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Trimalleolar Fracture

Trimalleolar Fracture Ankle

A trimalleolar fracture affects the lateral, medial, and posterior malleolus.


Presentation

The fractured ankle will typically present with pain, tenderness to palpation, swelling, discoloration, ecchymosis, and gross deformity. Additionally, patients are unable to bear weight on the injured ankle.

Physical exam

The main components of the physical exam will include testing for the range of motion, palpating the bones and ligamentous structures, and assessing the neurovascular status to rule out compartment syndrome [5]. Also, the knee and foot should be evaluated.

Walking with a Cane
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Hypotension
  • Hg, which had been treated for a year by hypotensive agents. She had no known cardiac complication.[jamanetwork.com]
Ulcer
  • Thirteen years before admission she had had an episode of upper gastrointestinal bleeding diagnosed as a peptic ulcer, which had responded well to medical therapy. X-ray films of the ankle revealed a trimalleolar fracture dislocation (Fig. 1).[jamanetwork.com]
Osteophyte
  • Discrete, non-progressive osteophytes were seen in all patients. Delay in reconstruction did not preclude a good result, although early reoperation is felt to be preferable. 1. Austin, RT.[fai.sagepub.com]
Ankylosis
  • The complications are that partial ankylosis result of soft tissue contracture is seen in 2 cases (10%) and post-traumatic arthritis is seen in 1 cases (5%) and 17 cases (85%) of all patients are showed excellent AOFAS score.[synapse.koreamed.org]
Indecisiveness
  • If there is any indecision regarding the need to fix the posterior malleolus, now is the time to decide.[healio.com]
Tingling
  • Symptoms of a fracture are Intense pain Deformity - the limb looks out of place Swelling, bruising, or tenderness around the injury Numbness and tingling Problems moving a limb You need to get medical care right away for any fracture.[icdlist.com]
  • It was tingling & numb, but had excrutiating pain...all at the same time! My husband gave me 4 Advils. My children grabbed a square block ice pack & a Lightening McQueen booboo buddy, and gave them to me.[nikkibrokeherankle.blogspot.com]
  • My toes felt REALLY cold all the time, and sometimes they would tingle and feel somewhat numb. Googling this didn't help, because according to the internet every symptom you have means that you're about to lose your foot. DO NOT GOOGLE.[healingmytrimalleolarfracture.blogspot.com]

Workup

The clinician should obtain the history about the mechanism of the injury and determine if there are risk factors or prior trauma. As for the workup, the Ottawa ankle rules recommend radiography in patients with pain in the malleolar zone, and one of the following criteria: 1) tenderness over the suspected fracture or 2) the inability to walk four steps immediately after sustaining the injury and in the emergency department [6] [7].

There are guidelines that propose 3 views of radiograph studies, which are anteroposterior (AP), lateral, and mortise [8]. Furthermore, x-rays with an externally rotated lateral view [9] and computed tomography (CT) [10] should be considered for the evaluation of a fracture in the posterior malleolus.

Treatment

Once the assessment is complete and the diagnosis is achieved, the trimalleolar fracture is treated with the open reduction and internal fixation (ORIF) procedures. Following surgery, the ankle is placed in a neutral position with the help of a backslab. The patient is instructed to avoid bearing weight on the affected extremity for 6 weeks. After this time period, weight-bearing exercises are initiated as physical rehabilitation is crucial for the restoration of the ankle's function.

Prognosis

Prompt recognition and management will improve the outcome and decrease the morbidity. The prognosis of ankle fractures is worse when a posterior malleolar fragment is involved, especially if it is big in size [2] [3]. Furthermore, one main complication of trimalleolar fractures is posttraumatic arthritis [2] [4].

Etiology

Ankle fractures are caused by falls and sports-related injuries, especially when excessive inversion occurs. Likely risk factors include obesity, osteoporosis, and diabetes mellitus.

Epidemiology

The incidence of ankle fractures is about 187 individuals in a population of 100,000, of which trimalleolar fractures account for 7% of cases [1]. Ankle fractures are commonly seen in women in the older age group which may be due to osteoporosis.

Sex distribution
Age distribution

Pathophysiology

The ankle joint functions as a hinge, which is stabilized by the ligaments, tendons, muscles, and other structures of the lower leg. Due to the anatomy of the ankle, the majority of fractures are accompanied by ligament damage. Also, the direction and amount of force on the ankle determine the fracture pattern.

Prevention

Preventative strategies include wearing appropriate footwear during sports and exercising caution when in rainy weather.

Summary

A trimalleolar fracture involves the lateral and medial malleolus in addition to the distal posterior tibia, which is the posterior malleolus. It should be assessed with a detailed history and physical exam as well as imaging studies. This unstable fracture warrants a prompt diagnosis and urgent surgery.

Patient Information

A trimalleolar fracture consists of 3 fractures in the bones of the ankle. This can be caused by a fall or sports activities. The symptoms include pain, swelling, and the inability to apply weight on the injured ankle. The diagnosis is achieved with a history, physical exam, and x-rays of the ankle. It is treated with surgery and physical rehabilitation.

References

Article

  1. Court-Brown CM, McBirnie J, Wilson G. Adult ankle fractures: an increasing problem? Acta Orthopaedica Scandinavica. 1990; 69(1):43–7.
  2. McDaniel WJ, Wilson FC. Trimalleolar fractures of the ankle. An end result study. Clinical Orthopaedics and Related Research. 1977; 122:37–45.
  3. Mont MA, Sedlin ED, Weiner LS, Miller AR. Postoperative radiographs as predictors of clinical outcomes in unstable ankle fractures. Journal of Orthopaedic Trauma 1992; 6(3):352–7.
  4. Wilson FC Jr, Skilbred LA. Long-term results in the treatment of displaced bimalleolar fractures. Journal of Bone and Joint Surgery. American volume. 1966; 48(6):1065-1078.
  5. Ashworth MJ, Patel N. Compartment syndrome following ankle fracture-dislocation: a case report. Journal of Orthopedic Trauma. 1998; 12(1):67-8.
  6. Broomhead A, Stuart P. Validation of the Ottawa Ankle Rules in Australia. Emergency Medicine (Fremantle). 2003; 15(2):126-32.
  7. Tiemstra JD. Update on acute ankle sprains. American Family Physician. 2012; 85(12):1170-6.
  8. Mosher TJ, Kransdorf MJ, Adler R, et al. ACR Appropriateness Criteria acute trauma to the ankle. Journal of the American College Radiology 2015; 12(3):221-7.
  9. Gonzalez O, Fleming JJ, Meyr AJ. Radiographic assessment of posterior malleolar ankle fractures. Journal of Foot and Ankle Surgery. 2015;54(3):365-9.
  10. Palmanovich E, Brin YS, Laver L, Kish B, Nyska M, Hetsroni I. The effect of minimally displaced posterior malleolar fractures on decision making in minimally displaced lateral malleolus fractures. International Orthopaedics. 2014; 38(5):1051-1056.

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Last updated: 2018-06-22 02:23