Slideshow
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Figure 1. Lateral radiograph showing ankle fracture dislocation.
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Figure 2. Anteroposterior view of ankle after closed reduction.
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Figure 3. Lateral view of ankle after closed reduction.
A 21-year-old man presents to the emergency department (ED) with severe right ankle pain and deformity. He jumped off a ledge and fell awkwardly on his right ankle. On physical examination, he has an obvious deformity to the ankle but his skin and neurovascular status are intact. Imaging is performed at the time of the ED visit and after treatment (Figures 1-3). Radiographs appear to show an osteochondral lesion of the talus.
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Ankle fractures are common injuries seen in orthopedic practice. Unstable ankle fractures are frequently treated with open reduction and internal fixation to restore the anatomic alignment of the ankle. One aspect of an ankle fracture that is often missed at the initial presentation is an osteochondral injury.1-4
Osteochondral injuries that occur with ankle fractures are known to cause significantly poorer results compared with ankle fractures alone. Damage to the articular cartilage of the ankle can cause early ankle arthritis.1,2
Osteochondral injuries are frequent, occurring in up to 80% of ankle fractures. They typically occur at the talar dome. Aktas et al found that osteochondral injuries occurred in 15% of bimalleolar fractures, 40% of trimalleolar fractures, and 70% of distal fibular fractures.3 It is hypothesized that more stable injuries transmit the force of impact through the cartilage and less on bone.
Kwok et al found that these lesions are not present with Weber A fractures but are present in 26% of the Weber B fractures, 24% of the Weber C fractures, and 20% of isolated medial malleolus fracture cases.4
The patient in this case underwent an ankle arthroscopy at the time of fracture fixation, which revealed an osteochondral impact injury to the talar dome. The osteochondral lesion was debrided prior to ankle fixation.
Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor in chief of the Journal of Orthopaedics for Physician Assistants.
References
1. Ackermann J, Fraser EJ, Murawski CD, Desai P, Vig K, Kennedy JG. Trends of concurrent ankle arthroscopy at the time of operative treatment of ankle fracture: a national database review. Foot Ankle Spec. 2016;9(2):107-112. doi:10.1177/1938640015599034
2. Thordarson DB, Bains R, Shepherd LE. The role of ankle arthroscopy on the surgical management of ankle fractures. Foot Ankle Int. 2001;22(2):123-125. doi:10.1177/107110070102200207
3. Aktas S, Kocaoglu B, Gereli A, et al. Incidence of chondral lesions of talar dome in ankle fracture types. Foot Ankle Int. 2008;29(3):287-292. doi:10.3113/FAI.2008.0287
4. Chan KB, Lui TH. Role of ankle arthroscopy in management of acute ankle fracture. Arthroscopy. 2016;32(11):2373-2380. doi:10.1016/j.arthro.2016.08.016
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