Sonographic diagnosis of talar lateral process fracture. 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. e.g. Avulsion fractures are breaks or splits in the bone. Mosby. First study the radiographs and then continue with the CT. PubMed. However, the anterior talofibular ligament (ATFL) is ruptured with a posterior fiber retraction. It is important to see your doctor as soon as the accident takes place to prevent more damage. ADVERTISEMENT: Supporters see fewer/no ads. J Ultrasound Med. At surgery the ankle was found to be unstable and syndesmosis screws were inserted. This patient has an unstable ankle injury and a syndesmotic screw needs to be inserted. Imaging of the proximal fibula should also be . In that case we have the following combination: An isolated tertius fracture on the ankle radiographs indicates the presence of an unstable ankle injury. Stage 1 is rupture of the medial collateral ligaments and stage 3 is a fibula fracture above the level of the syndesmosis. Yellow arrow indicates os subfibulare. short-leg AO splint. Check for errors and try again. 10) Takakura Y. et al. In this article we will focus on detection of fractures, that may not be so obvious at first sight. Type IV is a fracture through all three elements of the bone, the growth plate, metaphysis and epiphysis. Study these images carefully and remember the stages of an exorotation injury. Alignment has been maintained. The most effective methods for assessing tibiotalar instability include stress and weight-bearing radiographs. There are five types of medial malleolus fractures: Chip 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). 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. 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. 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. Maisonneuve fracture) should always be considered a deltoid / medial malleolus injury. They can happen when you take an awkward or uneven step that causes you to twist or roll your ankle. A Tillaux fracture is more commonly seen in adolescents at the age of 12 -15 years. This fracture is named triplane because it occurs in the coronal, sagittal and axial plane. Frequently missed findings in acute ankle injury. the 7th character must always be the 7th position of a code. Most inversion injuries result in an isolated sprain of the anterior talofibular ligament. Avulsion injuries of the TN ligament were better assessed in the plantar-flexed radiographs with lateral beam angulation. 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. In many cases there is only minimal or no displacement. These injuries generally occur when the ankle is either twisted or rolled, frequently with an awkward or unequal action. On the AP-view there is a lucency within the epiphysis, which is the epiphyseal fracture in the sagittal plane. Feel a stretch in the back of your calf. When the fracture happens, the tendon or ligament pulls away, and a small piece of. The hip, elbow and ankle are the most common locations for avulsion fractures in the young athlete. Since there is no fibula fracture seen on the x-rays of the ankle, there must be a high fibular fracture. 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. If this is not visible in the distal fibula then further X-rays of the proximal fibula should be performed. A, Lateral radiograph shows fracture ( straight arrow) through enthesophyte emanating from medial plantar process. Unable to process the form. 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. 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. Deltoid ligament injuries, be it sprain, tear, or avulsion, are much less common than lateral collateral or syndesmotic injuries. Less frequently it leads to an avulsion of the anterolateral tibial epiphysis. Soft tissue swelling over the lateral malleolus. One of the first stages in this injury is rupture of the anterior tibiofibular ligament (or anterior syndesmosis). This is the most common type of growth plate fracture, and tends to occur in older children. Medial soft tissue swelling and a tertius fracture are both indications of a Weber C or Pronation Exorotation injury. These are discussed in the next chapter. Fractures of the lateral margin of the distal tibia are usually avulsion fractures of the anterior or posterior tibial tubercle, caused when the anterior or posterior inferior tibiofibular ligament fails to tear during an injury. {"url":"/signup-modal-props.json?lang=us\u0026email="}, Knipe H, Medial malleolus avulsion fracture. Trnka HJ, Zettl R, Ritschl P. Fracture of the anterior superior pro- It is the most common type of ankle fracture and may happen. As in most ankle fractures the mechanism is external rotation. The avulsion fragment is quite large. 15.19 ). Maybe the fracture is seen on the AP-view as indicated by the red arrows, but this is questionable. 60 (6), 1953 . This spot was marked and a fracture was found. The ankle is the most frequently injured joint. Seen with medial malleolus shearing injuries and triplane fractures. A lateral malleolus fracture usually requires the person to keep weight off the affected foot for a few weeks. They are commonly injured in the case of ankle sprains. Case study, Radiopaedia.org (Accessed on 11 Dec 2022) https://doi.org/10.53347/rID-89034. The images show an obvious Weber B fracture. It is a high Weber C fracture. 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. The alignment is so perfect, that you do not see the fracture on the radiographs. Radiographics. Campbell's Operative Orthopaedics. So even in a Weber C stage 4 sometimes only a fracture of the medial malleolus will be visible. lateral malleolus fracture with talar shift (static or stress view) technique. Unable to process the form. By the way.there are two fractures. You may need to spend a few weeks on crutches if you have an avulsion fracture around your hip. RadioGraphics 1994; 14:1191-1210. The AO Surgery Reference is a huge online repository of surgical knowledge, consisting of more than 7000 pages. The lateral malleolus of the flexed leg lies across the other leg superior to the patella. Study the images and then continue reading. Anterior distal tibial spurring. On the left image the lateral malleolus is pushed off by exorotation of the talus. With an avulsion fracture, an injury to the bone occurs near where the bone attaches to a tendon or ligament. Crush injury to the physis. avulsion tip fractures of medial or lateral malleolus . A Weber B fracture is easily detected because of the characteristic oblique fracture. Often, x-rays of a child with a type I growth plate fracture will appear normal. An ankle avulsion fracture is a bone chip caused by a ligament or tendon that tears away a part of the bone. Usually, you will need to stay off the ankle for several weeks after surgery. 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. As many as 40-50% of fractures are missed on radiographs due to overlapping osseous structures 2. This is generally a stable injury. Study the images and then continue reading. It is actually a Salter-Harris type IV. Alignment has been maintained. Diagnostic guidelines for suspected ankle fracture are from the American College of Radiology. A subtle high fibula fracture is seen (arrow). Weber C fractures can be further subclassified as 6. It is the most common of the ankle joints to fracture. The use of preperitoneal pelvic packing for unstable pelvic fractures as well as early fracture immobilization with external fixators are paradigm shifts in management. Ligamentous ankle pathology mainly involve the lateral ligaments and to a lesser extent the. The bright side is that the majority of lateral malleolus fractures are considered steady ankle fractures and can be treated without surgery. The patient was treated with immobilization for 4 weeks and anti-inflammatory agents. Stress placed on the bone by a tendon or ligament causes the fracture. The most effective methods for assessing tibiotalar instability include stress and weight-bearing radiographs. 16). Almost all fractures of the posterior malleolus are part of a rotational injury resulting in a Weber B or Weber C fracture. Lateral X-ray Frontal Anteromedial soft tissue swelling. Continue with the images of the lower leg. 1996;47: 1170-5. The most common is type II, which accounts for 75%. Fractures of the ankle, combined experimental-surgical and experimental-roentgenologic investigationsby N. Lauge-Hansen (1948). 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. The severity an ankle avulsion fracture can result in anything from a minor issue to something that requires surgery. A lateral malleolus fracture commonly occurs in association with a rolled ankle particularly with significant weight bearing forces. Case Discussion It is important to find these fractures, since a tertius fracture can be the only clue to an unstable ankle injury. A proximal fibular injury (i.e. HAWKINS LG. The tertius fracture is stage 3 in Weber B and stage 4 in Weber C (figure). Do you have an idea what kind of injury this is? 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. On the lateral projection, an os trigonum can be appreciated. Acta Clin Croat, Vol. Often type II growth plate fractures must be repositioned under anesthesia, but healing is usually quick and complications are uncommon. In this case no fracture is seen, but only soft tissue swelling on the medial side. This should make you consider a tertius fracture. So this is the fracture of the metaphysis in the coronal plane. This woman had a distortion of the ankle and had pain on both medial and lateral side. Hold both stretches for up to 30 seconds and repeat 3 times. Anterior distal tibial spurring. The chronic fracture may then require a subtalar fusion. In the setting of an isolated lateral malleolus fracture, identifying injury to this ligament and associated ankle instability influences management. It is actually a Salter-Harris type IV. We have to assume that there is an epiphysiolysis of this lateral portion. 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). Since they are generally the result of external rotation and abduction, they are almost always seen in . Conclusion In trimalleolar ankle fractures, the AO/OTA classication is a reliable system to characterize the type of fracture, Lee P, Hunter TB, Taljanovic M. Musculoskeletal colloquialisms: how did we come up with these names?. You can enlarge the images by clicking on them. The pain was worse with weight-bearing. posterior malleolar fracture with < 25% joint involvement or < 2mm step-off. J Bone Joint Surg Am. 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. Soft tissue swelling over the lateral malleolus. 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). 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. 2. The Salter-Harris classification describes fractures that involve the epiphyseal plate or growth plate. Radiology 1986; 159:467-469. 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. modalities. Truely isolated fractures of the posterior malleolus are very uncommon. 1. There is only a small metaphyseal fragment, which is usually the case (red arrow). Standard projections were found to adequately depict avulsion fractures related to the TC and CF . 2b: >2 mm displacement of fracture fragments; grade 3: cortical avulsion fracture; MRI. In the illustration we see the fractures and ligamentous injury on the left and the resulting x-rays on the right. the ICD-10-cm. Study the images and then scroll to the next images. The CT shows an avulsion of the tertius at the insertion of the posterior syndesmosis (red arrows). In children, a fibula fracture usually requires a short leg cast and six weeks of non-weight bearing. 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 Type V. 1%. PE stage 4. Any medial painful swelling or hematoma Small ankle joint effusion. Details of type 7 intraepiphyseal injuries and accessory ossicle are . 80 (4), 1998, 684-8. Also notice the soft tissue swelling on the medial side indicating rupture of the medial collateral ligaments (arrow). Notice also that the medial epiphysis is already closed, while the lateral portion is still open(blue arrows). 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. unfit for surgery. Link, Google Scholar; 19 Goldman AB, Pavlov H, Rubenstein D. Normal radiographs do not rule out a Weber C fracture. Small fleck lying posterior to the posterior malleolus may represent a further avulsion fracture. {"url":"/signup-modal-props.json?lang=us\u0026email="}, Morgan M, Hacking C, Hacking C, et al. Failure to detect the fracture may lead to non-union,ankle instability, and accelerated osteoarthritis. These injuries also tend to affect older children in whom the growth plate is partially closed. The x-ray shows a subtle Tillaux fracture, which is better appreciated on the CT-images. Small fleck lying posterior to the posterior malleolus may represent a further avulsion fracture. The fracture occurs when the foot is dorsiflexed and inverted, as can happen with snowboarding (hence the term "snowboarder fracture")1. Type V growth plate fractures carry the most concerning prognosis as bone alignment and length can be affected. Fractures of the proximal fifth metatarsal, in contrast, are usually transverse to the metatarsal base, although oblique fractures may occur (see Chap. . Knowing that this can be the only clue to a high Weber C, additional radiographs were taken. ATFL injuries can present as an isolated tear or accompanied with avulsions of the lateral malleolus. Example 1 View larger version (251K) Fig. A fracture of the posterior malleolus as an isolated finding is very uncommon. Almost always the avulsion is seen as a horizontal fracture. Always look for higher stages of an exorotation injury. 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) 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. ISBN:B0040SYP2C. Continue with the CT. It is seen when someone's foot hits the ground and a fragment of the posterior malleolus is pushed off by the talus. Semin Musculoskelet Radiol. There was no evidence of joint instability. The size of this fragment depends on the direction of the force (figure). ADVERTISEMENT: Supporters see fewer/no ads. 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. Mosby. A fracture should be suspected when there is soft tissue swelling inferior to the lateral malleolus. 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. Diagnosis of avulsion fractures of the distal fibula after lateral ankle sprain in children : a diagnostic accuracy study comparing ultrasonography with radiography. The repair is typically done with a plate and screws. 30. Soft tissue swelling both medial and lateral (red arrows). In some cases the tertius fractures are easily seen on the x-rays, but frequently they can be difficult to detect. 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. Example 3 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. 7-32). So we have to look for higher stages. short-leg cast. Mildly displaced avulsion fracture from the tip of the medial malleolus in keeping with a deltoid ligament injury. Case Discussion. External rotation injury of the ankle is the most common ankle injury and can lead to a Weber B or Weber C fracture. An avulsion fracture is where a fragment of bone is pulled away at the ligamentous or tendinous attachment. There is an avulsion of the lateral malleolus, a Tillaux and a medial malleolar fracture. were recorded: medial malleolus, lateral malleolus/distal fib-ula, posterior malleolus, talus, calcaneus, navicular, cuboid, . . Type III is a fracture through the growth plate and epiphysis sparing the metaphysis. 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. Do you now see the tertius fracture on the axial CT-image? Fractures of the lateral malleolus are the most common type of ankle 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. 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. A type II growth plate fracture starts across the growth plate, but the fracture then continues up through the metaphysis. Abstract. It is the most commonly injured ligament in the ankle. There is a subtle widening of the lateral part of the growth plate of the right ankle. Radiology. Can occur with lateral malleolus fractures, usually SH I or II. Simulated avulsion injuries related to these ligaments were created, and the visibility of these structures was assessed. A common spot for avulsion fractures is at the lateral malleolus or outside ankle bone. 2013;17 (04): 416-28. The injury produces pain, tenderness, and swelling of the ankle making weight-bearing difficult or impossible. Oblique fracture. We will discuss these fractures in a moment. And finally we tend not to look carefully at the epiphysis. Lateral talar process fracture. CAM boot. Proper positioning is also essential with type IV growth plate fractures, and surgery may be needed to hold the bone fragments in proper position. Tillaux fracture. This small fragment is best seen on the AP view just inside the medial malleolus. There is a Tillaux fracture due to avulsion of the anterolateral part of the distal tibia by the anterior syndesmosis. Check for errors and try again. Study the images and then scroll to the next images. Yellow arrow indicates os subfibulare. 4. Most type I growth plate injuries are treated with a cast. There is also a very subtle fracture through the epiphysis. Weber-A stage I Stage 1 [3] for medial malleolus fractures (Fleiss' = 0.59, 95% CI 0.54-0.65). Alignment has been maintained. Healing of type I fractures tends to be rapid and complications are rare. The fracture may sometimes be difficult to identify on radiographs and CT may be necessary to identify the fracture line. For acute trauma to the ankle, according to the ACR, radiographs are usually . 1 These breaks are the most common type of ankle fracture. On the AP-view the linear lucency is the clue to a tertius fracture (red arrow). Increased risk of physeal arrest. 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. 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. 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 The diagnosis is made by x-raying the ankle. 48, No. Although a fracture of the medial malleolus can be a serious injury, the outlook for recovery is good, and complications are . Jibri Z, Mukherjee K, Kamath S et-al. A common spot for avulsion fractures is at the lateral malleolus or outside ankle bone . Scroll through the images. Clinical examination findings are important but less reliable. This juvenile Tillaux is especially seen in young athletes. The diagnosis of apophyseal separation should be made with caution, since the normal ossific portion of the apophysis may be quite lateral in the cartilaginous mass (Fig. The technician made the standard AP-, Mortise- and lateral view and showed them to the radiologist, who was a little bit puzzled. 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. 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. Stage 1: stable ankle fracture Stage 1 Here a typical avulsion or pull-off fracture of the lateral malleolus. Additional x-rays of the lower leg were taken. Here more examples of the bright line that indicates a tertius fracture. Here, it is possible for further ligamentous injuries, especially at the posterior malleolus given the small bone flake suspicious for a PITFL injury. Lateral malleolus avulsion fracture with os subfibulare. This combination of findings implicate that the ankle is unstable. Icd-10-cm code s82.64 - nondisplaced fracture of lateral Icd-10-cm code s82.64 nondisplaced fracture of lateral malleolus of right fibula. 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 fracture is named triplane because it occurs in the coronal, sagittal and axial plane. 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. Here another example. Another Tillaux in a patient with a strange combination of findings. At first this looks like a Weber B fracture with an oblique fracture in the fibula as seen on the lateral view (black arrows). She suffered a sprain of the left ankle one week before. This case illustrates the importance of medial soft tissue swelling aswell as the finding of a tertius fracture. It results from subtle malalignment of the fracture fragment. On the lateral projection, an os trigonum can be appreciated. Type I Salter-Harris fractures tend to occur in younger children (5). It is amazing, that such a large tertius fragment is so difficult to see on the radiographs. Skeletal anatomy of the ankle Ligaments connect bone to bone to provide stability of the joints. You can use Radiopaedia cases in a variety of ways to help you learn and teach. It can be caused by traumatic traction (repetitive long-term or a single high impact traumatic traction) of the ligament or tendon. Link, Google Scholar; 18 Capps GW, Hayes CW. Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. A syndesmotic screw has to be inserted. You may have to enlarge the image, turn down the room lights, and adjust the contrast and brightness on your monitor. {"url":"/signup-modal-props.json?lang=us\u0026email="}, Knipe H, Lateral malleolus avulsion fracture with os subfibulare. The lateral malleolus is part of the fibula, one of two bones of the lower leg, which carries about about 10% of your weight. 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. In the setting of an isolated lateral malleolus fracture, identifying injury to this ligament and associated ankle instability influences management. In 1840 Maisonneuve described a frature of the proximal shaft of the fibula, which was caused by exorotation force applied to the ankle. Can be difficult to identify on initial presentation (diagnosis is usually made when growth arrest is seen on follow-up radiographs) 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. The fracture through the growth plate is usually obscure and difficult to differentiate from normal variations of the growth plate. Study free Radiology flashcards about RAD Pathology created by bre092795 to improve your grades. Incidental note of os subfibulare and os trigonum. 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). 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. Isolated fracture of the posterior malleolus This may be hard to see. ( avulsion fracture) Transverse fracture (like our case) Vertical fracture. Put a towel/bandage around your foot and pull it towards you. Surgical Treatment Surgical repair is necessary when a lateral malleolus fracture is displaced. Proper positioning is essential after a type II growth plate fracture. Mildly displaced avulsion fracture from the tip of the medial malleolus in keeping with a deltoid ligament injury. A lateral malleolus fracture is a type of ankle fracture that occurs when the fibula fractures just above the ankle joint. ADVERTISEMENT: Supporters see fewer/no ads. Case study, Radiopaedia.org (Accessed on 11 Dec 2022) https://doi.org/10.53347/rID-26255, Lateral malleolus avulsion fracture with os subfibulare. C1: diaphyseal fracture of the fibula, simple; C2: diaphyseal fracture of the fibula, complex; C3: proximal fracture of the fibula. Lateral Malleolus Fractures are generally stable fractures but traumatic events such as a fall or trip can lead to an unstable fracture. An oblique or vertically oriented fracture indicates 'push-off'. Incidental note of os subfibulare and os trigonum. Comminuted fracture. It is a transverse fracture through the cartilage of the growth plate or physis. Final diagnosis is a Weber C fracture or according to Lauge Hansen: Pronation Exorotation injury stage 4. Ankle - Fractures 2 - Fracture mechanism and Radiography. Lateral talar process fracturesor snowboarder fractures are talusfractures that can mimic a lateral ankle sprain. There are three situations in which we should suspect a high Weber C or Maisonneuve fracture: Isolated fracture of the medial malleolus She was referred to the radiology department by her general practitioner. The lateral malleolus sits on the outside of the ankle joint and absorbs approximately 10% of your weight in standing. Notice however that this fracture line stops at the level of the epiphyseal plate. Clinical examination findings are important but less reliable. This case demonstrates why a knowledge of common anatomical variants is essential. The fracture through the epiphysis can be easily missed (blue arrow). The CT-images nicely display the fracture through the growth plate and the epiphysis. It may be an isolated fracture or occur as a component of more complex ankle fractures. 2004;24 (4): 1009-27. Note saucerlike defect in inferior aspect of calcaneus from bone lysis ( curved arrow ). These types of fractures may permanently injure the growth plate, requiring later treatment to restore alignment of the limb. The type of treatment depends on the fracture grade 6: If symptomatic non-union occurs, debridement may be necessary. 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. Whenever you see such a fracture, you have to look for higher stages of this exorotation injury. This patient had a twisted ankle and the only abnormality is seen on the lateral view. A transverse or horizontal fracture is the result of a 'pull-off'. These fractures are also named triplane fractures. {"url":"/signup-modal-props.json?lang=us\u0026email="}, Knipe H, Lateral malleolus avulsion fracture with os subfibulare. The radiologist decided first to order a CT to find out if there really was a tertius fracture. FRACTURE OF THE LATERAL PROCESS OF THE TALUS. ADVERTISEMENT: Supporters see fewer/no ads. At that age it is a fracture through the growth plate and is then called a juvenile Tillaux. Recently resuscitative endovascular balloon occlusion (REBOA) has been added to the armamentarium for life-threatening pelvic fracture bleeding57,58 (Fig. A small avulsion fracture is noted between the dome of the talus and the medial malleolus. In such a case, you have to rule out a Maisonneuve fracture, which is a high Weber C fracture. Easily missed injuries around the knee. Segond tibial condyle fracture: lateral capsular ligament avulsion. The CT-images show a epiphysiolysis fracture Salter Harris type 3. As the force cannot continue into the medial part of the growth plate since this is already closed, the epiphysis will fracture. 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. Continue with the CT and be amazed. There is also an avulsion fracture at the tip of the lateral malleolus ( best seen on T1 sequences ), with associated bone marrow edema. First study the images and then continue reading. Radiology. So now we start looking for stage 4, which is rupture or avulsion of the posterior syndesmosis. 2003;22 (6): 635-40. Fractures Avulsion fractures are breaks or splits in the bone. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. A lateral malleolus fracture is classified as nondisplaced when the bone fragments are not out of place. 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. According to Lauge-Hansen this is the first stage of a pronation exorotation injury, which results in a Weber C fracture. On the left images of a patient with a hematoma on the medial side. 3. 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. 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. This is also a Salter-Harris type III fracture. Lateral malleolus fractures are common in running and . Likewise in some cases malalignment can result in a linear density. Stages of exorotation injuries of the ankle. This can be a stage 2 of a Weber C fracture. Blue arrow indicates avulsion fracture. 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. Case study, Radiopaedia.org (Accessed on 11 Dec 2022) https://doi.org/10.53347/rID-26255. Notice that there is also a Tillaux fracture. 5. 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. 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. 6. This was thought to be an avulsion of the posterior malleolus. Small ankle joint effusion. Most fractures of the posterior malleolus are part of a complex ankle injury, either Weber B or Weber C. Unable to process the form. When we study the radiographs of a patient with an ankle injury, we have to study the region of the posterior malleolus very carefully. 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