Journal Reading Focus On Ankle Fracture
Journal Reading Focus On Ankle Fracture
Penguji
dr. Novita E. R, Sp. Rad
Disusun Oleh :
Setyo Sutanto 161 0221 141
Oleh :
Setyo Sutanto
161 0221 141
Penguji
1
Ankle Fractures
Ankle fractures (fraktur pergelangan kaki) dilaporkan 9% dari patah tulang, mewakili sebagian
besar beban kerja trauma: fraktur femoral proksimal adalah satu-satunya fraktur anggota badan
bagian bawah yang lebih sering terjadi. Fraktur pergelangan kaki memiliki distribusi usia
bimodal dengan puncak pada laki-laki muda dan perempuan yang lebih tua. Terdapat
peningkatan tiga kali lipat dalam kejadian di antara wanita tua selama tiga dekade terakhir.
Selain itu, di antara banyak pasien yang mengalami luka cedera kaki adalah secara prognostik:
mereka yang bertahan dengan luka mereka jauh lebih terganggu secara fungsional jika
mengalami cedera kaki di samping trauma multisistem. Tinjauan ini memberikan ringkasan
Klasifikasi
Sistem klasifikasi pertama untuk fraktur pergelangan kaki, dikembangkan oleh Percival Pott,
menggambarkan fraktur dalam hal jumlah malleoli yang terlibat, sehingga membagi luka
menjadi unimalleolar, bimalleolar dan trimalleolar. Meski mudah digunakan dengan keandalan
intraobserver yang baik, tetapi tidak membedakan antara cedera stabil dan tidak stabil.
Dua sistem klasifikasi umum lainnya untuk fraktur pergelangan kaki rotasi mencoba untuk
membantu perbedaan ini. Sistem klasifikasi Danis-Weber, ditunjukkan pada Tabel I dan
fibrosis distal berhubungan dengan syndesmosis. Sistem Lauge-Hansen (Tabel II), klasifikasi
mekanistik, menggambarkan pertama, posisi kaki pada saat cedera dan kedua, kekuatan
deformasi pada pergelangan kaki dan memberikan informasi lebih lanjut tentang stabilitas dan
2
Diagnosa
Fitur Klinis
Riwayat
• Posisi pergelangan kaki pada saat cedera dan arah gaya selanjutnya secara umum
menentukan pola fraktur, seperti yang dijelaskan oleh sistem klasifikasi Lauge Hansen.
• Pada kejadian, pasien diabetes yang menyajikan riwayat sedikit atau tidak ada trauma, harus
• Faktor lain yang terkait dalam riwayat termasuk komorbiditas medis seperti diabetes,
penyakit vaskular perifer dan merokok, yang dapat mempersulit penyembuhan luka dan
patah tulang.
• Riwayat sosial harus diambil untuk mengidentifikasi tingkat mobilitas pra-luka pasien,
situasi rumah dan kegiatan rutin serta aspirasi fungsional masa depan mereka.
3
Tabel I. Sistem Klasifikasi Danis-Weber untuk fraktur pergelangan kaki rotasi
B Fraktur dimulai pada tingkat sendi dan meluas ke proksimal dalam mode
miring. Bila disertai fraktur malleolus medial atau dengan ruptur ligamen
deltoid (berkorelasi dengan cedera rotasi supination eksternal; Gambar 2)
pergelangan kaki dianggap tidak stabil.
Tabel II. Sistem klasifikasi Lauge-Hansen untuk fraktur pergelangan kaki rotasi
Jenis Deskripsi
4
fraktur vertikal klasik maleolus medial. Impaksi plafon
terkait memerlukan pengurangan sebelum fiksasi fraktur.
Pemeriksaan
• Pemeriksaan awal harus mengidentifikasi luka terbuka dan bukti dislokasi, keduanya
• Palpasi kemudian meneruskan dalam urutan logis menggabungkan kedua sisi medial dan
lateral, dan termasuk seluruh panjang kaki ke lutut untuk menghindari kehilangan fraktur
fibula tinggi (Maisonneuve). Perhatikan bahwa tidak adanya nyeri tekan sisi medial tidak
• Status neurovaskular anggota badan harus diperiksa sebelum dan sesudah reduksi.
anteroposterior, lateral, dan mortise, umumnya cukup untuk mengklasifikasikan luka-luka ini
Dimana pasien memiliki kelembutan kaki lebih proksimal atau pelebaran ruang yang jelas
secara medial tanpa fraktur fibula jelas, radiografi tibia dan fibula penuh harus diperoleh untuk
menyingkirkan adanya cedera Maisonneuve. Pencitraan aksial yang lebih kompleks jarang
Pengobatan
5
Penatalaksanaan semua fraktur pergelangan kaki melibatkan pengurangan (di tempat yang
berpindah), dan imobilisasi awal pada belat atau cor. Begitu fraktur telah diimobilisasi,
keputusan mengenai perlakuan defensif bergantung pada dua ciri utama: konglemen dan
stabilitas tibio-talar.
Hasil yang baik dapat diantisipasi saat talus dipegang secara anatomis di dalam adonan
sampai penyembuhan patah tulang. Bila hal ini tidak dapat dicapai dengan pengurangan
tertutup, pengurangan terbuka harus dilakukan, asalkan tidak ada kontraindikasi medis.
dengan residu perpindahan talus minimal. Satu studi menunjukkan bahwa perpindahan fibula
pada model fraktur rotasi pronasi/eksternal meningkatkan tekanan kontak paling banyak
dengan memperpendek fibula, diikuti oleh translasi lateral, diikuti oleh rotasi eksternal.
Bila reduksi anatomi tertutup bisa dicapai, maka kestabilan cedera harus diperhatikan.
Ketidakstabilan mungkin disarankan oleh pola fraktur atau mungkin memerlukan pencitraan
lebih lanjut dengan radiografi tekanan atau MRI. Fraktur stabil dapat diobati secara konservatif
baik dalam moonboot atau cast untuk periode enam minggu dengan hasil baik. Cedera tidak
stabil dapat ditangani baik secara operasi maupun konservatif. Tetapi perawatan non-operasi
masukan bedah lebih lanjut, seringkali dilakukan secara bedah. Akibatnya banyak yang
Pengelolaan operatif malleolus lateral paling sering melibatkan pengurangan terbuka dan
fiksasi internal mengikuti teknik AO standar. Variasi teknik ini telah dipelajari namun belum
Pelat pengunci telah menunjukkan stabilitas mengesankan pada pengujian biomekanik pada
mayat tetapi hasil klinis kurang memuaskan dengan tingkat infeksi lebih tinggi bila
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dibandingkan dengan plat tubular sepertiga. Teknik pelapisan antiglide tampaknya tidak
menghasilkan hasil berbeda secara signifikan pada teknik pelapisan tradisional. Fiksasi hanya
lag screw nampaknya memberikan hasil baik pada populasi pasien muda. Baru-baru ini fiksasi
intramedulla dari malleolus lateral telah diteliti dengan hasil baik. Teknik ini tampaknya
memiliki manfaat khusus bagi mereka yang memiliki jaringan lunak lemah termasuk orang tua
dan mereka yang memiliki komorbiditas signifikan. Fiksasi malleolar medial dapat dicapai
dengan sekrup cancellous ulir parsial atau teknik wire band tension (Gambar 4).
Kestabilan syndesmotik harus dinilai mengikuti fiksasi fibula. Kebanyakan ahli bedah
menganjurkan penilaian stabilitas intraoperatif setelah plating fraktur fibula di atas tingkat
plafon di mana cedera membran syndesmotic dan interosseous mungkin terjadi (Gambar 5).
syndesmosis harus ditempatkan sampai penyembuhan jaringan lunak terjadi. Tidak ada
konsensus mengenai metode stabilisasi: terdapat kontroversi mengenai sekrup yang lebih kecil
(3,5 mm) versus yang lebih besar (4,5 mm) atau tiga korteks (Gambar 6) versus fiksasi empat
korteks setelah luka-luka ini, atau untuk perangkat jahitan yang dapat dieksploitasi (Gambar
7). Tidak ada keuntungan yang ditunjukkan pada setiap konfigurasi tertentu, atau untuk
penghapusan sekrup syndesmosis selanjutnya, meskipun banyak ahli bedah menawarkan ini.
Gambar 1. X-ray anteroposterior (A) dan lateral (B) menunjukkan Fraktur pergelangan kaki
Weber A. Perhatikan fraktur melintang fibula di bawah tingkat plafon dan fraktur vertikal
malleolus medial.
Gambar 2. X-ray anteroposterior (A) dan lateral (B) menunjukkan fraktur pergelangan kaki
Weber B. Perhatikan pola bimalleolar dengan fraktur transversal malleolus medial dan fraktur
oblik pada fibula yang dimulai pada waktu yang tepat.
Gambar 3. X-ray anteroposterior (A) dan lateral (B) menunjukkan fraktur pergelangan kaki
Weber C. Perhatikan fraktur fibula di atas tingkat plafon dengan malleolus medial dalam kasus
ini.
7
Gambar 4. X-ray anteroposterior (A) dan lateral (B) pasca operasi menunjukkan fiksasi fraktur
pergelangan kaki supinasi Weber B bimalleolar/fraktur pergelangan kaki rotasi eksternal.
Gambar 5. Pandangan stress rotasi eksternal intraoperatif dengan Weber B/SER IV setara
fraktur. Catatan ditandai dengan ketidakstabilan medial menunjukkan ligamentum deltoid
pecah sehingga pola patah tulang tidak stabil.
Gambar 6. AP X-ray pasien yang menjalani reduksi terbuka dan fiksasi internal fraktur
pergelangan kaki Weber C/PER IV dengan medial standar dan fiksasi plat lateral dan stainless
steel 3.5mm kortikal sekrup melalui 3 korteks.
Gambar 7. X-ray mortise dan lateral mengikuti fiksasi fraktur fibula tinggi (fraktur
Maissoneuve) dengan sekrup stainless steel 3.5mm kortikal dan tombol fleksibel jahitan
perangkat (Tightrope; Athrex, Maples, Florida).
Hasil
Secara umum, hasil setelah pengurangan anatomis fraktur pergelangan kaki berpindah adalah
baik. Arthritis paska traumatik telah dijelaskan pada 14% pasien meskipun terdapat
pengurangan anatomis, kemungkinan besar akibat cedera chondral yang diderita pada saat
cedera awal. Satu studi artroskopik menemukan 79% pasien memiliki beberapa tingkat cedera
chondral, terutama pada pasien dengan fraktur Weber C/PER. Meskipun beberapa tingkat
kekakuan harus diantisipasi, sebagian besar pasien melanjutkan aktivitas penuh setelah
8
Focus On
Ankle Fractures
Ankle fractures account for 9% of fractures1 representing a Table I. The Danis-Weber classification system for rotational ankle fractures
significant portion of the trauma workload: proximal femoral
fractures are the only lower limb fracture to present more
frequently. Ankle fractures have a bimodal age distribution with Type Description
peaks in younger males and older females.2 There has been
three-fold increase in the incidence amongst elderly females A Fracture below the syndesmosis. Avulsion injuries associated
over the past three decades.3 In addition, amongst multiply frequently with oblique or vertical medial malleolar fractures
(correlates with supination adduction injury; Fig. 1).
injured patients foot injuries are prognostically important: those
who survive their injuries are far more impaired functionally if B Fracture begins at joint level and extends proximally in an
oblique fashion. When accompanied by medial malleolus
they have a foot injury in addition to multisystem trauma.4 This fracture or with deltoid ligament rupture (correlates with
review provides a summary of ankle fractures, including the supination external rotational injury; Fig. 2) the ankle is
classification, clinical presentation, appropriate radiological considered unstable.
evaluation, treatment and outcomes. C Fractures above the joint line, generally with syndesmotic injury.
Can be associated with transverse avulsion medial malleolus
fracture or deltoid ligament rupture (includes some pronation-
Classification abduction and pronation-external rotation fractures; Fig. 3).
The first classification system for ankle fractures, developed
by Percival Pott,5 describes fractures in terms of the number
of malleoli involved, thus dividing injuries into unimalleolar,
bimalleolar and trimalleolar. Although easy to use, with good
intraobserver reliability, it does not distinguish between stable
and unstable injuries. Table II. Lauge-Hansen classification system for rotational ankle fractures
Two other common classification systems for rotational
ankle fractures attempt to aid in this distinction. The Danis-
Weber classification system,6,7 shown in Table I and Figures 1
Type Description
to 3, categorises ankle fractures on the basis of the location of
the distal fibular fracture in relation to the syndesmosis. The
Lauge-Hansen system8 (Table II), a mechanistic classification, Supination-external rotation (SER) Most common ankle fracture.
Fibular component is Weber B
describes firstly the postion of the foot at the time of injury and The SER fracture type II, has no
secondly the deforming force on the ankle and provides further medial injury and because these
information about the stability and hence the treatment likely to are mechanically stable injuries
be required. do not require surgery and can
begin immediate weightbearing
to tolerance. The SER IV fracture
Diagnosis has a medial component: either a
Clinical Features. History. medial malleolar fracture or a deltoid
• Ankle fractures are usually due to a twisting mechanism9 rupture. It may look very similar if
the medial malleolus is intact, but
sustained as a result of a low-energy injury. is distinguished by talar subluxation
• The position of the ankle at the time of injury and on presentation, or with mechanical
subsequent direction of force generally dictates the stress.
fracture pattern, as described by the Lauge Hansen Pronation-external rotation (PER) Correlates to Weber C
classification system.8 The fracture is proximal to the
• On occasion, a diabetic patient presents with a history of plafond, and may be as high as
fibular neck (Maisonneuve) with
little or no trauma, which should raise the suspicion of associated syndesmotic injury.
Charcot neuroarthropathy.
Supination-adduction Correlates to Weber A
• A higher energy mechanism should raise the possibility of Transverse fracture of the lateral
compartment syndrome of the leg10 or a more severe injury malleolus inferior to the ankle joint
to the plafond: the pilon fracture. with classically vertical fracture of
the medial malleolus. Associated
• Other pertinent factors in the history include medical plafond impaction may require
comorbidities such as diabetes, peripheral vascular reduction prior to fracture fixation.
disease and smoking, which can complicate wound and
Pronation-abduction Comminuted fracture of fibula above
fracture healing.11,12 ankle mortise with medial malleolar
• A social history should be taken to identify the patient’s fracture or deltoid ligament tear (Fig.
pre-injury level of mobility, home situation and regular 4). The fibular fracture may require a
activities as well as their future functional aspirations. bridging technique or a nail.
Examination
• Initial examination should identify open injuries and
any evidence of dislocation, both of which require
urgent intervention. Dislocation with skin compromise
necessiates immediate reduction on recognition to prevent
skin necrosis.
• Palpation then procedes in a logical sequence
incorporating both medial and lateral sides, and including
the whole length of the leg to the knee in order to avoid
missing the high fibular (Maisonneuve) fracture13. Note
that the absence of medial-sided tenderness does not
however, exclude a deltoid ligamentous injury14 and thus
instability. Fig. 1
• The neurovascular status of the limb should be checked
Anteroposterior (A) and lateral (B) x-rays demonstrating Weber
before and after reduction. A fracture of the ankle. Note transverse fracture of fibula
below the level of plafond and vertical fracture of the medial
Radiological Features. A standard radiological series of malleolus.
the ankle, including anteroposterior, lateral, and mortise
radiographs, is generally sufficient to classify these injuries and
plan treatment.
Where a patient has more proximal leg tenderness or medial
clear space widening with no obvious fibular fracture, full-length
radiographs of the tibia and fibula should be obtained to rule
out the presence of a Maisonneuve injury.13
More complex axial imaging is rarely indicated; exceptions
include triplane and pilon fractures.
Treatment
The management of all ankle fractures involves reduction
(where displaced), and initial immobilisation in a splint or cast.
Once the fracture has been immobilised the decision regarding
definitive treatment depends on two key features: tibio-talar Fig. 2
congruence and stability.
Anteroposterior (A) and lateral (B) x-rays demonstrating
Good outcomes can be anticipated when the talus is Weber B fracture of the ankle. Note the bimalleolar pattern
held anatomically within the mortise until fracture healing. with transverse fracture of the medial malleolus and oblique
When this cannot be achieved with closed reduction, open fracture of fibula beginning at the mortise.
reduction should be undertaken, so long as there is no medical
contraindication. Previous studies have demonstrated a
significant increase in intra-articular contact stresses with
minimal residual displacement of the talus.15,16 One study
demonstrated that displacement of the fibula in a pronation/
external rotation fracture model increases contact stresses most
with shortening of the fibula, followed by lateral translation,
followed by external rotation.17
When closed anatomical reduction can be achieved then the
stability of the injury should be considered. Instability may be
suggested by the fracture pattern or may require further imaging
with stress radiographs or MRI. Stable fractures can be treated
conservatively in either a moonboot or a cast for a period of six
weeks with good outcomes.18 Unstable injuries may be treated
either operatively or conservatively. However, non-operative
treatment requires close surveillance to assess for any late
displacement requiring further, often surgical, input. As a result
many chose to manage unstable injuries operatively.
Operative management of the lateral malleolus most Fig. 3
commonly involves open reduction and internal fixation following Anteroposterior (A) and lateral (B) x-rays demonstrating Weber
standard AO techniques19. Variations on this technique have C ankle fracture. Note fibular fracture above the level of the
been studied but there have been no significant conclusions. plafond with intact medial malleolus in this case.
Locking plates have shown impressive stability on biomechanical Syndesmotic stability should be assessed following fibular
testing in cadavers20 but clinical results have been less fixation. Most surgeons advocate intraoperative stability
satisfactory with a higher infection rate when compared with assessment after plating fibular fractures above the level of the
one-third tubular plates.21 Antiglide plating techinques do plafond where syndesmotic and interosseous membrane injury
not appear to result in significantly different outcomes to may have occurred (Fig 5). Where there is evidence of disruption
traditional plating techniques.22 Lag screw only fixation appears of the syndesmosis a syndesmotic screw to stabilise the
to give good results in a young patient population.23 Recently syndesmosis should be placed until soft-tissue healing occurs.
intramedullary fixation of the lateral malleolus has been No consensus exists regarding the method of stabilization:
investigated with good results24 This technique appears to controversy exists regarding smaller (3.5 mm) versus larger (4.5
have particular benefits for those with poor soft tissue including mm) screws26,27 or three-cortex (Fig 6) versus four-cortex fixation
the elderly and those with significant comorbidities.25 Medial following these injuries,28,29 or for flexible suture devices (Fig 7).
malleolar fixation may be achieved with partially threaded No advantage has been shown for any particular configuration,
cancellous screws or a tension band wire technique (Fig 4). or for the later removal of the syndesmosis screw,30 although
many surgeons offer this.
Fig. 4 Fig. 5
Postoperative anteroposterior (A) and lateral (B) x-rays Intraoperative external rotation stress view with Weber B/
demonstrating fixation of bimalleolar Weber B supination/ SER IV equivalent fracture. Note marked medial instabilty
external rotation ankle fracture. indicating ruptured deltoid ligament thus an unstable fracture
pattern.
Fig. 6 Fig. 7
AP xray of patient who underwent open reduction and internal Mortise and lateral x-ray following fixation of high fibular
fixation of Weber C/PER IV ankle fracture with standard fracture (Maissoneuve fracture) with stainless steel 3.5mm
medial and lateral plate fixation and stainless steel 3.5mm cortical screw and flexible suture button device (Tightrope;
cortical screw through 3 cortices. Athrex, Maples, Florida).
4 K. E. BUGLER, T. O. WHITE, D. B. THORDARSON
Outcomes 13. Maisonneuve JG. Recherches sur la fracture du péroné. Arch Gen Med 1840;7:165-
In general, the results following an anatomic reduction of a 87.
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has been described in 14% of patients despite an anatomic deltoid ligament incompetence in supination-external rotation type ankle fractures? J
reduction,31 most likely as a result of chondral injury sustained Orthop Trauma. 2007;21:244-7.
at the time of initial injury. One arthroscopic study found 79% of 15. Ramsey PL, Hamilton W. Changes in tibiotalar area of contact caused by lateral
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D. B. Thordarson 1980;51:695-702.
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E-mail: kate.bugler@doctors.org.uk wound complications with locking plates in distal fibular fractures. Injury 2011;42:1125-9.
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