foreign [Music] injuries involving a break in one or more of the bones that make up the ankle joint there are three bones that make up the ankle the tibia fibula and Talus specifically the medial and posterior malleoli of the tibia and the lateral malleolus of the fibula there is an additional joint between the tibia and fibula called the tibiofibular syndesmosis this is a fibrous structure made up of the anterior and posterior inferior tibiofibular ligaments and the interosseous membrane the ankle is a hinge joint primarily allowing for plantar and dorsiflexion and is at its least stable in plantar flexion it is described as a mortise and Tenon joint which are essentially a hole and a projection that fits that Hull in this case the space formed by the tibia and fibula and the projection which is the Dome of the talus bone ligaments help to provide more stabilization there is the medial or deltoid ligament coming from the medial malleolus which branches into four ligaments and is mostly involved in preventing over eversion while the lateral ligament comes from the lateral malleolus and is made up of three ligaments with the main function of preventing over inversion of the foot in 70 of cases there is an isolated fracture of either the medial or lateral malleolus if both are fractured this is termed a bimaliola fracture seen in 20 of cases and if the posterior malleolus is also fractured this is called a tri-malleolar fracture but this is only the case in fewer than 10 percent of patients in roughly 10 percent of cases the syndismosis is also injured there are multiple classifications of ankle fractures Weber is used in lateral malleolus fractures based on the location of the fracture relative to the syndesmosis generally with more proximal fractures indicating a higher risk of instability a is below the syndesmosis B is at its level and C is proximal to it the log Hanson classification is more detailed considering also the position of the ankle during injury and the forces sustained during it other types of fractures include a mesoneurve injury where there is a proximal fibular fracture with syndesmosis and deltoid ligament injury this is an unstable injury that will need surgical intervention this is why the knee should also be examined in patients with ankle injuries pylon is another typically due to a fall from height where there is a fracture of the distal tibia that also includes the articular surface there can be multiple mechanisms leading to ankle fractures ranging from ankle inversion during walking to high energy collisions with direct impact or even crushing it is most common between the ages of 15 and 24 in males and also in females above 75 years pain is the most common symptom which may also be present or worsened during movement and there is generally an inability to bear weight and walk link to this there can also be a reduced range of motion there is often swelling and bruising around the ankle and there may be an obvious deformity in displaced fractures neurovascular compromise needs to be considered which could be indicated by a cold pale pulseless foot as well as motor or sensory disturbances and this should be assessed before and after any treatment a combination of the history physical exam and imaging is used for diagnosis most commonly x-rays since most ankle injuries do not involve fractures the Ottawa rules for ankle x-rays are used to estimate if a fracture is likely and therefore if an x-ray is indicated these are pain on any malleola Zone and tenderness on the distal six centimeters of the tibia or fibula or if the patient is unable to bear weight immediately after the injury and in the consultation for at least four steps a foot x-ray would also be indicated if there is pain in the midfoot and either tenderness on the base of the fifth metatarsal or the navicular bone the typical views used are a modified AP View and lateral view weight bearing or stress views are used as well in some cases in general a fracture is indicated by a disturbance in the normal cortical outline or alignment of the bones the clear space around the talus may be disrupted for example if there is widening of the medial clear space it suggests injury to the syndesmosis if there is widening throughout no clear fracture the proximal bones should be checked as it could be a Mesa nerve fracture SCT is useful in planning operations especially in complex fractures like trimaliola fractures and MRI is used to evaluate soft tissue injuries the treatment involves prompt reduction of the fracture which means repositioning the bones to their anatomical positions this can be done conservatively or it can be done with surgery in general indications for conservative treatment or a closed reduction as stable fractures for example non-displaced fractures of the medial malleolus Weber a or Weber B fractures people who are deemed not fit for surgery and cases with a soft tissues are too significantly impaired an open reduction involves opening the skin to reduce the fracture which will also include internal fixation which means internally setting and stabilizing the fractured bones this is commonly referred to as an orif this is indicated mostly in open fractures so fractures where the skin has been broken unimalleola fractures with Taylor shift buy or try malleolar fractures as well as the mesoneerve or pylon fractures in ninety percent of cases most people have little to no ankle pain or limitation after one year however there are some potential complications like malunion or non-union ankle stiffness or post-traumatic arthritis venous thromboembolism like deep vein thrombosis or pulmonary embolism and even ulcerations from the cast operative complications include poor wound healing or infections particularly in diabetic patients and nerve injuries The Superficial perineal nerve being injured in 15 percent of cases