35.6). This is especially true for injuries around the ankle, for which multiple surgical incisions are often required and the injuries and soft tissues provide little leeway for surgical mistakes. Type S-AD fractures (Fig. Fracture-dislocation example - Ankle. Dislocations of the distal tibiofibular joint reported in the literature are mostly associated with the tibial portion. This concept has been challenged by Tornetta,30 who demonstrated that medial-only fixation is sufficient in many bimalleolar injuries. The syndesmosis maintains the ankle mortise and consists of four ligaments: the anterior and posterior inferior tibiofibular ligaments, the inferior transverse tibiofibular ligament, and the interosseous ligament. In this rare injury to the distal tibial growth plate, the distal tibial epiphysis undergoes true rotational displacement with posterior displacement of the fibula but without fracture of the fibula. These devices enable fixation in the distal fragment of the lateral malleolus, syndesmotic screw fixation through the nail, and target-guided screws proximal to the nail. At times, the skin incision may be moved posteriorly (or anteriorly) depending on the soft tissues, site of plate placement, desire to access the postero- and antero-lateral tibia, or other reasons. Fractures that are often stable enough for nonoperative treatment include most of the Weber type A fractures, as well as some of the Weber type B fractures, including low-grade Lauge-Hansen S-AD or S-ER fractures (types 1 and 2). A great deal has been written regarding the diagnosis and treatment of ankle fractures, although controversy persists regarding some aspects of their treatment.2–5 The ankle joint may be injured as the result of direct or more often indirect trauma (rotational, translational, or axial forces). The supramalleolar skin over the medial distal tibia is most often at risk, as subluxation of the talus and malleoli typically occurs laterally. Forethought as to which injury may need surgical treatment and what approaches may optimally provide access to each injury is typically time well spent. im Rahmen einer Knieluxation. The “nail” is inserted percutaneously in a retrograde manner through a small incision distal to the tip of the fibula. Frakturen der distalen Fibula (43f-M2/3 oder 43f-E1/2) treten meist in Kombination mit einer Epiphysenlösung der distalen Tibia auf. Thus, the goals of treatment for ankle fractures and dislocations are a stable congruent joint that enables early ankle mobility, fracture healing, and, ultimately, the prevention of arthritis. One should carefully scrutinize all three radiographic views of the ankle in assessing these injuries, and even then they may be better visualized with a CT scan. The Lauge-Hansen system is based on the mechanism of injury and is more encompassing than the Danis-Weber system. The external rotation stress test described above for ankle instability can also be used to evaluate competency of the syndesmosis. This chapter discusses the practical operative management of ankle fractures, including surgical indications, operative methods and technical pearls, and pre- and postoperative management, based on the available literature and the authors’ experiences. The patient was subsequently taken … It is important to understand the anatomy, as it is usually a combination of bony and ligamentous injury that will render an ankle unstable and require surgical stabilization.22–25. Distal fibula fractures are the most common type at the ankle and are usually the result of an inversion injury with or without rotation. Die Fibula kann weiter zusammen mit der Tibia gebrochen sein, was man unter einer kompletten Unterschenkelfraktur versteht. Other therapeutic options, often used in cases in which the dislocation is diagnosed later, include removal of the fibula head [8–10] or peroneal osteotomy. Diagnosis of an associated deltoid ligament injury is not always easy. Useful techniques for gaining reduction include indirect reduction methods. S-ER is the most common type (up to 85% of fractures) and includes an oblique or spiral fracture of the fibula along with a variable medial injury. The superior migration of the entire fibula commonly results from high-energy ankle injuries. Mont and associates7 found that residual radiographic abnormalities after ankle fracture surgery, especially if multiple, correlated with poorer clinical outcomes. 35.4) or other more vertically oriented fractures that extend further into the tibia should be fixed with an antiglide plate (with or without lag screws) to prevent vertical migration (Fig. 35.4). An alternative method is to use a pointed reduction clamp to carefully correct rotation and bring the fibula out to length.36 One or two small Kirschner wires (K-wires) can then be used to pin the fibula to the talus or distal tibia. Surgical approach to the distal fibula and applied anatomy. After fixation of most unstable ankle fractures, stress views of the ankle should be performed to search for syndesmosis injuries. Urban & Fischer, München 2009, Grifka, J., Krämer, J.: Orthopädie, Unfallchirurgie. A new alternative treatment implant is the fibular nail with interlocking screws (e.g., Acumed, Hillsboro, OR). The goals of treatment for ankle fractures and dislocations are the maintenance of a stable, congruent joint that enables early joint mobility, fracture healing, and ultimately the prevention of arthritis. The timing of surgery is somewhat controversial, but ultimately depends on the condition of the soft tissues. Once the wounds have been irrigated, the surgeon may proceed with either formal open reduction and internal fixation (ORIF) or, if this is not appropriate because of the severity of bone or soft tissue injury, ankle-spanning external fixation. The incision can be moved posteriorly to accommodate positioning of the plate on the posterior surface of the fibula or to allow for a posterolateral approach to the distal tibia (posterior malleolus). Radiographs were taken showing a posterior dislocation of an intact distal fibula associated with a fracture of the medial malleolus and disruption of the ankle mortise (Figure 1a,b). Using this method, the lateral side of the ankle is placed down on the table with the majority of the ankle off the edge of the table. The injury is caused by severe external rotation of the ankle. Fibular anterior dislocation of this joint is rare. These more rigid plates must be carefully precontoured to include the anatomic rotation of the distal fibular shaft or they may tend to malreduce the fracture as the bone moves to the plate during screw insertion. subluxation and 3 types of dislocation . Other radiographic clues that significant injury has occurred include alterations in the talocrural angle, talar tilt, widened tibiofibular clear space, loss of alignment of the subchondral plates at the tibiofibular line, and shortening of the fibula by loss of parallelism of the subchondral lines of lateral malleolus and that of the lateral talus8,9 (Fig. This regional block can give excellent postoperative pain control for the lateral side of the leg when given as a onetime bolus, or as an indwelling catheter. Here, we discuss a case of a complete proximal and distal tibiofibular syndesmotic complex dislocation associated with a tibial shaft fracture. Considerations regarding the timing of surgery and soft tissue management are therefore critical in minimizing the risks of perioperative complications, and are discussed at length in this chapter. Blisters, considerable swelling, or other signs of soft tissue trauma should alert the surgeon to delay surgery until these issues resolve. “Composite” plates that are one-third tubular distally and 3.5 mm proximally (DePuy, Warsaw, IN) may be useful in patients with poor bone quality or in cases with proximal fracture extension. The ankle joint consists of the articulation of three bones (tibia, talus, and fibula) that move relative to one another and are restrained by three ligament complexes (Fig. A plate can then be applied and the K-wires removed. Generally, most experts agree that swelling and edema should be controlled before surgery is undertaken in order to minimize the risk of soft tissue complications. A fracture of the fibula cannot be reduced with the aid of a locked plate and all locking screws. Less commonly, isolated ligament injuries can result in the dislocation. A small fragment posterior to the distal fibula may represent an avulsion of the superficial peroneal retinaculum. Initial attempts at closed reduction under sedation were unsuccessful. Radiographic findings of obvious ankle instability may include significant fracture displacement, subluxation or dislocation of the talus under the plafond, and widening of the medial joint space. ): Sportverletzungen – Diagnose, Management und Begleitmaßnahmen. Rarely, computed tomography (CT) may be indicated to judge the size and position of a posterior malleolar fragment, or involvement of the distal tibiofibular joint. The tibia and fibula are the two long bones of the lower leg (figure 1). Deformity from an ankle fracture-dislocation may cause pressure necrosis of the skin over the supramalleolar area. Two pillows or a foam base (or later a sterile towel roll) is placed under the fractured leg to elevate it above the contralateral leg; this assists in the surgical approaches and in obtaining lateral radiographs. 35.2). Dislocation of the distal tibiofibular joint. Fracture reduction can be judged by visualizing the proximal fracture spike and ensuring that it is keyed in at the fracture′s apex. Springer, Heidelberg 2013, Niethard, F., Pfeil, J., Biberthaler, P.: Orthopädie und Unfallchirurgie. Das Fibulaköpfchen frakturiert z.B. However, when viewed from above, the talus is trapezoidal in shape, and thus with ankle dorsiflexion there is also widening of the mortise and external rotation of the fibula.22 The ankle might best be regarded as a complicated hinge. Some surgeons prefer a straight longitudinal medial incision extending over the fracture and the tip of the medial malleolus or a curved incision that extends around the posterior aspect of the medial malleolus.41 The major limitation of these approaches is impaired visualization of the articular reduction and any articular injury. We present a case report of a variation of a Bosworth fracture, which is a posterior dislocation of the proximal fragment of a distal fibula fracture. Synonym: tibiofibulare Syndesmose, Syndesmosenkomplex Englisch: tibiofibular syndesmosis. 4 Symptome. Once the fibula reduction is obtained (usually open), a 3.5-mm or other oscillating drill gains access to the intramedullary canal of the fibula. It was originally shown by Ramsey and Hamilton6 that mild malalignment of the ankle joint leads to abnormal pressure distribution and loading of the articular cartilage, potentially increasing the risk of subsequent arthritis. Next the selected nail implant is inserted across the fracture in line with the intramedullary canal in both AP and lateral views on image intensification. These deformities are restored when the subchondral contour of the lateral talus matches that of the medial distal fibula, and the tibiofibular line is restored on the mortise view (Figs. 35 They are commonly found in conjunction with lateral malleolar and tibial fractures. We herein presented a case in which the fibula was anteriorly dislocated from the distal tibiofibular groove resulting in a lateral ankle joint diastasis. The standard radiographic assessment of the ankle includes three views: anteroposterior (AP), mortise (15- to 20-degree internal rotation), and lateral (Fig. The disadvantage of this approach is that the surgeon necessarily encounters the saphenous vein and nerve, which must be carefully preserved. Dislocations may be anterior where the ankle will appear dorsiflexed and the foot looks elongated. Vor allem tritt die Distale Fibulafraktur oft als Sportverletzungauf. Normally, the talus sits in the ankle “mortise,” articulating with the weight-bearing tibial plafond, as well as the articular facets of the medial and lateral malleoli. Even a small amount of residual lateral subluxation of the talus can cause pressure necrosis of the medial ankle. Positioning of plates for the distal fibula. The advantage of this approach is the excellent visualization of the medial ankle joint and fracture reduction proximally. With significant injury to the ankle, a consistent pattern of in stability occurs, specifically lateral translation and external rotation of the talus relative to the tibial plafond. Patients who have type III fractures should receive the same dose of a cephalosporin plus an aminoglycoside, a broad-spectrum antibiotic (Zosyn), or fluoroquinolone for gram-negative coverage. They are the extension of a lateral collateral ligament injury. des fibulotalaren Bandapparates nach Supinationstraumen sind beim Kind selten. The effectiveness of this type of fixation has been shown in a few small studies.37 Specialty devices have been developed to enable a fibular nail to be inserted and locked proximally and distally to counteract these shortcomings (Fig. 35.4). common peroneal nerve lies distal to the proximal tibiofibular joint on the posterolateral aspect of the fibular neck ; Classification: Ogden classification . Comminuted fractures may require a tension band construct or even supplemental fixation with mini-fragment screws. Rarely, intramedullary devices are used to control fractures of the distal fibula, and tension band wire techniques are sometimes useful medially or laterally for highly comminuted, distal fractures that require fixation. (Hrsg. The proximal screw is placed immediately adjacent to the nail, maintaining length by blocking shortening. Most ankle fractures can undergo surgical treatment with no change in technique or complication rates up to 3 weeks after the injury. Additionally, the path of the superficial peroneal nerve is not always consistent, and meticulous dissection is required to assess whether the nerve is crossing through the operative wound, especially as the incision is carried proximally (Fig. If a closed reduction is determined to be adequate, with a medial clear space within 4 mm of the uninjured ankle and/or less than 2 mm of malleolar displacement,1 the patient may be treated with cast or splint immobilization and serial examinations. A study looking at the use of these locking fibular nails in fragility fractures showed this device to be a viable treatment option, though there was no comparison group.38, Medial malleolus fractures usually occur in conjunction with lateral malleolus fractures, but occasionally occur as an isolated injury in P-ER or P-AB injuries (Fig. Reduction … Obtaining soft tissue coverage over the lateral fibular plate with a full-thickness layer of soft tissue is desired. In the case presented, orthopedic reduction was unstable and osteosynthesis with a proximal tibiofibular screw was carried out. For a “do-it-yourself” nail, it is bent distally and cut short. A laterally applied plate may result in occasional problems with implant prominence, but this position does provide more direct access for plate application. The limb should always be checked proximally for tenderness over the fibula (Maisonneuve fracture), along with examination of the Achilles tendon and foot for associated injuries. Ein Außenknöchelbruch zählt zu den sogenannten Sprunggelenksfrakturen. It is often helpful to place a padded bump behind the buttock on the injured side to internally rotate the leg and provide comfortable access to the lateral malleolus. Subluxation des Sprunggelenks kommt. A third tubular plate from the small fragment set, or even a 2.7- or 2.4-mm mini-fragment plate, is effective as long as the screws are placed in the appropriate order and the purchase is acceptable. Der Drehfehler wird in Winkelgraden angegeben. Genauer beschreiben lässt sich ein Außenknöchelbruch mit Hilfe der gängigen AO-Klassifikation (Arbeitsgemeinschaft Osteosynthese), in die sich alle Bruchformen exakt einteilen lassen. Furthermore, making an incision of the skin directly over the fracture could lead to potentially catastrophic wound problems. Zusätzlich wird die Qualität des Drehfehlers als Innenrotation oder Außenrotation dokumentiert. The skin incision for posterior application of an antiglide plate is probably best modified by moving it 1 cm posteriorly to prevent soft tissue impingement during surgery. 60-4C). 35.5). If not addressed, this injury may lead to peroneal tendon subluxation. Because the deep deltoid ligament attaches to the posterior colliculus, injury to the deep deltoid ligament can coexist with an anterior collicular fracture. The fibula is usually palpable beneath the subcutaneous tissues and its borders can be defined fairly easily. A well-padded posterior and U-shaped splint is then applied to maintain reduction. A lag screw can then usually be placed through the plate to further increase fixation strength (Figs. Several authors have suggested that surgery is best performed within 6 to 8 hours of injury, before significant edema develops.26,27 However, the logistics of performing early surgery may be difficult. The bony and ligamentous anatomy of the ankle. Second, the ability of a cast to hold the reduction is reduced as limb swelling diminishes with time, thus reduction may be lost even if diligent care is provided. Injuries can occur to one or more of the structures that make up the distal syndesmosis1: 1. anterior Radiographs show a posterior dislocation of an intact distal fibula associated with a fracture of the medial malleolus and disruption of the ankle mortise. In this case, repair of the anterior malleolar fragment will not restore competence of the medial ligament and the ankle may remain potentially unstable. Locking plate technology may also be useful in some difficult ankle fractures. CONCLUSION Dislocations of the upper tibio-fibular joint are rare, and anterior dislocation is the most common. Fractures of distal tibia and fibula are divided into ... Often, long-axis compression throughout the proximal lower extremity can cause associated tibial plateau fracture, hip dislocation, or acetabular fracture. In the case of a more proximal fibula fracture without a medial fracture, a positive stress test likely indicates the presence of a combined deltoid and syndesmosis injury. For example, the plate can be used as an indirect reduction tool.35 Using this technique, the plate is initially applied to one side of the fracture (usually distal) and then length and rotation may be obtained using manual traction/manipulation, a mini-distractor, or the use of lamina spreaders against a “push-pull” screw. From Wikipedia, the free encyclopedia The Bosworth fracture is a rare fracture of the distal fibula with an associated fixed posterior dislocation of the proximal fibular fragment which becomes trapped behind the posterior tibial tubercle. There is a relatively thin soft tissue envelope around the ankle, which may be quite fragile in some patients. Weber type A and S-AD fractures associated with a medial injury, Weber type B and S-ER and P-AB fractures that occur as part of a more complex bimalleolar, trimalleolar, or bimalleolar equivalent fracture (fibular fracture with incompetent deltoid ligament), Weber type C and P-ER type 2 and 3 fractures, because of the syndesmosis injury and associated instability, Ankle fracture-dislocations with more extensive bone and soft tissue injury. We considered that the mechanism underlying the injury was axial … The one-third tubular plate has been a workhorse plate for distal fibula and other ankle fractures, as it easily contours to the local anatomy, has a low profile, and enables ample mechanical strength for most fractures. Comminuted or “crushed” lateral malleolus fractures may be much more difficult to properly reduce and fix. The fibula in these cases appears to be plastic enough to twist without breaking. Although this system is relatively straightforward, it does not provide any guidance regarding treatment of a medial injury, options for fixation (except for the syndesmosis), and prognosis. What are causes and risk factors for an ankle dislocation? Diese Seite wurde zuletzt am 30. The importance of reduction of the lateral malleolus and its impact on overall ankle joint congruency and mechanics has been well recognized.6,29 Yablon and associates29 concluded that the lateral malleolus was the key to the anatomic reduction of bimalleolar ankle fractures, because the displacement of the talus faithfully followed the displaced distal fibular fragment. Our patient had a distal fibula dislocation without fracture. Once dislocated, the fibular head sits in an anterolateral position, with the anterior surface of the superior tibia directly behind. The construct can be manipulated as necessary until an acceptable alignment is achieved, and then the plate may be secured proximally with screws. The position of the foot at the time of injury dictates which structures are taut and thus likely to fail at the onset of deformation. The patient fell and injured her right ankle during contact play in basketball. Der Außenknöchelbruch (distale Fibulafraktur = Bruch des unteren Wadenbeins) ... (Tibia) und Wadenbein (Fibula) zusammenhält. Attention must be paid to restoring proper length and rotation across the fracture. We prefer to apply a posterior antiglide plate for oblique fractures whenever possible. A direct lateral approach using a longitudinal incision is commonly used for the reduction and plating of fibula fractures (Fig. Im weiteren Sinn zählen alle zwischen Tibia und Fibula ziehenden Bänder und die gesamte Membrana interossea cruris zur Syndesmosis tibiofibularis. - Distal fibular fracture - Adult - Radiograph of an oblique fracture of the fibula with dislocation - Wide mortise associated with tibiofibular syndesmosis tear - Radiograph of Maisonneuve fracture - Maisonneuve stress view - Fibula shaft fracture ultrasound long axis - Imaging pilon fracture of distal … For this reason, if surgery is not to be performed immediately, a closed reduction should be performed and a splint applied that will maintain reduction of the talus beneath the plafond and decompress the skin “at risk.” The patient needs a thorough lower extremity exam despite the obvious ankle fracture. Using this system, though, little useful direction as to operative treatment or prognosis is attainable. The fracture must be reduced prior to applying locked screws. Recent work has demonstrated that soft tissue findings such as medial ankle pain and swelling are not reliable predictors of ankle instability associated with a supination/external rotation fracture of the distal fibula.10,11 Radiographic findings may also not clearly demonstrate the instability of this injury, and an AP or mortise stress view of the ankle taken while external rotation force is applied may be helpful in revealing lateral talar subluxation and associated medial joint space widening. This technique may be more mechanically effective than lateral plating, and it minimizes the risk of implant problems (as long as the plate is not placed far distally impinging on the fibula′s peroneal groove).33,34 If the first screw is placed just above the apex of the fracture, the plate aids in the reduction by pushing the fracture into position (Fig. For patients being treated for injuries of the medial or lateral ankle, positioning is usually supine on a radiolucent operating table. Full-length tibia and fibula radiographs did not demonstrate any other fractures or proximal tibiofibula dislocation . A surgical prep of the limb is performed, and a preoperative dose of antibiotic is administered prior to exsanguination of the leg and insufflation of the tourniquet. This puts added strain on the muscles which connect the fibula to the foot and toes such as the peroneal muscles.
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