Talus Visualization in Ankle Fractures: How Much Are We Really Seeing?

Background: Despite appropriate care, a subset of patients with ankle fractures has persistent pain. This condition may be associated with intra-articular pathology, which is present up to 65% of the time. Purpose: To quantify how much of the talus is visible through an open approach to a standard supination external rotation bimalleolar ankle fracture as a percentage of the entire weightbearing surface of the talus. Study Design: Descriptive laboratory study. Methods: Standard ankle approaches to lateral and medial malleolar fractures were performed in 4 cadaveric ankles from 2 cadavers. Osteotomies were made to simulate a supination external rotation bimalleolar ankle fracture based on the Lauge-Hansen classification. The visible segments of talar cartilage were removed. The tali were then exhumed, and the entire weightbearing superior portion of the talus was assessed and compared with the amount of cartilage removed by an open approach. The mean of the data points as well as the 95% confidence interval were calculated. Results: Four ankle specimens from 2 cadavers were used for these measurements. The mean surface area of the talus was 14.0 cm2 (95% CI, 13.3-14.7 cm2), while the mean area visible via an open approach was 2.1 cm2 (95% CI, 0.5-3.6 cm2). The mean proportion of the talus visualized via an open approach was 14.8% (95% CI, 3.6-26.1%). Conclusion: These findings indicate that the true area of weightbearing talar surface visible during an open exposure may be less than what many surgeons postulate. Clinical Relevance: Only a small fracture of the talus is visible via an open approach to the talus during fracture fixation. This could warrant arthroscopic evaluation of these injuries to evaluate and treat osteocondral lesions resulting from ankle fractures.

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

Acta Orthopaedica ◽

10.3109/17453674.2012.745657 ◽

2012 ◽

Vol 83 (sup347) ◽

pp. 1-31 ◽

Cited By ~ 19

Author(s):

Harri Pakarinen

Keyword(s):

Ankle Fracture ◽

External Rotation ◽

Ankle Fractures ◽

Mechanism Of Injury ◽

Syndesmosis Injury ◽

Fracture Management ◽

Supination External Rotation

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Weight-Bearing Cone-Beam CT Scan Assessment of Stability of Supination External Rotation Ankle Fractures in a Cadaver Model

Foot & Ankle International ◽

10.1177/1071100718761035 ◽

2018 ◽

Vol 39 (7) ◽

pp. 850-857 ◽

Cited By ~ 14

Author(s):

Mark C. Lawlor ◽

Melissa A. Kluczynski ◽

John M. Marzo

Keyword(s):

Ct Scan ◽

Ankle Fracture ◽

External Rotation ◽

Imaging Modality ◽

Cone Beam Ct ◽

Weight Bearing ◽

Ankle Fractures ◽

Cone Beam ◽

Clear Space ◽

Supination External Rotation

Background: The utility of computed tomography (CT) for measuring medial clear space (MCS) for determination of the stability of supination external rotation (SER) ankle fractures and in comparison to standard radiographs is unknown. We compared MCS on gravity stress (GS) radiographs to GS and weight bearing (WB) cone-beam CT (CBCT). Methods: An AO SER 44B3.1 ankle fracture was simulated in 10 human cadavers, also serving as controls. MCS was measured on GS radiographs, GS CBCT, and a simulated WB CBCT scan. Specimens were stable if MCS was <5 mm and unstable if MCS was ≥5 mm. Paired t tests were used to compare MCS from each imaging modality for controls versus SER injuries and stable versus unstable specimens. Results: Compared with controls assessed by GS radiographs, MCS was greater for an SER injury when assessed by GS radiograph and GS CBCT scan within the stable group. Compared with controls assessed by GS radiographs, MCS was greater for SER injuries when assessed by GS radiograph, GS CBCT scan, and WB CBCT within the unstable group. MCS was reduced for stable versus unstable SER injuries assessed by WB CBCT. Conclusion: In a cadaveric model of SER ankle fracture, the medial clear space was statistically significantly greater for the experimental condition when assessed by gravity stress radiograph and gravity stress CBCT scan. Under weight-bearing conditions, the cone-beam CT scanner distinguished between stable and unstable ankles in the experimental condition. Clinical Relevance: This study suggests that a WB cone-beam CT scan may be able to distinguish between stable and unstable SER ankle fractures and influence operative decision making.

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Characteristics of supination-external rotation Salter-Harris II ankle fractures in computed tomography

10.21203/rs.3.rs-968616/v1 ◽

2021 ◽

Author(s):

Yunfang Zhen

Keyword(s):

External Rotation ◽

Plantar Flexion ◽

Fracture Line ◽

Ankle Fractures ◽

Fibular Fracture ◽

Axial Ct ◽

The Mean ◽

Salter Harris ◽

Stage 1 ◽

Supination External Rotation

Abstract Background: Recent literature has shown that Salter-Harris (S-H)Ⅱfractures are the most common ankle fractures and carry a higher rate of growth disturbance. Recent literature has shown that Salter-Harris (S-H) Ⅱ fractures are the most common ankle fractures. CT characteristics of S-H Ⅱ ankle fractures are not well depicted. The purpose of this study was to evaluate supination-external rotation (SER) S-HⅡankle fractures by CT and to analyze the features of the associated fibular fracture to further determine the injury mechanism.Methods: The radiographs and CT with S-H Ⅱankle fractures were reviewed. Patients suffered from SER injury were included. The medial tibial cortex (MTC) of the distal tibia broken or intact, the metaphyseal fracture angle (MFA) 5-10mm proximal to the physis was documented in axial CT. The length of the metaphyseal fragment was measured in saggital CT. The correlation of the upper limits between fibular fracture and metaphyseal fragment was analyzed. In presence of the fibular fracture, the fracture pattern was classified based on the location and morphology of the fracture line.Results: Seventy-nine SER S-HⅡankle fractures were identified. Stage 1 was present in 35 and stage 2 in 44. In axial CT, the mean MFA was 11.2 degrees. MTC was fully broken in one case and 20, in stage 1 and stage 2, respectively (P=0.001). In saggital CT, the mean length of metaphyseal fragment was 35.3mm. The length of this fragment was 35.0mm, 35.5mm, in stage 1 and stage 2, respectively (P=0.868). The upper part of the fibular fracture line was located at the same level or higher than that of metaphyseal fragment. In 44 cases with associated fibular fracture, forty were in distal metaphysis with oblique fracture line for which 4 types were demonstrated with plantar flexion. Other 4 were in distal diaphysis with spiral fracture line.Conclusions: For SER S-H Ⅱ ankle fractures, MTC and orientation of the fracture plane can be shown in CT to help to make an appropriate preoperative plan. In addition to SER, majority of the concurrent fibular fracture was in the distal metaphysis with oblique fracture line and plantar flexion.

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BIMALLEOLAR ANKLE FRACTURE: A SIMPLE FRACTURE?

Acta Ortopédica Brasileira ◽

10.1590/1413-785220172501166234 ◽

2017 ◽

Vol 25 (1) ◽

pp. 48-51 ◽

Cited By ~ 2

Author(s):

JUNJI MILLER FUKUYAMA ◽

ROBINSON ESTEVES SANTOS PIRES ◽

PEDRO JOSÉ LABRONICI ◽

JOSÉ OCTÁVIO SOARES HUNGRIA ◽

RODRIGO LOPES DECUSATI

Keyword(s):

Ankle Fracture ◽

Fragment Size ◽

External Rotation ◽

Ankle Fractures ◽

Ligament Injury ◽

Deltoid Ligament ◽

Medial Malleolus ◽

Level Of Evidence ◽

Deltoid Ligament Injury ◽

Supination External Rotation

ABSTRACT Objective: To evaluate the frequency of deltoid ligament injury in bimalleolar supination-external rotation type fractures and whether there is a correlation between the size of the fractured medial malleolus and deltoid ligament injury . Methods: Twenty six consecutive patients underwent magnetic resonance exams after clinical and radiographic diagnosis of bimalleolar supination-external rotation type ankle fractures . Results: Thirteen patients (50%) presented deltoid ligament injury associated to bimalleolar ankle fracture. Partial injury was present in seven (26.9%) patients and total injury in six (23.1%). Regarding medial fragment size, the average was 2.88 cm in the absence of deltoid ligament injury. Partial injuries presented 1.93 cm and total 2.1 cm on average . Conclusion: Deltoid ligament injury was present in 50% of bimalleolar ankle fractures. Smaller medial malleolus fragments, especially concerning the anterior colliculus, presented greater association with partial deltoid ligament injuries. Level of Evidence IV, Cross Sectional Study.

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PO 18116 - Reproducibility assessment of the Lauge-Hansen classification for ankle fractures

Scientific Journal of the Foot & Ankle ◽

10.30795/scijfootankle.2019.v13.993 ◽

2019 ◽

Vol 13 (Supl 1) ◽

pp. 16S

Author(s):

Evandro Junior Christovan Ribeiro ◽

Fábio Farias ◽

S´érgio Damião Prata ◽

Marco Antônio Rizzo

Keyword(s):

Ankle Fracture ◽

Interobserver Agreement ◽

External Rotation ◽

Ankle Fractures ◽

Years Of Experience ◽

Study Results ◽

Common Diagnosis ◽

Supporting Material ◽

Supination External Rotation ◽

Consensus Decision

Objective: This study evaluated the reproducibility of the Lauge-Hansen classification among orthopedic residents and more experienced orthopedists. Methods: The inclusion criteria were ankle fractures with adequate radiographs taken in anteroposterior (AP), true AP and P (profile) views, which were individually analyzed by physicians. The analysis was performed based on the Lauge-Hansen classification. The raters were 5 orthopedic professionals from our department: 3 residents and 2 board-certified orthopedists (one with less than 10 years of experience, and the other with more 10 years of experience in the field). The professionals first analyzed and classified 30 ankle fracture radiographs; then, after 1 week, they were asked to perform a new evaluation. The radiographs were shown without names or other identifying information. The classifications were subsequently examined based on the analysis of the supporting material that had been previously provided for each individual. A consensus decision regarding the classification was made among all professionals at the end of the study. Results: The professionals were asked to analyze radiographs from 30 patients with ankle fracture, among whom supination-external rotation was the most common diagnosis. The results were outlined in tables and plotted in graphs; in a second evaluation performed after 1 week, there were 66% hits and 34% errors, whereas the percentage of hits in the first evaluation was 61.33%. Conclusion: The routine use of management classifications by physicians facilitates the understanding of these classifications by other professionals in the field while increasing interobserver agreement.

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Arthroscopic Findings During Routine Ankle ORIF: What is Being Missed?

Foot & Ankle Orthopaedics ◽

10.1177/2473011420s00262 ◽

2020 ◽

Vol 5 (4) ◽

pp. 2473011420S0026

Author(s):

Shain Howard ◽

Victor C. Hoang ◽

Troy S. Watson ◽

Candice L. Brady ◽

Adam Eudy

Keyword(s):

Fracture Fixation ◽

Ankle Fracture ◽

External Rotation ◽

Ankle Arthroscopy ◽

Ankle Fractures ◽

Osteochondral Lesions ◽

Fracture Type ◽

Syndesmotic Injury ◽

Patient Reported ◽

Articular Pathology

Category: Ankle; Arthroscopy; Trauma Introduction/Purpose: Ankle fractures are among the most common operatively treated injuries by orthopedic surgeons. However, up to 20% of patients will have continued pain and poor patient reported outcomes despite good/excellent radiographic results. Ankle fractures typically occur with varying degrees of intra-articular and soft tissue injury which can include ligamentous injury, loose bodies, and chondral lesions. The aim of study is to document intra-articular findings with ankle arthroscopy prior to ankle open reduction internal fixation (ORIF) and to contribute to the growing body of literature that shows this to be a safe adjunct to fracture fixation. Methods: IRB approval was obtained prior to chart review. This is a retrospective review of ankle fractures that were treated with arthroscopy and ORIF by a single surgeon. Between August 2016 and July 2018 Operative reports, office notes, and images were reviewed to identify intra-articular pathology and fracture type. Analysis was performed with regard to fracture type, presence and location of osteochondral lesions, presence of loose-body, syndesmotic injury, and deltoid injury. Results: Fifty-seven ankle fractures were identified that met inclusion criteria. 84.2% of the fractures had intra-articular pathology, most commonly a syndesmotic injury followed by loose joint body and osteochondral defect. Conclusion: Arthroscopic evaluation during ankle fracture ORIF, particularly pronation external rotation and supination external rotation patterns give a more detailed examination of associated pathology. Arthroscopy at the time of ankle fracture fixation is a safe adjunct and should be considered a potential compliment to routine ORIF of ankle fractures.

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The Surgical Outcomes of Unstable Ankle Fractures in Patients Aged >65 Years

Geriatric Orthopaedic Surgery & Rehabilitation ◽

10.1177/2151459321997765 ◽

2021 ◽

Vol 12 ◽

pp. 215145932199776

Author(s):

Adem Sahin ◽

Anıl Agar ◽

Deniz Gulabi ◽

Cemil Erturk

Keyword(s):

Surgical Outcomes ◽

External Rotation ◽

High Energy ◽

Ankle Fractures ◽

Medial Malleolus ◽

Aofas Score ◽

Non Union ◽

The Mean ◽

Medial Malleolus Fracture ◽

Mechanism Of Trauma

Aim: To evaluate the surgical outcomes and complications of patients over 65 years of age, with unstable ankle fractures. Material and Method: The study included 111 patients (73F/38 M) operated on between January 2015 and February 2019 and followed up for a mean of 21.2 months (range, 6-62 months).Demographic characteristics, comorbidities, fracture type, and mechanisms of injury were evaluated. Relationships between postoperative complications and comorbidities were examined. In the postoperative functional evaluations, the AOFAS score was used and pre and postoperative mobilization (eg, use of assistive devices) was assessed. Results: The mean age of the patients was 70.5 ± 6.1 years (range, 65-90 years). The mechanism of trauma was low-energy trauma in 90.1% of the fractures and high-energy trauma in 9.9%. The fractures were formed with a SER injury (supination external rotation) in 83.7% of cases and bimalleolar fractures were seen most frequently (85/111, 76%).Complications developed in 16 (14.4%) patients and a second operation was performed in 11 (9.9%) patients with complications. Plate was removed and debridement was performed in 5 of 6 patients due to wound problems. Nonunion was developed in the medial malleolus in 4 patients. Revision surgery was performed because of implant irritation in 2 patients and early fixation loss in the medial malleolus fracture in one patient. Calcaneotibial arthrodesis was performed in 3 patients because of implant failure and ankle luxation associated with non-union. A correlation was determined between ASA score and DM and complications, but not with osteoporosis. The mean follow-up AOFAS score was 86.7 ± 12.5 (range, 36-100).A total of 94 (84.7%) patients could walk without assistance postoperatively and 92 (82.9%) were able to regain the preoperative level of mobilization. Conclusion: Although surgery can be considered an appropriate treatment option for ankle fractures in patients aged >65 years, care must be taken to prevent potential complications and the necessary precautions must be taken against correctable comorbidities.

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The use and efficacy of intra-operative stress tests in supination-external rotation IV ankle fracture fixation

The Surgeon ◽

10.1016/j.surge.2014.02.002 ◽

2015 ◽

Vol 13 (1) ◽

pp. 9-14 ◽

Cited By ~ 5

Author(s):

Sarah L. Gill ◽

Amy Behman ◽

Lynda A. Cochrane ◽

Gavin J. Love

Keyword(s):

Fracture Fixation ◽

Ankle Fracture ◽

External Rotation ◽

Stress Tests ◽

Operative Stress ◽

Supination External Rotation

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Health Related Quality of Life in Patients with Supination-External Rotation Stage IV Ankle Fractures

Foot & Ankle International ◽

10.1177/107110070502601207 ◽

2005 ◽

Vol 26 (12) ◽

pp. 1038-1041 ◽

Cited By ~ 18

Author(s):

Ryan Finnan ◽

Luke Funk ◽

Michael S. Pinzur ◽

Steven Rabin ◽

Laurie Lomasney ◽

...

Keyword(s):

Quality Of Life ◽

External Rotation ◽

Stage Iv ◽

Ankle Fractures ◽

Health Related Quality ◽

Related Quality ◽

Health Related ◽

Rotation Stage ◽

Supination External Rotation

Background: While open reduction of displaced ankle fractures generally is accepted as the standard of care, relatively little is known about the health related quality of life after treatment. It is generally accepted that clinical results of treatment for supination-external rotation stage IV ankle fractures are favorable. The goal of this investigation was to determine the relationship between clinical results and health-related quality of life outcome measures in a consecutive series of patients treated for closed supination-external rotation stage IV ankle fractures. Methods: Twenty-six of 156 patients who had operative treatment for closed, displaced supination-external rotation stage IV ankle fractures during a 9-year period, completed the Short Musculoskeletal Function Assessment (SMFA) outcome questionnaire. Radiographs and clinical records were reviewed to determine quality of operative repair, postoperative morbidity, and the development of post-traumatic arthritis. Results: There were no postoperative complications. Of the 26 patients who returned the SMFA questionnaires, 19 had “good,” and seven had “fair” reduction of their fractures. Six showed radiographic evidence of arthritis at followup. Study participants reported scores that were similar to the general population in five of the six domains of the SMFA. Their scores in the mobility index were statistically less favorable (23.72 vs. 13.61, p = 0.016) when compared to the general population. Participants with “good” operative reductions and no evidence of arthritis at followup showed no significant difference to the general population. Participants with either a “fair” operative reduction or evidence of postoperative arthritis at followup had less favorable scores in the daily activities (mean 13.45 vs. 11.82, p = 0.004), mobility (43.43 vs. 13.61, p = 0.001), dysfunction (32.89 vs. 12.70, p = 0.014), and bother (35.80 vs. 13.77, p = 0.020) domains, when compared to the general population. Conclusions: The results of this investigation suggest that patients with excellent radiographic operative reductions and no arthritis as early as 6 months after surgery sustain no lasting unfavorable effect on health related quality of life. Patients with “fair” radiographic reduction, or presence of arthritis or both at followup, are likely to have a negative effect on their quality of life.

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