Kembara Xtra - Medicine - Ankle Fractures

Kembara Xtra - Medicine - Ankle Fractures 
ESSENTIAL DESCRIPTIONS 
Tibia, fibula, and talus are  ankle bones. Tibial plafond, medial and lateral malleoli, and syndesmotic, lateral, and medial collateral (deltoid) ligaments are ligaments of the ankle region.

DESCRIPTION Although they don't always predict fracture stability, two popular classification systems aid in the description of fractures.
Based on the level of the fibular fracture in reference to the ankle joint, the Danis-Weber system is used. Type A (30%): lower than the ankle joint; often stable
Type B (63%): Ankle joint level; may be steady or unstable Type C (7%): located above the ankle joint; typically unstable
Based on foot position and the direction of applied force in relation to the tibia, Lauge-Hansen (LH) (SA) Supination Adduction
The most frequent fracture type (40–75% of fractures) is supination-external rotation (SER). Pronation-external rotation (PER) and pronation-abduction (PA)

Classification based on stability - Stable
 Isolated nondisplaced medial malleolar fractures - Unstable Isolated lateral malleolar fractures (Weber A/B) without talar movement and with negative stress test
Bi- or trimalleolar fractures, high fibular fractures (Weber C), lateral malleolar fractures with medial injury and a favorable stress test, lateral malleolar fractures with talar shift/tilt (bimalleolar equivalent), and displaced medial malleolar fractures are among the fractures that might occur.
Pilon fracture: unstable axial loading-induced tibial plafond fracture 
Maisonneuve: increased risk of peroneal nerve damage and fracture of the proximal third of the fibula in conjunction with an unstable ankle fracture. Child Safety Considerations

Because ligaments are stronger than physis, ankle fractures occur more frequently in youngsters than sprains do in adults.
Talar dome: an osteochondral fracture of the talar dome is suspected in a youngster with an ankle "sprain" that does not heal or with repeated effusions. 
Tillaux fracture: a single Salter-Harris III fracture with involvement of the growth plate in the distal tibia; Triplane fracture: a Salter-Harris IV fracture with fracture lines orientated in various planes: variations in 2, 3, and 4 parts 

EPIDEMIOLOGY Ankle fractures account for 5% of fractures in children and 9% of fractures in adults.
Peak incidence: females aged 45 to 64; males aged 8 to 15 (average age 46).
107 to 184 incidents per 100,000 people annually


PATHOPHYSIOLOGY AND ETIOLOGY
Injuries from falls (38%), inversions (32%), and sports (10%) are the most frequent.
Plantar flexion, which makes the joint less stable. 
Axial loading: pilon fracture or tibial plafond

RISK FACTORS include age, history of falls, fractures, polypharmacy, drunkenness, obesity, sedentary lifestyles, sports, and physical activity, as well as history of diabetes or smoking and alcohol use and slick surfaces.

GENERAL PREVENTION Slip-resistant, flat, protective shoes Senior fall prevention

CONDITIONS OFTEN Associated with
The majority of ankle fractures are isolated wounds, however 5% of cases also have concomitant fractures, typically in the opposite lower limb.
Sprains caused by cartilage or ligament damage 
Subtalar or ankle dislocation
Other axial loading or shearing injuries, such as contralateral pelvic fractures or spinal compression

The precise mechanism of the injury is a crucial historical component in the diagnosis history. 
Assess for safety and fall risk (particularly in the elderly). Weight-bearing status following injury. History of ankle injury or surgery.

MEDICAL ANALYSIS
Check the integrity of the skin (closed versus open fracture).

 Determine the point of greatest sensitivity.
Analyze your neurovascular condition and weight-bearing capacity.
Take connected injuries into account.
To evaluate ankle stability, do the squeeze test and external rotation stress test on the tibiofibular syndesmosis, the talar tilt test for the lateral and medial ligaments, and the anterior drawer test for the anterior talofibular ligament (ATFL).

Ankle sprain; other fractures include talus, 5th metatarsal, and calcaneus; DIFFERENTIAL DIAGNOSIS

DETECTION & INTERPRETATION OF DIAGNOSIS
Plain radiographs are the primary line of treatment for suspected fractures according to the Ottawa Rules.
OAR: Ottawa Ankle Rules When used within the first 48 hours after trauma, adults' overall sensitivity of 98% rises to 99.6% (1)[A].
OAR: obtain films in patients between the ages of 18 and 55 if they exhibit any of the following symptoms: - Tenderness at the navicular or 5th metatarsal; - Tenderness at the posterior edge of the distal 6 cm of the tibia or tip of the medial malleolus; - Tenderness at the posterior edge of the distal 6 cm of the fibula or tip of the lateral malleolus; - Inability to bear

Get repeat x-rays if the initial one is normal but the severe symptoms last for more than 48 to 72 hours.
OAR sensitivity in children older than one year old is 98.5%.
OAR is not valid for individuals who are drunk, have multiple injuries, or have sensory deficiencies (neuropathy). 
Three common viewpoints
Anteroposterior (AP) - Lateral: Incongruity between the talar dome and distal tibia implies instability.
- Mortise (15 to 25 degree internal rotation view): Mortise should be symmetrical and there should be about 4 millimeters between the medial malleolus and talus.
- A second stress view might reveal instability (for instance, a larger medial clean area with manual outward rotation).
Child Safety Considerations

Stress views are unneeded in children and may result in physeal injury. Salter-Harris V is frequently overlooked and discovered when leg length disparity or angular deformity follows Salter-Harris I; it is rare, accounting for 1% of fractures. 

Tests in the Future & Special Considerations
MRI is not routinely indicated and does not improve sensitivity for detecting complex ankle fractures; however, it is useful for chronic instability, osteochondral lesions, occult fractures, and unexpected stiffness in children. CT is advised for surgical planning in trimalleolar, Tillaux, triplane, pilon, or fractures with intraarticular involvement. 

Other/Diagnostic Procedures
Bone scan or MRI for stress fractures Ultrasound for soft tissue damage brought on by displaced fractures


GENERAL TREATMENT MEASURES

Immobilize in a short-term cast or splint and guard with crutches or other non-weight-bearing devices.
- If there isn't an open or irreducible fracture, one to two weeks to allow for decreasing swelling 
Compression stockings have no value for swelling; instead, it is better to elevate and ice the affected extremity to relieve pain from swelling.
Closed ankle fractures: stability must be determined; stable = nonoperative
- Surgery is unsteady
- Surgery is required for talus lateral shifts of less than 2 mm or for malleolus displacements of 2 to 3 mm.- There is inadequate data to determine whether nonoperative treatment or surgery yields better long-term results in adults with displaced fractures.

Nonoperative for stable syndesmosis damage 
Immediate reduction for fracture dislocations - If there is a deformity or neurovascular impairment, imaging should be done right away.
Flex your hips and knees 90 degrees to make reduction easier.
- Postreduction x-rays and a neurovascular examination


First Line: MEDICATION
NSAIDs and/or acetaminophen for pain. Initial intramuscular pain injection (i.e., ketorolac, 60 mg or 30 mg q6h, max 120 mg daily; children 2 to 16 years old, 50 kg, or age of 65 years: 1 mg/kg, 30 mg, or 15 mg q6h, max 60 mg daily). For suspected open fractures: tetanus booster, broad-spectrum cephalosporin
Second-line opioid analgesics as a complementary treatment

QUESTIONS FOR REFERENCE

Consultation for compartment syndrome, tenting of the skin or open fractures, misplaced or unstable fractures, and neurovascular impairment 
All further fractures: Keep off the weight and follow up within a week. If you feel uncomfortable managing common fractures, consult an orthopedic specialist.

Nonoperative = cast immobilization - No difference in type of immobilization (Air-Stirrup, cast, orthosis) - Initially non-weight-bearing with crutches and then progress to 50% with crutches; full weight-bearing after 6 weeks post-injury - If removable cast, gentle range of motion exercises at 4 weeks - Open ankle fractures (2%) - Remove gross debris/contamination in ED.
- There is debate over the ideal time frame for antibiotic therapy. - Surgery is urgent; it is essential to have it done immediately.

SURGICAL AND OTHER PROCEDURE
Open reduction and internal fixation (ORIF), which is preferable in athletes and unstable fractures, is one surgical alternative. In cases of severe tissue damage or comminuted fractures, external fixation may be chosen; nonetheless, it may cause more malunion than ORIF and have similar wound problems. 
Surgery should be performed as soon as possible if there is neurovascular compromise, an open fracture, a failed reduction, or tissue necrosis. If not, surgery should be postponed for at least five days since inflammation can interfere with wound healing.
Recovery typically takes 6 to 8 weeks.


Child Safety Considerations
Salter-Harris I and II are not surgical Long leg cast for 4 to 6 weeks, followed by a short leg cast for 2 to 3 weeks, for the distal tibia (5)[C]
- Distal fibula: posterior splint or ankle brace for three to four weeks while bearing weight; if displacement occurs, short leg cast for six to eight weeks while not carrying weight (5)[C]
Limit reduction attempts to prevent damage to the growth plate (5,6)[C].
- Reduction not advised if presenting less than one week after injury (5)[C]
Intra-articular displacement of less than 2 mm in a youngster with more than 2 years of growth left = ORIF 
3. and 4. Salter-Harris:
- Distal tibia: ORIF (6) if >2 mm displacement[C]
- Rare, generally stable following tibial reduction: distal fibula (6)
[C]
Tillaux and triplane: ORIF if shifted by less than 2 mm

Aspects of Geriatrics
Age-related/comorbidity-related increased surgical risk Osteoporosis increases the chance of implant/fixation failure (4) [A].
 Problems with wound healing, pulmonary embolism, death, amputation, and reoperation are among the risks of surgery and anesthesia.

CONSIDERATIONS FOR ADMISSION, THE INPATIENT, AND NURSING

Admit the patient if they need emergency surgery, are disobedient, lack social support, are unable to maintain their non-weight-bearing position, or have serious concomitant injuries. - With regards to the mechanism of the damage (such as syncope, myocardial infarction, or head injury). 
Nursing: non-weight-bearing; maintenance of splint/cast; application of ice; maintenance of leg elevated; pain management; assistance with ADLs.
Standards for discharge:
- Uses a walker or crutches to go around.
- Medical workup is finished, if necessary. - Orthopedic follow-up is scheduled.

CONTINUING CARE AFTERCARE RECOMMENDATIONS
patient observation
Orthopedic follow-up: repeated x-rays - Sclerotic lines on x-rays (Parker-Harris growth arrest lines) in youngsters are an indication of a growth abnormality.
Immobilize for 4 to 6 weeks, and then gradually introduce weight-bearing exercise while wearing a detachable splint or boot.

Stretching, manual therapy, and exercise programs had the same results as physical therapy referrals.

If surgery is being considered, DIET NPO

PATIENT EDUCATION – Ice and elevate for two to three weeks; use a cane or crutches as directed; take care of a splint or cast (avoid getting it wet, etc.). 
Report any changes in pain, paresthesias, edema, or the color of the extremity to your doctor.


PROGNOSIS - The majority of patients return to activities in 3 to 4 months and achieve good results without surgery if the fracture is stable.
Most athletes resume their pre-injury levels of activity.
Ageing is connected with deteriorating mobility after fracture, not the severity of the injury.

COMPLICATIONS Include dislocated fractures or instability; delayed, improper, or non-union unions (0.9-1.9%); and postoperative wound issues such loss of fixation, further surgery, or amputation. Complex regional pain syndrome, extensor retinaculum syndrome in children, deep vein thrombosis, and so on. Osteomyelitis, an infection; post-traumatic arthritis; degenerative joint disease; child growth stop.