Ankle Fractures Flashcards
(232 cards)
1
Q
age distribution of ankle fractures
A
bimodal: young, active male 15-24 and elderly females 75-84
2
Q
percentage of each fracture type:
A
70% isolated malleolus fx
20% bimalleolar
7% trimalleolar
3
Q
what type of ankle fractures are most common?
A
isolated malleolus
4
Q
risk factors for ankle fractures
A
male
younger age
obesity
smoking
alcohol consumption
5
Q
mechanism of injury most common
A
twisting injury
6
Q
associated injuries
A
open fractures
syndesmotic injury
chondral injury
peroneal tendon tears
7
Q
most common associated injury
A
syndesmotic injury
8
Q
osteology of the ankle
A
modified hinge joint consisting of tibia, fibula, and talus
9
Q
3 ligamentous complexes that stabilize the ankle
A
deltoid
lateral ligament complex
syndesmosis
10
Q
deltoid two components
A
superficial & deep
11
Q
superficial deltoid component extends from______
A
medial malleolus to broad insertion onto navicular, sutentaculum tali, and talus
12
Q
extends from medial malleolus to broad insertion onto navicular, sutentaculum tali, and talus
A
superficial deltoid
13
Q
deep deltoid extends from_____
A
medial malleolus to talus
14
Q
extends from medial malleolus to talus
A
deep deltoid
15
Q
resists hind foot eversion
A
superficial deltoid
16
Q
superficial deltoid resists what motion
A
hindfoot eversion
17
Q
deep deltoid resists what motion
A
ER of talus
18
Q
resists ER of talus
A
deep deltoid
19
Q
lateral ligament complex 3 components
A
anterior talofibular ligament (ATFL)
calcaneofibular ligament (CFL)
posterior talofibular ligament (PTFL)
20
Q
anterior talofibular ligament (ATFL)
calcaneofibular ligament (CFL)
posterior talofibular ligament (PTFL)
A
lateral ligament complex
21
Q
primary restraint to anterior displacement, IR, and inversion of talus
A
anterior talofibular ligament (ATFL)
22
Q
most frequently injured ligament
A
anterior talofibular ligament (ATFL)
23
Q
the ATFL is the primary restraint to ____
A
anterior displacement, IR, and inversion of talus
24
Q
calcaneofibular ligament is deep to ______ tendons
A
peroneal
25
2nd most commonly injured ligament
calcaneofibular ligament (CFL)
26
deep to peroneal tendons
calcaneofibular ligament (CFL)
27
strongest ligament of lateral complex
posterior talofibular ligament (PTFL)
28
least likely ligament to be disrupted
posterior talofibular ligament (PTFL)
29
5 components of the syndesmosis
anterior inferior tibiofibular ligament (AITFL)
posterior inferior tibiofibular ligament (PITFL)
intraosseous ligament (IOL)
intraosseous membrane
inferior transverse ligament (ITL)
30
originates from anterolateral tubercle of distal tibia
anterior inferior tibiofibular ligament (AITFL)
31
inserts anteriorly onto lateral malleolus
anterior inferior tibiofibular ligament (AITFL)
32
anterior inferior tibiofibular ligament (AITFL) originates from
anterolateral tubercle of distal tibia
33
anterior inferior tibiofibular ligament (AITFL) inserts anteriorly onto
lateral malleolus
34
broad origin from posterior tibia
posterior inferior tibiofibular ligament (PITFL)
35
inserts onto posterior aspect of lateral malleolus
posterior inferior tibiofibular ligament (PITFL)
36
strongest component of syndesmosis
posterior inferior tibiofibular ligament (PITFL)
37
posterior inferior tibiofibular ligament (PITFL) has broad origin from
posterior tibia
38
posterior inferior tibiofibular ligament (PITFL) inserts onto
posterior aspect of lateral malleolus
39
distal continuation of interosseous membrane
intraosseous ligament
40
what neurovascular structures are at risk with anterior approach to the ankle
anterior tibial artery and deep peroneal nerve
41
anterior tibial artery and deep peroneal nerve are at risk with what approach
anterior
42
course over anterior ankle between EDL and EHL
anterior tibial artery and deep peroneal nerve
43
anterior tibial artery and deep peroneal nerve course over
anterior ankle between EDL and EHL
44
posterior tibial artery and tibial nerve course posterior to
medial malleolus between FDL and FHL
45
posterior tibial artery and tibial nerve at risk with what approach
posteromedial approach
46
course posterior to medial malleolus between FDL and FHL
posterior tibial artery and tibial nerve
47
at risk with posteromedial approach
posterior tibial artery and tibial nerve
48
superficial peroneal nerve crosses anteriorly over
fibula about distal 1/3
49
superficial peroneal nerve at risk with what approaches
posterolateral
direct lateral
anterior/anterolateral
50
crosses anteriorly over fibula about distal 1/3
superficial peroneal nerve
51
at risk with posterolateral, direct lateral, anterior/anterolateral approaches
superficial peroneal nerve
52
sural nerve at risk with what approaches
posterolateral and direct approach to fibula
53
at risk with posterolateral and direct approach to fibula
sural nerve
54
acts as buttress to prevent lateral displacement of talus
fibula
55
the fibula acts a buttress to prevent what
lateral displacement of talus
56
dorsiflexion results in what motion of the fibula
ER and lateral translation
57
plantar flexion results in narrower, posterior aspect of the talus leading to ____
IR of talus
58
_____ results in narrower, posterior aspect of the talus leading to IR of the talus
plantarflexion
59
_____ results in fibula ER and lateral translation, accommodating anteriorly wider talus
dorsiflexion
60
classification of ankle fractures
lauge-hansen
61
classification for the location of fibular fractures
danis-weber
62
what is a supination-adduction ankle fracture
1. talofibular sprain or distal fibular avulsion
2. vertical medial malleolus and impaction of anteromedial distal tibia
63
1. talofibular sprain or distal fibular avulsion
2. vertical medial malleolus and impaction of anteromedial distal tibia
supination-adduction
64
1. anterior tibiofibular ligament sprain
2. lateral short oblique fibula fracture
3. posterior tibiofibular ligament rupture or avulsion of posterior malleolus
4. medial malleolus transverse fracture or disruption of deltoid ligament
supination-external rotation
65
supination-external rotation type
1. anterior tibiofibular ligament sprain
2. lateral short oblique fibula fracture
3. posterior tibiofibular ligament rupture or avulsion of posterior malleolus
4. medial malleolus transverse fracture or disruption of deltoid ligament
66
1. medial malleolus transverse fracture or disruption of deltoid ligament
2. anterior tibiofibular ligament sprain
3. transverse comminuted fracture of the fibula above the level of the syndesmosis
pronation-abduction
67
pronation-abduction type
1. medial malleolus transverse fracture or disruption of deltoid ligament
2. anterior tibiofibular ligament sprain
3. transverse comminuted fracture of the fibula above the level of the syndesmosis
68
1. medial malleolus transverse fracture or disruption of deltoid ligament
2. anterior tibiofibular ligament disruption
3. lateral short oblique or spiral fracture of fibula
4. posterior tibiofibular ligament rupture or avulsion of posterior malleolus
pronation-external rotation
69
pronation-external rotation type=
1. medial malleolus transverse fracture or disruption of deltoid ligament
2. anterior tibiofibular ligament disruption
3. lateral short oblique or spiral fracture of fibula
4. posterior tibiofibular ligament rupture or avulsion of posterior malleolus
70
Danis-weber type A=
infrasyndesmotic
71
Danis weber type B=
transsyndesmotic
72
Danis weber type C=
suprasyndesmotic
73
curbstone fracture=
avulsion fracture of posterior tibia resulting from tripping
74
avulsion fracture of posterior tibia resulting from tripping
curbstone fracture
75
AITFL avulsion off anterior fibular tubercle usually seen with SER-type fracture patterns
LeFort-Wagstaffe fracture
76
LeFort-Wagstaffe fracture
AITFL avulsion off anterior fibular tubercle usually seen with SER-type fracture patterns
76
AITFL avulsion of anterior tibial margin
Tillaux-Chaput fracture
77
Tillaux-Chaput fracture
AITFL avulsion of anterior tibial margin
78
on exam, palpate proximal fibula for ____
Maisonneuve fracture
79
physical exam:
ecchymosis and swelling around the ankle
deformity
soft tissue assessment
80
recommended Xray views
ankle series-AP, lateral, mortise
dynamic stress views
full length tibia radiographs
81
manual stress view is the most appropriate stress radiograph to assess competency of _____
deltoid ligament
82
Xray findings indicative of syndesmotic injury
decreased tibiofibular overlap
increased medial clear space
increased tibiofibular clear space
83
decreased tibiofibular overlap
increased medial clear space
increased tibiofibular clear space
syndesmotic injury
84
normal tibiofibular overlap on AP
>6 mm
85
medial clear space of >______ mm with external rotation stress applied to a dorsiflexed ankle is predictive of deep deltoid disruption
5
85
normal tibiofibular overlap on mortise view
>1 mm
85
medial clear space of >5 mm with external rotation stress applied to a dorsiflexed ankle is predictive of____
deep deltoid disruption
85
normal medial clear space on mortise or stress view
<4 mm
86
normal tibiofibular clear space on both AP and mortise views
<6 mm
87
bisection of line through tibial anatomical axis and line through tip of both malleoli
talocrural angle
88
talocrural angle=
bisection of line through tibial anatomical axis and line through tip of both malleoli
89
shortening of lateral malleoli fractures can lead to increased ____
talocrural angle
90
double contour sign
misty mountains sign
spur sign
posterior malleolus fracture
91
signs suggestive of posterior malleolus fracture
double contour sign
misty mountains sign
spur sign
92
CT indications
trimalleolar fracture operative planning
assess morphology of posterior malleolus
supination adduction injury
93
most useful CT views to assess posterior malleolus
axial and sagittal views
94
CT findings
size and shape of posterior malleolus fragment
entrapped loose fragments
impaction
comminution
95
MRI indications
evaluate soft tissue or cartilaginous injuries
96
MRI findings
deltoid injury
syndesmotic injury
lateral ankle ligament complex
peroneal tendon injury
chondral lesions of talus
97
may be able to bear weight
positive anterior drawer or talar tilt test
XR shows no fracture
ankle sprain
98
positive Hopkin's squeeze test
increased medial clear space or tibiofibular diastases on stress view
syndesmotic injury
99
palpable gap over achilles
inability or weakness with plantar flexion
increased resting dorsiflexion when prone with knees bent
positive Thompsons test
achilles tendon rupture
100
high energy, axial load
significant articular involvement
chaput fragment, volkmann fragment, medial malleolus, central impaction
pilon fracture
101
high energy with extensive soft tissue injury
XR shows dislocation of talus from calcaneus or navicular bone
subtalar dislocation
102
indications for nonoperative treatment
stable ankle fracture
isolated stable medial malleolus fracture
isolated stable lateral malleolus fracture
avulsion tip fractures of medial or lateral malleolus
posterior malleolar fracture with < 25% joint involvement or < 2mm step-off
unfit for surgery
103
stable ankle fracture op or non op?
non op
104
isolated stable medial mall op or non op?
non op
105
isolated stable lateral mall op or non op?
non op
106
avulsion tip fractures of medial or lateral malleolus op or non op?
non op
107
posterior malleolar fracture with < 25% joint involvement or < 2mm step-off op or non op?
non op
108
non op modalities:
CAM boot
short leg splint
short leg cast
109
ORIF indications
any talar displacement
bimalleolar or bimalleolar-equivalent fracture
posterior malleolar fracture with > 25% or > 2mm step-off
Maisonneuve fracture
Bosworth fracture-dislocations
open fractures
symptomatic malleolar nonunions
110
any ____ displacement -> ORIF
talar
111
bimalleolar or bimalleolar-equivalent fracture op or non op?
op
112
posterior malleolar fracture with > 25% or > 2mm step-off op or non op?
op
113
Maisonneuve fracture op or non op?
op
114
Bosworth fracture-dislocations op or non op?
op
115
open fractures op or non op?
op
116
symptomatic malleolar nonunions op or non op?
op
117
goal of treatment is stable anatomic reduction with restoration of ______
mortise
118
approach options
direct lateral
posterolateral
posteromedial
direct medial
119
direct lateral approach ->
common approach for fibula ORIF syndesmotic fixation
syndesmotic fixation
120
common approach for fibula ORIF syndesmotic fixation
syndesmotic fixation
direct lateral approach
121
posterolateral approach ->
concomitant access to posterior fibula and posterior malleolus
prone or lateral
122
concomitant access to posterior fibula and posterior malleolus
prone or lateral
posterolateral approach
123
access to medial malleolus and posterior malleolus
posteromedial approach
124
common approach for medial malleolus ORIF
direct medial approach
125
considered most important factor for satisfactory outcome
anatomic reduction
126
1 mm shift of talus leads to ____% decrease in tibiotalar contact area
42
127
______ mm shift of talus leads to 42% decrease in tibiotalar contact area
1
128
worse outcomes associated with:
decreased level of education
smoking
alcohol use
presence of medial malleolar fracture
129
restoration of ______ in SA ankle fracture leads to optimal functional outcomes
marginal impaction of tibial plafond
130
improved incisional perfusion with _______ sutures
Allgöwer-Donati
131
proper braking response time (driving) returns to baseline at _____ weeks after surgery
9
132
braking travel time is significantly increased until _____ weeks after initiation of weight bearing in both long bone and periarticular fractures of lower extremity
6
133
indications for ex fix
severe open fractures with gross contamination
poor soft tissue requiring close monitoring
unstable reduction
134
ex fix has lower risk of ______ versus a splint
redislocation and skin complication
135
non op indications for isolated medial mall fracture
isolated medial malleolus fracture without talar shift
avulsion tip fracture
136
non op technique for isolated medial mall fracture
NWB for 4-6 weeks
137
outcomes of isolated medial mall fracture non op treatment
good outcomes with >95% union rate for isolated injury
138
indications for ORIF of isolated medial mall fx
any talar shift
139
ORIF techniques for isolated medial mall fx
lag screw
antiglide plate with lag screw
tension band fixation
140
lag screw fixation stronger if placed _____
perpendicular to fracture line
141
antiglide plate with lag screw
best for ______ isolated medial mall fractures
vertical shear
142
tension band fixation for isolated medial mall is useful when
fragment too small
poor bone quality
143
non op indications of isolated lateral mall
stable mortise with no talar shift
144
>______mm of medial clear space widening on stress views considered unstable in isolated lateral mall fx
4-5
145
isolated lateral mall non op techniques
immediate WBAT in CAM boot
brief period of immobilization in splint
146
ORIF indications of isolated lateral mall fracture
presence of talar shift on static or stress view (bimalleolar equivalent)
>3 mm displacement
147
isolated lateral mall ORIF techniques
plate
retrograde intramedullary fixation
148
stiffest fixation construct for the fibula is a ____ plate
locking
149
one-third tubular or anatomic distal fibular plate
stiffest fixation construct for the fibula is a locking plate
lateral plate
150
one-third tubular plate (antiglide mode)
posterior antiglide plating is biomechanically superior to lateral plate
disadvantage of peroneal tendon irritation if plate too distal
posterolateral plate
151
when is retrograde intramedullary nailing of isolated lateral mall useful
poor soft-tissue envelopes or high risk for wound-healing complication
152
what is a bimalleolar equivalent?
DELTOID LIGAMENT TEAR WITH FIBULAR FRACTURE
153
bimalleolar fracture non op indications
low demand and unable to undergo surgical intervention
154
ORIF indications in bimalleolar fractures
any displacement or talar shift (static or stress view)
155
bimalleolar ORIF fibular techniques
lateral plate
posterolateral plate
retrograde intramedullary fixation
156
bimalleolar fracture medial mall techniques
antiglide plate
tension band wiring
lag screws
157
posterior malleolus fracture non op indications
< 25% of articular surface involved
size should be calculated on CT since plain radiographs are unreliable
< 2 mm articular stepoff
stable syndesmosis
158
ORIF indications of posterior malleolus fracture
> 25% of articular surface
> 2 mm articular stepoff
syndesmotic instability
posterior subluxation of talus
159
ORIF posterior mall approaches
posteromedial
posterolateral
percutaneous
160
interval for posterolateral approach to isolated medial mall
between FHL and peroneal tendons
161
posterior malleolus fixation methods
antiglide plate
percutaneous A to P lag screws
162
stiffness of syndesmosis restored to ________% normal with isolated fixation of posterior malleolus vs 40% with isolated syndesmosis fixation
70
163
_____ may remain attached to posterior malleolus and syndesmotic stability may be restored with isolated posterior malleolar fixation
PITFL
164
stress examination of _______ still required after posterior malleolar fixation
syndesmosis
165
40-90% of distal third spiral tibia fractures have an associated ______ fracture
posterior malleolus
166
40-90% of _______ fractures have an associated posterior malleolus fracture
distal third spiral tibia
167
rare fracture-dislocation of ankle where fibula is entrapped behind tibia and is irreducible
Bosworth fracture dislocation
168
what is a Bosworth fracture
rare fracture-dislocation of ankle where fibula is entrapped behind tibia and is irreducible
169
Bosworth fracture treatment
ORIF
170
posterolateral ridge of the distal tibia hinders reduction of the fibula
Bosworth fracture dislocation
171
fracture-dislocation of the ankle due to hyperplantarflexion
hyperplantarflexion variant
172
main feature is a vertical shear fracture of the posteromedial tibial rim
hyperplantarflexion variant
173
hyperplantarflexion variant main feature
vertical shear fracture of the posteromedial tibial rim
174
"spur sign" is pathognomonic
hyperplantarflexion variant
175
hyperplantarflexion variant pathognomonic feature
spur sign
176
double cortical density at the inferomedial tibial metaphysis
spur sign
177
what is the spur sign?
double cortical density at the inferomedial tibial metaphysis
178
hyperplantarflexion variant treatment
ORIF of posterior malleolus with antiglide plating
179
open ankle fracture operative options
emergent operative debridement and ORIF
ex fix
180
open ankle fracture ex fix indications
significant soft tissue compromise
unstable fracture in splint/cast
181
_____% of all ankle fractures have associated syndesmotic injury
10%
182
higher incidence with higher fibula fractures
syndesmotic injury
183
syndesmotic injury higher incidence with _____ fractures
higher fibula
184
fixation of associated syndesmotic injury usually not required when fibula fracture within ______ cm of plafond
4.5
185
Weber A fracture has <______% associated syndesmotic injruy
10
186
Weber B fracture has ______% associated syndesmotic injury
40-50%
187
Weber C fracture has ______% associated syndesmotic injury
>80%
188
static views of ankle with associated syndesmotic injury shows what?
tibiofibular clear space
tibiofibular overlap
medial clear space
189
dynamic views of syndesmotic injury
gravity stress
manual external-rotation stress
cotton/hook test
190
how do you get a manual external-rotation stress view?
abduction/external rotation stress of dorsiflexed foot
191
instability of the syndesmosis is greatest in the _______ direction
anterior-posterior
192
how to get a gravity stress test
patient placed in lateral decubitus position
similar effectiveness to manual ER stress test
193
how to get a cotton/hook test?
intraoperative assessment
bone hook around fibula used to pull while placing counter traction on tibia
194
intraoperative assessment
bone hook around fibula used to pull while placing counter traction on tibia
cotton/hook test
195
treatment of syndesmotic injruy
syndesmotic screw or suture fixation
196
indications for syndesmotic screw fixation of associated syndesmotic injruy
widening of medial clear space
tibiofibular clear space (AP) greater than 5 mm
tibiofibular overlap (mortise) narrowed
197
syndesmotic fixation: length and rotation of _____ must be accurately restored
fibula
198
"Dime sign"/Shentons line to determine ______
length of fibula
199
syndesmotic fixation outcomes are strongly correlated with ______
anatomic reduction
200
syndesmotic fixation: placing reduction clamp on _______ (1-2 cm proximal to mortise) will achieve reliable anatomic reduction
middle medial tibial ridge and the lateral fibular ridge at the level of the syndesmosis
201
syndesmotic fixation: one or two cortical screw(s) or suture-button devices 2-4 cm above joint angled posterior to anterior _______ degrees (fibula posterior to tibia)
20-30
202
suture button or screws have lower rate of malreduction and reoperation rate in syndesmotic fixation?
suture button
203
syndesmotic screws should be maintained in place for at least ____ weeks
8-12
204
syndesmotic injury post op: must remain _____, as screws are not biomechanically strong enough to withstand forces of ambulation
non weightbearing
205
any postoperative malalignement or widening after syndesmotic fixation should be treated with
open debridement, reduction, and fixation
206
diabetic ankle fracture pathophysiology
poor circulation impairs wound and fracture healing
loss of protective sensation
poor bone quality
207
non op management of ankle fractures in diabetic patients can lead to what complications
loss of reduction (greatest risk)
Charcot arthropathy
malunion
nonunion
208
non op indications for diabetic ankle fractures
stable isolated unimalleolar fracture
209
risks of operative treatment of diabetic ankle fractures
prolonged healing
high risk of hardware failure
high risk of infection
lower functional outcomes
need for future amputation
210
how to enhance fixation in diabeticc ankle fractures
multiple quadricortical syndesmotic screws (even in the absence of syndesmotic injury)
tibiotalar Steinmann pins or hindfoot nailing
ankle spanning external fixation
augment with intramedullary fibula K-wires
stiffer, more rigid fibular plates
211
maintain non-weightbearing postop ankle fractures in diabetics for ____ weeks
8-12 weeks
212
how long to maintain non weight bearing in diabetics versus normal patients
8-12 weeks in diabetics vs 4-8 weeks in normal patients
213
complications of non op ankle fracture management
ulceration from cast
delayed union or nonunion
malunion
post-traumatic arthritis
DVT (5%)
ankle stiffness
214
complications of operative management of ankle fractures
wound problems (~5%)
deep infections (1-2%)
post op stiffness
posttraumatic arthritis
neurologic injury
hardware irritation
complex regional pain syndrome
215
deep infections occur in diabetic patients up to ____%
20
216
largest risk factor for deep infections in diabetic patients is presence of ______
peripheral neuropathy
217
_______ of tibial plafond in SAD injuries should be addressed at time of surgery
articular impaction
218
post-operative stiffness-can have
loss of dorsiflexion with _____ fixation
posterior
219
post traumatic arthritis very common in _____ type injuries
log splitter in which trans-syndesmotic fracture-dislocations in which the talus is driven into the distal tibiofibular articulation)
220
log splitter injuries aka trans-syndesmotic fracture-dislocations in which the talus is driven into the distal tibiofibular articulation) are associated with what complication
posttraumatic arthritis
221
At risk with lateral approach to distal fibula, posterolateral, and anterior/anterolateral approaches
superficial peroneal nerve
222
risk factors for hardware irritation
younger age
women
longer operative time
223
posterolateral plating of fibula
risk factors
distal placement of fibula plate
protruding screw head in most distal hole of fibula plate
peroneal tendonitis
224
risk factors for peroneal tendonitis
distal placement of fibula plate
protruding screw head in most distal hole of fibula plate
225
at risk with posterior medial malleolus screw placement
posterior tibial tendonitis
226
risk for posterior tibial tendonitis
posterior medial mall screw placement
227
risk factors for adverse outcomes
older age
osteoporosis
diabetes
peripheral vascular disease
female
higher ASA
smoking
alcohol use
lower level of education
228
positive predictors for good outcomes
age <40
male
ASA 1 or 2
absence of diabetes
