Ankle Fractures

Description and ID:

X-ray read points to make: Position of talus to mortis (dislocation....), syndesmotic rupture, malleoli involved (tri, bi - mal fx), displaced or not, medial or lateral clear space (>4mm =deltoid injury), medial fibulas/anterior tibia overlap (>10mm), fibular shortening, avulsions, "Shenton Line" (tibial subchondral bone lines up with small spike on fib adjacent to syndesmotic space). 

Lauge-Hanson - Ankle fractures

Classification system described by the direction of movement on the talus on tibia (Key identifies in green). 

Supination-Adduction

Stage I: Transverse fracture of the fibula below the level of the ankle joint or rupture of the lateral collateral ligaments.

Stage II: Near vertical fracture of the medial malleolus

Supination-External Rotation

Stage I: Rupture of the anterior inferior tib-fib ligament or avulsion of the ligament (Wagstaff or Tilluax-Chaput)

Stage II: Spiral fracture of the fibula with a posterior spike on the lat X ray beginning at the level of the ankle joint

Stage III: Rupture of the posterior inferior tib-fib ligament or avulsion of the ligament off the posterior malleolus (Volkmann’s)

Stage IV: Avulsion fracture of the medial malleolus or rupture of the deltoid ligament

Pronation-Abduction

Stage I: Transverse fracture of the medial malleolus or rupture of the deltoid ligament

Stage II: Rupture of the anterior and inferior tib-fib ligaments (Wagstaff or Tillaux-Chaput Fx)

Stage III: Fibular fracture at the level of the ankle joint with the appearance of a spiral fracture on the AP X ray and a transverse fracture on the lat X ray (butterfly fragment)

Pronation-External Rotation

Stage I: Avulsion fracture of the medial malleolus or rupture of the deltoid ligament

Stage II: Rupture or avulsion fracture of the anterior inferior tib-fib ligament (Wagstaff or Tilluax-Chaput) and rupture of the interosseous membrane

Stage III: Short oblique fibular fracture starting above the ankle joint and extends up the fibula depending on the extent of the interosseous rupture. Fracture runs distal posterior to proximal anterior

Stage IV: Rupture or avulsion fracture of the posterior inferior tib-fib ligament (Volkmann’s)

Danis Weber- Lateral Malleolar Fracture

Type A: Transverse avulsion fracture of the fibula beginning below the syndesmosis (SAD)

Type B: Spiral, oblique fracture of the fibula beginning at the level of the syndesmosis (SER/PAB)

Type C: Fracture of the fibula beginning above the level of the syndesmosis (PER)

Treatment:

Initial closed reduction and stabilization (posterior splint). 

DW-A --> Tension band wiring, screw/plate depending on fragment size. 

DW-B --> Neutralization plate.

ATFL should always be repaired. 

Posterior avulsion (SER 3, PER 4) repaired of >25% of joint involved. 

DW-C --> syndesosis needs to be repaired if deltoid is ruptures. 

Syndesmotic Screws --> 1x, 2x, 3.5mm or 4.5mm screws, 3 corticies or 4 corticies inserted approx 2cm above ankle joint after tapping. Removes screws usually 8-12weeks.