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Ankle – anatomy, soft tissue injuries & fractures

Ankle – anatomy, soft tissue injuries & fractures. Aims. Anatomy Fractures Sprains Other soft tissue injuries. Case 1. 25 yr old male 2/52 post fall Attended ED at time of injury – XR NBI Ankle sprain card Swelling now settled Foot drop Altered sensation dorsum of foot. Diagnosis.

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Ankle – anatomy, soft tissue injuries & fractures

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  1. Ankle – anatomy, soft tissue injuries & fractures

  2. Aims • Anatomy • Fractures • Sprains • Other soft tissue injuries

  3. Case 1 • 25 yr old male 2/52 post fall • Attended ED at time of injury – XR NBI • Ankle sprain card • Swelling now settled • Foot drop • Altered sensation dorsum of foot

  4. Diagnosis • A) Spinal/back injury • B) Missed fracture • C) Soft tissue injury • D) Common peroneal nerve injury

  5. Bony anatomy

  6. Ligament Anatomy Medial collateral ligaments • Deltoid ligament • Composed of: • Post. tibiotalar • Tibiocalcaneal • Tibionavicular

  7. Anatomy Lateral collateral ligaments • Ant. talofibularlig. • Calcaneofibularlig. • Post. talofibularlig. Tibia-fibular ligaments • Ant. & post. tibiofibular ligaments • Intraosseous ligament • Inf. transverse ligament

  8. Muscles & tendons

  9. Nerves & blood supply Vascular supply Nerves • Sciatic nerve

  10. Examination of ankle • History important: • Mechanism of injury • Fracture more likely if unable to WB immediately after injury • Examination includes: • proximal fibula - calcaneum • both malleoli - Achilles tendon • navicular - base 5th metatarsal • neurovascular status -ankle movements

  11. Ottawa ankle rules • Combined results give sensitivity 97.8% and specificity 31.5% for excluding fractures

  12. Fractures • Ankle = mortice joint • Always look for talar shift

  13. AO/Weber classification Type A • # fibula below syndesmosis • Conservative mx if undisplaced & no medial # • Refer if # medial malleolus

  14. AO/Weber classification Type B • # at level of syndesmosis • May be associated with # or ligamentous injury to medial side or posterolateral tibia • Refer Ortho as rarely treated conservatively

  15. AO/Weber classification Type C • above the syndesmosis • Also includes # of proximal fibula in this classification • Need ORIF

  16. Fractures Bimalleolar fracture • Align and repeat X-Ray post back-slab

  17. Fractures Trimalleolar fracture • Fracture of: • Medial malleolus • Lateral malleolus • Posterolateral tibia • Unstable

  18. Fractures Pilon fracture • Distal tibial metaphyseal including medial malleolus • 75% have lateral malleoli # • Consider other related fractures

  19. Fractures Maisonneuve fracture • # medial malleolus plus # proximal fibula • Patient may not complain of pain due to fibular # so examine specifically for it

  20. Fractures Talar avulsion fracture • Mechanism similar to ankle sprain • Focal pain & swelling • Conservative mx unless large fragment • Don’t confuse with the os trigonum

  21. Talar avulsion fractures

  22. Ankle dislocation Posterior dislocation • Most common type • Talus moves posteriorly in relation to tibia • Talus wider anteriorly so joint space pushed apart or # lat. malleolus

  23. Ankle dislocation • Management: • Orthopaedic emergency • Assess skin and neurovasc. status • Reduction precedes X-Ray • Adequate analgesia or sedation • Repeat X-Ray post reduction

  24. Ankle sprain • Grade 1 = stretching or minor tear • Grade 2 = partial tear • Grade 3 = complete tear • 90% involve lateral ligaments • 5% deltoid ligament • 5% ATFL or PTFL

  25. Stability • Anterior drawer test –if talus moves anteriorly more than 3mm then may be significant but if more than 1cm then definitely significant • Lateral ligaments – tear in sequence from anterior to posterior. So anterior talofibular ligament first then calcaneofibular lig then rarely the post talofibular ligament. Anterior drawer test will be positive if first two are ruptured

  26. Ankle sprain - management • Rest, ice, elevation • Advice leaflet with exercises • Refer physio if severe • Consider immobilisation if struggling (3/12 improved by 9/12 no difference (lancet ‘09)) • Rehab ROM, strength & proprioception • Functional tests for return to sport

  27. Ankle sprains - complications • Instability: • refer physio • Peroneal nerve injury: • neuropraxia due to stretching of branches or nerve at time of injury • reduced sensation on dorsum of foot • reduced proprioception (articular branches) • Peroneal tendon subluxation: • Clicking & sense of something slipping • Reproduce it if move ankle especially eversion

  28. Other soft tissue injuries Achilles tendon rupture • Usually due to sudden forceful contraction of the calf muscle • Describe sudden sharp blow/pain to back of ankle • Pain, swelling, bruising & often palpable gap in tendon • Simmonds test positive • May still be able to plantarflex foot • Occasionally partial tear so if suspect, bring back for USS • Plaster/boot with foot in equinus • Cochrane review – BK plaster

  29. Other soft tissue injuries Achilles tendonitis & Tennis calf • Usually hx of unaccustomed activity or overuse • Localised pain, swelling & palpable crepitus • Treat with NSAIDS, rest for 2 days then exercise as pain allows. Heel pad may help.

  30. Any questions?

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