82. Ankle
From Primary Surgery
82 The ankle
82.1 Introduction and examination
Ankle injuries are common and commonly mismanaged. They include minor sprains, disabling tears of the collateral ligaments, usually the lateral one, serious malleolar fracture dislocations, and ruptures of the Achilles tendon. Occasionally, a child displaces his lower femoral epiphysis.
EXAMINING THE FOOT AND ANKLE
Is the patient's foot normally aligned with his leg? Is it internally or externally rotated, everted, inverted or swollen? Is one malleolus abnormally prominent, or his heel displaced backwards? (malleolar fracture). Is his heel abnormally broad? (fractured calcaneus).
Can he walk normally on his heels? This tests the power of his dorsiflexors. Can he walk on the balls of his feet (his metatarsal heads)? He can only do this if his calf muscles and his Achilles tendon are normal.
Ask him to point to the site of the pain. Feel for the exact
site of tenderness. Palpate his two malleoli, and the medial
and lateral ligaments of his ankle. Abnormal inversion, and
tenderness below his lateral ligament suggest that it is
sprained or ruptured. If tenderness is maximal over a
malleolus, it is probably fractured.
Feel his tarsal and metatarsal bones, and especially the
base of the fifth. Feel his calcaneus between your fingers and
thumb.
How far can the patient flex and extend his ankle? How far can you or he invert or evert his heel on his ankle? This tests the movement of his subtalar joint. Examine it further by grasping his heel with one hand and his lower tibia with the other. Move his injured ankle from side to side and compare it with the movement of his normal one. Palpate the subcutaneous surface of his tibia, and 'spring' his fibula against it.
If he has no signs of an acute injury, and he can walk, watch him do so. Does he limp? Is his heel and toe strike normal? Remove his socks and shoes, and observe how his shoes are worn.
X-RAYS are unnecessary if he can walk normally bearing his full weight.
If you are going to X-ray him, decide if you want X-rays of his ankle or his foot.
If his ankle is injured, take an AP view in 20° of internal rotation to compensate for the external rotation of a normal ankle. Also take a true lateral view.
If you are worried about the integrity of one of his coll ateral ligaments, especially the lateral one, take forced inversion views.
If his foot is injured, take an AP, a lateral, and an oblique view of his foot.
If you suspect he might have injured his calcaneus, ask for a special axial view of it.
There are many variations in the structure of the foot, including many accessory ossicles, which you can confuse with fractures. His other foot will probably show the same anomaly, so, if you are in doubt, X-ray that too.
82.2 Sprained and torn ankle ligaments
A sprain tears only some of the fibres of a collateral ligament, usually the lateral one. A sprained ankle is swollen, and its collateral ligament is tender. Although a patient with a sprained ankle may walk with difficulty, his ankle will eventually recover, even if you do nothing. But if the lateral ligament of his ankle is completely torn, and is not correctly managed, his ankle will be unstable and cause difficulty when he walks on rough ground.
Ruptures of the lateral ligament are often missed because the talus tilts over temporarily and then returns to its normal position, so that the ordinary AP and lateral films look normal. The critical test is to ask the patient to walk. If he cannot walk after an ankle injury, suspect some more serious injury than a minor sprain. X-ray his foot to exclude a fracture, and test the stability of the ligaments of his ankle. If the diagnosis is seriously in doubt, X-ray his ankle in the same position of forced inversion which caused the original injury. If you are still in doubt, overtreatment is probably better than undertreatment.
SPRAINS AND TEARS OF THE ANKLE LIGAMENTS
This section describes the care of the common injuries of the lateral collateral ligament. Treat the rarer injuries of the medial (deltoid) ligament in a similar way.
If you are not certain if one of a patient's collateral ligaments is sprained or torn, take a forced inversion (or eversion) X-ray. These are only rarely needed.
FORCED INVERSION X-RAY
Give the patient an analgesic, such as pethidine. Some radiologists inject 2% Iignocaine into the haematoma around the ankle. Forcibly invert his ankle while you take an AP X-ray. If his lateral ligament is completely ruptured, the joint will open up as shown in C, Fig. 82-1.
THE TREATMENT OF SPRAINED AND TORN ANKLE LIGAMENTS
If a patient's lateral ligament is not ruptured, and there is only minor swelling, apply adhesive strapping and encourage him to walk normally.
If his lateral ligament is not ruptured, but there is more severe swelling, apply a below-knee walking cast with his ankle in neutral and his foot in slight eversion. Encourage him to walk in the cast. As soon as he feels that his cast is loose when he gets up in the morning, ask him to come and have it changed. This must be done while the swelling is down.
If necessary admit him for a night so that his leg can be elevated. Leave the cast on for 3 to 6 weeks.
If his lateral ligament is ruptured with wide opening of his ankle joint, treat him in a below-knee walking cast as above, but leave the cast on for 6 to 10 weeks, so that his torn ligament can unite.
After removing the cast, apply a crepe bandage or adhesive strapping, and encourage him to walk without a limp. By walking normally he uses his muscles normally, which strengthens both them and his ankle (77.1). If he limps, he uses some muscles excessively and others not at all. The muscles which are not used waste, and this may make his ankle unstable permanently.
If his ankle becomes permanently unstable, repair may be possible, so refer him.
A NEGLECTED TORN LIGAMENT IS AS SERIOUS AS A FRACTURE
82.3 Malleolar fractures classified
Hippocrates had difficulty treating these fractures, so has everyone who has treated them ever since, and so will you. Displaced malleolar fractures are major injuries, and are often not taken seriously enough. If you don't treat a patient correctly, he will be disabled for life by a stiff, painful equinus ankle, like that in Fig. 82-2, and may need a difficult arthrodesis to give him a useful foot.
When a patient sustains one of these injuries, his foot remains fixed on the ground in an abnormal position, while his body continues onwards. The position of his foot and the movement of his body relative to it, determine how the bones of his ankle will break and its ligaments tear. This is the basis of the most meaningful classification of these fractures. The movements of the foot are complex, and similar to those in the hand. Supination combines inward rotation of the forefoot with inversion of the hindfoot. Pronation combines outward rotation of the forefoot and eversion of the hindfoot. If a patient's foot locks, either in extreme supination, or in extreme pronation, it becomes a rigid inflexible structure, and readily breaks at his ankle when a force is applied between it and his leg.
There are four groups of fractures with several stages within
each group.
Supination-external rotation fractures are the most common. The patient's foot remains supinated on the ground, while his body and leg continue to move in such a way that his foot rotates externally on his leg. The first thing that happens is that his anterior tibio-fibular ligament ruptures (Stage I). His distal fibula then fractures spirally (Stage II). As the forces continue, the posterior part of his tibia fractures, to form a posterior tibial fragment, and, or, his posterior tibio-fibular ligament ruptures (Stage III). Next, his deltoid ligament ruptures, or his medial malleolus fractures. This is Stage IV and is the classical Potts fracture. Finally, his ankle may dislocate. The process may stop at any stage to produce injuries of varying severity. The distinguishing feature of this group of fractures is the spiral fracture of the distal fibula. Other varieties of this injury include fracture of the fibula several centimetres above the ankle, and sometimes even as high as its neck.
Supination-adduction fractures are caused by a patient's body moving laterally on his supinated foot. His lateral collateral ligament ruptures, or his fibula fractures transversely, and his medial malleolus fractures, usually vertically. The remaining two groups of fractures (pronation-abduction and pronation-external rotation fractures) are less common, and will not be discussed further here.
One of the advantages of classifying these fractures by the force that caused them is that you can use the opposite force to reduce them. In practice, recognition of the exact type of fracture is not important. The main principle is to recognize the incongruity between a patient's talus and his tibia, to replace them exactly in contact with one another, and then to immobilize his foot without weight bearing until his broken bones and torn ligaments have healed. The mortice between his talus and his tibia is small, and transmits his whole weight, so you must replace its joint surfaces exactly-if you want his ankle to bear weight normally afterwards. Unfortunately, the ankle is not one of those joints which you can allow to mould itself by early active movements (69.4).
Lauge-Hansen. Acta Orthopaedica Scandinavica. 1978: 51;181-192
82.4 The early management of malleolar fractures
A patient's malleolar fracture can be treated by immediate internal fixation, preferably using AO methods, or by the closed methods describe later. Try closed methods first. If you succeed, good.
If you fail, and you can refer him, subsequent internal fixation will be easier, because the fragments will at least be in nearly the right position. Meanwhile, here are some critical steps in his early management.
EARLY MANAGEMENT FOR A MALLEOLAR FRACTURE HOW URGENT IS REDUCTION ?
If the patIent's talus has dislocated (is grossly out of place), reduce it immediately, whatever the swelling.
If his ankle is only subluxed (the fragments are more or less in their normal places), you can either reduce the fracture immediately, within a few hours, before it starts to swell, which is best, or 3 to 7 days later when the swelling is less.
Meanwhile, keep his ankle in stockinette traction (Quigley traction) as described below, to allow the swelling to subside and make reduction easier. Manipulating a very swollen ankle is not easy.
CAUTION ! Never let a malleolar fracture remain, even temporarily, in an undesirable position, particularly in equinus. The blood in the joint will organize, and the ligaments will tighten into undesirable positions, so that later reduction will be difficult or impossible.
STOCKINETTE TRACTION FOR THE EARLY MANAGEMENT OF MALLEOLAR FRACTURES
Thread the patient's leg through a tube of stockinette, and fix this to his thigh with several short pieces of zinc oxide strapping, as in Fig. 82-5. Don't put strapping around his thigh because it may obstruct his circulation. Suspend the loose end of the stockinette from a drip stand, so that his foot lies about 20 cm above his bed. Most fractures will reduce themselves automatically in 2 or 3 days, while the swelling subsides.
If you don't have stockinette, and the swelling is severe, reduce the fracture by the method to be described, and temporarily hold the best position with a long horse shoe plaster splint which extends down one side of the patient's leg, around his foot, and up the other side. Hold it with a crepe bandage. Keep him in bed with the foot of his bed raised until the swelling has subsided. Tighten the crepe bandages as swelling subsides, and then apply a cast as in Fig. 82-9.
82.5 Is reduction good enough ?
Before you reduce a fracture you will want to know if you have succeeded. This section tells you what to aim for; the next one tells you how to achieve it. The purpose of reduction is to align a patient's talus with the anterior part of the joint surface of his tibia. So look for congruity there. Gross displacement or widening of his ankle joint is easy to recognize, but minor degrees of non-congruity may be difficult to distinguish from. a normal joint. When you reduce his fracture, take great care to obtain the highest possible degree of congruity. A common error is to accept an unnecessary degree of non-congruity.
POST-REDUCTION X-RAYS FOR MALLEOLAR FRACTURES
ANTE RO-POSTERIOR VIEW IN 20° OF INTERNAL ROTATION.
This must be taken correctly, as in Fig. 82-1: (1) The gap between the patient's talus and his medial and lateral malleoli should be about the same as the gap between his talus and the lower surface of his tibia. (2) The saddle-shaped surfaces of his talus and his tibia should be congruous. (3) Close reduction of his medial malleolus should show that there are no soft tissues between the fragments and indicate an excellent prognosis. (4) Compare the length of his two malleoli, and the congruity of his fibula to his talus. His lateral malleolus should project more distally than his medial one. If you cannot correct proximal displacement or obvious incongruity, refer him for open reduction and internal fixation.
A TRUE LATERAL VIEW
The anterior surface of a patient's tibia should be congruous with his talus.
If there is a posterior tibial fragment, i t will almost certainly be displaced upwards. This is less important, provided his talus is accurately aligned with the anterior part of his tibia, as in B, Fig. 82-6. Misalignment of the talus and the shaft of the tibia, as in C, produces a high spot on the joint surface so that osteoarthritis is sure to follow.
If his talus and tibia are misaligned, in the lateral view, you will have to remove the cast and try to improve reduction. If a gap remains in the AP view between his medial malleolus and his talus, there is soft tissue in the joint. This is especially likely to happen if the patient's medial malleolus is intact, trapping his torn deltoid ligament in his ankle joint between his talus and his medial malleolus.
If in a lateral view, one third or more of the posterior lip of a patient's tibia has been fractured, his ankle will be unstable in an AP plane, so try to refer him for open reduction and screw fixation. If this is impossible, we describe a method later which may help you to replace the fragment -see 'If the posterior fragment is large'.
82.6 Treating a malleolar fracture
This is one of the fractures in which expert internal fixation gives excellent results. If you cannot refer a patient for it, careful closed reduction by Charnley's method is satisfactory in most cases.
These are difficult fractures by any method. Be sure to admit the patient who will need 10 to 14 days of in-patient care. Your results will be better if you either reduce his fracture immediately before his ankle starts swelling, or if you allow the swelling to subside first. A malleolar fracture needs careful manipulation using three point fixation, several X-rays, some well applied casts, and, finally proper follow-up during several out-patient visits to make sure that the position of the fragments is not lost. The way the casts are applied is critical. Always put them on yourself. This is not an easy fracture to treat-it needs particular care.
Your main difficulty will be less in reducing a patient's fracture, than in making sure it stays reduced. In spite of the complexity of these fractures, in most of them there are really only two fragments. The shafts of his tibia and fibula form one fragment, while his foot and his malleoli form the other one. The fragments attached to his foot move as one piece because they are all firmly joined by ligaments. If you can put his talus back accurately under his tibia, the other fragments will usually reduce themselves. Align his foot on his leg by eye and by feel, and you will find you have reduced his fracture. If there is a posterior tibial fragment which is less than one third of the width of his tibia, you can usually leave it to look after itself, but if it is larger than this you may have to use the special method for it that we describe later.
You will be able to feel that a patient's talus is back under his tibia more easily when there is no plaster on his foot. So explore the mobility of his foot before you apply it. Start by getting the feel of where his talus should be. Then apply plaster, fit his talus back in position, and hold it there urtil the plaster has set, as in B, Fig. 82-9.
The common supination-external rotation fracture is caused by external rotation of a patient's ankle on his leg, so you will need moderate internal rotation of his foot to correct it. Use one of your hands to support his heel and nudge his lateral malleolus medially, while your other hand presses his tibia laterally. Meanwhile, ask your assistant to steady his knee. Between you, you will be able to apply three point fixation.
After reduction the patient's foot must not rotate on his leg if it does, reduction will certainly be lost. So, the cast must extend above his knee, and his knee must be gently flexed. There are no short cuts. Be sure to: (1) Apply the cast as described. (2) X-ray the patient at least once before 2 weeks have elapsed, so that you can have another attempt to reduce his fracture before it is too late. Most reductions are lost during this period. (3) Prevent him from walking on his cast too earlythis is a very common error.
MOST MALLEOLAR FRACTURES HAVE ONLY TWO PARTS SUCCESS DEPENDS ON GETTING THE DETAILS RIGHT
===CHARNLEY'S METHOD FOR MALLEOLAR
FRACTURES
MANAGEMENT===
INITIAL X-RAYS
Study these carefully. Order all the X-rays when you first see the patient, make sure they are taken on the right days, look at them within hours of their being taken, and act on them that day. If you forget to do this, nobody will bother to see they are taken.
If there is only a hairline crack in a patient's lateral malleolus, firm strapping may be enough.
If there Is more than a hairline crack, but no incongruity In the joint surfaces, apply a short leg walking cast (not a malleolar cast) for 2 weeks. If a forced inversion X-ray shows that his lateral ligament has been ruptured, leave it on for 8 to 10 weeks. Encourage him to walk without a limp as soon as he comfortably can.
If there is any incongruity of the joint space, admit him and treat him by closed reduction as described below.
If there is a large upwardly displaced posterior tibial fragment, expect difficulty, and try to reduce it by the special method described later.
CAUTION ! (1) A severe malleolar fracture is not suitable for out-patient treatment. (2) If he cannot walk, even a few steps on the night of admission, suspect a serious ankle injury. If X-rays show no fracture, he may have ruptured his lateral ligament. If clinical signs are inconclusive, take a forced inversion X-ray (Fig. 82-1). If you delay treatment, your chances of success will be much less.
CLOSED REDUCTION
CONTRAINDICATIONS
If the patient has a severe open or comminuted malleolar fracture, treat him as in the next sec. tion. If possible, refer him for internal fixation if he has: (1) Shortening of his fibular malleolus. (2) Impaction of his tibial plateau. (3) A posterior fragment more than one third of the width of his tibia. If you cannot refer him, do what you can by closed methods.
ANAESTHESIA
Give him a general anaesthetic, or ketamine (A 8.2).
EXPLORING THE MOBILITY OF A MALLEOLAR FRACTURE
The following description applies to the common severe Stage III or IV supination-external rotation trimalleolar fractures, in which a patient's talus and his foot together are displaced posteriorly. In other fractures, and particularly the rarer ones in which his talus is displaced anteriorly, adjust your manipulations appropriately.
Lie him with his legs over the end of the table. Find an assistant.
Finding the position of reduction Explore the up and down and side to side mobility of the patient's ankle joint, as in Fig. 82-8, while you try to find the best position of reduction.
If you hold his heel in the palm of your hand, with his leg horizontal and in slight external rotation, as in A, Fig. 82-9, the fracture will probably reduce itself.
If it is not reduced, rotate his foot internally a little, and fit his talus back into the lower end of his tibia. Align his patella carefully with his toes, so that it is the same on the fractured side as on the normal one. In this position the fracture should stay reduced. Ask an assistant to hold the patient's leg, and see if you can improve the position by applying three point fixation, as in B, Fig. 82-9. Feel if there seems to be any danger of over-reduction. This is usually not possible.
Memorize the most stable position where you can most easily apply pressure to reduce the fracture. Remember carefully just how far forwards and how far medially you have to move his foot. You will need to return it to this same position while the plaster sets.
APPLYING THE FIRST MALLECLAR CAST
Ask your assistant to hold the patients toes. Apply 1 cm of cotton wool padding to his foot, ankle, and calf. Bind the wool on tightly and smooth it carefully. Use cold water to make the cast set slowly. Quickly wet and apply three 20 cm plaster bandages lightly from his MP joints to just below his knee. Three bandages will make the cast thick enough to hold his foot reduced, without obscuring the feel of reduction. At this stage disregard the reduction of the fracture, and the position of his foot.
As soon as the plaster is on, and while it is still soft, take his leg from your assistant. Massage the plaster thoroughly to remove air bubbles from between the layers of the bandage.
If the posterior tibial fragment is small, ignore it. Feel the fracture by moving his foot about inside the soft cast. Use the experience you have already gained to reduce it. Apply three point fixation, as in B, Fig. 82-9. Ask your assistant to steady the patient's knee (1). With one of your hands press the lower end of his tibia laterally (2). With your other hand press his heel upwards and press his lateral malleolus medially (3), while you rotate his foot internally a little (4). His lateral malleolus is attached to his foot. So, the pressure of the palm of your hand medially on his ankle will restore it to its correct position. Very little force is necessary, and if you have placed his foot correctly, gravity alone should be almost enough.
CAUTION ! (1) Keep his foot absolutely still until the cast has set. Don't apply any finishing touches until it is hard. (2) Don't apply the cast with his ankle inverted. (3) As an additional check, make sure both his feet are similarly aligned in relation to his patellae. (4) Avoid the errors in Fig. 82-10.
If the posterior fragment is large, is displaced upwards, and does not come down on the usual manipulation, make use of the distal tibial origin of the patient's flexor hallucis longus muscle. Strongly plantar flex his ankle into equinus. Dorsiflex his big toe sharply. Then, holding his toe dorsiflexed, bring his foot into the neutral position. Hold his foot in this position and apply a cast as described above.
If the posterior fragment is large (more than 1/3 of the width of his tibia), and does not come down by this method, refer him.
AFTER THE CAST AROUND HIS ANKLE HAS SET
When the first coating of plaster has set, and there is no danger of his fracture slipping, complete the cast up to his mid-thigh, with his knee flexed to 20°. Finish its top and bottom edges, and apply extra plaster bandages to strengthen it if necessary. While it is still soft, split the lower leg portion anteriorly down to his skin, but don't spread it.
CHECK X-RAYS
Take an AP view in 2U° of internal rotation and a lateral view immediately after reduction. If his talus is not in exactly its right place (Fig. 82-6), remove the foot and ankle part of the cast, have another try, and complete the cast once more, making sure that the junction of the new and oId parts do not press on his skin.
POSTOPERATIVE CARE FOR A MALLEOLAR FRACTURE
Put the patient to bed, raise his leg to reduce swelling (81-1), and observe the circulation of his toes carefully for 24 hours. If it is impaired, or if he is in pain, spread or remove the cast, and reduce the fracture again later. Ask him to move his leg and toes inside the cast as much as he can. Keep him in bed for 2 weeks. If the swelling was allowed to subside before you manipulated and reduced his fracture, keep him in bed for a few days, and then get him up on crutches.
One week after reduction, X-ray him to make sure the position has not been lost.
If reduction is satisfactory, discharge him, on crutches without weight bearing.
If reduction is not satisfactory, have another attempt at closed reduction. If this fails, refer him for internal fixation, if you can.
Two weeks after reduction, take another check X-ray. If reduction is not satisfactory, have a final attempt at reduction.
If this fails, refer him for open reduction.
CAUTION ! If his fracture is severe, make sure he understands that he must not bear weight on his ankle until 6 weeks after the injury. Keep him on crutches. If his fracture ' s less severe, he can start to bear weight at 4 weeks. Six weeks after reduction i s the normal time for weight bearing to start.
Eight weeks after reduction, rhange his full length malleolar cast for a short leg walking cast (81.5). Carefully mould its upper end by triangular compression (Fig. 81-5) and fit it with a walking heel. Let him continue walking on crutches with increasing weight bearing to tolerance for 4 more week.
At 10 to 12 weeks, remove his short leg walking cast. ALTERNATIVELY: (1) If necessary, you can end the cast below his knee and incorporate an oblique Steinmann pin in it (81.12). (2) The number of X-rays you take and casts you apply can, if absolutely necessary, be reduced. Always X-ray a patient immediately after reduction and at the end of the first week.
DIFFICULTIES WITH MALLEOLAR FRACTURES
If a patient's FOOT IS POSTERIORLY DISPLACED on his lower leg, pull his leg forwards and suspend the foot in stockinette until the swelling has gone. This is common when there is a large posterior tibial fragment.
If you CANNOT REDUCE AND HOLD THE FRACTURE by three point fixation, there are probably soft tissues between the fragments, or in the joint cavity, as in C, Fig. 82-4. If you rely on closed reduction, the fracture will probably slip later, so refer him for open reduction.
REDUCE THE PATIENT'S FRACTURE CAREFULLY APPLY THE CAST PROPERLY X-RAY HIM AT THE END OF THE FIRST WEEK DON'T LET HIM BEAR ANY WEIGHT FOR 6 WEEKS
82.7 Open or comminuted malleolar fractures
Severe open or comminuted malleolar fractures are not suited to the method in the previous section. You will meet with various difficulties: (1) The end of the patient's tibia may be comminuted, and his talus driven up into it, as in Fig. 82-11. (2) One or other, or commonly both, the collateral ligaments of his ankle may be stretched or ruptured completely. (3) His foot may be displaced posteriorly, and the lower end of his tibia may be sticking out of a dirty wound.
If there is an open wound over a malleolar fracture, do a thorough wound toilet, and reduce the fragments as best you can by closed methods. Then leave it open. If you fail to do an adequate wound toilet, or you close it by immediate primary suture, the patient's ankle joint is certain to become infected. He has little hope of a pain-free moveable, ankle, so make quite sure that what little movement he will have will be about the position of function in neutral. An ankle fixed in equinus, as in Fig. 82-2, is a real disaster. If pain becomes a major handicap, his ankle can be fused later.
AN OPEN OR GROSSLY DISORGANIZED ANKLE
If a patient's malleolar fracture fracture is open, take him to the theatre, anaesthetize him, and do a thorough wound toilet (54.1). Scrape the dirt out of his ankle, squirt saline into it, scrub his wound well, explore it, and enlarge it if necessary.
Restore the position of his bones as best you can. Make a special point of trying to align his talus with his intact malleolus and his tibial plateau. If both his malleoli are fractured, line his talus up with his tibia as best you can.
CAUTION! Don't close his wound!
If possible, refer him at this stage, his fracture may be one of those in which skilled internal fixation can give him a useful ankle. If you cannot refer him, proceed as follows.
If there is serious damage to the weight bearing part of his ankle joint, as in Fig. 82-11, the best he can hope for is early spontaneous fusion. Start by applying medial and lateral splints until the swelling has subsided. Then apply a long leg cast, and start partial weight bearing with crutches as soon as pain will allow. If his ankle does not fuse, it may need to be fused surgically.
If the weight bearhig part of his ankle is not seriously injured, try to preserve some function, and apply calcaneal traction (if his calcaneus has not been injured). Pass a Steinmann pin through his calcaneus (70.11), apply 5 kg traction, and raise the foot of his bed 25 cm. Cradle his leg on a pillow. On the day after the accident, encourage him to start movi ng his ankle. Maintain traction for 6 weeks. After that he can get up, but he must not bear weight for another 6 weeks.
If his foot is warm and sensation is present, don't amputate, however severe his injury is. Some sort of a foot is likely to be better than none. Only amputate if his foot is cold and without sensation, and if he can get a prosthesis.
CAUTION ! if movement is likely to be limited subsequently, it must be about the neutral position.
82.8 High spiral fractures of the fibula (Maisonneuve fracture)
This rare fracture is really a variety of malleolar fracture in which a patient's fibula, instead of breaking at his ankle, separates from his tibia at his ankle, twists, and breaks just below his knee. His lower tibio-fibular ligament ruptures, so does the whole of his interosseous membrane from top to bottom.
HIGH SPIRAL FRACTURES OF THE FIBULA
Treat the patient as if he had a malleolar fracture (82.6).
If you can reduce the fracture satisfactorily, apply a long leg cast with his knee in a slight flexion. X-ray him weekly to make sure that reduction is maintained. if it is lost, correct it immediately before malunion occurs.
If you cannot reduce the fracture satisfactorily, refer him.
82.9 Separation of the distal tibial epiphysis
This is a child's equivalent of a malleolar fracture. You can usually manage Salter Harris type II epiphyseal injuries (69.6a), like those in Fig. 82-12, by closed reduction. Type III injuries, in which the fracture line opens into the joint, need open reduction to restore a smooth joint surface. This is also the most common site for the Type V injuries which crush the epiphyseal plate.
Because there is no displacement, you may think that a child has only sprained his ankle, until growth deformities occur years later.
SEPARATION OF THE LOWER TIBIAL EPIPHYSIS
Anaesthetize the child, exert strong traction on his foot and manipulate his ankle into position. Take great care to correct rotation. Apply a long leg walking cast for 6 weeks.
82.10 Injuries to the flexor mechanism of the ankle
Injuries of the flexor mechanism of the ankle can be open, as when cut by a kinfe, or closed. Closed injuries are the result of spontaneous rupture of flexor mechanism during violent or even moderate activity. They take two forms:
(1) Rupture of the plantaris tendon or a minor tear of the gastrocnemius muscle present as a sudden pain in the calf muscle, often during only minor exertion, accompanied by exquisite tenderness in the middle of the calf. This is a much less serious injury than rupture of the Achilles tendon. Distinguish it from rupture of the Achilles tendon by the 'kneeling on a chair test' in Fig. 82-13. It will recover spontaneously in a few days. A raised shoe will ease symptoms.
(2) Rupture of the Achilles tendon occurs during some violent sport. The patient hears a loud snap and cannot rise on the ball of his foot. You may be able to feel a gap just above his calcaneus. This injury is commonly missed, because nobody tests the integrity of his tendon as described below. Treat him conservatively-its frayed ends are difficult to repair. An open injury, as by a knife, can be repaired without difficulty by the standard methods. Or, you can treat the patient conservatively in an equinus cast. If he has a ragged wound, an equinus cast is better, because the Achilles tendon has a poor blood supply and is easily infected. Some surgeons prefer it for all open Achilles tendon injuries, because the results are so good. Although injuries (1) and (2) are usually considered to be distinct, there is probably a continuum between them. The important distinction as far as treatment is concerned is whether the 'kneeling on a chair test' is positive (indicating the need for an equinus cast) or not. If you leave an injury of the Achilles tendon totally untreated, the patient's calf muscles will pull the proximal end of his tendon upwards, and leave a space that will fill with scar tissue, so that he loses the take off of a normal gait.
ACHILLES TENDON INJURIES
DIAGNOSIS
A patient's Achilles tendon mechanism is intact and he needs no special treatment if: (1) He can plantar flex his foot against resistance. Or, (2) his foot plantar flexes when you pinch his calf muscles as he kneels on a chair If it is not intact, his foot will remain still, and he needs treatment as described below.
SPONTANEOUS RUPTURE
Keep the patient's foot plantar flexed in a cast in gravity equinus for 8 weeks. This is the amount of equinus which gravity alone produces but no more. Build up the base of the cast and apply a walking heel as in Fig. 81-3. After 48 hours, encourage him to walk-it will stimulate the repair of his tendon.
At 8 weeks remove the cast. Protect his tendon for a further 8 weeks by raising his heel at least 3 cm (a cobbler should have been doing this during the first 8 weeks). Caution him against running, or any violent excercise for 3 more months.
CUT ACHILLES TENDON
Toilet the patient's wound thoroughly, and suture it by the methods in Section 55.11. Leave at least part of it open for delayed primary closure. Or, treat him as above.
If you cannot suture his Achilles tendon, or have decided against suture because his wound is ragged or contaminated, or for any other reason, put him into an equinus cast as described above.
