Ankle fracture: Difference between revisions
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*[[Ankle Sprain]]
*[[Ankle Sprain]]


{{Ankle fractures DDX}}
{{Distal leg fractures DDX}}


== Management ==
== Management ==

Revision as of 07:41, 10 January 2015

Physical Exam

  • Examine for ecchymoses, abrasions, or swelling
  • vascular and neurologic assessment
    • DPs and PTs
    • 4 sensation distributions: saphenous nerve (medial mal), superficial fib (lat mal), sural nerve (lateral 5th digit), deep fib (1st web space)
  • Note skin integrity and areas of tenderness or crepitus over ankle
  • Range joint passively and actively to evaluate for stability
  • Examine Joints above and below the ankle
  • Perform anterior drawer test (positive exam suggests torn ATFL)
  • Always palpate entire length of fibula to rule-out Maisonneuve Fracture (fibulotibialis ligament tear)
    • Perform a crossed-leg test to detect syndesmotic injury
  • Evaluate integrity of Achilles tendon (Thompson test)
  • Palpate midfoot and base of 5th metatarsal for tenderness

Diagnosis

  • Ottawa Ankle Rules (sen 96-99% for excluding fx)
  • 3 views:
    • AP: Best for isolated lateral and medial malleolar fractures
    • Oblique (mortise)
      • Best for evaluating for unstable fracture or soft tissue injury
      • At a point 1 cm proximal to tibial plafond space between tib/fib should be ≤6mm
    • Lateral: Best for posterior malleolar fractures
  • consider proximal tib/fib films and talus fxs

Types of Fractures

  • unimalleolar fx - look for other fracture. splint. possible ORIF
  • bimalleolar fx - fracture involves lateral and medial malleoli
    • unstable: ORIF
  • trimalleolar fx - fracture involves lateral malleolus, medial malleolus, and the distal posterior aspect of the tibia (posterior malleolus)
    • unstable: ORIF
Weber A Oblique
Weber B Oblique
Weber B AP
Weber C Oblique
Weber C AP

Classification (Danis-Weber System)

WeberclassRadioped.jpg
  • system based on level of the fibular fx and characterizes stability of fx
  • tibial plafond and the two malleoli is referred to as the ankle "mortise" (or talar mortise)

Type A

  • fibula fx below ankle joint/distal to plafond
    • medial malleolus often fractured
    • tibiofibular syndesmosis intact
    • usually stable: occasionally requires ORIF

Type B

  • fibula fx at the level of the ankle joint/at the plafond
    • can extend superiorly and laterally up fibula
    • tibiofibular syndesmosis intact or only partially torn
    • no widening of the distal tibiofibular articulation
    • medial malleolus may be fracture
    • possible instability

Type C

  • fibula fx above the level of the ankle joint/proximal to plafond
    • tibiofibular syndesmosis disrupted with widening of the distal tibiofibular articulation
    • medial malleolus fracture
    • unstable: requires ORIF

Differential Diagnosis

Distal Leg Fracture Types

Management

  • Determined by stability of fx:
    • Stable, nondisplaced, isolated malleolar fx: Splint or cast, early wt bearing, RICE
    • Unstable or displaced fx: Requires ORIF, ortho consult, reduce and splint
  1. Isolated lateral malleolar Fx
    1. If stable (see Weber classification) treat like severe Ankle Sprain
    2. Signs of instability:
      1. Displacement >3mm
      2. Associated medial malleolus fx
      3. Signs of medial (deltoid) ligament disruption such as medial swelling, ecchymosis, or TTP
      4. Widening of medial clear space (suggests deltoid ligament injury)
  2. Isolated medial or posterior malleolar Fx
    1. Must rule-out other injuries
    2. If non-displaced, isolated:
      1. Short-Leg Posterior Splint (ankle at 90o)
      2. Non-weight bearing
      3. Refer to Ortho in 5-7d
  3. Lateral malleolar fx with deltoid injury OR bimalleolar OR trimalleolar fx
    1. Short-Leg Posterior Splint (ankle at 90o)
    2. Immediate ortho consult in ED

See Also

Source

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