The patient usually has a history of a rapid inversion and dorsiflexion injury.79 Fractures of the lateral process range from avulsion fractures of the capsular ligaments to intra-articular injuries involving the ankle and subtalar joints.9, Physical examination findings are similar to those in lateral ankle ligamentous injuries. Ankle avulsion fracture opinions needed. A lateral malleolus fracture is relatively common among the elderly, but can also occur in the younger patient. Frontal. They can be distal, at or proximal to the joint line of the ankle. The dome of the talus articulates with the tibia and fibula, and has a key role in ankle motion and in supporting the axial load during weight bearing14 (Figures 1 and 2). and our A posterior subtalar effusion seen on the lateral view is highly suggestive of an occult lateral process fracture.13 A CT scan can clearly show this injury and may be required to confirm a suspected fracture.11, A nonweight-bearing, short leg cast can be used if anatomic position with less than 2 mm displacement can be maintained.7,11 A nonweight-bearing cast should be maintained for four to six weeks, followed by two weeks in a walking cast and initiation of rehabilitation exercises.7 For large and displaced fragments, the treatment of choice is usually surgical reduction and fixation.7,8, The posterior process of the talus is composed of two tubercles, the lateral and medial (Figures 1 and 2). A plate and screws is placed on the fibula after reduction and 2 Arthrex Tightrope is placed across the syndesmosistomaintain reduction. Bimalleolar ankle fracture: This second-most common type involves breaks of both the lateral malleolus and of the . The lateral talar process is an osseous protuberance that articulates superolaterally with the fibula, helping to stabilize the ankle mortise, and inferomedially with the calcaneus, forming the lateral portion of the subtalar joint7 (Figures 1 and 2). The patient must be either immobolized and kept non-weightbearing in a cast depending on various factors including age of patient and pain level. This occurs as tendons can bear more load than the bone. In general, extra-articular fractures of the talus and calcaneus can be managed with nonsurgical treatment. Avulsion fractures can occur on any part of the body, but they are most common in the ankles, hips, and elbows. Usually, a plate and screws is utilized. Copyright 2002 by the American Academy of Family Physicians. Tenderness anterior to the lateral malleolus, along the anterior border of the talus, Mortise view: shallow, wafer-shaped lesion, Inversion with plantar flexion or atraumatic, Tenderness posterior to the medial malleolus, along the posterior border of the talus. Incidental note of os subfibulare and os trigonum. Case study, Radiopaedia.org (Accessed on 11 Dec 2022) https://doi.org/10.53347/rID-21949. However, CT (Figure 8) or MRI may be necessary if the diagnosis is unclear.16,17, Medial tubercle fractures are treated in a manner similar to that for lateral tubercle fractures.17,18,20, The anterior process of the calcaneus is a saddle-shaped bony protuberance that articulates with the cuboid. Non-surgical and surgical options exist to treat medial malleolus fractures, but the choice often comes down to the extent of the fracture. Avulsion fractures are breaks or splits in the bone. Usually, 4-8 weeks nonweightbearing followed by protected weightbearing with a cast. Usually, 4-8 weeks nonweightbearing followed by protected weightbearing with a cast. April 20 rolled ankle. A fracture is a break or crack in a bone that often results from an injury. Symptoms of an ankle avulsion fracture are very similar to an ankle sprain. Info: I've been told that the bone is likely to not re-attach itself naturally due to the distance, but . X-ray. Diagnosis is made with plain radiographs of the ankle. Spondylosis Spondylolysis Spondylolisthesis. 84th Avenue, Suite 102 Plantation, FL 33324, 17842 NW 2nd St., Pembroke Pines, FL 33029, 220 S.W. Multiple loose bodies are seen just below medial malleolus. Isolated Nondisplaced Lateral Malleolar Fractures. Lateral talar process fractures are characterized by point tenderness over the lateral process. In Fracture Management for Primary Care (Third Edition), 2012. ADVERTISEMENT: Supporters see fewer/no ads. (OBQ20.15) Figure A is the radiograph of a 55-year-old female who is a poorly-controlled diabetic with neuropathy and peripheral vascular disease (PVD) that underwent ankle open reduction internal fixation (ORIF) two years ago at an outside facility. The pain is often exacerbated by activities requiring plantar flexion.15 Physical examination findings in lateral tubercle fractures of the posterior process are highly consistent for tenderness to deep palpation anterior to the Achilles tendon over the posterior talus. 8,9 Small nondisplaced avulsion fractures of the tip of the lateral malleolus (Figure 13-4) are best treated with early mobilization similar to . The injury occurs at the site where a tendon or ligament attaches and happens because the tendon or ligament pulls abruptly and breaks a piece of bone away. When part of this bone fractures, the ankle can become unstable. Most avulsion fractures heal very well without surgical intervention. Some recent reports79,12 implicate snowboarding accidents in these fractures. X-ray. Fracture was repaired with plate and screws with a syndesomotic screw. Age: 32 Sex: male Height: 511 Weight: 160lbs Race: cacausian Duration of complaint: 1 week Location: ankle (lateral malleolus) Any existing relevant medical issues: no Current medications: None. Tells me it is a small undisplaced fracture of lateral malleolus. A fractured ankle can range from: A simple break in one bone, which may not stop you from walking, to. Privacy Policy. Feel a stretch in the back of your calf. Frontal. Ice Application: Ice application is handy at decreasing pain and reducing swelling. By rejecting non-essential cookies, Reddit may still use certain cookies to ensure the proper functionality of our platform. This page will discuss ankle and foot fractures and the role that physiotherapists play in the rehabilitation of such injuries. When the diagnosis is unclear and clinical suspicion is present, an MRI or CT will clearly demonstrate this fracture.16, Nondisplaced or minimally displaced fractures can be treated with a non-weight-bearing, short leg cast for four to six weeks.9,15 After this period of immobilization, weight bearing is allowed as tolerated. This is indicative of calcaneo-fibular ligament tear. The other two are the lateral and the posterior malleolus. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. There are two parts involved in the treatment of a stable lateral malleolus fracture. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. Then, you can gradually progress to putting weight on the ankle again. Incidental note of os subfibulare and os trigonum. It can be caused by traumatic traction (repetitive long-term or a single high impact traumatic traction) of the ligament or tendon. CONSERVATIVE CARE: If non-displaced and stable,these fractures can be treated non-operatively with cast immobilization. The lateral tubercle is the larger of the two and serves as the attachment of the posterior talocalcaneal and posterior talofibular ligaments.9,14,15 The medial tubercle serves as the attachment for the posterior third of the deltoid ligament.9,14,15 The under-surface of both tubercles forms the posterior fourth of the subtalar joint.9,14, An accessory bone known as the ostrigonum is relatively common, posterior to the lateral tubercle.6,15 The os trigonum can be a source of pathology, and a normal os trigonum may be confused with a fracture of the lateral tubercle.2,9,14. Nevertheless, some patients with these fractures are able to ambulate and, because patients with these fractures generally do not present with tenderness along the posterior border of the lateral or medial malleolus, radiographic evaluation may not be indicated under the Ottawa guidelines. The medial malleolus is the largest of the three bone segments that form your ankle. Medial tubercle fractures are relatively rare.17,18 They were first described by Cedell,18 who presented four cases of medial tubercle fractures that had originally been treated as ankle sprains. Post-surgical repair with open reduction of the fracture with internal fixation involving screws and plate (right) allow re-alignment of the fracture fragments will allow the bones to heal correctly and in a timely fashion. Alignment has been maintained. This article features subtle fractures to facilitate timely diagnosis and treatment of these less-common injuries. Treatment options fragment excision range from arthroscopy with or without subchondral bone drilling to open reduction internal fixation.4,5. If suggested by the clinical scenario, fractures not visualized with plain radiographs may require magnetic resonance imaging (MRI) or computed tomography (CT).6 The fracture classification developed by Berndt and Harty is widely used to stage talar dome lesions (Table 3).5, An orthopedic surgeon should be consulted for treatment of talar dome lesions because of the high functional demands of for the talar dome and the potential for complications. The findings are consistent with isolated lateral malleolar fracture. Fractures of the anterior process account for approximately 15 percent of all calcaneal fractures and are commonly misdiagnosed as ankle sprains. Age: 32 Sex: male Height: 5'11" Weight: 160lbs Race: cacausian Duration of complaint: 1 week Location: ankle (lateral malleolus) Any existing relevant medical issues: no Current medications: None. Anyone can suffer an avulsion fracture of the ankle, but athletes and children are more prone to them than the rest of us. An avulsion fracture occurs when a muscle or tendon is pulled so hard at the spot where it attaches to the bone that it tears a small piece of bone away. LATERAL MALLEOLAR FRACTURES. report an incidence of up to 174 cases per 100 000 persons per year in a Finish population. The lateral process can be palpated anteriorly and inferiorly to the tip of the lateral malleolus.8,11, Fractures can usually be visualized on a standard ankle series9 (Figure 5). External rotation injury of the ankle is the most common ankle injury and can lead to a Weber B or Weber C fracture. However, the clinical presentation of subtle fractures can be similar to that of ankle sprains, and these fractures are frequently missed on initial examination. After the deltoid and syndesomosis is healed, we replace the long screw (RED ARROW) with a Arthrex Tightrope (GREEN ARROW)that allows physiologic motion but maintains stability. Treatment of Lateral Malleolus Fractures. A CT scan may be required to further characterize the fracture pattern and for surgical planning. Fibula Fracture ORIF with Syndesmotic and Deltoid Rupture. Diagnosis of talar dome lesions can often be made with standard anteroposterior (AP), lateral, and mortise ankle radiographs. [1] [2] It can occur at numerous sites in the . Treatment of a stable lateral malleolus fracture need to include efforts to minimize swelling following by a gradual development in weight-bearing. The patient had a temporary screw (RED ARROWS) placed across the syndesmosis for 12-16 weeks and then permanently implanted an Arthrex Tightrope (GREEN ARROWS) to maintain stability but allow physiologic motion. The fracture may then be diagnosed and treated soon enough after the injury to avoid an adverse prognosis. An avulsion fracture is where a fragment of bone is pulled away at the ligamentous or tendinous attachment. Most ankle injuries are straightforward ligamentous injuries. Bruising may develop later and the athlete will most likely have difficulty moving the . When treatment is delayed, patients tend to have a more complex clinical course. This condition is known as a lateral malleolus fracture. {"url":"/signup-modal-props.json?lang=us\u0026email="}, Benoudina S, Lateral malleolar fracture. Anterior process fractures result . Studies have shown a fibular fracture displaced by 1 mm can decrease the contact area of the ankle joint by 42%. Furthermore, in the case of a suspected ankle sprain that does not improve as expected or is accompanied by tenderness over a potential fracture site, radiographic analysis at a follow-up evaluation may be indicated. Pain with plantar flexion, dorsiflexion, and subtalar joint movement is generally present.7 Although the normal anatomy of the ankle may be obscured by soft tissue swelling, a helpful diagnostic indicator is point tenderness over the lateral process. Soft tissue swelling over the lateral malleolus. At first, the patient may think they have sprained their ankle with symptoms of immediate pain and swelling. When a medial malleolus fracture occurs by itself . Prospective studies have validated the effectiveness of these guidelines and shown the rules to be 100 percent sensitive for clinically significant fractures.25,26. Info: I've been told that the bone is likely to not re-attach itself naturally due to the distance, but that surgery is not needed so l'm seeking additional opinions. Cookie Notice Soft tissue swelling over the lateral malleolus. Alignment has been maintained. Lateral lesions are best visualized on a mortise view and are generally thin and wafer-shaped.1,4 (Figure 4). This is consistent with an avulsion fracture involving the superior peroneal retinaculum. A common spot for avulsion fractures is at the lateral malleolus or outside ankle bone. This injury tends to be extra-articular and accounts for most of the anterior process fractures that are initially diagnosed as ankle sprains.2123, Anterior process fractures secondary to compression generally occur when the foot is forcefully dorsiflexed and the anterior process is pressed against the cuboid.22 Because of the energy involved with this mechanism, anterior process fractures secondary to compression are often intra-articular and are commonly associated with other fractures.7,23, Patients with anterior process fractures generally have a history of a previous inversion injury or involvement in a motor vehicle crash.21 Clinically, patients generally show signs and symptoms similar to those of a lateral ankle sprain.21,23 The pain may be minimal with standing but increases substantially with ambulation.21,23 An important diagnostic feature is point tenderness over the calca-neocuboid joint that is localized approximately 1 cm inferior and 3 to 4 cm anterior to the lateral malleolus, just distal to the anterior talofibular ligament insertion.21,22,23 Careful assessment of the point of maximal tenderness may help differentiate this fracture from a lateral ligament sprain.21,23, Although this fracture can be difficult to assess on routine radiographs of the foot and ankle, a careful inspection of the lateral view of the calcaneus often reveals this subtle fracture21,24 (Figure 9). X-ray showed a small loose body at the tip of lateral malleolus. Generally, medial tubercle fractures are secondary to dorsiflexion, pronationtype injuries, because the medial tubercle is avulsed by the deltoid ligament.17,18, On clinical assessment, there may be only slight pain with ambulation and range-of-motion testing.6,18 Patients with medial tubercle fractures typically have swelling and pain posterior to the medial malleolus and anterior to the Achilles tendon.17,18,20, Visualization of the medial tubercle fracture on plain radiograph may be challenging, but the fracture can generally be seen on an oblique projection with the foot and ankle externally rotated 40 degrees and the beam centered 1 cm posterior and inferior to the medial malleolus16,17 (Figure 7). Posterior process fractures can occur at either or both tubercles.1418 Lateral and medial tubercle fractures are discussed separately. Treatment of an avulsion fracture typically includes resting and icing the affected area. Reddit and its partners use cookies and similar technologies to provide you with a better experience. She was noncompliant with her immediate postoperative weight-bearing instructions and went on to fixation failure. It is very difficult to tell the difference without an X-ray or MRI scan. Dr. has x-ray completed. Again, these fractures have been commonly misdiagnosed as ankle sprains.2,9,15,16 In one case series,15 17 of 20 patients with fractures were misdiagnosed with ankle sprains. Copyright 2022 American Academy of Family Physicians. OVERVIEW: Lateral malleolar fractures are fractures that occur in the distal aspect of the fibula. 220 S.W. Stress placed on the bone by a tendon or ligament causes the fracture. Thin bony fragments adjacent to the lateral aspect of tip of the lateral malleolus and cortical irregularity at the lateral talus, likely representing avulsion fractures. As these osteochondral fragments (often referred to as osteochondritis dissecans lesions) become loose in the joint, they can cause pain, locking, crepitance, and swelling.1,4,5, Clinical diagnosis of talar dome fractures can be highly challenging because there are no pathognomonic signs or symptoms.5 The patient may have sustained a fall or a twisting injury to the ankle and may generally ambulate with an antalgic gait. Although the etiology in atraumatic lesions is unclear, osteochondral fragments can separate from the surrounding cartilage surface and dissect into the joint space. Posterior talar process fractures are often associated with tenderness to deep palpation anterior to the Achilles tendon over the posterolateral talus, and plantar flexion may exacerbate the pain. Six to eight weeks of nonweightbearing cast followed by Cam Walker and physical therapy. Go get aircast, use crutches (NWB) and follow up with family Dr in 2 weeks. The x-rays below demonstrate a lateral malleolar fracture that is displaced and has shortening which requires surgical repair (left). However, the clinical presentation of some subtle fractures can be similar to that of routine ankle sprains, and they are commonly misdiagnosed as such. This step optimizes the chance for a full recovery and decreases the incidence of post-traumatic arthritis and associated morbidities. Fractures of the anterior process account for approximately 15 percent of all calcaneal fractures and are commonly misdiagnosed as ankle sprains.6,21,23,24, Anterior process fractures result from avulsion or compression. If there is a small avulsion fracture off the tip of the fibula, these can often be treated by weightbearing cast immobilization followed by Cam Walker and physical therapy. Some patients do well with weightbearing protected immobilization in a cast boot. Appropriate radiographs are essential to the diagnosis of these fractures but, in the work-up of an ankle injury, radiographs are not always required. It is attached to the cuboid by an interosseous ligament and to the cuboid and navicular bones by the strong bifurcate ligament21,22 (Figures 1 and 2). There are two theories regarding the origin of os subfibulare 2: An avulsion fracture attributable to pull of the anterior talofibular ligament. The Ottawa ankle rules (Figure 1025 ) offer the physician clinical guidance as to which injuries require radiographs. Case 1 - Avulsion Fracture of the Superior Peroneal Retinaculum. They can be distal, at or proximal to the joint line of the ankle. Lateral. In this case, the avulsion involves the peroneal retinaculum, which is a fibrous retaining band that binds down the tendons of the peroneus longus and brevis as they run across the side of the ankle. Many of these injuries, if left without a definitive diagnosis, result in long-term disability (Table 1). Fractures of the lateral tubercle can be caused by hyperplantar flexion or inversion.1,2,15 Hyperplantar flexion injuries tend to cause compression fractures, while inversion injuries tend to produce avulsion fractures.1,2,15 Both of these injuries have been described after falls and have been associated with football and rugby kicking injuries, which place the ankle in a forced plantar flexed position.19 If present, an os trigonum can be injured by the same mechanisms described above.2,19, Clinically, patients with a fracture of the lateral tubercle present with pain and swelling in the posterolateral area of the ankle. An unfused accessory ossification center. Point your toes down as far as they go, then use the other foot on top to apply some pressure to create a stretch on the top of your foot. SURGICAL CARE: If unstable, and/or displaced, these fractures need to be brought to the OR to have open reduction and internal fixation (ORIF). Most common ankle fractures. When the . Ankle views showed grossly swollen soft tissue over lateral malleolus. Annotated image. By accepting all cookies, you agree to our use of cookies to deliver and maintain our services and site, improve the quality of Reddit, personalize Reddit content and advertising, and measure the effectiveness of advertising. Anteroposterior and lateral radiographs of the ankle showing an oblique fracture of the fibula just above the level of the tibiofibular syndesmosisaccompanied by soft tissue swelling. First, you need to focus on resting and getting the swelling to go down. Point tenderness over the calcanealcuboid joint (approximately 1 cm inferior and 3 to 4 cm anterior to the lateral malleolus), Lateral radiograph (an accessory ossicle, the calcaneus secondarium, may be present), Small nondisplaced fracture: nonweight-bearing with compressive dressing or NWBSLC for four to six weeks, Joint rest, ice, compression, and elevation (RICE), Progressive range-of-motion and proprioceptive exercises, Protection from further ankle injury with a wrap or brace, Completely detached fragment without displacement, Completely detached fragment with displacement. This is consistent with an avulsion fracture involving the superior peroneal retinaculum. Computed tomographic scans or magnetic resonance imaging may be required because these fractures are difficult to detect on plain films. In a different patient, after conservative care,a patient with a healed high fibular fracture with fracture callus surrounding the fracture site is seen on the X ray (GREEN ARROW). The button on the right of the bone is what holds the strong suture like material connected between the 2 bones. Ice application: Apply ice to help reduce pain and swelling. 84th Avenue, Suite 102, Plantation FL, 33324 (954) 720-1530, fter conservative care,a patient with a healed high fibular fracture with fracture callus surrounding the fracture site is seen on the X ray, shows the increased clear space which is abnormal and exemplifies a syndesmosis tear, 1600 Town Center Blvd Ste C Weston, FL 33326-3635, 17842 NW 2nd St Pembroke Pines, FL 33029-2806, 220 S.W. AP view: deep, cup-shaped lesion; initial radiograph can be normal because changes in subchondral bone may not develop for weeks. The patient has an ORIF Fibula fracture and a temporary screw (RED ARROWS)placed across the syndesmosis for 12-16 weeks and then permanently implanted an Arthrex Tightrope (GREEN ARROWS)to maintain stability but allow physiologic motion. These types of fractures can be very disabling. Can it cause issues like abrasion to surrounding areas? OVERVIEW: Lateral malleolar fractures are fractures that occur in the distal aspect of the fibula. Pre and Postop Fibula Fracture ORIF (Below), Plate and Screws are placed as well as a syndesmotic screw after reductionto give stability due to theligamentous injury. Fractures of the talar dome are generally the result of inversion injuries of the ankle. Skinner H. Current Diagnosis & Treatment in Orthopedics, Fourth Edition. He said I would be "good to go" in 4-6 weeks. Generally, the AP ankle view is best for visualizing deep, cup-shaped medial lesions,1,4 although the lesions are often appreciated on the mortise view as well (Figure 3). However, as with all guidelines, clinical judgment and experience may be grounds for radiographic analysis in unique cases. However, repeated radiographs may be necessary because initial films may appear normal. 6, 21, 23, 24. A fracture can be caused by a fall, a blow to the . Displaced filbular fracture with ankle dislocation. Typically, the secondary center of ossification of the lateral malleolus appears during the first year of life and fuses with the shaft at 15 years. Stage I, II, and III medial lesions can usually be treated nonsurgically with six weeks in a nonweight-bearing cast.1,3,5 Adequate reduction and immobilization are crucial for fracture healing and to avoid avascular necrosis of the fracture fragment.5, Patients with stage III lateral lesions, stage IV lesions, and persistent symptoms are generally treated surgically. Lateral. Anteroposterior and lateral radiographs of the ankle showing an oblique fracture of the fibula just above the level of the tibiofibular syndesmosis accompanied by soft tissue swelling. As the clinical scenario dictates, a CT scan or MRI may be necessary.9,21,23 In addition, an accessory ossicle (calcaneus secondarium) maybe located near the anterior process and could be misinterpreted as a fracture.21,24, For small, nondisplaced fractures, early immobilization in a nonweight-bearing, short leg cast or compressive dressing for four to six weeks followed by range-of-motion exercises and a gradual return to weight bearing has been successful.21,23, Although fracture healing may appear radiographically to be complete, approximately 25 percent of patients require more than a year before becoming asymptomatic.21 Following nonsurgical management, most patients report satisfactory results and a return to preinjury activity levels.21,23,24 Symptomatic nonunions or large, displaced fractures may require surgical intervention.21,24. Hold both stretches for up to 30 seconds and repeat 3 times. Elevation: Elevation is important to keep swelling restricted. 1600 Town Center Blvd, Weston FL, 33326 (954) 389-5900 This guy twisted his ankle. Kannus et al. This can be seen as the two "buttons" on the right side of the xrays on the tibia. There is a small loose body (arrow) indicating an avulsion injury. This content is owned by the AAFP. It is a break of the lateral malleolus, the knobby bump on the outside of the ankle (in the lower portion of the fibula). 2. These fractures should be considered in the differential diagnosis of any acute ankle sprain, as well as any suspected sprain that does not improve with routine treatment (Table 2). 17842 NW 2nd St., Pembroke Pines, FL 33029 (954) 430-9901 -If I were to have surgery, is there a time window that I should have it done post accident to guarantee it heals correctly. Medial malleolus-distal end of tibia that forms the medial ankle bone.Hallux-meaning 'big toe', digit 1.Foot and ankle bones Tibia-medial malleolus Fibula-lateral malleolus Tarsals Talus Calcaneus Cuboid Cuneiforms (medial, middle, lateral) Navicular . Ankle Fractures are very common fractures in the pediatric population that are usually caused by direct trauma or a twisting injury. Lateral malleolus fracture: This is the most common type of ankle fracture. They are located medially or laterally with equal frequency and occasionally through both.35 Lateral talar dome fractures are almost always associated with trauma, while medial talar dome lesions can be traumatic or atraumatic in origin. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. 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