Vector Appropriate Distraction and Reduction of a Neglected Trimalleolar Fracture-Dislocation Performed with a Temporary Intraoperative External Fixator

Traumatic fractures of the ankle can occur with concomitant tibiotalar dislocations, necessitating complex treatment. These injuries have higher rates of loose bodies, open injuries, postoperative complications, and worse patient reported outcomes compared to ankle fractures without dislocation. Patients with neglected or delayed presentations are associated with even higher rates of postoperative complications and worse outcomes compared to acute injuries. The chronicity of the injury leads to soft tissue contractures and malunited fractures, obligating a care plan which involves gradual reduction with a multiplanar external fixator with or without internal fixation at a later date. We discuss a 60-year-old homeless man who presented four weeks after an open trimalleolar fracture-dislocation and was definitely treated with an acute one-stage procedure. Anatomic reduction and stable fixation was achieved through a lateral malleolus osteotomy, soft tissue releases, TAL, and a temporary intraoperative external fixator. This technique was advantageous in this instance of anticipated patient noncompliance. We advocate for the judicious use of the described technique in similar challenging situations.

Trimalleolar fracture: The endless posterior malleolus fracture debate, to repair or not to repair?

Ankle fracture is one of the most common fractures presenting in the emergency department. The fracture varies from unimalleolar, bimalleolar or trimalleolar. Involvement of the posterior malleolus is common and ranges from small avulsions to large intraarticular fragments causing subluxation of the talus. If left untreated, the resulting step-off, comminution or posterior talar subluxation may lead to osteoarthritis and further disability. To date, no consensus exists regarding the management of posterior malleolus fractures in the set-up of trimalleolar fractures. In this review we provide an overview of the literature on the available treatment options for posterior malleolar fracture in the set-up of trimalleolar fractures.

Operatively treated ankle fractures in Switzerland, 2002–2012: epidemiology and associations between baseline characteristics and fracture types

Background Ankle fractures are common, and their incidence has been increasing. Previous epidemiological studies have been conducted in the US, Scandinavia, and Scotland. Our objectives were to provide a current epidemiological overview of operatively treated ankle fractures and to evaluate the influence of age, sex, lifestyle factors, and comorbidities on fracture types. Methods We performed a population-based epidemiological study of all ankle fractures treated operatively in a 10- year period from 2002 to 2012. Results Two thousand forty-five ankle fractures were operated upon. Men and women differed significantly in age (median 41 vs. 57 years old), obesity (16% vs. 23%), diabetes (5% vs. 10%), smoking (45% vs. 24%), and accident type (daily activities 48% vs. 79%, transportation 24% vs. 9%, sports 21% vs. 8%) respectively. Overall, there were 2% Weber A, 77% Weber B, and 21% Weber C fractures; 54% were uni-, 25% bi-, and 21% trimalleolar; 7.5% of all fractures were open. Weber C fractures were much more frequent among men and with higher BMI (lowest vs. highest category: 14% vs. 32%), but slightly less frequent with older age and among current smokers. Trimalleolar fractures were twice as frequent in women and increased with age. Conclusion Men and women differed substantially in age, lifestyle factors, comorbidities, accident type, and type of ankle fracture. Male sex and higher BMI were more frequently associated with Weber C fractures, whereas female sex and older age were associated with trimalleolar fracture. The risk for severe fracture increased linearly with the degree of obesity.

A CASE REPORT OF TRIMALLEOLAR FRACTURE TREATED WITH PLATING AND TENSION BAND WIRING

A case of trimalleolar fractures of left ankle has been described here. Fractures around the ankle joint mainly depend on the direction of forces during trauma ,position of the ankle and foot at the hour of injury. A 44 year-old man fell off a two wheeler on a road and sustained injury to his left ankle. X-ray radiographs were taken and patient was diagnosed to have left sided post traumatic closed trimalleolar fracture with lauge Hansen classification of supination external rotation without any distal neurovascular deficit. Patient underwent osteosyntheses and During the post-operative period there was no complications.

Kinesitheraphy in trimalleolar fracture – case report

The purpose of the paper is to prove the efficacy of a kinesitherapeutic program intherecovery of a patient with trimalleolar fractureofthe left lower limb.We present a 42-year-old patient with a trimalleolar fracture and paresis of n. peroneus communis. Kinesitherapy was performed after thirteen weeks of surgery for ten consecutive days. The kinesitherapeuticmeans included: cryotherapy, lymphatic drainage massage, isometric contractions for the femur muscles, active exercises with and without resistance, active exercises with and on gymnastic apparatuses, post-isometric relaxation for the sciatic musculature and m. triceps surai, training in walking.As a result of the kinesitherapeutic exercises, the ankle swelling decreased.The volume of movement increased, pain was reduced as well as the muscle spasm in the ankle joint. The gait improved.

Management and Clinical Outcome of Trimalleolar Fracture of Ankle: a case report

Objectives: Ankle fractures are one of the most common lower limb fractures, where account for 9% of all fractures. Most ankle fractures are isolated malleolar fractures, while trimalleolar fractures occur in the remaining 7-11% cases. The trimalleolar fracture involves fracture of the medial malleolus, fibula and posterior lip of articular surface of the tibia, associated with subluxation or dislocation of tibiotalar joint and rupture of one or more ligaments. These fractures are commonly caused by a twisting mechanism. The management of the trimalleolar fracture is by open reduction and internal fixation due to its unstable position. The postoperative outcome is evaluated by using the American Orthopedics Foot and Ankle Society (AOFAS) scoring system. Case presentation: A 38-year-old woman was admitted to the ER with chief complain a painful left ankle after a motor vehicle accident. She was previously riding a motorcycle, then stopped at the traffic light with left leg stepping on the road. Her left leg was hit from behind by a moving car. On the physical examination at the left ankle region, there was laceration with size 5x1x1 cm at the anteromedial side. There was also swelling around the left ankle with no deformity. From the palpation, there was tenderness around the left ankle and a. dorsalis paedis was still palpable with capillary refill time < 2 seconds. We performed the ankle X-Ray which considered as a fracture of distal os. tibia and os. fibula. We diagnosed this patient as a closed fracture of the left ankle with a classification of Lauge-Hansen supination external rotation (SER) injury. We did an ORIF, and the patient has been doing rehabilitation for 12weeks. We evaluated the outcome by the AOFAS scoring system, resulting in 85out of 100. Results The incidence of ankle fractures is approximately 187 fractures per 100,000 people each year, where the percentage of trimalleolar fracture occurs in 7 to 11% cases. Many of stable fractures are reduced by conservative treatment and the other unstable displaced and open fractures require open reduction internal fixation. From anamnesis, physical examination and radiographic imaging, we diagnosed this patient as closed fracture of left ankle Lauge-Hansen supination external rotation (SER). SER injury is the most common occurring among Lauge-Hansen’s categories, where firstly in the first stage the anterior inferior tibiofibular ligament (AITFL) was injured. Then in the second stage, an oblique/spiral fracture of the distal fibula occurred. With more force, the posterior inferior tibiofibular ligament (PITFL) was injured or the posterior malleolus was fractured in third stage. Finally, in fourth stage, the medial malleolus was fractured or the deltoid ligament was injured. We considered the fracture as unstable trimalleolar fracture, therefore we performed ORIF by using plate for lateral malleolus, wires for medial malleolus and screw for posterior malleolus. The patient was kept non-weight-bearing for a total of nine weeks postoperatively. We did a 3-months follow-up by clinical outcome and ankle X-Ray. The clinical outcome was measured by AOFAS scoring system and showed a good result which is 85/100. This result is in accordance with the previous study in 2014 which showed a quick recover of adults in activity limitation in the first 3 months following the fracture. Conclusion Trimalleolar fracture is a rare case which needs a challenging management to achieve the goal of reduced and stable fixation. Understanding the trauma mechanism is essential for good reduction and internal fixation. The concern of treatment and clinical outcome evaluation are needed to prevent complications, e.g. non-union, joint stiffness and secondary osteoarthritis.

Medial malleolar fractures

The medial malleolus, once believed to be the primary stabilizer of the ankle, has been the topic of conflicting clinical and biomechanical data for many decades. Despite the relevant surgical anatomy being understood for almost 40 years, the optimal treatment of medial malleolar fractures remains unclear, whether the injury occurs in isolation or as part of an unstable bi- or trimalleolar fracture configuration. Traditional teaching recommends open reduction and fixation of medial malleolar fractures that are part of an unstable injury. However, there is recent evidence to suggest that nonoperative management of well-reduced fractures may result in equivalent outcomes, but without the morbidity associated with surgery. This review gives an update on the relevant anatomy and classification systems for medial malleolar fractures and an overview of the current literature regarding their management, including surgical approaches and the choice of implants. Cite this article: Bone Joint J 2019;101-B:512–521.