PRESENTER: Dr.

ANKUR MITTAL

Ankle is a three bone joint

composed of the tibia , fibula
an talus

Talus articulates with the tibial

plafond superiorly , posterior
malleolus of the tibia
posteriorly and medial
malleolus medially

Lateral articulation is with

malleolus of fibula

The joint is considered saddle-shaped with the dome itself is wider

anteriorly than posteriorly, and as the ankle dorsiflexes, the fibula rotates
externally through the tibiofibular syndesmosis, to accommodate this
widened anterior surface of the talar dome
The tibiotalar articulation is considered to be highly congruent such that 1
mm talar shift within the mortise decreases the contact area by 42 %

Origin: anterior colliculus

Intercollicular Groove

Anterior Colliculus
Posterior Colliculus

Medial malleolus consists of:

-Anterior Colliculus
-Intercollicular Groove
-Posterior Colliculus

Anterior colliculus

Medial talar
tubercle

Navicular
tuberosity

Sustantaculm tali

Intercollicular groove

Posterior colliculus

Medial talus

Lateral Ligamentous Complex

Lateral Ridge
Articular surface
Malleolar fossa
Medial view of fibula
McMinn 1996

Volkman
tubercle

Chaput tubercle
Wagstaffe
tubercle

MEDIAL SIDE

LATERAL SIDE

LACINATE LIG.

TARSAL TUNNEL

ANTERIOR
SIDE

INTRODUCTION
Ankle fractures are among the most common injuries and
management of these fractures depends upon careful
identification of the extent of bony injury as well as soft tissue
and ligamentous damage.
Once defined, the key to successful outcome following
rotational ankle fractures is anatomic restoration and healing of
ankle mortise.

IMAGING AND DIAGNOSTIC MODALITIES

OTTAWA ANKLE RULES
To manage the large volume of ankle injuries of patients who
presented to emergency certain criteria has been established for
requiring ankle radiographs.
Pain exists near one or both of the malleoli PLUS one or more of the
following:
Age > 55 yrs old
Inability to bear weight
Bone tenderness over the posterior edge or tip of either malleolus .

Although the OTTAWA RULES have been validated and found to be both cost
effective and reliable (up to 100% sensitivity their implementation has been
inconsistent in general clinical practice
Plain

Films
AP, Mortise, Lateral
views of the ankle
Image the entire
tibia to knee joint
Foot films when
tender to palpation
Common
associated fractures
are:
5th metatarsal
base fracture
Calcaneal fracture

An initial evaluation of the radiograph should 1 st focus on

Tibiotalar articulation and access for fibular shortening
Widening of joint space
Malrotation of fibula
Talar tilt

Identifies fractures
of

malleoli
distal tibia/fibula
plafond
talar dome
body and lateral
process of talus
calcaneous

On the anteroposterior view,

the distal tibia and fibula, including the
medial and lateral malleoli, are well
demonstrated .
important note is that the fibular
(lateral) malleolus is longer than the tibial
(medial) malleolus.
This anatomic feature, important for maintaining ankle stability, is crucial
for reconstruction of the fractured ankle joint. Even minimal displacement
or shortening of the lateral malleolus allows lateral talar shift to occur and
may cause incongruity in the ankle joint, possibly leading to posttraumatic
arthritis.

Quantitative analysis

Tibiofibular overlap

<10mm is abnormal - implies

syndesmotic injury

Tibiofibular clear space

>5mm is abnormal - implies
syndesmotic injury

Talar tilt

>2mm is considered abnormal

Consider a comparison with

radiographs of the normal side if there
are unresolved concerns of injury

Lateral malleolar fracture

Tib/fib clear space <5mm

Tib/fib overlap >10 mm

No evidence of
syndesmotic injury

Taken with ankle

in 15-25 degrees
of internal rotation
Useful in
evaluation of
articular surface
between talar
dome and mortise

10 degrees internal rotation of 5th MT with respect to a vertical line

Medial clear space

Between lateral border
of medial malleous and
medial talus
<4mm is normal
>4mm suggests lateral
shift of talus

Abnormal

findings:

Medial joint space

widening
Talocrural angle: <8
or >15 degrees
Tibia/fibula
overlap:<1mm

Consider a comparison with

radiographs of the normal side if there
are unresolved concerns of injury

FIBULAR LENGTH:

1. Shentons Line of the ankle

2. The dime test

Posterior

mallelolar

fractures
AP talar subluxation
Distal fibular translation
&/or angulation
Syndesmotic relationship
Associated or occult
injuries

Lateral process talus

Posterior process talus
Anterior process calcaneus

The ankle is a ring

Tibial plafond
Medial malleolus
Deltoid ligaments
calcaneous
Lateral collateral ligaments
Lateral malleolus
Syndesmosis

Fracture of single part

usually stable
Fracture > 1 part =
unstable

Source: Rosen

Stress Views

Gravity stress view

Manual stress views

Joint involvement
Posterior malleolar
fracture pattern
Pre-operative planning
Evaluate hindfoot and
midfoot if needed

CT

MRI

Ligament and tendon

injury
Talar dome lesions
Syndesmosis injuries

Some ligament injuries may be diagnosed on the basis of disruption of the ankle
mortise and displacement of the talus; others can be deduced from the
appearance of fractured bones.
For example,
fibular fracture above the level of the ankle joint indicates that the distal anterior
tibiofibular ligament is torn.
Fracture of the fibula above its anterior tubercle strongly suggests that the
tibiofibular syndesmosis is completely disrupted.
Fracture of the fibula above the level of the ankle joint without accompanying
fracture of the medial malleolus indicates rupture of the deltoid ligament.

Transverse fracture of the medial malleolus indicates that the deltoid

ligament is intact.
High fracture of the fibula associated with a fracture of the medial
malleolus or tear of the tibiofibular ligament, the so-called Maisonneuve
fracture (see later), indicates rupture of the interosseous membrane up to
the level of the fibular fracture

When radiographs of the ankle are normal,

however, stress views are extremely important in
evaluating ligament injuries .
Inversion (adduction) and anterior-draw stress
films are most frequently obtained; only rarely is
an eversion (abduction)-stress examination
required.

Inversion stress view. (A) For inversion

(adduction)-stress examination of the ankle, the
foot is fixed in the device while the patient is
supine. The pressure plate, positioned
approximately 2 cm above the ankle joint, applies
varus stress adducting the heel. (If the
examination is painful, 5 to 10 mL of 1%
Xylocaine or a similar local anesthetic is injected
at the site of maximum pain.) (B) On the
anteroposterior film, the degree of talar tilt is
measured by the angle formed by lines drawn
along the tibial plafond and the dome of the
talus. The contralateral ankle is subjected to the
same procedure for comparison.

This angle helps diagnose tears of the

lateral collateral ligament

The anterior-draw stress film, obtained in the lateral projection, provides a

useful measurement for determining injury to the anterior talofibular ligament
Values of up to 5 mm of
separation between the
talus and the distal tibia
are considered normal;
values between 5 and 10
mm may be normal or
abnormal, and the opposite
ankle should be stressed
for comparison. Values
above 10 mm always
indicate abnormality.

Radiography after reduction should be studied with

following requirements in mind:
Normal relationship of ankle mortise must be restored.
Weight bearing alignment of ankle must be at right angle to the
longitudinal axis of leg
Counters of the articular surface must be as smooth as possible

Classification systems
Lauge-Hansen
Weber
OTA
Additional Anatomic Evaluation
Posterior Malleolar Fractures
Syndesmotic Injuries
Common Eponyms

Based on cadaveric study

First word: position of foot at time of injury
Second word: force applied to foot relative to
tibia at time of injury

Types:
Supination External Rotation
Supination Adduction
Pronation External Rotation
Pronation Abduction

In each type there are several stages of injury

Imperfect system:
Not every fracture fits exactly into one category
Even mechanismspecific pattern has been
questioned
Inter and intraobserver variation not ideal
Still useful and widely used

Remember the injury starts on the tight side of the ankle!

The lateral side is tight in supination, while the medial
side is tight in pronation.

Primary advantage :

Characteristic fibular # pattern

useful for reconstructing the mechanism of injury

a guide for the closed reduction

Sequential pattern inference of ligament injuries

Disadvantages:

complicated, variable inter observer reliability

doesnt signify prognosis

internal rotation injuries (Weber A3) missed

doesnt indicate stability

Stage 1 Anterior
tibio- fibular
ligament
Stage 2 Fibula fx
Stage 3 Posterior
malleolus fx or
posterior tibiofibular ligament
4

1
3

Stage 4 Deltoid
ligament tear or
medial malleolus
fx

Lateral Injury: classic posterosuperioranteroinferior fibula fracture

Medial Injury: Stability maintained
Standard: Closed management

Lateral Injury: classic posterosuperioranteroinferior fibula fracture

Medial Injury: medial malleolar fracture &*/or deltoid ligament injury
Standard: Surgical management

GOAL: TO EVALUATE DEEP DELTOID [i.e. INSTABILITY]

METHOD:

MEDIAL TENDERNESS
MEDIAL SWELLING
MEDIAL ECCHYMOSIS
STRESS VIEWS- GRAVITY OR MANUAL

SER-2
+StressView
Negative Stress view

WidenedMedialClearSpace

External rotation of
foot with ankle in
neutral flexion (00)

SE4

Stage 1: fibula
fracture is
transverse below
mortise.

Stage 2: medial
malleolus fracture is
classic vertical
pattern.

Lateral Injury: transverse fibular fracture at/below level of mortise

Medial injury: vertical shear type medial malleolar fracture
BEWARE OF IMPACTION

Important to restore:
Ankle stability
Articular congruity- including medial
impaction

1
4

Stage 1 Deltoid
ligament tear or
medial malleolus
fx
Stage 2 Anterior
tibio-fibular
ligament and
interosseous
membrane
Stage 3 Spiral,
proximal fibula
fracture
Stage 4 Posterior
malleolus fx or
posterior tibiofibular ligament

Medial injury: deltoid ligament tear &/or transverse medial malleolar fracture
Lateral Injury: spiral proximal lateral malleolar fracture
HIGHLY UNSTABLESYNDESMOTIC INJURY COMMON

Must x-ray knee to ankle to assess

injury
Syndesmosis is disrupted in most cases
Eponym: Maissoneuve Fracture

Restore:
Fibular length and rotation
Ankle mortise
Syndesmotic stability

1
2

Stage 1 Transverse
medial malleolus fx
distal to mortise

Stage 2 Posterior
malleolus fx or
posterior tibio-fibular
ligament

Stage 3 Fibula fracture,

typically proximal to
mortise, often with a
butterfly fragment

Medial injury: tranverse to short oblique medial malleolar fracture

Lateral Injury: comminuted impaction type distal lateral malleolar fracture

Classification systems
Lauge-Hansen
Weber
OTA
Additional Anatomic Evaluation
Posterior Malleolar Fractures
Syndesmotic Injuries
Common Eponyms

Based

on location of fibula
fracture relative to mortise
and appearance
Weber A fibula distal to
mortise

Weber B fibula at level

of
mortise

Weber C fibula
proximal to
mortise

Concept

- the higher the

fibula the more severe the
injury

SKELETAL TRAUMA

Classification systems
Lauge-Hansen
Weber
OTA
Additional Anatomic Evaluation
Posterior Malleolar Fractures
Syndesmotic Injuries
Common Eponyms

AO classification divides the three Danis Weber types further

for associated medial injuries.

Alpha-Numeric
Code

Infrasyndesmotic=44A

+
Malleolar segment =4
Tibia =4

Transsyndesmotic=44B

Suprasyndesmotic=44C

Infrasyndesmotic=44A

Alpha-Numeric
Code

Transsyndesmotic=44B

Alpha-Numeric
Code

Suprasyndesmotic=44C

Alpha-Numeric
Code

Classification systems
Lauge-Hansen
Weber
OTA
Additional Anatomic Evaluation
Posterior Malleolar Fractures
Syndesmotic Injuries
Common Eponyms

Function:
Stability- prevents posterior translation of talus &
enhances syndesmotic stability
Weight bearing- increases surface area of ankle joint

Fracture pattern:
Variable
Difficult to assess on standard lateral
radiograph
External rotation lateral view
CT scan

67%

19%

Type I- posterolateral oblique type

Type II- medial extension type

14%

Type III- small shell type

Classification systems
Lauge-Hansen
Weber
OTA
Additional Anatomic Evaluation
Posterior Malleolar Fractures
Syndesmotic Injuries
Common Eponyms

FUNCTION:
Stability- resists external rotation, axial, & lateral
displacement of talus
Weight bearing- allows for standard loading

Classification systems
Lauge-Hansen
Weber
OTA
Additional Anatomic Evaluation
Posterior Malleolar Fractures
Syndesmotic Injuries
Common Eponyms

 Maisonneuve Fracture
Fracture of proximal fibula with
syndesmotic disruption
Volkmann Fracture
Fracture of tibial attachment of
PITFL
Posterior malleolar fracture type
Tillaux-Chaput Fracture
Fracture of tibial attachment of
AITFL

Pott fracture.
In the Pott fracture, the fibula is
fractured above the intact distal
tibiofibular syndesmosis, the deltoid
ligament is ruptured, and the talus is
subluxed laterally

Dupuytren fracture.
(A) This fracture usually
occurs 2 to 7 cm above
the distal tibiofibular
syndesmosis, with
disruption of the medial
collateral ligament and,
typically, tear of the
syndesmosis leading to
ankle instability. (B) In
the low variant, the
fracture occurs more
distally and the
tibiofibular ligament
remains intact.

Wagstaffe-LeFort fracture.
In the Wagstaffe-LeFort
fracture, seen here
schematically on the
anteroposterior view, the
medial portion of the fibula is
avulsed at the insertion of the
anterior tibiofibular ligament.
The ligament, however, remains
intact.

Collicular

Fractures
Avulsion fracture of distal
portion of medial malleolus
Injury may continue and
rupture the deep deltoid
ligament
Bosworth fracture
dislocation
Fibular fracture with posterior
dislocation of proximal fibular
segment behind tibia

INTERCOLLICULAR GROOVE

POSTERIOR COLLICULUS

ANTERIOR COLLICULUS

Tibial Pilon Fractures

The terms tibial plafond fracture, pilon fracture, and distal tibial
explosion fracture all have been used to describe intraarticular fractures
of the distal tibia.
These terms encompass a spectrum of skeletal injury ranging from
fractures caused by low-energy rotational forces to fractures caused by
high-energy axial compression forces arising from motor vehicle
accidents or falls from a height.
Rotational variants typically have a more favorable prognosis, whereas
high-energy fractures frequently are associated with open wounds or
severe, closed, soft-tissue trauma.

Source:Rosen

Rotational fracture of the ankle can be viewed as a continuum,

progressing from single malleolar fractures to bimalleolar fractures to
fractures involving the distal tibial articular surface.
Lauge-Hansen described a pronation-dorsiflexion injury that produces
an oblique medial malleolar fracture, a large anterior lip fracture, a
supraarticular fibular fracture, and a posterior tibial fracture.
Giachino and Hammond described a fracture caused by a combination
of external rotation, dorsiflexion, and abduction that consisted of an
oblique fracture of the medial malleolus and an anterolateral tibial
plafond fracture..

These fractures generally have little comminution, no significant

metaphyseal involvement, and minimal soft-tissue injury. They can be
treated similarly to other ankle fractures with internal fixation of the
fibula and lag screw fixation of the distal tibial articular surface through
limited surgical approaches

CLASSIFICATION OF ANKLE FRACTURES IN CHILDREN

Salter-Harris anatomic classification as applied to injuries of the distal

tibial epiphysis.

Classification of Ankle Fracture in Children (Dias-Tachdjian)

Supination Inversion

grade I adduction or inversion force avulses the distal fibular epiphysis

(Salter-Harris type I or II fracture). Occasionally, the fracture is
transepiphyseal; rarely, the lateral ligaments fail.
grade II further inversion produces a tibial fracture, usually a Salter-Harris
type III or IV and, rarely, a Salter-Harris type I or II injury, or the fracture
passes through the medial malleolus below the physis

Variants of grade II supination inversion injuries (Dias-Tachdjian

classification).

A.Salter-Harris I fracture of the distal tibia

and fibula.
B. B. Salter-Harris I fracture of the fibula,
Salter-Harris II tibial fracture.
C.C. Salter-Harris I fibular fracture, SalterHarris III tibial fracture.
D.D. Salter-Harris I fibular fracture, SalterHarris IV tibial fracture.

Supination Plantarflexion
The plantarflexion force displaces the epiphysis directly posteriorly,
resulting in a Salter-Harris type I or II fracture. Fibular fractures were not
reported with this mechanism. The tibial fracture usually is difficult to see
on anteroposterior x-rays

Supination External Rotation

In grade I the external rotation force results in a Salter-Harris type II
fracture of the distal tibia The distal fragment is displaced posteriorly, as in
a supination plantarflexion injury, but the Thurston-Holland fragment is
visible on an anteroposterior x-ray, with the fracture line extending
proximally and medially. Occasionally, the distal tibial epiphysis is rotated
but not displaced.

In grade II, with further external rotation, a spiral fracture of the fibula is
produced, running from anteroinferior to posterosuperior (

Pronation Eversion External Rotation

A Salter-Harris type I or II fracture of the distal tibia occurs
simultaneously with a transverse fibular fracture. The distal tibial
fragment is displaced laterally, and the Thurston-Holland fragment,
when present, is lateral or posterolateral . Less frequently, a
transepiphyseal fracture occurs through the medial malleolus (Salter
type II).