Ankle fractures

　　Ankle fractures are the most common intra-articular fractures. They are usually caused by indirect external forces, with a very few caused by longitudinal compression. Intra-articular fractures require anatomical or near-anatomical fixation. In addition, ankle fractures often accompany ankle dislocation or subluxation. The articular surface of the ankle joint is smaller than that of the hip and knee joints, but it bears a significant weight and has a large range of motion, making it prone to injury. They account for 3.83% of all fractures. They are more common in adolescents, and improper treatment can lead to traumatic arthritis.

　　Etiology and classification of ankle fractures:

　　Ankle fractures are often caused by indirect violence, most commonly due to ankle inversion injuries, where force transmission leads to fractures. Due to the varying magnitude, direction of action, and posture of the ankle and foot, different types of fractures can occur. Sometimes, direct impact can also result in complex fractures. There are many classification methods for ankle fractures, but from a clinical application perspective, the combined classification method of Davis-Weber and Lange-Hanson is more practical.

　　1. Type I varus adduction type

　　When the ankle joint is injured in an extreme varus position (pronation), the force of action is transmitted to the lateral collateral ligament, causing a fracture of the lateral malleolus below the level of the tibiofibular inferior ligament. If the force of action does not decrease due to the fracture of the lateral malleolus, it continues to be transmitted to the talus, causing the talus to collide with the medial malleolus, resulting in an oblique fracture of the medial malleolus from bottom to top.

　　2. Type II is divided into two subtypes

　　(1) Varus abduction type: The ankle joint is injured by indirect force, in an extreme varus position, or by a heavy object striking the lateral malleolus, causing the ankle joint to be extremely varus. The force is transmitted through the medial collateral ligament, pulling the medial malleolus and causing a fracture. If the force continues to be transmitted, the talus collides with the lateral and posterior malleoli, causing the lateral malleolus to occur a oblique fracture from bottom to top, and at the same time, the ankle joint fracture occurs, and the fracture is mostly at the level of the tibiofibular inferior ligament.

　　(2) Varus external rotation type: The force acts on the lateral malleolus, first causing粉碎性骨折 and posterior malleolar fracture, but the tibiofibular inferior ligament is intact. The force continues to be transmitted, and the external rotation force of the ankle causes the medial collateral ligament to pull the medial malleolus, resulting in avulsion fracture of the medial malleolus. All fractures of type II are tri-malleolar fractures. The integrity of the tibiofibular inferior ligament and the absence of ankle joint dislocation are the characteristics of this type of fracture.

　　3. Type III varus external rotation type

　　When the ankle joint is subjected to an external inversion (pronation) force, it causes the medial collateral ligament to become tense, leading to avulsion fracture of the medial malleolus. If the force does not decrease, it causes the talus to collide with the lateral malleolus, resulting in a rupture of the tibiofibular inferior ligament and the separation of the tibiofibular inferior joint. If the force continues to act, it is transmitted through the interosseous membrane between the tibia and fibula, causing oblique or comminuted fractures of the fibula above the level of the tibiofibular inferior ligament. Sometimes the force can be transmitted to the upper end of the fibula, causing high-level fibular fractures. Clinically, misdiagnosis often occurs due to insufficient understanding of this injury mechanism.

　　Fractures and dislocations of the ankle joint and foot are common injuries in orthopedics. The articular surface of the ankle joint is smaller than that of the hip and knee joints, but it bears a large weight and activity, so it is prone to injury. It accounts for 3.83% of all fractures, and is more common in adolescents.

　　In ankle fractures, especially after oblique or spiral fractures of the fibula, there may be shortening of the fibula, external inclination and displacement of the talus, and joint disorganization. The functional recovery after injury to the outer malleolus varies with the quality of reduction.

　　The most common complication of this disease is traumatic arthritis. When the patient is injured, the outer malleolus moves outward by 2 mm, and the talus also moves outward by 1 to 2 mm, accompanied by a 1 to 2° external rotation of the talus. The contact surface of the tibio-talar joint decreases by 51%. Ramsey pointed out that the external displacement of the talus causes changes in the contact surface of the tibio-talar joint. When the talus displaces outward by 1 mm, the contact surface of the tibio-talar joint decreases by 42%. As the distance of displacement increases, the contact surface gradually decreases, while the local pressure increases, which is the main reason for the occurrence of traumatic arthritis in the late stage.

　　In addition, ankle fractures are intra-articular fractures, often accompanied by subluxation of the ankle joint. The treatment requires anatomical or nearly anatomical reduction of the fracture. Subluxation should be corrected. Otherwise, it may lead to joint instability, or due to rough articular surfaces, it can also lead to traumatic arthritis, affecting daily life and work. For such fractures, it is recommended to seek timely diagnosis and treatment from an orthopedic doctor.

　　Ankle fractures are mostly caused by indirect violence, most commonly due to ankle inversion sprains, where the force is transmitted to cause a fracture. Due to the different sizes, directions of action, and positions of the ankle and foot, different types of fractures can occur. The clinical manifestations of ankle fractures are as follows:

　　(1) Local pain, swelling, ecchymosis, and deformity of the ankle joint in varus or valgus.

　　(2) Local tenderness is obvious, and bone rub sound can often be detected.

　　(3) Severe pain in the injured area when moving the ankle joint.

　　(4) Limited range of motion of the ankle joint.

　　Fractures and dislocations of the ankle and foot are common orthopedic injuries. The articular surface of the ankle joint is smaller than that of the hip and knee joints, but it bears a large weight and has a high degree of activity, so it is prone to injury. It accounts for 3.83% of all fractures and is more common in adolescents and young adults. This disease usually occurs in individuals with trauma, especially among young and middle-aged athletes. Therefore, in order to prevent ankle fractures, it is mainly necessary to pay attention to safety, protect the ankle joint, and avoid trauma.

　　Preventive measures after ankle fractures

　　1. After manual reduction and fixation, immediately perform fluoroscopy or radiography to review the reduction effect of the ankle joint. If it is not ideal, re-reduction and fixation should be performed to prevent malunion.

　　2. Elevate the affected limb, closely monitor the blood circulation and swelling of the toes, and adjust the tightness of the fixation promptly.

　　3. During the first week, check the alignment of the fracture by fluoroscopy or radiography 1 to 2 times to prevent the fracture from moving again.

　　4. Small splints fixed in varus or valgus positions should be gradually changed to neutral position fixation after 3 weeks to prevent overcorrection.

　　5. External fixation should be maintained for 4 to 5 weeks, not too long, to prevent stiffness of the ankle joint or premature and excessive degenerative changes.

　　Fractures of the ankle are mainly caused by traumatic factors. The diagnosis of ankle fractures in clinical practice is not difficult. Generally, diagnosis can be made based on the history of trauma and clinical manifestations. However, some auxiliary examinations are needed to confirm the diagnosis for the benefit of treatment.

　　1. X-ray examination

　　When stress fractures are obvious, X-ray films show fractures of the bone cortex, and some may show thickening of the periosteum. If the fracture is early and only limited to the bone cortex, or the periosteum thickening is not obvious, X-ray films are prone to miss the diagnosis. X-ray films can only find large avulsion bone fragments, but are unable to detect small avulsion bone fragments. It is also difficult to find hematomas around the joint and effusion or blood in the joint cavity, as well as bursitis, with X-ray films.

　　2. CT examination

　　High-resolution CT scans can clearly show the fracture of bone cortex and the arrangement of trabeculae, as well as slight periosteal reactions. CT scans can also clearly show joint effusion caused by fractures, bursitis, and small avulsion bone fragments, which helps clinicians to handle them in a timely manner.

　　Ankle fractures are common in daily life, among which ankle ligament injuries are the most common. They usually occur during marching, labor, and physical exercise and are commonly known as ankle sprains. However, greater violence can cause fractures, such as fall injuries, crush injuries, and碾压 injuries. Ankle injuries caused by firearm wounds are also common during war. Due to poor blood circulation in the ankle and its low position in the body, swelling is more likely to occur after injury, and the ability to heal and resist infection is poor, with a longer recovery time. After joint injuries, deformities and joint stiffness are prone to occur, mainly deformities such as talus flexion deformity, which seriously affects the patient's weight-bearing walking function, and attention should be paid to preventing it during treatment. When treating ankle bone fractures, attention should be paid to the following points in diet to avoid unnecessary troubles.

　　Dietary taboos for ankle fractures:

　　(1) Avoid blind calcium supplementation

　　Calcium is an important raw material for bone formation. Some people think that supplementing more calcium after ankle fractures can accelerate the healing of broken bones. Increasing the intake of calcium does not accelerate the healing of broken bones, and for fracture patients who have been lying in bed for a long time, it may pose a potential risk of elevated blood calcium levels, accompanied by decreased blood phosphorus levels. This is due to the fact that long-term bed rest inhibits the absorption and utilization of calcium on one hand and increases the reabsorption of calcium by the renal tubules on the other hand. Therefore, for fracture patients, the body does not lack calcium. As long as the patient follows the doctor's advice, strengthens functional exercises, and starts to move as soon as possible, it can promote the absorption and utilization of calcium by the bones, accelerate the healing of broken bones. Especially for patients who are bedridden after fractures, blindly supplementing calcium is of no benefit and may even be harmful.

　　(2) Avoid eating too much meat and bone

　　Some people believe that eating more meat and bone after ankle fractures can promote early healing. In fact, eating more meat and bone by fracture patients not only cannot promote early healing but may also delay the healing time of fractures. The reason for this is that the regeneration of bone after injury mainly relies on the functions of the periosteum and bone marrow. The periosteum and bone marrow can only better perform their functions under the condition of increasing collagen. The main components of meat and bone are phosphorus and calcium. If a large amount is consumed after a fracture, it will promote an increase in the inorganic component of the bone, causing a disorder in the proportion of organic matter in the bone. Therefore, it will hinder the early healing of fractures. However, the fresh meat and bone soup tastes delicious and has a stimulating effect on appetite, so eating a small amount is harmless.

　　(3) Avoid one-sided diet

　　Fracture patients of the ankle often have local swelling, congestion, hemorrhage, and muscle tissue damage. The body itself has resistance and repair capabilities for these conditions. The raw materials for the repair of tissues, the growth of muscle, the formation of callus, and the removal of blood stasis and swelling rely on various nutrients. Therefore, it can be known that the key to the smooth healing of fractures is nutrition.

　　(4) Avoid indigestible foods

　　Fracture patients are restricted in their activities due to the use of plaster casts or splints, accompanied by swelling and pain at the injury site, and mental distress, so their appetite is often poor, and constipation may occur occasionally. Therefore, food should be both nutritious and easy to digest and defecate. It is advisable to avoid foods that are easy to cause flatulence or indigestion, such as sweet potatoes, taro, and glutinous rice, and to eat more fruits and vegetables.

　　In the treatment of this disease, due to the smaller surface area of the ankle joint than that of the hip and knee joints, but the weight it bears is greater than that of the hip and knee joints, and the ankle joint is close to the ground, the bearing stress on the ankle joint cannot be cushioned, so the treatment of ankle joint fractures is more demanding than other parts. The importance of anatomical reduction of ankle joint fractures is increasingly recognized by people. If there is any unevenness on the joint surface or any increase in the joint gap after the fracture, traumatic arthritis can occur.

　　For the treatment of any type of fracture, it is required that the distal end of the tibia, that is, the talus, and the saddle-shaped joint surface of the talus are matched, and that the medial and lateral malleoli recover their normal physiological obliquity to adapt to the posterior narrow and anterior wide shape of the talus.

　　One, non-displaced fractures

　　For non-displaced unilateral or bilateral ankle fractures, it is generally only necessary to use small splint fixation, or use a cast to fix the ankle joint in a neutral position. Start walking. Fix the ankle joint in a 90° neutral position with a lower leg cast, and change once after 1-2 weeks when the swelling subsides and the cast becomes loose. The time for cast fixation is generally 6-8 weeks, and the external fixation is removed after 4 weeks, and walking can begin.

　　Two, displaced fractures

　　For displaced unilateral or bilateral ankle fractures, manual reduction and small splint fixation or tibial cast fixation are performed under local anesthesia. The reduction technique varies according to the type of fracture, with the basic principle being to reduce in the opposite direction of the violence.

　　Three, reduction of ankle fracture

　　1, first manually reduce the medial and lateral malleoli, and then reduce the posterior malleolus. When reducing the posterior malleolus, the foot should be slightly plantar flexed to prevent the talus from being compressed by the Achilles tendon and the distal end of the tibia, then push the heel forward with force to correct the posterior displacement of the talus, then dorsiflex the ankle joint, and use the tense posterior joint capsule to pull down the posterior malleolus until it is level with the distal tibial joint surface, then the posterior malleolar fracture fragment can be reduced.

　　2, surgical reduction and internal fixation

　　Four, drug treatment for ankle fracture

　　For non-surgical patients, analgesics are used, and early use of Peach Red Four Herbs Decoction, later Baizhen Decoction, and external washing with Shujin Decoction can be used; for surgical patients, antibiotics are used to prevent infection, and the drug can be stopped after three days if there is no infection at the wound. It is used for fracture treatment.