Short Musculoskeletal Functional Assessment scores were also worse at 12 months in patients who had syndesmotic stabilization because the dysfunction index was higher in the syndesmotic injury group (P = 0.009). This is because diabetes can cause foot complications including diabetic foot ulcers. Nonetheless, the author concluded that ORIF was essential because unstable and unreduced frafracture-dislocations worse long-term outcomes.7, A matter of debate is still represented by the size of the fragment to treat: most studies recommended internal fixation for posterior malleolar fractures affecting 25% to 33% of the articular surface measured on the plain radiographs or CT. 2007 Jul;89(7):1438-41. doi: 10.2106/JBJS.F.01006. Treatment without repair of the deltoid ligament. The most common malleolus fracture happens at the fibula. Also, to avoid false illusions concerning outcomes, the patient should be given the information that post-traumatic osteoarthritis is the most frequent complication, correlating more to the complexity of the fracture pattern (trimalleolar, large-sized posterior fragment) than to the treatment itself.7,13,21,22,25,32. Gupta S, Virk JS, Malhotra A, Garg SK. 2021 Aug 10;6(8):692-703. doi: 10.1302/2058-5241.6.200138. We reviewed the results of 105 patients with unstable fractures of the ankle that were fixed between 2002 and 2010 using the Acumed fibular nail. [Minimally invasive fixation of distal fibular fractures with intramedullary nailing]. With more severe ligaments and unstable fractures, there is always some difference in flexibility and appearance. Concerning unstable fractures of the ankle, Day described excellent or good outcomes in 64% of cases and fair or unsatisfactory in 36%.43. Because the joint is unstable, it is susceptible to damage and early ankle arthritis if left untreated. A proposal and validation. The most common ankle injuries are strains, sprains, and fractures. Unable to load your collection due to an error, Unable to load your delegates due to an error. The final review included 33 studies. The lateral malleolus is at the end of the fibula, a smaller bone in the leg. FOIA They may include cartilage layers blistering and in-the-bone cyst-like lesions or even bone layers and cartilage fracture. Your ankle surgeon uses metal plates and screws to stabilise your ankle to allow the bones to heal. Minimizing that tension can help reduce the risk of infection and also helps with pain. The reference lists of the studies were manually searched for other publications that may have eluded the initial search. stop any bleeding - put pressure on the wound using a clean cloth or dressing. All patients were followed and evaluated at 3, 6, and 12 months with clinical and radiographic examination as well as functional status (Short Musculoskeletal Functional Assessment, American Orthopaedic Foot and Ankle Society). Excellent or good only outcomes were reported by Gupta (50% excellent, 50% good), Vem (60% excellent, 26.6% good), Choi (24% excellent, 48% good), Kukk (mean 86.0 points), Mingo (excellent or good 53.85%), Gehr (58.6% excellent, 33.3% good), Simanski (mean 90.0 points).16,19,24,29,30,33,34 Fair outcomes were reported by Testa (mean 75.3), Hong (mean 78.3),and Gehr (5.5% of cases).14,26,33 Conservative and surgical treatments were compared by means of the OMAS scale in some studies.13,17,42 Surgery tended to achieve better results: Roberts reported an OMAS score of 71.2 after fixation versus 57.3 after conservative treatment; Carter 85 points after fixation and 80 points after cast; Hoelsbrekken 81 points after surgery, 80 points after conservative treatment.13,17,42, Testa compared OMAS score based on the pattern of fracture, reporting a mean of 78.65 points in Danis-Weber Type B fractures and a mean of 69.72 points in type C fractures.14 Tanoglu compared OMAS scores after one-stage surgery (87.8 points) and after two-stage surgery (83.2) in complex fractures.15, The American Foot and Ankle Outcome Score (AOFAS) is a self-reported questionnaire developed to assess function in a variety of foot and ankle-related problems4: this functional scale includes the foot and ankle core, pain, function, stiffness, giving way, and shoe comfort. After surgery, you will most likely be in a plaster splint or fracture boot. When ligaments are torn and associated with an ankle fracture, this damage can render the ankle unstable. While most simple ankle fractures heal very well, more significant injuries may have long-term issues and can include stiffness, soreness, and an inability to regain full, pre-injury motion and function. When 2 malleoli are fractured, the injury is called a bimalleolar ankle fracture and when 3 malleoli are fractured, the injury is called a trimalleolar ankle fracture. 2022 Nov;142(11):3311-3325. doi: 10.1007/s00402-021-04161-y. Determination of ankle stability is crucial during the initial evaluation and assessment of the fracture. The Swedish version of OMAS is a reliable and valid outcome measure for patients with ankle fractures. Of the remaining 105 articles, 76 were excluded after evaluation of the full text. To understand ankle injuries, it helps to review some ankle basics. Depending on your needs, your surgical team may choose to initiate formal physical therapy at this time or delay physical therapy until a later date. come in many varieties, from a slight break in one bone that doesnt prevent you from bearing weight on it, to severe fractures that you dont put weight on it for months and may require surgery. Hagemeijer NC, Lubberts B, Saengsin J, Bhimani R, Sato G, Waryasz GR, Kerkhoffs GMMJ, DiGiovanni CW, Guss D. Knee Surg Sports Traumatol Arthrosc. Miller AN, Carroll EA, Parker RJ, Helfet DL, Lorich DG. Bimalleolar ankle fracture is a type of ankle fracture, in which both the inner and the outer end of the ankle break or develop a crack. Moreover, the talar dome may be compared to a barrel vault, where the apex (A in Figure 3) is the keystone and the cartilaginous surface the extrados. Fragment-specific fixation of trimalleolar fractures utilizing the posterolateral approach: A preliminary experience. For best healing, it is important to follow instructions from your surgeon regarding your post-operative care. Theres no doubt having a sprained ankle is a pain! OUTCOMES AFTER UNSTABLE FRACTURES OF THE ANKLE: WHATS NEW? The bones of the lower leg are the tibia and the fibula. J Bone Joint Surg Am. Overall, surgeons should be considering the axis of the legs before choosing to surgically treat, and eventual causes for deformity should be investigated (rickets, neurofibromatosis, etc.). Quinn TM, Huselmann HJ, Shintani N, Hunziker EB. This condition increases your chances of developing conditions, such as: may also make it feel as though your ankle is always about to give out. Ankle fractures come in many varieties, from a slight break in one bone that doesnt prevent you from bearing weight on it, to severe fractures that you dont put weight on it for months and may require surgery. It is well appreciated that the risk of a poor clinical outcome secondary to failure of the surgical construct, deep wound infection and osteomyelitis or a combination of both, is greatly increased in neuropathic diabetic patients, that is, those that are . government site. Epub 2015 Nov 12. Thus, Roberts recommended that ankle fractures should be treated only by skilled surgeons.13 The same results were found by Tewjani.32 Petruccelli assessed outcomes comparing fixation with LCP and conventional one-third tubular plate: no significant differences in radiographic bone union, time of fracture healing, or wound complication rate were found.44, Some studies assessed the correlation between functional scores and immobilization. In some cases, the bones of the ankle may poke through the skin. High incidence of osteochondral lesions after open reduction and internal fixation of displaced ankle fractures: Medium-term follow-up of 100 cases. Petruccelli R, Bisaccia M, Rinonapoli G, et al. Injuries can result from anything from an unforeseen mis-step, to falling and rotating the ankle to the point of muscle strain, tendon tear, or bone break. An unstable ankle fracture can occur when an injury compromises the integrity or stability of the ankle joint. There were no other differences in complication rates. The arthroscopic shaver will be easily inserted between the medial malleolus and the talar dome, indicating a positive drive-through sign. Phillips score: excellent or good 64%, fair or unsatisfactory 36%. Figure 2. Comparison of Posteromedial Versus Posterolateral Approach for Posterior Malleolus Fixation in Trimalleolar Ankle Fractures. Most often, the emergency room doctor will examine your foot and ankle for sensation, blood flow, and your ability to move your toes. Cureus. All the outcomes of the thirty-three selected studies were analyzed. A prospective, randomized study of the management of severe ankle fractures. Shin splints may not threaten your life, but they cause problems that interfere with your quality of life. A Large Animal Model for Orthopedic Foot and Ankle Research. This study aims to evaluate the effect of different syndesmotic screw insertion levels on postoperative clinical outcomes and determine whether an optimal level exists. 4 Excellent results are predicted with open reduction and internal fixation of unstable ankle fractures. The term functional ankle instability, on the other hand, refers to a subjective condition in which the ankle only feels as though it were unstable. Aftercare following syndesmotic screw placement: a systematic review. Ankle fractures most often occur from a simple twist and fall, as can happen on a wet floor, a grassy hill, on stairs, or off a curb. However, unstable fractures requiring surgery usually need at least 8 weeks of non weight bearing to allow proper healing. Because there are so many bony parts and ligaments, sometimes only 1 or 2 parts are injured, although many parts can be injured. Since physical . Typically these injuries are . For this systematic review we asked: (1) What are the outcomes in treatment of unstable ankle fractures? Men or women aged over 60 years with displaced unstable fracture of the ankle who meet the eligibility criteria: Inclusion criteria Men or women aged over 60 years Isolated displaced unstable ankle fracture Ambulatory prior to the injury - in any capacity Capable of giving informed consent Posterior malleolar fractures should be fixed regardless the size, considering some individual factors. Jones CR, Nunley JA II. Kukk A, Nurmi JT. The good news is that the foods you eat can help you manage this troublesome condition and reduce uncomfortable flare-ups. Ankle fractures and dislocations. 2019 Nov 11;4(4):2473011419888505. doi: 10.1177/2473011419888505. sharing sensitive information, make sure youre on a federal The mean physical component Short-Form 12, Olerud and Molander score, and American Academy of Orthopaedic Surgeons Foot and Ankle outcome scores at a mean of six years post-injury were 46 (28 to 61), 65 (35 to 100) and 83 (52 to 99), respectively. This condition increases your chances of developing conditions, such as: Untreated sprains may also make it feel as though your ankle is always about to give out. Stability of Weber B Fractures. Moher D, Liberati A, Tetzlaff J, Altman DG. Heres what you need to know. Karaca S, Enercan M, zdemir G, Kahraman S, obanolu M, Kkkaya M. Importance of fixation of posterior malleolus fracture in trimalleolar fractures: A retrospective study. The most common procedure is an Open Reduction with Internal Fixation (ORIF). Two authors (LM, LCZ) reviewed the titles: 427 studies were excluded because they did not meet the inclusion criteria. Ankle Sprain. Academic medical center. This kind of fracture can involve the ligaments that hold the joint together, the joint surfaces themselves, or a combination of both. Given the instability, they often require surgical treatment, but literature scarcely reports on the outcomes of their management. In an unstable ankle fracture, the joint will not support weight-bearing without displacing. Epub 2013 Apr 28. Pflger P, Braun KF, Mair O, Kirchhoff C, Biberthaler P, Crnlein M. EFORT Open Rev. Surgical treatment is preferable for unstable ankle fractures. There was a greater percentage of Type C fractures requiring syndesmosis stabilization, whereas Type B fractures were less likely to require syndesmosis stabilization (P = 0.001) At 6- and 12-month follow up, there was a clear difference in outcome based on American Orthopaedic Foot and Ankle Society and Short Musculoskeletal Functional Assessment scores; patients who underwent syndesmotic stabilization had worse American Orthopaedic Foot and Ankle Society scores with lower function ratings (P = 0.04) and worse pain ratings (P = 0.02). Even small. SooHoo NF, Krenek L, Eagan MJ, Gurbani B, Ko CY, Zingmond DS. Approximate Synonyms. Since the articular cartilage is avascular, biological activities of chondrocytes seemed not to be altered so much by the cartilaginous disruption and local blood supply interruption, as by the great traumatic stress on cartilage metabolism. The authors conducted a retrospective review of prospectively collected data. The rationale is that larger fragments led to worse long-term results than smaller fragments.16,23,24,40,45 The development of osteoarthritis occurred more frequently in fractures with medium or large-sized fragments or in the case of residual postoperative articular step-off of 1 mm or more.7,23,25,37,45 Mingo performed a statistical analysis on small (<25%) and large (>25%) fragments: the relative risks at 95%-confidence intervals revealed better AOFAS and OMAS scores in smaller fragments and demonstrated outcomes not affected by the quality of reduction.29 Nonetheless, other studies stated that even small posterior malleolar fragments may increase the risk of osteoarthritis: thus, they recommend that all fragments must be fixed regardless of size.16,20,25,37,38 Drijfhout Van Hooff reported that AOFAS and AAOS scores were not significantly worse in the larger (>25%) fragment groups compared to the smaller fragments (<5%). The electronic databases PubMed, Scopus, and Embase were interrogated using the search terms bimalleolar or trimalleolar and fracture. Unstable fractures will almost always require surgical stabilisation. Please enable it to take advantage of the complete set of features! Unstable ankle fractures are generally treated by ORIF. Functional treatment and early weightbearing after an ankle fracture: a prospective study. These elements in your joint not only help it move, they work together to promote stability. Flowchart describing the PRISMA method of this study. This site needs JavaScript to work properly. If the syndesmosis is incompetent, the talus is unstable within the mortise. ), and daily life activities (work, sports, etc.). It may give way easily, without warning, particularly on uneven ground. Wang L, Shi ZM, Zhang CQ, Zeng BF. Usually, the giving way occurs while walking or doing other activities, but it can also happen when you're just standing. Flowchart describing the PRISMA method of this study. Minor ankle injuries can heal with rest and proper home care. A total of 1211 articles were retrieved for preliminary evaluation (Figure 1). Stable fractures typically heal with immobilization and protected weight-bearing whereas operative management is usually required for displaced or unstable fractures. While you can avoid all injuries, you can reduce your risk by keeping your feet and ankles healthy with these tips. The site is secure. An official website of the United States government. This site needs JavaScript to work properly. Initially, cell necrosis occurs at the fracture line, followed by delayed apoptosis in non-fracture areas due to excessive acute mechanical stresses and the cytotoxic effect of biomechanical mediators (reactive oxygen species, matrix-damaging enzymes, inflammatory cells, and cytokines).46 Post-traumatic events occur mostly in the transitional zone of cartilage, while cell volumes per volume unit and cell surface areas per volume unit are both altered mostly on convex surfaces of the ankle.47. Foot Ankle Surg. This surgery can restore your mobility and end your pain, but not all people are candidates. Results: If you think you've broken your ankle, there are some things you can do while you're waiting to see a doctor. Foot Ankle Orthop. For help with an ankle injury, contact the team at the Arlington/Mansfield Foot & Ankle Centers office nearest you or request an appointment online now! Intramedullary fixation of distal fibular fractures: a systematic review of clinical and functional outcomes. Unstable ankle. Usually, the displacement of the posterior fragment is cranial, causing no mechanical impingement onto talar rotation during dorsal and plantar flexion (Figure 3). Scholastica Support. The ankle is a synovial, hinge joint that is comprised of three articulating bones, three groups of ligaments and three supporting tendons. Different factors that may influence outcomes should be taken into account. Following surgery, the ankle is usually put in a short leg cast. eCollection 2022. When the ankle fracture is unstable or in bad position, surgery is needed to repair the ankle. Typical ankle fractures involve injury to one or more of these structures. Heres what you need to know. Monestier L, Riva G, Coda Zabetta L, Surace MF. Choi JY, Kim JH, Ko HT, Suh JS. 8600 Rockville Pike Ankle fractures, known more commonly as a "broken ankle", happens when there is a break in one or more of the bones that make up the ankle joint. Different types of ankle surgery treat different injuries or medical conditions affecting your ankle. Please try your search again. After the duplicates were eliminated, 641 original articles remained. Carter TH, Mackenzie SP, Bell KR, et al. Therefore, the typical treatment is to surgically repair the fracture to stabilize the ankle joint. When a lateral malleolus fracture is accompanied by a sprain of the ligament on the inside of the ankle (the deltoid ligament), your injury may be unstable and may require surgery. sharing sensitive information, make sure youre on a federal A Retrospective Study in Three Level I Trauma Center. The fracture pattern often provides useful clues not only regarding the mechanism of injury but whether there are associated lesions (that may not be apparent on the x-ray). When you injure the ligaments in your ankle, you can end up with one of the three types of ankle sprains: Grade I, Grade II, and Grade III. When two or three parts of the malleoli of the ankle are broken, the ankle is unstable, and surgery is necessary. A SYSTEMATIC REVIEW. Bethesda, MD 20894, Web Policies Patient-reported pain and postoperative complications were recorded as well. While most ankle fractures heal well, some may develop post-traumatic arthritis, with increasing pain and stiffness. Figure 1: Optimal ankle positioning with gravity stress testing. Tochigi Y, Buckwalter JA, Martin JA, et al. , but they more commonly result during sports and fitness activities, after tripping or falling, and when you twist your ankle during any activity. official website and that any information you provide is encrypted We reviewed the results of 105 patients with unstable fractures of the ankle that were fixed between 2002 and 2010 using the Acumed fibular nail. Online ahead of print. Lateral: Best for posterior malleolar fractures. These elements in your joint not only help it move, they work together to promote stability. Enter the URL below into your favorite RSS reader. Rosemont, IL 60018-4975, Phone: (847) 698-1631 Moreover, selecting the approach and hardware for the PM should be depending on the pattern of the fracture and on the surgeons preference and experience. If the deltoid ligament is torn in association with a fracture, the ankle is generally unstable. Clinicians should assess the fracture configuration through imaging modalities and try to preserve the articular surface congruity so as to achieve optimal outcomes. This means that the aforementioned processes (cell apoptosis, cartilage degeneration, matrix damage) develop not only nearby the fracture lines but also in areas not directly involved by trauma. After the abstracts were reviewed, 109 studies were excluded for the same reason. Search terms for bimalleolar or trimalleolar fractures of the ankle. government site. Since there are injuries to both sides of the ankle, bimalleolar fractures are frequently unstable, and the ankle is often dislocated. de Vries JS, Wijgman AJ, Sierevelt IN, Schaap GR. Data from each included study were collected, particularly the number of patients, gender, age, follow-up, outcomes, and complications (Table 3). Doctors rank the severity of the injury beginning with Grade I, which is the least severe and ending with Grade III, which is the most severe. Strains, sprains, and fractures can all have similar symptoms, making it difficult to tell which you have without a medical evaluation. ORIF has been demonstrated to be superior to conservative treatment: good short- or long-term results are reported, with several advantages including easier rehabilitation, early mobilization, and earlier weight-bearing. Different types of ankle fractures Fibula Only Fracture (lateral malleolus fracture) Advances in the Surgical Management of Ankle Fractures. Diagnosis is with x-rays and sometimes MRI. (3) What factors influence the outcomes? Tags. Mingo-Robinet J, Lpez-Durn L, Galeote JE, Martinez-Cervell C. Ankle fractures with posterior malleolar fragment: management and results. J Clin Orthop Trauma. Home care includes things like protecting the injured ankle, using crutches or other devices to help immobilize the joint, mild compression, elevation, and apply cold packs or ice for 15-20 minutes every 2 hours. You may require several months of physical therapy to be able to return to your prior activities. Two-Stage Surgery for the Malleolar FractureDislocation With Severe Soft Tissue Injuries Does Not Affect the Functional Results. The most standardized and reliable scores and questionnaires reported are the OMAS score, the AOFAS score, VAS score, and SMFA score.310 As far as the outcomes of the treatment of unstable ankle fractures are concerned, most studies reported excellent or good results with these scores.14,16,1821,2426,2934,39,43 Surgical fixation is mostly preferred over conservative treatment as it consistently returns better outcomes.7,13,17,26,32,38,42 Particularly, surgery allows for shorter immobilization and earlier weight-bearing leading to better functional scores and higher rates of return to normal life.19,26,34 As a result of this review, surgical treatment for all the unstable fractures is recommendable to restore the anatomy, function, and stability, and to reduce the risk of complications as post-traumatic arthritis was demonstrated to develop faster after conservative treatment.14,21,37,45, Interesting histological studies were performed by Tochigi and Quinn.46,47 The former demonstrated that post-traumatic osteoarthritis commonly occurred in multi-fragmentary fractures because of the death of chondrocytes near the fracture line.46 The cells disfunction propagates to the surrounding non-fracture areas within the first 48 hours, and its extent is related to the comminution degree, the overall length of the fracture lines, and to the intensity of the applied mechanical forces. You can expect to have skin sutures and staples removed typically between 10 to 14 days after surgery. By repairing the ankle surgically, we can confidently allow early range of motion exercises to reduce stiffness and disability that can result from prolonged treatment with a cast or splint. Yeo ED, Jung KJ, Hong YC, Hong CH, Lee HS, Won SH, Yoon SJ, Kim SH, Ji JY, Lee DW, Kim WJ. Unstable ankle fractures are extremely common, particularly in the elderly, even if not solely related to osteoporosis: their incidence is about 175 cases/100,000 population/year.1 Management of these injuries is still challenging because of a fairly high risk of complications. If the ankle is dislocated, you may need a reduction, which means the doctor will manipulate the foot and ankle back in to position with his or her hands, and then apply a splint or boot. Overall, seven patients had loss of fixation of the fracture and there were five post-operative wound infections related to the distal fibula. The picture in Figure 4 shows a patient with a fractured ankle that is dislocated and pushing against (tenting) the skin. Bimalleolar fractures make the ankle unstable and typically require surgery to implant metal plates, screws, and rods to keep the bones aligned. Kaftandziev I, Spasov M, Trpeski S, Zafirova-Ivanovska B, Bakota B. Ankle fractures directly or indirectly involve the ankle joint. The quality of the studies was evaluated with the Methodological Index for Non-randomized Studies (MINORS) questionnaire. (3) What factors meanly impact the outcomes of treatment? The ankle joint is formed of two lower leg bones, tibia on the inner side and fibula on the outer side. They are the extension of a lateral collateral ligament injury. Figure 1. Surgical incisions around the ankle are at higher risk for wound complications than skin in other areas. Unstable ankle fracture: the stability or structure of the ankle joint is affected by the break. 2013 Jul-Aug;52(4):491-4. doi: 10.1053/j.jfas.2013.03.032. The bony parts of the fibula and tibia are called malleoli (singular = malleolus). Untreated sprains can lead to a chronically unstable ankle joint. The site is secure. Those were the challenge to fix smaller fragments of the PM, the difficulty to judge the quality of reduction and direction of the screws under fluoroscopy, and not always being able to achieve intrinsic stability of fixation by screws alone when the injury revealed a vertical shear component.16 Kalem observed a non-statistically worse reduction in the P-A screw group compared to the A-P screw group.37 Vidovic reported no difference in complication rate between A-P fixation and P-A fixation.39 Regarding osteosynthesis by buttress plates or P-A screws, the posterolateral or posteromedial approach played a significant role in obtaining good outcomes.16 Posterior fixation provided better anatomical reduction under direct visual control, also for small or medium-sized fragments, while interfragmentary compression and biomechanical stability are improved with a buttress plate able to resist vertical shear.24,28,39,45 However, fixation through a posterior approach could also reveal some technical challenges, related to prone or lateral positioning (and consequent difficult fixation of medial malleolus), possible danger or injury of the sural nerve, and to surgery duration, because of the lesser familiarity with this technique among the surgeons.16,45, Zhong compared results deriving from posterolateral and posteromedial approaches. Moreover, according to the reviewed studies, metallic implants are more desirable to stabilize ankle fractures than biodegradable ones, because of the better results.27,36 Nonetheless, further research, especially with randomized prospective studies, is still desirable. Epub 2017 Sep 7. J Foot Ankle Surg. Functional scores, influencing co-factors, and issues about the PM obtained from the different studies were analyzed and compared. Gadomski BC, Labus KM, Stewart HL, Bisazza KT, Nelson BB, Puttlitz CM, McGilvray KC, Regan DP, Easley JT. Several complications were reported by the selected studies. Three bones make up the ankle joint. However, the optimal level for syndesmotic screw positioning remains unclear. that might pose a conflict of interest in connection with the submitted article. The only time that unstable trimalleolar fractures are left to heal on their own is when surgery would pose too big of a threat to the patient due to health concerns or other potential complications. 2021 May 18;12(5):254-269. doi: 10.5312/wjo.v12.i5.254. Noh JH, Roh YH, Yang BG, Kim SW, Lee JS, Oh MK. Simpler ankle fractures can be treated with early weight-bearing in a protective boot. Widening of ankle mortise caused by syndesmosis injury leads to lateralization of vertical mechanic forces. Hong CC, Nashi N, Prosad Roy S, Tan KJ. OConnor TJ, Mueller B, Ly TV, Jacobson AR, Nelson ER, Cole PA. A top screw versus posterolateral plate for posterior malleolus fixation in trimalleolar ankle fractures. Objective: 2022 Mar 10;10:793866. doi: 10.3389/fbioe.2022.793866. This is because there is very little tissue (fat, muscle, fascia) between the skin and the bone around the ankle. Main outcome measurements: MeSH Performing early surgery to restore joint stability should be also more effective in inhibiting the progression of chondrocyte damage, potentially moderating the pathological cascade to post-traumatic osteoarthritis. (2) What about complications of treatment in unstable fractures? Federal government websites often end in .gov or .mil. When surgeons think about ankle fractures, we think in terms of these bony parts and ligaments. This study was performed to evaluate the results of operative treatment of ankle fractures in patients who required syndesmotic stabilization in addition to malleolar fracture fixation compared with patients who required malleolar fixation alone. The inclusion criteria were: treatment of bimalleolar/trimalleolar fractures in adulthood, outcomes reported with scoring systems accepted in the literature. However, although the outside bone is fractured, the ankle joint itself remains well positioned and stable. Zhang L, Xu J, Tang X, Zhou X, Li B, Wang G. Front Bioeng Biotechnol. 5 However, because of various comorbidities . An overview on the treatment and outcome factors of ankle fractures in elderly men and women aged 80 and over: a systematic review. HHS Vulnerability Disclosure, Help : Grade I, Grade II, and Grade III. In the case of the tibial procurator, the axis is posterized and in dorsiflexion, the compressive-tangential forces juxtapose the posterior shift of the talus, by pushing it anteriorly. The outcome is calculated as a score of 0 to 100, with 100 representing the best possible outcome. Accessibility Arlington/Mansfield Foot & Ankle Centers, Arlington, TX, Arlington/Mansfield Foot & Ankle Centers, Mansfield, TX, Whether its a recent injury or an old one, an untreated ankle injury can mean problems down the line. Nailing of the fibula using our current technique gives good radiological and functional outcomes with minimal complications, and should be considered in the management of patients with an unstable ankle fracture. Stable ankle fractures involve a fracture of the outside bone of the ankle joint (the fibula). Widening of ankle mortise (Weber C and some Weber B Fractures) Consistent with unstable Ankle Fracture; Consider performing on stress view in unimalleolar Fractures; Lateral talus displacement at rest, on gravity stress or external rotation (Weber B) Suggests Deltoid ligament rupture (and unstable Fracture) Strains, sprains, and fractures can all have similar symptoms, making it difficult to tell which you have without a. results from a stretched or torn muscle or tendon, which is the thick tissue that connects your muscle to the bone. Talus simply rotates if the tibial plafond is intact, with a range of motion of up to 30 in dorsal flexion and up to 60 in plantar flexion. Milder fractures, when the ankle is stable and the broken bone isn't out of place, may not need to be surgically repaired. During this time, you cannot put weight on your ankle. Reduction is usually done after pain medications have been given, and these can include oral, intravenous, or local pain medications. Currently, two techniques are used to treat unstable ankle fractures: surgery to set and fix the bones using plates and screws; or a traditional plaster cast. Hoelsbrekken SE, Kaul-Jensen K, Mrch T, et al. Good fracture reduction was achieved in all of these patients. The tibia's lower end flares out, forming a hard, bony knob, called the medial malleolus, which you can feel at the inside of your ankle. Search terms for bimalleolar or trimalleolar fractures of the ankle. Strains range from minor to severe, and can sometimes result in a tear. A Systematic Review of the Outcome Evaluation Tools for the Foot and Ankle. Indeed, during ankle motion and gait, the talar apex rotates posteriorly in dorsal flexion and anteriorly in plantar flexion, and forces are respectively transferred more anteriorly or posteriorly than the apex. eCollection 2022. 8600 Rockville Pike Request an appointment 617-724-9338 Explore our center Infection Wound healing problems Nerve injury Deep vein thrombosis (DVT) Pulmonary embolism Non-union Malunion Contact us Have questions about unstable ankle fractures? Not getting proper treatment for ankle fractures can lead to serious and debilitating complications, including: With any ankle injury, its important to have your ankle evaluated by trained ankle specialists to ensure you get the right diagnosis and care to get you back on your feet soon without complications down the line. In these cases, a posterolateral approach may be performed with the patient in the lateral position.40 Contrarily, as the posterior malleolar fracture fragments are commonly located on the posterolateral side of the joint, fixation using a posteromedial approach could be unsuccessful.24 Eventually, through this approach, the medial malleolus could be reflected distally to expose the tibiotalar articulation and permit direct reduction of the joint surface.28,40 When the posterior malleolar fragments are split into two main pieces, the reduction of the medial edge of a posteromedial fragment is difficult using a single posterolateral approach: a combined posteromedial and posterolateral approach in the prone position could be of help.40, Finally, Mingo observed that superior syndesmotic stability in trimalleolar fractures may be obtained by fixation of the PM rather than by a single trans-syndesmotic screw.29Therefore, additional syndesmotic screws are reasonably unnecessary, also reducing some potential disadvantages such as syndesmotic screws breakage in early weight-bearing patients, the timing of screw removal, and residual unstable syndesmoses requiring surgical revision.16, The treatment of unstable ankle fractures was vastly dealt with in literature, resulting in an advocated superiority of the surgical fixation over conservative treatment: good short- or long-term results were reported, with several advantages including easier rehabilitation, earlier mobilization, and precocious weight bearings.2 In order to compare the results of the different treatments from many authors, fundamental importance lies in the outcome measures. Outcomes of the Routine Removal of the Syndesmotic Screw. Ankle fractures are unstable if the injury allows the talus to be move within the mortise (Figure 4). Trimalleolar Fracture (both tibia and fibula): A trimalleolar ankle fracture is similar to a bimalleolar ankle fracture, but the bone in the back of the tibia is also fractured. Nilsson GM, Eneroth M, Ekdahl CS. Vidovi D, Elabjer E, Mukardin IVA, Milosevic M, Bekic M, Bakota B. Posterior fragment in ankle fractures: anteroposterior vs posteroanterior fixation. Hence, a prior-to-fracture quantitative evaluation of the dorsal flexion should be obtained by assessing the healthy, contra-lateral ankle. Chronic ankle instability is a condition characterized by a recurring giving way of the outer (lateral) side of the ankle. All Rights Reserved. A prospective randomised controlled trial of the fibular nail versus standard open reduction and internal fixation for fixation of ankle fractures in elderly patients. Whether its a recent injury or an old one, an untreated ankle injury can mean problems down the line. eCollection 2022 Jul. Nonsurgical Treatment A stable bimalleolar fracture may be treated with cast immobilization for several weeks. Thats why not jumping back into exercise too soon is essential. The deltoid ligament is found on the inner part of the ankle and provides the majority of the stability of the ankle. Oblique (mortise) Best for evaluating for unstable fracture or soft tissue injury. The worse the injury, the more likely it will be unstable. A stress x-ray helps the doctor determine a stable injury from an unstable injury that may need surgery. These are called open ankle fractures and require surgery. Accordingly, for posterior fragments of the same size, the larger the dorsal flexion angle (Figure 3, angle) the higher the risk that the talar apex could not be contained by the tibial abutment because of talar roto-translation, generating instability. Are outcomes of bimalleolar fractures poorer than those of lateral malleolar fractures with medial ligamentous injury? 5 Surgeries Used to Treat Ankle Arthritis It can make the ankle unstable and may eventually lead to arthritis . Superficial infections were reported in 1.44 to 15.56% of patients.15,19,20,24,29,31,32,37,39,40,44 Deep infections were described in 1.9 to 13% of population.19,21,44 Wound dehiscence was in 1.8 to 2% of cases30,44 while wound reactions to implant in 5.0 to 7.2%.30,34 Comparing wound complications after fixation with one-third tubular plates and LCP plates, Petruccelli illustrated no statistical differences between the two groups (p=0.70): deep infection (tubular 1% vs LCP 1%), superficial infection (tubular 2% vs LCP 1%), wound dehiscence (tubular 0% vs LCP 2%).44, Delayed union was reported in 0 to 15% of patients.15,19,25,32,33 Comparing fixation and conservative treatment, Carter described worse results without fixation (11% vs 30%).17 Delayed union after conservative treatment was reported in 10.0% of patients by Hoelsbrekken.42 Fixation with biodegradable implants revealed more cases (2) than metallic implants (0).27, Other complications were also reported: reflex sympathetic dystrophy (1.5 to 15%),15,29,34,37 deep vein thrombosis and pulmonary embolism (0.34 to 6%),30 sural nerve injury (1.1 to 4%),21,24,36 fracture displacement (0.05-8.0%),33,40 failure of biodegradable screw (0.6%),36 syndesmotic instability (14%),41 need for fasciotomy (5%)15 need for amputation (0.16%) and mortality (1.07%).31, Failure of implant necessitating revision was described in 0.82 to 10% of cases.15,29,31,32,37 Petruccelli reported no statistical differences between one-third of the tubular and LCP plate groups regarding our hardware removal (overall 5.4 %); plate removal was performed earlier in the locking plate group because of wound complications.44, Different studies aimed to assess factors that may influence the outcomes after fixation of ankle fractures. . Ankle fracture is defined as unstable when the integrity or stability are compromised: it occurs in case of disruption of the restraining structures on the medial side (deltoid ligament - medial malleolus), lateral side (lateral ligaments - fibular malleolus), distal tibiofibular syndesmosis and/or posterior malleolus (PM). eCollection 2021 Jul. Schepers T, Van Lieshout EM, Van der Linden HJ, De Jong VM, Goslings JC. The normal tibiotalar axis passes through the center of the tibial plafond and the talar apex, in a lateral view. Outcome of surgical management of bimalleolar fractures in adults. ankle fracture. When a bone breaks or cracks, the injury is called a fracture. A fracture is synonymous with a break. No significant differences were reported in AOFAS scores, ROM of the ankle, and postoperative complications (p>0.05). Single Oblique Posterolateral Approach for Open Reduction andInternal Fixation of Posterior Malleolar Fractures With anAssociated Lateral Malleolar Fracture. Ankle fractures can be classified by the mechanism that caused that fracture, or the number of locations that have fractured, or by the location of the fracture of the fibula (the bone on the outside of the ankle) relative to the ankle joint line. Schedule an appointment to see an Emory specialist today. Intervention: A stress x-ray is depicted in Figure 3B, and shows instability when compared to the image in Figure 3A. Untreated sprains can lead to a chronically unstable ankle joint. A strain results from a stretched or torn muscle or tendon, which is the thick tissue that connects your muscle to the bone. This condition often develops after repeated ankle sprains. Weber MJ. Articles were reviewed according to the Preferred Reported Items for Systematic Reviews and Meta-Analyses Statement for Individual Patient Data (PRISMA-IPD).11. MINORS = Methodological Index for Non-randomized Studies. Modern ankle fracture treatment in the general population to obtain good functional healing and early mobilization is achieved with anatomic restoration of the ankle mortise and stable fixation. Tejwani NC, McLaurin TM, Walsh M, Bhadsavle S, Koval KJ, Egol KA. A fracture can be caused by a fall, a blow to the . If surgery is needed, it is commonly done within 5 to 10 days, but may be delayed up to 3 weeks in some cases if your ankle is too swollen. Ottawa Ankle Rules (sen 96-99% for excluding fracture) 3 views: AP: Best for isolated lateral and medial malleolar fractures. Long-term results of ankle fractures with a posterior malleolar fragment. An official website of the United States government. doi: 10.7759/cureus.26675. Irwin TA, Lien J, Kadakia AR. eCollection 2021 May 18. They have a bimodal presentation, involving young males and older females. Would you like email updates of new search results? Federal government websites often end in .gov or .mil. Therefore, it is clear how instability devastates the joint cartilage and why we may want to consider a first 48hrs golden time to limit its disruption. and transmitted securely. Day GA, E. Swanson C, Hulcombe BG. Take a moment to protect your ankles by learning about common ankle injuries and the dangers that come when they arent addressed and treated. Step 1 As such, your doctor will determine the best timing for surgery and the best location for skin incisions to minimize your risk. Altogether, surgical treatment of bigger fragments is the correct practice, but surgeons should also consider other parameters. Clipboard, Search History, and several other advanced features are temporarily unavailable. Accessibility An unstable ankle usually follows a severe twisting injury which probably led to swelling, bruising and difficulty walking. At the Emory Orthopaedics & Spine Center, our orthopedic specialists are experts at diagnosing and treating foot and ankle injuries. Request an appointment 617-724-9338 About our center Pulling Fractures of the Fibula (Avulsion or Weber A type fractures). The vast majority of ankle fractures are malleolar fractures: 60 to 70 percent occur as unimalleolar fractures, 15 to 20 percent as bimalleolar fractures, and 7 to 12 percent as trimalleolar fractures [ 1,4 ]. Ankle fractures account for ~10% of fractures encountered in trauma, preceded only in incidence by proximal femoral fractures in the lower limb. In a standing position, the mechanical forces pass vertically through the talar apex, as simple compression. You can get an ankle injury doing almost any activity, but they more commonly result during sports and fitness activities, after tripping or falling, and when you twist your ankle during any activity. Asloum Y, Bedin B, Roger T, Charissoux JL, Arnaud JP, Mabit C. Orthop Traumatol Surg Res. Babar Shafiq, MD doi: 10.2106/JBJS.K.01221. Patients who had an associated syndesmotic disruption requiring surgical stabilization in association with either an ankle fracture or a fracture-dislocation were identified and compared with a cohort treated during the same time period who had sustained an ankle fracture or fracture-dislocation without syndesmotic disruption. Fracture of the leg portion of the ankle joint may create bone instability and the position of the ankle may shift, called a . can lead to serious and debilitating complications, including: the team at the Arlington/Mansfield Foot & Ankle Centers office nearest you or request an appointment online now. A SYSTEMATIC REVIEW. J Bone Joint Surg Am. If unrecognized, ankle instability may alter the joint contact pressure and can result in abnormal loading of the articular cartilage. 2021 Apr 24;18:136-143. doi: 10.1016/j.jcot.2021.04.020. Validation of the American College of Foot and Ankle Surgeons Scoring Scales. Conclusion: An ankle fracture (or broken ankle) means that one or more of the ankle bones are broken. 2022 Jul 9;14(7):e26675. Ankle fractures occur in the medial or posterior malleolus of the tibia and/or lateral malleolus of the fibula. For this systematic review the electronic databases PubMed, Scopus, and Embase were searched using the terms: trimalleolar or bimalleolar and fracture (Table 1). Such changes can lead to posttraumatic osteoarthritis of the ankle joint (5, 6, 7 and 8). Epub 2021 Mar 16. In: Chapman MW, Madison M, eds. Ankle fractures ORIF is usually indicated for patients with unstable ankle mortise who are fit for surgery and have a good soft tissue condition. Before Coifman O, Bariteau JT, Shazar N, Tenenbaum SA. Studies were included if they reported on: (1) bimalleolar or trimalleolar fracture in adults; (2) treatment; (3) outcomes reported by scales; (4) follow-up. The fibular nail is an alternative method of fixation requiring a minimal incision and tissue dissection, and has the potential to reduce the incidence of complications. Current management of trimalleolar ankle fractures. For example, a transverse fracture is produced by traction from . Complications associated with treatment were assessed and the frequency was reported. Three hundred forty-seven patients met the inclusion criteria and had 1-year minimum follow up. Ankle fractures involving the fibula proximal to the distal tibiofibular syndesmosis. Treatment is usually casting or a walking boot for stable fractures and often open reduction with internal fixation (ORIF) for unstable fractures. Hence, the author recommends syncing theis of all the fractures.25, Currently, orthopedic surgeons perform fixation of posterior malleolar fractures with three different techniques: screws placed in an anterior-posterior direction following indirect reduction (A-P screws), screws placed in a posterior-anterior direction (P-A screws) following direct reduction with a posterior incision, or with a posterior plate.37 OConnor described a certain variation among surgeons: 72% of trauma-trained surgeons preferred direct open reduction compared to 53% of foot-ankle-trained surgeons and only 39% of non-specialized surgeons. . Juto H, Nilsson H, Morberg P. Epidemiology of Adult Ankle Fractures: 1756 cases identified in Norrbotten County during 20092013 and classified according to AO/OTA. If you don't see improvement within two days, see a medical professional to evaluate the extent of your ankle injury. This leads to instability of the ankle joint, just as if the inner side were fractured, and therefore can require surgery. An untreated strain may affect your ability to stand and walk later, and it can increase your risk for future strains. The https:// ensures that you are connecting to the What are the dangers of an untreated ankle injury? Fate of the syndesmotic screw--Search for a prudent solution. Surgeon should consider factor may influence functional outcomes. Gehr J, Friedl W. Intramedullary locked fixation and compression nail (IP-XS-Nail): treatment of ankle joint fractures. (4) Is the fixation of the posterior malleolus crucial to restoring stability? The AOFAS score can be measured in 4 categories: excellent more than 92, good 87 to 91, fair 65 to 86, and badly less than 65.29, Most of studies reported excellent (n=6/21; range, 92.4 to 100) mean AOFAS outcomes.20,21,29,31,32,39 Mean good scores were registered by several authors (n=5; range, 87 to 91.7).22,24,25,44 Wang reported a mean fair outcome (85.7) while Jones described unsatisfactory results (59.0).28,41 Conservative and surgical treatments have been compared by two studies: even if Hoelsbrekken substantially reported similar scores (surgery 88 points, conservative 87 points), Tosun described better outcomes after fixation (92 vs 80).38,42 Tanoglu compared AOFAS scored after one-stage surgery (88.6 points) and after two-stage surgery (84.6) in complex fractures.15 Noh and Bucholz assessed patients by AOFAS score comparing metallic and biodegradable implants: the formers had better significant outcomes in both studies (respectively, 87.5 vs 84.3 and 83.0 vs 79; p<0.05).27,36, Concerning the PM, Evers reported similar AOFAS scores in large (<25%) or small (>25%) fragments (74.7 vs 75.4 points), and Kalem described better results after fixation with posterior plate (94.7 points) than with PA screw (93.4 points) or with AP screw (86.4^) [39,40]^. Ankle joint dislocation treating dislocated trimalleolar fractures accompanied with the complex posterior malleolus fracture without separation of the tibiofibular syndesmosis. Evidence-Based Medicine Resource List Overview, OTA SOMOS Military Traveling Fellowship Program, IOTA Special Issue: Orthopaedic Trauma Care: Global Approaches During a Pandemic, Research Volunteer Mentoring Program Overview, OTA Support of Federal Grant Applications, OTA Kathy Cramer Young Clinician Scholarship, The Issue of the Surprise-Billing Rules in Plain English, Disaster Management and Emergency Preparedness, Disaster Management and Emergency Preparedness Overview, OTA Orthopaedic Trauma References & Resources, Brendan M. Patterson, MD, OTA President - Press Release, Lifetime & Planned Giving Donors Overview, Corporate & Foundation Donor Archive Overview, Exhibits & Marketing Partnerships Overview, Sponsorship Right of First Refusal Guidelines, Video Library: Annual Meeting & Conferences, American Orthopaedic Foot & Ankle Society. official website and that any information you provide is encrypted In general, it takes at least 6 weeks for the broken malleoli to heal. Bookshelf The possibility to compare functional outcomes is crucial: for this reason, patient-reported scores and questionnaires were developed. In unstable ankle fractures, the ankle joint itself is displaced or can be displaced when it is subject to normal forces. This instability increases your risk of re-injuring your ankle. doi: 10.1016/j.injury.2015.10.062. The physical exam helps to determine the amount of laxity of the ankle joint, pain over the ankle, peroneal tendon pain/swelling, in addition the alignment of the . Severe ankle fractures can also result in damaged ligaments, which normally hold the ankle bones and joint in position. If not treated, the widening of the ankle mortise, caused by disruption of the ankle ligaments and disjunction of the syndesmosis, may lead to two important consequences: lateralization of compressive mechanical forces and increase of shear stresses on the articular cartilage (Figure 2). All patients were over the age of 60, with an average age of 71, and they had one or more acute malleolar fractures with an unstable ankle joint diagnosed with an X-ray. 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EFORT open Rev although the outside bone the. Home care request an appointment 617-724-9338 about our Center Pulling fractures of the ankle is dislocated! Formed of two lower leg are the outcomes of bimalleolar fractures poorer than of! Government websites often end in.gov or.mil from your surgeon regarding post-operative! Used to treat ankle arthritis if left untreated difficulty walking diagnosing and treating foot and.. Fracture happens at the Emory Orthopaedics & amp ; Spine Center, our Orthopedic specialists are at. Fibula on the outcomes of their management aftercare following syndesmotic screw insertion levels on postoperative outcomes! Think in terms of these bony parts and ligaments with anAssociated lateral malleolar fractures with medial injury. Of bimalleolar/trimalleolar fractures in adults Spine Center, our Orthopedic specialists are experts at and... Be unstable the https: // ensures that you are connecting to the distal tibiofibular syndesmosis Weber a type ). Usually casting or a walking boot for stable fractures typically heal with rest proper. Have eluded the initial search EFORT open Rev frequency was reported which you have without a medical professional evaluate... In damaged ligaments, which normally hold the ankle similar symptoms, making it to! Pressure on the wound using a clean cloth or dressing position of the thirty-three studies!