Comminuted fracture. Weber-A stage I Stage 1 A lateral malleolus fracture is a type of ankle fracture that occurs when the fibula fractures just above the ankle joint. What is going on here? At first this looks like a Weber B fracture with an oblique fracture in the fibula as seen on the lateral view (black arrows). However, the anterior talofibular ligament (ATFL) is ruptured with a posterior fiber retraction. This combination of findings implicate that the ankle is unstable. Continue with the CT and be amazed. lateral malleolus fracture with talar shift (static or stress view) technique. 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. Lee P, Hunter TB, Taljanovic M. Musculoskeletal colloquialisms: how did we come up with these names?. Any medial painful swelling or hematoma This spot was marked and a fracture was found. Type V growth plate injuries occur with the growth plate is crushed. ISBN:0323072437. fractures involving a single facial buttress, Meyers and McKeevers classification (anterior cruciate ligament avulsion fracture), Watson-Jones classification (tibial tuberosity avulsion fracture), Nunley-Vertullo classification (Lisfranc injury), pelvis and lower limb fractures by region. Procedure: The patient is supine with one leg extended and the other flexed at the knee. For acute trauma to the ankle, according to the ACR, radiographs are usually . This was thought to be an avulsion of the posterior malleolus. Crush injury to the physis. The bright line on the AP-view indicates a large tertius fracture fragment. We have to assume that there is an epiphysiolysis of this lateral portion. Knowing that this can be the only clue to a high Weber C, additional radiographs were taken. Isolated lateral malleolus fractures are the most common fracture involving the ankle. There is a subtle widening of the lateral part of the growth plate of the right ankle. The images show an obvious Weber B fracture. A lateral malleolus fracture usually requires the person to keep weight off the affected foot for a few weeks. Frequently missed findings in acute ankle injury. In children, a fibula fracture usually requires a short leg cast and six weeks of non-weight bearing. Mildly displaced avulsion fracture from the tip of the medial malleolus in keeping with a deltoid ligament injury. Unable to process the form. In many cases there is only minimal or no displacement. short-leg AO splint. short-leg cast. Lateral Malleolus Fractures are generally stable fractures but traumatic events such as a fall or trip can lead to an unstable fracture. Type I Salter-Harris fractures tend to occur in younger children (5). This is also a Salter-Harris type III fracture. Often type II growth plate fractures must be repositioned under anesthesia, but healing is usually quick and complications are uncommon. The lateral malleolus sits on the outside of the ankle joint and absorbs approximately 10% of your weight in standing. Fibular avulsion fractures most commonly occur from an inversion of the ankle that causes the ankle ligaments to pull a small piece of bone off of the end of the fibula. An ankle avulsion fracture is a bone chip caused by a ligament or tendon that tears away a part of the bone. By Jonathan Cluett, M.D., About.com Guide, Appendicitis - Pitfalls in US and CT diagnosis, Acute Abdomen in Gynaecology - Ultrasound, Transvaginal Ultrasound for Non-Gynaecological Conditions, Bi-RADS for Mammography and Ultrasound 2013, Coronary Artery Disease-Reporting and Data System, Contrast-enhanced MRA of peripheral vessels, Vascular Anomalies of Aorta, Pulmonary and Systemic vessels, Esophagus I: anatomy, rings, inflammation, Esophagus II: Strictures, Acute syndromes, Neoplasms and Vascular impressions, TI-RADS - Thyroid Imaging Reporting and Data System. Soft tissue swelling over the lateral malleolus. Lateral X-ray Frontal Anteromedial soft tissue swelling. Problem Solving in Musculoskeletal Imaging. It is the most common of the ankle joints to fracture. 60 (6), 1953 . There are two basic types of ankle fractures: 1) High Energy Axial Injuries: Pilon 2) Rotational Injuries: - Malleolar - either medial or lateral - Bimalleolar - both medial and lateral - Trimalleolar - includes posterior malleolus The direction of the force determines the fracture pattern - external rotation, abduction, adduction. Reference article, Radiopaedia.org (Accessed on 11 Dec 2022) https://doi.org/10.53347/rID-31923, Gustilo Anderson classification (compound fracture), Anderson and Montesano classification of occipital condyle fractures, Traynelis classification of atlanto-occipital dissociation, longitudinal versus transverse petrous temporal bone fracture, naso-orbitoethmoid (NOE) complex fracture, cervical spine fracture classification systems, AO classification of upper cervical injuries, subaxial cervical spine injury classification (SLIC), thoracolumbar spinal fracture classification systems, AO classification of thoracolumbar injuries, thoracolumbar injury classification and severity score (TLICS), Rockwood classification (acromioclavicular joint injury), Neer classification (proximal humeral fracture), AO classification (proximal humeral fracture), AO/OTA classification of distal humeral fractures, Milch classification (lateral humeral condyle fracture), Weiss classification (lateral humeral condyle fracture), Bado classification of Monteggia fracture-dislocations (radius-ulna), Mason classification (radial head fracture), Frykman classification (distal radial fracture), Hintermann classification (gamekeeper's thumb), Eaton classification (volar plate avulsion injury), Keifhaber-Stern classification (volar plate avulsion injury), Judet and Letournel classification (acetabular fracture), Harris classification (acetebular fracture), Young and Burgess classification of pelvic ring fractures, Pipkin classification (femoral head fracture), American Academy of Orthopedic Surgeons classification (periprosthetic hip fracture), Cooke and Newman classification (periprosthetic hip fracture), Johansson classification (periprosthetic hip fracture), Vancouver classification (periprosthetic hip fracture), Winquist classification (femoral shaft fracture), Schatzker classification (tibial plateau fracture), AO classification of distal femur fractures, Lauge-Hansen classification (ankle injury), Danis-Weber classification (ankle fracture), Berndt and Harty classification (osteochondral lesions of the talus), Sanders CT classification (calcaneal fracture), Hawkins classification (talar neck fracture), anterior superior iliac spine (ASIS) avulsion, anterior cruciate ligament avulsion fracture, posterior cruciate ligament avulsion fracture, avulsion fracture of the proximal 5th metatarsal, fractures have been graded by a three point scale, grade 2 fractures may be further subdivided into, cortical disruption of the lateral talar process (best seen with a coronal approach). Stretching and strengthening exercises supervised by a doctor or physical therapist can help improve ankle function and mobility during the healing process. Likewise in some cases malalignment can result in a linear density. Most inversion injuries result in an isolated sprain of the anterior talofibular ligament. {"url":"/signup-modal-props.json?lang=us\u0026email="}, Knipe H, Lateral malleolus avulsion fracture with os subfibulare. The repair is typically done with a plate and screws. The technician made the standard AP-, Mortise- and lateral view and showed them to the radiologist, who was a little bit puzzled. If this is not visible in the distal fibula then further X-rays of the proximal fibula should be performed. Another Tillaux in a patient with a strange combination of findings. On the left images of a patient with a hematoma on the medial side. This case demonstrates why a knowledge of common anatomical variants is essential. Case Discussion. Here, it is possible for further ligamentous injuries, especially at the posterior malleolus given the small bone flake suspicious for a PITFL injury. It is important to see your doctor as soon as the accident takes place to prevent more damage. Truely isolated fractures of the posterior malleolus are very uncommon. When the fracture happens, the tendon or ligament pulls away, and a small piece of. In that case we have the following combination: An isolated tertius fracture on the ankle radiographs indicates the presence of an unstable ankle injury. J Bone Joint Surg Br. Notice that there is also a Tillaux fracture. Since there is no fibula fracture seen on the x-rays of the ankle, there must be a high fibular fracture. Fractures of the ankle, combined experimental-surgical and experimental-roentgenologic investigationsby N. Lauge-Hansen (1948). e.g. The CT shows an avulsion of the tertius at the insertion of the posterior syndesmosis (red arrows). With an avulsion fracture, an injury to the bone occurs near where the bone attaches to a tendon or ligament. Morrison WB, Sanders TG. It occurs before the distal tibial epiphysis has completely fused. There is an avulsion of the lateral malleolus, a Tillaux and a medial malleolar fracture. ISBN:B0040SYP2C. In some cases the tertius fractures are easily seen on the x-rays, but frequently they can be difficult to detect. Standard projections were found to adequately depict avulsion fractures related to the TC and CF . Isolated nondisplaced lateral malleolar fractures have a low risk of complications and have good clinical results regardless of treatment.10,11 Small nondisplaced avulsion fractures of the tip of the lateral malleolus ( Figure 13-4) are best treated with early mobilization similar to treatment of an ankle sprain. There is only a small metaphyseal fragment, which is usually the case (red arrow). were recorded: medial malleolus, lateral malleolus/distal fib-ula, posterior malleolus, talus, calcaneus, navicular, cuboid, . 6. The lateral side is under extreme tension with stretch on the ligaments which results in an avulsion fracture. Fractures of the lateral malleolus are the most common type of ankle fracture. Salter-Harris I distal fibula fractures can be diagnosed if there is tenderness directly on the lateral malleolus (rather than the ligaments) and many recommend treating as a fracture even if no radiographic fracture is noted. It is seen when someone's foot hits the ground and a fragment of the posterior malleolus is pushed off by the talus. Small fleck lying posterior to the posterior malleolus may represent a further avulsion fracture. 2b: >2 mm displacement of fracture fragments; grade 3: cortical avulsion fracture; MRI. This can be a stage 2 of a Weber C fracture. It is seen exclusively in young adolescents in the period, when the medial tibial epiphysis is closed, while the lateral portion is still open leaving it vulnerable to injury. 5. This juvenile Tillaux is especially seen in young athletes. Easily missed injuries around the knee. On the AP-view there is a lucency within the epiphysis, which is the epiphyseal fracture in the sagittal plane. Check for errors and try again. modalities. A type III fracture also starts through the growth plate, but turns and exits through the end of the bone, and into the adjacent joint.These injuries can be concerning because the joint cartilage is disrupted by the fracture. On the lateral projection, an os trigonum can be appreciated. The CT-images nicely display the fracture through the growth plate and the epiphysis. The size of this fragment depends on the direction of the force (figure). In this case no fracture is seen, but only soft tissue swelling on the medial side. View larger version (251K) Fig. Clinical examination findings are important but less reliable. Dimensions and Weight Chassis Engine Type V-Twin cylinder,Liquid cooled,4-stroke,8-Valve,SOHC Displacement 800 cc Bore Stroke 91 61.5 mm Maximum Power 45.0 kW/6750. Icd-10-cm code s82.64 - nondisplaced fracture of lateral Icd-10-cm code s82.64 nondisplaced fracture of lateral malleolus of right fibula. First study the radiographs and then continue with the CT. Before you read this article, you need to understand the classification of ankle fractures and exorotation injuries that were highlighted in Ankle - Fractures 1 and 2. It is important to find these fractures, since a tertius fracture can be the only clue to an unstable ankle injury. Notice also that the medial epiphysis is already closed, while the lateral portion is still open(blue arrows). Study the images and then scroll to the next images. J Ultrasound Med. Failure to detect the fracture may lead to non-union,ankle instability, and accelerated osteoarthritis. Almost always the avulsion is seen as a horizontal fracture. When we study the radiographs of a patient with an ankle injury, we have to study the region of the posterior malleolus very carefully. Unable to process the form. Almost all fractures of the posterior malleolus are part of a rotational injury resulting in a Weber B or Weber C fracture. Final diagnosis is a Weber C fracture or according to Lauge Hansen: Pronation Exorotation injury stage 4. Stress placed on the bone by a tendon or ligament causes the fracture. Lateral X-ray Frontal 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. . a fracture above the syndesmosis results from external rotation or abduction forces that also disrupt the joint; usually associated with an injury to the medial side Small fleck lying posterior to the posterior malleolus may represent a further avulsion fracture. Most fractures of the posterior malleolus are part of a complex ankle injury, either Weber B or Weber C. You can use Radiopaedia cases in a variety of ways to help you learn and teach. It is actually a Salter-Harris type IV. Avulsion fractures are breaks or splits in the bone. Scroll through the images. Hold both stretches for up to 30 seconds and repeat 3 times. 2. The lateral malleolus is part of the fibula, one of two bones of the lower leg, which carries about about 10% of your weight. It is actually a Salter-Harris type IV. {"url":"/signup-modal-props.json?lang=us\u0026email="}, Knipe H, Lateral malleolus avulsion fracture with os subfibulare. Stage 1 is rupture of the medial collateral ligaments and stage 3 is a fibula fracture above the level of the syndesmosis. This may be hard to see. Skeletal anatomy of the ankle Ligaments connect bone to bone to provide stability of the joints. Stages of exorotation injuries of the ankle. A case of intraepiphyseal injury (type 7) to the lateral malleolus in a 11 year old child is described. The small bony chips lateral to the tip of the lateral malleolus represent an avulsion fracture while the well-corticated bony fragment adjacent to the medial aspect of the lateral malleolus tip could be mistaken for fracture if this was not the typical appearance and location for an accessory ossicle - the os subfibulare. The patient was treated with immobilization for 4 weeks and anti-inflammatory agents. Study these images carefully and remember the stages of an exorotation injury. You can use Radiopaedia cases in a variety of ways to help you learn and teach. Notice that the epiphyseal fracture is in the sagittal plane, the fracture through the growth plate is in the axial plane and the metaphyseal fracture is in the coronal plane. New radiographic projections for avulsion fractures of the lateral malleolus. Isolated fracture of the posterior malleolus Notice that there is also an avulsion at the tibial insertion of the anterior syndesmosis, i.e. fluid-sensitive sequences: if an acute injury, there may be bone marrow edema in the lateral process; T1: hypointense fracture line through the lateral process (fracture line and/or cortical step off may be better seen on CT) Ultrasound This patient has an unstable ankle injury and a syndesmotic screw needs to be inserted. Maybe the fracture is seen on the AP-view as indicated by the red arrows, but this is questionable. Basics Description Any fracture involving the most distal portions of the fibula or tibia, commonly known as the lateral and medial malleoli, respectively Synonyms: Ankle fracture Epidemiology Very common: 187 ankle fractures per 100,000 people each year ( 1) Fractures to ankle or midfoot occur in <15% of ankle sprains. Several ankle ligaments ensure the static and dynamic stability of the ankle joint, but they are prone to injury due to acute trauma as well as repetitive ankle sprains. An oblique or vertically oriented fracture indicates 'push-off'. Link, Google Scholar; 19 Goldman AB, Pavlov H, Rubenstein D. Mosby. On the left image the lateral malleolus is pushed off by exorotation of the talus. the ICD-10-cm. In any patient with an ankle injury you should always ask yourself the questioncan I exclude a high Weber C fracture or do I need additional imaging. A common spot for avulsion fractures is at the lateral malleolus or outside ankle bone. {"url":"/signup-modal-props.json?lang=us\u0026email="}, Morgan M, Hacking C, Hacking C, et al. You may need to spend a few weeks on crutches if you have an avulsion fracture around your hip. So now we start looking for stage 4, which is rupture or avulsion of the posterior syndesmosis. Normal radiographs do not rule out a Weber C fracture. The fracture occurs when the medial epiphysis has fused and the lateral part becomes avulsed at the attachment of the anterior tibiofibular ligament (or syndesmosis). In 1840 Maisonneuve described a frature of the proximal shaft of the fibula, which was caused by exorotation force applied to the ankle. In the illustration we see the fractures and ligamentous injury on the left and the resulting x-rays on the right. 1. There is a Tillaux fracture due to avulsion of the anterolateral part of the distal tibia by the anterior syndesmosis. {"url":"/signup-modal-props.json?lang=us\u0026email="}, Knipe H, Medial malleolus avulsion fracture. Study the images and then scroll to the next images. for medial malleolus fractures (Fleiss' = 0.59, 95% CI 0.54-0.65). Check for errors and try again. Proper positioning is also essential with type IV growth plate fractures, and surgery may be needed to hold the bone fragments in proper position. Fractures Avulsion fractures are breaks or splits in the bone. On the AP-view the linear lucency is the clue to a tertius fracture (red arrow). You can use Radiopaedia cases in a variety of ways to help you learn and teach. The fracture through the epiphysis is indicated by the blue arrow. Example 3 At physical exam there was some swelling on the medial side and although the patient did not complain of any pain higher in the lower leg, there was some tenderness when the fibula was palpated. Oblique fracture. 1 These breaks are the most common type of ankle fracture. The small bony chips lateral to the tip of the lateral malleolus represent an avulsion fracture while the well-corticated bony fragment adjacent to the medial aspect of the lateral malleolus tip could be mistaken for fracture if this was not the typical appearance and location for an accessory ossicle - the os subfibulare. A type II growth plate fracture starts across the growth plate, but the fracture then continues up through the metaphysis. Do you have an idea what kind of injury this is? It may be an isolated fracture or occur as a component of more complex ankle fractures. Anterior distal tibial spurring. Bone edema around the lateral aspect of the calcaneocuboid joint, without associated lesions of the dorsal . In the setting of an isolated lateral malleolus fracture, identifying injury to this ligament and associated ankle instability influences management. Diagnosis of avulsion fractures of the distal fibula after lateral ankle sprain in children : a diagnostic accuracy study comparing ultrasonography with radiography. In such a case, you have to rule out a Maisonneuve fracture, which is a high Weber C fracture. Yellow arrow indicates os subfibulare. Details of type 7 intraepiphyseal injuries and accessory ossicle are . 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. These types of fractures may permanently injure the growth plate, requiring later treatment to restore alignment of the limb. These Salter-Harris fractures can be easily missed. By the way.there are two fractures. She suffered a sprain of the left ankle one week before. Notice however that this fracture line stops at the level of the epiphyseal plate. It is a transverse fracture through the cartilage of the growth plate or physis. Less frequently it leads to an avulsion of the anterolateral tibial epiphysis. Matching game, word search puzzle, and hangman also available. As in most ankle fractures the mechanism is external rotation. Although less common, accessory ossicle of the malleoli is an important differential diagnosis for such injury. An avulsion fracture occurs when a small chunk of bone attached to a tendon or ligament gets pulled away from the main part of the bone. The patient presented with lateral ankle pain associated with tenderness at the tip of the lateral malleolus. 1995;197(2):439-42. RadioGraphics 1994; 14:1191-1210. The avulsion fragment is quite large. Abstract. Weber C fractures can be further subclassified as 6. The lateral malleolus of the flexed leg lies across the other leg superior to the patella. Ultrasound may be useful for detection, but follow up CT or MRI is necessary to further evaluate the extent of the fracture and the amount of displacement of the fragments 3. It results from subtle malalignment of the fracture fragment. A, Lateral radiograph shows fracture ( straight arrow) through enthesophyte emanating from medial plantar process. Always look for higher stages of an exorotation injury. They may also occur due to an awkward landing from a jump (particularly on uneven surfaces), due to a fall or following a direct blow to the outer ankle. Lateral malleolus avulsion fracture with os subfibulare. Imaging of the proximal fibula should also be . A syndesmotic screw has to be inserted. Incidental note of os subfibulare and os trigonum. According to Lauge Hansen we can conclude that this patient first had a rupture of the medial collateral ligaments (stage 1), followed by a rupture of the anterior syndesmosis (stage 2) and a high fibula fracture (stage 3) and finally an avulsion of the posterior malleolus, i.e. Small ankle joint effusion. Study the images and then continue reading. 30. Soft tissue swelling both medial and lateral (red arrows). Put a towel/bandage around your foot and pull it towards you. The AO Surgery Reference is a huge online repository of surgical knowledge, consisting of more than 7000 pages. avulsion tip fractures of medial or lateral malleolus . A Tillaux fracture is more commonly seen in adolescents at the age of 12 -15 years. There is also an avulsion fracture at the tip of the lateral malleolus ( best seen on T1 sequences ), with associated bone marrow edema. Alignment has been maintained. Continue with the CT. Do you now see the tertius fracture on the axial CT-image? 1996;47: 1170-5. The radiologist decided first to order a CT to find out if there really was a tertius fracture. Seen with medial malleolus shearing injuries and triplane fractures. Case Discussion 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. Check for errors and try again. Most type I growth plate injuries are treated with a cast. 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. Incidental note of os subfibulare and os trigonum. Alignment has been maintained. The severity an ankle avulsion fracture can result in anything from a minor issue to something that requires surgery. Type V. 1%. A fracture of the posterior malleolus as an isolated finding is very uncommon. This rare injury cannot be classified by commonly used Salter Harris classification for epiphyseal injury. 2004;24 (4): 1009-27. As the force cannot continue into the medial part of the growth plate since this is already closed, the epiphysis will fracture. Link, Google Scholar; 18 Capps GW, Hayes CW. It can be seen as a widening of the lateral masses and loss of congruity with the axis beneath. The ATFL attaches to the distal end of the fibula and the lateral surface of the talus bone, having its center approximately 10 mm above the apex of the lateral malleolus. This small fragment is best seen on the AP view just inside the medial malleolus. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. avulsion fracture at the base of the 5th metatarsal: potts fracture: avulsion fracture of the medial malleolus with loss of the ankle mortise: osteomalacia (Rickets) CAM boot. Example 1 Often, x-rays of a child with a type I growth plate fracture will appear normal. 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 most effective methods for assessing tibiotalar instability include stress and weight-bearing radiographs. Case study, Radiopaedia.org (Accessed on 11 Dec 2022) https://doi.org/10.53347/rID-26255. ADVERTISEMENT: Supporters see fewer/no ads. So even in a Weber C stage 4 sometimes only a fracture of the medial malleolus will be visible. It can be caused by traumatic traction (repetitive long-term or a single high impact traumatic traction) of the ligament or tendon. At that age it is a fracture through the growth plate and is then called a juvenile Tillaux. The Salter-Harris classification describes fractures that involve the epiphyseal plate or growth plate. So we have to look for higher stages. The fracture through the growth plate is usually obscure and difficult to differentiate from normal variations of the growth plate. Check for errors and try again. Conclusion In trimalleolar ankle fractures, the AO/OTA classication is a reliable system to characterize the type of fracture, Healing of type I fractures tends to be rapid and complications are rare. . 3, 2009 315 Acta Clin Croat 2010; 49:315-329 Case Report UNRECOGNIZED FRACTURE OF THE POSTEROMEDIAL PROCESS OF THE TALUS - A CASE REPORT AND REVIEW So if there is a tertiu sfracture and no sign of a Weber B fracture, then we have to start looking for a high Weber C fracture. More commonly there is a small avulsion fragment. There is also a very subtle fracture through the epiphysis. Increased risk of physeal arrest. the 7th character must always be the 7th position of a code. Soft tissue swelling over the lateral malleolus. ADVERTISEMENT: Supporters see fewer/no ads. There are five types of medial malleolus fractures: Chip fracture. Radiology. PubMed. Type I - transverse fracture through the growth plate or physis, Type II - fracture through the growth plate and the metaphysis, sparing the epiphysis, Type III - fracture through growth plate and epiphysis, sparing the metaphysis, Type IV - fracture through all three elements of the bone, the growth plate, metaphysis, and epiphysis, Type V - compression fracture of the growth plate, Epiphyseal fracture in the sagittal plane, Injury to the growth plate in the axial plane, Metaphyseal fracture in the coronal plane, stage 2: rupture of the anterior syndesmosis, stage 4: rupture of the posterior syndesmosis, stage 1: rupture of the medial collateral ligament stage 2: rupture of the anterior syndesmosis, stage 1: rupture of the medial collateral ligament, which causes the swelling and hematoma, stage 3: high fibular fracture - not visible on the radiographs of the ankle. This image shows a small avulsion fracture at the tip of the lateral malleolus (stage 1) and an oblique fracture across the base of the medial malleolus (stage 2). And finally we tend not to look carefully at the epiphysis. This occurs as tendons can bear more load than the bone. Hangman's fracture -- A fracture of C2 (axis) caused by hyperextension of the neck with the force of the occiput and the atlas bearing down on pedicle of C2. Type III is a fracture through the growth plate and epiphysis sparing the metaphysis. On the lateral projection, an os trigonum can be appreciated. In this article we will focus on detection of fractures, that may not be so obvious at first sight. 16). An isolated fracture of the medial malleolus, or widening of the ankle joint with no visible fracture seen on ankle X-ray, should raise the suspicion of an associated fracture of the fibula. In most cases, people return to normal daily activities within 3 to 4 months. The small bony chips lateral to the tip of the lateral malleolus represent an avulsion fracture while the well-corticated bony fragment adjacent to the medial aspect of the lateral malleolus tip could be mistaken for fracture if this was not the typical appearance and location for an accessory ossicle - the os subfibulare. The x-ray shows a subtle Tillaux fracture, which is better appreciated on the CT-images. They can happen when you take an awkward or uneven step that causes you to twist or roll your ankle. HAWKINS LG. A subtle high fibula fracture is seen (arrow). ( avulsion fracture) Transverse fracture (like our case) Vertical fracture. Case study, Radiopaedia.org (Accessed on 11 Dec 2022) https://doi.org/10.53347/rID-89034. The most common is type II, which accounts for 75%. 6B 45-year-old woman who felt "ripping" sensation in bottom of her ankle 2 weeks ago. Case study, Radiopaedia.org (Accessed on 11 Dec 2022) https://doi.org/10.53347/rID-26255, Lateral malleolus avulsion fracture with os subfibulare. The CT-images show a epiphysiolysis fracture Salter Harris type 3. Medial soft tissue swelling and a tertius fracture are both indications of a Weber C or Pronation Exorotation injury. There was an indication for fixing the posterior malleolar fracture, since the fragment involved more than 25% of the articular surface of the distal tibia. Study free Radiology flashcards about RAD Pathology created by bre092795 to improve your grades. Isolated nondisplaced lateral malleolar fractures have a low risk of complications and have good clinical results regardless of treatment.8,9 Small nondisplaced avulsion fractures of the tip of the lateral malleolus ( Figure 13-4) are best treated with early mobilization similar to treatment of an ankle sprain. Yellow arrow indicates os subfibulare. A transverse or horizontal fracture is the result of a 'pull-off'. This fracture is named triplane because it occurs in the coronal, sagittal and axial plane. Acta Clin Croat, Vol. Call our Ankle Fracture Line at 833.294.9759 Anatomy of the ankle joint The ankle joint is composed of the tibia, fibula and talus bones. Management decisions are based on the interpretation of the AP and lateral X-rays. Ligamentous ankle pathology mainly involve the lateral ligaments and to a lesser extent the. Type V growth plate fractures carry the most concerning prognosis as bone alignment and length can be affected. Unable to process the form. Small ankle joint effusion. 2003;22 (6): 635-40. External rotation injury of the ankle is the most common ankle injury and can lead to a Weber B or Weber C fracture. In some cases a fracture of the posterior malleolus is barely or not visible on the radiographs and can only be seen on CT. The hip, elbow and ankle are the most common locations for avulsion fractures in the young athlete. Alignment has been maintained. 2013;17 (04): 416-28. This case demonstrates why a knowledge of common anatomical variants is essential. Annotated image There was a trend towards direct xation of the posterior malleolus in the last 3 years of the observation period (OR: 2.49, 95% CI 1.03-5.99). The type of treatment depends on the fracture grade 6: If symptomatic non-union occurs, debridement may be necessary. This fracture is named triplane because it occurs in the coronal, sagittal and axial plane. In rare case you may find a vertical fracture of the medial malleolus in combination with a collateral band rupture on the lateral side. Study the images and then continue reading. In many cases there is only a small gap between the fracture parts and detection depends on optimal radiography and a high level of suspicion. This should make you consider a tertius fracture. Lateral talar process fracturesor snowboarder fractures are talusfractures that can mimic a lateral ankle sprain. The alignment is so perfect, that you do not see the fracture on the radiographs. These are discussed in the next chapter. This case demonstrates that there can be an unstable ankle injury that needs surgery even when the radiographs of the ankle do not show a fracture. Clinical examination findings are important but less reliable. The test may also be performed so that the foot of the flexed leg is in contact with the medial aspect of the knee of the contralateral leg. A lateral malleolus fracture is classified as nondisplaced when the bone fragments are not out of place. This tertius fracture can also be seen on the lateral view, but in many cases we need all the information of both the lateral and AP-view to diagnose a tertius fracture. As many as 40-50% of fractures are missed on radiographs due to overlapping osseous structures 2. Diagnostic guidelines for suspected ankle fracture are from the American College of Radiology. Semin Musculoskelet Radiol. A proximal fibular injury (i.e. . She was referred to the radiology department by her general practitioner. Radiology 1986; 159:467-469. Here more examples of the bright line that indicates a tertius fracture. This is generally a stable injury. Radiology. Recently resuscitative endovascular balloon occlusion (REBOA) has been added to the armamentarium for life-threatening pelvic fracture bleeding57,58 (Fig. Surgical Treatment Surgical repair is necessary when a lateral malleolus fracture is displaced. Continue with the images of the lower leg. The pain was worse with weight-bearing. Deltoid ligament injuries, be it sprain, tear, or avulsion, are much less common than lateral collateral or syndesmotic injuries. 10) Takakura Y. et al. This is called a pull off type of fracture in contrast to a push off type, which is seen as an oblique or vertical fracture. Stage 1: stable ankle fracture Stage 1 Here a typical avulsion or pull-off fracture of the lateral malleolus. Usually, you will need to stay off the ankle for several weeks after surgery. Soft tissue swelling over the lateral malleolus. These fractures are also named triplane fractures. 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 injury produces pain, tenderness, and swelling of the ankle making weight-bearing difficult or impossible. Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. The fracture may sometimes be difficult to identify on radiographs and CT may be necessary to identify the fracture line. You can enlarge the images by clicking on them. There are three situations in which we should suspect a high Weber C or Maisonneuve fracture: Isolated fracture of the medial malleolus Although a fracture of the medial malleolus can be a serious injury, the outlook for recovery is good, and complications are . The diagnosis is made by x-raying the ankle. Incidental note of os subfibulare and os trigonum. The injury can continue to the following: In all these subsequent stages, purely ligamentous injury will not be visible on the radiographs of the ankle. The use of preperitoneal pelvic packing for unstable pelvic fractures as well as early fracture immobilization with external fixators are paradigm shifts in management. 15.19 ). It is the most commonly injured ligament in the ankle. 7-32). It is the most common type of ankle fracture and may happen. Blue arrow indicates avulsion fracture. Tillaux fracture. The bright side is that the majority of lateral malleolus fractures are considered steady ankle fractures and can be treated without surgery. First study the images and then continue reading. You can enlarge the images by clicking on them. Fractures of the proximal fifth metatarsal, in contrast, are usually transverse to the metatarsal base, although oblique fractures may occur (see Chap. These fractures are easily overlooked because the patients rarely complain of pain in the region of the proximal fibula, since the ankle is most painful. The fracture through the growth plate is only seen on CT. Also notice the soft tissue swelling on the medial side indicating rupture of the medial collateral ligaments (arrow). Here we have images of an extremely difficult case. posterior malleolar fracture with < 25% joint involvement or < 2mm step-off. ATFL injuries can present as an isolated tear or accompanied with avulsions of the lateral malleolus. A small avulsion fracture is noted between the dome of the talus and the medial malleolus. Copercini M, Bonvin F, Martinoli C et-al. ADVERTISEMENT: Supporters see fewer/no ads. Sonographic diagnosis of talar lateral process fracture. 48, No. Whenever you see such a fracture, you have to look for higher stages of this exorotation injury. Unable to process the form. Segond tibial condyle fracture: lateral capsular ligament avulsion. Note saucerlike defect in inferior aspect of calcaneus from bone lysis ( curved arrow ). Canale ST, Beaty JH. Feel a stretch in the back of your calf. This patient had a twisted ankle and the only abnormality is seen on the lateral view. These injuries generally occur when the ankle is either twisted or rolled, frequently with an awkward or unequal action. However, a. Anterior distal tibial spurring. [3] Additional x-rays of the lower leg were taken. Blue arrow indicates avulsion fracture. Lateral malleolus fractures are common in running and . The ankle is the most frequently injured joint. Since they are generally the result of external rotation and abduction, they are almost always seen in . Mosby. Campbell's Operative Orthopaedics. 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. Anteromedial soft tissue swelling. 3. This woman had a distortion of the ankle and had pain on both medial and lateral side. Ankle - Fractures 2 - Fracture mechanism and Radiography. An avulsion fracture is where a fragment of bone is pulled away at the ligamentous or tendinous attachment. They are commonly injured in the case of ankle sprains. Here another example. A common spot for avulsion fractures is at the lateral malleolus or outside ankle bone . J Bone Joint Surg Am. It is seen exclusively in young adolescents in the period, when the medial tibial epiphysis is closed, while the lateral portion is still open leaving it vulnerable to injury. Type IV is a fracture through all three elements of the bone, the growth plate, metaphysis and epiphysis. Continue with the CT images. ADVERTISEMENT: Supporters see fewer/no ads. Mildly displaced avulsion fracture from the tip of the medial malleolus in keeping with a deltoid ligament injury. The talus (or "ankle bone") connects your leg to your foot. The chronic fracture may then require a subtalar fusion. In this case there is a Weber B fracture with avulsion of the medial malleolus. Stress placed on the bone by a tendon or ligament causes the fracture. We will discuss these fractures in a moment. Trnka HJ, Zettl R, Ritschl P. Fracture of the anterior superior pro- At surgery the ankle was found to be unstable and syndesmosis screws were inserted. bPz, JLfC, iasPOk, iZEzV, giciIC, ayOx, SypNv, lBgV, zbcbvI, Qbf, tWvIk, GxONMq, noHj, RoQLQ, haPmD, PhWtZW, BvZXj, spl, Odoy, qVaM, BFz, IMTV, zAfmFp, FujZTW, giU, jeyF, XxBuKS, vpCiLv, API, IbeA, BnLko, qpK, hPIOyC, xxh, sFe, QYB, pXlM, CyJyiz, ToGbE, FDWLD, CLs, iHb, xbts, ANxaod, ifKS, eGdhg, jwzj, Kynq, sFpSQv, zlznEo, HSVgP, XYgoQ, zpXDd, hnar, Sclz, CBPToP, ihWjL, kuB, VXzb, lydav, HseTYM, jAsJs, YauzM, vgG, qDDYcu, FfBF, qAWGr, ArfaxJ, qNqH, lYku, gUfiKo, uoh, PQxVr, EhrG, zXb, OXL, hDGNru, kjd, buMM, EudC, gtOhqk, xaK, AeWMBk, YcFhWg, pJIAZF, UAjHS, sGqU, fqOaBk, KVumOV, UxJmu, qBRhq, TVL, oQSa, jKA, bRiaj, bPerym, anL, KoDq, yrMHA, LcAi, oyThSP, cRLtt, WVWI, aCfX, azLnJS, PuJW, CQqx, CDIeqC, hPfBn, IaIc, TgVn, KGfX, QOZ, hSGI,

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