Fracture of the tibia with additional injury of the ankle joint. A frequent and undervalued combination Eine h?ufige, aber wenig beachtete Kombination

There are 2 types of a combined tibia fracture and ankle injury: in Type I the tibia fracture extends directly into the ankle joint, in Type II the tibia fracture goes along with a fracture of the fibula and disruption of the fibular-tibial syndesmosis. This type of fracture must be distinguished from a pilon tibiale fracture. The typical mechanism for this combined tibia and ankle injury is the indirect torsional trauma with pronation-eversion. From 1995 to 1997 188 patients with fractures of the tibia were treated by internal fixation in our Trauma Department. 27 of these patients (13.6 %) had a combined tibia and ankle injury. Most of the tibia fractures were located in the distal third, a spiral fracture (16 patients) or a comminuted fracture (6 patients), and another group extending directly into the ankle (5 patients). The ankle lesion was a distal fibular fracture (Weber Typ B + C) in 14 patients, a proximal fibular fracture (Type maisoneuve) in 6 patients, a postero-lateral fragment in 11 cases and a fracture of the medial melleolus in 10 cases. A disrupture of the anterior tibio-fibular syndesmosis was seen in 18 patients, 3 times as an isolated lesion of the ankle joint without fracture of the fibula. The osteosynthesis of the tibia fracture was performed with an unreamed tibia nail in 20 patients, with elastic-biologic plate fixation in 6 and with external fixation in 1 patient. The fibula fractures were stabilized by small fragment titaneum plates, the dorsolateral fragment and the medial malleolus were stabilized by lag-screws, the tibio-fibular ligament was sutured and, in a few cases only, held in place by a positioning screw. The outcome was controlled after 20,7 month according to the Phillip's Score (1996). We found not more than one pour results. It must be considered, that most of the combined injuries of the tibia and the ankle joint concerning 13,6 % of all tibia shaft fractures are usually not recognized and may result in an arthrosis of the ankle joint. The attention should be focused to the ankle joint in any spiral fractures of the distal tibia after indirect trauma, especially with a proximal fibular fracture or an intact fibula. Additional X-ray examination of the ankle joint is recommended during internal fixation of the tibia. Posttraumatic arthrosis of the ankle joint can be prevented by diagnosis and adequate anatomical reconstruction of the additional ankle joint injury.     

Tibial shaft fracture and ankle joint injury

OBJECTIVE: Detection of tibial fractures in which a concomitant ankle injury may exist. DESIGN: Prospective study. SETTING: Department of Trauma Surgery, University Hospital. PATIENTS: 43 (20.1%) of 214 patients with a tibial fracture were found to have an associated injury of the ankle joint. INTERVENTION: Analysis of all patients with tibial fractures regarding typical mechanisms of injuries and typical radiographic criteria for concomitant injuries of the ankle joint. MAIN OUTCOME MEASURES: Primary x-rays were analyzed looking for spiral fractures of the tibia or proximal fibular fractures or an intact fibula, typically associated with syndesmotic injury. The assessment of patients was based on radiological findings and functional recovery. RESULTS: 45 ankle injuries in 43 patients were found. There were distal fibular fractures in 14, Maisonneuve fractures in 13, isolated ruptures of the syndesmosis in 3, fractures of the posterior malleolus in 8, and fractures of the medial malleolus in 7 of the cases. In 38 of the 43 patients, the distal tibiofibular syndesmosis was ruptured, and 88.4% of the tibia injuries were spiral fractures located in the distal third. Of the 38 patients who could be followed, 31 were categorized according to the Phillip's Score as very good, 3 as good, 2 as satisfactory, and 2 as unsatisfactory after an average of 19.8 months (12-26). CONCLUSION: Due to the obvious injury of the tibia, the potential instability of the ankle joint is often overlooked, and the risk of development of secondary osteoarthritis is often consequently underestimated. Added attention should be paid to the ankle in the following tibial fracture cases: pronation-eversion trauma, spiral fracture of the tibia, proximal fibular fracture, or intact fibula. Using these markers, we were able to diagnose 20.1% of combined injuries compared to our retrospective study in 1999, in which only 13.6% of these injuries could be detected (Pearson r=0.1305, not significant).     

Evaluation of the syndesmotic-only fixation for Weber-C ankle fractures with syndesmotic injury

Background:

With the length of the fibula restored and the syndesmosis reduced anatomically, internal fixation using a plating device may not be necessary for supra-syndesmotic fibular fractures combined with diastasis of inferior tibio-fibular joint. A retrospective observational study was performed in patients who had this injury pattern treated with syndesmosis-only fixation.

Materials and Methods:

12 patients who had Weber type-C injury pattern were treated with syndesmosis only fixation. The treatment plan was followed only if the fibular length could be restored and if the syndesmosis could be anatomically reduced. Through a percutaneous or mini-open reduction and clamp stabilization of the syndesmosis, all but one patient had a single tricortical screw fixation across the syndesmosis. Patients were kept non-weight-bearing for 6 weeks, followed by screw removal at an average of 8 weeks. Outcomes were assessed using an objective ankle scoring system (Olerud and Molander scale) and by radiographic assessment of the ankle mortise.

Results:

At a mean follow-up of 13 months, the functional outcome score was 75. Excellent to good outcomes were noted in 83% of the patients. Ankle mortise was reduced in all cases, and all but one fibular fracture united without loss of fixation. Six patients had more than one malleolar injury, needing either screw or anchor fixations. One patient had late diastasis after removal of the syndesmotic screw and underwent revision surgery with bone grafting of the fibula. This was probably due to early screw removal, before union of the fibular fracture had occurred.

Conclusion:

We recommend syndesmosis-only fixation as an effective treatment option for a combination of syndesmosis disruption and Weber type-C lateral malleolar fractures.     

Fracture of the lower leg with involvement of the posterior malleolus; a neglected combination?

In 17 of 148 fractures of the leg (11.5 per cent) we found an isolated fracture of the posterior malleolus of the tibia as a sign of associated injury of the ankle joint. In two cases there was even disruption of the anterior syndesmosis. All fractures of the tibia were oblique and closed without severe soft tissue injury and caused by a rotational force with low energy. In fracture of the leg of this specific type a radiological examination of the ankle joint in search for a posterior malleolar fracture is needed. If present, instability of the distal tibio-fibular joint must be excluded.     

Is Fibular Fracture Displacement Consistent with Tibiotalar Displacement?

We believed open reduction with internal fixation is required for supination-external rotation ankle fractures located at the level of the distal tibiofibular syndesmosis (Lauge-Hanssen SER II and Weber B) with 2 mm or more fibular fracture displacement. The rationale for surgery for these ankle fractures is based on the notion of elevated intraarticular contact pressures with lateral displacement. To diagnose these injuries, we presumed that in patients with a fibular fracture with at least 2 mm fracture displacement, the lateral malleolus and talus have moved at least 2 mm in a lateral direction without medial displacement of the proximal fibula. We reviewed 55 adult patients treated operatively for a supination-external rotation II ankle fracture (2 mm or more fibular fracture displacement) between 1990 and 1998. On standard radiographs, distance from the tibia to the proximal fibula, distance from the tibia to the distal fibula, and displacement at the level of the fibular fracture were measured. These distances were compared preoperatively and postoperatively. We concluded tibiotalar displacement cannot be reliably assessed at the level of the fracture. Based on this and other studies, we believe there is little evidence to perform open reduction and internal fixation of supination-external rotation II ankle fractures.     

A Pilon Fracture With Fibular Head Dislocation Treated With the Use of 3D Preoperative Planning: A Case Report and Literature Review

Pilon fractures with intact fibula have been associated with low-energy trauma. However, the compression force onto the ankle joint can damage the tibiofibular linkage as in a Maisonneuve fracture. Herein, we describe a case of a patient who had a pilon fracture (AO type 43 C3.2) without a fibular fracture. Three-dimensional preoperative simulation by reduction with the surface registration technique was performed as the fibular length was intact and there was no reference for the tibial length. The preoperative simulation revealed superior fibular head dislocation and shortening of the distal tibia. After emergency external fixation on the day of arrival, a 2-staged surgery was performed. During the first operation, the fibular head was reduced and the tibial posterolateral fragment was fixed to restore the tibia length. During the second operation, medial and anterolateral fragments were fixed in order to reduce joint surface of the distal tibia. In general, proximal fibular head fractures are easily overlooked. In the case of pilon fractures with severe length shortening of the tibia without a fibular fracture, a proximal tibiofibular injury should be suspected.     

Displaced Salter-Harris Type I Distal Fibula Fractures: Two Case Reports and a Review of the Literature

Salter-Harris type I (SH-I) fractures of the distal fibula are commonly encountered in pediatric orthopedics. We describe 2 unique cases of adolescents with completely displaced SH-I distal fibula fractures that were treated operatively. In the first case, a closed reduction attempt failed and the patient required open reduction and internal fixation of the distal fibula and syndesmosis. The syndesmotic ligaments were avulsed from the distal fibular metaphysis. In the second case, closed reduction of the distal fibula fracture was partially successful, but anatomic reduction could not be achieved without open reduction. The distal fibula fracture was fixed with an intramedullary screw. We believe this pattern of injury represents a variant of the adolescent transitional ankle fracture. Because the distal tibial physes were nearing complete closure in these patients, the energy propagated through the distal fibular physis. To the best of our knowledge, this combination of injuries has not been previously reported. This type of physeal fracture raises concern for premature physeal closure, fibular growth disturbance, syndesmotic instability, and medial (deltoid ligament) injury. Both patients had excellent outcomes after anatomic reduction and fixation of the displaced SH-I distal fibula fractures at 1 and 6 years of follow up, respectively.     

Syndesmotic Stabilization in Pronation External Rotation Ankle Fractures

Boden et al. suggested syndesmosis fixation was not necessary in distal pronation external rotation (PER) ankle fractures if rigid bimalleolar fracture fixation is achieved and was not necessary with deltoid ligament injury if the fibular fracture is no higher than 4.5 cm of the tibiotalar joint. We asked whether height of the fibular fracture with or without medial stability predicted syndesmotic instability as compared with intraoperative hook testing in these fractures. We reviewed 62 patients (35 male, 27 female) with a mean age of 45.6 years (range, 19–80 years). Using a bone hook applied to the distal fibula with lateral force to the distal fibula in the coronal plane, we fluoroscopically assessed the degree of syndesmosis diastasis in all patients. The mean height of the fibular fracture in patients with a positive hook test was higher than in patients with a negative hook test (54.2 mm; standard deviation [SD], 29.3 versus 34.8 mm; SD, 21.4, respectively). The height of the fibular fracture showed a positive predictive value of 0.93 and a negative predictive value of 0.53 in predicting syndesmotic instability; specificity of the criteria of Boden et al. was high (0.96). However, sensitivity was low (0.39) using the hook test as the gold standard. The criteria of Boden et al. may be helpful in planning, but may have some limitations as a predictor of syndesmotic instability in distal PER ankle fractures.     

Inferior tibio-fibular diastasis treated by staple fixation

This paper concerns the operative treatment of the total syndesmotic rupture of the ankle fractures classified as pronation-eversion fractures, stage III and IV, according to Lauge Hansen in 1942. Stabilization of the syndesmosis by a screw between the fibula and the tibia is well known. However, the method involves a risk of inaccurate positioning of the fibula in the incisura tibiae and of injury of the syndesmosis. A method of staple fixation of the syndesmosis in combination with rigid and anatomic osteosynthesis or the fibular fracture is presented and found suitable for securing the syndesmosis during healing. The followup results, range 3 to 10 years, of 16 ankle fractures treated in this way are promising.     

螺钉固定与Tight-rope固定治疗下胫腓前联合损伤的初步有限元分析

目的 :建立下胫腓前联合损伤(anterior inferior tibiofibular syndesmosis injuries,AITSI)螺钉固定及Tightrope固定(TR)模型,比较其受力及位移情况,为临床诊治提供依据。方法 :选取1例正常人的踝关节CT图像建立3D模型。然后建立AITSI损伤模型,对损伤模型置入螺钉得到螺钉固定模型,使用Tight-rope固定得到TR模型。分析各模型单脚站立时的中立位、踝关节内旋以及外旋3种受力情况,观察胫腓骨及距骨关节面应力变化,以及胫腓骨远端位移情况。结果:AITSI导致胫腓骨及距骨关节面受力增加,胫腓骨位移增加。使用螺钉固定及TR均能有效减少AITSI导致的胫腓骨远端过度位移,但在螺钉固定模型中,胫腓骨位移明显小于正常模型,且胫腓骨远端及距骨关节面受力增大,螺钉受力集中。螺钉固定模型中的胫骨及腓骨最大受力为TR模型的1.3倍以上,距骨关节面接触力为1.8倍,螺钉固定模型中下胫腓前韧带胫骨附着点位移约为正常模型的0.6倍,而TR模型中该数据约为正常模型的1.1倍,但TR对于腓骨位移控制欠佳。结论:严重的下胫腓前联合损伤将改变踝关节受力及位移情况,应该行内固定治疗。下胫腓联合螺钉及TR都能有效地治疗下胫腓前联合分离,Tight-rope固定相较于螺钉固定在骨骼受力、踝关节微动及内固定物断裂方面具有优势,但存在腓骨旋转控制欠佳的劣势。伴有Weber C型踝关节骨折以及肥胖的患者更适合螺钉固定。     

一种特殊类型的Maisonneuve损伤的诊断和治疗

目的报道一种特殊类型的Maisonneuve损伤的诊断和治疗效果。方法回顾性分析首都医科大学附属北京朝阳医院骨科自2015年1月至2019年7月收治的4例Maisonneuve损伤患者资料。男3例,女1例;年龄34~61岁,平均45.3岁;患者均为闭合性损伤。所有患者初始X线片表现为踝关节后脱位,手法复位后复查X线及CT显示复位良好无合并踝关节骨折,故急诊漏诊,门诊复查后显示下胫腓联合分离。所有患者均采用恢复腓骨长度、固定下胫腓联合及修复三角韧带的方法治疗。术后12个月采用美国足踝外科协会(AOFAS)的踝-后足评分评价患者术后功能。结果41例患者术后获12~14个月(平均12.7个月)随访。术后骨折愈合时间为110~185 d,平均149.3 d。术后未出现相关并发症,术后12个月AOFAS的踝-后足评分为82~96分(平均90.5分);其中优3例,良1例。结论临床表现为踝关节后脱位且不伴有明显踝关节骨折的Maisonneuve损伤临床上易漏诊,对单纯踝关节后脱位的患者复位后结合体格检查需要拍摄胫腓骨全长X线片明确诊断。一旦确诊,需行手术治疗。通过修复踝关节三角韧带及稳定下胫腓联合的方法可以达到满意的疗效。     

弹性外固定器治疗合并下胫腓损伤的踝关节骨折

对于合并下胫腓损伤的踝关节骨折，需可靠的固定以确保下胫腓韧带在解剖位愈合。保守治疗比较困难，而用骨螺钉和骨栓固定下胫腓将限制下胫腓的生理活动。为此作者设计并使用下胫腓弹性外固定器治疗此类骨折，其特点是直接将作用力施加于胫腓骨下端骨皮质上，由于外固定器由不锈钢材料制成，具有一定的弹性，在恢复下胫腓稳定的同时，不影响下胫腓正常生理活动。此装置设计在承重３０ｋｇ时远端张开，随踝关节背伸及屈曲活动，外固定器远端横径距离改变２～４ｍｍ。同时，利用外固定器的其他部分可将内、外踝复位及固定。自１９８９年开始用此种方法治疗６１例患者，平均随访２年，优良率达９４％。     

Tibial lengthening: does the fibula migrate?

A retrospective study of 32 patients who underwent tibial lengthening was performed in order to establish the need for distal tibio-fibular fixation. In 16 patients stabilization of the inferior tibio-fibular joint was carried out and in the other 16 no stabilization was performed. Three established and one new radiographic index of the tibio-fibular relationship at the ankle were used to assess proximal fibular migration. All patients showed proximal migration of the distal fibula, but those without stabilization demonstrated marked migration of the fibula associated with a valgus tendency. The difference between the groups was statistically significant ( <0.001), confirming the need for fibular fixation.     

Stabilisation of the fractured fibula plays an important role in the treatment of pilon fractures: a retrospective comparison of fibular fixation methods

Ninety-eight pilon fractures associated with ipsilateral distal fibular fracture were included in this study. The pilon fractures were treated by open reduction and plating. The 98 fractures were divided into three groups based on the treatment method of fractured fibula. Group A was composed of 50 fibular fractures treated by open reduction and plate fixation. Group B was composed of 23 fibular fractures treated by open reduction and pin fixation. Group C was composed of 25 fibular fractures treated conservatively by closed reduction. The radiographs were reviewed for adequacy of fracture reduction and posttraumatic arthrosis. At the end of follow-up, the clinical outcomes were evaluated using a rating scale. The three groups were similar in respect to Ruedi type, open fracture grade, and demographics (all p values >0.25). Group A showed a decreasing trend of malunion and ankle arthrosis compared to group C (p = 0.091 and p = 0.099, respectively). Group A had a better clinical outcome than group C (p = 0.008). In addition, group A showed an increasing trend of satisfactory outcome compared to group B (p = 0.096). In conclusion, for pilon fractures associated with ipsilateral fibular fractures, stabilisation of the fractured fibula plays an important role in the decrease of distal tibial malunion and post-traumatic ankle arthrosis as well as improvement of clinical outcomes.     

Biomechanical analysis of different internal fixation methods for special Maisonneuve fracture of the ankle joint based on finite element analysis

ObjectiveThe objective of this study was to evaluate the biomechanical properties of different internal fixation methods for Maisonneuve fractures under physiological loading conditions.MethodsFinite element analysis was used to numerically analyze various fixation methods. The study focused on high fibular fractures and included six groups of internal fixation: high fibular fracture without fixation + distal tibiofibular elastic fixation (group A), high fibular fracture without fixation + distal tibiofibular strong fixation (group B), high fibular fracture with 7-hole plate internal fixation + distal tibiofibular elastic fixation (group C), high fibular fracture with 7-hole plate internal fixation + distal tibiofibular strong fixation (group D), high fibular fracture with 5-hole plate internal fixation + distal tibiofibular elastic fixation (group E), and high fibular fracture with 5-hole plate internal fixation + distal tibiofibular strong fixation (group F). The finite element method was employed to simulate and analyze the different internal fixation models for the six groups, generating overall structural displacement and Von Mises stress distribution maps during slow walking and external rotation motions.ResultsGroup A demonstrated the best ankle stability under slow walking and external rotation, with reduced tibial and fibular stress after fibular fracture fixation. Group D had the least displacement and most stability, while group A had the largest displacement and least stability. Overall, high fibular fracture fixation improved ankle stability. In slow walking, groups D and A had the least and greatest interosseous membrane stress. Comparing 5-hole plate (E/F) and 7-hole plate (C/D) fixation, no significant differences were found in ankle strength or displacement under slow walking or external rotation.ConclusionCombining internal fixation for high fibular fractures with elastic fixation of the lower tibia and fibula is optimal for orthopedic treatment. It yields superior outcomes compared to no fibular fracture fixation or strong fixation of the lower tibia and fibula, especially during slow walking and external rotation. To minimize nerve damage, a smaller plate is recommended. This study strongly advocates for the clinical use of 5-hole plate internal fixation for high fibular fractures with elastic fixation of the lower tibia and fibula (group E).     

Fibular nonunion and equinovarus deformity secondary to posterior tibial tendon incarceration in the syndesmosis: a case report after a bimalleolar fracture-dislocation.

A 39-year-old woman sustained a grade II open bimalleolar fracture-dislocation of the left ankle. Six months after an ORIF of these fractures was performed, she presented with a nonunion of the distal fibula fracture and with a fixed hindfoot equinovarus and forefoot adduction deformity. At surgery for repair of the fibular nonunion, the posterior tibial tendon (PTT) was found to be entrapped in the posterior tibiotalar joint, with a portion of the tendon interposed between the tibia and the fibula in the area of the posterior syndesmosis. After extrication of the PTT, the hindfoot varus and forefoot adduction deformity were corrected. To our knowledge, this is the first case report in the English literature of a missed PTT syndesmotic entrapment that resulted in a fibular nonunion and in a fixed foot deformity after an open bimalleolar ankle fracture dislocation.     

Maisonneuve骨折临床分析及相关实验研究

目的 探讨Ｍａｉｓｏｎｎｅｕｖｅ骨折（ＭＦＦ）创伤机制及临床治疗方法。方法 ＭＦＦ患者１９例,８例行保守治疗,１１行手术治疗,８例术前行ＭＲＩ检查;平均随访时间１６．８个月,另外取新鲜尸体大腿截肢标本进行截骨及骨间膜顺序切断实验,观察踝关节应力像表现。结果 （１）踝关节功能恢复情况;１１例手术患者中８例良好,３例可;８例保守治疗患者中３例良好,３例可,２例差;（２）ＭＲＩ检查结果,骨间膜损伤水平在     

骨折后腓骨长度的恢复与踝关节创伤性关节炎的关系

目的　探讨胫腓骨下段粉碎骨折后腓骨长度的恢复与踝关节创伤性关节炎发生的关系。方法　 1986～ 1996年间收治的胫腓骨双骨折病例中 ,有 15 0例获得随访的经过手术治疗的闭合性胫腓骨下段粉碎骨折。平均随访时间为 6年 (2～ 10年 )。15 0例中 30例在固定胫骨的同时固定腓骨 ,恢复腓骨长度 ,12 0例仅固定胫骨。术后均以石膏托固定 4～ 6周。结果　腓骨固定组术后踝关节不同程度创伤性关节炎的发生率为 6 % ,而单纯固定胫骨者 ,创伤性关节炎的发生率为 30 %。结论　踝关节创伤性炎症的发生与小腿双骨折后腓骨长度是否恢复有关 (r=0 0 0 98) ,在治疗胫腓骨下段骨折时应注意恢复腓骨的长度     

Ankle Fracture with a Complex Injury Mechanism and Misleading Hook Test Result: A Case Report

Ankle fractures and their mechanisms of injury can be complex. We report a case of a patient with an uncertain mechanism of injury and an uncommon combination of lower extremity fractures, which fit the criteria for a Lauge-Hansen classification pronation-external-rotation fracture, Maisonneuve fracture, Wagstaffe fracture, and posterior pilon fracture. Plain radiographs and computed tomography scan revealed Chaput tubercle avulsion fractures, an anterior distal fibular fracture fragment, multiple lateral malleolar fractures, a posterior malleolar fracture fragment with proximal displacement, a die-punch fragment between the posterior malleolar fragment and the tibia, a proximal fibular fracture, and possible ankle syndesmotic diastasis. Intraoperative hook test was negative after fixation of the fractures, so syndesmotic fixation was not performed. At 3-month follow-up, plain radiographs showed obvious syndesmotic diastasis. At 1-year follow-up, symptoms persisted and syndesmotic fusion was recommended but declined by the patient. This case demonstrates that both ankle fractures and their mechanisms of injury can be remarkably complex and confusing, posterior pilon fractures can occur along with pronation-external-rotation ankle fractures, syndesmotic fixation should be considered for all patients with Maisonneuve fractures, reliance on the hook test for surgical management decisions may not always be reliable, and there exists a need for a more accurate and reliable intraoperative test to determine the presence of ankle syndesmotic injury.     

腓骨内固定对胫骨愈合及踝关节稳定的作用

目的：探讨腓骨内固定的理论依据。方法：总结３０５例胫腓骨骨折双内固定的骨折愈合情况。结果：３０５例胫腓骨骨折病人除２例延迟愈合外全部愈合。本组骨折愈合率明显高于文献中记载。结论：（１）腓骨内固定后有益于胫骨内固定的稳定。（２）恢复了腓骨的解剖连续,促进踝关节的稳定。（３）提高胫腓骨双骨折病人的骨折愈合率。