Trimalleolar CASE PRESENTATION

CASE PRESENTATION

INTRODUCTION:

                             Ankle fractures are the most common injuries that are treated by most orthopedic surgeons. The ankle is one of the strongest mortise joint (also known as the WOODWORK joints or the talocrural joint). In the body, this is the formation of hinge joint by the lower end of the tibia and the fibula that articulates with the talus. Ankle fractures occur when one or both sides of the ankle are completely or partially broken due to twisting injuries or fall injuries expressed during play or sports.

ANATOMY:

CLASSIFICATION:

                Classification of ankle fractures is important in order to estimate the extent of the ligamentous injury and the stability of the joint.
The Weber classification focuses on the integrity of the syndesmosis, which holds the ankle mortise together.
The Lauge-Hansen system focuses on the trauma mechanism.
Adding the stages of Lauge-Hansen to the Weber system will help you to predict ligamentous injury and instability.

Ø Weber A (Infrasyndesmotic) – Lauge Hansen Supination adduction.

Ø Weber B (Transyndesmotic) – Lauge Hansen Supination exorotation.

Ø Weber C (Suprasyndesmotic) – Lauge Hansen Pronation exorotation.

PATIENT INFORMATION:

Ø  Patient Name: “ X”

Ø  Age: 48yrs/Female.

Ø  Date of Admission: 05/04/2017.

Ø  Date of Surgery: 08/04/2017.

CHIEF COMPLAINT:

                Patient has restricted right ankle movements and inability to stand and walk few steps since today (05/04/2017).

HISTORY OF PRESENT ILLNESS:

               Patient came with complaints of pain ,swelling over the right ankle and was unable to stand and walk few steps since today (05/04/2017). Patient gave history of slip and fall at bathroom (at home) today evening. Since then patient complaints of pain, swelling, deformity and inability to use right leg (ankle). After the injury patient came to emergency department of our hospital.

v  Previous Injury: No

v  Developmental History: No any developmental histories

v  Drug History: No known drug allergies. Not on any chronic medication

v  Past medical History: No Diabetes Mellitus; No Hypertension; No Bronchial Asthma;                                                No Thyroid diseases.

ON EXAMINATION:

            Patient is conscious, oriented.

Vital Signs: 

·         BP – 140/90 mm/Hg

·         PR – 100b/min

·         SpO2 – 98%

·         Temp – 98° F

LOCAL EXAMINATION:

Ø  Pain and swelling over the right ankle (medial & lateral) is present.

Ø  Tenderness and crepitus over the right ankle (medial & lateral) is present.

Ø  Deformity and angulation over the right ankle (medial & lateral) is present.

Ø  Any attempted movements of the ankle are painful.

Ø   Distal pulse palpable (A.Dorsalis Pedis).

  

X-RAY FINDING:

        Before Reduction by POP (Below Knee Slab)

           After Reduction by POP (Below Knee Slab)

Findings:

             TRIMALLEOLAR FRACTURE

1.      FRACTURE DISTAL THIRD OF FIBULA RIGHT SIDE.

2.      FRACTURE POSTERO MEDIAL ASPECT OF MEDIAL 

                          MALLEOLUS RIGHT ANKLE WITH SUBLUXATION OF

                          RIGHT ANKLE.

3.      UNDISPLACED FRACTURE BASE OF 2^ND ,3^RD & 4^TH

                         METATARSAL RIGHT FOOT.

PREPARATION:

           Supine Position by Lateral and Medial Access:

                The patient is positioned supine on a radiolucent table with a sand bag under the ipsilateral buttock. The injured leg may be placed over a folded blanket with the knee slightly flexed. This position allows free access to both lateral and the medial sides by hip rotation. Moving the leg towards the edge of the table stabilizes the position of leg and ankle.

SKIN INCISION:

LATERAL INCISION: 

          The longitudinal lateral incision is the standard approach for most lateral fractures.

*[If access to the anterior syndesmosis is required, or a lag screw from anterior to posterior (Chaput lesion) is planned, place the incision slightly anteriorly.]*

Make a 10-15 cm incision in line with the fibula, centered over the fracture. If necessary, the incision may be extended distally to reduce and hold the syndesmosis.

The fracture site was exposed. Fracture was reduced.  Fracture was fixed with 7 holed reconstruction plate with 3 screws proximally & 3 screws distally.

MEDIAL INCISION:

              The incision started 2 cm distal to the anterior tip of the medial malleolus. Curve the incision towards the anterior edge of the medial malleolus and in the direction of the middle of the distal tibia.

The fracture in the postero-medial aspect was exposed. Fracture was reduced and was fixed with K-Wire. K-wire was replaced with cannulated screws with washer.

The fracture reduction with plate & screws checked under C-Arm & was found satisfactory.

AP view:

LAT view:

CLASSIFICATION:

          According to the classification. The fracture is classified:

             Weber C This is a fracture above the level of the syndesmosis. Usually there is a total rupture of the syndesmosis with instability of the ankle.
According to Lauge-Hansen, it is the result of an exorotation force on the pronated foot.

 

 

Ø  Stage 1 - Avulsion of the medial malleolus
or - ligamentous rupture

Ø  Stage 2 - Rupture of the anterior syndesmosis

Ø  Stage 3 - Fibula fracture above the level of the syndesmosis (this is the true Weber C fracture)

Ø  Stage 4 - Avulsion of the posterior malleolus
or - rupture of the posterior syndesmosis

POST-OPERATIVE Range Of Movements:

14 Months after Surgery:

DORSI FLEXION:

PLANTAR FLEXION:

CONCLUSION:

Ø  Early surgery, good anatomical reduction and internal fixation help to recover the full range of movements.

Ø  Stability has been RESTORED.

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