Stability of Ankle Fracture-Dislocations following Successful Closed Reduction

Transcription

1 Stability of Ankle Fracture-Dislocations following Successful Closed Reduction Andrew P. Matson 1, MD Cynthia L. Green 1, PhD Shepard R. Hurwitz 2, MD Robert D. Zura 3, MD 1. Duke University School of Medicine, Durham, NC 2. University of North Carolina School of Medicine, Chapel Hill, NC 3. Louisiana State University Health Sciences Center, New Orleans, LA

2 Disclosure The authors have no conflicts of interest to disclose.

3 Ankle Fracture-Dislocation Stability Ideal timing of definitive fixation for reduced ankle fracture-dislocations is not well-understood Factors associated with interim loss of closed reduction have not been described Aims: 1. Report the rate of loss of reduction 2. Identify factors associated with loss of reduction

4 Ankle Fracture-Dislocation Stability Methods: Retrospective case series 30 consecutive, isolated, closed, ankle fracture-dislocations All successfully reduced in the ED Institutional protocol enables clinical followup to schedule surgery semi-electively

5 Ankle Fracture-Dislocation Stability Methods: Variables Patient Injury Radiographic Outcomes Success: radiographically congruent joint, medial clear space < 5mm at clinical follow-up Failure: interim loss of reduction

6 Ankle Fracture-Dislocation Stability Methods: Variables Patient Injury Radiographic Outcomes Success: radiographically congruent joint, medial clear space < 5mm Failure: interim loss of reduction

7 Results Success Failure P-value N 17 (57%) 13 (43%) Injury Mechanism Supination 15 (88.2%) 9 (69.2%) Pronation 2 (11.8%) 4 (30.8%) Fibular Comminution None 8 (47.1%) 2 (15.4%) Mild-moderate 6 (35.3%) 7 (53.8%) Severe 3 (17.6%) 4 (30.8%) Posterior Malleolus Fractured 10 (62.5%) 11 (84.6%) Intact 6 (37.5%) 2 (15.4%) Talus Displacement None 6 (37.5%) 1 (7.7%) (coronal plane) 0-50% 7 (43.8%) 7 (53.8%) % 3 (18.8%) 2 (15.4%) >100% 0 (0%) 3 (23.1%) Talus Displacement None 1 (6.2%) 0 (0%) (sagittal plane) 0-50% 8 (50.0%) 9 (69.2%) % 2 (12.5%) 3 (23.1%) >100% 5 (31.2%) 1 (7.7%) Medial Injury Bony 12 (75.0%) 11 (84.6%) Ligamentous 4 (25.0%) 2 (15.4%)

8 Results Success (mm) Failure (mm) P-value N MM Fragment Size 9.0 ± ± MM Fragment 3.8 (0.0, 7.0) 10.4 (7.1, 19.2) Displacement Medial Clear space 5.8 (4.1, 7.2) 6.5 (4.8, 8.4) Fibular Shortening 0.6 (0.0, 7.9) 4.8 (3.7, 5.5) Fibular Sagittal 7.2 ± ± Displacement PM Fragment Size 3.0 (0.0, 5.1) 5.1 (4.2, 8.5) PM Fragment Size (no 5.0 ± ± zeros) TF Clear Space 6.4 (4.9, 7.3) 7.6 (6.0, 13.6) TF Overlap (AP view) 6.4 ± ± TF Overlap (mortise view) 3.4 (0.0, 4.6) 0.0 (0.0, 1.9) Wound Comp. (all) 5 (29%) 4 (31%) Wound Comp. (major) 0 (0%) 2 (15%) 0.094

9 Results 20 Number of Patients 10 2 (18%) 9 (82%) 11 (65%) 6 (35%) 0 Failure Success 0.1 > 0.1 Posterior Malleolus Fracture Ratio

10 Ankle Fracture-Dislocation Stability Discussion: A significant portion of patients (43%) lose reduction in the interim Larger posterior malleolus fracture fragment size was predictive of loss of reduction Recommend semi-urgent fixation if posterior malleolus fracture ratio > 0.1 Limitations: retrospective design, non-ct measurements

11 Ankle Fracture-Dislocation Stability Limitations: Retrospective biases Non-CT measurement Patient Compliance Future directions: Prospective study to evaluate utility of criteria Impact of loss of reduction on outcomes

12 References Baker J.R., Patel S.N., Teichman A.J., et al. Bivalved Fiberglass Cast Compared With Plaster Splint Immobilization for Initial Management of Ankle Fracture-Dislocations A Treatment Algorithm. Foot Ankle Spec. 5(3): , Davidovitch R.I., Egol K.A. Rockwood and Green s: Fractures in Adults, 7 th edition. Lippincott, Philadelphia, Lindsjo U. Operative treatment of ankle fracture-dislocations: a follow-up study of 306/321 consecutive cases. Clin Orthop Relat Res.199: 28-38, 1985 Pettrone F.A., Gail M., Pee D., et al. Quantitative criteria for prediction of the results after displaced fracture of the ankle. J Bone Joint Surg Am. 65(5): , Phillips W.A., Schwartz H.S., Keller C.S., et al. A prospective, randomized study of the management of severe ankle fractures. J Bone Joint Surg Am. 67(1): 67-78, 1985 Federici A., Sanguineti F., and Santolini F.. The closed treatment of severe malleolar fractures. Acta Orthop Belg. 59(2): , White B.J., Walsh M., Egol K.A., et al. Intra-articular block compared with conscious sedation for closed reduction of ankle fracture-dislocations. J Bone Joint Surg Am. 90(4): , Lauge-Hansen N. Fractures of the ankle: II. Combined experimental-surgical and experimental-roentgenologic investigations. Arch Surg. 60(5): , Palmanovich, E., Brin, Y. S., Laver, L., et al. The effect of minimally displaced posterior malleolar fractures on decision making in minimally displaced lateral malleolus fractures. Int Orthop. 38(5), , Magid, D., Michelson, J. D., Ney, D. R., et al. Adult ankle fractures: comparison of plain films and interactive two-and three-dimensional CT scans. Am J Roentgenol. 154(5), , Bagger J., Hölmer P., Nielsen K.F. The prognostic importance of primary dislocated ankle joint in patients with malleolar fractures. Acta Orthop Belg. 59(2): , 1992