Radiographic analysis of adult ankle fractures using combined Danis-Weber and Lauge-Hansen classification systems.

This study was to analyze ankle fractures for determining the epidemiology, types, distribution, possible mechanisms and diagnosis precision. Between January 2013 and December 2017, all Chinese patients older than 16 years of age with ankle fractures excluding old ankle fractures and pathological fractures in a tertiary care hospital were analyzed by using the Danis-Weber and Lauge-Hansen classification systems. Among 3952 patients with ankle fractures, 1225 fractures (31%) were Danis-Weber type A, 1640 (42%) were type B, 751 (19%) were type C, and 336 (9%) were perpendicular compression fracture. There were 1949 fractures on the left side and 2003 on the right with no significant difference (P > 0.05). Male patients between 16 and 50 years of age and women over 50 years had a higher incidence of ankle fractures accounting for 38.4% (1517/3952) and 22.2% (800/3952), respectively. Posterior malleolar fractures, fibular fractures above the inferior tibiofibular joint and Tillaux fractures were easily missed in the diagnosis, with 38 fractures (0.96%) being missed in the diagnosis. In conclusion, young and middle-aged men and older women have a higher incidence of ankle fractures, and use of the Lauge-Hansen and Danis-Weber classification systems can better help assessing the varied and complex ankle fractures, predicting the injuries, increasing diagnostic precision and decreasing misdiagnosis rate.

Preoperative planning and surgical technique for optimizing internal fixation of posterior malleolar fractures: CT versus standard radiographs.

BACKGROUND: A proper reduction and internal fixation of posterior malleolar fractures can be challenging, as intraoperative fluoroscopy often underestimates the extent of the fracture. Our aim was to assess the value of a modified classification system for posterior malleolar fractures, which is based on computed tomography (CT) images, optimizing screw trajectory during fluoroscopic-guided surgery, and to compare it to the Lauge-Hansen classification system to the CT-based classification. METHODS: A retrospective review of all ankle fracture operations from January 2014 to December 2016 was performed. Fractures were included if a CT scan was performed within 1 week of the surgery, and the posterior malleolar fragment occupied one third or more of the antero-posterior talar surface or jeopardize the ankle stability. Eighty-five adult ankle fractures with posterior malleolar fragments were included in this study. Fractures were categorized into one of three types, namely "postero-lateral," "postero-medial," or "postero-central," according to the location of the fracture fragment on axial CT image. An optimal trajectory angle for a single-lag screw fixation was measured on the CT cut between a central antero-posterior line and the line intersecting the posterior fragment perpendicular to the major fracture line. Mean trajectory angles were calculated for each fracture type. Fractures were also categorized according to the Lauge-Hansen system. RESULTS: The mean trajectory angle was 21° lateral for "postero-lateral" fragments, 7° lateral for "postero-central" fragments, and 28° medial for "postero-medial" fragments (p < 0.01 for comparisons among the groups). The range of trajectory angles within each group was about 10°, as compared to about 20° within each Lauge-Hansen type. There were no differences in trajectory angle among the Lauge-Hansen groups (p > 0.05 for all comparisons). CONCLUSIONS: There are 3 distinct anatomic subgroups of posterior malleolar fragments, each with an ideal screw trajectory that needs to be used in order to achieve an optimal reduction and fixation.

Treatment of a high-energy transsyndesmotic ankle fracture: A case report of "logsplitter injury".

INTRODUCTION: The "logsplitter injury" is a special type of ankle fractures that results from high energy violence with combined rotational forces and axial loads. So far, the diagnose and treatment of "logsplitter injury" remain largely unsettled and related literature is rare. PATIENT CONCERNS: An 18-year-old male fell from a fence and got his left ankle injured with severe malformation and swollen condition. No open wound was observed. DIAGNOSIS: Logsplitter injury, ankle fracture (AO/OTA classification 44C1.1, Lauge-Hansen classification: pronation-external rotation). INTERVENTIONS AND OUTCOMES: The patient was initially treated by internal fixation of fibular, repair of deltoid ligaments, and 1 syndesmotic screw fixation. When the X-ray applied after surgery, another 2 syndesmotic screws were performed to enhance stability. The syndesmotic screws were removed at 12-week and 16-week respectively. The patient was allowed for full weight-bearing immediately. However, the syndesmotic space was slightly increased compared to the contralateral side in CT views at 1-year follow-up, the function outcome was satisfied. CONCLUSION: The logsplitter injury is a high-energy ankle fracture that requires both axial and rotational load. It is categorized as 44B or 44C by the AO/OTA classification. In the classification scheme of Lauge-Hansen, our case is in line with the pronation-external rotation classification. Anatomic reduction and fixation of ankle syndesmotic injuries are required to restore the biomechanics of the ankle joint so that long-term complications can be prevented. How to fixation the syndesmosis, whether to reconstruct the deltoid ligament remains in debate in the treatment of logsplitter injury, whether and when to remove the syndesmotic screws were still debated. Correct surgical intervention is successful in the treatment of "logsplitter injury", however, the optimal fixation of syndesmosis and repair of deltoid ligaments need further investigate.

Pediatric ankle injuries: utilizing the Dias-Tachdjian classification.

Pediatric ankle injuries require timely diagnosis due to their involvement of the distal tibial physis and subsequent impact on long bone growth. These injuries occur in a predictable pattern based on ankle position, direction of force, and degree of closure of the distal tibial physis. The Dias-Tachdjian classification describes possible ankle injury patterns for the completely open physis, and we present a simplified algorithm for applying this system in routine radiographic interpretation. Similar to the Lauge-Hansen classification in adults, the Dias-Tachdjian system is based on the position of the foot and direction of force at the time of injury with four major patterns: supination-inversion, pronation-eversion external rotation, supination-plantar flexion, and supination-external rotation. In addition, we examine the effect that the closing distal tibial physis has on adolescent fracture patterns (specifically, Tillaux and triplane fractures). Awareness of these injury patterns helps the radiologist to identify nondisplaced fractures and subtle physeal injuries with implications for surgical and/or conservative management.

Relationship between fracture morphology of lateral malleolus and syndesmotic stability after supination-external rotation type ankle fractures.

BACKGROUND: Syndesmotic injury with supination-external rotation (SER)-type ankle fractures are well known for the serious damages to the osseous and soft tissue envelope. However, the Lauge-Hansen classification system does not provide sufficient information related to syndesmotic injury. In this study, we aimed to investigate factors for preoperative detection of syndesmotic injury according to fracture patterns in SER III and IV ankle fractures by using radiography and computed tomography (CT). METHODS: All operative SER III and IV ankle fractures treated by a single surgeon from 2009 to 2015 were enrolled in a retrospective database. Based on computed tomographic evidence and intra-operative Cotton test, stable and unstable groups of the ankle factures were divided. RESULTS: A total of 52 patients with SER III, 75 patients with SER IV, and 27 patients with SER IV equivalent ankle fractures were identified, with 106 in the unstable syndesmosis group (68.8%) and 48 patients in the stable syndesmosis group (31.2%). Medial space widening and fragment angle of the fibular posterior cortex were significant predictors. The cutoff values of these factors were 4.4 mm and 32.8 degrees, respectively. CONCLUSIONS: CT was superior to simple radiography in predicting syndesmotic injury at the preoperative period in SER-type III and IV. Medial space widening and fragment angle of the fibular posterior cortex, as predictive factors, showed significant correlations. In particular, sharper fragment angle of the posterior cortex indicated higher probability of instability that remained after fracture fixation.

Sarcoidosis al descubierto: Lo que deberíamos informar en las imágenes torácicas / Sarcoidosis Uncovered: What we should Report in Thoracic Image

La sarcoidosis es una enfermedad granulomatosa no caseificante, multisistémica, de causa desconocida, que compromete al pulmón y a los ganglios linfáticos mediastinales entre el 90 y el 95% de los casos. También puede afectar otros órganos, como las glándulas salivales, piel, ojos, hígado, bazo, corazón, huesos y sistema nervioso central. La sarcoidosis tiene una baja prevalencia en Latinoamérica y es subdiagnosticada debido a la alta frecuencia de otros trastornos similares, como tuberculosis, lepra y micosis profundas. El diagnóstico presuntivo se establece con hallazgos imagenológicos característicos dentro de un contexto clínico apropiado y se confirma con la evidencia histológica de granulomas no caseificantes de células epiteliales, en ausencia de otras etiologías. Los hallazgos torácicos incluyen la afectación pulmonar, ganglionar y bronquial, los cuales son detectados a través de la radiografía (Rx) y tomografía computada (TC) de tórax, siendo esa última más sensible y específica. En este artículo, resaltamos la importancia de reconocer los patrones de presentación típicos y atípicos de la sarcoidosis en Rx y TC, así como la relevancia de las imágenes torácicas como elemento clave en el algoritmo diagnóstico de esa patología. También describimos la utilidad de la resonancia magnética (RM), como método adicional para el diagnóstico en casos de afectación cardíaca y el papel de la tomografía por emisión de positrones (PET-CT) en el seguimiento terapéutico.

Sarcoidosis is a non-caseating granulomatous, multisystemic disease of unknown cause that involves the lung and mediastinal lymph nodes in 90-95% of cases. It can also affect other organs such as the salivary glands, skin, eyes, liver, spleen, heart, bones and the central nervous system. Sarcoidosis has a low prevalence in Latin America and it is underdiagnosed due to the high frequency of other similar disorders such as tuberculosis, leprosy and deep mycosis. The presumptive diagnosis is established based on characteristic imaging findings within an appropriate clinical setting and is confirmed by histological evidence of non-caseating epithelioid cell granulomas, in the absence of other etiologies. Thoracic imaging findings include pulmonary, nodal and bronchial involvement, which are detected on chest radiography (CXR) and computed tomography (CT), this last one having a higher sensitivity and specificity. In this article, we highlight the importance of recognizing the typical and atypical presentation patterns of sarcoidosis on CXR and CT, as well as the relevance of thoracic images as key elements in the diagnostic algorithm of this pathology. We also describe the usefulness of magnetic resonance (MR) imaging as an additional method for diagnosis in cases of cardiac involvement and the role of positron emission tomography (PET-CT) in therapeutic follow-up.

Reproducibility of the stability-based classification for ankle fractures.

BACKGROUND: Classification of ankle fracture is important when deciding for operative or conservative treatment. This study rates the reproducibility of ankle stability assessment and compares it with the classification by Lauge-Hansen and Arbeitsgemeinschaft für Osteosyntesefragen (AO) in adult patients with primary ankle fractures. METHODS: A total of 496 consecutive ankle fractures were included, and the X-ray images were reviewed 2 times by 2 medical students, 2 residents, and 1 consultant in orthopedic traumatology. The raters were blinded to each other and to their own results. Unweighted Kappa statistics were used to assess reproducibility. RESULTS: Overall mean (95% CI) interrater Kappa results were 0.65 (0.64; 0.68) for Lauge-Hansen, 0.62 (0.60; 0.63) for AO and 0.61 (0.57; 0.62) for the stability assessment. The intrarater results ranged from a mean Kappa of 0.64-0.80 for the medical students, 0.65-0.81 for the residents and 0.82-0.84 for the consultant. CONCLUSION: The stability assessment has substantial to almost-perfect agreement which is comparable to the Lauge-Hansen and AO classifications.

Minimally Invasive Treatment of Ankle Fractures in Patients at High Risk of Soft Tissue Wound Healing Complications.

The complex nature of ankle fractures is magnified when seen in patients at high risk of soft tissue wound healing complications. The major categories include associated soft tissue injury, diabetes, tobacco use, peripheral vascular disease, malnutrition, alcoholism, and corticosteroid use. Because of the potential for wound dehiscence and infection with open reduction and internal fixation of ankle fractures in these patients, minimally invasive procedures have been described. The aims of the present study were to assess the possibility for, and evaluate the results and complications of, minimally invasive techniques for different types of malleolar fractures in high-risk patients. We report the clinical results of 47 high-risk patients who presented with malleolar fractures from January 2007 to December 2012 and underwent minimally invasive reduction and fixation. One patient (0.5%) developed a superficial infection; however, none of the patients displayed wound dehiscence or deep infection. Five patients (10.6%) required open reduction because of intraoperative failure to achieve anatomic reduction. Using the American Orthopaedic Foot and Ankle Society ankle-hindfoot scale, 15 of the patients (36%) treated with minimally invasive techniques experienced an excellent outcome. In contrast, 23 patients (55%) had a good, 3 (7%) a fair, and 1 (2.5%) a poor outcome. The results of our study have shown that minimally invasive fixation appears to be a satisfactory method for the management of malleolar fractures in high-risk patients and could be helpful in the avoidance of the complications associated with conventional open reduction and internal fixation.

Ankle fracture classification: a comparison of reliability of three X-ray views versus two.

Our hypothesis was that malleolar ankle fractures could be classified with two radiographic views as reliably as with three views. Four different observers independently evaluated 99 sets of ankle radiographs. The examiners classified the ankle fractures by using both the Lauge-Hansen and Danis-Weber systems. The interobserver and intraobserver variations were analyzed by kappa statistics. With regard to intraexaminer reliability, the examiners demonstrated excellent accord in classifying the fractures in the Danis-Weber system with either three views or two views. The kappa values were comparable. In the Lauge-Hansen system, three examiners demonstrated excellent accord and one examiner demonstrated good accord in classifying the fractures. Similar kappa values were generated when examiners classified fractures with either three views or two views. With regard to interexaminer reliability, good to excellent accord was demonstrated overall among the four examiners when they used the Danis-Weber system with either three views or two views. The examiners were in good agreement when they used the Lauge-Hansen system. Similar kappa values were generated whether the examiners used three views or two views. Three radiographic views are usually ordered for evaluation of an acute ankle injury. Previous studies have shown that only two views are needed for diagnosis of a malleolar ankle fracture. This study demonstrates that malleolar ankle fractures can be classified with two views, lateral or mortise, with a reliability as good as that achieved with three views. The best agreement is achieved with lateral and mortise views.