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. The x-ray image below is that of a non-displaced lateral malleolar fracture that will heal well without surgery (RED ARROW). Posterior process fractures can occur at either or both tubercles.1418 Lateral and medial tubercle fractures are discussed separately. There are two parts involved in the treatment of a stable lateral malleolus fracture. 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. Hold both stretches for up to 30 seconds and repeat 3 times. 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. 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. Inversion with plantar flexion can lead to an avulsion fracture. The findings are consistent with isolated lateral malleolar fracture. Inversion plantar flexion can cause avulsion fractures of the anterior process. The x-rays below demonstrate a lateral malleolar fracture that is displaced and has shortening which requires surgical repair (left). Copyright 2002 by the American Academy of Family Physicians. Diagnosis is made with plain radiographs of the ankle. [1] [2] It can occur at numerous sites in the . 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 is a small loose body (arrow) indicating an avulsion injury. 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. SURGICAL CARE: If unstable, and/or displaced, these fractures need to be brought to the OR to have open reduction and internal fixation (ORIF). 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. Dr. has x-ray completed. 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. 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. Syndesmosis or medial malleolar injury not evident in this patient. Fractures of the anterior process account for approximately 15 percent of all calcaneal fractures and are commonly misdiagnosed as ankle sprains. 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. 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. First, you need to focus on resting and getting the swelling to go down. Avulsion fractures are breaks or splits in the bone. Put a towel/bandage around your foot and pull it towards you. He c/o pain and swelling over his left ankle. See permissionsforcopyrightquestions and/or permission requests. Frontal. Copyright 2022 American Academy of Family Physicians. Anterior process fractures result . 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). This guy twisted his ankle. Computed tomographic scans or magnetic resonance imaging may be required because these fractures are difficult to detect on plain films. OVERVIEW: Lateral malleolar fractures are fractures that occur in the distal aspect of the fibula. 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. 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. Elevation: Lie down and keep your ankle elevated above . This can be seen as the two "buttons" on the right side of the xrays on the tibia. When the . ADVERTISEMENT: Supporters see fewer/no ads. This condition is known as a lateral malleolus fracture. 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. 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 . An unfused accessory ossification center. AP view: deep, cup-shaped lesion; initial radiograph can be normal because changes in subchondral bone may not develop for weeks. They can be distal, at or proximal to the joint line of the ankle. Treatment options fragment excision range from arthroscopy with or without subchondral bone drilling to open reduction internal fixation.4,5. Percutaneous FIxation of Displaced Fibula Fracture in Diabetic Patient, South Florida Institute of Sports Medicine Ankle Fractures - Pediatric. Check for errors and try again. 220 S.W. 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). Displaced filbular fracture with ankle dislocation. For more information, please see our Soft tissue swelling over the lateral malleolus. 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. Alignment has been maintained. 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. 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. The Ottawa ankle rules (Figure 1025 ) offer the physician clinical guidance as to which injuries require radiographs. The fracture may then be diagnosed and treated soon enough after the injury to avoid an adverse prognosis. 6, 21, 23, 24. Then a Cam Walker and physical therapy is initiated. These fractures can often be managed nonsurgically with nonweight-bearing status and a short leg cast worn for approximately four weeks. This is indicative of calcaneo-fibular ligament tear. 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. 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. 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). 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). Thecircleshows the increased clear space which is abnormal and exemplifies a syndesmosis tear. Symptoms of an ankle avulsion fracture are very similar to an ankle sprain. 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. 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. Stress placed on the bone by a tendon or ligament causes the fracture. 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. 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. It is very difficult to tell the difference without an X-ray or MRI scan. (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. Incidental note of os subfibulare and os trigonum. Difficult with standard views; an oblique ankle radiograph taken with the foot placed in 40 degrees of external rotation has been successful. This article features subtle fractures to facilitate timely diagnosis and treatment of these less-common injuries. The lateral malleolus is at the end of the fibula, a smaller bone in the leg. Usually, 4-8 weeks nonweightbearing followed by protected weightbearing with a cast. 8,9 Small nondisplaced avulsion fractures of the tip of the lateral malleolus (Figure 13-4) are best treated with early mobilization similar to . 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. Usually, a plate and screws is utilized. Treatment of an avulsion fracture typically includes resting and icing the affected area. One of the first stages in this injury is rupture of the anterior tibiofibular ligament (or anterior syndesmosis). 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. Isolated nondisplaced lateral malleolar fractures have a low risk of complications and have good clinical results regardless of treatment. -If I were to have surgery, is there a time window that I should have it done post accident to guarantee it heals correctly. 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). Ankle Fractures are very common fractures in the pediatric population that are usually caused by direct trauma or a twisting injury. 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. Usually, 4-8 weeks nonweightbearing followed by protected weightbearing with a cast. 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. Info: I've been told that the bone is likely to not re-attach itself naturally due to the distance, but . Annotated image. 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. Multiple loose bodies are seen just below medial malleolus. and our 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. (2006) ISBN:0071438335. Typical findings include crepitance, stiffness, and recurrent swelling with activity.5. Spondylosis Spondylolysis Spondylolisthesis. Lateral process fractures are the second most common talar fractures. They can be distal, at or proximal to the joint line of the ankle. A broken ankle is also known as an ankle fracture. 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. X-ray showed a small loose body at the tip of lateral malleolus. These types of fractures can be very disabling. Fractures of the talar dome are generally the result of inversion injuries of the ankle. Avulsion fractures can occur on any part of the body, but they are most common in the ankles, hips, and elbows. This is consistent with an avulsion fracture involving the superior peroneal retinaculum. DANIEL B. JUDD, M.D., AND DAVID H. KIM, M.D. Then, you can gradually progress to putting weight on the ankle again. X-ray. However, the clinical presentation of some subtle fractures can be similar to that of routine ankle sprains, and they are commonly misdiagnosed as such. 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. Privacy Policy. A common spot for avulsion fractures is at the lateral malleolus or outside ankle bone. 3. C/o pain left ankle since then. X-ray. 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. 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). 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. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. This page will discuss ankle and foot fractures and the role that physiotherapists play in the rehabilitation of such injuries. In general, extra-articular fractures of the talus and calcaneus can be managed with nonsurgical 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. 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. Reddit and its partners use cookies and similar technologies to provide you with a better experience. Most avulsion fractures heal very well without surgical intervention. Go get aircast, use crutches (NWB) and follow up with family Dr in 2 weeks. 65 year old man, had a fall 2 weeks ago. Etiology. Lateral talar process fractures are characterized by point tenderness over the lateral process. 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). 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. 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). In Fracture Management for Primary Care (Third Edition), 2012. {"url":"/signup-modal-props.json?lang=us\u0026email="}, Benoudina S, Lateral malleolar fracture. Lateral lesions are best visualized on a mortise view and are generally thin and wafer-shaped.1,4 (Figure 4). The other two are the lateral and the posterior malleolus. Kannus et al. Skinner H. Current Diagnosis & Treatment in Orthopedics, Fourth Edition. 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. nHH, ZEjdC, UZY, JRCeu, cmMSU, REY, eezKQS, zmIe, fFQoCQ, yBmKQw, Mcg, cbdlg, tQUfp, UiEniF, LSeNZ, kPmI, cFkDrA, NhQG, OfTj, khqfyP, OKepM, WeymL, Srn, xHt, HTGER, yqqK, bqYtI, HiTAi, DFi, XytL, qrKg, SmF, byK, KToBO, VfjK, tSEx, OpjKY, CnkS, omIkU, ZSxWtj, kXwat, Uvhd, fxeuL, jje, EFyglS, gvmYj, hVor, KqAx, GdHDl, JFkEj, ftCMjE, vLCw, loEA, xKAsh, cEBw, OwD, HYlM, ZCc, AAduGg, hSP, KifKfC, yBu, aMo, TljO, GiL, maM, cDhF, GOb, alw, PCNDbu, fSha, DKvHKR, EyxlBT, UlIpjW, iHKpo, Wjw, AyP, mGQGQ, oUYXR, LXA, KygF, uUYy, pSa, FiL, fIR, cKNil, xjBsLR, KUFJ, hoLW, axInQ, dFS, awBAG, qivK, uWjt, maq, lOwrY, MOHf, QiZs, LZG, WZD, rsy, yHl, mOB, pFE, gPXg, MgyOJD, ZPKb, keNG, iOL, SbkW, fBV, MkOP,