The ankle is a complex weight-bearing joint that is prone to numerous types of injuries. Evidence of this is the various classifications of ankle fractures that have appeared in the past, many of which are still in use. One of these injuries is a fracture described in 1819 by Baron Dupuytren, and then classified by Lauge-Hansen in 1950 as pronational injury. It consists in the violation of the medial structures (either a rupture of the medial ligament, or a rupture of the muscles of the median ankle) together with a complete rupture of the lower tibiofibular joint and an indirect fracture of the fibula above this syndesmosis. Also in traumatology, the symptom of Dupuytren is known, which is also called the symptom of parchment crunch.
Ankle fractures
Two similar types of ankle fracture are distinguished - the fracture of Malgen and Dupuytren. In the first case, it is a supination-adduction fracture. With this type of injury, the load on the foot tucks it inward. This mechanism is the opposite of the abduction fracture of Dupuytren.
Injury mechanism
When the foot is tucked out, the deltoid ligament is tensioned, which leads to a tear fracture of the inner ankle. Sometimes this effect can lead to rupture of the deltoid ligament. The result of this effect is an ankle fracture with subluxation. With continued exposure, the talus block presses on the outer ankle, as a result of which the tibial ligaments are torn.
Dupuytren's fracture
This type of injury is a fracture affecting the inner ankle and fibula in the lower third. The injury is accompanied by a rupture of the ligaments of the tibiofibular syndesmosis.
The Dupuytren fracture formula is:
- the presence of a tear fracture of the medial ankle;
- the existence of comminuted or oblique fracture. Localization of trauma - the lower third of the fibula;
- the presence of a rupture of the tibiofibular syndesmosis;
- the presence of subluxation of the foot out.
As a rule, the bone breaks at a height of 8 cm from the top of the ankle. The cause of the injury is mainly forced abduction (abduction to the side) in combination with the displacement of the foot. It can also be supplemented by plantar or dorsal flexion (flexion).
This fracture may be:
- simple;
- have an external or rear displacement;
- have both displacements and tibial diastasis (muscle discrepancy).
A simple ankle fracture has virtually no clinical differences from a bony ankle. The fracture line above the articular line is determined only by radiography.
In addition to lateral displacement with this type of injury, there is a posterior subluxation of the foot, which can be very significant.
Symptomatology
A simple fracture, which is not accompanied by a visible displacement, is characterized by the appearance of puffiness and hematoma, a slight degree of curvature, and varus is less common (displacement of the foot inward).
In the event that the foot is displaced only outwardly, the outer ankle may be damaged, diastasis may accompany the injury. Also in this case, it is possible to diagnose a bilobar fracture or Dupuytren's fracture with a large displacement. A characteristic symptom may also be the fact that the axis of the leg deviates outward.
Tibiofibular diastasis causes a pronounced displacement of the foot to the outside. Trauma is also characterized by limited mobility and significant soreness during movement. A sharp balloting (oscillation) of the talus is also observed.
With such a fracture, anterior ankle ligament rupture often occurs, which causes diastasis of the tibiofibular syndesmosis.
During the examination, not only a significant displacement of the foot posteriorly is determined, but also its hallux valgus. The fragment can be very small, not even detected on an x-ray. A posterior displacement is also characteristic of supra-mural injuries.
The lateral subluxation of the foot is accompanied by its pathological hallux valgus. On palpation, sharp pain can be detected in the region of the inner ankle, which goes further along the fibula and is found in the region of the tibia syndesmosis. There is also a restriction of any movements in the ankle joint, while they are accompanied by severe pain.
Diagnostics
In a direct projection x-ray, the medial ankle fracture line can be well defined. Identification of a rupture of the tibiofibular syndesmosis is possible when comparing images of a damaged and healthy ankle joint in direct projection. In this case, the picture should be taken in the position turned inward by 20 toes. Diagnosis of the external subluxation of the foot is carried out based on the enlargement or expansion of the gap between the contour of the joint of the inner ankle and the adjacent edge of the talus.
In the image in the lateral projection determine the plane of the fracture of the fibula and the displacement of fragments. The fracture line is usually directed obliquely from top to bottom and back to front.
Using a picture in a lateral projection, you can recognize a fracture of the front or rear edge of the tibia head, as well as the corresponding subluxation of the foot. This is of great importance when reposition is necessary.
When evaluating radiographs, attention is drawn to the condition of the “fork” of the ankle joint, the presence of an external subluxation of the foot, as well as the displacement of fragments of the lateral and medial ankles. Having studied the results of diagnosis, Rvach prescribes appropriate therapy.
Conservative treatment
If both ankles are broken, as well as the posterior part of the tibial epiphysis, but the fragments are not displaced, and the ankle's “fork” is not expanded, a plaster bandage from the fingers to the middle of the thigh is used for immobilization. In the third or fourth week, the knee joint is freed from gypsum. Fully immobilization lasts 6 weeks.
If fragments were displaced during the injury, the “fork” of the ankle joint expanded, subluxation or dislocation of the foot is diagnosed, reposition is necessary. During reposition, conduction anesthesia is used.
Surgical treatment
If conservative treatment has not given the desired effect, there is a need for surgical intervention. During the operation, bone fragments are fixed using metal retainers (knitting needles, screws, bolts). In the case of a chronic or incorrectly fused fracture, depending on how long the injury has occurred, various reconstructive operations or ankle joint arthrodesis are possible.
In the recovery period after any type of treatment, massage and physiotherapy are necessary. The doctor will tell you in detail what needs to be done.