Foot and Ankle Fractures

Ankle

Eponymous Types

Maisonneuve
either a med malleolus fracture or deltoid lig tear with a high fibular fracture

Le Fort - Wagstaffe
avulsion fracture of anterior margin of distal fibula at insertion of anterior tibio-fibular lig

Tillaux-Chaput
avulsion fracture of anterior tibial margin by the anterior tibio- fibular lig

Volkmanns triangle
the postero lat malleolar fracture

Classification: (Weber/ AO)

Type A
Transverse avulsion fracture of the fibula at the level of the ankle joint or below
Medial malleolus may be intact or sheared, and may be an associated compression fracture of the tibial edge
The tibio-fibular ligament complex is always intact
A1 isolated fibular fracture
A2 with fracture of med malleolus
A3 with a posteromedial fracture

Type B
Spiral fracture of the distal fibula beginning at the level of the syndesmosis
Part of the tibio-fibular syndesmotic ligament may be involved but the ankle mortise is stable following reduction of the fracture
B1 isolated fibular fracture
B2 with a med lesion ( malleolus or ligament)
B3 with a med lesion and fracture of posterolat tibia

Type C
Fracture of the fibula anywhere between the syndesmosis and the head of the fibula
The tibio-fibular ligament complex is always disrupted and diastasis screws should be inserted if it remains unstable after fixation of the fracture (ankle in neutral position when inserted)
C1 diaphyseal fracture of fibula- simple
C2 diaphyseal fracture of fibula- complex
C3 proximal fracture of fibula

Investigation

XRay
AP/lat/mortise views
stress views

Tomograms

CT
If X-Rays show a displaced malleolar fracture there must be a ligament injury somewhere around the mortice
Ramsey and Hamilton (1976) showed that lateral displacement of the talus in the mortice of 1mm an average 42% loss of articular contact and congruency

Treatment

Nonoperative

Indications
for undisplaced or stable fractures
for displaced fractures when anatomical reduction can be obtained and maintained without repeated manipulation
when pt general condition does not permit
when operative treatment delayed
obtained by reversing the mechanism of injury
maintained by AKPOP for rotationally unstable injuries, 3- point molding, ankle at 90
Undisplaced or stable fractures can be managed in BKPOP, WB PRN

Operative

Indications
failure of CR
when CR requires forced, abnormal positioning of the foot
for displaced or unstable fractures that result in displacement of the talus or
widening of the mortise of more than 1-2 mm

Aims
restore fibular length
anatomical jt surface reconstruction
close mortise: anatomic reconstruction of the fibula usually restores the mortise and restores stability to the syndesmosis
Syndesmotic fixation if: tibiofibular diastasis +/- high fibular fracture
instability post ORIF of fibula
Diastasis screws should be tri-cortical and not lagged
remove prior to WB
posterior malleolus- fix if more than 25% of artic surface and displaced more than 2mm most reduce with the fibular reduction

No significant benefit has been identified in the generally accepted regime of delayed application of plaster until after a reasonable range of movement has been achieved.

A paper from Nottingham suggests that females over 50 have higher incidence of complications of operative treatment- however this is a retrospective review and their overall figures are not very impressive ( Beauchamp etal "displaced ankle fractures in patients over 50 yrs of age" JBJS 65B: 329-332, 1983).
Their recommendation must be viewed with a degree of caution . A prospective trial from Chicago suggests that ORIF gives a better result in pts who are more than 50 yo ( Phillips etal JBJS 67A: 67, 1985)

Complications

Bone

nonunion
most of the med malleolus treated with CR- due to interposed tissue
treat if symptomatic with ORIF + BG

malunion

Wound

skin necrosis marginal necrosis in ~ 3%
care in handling tissue etc- treat with dressings

Infection

less than 2%, treat infection, leave fixation until fracture healed

Arthritis

incidence with severity of injury
degen changes in 10% of anatomically fixed , 85% if not adequately reduced - changes apparent within 18 mths
ref: Klossner "Late results of operative and nonoperative treatment of severe ankle fractures" Acta Chir Scand Suppl. 293: 1-93, 1962

Prognosis

There is a reduction in the incidence of arthrosis in patients where an anatomical reduction has been achieved
ref: Phillips etal JBJS 67A: 67-78, 1985 Prospective trial shows higher total ankle scores in those that are operatively treated- especially so in those pts more than 50 yrs old

Tillaux Fractures

Avulsion fracture of the anterolat distal tibia at site of attachment of the anterior tibio-fibular lig
= SH3 fracture

Triplane Fractures


Combine a Tillaux fracture with a type 2 S-H fracture
May be two or three part and fixation may cross the physis in these injuries as they occur when closure of the physis is imminent
Growth arrest occurs in 14% of all ankle fractures in the skeletally immature and appearance may be delayed for up to six months therefore need to check growth at one year

Treatment

ORIF

Prognosis

Residual dis