Fracture of anklebones – violation of integrity of anklebones as a result of traumatic influence. Usually arises at the indirect mechanism of a trauma – a podvorachivaniya of foot of a knaruzha or a knutra. It is shown by pain, hypostasis, bruises, restriction of a support and movements. In some cases the krepitation, deformation and pathological mobility is observed. For specification of the diagnosis appoint a X-ray analysis of an ankle joint. Treatment more often conservative, at inefficiency of the closed repozition is required operation.
Fracture of anklebones
Fracture of anklebones – one of the most widespread skeletal injuries. Can arise at patients of any age and a floor, however people of middle and advanced age suffer more often that is caused by deterioration in coordination of movements and the general physical shape. Frequency of fractures of anklebones sharply increases in the winter, especially in the period of ice. Damage can be followed or not be followed by a rupture of sheaves, an incomplete dislocation and shift of otlomk. There is one - two - or trekhlodyzhechny. The forecast, and also tactics and terms of treatment depend on features of a change.
Usually the fracture of anklebones is the isolated damage, comes to light as a part of the combined trauma less often. In the latter case it can be caused by blow, falling of a heavy subject or a sdavleniye of area of an ankle joint at road or production accident. It can be combined with fractures of other bones of extremities, injury of a thorax, ChMT, a basin change, a stupid injury of a stomach, injury of a kidney etc. The isolated fractures of anklebones, as a rule, closed. At the combined trauma open damages and a razmozzheniye are quite often observed. Treatment is performed by traumatologists.
Depending on the mechanism of damage to traumatology distinguish the following types of fractures of anklebones:
- Pronatsionno-abduktsionnye fractures of anklebones. Arise at excessive violent turning of foot of a knaruzha. Separations of an internal anklebone at the basis in combination with a fracture of an external anklebone at the level of a joint are characteristic or are 5-7 cm higher than it, in the thinnest part of a low-tibial bone. The rupture of a forward intertibial sheaf with insignificant (1-2 mm) a divergence of tibial bones is possible. In hard cases the rupture of both intertibial sheaves with formation of the expressed knaruzha incomplete dislocation is observed.
- Supinatsionno-adduktsionny fractures of anklebones. Arise at violent excessive turn of foot of a knutra. The fracture of an external anklebone at the level of a joint or a separation of a top of an external anklebone is characteristic. The line of a break of an internal anklebone is located above, than at pronatsionno-abduction changes, and quite often takes a nizhnevnutrenny part of a tibial bone. The incomplete dislocation of foot of a knutra is possible.
- Rotational fractures of anklebones. Are formed at an excessive reversing of foot (as a rule, knaruzh, are more rare – knutr). The fracture of both anklebones at the level of a joint is usually observed, at the forced influence also the separation of the rear edge of a tibial bone with formation of a triangular otlomk is possible.
- The isolated sgibatelny changes of the rear edge of a tibial bone. Are formed at violent plantar bending of foot, come to light very seldom. Are followed by formation of a triangular otlomk. Shift, as a rule, is absent.
- The isolated razgibatelny changes of a first line of a tibial bone. Are formed at violent back bending of foot or at direct stroke to the forward surface of an ankle joint. At such trauma triangular it is formed not on back, and on the forward surface of a tibial bone, the shift of a fragment of a kpereda and up is usually observed.
- The combined (combined) fractures of anklebones. Arise at simultaneous operation of several listed above mechanisms.
In clinical practice fractures of one anklebone call odnolodyzhechny, fractures of both anklebones (internal and external) – dvukhlodyzhechny, fractures of both anklebones and the first or rear edge of a tibial bone – trekhlodyzhechny. One - and dvukhlodyzhechny damages in 50-70% of cases are not followed by the shift of fragments. Trekhlodyzhechny changes belong to the category of heavy damages, at them the expressed shift, a divergence of a fork of an ankle joint, an incomplete dislocation and a rupture of sheaves is, as a rule, observed.
The patient complains of an ankle joint pain or areas of the injured anklebone. Expressiveness of symptoms directly depends on a damage rate of the copular device, and also on the shift of anklebones, foot and the peripheral end of a tibial bone. At damages without shift (especially odnolodyzhechny) the clinical picture can remind a bruise or an anguish of sheaves. Hypostasis is local, hemorrhages in a joint are expressed slightly or are absent. The support and the movements are moderately complicated. Axial loading on an axis of a shin is painful, but is possible. At a palpation pain is localized above a top of anklebones. The positive "symptom of irradiation" - pain in anklebones comes to light at compression of bones of a shin in an average third.
At changes with shift the joint is strongly edematous, deformed. Skin with a cyanotic or crimson shade, there are expressed bruises sometimes extending to the back of foot and a sole. Anklebones do not konturirutsya because of hypostasis. Between a shin and foot the corner opened knaruzh or knutr is formed (depending on a type of an incomplete dislocation). Pathological mobility is noted, the krepitation in certain cases is defined. The movements and a support are impossible because of pain.
Fractures of anklebones should be differentiated with injury of ligaments of ankle joint. At changes pain is, as a rule, localized above, the maximum morbidity is defined at a palpation of bones, but not myagkotkanny educations. For statement of the final diagnosis the X-ray analysis of an ankle joint in two standard projections is appointed (side and perednezadny). In pictures lines of breaks, the direction and degree of shift of otlomk, a type of an incomplete dislocation and degree of a divergence of tibial bones are defined. In doubtful cases appoint KT of an ankle joint, if necessary to estimate a condition of myagkotkanny structures – MRT of an ankle joint.
treatment should be carried out only under the supervision of a doctor. Self-treatment is unacceptable!!!
The main objective at treatment of injuries of anklebones is exact restoration of the broken anatomic ratios between various elements of an ankle joint as without such restoration normal functioning of a joint is impossible. At changes without shift the ratio between elements of a joint is not broken therefore it is enough to apply a plaster bandage for a period of 4-8 weeks. At changes with shift the one-stage closed repozition is carried out.
Repozition is carried out under local anesthesia in the conditions of a hospital. At an incomplete dislocation of a joint of a knaruzha the traumatologist one hand presses on the external surface of a joint, and another – on the internal surface of a shin is higher than an anklebone. After reposition of an incomplete dislocation it squeezes a fork of an ankle joint, eliminating a divergence of tibial bones. At an incomplete dislocation of a joint of a knutra similar manipulations are carried out, but hands of the traumatologist settle down on the contrary: one – on the internal surface of a joint, the second – on the external surface of a shin is higher than an anklebone.
At damage of the rear edge of a tibial bone foot is removed forward, making back bending, at damage of a first line – back, making plantar bending. Then on a leg impose a plaster boot in the provision of hyper correction and carry out control pictures. To the patient appoint anesthetics and UVCh. After falling off of hypostasis plaster circulate. The term of an immobilization depends on the nature of damage and makes 4 weeks at odnolodyzhechny changes, 8 weeks – at dvukhlodyzhechny changes and 12 weeks – at trekhlodyzhechny changes.
The indication to surgical intervention is the ineradicable shift of anklebones, an incomplete dislocation of foot and a divergence of a fork of a joint, and also impossibility of deduction of fragments in the correct situation. Besides, operations are performed at not accrete fractures, intensive pains, the expressed malfunction and statics. At fresh damages surgical intervention is usually carried out for 2-5 day after a trauma, at old – in a planned order.
The internal anklebone is fixed a two-bladed nail or screws. At ruptures of an intertibial sindesmoz make rapprochement of tibial bones, using the long screw or a special bolt. Apply a nail or a spoke to fixing of an external anklebone. At changes of a rear and first line make an osteosynthesis of anklebones the screw or a nail. Then the wound is layer-by-layer taken in and drained, on a leg impose plaster. In the postoperative period carry out antibiotic treatment, appoint analgetics, UVCh and physiotherapy exercises. After removal of plaster carry out actions for development of a joint.
Fractures of anklebones without shift, as a rule, well grow together and further do not give an inconvenience to patients. The unsharp pains connected with change of weather or with considerable load of a joint are sometimes noted. At correctly otreponirovanny changes with shift the post-traumatic dystrophic pain syndrome – the expressed pains in foot and an ankle joint making impossible a support on a leg occasionally develops. Vascular and neurotrophic disorders are the reason of development of such syndrome. Treatment conservative – an electrophoresis with novocaine, paraffin, novokainovy blockade, LFK and vitamin therapy. Usually recovery occurs within a year.
Constant pains, deformation and hypostasis of a joint, restriction of movements, instability and uncertainty when walking, lameness become an outcome of nereponirovanny fractures of anklebones with shift. Quickly the deforming arthrosis which complicates a support and the movements in an ankle joint even more develops. In similar cases recovery operations which can provide excision of cicatricial fabrics, an osteosynthesis with application of various metalwork, use of bone transplants and plasticity of sheaves are required.