Rev. bras. ortop. vol.51 número5

r e v b r a s o r t o p . 2016;51(5):597–600

SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

w w w . r b o . o r g . b r

Case

Report

Tibial

shaft

fracture

and

ankle

injury

–

Case

report

夽

Caio

Zamboni

,

Felipe

Augusto

Garcez

de

Campos

,

Noel

Oizerovici

Foni

,

Rafael

Carboni

Souza

_,

_Ralph

_Walter

_Christian

_,

_Marcelo

_Tomanik

_Mercadante

a_{IrmandadedaSantaCasadeMisericóridiadeSãoPaulo,SãoPaulo,SP,Brazil}

b_{FaculdadedeCiênciasMédicasdaSantaCasadeSãoPaulo,SãoPaulo,SP,Brazil}

a

r

t

i

c

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e

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Articlehistory:

Received14August2015 Accepted31August2015 Availableonline10August2016

Keywords:

Internalfracturefixation Jointinstability

Ankle

a

b

s

t

r

a

c

t

Theauthorsreportonacaseoftibialshaftfractureassociatedwithankleinjury.Theclinical, radiologicalandsurgicalcharacteristicsarediscussed.Assessmentofassociatedinjuriesis oftenoverlookedandtheseinjuriesarehardtodiagnose.Whentorqueoccursinthelower limb,theanklebecomessusceptibletosimultaneousinjury.Itisessentialtomakecareful assessmentbasedonclinical,radiographic,intraoperativeandpostoperativecharacteristics inordertoattainfunctionalrecovery.

©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http:// creativecommons.org/licenses/by-nc-nd/4.0/).

Fratura

diafisária

da

tíbia

e

lesão

do

tornozelo

–

Relato

de

caso

Palavras-chave:

Fixac¸ãointernadefraturas Instabilidadearticular Tornozelo

r

e

s

u

m

o

Osautoresrelatamumcasodefraturadiafisáriadetíbiaassociadoàlesãodotornozelo. Ascaracterísticasclínicas,radiológicasecirúrgicassãodiscutidas.Aavaliac¸ãodelesões associadassãomuitasvezesnegligenciadasededifícildiagnóstico.Quandoumtorqueno membroinferiorocorre,otornozeloficasuscetívelaumalesãosimultânea.Éessencialuma avaliac¸ãocuidadosabaseadanoaspectoclínico,radiográfico,intraepós-operatóriopara recuperac¸ãofuncional.

©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevierEditora Ltda.Este ´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND(http:// creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction

Thefirst description ofthe associationof diaphyseal tibial fractureswithadditionalankle injurywasmadebyWeber1

夽

StudyconductedattheSantaCasadeSãoPaulo,DepartamentodeOrtopediaeTraumatologia,GrupodeCirurgiadoTrauma,São Paulo,SP,Brazil.

∗ _{Correspondingauthor.}

E-mail:caiozamboni@hotmail.com(C.Zamboni).

in1972.Asthetibialinjuryisvisibleandobvious,apotential associatedankleinjurymaybeneglected.Distaltibiofibular syndesmosisinstabilitymayleadtosubluxationofthetalus. Onceundiagnosed,anklearthrosismaytakeplaceevenifthe

http://dx.doi.org/10.1016/j.rboe.2016.08.003

598

Fig.1–Imageoftheopendiaphysealfractureofthelegwithnoevidenceofinjuryintheanklejoint.

treatmentforthediaphysealtibialfracturehasprovided excel-lentreduction,stabilization,andconsolidation.2

Clinical

report

Male patient, 28 years old, involved in a motorcycle acci-dentwithopenfractureoftherightleg(Fig.1)classifiedas GustiloIIIA.3_{Heunderwentcleaning,woundlavage,} debride-mentoftissuelesions,andtransarticularexternalfixationof thelegbonesattheanklejointaimingtoprovidelocaldamage control.

Onthesixthdayafterthetrauma,withtheimprovement of the soft-tissueenvelopeof the left leg, internalfixation wasperformedwithalockedintramedullarynailforthetibial fracture. Duringthesurgicalprocedure,anteriordislocation oftheanklejointwasobserved(Fig.2AandB).Theauthors opted foropenreductionandinternalfixationofthe ankle fracture-dislocationwithplateandscrewsinthefibula; insta-bilityofthe anklesyndesmosiswasprovenwithapositive Cotton4_{test.Weassociatedthestabilizationofthetibiofibular} mortise using apositioning screw through the fibular cor-texandthelateralcortexofthetibia,proximaltothedistal tibiofibularjoint,withoutadirectapproachtotheformer.Final

rev bras ortop.2016;51(5):597–600

599

Fig.3–(A)Radiographyafteropenreductionandinternalfixationofthefibulawithasuprasyndesmotictricorticalscrewon anteroposteriorview.(B)AxialplaneCTscanshowingtheincongruityofthedistaltibiofibularjointanditssubluxation.

radiographyrevisionshowedajointincongruityofthefibula withamultifragmentaryfracturelineonthefirst postopera-tiveday.Axialcomputedtomographyoftheankleconfirmed theexistenceofaprevioustibiofibular subluxation(Fig. 3A andB).

Duringhospitalization,sixdaysaftersurgery,thepatient underwentthethirdsurgicalprocedureaimingopen reduc-tion,ligamentreconstruction,andstabilizationofthedistal tibiofibularjointafterrevisionofpreviousosteosynthesis.

During surgery, avulsion ofthe articular capsule ofthe anklejointatthesuperiorandlateralregionswasobserved, aswellasoftheanteriortibiofibularligament(Fig.4).The sur-gicaltechniqueadoptedwastheremovalofthefibularplate inordertoreviewthereductionoftheanklefracture.

Underdirectview,theauthorsproceededtothereduction ofthedistalfibulatothefibularnotchofthetibia,with tempo-raryfixationofthejointusingsmoothKirschnerwire(Fig.5). Oncethejointreductionwasattested,theosteosynthesisof thefibularfracturewasaddressedusingalongreconstruction plate,asabonedefectwasobservedintheareaofthefracture fragmentation.Autologouscancellousbonegraftwasusedfor defectreconstruction.Sutureofthearticularcapsule,anterior tibiofibularligamentandanteriorsyndesmosiswasexecuted

Fig.4–Intraoperativeclinicalpictureshowingtorn articularcapsuleandanteriortibiofibularligament.

attheankle.Forprotectingtheligamentreconstruction,two positioningscrewswereapplied.Thelockedintramedullary nailusedforthetreatmentofthediaphysealtibialfractures didnotpresentcomplicationsandwasmaintained.

Activeanklemotionwasstimulatedimmediatelyafterthe procedure.Eightweeksafterthelastprocedure,the position-ingscrewsofthedistaltibiofibularjointwereremoved.

Currently, the patient presents no pain complaints and walkswithfullweightbearingandwithoutassistance.The rangeofmotionattheendoftreatmentwas20◦_{ofdorsiflexion}

and40◦_{ofplantarflexion,symmetricaltothecontralateral.}

The final functional evaluation was excellent, totaling 99 pointsintheAmericanOrthopaedicFootandAnkleSociety (AOFAS)Ankle-HindfootScalequestionnaire.

600

Discussion

Diaphysealtibialfracturesassociatedwithligamentinjuriesin theanklepresentahighpotentialforinstabilityandareoften neglected,posingariskofcomplicationssuchasthe develop-mentofsecondaryosteoarthritisandunfavorablefunctional performancewhenundiagnosedanduntreated.2,5

For the reported patient, intraoperative evaluation with Cottontestprovedsufficientandefficienttoassessthe syn-desmosis,waivingtheneedforotherteststoproveligament incompetence.6

Control radiographies after the second surgery showed subluxationoftheankle,althoughthiswasnotobservedin thefinalmomentsofsurgery.ACTscanoftheankleconfirmed thepoorreductionandmadeitpossibletoidentifythe inade-quateroutetakenbythepositioningscrew.Itwasshowntobe effectiveauxiliarytool,notonlyforelucidatingpossible diag-nosticuncertaintiesintheassessmentoftheaxialsections,7 butalsoforhelpingtoplanthedefinitivetreatment.

Inliterature,intraoperative temporary stabilization with Kirschnerwiresisanalternativetoclamps,withareported decrease in the rates ofpoor reductionsofneglected syn-desmosis,asthetechniqueemployedinthethirdoperative procedure in this case.7 _{Adequate reduction of the distal} tibiofibular joint hasbeen shown to be animportant pro-gnosticfactorforfunctional outcomeinankleinjurieswith syndesmoticinjury.7–9

Thepossiblevariationsintheuse ofpositioningscrews, whichprotecttheligamentrepairsoftheanklejointduring freemovement,arethesubjectofdebate.Thenumber, diam-eter,andfixationinthreeorfourcorticesarealsostilldebated inthe literature.10 _{Inthepresentpatient,theoptiontouse} two3.5-mmscrewswasduetothepoorqualityofthefixation ofthefirstscrewinstalled,themostdistalbeingtricortical, whichreachedtothetibiainthemetaphysealareawherethe lateralcortexwasthin.

Theliterature suggests that there are no differences in outcomebetweenpatientswhohaveorhavenotundergone removalofthesupra-syndesmoticpositioningscrewsbefore weightbearinggait.11 _{Withthe present patient,the screws} wereremovedaftereightweeks.

Intheshort-termfollow-up,jointfunctionisadequateand symmetric,andthepatientpresentsnocomplaints.Wethink ofnoreasonforadiverseevolutionofanklefractureswhenthe physiologicalandbiomechanicalrelationshipsaremaintained afterconsolidation.

Conclusion

Theliteraturedescribesthat ankleinjuriesassociatedwith diaphysealfracturesofthetibiaarefrequentlyneglecteddue toitsdifficultdiagnosis,suchasinthepresentcase.Careful pre-andintraoperativeassessmentsbaseduponboth clini-calpracticeandradiography arerequired;thepossibilityof associatedinjuryshouldbekeptinmind.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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1.WeberBG.Injuryoftheanklejoint.Huber:BernStuttgart Wien;1972.

2.GeorgiadisGM,EbraheimNA,HoefllingerMJ.Displacementof theposteriormalleollusduringintramedullarytibianailing.J Trauma.1996;41(6):1056–8.

3.GustiloRB,AndersonJT.Preventionofinfectioninthe treatmentofonethousandandtwenty-fiveopenfracturesof longbones:retrospectiveandprospectiveanalyses.JBone JointSurgAm.1976;58(4):453–8.

4.CottonFJ.Fracturesandjointdislocations.Philadelphia:WB Saunders;1910.

5.StuermerEK,StuermerKM.Tibialshaftfractureandankle jointinjury.JOrthopTrauma.2008;22(2):107–12.

6.StoffelK,WysockiD,BaddourE,NichollsR,YatesP. Comparisonoftwointraoperativeassessmentmethodsfor injuriestotheanklesyndesmosis.Acadavericstudy.JBone JointSurgAm.2009;91(11):2646–52.

7.SchwarzN,KöferE.Postoperativecomputed

tomography-basedcontrolofsyndesmoticscrews.EurJ Trauma.2005;31(3):66–70.

8.NimickCJ,CollmanDR,LagaayP.Fixationorientationinankle fractureswithsyndesmosisinjury.JFootAnkleSurg. 2013;52(3):315–8.

9.SagiHC,ShahAR,SandersRW.Thefunctionalconsequence ofsyndesmoticjointmalreductionataminimum2-year follow-up.JOrthopTrauma.2012;26(7):439–43.

10.MooreJAJr,ShankJR,MorganSJ,SmithWR.Syndesmosis fixation:acomparisonofthreeandfourcorticesofscrew fixationwithouthardwareremoval.FootAnkleInt. 2006;27(8):567–72.

11.SchepersT.Toretainorremovethesyndesmoticscrew:a reviewofliterature.ArchOrthopTraumaSurg.