Ankle fracture: Difference between revisions
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''For pediatric patients, see [[Ankle fracture (peds)]] | |||
==Background== | ==Background== | ||
==Clinical Features== | ==Clinical Features== | ||
*Examine for ecchymoses, abrasions, or swelling | *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) | **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 | *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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{{Foot and toe fractures DDX}} | {{Foot and toe fractures DDX}} | ||
== | ==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]] | ||
*[[Ottawa Ankle Rules]] (sen 96-99% for excluding | *[[Ottawa Ankle Rules]] (sen 96-99% for excluding fracture) | ||
*3 views: | *3 views: | ||
**AP: Best for isolated lateral and medial malleolar fractures | **AP: Best for isolated lateral and medial malleolar fractures | ||
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***At a point 1 cm proximal to tibial plafond space between tib/fib should be ≤6mm | ***At a point 1 cm proximal to tibial plafond space between tib/fib should be ≤6mm | ||
**Lateral: Best for posterior malleolar fractures | **Lateral: Best for posterior malleolar fractures | ||
*consider proximal tib/fib films and talus | *consider proximal tib/fib films and talus fractures | ||
===Classification (Danis-Weber System)=== | ===Classification (Danis-Weber System)=== | ||
[[File:WeberclassRadioped.jpg|thumb|]] | [[File:WeberclassRadioped.jpg|thumb|]] | ||
*system based on level of the fibular | *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 | *fibula fracture below ankle joint/distal to plafond | ||
**medial malleolus often fractured | **medial malleolus often fractured | ||
**tibiofibular syndesmosis intact | **tibiofibular syndesmosis intact | ||
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====Type B==== | ====Type B==== | ||
*fibula | *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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====Type C==== | ====Type C==== | ||
*fibula | *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 | ||
== Management & Disposition== | ==Management & Disposition== | ||
{{General Fracture 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 | ||
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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 reduction or ortho consult in ED | *Immediate reduction or ortho consult in ED | ||
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*[[Ankle Sprain]] | *[[Ankle Sprain]] | ||
*[[Ankle Fracture (Peds)]] | *[[Ankle Fracture (Peds)]] | ||
*[[ | *[[Ottawa Ankle Rules]] | ||
*[[Maisonneuve Fracture]] | *[[Maisonneuve Fracture]] | ||
*[[Pilon Fracture]] | *[[Pilon Fracture]] | ||
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*[[Splinting]] | *[[Splinting]] | ||
== | ==References== | ||
<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
- Tibial plateau fracture
- Tibial shaft fracture
- Pilon fracture
- Maisonneuve fracture
- Tibia fracture (peds)
- Ankle fracture
- Foot and toe fractures
Foot and Toe Fracture Types
Hindfoot
Midfoot
Forefoot
Evaluation
- 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)
- 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
- Acute pain management
- Open fractures require immediate IV antibiotics and urgent surgical washout
- Neurovascular compromise from fracture requires emergent reduction and/or orthopedic intervention
- Consider risk for compartment syndrome
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:
- Short-Leg Posterior Splint (ankle at 90o)
- Non-weight bearing
- Refer to Ortho in 5-7d
Lateral malleolar fracture with deltoid injury OR bimalleolar OR trimalleolar fracture
- Short-Leg Posterior Splint (ankle at 90o)
- Immediate reduction or ortho consult in ED
See Also
- Ankle (Main)
- Ankle Sprain
- Ankle Fracture (Peds)
- Ottawa Ankle Rules
- Maisonneuve Fracture
- Pilon Fracture
- Fracture (Main)
- Splinting
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)
- Ottawa Ankle Rules - http://www.ncbi.nlm.nih.gov/pubmed?term=12595378