Classifications
What is the Danis Weber classification system?
Type A: Distal fibular avulsion fracture at or below the ankle joint. May have vertical medial malleolus
Type B: Short Oblique or spiral fibular fracture beginning at the level of the ankle joint. May have AITF and deltoid or medial malleolus avulsion fracture
Type C: Fibular fracture above the level of the ankle joint. May be spiral, oblique or complex and comminuted. May have deltoid ligament and/or syndesmotic injuries (ie AITFL, PITFL, IOL) associated
What is the "wrinkle test"?
The “wrinkle test” is a method to determine when skin and edema are ready for surgical intervention when operative stabilization is delayed from time of injury. Skin wrinkles will reappear when the swelling of the soft tissues has subsided enough to allow for wound closure following the surgery
As little as ____ mm of lateral talar translation has been reported to decrease the tibiotalar contact area by ~___%
As little as 1 mm of lateral talar translation has been reported to decrease the tibiotalar contact area by ~42%
Name indications for nonoperative treatment of ankle fractures.
Stable, nondisplaced, isolated lateral malleolar injuries are generally treated nonoperatively
No evidence of medial injury or increased medial clear space
No evidence of syndesmosis injury
<2 mm of fibular displacement
True or False. At 4 weeks postoperatively, isolated lateral malleolus fractures and those with syndesmotic repair begin to weight-bear in a boot assuming satisfactory radiographs.
True
Lauge-Hansen Classification: Describe each stage of Supination Adduction and Supination External Rotation fracture patterns.
SAD
Stage 1: Lateral ligament disruption. Distal fibular avulsion fracture at or below the ankle joint
Stage 2: Vertical medial malleolus fracture*
SER
Stage 1: AITFL or associated avulsion fracture
Stage 2: Spiral oblique fibular fracture beginning at the level of the ankle joint
Stage 3: PITFL disruption or associated avulsion fracture
Stage 4: Medial malleolus transverse fracture or disruption of the deltoid ligament
Compartment syndrome is rare in isolated malleolar ankle fractures but should always remain on the differential diagnosis list, especially with the _____ variation. Posterior compartment syndrome is the most common to occur with ankle fractures and the most difficult to assess clinically. Painful passive dorsiflexion of the digits is the most likely clinical sign to raise suspicion in this setting.
Compartment syndrome is rare in isolated malleolar ankle fractures but should always remain on the differential diagnosis list, especially with the Bosworth variation. Posterior compartment syndrome is the most common to occur with ankle fractures and the most difficult to assess clinically. Painful passive dorsiflexion of the digits is the most likely clinical sign to raise suspicion in this setting.
When evaluating the overlap, there should not be < ____ mm of overlap between the medial border of the distal fibula and the lateral border of the anterior tibia on the A-P radiograph.
When evaluating the overlap, there should not be <6 mm of overlap between the medial border of the distal fibula and the lateral border of the anterior tibia on the A-P radiograph.
Name indications for operative treatment of ankle fractures.
Unstable fracture or ligamentous injuries are treated with operative reduction and fixation
Medial and lateral malleolar fractures
Evidence of syndesmosis injury
Increase in medial clear space
>2 mm of fibular displacement
Open fractures are treated operatively
How long do you keep a bimalleolar fracture NWB post op?
Bimalleolar fractures are kept non–weight-bearing until week 7 when they are transitioned into a boot.
Lauge-Hansen Classification: Describe each stage of Pronation Abduction and Pronation External Rotation fracture patterns.
PAB:
Stage 1: Medial Malleolus transverse fracture. Deltoid ligament disruption.
Stage 2: AITFL and PITFL or associated avulsion fracture
Stage 3: Short oblique or transverse comminuted fracture of the fibula beginning at the level of the ankle joint
PER:
Stage 1: Medial Malleolus transverse fracture. Deltoid ligament disruption.
Stage 2: AITFL or associated avulsion fracture
Stage 3: Spiral oblique fracture of the fibula above the level of the ankle joint with syndesmosis disruption
Stage 4: PITFL or associated avulsion fracture
Evaluation of the ______ and _______ of the ankle is a top priority in the physical examination of pilon fractures
Evaluation of the soft tissues and vascular status of the ankle is a top priority in the physical examination of pilon fractures
Double Jeopardy
The talocrural angle can also be used to assess fibular length. This angle should be within ___ degrees of the contralateral side with an average angle of ____ ± ____ degrees
The talocrural angle can also be used to assess fibular length. This angle should be within 2 degrees of the contralateral side with an average angle of 83 ± 4 degrees
Langenhuijsen et al. retrospectively reviewed 57 patients with ankle fractures involving the posterior malleolus and found that joint congruity, with or without internal fixation, was a significant influence in patient outcome in fragments as small as ____% of the articular surface.
Langenhuijsen et al. retrospectively reviewed 57 patients with ankle fractures involving the posterior malleolus and found that joint congruity, with or without internal fixation, was a significant influence in patient outcome in fragments as small as 10% of the articular surface.
What is the author's preferred VTE prevention strategy after ankle fractures?
Authors preferred VTE prevention strategy after ankle fractures includes Aspirin daily for all patients and Lovenox for patients with multiple of the previously mentioned risk factors and both are continued through the duration of non–weight-bearing.
In addition, we recommend use of antiembolism stockings on the opposite extremity and advice patients to get up and move about frequently, even during the nonoperative recovery period.
Name 2 classification systems for describing Pilon fractures.
Ruedi and Allgower
AO/OTA
Lauge-Hansen
_______, _______, or ______ should be treated in a staged fashion. (Name at least 2)
Open injuries, significant soft tissue swelling, or fracture blisters should be treated in a staged fashion.
What are the 2 radiographic stress tests you can perform when there is an isolated distal fibular fracture with SER pattern?
Gravity stress test
Manual external rotation stress test
Both tests must have talus at 90 degrees
Care should be taken to not violate the superficial peroneal nerve (SPN). The mean distance of the nerve from the tip of lateral malleolus is ____ cm; however, it has been shown to be as low as ____ cm from the tip of the malleolus
Care should be taken to not violate the superficial peroneal nerve (SPN). The mean distance of the nerve from the tip of lateral malleolus is 10 cm; however, it has been shown to be as low as 2.5 cm from the tip of the malleolus
What is the most common late complication of pilon fractures?
What is the Ruedi and Allgower classification system?
Type 1: nondisplaced fractures
Type 2: displaced fractures
Type 3: displaced and severely comminuted fractures with impaction
It is useful to identify patient comorbidities that predispose them toward soft tissue complications such as ________, ________, ______, _______ ________, _________, and _______. The wound breakdown of pilon fixation can lead to the need for a free flap, and significant complications can occur that include flap failure and the ultimate need for subsequent amputation. (Name 3)
It is useful to identify patient comorbidities that predispose them toward soft tissue complications such as peripheral vascular disease, malnutrition, alcoholism, diabetes, neuropathy, tobacco use, and osteoporosis. The wound breakdown of pilon fixation can lead to the need for a free flap, and significant complications can occur that include flap failure and the ultimate need for subsequent amputation.
When should you order a CT image for a Pilon fracture?
It is advisable to wait until after the fracture has been reduced, distracted out to length, and spanned with a stabilizing external fixator before obtaining CT images in order to achieve the most useful visualization of the fracture morphology. If the CT scan is ordered prior to gross reduction, the surgeon will not be able to properly assess the intra-articular fragments and marginal impaction.
What are the 4 treatment principles of the Swiss Study Group/AO for Pilon fractures
1. Reconstruction of the fibular fracture
2. Reconstruction of the tibial articular surface
3. Cancellous bone graft to fill the distal tibial metaphyseal defect
4. Buttress plate application to the medial aspect of the tibia
In compression pilon fractures, the patient must refrain from weight bearing for a minimum of _____ to allow fracture consolidation.
In compression pilon fractures, the patient must refrain from weight bearing for a minimum of 3 months to allow fracture consolidation.