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The Journal of the American Academy of... Jul 2019The last stage of a supination-external rotation ankle fracture involves either transverse fracture of the medial malleolus or rupture of the deltoid ligament. When the... (Review)
Review
The last stage of a supination-external rotation ankle fracture involves either transverse fracture of the medial malleolus or rupture of the deltoid ligament. When the deltoid ligament ruptures, a "bimalleolar equivalent" ankle fracture occurs, and the surgeon is presented with several diagnostic and therapeutic challenges. In the native ankle, the deltoid ligament provides restraint to eversion and external rotation of the talus on the tibia. In bimalleolar equivalent ankle fractures, there is often gross medial instability even after fibular reduction. Retraction of the deltoid with subsequent healing in a nonanatomic position theoretically may cause instability, persistent medial gutter pain, and loss of function with risk of early arthritis. In mild cases, deltoid injury may not be obvious, and potential diagnostic techniques include preoperative and intraoperative stress radiography, MRI, and ultrasonography. The most common injury pattern is avulsion from the medial malleolus, and most current repair techniques involve direct repair of the capsular and deltoid injuries involving suture anchors in the medial malleolus and imbrication of the superficial and deep deltoid fibers. To date, there is limited evidence of superior clinical outcomes with the addition of deltoid repair compared with open reduction and internal fixation of the fibula alone.
Topics: Ankle Fractures; Ankle Injuries; Biomechanical Phenomena; Diagnostic Imaging; Female; Fracture Fixation, Internal; Humans; Ligaments, Articular; Male; Open Fracture Reduction; Orthopedic Procedures; Rupture; Treatment Outcome
PubMed: 30475279
DOI: 10.5435/JAAOS-D-18-00198 -
Foot and Ankle Clinics Mar 2017Injuries to the posterior malleolus are of prognostic relevance in ankle fracture-dislocations. The three-dimensional outline of the fragments as reflected by computed... (Review)
Review
Injuries to the posterior malleolus are of prognostic relevance in ankle fracture-dislocations. The three-dimensional outline of the fragments as reflected by computed tomography classification, involvement of the fibular notch, and the presence of intercalary fragments seem to be of greater therapeutic relevance than the size of the fragment and amount of the articular surface involved. Operative treatment aims at reconstruction of the posterior tibial plafond, the fibular notch, and the integrity of the posterior inferior tibiofibular syndesmosis. Direct open reduction and fixation of posterior malleolus fragments via posterior approaches is biomechanically more stable than indirect reduction and anteroposterior screw fixation.
Topics: Ankle Fractures; Biomechanical Phenomena; Fracture Dislocation; Fracture Fixation; Humans; Tomography, X-Ray Computed
PubMed: 28167058
DOI: 10.1016/j.fcl.2016.09.009 -
The Journal of Foot and Ankle Surgery :... May 2019A good classification system is important for clinical handoffs, research, and clinical treatment guidelines. A reliable classification system shows good interobserver...
A good classification system is important for clinical handoffs, research, and clinical treatment guidelines. A reliable classification system shows good interobserver and intraobserver agreement. This study analyzed the interobserver and intraobserver agreement of a descriptive system for ankle fractures and the Lauge-Hansen classification. Three groups of observers (experts, semiexperts, and novices) scored a total of 20 ankle radiographs. All ankle radiographs were classified according to the Lauge-Hansen and Danis-Weber classifications. The ankle fractures were subsequently reviewed in a descriptive manner for the following features: number of affected malleoli, type of fracture of the lateral and medial malleolus, and congruence of the ankle joint. After 2 weeks, the same set of radiographs were reviewed. For interobserver and intraobserver variability, the separate groups were used for analysis, and the Fleiss (multirater) κ values were calculated. The interobserver agreement for the Lauge-Hansen classification was moderate for the experts, fair for semiexperts, and slight for novices (κ = 0.45, κ = 0.37, and κ = 0.16). All factors of the descriptive system had better interobserver agreement than the Lauge-Hansen classification, except for the agreement on the type of fracture of the lateral malleolus. The intraobserver agreement of the Lauge-Hansen classification was substantial for the experts, moderate for the semiexperts, and fair for the novice observers (κ = 0.70, κ = 0.49, and κ = 0.26). The intraobserver agreement was better for all factors of the descriptive system compared with the Lauge-Hansen classification. The descriptive system presented in this study shows less variability between observers than the Lauge-Hansen classification. This system has clinical implications and is easy to use for clinicians with mixed levels of experience. It has the potential to improve clinical and research handoffs and overcome the limitations of current classification systems.
Topics: Ankle Fractures; Clinical Competence; Humans; Observer Variation; Radiography; Reproducibility of Results
PubMed: 30795890
DOI: 10.1053/j.jfas.2018.09.028 -
Rozhledy V Chirurgii : Mesicnik... 2023Maisonneuve fracture (MF) is defined as an ankle fracture-dislocation associated always with a fracture of the proximal quarter of the fibula and rupture of the anterior...
Maisonneuve fracture (MF) is defined as an ankle fracture-dislocation associated always with a fracture of the proximal quarter of the fibula and rupture of the anterior and interosseous tibiofibular ligaments. Other injuries are variable. Recent CT studies have demonstrated that MF is a far more complex injury than initially supposed. Therefore it is necessary to change substantially the current concepts related to this issue. MF is combined in about 80% of cases with a fracture of the posterior malleolus and also with malposition of the distal fibula in the fibular notch. An exact assessment of these injuries requires post-injury CT examination which should be used as a standard in MFs. The main goal of treatment is anatomical reduction of the distal fibula into the fibular notch. In case of avulsion of a larger fragment of the posterior malleolus, it is necessary to perform as the first step its reduction and fixation from the posterolateral approach and thus restore integrity of the notch. Closed reduction of the distal fibula is associated with malposition in up to 50% of cases and therefore open reduction from a short anterolateral approach is preferred. Accuracy of reduction should be always checked by postoperative CT scan.
Topics: Humans; Ankle Fractures; Fracture Fixation, Internal; Ankle Joint; Fibula; Tibia; Fibula Fractures; Joint Dislocations
PubMed: 37185026
DOI: 10.33699/PIS.2023.102.2.48-59 -
Journal of Orthopaedic Trauma Jan 2018The diagnosis and treatment of syndesmotic ankle fractures is controversial. This systematic review was performed to clarify the current understanding addressing several... (Review)
Review
OBJECTIVES
The diagnosis and treatment of syndesmotic ankle fractures is controversial. This systematic review was performed to clarify the current understanding addressing several clinical questions that arise in the treatment of such injuries.
DATA SOURCES
The English language literature was searched using PubMed, EMBASE, and Web of Science. The search terms were "syndesmosis" or "syndesmotic" in combination with the terms "ankle fracture" or "fracture." The included dates were between 1967 and July 2015.
STUDY SELECTION
Inclusion criteria were number of patients >20, patient age ≥18 years, follow-up ≥1 year, ankle fracture classification was reported, criteria for surgery was reported, technique of surgery was reported, and a validated outcome measure was used. Studies limited to biomechanical or imaging investigations were excluded.
DATA EXTRACTION
Information was abstracted using a standardized template, which encompassed the inclusion criteria together with the study type, postoperative regimen, and complications. Study quality was evaluated using the modified CONSORT statement and Coleman criteria. Study bias was assessed, and methodological quality was rated. Any difference in ratings was resolved by consensus.
DATA SYNTHESIS
None.
CONCLUSIONS
The overall quality of the studies was poor. The number or placement of syndesmotic screws or the breakage of trans-syndesmotic screws postoperatively had no adverse effect on outcomes (both with moderate strength of evidence). The use of alternative fixation devices (bioabsorbable and endobutton) had poor strength of evidence, as did the opinion that nondisplaced, unstable by stress test, syndesmotic injuries required fixation. There are insufficient data that link subtle rotational syndesmotic malreduction to clinical outcomes.
LEVEL OF EVIDENCE
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Topics: Ankle Fractures; Humans
PubMed: 28708780
DOI: 10.1097/BOT.0000000000000937 -
The Orthopedic Clinics of North America Jan 2017Posterior malleolus fractures vary in morphology. A computed tomography scan is imperative to evaluate fragment size, comminution, articular impaction, and syndesmotic... (Review)
Review
Posterior malleolus fractures vary in morphology. A computed tomography scan is imperative to evaluate fragment size, comminution, articular impaction, and syndesmotic disruption. Despite an increasing body of literature regarding posterior malleolus fractures, many questions remain unanswered. Although, historically, fragment size guided surgical fixation, it is becoming evident that fragment size should not solely dictate treatment. Surgical treatment should focus on restoring ankle joint structural integrity, which includes restoring articular congruity, correcting posterior talar translation, addressing articular impaction, removing osteochondral debris, and establishing syndesmotic stability.
Topics: Ankle Fractures; Ankle Joint; Fracture Fixation, Internal; Humans; Tomography, X-Ray Computed
PubMed: 27886685
DOI: 10.1016/j.ocl.2016.08.004 -
Clinics in Podiatric Medicine and... Jul 2023Using ankle arthroscopy in conjunction to open reduction internal fixation of traumatic ankle injuries can play an important role in the management of these injuries by... (Review)
Review
Using ankle arthroscopy in conjunction to open reduction internal fixation of traumatic ankle injuries can play an important role in the management of these injuries by way of treating intra-articular pathologies, leading to improved patient outcomes. While a majority of these injuries are not treated with concurrent arthroscopy, its addition may lead to more prognostic information to dictate the patient's course. This article has illustrated its use in managing malleolar fractures, syndesmotic injuries, pilon fractures and pediatric ankle fractures. While additional studies may be needed to further support AORIF, it may prove to play a vital role in the future.
Topics: Humans; Child; Ankle; Arthroscopy; Ankle Injuries; Ankle Fractures; Ankle Joint; Fracture Fixation, Internal; Treatment Outcome; Retrospective Studies
PubMed: 37236689
DOI: 10.1016/j.cpm.2022.12.003 -
The Orthopedic Clinics of North America Jan 2018Interest in outpatient orthopedic surgery has been fueled by provider desire to control costs and development of rapid recovery protocols. Open reduction and internal... (Review)
Review
Interest in outpatient orthopedic surgery has been fueled by provider desire to control costs and development of rapid recovery protocols. Open reduction and internal fixation (ORIF) is a commonly elected treatment strategy for ankle fracture that may be performed in an outpatient setting. Lessons on cost-savings of the outpatient model in orthopedics can be learned in total joint replacement and spine surgery. Moreover, in properly selected patients, outpatient ORIF has been shown to be comparably safe. Reasons for admission of the surgically managed patient with ankle fractures, including concern for surgical delay and additional social factors, warrant further investigation.
Topics: Ambulatory Surgical Procedures; Ankle Fractures; Fracture Fixation, Internal; Humans; Open Fracture Reduction
PubMed: 29145978
DOI: 10.1016/j.ocl.2017.08.012 -
Foot and Ankle Clinics Sep 2022The management of ankle fractures in the diabetic population requires special attention as the risks of injury or treatment-related complications are high. Thorough... (Review)
Review
The management of ankle fractures in the diabetic population requires special attention as the risks of injury or treatment-related complications are high. Thorough review of clinical history and detailed assessment provide the treating surgeons with key information to guide treatment pathway. Vigilance is required when opting for nonoperative treatment in undisplaced stable ankle fractures in patients with peripheral neuropathy. The presence of critical ischemia in injured limb demands vascular consultation and ultimately, an intervention before surgical fixation of ankle fracture. An extended period of immobilization is one of the key principles in the management of ankle fracture patients with diabetes.
Topics: Ankle; Ankle Fractures; Ankle Injuries; Ankle Joint; Diabetes Mellitus; Humans
PubMed: 36096556
DOI: 10.1016/j.fcl.2022.02.002 -
British Journal of Hospital Medicine... Apr 2019Ankle fractures are a common injury in children and adolescents - 1 in 1000 children will sustain an ankle fracture each year. Understanding the diagnosis and management... (Review)
Review
Ankle fractures are a common injury in children and adolescents - 1 in 1000 children will sustain an ankle fracture each year. Understanding the diagnosis and management of these injuries is vital for any doctor or clinician working in the emergency department, orthopaedics or providing community care. This review identifies the important features of high- and low-risk ankle fractures, how to prevent the use of unnecessary radiation and the management of these injuries. Fractures may be at high or low risk of instability and are managed accordingly. Many can be treated with conservative management in a cast, including unstable injuries following reduction. However, particular fracture patterns associated with the tibial growth plate need careful assessment of fracture reduction with cross-sectional imaging before committing to conservative management.
Topics: Ankle Fractures; Child; Clinical Decision-Making; Disease Management; Epiphyses; Fracture Fixation; Fractures, Avulsion; Humans; Radiography; Salter-Harris Fractures
PubMed: 30951430
DOI: 10.12968/hmed.2019.80.4.201