4/3/2012

Ankle Anatomy and Radiology

Mark C. Reilly
Chief, Orthopaedic Trauma Service
New Jersey Medical School
Anatomic Pictures c/o Primal Pictures

Speakers
David Stephen
U Toronto, Sunnybrook Hospital

David Barei
U Washington, Harborview Medical Center

Michael Sirkin
New Jersey Medical School

Hobie Summers
Loyola University Medical School

Stability
Bony anatomy
Ligamentous anatomy
Joint capsule

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Ligaments
Important component of ankle fractures and
injuries

Syndesmotic
Lateral collateral
Medial collateral

Syndesmotic

Interosseous membrane
Interosseous ligament
Anterior tibiofibular l.
Posterior tibiofibular l.
Transverse tibiofibular l.

Medial Collateral
Superficial Deltoid
Anterior colliculus
Posterior Tibiotalar
Tibiocalcaneal
Tibionavicular

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Medial Collateral
Deep Deltoid
Posterior colliculus
Prevents lateral
subluxation

Fibular collateral
Three bands
Anterior talofibular
plantarflexion

Calcaneofibular
dorsiflexion

Posterior talofibular
Posterior subluxation
Rotatory

Radiographs

AP
Lateral
Mortise
10-15 internal rotation of tibia

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AP
Medial and lateral
gutters not equally
visible
Fibula overlaps talus
and tibia

AP
Medial border fibula
Incisural border
5mm

Tib-fib overlap
AP radiograph
Medial border fibula
Lateral border of
Chaput tubercle
10mm

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Talocrural
Angle
Mortise
About 83
75-87

Measure of
fibular length

Mortise
Medial and lateral clear space
should be equal to superior
clear space

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Mortise
Medial clear space 4mm
Compare to tibio-talar
joint

Mortise
Lateral border of talus
aligned with medial
border incisura

Mortise
Fibular Articular surface
congruent to Lateral
Talus
Shentons Line

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Talar Dome Lateral

Fibula/Tibia Relationship
Anterior and Posterior
Colliculi of Medial Malleolus

Talar Dome Lateral

Fibula/Tibia Relationship
Anterior and Posterior
Colliculi of Medial Malleolus

Need for CT
Suspicion of/ evaluate:

impaction
posterior malleolus
anterolateral fragment
associated fractures

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Dont Forget Tibial Films

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Conclusion
Understand the relevant osseous and
ligamentous anatomy
Understand the normal radiographic
relationships
Both osseous and ligamentous structures
make significant contribution to ankle stability
after injury

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Syndesmosis injuries
David Stephen
Sunnybrook HSC
University of Toronto
Toronto, Canada

Disclosures
Research support: Synthes Canada
Speaker: Synthes USA / Canada

Objectives:
Challenges
Management strategies
Take home points

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Syndesmosis disruptions
Controversies:
screw only vs plate & screw
1 vs 2 screws
3 vs 4 cortices
remove vs leave screw(s)
3.5mm vs 4.0mm vs 4.5mm screws
Suture anchors??

Challenges
Diagnosis
Accurate reduction
Stable fixation

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I read that you can just

pull the fibula down and
perc it

Syndesmosis screws removed @10 weeks

4 months postop 6 weeks post screw removal

Problems:

syndesmosis widening

fibular length

medial malleolar malreduction

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Ankle Fractures: Malunion

Biomechanics
Fibular shortening
External rotation fibula
Lateral talar shift

peak pressures
TT contact
shear stress
instability

OA

4 months postop 6 weeks post screw removal

Management:

Fibular osteotomy
Debride syndesmosis/medial jt
Orif syndesmosis

2 year follow-up

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KEYS: lateral side

fibula:
length
rotation

Syndesmosis
low threshold for
open reduction

32 yo fall down stairs: seen at

local hospital reduction / cast

CT to assess syndesmosis/
posterior malleolus

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Surgical tactic

Lateral position
Posterolateral approach
Debridement chondral debris
Fixation posterior malleolus
Direct open reduction/ fixation
syndesmosis (4.0mm cortical screws)

3 months postoperative

Syndesmosis: Challenges
Diagnosis
Accurate reduction
Stable fixation

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Take Home points

Understand the injury
Preoperative CT

KEYS to reconstruction
Open reduction
Stable fixation (screws)
Consider postoperative CT if concern

Thank You

3/30/2012

AO Trauma NA
Complex Ankle Fractures Webinar
Posterior Malleolus Fracture Management

David P. Barei MD, FRCSC

Harborview Medical Center
University of Washington
Seattle

Disclosure
Teaching Honoraria (AO, Synthes)
Synthes Consultant (implant design)
Journal Reviewer
JBJS-A, J Orthop Trauma, CORR, J Knee Surgery

AO Fellowship Committee

Institutional-UW Orthop-Research

AO Spine North America

AO-Stiftung-ASIF Foundation
Bank of America Foundation
The Center, Orthopaedics and Neurological Surgeons
Fidelity Investments
Helena Orthopaedics Clinic
Illinois Orthopaedics & Hand Center
Inland Orthopaedics of Spokane
JMS Hand Associates
Northwest Biomet, Inc.
Pacific Rim Orthopaedics
Proliance Surgeons, Inc.
Proliance Orthopeadics & Sports Medicine
The Seattle Foundation
Seattle Christian Foundation
Silicon Valley Community Foundation
Simonian Sports Medicine Clinic
SKS Plastic Surgery
Spectrum Research
Synthes U.S.A.
Synthes Spine Co.
Washington Research Foundation
Washington State Orthopaedics Association
Webber Lawn & Yard Care

National Institutes of Health (NIH)

National Science Foundation (NSF)
Veterans Affairs Rehabilitation Research and
Development Service
Orthopaedic Research and Education Foundation (OREF)
A.O. North America
Amgen, Inc.
Bayer AG
BioAxone Therapeutique, Inc.
CeraPedics, LLC
Christopher Reeve Paralysis Foundation
Depuy (Johnson & Johnson, Inc. )
Foundation for Orthopedic Trauma
Integra Lifesciences Corporation
National Science Foundation
Ostex International, Inc.
Orthopaedic Trauma Association
Paradigm Spine
Smith & Nephew
Synthes Spine Co.
The Boeing Company
US Army Research Office
US Department of Education

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Anatomy
Evolution of understanding
Conceptually simple
Focus on articular surface

McDaniel CORR, 1977

Treatment Evidence
Poorly described
Large fragments
20-30% of the articular surface
Talar subluxation, arthrosis, worse outcomes
Smaller fragments didnt seem to be associated with
problems
Trimalleolar fractures seem to have worse outcomes than
bimalleolar
Thought to be secondary to chondral injury and disrupted
tibiotalar congruity

Anatomy
Evolution of understandingSoft tissue
attachments
Syndesmosis
PITFL
Osseous incisura

Tibiotalar
Capsular attachments
Articular congruity
Hermans J. Anat, 2010

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Posterior Malleolus Fractures

Contributes to syndesmotic stability (PITFL)
Indications for fixation controversial
>25% versus larger versus smaller versus all?
Posterior subluxation?

Pathoanatomy
19%

Frequency
67%

19%

14%

12%

Cross-Section Area
30%

N/A
Haraguchi JBJSA, 2006

Reduction and Fixation Choices

Indirect Reduction
Ankle dorsiflexion
Rarely adequate for an accurate
reduction
Direct Reduction
Visualize the cortical exit
Fixation
Anterior to posterior screws
Posterior to anterior screws
Posterior anti-glide plate

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What we do know
Tibiotalar incongruity & subluxation = arthrosis
Large fragments result in syndesmosis disruption:
Incisura deformity
PITFL disruption

We are bad at reducing a syndesmosis closed,

Posterior malleolar ORIF provides more stability to the
syndesmosis than trans-syndesmotic fixation
PITFL stays attached to the posterior malleolus

Good ankle fracture outcomes seem to be increasingly

related to anatomic and stable syndesmosis

Surgeon Practices
Gardner Foot Ankle Int, 2011
Wide variation in practices
Noted that fragment size wasnt the sole
indication
Other considerations:
Joint stability,
Syndesmosis reduction,
Syndesmosis stability

The Problem
Posterior talar subluxation
Point contact loading on the plafond and talus
Chondral destruction
Syndesmotic dislocation and dysfunction

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The Other Problem

If you are considering that a given posterior
malleolus requires reduction and fixation,
strongly consider a CT scan.

Case 1

Large fragment
articular incongruity
no gross tibiotalar displacement/dislocation
Antiglide plate and screw fixations
tibiotalar subluxation and arthrosis

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Case 2

Small fragment with gross tibiotalar instability and fibular syndesmotic comminution
Posterior anterior screw with a small modified plate as a washer
for syndesmosis reduction and stability

Posterolateral

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Case 3

Case 3 Approach?
1. Anteromedial
2. Anterolateral
3. Posterolateral
4. Posteromedial
5. Combined
posterior and
anterior

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Radiologic medial double density

Large posteromedial fragment

Posteromedial osteochondral fragments
Smaller posterolateral fragment

Posterolateral

Posterolateral

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Posterolateral

Posterolateral

Posteromedial

10

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Posteromedial

Posteromedial

11

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Case 4

Main concern with last 2 cases:

Tibiotalar arthrosis
Posteromedial talar subluxation

12

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Posteromedial

Summary
Relative anatomic importance:
Syndesmotic stability via PITFL
Osseous incisura
Tibiotalar congruity/stability

Varying morphologies
Consider CT scan in those that you deem operative

Fixation strategies
Posterolateral/posteromedial approaches
Antiglide fixation for large fragments

13

Ankle
Fractures
Fixation in the elderly:
Avoiding problems:

Michael Sirkin, MD
Vice Chairman, Department of Orthopaedics
New Jersey Medical School

Disclosures
Consultant for Biomet
Editorial Board
JAAOS
JOT
Journal of Trauma

Today
Define the problem
Basics to understand
Fixation strategies
Examples

Avoiding problems

The problem
95 year
old
Fell on
ice
Closed
fracture

The problem
Follow up
Loss of
reduction

Backing out
of screws

Stability
Bony anatomy
Poor bone quality
Fixation techniques need
modification
Ligamentous anatomy
Joint capsule

Standard
Fixation
Techniques

Medial

Common medial fixation

Tension Bands

Screw and
wire

Lateral

Cancellous
screws

Neutralize

Lag Screws

Common Techniques

Antiglide

Standard Fixations

Elderly Fixation
Special techniques may be
need in osteoporotic bone
Hardware not as well held in
place
Prevent displacement
Preserve reduction

Medial

Special fixation
Cancellous screw position
Cortical lag screws
Long

Plates
Supplemental k-wires

Medial

Cancellous screws
If using partially threaded
screws-use right size
Just long enough for thread
to cross fracture
Have threads in
metaphyseal bonenot
intramedullary canal

Medial

Cortical screws

Cortical screwslag technique

Lag by technique
Allows maximal
purchase
May use very
long screws
Can be bicortical
if necessary

Medial

Cortical screws

Cortical screwslag technique

Lag by technique
Allows maximal
purchase
May use very
long screws
Can be bicortical
if necessary

Medial

Plates

Good for
comminution
No bony stability

Medial

Plates

Good for
comminution
No bony stability

Small fragments
Vertical fractures
Act as a buttress

Medial

K-wires
Can be used with
screws/plates
Small fragment
Bad screw purchase
Multiple points of
fixation
Can be bicortical

Elderly Fixation
Special techniques may be
need in osteoporotic bone
Hardware not as well held in
place
Prevent displacement
Preserve reduction
Techniques

Fibula
Reduction

Lateral

Special Fixation
Distal cross screws
Intramedullary k-wires
Longer plates
Use tibia for fixation
Locked plates

Lateral

Distal screw

1/3rd Tubular plate

Flatten plate
Cross Screws
distally
Creates bony triangle
Longer screws
Metal on metal
Longer screws
20mm

Lateral

Intramedullary K-wires
Used with plates
and screws
K-wire placed prior
to screws
Increases purchase
of screws
Metal on metal
interdigitates

Lateral

Longer plate
Distal fixation less
important
Buttress to distal fragment
Rely on proximal fixation
to hold distally

Lateral

Tibial fixation

Tetra cortical screws

Use tibia for lateral
fixation

Increased bony
purchase
Function not as
syndesmotic screws
Use as many as
needed

80 yof fall in grocery store

3 months postop

10

Locked plates
Small screws in
distal fragment
Questionable
benefit

Fixation held
proximally

Locked plates
Multiple small
screws probably
better

Locked plates
Small screws in distal
fragment
Fixation held
proximally
Can also gain fixation
in tibia

11

External Fixation
Can use ex-fix to
protect fixation
Typically 6
weeks

Frequently more than one

technique is needed
Use both medial and lateral
techniques

Longer lateral
plate
Longer
medial
cortical lag
screws

12

 85 year old
Twist and fall
Over last 2 years
Fractures Wrist
Compression of L5

Multiple Techniques
Medial
Longer screws
Bicortical screws

Lateral
Longer plate
Add intramedullary Kwire
Cross screws distally

Conclusions
Care must be taken when
treating the osteopenic
Special techniques may be
needed
Can be done

13

 Frequently more than one

technique is needed
Use both medial and lateral
techniques
All techniques can be used

65 year old
Diabetic
Dialysis
dependent
Walking to
bathroom
twisted ankle

Lateral
Intramedullary wires
Longer plate
Tetracortical screws
Crossed distal
screws

Medial
Plate
K-wires
Long screws

14

6 weeks, no loss of
reduction

Thank

You

15

4/3/2012

Medial and Lateral Impaction in

Ankle Fractures
Hobie Summers, MD
VuMedi Event
April 3, 2012

Disclosures
Institutional grant from Synthes for research
coordinator
Synthes consultant for representative
education

Common Issues
Easily unrecognized on initial imaging
Must keep a high index of suspicion
Adduction and Abduction type patterns
Supination/Adduction
Pronation/Abduction

Still look for impaction in rotational injuries,

especially with dislocation

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Where to look
Supination/Adduction
Medial impaction

Pronation/Abduction
Lateral impaction vs Chaput fragment

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15 months

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Summary

Beware of adduction/abduction injuries

Disimpact the articular surface
Bone graft
Buttress plating works well

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32 y/o homeless female

Falls while intoxicated

Splinted in ER and referred to

clinic
By report, minimal pain medially, not
particularly swollen either

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Stress

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Stress

43 year old firefighter

Fall onto Lower Extremity
Closed, Isolated Injury

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Anterior

Medial

Posterior

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48 y/o male s/p motorcycle crash

10cm transverse medial open wound
Isolated injury

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46 year old male seen and splinted

after twisting injury to ankle

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