Soft Tissue Management in Ankle Fracture Dislocation.
Soft Tissue Management in Ankle Fracture Dislocation
A Case Report
IGK SatrioAdiwardhana*
I WayanSubawa**
*Resident of Orthopaedic and Traumatology Departement, Sanglah General Hospital-Udayana University, Bali
**Staff of Orthopaedic and Traumatology Departement, Sanglah General Hospital-Udayana University, Bali
ABSTRACT
Introduction
The ankle is a complex hinge in which if there is an injury of the ankle region it may affect -in addition to bone,
articular surface, and ligament- any of the tendons, nerves, or blood vessels that cross it. The annual incidence of
ankle fractures (AF) is approximately 122-184/100,000 person years (1:800).2.In cases of fracture dislocation of the
ankle, potentially causes several complications of the bone and soft tissue and has poor functional outcome.The
ideal management strategy for unstable ankle fracture dislocations with critical soft tissues remains a topic of
debate.3,4 The widely used concept of closed reduction and temporary splint immobilization until definitive fracture
fixation bears the risk of prolonged soft tissue swelling and ongoing skin tension due to the unstable ankle joint. 5
Alternative options include immediate definitive surgical management with open reduction and internal fixation
(ORIF) and the more conservative “damage control” approach of temporizing external fixation. Definitive
management must provide anatomic alignment of the joint as well as consideration of the surrounding soft tissues.
Material And Method
A 46-year-old male with a previously neglected fracture dislocation of the ankle, presented after ahistory for being
involved in a high-velocity motorcycle accident 4 months ago and brought his foot to the bonesetter.The clinical
examination showed deformityof the right ankle with a preserved soft tissue envelope. Neurovascular status was
noted to be intact. Radiographic review showed talar dislocation into lateral side and avulsion of the medial
malleolus fragment. We perform two approach, anterolateral and anteromedial for soft tissue identification,
reduction, anatomical restoration, and stabilization of the fractures.
Results
Postoperatively, from clinical examination showed skin intact, warm, without swelling, and no infection. Without
tenderness, neurovascular status was good. Flexion ankle 100, extension ankle 200. From radiographic review, good
positioning of Kirschner wire internal fixation, no dislocation and no fracture line in ankle.
Discussion
If the medial malleolar fragment is very small or comminuted, fixation with a screw may be impossible; in these
cases, use several Kirschner wires or tension band wiring for fixation1 Make an anteromedial curved incision then
identify the deltoid ligament.After that, make an anterolateral longitudinal incision, and expose the lateral malleolus
and the sinus tarsi area. Although additional soft tissue damage is unavoidable in case of operative treatment, it does
not negatively affect outcome in the long term3
Conclusion
Overall, there was not enough reliable evidence to draw conclusions about whether surgery or conservative
treatment is more appropriate for treating broken ankles in adults 4.In this patient, we found good result
bothradiologically and clinically. It need further follow up for these patients to evaluate range of movement.
Keywords: Soft Tissue Management Ankle Fracture Dislocation
A Case Report
IGK SatrioAdiwardhana*
I WayanSubawa**
*Resident of Orthopaedic and Traumatology Departement, Sanglah General Hospital-Udayana University, Bali
**Staff of Orthopaedic and Traumatology Departement, Sanglah General Hospital-Udayana University, Bali
ABSTRACT
Introduction
The ankle is a complex hinge in which if there is an injury of the ankle region it may affect -in addition to bone,
articular surface, and ligament- any of the tendons, nerves, or blood vessels that cross it. The annual incidence of
ankle fractures (AF) is approximately 122-184/100,000 person years (1:800).2.In cases of fracture dislocation of the
ankle, potentially causes several complications of the bone and soft tissue and has poor functional outcome.The
ideal management strategy for unstable ankle fracture dislocations with critical soft tissues remains a topic of
debate.3,4 The widely used concept of closed reduction and temporary splint immobilization until definitive fracture
fixation bears the risk of prolonged soft tissue swelling and ongoing skin tension due to the unstable ankle joint. 5
Alternative options include immediate definitive surgical management with open reduction and internal fixation
(ORIF) and the more conservative “damage control” approach of temporizing external fixation. Definitive
management must provide anatomic alignment of the joint as well as consideration of the surrounding soft tissues.
Material And Method
A 46-year-old male with a previously neglected fracture dislocation of the ankle, presented after ahistory for being
involved in a high-velocity motorcycle accident 4 months ago and brought his foot to the bonesetter.The clinical
examination showed deformityof the right ankle with a preserved soft tissue envelope. Neurovascular status was
noted to be intact. Radiographic review showed talar dislocation into lateral side and avulsion of the medial
malleolus fragment. We perform two approach, anterolateral and anteromedial for soft tissue identification,
reduction, anatomical restoration, and stabilization of the fractures.
Results
Postoperatively, from clinical examination showed skin intact, warm, without swelling, and no infection. Without
tenderness, neurovascular status was good. Flexion ankle 100, extension ankle 200. From radiographic review, good
positioning of Kirschner wire internal fixation, no dislocation and no fracture line in ankle.
Discussion
If the medial malleolar fragment is very small or comminuted, fixation with a screw may be impossible; in these
cases, use several Kirschner wires or tension band wiring for fixation1 Make an anteromedial curved incision then
identify the deltoid ligament.After that, make an anterolateral longitudinal incision, and expose the lateral malleolus
and the sinus tarsi area. Although additional soft tissue damage is unavoidable in case of operative treatment, it does
not negatively affect outcome in the long term3
Conclusion
Overall, there was not enough reliable evidence to draw conclusions about whether surgery or conservative
treatment is more appropriate for treating broken ankles in adults 4.In this patient, we found good result
bothradiologically and clinically. It need further follow up for these patients to evaluate range of movement.
Keywords: Soft Tissue Management Ankle Fracture Dislocation