Supination-external Rotation Injury Research Articles

Understanding the mechanism of injury and fracture pattern of paediatric triplane ankle fractures versus adult trimalleolar fractures.

Paediatric triplane fractures and adult trimalleolar ankle fractures both arise from a supination external rotation injury. By relating the experience of adult to paediatric fractures, clarification has been sought on the sequence of injury, ligament involvement, and fracture pattern of triplane fractures. This study explores the similarities between triplane and trimalleolar fractures for each stage of the Lauge-Hansen classification, with the aim of aiding reduction and fixation techniques. Imaging data of 83 paediatric patients with triplane fractures and 100 adult patients with trimalleolar fractures were collected, and their fracture morphology was compared using fracture maps. Visual fracture maps were assessed, classified, and compared with each other, to establish the progression of injury according to the Lauge-Hansen classification. Four stages of injury in triplane fractures, resembling the adult supination external rotation Lauge-Hansen stages, were observed. Stage I consists of rupture of the anterior syndesmosis or small avulsion of the anterolateral tibia in trimalleolar fractures, and the avulsion of a larger Tillaux fragment in triplanes. Stage II is defined as oblique fracturing of the fibula at the level of the syndesmosis, present in all trimalleolar fractures and in 30% (25/83) of triplane fractures. Stage III is the fracturing of the posterior malleolus. In trimalleolar fractures, the different Haraguchi types can be discerned. In triplane fractures, the delineation of the posterior fragment has a wave-like shape, which is part of the characteristic Y-pattern of triplane fractures, originating from the Tillaux fragment. Stage IV represents a fracture of the medial malleolus, which is highly variable in both the trimalleolar and triplane fractures. The paediatric triplane and adult trimalleolar fractures share common features according to the Lauge-Hansen classification. This highlights that the adolescent injury arises from a combination of ligament traction and a growth plate in the process of closing. With this knowledge, a specific sequence of reduction and optimal screw positions are recommended.

Radiological characteristics and injury mechanism of Logsplitter injury: a descriptive and retrospective study

BackgroundLogsplitter Injury is a type of high-energy ankle fracture dislocation. The mechanism of injury has not been described in detail. A detailed understanding of the radiological features and pathological changes can further guide treatment.MethodsBetween April 2009 and December 2018, a retrospective analysis was conducted on 62 patients with Logsplitter injury. The study analysed the characteristics of fibular injury, tibial injury, syndesmosis injury, medial injury and lateral ligament injury on preoperative X-ray and CT scans. The incidence of the different injury types was summarised. The correlation between Logsplitter injuries and the mechanisms causing them were analysed using the Lauge-Hansen classification of ankle fractures.ResultsThe study provides data on the types of fractures observed. Of the total fractures, 98.4% were open fractures. The fibula injuries were classified as no fracture (1.6%), transverse or short oblique fractures (61.3%), butterfly fragments (25.8%), and comminuted fractures (11.3%). The tibial injuries included compression of lateral articular surfaces (38.7%) and posterior compressions (6.5%). Medial injuries, including medial malleolar fractures, accounted for 87.1%, and deltoid ligament rupture accounted for 12.9%. The study found that injuries to the syndesmosis consisted of simple ligament ruptures (11.3%), Tillaux fractures (8.1%), Volkmann fractures (43.5%), and Tillaux and Volkmann fractures (37.1%). In 12.9% of cases, there was a complete rupture of the lateral collateral ligament. Based on the Lauge-Hansen classification, 87.1% of injuries were pronation-abduction injuries, while 8.1% were pronation and external rotation injuries, and 1.6% were supination external rotation injuries. Furthermore, 3.2% of cases could not be classified.ConclusionThe pathoanatomic characteristics of Logsplitter injury are diverse, with some cases accompanied by collateral ligament injury. It is important to note that these evaluations are objective and based on current results. The most common injury mechanism is vertical violence combined with abduction, although in some cases, it may be a vertical combined external-rotation injury.Level of evidence(4) case series.Trial registrationThis study has been approved by the ethical research committee of the Honghui Hospital of Xi’an Jiaotong University, under the code: 202,003,002.

Temporary Cast Application in Dislocated Ankle Fractures Leads to High Rates of Secondary Loss of Reduction: Does the Lauge-Hansen Injury Type Matter?

For the temporary treatment of ankle fracture dislocations (AFDs), previous studies indicate higher rates of secondary loss of reduction (LOR) with splint immobilization, prompting consideration for expanding indications for external fixation (ExFix). However, these studies did not investigate the influence of fracture morphology to further improve patient selection. The aim of this study was to investigate the influence of Lauge-Hansen injury type on the LOR rate in bimalleolar or trimalleolar AFDs for temporary cast vs ExFix immobilization. In this retrospective cohort study, patients with isolated AFD cases treated at our institution from 2011 to 2020 were reviewed. Inclusion criteria required radiographs depicting initial dislocation and appropriate reduction after Cast or ExFix immobilization. Exclusion criteria encompassed concomitant injuries, open fractures, conservative management as well as surgery performed within 48 hours or at a different facility. Patients were grouped by temporary treatment (Cast or ExFix). The primary endpoint was LOR prior to definitive surgery across various Lauge-Hansen types. The LOR rate was significantly higher in the cast group (40/152, 26.3%) compared to the ExFix group (5/191, 2.6%; P < .0001). In the cast group, LOR was associated with an increase in time to definitive surgery by a mean of 3 days (P < .002). During cast treatment, LOR was significantly more likely for pronation abduction (P = .001) and supination external rotation injuries (P < .0001), whereas no significant differences were observed for pronation external rotation (P = .006), supination adduction (P > .99), and fractures not classifiable (P > .99). In cases of AFDs resulting from supination external rotation or pronation abduction trauma according to the Lauge-Hansen classification, especially in the setting of an additional posterior malleolar fracture, primary application of external fixation should be considered to reduce the risk for secondary loss of reduction. Level III, retrospective cohort study.

Patterns of Ankle Fractures Based on Radiographs and CT Images of 1000 Consecutive Patients.

The knowledge of different types of ankle fractures based on plain radiographs and computed tomography (CT) images can help improve patients' management. This cross-sectional study assessed the plain radiographs and CT images of 1,000 consecutive patients observed in an emergency department between March 2015 and March 2020. Fractures were labeled as uni-, bi-, or trimalleolar. Malleolar fractures were classified into medial, lateral, and posterior ones based on Herscovici, Danis-Weber, and Mason and Molloy classifications, respectively. Bi- and trimalleolar fractures, on the other hand, were categorized according to the Lauge-Hansen classification. This study included 1,000 patients with 1,003 ankle fractures. Of them, 901 were adults (mean±SD age: 41.6±16.7, male: 567 [62.9%]) with 904 fractures. In total, 53% of adult patients were 18 to 39 years old. Considering unilateral ankle fractures, the medial malleolar fracture was the most common unimalleolar fracture (62.6%), with Herscovici C being the most frequent subtype (65.3%). On the other hand, the most common type of lateral malleolar fracture was Danis-Weber type B (65.5%). There were also 209 (23.3%) bimalleolar and 114 (12.7%) trimalleolar fractures, 5.8% (16 fractures) of which could not be classified based on the Lauge-Hansen classification. Unimalleolar fractures were also observed in 87 (87.9%) children, with the medial malleolar fracture being the most common type (89.7%). Medial malleolar fractures were the most frequent malleoli in patients observed in the emergency department under study. Among bi- and trimalleolar ankle fractures, supination-external rotation and pronation-external rotation injuries were the most common patterns. The Lauge-Hansen classification was not applicable in 5.8% of bi- and trimalleolar fractures.

Trans-syndesmotic fixation in supination external rotation type 4 injuries: Are intraoperative tests reliable?

Ankle fractures occur due to a rotational mechanism. According to the Lauge-Hansen classification, supination-external rotation (SER) injuries are the most common type. Following osseous fixation, the evaluation and treatment of syndesmotic injuries in these injuries are controversial. This study aimed to evaluate the clinical, functional, and radiological results of trans-syndesmotic fixation using intraoperative tests in SER type 4 ankle injuries. Ankle syndesmosis was intraoperatively evaluated using cotton/hook and manual external rotation stress tests in 64 patients with SER type 4 fracture dislocation injuries. These patients were divided into two groups: those treated with and without trans-syndesmotic fixation in addition to open reduction and internal fixation of the fractures. Ankle range of motion (ROM), American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score, and Olerud-Molander Ankle Score (OMAS), tibiofibular overlap, tibiofibular clear space, and joint arthritis based on the Kellgren-Lawrence (K-L) scale were evaluated. Median values of OMAS (Z=-3.92, p<0.001), AOFAS (Z=-4.31, p<0.001), and ROM (Z=-2.95, p=0.003) were higher in Group 1. There were no differences between the groups regarding tibiofibular overlap median values (Z=-0.59, p=0.0554), tibiofibular clear space (Z=-1.13, p=0.258), and Kellgren-Lawrence arthritis scale. Lack of posterior malleolus fixation was found to increase the risk of arthritis by 18.197 times, despite having trans-syndesmotic fixation, which was statistically significant (Confidence Interval, CI: 2.482-133.417, p=0.004) (Table 4). Median values of OMAS, AOFAS, and ROM in patients without trans-syndesmotic fixation were lower. These results indicate that intraoperative tests may not provide entirely accurate results in SER type 4 injuries. Failure to detect a syndesmotic injury timely can result in instability. Therefore, we think that routine trans-syndesmotic fixation, as well as posterior malleolus fixation in SER type 4 ankle injuries, may improve outcomes.

Should all Small Shell Posterior Malleolar Fractures be Considered for Fixation? Results from a 3D Fracture Mapping Study

Category: Ankle; Trauma Introduction/Purpose: Approximately 10-15% of posterior malleolar fractures (PMFs) are "small shell," extra-articular fragments. Current classification systems present difficulties to perform a uniform typification of PMFs and contain no consensus on whether they should be fixed. Anatomical studies have identified two distinct components of the posterior inferior tibiofibular ligament (PITFL); the superficial band is thought to be more important than its deep counterpart in imparting syndesmotic stability. However, the involvement of one or both bands of the PITFL by small shell PMFs has not been evaluated so far. Hence, we conducted this study to perform 3D mapping of small shell PMFs and to determine whether surgeons should fix these routinely. Methods: Ankle fracture patients with a ‘small shell’ PMF (Haraguchi 3/Mason 1/Bartoníček 1 or 2) were included. Demographics, radiological features, treatment, and outcomes were recorded. 3D models of the fractured tibiae were generated from CT scans and superimposed on a statistical shape model of the right tibia, which served as a template. Fracture lines along with footprints of superficial and deep PITFL were marked on the template. 3D fracture heat maps were generated. Size of the fracture fragments and involvement of the superficial and deep PITFL footprints were quantified using a custom MATLAB script (Figure 1). Sparing of the footprint was defined as an overlap of &lt; 1% between the fracture line and the footprint areas. Odds ratios (OR) with 95% confidence intervals (CI) were determined to determine which variables correlated with sparing of the PITFL footprint; P-values of &lt; 0.05 were considered significant. Results: Thirty-nine patients were included. The superficial PITFL footprint was spared in 15 (38%), deep PITFL in 10 (26%), and both in 4 cases (10%). Males and Weber C fractures had a higher likelihood of sparing the superficial and deep PITFL footprints, respectively (P = 0.04). Supination external rotation (SER) patterns were less likely to demonstrate syndesmotic widening if either PITFL footprint was spared. Direct fixation of the PMF was done in 1 case; syndesmotic fixation in 25 cases and in 14 cases, no syndesmotic fixation was done. Of these, 11 were SER injuries where stability was achieved after fixation of medial and lateral malleoli. In 1 SER and pronation external rotation (PER) injury case, the syndesmosis was stable after fixation of a large Chaput fragment. Conclusion: This study demonstrated that 48% of small shell PMFs spare either the superficial or deep footprint of the PITFL; in 10% both PITFL footprints were spared. Hence, 58 % of small-shell PMFs may not benefit from direct fixation. Additionally, SER injuries with small shell PMFs that spare either PITFL footprint may not demonstrate radiographic instability and may not need direct or indirect fixation after addressing other components of the ankle fracture. However, given the fact that syndesmotic stability is not dictated by the PITFL alone, it remains prudent to stress the syndesmosis per-operatively to determine if syndesmotic fixation is needed.

561 A Morphological Review of Medial Malleolar Fractures – a Large Single Centre Series

Abstract Background Medial Malleolus Fractures (MMF) are frequently managed by orthopaedic surgeons and are one of the most treated fractures of the ankle. Many approaches to management are described in the literature however, their morphology is under investigated. Method Patients who had surgical fixation of their MMF were identified from 2012 to 2022. Analysis of their pre-operative, intra-operative and post-operative radiographs was performed. Lauge-Hansen classification was used to characterise ankle fracture morphology and Herscovici classification to characterise MMF morphology. Results A total of 647 patients were identified across a 10-year period who had sustained a medial malleolar fracture. The most common Herscovici fracture in Supination Adduction injuries was a Herscovici D (43.9%, 17/39), in supination external rotation injuries was Herscovici C (52.75%, 259/491), in pronation external rotation injuries was Herscovici C (48.81%, 41/84) and in pronation abduction injuries was Herscovici B (45.45%, 12/33). Medial wall blowout occurred in 19.23%, occurring in supination adduction injuries most commonly (51.28%, 20/39). Herscovici A fractures were significantly more malreduced at time of surgery compared to other fracture types (21.88%, 7/32, p = .003). There was no significant difference in union rates across the classification groups (range 11.67% Herscovici D to 22.86% for Herscovici B). Conclusions Knowledge of the medial malleolar morphology allows greater assessment and planning in their surgical treatment. There was a high rate of medial wall blowout even in the non-adduction fracture types, and this should be assessed to prevent over compression during surgical treatment. Herscovici A fracture malunions may need further investigation and different methods of fixation.

Bilateral simultaneous rotational ankle fractures: case series and literature review

Bilateral Simultaneous rotational ankle injuries are rare entities with little number of cases reported in literature. Unlike axial type ankle fractures, they tend to happen as a result of pivoting trauma on the supportive limb. We conducted a case series and literature review of patients who presented with simultaneous bilateral ankle injuries and discussed their presentation and imaging. A total of Four cases in our institute and 6 separate cases reported in literature were found who sustained bilateral simultaneous rotational ankle fractures. There were 10 cases, nine of which were simultaneous and symmetrical ankle injuries. Injuries found were; Maisonneuve fracture, Tillaux fracture, Syndesmotic injury, Lauge-Hansen’s supination external rotation (SER), pronation external rotation (PER), supination adduction (SAD), and pronation abduction (PA). Four cases were presented in our institute over the last 10 years. A single case was asymmetrical in nature given the presence of an associated distal tibial metaphyseal fracture. Bilateral rotational ankle injuries are rare entity presenting simultaneously unlike axial type ankle fractures. When they present, they are likely caused by higher mechanism of injury than typical unilateral rotational ankle fractures. SER injuries are the most commonly found mechanism in both unilateral and bilateral ankle injuries.

A Prospective Study on Functional Outcome of Surgical Management of Bimalleolar Fractures of the Ankle

Background: Ankle joint is hinged synovial joint. Ankle is a close fitting hinge-like joint of which two parts interlock like mortise (the box formed by the distal end of Tibia and Fibula) and the tenon (upward projecting Talus). Ankle fractures are very common. The various surgical modalities include fixation with cancellous lag screws, malleolar screw, tension band wiring, semi-tubular plating, fixation with rush pin. These operative methods restore the anatomy and contact loading characteristic of the ankle including easier rehabilitation, early mobilization and earlier weight bearing. Aims: To evaluate the functional outcome of surgical management of the bimalleolar fractures of ankle. Material and Methods: Present study was prospective study, carried out among patients with bimalleolar fractutes of the ankle coming to Orthopaedic department of Tertiary health care centre for duration of November 2020-22. Data analysis: Following the above procedure, the findings were recorded in the proforma. These findings were entered in Microsoft Excel 2010. The results were compiled by using suitable tables and graphs wherever necessary. The variations were analysed as a percentage of the total and reported. Data analysis was done with the help of openepi software version 2.3.1. Results: The mean age of the patients was 39.86 ± 10.67 years. Majority of the patients 24 (80%) included in the study were male. Almost 15 (50 %) patients had pain score of 1 and 9(30%) patients had zero score. On range of movement 93.3% had zero score and 6.7% had score 2. On final objective scoring majority 73.3% had good, 20% had fair and 6.7%had poor outcome. Conclusion: Supination-external rotation injury is the most common type of bimalleolar ankle fracture and also common type associated with dislocations and complications. Good functional outcome was achieved by restoring sufficient stability and providing good mobility at the ankle joint. Anatomical reduction of the fracture is associated

Lateral talar subluxation (LTS) in SER ankle fractures is more responsive than medial clear space widening: A cadaveric biomechanical study

Category: Ankle; Trauma Introduction/ Purpose: Supination-external rotation (SER) ankle fractures are characterized by posterolateral translation and external rotation. In isolated fibula fracture SER variants, medial soft tissue structure incompetence can be identified with medial clear space (MCS) widening or with lateral talar subluxation (LTS), frequently obtained on stress view imaging. This assessment is a key determination of which patients may require surgical management to restore ankle joint stability. Current radiographic studies demonstrated increased sensitivity and specificity of LTS versus MCS which may be due to increased rotational movement occurring in the direction of the talar displacement. Biomechanical data has not yet been established. The purpose of this study was to investigate MCS and LTS displacements in a cadaveric biomechanical study to confirm this rotational movement principle in a controlled setting. Methods: An open approach was utilized to surgically create an SER isolated fibula fracture in five below-knee cadaveric specimens. Open anteromedial and lateral ankle approaches were created for visualization of the medial and lateral structures, also allowing direct measurement of the MCS and LTS with a ruler. There was no ankle instability prior to injury, MCS and LTS were zero in each specimen prior to experimental model creation. An SER-pattern fibular osteotomy was made with an oscillating saw. The superficial and deep deltoid were then released from the medial malleolus, and the foot was displaced maximally creating an SER-4b variant ankle fracture. The MCS and LTS were then measured. Differences were analyzed using a paired Student’s t-test. Effect size (Cohen’s d) was measured to characterize statistical significance and determine relative importance in the degree of change. Results: There was no underlying ankle stability, deformity, or arthritis in any of the 5 cadaveric ankle specimens. In our simulated SER-4b ankle fractures, the mean MCS widening using medial landmarks was 7.2 mm (+/- 1.3mm). The mean lateral displacement utilizing the LTS landmarks was 11.2mm (+/- 1.3mm). The difference between medial and lateral displacement was found to be statistically significant (p = 0.0067, 95% CI [1.85, 6.15]). Cohen’s d was equal to 3.1 (95% CI [1.24, 4.90]), demonstrating a large effect size, showing the mean to be different by 3 standard deviations. The increase in mean lateral displacement was 43% greater when compared to the mean medial displacement. Conclusion: In this cadaveric study, LTS displacement was significantly greater than MCS widening following simulation of SER type IV ankle fracture injuries. The effect size of 3.1 confirms statistical significance. This data supports that talus external rotation is a significant factor in SER pattern displacement. The rotational moment arm is largest laterally with external rotation, and posterolateral displacement. Our study supports the idea of measuring the LTS radiographically as a marker to assist in surgical decision-making. Further characterization of the displacement pattern of SER injuries will be helpful to assist surgical decision- making in these common ankle injuries.

Biomechanical investigation of the effects of various treatment options on the talus in supination external rotation type 4 ankle injuries with ruptured deltoid ligament: Finite element analysis

Purpose: The purpose of this study is the biomechanical investigation of the rotation, stress and deformation caused in the talus, under a specific load, by various fixation methods in ankle which has supination external rotation (SER) injury and deltoid rupture.&#x0D; Method: Ankle of a healthy individual was analyzed with the help of a package program which was based on finite elements method (FEM). Then, SER injury model was created. Lateral malleolar plate was fixed with a screw and created different repair models for ankle fit. In the analysis section, forces obtained from the literature were applied to the healthy and repaired models. As the result of the analyses, mechanical values which occured in the talus were obtained.&#x0D; Results: As a result of this study, mechanical changes in talus, which were caused by, (in order) deltoid ligament repair, suture button syndesmosis fixation, syndesmosis fixation with transfixation screw, suture button fixation + deltoid ligament repair and transfixation screw + deltoid ligament repair in the SER type 4 injury model with deltoid ligament rupture, were evaluated.&#x0D; Conlusion: This study showed that the application of syndesmosis screw together with deltoid ligament repair in the treatment of SER type 4 ankle injuries with rupture of deltoid ligament made regression, displacement and talus rotations on the talus almost normal. In addition, syndesmosis fixation screw applications give better results than syndesmosis fixation suture button applications.

Role of the posterior deep deltoid ligament in ankle fracture stability: A biomechanical cadaver study

The deltoid ligament is a key component of ankle fracture stability. Clinical tests to assess deltoid ligament injury have low specificity. In supination external-rotation (SER) type-IV ankle fractures, there is either a medial malleolus fracture or deltoid ligament injury. These injuries are often considered unstable, requiring surgical stabilisation. We look to identify the anatomical basis for this instability. This study investigates the anatomical basis for such instability by re-creating SER type ankle fractures in a standardised cadaveric study model, investigating the anatomical basis for such instability. To investigate the anatomical basis for fracture instability in SER type ankle fractures. Four matched pairs of cadaveric limbs were tested for stability both when axially loaded and under external rotation stress. Four matched pairs of cadaveric limbs (8 specimens) were tested for stability when axially loaded to 750 N with a custom rig. Specimens were tested through increasing stages of SER injury in a stepwise fashion before restoring the lateral side with open reduction and internal fixation (ORIF). Clinical photographs and radiographs were recorded at each step. We defined instability in accordance with well accepted radiological parameters: > 4 mm medial clear space opening on a mortise-view radiograph or > 7 degrees of talar tilt. All specimens with an intact posterior deep deltoid ligament were stable. Once the posterior deep deltoid ligament was sectioned there was instability in all specimens. Stabilisation of the lateral side prevented talar shift, but not talar tilt. If the posterior deep deltoid ligament is intact then SER fractures can be managed without surgery. If the posterior deep deltoid is incompetent, ORIF and cautious rehabilitation is recommended because the talus can still tilt in the mortise.

Malleolar Fractures - Indication for Nonoperative and Operative Treatment

Malleolar Fractures - Indication for Nonoperative and Operative Treatment Abstract. In order to understand the trauma mechanism and the expected pattern of injury, malleolar fractures can be classified according to Lauge-Hansen [1]. For isolated lateral malleolar fractures, the Weber classification is also frequently used [2]. For most Weber A fractures and 80% of Weber B fractures conservative treatment is indicated. In all isolated Weber B fractures a supination-external rotation (SER) injury has to be distinguished from a pronation-abduction (PA) injury according to the Lauge-Hansen classification. In SER fractures, stability should be assessed by a gravity stress and a weightbearing radiograph. If the fracture is stable, it can be treated nonoperatively. We recommend surgical treatment for unstable Weber B SER injuries, Weber B PA injuries, and Weber C fractures.

Early Unprotected Weight Bearing and Pre-Scheduled Supervised Rehabilitation Program after Surgical Treatment of Ankle Fractures.

Ankle fractures represent one of the most common orthopedic injuries in the lower extremity. Weight-bearing and rehabilitation protocols after surgical treatment of ankle fracture have recently evolved from traditional methods to full weight-bearing protocols. However, more evidence is needed on unprotected immediate weight-bearing along with a standardized rehabilitation program. The purpose of this study was to evaluate effects of unprotected immediate weight-bearing as tolerated and an eight-week prescheduled supervised rehabilitation program on the mid-term clinical and functional outcomes of surgically treated ankle fractures, and to compare functional results with the unaffected side. Eighty patients (24F and 56M) who underwent rigid fixation of bimalleolar ankle fractures were included (mean age 41.57±13.22 years). Preoperative radiographs and computed tomography scans were used to evaluate and classify the fractures. The fractures were classified using Lauge-Hansen classification system. Ankle ROMs, Pain Disability Index (PDI), American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scores, and Short Form-36 scores were evaluated. Patients were allowed unprotected weight-bearing on the immediate postoperative period and a standardized supervised prescheduled rehabilitation program was undertaken following surgery. The mean follow-up period was 30.32±6.91 months. Based on Lauge-Hansen classification, supination-external rotation injuries were found in 32(40%) patients, supination adduction injuries in 14(17.4%) patients, pronation-external rotation injuries in 28(35%) patients, and pronation-abduction fractures in 6(7.6%) patients. The solid union was achieved in all patients at the final follow-up. The mean PDI score was 12.78±14.78, and the AOFAS score was 80.93±17.24. Although patients' health-related quality of life was at a good level, the injured-side ankle ROM was lower than the healthy side (p ≤ 0.05). Satisfactory clinical and functional outcome can be achieved at mid-term with unprotected weight-bearing as tolerated and pre-scheduled supervised eight-week rehabilitation program following rigid internal fixation of ankle fractures. However, this protocol is not studied in patients with associated comorbidities.

Combining Salter-Harris and Dias-Tachdjian could be better at determining the prognosis of distal tibial physeal fractures

ObjectivesThe aim of this study is determining the factors that affect prognosis of distal tibial physeal fractures (DTPF) and analyzing whether Salter-Harris (SH) or Dias-Tachdjian (DT) classification is more predictive for outcomes. MethodsPatients treated for DTPF were retrospectively analyzed. Fracture patterns were classified according to SH and DT. Treatment methods and fracture characteristics were noted. Distal tibial angles and joint irregularities were analyzed on patient's final ankle radiographs followed by American Orthopedic Foot and Ankle Score questionnaire. Results75 patients followed-up between 6 and 96 months meeting the inclusion criteria were evaluated. Joint irregularity was observed in 41.3% and partial premature physeal closure (PPC) in 34.7% of the patients. Lateral distal tibial angle (LDTA) and talocrural angle related deformity were detected in 20% and 14.7% of the patients, respectively. Partial PPC and joint irregularities that have been developed in pronation-eversion-external rotation and supination-inversion injuries (SH type 3, 4) were 62% and 50%, and 42% and 75%, respectively. On follow-ups of supination-external rotation injuries (SH type 2) joint irregularity has never been observed. Following supination-external rotation and supination-plantar flexion injuries, a low rate of partial PPC have been developed; LDTA related deformity was revealed at a high rate of 39.1% after supination-inversion injuries. There weren't any differences observed between the initial displacement, residual displacement or surgical technique and PPC, joint irregularity and angular deformities. Patients treated by ORIF technique had lower AOFAS scores than patients treated by other surgical techniques. ConclusionsIn this study it was revealed that SH classification system is not sufficient alone to determine the prognosis of DTPF, the injury mechanisms causing SH types might be also significant in prediction of the prognosis of DTPF.

Dynamic Portable Ultrasound Cutoff Values for Diagnosing Medial Ankle Instability in Supination External Rotation Ankle Injury: A Cadaveric Study

Category:Ankle; TraumaIntroduction/Purpose:In the setting of an isolated lateral malleolar fracture, stability is predicated by whether the deep deltoid ligament is intact. Portable ultrasound (P-US) has also been used in the clinical setting, allowing dynamic and non-invasive evaluation at the point of care. This study aimed to determine the cutoff values, as well as its sensitivity and specificity for diagnosing supination external rotation (SER) ankle injury stage IVb (with complete deltoid ligament rupture) using the P-US.Methods:Ten fresh-frozen cadaveric specimens were used. Medial ankle instability was assessed by the P-US. The assessment was performed with all structures intact and later with sequential transection of the AITFL, Weber-B fibular fracture, the PITFL, the superficial and deep deltoid ligament. In all scenarios, three loading conditions were considered, including the GST, the external rotation stress test (45N), and the simulated weight-bearing (750N). The P-US measurement of the MCS was assessed at the anteromedial aspect and inferomedial aspect of the ankle joint. The P-US measurement of the MCS was assessed by placing the ultrasound probe perpendicularly to the medial gutter at the anteromedial aspect and inferomedial aspect of the ankle joint. Three different MCS distances were measured, as demonstrated in Figure 1. To determine the sensitivity and specificity of the diagnosis of SER injury type IV using the P-US, a receiver operating characteristic (ROC) curve analysis was performed.Results:The MCS optimal cutoff point to distinguish SER ankle injury stage IVb from other injury stages ranged from 10.4 to 13.8 during the GST, 4.2 to 7.9mm during the weight-bearing stress, and 10.6-17.9mm during the external rotation stress test (Table 1). All P-US cutoff values provided acceptable sensitivity (60-100%), specificity (84-100%), and the area under ROC curve (0.8-1.0) for diagnosing SER ankle injury stage IVb.Conclusion:MCS cutoff points assessed with the P-US under the GST, weight-bearing, and the external rotation stress test demonstrate high sensitivity and specificity for detecting SER ankle injury stage IVb. The cutoff values vary depending on which loading condition is being used. Additional clinical studies are necessary in the in vivo setting to better understand the implications of these test conditions.

Morphological study of CT image of posterior pilon variant fracture and its possible clinical significance.

The incidence of posterior pilon variant fractures has been underestimated. The purpose was to study the characteristics of posteromedial (PM) and posterolateral (PL) fragments in CT imaging of posterior pilon variant fractures, and to provide help for clinical diagnosis and treatment. CT imaging data of 109 cases of posterior pilon variant fractures in our hospital from January 2013 to December 2020 were retrospectively analyzed. According to Mason and Molloy classification, PM fragments were further divided into pilon subtypes and avulsed subtypes. The largest actual area of fragments in axial and sagittal were selected as the study plane, and the maximum axial lengths of X, Y and Z, α angle, β angle, fragment area (S1-7) and fragment area ratio (FAR1-4), interfragmentary (IF) angle, and back of tibia (BT) angle were measured. A total of 109 cases were included in this study, 61 of whom were pilon subtypes [90.16% were supination-external rotation (SER) injuries]. 48 cases were avulsed subtypes [81.25% were pronation-external rotation (PER) injuries]. Pilon subtypes were larger than avulsed subtypes in X, Y, Z, α2 Angle, β2 Angle, fragment area and ratio, and IF and BT angle (P < 0.05). There was no difference between α1 and β1 angle (P > 0.05). The morphology of pilon subtype was larger than that of avulsion subtype. According to fragment size, morphology, and injury mechanism, two fragments of pilon subtype should be anatomic reduction and fixation. However, the PL fragment of avulsion subtype should to be fixed, while PM fragment may only need conservative treatment.

A prospective study of functional and radiological outcome of open reduction and internal fixation of malleolar fracture and associated complications

Background: Malleolar fractures are a kind of regularly seen fractures in orthopedic department. As with all intra articular fractures, malleolar fractures necessitate anatomical reduction and stable internal fixation.Objective: To study functional and radiological outcome of open reduction and internal fixation of malleolar fracture and associated complications and to study role of early mobilization and graded weight bearing.Materials and Method: This study prospectively evaluated clinical, radiological and functional outcome of 39 patients of malleolar fracture treated with open reduction and internal fixation at Madras institute of orthopaedics and traumatology, Chennai from May 2016 to May 2017. After open reduction, patients were followed clinically and radio logically at 6 weeks, 3 months and 6 months. After operative procedure, functional and radiological outcome was assessed using Baird and Jackson score system.Results: Majority were Supination-External Rotation injuries 19 cases. Most common implant used for medial malleolus fracture was 3.5mm cortical screw (84.6%) cases and for lateral malleolus semi tubular plate (64.1%). According to Baird and Jackson scoring system our results were excellent in 6 cases (15.4%), good in 22 cases (56.4%), fair in 8 cases (20.5%), poor in 3 cases (7.7%). Good results were observed in maximum patients, one patient developed infection and two patients developed ankle stiffness.Conclusion: Open reduction and internal fixation of malleolar fracture is necessary to achieve anatomical reduction of the fracture fragments, ankle mortise congruity, restoration of the length of the fibula and restoration of syndesmotic integrity. We recommend to apply POP cast to prevent equines deformity and to start early range of motion of ankle as early as possible in cast after making dorsal window cut for 1 month.

Fibula pro-tibia vs standard locking plate fixation in an ankle fracture saw bone model.

BACKGROUNDLocking plate fixation in osteoporotic ankle fractures may fail due to cut-out or metalwork failure. Fibula pro-tibia fixation was a technique prior to the advent of locking plates that was used to enhance stability in ankle fractures by achieving tri or tetra-cortical fixation. With locking plates, the strength of this fixation construct can be further enhanced. There is lack of evidence currently on the merits of tibia-pro-fibula augmented locking plate fixation of unstable ankle fractures.AIMTo assess if there is increased strength to failure, in an ankle fracture saw bone model, with a fibula pro-tibia construct when compared with standard locking plate fixation.METHODSTen osteoporotic saw bones with simulated supination external rotation injuries were used. Five saw bones were fixed with standard locking plates whilst the other 5 saw bones were fixed with locking plates in a fibula pro-tibia construct. The fibula pro-tibia construct involved fixation with 3 consecutive locking screws applied across 3 cortices proximally from the level of the syndesmosis. All fixations were tested in axial external rotation to failure on an electromagnetic test frame (MTS 858 Mini-Bionix test machine, MTS Corp, Eden Praire, MN, United States). Torque at 30 degrees external rotation, failure torque, and external rotation angle at failure were compared between both groups and statistically analyzed.RESULTSThe fibula pro-tibia construct demonstrated a statistically higher torque at 30 degrees external rotation (4.421 ± 0.796 N/m vs 1.451 ± 0.467 N/m; t-test P = 0.000), as well as maximum torque at failure (5.079 ± 0.694N/m vs 2.299 ± 0.931 N/m; t-test P = 0.001) compared to the standard locking plate construct. The fibula pro-tibia construct also had a lower external rotation angle at failure (54.7 ± 14.5 vs 67.7 ± 22.9).CONCLUSIONThe fibula pro-tibia locking plate construct demonstrates biomechanical superiority to standard locking plates in fixation of unstable ankle fractures in this saw bone model. There is merit in the use of this construct in patients with unstable osteoporotic ankle fractures as it may aid improved clinical outcomes.

Antiglide plating for distal fibula fractures caused by supination-external rotation injury

Supination-external rotation type of fracture is the most common pattern of ankle fractures. Anatomical reduction of ankle is always desired and poor reduction usually leads to shortening of fibula, or alter the biomechanics of ankle leading to chronic pain as a result of failure of fixation always. Both lateral and antiglide plating of fibula achieve in accurate anatomical reduction of these fractures. But, maintaining the reduction until bony union is also required to avoid failure of hardware or non union. Antiglide construct enhances biomechanics strength of the fixation device due to its anti gliding effect of the applied plate upon weight bearing and thereby is more favourable. This study evaluated clinical outcomes and complications seen in fixations done by antiglide technique done during 2018-2021 among patients admitted with SER pattern injuries at our institute. A total of 24 patients were included in the study. Mean operative time in the study group was 57.5 ± 27.4 (range 20–120) minutes. The most commonly used plates were five-hole plates in 10 (42%) patients, six holed plates in 10 (42%) patients and seven holed in 4 (16%) patients. The median number of screws distal to the fracture line in the antiglide plate was 0.5 (range 0–2); 10 (50%) fibulas with no fixation, 8 (40%) with one and 2 (10%) with two screws. The AOFAS in the antiglide group performed at one year after surgery was 94.5 ± 6.0 (range 85–100).We conclude that the use of the antiglide plate in a posterolateral position, without using unreasonable distal screws, is an appropriate method of fixation in every short oblique lateral malleolus fractures occurring as a part of SER pattern injury of ankle.