain or maintain anatomic reduction
           Case Example
Preop AP

             Postop AP


                          Postop Lateral
          Navicular Fractures
• Anatomy: a
  horseshoe shaped
  disc sitting between
  the talus and
  cuneiforms
• Numerous short
  ligaments attach
  dorsally, plantarly,
  and laterally
• Deltoid attaches
  medially
            Navicular Fractures
• Avulsion fractures:
  usually dorsal lip
  (essentially severe
  sprain)
• Treatment:
  1. Immobilization &
  progressive weight
  bearing
  2. Excision of fragment if
  painful
           Navicular Fractures
• Tuberosity fractures:
  avulsion by p. tibial
  tendon and spring lig.
• Usually minimally
  displaced
• May have associated
  calcaneocuboid
  impaction
• ORIF depending on
  degree of displacement (
  > 5mm.)
      Navicular Fractures
  Body Fractures Classification
• Sangeorzan Type 1:
  coronal fracture plane
      Navicular Fractures
  Body Fractures Classification
• Sangeorzan Type 2:
  primary fracture
  dorsolateral to plantar
  medial with medial
  displacement of
  major fragment and
  forefoot
      Navicular Fractures
  Body Fractures Classification
• Sangeorzan Type 3:
  comminution of the
  body in the sagittal
  plane with forefoot
  laterally displaced
        Navicular Fractures
         Body Fractures
• High energy trauma with axial foot loading
• Frequently associated with talonavicular
  subluxation
• CT scans helpful for preop planning
• Anatomic reduction essential
            Navicular Fractures
             Body Fractures
•   Treatment:
    1. ORIF if any
       displacement
    2. Anteromedial incision
       along medial aspect
       Tib. Ant.
    3. Second anterolateral
       incission to help
       reduce lateral
       fragment
          Navicular Fractures
           Body Fractures
• Treatment cont.:
  4. May require
  stabilization or fusion
  to cuneiforms
  5. Avoid fusion of
  essential talonavicular
  joint if at all possible


      Missed navicular fx required
      orif and primary fusion
      secondary to arthritis
           Cuboid Fractures
• Isolated fractures are
  rare
• Most often associated
  with other fractures
  &/or dislocations
• Two types of
  fractures usually seen
            Cuboid Fractures
• Avulsion fractures:
  most common
• Compression
  fractures: mechanism
  of injury “nutcracker”
  axial loading with
  plantar flexion and
  forefoot abduction
          Cuboid Fractures
            Treatment
• Isolated and nondisplaced: immobilization
  6 to 8 weeks
• Displaced: ORIF
  1. Often requires bone graft and small
  plate
  2. Can use small external fixateur for
  distraction
   Indications for Surgery: Cuboid
              Fractures
• > or = 2 mm displacement of articular
  surface
• Cuboid subluxation with weight bearing or
  stress x-rays (May require transarticular
  pin fixation or external fixator)
• Loss of bony length
         Cuneiform Fractures
• Isolated fractures        • Mechanisms of injury:
  quite rare                  1. Direct trauma –
• Displacement of             most common and
  these fractures is          heal rapidly with
  unusual                     nonoperative
• Healing with few            treatment
  complications is likely     2. Indirect trauma
                              (Lisfranc variants):
                              ORIF
        Cuneiform Instability
• May occur in any direction including axial
  shortening
• Requires ORIF
• Usually seen in conjunction with Lisfranc
  injuries
 Fractures of
the Calcaneus
     HINDFOOT FUNCTION

Calcaneus
• Lever arm powered by
  gastrocnemius
• Foundation for body wt.
• Supports/ maintains lat.
  column of foot
     HINDFOOT FUNCTION

Subtalar Joint
• Inversion/ eversion
  of hindfoot
• Hindfoot position
  locks/ unlocks
  midfoot joint
    “EXTRA-ARTICULAR”
        FRACTURES

• Anterior process
  fracture
• Tuberosity (body)
  fracture
• Tuberosity avulsion
• Sustentacular fracture
      ANTERIOR PROCESS
          FRACTURE

• Inversion “sprain”
• Frequently missed
• Most are small: treat
  like sprain
• Large/displaced:
  ORIF
   TUBEROSITY FRACTURE

• Fall/MVA
• Usually non-
  operative
  ─ Swelling control
  ─ Early ROM
  ─ PWB
    TUBEROSITY AVULSION

• Achilles
  avulsion
• Wound
  problems
• Surgical urgency
  ─ Lag screws or
    tension band
        SUSTENTACULAR
          FRACTURE

• May alter ST jt. mechanics
• Most small/ nondisplaced:
  ─ Non-operative
• Large/ displaced
  ─ ORIF (med. approach)
  ─ Buttress plate
“INTRA-ARTICULAR”
    FRACTURES
         PATHOANATOMY

• Articular incongruity
• Hindfoot varus
• Shape of foot
  ─ Wide
  ─ Loss of height/Short
• Peroneal impingement
• Heel pad crush
      CLINICAL PROBLEMS

•   Stiffness
•   Loss of normal gait
•   Walk on lateral border- varus hindfoot
•   Shoewear problems- wide heel
•   Arthritic pain- mainly subtalar joint
•   Peroneals- subluxation or entrapment
•   Heel pad pain
     IMAGING: Plain Films
Standard Views          1.

• 1. Lateral
• 2. Broden’s
• 3. Axial (HLA)
                   2.        3.
 LATERAL VIEW


       Bohler’s
                Gissane’s
       Angle
                Angle




Normal 25˚-40˚         Normal 120˚-140˚
            BRODEN’S VIEW

• Posterior facet
• Positioning
  A. 20° IR view (mortise)
  B. 10°-40° plantar flex.
              BRODEN’S
                VIEW


• Posterior facet
     AXIAL VIEW

• Assess varus/valgus
• 45° axial of heel
• 2nd toe in line w/ tibia
• Normal »10° valgus
           IMAGING: CT

                     CORONAL
Foot flat on table
• Coronal
• Transverse
• Sagittal
  Reconstruction
      NON-OP TREATMENT:
        Natural History
 Nade and Monahan, Injury, 1973
 • 57% long term symptoms (pain, swelling,
   stiffness)
 • 95% symptoms on uneven ground
 • 76% broad heel

As a standard treatment …..”[results] are not
good enough and deserve further studies”
      NON-OP TREATMENT:
         Complications

Malunion
 • Varus hindfoot
      ─ Locks midfoot
      ─ Medializes “foundation” for stance
  •   Shortened foot = short lever arm
  •   Peroneal impingement/ dislocation
  •   Shoewear problems
  •   Subtalar arthritis
 NON-OP TREATMENT:

Injury
 NON-OP TREATMENT
Malunion
   OPERATIVE TREATMENT:
         Rationale
• Restore anatomy
   ─ Shape and alignment of hindfoot
   ─ Articular congruency
• Return to function & prevent arthritis
• Typically, restoring articular anatomy
  gives improved results if complications
  are avoided
Fixation Options
   Surgical Tips:
Skin Closure & Splint




Nylon
      POSTOPERATIVE CARE

•   Elevate, splint
•   Sutures out @ 3 wks.
•   Fracture boot
•   Early motion
•   NWB for 8-12 weeks
•   Improvement up to 2 yrs.
Fractures of the Talus and
  Subtalar Dislocations
             Canale View
• Ankle plantarflexion
• 15 degree pronation
• Tube 15 degree off vertical

                                Canale View
             CT Scan
• Can be a useful assessment
  tool
• Confirms truly undisplaced
  fractures
• Demonstrates subtalar
  comminution, osteochondral
  fractures
Case Example

        • 29 yo male
        • ATV rollover
        • Isolated injury
          LLE
    Treatment of Talar Neck
          Fractures
• Emergent reduction of dislocated joints
• Stable internal fixation
• Choice of fixation and approach
  depends upon personality of fracture
Hawkins I Fracture
         Options:
         • Non-Weight-Bearing Cast
           for 4-6 weeks followed by
           removable brace and
           motion
         • Percutaneous screw
           fixation and early motion
        Anterior Screw Fixation:
Non-comminuted fractures:
  – Easy to insert under direct
    visualization and no cartilage
    damage
  – Displaced type 2: 3 A-P screws
    including medial “buttress” fully
    threaded cortical screws and
    lateral “shoulder” screws
      Anterior Screw Fixation:

Comminuted
 fractures:
– Buttress screw:
  comminuted column;
  compression screws
  through non-
  comminuted column
– Mini-fragment screws
  for osteochondral
  fragments
             Anterior Plate
               Fixation:
• Comminuted fractures:
  – Medial and / or lateral
    mini-fragment plates
         Talar Body Fractures
• Treatment strategy
  and outcomes similar
  to talar neck fractures
• Medial or Lateral
  Malleolar Osteotomy
  frequently required
   Medial Malleolar Osteotomy
• Predrill and pretap
  malleolus
• Osteotomy aims for
  medial corner of
  mortise
• Osteotome to crack
  cartilage helps avoid
  mortise malalignment
  Talar Body + Fibula Fracture
• Visualize body through the fibula fracture
       Talar Body Case
           Example
• 58 year old female
• 4 week old fracture
• Missed initially
             Case, cont’d
• Extensive comminution into subtalar joint
• Fragments very small
         Selected Rx: Primary
             Arthrodesis
Tricortical bone graft to
reconstitute talar height
      Osteochondral Injuries
• Frequently encountered with talus neck
  and body fractures
• Require small implants for fixation
• Excise if unstable and too small to fix
Osteochondral Injuries
Osteochondral Fragment
       Repair




Large fragment repaired, small fragment excised
     Talar Head and Process
            Fractures
• Treat according to injury
• Operate when associated with joint
  subluxation, incongruity, impingement or
  marked displacement
• Fragments often too small to fix and
  require excision
     Case Example: Talar Head
            Fracture
• Talar head injury
• Subtle on plain x-ray
Talar Head Fracture, continued
• CT demonstrates
  subtalar injury and
  subluxation
     Treatment of Talar Head
            Fracture
• Required 2 incisions
  to debride subtalar
  joint from lateral
  approach, and reduce
  / stabilize fracture
  from medial side
   Lateral Process Example
• Usually require CT scan
• Often excised due to size of fragments
• Difficult to achieve union
Lateral Talar Process Fractures
• “Snowboarder’s fracture”
• Mechanism: may occur from inversion (avulsion
  injury) or eversion and axial loading (impaction
  fracture)
• Often misdiagnosed as “ankle sprain”
• Best results if treated early, either by
  immobilization, ORIF or fragment excision
• If diagnosed late consider fragment excision as
  attempts to achieve union often fail
     Posterior Talar Process
            Fracture
• 2 components: medial and lateral tubercle
• Groove for FHL tendon separates the two
  tubercles
• Differentiate fracture from os trigonum –
  well corticated, smooth oval or round
  structure
Ankle Fractures
Anatomy
Anatomy
       Radiographic Imaging
• Plain Films
  – AP, Mortise and lateral views of the ankle
  – Image the entire tibia to knee joint
  – Foot films when tender to palpation
  – Common associated fracture are:
     • 5th metatarsal base fracture
     • Calcaneal fracture
Radiographic Imaging (AP view)
Radiographic Imaging (AP view)
   Radiographic Imaging (AP view)
• Tibiofibular overlap
    – <10mm is abnormal - implies
      syndesmotic injury
• Tibiofibular clear space
    – >5mm is abnormal - implies
      syndesmotic injury
• Talar tilt
    – >2mm is considered abnormal

Consider a comparison with radiographs of
the normal side if there are unresolved
concerns of injury
Radiographic Imaging
    (Mortis view)
           Radiographic Imaging
               (Mortis view)
• Foot is internally rotated
  and AP projection is
  performed
• Abnormal findings:
   – medial joint space
     widening
   – talocural angle <8 or >15
     degrees (comparison to
     normal side is helpful)
   – tibia/fibula overlap <1mm
Radiographic Imaging
    (Mortis view)
                Syndesmotic Injury
                   with Deltoid
                 Ligament Rupture


                       < 1 mm
                       overlap

                  Medial joint space
                  widening

                           Talocural
                           angle
           Radiographic Imaging
              (Lateral view)

• Posterior mallelolar
  fractures
• Anterior/posterior
  subluxation of the talus
  under the tibia
• Angulation of distal fibula
• Talus fractures
• Associated injuries
        Radiographic Imaging

• Stress Views of the Ankle
  – Evaluate integrity of the syndesmosis -
• CT
  – Helps to delineate joint involvement
  – Aids in pre-operative planning
  – Evaluate hindfoot and midfoot if needed
• MRI
  – Identify ligament and tendon injury and well as
    talar dome lesions
  – Syndesmosis injuries
Lauge-Hansen classification
   Stress Radiograph - Technique
Lauge-Hansen classification


                    + Stress View

              Widened Medial Clear Space




                    SE-4
    Common Names of Fracture Variants
•   Maisonneuve Fracture
     – Fracture at the proximal 1/3 of the
         fibula - PER IV
•   Volkmann Fracture
     – Posterior malleolus fracture
•   Wagstaffe Fracture
     – Anterior fibular tubercle avulsion
         fracture by the anterior inferior
         tibiofibular ligament (AITF)
•   Tillaux-Chaput Fracture
     – Avulsion of the anterior lateral
         tibia due to the AITF
•   Collicular Fractures
     – Avulsion fracture of distal portion
         of medial malleolus
     – Injury may continue and rupture
         the deep deltoid ligament
       Nonoperative Treatment

• Indications:
  – Nondisplaced (<2mm) stable fracture with intact
    syndesmosis, no fibula shortening.
  – Patient whose overall condition is unstable and
    would not tolerate an operative procedure
• Management:
  – Below the knee cast for 4-6 weeks
  – Follow with serial x-rays and transition to
    walking boot or short-leg walking cast
           Surgical Indications

• Instability
  – Talar subluxation
• Malposition
  – Joint incongruity
  – Articular stepoff
  – Fibular shortening
     Lateral malleolus fracture
• Antiglide plating:
    Lateral malleolus fracture
• Repair of type C:
The anterior inferior tibiofibular
           ligament
The posterior inferior tibiofibular
           ligament
Medial malleolus fracture
       Summary
• Careful clinical and radiographic evaluation
• Restoration of ankle joint anatomy
  – Fibular length
  – Syndesmotic stability
  – Neutral varus/valgus orientation
• Delay ORIF until the surrounding soft tissue
  swelling and blisters have resolved
• Prepare patient for possible development of
  post traumatic arthrosis

								
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