Injury of the upper ankle joint in tibial fracture. A frequent, but undervalued combination

Abstract

There are 2 types of a combined tibia fracture and ankle injury: in Type I the tibia fracture extends directly into the ankle joint, in Type II the tibia fracture goes along with a fracture of the fibula and disruption of the fibular-tibial syndesmosis. This type of fracture must be distinguished from a pilon tibiale fracture. The typical mechanism for this combined tibia and ankle injury is the indirect torsional trauma with pronation-eversion. From 1995 to 1997 188 patients with fractures of the tibia were treated by internal fixation in our Trauma Department. 27 of these patients (13.6%) had a combined tibia and ankle injury. Most of the tibia fractures were located in the distal third, a spiral fracture (16 patients) or a comminuted fracture (6 patients), and another group extending directly into the ankle (5 patients). The ankle lesion was a distal fibular fracture (Weber Type B + C) in 14 patients, a proximal fibular fracture (Type maisoneuve) in 6 patients, a postero-lateral fragment in 11 cases and a fracture of the medial melleolus in 10 cases. A disrupture of the anterior tibio-fibular syndesmosis was seen in 18 patients, 3 times as an isolated lesion of the ankle joint without fracture of the fibula. The osteosynthesis of the tibia fracture was performed with an unreamed tibia nail in 20 patients, with elastic-biologic plate fixation in 6 and with external fixation in 1 patient. The fibula fractures were stabilized by small fragment titaneum plates, the dorsolateral fragment and the medial malleolus were stabilized by lag-screws, the tibio-fibular ligament was sutured and, in a few cases only, held in place by a positioning screw. The outcome was controlled after 20.7 month according to the Phillip's Score (1996). We found not more than one pour results. It must be considered, that most of the combined injuries of the tibia and the ankle joint concerning 13.6% of all tibia shaft fractures are usually not recognized and may result in an arthrosis of the ankle joint. The attention should be focused to the ankle joint in any spiral fractures of the distal tibia after indirect trauma, especially with a proximal fibular fracture or an intact fibula. Additional X-ray examination of the ankle joint is recommended during internal fixation of the tibia. Posttraumatic arthrosis of the ankle joint can be prevented by diagnosis and adequate anatomical reconstruction of the additional ankle joint injury.