PURPOSE: The aim of this study was to describe pathoanatomy and to raise awareness of a fracture of the lateral malleolus combined with a high subcapital fracture of the fibula caused by a dislocation mechanism. METHODS: The study comprised 11 patients, 5 men and 6 women, with the mean age of 57 years (range, 21-87), with a "Double Maisonneuve fracture". Individual lesions of ankle structures were described on the basis of radiographs, CT, and intraoperative findings. RESULTS: The distal fibular fracture was classified as Weber type B in 1 case and Weber type C in 10 cases. The proximal fibular fracture was described as a subcapital oblique spiral fracture with metadiaphyseal involvement in nine cases and a high short oblique fracture with fibular head involvement in two cases. Injury to the deltoid ligament was revealed in six cases; a bicollicular fracture of the medial malleolus was found in five patients. Posterior malleolar fractures were classified as type 1 in eight cases and type 2 in three cases. Avulsion of the Chaput tubercle was detected in four cases. Injury to the interosseous tibiofibular ligament was assessed in nine patients. CONCLUSION: Double Maisonneuve fracture is a rare but probably underreported injury that must be taken into consideration during examination, as it may be easily overlooked. The essential part of diagnosis is a careful clinical examination and radiological assessment of the lower leg with additional CT examination of the ankle.
- MeSH
- fibula diagnostické zobrazování MeSH
- fraktury kotníku * diagnostické zobrazování chirurgie MeSH
- hlezenní kloub patologie MeSH
- lidé středního věku MeSH
- lidé MeSH
- mnohočetné fraktury * MeSH
- poranění kotníku * diagnostické zobrazování chirurgie MeSH
- tibie zranění MeSH
- vnitřní fixace fraktury MeSH
- Check Tag
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
»: Maisonneuve fractures (MFs), originally described as subcapital (high) fibular fractures with additional injury to the anterior and interosseous tibiofibular ligaments, display a variable injury pattern, ranging from stable to highly unstable fractures. »: The high incidence of associated fractures of the posterior malleolus, the medial malleolus, and the anterolateral distal tibia (the "anterior malleolus") as well as the variable position of the fibula in the fibular notch (FN) warrant preoperative examination via computed tomography (CT). »: The main goal of treatment is anatomic reduction of the distal fibula into the FN, which requires prior reduction of displaced posterior malleolar fractures, if present, to restore the integrity of the FN. »: Open reduction of the distal fibula into the FN and fixation with 2 transsyndesmotic screws or fixation with a screw(s) and suture-button implant, under direct vision, on the lateral aspect of the ankle joint and anterior tibiofibular alignment are preferred over closed reduction to avoid sagittal or rotational malpositioning, which is associated with an inferior outcome. »: Intra- or postoperative 3D CT visualization is essential for assessment of the accuracy of the reduction of the distal fibula into the FN.
- MeSH
- fibula diagnostické zobrazování chirurgie MeSH
- fraktury kotníku * diagnostické zobrazování chirurgie MeSH
- hlezenní kloub diagnostické zobrazování chirurgie MeSH
- kotník MeSH
- lidé MeSH
- poranění kotníku * diagnostické zobrazování chirurgie MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- časopisecké články MeSH
- přehledy MeSH
In patients with ankle fractures, the presence of a posterior malleolar fracture has a negative impact on the prognosis. Computed tomography (CT) scanning is essential for fracture classification and treatment planning, as the indication for surgery depends on the 3-dimensional fragment outline and displacement, incisura involvement, and the presence of joint impaction. Anatomic reduction of a posterior malleolar fragment restores the incisura, facilitating reduction of the distal part of the fibula, and it also restores the integrity of the posterior portion of the syndesmosis, reducing the need for additional syndesmotic stabilization. Direct open reduction and fixation of posterior malleolar fragments from a posterior orientation is biomechanically more stable and provides a more accurate reduction than does indirect reduction and anterior-to-posterior screw fixation. Intra-articular step-off of >=2 mm is an independent risk factor for an inferior outcome and the development of posttraumatic arthritis, irrespective of the fragment size.
- MeSH
- fraktury tibie klasifikace diagnóza etiologie chirurgie MeSH
- lidé MeSH
- poranění kotníku klasifikace diagnóza etiologie chirurgie MeSH
- prognóza MeSH
- vnitřní fixace fraktury metody MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- časopisecké články MeSH
- přehledy MeSH
- MeSH
- artroskopie MeSH
- dospělí MeSH
- fibula diagnostické zobrazování zranění MeSH
- kloubní chrupavka patologie zranění MeSH
- kloubní ligamenta diagnostické zobrazování zranění MeSH
- lidé středního věku MeSH
- lidé MeSH
- nestabilita kloubu * chirurgie diagnostické zobrazování komplikace MeSH
- patní kost diagnostické zobrazování zranění MeSH
- poranění kotníku chirurgie diagnostické zobrazování patofyziologie MeSH
- talus diagnostické zobrazování zranění MeSH
- Check Tag
- dospělí MeSH
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- ženské pohlaví MeSH
- MeSH
- fixace fraktury metody metody MeSH
- interní fixátory MeSH
- kotník anatomie a histologie chirurgie krevní zásobení MeSH
- lidé MeSH
- pooperační komplikace epidemiologie etiologie MeSH
- poranění kotníku * chirurgie diagnostické zobrazování etiologie terapie MeSH
- vnitřní fixace fraktury metody přístrojové vybavení MeSH
- Check Tag
- lidé MeSH
- MeSH
- dospělí MeSH
- lidé MeSH
- ligamentum laterale articulationis talocruralis chirurgie patofyziologie zranění MeSH
- mechanický stres MeSH
- mrtvola MeSH
- nestabilita kloubu diagnostické zobrazování patofyziologie MeSH
- peroperační doba MeSH
- poranění kotníku * chirurgie diagnostické zobrazování patofyziologie MeSH
- senioři MeSH
- Check Tag
- dospělí MeSH
- lidé MeSH
- mužské pohlaví MeSH
- senioři MeSH
- ženské pohlaví MeSH
INTRODUCTION: Reduction of the distal fibula into the fibular notch (FN) poses a problem that has not been fully resolved, yet. A number of methods have been developed for the assessment of the position of the fibula in the FN, but none of them is ideal. A majority of authors assess the FN 1 cm above the tibiotalar joint space, without specifying the reason for the choice of this distance. None of the previous studies has addressed at what level the FN is the deepest. Our findings show that it is 4-5 mm above the ankle joint space and verification of this hypothesis has been the aim of this study. MATERIALS AND METHODS: Dry adult tibial bone specimens from the Pachner's collection of the Institute of Anatomy of 1st Faculty of Medicine, Charles University, Prague were used in the study. Height of the FN at its widest point, 3 mm and 10 mm above the articular surface of the distal tibia were measured in each specimen, as well as the depth of the FN at the deepest point, 3 mm and 10 mm above the articular surface of the distal tibia and the distance between the highest point of this surface and the deepest point of the notch. RESULTS: The mean length of the tibia was 350 mm; the mean height of the FN was 42.5 mm; the mean width of the FN at its widest point was 23.6 mm, at 3 mm above the tibiotalar joint space 22 mm, 10 mm above this articular surface of distal tibia (tibial plafond) 18.9 mm. The mean depth of the notch at 3 mm above the tibial plafond was 3.8 mm, at 10 mm above this surface 4.1 mm. The maximum mean depth of the notch was 4.5 mm, the distance from this point to the highest point of the tibial plafond was 5.3 mm. CONCLUSION: The deepest point of the FN lies 5 mm above the articular surface of the tibial plafond, with the mean value of the depth being 4.5 mm. This region is, therefore, ideal for assessment of the position of the distal fibula in the FN.
PURPOSE OF THE STUDY Ankle fractures are characterised by a high variability of damage to bone and ligament structures which leads to diverse clinical conditions. This study aims to analyse a group of patients with surgically treated ankle fractures, with a focus on evaluating the outcomes of treatment of ankle joint medial structure injuries (medial malleolar fracture, ligament lesions). MATERIAL AND METHODS The analysed group included 186 patients (102 men and 84 women), in whom an ankle fracture surgery was performed in 2015 and 2016. The outcomes of the treatment were evaluated in 111 patients with type B and type C fractures, who underwent a follow-up examination at one year after the surgery consisting in subjective and objective assessment of the condition and an ankle radiograph. The obtained outcomes were processed using the techniques of descriptive statistics and subsequently evaluated through the Pearson´s chi-square test at 5% significance level, or the Fisher´s exact test for low frequencies. RESULTS The mean age of patients in the group was 48.6 years, while it was lower in men than in women (42.8 years compared to 53.9 years). According to Weber classification, 1 % of fractures were classified as a type A fracture, 68 % as a type B, 27 % as a type C. The group of isolated medial malleolar fractures represented 4 % of cases. The medial side of the ankle joint more frequently suffered a ligament lesion (56 %) than a medial malleolar fracture (44 %). The mean age of the patients with a medial malleolar fracture was 51.9 years, whereas the mean age of the patients with a ligament lesion on the medial side of the ankle was 44.2 years. When evaluating the outcomes using the OMA score at one year postoperatively, a statistically significant difference was found (p = 0.002) between the patients with a medial malleolar fracture (OMA 79.9) and the patients with a ligament lesion at the medial side of the ankle joint (OMA 91.2). DISCUSSION The aim of the study was to add more information on medial structures of ankle joint that are of major importance for ensuring stability of ankle fractures. In agreement with the literature, when managing the ankle fractures with an injury suffered on the medial side there is obviously a more uniform approach in cases with medial malleolar fractures. The situation is different in case of the deltoid ligament lesion, when historically there is a certain level of non-uniformity in indications for revision surgeries and treatment of the injured ligament structures. In our group, in the case of ligament lesion on the medial side of the ankle joint an emphasis is put on the fluoroscopy control of the symmetry of tibiotalar joint space before the beginning of the surgery and also after the fibular fracture stabilisation. The revision surgery was indicated in cases where asymmetry of ankle fork was found. The patients considered the treatment outcome better in cases with a ligament lesion than in cases with a medial malleolar fracture. CONCLUSIONS Proper treatment of medial structures of the ankle joint is important for ensuring the stability of ankle fractures. The patients with type B fractures reported better results at one year postoperatively compared to the patients with type C fracture according to the Weber classification. A statistically significantly better results after the ankle fracture surgery were achieved in patients with the presence of a medial ligament lesion compared to the patients with a medial malleolar fracture. Key words:ankle fracture, injury of medial structures, epidemiology, outcomes of treatment.
- MeSH
- dospělí MeSH
- fraktury kotníku epidemiologie chirurgie MeSH
- lidé středního věku MeSH
- lidé MeSH
- poranění kotníku epidemiologie chirurgie MeSH
- vnitřní fixace fraktury MeSH
- výsledek terapie MeSH
- Check Tag
- dospělí MeSH
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
AO Trauma
xviii, 642 stran : ilustrace ; 29 cm
- MeSH
- fraktury kotníku chirurgie MeSH
- ortopedické fixační pomůcky MeSH
- ortopedické výkony metody MeSH
- poranění kotníku chirurgie MeSH
- poranění měkkých tkání chirurgie MeSH
- poranění nohy (od hlezna dolů) chirurgie MeSH
- Publikační typ
- příručky MeSH
- Konspekt
- Ortopedie. Chirurgie. Oftalmologie
- NLK Obory
- ortopedie
- chirurgie
- NLK Publikační typ
- kolektivní monografie
