0:01

So let's move on now

0:02

and let us uh, talk about the classification systems

0:07

that have been introduced to categorize the patterns

0:12

of ankle injury.

0:14

Most of the residents

0:16

and fellows that I have in encountered

0:18

through the years have preferred this particular

0:22

classification system known

0:24

as the Weber classification system.

0:27

It judges the level

0:29

of the fibular fracture using the joint line

0:32

as its reference.

0:34

A type A fracture is below the joint line.

0:39

A type B fracture is at the joint line

0:42

and a type C fracture is above the joint line.

0:47

It seems like a very simple system that might be useful.

0:51

The problem is the variability, particularly in the type B

0:56

fracture at the frac at the joint line.

0:59

In trying to to state whether

1:01

or not the syndesmotic ligaments are intact

1:06

with type A fractures below the joint line.

1:09

Indeed they remain intact.

1:11

But when you deal with high fractures,

1:14

generally there's an abnormality of them.

1:17

But with the Weber system, we run into

1:21

uncertainty when dealing with fractures

1:23

of the fibula at the joint line.

1:27

And because of that I like

1:28

to use a slightly more complicated system named

1:32

after a Danish radiologist.

1:35

This is the Logie Hansen system

1:39

and I'm gonna show you some slides looking at

1:41

that particular uh, system.

1:44

But there are problems with it.

1:45

So I thought I at least show you some of the critiques

1:49

of the Logie Hansen system.

1:51

These are some of the points that have been made

1:54

that when logging Hansen studied fractures about the ankle,

1:59

he only looked at three primary directions of loading.

2:04

Okay? He loaded using hands rather than in fact

2:09

machine loading.

2:10

He utilized only a small number of cadavers

2:14

and recent Cric evidence have found some exceptions

2:19

to his classification system.

2:21

And I'm gonna point out some of those exceptions

2:24

as we go through this.

2:26

The Logie Hansen system relates to two factors.

2:31

The first of this is the position of the foot.

2:34

Is the foot pronated shown here with outward rotation

2:39

and aversion of the forefoot, an abduction of the hind foot,

2:43

or is it supinated with inward rotation

2:47

and version of the four foot with abduction of the hindfoot?

2:52

So the first thing you you described,

2:55

and you'll see it in the descriptions of the injuries,

2:59

is in fact a foot pronated

3:01

or supinated at the time of injury.

3:05

The second factor is a direction of tailored displacement

3:10

or rotation with five possibilities that are listed here.

3:15

External rotation, and you can see the definitions here,

3:19

internal rotation, abduction, AB deduction, abduction,

3:25

ad deduction, or dorsiflexion.

3:28

So those were the criteria that was, that were used

3:32

by Logie Hansen.

3:33

Ending up with the number of injury patterns

3:37

that I will show you

3:38

and show Mr images of these various patterns.

3:43

One of the most common patterns

3:44

that we encounter is supination external rotation,

3:49

often abbreviated SCR.

3:52

What occurs in this particular pattern are four stages.

3:57

The classic stage one rupture

3:59

of the anter tibial fibrile ligament

4:02

or avulsion at one of its sites of insertions

4:06

shown in figure B subsequent to

4:10

that stage two, which is stage one plus a trans

4:15

syndesmotic fracture of the fibula.

4:18

And this is the characteristic finding of the SER injuries.

4:23

Stage three are the findings of stage two,

4:26

but now rupture of the posterior tibial fibula ligament

4:30

or fracture of the posterior tibia shown in

4:35

diagram D.

4:37

And then finally, stage four,

4:39

as things get back onto the medial side, here we deal

4:44

with rupture of the deltoid ligament shown in figure E

4:48

or fracture of the medial maus.

4:51

The fracture of the medial malali is an avulsion fracture,

4:55

typically transversely oriented as shown here.

5:00

So two characteristic fractures, an obliquely oriented trans

5:05

desmo fracture of the fibula

5:07

and a transverse fracture line of the medial maus.

5:11

Let's look at an example with Mr Images.

5:14

Here's stage one with an avulsion fracture related

5:17

to the anterior tibial fibular ligament.

5:21

Here's the classic fracture,

5:23

obliquely oriented lower anteriorly, higher posteriorly,

5:28

often beginning anteriorly at the level

5:31

of the ankle joint on it.

5:34

The stage three in this case is that VPR fracture fragment

5:39

where the posterior tibial fibula ligament attaches

5:42

to the distal tibia

5:44

and then the stage four in this particular patient

5:47

as abnormality of the deltoid, particularly

5:50

the deep posterior portion of the deltoid ligament.

5:55

Now when we get

5:56

To recent evidence, there have been exceptions

6:00

to this general rule.

6:02

Supination external rotation injuries

6:06

generally will reproduce stages two, three, and four.

6:11

But stage one findings are inconsistent in some studies

6:17

and medial ligament injuries that is stage four

6:20

may precede the stage three injury

6:24

to the posterior tibial fibular ligament.

6:27

So that those are recent data regarding this mechanism here.

6:31

Another example, stage one, the anterior uh,

6:36

tib fib stage two, the classic fracture.

6:39

Alright, and here stage three with the poster post

6:45

malar fracture line, SER injuries,

6:49

common pattern of injury.