Secrets To Treating Ankle Fractures In Athletes

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What You Should Know About The Lauge-Hansen Classification System

Supination Adduction
Stage I Transverse avulsion fracture of the fibula at or below the ankle joint or rupture of the lateral collateral ligaments
Stage II Stage I plus an oblique to vertical fracture of the medial malleolus
* Supination adduction constitutes 16 to 20 percent of all ankle fractures.
* Stage I accounts for 33 to 50 percent of supination adduction injuries.

Supination External Rotation
Stage I Rupture of the anterior inferior tibiofibular ligament or Tillaux-Chaput (tibia)/ Wagstaffe (fibula) avulsion fracture
Stage II Stage I plus spiral oblique fracture of the fibula beginning at the ankle joint (posterior spike on lateral X-ray)
Stage III Stage II plus rupture of the posterior inferior tibiofibular ligament or an avulsion fracture of the posterior malleolus (small fragment fracture – Volkmann)
Stage IV Stage III plus an avulsion fracture of the medial malleolus or rupture of the deltoid ligament
* Supination external rotation (SER) is the most common ankle fracture, accounting for 60 to 80 percent of ankle fractures.
* Stage I accounts for 1 to 31 percent of SER fractures.
* Stage II is the most common SER fracture, accounting for 60 percent of SER fractures.
* Stage III accounts for 2.3 to 16.5 percent of SER fractures.

Pronation Abduction
Stage I Transverse avulsion fracture of the medial malleolus or rupture of the deltoid ligament
Stage II Stage I plus rupture of the anterior and posterior inferior tibiofibular ligaments without diastasis
Stage III Stage II plus a short oblique fracture of the fibula with the fracture line beginning proximal to the ankle joint with an occasional butterfly fragment
* Pronation abduction injuries occur account for approximately 12 to 25 percent of all ankle fractures.

Pronation External Rotation
Stage I Transverse fracture of the medial malleolus or rupture of the deltoid ligament
Stage II Stage I plus rupture of the anterior inferior tibiofibular ligament (diastasis)
Stage III Stage II plus high spiral oblique fibular fracture above level of ankle joint (posterior spike)
Stage IV Stage III plus rupture of the posterior inferior tibiofibular ligament or avulsion fracture of the posterior malleolus
* Pronation external rotation is the most destructive ankle injury.

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Secrets To Treating Ankle Fractures In Athletes
Here one can see a pronation/abduction stage 1 injury following a softball injury.
This photo shows an intraoperative reduction of a medial malleolus fracture.
This post-op photo shows open reduction internal fixation.
Here is a post-op photo for a patient who had Stage IV supination and external rotation due to a volleyball injury.
This intraoperative photo demonstrates reduction of the fibular fracture with the use of a reduction clamp.
Here one can see a postoperative view of open reduction internal fixation.
48
Author(s): 
By Damieon Brown, DPM, Lawrence DiDomenico, DPM, FACFAS, and Michael VanPelt, DPM

      More and more people are in the pursuit of becoming active and staying fit. More often than not, individuals tend to achieve this goal by participating in sporting activities. Whether they are participating in intramural or competitive activities, these athletes place a great demand on the ankles and feet.

      According to the National Collegiate Athletic Association Injury Surveillance System for 2000-2001, the ankle, knee and lower extremity were common sites of injury. The ankle joint is reportedly one of the most common sports-related injuries clinicians see in emergency rooms and private offices.1 Of these visits, ankle sprains make up 10 to 28 percent and ankle fractures occur 4 to 15 percent of the time.2-4 They account for approximately 3 to 5 million injuries occurring among competitive and recreational athletes in the United States, and cost nearly $1 billion annually in treatment.5

      More often than not, most ankle injuries are sprains or strains and tend to heal with conservative therapy. When the athlete applies greater force on the ankle joint than the joint can resist, a fracture tends to occur. Although the reported incidence of ankle fractures in the athletic population is low, they tend to lead to deleterious results.

      Treatment of ankle injuries and fractures in the highly competitive athletes can be challenging because of the great demand placed on the ankle joint. Despite the tremendous amount of controversy, much attention has been focused on extrinsic and intrinsic risk factors for ankle injuries. Loss of playing time, decline in performance and the expectation to return to pre-injury status are areas in which athletes have great concern.2 Regardless of the competitiveness, the margin of error for accurate diagnosis and treatment of these patients is low.

      When these athletes present with an ankle fracture, one must assess and differentiate between closed versus open fractures and stable versus unstable fractures. Foot and ankle surgeons must also identify injuries to other soft tissue and/or osseous structures. After noting all of the above, clinicians must implement radiographic evaluation to determine the extent of the injury. Surgeons commonly use the Lauge-Hansen and Danis-Weber classification systems to describe ankle fractures, and employ the Berndt and Harty, and Salter-Harris classification systems to assess the degree of talar dome lesions and epiphyseal injuries respectively.5
      Accordingly, let us review these classification systems, risk factors for ankle fractures, treatment options for ankle fractures and their respective outcomes. For this article, we will take a closer look at managing the athletic patient with a particular emphasis on rehabilitation and early weightbearing.

A Guide To Key Classification Systems

      The Lauge-Hansen classification system is the most widely used system to assess ankle fractures.6 This system helps the physician visualize the mechanism of injury, the ability to reproduce the fracture, ascertain the anatomy involved and ability to reduce the fracture. (See “What You Should Know About The Lauge-Hansen Classification System” below.) This classification system was solely based on experimental cadaveric studies and clinical experiences with common fractures. The first term describes the position of the foot at the time of injury while the second term describes the direction of the pathologic force on the talus. The staging in this classification is as follows: supination-adduction, supination-eversion (supination–external rotation), pronation-abduction, pronation-eversion (pronation-external rotation).6

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