Ankle fracture: Difference between revisions
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==Physical Exam==
''For pediatric patients, see [[Ankle fracture (peds)]]
==Background==
 
==Clinical Features==
*Examine for ecchymoses, abrasions, or swelling
*Examine for ecchymoses, abrasions, or swelling
*vascular and neurologic assessment
*Vascular and neurologic assessment
**DPs and PTs
**DP and PT pulses
**4 sensation distributions: saphenous nerve (medial mal), superficial fib (lat mal), sural nerve (lateral 5th digit), deep fib (1st web space)
**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
*Note skin integrity and areas of tenderness or crepitus over ankle
*Range joint passively and actively to evaluate for stability
*Range joint passively and actively to evaluate for stability
*Examine Joints above and below the ankle
*Examine joints above and below the ankle
*Perform anterior drawer test (positive exam suggests torn ATFL)
*Perform anterior drawer test (positive exam suggests torn ATFL)
*'''Always palpate entire length of fibula to rule-out [[Maisonneuve Fracture]] (fibulotibialis ligament tear)'''
*'''Always palpate entire length of fibula to rule-out [[Maisonneuve Fracture]] (fibulotibialis ligament tear)'''
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*Palpate midfoot and base of 5th metatarsal for tenderness
*Palpate midfoot and base of 5th metatarsal for tenderness


==Diagnosis==
==Differential Diagnosis==
*[[Ottawa Ankle Rules]] (sen 96-99% for excluding fx)
{{Other ankle injuries DDX}}
*3 views:
 
**AP: Best for isolated lateral and medial malleolar fractures
{{Distal leg fractures DDX}}
**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==
{{Foot and toe fractures DDX}}
*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


==Evaluation==
[[File:WeberARadiopediaOB.jpg|thumb|Weber A Oblique]]
[[File:WeberARadiopediaOB.jpg|thumb|Weber A Oblique]]
[[File:WeberBRadiopedOB.jpg|thumb|Weber B Oblique]]
[[File:WeberBRadiopedOB.jpg|thumb|Weber B Oblique]]
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[[File:WeberCAPMedp.jpg|thumb|Weber C AP]]
[[File:WeberCAPMedp.jpg|thumb|Weber C AP]]


==Classification (Danis-Weber System)==
*[[Ottawa Ankle Rules]] (sen 96-99% for excluding fracture)
*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 fractures
 
===Classification (Danis-Weber System)===
[[File:WeberclassRadioped.jpg|thumb|]]
[[File:WeberclassRadioped.jpg|thumb|]]
*system based on level of the fibular fx and characterizes stability of fx
*system based on level of the fibular fracture and characterizes stability of fracture
*tibial plafond and the two malleoli is referred to as the ankle "mortise" (or talar mortise)
*tibial plafond and the two malleoli is referred to as the ankle "mortise" (or talar mortise)


===Type A===
====Type A====
*fibula fx below ankle joint/distal to plafond
*fibula fracture below ankle joint/distal to plafond
**medial malleolus often fractured
**medial malleolus often fractured
**tibiofibular syndesmosis intact
**tibiofibular syndesmosis intact
**usually stable: occasionally requires ORIF
**usually stable: occasionally requires ORIF


===Type B===
====Type B====
*fibula fx at the level of the ankle joint/at the plafond
*fibula fracture at the level of the ankle joint/at the plafond
**can extend superiorly and laterally up fibula
**can extend superiorly and laterally up fibula
**tibiofibular syndesmosis intact or only partially torn
**tibiofibular syndesmosis intact or only partially torn
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**possible instability
**possible instability


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


==Differential Diagnosis==
==Management & Disposition==
*[[Ankle Sprain]]
{{General Fracture Management}}
 
{{Distal leg fractures DDX}}


== Management ==
===General Ankle Fracture===
*Determined by stability of fracture:  
*Determined by stability of fracture:  
**Stable, nondisplaced, isolated malleolar fracture: Splint or cast, early wt bearing, RICE  
**Stable, nondisplaced, isolated malleolar fracture: Splint or cast, early wt bearing, RICE  
**Unstable or displaced fracture: Requires ORIF, ortho consult, reduce and splint
**Unstable or displaced fracture: Requires ORIF, ortho consult, reduce and splint


===Isolated lateral malleolar Fracture===
===Isolated lateral malleolar fracture===
*If stable (see Weber classification) treat like severe [[Ankle Sprain]]  
*If stable (see Weber classification) treat like severe [[Ankle Sprain]]  
*Signs of instability:  
*Signs of instability:  
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**Widening of medial clear space (suggests deltoid ligament injury)  
**Widening of medial clear space (suggests deltoid ligament injury)  


===Isolated medial or posterior malleolar Fracture===
===Isolated medial or posterior malleolar fracture===
*Must rule-out other injuries  
*Must rule-out other injuries  
*If non-displaced, isolated:  
*If non-displaced, isolated:  
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**Refer to Ortho in 5-7d  
**Refer to Ortho in 5-7d  


===Lateral malleolar fracture with deltoid injury OR bimalleolar OR trimalleolar fracture ===
===Lateral malleolar fracture with deltoid injury OR bimalleolar OR trimalleolar fracture===
[[File:Bimalleolar fracture legend.jpg|thumb|Bimalleolar fracture and right ankle dislocation on X-ray (anteroposterior). Both the end of the fibula (1) and the tibia (2) are broken and the malleolar fragments (arrow: medial malleolus, arrowhead: lateral malleolus) are displaced.]]
*[[Short-Leg Posterior Splint]] (ankle at 90<sup>o</sup>)  
*[[Short-Leg Posterior Splint]] (ankle at 90<sup>o</sup>)  
*Immediate ortho consult in ED
*Immediate reduction or ortho consult in ED


==See Also==
==See Also==
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*[[Ankle Sprain]]
*[[Ankle Sprain]]
*[[Ankle Fracture (Peds)]]
*[[Ankle Fracture (Peds)]]
*[[Ottowa Ankle Rules]]
*[[Ottawa Ankle Rules]]
*[[Maisonneuve Fracture]]
*[[Maisonneuve Fracture]]
*[[Pilon Fracture]]
*[[Pilon Fracture]]
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*[[Splinting]]
*[[Splinting]]


==Source==
==References==
*Tintinalli, Uptodate, Medpix Radiology Teaching Files (Images by Dr. Timothy Sanders)
<references/>
, Uptodate, Medpix Radiology Teaching Files (Images by Dr. Timothy Sanders)
*http://radiopaedia.org/articles/weber_ankle_fracture_classification (Images by Dr. Frank Gaillard; CC SA NC BY licence)
*http://radiopaedia.org/articles/weber_ankle_fracture_classification (Images by Dr. Frank Gaillard; CC SA NC BY licence)
*Ottawa Ankle Rules - http://www.ncbi.nlm.nih.gov/pubmed?term=12595378
*Ottawa Ankle Rules - http://www.ncbi.nlm.nih.gov/pubmed?term=12595378
[[Category:Orthopedics]]
[[Category:Orthopedics]]

Revision as of 02:50, 18 September 2019

For pediatric patients, see Ankle fracture (peds)

Background

Clinical Features

  • Examine for ecchymoses, abrasions, or swelling
  • Vascular and neurologic assessment
    • DP and PT pulses
    • 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

Differential Diagnosis

Other Ankle Injuries

Distal Leg Fracture Types

Foot and Toe Fracture Types

Hindfoot

Midfoot

Forefoot

Evaluation

Weber A Oblique
Weber B Oblique
Weber B AP
Weber C Oblique
Weber C AP
  • Ottawa Ankle Rules (sen 96-99% for excluding fracture)
  • 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 fractures

Classification (Danis-Weber System)

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

Type A

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

Type B

  • fibula fracture 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 fracture 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

Management & Disposition

General Fracture Management

General Ankle Fracture

  • Determined by stability of fracture:
    • Stable, nondisplaced, isolated malleolar fracture: Splint or cast, early wt bearing, RICE
    • Unstable or displaced fracture: Requires ORIF, ortho consult, reduce and splint

Isolated lateral malleolar fracture

  • If stable (see Weber classification) treat like severe Ankle Sprain
  • Signs of instability:
    • Displacement >3mm
    • Associated medial malleolus fracture
    • Signs of medial (deltoid) ligament disruption such as medial swelling, ecchymosis, or TTP
    • Widening of medial clear space (suggests deltoid ligament injury)

Isolated medial or posterior malleolar fracture

  • Must rule-out other injuries
  • If non-displaced, isolated:

Lateral malleolar fracture with deltoid injury OR bimalleolar OR trimalleolar fracture

Bimalleolar fracture and right ankle dislocation on X-ray (anteroposterior). Both the end of the fibula (1) and the tibia (2) are broken and the malleolar fragments (arrow: medial malleolus, arrowhead: lateral malleolus) are displaced.

See Also

References

, Uptodate, Medpix Radiology Teaching Files (Images by Dr. Timothy Sanders)

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