[Malleolar Fractures - Indication for Nonoperative and Operative Treatment]. / Malleolarfrakturen.

Malleolar Fractures - Indication for Nonoperative and Operative Treatment Abstract. In order to understand the trauma mechanism and the expected pattern of injury, malleolar fractures can be classified according to Lauge-Hansen [1]. For isolated lateral malleolar fractures, the Weber classification is also frequently used [2]. For most Weber A fractures and 80% of Weber B fractures conservative treatment is indicated. In all isolated Weber B fractures a supination-external rotation (SER) injury has to be distinguished from a pronation-abduction (PA) injury according to the Lauge-Hansen classification. In SER fractures, stability should be assessed by a gravity stress and a weightbearing radiograph. If the fracture is stable, it can be treated nonoperatively. We recommend surgical treatment for unstable Weber B SER injuries, Weber B PA injuries, and Weber C fractures.

A rare type of ankle fracture: Syndesmotic rupture combined with a high fibular fracture without medial injury.

High fibular spiral fractures are usually caused by pronation-external rotation mechanism. The foot is in pronation and the talus externally rotates, causing a rupture of the medial ligaments or a fracture of the medial malleolus. With continued rotation the anterior and posterior tibiofibular ligament will rupture, and finally, the energy leaves the fibula by creating a spiral fracture from anterior superior to posterior inferior. In this article we demonstrate a type of ankle fracture with syndesmotic injury and high fibular spiral fractures without a medial component. This type of ankle fractures cannot be explained by the Lauge-Hansen classification, since it lacks injury on the medial side of the ankle, but it does have the fibular fracture pattern matching the pronation external rotation injury (anterior superior to posterior inferior fracture). We investigated the mechanism of this injury illustrated by 3 cases and postulate a theory explaining the biomechanics behind this type of injury.

Paratrooper's ankle fracture: posterior malleolar fracture.

BACKGROUND: We assessed the frequency and types of ankle fractures that frequently occur during parachute landings of special operation unit personnel and analyzed the causes. METHODS: Fifty-six members of the special force brigade of the military who had sustained ankle fractures during parachute landings between January 2005 and April 2010 were retrospectively analyzed. The injury sites and fracture sites were identified and the fracture types were categorized by the Lauge-Hansen and Weber classifications. Follow-up surveys were performed with respect to the American Orthopedic Foot and Ankle Society ankle-hindfoot score, patient satisfaction, and return to preinjury activity. RESULTS: The patients were all males with a mean age of 23.6 years. There were 28 right and 28 left ankle fractures. Twenty-two patients had simple fractures and 34 patients had comminuted fractures. The average number of injury and fractures sites per person was 2.07 (116 injuries including a syndesmosis injury and a deltoid injury) and 1.75 (98 fracture sites), respectively. Twenty-three cases (41.07%) were accompanied by posterior malleolar fractures. Fifty-five patients underwent surgery; of these, 30 had plate internal fixations. Weber type A, B, and C fractures were found in 4, 38, and 14 cases, respectively. Based on the Lauge-Hansen classification, supination-external rotation injuries were found in 20 cases, supination-adduction injuries in 22 cases, pronation-external rotation injuries in 11 cases, tibiofibular fractures in 2 cases, and simple medial malleolar fractures in 2 cases. The mean follow-up period was 23.8 months, and the average follow-up American Orthopedic Foot and Ankle Society ankle-hindfoot score was 85.42. Forty-five patients (80.36%) reported excellent or good satisfaction with the outcome. CONCLUSIONS: Posterior malleolar fractures occurred in 41.07% of ankle fractures sustained in parachute landings. Because most of the ankle fractures in parachute injuries were compound fractures, most cases had to undergo surgical repairs.

Epidemiology, management, and outcome of sport-related ankle fractures in a standard UK population.

BACKGROUND: The literature on the outcome of sport-related ankle fractures has focused on operatively managed fractures, despite a large proportion being treated nonoperatively. We describe the epidemiology, management, and outcome of acute sport-related ankle fractures in a UK population. METHODS: All sport-related ankle fractures sustained during 2007 to 2008 in the Lothian Population were prospectively collected when patients attended the only adult orthopaedic service in Lothian. Fractures were classified using the Lauge Hansen and the Pott's Classification. The presence of fracture displacement was also recorded. Patients were contacted in February 2011 to ascertain their progress in return to sport. RESULTS: Ninety-six sport-related ankle fractures were recorded in 96 patients. Eighty-four fractures (88%) were followed up at a mean interval of 36 months (range, 30-42). Most common associated sports were soccer (n = 49), rugby (n = 15), running (n = 5), and ice skating (n = 3). The mean time for return to sport was 26 weeks (range, 4-104), the return rate to sport 94%, and the persisting symptom rate 42%. Fifty-two fractures (all nondisplaced) were managed nonoperatively-43 isolated lateral malleolar (30 Weber B, 13 Weber A), 2 isolated medial malleolar, 7 bimalleolar. Forty-four fractures were managed operatively-42 were displaced (2 isolated lateral malleolar, 3 isolated medial malleolar, 18 bimalleolar equivalent, 9 bimalleolar, 3 trimalleolar equivalent, 7 trimalleolar), 2 were un-displaced (2 trimalleolar). The mean times for return to sport were 20 weeks (range, 4-52) for the nonoperative cohort (NOC) and 35 weeks (range, 8-104) for the operative cohort (OC) (P < .001), the return rates to sport were 100% for NOC and 87% for OC (P < .016), and the persisting symptom rates were 17% for NOC and 71% for OC (P < .001). CONCLUSIONS: Nondisplaced ankle fractures in athletes were successfully managed with nonoperative care. They had greater return rates to sport, quicker return times, and lower persisting symptom rates but had less severe injuries. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

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.

Determinants of outcome in operatively and non-operatively treated Weber-B ankle fractures.

INTRODUCTION: Treatment of ankle fractures is often based on fracture type and surgeon's individual judgment. Literature concerning the treatment options and outcome are dated and frequently contradicting. The aim of this study was to determine the clinical and functional outcome after AO-Weber B-type ankle fractures in operatively and conservatively treated patients and to determine which factors influenced outcome. PATIENTS AND METHODS: A retrospective cohort study in patients with a AO-Weber B-type ankle fracture. Patient, fracture and treatment characteristics were recorded. Clinical and functional outcome was measured using the Olerud-Molander Ankle Score (OMAS), the American Orthopaedic Foot and Ankle Society ankle-hindfoot score (AOFAS) and a Visual Analog Score (VAS) for overall satisfaction (range 0-10). RESULTS: Eighty-two patients were treated conservatively and 103 underwent operative treatment. The majority was female. Most conservatively treated fractures were AO-Weber B1.1 type fractures. Fractures with fibular displacement (mainly AO type B1.2 and Lauge-Hansen type SER-4) were predominantly treated operatively. The outcome scores in the non-operative group were OMAS 93, AOFAS 98, and VAS 8. Outcome in this group was independently negatively affected by age, affected side, BMI, fibular displacement, and duration of plaster immobilization. In the surgically treated group, the OMAS, AOFAS, and VAS scores were 90, 97, and 8, respectively, with outcome negatively influenced by duration of plaster immobilization. CONCLUSION: Treatment selection based upon stability and surgeon's judgment led to overall good clinical outcome in both treatment groups. Reducing the cast immobilization period may further improve outcome.

Surgical versus nonsurgical treatment of the SE4-equivalent ankle fracture: a retrospective functional outcome study.

Treatment of Lauge-Hansen supination-eversion (SE)4-equivalent ankle fractures is controversial. This retrospective study conducted at a level-I trauma center compared the clinical outcome of nonsurgical vs open management of these fractures. One thousand eight ankle fractures treated between 1998 and 2003 were reviewed. Forty-three patients who met the criteria for a SE4-equivalent ankle fracture were identified. Average patient age of 23 men and 20 women was 42 years (range, 18-84 years). Olerud Molander ankle scores were recorded. Medical records and radiographs of all patients were reviewed. Average follow-up was 20 months.Twenty-six patients were treated nonsurgically, with an average ankle score of 84 ± 4. Seventeen patients treated surgically had an average ankle score of 63 ± 5. The difference is statistically significant (unpaired t test, P=.0035). There was no difference between open vs closed treatment in maintaining a reduction. To investigate the reason for poor results in the surgical group, we sought an association between functional ankle score and common covariables and found that age and preoperative radiographic grading were important variables for ankle score. Patients younger than 30 years had an average ankle score of 85, whereas those older than 50 years had an average score of 61 (P<.001). Type 1 fractures (medial clear space >5 mm in stress view only) had an average ankle score of 89, type 2 (medial clear space >5 mm but <10 mm) an average score of 76, and type 3 (medial clear space >10 mm or presented with fracture dislocation and/or syndesmosis injury) an average score of 61. Our data support that type 1 and 2 fractures can effectively be treated nonsurgically.

Stability criteria for nonoperative ankle fracture management.

BACKGROUND: This study was designed to see if stability based criteria are useful in choosing between nonoperative and operative treatment of ankle fractures. MATERIALS AND METHODS: One hundred sixty ankle fractures in skeletally mature patients were retrospectively analyzed to obtain an epidemiological profile in a population of about 130,000. One hundred thirty patients had followup of more than 2 years. A decision between operative and nonoperative treatment was made by the surgeon-on-duty, based on accepted stability criteria. Fractures were classified according to Weber and Lauge-Hansen systems. Clinical outcome was assessed using the scoring systems of Olerud-Molander, the RAND 36-Item Health Survey and the Visual Analogue Scale (VAS), measuring pain and function. RESULTS: The overall incidence of ankle fractures was 154/100,000. Nonoperatively treated patients had more displacement of the distal fibula after treatment, but less pain and better Olerud-Molander (good or excellent, 89% vs. 71%) and VAS functional scores. Independent factors for worse outcome were female gender, older age, unstable fracture and co-morbidity. No nonoperatively treated patients needed operative fixation during followup. CONCLUSION: Stability-based fracture classification was a simple and useful tool in decision-making for the treatment of ankle fractures. We found lateral malleolar fractures could be treated nonoperatively with success if the ankle mortise was stable. Displacement of the distal fibula after treatment did not affect functional scores or pain.

The use of weightbearing radiographs to assess the stability of supination-external rotation fractures of the ankle.

BACKGROUND: Isolated lateral malleolar fractures usually result from a supination-external rotation (SER) injury and may include a deltoid ligament rupture. The necessity of operative treatment is based on the recognition of a relevant medial soft-tissue disruption. Currently used tests to assess ankle stability include manual stress radiographs and gravity stress radiographs, but seem to overestimate the need for fracture fixation. METHODS: We investigated the use of weightbearing radiographs to distinguish stable and unstable isolated lateral malleolar fractures induced by the SER mechanism in 57 patients. Patients with stable fractures (SER type II according to the Lauge-Hansen classification) were treated non-operatively with varying external support. Forty-seven patients were evaluated by questionnaire and AOFAS ankle-hindfoot score. Follow-up was 18-120 months (mean 62). RESULTS: Fifty-one of fifty-seven (90%) patients were found to have stable fractures (SER type II) and were treated nonoperatively. The AOFAS score was 96.1 points on average (range 85-100) at latest follow-up. Four patients reported minor complaints. A "moderate" correlation of risk factors (i.e. smoking) to delayed bone healing was found while the correlation of varying external support (i.e. bandage, cast) to the AOFAS score and delayed bone healing was "poor". CONCLUSION: The use of weightbearing radiographs is an easy, pain-free, safe and reliable method to exclude the need for operative treatment, with excellent clinical outcome in the majority of the patients seen at latest follow-up. The delay of 3-10 days until the decision about surgical treatment is well accepted by the patients.

[Prognostic value of Lauge-Hansen and Danis-Weber classification in nonoperative and operative tibia ankle fracture treatment]. / Wartosc prognostyczna klasyfikacji Laugego-Hansena i Danisa-Webera w leczeniu nieoperacyjnym i operacyjnym zlaman kostek goleni.

Tibia ankle fractures and traumatic injuries of the ankle-tibia joint area are one of the most intractable problems in orthopedic and traumatic surgery. Because of the displacement of these fractures they require precise opening of the joint surface area to undertake the early repositioning in order to gain eficient walk. The objective of this paper was to evaluate and compare the final results of nonoperative and operative treament methods, specificlly the two most common prognosis values of tibia ankle fracture clasifications by Danis-Weber and Lauge-Hansen. This is the prognositic marking in the range of functional and radiological results dependant upon the method beeing applied. The repetetiveness and accordance of these two classifications has been evaluated as well. This research was conducted on the retrospective evalutaion based on the X-rays of 61 patients (28 women and 33 men) between the ages of 20-76 making the average age 49.5. The definition of accordance and repetitivenes was conducted by three doctors, who evaluated the x-rays from the standard fornt, back, and side projection of relaxed joint ankle.

[Long-term follow-up of osteoarthritis after conservative treatment of ankle fractures]. / Dugotrajno pracenje osteoartritisa nakon konzervativno lijecenog prijeloma gornjeg noznog zgloba.

In a period between 1982 and 1998 a total of 171 patients with ankle fracture were treated conservatively and rehabilitated in the same rehabilitation institution. All patients were seen at follow up in 1998 exactly at the date of the fracture in five groups with one, two, three, eleven and sixteen years from the fracture respectively. There were not significant differences in sex and age among groups. According to Danis-Weber's system, in the total material there were 53.8% type A, 40.9% type B and 5.3% type C fractures, and according to Lauge-Hansen's system there were 54.4% type SA, 34.5% type SE, 7.6% type PA and 3.5% type PE fractures. According to the Olerud's and Molander's scoring system there were the highest percentages of good results in all series (in average 52%) and there were not found significant differences between the results of the groups (P = 0.154). According to linear analogue scale of function there were the highest percentages of good results in all groups (in average 55.6%) and with significant differences between the results of the groups (P = 0.012). There were found significant differences between the results of late reductions of malleolar fragments of the groups (P = 0.028) with changing for the worse in groups with longer time interval from fracture. Posttraumatic osteoarthritis was found in first year after fracture already (41.5%). There were found significant differences between the results of the groups (P = 0.001) with severe degrees of osteoarthritis in groups with longer time from fracture.

Motion of the ankle in a simulated supination-external rotation fracture model.

UNLABELLED: An experimental study was undertaken with use of axially loaded, unconstrained cadaver ankles to determine the motion patterns seen with progressive stages of the supination-external rotation type of fracture. As described by Lauge-Hansen, these fractures were modeled by transection of the anterior aspect of the capsule and the anterior tibiofibular ligament (stage I), followed by oblique fibular osteotomy ending at the level of the ankle joint (stage II), transection of the posterior aspect of the capsule (stage III), and sequential sectioning of the superficial and deep fibers of the deltoid ligament (stage IV). Thirteen specimens were tested on an apparatus that allowed for controlled loading while the ankle was passed through a physiological range of dorsiflexion and plantar flexion. The ankles were unconstrained about the axial (internal and external rotation) and coronal (varus and valgus angulation) axes. Measurements were made throughout the range of motion in these axes in order to define the kinematic behavior. In the intact specimens, maximum plantar flexion was associated with a mean (and standard deviation) of 1.9 +/- 4.12 degrees of internal rotation of the talus and maximum dorsiflexion, with a mean of 7.2 +/- 3.88 degrees of external rotation. Varus angulation increased slightly with plantar flexion compared with the value in dorsiflexion (2.4 +/- 2.40 compared with 0.3 +/- 1.96 degrees). Internal and external rotation was not affected by fibular osteotomy or by transection of the superficial fibers of the deltoid ligament. Transection of the deep fibers of the deltoid ligament caused a significant (p < 0.02) increase in external rotation of the talus at maximum plantar flexion; this was corrected incompletely by insertion of an anatomical fibular plate. With the numbers available for study, we could not show that varus or valgus angulation was significantly affected by any combination of sectioning of the deltoid ligament and fibular osteotomy. These experiments were repeated with the addition of fixation of the subtalar joint with a talocalcaneal screw. With the number of specimens available, we could detect no significant difference, with respect to axial rotation, due to fixation of the subtalar joint. However, along the coronal axis, increased valgus angulation (p < 0.02) was seen during plantar flexion when either the deep or the superficial fibers of the deltoid ligament had been cut. CLINICAL SIGNIFICANCE: These results indicate that stability of the loaded ankle is primarily due to the deltoid ligament, which exerts a restraining influence on external rotation of the talus. Complete fibular osteotomy did not cause abnormal motion of the ankle in the absence of a medial injury. In the presence of a complete injury, lateral reconstruction only partially restored the mechanical integrity of the ankle. The results provide justification for the non-operative treatment of isolated fractures of the lateral malleolus. The data also suggest that a lateral fracture associated with a major injury of the deltoid ligament should be treated with anatomical lateral fixation followed by immobilization without early motion, to allow adequate healing of the deltoid ligament at its resting length.

Fracturas de tobillo, clasificación, diagnóstico y tratamiento / Ankle fractures: classification, diagnosis and treatment

Las fracturas de tobillo constituyen en la práctica de la especialidad una patología frecuente. En el presente trabajo se expone un resumen de la clasificación, diagnóstico y tratamiento de las fracturas del tobillo. Las clasificaciones más aceptadas hoy en día son las de Lange-Hansen y la del grupo Ao. El pilar fundamental para el diagnóstico es la RX: A-P, lateral y A-P con 20º de rotación interna. El tratamiento puede ser ortopédico o quirúrgico dependiendo de ciertos parámetros radiográficos y de estabilidad