Symptoms of an ankle avulsion fracture are very similar to an ankle sprain. Tells me it is a small undisplaced fracture of lateral malleolus. 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. A fracture can be caused by a fall, a blow to the . and our In general, extra-articular fractures of the talus and calcaneus can be managed with nonsurgical treatment. C/o pain left ankle since then. The findings are consistent with isolated lateral malleolar fracture. 6, 21, 23, 24. Fractures of the talar dome may be medial or lateral, and they are usually the result of inversion injuries, although medial injuries may be atraumatic. -If I were to have surgery, is there a time window that I should have it done post accident to guarantee it heals correctly. Difficult with standard views; an oblique ankle radiograph taken with the foot placed in 40 degrees of external rotation has been successful. Medial tubercle fractures are relatively rare.17,18 They were first described by Cedell,18 who presented four cases of medial tubercle fractures that had originally been treated as ankle sprains. Elevation: Lie down and keep your ankle elevated above . This young boy allegedly twisted his left ankle 3 days ago. Treatment of a stable lateral malleolus fracture need to include efforts to minimize swelling following by a gradual development in weight-bearing. It can be caused by traumatic traction (repetitive long-term or a single high impact traumatic traction) of the ligament or tendon. Treatment of an avulsion fracture typically includes resting and icing the affected area. Usually, a plate and screws is utilized. 84th Avenue, Suite 102, Plantation FL, 33324, (954) 430-9901 - Pembroke Pines-Silver Lakes, Foot, Ankle, & Leg Specialists Insurance Accepted, ACUTE AND CHRONIC CARE OF MUSCULOSKELETAL INJURIES JOINT SURGERY, SOFT TISSUE INJURIES (TENDON, LIGAMENT, MUSCLE). Most ankle injuries are straightforward ligamentous injuries. Stage I, II, and III medial lesions can usually be treated nonsurgically with six weeks in a nonweight-bearing cast.1,3,5 Adequate reduction and immobilization are crucial for fracture healing and to avoid avascular necrosis of the fracture fragment.5, Patients with stage III lateral lesions, stage IV lesions, and persistent symptoms are generally treated surgically. These are avulsion fractures of the medial ankle ligaments. The pain is often reproduced with plantar flexion and occasionally accentuated with dorsiflexion of the great toe. Ankle injuries are commonly evaluated by primary care and emergency physicians. Less frequently it leads to an avulsion of the anterolateral tibial epiphysis. CONSERVATIVE CARE: If non-displaced and stable, these fractures can be treated non-operatively with cast immobilization. Most common ankle fractures. This page will discuss ankle and foot fractures and the role that physiotherapists play in the rehabilitation of such injuries. A fractured ankle can range from: A simple break in one bone, which may not stop you from walking, to. -If it doesn't get re-attached, what happens to the floating bone fragment? Usually, 4-8 weeks nonweightbearing followed by protected weightbearing with a cast. 3. In a different patient, after conservative care,a patient with a healed high fibular fracture with fracture callus surrounding the fracture site is seen on the X ray (GREEN ARROW). The button on the right of the bone is what holds the strong suture like material connected between the 2 bones. Furthermore, in the case of a suspected ankle sprain that does not improve as expected or is accompanied by tenderness over a potential fracture site, radiographic analysis at a follow-up evaluation may be indicated. Point tenderness over the calcanealcuboid joint (approximately 1 cm inferior and 3 to 4 cm anterior to the lateral malleolus), Lateral radiograph (an accessory ossicle, the calcaneus secondarium, may be present), Small nondisplaced fracture: nonweight-bearing with compressive dressing or NWBSLC for four to six weeks, Joint rest, ice, compression, and elevation (RICE), Progressive range-of-motion and proprioceptive exercises, Protection from further ankle injury with a wrap or brace, Completely detached fragment without displacement, Completely detached fragment with displacement. Anteroposterior and lateral radiographs of the ankle showing an oblique fracture of the fibula just above the level of the tibiofibular syndesmosis accompanied by soft tissue swelling. Point tenderness over the lateral process (anterior and inferior to the lateral malleolus), Mortise view; lateral view may show subtalar effusion, Small fragment with <2 mm Displacement: NWBSLC for four to six weeks, Posterior talar Process (lateral tubercle), Tenderness to deep palpation anterior to the Achilles tendon over posterolateral talus, Lateral radiograph (an accessory ossicle, the os trigonum, may be present), Minimally displaced fracture: NWBSLC for four to six weeks, Posterior talar process (medial tubercle), Tenderness to deep palpation between the medial malleolus and the Achilles tendon. However, intra-articular fractures require special attention to ensure that the articular surface is restored to anatomic congruity and that the correct mechanical alignment is maintained. They are located medially or laterally with equal frequency and occasionally through both.35 Lateral talar dome fractures are almost always associated with trauma, while medial talar dome lesions can be traumatic or atraumatic in origin. Inversion plantar flexion can cause avulsion fractures of the anterior process. However, repeated radiographs may be necessary because initial films may appear normal. Incidental note of os subfibulare and os trigonum. If symptoms persist, an additional four to six weeks of immobilization would be recommended.6 If the fracture site continues to be symptomatic after six months, fragment excision is usually curative.6,9 Larger and more displaced fractures may require open reduction internal fixation.6,16. Treatment options fragment excision range from arthroscopy with or without subchondral bone drilling to open reduction internal fixation.4,5. Lateral talar process fractures are characterized by point tenderness over the lateral process. Syndesmosis or medial malleolar injury not evident in this patient. CONSERVATIVE CARE: If non-displaced and stable,these fractures can be treated non-operatively with cast immobilization. Ankle Fractures are very common fractures in the pediatric population that are usually caused by direct trauma or a twisting injury. Lateral. Some patients do well with weightbearing protected immobilization in a cast boot. Typical findings include crepitance, stiffness, and recurrent swelling with activity.5. Studies have shown a fibular fracture displaced by 1 mm can decrease the contact area of the ankle joint by 42%. 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. Anyone can suffer an avulsion fracture of the ankle, but athletes and children are more prone to them than the rest of us. Most avulsion fractures heal very well without surgical intervention. 2. After the deltoid and syndesomosis is healed, we replace the long screw (RED ARROW) with a Arthrex Tightrope (GREEN ARROW)that allows physiologic motion but maintains stability. McGraw-Hill Medical. 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. Delays in treatment can result in long-term disability and surgery. Anterior process fractures result . Frontal. In the acute setting, the symptoms of a talar dome fracture are similar to and often occur with an ankle sprain.3,5, In lateral talar dome lesions, tenderness is generally found anterior to the lateral malle-oli, along the anterior lateral border of the talus.3,6 In medial talar dome lesions, tenderness is usually located posterior to the medial malleolus, along the posterior medial border of the talar dome.3,6 Chronic talar dome lesionstraumatic and atraumatic osteo-chondritis dissecans lesionsmay have a clinical presentation similar to that of arthritis. By rejecting non-essential cookies, Reddit may still use certain cookies to ensure the proper functionality of our platform. First, you need to focus on resting and getting the swelling to go down. OVERVIEW: Lateral malleolar fractures are fractures that occur in the distal aspect of the fibula. 8,9 Small nondisplaced avulsion fractures of the tip of the lateral malleolus (Figure 13-4) are best treated with early mobilization similar to . Kannus et al. However, the clinical presentation of some subtle fractures can be similar to that of routine ankle sprains, and they are commonly misdiagnosed as such. All Rights Reserved. Generally, the AP ankle view is best for visualizing deep, cup-shaped medial lesions,1,4 although the lesions are often appreciated on the mortise view as well (Figure 3). The patient has an ORIF Fibula fracture and a temporary screw (RED ARROWS)placed across the syndesmosis for 12-16 weeks and then permanently implanted an Arthrex Tightrope (GREEN ARROWS)to maintain stability but allow physiologic motion. [1] Fractures of the foot are less common. The lateral talar process is an osseous protuberance that articulates superolaterally with the fibula, helping to stabilize the ankle mortise, and inferomedially with the calcaneus, forming the lateral portion of the subtalar joint7 (Figures 1 and 2). Treatment of Lateral Malleolus Fractures. This young boy allegedly twisted his left ankle 3 days ago. Non-surgical and surgical options exist to treat medial malleolus fractures, but the choice often comes down to the extent of the fracture. Some recent reports79,12 implicate snowboarding accidents in these fractures. [1] [2] It can occur at numerous sites in the . Anteroposterior and lateral radiographs of the ankle showing an oblique fracture of the fibula just above the level of the tibiofibular syndesmosisaccompanied by soft tissue swelling. ADVERTISEMENT: Supporters see fewer/no ads. Most of these injuries do not pose a diagnostic dilemma and can be managed nonsurgically without a prolonged or costly work-up. Copyright 2002 by the American Academy of Family Physicians. Alignment has been maintained. These fractures can often be managed nonsurgically with nonweight-bearing status and a short leg cast worn for approximately four weeks. This is indicative of calcaneo-fibular ligament tear. SURGICAL CARE: If unstable, and/or displaced, these fractures need to be brought to the OR to have open reduction and internal fixation (ORIF). report an incidence of up to 174 cases per 100 000 persons per year in a Finish population. 65 year old man, had a fall 2 weeks ago. However, as with all guidelines, clinical judgment and experience may be grounds for radiographic analysis in unique cases. X-ray showed a small loose body at the tip of lateral malleolus. Alignment has been maintained. With an avulsion fracture, an injury to the bone occurs near where the bone attaches to a tendon or ligament. Avulsion fractures are breaks or splits in the bone. 84th Avenue, Suite 102 Plantation, FL 33324, 17842 NW 2nd St., Pembroke Pines, FL 33029, 220 S.W. Unable to process the form. Multiple loose bodies are seen just below medial malleolus. He c/o pain and swelling over his left ankle. Many of these injuries, if left without a definitive diagnosis, result in long-term disability (Table 1). Post-surgical repair with open reduction of the fracture with internal fixation involving screws and plate (right) allow re-alignment of the fracture fragments will allow the bones to heal correctly and in a timely fashion. Inversion with plantar flexion can lead to an avulsion fracture. Put a towel/bandage around your foot and pull it towards you. Dr. has x-ray completed. Cookie Notice Ankle Fractures - Pediatric. However, CT (Figure 8) or MRI may be necessary if the diagnosis is unclear.16,17, Medial tubercle fractures are treated in a manner similar to that for lateral tubercle fractures.17,18,20, The anterior process of the calcaneus is a saddle-shaped bony protuberance that articulates with the cuboid. Then a Cam Walker and physical therapy is initiated. Info: I've been told that the bone is likely to not re-attach itself naturally due to the distance, but . This occurs as tendons can bear more load than the bone. Overall, optimal results are achieved with early diagnosis and treatment of these fractures. As these osteochondral fragments (often referred to as osteochondritis dissecans lesions) become loose in the joint, they can cause pain, locking, crepitance, and swelling.1,4,5, Clinical diagnosis of talar dome fractures can be highly challenging because there are no pathognomonic signs or symptoms.5 The patient may have sustained a fall or a twisting injury to the ankle and may generally ambulate with an antalgic gait. Elevation: Elevation is important to keep swelling restricted. Although fractures of the talus were vary rarely encountered in the Ottawa ankle trials, the fractures discussed in this article would likely be identified using the Ottawa ankle rules, because of the inability of the patient to bear weight after the injury and during the examination. This guy twisted his ankle. The Ottawa ankle rules (Figure 1025 ) offer the physician clinical guidance as to which injuries require radiographs. 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. Case study, Radiopaedia.org (Accessed on 11 Dec 2022) https://doi.org/10.53347/rID-21949. He said I would be "good to go" in 4-6 weeks. Age: 32 Sex: male Height: 511 Weight: 160lbs Race: cacausian Duration of complaint: 1 week Location: ankle (lateral malleolus) Any existing relevant medical issues: no Current medications: None. As the clinical scenario dictates, a CT scan or MRI may be necessary.9,21,23 In addition, an accessory ossicle (calcaneus secondarium) maybe located near the anterior process and could be misinterpreted as a fracture.21,24, For small, nondisplaced fractures, early immobilization in a nonweight-bearing, short leg cast or compressive dressing for four to six weeks followed by range-of-motion exercises and a gradual return to weight bearing has been successful.21,23, Although fracture healing may appear radiographically to be complete, approximately 25 percent of patients require more than a year before becoming asymptomatic.21 Following nonsurgical management, most patients report satisfactory results and a return to preinjury activity levels.21,23,24 Symptomatic nonunions or large, displaced fractures may require surgical intervention.21,24. There are two parts involved in the treatment of a stable lateral malleolus fracture. This is consistent with an avulsion fracture involving the superior peroneal retinaculum. Bruising may develop later and the athlete will most likely have difficulty moving the . The patient must be either immobolized and kept non-weightbearing in a cast depending on various factors including age of patient and pain level. This can be seen as the two "buttons" on the right side of the xrays on the tibia. Fractures of the anterior process account for approximately 15 percent of all calcaneal fractures and are commonly misdiagnosed as ankle sprains.6,21,23,24, Anterior process fractures result from avulsion or compression. The x-rays below demonstrate a lateral malleolar fracture that is displaced and has shortening which requires surgical repair (left). Nevertheless, some patients with these fractures are able to ambulate and, because patients with these fractures generally do not present with tenderness along the posterior border of the lateral or medial malleolus, radiographic evaluation may not be indicated under the Ottawa guidelines. In Fracture Management for Primary Care (Third Edition), 2012. The patient usually has a history of a rapid inversion and dorsiflexion injury.79 Fractures of the lateral process range from avulsion fractures of the capsular ligaments to intra-articular injuries involving the ankle and subtalar joints.9, Physical examination findings are similar to those in lateral ankle ligamentous injuries. Fracture was repaired with plate and screws with a syndesomotic screw. Can it cause issues like abrasion to surrounding areas? See permissionsforcopyrightquestions and/or permission requests. The fractures discussed here can be serious injuries and cause prolonged disability. Info: I've been told that the bone is likely to not re-attach itself naturally due to the distance, but that surgery is not needed so l'm seeking additional opinions. Go get aircast, use crutches (NWB) and follow up with family Dr in 2 weeks. Fractures of the lateral tubercle can be caused by hyperplantar flexion or inversion.1,2,15 Hyperplantar flexion injuries tend to cause compression fractures, while inversion injuries tend to produce avulsion fractures.1,2,15 Both of these injuries have been described after falls and have been associated with football and rugby kicking injuries, which place the ankle in a forced plantar flexed position.19 If present, an os trigonum can be injured by the same mechanisms described above.2,19, Clinically, patients with a fracture of the lateral tubercle present with pain and swelling in the posterolateral area of the ankle. Now, the ankle joint is anatomic and symmetrical. (2006) ISBN:0071438335. The medial malleolus is the largest of the three bone segments that form your ankle. Feel a stretch in the back of your calf. The other two are the lateral and the posterior malleolus. In this case, the avulsion involves the peroneal retinaculum, which is a fibrous retaining band that binds down the tendons of the peroneus longus and brevis as they run across the side of the ankle. Annotated image. Privacy Policy. -Should this be surgically re-attached? This content is owned by the AAFP. Soft tissue swelling over the lateral malleolus. Age: 32 Sex: male Height: 5'11" Weight: 160lbs Race: cacausian Duration of complaint: 1 week Location: ankle (lateral malleolus) Any existing relevant medical issues: no Current medications: None. An unfused accessory ossification center. When a medial malleolus fracture occurs by itself . This article features subtle fractures to facilitate timely diagnosis and treatment of these less-common injuries. Ice application: Apply ice to help reduce pain and swelling. Fractures of the talar dome are generally the result of inversion injuries of the ankle. The symptoms of a medial malleolus fracture are fairly predictable: Pain on the inner side of the ankle, swelling and bruising, and difficulty walking. However, the clinical presentation of subtle fractures can be similar to that of ankle sprains, and these fractures are frequently missed on initial examination. Percutaneous FIxation of Displaced Fibula Fracture in Diabetic Patient, South Florida Institute of Sports Medicine If there is a small avulsion fracture off the tip of the fibula, these can often be treated by weightbearing cast immobilization followed by Cam Walker and physical therapy. It is a break of the lateral malleolus, the knobby bump on the outside of the ankle (in the lower portion of the fibula). A common spot for avulsion fractures is at the lateral malleolus or outside ankle bone. 1. There is a small loose body (arrow) indicating an avulsion injury. Tenderness anterior to the lateral malleolus, along the anterior border of the talus, Mortise view: shallow, wafer-shaped lesion, Inversion with plantar flexion or atraumatic, Tenderness posterior to the medial malleolus, along the posterior border of the talus. Lateral malleolus fracture: This is the most common type of ankle fracture. From 33 to 41 percent of these fractures are missed on initial presentation.811 Traditionally, the causative injuries are falls, motor vehicle crashes, or direct trauma. Spondylosis Spondylolysis Spondylolisthesis. This condition is known as a lateral malleolus fracture. This is consistent with an avulsion fracture involving the superior peroneal retinaculum. In acute injuries, this rough irregular surface may help distinguish a fracture from a normal os trigonum, which generally has a smooth, rounded cortical surface.15 In chronic cases, these differences may be less distinct, making the distinction between a fracture and a normal os trigonum difficult. Secondary changes in the subchondral bone (visible on plain radiographs) caused by a compression fracture of the articular osteochondral surface may take weeks to appear.2,4 In addition, small chondral fragments are radiolucent and not evident on standard radiographs. Posterior talar process fractures are often associated with tenderness to deep palpation anterior to the Achilles tendon over the posterolateral talus, and plantar flexion may exacerbate the pain. Incidental note of os subfibulare and os trigonum. The lateral tubercle is the larger of the two and serves as the attachment of the posterior talocalcaneal and posterior talofibular ligaments.9,14,15 The medial tubercle serves as the attachment for the posterior third of the deltoid ligament.9,14,15 The under-surface of both tubercles forms the posterior fourth of the subtalar joint.9,14, An accessory bone known as the ostrigonum is relatively common, posterior to the lateral tubercle.6,15 The os trigonum can be a source of pathology, and a normal os trigonum may be confused with a fracture of the lateral tubercle.2,9,14. He c/o pain and swelling over his left ankle. The injury occurs at the site where a tendon or ligament attaches and happens because the tendon or ligament pulls abruptly and breaks a piece of bone away. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. AP view: deep, cup-shaped lesion; initial radiograph can be normal because changes in subchondral bone may not develop for weeks. The x-ray image below is that of a non-displaced lateral malleolar fracture that will heal well without surgery (RED ARROW). For more information, please see our X-ray. Frontal. Often a fracture of the lateral malleolus occurs in combination with a sprained ankle or other fractures of the foot, ankle or lower leg (such as following trauma). Ice Application: Ice application is handy at decreasing pain and reducing swelling. When the diagnosis is unclear and clinical suspicion is present, an MRI or CT will clearly demonstrate this fracture.16, Nondisplaced or minimally displaced fractures can be treated with a non-weight-bearing, short leg cast for four to six weeks.9,15 After this period of immobilization, weight bearing is allowed as tolerated. A posterior subtalar effusion seen on the lateral view is highly suggestive of an occult lateral process fracture.13 A CT scan can clearly show this injury and may be required to confirm a suspected fracture.11, A nonweight-bearing, short leg cast can be used if anatomic position with less than 2 mm displacement can be maintained.7,11 A nonweight-bearing cast should be maintained for four to six weeks, followed by two weeks in a walking cast and initiation of rehabilitation exercises.7 For large and displaced fragments, the treatment of choice is usually surgical reduction and fixation.7,8, The posterior process of the talus is composed of two tubercles, the lateral and medial (Figures 1 and 2). A broken ankle is also known as an ankle fracture. One of the first stages in this injury is rupture of the anterior tibiofibular ligament (or anterior syndesmosis). This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. The lateral malleolus is at the end of the fibula, a smaller bone in the leg. The lateral process can be palpated anteriorly and inferiorly to the tip of the lateral malleolus.8,11, Fractures can usually be visualized on a standard ankle series9 (Figure 5). You can use Radiopaedia cases in a variety of ways to help you learn and teach. Lateral process fractures are the second most common talar fractures. Bimalleolar ankle fracture: This second-most common type involves breaks of both the lateral malleolus and of the . Case 1 - Avulsion Fracture of the Superior Peroneal Retinaculum. An avulsion fracture is where a fragment of bone is pulled away at the ligamentous or tendinous attachment. Typically, the secondary center of ossification of the lateral malleolus appears during the first year of life and fuses with the shaft at 15 years. An avulsion fracture occurs when a muscle or tendon is pulled so hard at the spot where it attaches to the bone that it tears a small piece of bone away. It is very difficult to tell the difference without an X-ray or MRI scan. External rotation injury of the ankle is the most common ankle injury and can lead to a Weber B or Weber C fracture. Isolated nondisplaced lateral malleolar fractures have a low risk of complications and have good clinical results regardless of treatment. A CT scan may be required to further characterize the fracture pattern and for surgical planning. 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