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The Journal of Foot and Ankle Surgery :... 2020Ankle fractures and their mechanisms of injury can be complex. We report a case of a patient with an uncertain mechanism of injury and an uncommon combination of lower...
Ankle fractures and their mechanisms of injury can be complex. We report a case of a patient with an uncertain mechanism of injury and an uncommon combination of lower extremity fractures, which fit the criteria for a Lauge-Hansen classification pronation-external-rotation fracture, Maisonneuve fracture, Wagstaffe fracture, and posterior pilon fracture. Plain radiographs and computed tomography scan revealed Chaput tubercle avulsion fractures, an anterior distal fibular fracture fragment, multiple lateral malleolar fractures, a posterior malleolar fracture fragment with proximal displacement, a die-punch fragment between the posterior malleolar fragment and the tibia, a proximal fibular fracture, and possible ankle syndesmotic diastasis. Intraoperative hook test was negative after fixation of the fractures, so syndesmotic fixation was not performed. At 3-month follow-up, plain radiographs showed obvious syndesmotic diastasis. At 1-year follow-up, symptoms persisted and syndesmotic fusion was recommended but declined by the patient. This case demonstrates that both ankle fractures and their mechanisms of injury can be remarkably complex and confusing, posterior pilon fractures can occur along with pronation-external-rotation ankle fractures, syndesmotic fixation should be considered for all patients with Maisonneuve fractures, reliance on the hook test for surgical management decisions may not always be reliable, and there exists a need for a more accurate and reliable intraoperative test to determine the presence of ankle syndesmotic injury.
Topics: Ankle Fractures; Ankle Injuries; Ankle Joint; Fracture Fixation, Internal; Humans; Retrospective Studies; Tibial Fractures
PubMed: 32830018
DOI: 10.1053/j.jfas.2019.10.014 -
Journal of Pediatric Orthopedics 2018Pediatric ankle injuries are common, giving rise to ∼17% of all physeal injuries. An os subfibulare in a child with an ankle sprain may be confused with a type VII...
BACKGROUND
Pediatric ankle injuries are common, giving rise to ∼17% of all physeal injuries. An os subfibulare in a child with an ankle sprain may be confused with a type VII transepiphyseal fracture. Here, we evaluate the clinical and radiographic features of type VII transepiphyseal fractures to those of os subfibulare presenting with acute ankle trauma with the hypothesis that radiographs are necessary for final diagnosis and neither clinical history nor examination would be diagnostic.
METHODS
We performed an internal review board-approved, retrospective chart review of patients identified with a traumatic os subfibulare or type VII ankle fracture over an 18-month period. Charts were reviewed for demographics, mechanism, and clinical findings on initial presentation. Radiographic measurements of the distal fibular fragment as well as epiphysis were made on presenting ankle series radiographs.
RESULTS
A total of 23 patients were identified. Eleven patients had a traumatic type VII ankle fracture and 12 had trauma associated with an os subfibulare on initial radiographs. The history and clinical presentations were similar and were nondiagnostic. The ratio of the width of the fibula at its largest point on the anterior posterior view to the width of the fibular fragment was significantly larger in the type VII ankle fractures (P=0.05). All os subfibulare were located within the inferior third of the epiphysis, whereas all type VII fractures were either at the equator or within the middle third of the fibular epiphysis.
CONCLUSIONS
Radiographs, not clinical presentation, can differentiate an os subfibulare from a type VII transepiphyseal fracture. Children with type VII fractures have a long, irregular fracture line within the middle third of the distal fibular epiphysis. Those with an ankle sprain and os subfibulare have a smooth-edged ossicle of relatively short length located within the inferior pole of the epiphysis. Furthermore, the radiographic width of the fragment in the type VII fractures is significantly larger in width than the os subfibulare.
LEVEL OF EVIDENCE
Level II.
Topics: Ankle Fractures; Ankle Injuries; Child; Epiphyses; Female; Fibula; Growth Plate; Humans; Male; Radiography; Retrospective Studies; Tarsal Bones
PubMed: 30199459
DOI: 10.1097/BPO.0000000000001246 -
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 -
The Iowa Orthopaedic Journal Jun 2022Rotational ankle fractures are common injuries associated with high rates of intra-articular injury. Traditional ankle fracture open reduction and internal fixation...
Utilization of Arthroscopy During Ankle Fracture Fixation Among Early Career Surgeons: An Evaluation of the American Board of Orthopaedic Surgery Part II Oral Examination Database.
BACKGROUND
Rotational ankle fractures are common injuries associated with high rates of intra-articular injury. Traditional ankle fracture open reduction and internal fixation (ORIF) techniques provide limited capacity for evaluation of intra-articular pathology. Ankle arthroscopy represents a minimally invasive technique to directly visualize the articular cartilage and syndesmosis while aiding with reduction and allowing joint debridement, loose body removal, and treatment of chondral injuries. The purpose of this study was to evaluate temporal trends in concomitant ankle arthroscopy during ankle fracture ORIF surgery amongst early-career orthopaedic surgeons while examining the influence of subspecialty fellowship training on utilization.
METHODS
The American Board of Orthopaedic Surgery (ABOS) Part II Oral Examination database was queried to identify all candidates performing at least one ankle fracture ORIF from examination years 2010 to 2019. All ORIF cases were examined to identify those that carried a concomitant CPT code for ankle arthroscopy. Concomitant ankle arthroscopy cases were categorized by candidates self-reported fellowship training status and examination year. Descriptive statistics were performed to report relevant data and linear regression analyses were utilized to assess temporal trends in concomitant ankle arthroscopy with ORIF for ankle fractures. Statistical significance was defined as p<0.05.
RESULTS
During the study period, there were 36,113 cases of ankle fracture ORIF performed of which 388 cases (1.1%) were performed with concomitant ankle arthroscopy. Ankle fracture ORIF was most frequently performed by trauma fellowship trained ABOS Part II candidates (n=8,888; 24.6%), followed by sports medicine (n=7,493; 20.8%) and foot and ankle (n=6,563; 18.2%). Arthroscopy was most frequently utilized by foot and ankle fellowship trained surgeons (293/6,270 cases; 4.5%) followed by sports medicine (29/7,464 cases; 0.4%) and trauma (4/8,884 cases; 0.1%). With respect to arthroscopic cases, 293 cases (75.5%) were performed by foot and ankle fellowship trained surgeons, 29 (7.5%) sports medicine, and 4 (1.0%) trauma. Ankle arthroscopy utilization significantly increased from 3.65 cases per 1,000 ankle fractures in 2010 to 13.91 cases per 1,000 ankle fractures in 2019 (p=0.010). Specifically, foot and ankle fellowship trained surgeons demonstrated a significant increase in arthroscopy utilization during ankle fracture ORIF over time (p<0.001; OR: 1.101; CI: 1.054-1.151).
CONCLUSION
Ankle arthroscopy utilization during ankle fracture ORIF has increased over the past decade. Foot and ankle fellowship trained surgeons contribute most significantly to this trend. .
Topics: Ankle; Ankle Fractures; Arthroscopy; Diagnosis, Oral; Fracture Fixation; Humans; Orthopedic Surgeons; United States
PubMed: 35821943
DOI: No ID Found -
BMC Health Services Research Mar 2022The aim of this study is to investigate the experiences of physicians presented with a knowledge support system while registering data on ankle fractures in the Swedish...
BACKGROUND
The aim of this study is to investigate the experiences of physicians presented with a knowledge support system while registering data on ankle fractures in the Swedish Fracture Register. The present study aims to answer the following research questions: • "How is receiving knowledge support while registering a fracture in the Swedish Fracture Register experienced by the physicians using it?". • "Can a feeling of increased usability of a quality register be achieved by providing the user with real-time feedback?".
METHODS
A total of 20 physicians using the Swedish Fracture Register were recruited using a purposive sampling strategy. Qualitative content analysis was performed on individual semi-structured interviews performed in May and June 2020.
RESULTS
The present study demonstrates that the knowledge support system in the Swedish Fracture Register was perceived by the physicians as strengthening the evidence base and improving the quality of ankle fracture treatment. The knowledge support system was evaluated as a good tool for validating clinical decisions and managing the information that needs to be processed to make informed decisions.
CONCLUSIONS
The present study affirms that being provided with knowledge support is appreciated by physicians, increase value for work and enhance the initiative to register. The physicians experienced that the knowledge support provided an appreciated validation of the clinical decisions taken and a feeling of improved care. When incorporating knowledge support into an NQR, consideration must be given to physicians' fears of becoming overly reliant on a template and losing control of the clinical base.
Topics: Ankle Fractures; Feedback; Humans; Physicians; Qualitative Research; Sweden
PubMed: 35321701
DOI: 10.1186/s12913-022-07799-5 -
The Journal of Foot and Ankle Surgery :... 2023The standard surgical treatment for unstable ankle fractures involves open reduction and internal fixation (ORIF) with plates. However, ORIF has been associated with... (Meta-Analysis)
Meta-Analysis Review
The standard surgical treatment for unstable ankle fractures involves open reduction and internal fixation (ORIF) with plates. However, ORIF has been associated with several complications, such as soft tissue irritation, wound infection, and nerve injury. Previous studies have shown that closed reduction and internal fixation with locked intramedullary nails (LIMNs) yields satisfactory efficacy in the treatment of ankle fractures and is associated with low complication rates. Therefore, a systematic review and meta-analysis of randomized controlled trials is imperative to provide evidence on whether or not LIMN fixation is comparable to or superior than traditional ORIF. We conducted a comprehensive literature search in the PubMed, Cochrane Library and EMBASE databases. A total of 4 randomized controlled trials involving 359 participants who suffered ankle fractures were included in this systematic review and meta-analysis. The results showed that the LIMN fixation group was statistically significant in terms of functional outcomes at the 3-month follow-up and wound-related complications. There was no statistical advantage for patients in the LIMN fixation group in terms of nonwound-related complications, total complications, or mid-term follow-up functional outcomes. There was no statistical difference between the LIMN and ORIF groups regarding operation time and quality of reduction. We believe LIMN fixation is a viable option for the treatment of unstable ankle fractures in both young and elderly individuals.
Topics: Humans; Aged; Ankle Fractures; Fibula; Treatment Outcome; Fracture Fixation, Internal; Fracture Fixation, Intramedullary; Bone Plates
PubMed: 36333182
DOI: 10.1053/j.jfas.2022.10.003 -
BMC Musculoskeletal Disorders Nov 2021A supination-adduction (SAD) ankle fracture is a special type of ankle fracture that results in collapse of the distal tibial articular surface; as such, orthopaedic...
A comparative study of the clinical efficacy of supination-adduction type II ankle fracture surgery based on the medial pilon fracture concept versus the ankle fracture concept.
BACKGROUND
A supination-adduction (SAD) ankle fracture is a special type of ankle fracture that results in collapse of the distal tibial articular surface; as such, orthopaedic surgeons require greater awareness of this type of fracture. The severity of this injury lies between that of an ordinary ankle fracture and a pilon fracture, and the treatment of such fractures based on the ankle fracture concept leads to extremely high rates of postoperative complications and a poor prognosis. In this retrospective study, we aimed to explore the treatment of SAD fractures based on the pilon fracture concept.
METHODS
We retrospectively analysed the clinical data of 67 patients with Lauge-Hansen supination-adduction type II (SAD-II) ankle fractures, most of whom had a 44-A AO classification. Patients underwent surgical treatment at the Second Affiliated Hospital of Anhui Medical University from January 2009 to June 2019. The patients were divided into two groups based on the surgical concept employed: 43 patients were included in the ankle fracture surgical concept group, and 24 patients were included in the medial pilon fracture surgical concept group. The therapeutic effect was evaluated based on the Burwell-Charnley radiological reduction standard, the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score and postoperative visual analogue scale (VAS) pain score 1 year after surgery using regression with adjustment for confounding factors.
RESULTS
All 67 patients were followed up. Twenty-four patients were treated according to the medial pilon fracture concept, and forty-three patients were treated according to the ankle fracture concept. The AOFAS score 1 year after surgery in the medial pilon group (89.83 ± 2.77) was higher than that in the ankle fracture group (83.63 ± 7.97) (p < 0.05). The VAS score 1 year after surgery in the medial pilon fracture group (1.17 ± 0.96) was significantly better than that in the ankle fracture group (2.28 ± 0.96) (p < 0.05).
CONCLUSION
Patients with Lauge-Hansen SAD-II ankle fractures treated based on the medial pilon fracture surgical concept had better postoperative outcomes than those treated based on the ankle fracture surgical concept.
LEVEL OF EVIDENCE
Level III, retrospective cohort study.
Topics: Ankle Fractures; Fracture Fixation, Internal; Humans; Retrospective Studies; Supination; Tibial Fractures; Treatment Outcome
PubMed: 34758803
DOI: 10.1186/s12891-021-04818-0 -
Foot and Ankle Surgery : Official... Dec 2021Whether calf muscles and peroneal muscles have a role in the occurrence of an ankle fractures remains unclear. This study aimed to quantify the calf muscle mass and...
BACKGROUND
Whether calf muscles and peroneal muscles have a role in the occurrence of an ankle fractures remains unclear. This study aimed to quantify the calf muscle mass and peroneal muscle mass in patients with an ankle fracture and in controls, then to analyze them together with demographic factors to identify the effects of the regional muscles on the risk of developing ankle fracture.
METHODS
A total of 101 ankles with computed tomography (CT) images were retrospectively reviewed. Of them, 51 ankles showed fractures (all unilateral) and 50 ankles, in controls who underwent CT for screening the other diseases, were clinically diagnosed with simple contusion. The cross-sectional areas (CSA) of the calf muscles and the peroneal muscles were measured at approximately 6 cm above the Achilles myotendinous junction in the axial plane of ankle CT. These parameters were compared between the two groups and analyzed with respect to age, sex, body mass index (BMI), laterality, and bone attenuations of the ankle.
RESULTS
The demographic factors, including bone attenuation of the ankle showed no significant association with ankle fracture. The ratio of the CSA of the peroneal muscle group to the CSA of the entire calf muscle group was smaller in patients with an fracture (0.12 ± 0.03) than in controls (0.14 ± 0.02) (p = 0.027). The odds ratio for the effect of the calf muscle CSA on the risk of developing ankle fractures was 1.38 (95% confidence interval 1.12-1.69, p = 0.003), whereas that for the effect of peroneal muscle CSA on the risk of developing ankle fractures was 0.18 (95% confidence interval 0.05 to 0.66, p = 0.010).
CONCLUSION
The ratio of the peroneal muscle CSA to the entire calf muscle CSA was negatively related to the occurrence of ankle fractures in this study. Further prospective studies on whether peroneal muscle-strengthening exercise are effective in preventing ankle fractures may be needed.
LEVEL OF EVIDENCE
III, case-control study.
Topics: Ankle Fractures; Case-Control Studies; Humans; Muscle, Skeletal; Prospective Studies; Retrospective Studies
PubMed: 33303352
DOI: 10.1016/j.fas.2020.11.006 -
Foot & Ankle International May 2016Ankle fractures represent one of the most common orthopaedic injuries requiring operative treatment. Although open reduction and internal fixation (ORIF) of ankle... (Review)
Review
BACKGROUND
Ankle fractures represent one of the most common orthopaedic injuries requiring operative treatment. Although open reduction and internal fixation (ORIF) of ankle fractures leads to good results in most patients, poor functional outcomes continue to be reported in some patients for whom anatomic reduction was achieved. It has been theorized that these lesser outcomes may in part be due to a component of missed intra-articular injury that reportedly ranges between 20% and 79%, although to date the true explanation for this subset of lower functional outcomes remains unknown. Such concerns have recently spawned novel techniques of arthroscopically assisted ankle fracture assessment in hopes of enabling better detection and treatment of concomitant intra-articular ankle injuries. The purpose of this systematic review was to summarize the literature comparing standard ORIF to arthroscopically assisted ORIF (AAORIF) for ankle fractures.
METHODS
A systematic review of the English literature was performed using the PubMed database to access all studies over the last 50 years that have documented the functional outcomes of acute ankle fracture management using either a traditional ORIF or an AAORIF technique in the adult population. Relevant publications were analyzed for their respective Levels of Evidence as well as any perceived differences reported in operative time, outcomes, and complications.
RESULTS
A total of only 14 ORIF and 4 AAORIF papers fit the criteria for review. There is fair quality (grade B) evidence to support good to excellent outcomes following traditional ORIF of malleolar fractures. There is fair-quality (grade B) evidence that ankle arthroscopy can be successfully employed for identification and treatment of intra-articular injuries associated with acute ankle fractures, but insufficient (grade I) evidence examining the functional outcomes and complication rates after treatment of these injuries and little documentation that this approach portends any improvement in patient outcome over historical techniques. There is also insufficient (grade I) evidence from 2 prospective randomized studies and 1 case-control study to provide any direct comparative data on functional outcomes, complication rates or total operative time between AAORIF and ORIF for the treatment of acute ankle fractures.
CONCLUSIONS
Ankle arthroscopy is a valuable tool in identifying and treating intra-articular lesions associated with ankle fractures. The presence of such intra-articular pathology may lead to the unexpectedly poor outcomes seen in some patients who undergo surgical fixation of ankle fractures with otherwise anatomic reduction on postoperative radiographs; the ability to diagnose and address these lesions therefore has the potential to improve patient outcomes. To date, however, currently available literature has not shown that treatment of these intra-articular injuries provides any improvement in outcomes over standard ORIF, and few prospective randomized controlled studies have been performed comparing these 2 operative techniques-rendering any suggestion that AAORIF improves clinical outcomes over traditional ORIF difficult to justify. Further research is indicated for what may be a potentially promising surgical adjunct before we can advocate its routine use in these patients.
LEVEL OF EVIDENCE
Level II, systematic review.
Topics: Ankle Fractures; Arthroscopy; Fracture Fixation, Internal; Humans; Open Fracture Reduction; Treatment Outcome
PubMed: 26660864
DOI: 10.1177/1071100715620455 -
Injury Feb 2023
Topics: Humans; Ankle Fractures; Arthroscopy; Ankle; Ankle Joint; Fracture Fixation, Internal; Retrospective Studies; Treatment Outcome; Open Fracture Reduction
PubMed: 36443115
DOI: 10.1016/j.injury.2022.11.044