Stability-based classification for ankle fracture management and the syndesmosis injury in ankle fractures due to a supination external rotation mechanism of injury.

The aim of this thesis was to confirm the utility of stability-based ankle fracture classification in choosing between non-operative and operative treatment of ankle fractures, to determine how many ankle fractures are amenable to non-operative treatment, to assess the roles of the exploration and anatomical repair of the AITFL in the outcome of patients with SER ankle fractures, to establish the sensitivities, specificities and interobserver reliabilities of the hook and intraoperative stress tests for diagnosing syndesmosis instability in SER ankle fractures, and to determine whether transfixation of unstable syndesmosis is necessary in SER ankle fractures. The utility of stability based fracture classification to choose between non-operative and operative treatment was assessed in a retrospective study (1) of 253 ankle fractures in skeletally mature patients, 160 of whom were included in the study to obtain an epidemiological profile in a population of 130,000. Outcome was assessed after a minimum follow-up of two years. The role of AITFL repairs was assessed in a retrospective study (2) of 288 patients with Lauge-Hansen SE4 ankle fractures; the AITFL was explored and repaired in one group (n=165), and a similar operative method was used but the AITFL was not explored in another group (n=123). Outcome was measured with a minimum follow-up of two years. Interobserver reliability of clinical syndesomosis tests (study 3) and the role of syndesmosis transfixation (study 4) were assessed in a prospective study of 140 patients with Lauge-Hansen SE4 ankle fractures. The stability of the distal tibiofibular joint was evaluated by the hook and ER stress tests. Clinical tests were carried out by the main surgeon and assistant, separately, after which a 7.5-Nm standardized ER stress test for both ankles was performed; if it was positive, the patient was randomized to either syndesmosis transfixation (13 patients) or no fixation (11 patients) treatment groups. The sensitivity and specificity of both clinical tests were calculated using the standard 7.5-Nm external rotation stress test as reference. Outcome was assessed after a minimum of one year of follow-up. Olerud-Molander (OM) scoring system, RAND 36-Item Health Survey, and VAS to measure pain and function were used as outcome measures in all studies. In study 1, 85 (53%) fractures were treated operatively using the stability based fracture classification. Non-operatively treated patients reported less pain and better OM (good or excellent 89% vs. 71%) and VAS functional scores compared to operatively treated patients although they experienced more displacement of the distal fibula (0 mm 30% vs. 69%; 0-2 mm 65% vs. 25%) after treatment. No non-operatively treated patients required operative fracture fixation during follow-up. In study 2, AITFL exploration and suture lead to equal functional outcome (OM mean, 77 vs. 73) to no exploration or fixation. In study 3, the hook test had a sensitivity of 0.25 and a specificity of 0.98. The external rotation stress test had a sensitivity of 0.58 and a specificity of 0.9. Both tests had excellent interobserver reliability; the agreement was 99% for the hook test and 98% for the stress test. There was no statistically significant difference in functional scores (OM mean, 79.6 vs. 83.6) or pain between syndesmosis transfixation and no fixation groups (Study 4). Our results suggest that a simple stability-based fracture classification is useful in choosing between non-operative and operative treatment of ankle fractures; approximately half of the ankle fractures can be treated non-operatively with success. Our observations also suggest that relevant syndesmosis injuries are rare in ankle fractures due to an SER mechanism of injury. According to our research, syndesmotic repair or fixation in SER ankle fracture has no influence on functional outcome or pain after minimum one year compared with no fixation.

Fracture of calcaneum following drop foot surgery--a case report.

The usual protocol for correction of drop foot in leprosy, a consequence of damage to the common peroneal nerve, is a tendon transfer, immobilisation to heal the tendon juncture and post-operative exercises to put the transfer into use. Tarsal disintegrations have been reported in literature in drop foot patients when the transferred tendons were inserted into the bone making a drill hole to ensure firm anchorage. Such disintegrations are rarely seen these days because bony insertion of the tendon transfers is not performed in the leprosy-affected foot. We report here a case of drop foot that developed a fracture of the calcaneum during the post-operative period after tibialis posterior two tail transfer (to tibialis anterior and extensor digitorum longus) along with lengthening of the tendoachillis. The case is interesting in the sense that osteoporosis and walking strains resulted in a fracture of the body of the calcaneum which healed with conservative treatment and controlled mobilisation of the patient.

The often overlooked digital tuft: clues to diagnosis and pathophysiology of neuropathic disease and spondyloarthropathy.

OBJECTIVE: To assess diagnostic implications of abnormalities of the pedal digital tufts and to identify features to facilitate distinguishing of spondyloarthropathy and leprosy. BACKGROUND: Better criteria for distinguishing between these disorders are necessary if their character, natural history, and evolution are to be understood. METHODS: Pedal x rays of 91 consecutive patients with diabetes, 21 alcoholic patients, 100 with spondyloarthropathy, 8 with scleroderma, and 137 with leprosy, and 188 defleshed skeletons of individuals with alcoholism, syphilis, cerebrovascular disease, and paraplegia from the Terry and Hamman-Todd collections were examined for evidence of osseous and articular pathologies. Digital tuft abnormalities were divided into irregularity, divot, flattening, resorption, whittling, and fragmentation. RESULTS: Tuft divots were more common in alcoholics than in diabetic, and were more common in both than in the other groups studied. Tuft flattening was limited to alcoholic and neurosyphilis groups. Tuft whittling was especially prominent among individuals with spondyloarthropathy, contrasted with leprosy and diabetes. Aligned fractures were more common in diabetics than individuals with leprosy. Misaligned fractures were limited to individuals with leprosy and neurosyphilis. Leprosy and spondyloarthropathy were complicated by phalangeal and metatarsal whittling more commonly than other diseases studied. Background pedal abnormalities, derived from individuals with cardiovascular syphilis, cerebrovascular accidents, and paraplegia, was limited to abnormal divots only. CONCLUSIONS: Pedal digital tufts undergo a variety of pathological alterations useful in the recognition of disorders traditionally considered neuropathic in aetiology and in distinguishing differential considerations. Tuft flattening appears specific for alcoholism and neurosyphilis, and misaligned fractures seem specific for neurosyphilis and leprosy, providing differential assistance related to spondyloarthropathy. Conversely, periosteal reaction distinguishes spondyloarthropathy from leprosy.

Ankle fractures. The Lauge-Hansen classification revisited.

Rational treatment of ankle fractures requires knowledge of the extent of bone and soft tissue injury. Although the Lauge-Hansen classification attempts to do this by relating specific fracture patterns to injury mechanism, the experimental underpinning for this classification has not been reexamined rigorously using modern experimental methods. This study examines the hypothesis that the clinically occurring supination and external rotation injury pattern does not result from the mechanism described by Lauge-Hansen. Thirty-two anatomic specimen ankles were mounted on an MTS machine for combined axial loading with external rotation to failure testing. A foot plate supinated the foot 25 degrees. Testing was performed with the ankle at neutral, 25 degrees plantar flexed, 10 degrees to 15 degrees dorsiflexed, and in 6 degrees to 8 degrees leg valgus. Pure supination and external rotation with the ankle in neutral did not result in the Lauge-Hansen supination and external rotation type fractures. This outcome was not altered if the ankle specimens initially were placed in plantar flexion or dorsiflexion. The addition of a valgus load, which pushes the talus laterally against the fibula, resulted in the classic Lauge-Hansen supination and external rotation type fracture. All specimens had an isolated lateral injury or a lateral injury that preceded medial injury.

Isolated posterior malleolar ankle fractures.

The isolated posterior malleolar fracture is a genuine clinicopathologic entity, albeit a relatively rare one. Frequency of occurrence is approximately 1% of all reported ankle fractures. It can be mechanistically explained within the parameters of the Lauge-Hansen classification. An understanding of the mechanism of injury is crucial to the diagnosis of associated soft tissue injury and to the correct management of the entire complex of peritalar disruption. Two cases of isolated posterior malleolar fracture are presented.

[The pattern of injuries of the ankle joint in ski boots--a retrospective analysis]. / Das Verletzungsmuster des Sprunggelenkes im Skischuh--eine retrospektive Analyse.

This study is dealing with the analysis of isolated ankle fractures in ski boots which are nowadays very seldom. Modern equipment and excellent prepared skiing facilities reduced this kind of trauma. In the early sixties about 60% of lower extremity injuries were caused by ankle fractures. Now, 25 years later, only 10% of injuries concerning to lower extremity are injuries of medial and lateral ankle or of the talofibular ligaments. At the department of trauma surgery of the university hospital of Innsbruck we use a questionnaire for winter sports injuries. We made a retrospective follow up study of the last three years, in which we found 100 patients with ankle injuries. Pilon tibial- and tibia shaft fractures are not included. The classification was made by the Lauge-Hansen system. Supination-inversion and supination-eversion fractures were found more often than others. Fractures of both medial and lateral ankles were only seen in three cases. One reason for this result could be a lack of movement of the ankle in the ski-boot. Modern plastic boots seem to protect ankle and distal tibia and fibula. Another remarkable result was the fact that we could not find any difference in the types of fractures comparing patients with released and not released bindings.

Epidemiology of ankle fractures in Rochester, Minnesota.

The epidemiology of ankle fractures was examined among Rochester, Minnesota, residents during the 3-year period 1979-1981. Ankle fractures occurred with an overall age- and sex-adjusted incidence rate of 187 per 100,000 person-years; this is higher than in earlier population-based studies. The most frequent cause of ankle fractures was sports-related trauma. The incidence of fractures associated with moderate trauma, on the other hand, increased markedly in middle-aged women, but declined in elderly women. Diabetes mellitus and obesity were associated with fractures in middle-aged and older adults. Of accepted classifications, the Lauge-Hansen system provided the most clinically relevant information.