Elevation: Lie down and keep your ankle elevated above . Many of these injuries, if left without a definitive diagnosis, result in long-term disability (Table 1). 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. Feel a stretch in the back of your calf. Difficult with standard views; an oblique ankle radiograph taken with the foot placed in 40 degrees of external rotation has been successful. 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. Frontal. Avulsion fractures can occur on any part of the body, but they are most common in the ankles, hips, and elbows. X-ray. Pre and Postop Pics of ORIF Fibula Fracture with Deltoid Rupture, Pre and Post-op X-rays status post ORIF Lateral Malleolar Fracture (Below), Pre and Postop X-rays of Lateral Malleolar Fracture, Seriesof 15 y/o Displaced Fibular Fracture with syndesmosis and deltoid rupture, Note displacement of fracture and increase space at medial ankle, Intraop, stress of the ankle reveals even more widening of ankle joint (RED ARROWS). [1] [2] It can occur at numerous sites in the . 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). 8,9 Small nondisplaced avulsion fractures of the tip of the lateral malleolus (Figure 13-4) are best treated with early mobilization similar to . However, repeated radiographs may be necessary because initial films may appear normal. 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. One of the first stages in this injury is rupture of the anterior tibiofibular ligament (or anterior syndesmosis). Elevation: Elevation is important to keep swelling restricted. Etiology. Fractures of the anterior process account for approximately 15 percent of all calcaneal fractures and are commonly misdiagnosed as ankle sprains. Some patients do well with weightbearing protected immobilization in a cast boot. Fractures of the talar dome are generally the result of inversion injuries of the ankle. Lateral lesions are best visualized on a mortise view and are generally thin and wafer-shaped.1,4 (Figure 4). Although fractures of the talus were vary rarely encountered in the Ottawa ankle trials, the fractures discussed in this article would likely be identified using the Ottawa ankle rules, because of the inability of the patient to bear weight after the injury and during the examination. These fractures can often be managed nonsurgically with nonweight-bearing status and a short leg cast worn for approximately four weeks. Most common ankle fractures. April 21 - Visit ER. 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. Case study, Radiopaedia.org (Accessed on 11 Dec 2022) https://doi.org/10.53347/rID-21949. 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). Displaced filbular fracture with ankle dislocation. Check for errors and try again. By rejecting non-essential cookies, Reddit may still use certain cookies to ensure the proper functionality of our platform. 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. This means that one or more of the bones that make up the ankle joint are broken. An avulsion fracture, also known as a sprain fracture, is a detachment of bone fragment that occurs when a ligament, tendon or joint capsule pulls away from its point of attachment. In acute injuries, this rough irregular surface may help distinguish a fracture from a normal os trigonum, which generally has a smooth, rounded cortical surface.15 In chronic cases, these differences may be less distinct, making the distinction between a fracture and a normal os trigonum difficult. Treatment of an avulsion fracture typically includes resting and icing the affected area. Syndesmosis or medial malleolar injury not evident in this patient. External rotation injury of the ankle is the most common ankle injury and can lead to a Weber B or Weber C fracture. Skinner H. Current Diagnosis & Treatment in Orthopedics, Fourth Edition. 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. DANIEL B. JUDD, M.D., AND DAVID H. KIM, M.D. These types of fractures can be very disabling. (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. Delays in treatment can result in long-term disability and surgery. There are two theories regarding the origin of os subfibulare 2: An avulsion fracture attributable to pull of the anterior talofibular ligament. Usually, 4-8 weeks nonweightbearing followed by protected weightbearing with a cast. Frontal. Ankle avulsion fracture opinions needed. Percutaneous FIxation of Displaced Fibula Fracture in Diabetic Patient, South Florida Institute of Sports Medicine Fibula Fracture ORIF with Syndesmotic and Deltoid Rupture. 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). When part of this bone fractures, the ankle can become unstable. 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. Then, you can gradually progress to putting weight on the ankle again. Most ankle injuries are straightforward ligamentous injuries. This young boy allegedly twisted his left ankle 3 days ago. This can be seen as the two "buttons" on the right side of the xrays on the tibia. Unable to process the form. She was noncompliant with her immediate postoperative weight-bearing instructions and went on to fixation failure. Ankle Fractures - Pediatric. Bruising may develop later and the athlete will most likely have difficulty moving the . Alignment has been maintained. OVERVIEW: Lateral malleolar fractures are fractures that occur in the distal aspect of the fibula. Lateral. 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. A plate and screws is placed on the fibula after reduction and 2 Arthrex Tightrope is placed across the syndesmosistomaintain reduction. Put a towel/bandage around your foot and pull it towards you. A common spot for avulsion fractures is at the lateral malleolus or outside ankle bone. Fractures of the talar dome may be medial or lateral, and they are usually the result of inversion injuries, although medial injuries may be atraumatic. This content is owned by the AAFP. [1] Fractures of the foot are less common. However, the clinical presentation of some subtle fractures can be similar to that of routine ankle sprains, and they are commonly misdiagnosed as such. 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). Alignment has been maintained. An avulsion fracture is where a fragment of bone is pulled away at the ligamentous or tendinous attachment. Usually, 4-8 weeks nonweightbearing followed by protected weightbearing with a cast. You can use Radiopaedia cases in a variety of ways to help you learn and teach. report an incidence of up to 174 cases per 100 000 persons per year in a Finish population. Isolated nondisplaced lateral malleolar fractures have a low risk of complications and have good clinical results regardless of treatment. 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. The x-ray image below is that of a non-displaced lateral malleolar fracture that will heal well without surgery (RED ARROW). 2. Anterior process fractures result . and our 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. He said I would be "good to go" in 4-6 weeks. All Rights Reserved. Often a fracture of the lateral malleolus occurs in combination with a sprained ankle or other fractures of the foot, ankle or lower leg (such as following trauma). 84th Avenue, Suite 102, Plantation FL, 33324, (954) 430-9901 - Pembroke Pines-Silver Lakes, Foot, Ankle, & Leg Specialists Insurance Accepted, ACUTE AND CHRONIC CARE OF MUSCULOSKELETAL INJURIES JOINT SURGERY, SOFT TISSUE INJURIES (TENDON, LIGAMENT, MUSCLE). Appropriate radiographs are essential to the diagnosis of these fractures but, in the work-up of an ankle injury, radiographs are not always required. With an avulsion fracture, an injury to the bone occurs near where the bone attaches to a tendon or ligament. 220 S.W. The patient must be either immobolized and kept non-weightbearing in a cast depending on various factors including age of patient and pain level. The pain is often reproduced with plantar flexion and occasionally accentuated with dorsiflexion of the great toe. 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. 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. This is caused by compression of the fracture fragment as the flexor hallucis longus tendon passes between the medial and lateral tubercle.15, Careful physical examination and correlation with radiographic findings may be necessary to differentiate a fracture of the lateral tubercle, a fracture of a fused os trigonum, a tear in the fibrous attachment of the ostrigonum to the lateral tubercle, or a normal os trigonum.2,6,19, A lateral radiograph of the foot usually best visualizes the lateral tubercle and, if present, the os trigonum.6,9 When evaluating the fracture line, a rough, irregular cortical surface suggests the presence of an acute fracture (Figure 6). 6, 21, 23, 24. McGraw-Hill Medical. A fracture is a break or crack in a bone that often results from an injury. In the acute setting, the symptoms of a talar dome fracture are similar to and often occur with an ankle sprain.3,5, In lateral talar dome lesions, tenderness is generally found anterior to the lateral malle-oli, along the anterior lateral border of the talus.3,6 In medial talar dome lesions, tenderness is usually located posterior to the medial malleolus, along the posterior medial border of the talar dome.3,6 Chronic talar dome lesionstraumatic and atraumatic osteo-chondritis dissecans lesionsmay have a clinical presentation similar to that of arthritis. Secondary changes in the subchondral bone (visible on plain radiographs) caused by a compression fracture of the articular osteochondral surface may take weeks to appear.2,4 In addition, small chondral fragments are radiolucent and not evident on standard radiographs. This is consistent with an avulsion fracture involving the superior peroneal retinaculum. Hold both stretches for up to 30 seconds and repeat 3 times. CONSERVATIVE CARE: If non-displaced and stable,these fractures can be treated non-operatively with cast immobilization. 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. This condition is known as a lateral malleolus fracture. Incidental note of os subfibulare and os trigonum. Non-surgical and surgical options exist to treat medial malleolus fractures, but the choice often comes down to the extent of the fracture. Treatment of Lateral Malleolus Fractures. Go get aircast, use crutches (NWB) and follow up with family Dr in 2 weeks. He c/o pain and swelling over his left ankle. Typical findings include crepitance, stiffness, and recurrent swelling with activity.5. 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. Symptoms of an ankle avulsion fracture are very similar to an ankle sprain. Inversion plantar flexion can cause avulsion fractures of the anterior process. LATERAL MALLEOLAR FRACTURES. Point tenderness over the lateral process (anterior and inferior to the lateral malleolus), Mortise view; lateral view may show subtalar effusion, Small fragment with <2 mm Displacement: NWBSLC for four to six weeks, Posterior talar Process (lateral tubercle), Tenderness to deep palpation anterior to the Achilles tendon over posterolateral talus, Lateral radiograph (an accessory ossicle, the os trigonum, may be present), Minimally displaced fracture: NWBSLC for four to six weeks, Posterior talar process (medial tubercle), Tenderness to deep palpation between the medial malleolus and the Achilles tendon. Multiple loose bodies are seen just below medial malleolus. An unfused accessory ossification center. 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. Ankle Fractures are very common fractures in the pediatric population that are usually caused by direct trauma or a twisting injury. Copyright 2022 American Academy of Family Physicians. When treatment is delayed, patients tend to have a more complex clinical course. Then a Cam Walker and physical therapy is initiated. X-ray showed a small loose body at the tip of lateral malleolus. Studies have shown a fibular fracture displaced by 1 mm can decrease the contact area of the ankle joint by 42%. 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). This step optimizes the chance for a full recovery and decreases the incidence of post-traumatic arthritis and associated morbidities. 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. 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). Bimalleolar ankle fracture: This second-most common type involves breaks of both the lateral malleolus and of the . 65 year old man, had a fall 2 weeks ago. It is very difficult to tell the difference without an X-ray or MRI scan. 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. Anyone can suffer an avulsion fracture of the ankle, but athletes and children are more prone to them than the rest of us. Spondylosis Spondylolysis Spondylolisthesis. Tells me it is a small undisplaced fracture of lateral malleolus. 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. C/o pain left ankle since then. 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). 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. A fractured ankle can range from: A simple break in one bone, which may not stop you from walking, to. If symptoms persist, an additional four to six weeks of immobilization would be recommended.6 If the fracture site continues to be symptomatic after six months, fragment excision is usually curative.6,9 Larger and more displaced fractures may require open reduction internal fixation.6,16. The fracture may then be diagnosed and treated soon enough after the injury to avoid an adverse prognosis. 2 weeks later follow up with family Dr. She tells me to have to x-rayed again . Some recent reports79,12 implicate snowboarding accidents in these fractures. The findings are consistent with isolated lateral malleolar fracture. When a medial malleolus fracture occurs by itself . In Fracture Management for Primary Care (Third Edition), 2012. These are avulsion fractures of the medial ankle ligaments. See permissionsforcopyrightquestions and/or permission requests. Posterior process fractures can occur at either or both tubercles.1418 Lateral and medial tubercle fractures are discussed separately. 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). 1600 Town Center Blvd, Weston FL, 33326 (954) 389-5900 Diagnosis is made with plain radiographs of the ankle. Less frequently it leads to an avulsion of the anterolateral tibial epiphysis. Six to eight weeks of nonweightbearing cast followed by Cam Walker and physical therapy. CONSERVATIVE CARE: If non-displaced and stable, these fractures can be treated non-operatively with cast immobilization. Several fractures, which may require surgery. 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. 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. 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. It can be caused by traumatic traction (repetitive long-term or a single high impact traumatic traction) of the ligament or tendon. As the bone breaks, the part of the bone that is attached to the tendon or ligament pulls away from the rest of the bone. First, you need to focus on resting and getting the swelling to go down. Can it cause issues like abrasion to surrounding areas? Annotated image. A broken ankle is also known as an 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. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. Preop and Postop Fibula Fracture ORIF with Syndesmotic Rupture. This guy twisted his ankle. Incidental note of os subfibulare and os trigonum. 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. There are two parts involved in the treatment of a stable lateral malleolus fracture. 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. SURGICAL CARE: If unstable, and/or displaced, these fractures need to be brought to the OR to have open reduction and internal fixation (ORIF). This is consistent with an avulsion fracture involving the superior peroneal retinaculum. 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. Diagnosis of talar dome lesions can often be made with standard anteroposterior (AP), lateral, and mortise ankle radiographs. At first, the patient may think they have sprained their ankle with symptoms of immediate pain and swelling. The symptoms of a medial malleolus fracture are fairly predictable: Pain on the inner side of the ankle, swelling and bruising, and difficulty walking. This article features subtle fractures to facilitate timely diagnosis and treatment of these less-common injuries. Ankle injuries are commonly evaluated by primary care and emergency physicians. 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. Fractures of the ankle joint are common amongst adults. 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). For more information, please see our 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. A CT scan may be required to further characterize the fracture pattern and for surgical planning. 1. From 33 to 41 percent of these fractures are missed on initial presentation.811 Traditionally, the causative injuries are falls, motor vehicle crashes, or direct trauma. Isolated Nondisplaced Lateral Malleolar Fractures. Dr. has x-ray completed. Case 1 - Avulsion Fracture of the Superior Peroneal Retinaculum. Stress placed on the bone by a tendon or ligament causes the fracture. Foot/ ankle and lower leg bone and ligaments terminology Lateral malleolus-distal end of fibula that forms the lateral ankle bone. 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. Lateral malleolus fracture: This is the most common type of ankle fracture. Cookie Notice 84th Avenue, Suite 102 Plantation, FL 33324, 17842 NW 2nd St., Pembroke Pines, FL 33029, 220 S.W. 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. Fracture was repaired with plate and screws with a syndesomotic screw. 17842 NW 2nd St., Pembroke Pines, FL 33029 (954) 430-9901 X-ray. Introduction:Traumatic rupture of posterior tibialis tendon in association with medial malleolus fracture is extremely rare.Case Presentation:We demonstrate our experience in the management of a co. OVERVIEW: Lateral malleolar fractures are fractures that occur in the distal aspect of the fibula. Syndesmosis or medial malleolar injury not evident in this patient. 3. (2006) ISBN:0071438335. 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. -Should this be surgically re-attached? However, intra-articular fractures require special attention to ensure that the articular surface is restored to anatomic congruity and that the correct mechanical alignment is maintained. The other two are the lateral and the posterior malleolus. This page will discuss ankle and foot fractures and the role that physiotherapists play in the rehabilitation of such injuries. Copyright 2002 by the American Academy of Family Physicians. Most avulsion fractures heal very well without surgical intervention. The button on the right of the bone is what holds the strong suture like material connected between the 2 bones. Kannus et al. Soft tissue swelling over the lateral malleolus. 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. 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. ADVERTISEMENT: Supporters see fewer/no ads. They can be distal, at or proximal to the joint line of the ankle. The Ottawa ankle rules (Figure 1025 ) offer the physician clinical guidance as to which injuries require radiographs. When the . 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 . 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. 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. 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. Frontal. Most of these injuries do not pose a diagnostic dilemma and can be managed nonsurgically without a prolonged or costly work-up. Inversion with plantar flexion can lead to an avulsion fracture. The fractures discussed here can be serious injuries and cause prolonged disability. However, the clinical presentation of subtle fractures can be similar to that of ankle sprains, and these fractures are frequently missed on initial examination. A lateral malleolus fracture is relatively common among the elderly, but can also occur in the younger patient. 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. April 20 rolled ankle. AP view: deep, cup-shaped lesion; initial radiograph can be normal because changes in subchondral bone may not develop for weeks. 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. -If I were to have surgery, is there a time window that I should have it done post accident to guarantee it heals correctly. Ankle views showed grossly swollen soft tissue over lateral malleolus. They can be distal, at or proximal to the joint line of the ankle. Thecircleshows the increased clear space which is abnormal and exemplifies a syndesmosis tear. Privacy Policy. Lateral process fractures are the second most common talar fractures. Now, the ankle joint is anatomic and symmetrical. This is indicative of calcaneo-fibular ligament tear. 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. Avulsion fractures are breaks or splits in the bone. -If it doesn't get re-attached, what happens to the floating bone fragment? Reddit and its partners use cookies and similar technologies to provide you with a better experience. A fracture can be caused by a fall, a blow to the . However, as with all guidelines, clinical judgment and experience may be grounds for radiographic analysis in unique cases. Computed tomographic scans or magnetic resonance imaging may be required because these fractures are difficult to detect on plain films. Treatment of a stable lateral malleolus fracture need to include efforts to minimize swelling following by a gradual development in weight-bearing. Treatment options fragment excision range from arthroscopy with or without subchondral bone drilling to open reduction internal fixation.4,5. Soft tissue swelling over the lateral malleolus. 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. Ice application: Apply ice to help reduce pain and swelling. Ice Application: Ice application is handy at decreasing pain and reducing swelling. Although the etiology in atraumatic lesions is unclear, osteochondral fragments can separate from the surrounding cartilage surface and dissect into the joint space. There is a small loose body (arrow) indicating an avulsion injury. 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 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. In general, extra-articular fractures of the talus and calcaneus can be managed with nonsurgical treatment. Info: I've been told that the bone is likely to not re-attach itself naturally due to the distance, but . 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. Usually, a plate and screws is utilized. It is a break of the lateral malleolus, the knobby bump on the outside of the ankle (in the lower portion of the fibula). The lateral malleolus is at the end of the fibula, a smaller bone in the leg. This young boy allegedly twisted his left ankle 3 days ago. This occurs as tendons can bear more load than the bone. Lateral. Overall, optimal results are achieved with early diagnosis and treatment of these fractures. Prospective studies have validated the effectiveness of these guidelines and shown the rules to be 100 percent sensitive for clinically significant fractures.25,26. The medial malleolus is the largest of the three bone segments that form your ankle. The x-rays below demonstrate a lateral malleolar fracture that is displaced and has shortening which requires surgical repair (left). X-ray showed a small loose body at the tip of lateral malleolus. He c/o pain and swelling over his left ankle. {"url":"/signup-modal-props.json?lang=us\u0026email="}, Benoudina S, Lateral malleolar fracture. Lateral talar process fractures are characterized by point tenderness over the lateral process. 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