-
The Bone & Joint Journal May 2019The medial malleolus, once believed to be the primary stabilizer of the ankle, has been the topic of conflicting clinical and biomechanical data for many decades.... (Review)
Review
The medial malleolus, once believed to be the primary stabilizer of the ankle, has been the topic of conflicting clinical and biomechanical data for many decades. Despite the relevant surgical anatomy being understood for almost 40 years, the optimal treatment of medial malleolar fractures remains unclear, whether the injury occurs in isolation or as part of an unstable bi- or trimalleolar fracture configuration. Traditional teaching recommends open reduction and fixation of medial malleolar fractures that are part of an unstable injury. However, there is recent evidence to suggest that nonoperative management of well-reduced fractures may result in equivalent outcomes, but without the morbidity associated with surgery. This review gives an update on the relevant anatomy and classification systems for medial malleolar fractures and an overview of the current literature regarding their management, including surgical approaches and the choice of implants. Cite this article: 2019;101-B:512-521.
Topics: Ankle Fractures; Ankle Joint; Fracture Fixation; Humans; Orthopedic Fixation Devices; Postoperative Complications
PubMed: 31038989
DOI: 10.1302/0301-620x.101B5.BJJ-2019-0070 -
Deutsches Arzteblatt International May 2014Ankle fractures are common, with an incidence of up to 174 cases per 100 000 adults per year. Their correct classification and treatment are of decisive importance for... (Review)
Review
BACKGROUND
Ankle fractures are common, with an incidence of up to 174 cases per 100 000 adults per year. Their correct classification and treatment are of decisive importance for clinical outcome.
METHOD
Selective review of the literature.
RESULTS
Ankle fractures are initially evaluated by physical examination and then by x-ray. They can be classified according to either the AO Foundation (Association for the Study of Internal Fixation) or the Weber classification. Dislocated fractures need emergency treatment with immediate reduction; this is crucial for the prevention of hypoperfusion and nerve damage. Weber A fractures can usually be treated conservatively, while Weber B and C fractures are usually treated with surgery. An evaluation of the stability of the syndesmosis is important for anatomical reconstruction of the joint. Wound hematoma and wound-edge necrosis are the most common complications, and the postoperative infection rate is 2%. Up to 10% of patients develop ankle arthrosis over the intermediate or long term.
CONCLUSION
With properly chosen treatment, a good clinical outcome can be achieved. The long-term objective is to prevent post-traumatic ankle arthrosis. The evidence level for optimal treatment strategies is low.
Topics: Ankle Fractures; Combined Modality Therapy; Diagnostic Imaging; Foot Orthoses; Fracture Fixation; Humans; Physical Examination; Physical Therapy Modalities; Severity of Illness Index
PubMed: 24939377
DOI: 10.3238/arztebl.2014.0377 -
Revista Espanola de Cirugia Ortopedica... 2023Posterior malleolus fractures are frequent injuries, present in 7-44% of all ankle fractures. The objective of this study is to review the evidence to indicate the... (Review)
Review
Posterior malleolus fractures are frequent injuries, present in 7-44% of all ankle fractures. The objective of this study is to review the evidence to indicate the fixation of this fracture and to choose the appropriate surgical approach. The classic indications for fixation were fragment size greater than 25-30% of the articular surface and displacement greater than 2 mm. However, current evidence suggests that, rather than size, factors such as syndesmotic instability, intra-articular step-off greater than 1-2 mm, plafond impaction and the presence of intercalary fragments should be considered. When comparing the different surgical approaches, the literature supports the use of posterior approaches and reserves the recommendation of the traditional approach for exceptional cases. For the treatment of this injury it is essential to know the anatomy of the ankle and to consider all the factors described above, in addition to the presence of concomitant injuries.
Topics: Humans; Ankle Fractures; Fracture Fixation, Internal; Ankle Injuries; Ankle Joint; Treatment Outcome
PubMed: 36371071
DOI: 10.1016/j.recot.2022.10.019 -
Ugeskrift For Laeger Oct 2018Fractures of the ankle joint are among the most frequent fractures encountered in any accident and emergency department. The traditional classification systems, i.e. the... (Review)
Review
Fractures of the ankle joint are among the most frequent fractures encountered in any accident and emergency department. The traditional classification systems, i.e. the Lauge-Hansen- and the Weber classifications, have proven inadequate, when it comes to deciding, whether treatment should be surgical or conservative. About ten years ago, a stability-based classification was proposed in view of the fact, that the stabilisation of osteosynthesis depends on the stability of the ankle joint. The literature shows excellent long-term results for conservatively treated stable ankle joint fractures.
Topics: Algorithms; Ankle Fractures; Fracture Dislocation; Fractures, Open; Humans; Joint Instability; Postoperative Complications; Radiography
PubMed: 30327083
DOI: No ID Found -
Journal of Orthopaedic Surgery (Hong... 2023The deltoid ligament is the primary stabilizer of the medial side of the ankle joint. It is a complex structure with an origin at the medial malleolus from where it... (Review)
Review
The deltoid ligament is the primary stabilizer of the medial side of the ankle joint. It is a complex structure with an origin at the medial malleolus from where it spreads fan shaped distally with an insertion into the medial side of the talus, calcaneus and navicular bone. This chapter gives an overview of the anatomy, function, and pathology of the deltoid ligament.The deltoid ligament can become insufficient as a result of an ankle injury or prolonged strain. In the acute setting, deltoid insufficiency often coincides with multi ligament injury the ankle joint; syndesmosis injury, or ankle fractures. Management in the acute phase remains a subject of debate. Some orthopedic surgeons have a tendency towards repair, whereas most trauma surgeons often treat the deltoid nonoperatively. In the chronic setting the ligament complex is often elongated as a result of prolonged strain. It often coexists with a hindfoot valgus, as is the case in planovalgus feet. In such a case a realignment procedure should be combined with the deltoid repair.
Topics: Humans; Fracture Fixation, Internal; Ligaments; Ankle Fractures; Ankle Injuries; Ankle Joint; Ligaments, Articular
PubMed: 37449811
DOI: 10.1177/10225536231182345 -
BMJ Open Nov 2019Ankle fractures result in significant morbidity in adults, with prognosis worsening with increasing age. Previous trials have not found evidence supporting supervised... (Randomized Controlled Trial)
Randomized Controlled Trial
Progressive functional exercise versus best practice advice for adults aged 50 years or over after ankle fracture: protocol for a pilot randomised controlled trial in the UK - the Ankle Fracture Treatment: Enhancing Rehabilitation (AFTER) study.
INTRODUCTION
Ankle fractures result in significant morbidity in adults, with prognosis worsening with increasing age. Previous trials have not found evidence supporting supervised physiotherapy sessions, but these studies have not focused on older adults or tailored the exercise interventions to the complex needs of this patient group. The Ankle Fracture Treatment: Enhancing Rehabilitation study is a pilot randomised controlled trial to assess feasibility of a later definitive trial comparing best-practice advice with progressive functional exercise for adults aged 50 years and over after ankle fracture.The main objectives are to assess: (i) patient engagement with the trial, measured by the participation rate of those eligible; (ii) establish whether the interventions are acceptable to participants and therapists, assessed by intervention adherence levels, participant interviews and a therapist focus group; (iii) participant retention in the trial, measured by the proportion of participants providing outcome data at 6 months; (iv) acceptability of measuring outcomes at 3 and 6 month follow-up.
METHODS AND ANALYSIS
A multicentre pilot randomised controlled trial with an embedded qualitative study. At least 48 patients aged 50 years and over with an ankle fracture requiring surgical management, or non-operative management by immobilisation for at least 4 weeks, will be recruited from a minimum of three National Health Service hospitals in the UK. Participants will be allocated 1:1 via a central web-based randomisation system to: (i) best-practice advice (one session of face-to-face self-management advice delivered by a physiotherapist and up to two optional additional sessions) or (ii) progressive functional exercise (up to six sessions of individual face-to-face physiotherapy). An embedded qualitative study will include one-to-one interviews with up to 20 participants and a therapist focus group.
ETHICS AND DISSEMINATION
Hampshire B Research Ethics Committee (18/SC/0281) gave approval on 2 July 2018.
TRIAL REGISTRATION NUMBER
ISRCTN16612336.
Topics: Age Factors; Aged; Aged, 80 and over; Ankle Fractures; Clinical Protocols; Feasibility Studies; Female; Focus Groups; Follow-Up Studies; Humans; Male; Middle Aged; Patient Compliance; Physical Therapy Modalities; Pilot Projects; Prospective Studies; Qualitative Research; Treatment Outcome; United Kingdom
PubMed: 31678945
DOI: 10.1136/bmjopen-2019-030877 -
BMJ (Clinical Research Ed.) Jul 2021To assess function, quality of life, resource use, and complications in adults treated with plaster cast immobilisation versus a removable brace for ankle fracture. (Comparative Study)
Comparative Study Randomized Controlled Trial
OBJECTIVES
To assess function, quality of life, resource use, and complications in adults treated with plaster cast immobilisation versus a removable brace for ankle fracture.
DESIGN
Multicentre randomised controlled trial.
SETTING
20 trauma units in the UK National Health Service.
PARTICIPANTS
669 adults aged 18 years and older with an acute ankle fracture suitable for cast immobilisation: 334 were randomised to a plaster cast and 335 to a removable brace.
INTERVENTIONS
A below the knee cast was applied and ankle range of movement exercises started on cast removal. The removable brace was fitted, and ankle range of movement exercises were started immediately.
MAIN OUTCOME MEASURES
Primary outcome was the Olerud Molander ankle score at 16 weeks, analysed by intention to treat. Secondary outcomes were Manchester-Oxford foot questionnaire, disability rating index, quality of life, and complications at 6, 10, and 16 weeks.
RESULTS
The mean age of participants was 46 years (SD 17 years) and 381 (57%) were women. 502 (75%) participants completed the study. No statistically significant difference was found in the Olerud Molander ankle score between the cast and removable brace groups at 16 weeks (favours brace: 1.8, 95% confidence interval -2.0 to 5.6). No clinically significant differences were found in the Olerud Molander ankle scores at other time points, in the secondary unadjusted, imputed, or per protocol analyses.
CONCLUSIONS
Traditional plaster casting was not found to be superior to functional bracing in adults with an ankle fracture. No statistically difference was found in the Olerud Molander ankle score between the trial arms at 16 weeks.
TRIAL REGISTRATION
ISRCTN registry ISRCTN15537280.
Topics: Adult; Ankle Fractures; Braces; Casts, Surgical; Exercise Therapy; Female; Humans; Male; Middle Aged; Quality of Life; Range of Motion, Articular; Recovery of Function; Time Factors; Treatment Outcome; United Kingdom
PubMed: 34226192
DOI: 10.1136/bmj.n1506 -
Clinical Rehabilitation Mar 2018To evaluate the use of active controlled motion (ACM) after unstable ankle fractures needing initial partial weight-bearing. (Randomized Controlled Trial)
Randomized Controlled Trial
OBJECTIVE
To evaluate the use of active controlled motion (ACM) after unstable ankle fractures needing initial partial weight-bearing.
DESIGN
Prospective randomized controlled trial.
SETTING
Inpatient and outpatient clinic.
SUBJECTS
A total of 50 patients with unstable ankle fractures and the need for partial weight-bearing for six weeks.
INTERVENTIONS
Randomization in two groups: physiotherapy alone or physiotherapy with an additional ACM device.
MAIN MEASURES
Follow-up after 6 and 12 weeks. Range of motion, visual analogue scale for foot and ankle (VAS FA), Philip score, Mazur score, American Orthopaedic Foot & Ankle Society (AOFAS) score and dynamic pedobarography.
RESULTS
Range of motion was better in the ACM group at six weeks (mean 49° ± 11.1° vs. 41.3° ± 8.1°). Questionnaires revealed better outcome after six weeks in the VAS FA (56 ± 13.7 vs. 40.6 ± 10.5), Mazur score (64.4 ± 12.3 vs. 56.7 ± 11) and AOFAS score (71.2 ± 12 vs. 63.6 ± 8.7) ( P > 0.02 for all). Better outcome after 12 weeks in all questionnaires (VAS FA, 77.7 ± 13.8 vs. 61.4 ± 16.3; Philip score, 79.1 ± 10.9 vs. 60.1 ± 21.7; Mazur score, 83.9 ± 10.7 vs. 73.1 ± 14.1; AOFAS score, 87.5 ± 7.9 vs. 75.2 ± 11.7) ( P < 0.01 for all). Pressure balance was better under the midfoot region after 12 weeks in the ACM group (Δ P 4.4 N vs. 34.0 N; P = 0.01). The ACM group had an earlier return to work after 10.5 (range, 3-17) versus 14.7 (range, 9-26) weeks ( P = 0.02).
CONCLUSION
The use of ACM for patients needing initial partial weight-bearing after operatively treated unstable ankle fractures in the first six postoperative weeks leads to better clinical and functional results and an earlier return to work.
Topics: Adult; Aged; Ankle Fractures; Female; Follow-Up Studies; Fracture Fixation, Internal; Humans; Injury Severity Score; Joint Instability; Male; Middle Aged; Motion Therapy, Continuous Passive; Pain Measurement; Prospective Studies; Range of Motion, Articular; Recovery of Function; Risk Assessment; Trauma Centers; Treatment Outcome; Weight-Bearing; Young Adult
PubMed: 28805066
DOI: 10.1177/0269215517724192 -
Current Osteoporosis Reports Dec 2019Fractures of osteoporotic bone in elderly individuals need special attention. This manuscript reviews the current strategies to provide sufficient fracture fixation... (Review)
Review
PURPOSE OF REVIEW
Fractures of osteoporotic bone in elderly individuals need special attention. This manuscript reviews the current strategies to provide sufficient fracture fixation stability with a particular focus on fractures that frequently occur in elderly individuals with osteoporosis and require full load-bearing capacity, i.e., pelvis, hip, ankle, and peri-implant fractures.
RECENT FINDINGS
Elderly individuals benefit immensely from immediate mobilization after fracture and thus require stable fracture fixation that allows immediate post-operative weight-bearing. However, osteoporotic bone has decreased holding capacity for metallic implants and is thus associated with a considerable fracture fixation failure rate both short term and long term. Modern implant technologies with dedicated modifications provide sufficient mechanical stability to allow immediate weight-bearing for elderly individuals. Depending on fracture location and fracture severity, various options are available to reinforce or augment standard fracture fixation systems. Correct application of the basic principles of fracture fixation and the use of modern implant technologies enables mechanically stable fracture fixation that allows early weight-bearing and results in timely fracture healing even in patients with osteoporosis.
Topics: Ankle Fractures; Arthroplasty, Replacement, Hip; Biomechanical Phenomena; Femoral Neck Fractures; Fracture Fixation; Fracture Healing; Hemiarthroplasty; Hip Fractures; Hip Prosthesis; Humans; Osteoporotic Fractures; Pelvic Bones; Periprosthetic Fractures; Weight-Bearing
PubMed: 31755030
DOI: 10.1007/s11914-019-00535-9 -
Ugeskrift For Laeger May 2023This case report is about the rare combination of a concomitant ipsilateral occurrence of traumatic Achilles tendon rupture (ATR) and medial malleolar fracture (MMF) in... (Review)
Review
This case report is about the rare combination of a concomitant ipsilateral occurrence of traumatic Achilles tendon rupture (ATR) and medial malleolar fracture (MMF) in a 59-year-old male patient. We have conducted a literature review and found 12 published cases on the same topic with similar trauma mechanism and characteristic clinical findings. Nevertheless, either the ATR or the MMF was missed in the initial clinical examination in two-thirds of the reported cases. In this case report we discuss the trauma mechanism and clinical findings of ATR and MMF and aim to increase the awareness of the combination of both injuries.
Topics: Male; Humans; Middle Aged; Ankle Fractures; Achilles Tendon; Rupture; Ankle Injuries; Tendon Injuries
PubMed: 37264883
DOI: No ID Found