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Male Speaker: Our next speaker is Dr. Marie Williams. Marie and I go back a long way in many, many areas of education, workshops, lecturing in foot and ankle surgery. Iâve always called upon Marie to share her insight into more advanced type of problems, lateral ligament repairs, peroneal tendon disruption, posterior tibial tendon, Achilles. And today, weâre going to call upon her to deal with ankle fractures.
She is an accomplished surgeon. She is well-respected in our profession, excellent speaker, and sheâs a fabulous basketball player and has won awards for that. Sheâs probably prouder than that than She is being the foot and ankle surgeon. But in any event, please welcome Dr. Marie Williams
Marie Williams: Well, thank you. Yes, and I love basketball and ankle fractures and ankle injuries are really something that you see quite often in that sport. But when I look at the topic of ankle fractures, itâs a pretty didactic lecture. When I talk about that, itâs not like weâre going to see a hundred pictures because what you really want to do is understand the classifications for ankle fractures, understand the methods of the treatment for an acute ankle fracture, as well as know and understand the different types of fixations. Iâm just going to show you a few of the types of fixations for the both medial and lateral ankle fractures.
Fixation is really a thing where you, as a practitioner, will decide on what company you want to use. Sometimes a hospital will tell you and then youâre going to fit the needs of that to the patient. But whatâs important is you should know your anatomy, excuse me, you should know your anatomy, especially the ankle ligaments. This is -- I donât have to really review this with you, but itâs just a good picture to show all the different types of ligaments that youâre going to be dealing with once an ankle is injured.
When you look at the Lauge-Hansen classification, which is the classic classification, when I was in school, in podiatry school, I really felt that this was a difficult classification to learn because there were so many âmoving partsâ. It was created to just -- to tell you how to reduce the fracture. It was also used to show and identify where the fractures will be with the type of injury and it was really a biomechanical type of a classification. The -- it was created to direct your closed reduction. The reduction maneuver was used to actually put the ankle back in place to its original position and by reversing the mechanism of injury. So mechanism of injury became very important.
The concept has become less important in guiding treatment as operative fixation becomes more popular. So it was initially really designed to put that foot back in alignment and in this arena, presently, it really doesnât matter as far as the actual mechanism of injury when it comes right down what plate, or screw, or how youâre going to fix it. Weâll go over that a little bit more. But itâs important that you look at these because youâre going to be -- as residents, youâll definitely be tested on it.
You definitely think with the type and mechanism of injury when youâre trying to repair these things. And maybe when the reduction isnât going quite the way you want it, you go, âOh, wait a minute. Supination-external rotation.â What is it? Itâs an injury of the anterior-inferior tibiofibular ligament. Thereâs an oblique spiral fracture of the distal fibula which is very classic. Everybody asks that.
Itâs an injury to the posterior-inferior tibiofibular ligament or an avulsion fracture of the posterior malleoli. And the medial malleoli fracture or -- can be -- thereâs a medial malleoli or an injury to the deltoid. So thatâs what a supination-external rotation injury is. Itâs really the mechanism. They talk about it like a clock and the talus is moving as the foot is pronating or supinating and where that talus pushes up against the bone fragment in the direction of the foot.
So just an example of an SER. You can see here you get a small fibular fracture, medial -- a little spiral oblique fracture. And what youâre looking for also is diastasis. Iâm going to move on a little bit. This is just a spiral oblique fracture of the fibula. Youâre going to plate it. Youâre going to put interfrag screw on it to maintain the fracture. Itâs actually a simple fixation in a complex fracture because all youâre doing is youâre reducing the supination and the external rotation of the foot to the ankle and the fibula will realign.
Another one is now where it becomes a little bit more complex, where the foot continues to deform. And now, what youâll see is a fracture of the medial mal and the talus is butting up against the fibula, becoming the deforming force against the fibula. And now, youâll either destroy the deltoid ligament or youâll injure and have a fracture of the medial malleolus.
In a simple fixation, I use this fibula rod in a lot of the cases. Iâve done lectures on fibula rod because I love it, especially in the elderly where you donât want to open them up a lot. You want to put a -- align the fragment where youâre actually putting the fibula rod in with the medial mal screw.
Youâre talking about minimally invasive incisions which is the new terminology now of minimal-type surgery and yet, you can actually realign that fibula with good strength and get them ambulating much stronger.
This patient, by the way, that we did this on, was someone who had cardiac issues, was 92-years-old and, believe it or not, very active. If you would have not fixed the -- fixated that dislocated ankle, fracture dislocation of the ankle, she wouldnât walk and then she would be more debilitated. So to me, itâs important to look at all factors when youâre looking at an ankle fracture fixation.
Supination-adduction is a transverse fracture of the distal fibula and a vertical fracture of the medial mal. So youâre looking at the fracture pattern so you know that this foot was supinated and adducted and the talus will cause a POA fracture or transverse fracture of the distal fibula with a vertical fracture because itâs banging up into the medial mal, causing that vertical force. And hereâs an example of that where you can see you have the small fibula fracture with the vertical -- medial mal fracture supination-adduction.
Pronation-external rotation is a medial malleolar fracture or injury to the deltoid ligament. An injury of the anterior-inferior tibiofibular ligament which is important when youâre thinking about an ankle diastasis. An oblique spiral fracture of the fibula proximal to the tibial plafond. So you have a high fibula fracture and an injury of the in -- posterior-inferior tibiofibular ligament or an avulsion fracture of the posterior malleolus.
Just an example of a PER where you have a widening gap, where you have deltoid tear, and youâll have a higher fibular fracture. Sometimes youâll see that high-impact fracture or you can see where the arrows are where youâll have this spiral oblique fracture of the fibula, but youâll get that POAF or that transverse fracture of the medial mal and sometimes youâll get a diastasis.
Not fixing a diastasis in an ankle fracture, to me, is one of the biggest failures that you have when youâre fixating ankles because youâll have what we call a valgus or a valgus foot which leads to more pain long term. So weâll talk about that a in a little bit.
Pronation-abduction. The medial malleoli, thereâs a fracture there or an injury to the deltoid. Injury of the anterior-inferior tibiofibular ligament and a transverse or a comminuted fracture of the fibula proximal to the tibial plafond. So just high, again, fracture and you can see it here where you have the medial mal fracture and then youâll see the -- youâll see up in the leg. On the -- up on the leg, youâll see a fracture, a little bit higher up, a fibula fracture. But Iâm pointing out with the arrow there that this is something thatâs never talked about too much, but sometimes in these pronation-adduction injuries, you can get a calcaneal fracture in combination and Iâve seen that many times where you think itâs an isolated fracture, but itâs really a combination of both injuries. So donât be surprised if you have a calcaneal fracture with these.
To me, one of the easiest classifications and also can correlate with the Lauge-Hansen classification is the Danis-Weber classification. Itâs based on a fracture pattern that is determined from the radiographic appearance of the fracture site, the fibula. Itâs not based on foot position or the mechanism of injury. So itâs really a radiographic definition. The system ignores the medial side of the ankle, which plays an important role in determining ankle stability and function.
So weâre talking more of where is the fibular fracture, and then youâll see what else comes with it. So in a Danis-Weber Type A, itâs below the level of the talar dome, usually a transverse fracture. And the tibiofibular syndesmosis is intact so you donât have a diastasis. The deltoid ligament is intact. The medial mal occasionally is fractured but not usually. And usually, it is a very stable medial malleoli. And if itâs fractured, itâs also stable. So itâs a stable type of fracture, something that may not need surgical intervention. So hereâs just an example of that where you have a fracture of the distal fibula below the syndesmosis. No medial mal injury at all. And B, it actually gets a little bit more complex. You have a distal extension at the level of the talar dome. It may extend some distance proximally. So youâre coming either out of or above the talar dome. Itâs usually spiral -- spiral oblique type fracture. The tibiofibular syndesmosis usually is intact but widened at the distal tibiofibular joint, especially or straight on -- especially on stressed fuse. And it indicates a syndesmotic injury. The medial mal maybe fractured, the deltoid ligament may be torn, and indicates widening of the space between the medial mal and the talar dome.
And also itâs variably stable depending on the status of the medial mal structures or the medial structures in the syndesmosis. This is the type of fracture you definitely should -- it says may need ORIF, I say it needs ORIF. You really need to actually stabilize the medial side of the foot as well as the lateral side, fixate the fibula, and the medial mal. Thereâs a lot of literature out there now that states, âFix the medial side before you fix the lateral side.â We were always taught, you fix and align the fibula and then you go back and you fix the medial mal.
But I can tell you with experience that sometimes, as much as youâre trying to realign the fibula, you canât. And you, kind of, start scratching your head and you wonder why. Itâs because on the medial side of the foot, you have the posterior tibial tendon which is a very strong tendon. Sometimes it gets transposed in between or around the medial fractures. So unless you get those soft tissues freed and loosened, the fibula wonât go in alignment and neither will medial malleoli.
So this Danis-B Weber has three parts, one is just an isolated injury. The B2 is associated with the medial lesion or the medial malleolus and/or the ligament. And B3 is associated with the medial lesion and a fracture at the posterior lateral tibia. So it gets, as I said, the Danis-Weber B becomes a little bit more complex in a sense that it has either the fibular fracture or includes the medial side of the foot.
And hereâs an example where you have a fibular fracture above the talar dome. And then you also have gapping or widening in the medial ankle which you know the deltoid ligament is now injured. So you have to decide if you need to repair the deltoid. And you must repair that fibular fracture. It is slightly shortened and that needs to be put back in place.
Now, Danis-Weber C gets a little bit more complex because itâs above the level of the ankle joint. The tibiofibular syndesmosis is ruptured and thereâs widening in the distal tibiofibular articulation. I donât know if youâve ever seen a patient whose had an ankle fracture who never had that repaired, but itâs someone -- Iâve actually had cases where they come in a year, two years later and theyâre limping in, and they said, âI had my ankle repaired but my ankleâs still very painful. And it hurts on the outside -- around and the top of my ankle, on the anterior lateral side.â
They always point the anterior lateral side. And they say that their foot starts to pronate. They notice that the foot is turning in or turning out. So now, the footâs unstable and you actually just have to palpate right over where the anterior inferior tibiofibular ligament is, and it is exquisitely painful.
Those fractures, even though they had an ORIF fibular, the place look great, screws are perfect, itâs actually a failure in the sense that you didnât correct the diastasis. So donât forget to correct syndesmosis. A lot of times that gets missed and Iâm really a big proponent of making sure thatâs fixated.
The medial mal fractures are also noted in the Danis-Weber Type C with a deltoid injury. Fractures may arise at the proximal -- at proximal, at the level of the fibular neck as well, but sometimes not visualized with just basic ankle x-rays. So make sure youâre also x-raying the whole fibula of the leg, if you think that this is a Danis-Weber C. Because itâs going to be -- it can be a very high fracture as well. And theyâre very unstable and you should do ORIF of that ankle.
So hereâs -- they break it down into three parts, C1, C2 and C3. Thereâs a distal diaphyseal fracture of the fibula, which is a very simple fracture. Then thereâs a diaphyseal fracture of the fibular complex and a proximal fracture of the fibula. Thatâs 1, 2 and 3. A fracture above the syndesmosis results from external rotation or abduction forces that also cause disruption of the joint. And itâs usually associated with an injury to the medial side of the foot, whether you will get a deltoid injury and or a fracture of the medial mal.
And hereâs just some pictures of a Danis-Weber C.
The next classification is something that is now being used in January 2018, the reference is in the lecture. The orthopedic -- and the Orthopaedic Trauma Association came out with a new classification. They basically took into account the injuries of both the medial and posterior malleoli as well as the fibula. And it is a comprehensive evaluation of fractures based on the ability to speak doctor-to-doctor.
Itâs kind of interesting because if you just talk to -- if you talk to orthopedist and a trauma podiatrist, and a trauma orthopedist, they can talk this Lauge-Hansen, Weber classification. But if you were actually a resident trying to discuss this fracture with one of those non-trauma surgeons, this might be a better way to communicate. Why? The AO system actually was based on the ICD-10 Codes which is, kind of, crazy, the location, the type, the bone, they gave all the bones numbers. So when you see these numbers, theyâre based on that classification in the ICD-10.
For example, and this is just -- itâs a little bit hard to see as itâs a little -- oh, you can see it pretty well. Itâs an alphanumeric code and the tibia and the fibula are 4. So when you see something that says itâs a 44A, or a 44B, or 44C, youâre talking about the fibula and the tibia in lower distal areas. Above the -- below the syndesmosis, at the syndesmosis, and above the syndesmosis. Very close to the Danis-Weber classification. You can also put it into a Lauge-Hansen classification but itâs actually an alphanumeric code, and that is something that we tend to speak of now with the ICD-10.
So in Type A, you have a fibular fracture below the syndesmosis, itâs called infrasyndesmotic.
Usually thereâs either an isolated fracture of the fibula with no medial mal fracture, or the fracture -- you have the fibular fracture with a medial mal fracture, or you have the fibular fracture with, including with a posteromedial fracture or fragment. So you have A1, 2, and 3. So itâs called 44A1, fibular fracture below the syndesmosis.
Hereâs 1A2. So now you have the fibular fracture below the syndesmosis. Thereâs a little pull off at the fibula and then you have the transverse fracture, the medial mal A2.
And then you have A3 where it gets a little bit more where you have a -- you have a little bit of a -- you have the fibula fracture, the medial mal fracture, and you also have a small posterior fragment or a posterior fragment, A3. So thatâs it the A fractures.
Now you have the AO type B, fibular fracture at the level of the syndesmosis, so weâre doing it a like a Dani-Weber B and is isolated with no minimal mal fracture or deltoid ligament fracture. And then you have A1 which is now above the -- at the syndesmosis erba, a little bit above with beginnings to get some injury to the medial mal in B2 or a ligament fracture and also a rupture of the interior syndesmosis anterior-inferior tibiofibular ligament. So thatâs on AB2.
And there is the example of that where you have a fibular fracture, the widening gap of the medial mal with the -- with a medial mal fracture. To me, itâs really important to close that gap and get that repaired. So that when they arch long term, they donât get a valgus foot and also create injuries more to the talar tibial complex.
B3 is a wedge or a multi fragment fibular fracture above the syndesmosis with the medial injury at the medial -- and a medial lesion and a fracture of the posterior lateral tibia. So you can see the B3 where it gets a little bit more complex, youâre getting a little bit more of an injury to the ankle itself and youâre getting that POAF fracture immediately.
When you get to the type C, now you have the fibular fracture above the syndesmotic injuries, supra-syndesmotic. In the C1 you get the absolute fracture of the fibula simple with the rupture of the deltoid, it gets a little bit more complex. There you go. You can see the widening and medial aspect of the ankle with a deltoid rupture and a higher fibula fracture above supra-syndesmotic. This also has an anterior-inferior tibiofibular ligament disruption and you can see the widening there at the level of the syndesmosis, that should be fixed.
C2 is the fracture of the fibula diaphyseal fracture of the fibula which becomes more complex with a fracture of the medial mal. Thatâs a C2 and thatâs an example of that. And then the C3 is a proximal fracture of the fibula with the medial mal and a posterior mal fracture, trimalleolar.
And you can see that where you get more dislocation, disruption. You can see here where the actual -- let me just back up. Iâm sorry. Where the more disruption of the ankle, you get that push off fracture in the back of the tibia of the posterior mal. If itâs off significantly, you need to repair it. If it can be reduced, after you reduce your fibula and your medial mal, you donât have to go back and prepare it but if you have at least a third of it off and you have ankle joint disruption there, you should fixate it.
Now, this is interesting because this was a disruption of -- this is an ankle ligament injury. This was a basketball injury, the gentleman came down playing basketball, he rebounded, hits someoneâs foot and dislocated his whole ankle. What was a miracle about this is not one bone was fractured. This is him post reduction. There was no fibular fracture, there is no medial mal fracture, there was no syndesmotic injury.
But one of the things that was really, really critical to this repair, to me, was most -- the ortho just said, âOh, good put him in a cast and leave him alone.â This is a 19-year-old boy whoâs going to go back to playing basketball. He was like six-foot-four, six-foot-five. He could jump -- he could really jump. And a simple procedure of the deltoid deep and superficial ligament repair put this guy back on the court in 8 weeks, where normally if he didnât fixate it, he wouldnât be back to playing a game like that probably ever. So the deltoid I think needs to be repaired and addressed, thatâs very important.
Oh, hereâs that deltoid. Itâs like a miracle that none of the bones are broken but the deltoid was ripped into a complete draft transverse tear of the deltoid which we did an end-to-end repair with graft or after the ankle fracture dislocation.
Now, I donât know, when I go to the emergency room I see something like that, I go, âOh, let me see is that a SER 4 or is that a OAAO44CB?â No, I go there I go, âWow thatâs bad. Yeah, letâs get that reduced.â Number 1, most important thing is reduce the fracture. Donât let that sit there. Sometimes the ER residents are waiting for someone to come to reduce the fracture. That has to be reduced. You donât -- you donât want that foot being dislocated for that long.
Sometimes you try to reduce it and you canât. It goes to the OR that day. You donât wait. âOh, letâs wait for the swelling to go down.â âIt hasnât swelled yet, letâs fix it.â So I bring them right away as soon as I get them and theyâre not swollen, theyâre going to the OR. Minimally, they need to be reduced because right now, the talus is being impinged upon and damaged besides the fact that the fractures are very dislocated. The other thing you needed to do on these occasions is make sure that they have a good flow to their foot, Doppler the dorsalis pedis and post or tib.
This is that same patient went back when we did ORIF of both the medial mal and the fibula. We actually reduced the fracture quite readily and the fracture itself is in good alignment. You know that youâre going to get early active range of motion, youâre going to keep them six weeks or four to six weeks non-weight bearing but youâre going to get good active range of motion. I start them range of motion very soon. I make sure that the talus is back in the mortise.
The other thing that is missed on a lot of these repairs is that you get -- you fix the fibula, you fix the medial mal and the talus is dislocated, because with the type of injury you have the talus may shift in the ankle mortise. So I put the talus back, I do it with ankle sprains and I do it with ankle fractures. I always get that talus back in its mortise.
So basically, I personally am not someone who will tell you what type of injury -- I mean I know what injury it is. I know -- I could say thatâs a pronation external rotation. I could tell you that itâs a Danis-Weber B. I can tell you that itâs AOC3. I can tell you that, but really, that doesnât really help the patient very much. What you really need to know is the precise mechanism of the fracture and also make sure that you determine how much injury there is to the soft tissues and the remaining fracture segment.
Youâre going to look at the medial mal, youâre going to look at the fibula. Youâre going to look at the deltoid ligament, the anterior-inferior tibiofibular ligament which is very key to fixing an ankle fracture and making sure thatâs stable. Whether you do an interfrag screw or a tight rope, something must be done to make and ensure that actually is stabilized. And being able to look at the classifications will help you in the sense that you can identify the presence of the types of fractures, but in the ultimate end, what youâre really want to do is be able to rapidly get these patients fixed.
If theyâre there and theyâve been waiting and thereâs a lot of swelling, you do have a window of opportunity to wait seven days, five to seven days. If thereâs fracture blisters, definitely wait. But make sure that you have this reduced as best you can prior to actually putting them in a splint and waiting.
In the absence of a fibular fracture identify the medial mal fracture or the medial mortise widening or both the deltoid. And thatâs important or a helpful tool in classifying your ankle fractures. Make sure that that you know these are just some teaching points, the supination external rotation is the most common mechanism of the fractures accounting for 40% to 70% of all ankle fractures. So when I say to my residents, âWhat type of fracture is that?â And they go, âSER.â 70% of the time theyâre probably going to be right. Even if they donât know if theyâre right or not because itâs very common.
And these are some of the references. Thereâs just quite a few in the lecture I put there because I think that most important is that things are changing and I just -- you know, let me go back one picture. In the very end there, itâs -- the journal of orthopedic trauma in January 2018, they talked about all the segments.
I think itâs worth because itâs not really something that I found -- its newly being taught, so I think you should take a look at that if you havenât. I took a lot of time looking over that and understanding the bone fractures and fragments in numbers and I think thatâll help you as well.
So any questions? Thank you very much.
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