Soft Tissue Management in Ankle Fracture Dislocation
A Case Report
dr. I Gusti Kadek Satrio Adiwardhana dr. I Wayan Subawa, SpOT
PROGRAM PENDIDIKAN DOKTER SPESIALIS I BAGIAN/SMF ORTHOPAEDI DAN TRAUMATOLOGI
UNIVERSITAS UDAYANA
2015
ABSTRACT
Soft Tissue Management in Ankle Fracture Dislocation A Case Report
I Gusti Kadek Satrio Adiwardhana*, I Wayan Subawa**
*Orthopaedic and Traumatology Resident, Udayana University, Sanglah General Hospital, Denpasar
**Orthopaedic and Traumatology Staff, Udayana University, Sanglah General Hospital, Denpasar
Introduction
The ankle is a complex hinge in which both bones and ligaments play important and inseparable parts. An injury of the ankle region can affect -in addition to bone, articular surface, and ligament- any of the tendons, nerves, or blood vessels that cross it. Population-based studies suggest that the incidence of ankle fractures has increased dramatically since the early 1960s1. The annual incidence of ankle fractures (AF) is approximately 122-184/100,000 person years (1:800).2.In cases of fracture dislocation of the ankle, potentially causes several complications of the bone and soft tissue and has poor functional outcome.
Definitive management must provide anatomic alignment of the joint as well as consideration of the surrounding soft tissues.
Material And Method
A 46-year-old male with a previously neglected fracture dislocation of the ankle, presented after a history for being involved in a high-velocity motorcycle accident 4 months ago and brought his foot to the bonesetter. The clinical examination showed deformity of the right ankle with a preserved soft tissue envelope. Neurovascular status was noted to be intact. Radiographic review showed talar dislocation into lateral side and avulsion of the medial malleolus fragment. We perform two approach, anterolateral and anteromedial for soft tissue identification, reduction, anatomical restoration, and stabilization of the fractures.
Results
Postoperatively, from clinical examination showed skin intact, warm, without swelling, and no infection.
Without tenderness, neurovascular status was good. Flexion ankle 100, extension ankle 200. From radiographic review, good positioning of Kirschner wire internal fixation, no dislocation and no fracture line in ankle.
Discussion
If the medial malleolar fragment is very small or comminuted, fixation with a screw may be impossible; in these cases, use several Kirschner wires or tension band wiring for fixation1 Make an anteromedial curved incision then identify the deltoid ligament. After that, make an anterolateral longitudinal incision, and expose the lateral malleolus and the sinus tarsi area. the very long-term overall results of the stratified surgical treatment of SER type II-IV ankle fractures is "excellent" or "good" in the majority of patients and therefore seems justified. Although additional soft tissue damage is unavoidable in case of operative treatment, it does not negatively affect outcome in the long term3
Conclusion
Overall, there was not enough reliable evidence to draw conclusions about whether surgery or conservative treatment is more appropriate for treating broken ankles in adults4. In this patient, we found good result both radiologically and clinically. It need further follow up for these patients to evaluate range of movement.
Keywords: Soft Tissue Management Ankle Fracture Dislocation
Soft Tissue Management in Ankle Fracture Dislocation A Case Report
Introduction
The ankle is a complex hinge in which both bones and ligaments play important and inseparable parts. An injury of the ankle region can affect -in addition to bone, articular surface, and ligament- any of the tendons, nerves, or blood vessels that cross it. Population-based studies suggest that the incidence of ankle fractures has increased dramatically since the early 1960s1. The annual incidence of ankle fractures is approximately 122-184/100,000 person years (1:800).2 In cases of fracture dislocation of the ankle, potentially causes several complications of the bone and soft tissue and has poor functional outcome. A recent large case-control study in the United Kingdom revealed an incidence of 4% for superficial and 1.1% for deep surgical site infections after ankle fracture fixation. The ideal management strategy for unstable ankle fracture dislocations with critical soft tissues remains a topic of debate.3,4 The widely used concept of closed reduction and temporary splint immobilization until definitive fracture fixation bears the risk of prolonged soft tissue swelling and ongoing skin tension due to the unstable ankle joint.5,6 This modality also precludes adequate monitoring of the soft tissue envelope related to recurrent ankle joint dislocation or subluxation whenever the splint is removed. Alternative options include immediate definitive surgical management with open reduction and internal fixation (ORIF) and the more conservative “damage control” approach of temporizing external fixation. Definitive management must provide anatomic alignment of the joint as well as consideration of the surrounding soft tissues.
Material and Method
An outpatient 46-year-old male with a previously neglected fracture dislocation of the ankle, presented after a history for being involved in a high-velocity motorcycle accident 4 months ago and brought his foot to the bonesetter.
Neurovascular status was noted to be intact. A physical examination of the right ankle showed deformity of the right ankle with a preserved soft tissue envelope, inversion of the talus,
and also false movement of right ankle joint. No open wound, the pedal pulses were palpable, and the foot was warm with normal capillary refill. There were no signs of compartment syndrome.
Figure 1. Left To Right. Clinical picture showing the deformity, the right ankle showing inversion of right talus
Roentgenographic images revealed dislocation of right ankle and old fracture of the medial malleolus (Figs. 2) Radiographic review showed talar dislocation into lateral side and avulsion of the medial malleolus fragment.
Figure 2. Radiograph showing the dislocation of ankle joint and old fracture of the medial malleolus
Result
We make an anteromedial incision extends distally and slightly posteriorly, and ends approximately distal to the tip of the medial malleolus. We might see the posterior tibial tendon and its sheath are good and see the articular surfaces in the anteromedial aspect of the joint
Fig. 3. Clinical Picture Durante Operative
Fig. 4. Right Ankle Xray AP/Lateral/Mortis View Post Operative
Make an anteromedial curved incision. Identify the deltoid ligament, the superficial portion is almost torn across its middle. Open the sheath of the posterior tibial tendon, the deep portion torn from the tip of the malleolus, we repair with non-absorbable sutures through the ligament.
Make an anterolateral longitudinal incision, and expose the lateral malleolus and the sinus tarsi area. Anatomically reduce the talar dislocation and check for stabilization. If the reduction is satisfactory, insert two 1.8mm Kirschner wire drilled crossly as temporary fixation devices. When it has been rigidly fixed, snugly tie the sutures already placed in the deltoid ligament and passed through the talus. Close the anterolateral incision. Return to the medial side of the ankle, replace the posterior tibial tendon in its sheath, and close the sheath. Repair the superficial portion of the deltoid ligament with multiple interrupted, non-absorbable sutures
Handle the skin with care, reflecting the flap intact with its underlying subcutaneous tissue.
The blood supply to the skin of this area is poor so careful handling is necessary to prevent skin
sloughing. Protect the greater saphenous vein and its accompanying nerve. The medial malleolus and periosteum are still good.
Figure 5. Clinical picture post-operative
Postoperatively, from clinical examination showed skin intact, warm, without swelling, no infection, and two wires crossly. Without tenderness, neurovascular status was good. Flexion ankle 100, extension ankle 200. From radiographic review, good positioning of Kirschners wire internal fixation, no dislocation and no fracture line in ankle. The ankle was protected with a back slab and put on non–weight-bearing until the Kirschners were removed after 3 weeks. Plan for this patient regained full range of ankle motion and normal pain-free walking at 12 weeks.
Discussion
If the medial malleolar fragment is very small or comminuted, fixation with a screw may be impossible; in these cases, use several Kirschner wires or tension band wiring for fixation1 Make an anteromedial curved incision then identify the deltoid ligament. After that, make an anterolateral longitudinal incision, and expose the lateral malleolus and the sinus tarsi area. the very long-term overall results of the stratified surgical treatment of SER type II-IV ankle fractures is "excellent" or "good" in the majority of patients and therefore seems justified. Although additional soft tissue damage is unavoidable in case of operative treatment, it does not negatively affect outcome in the long term3
From a biomechanical perspective, another evident benefit of ankle pinning is the achievement of rigid stability and retention of tibiotalar joint reduction by transarticular K-wires, compared with the relative stability by spanning external fixators allowing residual micromotion at the ankle joint.
Conclusion
Overall, there was not enough reliable evidence to draw conclusions about whether surgery or conservative treatment is more appropriate for treating ankle fracture dislocation in adults4. In this patient, we found good result both radiologically and clinically in third weeks. Unfortunately we lost to follow up this patient.
Daftar Pustaka
1. Marsh, J.L and Saltzman, C.L, Ankle Fractures in Rockwood & Green's Fractures in Adults, 6th Edition. Ch.53, 2147.
2. Donken CC, Al-Khateeb H, Verhofstad MH, van Laarhoven CJ. Surgical versus conservative interventions for treating ankle fractures in adults. Cochrane Database System. Revision 2012; page 8: CD008470.
3. Michelson JD. Using decision analysis to assess comparative clinical efficacy of surgical treatment of unstable ankle fractures. Journal of Orthopaedic Trauma. 2013; 27(11): page 642-648.
4. Hoiness P, Engebretsen L, Stromsoe K. The influence of perioperative soft tissue complications on the clinical outcome in surgically treated ankle fractures. Foot Ankle International. 2001; 22(8): page 642-648.
5. Rammelt S, Grass R, Zwipp H. Ankle fractures [in German]. Unfallchirurg. 2008;
6. Hoiness P, Stromsoe K. The influence of the timing of surgery on soft tissue complications and hospital stay: a review of 84 closed ankle fractures. Annual Chirugica Gynaecologic.
2000; 89(1):6- 9.
7. Koval, K.J, Zuckerman, J.D. Ankle fracture in Handbook of Fractures, 3rd Edition.
Lippincott Williams & Wilkins.2006.p.38
