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78 terms

Ankle

STUDY
PLAY
ankle
*very constrained joint( as a result of both it's bony anatomy and the ligamentous support
motion of the ankle
limited to one plane
*dorsi and plantar flexion*
ankle function
works in concert with the *subtalar* and
*transverse tarsal joints* (talonavicular and
calcaneocuboid joints) to provide the full
motions of the foot and to shock absorb with foot impact.
ankle complex
Key to Ankle Function and
Stability
mortise anatomy and robust ligamentous support
mortise function
Shape of the Joint and the Ligamentous Support
arthritis
the result of Long Term Disruption of Either the Mortise Anatomy or the Ligamentous Stability
Bony Nomenclature of the Ankle
*medial malleolus* - medial shoulder of the distal tibia
*tibial plafond* - weight-bearing surface of the distal end of the tibia
posterior malleolus
-Not a precise anatomic structure
-refers to the curving posterior shoulder of the tibial plafond
-allows for better classification of ankle fractures
mortise
rectangular slot that accepts a tenon
achilles tendon
ligaments of the ankle
Lateral ligaments = ATFL, CFL, PTFL
deltoid ligament
*-Medial ligament*
-comprised of deep and superficial portions
-superficial deltoid inserts into the talus, calcaneous, in tarsal navicular bone
-superficial deltoid well-suited to resist hind foot eversion
-the deep deltoid ligament inserts in the central and posterior aspects of the medial talar surface
-resist external rotation, tilt, and lateral translation of the Talus
syndesmotic ligaments
factors that determine the characteristics of ankle injuries
Position of the Foot
Direction of Applied Force
Magnitude of Force
Patient Characteristics
-Age
-Weight
-Bone Quality
ankle sprains
*Lateral Ligaments Most Commonly Injured*
Inversion Injuries
ATFL → CFL → PTFL
Syndesmotic Involvement = High Ankle
Sprain
Degree of Damage = Grade
High Ankle Sprain
Syndesmotic Involvement
Most Commonly Injured ligament
lateral ligament
calcaneofibular ligament tear
results in abnormal inversion laxity talar tilt
lateral process talus fracture
ankle sprain impersonators
-OCLs of the talar dome
-ant process calcaneal fractures
-peroneal tendon dislocations
-lateral process talus fractures
peroneal tendon dislocation
achilles tendon rupture
-weekend warriors
-classic history
-physical findings
achilles tendon rupture diagnostic testing
*(+)ve Thompson test*
MRI
thompson test
tests Achilles tendon integrity
more common ankle fracture
malleolar fracture
more severe ankle fracture
pilon fracture
malleolar fracture type injury
Injury is
Torsion (Twisting)
and Bending
pilon fracture type injury
axial crush injury
Malleolar Fractures
-Medial Malleolar Fracture
-Lateral Malleolar Fracture (Fibula)
-Posterior Malleolar Fracture
-Bimalleolar Fracture: Medial and Lateral
Malleolar Fractures
-Trimalleolar Fracture: Medial, Lateral, and
Posterior Malleolar Fractures
The Goal of
All Ankle Fracture
Care
Maintain or Restore the *Mortise Alignment* of the Ankle Joint
normal mortise view
look for joint space symmetry
treatment of Fibular Fractures with Intact Mortise
nonoperative
treatment of Medial Malleolar Fx with Intact Mortise
nonoperative
Mortise Disrupted: Lateral Malleolar
Fracture with Deltoid Ligament Tear
Tx: ORIF
Ligaments of the ankle continued
Lateral malleolus
Distal end of the fibula that creates the lateral shoulder of the ankle joint
-has a strong ligamentous attachment to the distal tibia referred to as the syndesmosis of the ankle
-allows for limited rotational motion of the distal fibula relative to the tibia → results is increase in *ankle dorsiflexion*
tibial plafond
Weight-bearing surface of the distal end of the tibia
talar dome
-Weight-bearing surface of the talus
-mobile articular surface of the ankle joint
-wider anteriorly > posteriorly → need for fibula to rotate with dorsiflexion
3 main lateral ligaments of the ankle
-Anterior talofibular ligament (ATFL)
-calcaneofibular ligament (CFL)
-posterior talofibular ligament (PTFL)
Anterior talofibular ligament (ATFL)
-Primary *restraint to anterior displacement, internal rotation, and inversion of the talus*
-most commonly injured ligament of any joint
calcaneofibular ligament (CFL)
-Underneath the peroneal tendons
-most stressed under extremes of inversion
-*attaches distally onto calcaneus, contributing to subtalar joint stability*
posterior talofibular ligament (PTFL)
-*Strongest of the 3 main lateral ligaments*
-typically the last of the lateral ligaments to be injured, and only with severe injuries
superficial deltoid ligament
-inserts into the talus, calcaneous, in tarsal navicular bone
Superficial deltoid ligament function
-well-suited to *resist hind foot eversion*
deep deltoid ligament
-inserts in the central and posterior aspects of the medial talar surface
Deep deltoid ligament function
-resists* external rotation, tilt, and lateral translation of the Talus*
syndesmotic ligaments
-Consists of the anterior and *posterior inferior tibio-fibular ligaments, the interosseous ligament, and the inferior transverse ligament*
-allows for* rotational motions of the distal fibula in relationship to the distal tibia*
-as the ankle dorsiflexes, that fibula externally rotates to accommodate for the wider anterior portion of the talar dome
Factors determining the nature of ankle injuries
-Position of the foot
-direction of the applied force
-magnitude of the force
Factors determining the severity of ankle injuries
-Age, weight, and bone quality of the patient
Most common lower extremity injury
Ankle sprain
common ligament injured in sprains
Lateral ligaments
Most commonly injured ligament
Anterior talofibular ligament > CFL > PTFL
High ankle sprain
Involve the syndesmotic ligaments
Presentation of ankle injuries
-History of twist or fall
-audible pop possible
-difficulty preparing
-acute onset of swelling and bruising along the antero-lateral aspect of the ankle
-aching that increases with swelling
Determine the integrity of the ATFL
Anterior drawer test
stresses the CFL
Inversion testing/talar tilt
Symptoms of syndesmotic ligament involvement
Tenderness extending proximal to the ankle in the interval between the fibula and tibia
-*pain when squeezing the calf and compressing the fibula towards the tibia*
Management of ankle sprains
RICE
-Rest
-ice
-compression
-elevation
Bracing and crutches
Progressive weight bearing and functional rehabilitation
therapies that may help to optimize sprain recovery
-hydrotherapy
-soft tissue massage
-graduated exercises to restore motion, strength, balance training proprioception
ankle sprain impersonators
-Achilles tendon rupture
-ankle fractures
lateral malleolus fracture
medial malleolus fracture
posterior malleolus fracture
Achilles tendon rupture epidemiology
-Most occur during athletic activity
-most commonly in males between the ages of 30 and 40 years old
Achilles tendon rupture history
-often diagnostic → patients often describe been feeling as if they have been kicked in the back of the calf
Achilles tendon rupture diagnosis
*Based on history and exam findings*
-asymmetrical April resting position
-palpable Achilles tendon defect and tenderness
-positive/abnormal Thompson test
-decreased plantar flexion strength
positive Thompson test
Decreased or absent passive ankle plantar flexion with posterior calf muscles squeeze compared to the normal side
When MRI is required to make the diagnosis of Achilles tendon rupture
-If the presentation is delayed and the patient is diffusely swollen
Management of Achilles tendon ruptures
-Advocates of both non-operative and operative treatment
-decision based on individual variables
-generally operative treatment → patients with high activity demands
-nonoperative treatment → elderly, less active individuals, and those with significant medical comorbidities
-both treatment modalities require lengthy rehabilitation
pilon fracture
-High energy crushing injury
-often result from MVAs or falls from a significant height
-almost always require surgical management
-high rate of long-term disability
malleolar fracture
-Twisting or bending forces to the ankle, similar to sprains
- more common than pilon fractures
Key to managing ankle fractures
Determining the stability of the mortise alignment
-if alignment is not significantly altered, injury can be treated non-surgically with good results
-if mortise is disrupted, surgical management is almost always required
Radiographic view required for evaluation of the ankle
AP, lateral, and mortise
mortise view radiograph
-Ankle is positioned with 15-20° of internal rotation
-exposes all of the joint spaces
-if it of the medial, lateral, and superior joint bases are not symmetrical indicates disrupted mortise
lateral malleolar fracture
*Distill fibular fracture*
-most common isolated ankle fractures
-if there's associated disruption of the deltoid ligament, the talus shifts laterally and the mortise is disrupted requiring surgical reduction
Location of lateral malleolar fractures that are generally associated with syndesmotic ligament tears
Fractures that are proximal to the syndesmosis with either a tear in the deltoid ligament or a medial malleolus fracture
Medial malleolar fractures
-uncommon isolated injuries
-most can be treated non-operatively
Posterior malleolar fractures
-Uncommon isolated injuries
-usually an element of a more complex injury
bimalleolar fracture
*Medial and lateral malleolar* fracture
-typically disrupts the mortise
-usually treated with open reduction and internal fixation
trimalleolar fracture
*Medial, lateral, and posterior malleolar* fractures
-most severe injury
-often associated with dislocation of the ankle and significant joint damage
-always treated with open reduction and internal fixation