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Average 4.2 of 102 Ratings
Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC.
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Figure A shows an isolated left ankle injury in an active 48-year-old recreational hockey player. Past medical history includes insulin dependent diabetes mellitus for 35 years. On physical examination the patient is unable to feel a 5.07 gm monofilament on the plantar aspect of his foot. His pedal pulses are palpable. Of the following options, what would be the recommended treatment?
Closed reduction and casting for 6 weeks
Closed reduction and casting for 12 weeks
Open reduction and internal fixation with restricted weight bearing for 2 weeks
Open reduction and internal fixation with restricted weight bearing for 6 weeks
Open reduction and internal fixation with restricted weight bearing for 12 weeks
Select Answer to see Preferred Response
Figure A shows an unstable, ankle fracture-dislocation in a otherwise healthy 48-year-old diabetic patient. The most appropriate management would be open reduction and internal fixation with an extended period of restricted weight-bearing.
Surgical treatment of unstable ankle fractures in diabetic patients is associated with a high complication rates. Diabetic patients are inherently poor healers due to the alterations in their microvascular system. Over-fixation of the fracture and extended immobilization has been shown to reduce wound and bone healing complications associated with diabetes. Surgical techniques typically call for multiple syndesmotic screws, stronger plates (vs 1/3 tubular plates) and prolonged periods of immobilization.
Jani et al. retrospectively examined a cohort of 15 patients with diabetes mellitus who sustained unstable ankle fractures. The combination of transarticular fixation (Retrograde transcalcaneal-talar-tibial fixation using large Steinmann pins or screws) and prolonged (>12 weeks), protected weightbearing provided 13 of 15 patients with a stable ankle for weight bearing.
Wukich et al. compared the complication rates of ankle fracture fixation in 46 patients with complicated diabetes and 59 patients with uncomplicated diabetes. They found that patients with complicated diabetes had 3.4 times increased risk of a non-infectious complications (eg. malunion, nonunion or Charcot arthropathy) and 5 times higher likelihood of needing revision surgery/arthrodesis.
Figure A shows AP and lat radiographs of SER4 ankle fracture-dislocation.
Answer 1,2: Non-operative treatment would be appropriate in stable ankle fractures. Again, these need to be treated with an extended period of immobilization.
Answer 3,4: Internal fixation would be warranted in this patient, however the duration of immobilization should more than double the typical period of immobilization.
Jani MM, Ricci WM, Borrelli J Jr, Barrett SE, Johnson JE.
Foot Ankle Int. 2003 Nov;24(11):838-44. PMID: 14655888 (Link to Abstract)
Jani, FAI 2003
Wukich DK, Joseph A, Ryan M, Ramirez C, Irrgang JJ.
Foot Ankle Int. 2011 Feb;32(2):120-30. PMID: 21288410 (Link to Abstract)
Wukich, FAI 2011
Please rate question.
Average 4.0 of 12 Ratings
A 27-year-old man presents to the emergency department with an ankle fracture. CT scans note anteromedial marginal impaction. Which radiograph (Figures A-E) would best correlate with this finding?
This patient has anteromedial marginal impaction seen on CT scans. This is characteristic of a supination-adduction ankle fracture (Figure D).
In the Lauge-Hansen classification, ankle fractures are classified into supination-adduction (SA), supination-external rotation, pronation-abduction, pronation-external rotation. Certain considerations exist when treating SA fractures with marginal impaction: (1) An anteromedial approach will aid in visualizing and reducing the impaction (instead of standard medial approach). (2) Disimpaction of the articular fragment and possibly bone grafting of the resulting defect may be necessary rather than simple percutaneous fixation.
McConnell et al. reviewed marginal plafond impaction in supination adduction injuries. Supination-adduction injuries comprised 5% of 500 fractures (44 fractures), and 42% (8 fractures) of these had marginal impaction.
Illustration A is another example of a SA fracture depicting vertical fracture of the medial malleolus in association with marginal impaction of the plafond (arrow). Illustration B is an axial CT showing increased density at the level of the subchondral bone, characteristic of anteromedial marginal impaction. Illustration C is a coronal CT showing showing articular depression of the impacted segment and tibiotalar incongruity.
Answer 1: Figure A shows a pronation-abduction ankle fracture.
Answer 2: Figure B shows a talar body fracture.
Answer 3: Figure C shows a pronation-external rotation ankle fracture
Answer 5: Figure E shows a supination-external rotation ankle fracture.
Marginal impaction is not characteristic of these injuries.
McConnell T, Tornetta P 3rd.
J Orthop Trauma. 2001 Aug;15(6):447-9. PMID: 11514775 (Link to Abstract)
McConnell, JOT 2001
A 34-year-old female requests a second opinion following open reduction internal fixation (ORIF) of her left ankle three weeks ago. Which of the following is most appropriate step based on Figures A and B?
Progressive weightbearing in 3-4 weeks based on radiographs
Deltoid ligament repair vs reconstruction
Revision ORIF of fibula with lengthening
Revision ORIF of fibula and syndesmosis
Removal of syndesmotic screws in 3-6 months
The above clinical scenario shows acute postoperative fibular malrotation and tibiofibular syndesmotic malreduction. Restoration of the proper syndesmotic relationship involves regaining fibular length as well as reestablishing correct rotation and position of the fibula relative to the tibia. In addition, removal of interposed tissue (deltoid ligament) in the medial joint space may be necessary. However, deltoid reconstruction is not routinely required.
Syndesmosis screw fixation in ankle fractures with syndesmotic disruption is indicated if there is residual or dynamic instability with stress testing of the tibiofibular joint after fixation of the fibula. Syndesmotic screws are commonly maintained in place for at least 12 weeks before removal, if necessary or desired. Controversy exists over use of 1 or 2 screws, screw size, and purchase of 3 or 4 cortices.
Gardner et al. compared radiographic measurements vs CT scans to assess reduction of the tibiofibular syndesmosis in ankle fractures. They found CT was better able to detect syndesmotic malreduction. Although they did not seek to correlate this with functional outcomes, they recommended heightened vigilance for assessing accurate syndesmosis reduction.
Zalavras et al. performed a review on ankle syndesmotic injuries. In their review, they highlight that syndesmotic injuries may occur in isolation or may be associated with ankle fractures. In the absence of fracture, physical examination findings suggestive of injury include ankle tenderness over the anterior aspect of the syndesmosis and a positive squeeze or external rotation test. They recommend stress testing for detecting syndesmotic instability with fixation of the syndesmosis when evidence of a diastasis is present.
Figures A and B show an ankle fracture treated with ORIF and syndesmotic repair, with syndesmotic and fibular malreduction.
Answer 1&5: Would not address the current syndesmotic malreduction which should be addressed.
Answer 2: Would not address the syndesmotic malreduction.
Answer 3: Fibular length appears appropriate on AP and lateral radiographs.
Gardner MJ, Demetrakopoulos D, Briggs SM, Helfet DL, Lorich DG.
Foot Ankle Int. 2006 Oct;27(10):788-92. PMID: 17054878 (Link to Abstract)
Gardner, FAI 2006
Zalavras C, Thordarson D
J Am Acad Orthop Surg. 2007 Jun;15(6):330-9. PMID: 17548882 (Link to Abstract)
Zalavras, JAAOS 2007
Average 3.0 of 25 Ratings
A 25-year-old male sustains an ankle fracture dislocation and undergoes open reduction and internal fixation. He returns to clinic five months following surgery complaining of continued ankle pain and instability with weight bearing. His immediate post-operative AP radiograph is seen in Figure A. Which of the following could have prevented this patient from developing persistent pain?
Deep deltoid ligament repair
Quadricortical syndesmotic screw fixation
Restoration of fibular length and rotation
Lateral collateral ligament complex repair
Use of two syndesmotic screws
The patient presents with continued ankle pain and instability following open reduction and internal fixation. The radiograph in figure A demonstrates inadequate restoration of fibular length, likely leading to continued tibiotalar instability.
Illustration A demonstrates fibular malreduction with dislocation of the fibula anterior to the tibial incisura. Illustration B shows a comminuted fibula fracture along with a measurement of length from an intact fibula. The arc from the lateral process of the talus to the peroneal groove of the distal fibula is known as the "dime" sign and should remain unbroken if fibular length has been restored. Illustration C demonstrates the use of a push-pull screw and lamina spreader to regain length intraoperatively for a comminuted fibula fracture.
Chu and Weiner review management of malunions of the distal fibula. The authors state that restoration of fibular length, alignment and rotation leads to reduction of the talus, provides a buttress to talar motion in the setting of an incompetent deltoid, and allows the syndesmotic ligaments to heal at the appropriate tension.
Wikeroy et al conducted a study of patients from a prior prospective, randomized control trial comparing different methods of syndesmotic fixation. There was no significant difference in outcomes between tricortical or quadricortical 3.5mm screw fixation, however worse outcomes were seen with associated posterior malleolar fractures, obesity, a difference in sydesmotic width of 1.5mm or greater, and a CT confirmed tibio-fibular synostosis.
Sinha et al present a simple technique for fibular lengthening in the setting of distal fibula malunion. They found high union rates and improved AOFAS scores at short-term follow up with their technique.
Chu A, Weiner L.
J Am Acad Orthop Surg. 2009 Apr;17(4):220-30. PMID: 19307671 (Link to Abstract)
Chu, JAAOS 2009
Wikeroy AK, Hoiness PR, Andreassen GS, Hellund JC, Madsen JE
J Orthop Trauma. 2010 Jan;24(1):17-23. PMID: 20035173 (Link to Abstract)
Wikeroy, JOT 2010
Sinha A, Sirikonda S, Giotakis N, Walker C.
Foot Ankle Int. 2008 Nov;29(11):1136-40. PMID: 19026209 (Link to Abstract)
Sinha, FAI 2008
Average 4.0 of 28 Ratings
A 32-year-old female sustains the injury shown in Figure A. What is the most reliable method to evaluate the competence of the deltoid ligament?
Medial ankle tenderness
Medial ankle ecchymosis
Stress radiography of the ankle
Canale view radiograph
Figure A shows a lateral malleolar fracture from a rotational-type injury. Evaluation of the medial structures (deltoid ligament) is important for therapeutic reasons, as medial sided instability will portend a poor prognosis if treated nonoperatively.
The referenced study by McConnell et al showed that physical exam is a poor indicator of medial ankle injury and that stress radiography is needed for proper medial ankle evaluation. All ankles found to be stable via stress examination healed with an intact mortise.
The study by Gill et al showed that gravity stress radiographs are equivalent to manual stress radiographs of the ankle when evaluating rotational ankle fractures. This was true when both pronation-external rotation and supination-external rotation ankle fractures were examined.
Illustration A shows the proper way to obtain a gravity stress radiograph.
McConnell T, Creevy W, Tornetta P 3rd.
J Bone Joint Surg Am. 2004 Oct;86-A(10):2171-8. PMID: 15466725 (Link to Abstract)
McConnell, JBJS 2004
Gill JB, Risko T, Raducan V, Grimes JS, Schutt RC Jr.
J Bone Joint Surg Am. 2007 May;89(5):994-9. PMID: 17473136 (Link to Abstract)
Gill, JBJS 2007
Average 4.0 of 23 Ratings
In an isolated ankle syndesmotic injury, the fibula is unstable in the incisura fibularis of the tibia. In what direction is the fibula most unstable?
Equivalent instability in all axes
In an ankle syndesmosis injury, the fibula is most unstable in an anterior and posterior direction. This is whether or not there is an accompanying ankle fracture. Most commonly, the fibula will subluxate in an anterior-posterior direction in an ankle fracture model.
The first referenced article by Xenos et al found that stress lateral radiographs have more interobserver reliability than stress AP/mortise radiographs and that two syndesmotic screws are stronger than one.
The referenced article by Candal-Couto et al is a biomechanical study that found more anterior-posterior instability in a syndesmosis injury model, and more ankle instability is noted with syndesmosis injury and a concomitant deltoid injury.
The referenced article by Zalavras et al is an excellent review article on ankle syndesmosis injuries.
Xenos JS, Hopkinson WJ, Mulligan ME, Olson EJ, Popovic NA
J Bone Joint Surg Am. 1995 Jun;77(6):847-56. PMID: 7782357 (Link to Abstract)
Xenos, JBJS 1995
Candal-Couto JJ, Burrow D, Bromage S, Briggs PJ.
Injury. 2004 Aug;35(8):814-8. PMID: 15246807 (Link to Abstract)
Candal-Couto, INJURY 2004
Average 3.0 of 29 Ratings
A 34-year-old man sustains a twisting injury to his left ankle playing soccer. Radiographs from the ER are provided in figures A and B. Four hours later, he undergoes open reduction internal fixation. An intraoperative fluoroscopy image is provided in figure C. Which of the following is the best method to assess the integrity of the syndesmosis?
Measurement of medial clear space widening
Measurement of the tibiofibular overlap
Anterior drawer test with comparison to the contralateral ankle
External rotation stress radiograph
Evaluation of the syndesmosis on preoperative CT scan
The radiograph demonstrates a Weber B ankle fracture. A dynamic external rotation stress test with the ankle dorsiflexed to 90 degrees is the most accurate way to evaluate the integrity of the syndesmosis.
Nielson et al evaluated 70 ankle fractures with radiographs and MRI. Neither measurements of the tibiofibular clear space nor the tibiofibular overlap correlated with syndesmotic injury on MRI. Medial clear space widening of more than 4 mm occurred with MRI evidence of disruption of the deltoid and the tibiofibular ligaments.
Nielson et al used this same cohort of ankle fractures in a separate study to evaluate whether the level of the fibular fracture correlated with syndesmotic incompetence. They found no correlation. The level of fracture on the fibula cannot be used to accurately predict disruption of the syndesmosis.
Ebraheim et al reviewed a series of Weber B fibula fractures with deltoid injury and syndesmotic disruption. Their findings concluded that the surgeon's dynamic assessment of syndesmotic stability was more predictive of syndesmotic stability than any imaging parameters including radiographs and CT scans.
Nielson JH, Gardner MJ, Peterson MG, Sallis JG, Potter HG, Helfet DL, Lorich DG.
Clin Orthop Relat Res. 2005 Jul;(436):216-21. PMID: 15995444 (Link to Abstract)
Nielson, CORR 2005
Ebraheim NA, Elgafy H, Padanilam T.
Clin Orthop Relat Res. 2003 Apr;(409):260-7. PMID: 12671510 (Link to Abstract)
Ebraheim, CORR 2003
Nielson JH, Sallis JG, Potter HG, Helfet DL, Lorich DG.
J Orthop Trauma. 2004 Feb;18(2):68-74. PMID: 14743024 (Link to Abstract)
Nielson, JOT 2004
Average 4.0 of 16 Ratings
A 34-year-old male falls off of a ladder and sustains the ankle injury shown in Figure. Which of the following is unique with this particular ankle fracture pattern and must be recognized by the operating surgeon to optimize outcomes?
Marginal impaction of the anteromedial tibial plafond
Deltoid ligament tear
Posterolateral osteochondral lesion of the talus
The radiograph demonstrates a Lauge-Hansen supination-adduction fracture-dislocation. There is a transverse fibula fracture and a vertical medial malleolus fracture.
McConnell and Tornetta performed a Level 4 review and found that nearly 50% of these injuries have marginal impaction of the anteromedial tibial plafond and they found that anatomic reduction of that aspect of the injury led to good to excellent outcomes.
HPI - fall from height
How would you definitely treat this fracture
Average 3.0 of 31 Ratings
In which of the following radiographs of different types of ankle fractures should the medial malleolus be treated with screw fixation directed parallel to the ankle joint?
Figure A show a classic SAD (supination adduction) fracture according to the Lauge-Hansen Classfication. This is evident by the vertical medial malleolar fracture and supinated position of the foot. The vertical medial malleolar fracture is best treated by screw fixation parallel to the joint (perpendicular to the fracture line). Careful attention must be paid to the presence of any medial plafond impaction from the talar displacement; if this is present, disimpaction and stabilization must be performed in order to optimize outcomes.
The referenced review article by Michelson covers rotational ankle fractures, with a review of the diagnosis, treatment options, and patient outcomes. He notes that unstable fractures (bimalleolar, bimalleolar equivalent, etc.) usually are managed with open reduction and internal fixation for optimal outcomes.
Figure B shows a Weber C (high fibular) ankle fracture, PER, without any evidence of a medial malleolar fracture.
Figures C (SER IV), D (PER IV), and E (isloated medial malleolar fracture) all show fractures not suitable for screw fixation of the medial malleolus parallel to the joint since their fracture lines are not vertical.
J Am Acad Orthop Surg. 2003 Nov-Dec;11(6):403-12. PMID: 14686825 (Link to Abstract)
Michelson, JAAOS 2003
Average 3.0 of 28 Ratings
Following operative repair of lower extremity long bone and periarticular fractures, what is the time frame for patients to return to normal automobile braking time?
6 weeks after initiation of weight bearing
4 weeks postoperatively
8 weeks from the date of injury
Once full range of motion of the ankle and knee exist
At the time of bony union
According to the first referenced study by Egol et al, appropriate braking time returns at a point 6 weeks after initiation of weightbearing after treatment of lower extremity long bone and periarticular fractures, as examined with a driving simulator. No differences were seen in return of braking time between periarticular fractures and long bone injuries.
The second reference by Egol studied only operatively treated ankle fractures and found that time to appropriate braking returns at 9 weeks postoperatively. Interestingly, no significant association was found between the functional scores and normalization of total braking time.
Egol KA, Sheikhazadeh A, Koval KJ
J Trauma. 2008 Dec;65(6):1435-8. PMID: 19077638 (Link to Abstract)
Egol, JOT 2008
Egol KA, Sheikhazadeh A, Mogatederi S, Barnett A, Koval KJ
J Bone Joint Surg Am. 2003 Jul;85-A(7):1185-9. PMID: 12851340 (Link to Abstract)
Egol, JBJS 2003
Average 3.0 of 35 Ratings
A 31-year-old male sustains an irreducible ankle fracture-dislocation with the foot maintained in an externally rotated position. An AP and lateral radiograph are shown in figures A and B respectively. The attempted post reduction AP and lateral are shown in C and D. What structure is most likely preventing reduction?
Anterior-inferior tibiofibular ligament
Posterior-inferior tibiofibular ligament
Peroneus brevis tendon
Posterolateral ridge of the tibia
Flexor hallucis longus tendon
As described by Hoblitzell et al, the so-called "Bosworth fracture-dislocation" is a rare fracture-dislocation of the ankle where the fibula becomes entrapped behind the tibia and becomes irreducible. It can cause compartment syndrome, as reported by Beekman and Watson.
Hoblitzell et al stress the importance and difficulty of recognizing these injuries. Standard radiographs are difficult to interpret due to the often severe external rotation of the foot. Prompt treatment, though can lead to good results in patients. The posterolateral ridge of the distal tibia hinders reduction and reduction often requires an open technique
Mayer and Evarts stated AP and mortise radiographs can be hard to interpret due to the external rotation posture of the foot. In their series a closed reduction consisting of traction and medial rotation applied to the foot while the fibular shaft is pushed laterally was successful in 3/4 patients.
Beekman R, Watson JT.
J Bone Joint Surg Am. 2003 Nov;85-A(11):2211-4. PMID: 14630856 (Link to Abstract)
Beekman, JBJS 2003
Hoblitzell RM, Ebraheim NA, Merritt T, Jackson WT.
Clin Orthop Relat Res. 1990 Jun;(255):257-62. PMID: 2112075 (Link to Abstract)
Hoblitzell, CORR 1990
Mayer PJ, Evarts CM.
J Bone Joint Surg Am. 1978 Apr;60(3):320-4. PMID: 649635 (Link to Abstract)
Mayer, JBJS 1978
Average 3.0 of 42 Ratings
In the Lauge-Hansen classification system, a pronation-abduction ankle fracture has what characteristic fibular fracture pattern?
Transverse fracture below the level of the syndesmosis
Short oblique fracture running from anteroinferior to posteriosuperior
Short oblique fracture running from posteroinferior to anteriosuperior
Comminuted fracture at or above the level of the syndesmosis
In the Lauge-Hansen classification, the characteristic fibular fracture pattern in a pronation-abduction injury is a comminuted fibular fracture above the level of the syndesmosis. In the first stage of this injury pattern, the deltoid fails in tension, or an avulsion fracture of the medial malleolus occurs. In the second stage, the anterior inferior tibiofibular ligament ruptures, or a small bony avulsion of this ligament's insertion/origin occurs. The final stage includes the creation of a comminuted fibular fracture above the level of the syndesmosis.
The referenced article by Siegel et al noted that extraperiosteal bridge plating of these ankle injuries was safe and had excellent radiographic and clinical outcomes at final follow-up.
Siegel J, Tornetta P 3rd.
J Bone Joint Surg Am. 2007 Feb;89(2):276-81. PMID: 17272440 (Link to Abstract)
Siegel, JBJS 2007
Average 3.0 of 24 Ratings
An 18-year-old football player presents to the emergency department after sustaining an ankle injury. His radiograph is shown in figure A. What is the most appropriate definitive treatment?
Open reduction and internal fixation of the medial malleolus with syndesmosis reduction and suture-button repair
Repair of the anterior talo-fibular ligament
Open reduction internal fixation of the fibula with syndesmosis reduction and suture-button repair
Open reduction internal fixation of the medial malleolus and fibula
Open reduction internal fixation of the fibula and medial malleolus with syndesmosis reduction and suture-button repair
The radiograph demonstrates an ankle fracture-dislocation. There is diastasis of the distal tibia and fibula, indicating a syndesmosis injury.
Zalavras et al stated failure to recognize and treat the syndesomsis injury leads to inferior outcomes, and should be assessed after fibula and medial malleolar fixation. Treatment of choice is reduction of the syndesmosis and fixation.
Average 2.0 of 32 Ratings
Presence of diabetes-induced peripheral neuropathy has been shown to be an independent risk factor for postoperative complications of which of the following injuries?
Distal radius fractures
Distal femoral fractures
Presence of peripheral neuropathy has important implications in treating ankle fractures in diabetic patients. Increased immobilization periods, attention to tight glucose control, and adjunct/alternative operative techniques may be necessary for an optimal outcome.
The first referenced article by Chaudry et al is an excellent review of diabetic ankle fractures.
The second reference by Costigan et al noted that peripheral neuropathy is the most significant risk factor for postoperative complications, followed closely by lack of pedal pulses preoperatively.
The last referenced article by Jones et al noted a significantly higher complication rate in diabetics with operative ankle fractures, and reported that neuroarthropathy is a significant risk factor for postoperative complications.
Chaudhary SB, Liporace FA, Gandhi A, Donley BG, Pinzur MS, Lin SS.
J Am Acad Orthop Surg. 2008 Mar;16(3):159-70. PMID: 18316714 (Link to Abstract)
Chaudhary, JAAOS 2008
Costigan W, Thordarson DB, Debnath UK.
Foot Ankle Int. 2007 Jan;28(1):32-7. PMID: 17257535 (Link to Abstract)
Costigan, FAI 2007
Jones KB, Maiers-Yelden KA, Marsh JL, Zimmerman MB, Estin M, Saltzman CL.
J Bone Joint Surg Br. 2005 Apr;87(4):489-95. PMID: 15795198 (Link to Abstract)
Jones, BJJ 2005
Average 3.0 of 23 Ratings
A 19-year-old male sustains the injury shown in Figure A while skiing. Injury to what structure should be evaluated intraoperatively during fixation of the fibula?
Posterior tibial tendon
According to the referenced study by Jenkinson et al, up to 37% of operatively treated ankle fractures can have undetected syndesmotic instability when examined intraoperatively. This is important due to the negative effects of a displaced mortise and the abnormal loading forces seen on the talus with even a 2mm lateral shift. Also, fibular fractures >4.5cm proximal to the mortise are more likely to be associated with syndesmotic instability, especially when deltoid ligament tears are present. When fixing the syndesmosis, Tornetta et al's referenced study has shown that the syndesmotic compression has no negative effects on ankle range of motion.
Tornetta P 3rd, Spoo JE, Reynolds FA, Lee C.
J Bone Joint Surg Am. 2001 Apr;83-A(4):489-92. PMID: 11315776 (Link to Abstract)
Tornetta, JBJS 2001
Jenkinson RJ, Sanders DW, Macleod MD, Domonkos A, Lydestadt J.
J Orthop Trauma. 2005 Oct;19(9):604-9. PMID: 16247304 (Link to Abstract)
Jenkinson, JOT 2005
HPI - While running the patient twisted his ankle and had an immediate onset of pain and swelling.
How would you treat this fracture based on the Preoperative Radiographs alone?
A 35-year-old male with a pronation abduction ankle injury would have which of the following radiographs?
Figure D shows a pronation abduction ankle fracture according to the Lauge-Hansen classification. This injury pattern is associated with a comminuted fibula fracture above the level of the syndesmosis and frequently has a concominant syndesmotic injury.
Lauge-Hansen's classic article describes in detail his proposed classification of ankle fractures based on both the position of the foot (supination or pronation) and an externally applied deforming force (adduction, abduction, external rotation). The Lauge-Hansen classification system is based on cadaveric experiments using manually applied forces and roentographs performed at each stage of injury.
Edwards and DeLee review their results in managing diastasis of the tibiofibular joint without an associated fracture. The authors propose a classification system of this uncommon injury and and theorize that the injury results from a pronation abduction mechanism.
Answer 1: Figure A represents a supination adduction fracture based on the vertical medial malleolar fracture, medial dislocation on the talus, and low transverse fibula fracture.
Answer 2: Figure B represents a pronation external rotation injury; note the high oblique fibula fracture and corresponding transverse medial malleolus fracture.
Answer 3: Figure C represents a supination external rotation ankle injury based on the oblique fibula fracture at the level of syndesmosis and the associated transverse medial malleolar fracture.
Answer 4: Figure E represents a pilon fracture based on the significant articular comminution signifiying an axial loading mechanism instead of a rotational injury.
Arch Surg. 1950 May;60(5):957-85. PMID: 15411319 (Link to Abstract)
Edwards GS Jr, DeLee JC.
Foot Ankle. 1984 May-Jun;4(6):305-12. PMID: 6429020 (Link to Abstract)
Average 3.0 of 34 Ratings
A 68-year-old female sustains a closed ankle fracture and is treated with open reduction and internal fixation. Her postoperative radiographs are shown in Figure A. Widening of the tibia-fibular clear space with external rotation stress would be a result of injury of which structure?
Anterior ankle joint capsule
Anterior talofibular ligament
The radiograph shows a trimalleolar ankle fracture, which can be associated with syndesmosis injuries. The syndesmosis acts to maintain the relationship of the fibula in the incisura fibularis of the distal tibia as well as the congruity of the ankle joint. Failure to detect these injuries can lead to lateral talar shift and negative outcomes. So, if there was an isolated fibula fracture, the stress examination would test the deep fibers of the deltoid ligament complex. However, in this case, with fixation of the fibula, widening of the ankle joint would require an injury to the syndesmosis, as this structure would prevent it after restoration of the lateral column of the ankle (fibula).
Beumer et al describe that stress radiographs may be performed by external rotation stress on the hindfoot or by providing a lateral "pull" on the distal fibula after fixation (Cotton test).
Park et al showed that "ankle stress radiographs taken in dorsiflexion-external rotation were most predictive of deep deltoid ligament disruption after distal fibular fracture. Under this stress condition, a medial clear space of > or =5 mm was the most reliable predictor of deep deltoid ligament status."
Park SS, Kubiak EN, Egol KA, Kummer F, Koval KJ.
J Orthop Trauma. 2006 Jan;20(1):11-8. PMID: 16424804 (Link to Abstract)
Park, JOT 2006
Beumer A, van Hemert WL, Swierstra BA, Jasper LE, Belkoff SM.
Foot Ankle Int. 2003 Apr;24(4):358-63. PMID: 12735381 (Link to Abstract)
Beumer, FAI 2003
Average 3.0 of 32 Ratings
The Cotton test evaluates which of the following structures?
Lateral ulnar collateral ligament of the elbow
The inferior tibiofibular syndesmosis is a fibrous articulation consisting of four ligaments; the elasticity of these ligaments permits axial, vertical, anterior, posterior, and mediolateral motion at the ankle syndesmosis during weight bearing.
Of note, the Cotton test was originally described around 1910 by Frederic J. Cotton as the "talar glide test" evaluating the medial/lateral translation of the talus in the mortise. A positive result indicates disruption of the ankle syndesmosis in the face of an ankle injury.
Nielson et al reported that the level of the fibular fracture does not correlate reliably with the integrity or extent of the interosseous membrane (IOM) tears identified on MRI in operative ankle fractures. Therefore, one cannot consistently estimate the integrity of the IOM and subsequent need for transsyndesmotic fixation based solely on the level of the fibular fracture. This supports the need for intraoperative stress testing (ie, external rotation stress or Cotton test) of the ankle syndesmosis in all operative ankle fractures.
The study by Leeds et al noted a correlation between syndesmosis reduction (initial and final) and outcomes (radiographic and clinical).
The attached video shows the Cotton test during an ankle fixation procedure.
Leeds HC, Ehrlich MG.
J Bone Joint Surg Am. 1984 Apr;66(4):490-503. PMID: 6423645 (Link to Abstract)
Leeds, JBJS 1984
Average 3.0 of 27 Ratings
After undergoing the treatment seen in Figure A, when should a patient be expected to safely operate the brakes of an automobile?
2 -4 weeks
Figure A shows a patient after an open reduction and internal fixation of a bimalleolar ankle fracture.
Egol et al showed that by nine weeks, the total braking time of patients who had undergone fixation of a displaced right ankle fracture returns to the normal, baseline value.
Egol et al, also found that appropriate braking time returns at a point 6 weeks after initiation of weightbearing after treatment of lower extremity long bone and periarticular fractures, as examined with a driving simulator. No differences were seen in return of braking time between periarticular fractures and long bone injuries.
Average 2.0 of 40 Ratings
Appropriate treatment of the bimalleolar ankle fracture shown in Figure A includes which of the following?
Bridge plating of the fibula with oblique medial malleolar screws
Antiglide plating of the fibula with oblique medial malleolar screws
Intramedullary fibular screw with medial malleolar tension banding
Fibular plating with open correction of plafond impaction with medial malleolar antiglide plate
Fibular plating with open correction of syndesmosis and oblique medial malleolar screws
A supination-adduction type injury consists of a vertical displaced medial malleolus fracture with marginal impaction of the tibial plafond and a low transverse fibula fracture. This type of injury is also associated with hyperdorsiflexion. The mechanism of a supination–adduction injury to the ankle results in a low transverse lateral malleolus avulsion and a vertical fracture of the medial malleolus secondary to inversion of the talus in the ankle mortise. The initial injury is a rupture of the lateral ankle ligaments or avulsion of the lateral malleolus. As the talus continues to invert, the medial malleolus is pushed to failure and fractures in a vertical fashion. The correct treatment for this type of injury is open reduction and internal fixation (ORIF) with correction of the impacted articular component. Screws alone or a tension band would not provide a vertically stable construct.
In the referenced article by McConnell et al, 8 ankle fractures of this variety were all treated with open reduction and internal fixation, two with medial screws perpendicular to the fracture and the other 6 with medial screws and a one third tubular antiglide plate. 6 of the patients treated in the study had excellent results after 2.5 years of follow up, the other 2 had good results after 2.5 years.
Example of a representative fixation construct of the injury is shown in Illustration A.
A 34-year-old woman twists her right ankle stepping off the city bus. An AP ankle radiograph is provided in Figure A. Which of the following statements accurately describe this radiograph?
The tibiofibular overlap is less than 3 mm
The fibula demonstrates a Weber C fracture pattern
The tibiofibular clear space is less than 4 mm
The fracture is consistent with a Lauge-Hansen pronation-external rotation injury pattern
The medial clear space is greater than 5 mm
The AP radiograph demonstrates a stable, minimally displaced Weber B ankle fracture. It is consistent with a Lauge-Hansen supination-external rotation injury pattern.
Harper et al performed cadaveric measurements to define normal radiographic values for standard ankle imaging. The tibiofibular overlap is defined as the horizontal distance from the lateral border of the posterior tibial malleolus (the incisura fibularis) and the medial border of the fibula at the point where the posterior malleolus is widest on an AP radiograph should be great than 6 mm. Tibiofibular clear space is defined as the horizontal distance between the medial border of the fibula and the lateral border of the anterior tibial prominence on an AP radiograph, and should be <6mm. The medial clear space, defined as the distance between the lateral aspect of the medial malleolus and the medial border of the talus at the level of the talar dome on the mortise radiograph should be less than 4 mm.
Ostrum et al performed a radiographic study on human volunteers and noted gender differences. In this study, normal tibial clear space should be less than 5.2 mm in women and less than 6.5 mm in men. The tibiofibular overlap should be greater than 2.7 mm in women and greater than 5.7 mm in men.
Illustration A is an example of the proper measurement of the tib-fib clear space.
Harper MC, Keller TS.
Foot Ankle. 1989 Dec;10(3):156-60. PMID: 2613128 (Link to Abstract)
Ostrum RF, De Meo P, Subramanian R.
Foot Ankle Int. 1995 Mar;16(3):128-31. PMID: 7599729 (Link to Abstract)
Ostrum, FAI 1995
Average 2.0 of 62 Ratings
The talocrural angle of an ankle mortise x-ray is formed between a line perpendicular to the tibial plafond and a line drawn:
perpendicular to the medial clear space
parallel to the talar body
between the tips of the malleoli
perpendicular to the shaft of the fibular
parallel to the subtalar joint
The talocrural angle is formed by the intersection of a line perpendicular to the plafond with a line drawn between the malleoli (average = 83+/-4deg). When the lateral malleolus is shortened secondary to fracture, this can lead to increased talocrural angle. This malunion leads to lateral tilt of the talus.
Phillips et al looked at 138 patients with a closed grade-4 supination-external rotation or pronation-external rotation ankle fracture. Although the conclusions were limited due to poor follow up, they found the difference in the talocrural angle between the injured and normal sides was a statistically significant radiographic indicator of a good prognosis.
Pettrone et al looked at a series of 146 displaced ankle fractures, and the effect of open or closed treatment, and internal fixation of one or both malleoli. They found open reduction proved superior to closed reduction, and in bimalleolar fractures open reduction of both malleoli was better than fixing only the medial side.
Illustrations A and B are demonstrations of the talocrural angle.
Phillips WA, Schwartz HS, Keller CS, Woodward HR, Rudd WS, Spiegel PG, Laros GS.
J Bone Joint Surg Am. 1985 Jan;67(1):67-78. PMID: 3881447 (Link to Abstract)
Phillips, JBJS 1985
Pettrone FA, Gail M, Pee D, Fitzpatrick T, Van Herpe LB.
J Bone Joint Surg Am. 1983 Jun;65(5):667-77. PMID: 6406511 (Link to Abstract)
Pettrone, JBJS 1983
Lateral malleolus fractures can be treated with a variety of techniques, including posterior antiglide plating or lateral neutralization plating. What is an advantage of using lateral neutralization plating instead of posterior antiglide plating?
Decreased joint penetration of distal screws
Decreased need for delayed hardware removal
Decreased peroneal irritation
Improved distal fixation
Posterior antiglide plating is a technique that involves placement of a plate on the posterior aspect of the distal fibula, using the plate as a reduction tool and direct buttress against distal fracture fragment displacement.
Schaffer et al showed from a biomechanical standpoint that posterior antiglide plating was superior to lateral neutralization plating for distal fibula fracture fixation.
Weber et al reported a (30/70) 43% rate of plate removal secondary to peroneal discomfort. In addition, peroneal tendon lesions were found in 9 of the 30 patients.
Weber M, Krause F.
Foot Ankle Int. 2005 Apr;26(4):281-5. PMID: 15829211 (Link to Abstract)
Weber, FAI 2005
Schaffer JJ, Manoli A 2nd.
J Bone Joint Surg Am. 1987 Apr;69(4):596-604. PMID: 3571317 (Link to Abstract)
Schaffer, JBJS 1987
Average 4.0 of 14 Ratings
The Lauge-Hansen classification of ankle fractures identifies characteristic fracture patterns based on mechanism of injury. What is the mechanism for the fracture pattern shown in Figure A?
The 4 categories in the Lauge-Hansen classification are: supination-adduction, supination-external rotation, pronation-external rotation, and pronation-abduction.
The typical fracture pattern of supination-adduction is demonstrated in figure A and consists of a tension failure (transverse) fracture of the lateral malleolus combined with a vertical fracture of the medial distal tibia. There is frequently comminution where the fracture begins on the tibial plafond. This is caused by compression from the medial talar dome.
Average 4.0 of 25 Ratings
What is the most appropriate plating technique utilized for the medial malleolus fracture typically seen in a displaced supination-adduction ankle fracture?
Tension band plating
A supination-adduction ankle fracture leads to a vertical fracture of the medial malleolus. Traditional fixation of the medial malleolus with oblique screws from the tip of the malleolus directed proximally will ineffectively protect against shear forces at the fracture site; these also are directed quite obliquely to the vertical fracture line, and therefore have poor biomechanical resistance to failure. An antiglide plate is used medially to prevent displacement of the fracture segment due to shear forces.
According to the referenced article by Toolan et al, placement of two horizontal (perpendicular to the fracture line) lag screws from medial to lateral are biomechanically the most important aspect of the construct whether a plate is used or not.
Toolan BC, Koval KJ, Kummer FJ, Sanders R, Zuckerman JD.
Foot Ankle Int. 1994 Sep;15(9):483-9. PMID: 7820240 (Link to Abstract)
Toolan, FAI 1994
Average 4.0 of 26 Ratings
When comparing the fibular plating techniques shown in Figures A and B, the plate position shown in Figure B is associated with which of the following?
Decreased rate of hardware prominence
Increased risk of intra-articular screw penetration
Increased peroneal tendinitis
Figure A shows an antiglide (posterior) plating of the distal fibula, while Figure B shows a lateral neutralization plating of the distal fibula. Both methods are acceptable, but posterior antiglide plating is associated with increased construct stiffness and strength, decreased hardware prominence, decreased rates of ankle joint screw penetration, and improved biomechanical findings in osteoporotic bone. However, posterior plating is associated with an increased rate of peroneal tendonitis and irritation. Illustration A shows a lateral radiograph of a posterior fibular plate.
The referenced article by Ostrum et al is a case series of 32 patients who had antiglide plating; he reported a 100% union rate, 95% patient satisfaction rate, and only 4/32 reported peroneal tendinitis, with all resolving by 2 months.
The other referenced article by Schaffer et al reported that the posterolateral antiglide plate demonstrated improved biomechanical stability as compared to the lateral plating, with increased construct stiffness and load to failure.
J Orthop Trauma. 1996;10(3):199-203. PMID: 8667112 (Link to Abstract)
Ostrum, JOT 1996
Average 4.0 of 22 Ratings
Coupled with reduction of the syndesmosis, which of the following interventions is most important when surgically addressing the ankle malunion shown in Figure A?
Placement of an osteochondral allograft
Fibular lengthening osteotomy
Calcaneofibular ligament release
Medial malleolar shortening osteotomy
Deltoid ligament imbrication
Late correction with a corrective osteotomy of a fibular malunion associated with diastasis of the ankle mortise (Illustrations A and B) is an effective means of salvaging function in a joint otherwise destined to be stiff and painful.
The referenced study by Offierski et al reports that the factors that determined the success of the revision were the duration of the malunion, the quality of the reduction achieved, and the condition of the articular cartilage at the time of revision.
The referenced study by Chao et al reported that the fibular lengthening osteotomy was crucial in regaining the anatomy and stability of the ankle mortise.
The referenced study by Weber et al is a review of the technique of such an osteotomy, with commentary regarding its clinical success even if mild degenerative changes are seen. They also note that no differences are seen in outcomes between oblique and step-cut osteotomies.
The referenced study by Weber and Simpson is a case series of corrective lengthening osteotomies after malunited ankle fractures. They report that a lengthening and/or rotational osteotomy of a malunited fibula is successful in preventing further ankle arthrosis if no more than minimal degenerative radiographic changes are seen.
Offierski CM, Graham JD, Hall JH, Harris WR, Schatzker JL.
Clin Orthop Relat Res. 1982 Nov-Dec;(171):145-9. PMID: 7140062 (Link to Abstract)
Offierski, CORR 1982
Chao KH, Wu CC, Lee CH, Chu CM, Wu SS.
Foot Ankle Int. 2004 Mar;25(3):123-7. PMID: 15006331 (Link to Abstract)
Chao, FAI 2004
Weber D, Friederich NF, Müller W.
Int Orthop. 1998;22(3):149-52. PMID: 9728305 (Link to Abstract)
Weber, INTORT 1998
Weber BG, Simpson LA.
Clin Orthop Relat Res. 1985 Oct;(199):61-7. PMID: 4042497 (Link to Abstract)
Weber, CORR 1985
Average 2.0 of 55 Ratings
A 32-year-old taxi driver sustains a displaced supination external rotation ankle injury after slipping off of a curb. He subsequently undergoes surgical fixation, and a post-operative radiograph is shown in Figure A. At the eight-week postoperative visit, you are asked to fill out a return to work form. How long from today’s visit will his braking time be expected to return to normal?
Two weeks ago
One week from now
Three weeks from now
Six weeks from now
Eight weeks from now
Patients recover the ability to safely operate the brakes of an automobile 9 weeks following operative repair of an ankle fracture. Because this patient is currently 8 weeks out from surgery, his braking time will be expected to return to normal one week from now.
Egol et al studied the time braking ability returns to normal in patients with operatively treated ankle fractures. Patients were studied at 6, 9, and 12 weeks postoperatively and compared to healthy controls. It was determined that total breaking time returned to normal by 9 weeks.
Average 2.0 of 56 Ratings
A 33-year-old male is involved in a motor vehicle accident and suffers a right pilon fracture. Which of the bone fragments labeled on the distal tibia in the axial CT scan shown in Figure A is attached to the posterior tibiofibular ligament?
C and B
A and D
Figure A is an axial CT scan slice of an intra-articular distal tibia fracture. The bands of the posterior tibiofibular ligament pass obliquely from the fibula to the posterolateral aspect of the distal tibia. The ligaments of the ankle often remain intact after a pilon fracture producing the major fracture segments consisting of posterolateral or Volkmann's fragment (labeled D), the anterolateral or Chaput fragment (labeled B), and the medial fragment (labeled C). The fibula is labeled A. Any surgical approach taken to treat this injuries should respect these attachments.
Michelson reviews the important role of ankle ligamentous anatomy in his study on rotational ankle fractures.
Hermans et al review the anatomy of the ankle syndesmosis and state that stress on the posterior tibiofibular ligament results more often in a posterior malleolus avulsion fracture than in a rupture of the ligament. They go on to state that with direct reduction of the posterior malleolus avulsion fracture, the syndesmosis can often be stabilized.
Illustration A shows the posterior tibiofibular ligament highlighted in red on MRI imaging in a LEFT ankle (the CT image in the question is of a RIGHT ankle).
Hermans JJ, Beumer A, de Jong TA, Kleinrensink GJ.
J Anat. 2010 Dec;217(6):633-45. PMID: 21108526 (Link to Abstract)
Hermans, JANAT 2010
Average 1.0 of 197 Ratings
A 32-year-old female sustained a bimalleolar ankle fracture and was treated with open reduction and internal fixation four months ago. A radiograph of her ankle is shown in Figure A. Recommended management should consist of?
Physical therapy for ambulation assistance and proprioception training
Short leg bracing
Revision open reduction and internal fixation with open syndesmosis reduction
Addition of syndesmosis screw from fibula to tibia
Open medial ankle ligament reconstruction
This patient requires revision open reduction and internal fixation of her syndesmosis as post-operative radiographs demonstrate a severely malaligned ankle with obvious syndesmosis widening and fibular shortening.
Malalignment following ankle fracture fixation can alter the anatomical axis of the joint, articular congruency, and normal load distribution. This predisposes the patient to the development of chronic pain, functional impairment, and finally early post-traumatic ankle arthritis.
Marti et al. retrospectively reviewed the outcomes of 31 patients with malunited ankle fractures who underwent reconstructive osteotomies. The authors found that reconstruction resulted in good or excellent results in the majority of patients. They also note that minor post-traumatic arthritis was not a contraindication to reconstruction.
Ramsey et al. evaluated 23 cadaveric ankles using a carbon black transference technique to determine the contact area in the dissected tibiotalar articulations, with the talus in neutral position and displaced one, two, four, and six millimeters laterally. They found that 1 mm of lateral talar displacement resulted in a 42% decrease in tibiotalar contact area.
Figure A is a x-ray demonstrating severe malalignment of a bimalleolar ankle fracture following fixation of the fibula and medial malleolus. There is obvious shortening of the fibula and lateral shift and valgus tilt of the talus associated with a disrupted syndesmosis.
Answer 1 & 2: Physical therapy and short leg bracing are not indicated at this point as the anatomical malalignment needs to first be addressed via revision surgery.
Answer 4: The addition of a syndesmosis screw will not successfully reduce the syndesmosis as it has been chronically malreduced and will require open reduction and debridement prior to syndesmosis screw fixation.
Answer 5: Open medial ankle ligament reconstruction is insufficient in isolation to provide mechanical stability to the ankle fractures with syndesmosis disruption.
Marti RK, Raaymakers EL, Nolte PA.
J Bone Joint Surg Br. 1990 Jul;72(4):709-13. PMID: 2116416 (Link to Abstract)
Marti, BJJ 1990
Ramsey PL, Hamilton W.
J Bone Joint Surg Am. 1976 Apr;58(3):356-7. PMID: 1262367 (Link to Abstract)
Ramsey, JBJS 1976
HPI - Injury while playing football.
What is the fracture mechanism according to Lauge-Hansen Classification?
HPI - Trip and fall whilst hiking
How would you treat this injury?
HPI - Fell from height at a construction site injuring his right ankle
How would you treat the distal fibula fracture?
HPI - Direct trauma at work by saw. Laceration tibialis anterior/EHL/EDL with neurovascular bundle preserved.
Internal degloving up to medial malleolus with small saw cut in lateral tibia.
Once the soft tissue swelling has reduced to an appropriate level and the skin openings have healed, in addition to ORIF of the medial malleolus, how would you manage the fibula fracture?
HPI - A 23 year old male patient presented to ER after a RTA where he injured his left ankle.
Patient was non-weight bearing. Severe left ankle pain, swelling, and limited ROM.
Would you order a CT scan for this patient?
HPI - Ankle fracture 9/12 ago.
1st operation 9/12 ago at another institution.
Re-operation 6/12 ago with ex-fix, deltoid ligament reconstruction and syndesmosis screw at a different institution.
Patient presents with persistent pain on ambulation, ESR CRP normal, no neurovascular deficit.
How would you manage this patient?
HPI - The patient is a 52 year old man who works as a landscaper. He fell on the job sustaining a twisting injury to his ankle.
Is the medial clear space increased with the original external rotation stress?
HPI - 60 year old woman (nurse) status post motor vehicle accident.
Are XRays enough to determine whether or not a posterior malleolus fracture requires fixation?
HPI - Patient slipped and fell, injuring his left ankle, 1 week ago.
How would you manage this fracture?
HPI - Injured left ankle 3 months ago.
The fracture was treated in a cast with NWB for 8 weeks.
Currently, patient complains of continued pain and inability to weight bear on the affected extremity.
No further injuries to the left ankle since the initial fracture.
How would you manage this patient at this point?
HPI - Right ankle injury ankle 1 day earlier
After closed reduction and application of posterior splint (see Postoperative P1 images below) what would you do for definitive management?
HPI - History of fracture lateral Malleolus 10 months ago. Treated with ORIF by one third tubular plate and syndesmotic screw. Pt now complains of pain with ambulation
How would you treat this failed ORIF at this time?
HPI - An 84-year old female fell while walking up the stairs. She presents with neck pain and ankle pain. She reports she fell she recalls hitting her lateral leg on the edge of the stair.
How would you determine the stability and treat this ankle (fibular) fracture?
HPI - Trauma 7 years ago, in another state, treated with reduction and casting only. Always painful; is worsening.
How would you treat this?
HPI - Last evening, I had an interesting case of the commonly encountered "someone rolled up on my ankle". The player limped off but after removing shoe/sock he endorsed minimal tenderness throughout the ankle and no specific pain on the distal fibula. The ankle was taped and he was allowed to put weight on the ankle. at this point he mentioned pain with weightbearing and we then placed ice and reevaluated at end of 1st quarter. At this point, there was swelling over distal fibula and more tenderness. parents agreed with obtaining a XRay at the ER and images attached show a nondisplaced distal fibula fracture. (notice on the xray how much soft tissue swelling occurred just over the 70 minutes from the time of injury compared to the medial side of the ankle where there is no soft tissue swelling!) Treatment will include 6 weeks of a cast.
Do you find the ottawa ankle rules helpful in sideline evaluation of ankle injuries?
HPI - Fall at home 01 week back
HPI - Healthy woman, she received a tombstone on her rear leg and injured her left ankle. She was operated on 3 days later
Would you rather do ORIF to the fibula despite the intact syndesmosis
HPI - Sustained closed injury left ankle in a RTA on 18 Jun 2015.
What implant if any would you choose for the fibula fracture?
HPI - A 64 year old female patient presented to our dept. complaining of pain in the right ankle after falling downstairs.
How would you proceed?
HPI - 22 yo fall on ice. how would you treat this fracture pattern with fibula fracture 13cm proximal from mortise??
How would you treat this fracture pattern with fibula fracture 13cm proximal from mortise?
HPI - This lady has got bilateral feet ulcers and bad skin conditions of both leg and ankles for the last 9 months, skin graft was done and still on dressing and infection control.
The patient fell 3 months ago and hurt her Rt ankle. A splint was applied initially. The patient had a manipulation and cast for another one week.She continued to ambulate on the injured limb. External fixation was then applied and later removed.
How would you treat the initial injury?
HPI - Twisting ankle trauma caused complete tibiotalar dislocation with comminuted distal fibula , medial mallelous was exposed from a transverse wound 5 cm from in out , deltoid ligament completely avulsed from tibia with scanty remenants , neurovascular intact
What is the best method to treat the fibular fracture ?
HPI - Four months old badly displaced fracture ankle treated conservatively somewhere else post H/O twisting in a walker patient.
How to treat the fracture
HPI - A 58 year-old lady, well in herself, sustained 2 1/2 years ago, an open fracture (Gustilo I) of the right ankle (medial, lateral and posterior malleoli). She was managed with an ORIF of the lateral and posterior malleoli but the medial malleolus was not fixed due to poor skin condition above the incision area.
What is the appropriate treatment method?
HPI - A 15 years old football player injury his ankle during a match because of a fallen on the ball causing a forced inversion of the foot
HPI - Twisting injury of ankle
HPI - twisting injury on stairs today.attempts by another referring hospital at closed reduction unsuccessful under sedation
What would be your next step after reviewing the available imaging?
HPI - fall 3 days ago seen at another centre was put in a slab and advised to see the ortho consultant.patient seen by me after 3 days
What would be your FIRST line of treatment for this injury?
HPI - Several months painfull left ankle, no new trauma. Progressive pain after playing soccer and presenting at the Emergency Department.
How would you treat this patient?
HPI - Patient presented with a lateral malleolus fracture, SER IV, Weber B, about a week ago after rotational trauma to his left ankle.
What is your choice for fixation of such fracture? (initial treatment)
HPI - LEFT ANKLE INJURY ON MOTOR VEHICLE ACCIDENT. NO OTHER INJURIES.
How would you treat this fracture?
HPI - 2003 ankle fracture
yesterday accidental trauma
How would you treat it?
HPI - 2008 ORIF of previous trimalleolar ankle fracture
2009 Hardware removal + arthroscopic microfracture
What would be your next line of treatment for this patient?
HPI - H/O Road traffic injury 2 days back, presented to us with closed left trimalleolar fracture with blister ( 1*1 cm) over medial malleoli and edema.
What fixation u suggest for posterior malleoli and medial malleoli,if patient has to be operated quickly (out of bed) due to cardiac reasons?
HPI - Fall from standing,24 hours ago , due to an obstacle
HPI - vehicular accident 6 hours before he reached hospital.
for open grade 3 ankle dislocation choice of treatment to stablize ankle after fixing fracture
HPI - Fell off bicycle 4 weeks prior to presentation. Seen elsewhere and was recommended surgery. Did not follow up and now presents in cast
How would you treat this patient
HPI - 62 y/o diabetic male about 12 days out from ORIF ankle at an outside hospital. He comes back from vacation and decides to grace you with an office visit.
What would you do with this?
Supramalleolar Osteotomy for Coronal Deformity: Steven Steinlauf, MD(CSFA #22, 2...
Title: Lisfranc Injuries Fix or Fuse Author: John Ketz, MD Duration: 13:01
This is an example of the Cotton test for ankle syndesmosis injury.
This is an example of bimalleolar ankle fracture fixation using bicortical media...
the following text is written in handbook of fracture by Zuckerman while th...