Ankle fracture: Difference between revisions
No edit summary
(39 intermediate revisions by 8 users not shown)
Line 1: Line 1:
==Physical Exam==
{{Adult top}} [[ankle fracture (peds)]]
==Background==
 
==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)
*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)'''
**Perform a crossed-leg test to detect syndesmotic injury
**Perform a crossed-leg test to detect syndesmotic injury
*Evaluate integrity of Achilles tendon (Thompson test)
*Evaluate integrity of Achilles tendon ([[Achilles Tendon Rupture#Clinical Features|Thompson test]])
*Palpate midfoot and base of 5th metatarsal for tenderness
*Palpate midfoot and base of 5th metatarsal for tenderness


==Diagnosis==
==Differential Diagnosis==
*[[Ottawa Ankle Rules]]
{{Other ankle injuries DDX}}
 
{{Distal leg fractures DDX}}
 
{{Foot and toe fractures DDX}}
 
==Evaluation==
[[File:WeberARadiopediaOB.jpg|thumb|Weber A Oblique]]
[[File:WeberBRadiopedOB.jpg|thumb|Weber B Oblique]]
[[File:WeberBAPMedp.jpg|thumb|Weber B AP]]
[[File:WeberCOBMedp.jpg|thumb|Weber C Oblique]]
[[File:WeberCAPMedp.jpg|thumb|Weber C AP]]
 
*[[Ottawa Ankle Rules]] (sen 96-99% for excluding fracture)
*3 views:
*3 views:
**AP
**AP: Best for isolated lateral and medial malleolar fractures
***Best for isolated lateral and medial malleolar fractures
**Oblique (mortise)
**Oblique (mortise)
***Best for evaluating for unstable fracture or soft tissue injury
***Best for evaluating for unstable fracture or soft tissue injury
***At a point 1cm proximal to tibial plafond space between tib/fib should be ≤6cm
***At a point 1 cm proximal to tibial plafond space between tib/fib should be ≤6mm
**Lateral  
**Lateral: Best for posterior malleolar fractures
***Best for posterior malleolar fractures
*consider proximal tib/fib films and talus fractures
*Determine if ankle fracture is:
**Unimalleolar
**Bimalleolar
**Trimalleolar
 
==Classification (Danis-Weber System)==
System based on level of the fibular fx and characterizes stability of fx


===Type A (supination-adduction injury)===
===Classification (Danis-Weber System)===
[[File:WeberclassRadioped.jpg|thumb|]]
*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)


*Fibular Fx at or below level of ankle joint (talar mortise) without syndesmotic involvement
====Type A====
*Typically stable
*fibula fracture below ankle joint/distal to plafond
*Deltoid ligament usually intact, medial malleolus usually fx
**medial malleolus often fractured
**A1: isolated
**tibiofibular syndesmosis intact
**A2: medial malleolus fx
**usually stable: occasionally requires ORIF
**A3: posteromedial fx


===Type B (supination-external rotation injury)===
====Type B====
*Fibular Fx at level of ankle joint (talar mortise) w/ partial syndesmotic ligament injury
*fibula fracture at the level of the ankle joint/at the plafond
*Stability dictated by integrity of tibiofibular syndesmosis (no widening of distal tibiofibular articulation)
**can extend superiorly and laterally up fibula
*Deltoid ligament may be torn, medial malleolus usually fx
**tibiofibular syndesmosis intact or only partially torn
**B1: isolated
**no widening of the distal tibiofibular articulation
**B2: medial lesion (either malleolus or ligament)
**medial malleolus may be fracture
**B3: medial lesion and fx of posterolateral tibia
**possible instability


===Type C (pronation-eversion injury)===
====Type C====
*Fibular Fx above level of ankle joint (talar mortise) w/ complete syndesmotic disruption
*fibula fracture above the level of the ankle joint/proximal to plafond
*Unstable (widened distal tibiofibular articulation) and require surgical correction
**tibiofibular syndesmosis disrupted with widening of the distal tibiofibular articulation
*Deltoid ligament torn, medial malleolus fx
**medial malleolus fracture
**C1: simple diaphyseal fibular fracture
**unstable: requires ORIF
**C2: complex diaphyseal fibular fracture
**C3: proximal fracture


[[File:WeberclassRadioped.jpg|center|frame|300px]]<br>
==Management & Disposition==
{{General Fracture Management}}


== 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


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


==X-rays==
===Lateral malleolar fracture with deltoid injury OR bimalleolar OR trimalleolar fracture===
[[File:WeberARadiopediaOB.jpg|center|frame|100px|Weber A Oblique]]
[[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.]]
[[File:WeberBRadiopedOB.jpg|center|frame|50px|Weber B Oblique]]
*[[Short-Leg Posterior Splint]] (ankle at 90<sup>o</sup>)
[[File:WeberBAPMedp.jpg|center|frame|50px|Weber B AP]]
*Immediate reduction or ortho consult in ED
[[File:WeberCOBMedp.jpg|center|frame|100px|Weber C Oblique]]
[[File:WeberCAPMedp.jpg|center|frame|50px|Weber C AP]]


==See Also==
==See Also==
*[[Ankle (Main)]]
*[[Ankle Sprain]]
*[[Ankle Sprain]]
*[[Ankle Fracture (Peds)]]
*[[Ankle Fracture (Peds)]]
*[[Ottowa Ankle Rules]
*[[Ottawa Ankle Rules]]
*[[Maisonneuve Fracture]]
*[[Maisonneuve Fracture]]
*[[Pilon Fracture]]
*[[Pilon Fracture]]
Line 94: Line 102:
*[[Splinting]]
*[[Splinting]]


==Source==
==References==
*Tintinalli, Uptodate, Radiopaedia.org (Images by Dr. Frank Gaillard), Medpix Radiology Teaching Files (Images by Dr. Timothy Sanders)
<references/>
 
, Uptodate, Medpix Radiology Teaching Files (Images by Dr. Timothy Sanders)
[[Category:Ortho]]
*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
[[Category:Orthopedics]]

Revision as of 22:45, 28 November 2019

This page is for adult patients. 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)

Retrieved from "https://www.wikem.org/w/index.php?title=Ankle_fracture&oldid=238284"