Diferencia entre revisiones de «Ankle fracture»

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==Classification==
{{Adult top}} [[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


Danis-Weber system:
==Differential Diagnosis==
{{Other ankle injuries DDX}}


type A-fibular Fx at or below the joint line without syndesmotic involvement.
{{Distal leg fractures DDX}}


type B-fib Fx at joint level with partial syndesmotic ligament injury.
{{Foot and toe fractures DDX}}


type C-fibular Fx above the joint level and complete syndesmotic disruption.
==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]]


C-diaphyseal (Dupuytren Fx) or proximal fibular Fx (maissoneuve).
*[[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)===
[[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)


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


lateral malleolar-Tx depends on type A, B, or C
====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>


A-splinting in ED, 6-8 weeks in cast.NWB for three weeks.
====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


B-often requires a surgical repair.
==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


C-surgery usually required.
===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)


medial malleolar Fx-rare. non dispalced Fx usually managed with closed reduction and casting for 6 weeks (up to 15% nonunion rate unfortunately...). If displaced
===Isolated medial or posterior malleolar fracture===
 
*Must rule-out other injuries
Bimalleolar Fx-by definition unstable-needs ORIF
*If non-displaced, isolated:
 
**[[Short-Leg Posterior Splint]] (ankle at 90<sup>o</sup>)  
trimalleolar-bimalleolar with an accompanying Fx of the posterior lip of the talus.
**Non-weight bearing
 
**Refer to Ortho in 5-7d
 
==Disposition==
 
 
Ortho Consult Guidelines:
 
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.
 
 
==Treatment==
 
 
non-displaced close Fx w/ intact mortise-casted for 6 weeks.
 
disruption of ankle mortise alignment >1-2 mm (lateral alignment more important than medial) needs ORIF.
 
 
==Complications==
 
 
malunion
 
nonunion
 
chronic pain
 
traumatic arthritis
 
avascular necrosis
 
chronic instability
 
fracture blisters and skin necrosis from swelling
 
compartment syndrome
 
post surg wound infection/osteo
 
== ==


===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]]


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


Ortho:  Maisonneuve
==References==
 
<references/>
Ortho:  Pilon Fx
[[Category:Orthopedics]]
 
Ortho:  Ankle (Ottowa)
 
Ortho:  Ankle (Sprain)
 
 
 
 
[[Category:Ortho]]

Revisión actual - 22:50 5 mar 2025

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

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
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