Ankle fracture Maisonneuve Fracture – Everything You Need to Know

 

      Ankle fracture Maisonneuve Fracture – Everything You Need to Know

                         https://www.youtube.com/watch?v=m35lMOtMJHQ

Maisonneuve fracture involves fracture of the proximal fibula associated with an occult and unstable injury of the ankle. The problem in these patients occur when the ankle injury is presented without a fracture of the lateral malleolus, or the medial malleolus and the injury is mistakenly diagnosed as an ankle sprain and the proximal fibular fracture is missed. Examine the leg for tenderness in the proximal fibula to diagnose a proximal fibula fracture. The patient could be mistakenly treated for having an isolated proximal fibular fracture alone and the ankle injury is missed.

 High index of suspicion is necessary to diagnose and treat this injury. Maisonneuve fracture equals syndesmotic injury. Syndesmotic Injury equals Syndesmotic Reduction and Fixation. If ankle x-rays show medial or posterior malleolus fracture, or a medial clear space widening with no fracture of the lateral malleolus, then you must obtain a long-leg films to assess possible proximal fibular fracture. Clinical examination of their entire leg for pain and tenderness in addition to long leg films of the entire leg that includes the ankle, and the knee is mandatory in case of the patient with approximate fibular fracture to exclude the presence of an additional ankle injury, or if the patient has an unexplained increase in the medial clear space of the ankle joint. You should be searching for the presence of a high fibular fracture. Look for signs of syndesmotic injury such as an unexplained increase in medial clear space or tibiofibular clear space is widened and it should be less than 5 millimeters.

So how do you explain this injury? It is explained by the presence of rotation force to the ankle with transmission of the force through the interosseous membrane, which exits through a proximal fibular fracture. Maisonneuve fracture occurs from external rotation of the foot, most often with pronation mechanism. This force has to go somewhere! If you don't see a fracture of the fibula then do the squeeze test or the external rotation stress test (both will show syndesmotic). The injury can involve the deltoid ligament injury or medial malleolar fracture medially and a fibular fracture proximally. Additionally, the tibiofibular ligaments are also involved, which can be the anterior tibiofibular ligament, interosseous ligament, the posterior tibiofibular ligament or posterior malleolar fracture. This looks like a very unstable ankle injury that may not be very obvious at presentation and you have to look out for it.

So how do you treat an Maisonneuve Fracture? This treated by fixation of the tibiofibular syndesmotic injury (key of treatment) or syndesmotic screws. if you have a medial site injury and there is a tear of the deltoid ligament, leave it alone. if there's a medial malleolus fracture you should fix that of the lateral side if there's approximate fibular fracture leave it alone. If there is a medial malleolar fracture, it should be fixed. If there is a proximal fibular fracture on the lateral side, leave it alone. As for the Syndesmotic Injury, the fixation has to be stable and adequate. Because of the magnitude of the injury, the Maisonneuve fracture may require more syndesmotic screws than with a routine ankle fracture with syndesmotic injury. After the fixation you will give a short leg non-weight bearing splint for six to eight weeks. Here is a patient taste example: the proximal fibular fracture and you can see increase in the medial clear space and you can see that the syndesmosis is widened. You can see that in the posterior malleolar fracture the patient is fixed with syndesmotic screws.

25 Vitamin D- Tests Orthopedic Surgeons Should Think About

25 Vitamin D, Tests Ortho Surgeons Think About-Everything You Need To Know

Vitamin D 25 is the most appropriate study to assess and monitor vitamin D status in the body. Vitamin D is important for proper maturation and development of bone. Vitamin D is also important in immunity and plays a role in other conditions. The main function of Vitamin D is absorption of the calcium and phosphate from the intestine. Vitamin D comes from diet, supplements, and exposure to the sun. Vitamin D is naturally found in fish. Exposure to the sun for 15 minutes will give a person about 10,000 units of Vitamin D. The average daily requirement of Vitamin D is approximately 400-800 International Units (IUs). Vitamin D gets activated metabolically in the liver and in the kidney. The activation occurs by hydroxylation. Hydroxylation to 25 Vitamin D₃ occurs in the liver. The big organ takes the big number- 25, so 25(OH)-Vitamin D₃. Another hydroxylation occurs in the kidneys. ₂- Vitamin D₃. This is the active form of Vitamin D and works mainly on the intestines and bones. The activation of Vitamin D to 1, 25 hydroxyvitamin D is controlled by the parathyroid hormone. Any deficiency or any problem in the process of activating Vitamin D₃ to its active form will lead to deficiency of Vitamin D in the body. Vitamin D deficiency is very common and the majority of people are not aware of it. In fact, Vitamin D deficiency symptoms are subtle and nonspecific. 25-hydroxyvitamin D has a long half-life and a higher concentration. This is probably easier to measure and obtain 25 hydroxyvitamin D than the active form, which is 1,25-dihydroxyvitamin D. The half-life of 25-hydroxyvitamin D is 2-3 weeks. The half-life of 1,25-dihidroxyvitamin D is only 4-6 hours. The circulating levels of 25- hydroxyvitamin D is 1000x more than 1,25 dihydroxyvitamin D. therefore, 25-hydroxyvitamin D test is the best study to determine the Vitamin D deficiency in the body. A low level of 25- hydroxyvitamin D could mean that a person is not getting enough exposure to the sun, is not getting enough dietary Vitamin D, or there may be a problem with absorbing Vitamin D from the intestines. The patient may be taking Dilantin, which interferes with hydroxylation of Vitamin D in the liver. A low level of 1, 25-dihydroxyvitamin D usually indicates kidney disease. 40% of the United States population have Vitamin D deficiency.The small organ takes the small number-1. The result will be 1, 25 (OH)

Symptoms of Vitamin D deficiency may include:

·         Fatigue and tiredness

·         Not sleeping well

·         Muscle weakness

·         Bone pain

·         Osteoporosis/ Osteomalacia

·         Fractures

Elderly patients are vulnerable to Vitamin D deficiency because they usually live indoors or in nursing homes with no sun exposure or because these patients may not eat enough food containing Vitamin D or they may not receive enough supplements. Vitamin D deficiency may impair or affect wound healing. Vitamin D deficiency may cause bone loss and places the elderly patient at risk of fractures. Deficiency may cause slow healing of fractures or nonunion of the fractures. If you find a patient with fractures that are not healing well, or a patient with fractures due to low energy trauma where you find the bone mass is inadequate (osteoporosis), this is the time to get a 25- hydroxyvitamin D blood test. The Endocrine Society defines Vitamin D deficiency as 25 Vitamin D level below 20 ng/mL, and insufficiency as the level between 21-29 ng/mL. In general, a 25 Vitamin D level greater than 30 ng/mL is probably adequate, but these numbers are controversial.

Olecranon Fractures

Fractures of the olecranon may occur due to a direct blow to the elbow or from a fall onto an outstretched hand. Nondisplaced fractures have less than 2mm of separation and are considered stable. Fracture separation will not increase with elbow flexion. Extensor mechanism is intact and the patient will be able to extend the elbow against gravity. Displaced fractures could be an avulsion, oblique, transverse, comminuted, or dislocated.

Olecranon fracture dislocations can be anterior (transolecranon) or posterior (similar to monteggia fracture dislocation). An examination will show that the patient is unable to extend the elbow with these displaced fracture types. A true lateral view x-ray will clearly show the olecranon fracture. Usually, these fractures are followed by stiffness of the elbow in about 50% of the patients. However, this does not affect the function.

The goal of treatment for olecranon fractures should be restoration of the articular surface, preservation of the continuity of extensor mechanisms, maintain elbow stability, and avoid stiffness of the elbow. Nonoperative treatment is used for nondisplaced fractures and it may be used for some displaced fractures in elderly patients (treat elbow in some flexion with a splint). I would personally use minimally invasive techniques in these patients unless the skin is very bad, or the fracture is very comminuted.

There are three techniques used for surgical treatment: the tension band technique, detach olecranon and reattach triceps, and plate and screw fixation. The tension band technique is only used for transverse fractures with no comminution. K-wires and screws are used, and the surgeon may use either a 6.5mm screw or Kwires for the tension band. When doing the tension band technique, you want to engage the anterior cortex of the ulna. The surgeon should avoid over penetration to avoid affecting the forearm rotation or injuring the anterior interosseous nerve. The surgeon needs to be sure that the pins are not fixing the radius and that after the operation, the patient can perform pronation and supination of the forearm (pull the pins out slightly if needed). The distractive force of the triceps is converted to compression force at the articular surgace, especially when bending the elbow. The drill hole for the K-wire should be positioned about 4-5cm from the fracture which gives enough safe distance so that the fracture will not propagate. Place the tension band wire through the drilled holes before application of the K wires. The surgeon should be sure that the hook to the K-wire is posterior. Make sure that the tension band wire is close to the bone so there is no laxity in the fixation and instability. An intramedullary screw could be used. This screw fixation may need a washer to capture the tension band wire. Intramedullary 6.5mm screw fixation is a reasonable option for fixation but it may need to be supplemented with tension band wires. Never use cancellous screw alone. The tension band technique are for transverse fractures of the olecranon. If fractures comminution is present, change the plan of fixation.

When detaching the olecranon and reattaching the triceps, an excision of the fracture fragment and triceps advancement is used:

• If the fracture is less than 50%
• To treat elderly patients (especially if fracture is comminuted)
• For some nonunions when the fracture is small and cannot be fixed

The surgeon must be sure that the procedure is done with the elbow is stable. If the elbow has ligamentous instability and excision of the fracture fragment is done, this will make the elbow very unstable. The triceps should be attached closer to the articular surface.

Special olecranon plates are available when using a plate and screw fixation technique. The bridge plate and screw fixation technique is used in comminuted, Monteggia, oblique fractures extending to the coranoid, and fracture dislocation. The plate is placed on the tension side of the olecranon (dorsal side). Sometimes, an opening is made through the triceps and the plate is placed against the bone, then suturing the triceps tendon over the plate to avoid hardware prominence.

In summary, if the patient is elderly with a small, comminuted fracture fragment less than 50% of the joint space, excise the fragment, and reattach the triceps tendon to the olecranon. If the olecranon fracture is transverse and proximal to the base of the coranoid process, then use the tension band technique. Use plate fixation for all olecranon fracture scenerios, such comminuted fractures, oblique fractures, unstable fractures, dislocation, or fractures distal to the coranoid process. The typical exam question scenario will discuss a comminuted fracture that should be treated with a plate. You probably need to remove above 20% of the plate fixations due to hardware irritation. Hardware irritation is worse with the tension band surgical treatment (may need to remove in more than 50% of cases).

Triplane Fracture of the Distal Tibia

A triplane fracture of the distal tibia usually occurs during adolescence and occurs before complete closure of the distal tibial physis. The distal tibial physis (growth plate) is a weak area which closes from central to medial, with the lateral side being the last part to close. A Triplane fracture is a Salter-Harris Type IV Fracture, involving all three planes, the coronal (metaphysis), transverse (growth plate), and sagittal (epiphysis). The fracture has several variations and occurs due to external rotation forces. This fracture typically occurs in patients between 12-15 years of age.

Triplane fractures are complicated three-dimensional fractures. A two-part fracture is a Salter-Harris Type IV. A Three-part fracture is a combination of Salter-Harris Type III in an AP view and a Type II in a lateral view. CT scans are helpful.

An ORIF is necessary if there is displacement of the fragments of more than 2 mm.

Distal Femur Fractures & Nonunion- Use of Fibular Graft

The physician may be faced with some complex distal femur fractures or nonunion where the bony stock is not adequate or the fixation may have failed. It may also be a situation where a bone graft cannot be obtained from the patient. In some of these cases, I use an intramedually fibular graft in addition to plate fixation. The intramedullary fibular graft technique can be used in: complicated cases, comminuted fractures with osteoporosis, failure of traditional method of fixation, complex nonunion, and complex supracondylar periprothetic fractures.

How do you perform the technique?

The physician must find the starting point, which is the center of the intercondylar notch just

superior to the Blumensaat’s Line. The physician will insert a guide wire after reduction of the fracture. Then, the physician will ream over the guide wire to the appropriate size of the fibular graft, which you may need to fashion slightly. The physician needs to be sure to change the beaded guide wire to a smooth one and put the fibular graft through the guide wire into the medullary canal across the fracture of the nonunion. If the medullary canal of the fibula is small and it will not go through the guide wire, then place the fibular graft free hand. The physician should be sure that the fibular graft is not prominent through the joint. Next, fix the fracture or nonunion with a plate preferably a locking plate. You can augment the fixation with bone graft, allograft, or bone graft substitute. This procedure can also be helpful in periprosthetic fractures of the distal femur. If the prosthesisi is stable, you will do fixation of the fracture of the nonunion. It will be ideal to use a plate fixation after insertion of an intramedullary fibular graft, especially if the bony stock is very poor and if you can pass the fibular graft through the femoral component.

Isolated Fibular Fractures

Fibular fractures are usually associated with a complex injury, however they can be an isolated fracture. Complex injuries where a fibula fracture can occur include: fracture of the fibula and tibia, ankle fracture, pilon fracture, and Maisonneuve fractures.

Maisonneuve fractures involve a fracture of the proximal fibula associated with an occult injury of the ankle. Isolated fibular fractures are rare and usually the result of direct trauma. The fibula carries about 15% of the axial load and is the site of muscle attachment for the peroneus muscles and the flexor hallucis longus muscle. Check the patient who has a fibular fracture and no other fracture involving the tibia to rule out a possible Maisonneuve fracture, especially if there is no history of direct trauma to the leg. A high index of suspicion is necessary to diagnose and treat this injury. For high fibular fractures, the physician should look for signs of syndesmotic injury. Syndesmotic injury may include an unexplained increase in the medial clear space or the tibiofibular clear space is widened (should be less than 5mm). The x-ray will show the fracture to be rotational or oblique. Maisonneuve fractures require surgery to fix the syndesmosis.

Treatment will consist of reduction and fixation. It is important to determine if the injury is a Maisonneuve fracture or an isolated fibular fracture. An isolated fibular fracture will not need surgery.

Malunions of the Clavicle

It is difficult to reduce and maintain the reduction of clavicle fractures as there will be deforming forces in the midshaft area of the clavicle. The clavicle will heal regardless as to if a sling or figure 8 strap is used. Despite the presence of a bump, fracture displacement, and deformity, healing of the fracture still occurs rapidly. Healing occurs in about 85% of cases, however, the clavicle will not look aligned due to the difficulty in reducing the fracture. It is hard to achieve a reduction of these fracture without surgery. Without surgical reduction, the fracture may end with some degree of malunion and possible shortening of the clavicle. The fragments will not line up with the distal fragment appearing to be downward and anteriorly rotated. Shortening is clinically significant because it alters the dynamics of the muscles around the shoulder. It also narrows the costoclavicular space. The patient may complain of decreased shoulder strength and endurance if the patient had a displaced midshaft clavicle fracture that healed with more than 2 cm of shortening.

What are the symptoms of clavicle malunion?

Pain, easy fatigability, cosmetic problems (especially in females), neurological dysfunction (possible involvement of the brachial plexus—especially the ulnar nerve), and the patient may have thoracic outlet syndrome.

X-rays should be done of both shoulders. Bilateral panoramic views are beneficial in order to measure the shortening. The physician will also want to check the amount of overlap at the ends of the clavicle.

Treatment

Surgical treatment of the malunion may be successful in restoring the function and relieving the pain. A clavicle osteotomy is done in the plane of the healed fracture. The fracture is recreated with correction of the deformity and the length of the clavicle is restored. A local or iliac crest bone graft can be used if needed.

If an osteotomy is done with reduction of the clavicle to its preinjury position and leaves a significant bone defect, the physician will need a tricortical piece of bone at the osteotomy area. It is probably better to use a precontoured clavicle plate in the superior position with six cortices, three placed on each side of the osteotomy.

Tibial Spine Fractures in Children

Tibial Spine fractures are similar to ACL injuries in adults. It occurs due to hyperextension of the knee and is commonly seen during falls from a bicycle. An injured child with a swollen knee and who has fallen from a bicycle should alert the clinician to the possibility of a tibial spine fracture. A meniscal injury may also occur, especially with the medial meniscus. The interposition of the meniscus or rotation of the fracture may prevent a closed reduction.

Tibial spine fractures are classified using the Meyers and McKeever Classification and are separated into three types. Type I classifications are nondisplaced, Type II fractures are identified as being minimally displaced with an intact posterior hinge, and Type III fractures are classified as being completely displaced.

The presentation and examination is similar to an ACL tear with immediate swelling as well as a positive Lachman’s Test or Anterior Drawer Test. An x-ray will show the fracture and a CT scan will help in planning for surgery. An MRI may be required to show a trapped or a meniscal injury.

Treatment

Treatment will consist of an aspiration of the large hematoma. Nonoperative treatment is used for Type I fractures and reducible Type II fractures; a closed reduction and immobilization in 0-20 of flexion. Surgery is performed in Type II fractures and unreducible Type II fractures. An ORIF or arthroscopic reduction and fixation will be performed. During surgery, the trapped meniscus will be moved out of the way and the surgeon will use sutures or screws for fixation. It is important for the surgeon to remember to avoid the physis.

Complication

ACL laxity is common but not clinically significant. Stiffness or arthrofibrosis occurs with surgical fixation. Growth arrest is rare.

Clay Shoveler’s Fracture

A clay shoveler’s fracture is a stable fracture through the spinous process of the vertebra C6-T1 and typically occurs at the level of C6 or C7. Clay shoveler’s fracture gets its name from the common injury suffered by men diffing deep ditches in Australia during the 1930s.

Powerful hyperflexion of the neck combined with contraction of the paraspinous muscles during shoveling is the typical mechanism of injury. The tremendous force pulls on the spinous process, producing an avulsion fracture.

The fracture is best seen on a lateral view x-ray. There will be a ghost sign on AP view x-rays—double spinal process of C6 or C7, resulting from a displaced fractured spinous process.

Stable fractures can be treated nonoperatively, utilizing a collar and physical therapy.

Jefferson Fractures

Fifty percent of patients with Jefferson fractures will have associated spine injuries. The canal is wide with a low risk of spinal cord injuries unless the transverse ligament is disrupted. It is difficult to view Jefferson Fractures on an x-ray (usually seen on the lateral side”. This fracture is considered a “Junctional Fracture” and could be missed. The classic Jefferson fracture is a burst fracture that results from an axial load. It could be a four part fracture with bilateral fractures of the anterior and posterior arch. There are variations which include two and three part fractures and incomplete formations of the posterior arch can be mistaken as a fracture.

When speaking of Jefferson fractures, it is important to be familiar with the structures that may be involved. These bony structures include: The Atlas (C1), Axis (C2), and the odontoid process. C1 and C2 are stabilized together by the transverse ligament and C1 and C2 provide a 50% of rotation of the neck. The C1 is a ring. At the upper cervical region, the spinal canal is 2.5 times larger than the cord size. The stability and treatment of Jefferson fractures depends on the integrity of the transverse ligament and the displacement of the fracture. You need to know about the important ligaments related to the Jefferson fracture. These ligaments include: the transverse ligament, the apical ligament, and the Alar ligament.

Diagnosing ligamentous injury

In order to determine a ligamentous injury, the physician will want to check the Atlanto-dens interval (A.D.I). Normally, this interval should be less than 3mm in adults and less than 5mm in children. If the ADI is between 3-5mm, this indicates an injury to the transverse ligament; the transverse ligament holds the odontoid and C1 together, alar and apical ligaments will be intact. If the A.D.I measures greater than 5mm, then there is an injury to the transverse, alar, and apical ligaments.

Fracture Types

A bony injury with the intact transverse ligament and a lateral mass displacement less than 7mm and the A.D.I is less than 3mm is considered a stable fracture. Nondisplaced fractures of this nature should be treated with a rigid orthosis. If the fracture is displaced, a halo will need to be used.

Another type of fracture can occur at C1 with a transverse ligament tear. The Atlanto-dens interval will be more than 3 mm in adults. The treatment will depend on the type of injury to the transverse ligament. With bony avulsions of the transverse ligament, the halo will need to be used cautiously. However, some surgeons prefer to do a fusion of C1 and C2. If there is an intrasubstance tear of the transverse ligament, the surgeon will perform a fusion at C1-C2. The surgeon will need to do early surgery as this is a significant injury with a risk of spinal cord compression.

In regards to “Open Mouth Views”, the normal overhang is visible during an “Open Mouth View”. If it is just a bony injury Jefferson fracture, the combined overhang will be less than 7mm and the transverse ligament is intact and it is a stable fracture. If a Jefferson fracture has a combined overhang of more than 7mm, then the transverse ligament is probably torn and there is an unstable fracture present.

Radiological Studies

A CT scan is probably the best study in diagnosing the characteristics of the bony injury. An MRI is the best study in diagnosing any associated transverse ligament injuries.

Bone Growth in Children

A Special Thanks to Miranda Ebraheim for assisting with this article

There are growth plates within the long bones which contributes to the development of the bones in children.

The growth distribution in the humerus is about 80% in the proximal and 20% in the distal area. Displaced fractures of the proximal humerus in children are usually treated without surgery.

In regards to the ulna, the growth distribution is about 80% proximal and 20% distal. Growth arrest is common in fractures involving the distal ulna and occur approximately 50% of the time. Within the radius, it is about 25% proximal and 75% distal. Fractures at the distal radius usually heals and corrects its angulation after a closed reduction. Surgery is rarely necessary. Fractures involving the growth plate of the distal radius rarely involves growth arrest.

Within the femur, the growth rate distribution is about 30% proximal and 70% distal. Fractures involving the growth plate of the distal femur may cause major growth disturbances. It is expected that a child grows 1 cm per year from the distal femur growth plate. Boys will continue to grow up until 16 years old, while girls stop growing at the age of 14.

Finally, there are the bones of the tibia and fibula. The growth distribution in the tibia is about 55% proximal and 45% distal. Within the fibula, it is about 60% proximal and 40% distal.

A growth spur occurs at the time of puberty. Puberty typically occurs in females around 8-13 years of age, and at 10-15 years of age in males. Fractures near the growth plate remodel well.