Diferencia entre revisiones de «Ankle fracture»

Sin resumen de edición
(Move calculators to own section with header (visible in TOC), expanded, before External Links)
 
(No se muestran 114 ediciones intermedias de 11 usuarios)
Línea 1: Línea 1:
==Malleolar Fractures==
{{AdultPage|ankle fracture (peds)}}
==Background==
[[File:Weber Classification - latin.png|thumb|Danis–Weber classification of ankle fractures (Types A, B and C).]]


==Clinical Features==
*Examine for ecchymoses, abrasions, or swelling
*Vascular and neurologic assessment
**DP and PT pulses
**4 sensation distributions: saphenous nerve (medial mal), superficial fib (lat mal), sural nerve (lateral 5th digit), deep fib (1st web space)
*Note skin integrity and areas of tenderness or crepitus over ankle
*Range joint passively and actively to evaluate for stability
*Examine joints above and below the ankle
*Perform anterior drawer test (positive exam suggests torn ATFL)
*'''Always palpate entire length of fibula to rule-out [[Maisonneuve Fracture]] (fibulotibialis ligament tear)'''
**Perform a crossed-leg test to detect syndesmotic injury
*Evaluate integrity of Achilles tendon ([[Achilles Tendon Rupture#Clinical Features|Thompson test]])
*Palpate midfoot and base of 5th metatarsal for tenderness


* Isolated Malleolar
==Differential Diagnosis==
* Stable if displaced <2mm, joint surface involvement <25%, and no contralateral or syndesmotic injury
{{Other ankle injuries DDX}}
* Medial Malleolus Fx
* Is it really isolated? (frequently associated with lateral or posterior injuries)
* Posterior Malleolus Fx
* Usually occurs in association w/ post. tibiofibular ligament injury / fibular fx
* Rarely occurs in isolation!
* Bimalleolar
*  Lateral + medial malleoli fx
* Unstable
* Trimalleolar
* Lateral + medial + posterior malleoli fx
* Requires surgical stabilization
== ==


{{Distal leg fractures DDX}}


==Imaging==
{{Foot and toe fractures DDX}}


==Evaluation==
[[File:Danis–Weber classification on X-ray.jpg|thumb|Danis–Weber classification on X-ray.]]
[[File:WeberARadiopediaOB.jpg|thumb|Weber A Oblique]]
[[File:WeberBRadiopedOB.jpg|thumb|Weber B Oblique]]
[[File:WeberBAPMedp.jpg|thumb|Weber B AP]]
[[File:WeberCOBMedp.jpg|thumb|Weber C Oblique]]
[[File:WeberCAPMedp.jpg|thumb|Weber C AP]]


* Ottawa Ankle Rules  
*[[Ottawa Ankle Rules]] (sen 96-99% for excluding fracture)
* 3 views:
*3 views:
* AP - Best for isolated lateral and medial malleolar fractures
**AP: Best for isolated lateral and medial malleolar fractures
* Oblique (mortise) - Best for evaluating for unstable fracture or soft tissue injury
**Oblique (mortise)
* at a point 1cm proximal to the articular surface of the tibia the space between the tib/fib should be ≤6cm
***Best for evaluating for unstable fracture or soft tissue injury
* Lateral - Best for posterior malleolar fractures
***At a point 1 cm proximal to tibial plafond space between tib/fib should be ≤6mm
**Lateral: Best for posterior malleolar fractures
*Consider proximal tib/fib films and talus fractures


==Classification==
===Classification (Danis-Weber System)===
[[File:WeberclassRadioped.jpg|thumb|]]
*System based on level of the fibular fracture and characterizes stability of fracture
*Tibial plafond and the two malleoli is referred to as the ankle "mortise" (or talar mortise)


====Type A====
*Fibula fracture below ankle joint/distal to plafond
**Medial malleolus often fractured
**Tibiofibular syndesmosis intact
**Usually stable: occasionally requires ORIF


Danis-Weber system:
====Type B====
*Fibula fracture at the level of the ankle joint/at the plafond
**Can extend superiorly and laterally up fibula
**Tibiofibular syndesmosis intact or only partially torn
**No widening of the distal tibiofibular articulation
**Medial malleolus may be fracture
**Possible instability
***Use gravity or weight bearing stress X-rays to determine stability <ref>Tips for Managing Weber B Ankle Fractures By Joseph Noack, MD; and Spencer Tomberg, MD. ACEP Now April 14, 2020 https://www.acepnow.com/article/tips-for-managing-weber-b-ankle-fractures/?singlepage=1</ref>


type A-fibular Fx at or below the joint line without syndesmotic involvement.
====Type C====
*Fibula fracture above the level of the ankle joint/proximal to plafond
**Tibiofibular syndesmosis disrupted with widening of the distal tibiofibular articulation
**Medial malleolus fracture
**Unstable: requires ORIF


type B-fib Fx at joint level with partial syndesmotic ligament injury.
==Management & Disposition==
{{General Fracture Management}}


type C-fibular Fx above the joint level and complete syndesmotic disruption.
===General Ankle Fracture===
*Determined by stability of fracture:
**Stable, nondisplaced, isolated malleolar fracture: Splint or cast, early wt bearing, RICE
**Unstable or displaced fracture: Requires ORIF, ortho consult, reduce and splint


C-diaphyseal (Dupuytren Fx) or proximal fibular Fx (maissoneuve).
===Isolated lateral malleolar fracture===
*If stable (see Weber classification) treat like severe [[Ankle Sprain]]
*Signs of instability:
**Displacement >3mm
**Associated medial malleolus fracture
**Signs of medial (deltoid) ligament disruption such as medial swelling, ecchymosis, or TTP
**Widening of medial clear space (suggests deltoid ligament injury)  


===Isolated medial or posterior malleolar fracture===
 
*Must rule-out other injuries  
fracture types:
*If non-displaced, isolated:  
 
**[[Short-Leg Posterior Splint]] (ankle at 90<sup>o</sup>)  
lateral malleolar-Tx depends on type A, B, or C
**Non-weight bearing  
 
**Refer to Ortho in 5-7d
A-splinting in ED, 6-8 weeks in cast.NWB for three weeks.
 
B-often requires a surgical repair.
 
 
C-surgery usually required.
 
 
 
==Disposition==
 
 
* Emergent
* Open fracture
* Fx/dislocation with vascular compromise
* Fx/dislocation with significant tenting of the skin
* Recommended (pt often admitted for repair)
* Tillaux/triplane fractures
* Intrarticular fractures with displacement
* Pilon fractures (reduce if ortho unavailable)
* Trimalleolar fractures
* Maisonneuve Fx
* Any Fx with significant disruption of mortise
* Recommended (phone is ok)
* Bimalleolar Fx
* Minimally displaced medial or lateral malleolar Fx
 
==Management==
 
 
* Lateral malleolar Fx
* Stable - >90% have good clinical result
* Treat like severe ankle sprain
* Unstable = displacement >2mm, medial fx, or medial ligament disruption
* Medial tenderness indicates need for stress xrays to determine degree of instability
*  Medial or posterior malleolar Fx
* Must confirm no other injuries!
* If non-displaced, isolated:
* Short-leg posterior splint (ankle at 90o)
* Non-weight bearing
* Refer in 5-7 days
* Lateral malleolar fx with deltoid injury OR bimalleolar OR trimalleolar fx
* Short-leg posterior splint (ankle at 90o)
* Refer within few days for surgical intervention
 
==Complications==
 
 
* Nerve damage
* Peroneal nerve (lateral ankle injury)
* Weak foot dorsiflexion
* Tibial nerve (medial ankle injury)
* Compartment syndrome
* Nonunion or malunion
* Fracture blister/skin necrosis
== ==


===Lateral malleolar fracture with deltoid injury OR bimalleolar OR trimalleolar fracture===
[[File:Bimalleolar fracture legend.jpg|thumb|Bimalleolar fracture and right ankle dislocation on X-ray (anteroposterior). Both the end of the fibula (1) and the tibia (2) are broken and the malleolar fragments (arrow: medial malleolus, arrowhead: lateral malleolus) are displaced.]]
*[[Short-Leg Posterior Splint]] (ankle at 90<sup>o</sup>)
*Immediate reduction or ortho consult in ED


==See Also==
==See Also==
*[[Ankle (Main)]]
*[[Ankle Sprain]]
*[[Ankle Fracture (Peds)]]
*[[Ottawa Ankle Rules]]
*[[Maisonneuve Fracture]]
*[[Pilon Fracture]]
*[[Fracture (Main)]]
*[[Splinting]]


== Calculators ==
{{Ottawa_Ankle_Calculator}}


Ortho:  Maisonneuve
==External Links==
 
*http://radiopaedia.org/articles/weber_ankle_fracture_classification (Images by Dr. Frank Gaillard; CC SA NC BY licence)
Ortho: Pilon Fx
*Ottawa Ankle Rules - http://www.ncbi.nlm.nih.gov/pubmed?term=12595378
 
Ortho:  Ankle (Ottowa)
 
Ortho: Ankle (Sprain)
 
 
 


[[Category:Ortho]]
==References==
<references/>
[[Category:Orthopedics]]

Revisión actual - 15:07 21 mar 2026

This page is for adult patients. For pediatric patients, see: ankle fracture (peds)

Background

Danis–Weber classification of ankle fractures (Types A, B and C).

Clinical Features

  • Examine for ecchymoses, abrasions, or swelling
  • Vascular and neurologic assessment
    • DP and PT pulses
    • 4 sensation distributions: saphenous nerve (medial mal), superficial fib (lat mal), sural nerve (lateral 5th digit), deep fib (1st web space)
  • Note skin integrity and areas of tenderness or crepitus over ankle
  • Range joint passively and actively to evaluate for stability
  • Examine joints above and below the ankle
  • Perform anterior drawer test (positive exam suggests torn ATFL)
  • Always palpate entire length of fibula to rule-out Maisonneuve Fracture (fibulotibialis ligament tear)
    • Perform a crossed-leg test to detect syndesmotic injury
  • Evaluate integrity of Achilles tendon (Thompson test)
  • Palpate midfoot and base of 5th metatarsal for tenderness

Differential Diagnosis

Other Ankle Injuries

Distal Leg Fracture Types

Foot and Toe Fracture Types

Hindfoot

Midfoot

Forefoot

Evaluation

Danis–Weber classification on X-ray.
Weber A Oblique
Weber B Oblique
Weber B AP
Weber C Oblique
Weber C AP
  • Ottawa Ankle Rules (sen 96-99% for excluding fracture)
  • 3 views:
    • AP: Best for isolated lateral and medial malleolar fractures
    • Oblique (mortise)
      • Best for evaluating for unstable fracture or soft tissue injury
      • At a point 1 cm proximal to tibial plafond space between tib/fib should be ≤6mm
    • Lateral: Best for posterior malleolar fractures
  • Consider proximal tib/fib films and talus fractures

Classification (Danis-Weber System)

WeberclassRadioped.jpg
  • System based on level of the fibular fracture and characterizes stability of fracture
  • Tibial plafond and the two malleoli is referred to as the ankle "mortise" (or talar mortise)

Type A

  • Fibula fracture below ankle joint/distal to plafond
    • Medial malleolus often fractured
    • Tibiofibular syndesmosis intact
    • Usually stable: occasionally requires ORIF

Type B

  • Fibula fracture at the level of the ankle joint/at the plafond
    • Can extend superiorly and laterally up fibula
    • Tibiofibular syndesmosis intact or only partially torn
    • No widening of the distal tibiofibular articulation
    • Medial malleolus may be fracture
    • Possible instability
      • Use gravity or weight bearing stress X-rays to determine stability [1]

Type C

  • Fibula fracture above the level of the ankle joint/proximal to plafond
    • Tibiofibular syndesmosis disrupted with widening of the distal tibiofibular articulation
    • Medial malleolus fracture
    • Unstable: requires ORIF

Management & Disposition

General Fracture Management

General Ankle Fracture

  • Determined by stability of fracture:
    • Stable, nondisplaced, isolated malleolar fracture: Splint or cast, early wt bearing, RICE
    • Unstable or displaced fracture: Requires ORIF, ortho consult, reduce and splint

Isolated lateral malleolar fracture

  • If stable (see Weber classification) treat like severe Ankle Sprain
  • Signs of instability:
    • Displacement >3mm
    • Associated medial malleolus fracture
    • Signs of medial (deltoid) ligament disruption such as medial swelling, ecchymosis, or TTP
    • Widening of medial clear space (suggests deltoid ligament injury)

Isolated medial or posterior malleolar fracture

  • Must rule-out other injuries
  • If non-displaced, isolated:

Lateral malleolar fracture with deltoid injury OR bimalleolar OR trimalleolar fracture

Bimalleolar fracture and right ankle dislocation on X-ray (anteroposterior). Both the end of the fibula (1) and the tibia (2) are broken and the malleolar fragments (arrow: medial malleolus, arrowhead: lateral malleolus) are displaced.

See Also

Calculators

Ottawa Ankle Rules

Ottawa Ankle Rule
Criteria No (0) Yes (+1)
Ankle X-ray is required if there is pain in the malleolar zone AND any of the following:
  Bone tenderness along distal 6 cm of posterior edge of tibia or tip of medial malleolus 1
  Bone tenderness along distal 6 cm of posterior edge of fibula or tip of lateral malleolus 1
  Inability to bear weight both immediately and in the ED (4 steps) 1
Foot X-ray is required if there is pain in the midfoot zone AND any of the following:
  Bone tenderness at the base of the 5th metatarsal 1
  Bone tenderness at the navicular 1
  Inability to bear weight both immediately and in the ED (4 steps) 1
Positive Criteria / 6
Interpretation
Score = 0 No X-ray needed — Sensitivity 96.4–99.6% for clinically significant fractures.
Score ≥ 1 X-ray recommended — Ankle and/or foot x-ray indicated based on positive criteria location.
References
  • Stiell IG et al. A study to develop clinical decision rules for radiography in acute ankle injuries. Ann Emerg Med. 1992;21:384-390. PMID 1554175.
  • Stiell IG et al. Decision rules for radiography in acute ankle injuries: refinement and prospective validation. JAMA. 1993;269:1127-1132. PMID 8433468.

External Links

References

  1. ↑ Tips for Managing Weber B Ankle Fractures By Joseph Noack, MD; and Spencer Tomberg, MD. ACEP Now April 14, 2020 https://www.acepnow.com/article/tips-for-managing-weber-b-ankle-fractures/?singlepage=1
Obtenido de «https://www.wikem.org/w/index.php?title=Ankle_fracture&oldid=387929»