Ankle Injuries

Ankle injuries fall into the same basic categories as

do all athletic injuries:

Contusions
Sprains
Strains
Fractures

85% of all ankle sprains involve some plantar flexion of the ankle and
inversion of the foot.
The remaining 15% consist of eversion mechanisms which are often the
result of an outside force such as being fallen on from the outside.

Lateral aspect of the joints of the right ankle region

1- anterior inferior tibiofibular ligament
2- anterior oblique capsular reinforcement
3- talonavicular ligament
4- dorsal cuboideonavicular ligament
5- the two limbs of the bifurcate ligament
6- dorsal calcaneocuboid ligament
7- extensor digitorum brevis
8- cervical ligament
9- anterior talofibular ligament
10- lateral talocalcaneal ligament
11- calcaneofibular ligament
12- posterior intermalleolar ligament
13- posterior talofibular ligament
14- posterior talocalcaneal ligament

The syndesmosis ligament is often also injured

with an eversion force. If the tibia and fibula
spread on the talus, the ankle mortise is
disrupted and the ankle can become very
unstable. It is also not unusual to see an
associated fibula fracture with an eversion
mechanism. (see x-rays below) Assessment of a
syndesmosis sprain will be difficult for the
initial 24 to 48 hours. If the ankle is quite
swollen and edematous assessment of a
syndesmosis sprain may be difficult until the
pain and swelling have isolated to individual
areas or x-rays show some spreading of the
ankle mortise.

Ankle Ecchymosis

Distal Fibula fracture with

associated medial deltoid ligament
disruption. This injury is frequently
the result of the foot being planted
with a valgus load applied to the
leg.

Notice the disruption of the medial

deltoid ligament and the widening
between the medial malleolus and
the talus. This is indicative of a
ruptured deltoid ligament.

Ankle dislocation with no fractures. This takes a

high degree of trauma and force. In this case this
was generated as the result of a high flip off of a
trampoline and impact with the ground. The ankle
was in a plantar flexion and inverted position upon
impact. This was an open dislocation.

Ankle Sprains
Most common athletic injury. 25% of all
injuries.
The risk of ankle sprains varies with the
sport
21-53% basketball, 17-29% soccer, 25% volleyball.

Ankle sprains account for 10% to 15% of all

lost playing time
The medial malleolus is shorter than the
lateral mallelous so there is naturally more
inversion than eversion.

Ankle Sprains
Greater inversion increases the potential for overstretching of the lateral ligaments.
Most sprains involve the lateral ligaments from
excessive inversion.
Deltoid ligament is sprained less often (25% of
ankle sprains)
Of the lateral ligments, the ATFL is sprained the
most often followed by the CFL
Sprains ocur most often with the foot in plantar
flexion and inversion.

Lateral Collateral Ligament

Ankle Sprains

Classification of Sprains
1st Degree:

Stretching of the ATFL

little or no edema
tenderness
maintain function.

2nd Degree
Partial tear of the
ATFL and/or CFL
moderate edema
some function loss

3rd Degree
Complete tear ATFL,
CFL, and/or PTFL
total loss of function
significant edema

Ankle Sprains by Grade

Sign/symptom

Grade I

Grade II

Grade III

Tendon

No tear

Partial tear

Complete tear

Loss of functional ability

Minimal

Some

Great

Pain

Minimal

Moderate

Severe

Swelling

Minimal

Moderate

Severe

Ecchymosis

Usually not

Frequently

Yes

Difficulty bearing weight

No

Usually

Almost always

Ottawa rules
Before introduction of the rules, all
injured ankles were X-rayed but only
15% were positive for fracture
The ankle is the most commonly
injured weight bearing joint
UnnecessaryX-rays: costly,time
consuming, and possible health risk

 X-rays are only required if there is bony

pain in the malleolar zone AND any one
of the following:
1 Tenderness along the distal 6cm
of the posterior edge of the tibia
2 Tenderness along the distal 6cm
of the posterior edge of the fibula
3 Inability to bear weight
immediately after injury and in the ER

Treatment
AAFP(seetable3)
R.I.C.E.
Icefor20minutesonand20minutesoffforthefirst
twohours.
Afterthat,20minintervalsoverthenext4872
hours,
Compressionwrapwithdonutorhorseshoestofill
ingapsaroundmalleolusfrom2436hours;after
4872hourscontrastsbathswithROMexercisesfor
4minutesinwarmand1mininicewater.

Achilles Tendonitists
Causes

Rapidly increasing training

effort
Adding hills or stair climbing
to training
Starting too quickly after a
layoff
Poor footwear
Excessive pronation
Tight posterior leg muscles
If left untreated, it may
progress to a complete
rupture.

Achilles Tendon Rupture

Most frequently ruptured tendon
Complete ruptures are due to
eccentric loading during abrupt
stopping, landing from a jump.
Usually a popping sound is
heard with a complete tear.
There may or may not be an
obvious gap 2 to 6 cm from the
calcaneus attachment.
Treatment may or may not
include surgery but both require
immobilized for 3 months.

Plantar Fasciitis

The plantar fascia runs from the calcaneus to the

metatarsals.
This tight band acts like a bow string to maintain the
arch of the foot.
Plantar fasciitis refers to an inflammation of the
plantar fascia.

Plantar Fasciitis
Inflammation is
usually due to
repeated trauma to
where the tissue
attaches to the
calcaneus.
The trauma results in
microscpic tears at
the calcaneus
attachment site.
This may produce heal
spurs

Plantar Fasciitis
Pain is worse in the
morning or after a
period of inactivity
Causes
High arch
Excessive pronation
Footwear (worn out, stiff)
Increase in intensity

Ankle Exercises
Calf stretch
Soleus stretch
Resisted dorsal
and plantar
flexion
Heel raises
Step-up
Jump rope

ANKLE FRACTURE

EPIDEMIOLOGY
Most ankle fractures are isolated
malleolar fractures (2/3)
Bimalleolar(25%)
Trimalleolar(7%)
Open Fracture(2%)
Most common weight bearing
fracture(70% of all fractures)

 Bimodal Distribution

Men 15-65 years

Women >60 years
Not related to osteoporosis
Related to obesity

RADIOGRAPHY
Ottawa Ankle rules( 100% sensitivity
for detecting ankle fractures)

Pain near malleoli

Age > 55 years
Inability to bear weight
Bone tenderness at posterior edge or tip of
either malleolus

RADIOGRAPHY
Standard AP, Lateral views
Mortise view: X ray beam parallel to
trans
malleolar axis
Patients leg internaly rotated to 15
degrees

RADIOGRAPHY
X ray measurements of alignment
and stability:
Talo crural angle
Angle subtended by line drawn parallel to
articular surface of distal tibia and one
connecting tip of both malleoli
4 to 11 degrees
Any difference of 2-3 degrees to opposite
side is abnormal and indicates fibular
shortening

RADIOGRAPHY
Medial clear space
Between lateral
border of medial
malleolus and lateral
border of talus
Should be equal to
superior clear space
> 4mm abnormal

RADIOGRAPHY
Tibio fibular clear
space:
Syndesmosis injury
Between medial
surface of fibula and
incisural surface of
tibia
> 5mm implies
syndesmotic injury

CLASSIFICATIONS
Potts: Anatomical
Mono malleolar
Bimalleolar
Trimalleolar

LAUGE- HANSEN
CLASSIFICATION
Associates specific fracture patterns with
mechanism of injury
Supination External rotation (60%)
Supination Adduction(20%)
Pronation External rotation and Pronation
abduction(20%)
1st word- Foot position at time of injury
2nd word- Direction of deforming force on
talus

LAUGE- HANSEN
CLASSIFICATION
With foot supinated, lateral support
structures will fail first
With foot pronated medial support
structures fail first
Injuries are graded 1 to 4 based on
level of involvement and severity.

PATTERN OF FIBULA FRACTURE

S-ER: Spiral oblique fracture runs
from
antero inferior margin upto
posterior superior cortex
S-AD: Transverse fracture distal to
mortice or avulsion fracture of
tip
P-ER: Above syndesmosis, from
superior anterior cortex to postero
inferior cortex
P-AB: low transverse or slightly
oblique

Supination External Rotation

Supination Adduction

High fibula fracture with talar displacement

Pronation external rotation injury

DANIS WEBER CLASSIFICATION

Based on location and appearance of
fibula fracture
TYPE A:
Transverse # lat. Malleolus at or below
plafond with or without oblique fracture of
medial malleolus
Internal rotation and adduction

TYPE B:
Oblique # with rupture of ant. Tibio fibular
lig. With # medial malleolus or ruptured
deltoid

DANIS WEBER CLASSIFICATION

 TYPE C:
Abduction injury
C1 : oblique # prox to disrupted tibio fibular
ligament
C2 : Abduction + ext. rotation with prox # of
fibula and interosseous membrane

AO CLASSIFICATION
Based on Weber
A: Infra syndesmotic
B: Trans syndesmotic
C: Supra
syndesmotic

Type A and B based

on presence or
absence of medial
lesion and Type C
on characters of
fibula fractures

STABLE/UNSTABLE
UNSTABLE:
Bimalleolar/ Trimalleolar
When talus subluxated or tilted

STABLE/UNSTABLE
If Fibula is fractured and talus not shifted
Look for medial side swelling
Medial side swelling +

Medial side swelling -

Deltoid ligament injury

UNSTABLE

Stress Radiography
Talus shifts
UNSTABLE

Talus does not shift

STABLE

SYNDESMOTIC INJURIES
Most commonly due to PER and PAB
Fixation indicated if
Proximal fibula # with a medial injury
Syndesmotic injury > 5 cm proximal to
plafond

Integrity of syndesmosis can be

judged intra operatively: Fix fibula,
pull laterally with a hook, if lateral
shift > 3-4mm then essential to fix.

 Maisonneuves
fracture:
Spiral # of the
proximal fibula
ssociated with
unstable ankle injury
Pronation External
rotation
Requires reduction
and stabilization of
syndesmosis

 BOSWORTHS FRACTURE:
The distal end of the proximal fragment of
fibula gets displaced posterior to the tibia
and may be locked by tibias postero lateral
ridge
The bone cannot be released by
manupulation due to intact introsseous
membrane
Fibula is exposed and considerable force is
required to release the fibula, fracture then
fixed operatively

TREATMENT
Initial Management: Obtain AP,
lateral and mortice views
Reduce talus immediately
Failure
Urgent operative
intervention
ORIF
Spanning ex fix
Calcaneal
pin

Biomechanical Studies
Displacement of talus follows
displacement of fibula(Yablon)
1mm of lateral talar shift increases contact
loading of tibio talar joint by 42%
Recent studies have shown that ankle
function is normal after ISOLATED fibula
fractures
Without a deltoid ligament injury or a
displaced medial malleolus fracture, talus
is stable and CLOSED treatment may be
advocated
However, some surgeons still prefer ORIF
for isolated fibula #

STABLE INJURY T/T

# protected in a short leg cast or
brace for 4-6 weeks, allow partial wt.
bearing, FWB after 12 weeks

Open Treatment
Not indicated in stable fractures, only
if associated injuries like talar # or
osteochondral # of talar dome
Indicated in all unstable fractures

ORIF
Fibula Fixation:
1/3rd tubular plate( if
# above ankle)
Lag screws
Rush rod: if #
transverse
TBW: if fragment
small

ORIF
Medial Malleolus:
2 parallel 4.0 mm PTCS
TBW if fragment small and osteoporotic

Posterior Malleolus
Fixation important: otherwise may lead to posterior
subluxation of talus
Size of fragment important(CT scan)
If > 25% - 30% of joint surface fixation done
Fix associated # first and then do an intra op
posterior drawer test
Apply 1/3rd tubular plate posterior
Anterior to posterior intra fragmentary screw

 Syndesmotic Fixation
Indication: Prox fibula # associated with medial injury
When the medial clear space widens on intra op
stress views after fibula fixation
Screw fixed 2 -3 cm above ankle joint and parallel to
it and angled 30 degrees anteriorly
4.5 mm screw used- purchase 4 cortices
Tight screw in maximal dorsiflexion of ankle
Time of screw removal- controversial.. Most
surgeons prefer to remove the screw before weight
bearing is allowed (68 weeks)
Use syndesmotic screw only, without fixing the fibula
when # above mid fibula

POST OPERATIVE
Ankle immobilized in posterior
plaster splint
Splint removed after 3-4 days,
replaced with removable splint
ROM exercises are begun
NWB- 6 weeks
Partial wt. bearing allowed
Full wt. bearing after 12 weeks

AXIAL LOADING INJURIES: TIBIAL

PLAFOND FRACTURES
Articular and metaphyseal
comminution
Joint impaction
Proximal displacement of talus
High energy trauma associated with
soft tissue involvement
Fracture pattern depends upon
direction and position of foot

AP and lateral views of tibial

Plafond showing articular and
Metaphyseal comminution

The position of the foot at the time

Of axial load determines which part
Of the tibial plafond will fracture

CLASSIFICATION
Ruedi- Allgower
classification:
Type 1 :
Nondispaced
cleavage #
Type 2: Displaced
and minimally
comminuted #
Type 3: Highly
comminuted #

CLASSIFICATION
AO/ OTA:
A: Non- articular
B: Partial- articular
C: Total- articular

Divided into 3 sub

groups based on
degree of
comminution

TREATMENT
Initial Treatment:
Reduce any talar displacement
Articular reduction through either closed or open
methods
Splint the fracture which may require temporary
skeletal traction

Treatment Options:
Plate
Spanning external fixator
External fixator leaving the anlke

ADVANTAGES/ DISADVANTAGES
Fixation Techniques

Technique

Advantages

Disadvantages

Open reduction and internal fixation

Involves wide exposure for articular

reduction
Allows early motion of ankle joint

Disrupts tenuous soft tissue envelope

Involves large subcutaneous implants
Has highest incidence of wound healing problems
including:
Wound breakdown
Infection
Osteomyelitis
Amputation

Rigid cross-ankle external fixation

Involves minimal disruption of zone of

injury

Rigidly immobilizes ankle

External fixation of same side of joint

Allows motion at the ankle

Avoids large plates to stabilize metaphysis

Cannot be used for all fractures

Disrupts zone of injury
Is technically demanding

Articulated cross-ankle external

fixation

Allows motion at the ankle (limited)

Is technically easier to apply fixator
Involves minimal disruption of zone of
injury

Is difficult to align axis of hinge with axis of ankle joint

Requires pins in hind-foot bones
Value of motion through an articulated hinge is not proven

DECISION MAKING AND FACTORS

RELATING TO OUTCOME
Closed Treatment: Undisplaced type
A, Type B and Type C1 fractures
Open Treatment:
Immediate ORIF obsolete due to severe soft
tissue complications and high rate of
implant failure
Not favoured any longer

 Urgent stabilization done either by

Spanning external fixator

External fixator sparing the ankle joint
Illizarovs ring fixator
Calcaneal pin traction

Adequate time is given for the soft tissue

to heal(4-6 weeks)
Definative procedure is done after soft
tissue heals

 Spanning external fixator and

Illizarov external fixator can be used
for definitive management
Implants:
Small fragment 3.5 mm and 4.00 mm
screws for metaphyseal stabilization
Small plates- 1/3rd tubular, 3.5 mm DCP,
small clover leaf plates or T shaped plates
designed for distal radius, fixed angle
locking screw plates

RESULTS
High energy trauma
Result not always good
Depends on associated degree of soft
tissue trauma, wound condition and
infections
Average interval for fracture to heal 12
weeks
Average time to return to normal activity1 year
Rate of Post op arthiritis and c/o pain and
disability --- HIGH!!

SUMMARY
Common fractures
Anatomical reduction, restoration of
fibular length, syndesmotic repair
lead to excellent outcomes for the
patient
In plafond fractures management of
soft tissue component and adequate
stable fixation MANDATORY

Thank you!!