[MUSIC] [MUSIC] For purposes of repetition, this slide shows the anatomy of the ankle. The upper ankle contributes to the ability to move in dorsal extension 15 and in plantar flexion of 40°. The lower ankle contributes to movement of pronation of 15° and 35° with regard to supination. The ankle is stabilised by a seriesof ligamentary structures. These serve to ensure medial and lateral joint stability as well as of the joint groove. The anterior talofibular ligament is to be found lateral, as are the calcaneofibular ligament and also the posterior talofibular ligament. The deltoid ligament is positioned medial. The syndesmosis is also to be found. Ankle injuries are the most frequently occurring fractures in the lower limbs. 15% of patients with trauma caused by twisting of the ankle suffer from an osseous injury at the same time. Among these, 60 to 70% are unimalleolar fractures, 15 - 20 bi- and 7 to 12 trimalleor fractures. [NOISE] Dr. Neumaier, a holiday maker from North Germany has just presented who twisted her ankle whilst walking on Mount Wendelstein. >> How old is she...? >> She has already left? How people always run away. [BREAKE] Hello. You must be Mrs Vogt. >> Good day, Doctor. >> You must be Mrs Vogt. >> Yes, precisely. We are from North Germany. My husband and I are here on holiday We came because of the mountains and wanted to go hiking. >> So what have you been up to? >> Well, we travelled up >> onto Mount Wendelstein by cable car and then I twisted my ankle really badly up there on a concrete slab, even though I was wearing hiking boots. I could not stand on the ankle any more. I felt such pain in my leg. My husband managed to drag me back to the cable car somehow or other and then we came straight back down here. >> You presented straight away. You could not stand on the ankle at all anymore? >> No. Not at all. Absolutely not, no. >> Do you still recall exactly how you twisted your ankle, whether inwards or outwards or what exactly happened? >> It turned inwards. >> Mhm, Mhm. [BREAK] The most frequent accident mechanism is trauma caused by twisting of the ankle. If supination/adduction movement occurs, then Weber A fractures occur, Weber B in cases of supination and external rotation, with these also occurring pronation and abduction. If pronation and external rotation occur, then Weber C fractures can be suffered and in cases of pronation and eversion, Maisonneuve fractures. What is frequently involved is a combination of fractures with ligamentary and chondral damage being incurred. [NOISE] [BREAK] This slide shows the effect the corresponding accident mechanism has in the corresponding injuries. With maximum pronation, corresponding fibular or tibial fractures occur. In contrast, avulsion fractures of the fibula and the tibia occur with supination movements. OK, then we first need to look closely at the place where it hurts >> Yes. >> Where does it hurt? >> Yes, here. >> Where does it hurt most of all? >> Yes, here most of all. >> Outside therefore. >> Mhm. >> It can be seen how swollen it is here. Can we take off the left shoe... >> Yes. >> so as to make a comparison to see where it is swollen and how strongly? Was it at the beginning of your holiday or, hopefully, towards the end? >> No, unfortunately, we have only just begun our holiday. >> Oh dear. What bad luck. >> Yes, it is annoying. >> OK. The sock. >> [NOISE] Well, you can already see how, in comparison, this is considerably thicker here than is the right one. >> Yes. >> Hmm. So it mainly hurts on the outside? >> Yes. Mainly here in this area, Mainly here. Mainly here, yes. >> Mhm. Is there any pain up here, >> Yes. >> does anything up here still hurt,... Yes, that does hurt. >> Does that also hurt? >> The pain then radiates out downwards. >> Aha, ok. You can still move your toes OK? >> Yes, I can manage to do it, but everything hurts when I do. Yes. >> Can you feel anything? >> Yes. >> Ok. And what is it like here now? >> Ow, oh, that hurts. >> We now need to check the pulses quickly. Is that OK? >> Ow, the pain then pulls down there. Yes, that does hurt a bit. >>The pain is there and here again, it is also there. Aha. OK and here on the outside, there is swelling there. >> Ouch! >> Yes, it is already markedly swollen and bulging. >> Yes. >> Well, I do rather tend to the view it is broken. >> Oh really? Oh, Good Heavens. >> First of all, though, we need to take an x-ray image. >> OK. >> This will enable us to see,... ...what exactly is going on there,... >> Mhm >> whether it is broken... ... or ... >> Yes. >> ... there is a muscle rupture. >> Yes, precisely. >> Otherwise - is your husband waiting outside? >> Yes, he is still waiting outside. >> OK, then we’ll let him know what the position is. It will now take at least half an hour until we have obtained an x-ray image and well then see each other again here. >> Yes. >> I’ll then be able to show you more precisely,... ... or we will know, where the problem really is. >> Yes, good. Thank you. >> See you later. >> See you later. >> Until afterwards and then we’ll meet up again later. >> Yes, thank you. [NOISE] [NOISE] [BREAK] The history preceding ankle injuries is of great importance. Ask your patients about the precise injury mechanism of the pro- or supination. After this, inspection takes place for any haematoma or swelling as well as examination of the ankle for tenderness to pressure, perfusion, motoricity and peripheral sensitivity. The peroneal nerve is of particular importance in this regard. The clinical examination of the ankle provides for an anterior drawer test in bilateral comparison. Within this, instabilities in the anterior talofibular ligament can be identified. The ability to fold out laterally, likewise in bilateral comparison, is to be examined when examining the external ligaments. [BREAK] The stability of the syndesmosis can be examined by means of the Cross Leg Test, as shown here, or the external rotation test according to Frick. During this, a passive rotation of the foot is carried out for the purpose of triggering pain with a restricted lower leg. After every trauma caused by twisting of the ankle, any fracture must be excluded by means of radiological diagnostic investigation. This provides for imaging in two planes. The indication from this is derived from the Ottawa Ankle Rule, meaning the posterior edge of the tibia or fibula exhibits tenderness to pressure in their distal sections. If the patient can walk less than four steps, an x-ray diagnostic investigation should likewise be conducted. Any fracture of the proximal fibula must likewise be excluded. [BREAK] [NOISE] [BREAK] Ankle fractures are classified according to AO. This is an exception, as usually in AO classifications the diaphyseal bones are divided into three parts and the second number is used to designate the distal metaphysis. In the case of ankle fractures, however,it has been recognised that the combination between fibular and tibial injuries represents an exception and a special number is used for this. Ankle fractures are accordingly classified with the number 44. 44 Type A fractures are sub-divided into A1 unifocal, A2 bifocal and A3 circumference. B fractures involve fractures above the syndesmosis and are divided into B1 isolated lateral, B2 lateral and medial as well as B3 lateral, medial and posterior. With C fractures, the fracture line lies above the syndesmosis. Within this, C1 is used to designate simple diaphyseal fractures, C2 multi-fragmentary and C3 supplementary proximal fractures. [NOISE] The Weber classification scheme is very wide-spread and likewise refers to the syndesmosis as a reference point. Weber A fractures are fractures beneath the syndesmosis, Weber B fractures are fractures at the level of the syndesmosis and Weber C fractures those above the syndesmosis. This makes it clear that the syndesmosis assumes a really crucial significance when it comes to stabilising the ankle. [BREAKE] [NOISE] A special form is represented by the Maisonneuve fracture. On the one hand, this consists of a subcapital fibula fracture or an avulsion of the fibular collateral ligament at the knee. The interosseous membrane and the syndesmosis also have to be ruptured. Furthermore, a fracture of the medial malleolus or a concomitant rupture of the deltoid ligament is also involved. These images show on the left side a conventional x-ray image following a Maisonneuve fracture and on the right side the tomography image corresponding thereto. What can be clearly recognised are the high fibula fracture and also the osseous ligamentary avulsion injuries on the ankle. The fractures of the medial and lateral malleolus are designated as bimalleolar fractures. If an additional fracture of the distal tibia occurs due to the tension exerted by the posterior syndesmosis, then reference is made to a Volkmann triangle or trimalleolar fracture. >> Ah, Mrs Vogt. The news unfortunately is that it is broken. >> Really? >> You can see for yourself. Here the fracture is broken in several places. What is referred to as a Weber C fracture. And that is precisely the place which hurts so much, here externally. And it also hurts internally. It is also broken there. >> Oh, Good Heavens. >> And with fractures, Weber C type fractures, it is... always the syndesmosis, the fibrous joint between >> the shinbone and the fibula... which is torn and for this reason it is an unstable fracture. That means we unfortunately have to operate on it. >> Oh dear, and how will the operation be carried out? >> The fracture can be fixated with the use of screws and plates. I can show you something to help explain this. Just wait a moment. I think I have got some here. >> We would use a plate like this >> a one third tubular plate. This has to be used to stabilise the fracture, using screws, and for the fibrous joint down here a setting screw is needed, which would be a screw like this one, for example, which is inserted here – and which fixes the fibula and shinbone in place – otherwise, they would wobble about. And we would also treat the... medial malleolus with screws. >> Mhmm, yes. >> Overall, therefore, an operation probably lasting 1 to 1 1/2 hours to restore the cleft so that it is stable and can heal. >> Yes. >> After excluding any osseous injury, non-operative treatment of an ankle injury can be administered. This should be conducted in accordance with the PRICE Scheme, standing for Protection, (physical) Rest, Ice (cooling), Compression (elastic wrapping) and Elevation. Pain peaks can be reduced by means of non-steroidal anti-inflammatory drugs (NSAID). Non-dislocated Weber A fractures without any involvement of the syndesmosis can be treated non-operatively. Non-operative treatment consists of immobilisation for six weeks by means of, for example, Vacoped or lower leg plaster cast, non-weight bearing on crutches as well as thrombosis prophylaxis. The indication for surgical treatment stems from the degree of instability, for example in the case of dislocated fractures with a terraced joint exceeding 2 mm or Weber B and C fractures with the involvement of the syndesmosis. If dislocation fractures or any additional injuries of the soft tissue are present, the ankle can initially be fixed by means of a fixateur externe. The standard form of treatment with surgery is by carrying this out with the use of screws and plate osteosynthesis. These images show on the left side a conventional x-ray image following a trimalleolar ankle fracture and on the right side the corresponding tomography images. It can be clearly seen how the talus deviates to dorsal as an expression of instability. This injury has to be stabilised by means of fixateur externe in order to reduce the swelling in the soft tissue. These x-ray images show the postoperative condition following temporary fixation by means of fixateur externe. The stabilised situation of the joint can be clearly recognised. The standard surgical treatment for fibula fractures is administered by means of compression screws and neutralisation plates. If the syndesmosis is affected at the same time, then this is stabilised by means of setting screws. These x-ray images show the postoperative images made after surgical treatment of an ankle fracture. The lateral position of the neutralisation plate and of the compression screw can be seen clearly. Injuries to the syndesmosis are stabilised by means of setting screws. Here is the postoperative x-ray image of such an injury with a setting screw in place. >> Yes, and what will then happen after the operation? When will I be able to walk again, or will I then need crutches? >> Well, to begin with, you must not place any weight on it, that is to say for six to eight weeks. >> Oh dear, so long. The setting screw will then be removed again after six weeks and we can then really start with developing weight-bearing again. In overall terms, we are talking about eight weeks with plaster cast and crutches being used. >> Such bad luck, and how. >> Yes, it is a long time. Until everything has fully healed again, it will take four to six weeks until... you will be able to go hiking again. Do you have any further questions? >> No. >> The fact is, >> there is no alternative to conducting an operation. >> Yes. >> And now comes the question: You are from the far North of Germany, Do you want us to conduct the operation here or would you prefer to travel home with a plaster cast in place? >> No, I would prefer you to do it here. I am therefore prepared to stay here now. >> That is much more sensible. The swelling and pain mean... that transport would... really not be so pleasant. But you will still spend three or four days with us after the operation. That means you will probably spend a week here. >> Yes and that means my holiday is over. >> Yes, I am afraid so. >> My husband can now see the sights of Munich in his own. >> Yes, Munich is a beautiful city. >> Yes, it will be for him, but not for me. >> He will need to look after you. But for now, I’ll check on a room for you, a nice one and we then need to tell your husband what the situation is. >> Yes, he is waiting outside. If you could tell him. Indeed. >> Ok. Okay. You can keep the image, as a souvenir. OK, then we’ll meet up again later. >> Thank you, doctor. >> Until later, Mrs Vogt. [NOISE] >> Following surgical treatment, ankle fractures should be treated as follows: Non-weight bearing on crutches for six weeks, partial weight-bearing from the sixth week onwards and full weight-bearing from the eighth week onwards at the earliest. If a setting screw has been implanted, then it should be removed after six weeks and weight-bearing be increased for the patient thereafter. If the setting screw is still in situ, the patient must not be subjected to any weight-bearing at all, as otherwise the screw will break. [MUSIC]
