Macedonian Journal of Medical Sciences. 2011 Dec
15;
4(4):393-398.
http://dx.doi.org/10.3889/MJMS.1957-5773.2011.0192
Clinical Science
Fractures of Joint Ankle
Nermin A. Abdic1, Zoran Golubovic2, Stojanka Arsic3,
Miomir Pešic4
1Orthopaedic and Casualty Clinic, Clinical Centre of Montenegro,
Podgorica, Monte Negro; 2Orthopaedic and Casualty Clinic,
Clinical Centre of Niš, Niš, Serbia; 3Department of Anatomy,
Medical Faculty, Niš, Serbia; 4Surgery Clinic, Clinical Centre of
Niš, Niš, Serbia
Joint ankle represents one of the most complicated anatomic-functional
structures of locomotoric apparatus. Upper joint ankle (talocruralis) bind
low tip-end of shank (tibia) and fibula with joint bone (talus) and
represent joint among the bones of shank and foot bones. Upper joint ankle
joint together with lower ankle joint acts like functional, anatomical and
clinical entity not only in physiological conditions but as well in
injuries. These injuries cause not only damages of bone structure but also
of ligaments and soft structures. Fractures of maleolus as the most frequent
of low extremities represent 10-12% of all fractures. As the most frequent
mechanism of injury of joint ankle the inversion of foot is stated when it
is in supination and adduction. This analysis had 151 patient who had joint
ankle fracture both sexes, age 18-45, and among them there were 102 men
(67.55%) and 49 women (32.45%). The patients whose diagnosis was joint ankle
fracture were observed in Orthopedic - Casualty ward of Clinical Centre in
Podgorica. The research period was May 2005-May 2009. The results of our
research show that the most frequently fractures of joint ankle happened
while running 52 patients (34.44%) and the least by fall from the height 22
(14.57%). The most frequent fracture type was SE type 48 (31.79%) and the
least PA type 25 (16.56%).
...................
Citation: Abdic NA, Golubovic Z, Arsic S, Pešic M. Fractures of Joint
Ankle. Maced J Med Sci. 2011 Dec 15; 4(4):393-398.
http://dx.doi.org/10.3889/MJMS.1957-5773.2011.0192.
Key words: fracture; joint ankle; maleolus.
Correspondence: Nermin A. Abdic, MD. Orthopaedic and Casualty Clinic,
Clinical Centre of Montenegro, Podgorica, Monte Negro. E-mail:
drabdic@t-com.me
Received: 30-Jun-2011; Revised: 14-Aug-2011; Accepted: 04-Oct-2011; Online
first: 09-Oct-2011
Copyright: © 2011 Abdic NA. This is an open access article
distributed under the terms of the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any
medium, provided the original author and source are credited.
Competing Interests: The authors have declared that no competing
interests exist.
Ankle joint represents one of the most complicated anatomic-functional
structures of locomotoric system. Upper ankle joint together with lower
ankle joint acts like functional entity not only in physiological terms but
also in most injuries as well [1]. Injuries of ankle joint are important not
only because of their frequency but as well for their polymorphy of clinical
and radiographic picture. These injuries are considered to be the most
frequent cured injuries in orthopaedio-casualty ward and they are also the
most common injuries of locomotoric aparatus [1].
These injuries cause not only destruction of bone structure but also of
ligaments and soft tissues are endangered [1, 2]. Fractures of maleolus as
the most frequent fractures of low extremities are 10-12% of all fractures,
together with fractures of clavicular bone and fractures of low tipend of
radius represent 50% of all fractures, generally [2, 3].
Geppard and his associates say that 80-90% of all ankle joint injuries are
cured with satisfactory functional results, inoperative treatment, but 20%
of patients especially after harder injuries have residual studying of joint
ankle as well as of the injuries of ankles and soft tissues [2].
Lauge-Hensen, in 1942 qualified injuries of ankle joint as historical
period: clinical, experimental and radiographic [5]. Watson-Jones in 1962
found six different appearances of these injuries in which volume and
direction of dislocation of foot were changing [3, 4]. Cadets in West-Point
Academy during four years of schooling are said to have injury of joint
ankle at least once [2-4].
However, young persons till age of 35 are more exposed to these injuries due
to their higher physical activities [4, 5, 7]. Ivanovski said that 50% of
all injuries of shank go to injuries of ankle joint because of its
functional activity, pain and operative treatment is undertaken [7, 8].
Functional Anatomy and Biomechanics
Ankle joint consist of upper and lower parts upper ankle joint
(talocruralis) binds lower tip ends of shin-bone (tibia) and fibula ankle
bone (talus) so it represents joint among bones of shank and foot bones.
Lower ankle joint is split (sinus tarsi) into two ankles: posterior ankle
which binds and hell bone (subtalaris) and front ankle which binds ankle
joints, hell and conical bone (talocalcaneonavicularis) and each of these
two ankles has its own capsulae. Ankle joint transfers the highest pressure
of all ankles in the body and its function is tightly connected with the
function of this complex [8, 9].
Transversal axes which goes through the tip of each maleolus and manes
horizontal flat angle approx 20-300 with transversal axle of the knee. There
are the movements of flexia and extension in sagital line about it. This
axle directs in the field and towards back and together with tibial axle in
frontal line makes angle about 800 open towards medial with variations
approx 68-800 [8, 9].
As compared to the longitudinal axle in horizontal line they make an angle
of about 840 opened towards medial and forward with variations of about
66-990. Longitudinal axle of leg goes through the axle of shaft and around
it there are movements of abduction and adduction of foot in horizontal line
which is possible due to axial rotation in fractured knee. Longitudinal axle
is horizontal and it is in sagital line. It goes through II metatarsal bone
and around it there are movements of pronation and supination of feet.
Important place in biomechanics of joint ankle belongs to tibiofibular s
sindesmosys in which due to concavity of joint surfaces there is sinovial
recesus in the length of 1.5 cm [8-10].
Sindesmosys is linked by three ligaments: tibiofibular anterius,
tibiofibular posterius, tibiofibular interosseum. Movements in joint ankle
happen because of tetive and ligament structures which give static support.
In the case of physiological overweight of the ankle in the first stage
there are different degrees of soft tissues injuries and if the power still
acts it can appear injury of bone structures. The main role in stability of
joint ankle has the element of laterodorsal segment which consist of:
anterior maleolus, tibiofibular syndesmosis and posterious maleolus as it is
often called the back part of low joint surface of tibia together with the
edge while medial maleolus and deltoid ligament have less importance in
stability of joint ankle [8, 9].
Classification of Malleolar Fractures
If you want to understand injuries of joint ankle better you have to
understand mechanism which leads to the injury. Maleolar fracture is
followed by the injuries of ligament apparatus in 80-90% of cases so far
their understanding it is necessary to know the order of bone and ligament
lesia [9, 10].
Classification of these fractures is important as it shows choice of
treatment unoperative and operative and final prognosis. Since early days of
rendgen era anatomic classification was often used and it distincts
unimaleolar, bimaleolar, trimaleolar fractures. This classification had a
little significance in practice as it did not take into consideration
ligament lesions and mechanism of injuries [10].
Maisonneuve tried in 1839 to classify these injuries as mechanism and his
work was updated by Ashurs and Brower, 1922 [10, 11]. In their
classification there are 4 groups: 1. outrotational, 2. abducto-pronational,
3. adducto-supinational, 4. compressive fractures [11]. Lauge-Hansen in 1942
tried use his classification in therapeutic purposes causing cadaveric
joints fractures and proved that under certain circumstances emerge specific
forms of fractures and lesions of ligaments. He took into consideration bone
and ligament injuries explaining very precisely mechanism of fractures [5].
He divided fractures into 4 types: 1. supinatio-eversive; 2.
pronatio-eversive; 3. pronatio-abductional; and 4.supinatio-adductional. It
is considered that by Lauge-Hansens classification is taken into
consideration approx 93-99% of these fractures [11, 12]. Diagnosis of ankles
injuries is taken on the basis of anamnesis with particular view on the
mechanism of injury (the position in which there was, the time of haematoma
appearances) clinical (oedema, painfully palpable sensitivity of specific
points) manual tests (frontal draw, talar angled) and RTG checking.
Anamnesis is not often reliable because the most of injured patients can t
remember mechanism of injuring and clinical check must be undertaken before
radiography [11-13].
Cedell recommends parallel picture of both joint ankles [11]. As intra
articular fractures are considered, only restitution of anatomic relations
of joint bodies can guarantee functional restitution. Fractures of joint
ankle are very different by the form itself, and it hardens correct
diagnosis so if it is not properly diagnosed it can t be cured adequately.
Adequate curing of maleolar fractures mean total knowing of mechanism of
their emerging. The best way give Lauge-Hansen s genetic classification
which makes possible correct knowing if stable or unstable fracture matters,
and give the appropriate ways of their treatment [5, 11, 12].
However, there is still dilemma which kind of treatment is better when these
fractures are concerned; is it unoperative or operative? Many authors think
that it is necessary try at first manual reposition and if we don t get good
position of joint bodies operative procedure is undertaken [12, 13]. Besides
the level of injury we have to take into consideration general health of the
injured person, age, and the time since the injury if talk about the result
of curing [13, 14].
Unoperative treatment means manual reposition in the shortest possible time
after injury. Reposition is made by manoeuvring vice-versa of injury
mechanism. After reposition it is recommended immobilisation in duration of
6 weeks. Pressure begins after 8-10 weeks [13-15]. Supporters of operative
curing say that the aim of curing of all joint fractures is exact anatomic
reposition, stable inward fixation and early immobilisation. Optimal time
for operation is within 6-8 hours. Complications of operative treatment are:
infection, fracture of fixational material, redislocation of fragments,
ossification of syndesmosis and pseudoarthrosis and complications which
occur in operative or unoperative way are Sudeck s distrophy and arthrosis
[15-17].
The aim of this work is: 1) to determine the most frequent type of joint
ankle fractures; 2) to determine the most frequent mechanism of injuring
joint ankle; 3) to determine specific fractures at joint ankle.
Analysis included 151 patients (or examinees) of different profession, with
ankle joint fractures. The patients were males and females (age between
18-45 years), who came into ortopedo-casualty ward, after the injury of
joint ankle. The group consisted of 102 men (67.55%) and women 49 (32.54%).
The patients who undergo clinical and radiographic were diagnosed fracture
of joint ankle were observed in urgency ward as well as in Ortoped Casualty
Ward of Clinical Centre in Podgorica. The research was undertaken in period
of May 2005-May 2009.
The patients were examined in order to find the most often type of fracture
and the most frequent way of occurrence of fracture. In this work we used
Lauge-Hansen s method of classification which represents four types of joint
fractures as we mentioned above [5].
There were 102 men (67.55%), 49 women (32.45%) in examined group that is
shown in Table 1.
Table 1: Distribution of patients by sex.
The most frequent fractures were supinatio-eversional 48, (31.79%) then
pronatio-eversional 45 (29.80%), or supinatio-adductive 33 (21.85%) and the
smallest percentage was at pronatio-abductive 25 or (16.56%).
Presence of some fractures of joint ankle is shown in Table 2.
Table 2: Distribution of some types of joint ankle fractures.
When distribution of sextype is questioned we concluded: women had PA types
of fractures 16 (32.65%) and the least SE fractures 9 (18.37%). At men the
most frequent fracture was SE type 39 (38.24%) and the least PA types 9
(8.82%). Differences were statistically important and they are shown in
Table 3.
Table 3: Distribution of some types of fractures by sex division.
X2=15.73; p=0.0013; p<0.001.
When the most frequent occurrence of fracture is concerned we have following
results. The most frequent fractures of joint ankle occurred while running
52 (34.44%), then at landing and while walking 31(20.53%) and the least the
fall from the height 22 (14.57%) (Table 4).
Table 4: Presence of some ways in which occur fracture of joint ankle.
The way of occurrence of the injury: running walking, fall from the height,
landing etc. Running-SE type of fracture 18 (34.62%) and the least SA type 8
(15.38%). While walking the most frequent is SE type 11 (35.49%) and the
least PA and SA type 6 (19.35%). When the fall from the height is in
question equally occurred PE, SE and SA type fracture 4 (18.18%).
Table 5: The frequency of some types of fractures of joint ankle compared to
occurrance of injury.
X2=7.06; p=0.8536; P>0.05.
At landing occurred PE fractured type 12 (38.71%) and the least PA type 2
(13.33%). In this case of research important statistic differences were not
found, p>0,05 (Table 5).
Table 6: The way of occurrence at men and women in examined group.
X2=2.6; p=0.6268; P>0.05.
We compared the way of emerging of joint ankle fractures of men and women.
The men injured mostly while running 33 (32.35%) and the least by the fall
from the height 16 (15.69%). The women injured while walking 12 (24.49%) and
the least by fall from the height 6 (12.24%). The differences were not
statistically significant (Table 6).
This work researched 151 patient of both sexes 102 men (67.55%) and 49 women
(32.45%) who after the injury came into urgency block or ortopedic-casualty
ward of Clinical centre in Podgorica.
In series of C.A. Cedel, 1967 the number of women patients were 60.67%,
while the men were 39.33% [11]. In recent years the number of injuries of
joint ankle has grown up. There are many dates which prove this. Clanton in
his book Orthopaedic Sports Medicine-weekend recreationists claim that the
most frequent injuries at recreationist, and 3% of all injuries are related
to foot. Depending of sports which they train depends the type and degree of
injury [12]. The foot is very adjustable but vertical pressure of 0.6 times
of body weight, 7.9 times at running or jumping can lead to acute injury.
This is also caused by the fact that with the age the tissues lose their
flexibility so if there is no preparation they also lose strength,
elasticity and they are very opened to damages.
In our research the fractures of joint ankle the most frequently happened
while running 52 (34.44%) then while walking and at landing 31 each (20.53%)
and the least by the fall from height 22 (14.57%). Cedel’s research claim
that the most often injuries happened at the fall from height (40.5%) and
then fall from stairs (17.5%) and sports injuries (10.5%) [11].
When distribution of patients by the sex is regarded we got the following
figures: Women had the most frequent fracture of PA type 16 (32.65%) and the
least SE type (18.37%). Men had the most frequent SE type 39 (38.24%) and
the least PA types 9 (8.82%). Data of different studies gave different
results. Weisler et al researched connection between volume of movement in
joint ankle and injuries of joint ankle at professional dancers and they did
not find difference in incidence considering the sex [13]. Beynonn et al as
a risk for the injury of joint ankle among 118 sportsmen (football, hockey)
say that is the same for both sexes, but the risk factor at men was angled
talar and at women the higher varus of tibia [3]. Benell et al show
difference taking into consideration number of injuries by sexes but the
leading risk factor at men is not found, and at women it was menarch,
mineral consistence of bones and volume of shank [14].
The most frequent fracture type in our research was SE 48 (31.79%), then PE
45 (29.80%) then SA 33 (21.85%) and the least PA types 25 (16.56%). The most
frequent fracture by Lauge-Hansen s method was SE (66.9%) then PE (27.0%)
and the least PA types of fractures (5.0%) [5].
Conclusions
1) The most frequent type of fracture of joint ankle in our research was SE
type 48 (31.79%) and the least 25 (16.56%).
2) The most frequent type of fracture at women was PA 16 (32.65%) and the
least SE type 9 (18.37%). At men the most frequent type of fractures was SE
type 39 (38.24%) and the least PA type 9 (8.82%). The differences here are
not statistically significant.
3) The most frequently injuries happened while running 52 (34.44%) then at
landing and walking 31 (20.53%) and the least from the fall from height 22
(14.57%).
4) When the types of joint ankle fractures are question regarding occurrence
of injuries, i.e., specific characteristic of joint ankle we got the
following results: running-SE types of fractures 18 (34.62%) and the least
SA types 8 (15.38%); while walking there were the most frequent SE types 11
(35.49%) and the least PA and SA 6 (19.35%).
5) Fall from the height proved following figures equally PE, SE, SA fracture
types each 6 (27.27%) and the least PA type 4 (18.18%); at landing the most
frequent was PE fracture type 12 (38.71%) and the least PA type 2 (13.33%).
When the frequency of fractures of joint ankle is compared to the way of
injury statistically important difference was not found (p >0.05).
1. Butkovic I. Oboljenja skocnog zgloba i stopala. U: Vukašinovic Z. i sar
(ed), Specijalna ortopedija. Beograd, 2004:457-466.
2. Geppert MJ. Soft-tissue injuries of the ankle. In: Mizel M, Miller R,
Scioli M. Orthopaedic knowledge update-Foot and Ankle 2. American Academy of
Orthopaedic surgeons, American Orthopaedic Foot and Ankle Society; 1998:p
229-243.
3. Beynnon BD, Renstrom PA, Alosa DM, Baumhauer JF, Vacek PM. Ankle ligament
injury risk factors: a prospective study of college athletes. J Orthop Res.
2001;19:213-20.
4. Beauchamp CG, Clay NR et al. Displaced ankle fractures in patients over
50 years of age. J Bone Joint Surg. 65-B;3:329-32,1983.
5. Hansen N Lauge. Ankelbrud I. Genetisk diagnose og reposition. Diss.
Munksgaard: Kbhn, 1942.
6. Dašic Ž. Povrede skocnog zgloba i njihovo lijecenje. Medicinski fakultet
Podgorica 2002:10-32.
7. Ivanovski. Povrede skocnog zgloba. Prosveta: Novi Sad, 2000:54-55.
8. Stefanovic N. Anatomija donjeg ekstremiteta. Bones-Niš, izdanje
2002:111-119.
9. Bell NS, Mangione TW, Hemenway D. High injury rates among female army
trainees: a function of gender? Am J Prev Med. 2000;18(suppl 3):141-8.
10. Klenerman L. The menagement of sprained ankle. Br J Bone Joint Surg J Br
J. 1998;80:10-17.
11. Cedel CA. Ankle lesions. Acta Orthop Scand. 1975;46(3):425-45.
12. Clanton TO. Ethiology of injury to the foot and ankle, in: DeLee JC,
Drez D, Stanitski CL (eds). Orthopaedic Sports Medicine: Principles and
Practice. Philadelphia: WB Saunders, 1994:1642-1704.
13. Weisler ER, Hunter DM, Martin DF, Cure WW. Ankle flexibility and injury
patterns in dancers. Am J Sports Med. 1996;24:721-9.
14. Benell KL, Malcolm SA, Thomas SA, Reid SJ, Bruckner PD, Ebeling P et al.
Risk factors for stress fractures in track and field athletes. A
twelve-month prospective study. Am J Sports Med. 1996;24:810-18.
15. Chomiak J, Junge A, Peterson L. Severe injuries in football players.
Influencing factors. Am J Sports Med. 2000;28(suppl 5):S 52-73.
16. Carr G. Sports mechanism for coaches. Champaign, IL: Human Kinetics,
2004.
17. Bull NS, Mangione TW, Hemenway D. High injury rates among female army
trainees: a function of gender. Am J Prev Med. 2002;42(6):617-628.
18. Dvir Z. Clinical Biomechanics.Churchill Livingstone: Edinburgh, 2000.
19. Gayton CA. Medicinska fiziologija. Savremena administarcija - Medicinska
knjiga: Beograd, 1996.
20. Hong Y. International Research in Sports Biomechanics. New York:
Routledge, 2002.
21. Hosea TM, Carey CC, Harrer MF. The gender issue: Epidemiology of ankle
injuries in athletes who participate in basketball. Clin Orthop.
2000;372:42-56.
22. Jovovic, V. Biomehanika sportske lokomocije. Filozofski fakultet: Nikšic,
2003.
23. Lynch SA. Assesement of the Injured Ankle in the Athlete. J Athl Train.
2002;37(4):397-423.
24. Murphy DF,Connolly DJ and Beynnon BD. Risk factors for lower extremity
injury:a review of the literature. Br J Sports Med. 2003;37:11-43.
25. Osborne MD, Rizzo TR. Prevention and treatment of ankle Sprain in
athlets. Sports Med. 2003;33(15):1123-1157.
|