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Orthopaedics
Management of Acute Diabetic Fractures of the Ankle
Built from The Surgical Management of the Diabetic Foot and Ankle
What’s inside
11 sections · 115 slides
Overview
- Scope of this topic
- Standard care of ankle fractures
- Underestimation of ankle fracture severity in diabetes
How diabetes damages healing
- Effects of chronic hyperglycaemia on blood and nerves
- Consequences of microvascular compromise
- Impaired wound healing in hyperglycaemia
- Effects of hyperglycaemia on bone metabolism
- Delayed union times in diabetes
- Clinical burden of diabetic ankle fracture
- Principles guiding treatment choice
Epidemiology
- Prevalence of diabetes in the United States
- Comorbidity load in diabetic patients
- Achievement of glycaemic and blood pressure targets
- Incidence of adult ankle fractures
- Diabetic share of the ankle fracture population
Preoperative evaluation
- Urgency of surgery
- History taking
- Additional history points
- Inspection of the soft tissue envelope
- Neurological examination
- Semmes-Weinstein monofilament testing
- Clinical significance of peripheral neuropathy
- Vascular evaluation of the limb
- Vessel calcification in a fracture dislocation
- Pulse examination and Doppler ultrasound
- Ankle-brachial index and its limitation in diabetes
- Non-invasive tests of skin and toe perfusion
- Selecting a perfusion test in acute fracture
- Haemoglobin A1c and surgical risk
Fracture management
- Goals of treatment
- Indications for non-operative treatment
- Non-operative protocol
- Purpose of frequent review during casting
- Skin necrosis under a cast in a non-compliant patient
- Evidence base for non-operative management
- Complications reported with non-operative care
- Risk factors for complications
Operative treatment
- Indication for surgery and soft tissue timing
- Signs that soft tissues are ready for surgery
- Implants and instruments for preoperative planning
- Choice of fibular plate
- Four operative approaches
- Criteria for standard fixation
- Postoperative care after standard fixation
- Selection between standard and alternative fixation
- Operative principles for alternative techniques
- Reading the fixation and aftercare protocol
- Principles of fixation and postoperative care
- Principles of fixation and postoperative care (continued)
- Principles of fixation and postoperative care (continued)
- Aftercare timeline in alternative fixation
Trans-syndesmotic fixation
- Principle of trans-syndesmotic fixation
- Steps of trans-syndesmotic fixation
- Advantages of locking plate constructs
- Completing the fixation medially and posteriorly
- Trimalleolar fracture treated by trans-syndesmotic fixation
- Points to notice in the trans-syndesmotic case
Trans-articular fixation
- Trans-articular (non-fusion) fixation
- Steinmann pin augmentation
- Trans-articular pin fixation of a trimalleolar fracture
- Points to notice in the trans-articular pin case
- Retrograde tibio-talo-calcaneal nailing
- Retrograde nail fixation of a pilon fracture
- Points to notice in the pilon fracture case
- Immediate arthrodesis for non-reconstructable fractures
The combined technique
- Combined technique
- Layers of the combined construct
- Combined technique for a fracture dislocation
- Points to notice in the combined technique case
- Reading the surgical tactic table
- Surgical tactic for the combined technique
Complications and salvage
- The four major complications
- Overall complication rates
- Definition and causes of failure of fixation
- Mechanism of early weight-bearing failure
- Measures to prevent failure of fixation
- Broken plate and displacement after early weight-bearing
- Points to notice in the failed fixation case
- Salvage of failed fixation
- Malalignment following inadequate fixation
- Role of trans-articular external fixation in salvage
- Repeated fixation failure salvaged by double hindfoot arthrodesis
- Points to notice in the double arthrodesis salvage
- Pathophysiology of wound edge necrosis
- Additional factors impairing wound healing
- Early measures for wound and skin problems
- Stepwise management of an identified wound
- Rates and detection of infection
- Risk factors for infection
- Factors not associated with infection
- Management of superficial infection
- Management of deep infection
- Reconstruction after infection is controlled
- Charcot neuroarthropathy after ankle fracture
- Presentation and differential diagnosis of Charcot joint
- Indications for Charcot reconstruction
Summary
- Key conclusions
- Outcome expectations
- Checklist for the acute diabetic ankle fracture
- References
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- The Surgical Management of the Diabetic Foot and Ankle