Ankle Fracture

　　Ankle bone fractures are one of the most common injuries, usually caused by indirect violence.

　　Violence factors (50％)
　　Fractures occur in locations far from the site of the direct action of violence, rather than in the site of direct action of violence. Ankle joint fractures are caused by the transmission, lever, or rotational action of violence. Therefore, they are often caused by indirect violence.

　　Traffic accident factors (30％)
　　Refers to injury accidents that occur during driving (usually refers to motor vehicles such as cars). The injuries caused can be generally divided into deceleration injuries, impact injuries, crush injuries, crush injuries, and fall injuries, among which deceleration injuries and impact injuries are more common.

　　Pathogenesis
　　There is no unified opinion on the classification of ankle fractures, the original fracture classification was relatively simple, such as dividing stable and unstable fractures according to the shape of the fracture, or dividing single ankle, double ankle, and triple ankle fractures according to the range of the fracture involved.

　　The most common complication of ankle fractures is traumatic arthritis, but due to the deepening of treatment methods and understanding, this situation is becoming less and less; the skin of the ankle is a skin-covered bone, so soft tissue problems are a problem that needs to be paid attention to in ankle fractures. Surgery should be performed after the ankle joint is消肿, which will be safer, otherwise, it is easy to expose bones or internal fixation devices; other complications include non-union of fractures, malunion, and other general complications of fractures.

　　After an ankle injury, there may be pain and swelling in the ankle, subcutaneous ecchymosis and purple marks, and it is difficult to move the ankle joint, unable to walk. Examination may show deformity of the ankle joint, marked tenderness in the medial or lateral malleolus, and possibly bone grinding sounds.

　　To prevent fractures, attention should be paid to details in daily life. Observe the surrounding environment while driving or walking, respond flexibly to emergencies, and avoid外伤; moderate exercise can not only strengthen bone strength but also maintain muscle strength and good balance, reducing the chance of falls; eating more calcium-rich foods, maintaining a balanced diet, can also enhance bone health.

　　Diagnosing fractures based on the history of trauma, ankle pain, swelling, deformity, and X-ray findings is not difficult. However, when there is an ankle injury, there may be a high-level fibular neck fracture, so attention should be paid to the examination to avoid missed diagnosis. For high external malleolus or fibular fractures, attention should be paid to the evaluation of the possibility of tibiofibular joint injury. In addition, attention should be paid to check for other associated injuries, such as peripheral ligament injuries, injuries to the fibular tendon, Achilles tendon, posterior tibial tendon, etc., as well as talus osteochondral injury, nerve and vessel injury, etc.

　　Routine X-ray imaging

　　Generally, the anteroposterior and lateral X-ray films of the ankle joint can obtain an accurate diagnosis and classification. When taking the anteroposterior film, the lower leg should be internally rotated by 20° to make the axis through the ankle joint parallel to the X-ray. On this anteroposterior ankle joint film, the normal ankle joint can be seen:
　　1. The ankle joint space is parallel and the spacing is equal.
　　2. The 'Shenton' line of the ankle joint is smooth without a step-like appearance. The so-called 'Shenton' line refers to the articular surface of the distal end of the tibia, the outline of the dense cancellous bone under the cartilage, passing through the interval of the tibiofibular ligamentous joint, and forming a continuous arc line with a small bony prominence on the medial side of the fibula. The small prominence on the fibula is opposite the level of the subchondral bone under the distal articular surface of the tibia.
　　3. The distal end of the lateral articular surface of the talus is connected to the distal recess of the fibula (where the fibular tendon is located) to form an arc.
　　
　　Computed Tomography (CT)
　　CT can distinguish the coronal and sagittal fracture lines of the ankle joint that are not easily detected on ordinary X-ray films, as well as some minor fractures. It can be considered to choose it when necessary.

　　Special examination
　　If necessary, take X-rays under anesthesia and stress, and take anteroposterior and lateral X-rays of the ankle under internal and external rotation, plantar and dorsal flexion stress; in the case of anterior and external rotation fractures, high-level fibular fractures may occur, so do not forget to check. If possible, be sure to take X-rays for confirmation.

　　According to the course of the disease, the dietary requirements for patients with ankle fracture are as follows:

　　Early stage (1-2 weeks)

　　At this time, the swelling and pain at the injury site are obvious, the meridians and collaterals are blocked, and the flow of Qi and blood is not smooth. The treatment during this period focuses on promoting blood circulation and removing blood stasis, and promoting Qi to reduce swelling. In terms of diet, it is advisable to eat light and nutritious food, such as vegetables, eggs, dairy products, fruits, fish soup, lean meat, etc. Avoid spicy, dry and hot foods, and especially do not eat greasy and nourishing foods prematurely, such as bone soup, fatty chicken, beef and mutton, etc., otherwise it may lead to blood stasis accumulation and difficulty in dispersion, which can slow down the growth of bone callus and affect the recovery of joint function in the future.
　　Recommended food therapy recipe - Peach Kernel Porridge: Take 15 grams of peach kernel, an appropriate amount of brown sugar, crush the peach kernel, soak in water, then grind the juice and remove the dregs. Add brown sugar, sticky rice, and 400 milliliters of water, cook until soft and well blended into porridge. Eat twice a day, for 7 to 10 consecutive days, it has the effects of promoting blood circulation and removing blood stasis, and reducing swelling and relieving pain.

　　Middle stage (2-4 weeks)
　　At this time, the ecchymosis of the fracture site has been somewhat reduced, but the injury has not been completely resolved, and the callus begins to form. Treatment should focus on harmonizing the meridians and relieving pain, removing blood stasis and promoting new growth, and joining bones and tendons. Diet should gradually shift from light to moderate high-nutrition supplementation, and can add bone soup, Cordyceps chicken soup, etc. to the initial diet to supplement more vitamin A, D, calcium, and protein.
　　Recommended diet recipe - Angelica Sinensis and pork rib soup: Take 10 grams of Angelica Sinensis, 15 grams of Fructus seu Semen Forsythiae, 10 grams of续断, 250 grams of fresh pork ribs or beef ribs, boil for more than 1 hour, eat the soup and meat together, once a day, for 1-2 weeks. It is helpful for removing blood stasis and continuing the fracture.

　　Late stage (more than 4 weeks)
　　At this time, the ecchymosis of the fracture site has basically been absorbed, and the callus begins to grow. Treatment should focus on the word 'supplement'. By supplementing the liver and kidney, Qi and blood, promote the formation of a more solid callus. Diet should focus on tonifying deficiency, and the diet can be supplemented with old hen soup, pork bone soup, sheep bone soup, deer tendons soup, stewed fish, etc.
　　Recommended diet recipe - Angelica Sinensis, ginger, and mutton soup: Take 20 grams of Angelica Sinensis, 12 grams of ginger, 300 grams of mutton, add 1500 milliliters of water, cook together until soft and well-done. Eat the meat and drink the soup, once a day. This recipe has the effects of nourishing blood and activating blood, warming meridians and dispelling cold, and relieving pain, especially suitable for patients in the late stage of fracture and the elderly with deficiency.
　　

　　Ankle fractures are divided into the following situations, and the doctor should make a clear diagnosis based on the examination results, and then take different treatment measures.

　　1. Fracture of the medial malleolus

　　Non-displaced medial malleolus fractures are generally treated with cast immobilization. However, in some cases, for patients with high functional requirements for the ankle joint, internal fixation should be performed to promote fracture healing and rehabilitation. Displaced medial malleolus fractures should be treated surgically because persistent displacement can cause talus malalignment and lead to foot varus deformity, which is different from avulsion fractures at the tip of the medial malleolus and involvement of the ankle joint. The former has better stability, and generally does not require internal fixation unless there is obvious displacement; if symptoms are obvious, delayed internal fixation can be performed, commonly using 2 cancellous bone compression screws fixed vertically to the fracture direction of the medial malleolus; smaller fracture fragments can be fixed with 1 cancellous bone compression screw and 1 Kirschner wire to prevent rotation; for fractures that are too small or comminuted and cannot be fixed with screws, 2 Kirschner wires and tension band wires can be used for fixation; for vertical fractures extending to the metaphysis, a small curved support plate is needed for secure fixation.

　　2. Fracture of the lateral malleolus
　　If the fibula fracture is part of a double ankle fracture, we usually realign and internally fix the external malleolus or fibula fracture before fixing the medial malleolus, exposing the distal part of the tibia shaft and the lateral malleolus through a longitudinal incision on the anterolateral side, and protecting the peroneal nerve and superficial peroneal nerve. If the fracture line is completely oblique and both fracture ends are intact without bone fragments, 2 tension band screws can be拧入 from front to back to produce a compressive effect between the fracture fragments. If it is a transverse fracture, intramedullary fixation can be used, separating the fibers of the calcaneofibular ligament longitudinally, exposing the tip of the lateral malleolus, and inserting a Rush rod, fibula locking rod, or other intramedullary instruments.

　　3. Bilateral Malleolar Fractures
　　Bilateral malleolar fractures simultaneously destroy the stable structures of the medial and lateral ankle joints, reduce the contact area of the tibiofibular joint, and change the joint movement mechanics. Although closed reduction is often achieved, it cannot maintain the normal anatomical position after swelling subsides, so almost all bilateral malleolar fractures should be treated with open reduction and internal fixation. For general periarticular fractures, especially ankle joint fractures, surgical treatment should be limited to two periods, namely early and late. Open reduction and internal fixation can be performed within the first 12 hours after injury; otherwise, due to extensive swelling, it may be delayed to 2-3 weeks after injury. In surgery, if there is excessive soft tissue swelling, the incision can be delayed or skin grafting can be performed if necessary, which is more suitable for patients with severe closed soft tissue injury and blisters on the skin of the fracture site. For fractures with delayed open reduction and fixation, immediate closed reduction and splint fixation should be performed to prevent skin necrosis.

　　4. Deltoid Ligament Tear with Lateral Malleolus Fracture
　　The deltoid ligament, especially its deep structure, is very important for the stability of the ankle joint because it can prevent the talus from dislocating laterally and from external rotation. When the lateral malleolus fracture is accompanied by pain, swelling, and hematoma on the medial side of the ankle joint, one should suspect a deltoid ligament tear. Routine anteroposterior ankle X-rays may show that the talus has not moved outward, but when posterior and external rotation stress ankle X-rays are taken, the talus displacement and tilt can be found, and the lateral ankle joint space is significantly widened. In cases where skin conditions, patient age, and general condition allow, the best treatment for this injury is tibial osteotomy reduction and internal fixation, with or without deltoid ligament repair.