ABSTRACT
Abstract Objective To evaluate the results obtained from the surgical treatment of malleolar ankle fractures associated with distal tibiofibular syndesmosis (DTFS) injury submitted to conventional surgical procedure for fracture fixation and DTFS fixation by suture button (SB). Methods Forty-nine patients were retrospectively evaluated, with a mean age of 45 years old and a mean follow-up of 34.1 months. Clinical and functional evaluation was based on the visual analogue scale (VAS) and on the American Foot and Ankle Society Score (AOFAS) for ankle and hindfoot, return to routine activities, and return to sport. Results The postoperative mean AOFAS and VAS were, respectively, 97.06 (confidence interval [CI 95%: 95.31-98.81] and 0.16 [CI 95% 0,04 - 0,29]. All patients returned to previous daily activities, and only 12 showed some residual symptom. There was no postoperative instability in any patient. Forty-six patients returned to sports activities and, of these, only 1 did not return to the level prior to the injury. Only two patients presented SB-related alterations. There was no report of dissatisfaction. Conclusion In malleolar fractures of the ankle with DTFS injury, the fixation of syndesmosis with SB demonstrated excellent postoperative results. Level of Evidence IV, retrospective case series.
Resumo Objetivo Avaliar os resultados obtidos do tratamento cirúrgico das fraturas maleolares do tornozelo associadas a lesão da sindesmose tibiofibular distal (STFD) submetidas a procedimento cirúrgico convencional de fixação da fratura e fixação da STFD pelo suture button (SB). Métodos Avaliou-se retrospectivamente 49 pacientes com uma média de idade de 45 anos e seguimento médio de 34,1 meses. A avaliação clínica e funcional foi baseada na escala visual analógica (EVA) e na escala American Foot and Ankle Society Score (AOFAS, na sigla em inglês) para tornozelo e retropé, retorno às atividades da rotina e retorno ao esporte. Resultados As médias pós-operatórias das escalas AOFAS e EVA foram, respectivamente, 97,06 (índice de confiança [IC 95%: 95,31 - 98,81] e 0,16 [IC 95% 0,04 - 0,29]. Todos os pacientes retornaram às atividades prévias do cotidiano, sendo que apenas 12 apresentaram algum sintoma residual. Não se verificou instabilidade pós-operatória em nenhum paciente. Ao todo, 46 pacientes retornaram às atividades desportivas e, destes, apenas 1 não retornou ao nível prévio à lesão. Apenas dois pacientes apresentaram alterações relacionadas ao SB. Não houve relato de insatisfação. Conclusão Em fraturas maleolares do tornozelo com lesão da STFD, a fixação da sindesmose com o SB demonstrou excelentes resultados pós-operatórios. Nível de Evidência IV, série de casos retrospectiva.
Subject(s)
Humans , Male , Female , Outcome Assessment, Health Care , Aftercare , Ankle Fractures/surgery , Ankle Fractures/rehabilitation , Ankle Joint/surgeryABSTRACT
Objective:To propose a new classification of posterior malleolus fracture to further clarify its pathoanatomy.Methods:Twenty fresh frozen cadaver specimens of normal morphology of lower limbs were selected and dissected and the extent of the tibial insertion of posterior malleolus associated ligaments was measured. At the same time, a retrospective case series analysis was made on the clinical and CT information of 296 patients with posterior malleolus fracture treated at Tongji Hospital of Tongji University from January 2012 to July 2020 or at Karamay Central Hospital from January 2018 to July 2020. The percentage of articular involvement of the fracture, proximal displacement of the posterior malleolus fracture and extent of posterior talar subluxation were measured. A clinically practical new classification system for posterior malleolus fracture was created by correlating posterior malleolus associated ligaments with CT images of posterior malleolus fracture. The new classification included three types: type I was posterior malleolus fracture with only the tibial insertion of inferior transverse tibiofibular ligament involved; type II was posterior malleolus fracture with both the tibial insertions of inferior transverse tibiofibular ligament and posterior inferior tibiofibular ligament involved, which was divided into subtypes IIA and IIB based on the presence of articular cartilage and subchondral bone damage, compression or Die-Punch fragments; type III was posterior malleolus fracture that involved all the tibial insertions of inferior transverse tibiofibular ligament, posterior inferior tibiofibular ligament and posterior tibiotalar ligament, which was sub-classified into subtypes III A and III B according to number of fracture fragments. Anatomic characteristics of the extent of the tibial insertion of posterior malleolus associated ligament, CT imaging parameters for posterior malleolus fracture and corresponding fracture typing were determined. In addition, the new classification system for posterior malleolus fracture was compared with Haraguci classification and Mason classification.Results:Posterior malleolus associated ligaments included the posterior inferior tibiofibular ligament, inferior transverse tibiofibular ligament and posterior tibiotalar ligament from posterolateral to posteromedial tibia. The posterior inferior tibiofibular ligament was attached to the posterolateral tibia and the distance between the highest point of its tibial insertion and the joint line was (45.2±5.6)mm. The inferior transverse tibiofibular ligament was attached to the posterior distal tibia and the distance between the highest point of its tibial insertion and the joint line was (5.5±1.0)mm. The posterior tibiotalar ligament was attached to the posterior colliculus and intercollicular groove of the medial malleolus and the distance between the center of its tibial insertion and the intercollicular groove was (2.5±0.6)mm. Among 296 patients with posterior malleolus fracture, there were 36 patients with type I, 229 with type II (150 type IIA, 79 type IIB) and 31 with type III (11 type IIIA, 20 type IIIB). The percentage of articular involvement of the fracture, proximal displacement of posterior malleolus fracture and extent of posterior talar subluxation in type IIB fracture were significantly greater than those in type II A fracture [23.7(18.6, 28.8)% vs. 18.4(12.7, 21.7)%, 4.1(2.1, 6.0)mm vs. 1.9(0.2, 3.0)mm, 4.7(1.5, 6.2)mm vs. 2.3(1.1, 3.0)mm] (all P<0.01). The proximal displacement of posterior malleolus fracture and extent of posterior talar subluxation in type III fracture were significantly greater than those in type II fracture [7.2(6.0, 8.2)mm vs. 2.7(0.4, 4.0)mm, 10.1(6.0, 15.0)mm vs. 3.1(1.1, 5.0)mm] (all P<0.01). The new classification for posterior malleolus fracture combined the posterior malleolus ligament and injury mechanism of posterior malleolus fracture as compared with Haraguchi classification, which not only further detailed the classification, but also was more practical in clinic for increased the severity of injury was elevated with higher classification level. The new classification was more comprehensive as compared with Mason classification for it mainly added the type of simple-rotation-type posterior malleolus fracture (type IIA of the new classification). Conclusions:In combination with posterior malleolus associated ligaments, injury mechanism and fracture morphology, posterior malleolus fracture is divided into three types. The new classification system more comprehensively describes pathoanatomy of posterior malleolus fracture that contributes to related basic research and clinical diagnosis and treatment.
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Objective:To investigate the influential factors of internal fixation for closed posterior ankle fractures.Methods:The clinical data of 352 patients with closed ankle fractures who received treatment in Yeda Hospital from January 2016 to June 2020 were retrospectively analyzed. Among the 352 patients, 232 patients had posterior ankle fractures. These patients were grouped according to whether they had undergone internal fixation. The factors that affect internal fixation for closed posterior ankle fractures were analyzed by univariate and multivariate analyses.Results:232 patients out of 352 patients with closed ankle fractures had closed posterior ankle fractures, accounting for 65.91%. A total of 102 (43.97%) patients with posterior ankle fractures underwent internal fixation. There were significant differences in Bartonicek classification, the proportion of the posterior subluxation of the talus, the proportion of posterior ankle bone area, the proportion of posterior ankle bone area ≥ 25% displayed on X-ray image, the proportion of posterior ankle bone area ≥ 15% displayed on CT scan, the proportion of outward displacement of bone mass (92.31% vs. 41.82%) and the proportion of die-punch bone mass (94.23% vs. 40.00%) between patients receiving and not receiving internal fixation ( χ2 = 3.89, 0.26, 1.51, 0.31, 9.27, 8.67, 1.68, 5.84, 10.33, 12.47, 11.48, 10.69, 1.39, all P < 0.05). Multivariate analysis of a logistic regression model showed that posterior subluxation of the talus and the proportion of posterior ankle bone area ≥ 15% displayed on CT scan were independent influential factors of internal fixation for closed posterior ankle fracture ( OR = 5.47, 9.29, 95% CI:1.62-9.75, 3.24-27.01, all P < 0.05). Conclusion:In patients with closed ankle fractures, posterior ankle fractures and internal fixation are more common. At the same time, the posterior subluxation of the talus and the proportion of posterior ankle bone area ≥ 15% displayed on CT scan are closely related to receiving internal fixation.
ABSTRACT
Abstract Tillaux fractures are fractures of the lateral margin of the distal tibia, usually reported in children between 12 and 14 years old. As intraarticular fractures, they require anatomic reduction and fixation to avoid posttraumatic complications. Since the injury mechanism is external rotation of the foot on the leg, these injuries are commonly associated with other fractures or ligamentous lesions. Currently, arthroscopy is being increasingly used to assist and improve surgical treatment of ankle fractures. The authors describe a 12-month follow-up of a rare case of a missed Tillaux fracture associated with syndesmosis injury in a 76-year-old polytrauma patient, successfully treated by arthroscopically-assisted reduction and internal fixation.
Resumo As fraturas de Tillaux são fraturas da margem lateral da tíbia distal, geralmente relatadas em crianças entre 12 e 14 anos. Como fraturas intra-articulares, requerem redução e fixação anatômica para evitar complicações pós-traumáticas. Como o mecanismo de lesão é a rotação externa do pé na perna, essas lesões são comumente associadas a outras fraturas ou lesões ligamentares. Atualmente, a artroscopia está sendo cada vez mais utilizada para auxiliar e melhorar o tratamento cirúrgico das fraturas do tornozelo. Os autores descrevem um acompanhamento de 12 meses de um caso raro de uma fratura não percebida de Tillaux associada a lesão por sindesmose em um paciente de politrauma com 76 anos de idade, tratado com sucesso por redução e fixação interna assistida por artroscopia.
Subject(s)
Humans , Male , Aged , Tibial Fractures , Multiple Trauma , Ankle Injuries , Minimally Invasive Surgical Procedures , Intra-Articular Fractures , Arthroplasty, Replacement, Ankle , Ankle FracturesABSTRACT
Abstract Objective The present study aims to analyze the intra- and interobserver reproducibility of the Lauge-Hansen, Danis-Weber, and Arbeitsgemeinschaft für Osteosynthesefragen (AO) classifications for ankle fractures, and the influence of evaluators training stage in these assessments. Methods Anteroposterior (AP), lateral and true AP radiographs from 30 patients with ankle fractures were selected. All images were evaluated by 11 evaluators at different stages of professional training (5 residents and 6 orthopedic surgeons), at 2 different times. Intra- and interobserver agreement was analyzed using the weighted Kappa coefficient. Student t-tests for paired samples were applied to detect significant differences in the degree of interobserver agreement between instruments. Results Intraobserver analysis alone had a significant agreement in all classifications. Moderate to excellent interobserver agreement was highly significant (p ≤ 0.0001) for the Danis-Weber classification. The Danis-Weber classification showed, on average, a significantly higher degree of agreement than the remaining classification systems (p ≤ 0.0001). Conclusion The Danis-Weber classification presented the highest reproducibility among instruments and the evaluator's little experience had no negative influence on the reproducibility of ankle fracture classifications. Level of Evidence II, Diagnostic Studies - Investigating a Diagnostic Test.
Resumo Objetivo Avaliar a reprodutibilidade intra- e interobservador das classificações de Lauge-Hansen, Danis-Weber e Arbeitsgemeinschaft für Osteosynthesefragen (AO) para as fraturas de tornozelo, e a influência do estágio de formação dos participantes na avaliação. Métodos Foram selecionadas radiografias de 30 pacientes com fratura de tornozelo nas incidências anteroposterior (AP), perfil e AP verdadeiro. Todas as imagens foram avaliadas por 11 participantes em diferentes estágios de formação profissional (cinco residentes e seis cirurgiões ortopédicos), em dois momentos distintos. Analisou-se a concordância inter- e intraobservador por meio do coeficiente Kappa ponderado. O teste t de Student para amostras pareadas foi aplicado para verificar se havia diferença significativa no grau de concordância interobservador entre os instrumentos. Resultado Observou-se que existe concordância significativa em todas as classificações quando da análise intraobservador isolada. Existe concordância interobservador altamente significativa de grau moderado a ótimo na classificação de Danis-Weber (p ≤ 0,0001). A classificação de Danis-Weber apresentou, em média, grau de concordância significativamente maior que as outras classificações (p ≤ 0,0001). Conclusão A classificação de Danis-Weber se mostrou a mais reprodutiva entre os instrumentos avaliados, e a pouca experiência do avaliador não influencia negativamente a reprodutibilidade das classificações das fraturas do tornozelo. Nível de Evidência II, Estudos Diagnósticos - Investigação de um Exame para Diagnóstico.
Subject(s)
Humans , Reproducibility of Results , Diagnostic Tests, Routine , Fractures, Bone , Ankle Fractures/classification , Orthopedic SurgeonsABSTRACT
RESUMEN Fundamento: las luxaciones puras del tobillo son lesiones muy infrecuentes, causadas por trauma de alta energía en especial los accidentes del tránsito y caídas de alturas. El tratamiento es por lo general quirúrgico. Objetivo: conocer una paciente con luxación traumática, pura y abierta de la articulación del tobillo. Presentación del caso: paciente de 50 años de edad, mestiza, femenina sin antecedentes mórbidos de salud, la cual sufrió caída de una altura aproximada de tres metros y es traída al cuerpo de guardia del Servicio de Ortopedia y Traumatología por presentar dolor e impotencia funcional total del tobillo derecho. Mediante la exploración física se detectó luxación abierta del tobillo derecho con franca exposición de las superficies articulares de la tibia distal y el astrágalo, además de tendones y partes blandas. Al tener en cuenta todos los elementos anteriores, se decidió llevar la paciente al quirófano, para tratamiento de tipo quirúrgico. De manera inmediata se realizó limpieza, irrigación pulsátil y desbridamiento de la herida en la articulación del tobillo, sutura de las partes blandas dañadas y se colocó fijación externa tipo Hoffman® en configuración de tipo triangular. Conclusiones: el tratamiento por general consiste en la reducción e inmovilización por seis semanas, sin embargo, en caso de afección severa de las partes blandas, donde se necesite la observación y cura de las heridas de forma sistemática, está justificado el uso de la fijación externa como lo es en el caso que se presentó.
ABSTRACT
Objective:To investigate the curative effect of suture anchor in the treatment of ankle joint fracture complicated with distal tibiofibular syndesmosis injury.Methods:From January 2017 to August 2019, data of 65 patients with Weber C type ankle fracture combined with posterior malleolus fracture in our hospital who underwent surgical treatment were retrospectively analyzed and were divided into two groups according to the treatment method of injury: suture-anchor repair group (suture-anchor was used to repair the anterior inferior tibiofibular ligament) and screw fixation group (cortical bone screw was used to fix the tibiofibular syndesmosis). Among them, 17 cases were treated with suture-anchors to repair the anterior inferior tibiafibular ligament, including 7 males, 10 females, 11 left and 6 right. In the Lauge-Hanson subgroup, there were 10 cases of pronation external rotation (PER), and 7 cases of pronation abduction (PA). The mean age was 43.76±15.83 years old. Forty-eight patients were treated with cortical screw fixation, including 33 males, 15 females, 34 left and 14 right. In the Lauge-Hanson subgroup, there were 30 cases of PER, and 18 cases of PA. The mean age was 39.90±13.57 years old. The differences in operation time, number of fluoroscopy, quality of reduction and postoperative complications were compared between the two groups. The ankle joint function was compared at 16 weeks postoperatively and at the last follow-up. The ankle joint function score was based on the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score.Results:All the 65 patients were followed up and the average follow-up time of 65 cases was 16.88±4.46 months. All the fractures were clinically healed 12-16 weeks after operation. The operative time of screw fixation group was 123.71±41.36 min, and the number of fluoroscopy was 25.17±16.29 times, while the operative time of suture-anchor repair group was 99.94±24.16 min and the number of fluoroscopy was 16.26±10.58 times. The difference between the two groups was statistically significant ( t=2.048, 2.175; P=0.045, 0.033). In the screw fixation group, the mean anterior and posterior distance of the tibiofibular syndesmosis was 3.15±1.35 mm, and 6.48±1.43 mm, respectively. In the suture-anchor repair group, the mean anterior distance of the syndesmosis was 2.06±1.47 mm, and the mean posterior distance of the syndesmosis was 6.76±1.78 mm. There was statistically significant difference in the distance of anterior distance of the syndesmosis ( t=3.328, P=0.002), while there was no statistically significant difference in the posterior distance of the syndesmosis ( t=0.701, P=0.486). The incidence of postoperative complications was 16.67% (8/48) in the screw fixation group and 5.88% (1/17) in the suture-anchor repair group, which was no statistically different ( χ2=1.282, P=0.258). The excellent and good rates of AOFAS ankle-hindfoot scores were 91.67% (44/48) in the screw fixation group and 88.24% (15/17) in the suture-anchor repair group at 16 weeks; 95.83% (46/48) in the screw fixation group and 94.12% (16/17) in the suture-anchor repair group at the last follow-up. There was no significant difference ( P >0.05). Conclusion:Compare with screw fixation in the treatment of acute distal tibiofibular syndesmosis injury, suture-anchor repair of anterior inferior tibiofibular ligament is a safe and effective method. It can increase the anatomical reduction rate of anterior distance of the syndesmosis, and reduce the operation time without increasing the incidence of complications.
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RESUMEN La fractura luxación del tobillo se presenta con alguna frecuencia en la práctica médica. La asociación de una luxación en las fracturas de tobillo modifica su abordaje terapéutico puesto que la articulación no debe permanecer por más de seis horas en dicha situación y por ende se requerirá del tratamiento quirúrgico de urgencia. Son conocidas las complicaciones relacionadas con la no reducción de una luxación en el periodo de tiempo mencionado anteriormente, dentro de estas, la necrosis avascular del astrágalo representa la más temida debido a la incapacidad que genera. Por tales razones se decidió presentar un caso que muestra el tratamiento de una fractura -luxación del tobillo derecho, en una paciente de 30 años de edad, estabilizada mediante el empleo de un mini fijador RALCA, la cual fue seguida por un periodo de cinco años.
ABSTRACT Ankle fracture dislocation occurs with some frequency in medical practice. The association of a dislocation in ankle fractures modifies its therapeutic approach since the joint should not remain for more than six hours in this situation and therefore emergency surgical treatment will be required. Complications related to the non-reduction of a dislocation in the previously mentioned period of time are known; within these, avascular necrosis of the talus represents the most feared due to the disability it generates. For these reasons, it was decided to present a case that shows the treatment of a fracture -luxation of the right ankle, in a 30-year-old patient, stabilized by using a RALCA mini fixator, which was followed for a period of five years.
Subject(s)
Humans , Female , Adult , Ankle Fractures/complications , Ankle Fractures/therapy , Ankle Fractures/surgeryABSTRACT
Abstract Objective The literature entails various intramedullary and extramedullary methods for distal fibula fracture fixation; with no consensus yet over the ideal method of fixation. We have retrospectively analyzed the results of using a twisted and contoured 3.5 mm locking compression plate (LCP) as a posterior buttress plate. Methods Of the 62 cases with ankle fractures managed at our institute by the senior author from 1st January 2012 to 31st December 2015, 41 patients met our inclusion criteria (Danis-Weber types B and C). Results All 41 distal fibular fractures healed uneventfully, at a mean of 10.4 weeks (8-14 weeks) (Figs. 6, 7, 8 to 9) with no complications. The mean American Orthopaedic Foot & Ankle Society (AOFAS) score was 92.6 (86-100) at a mean follow-up of 31.5 months (14-61 months). Conclusions We have achieved excellent clinical and radiological outcomes using a twisted 3.5 mm LCP as a posterior buttress by combining the advantages of posterior antiglide plating and lateral LCP.
Resumo Objetivo A literatura discute diversos métodos intramedulares ou extramedulares para fixação de fraturas da fíbula distal, mas não há consenso acerca do método ideal de fixação. Analisamos retrospectivamente os resultados do uso de uma placa bloqueada de compressão (LCP) de 3,5 mm retorcida e com contorno como placa de apoio posterior. Métodos Dos 62 casos de fraturas de tornozelo tratadas em nosso instituto pelo autor sênior entre 1° de janeiro de 2012 e 31 de dezembro de 2015, 41 pacientes atenderam aos critérios de inclusão (tipos B e C de Danis-Weber). Resultados Todas as 41 fraturas fibulares distais cicatrizaram sem intercorrências, em uma média de 10,4 semanas (8-14 semanas) (Figuras 6 a 9) e sem complicações. A pontuação American Orthopaedic Foot & Ankle Society (AOFAS) média foi de 92,6 (86-100) em um período médio de acompanhamento de 31,5 meses (14-61 meses). Conclusões Obtivemos excelentes resultados clínicos e radiológicos com uso de LCP retorcida de 3,5 mm como apoio posterior ao combinar as vantagens da placa antideslizante posterior e a LCP lateral.
Subject(s)
Humans , Male , Female , Adult , Middle Aged , Aged , Bone Plates , Fractures, Bone , Fibula , Ankle Fractures , Fracture Fixation, InternalABSTRACT
Background Ankle fractures are one of the main causes of consultation with emergency services around the world, with an incidence of 187 / 100,000 inhabitants per year. The most common is type B in the Weber-Dannis classification, with a long-term evolution towards osteoarthritis of 14%. Although the diagnosis of distal fibular fracture on an ankle radiograph is very simple, its usefulness has probably been overestimated to provide the necessary insights to decide the appropriate treatment method for the fracture. The objective of the study is to evaluate the diagnostic utility of ankle radiographs and their inter-observer agreement for a treatment decision making in Weber B fractures. Methods A prospective, randomized, double-blind, multicenter trial using three-country surveys of orthopedic surgeons was conducted; orthopedic surgeons and foot and ankle surgeons, were exposed to four Weber B ankle fractures x-ray series where surgery was actually required as the only treatment option. Unilateral and comparative projections, where presented in different time and order to each surgeon, measuring the variability of surgical decisions. Results Fifty-one orthopedic surgeons (72.37%), 24 foot and ankle surgeons (15.79%), 4 surgeons of other orthopedic subspecialties (2.63%) and 14 orthopedic surgery residents (9.21%) were surveyed. An inter-observer agreement of 70.83% (p <0.05) was found in the comparative projections series and 55.31% (p <0.05) in the unilateral ones. When performing linear regression between the training degree, years of experience and the provenance country of the surgeons, no causality was found (power of ß <95%). Nevertheless, 100% of the respondents diagnosed the fracture of the distal fibula as a Weber B fracture. Discussion The unilateral and comparative radiographic series are not recommended for making an adequate surgical decision in Weber B ankle fractures, given their very low inter-observer agreement. For decision making in Weber B ankle fractures it is necessary to take other complementary examinations such as Computed Axial Tomography.
Introducción Las fracturas de tobillo constituyen una de las principales causas de consulta a los servicios de urgencias alrededor del mundo, con una incidencia de 187/100.000 habitantes año. La más frecuente es la tipo B en la clasificación de Weber, con una evolución hacia la artrosis a largo plazo del 14%. Aunque el diagnostico de la fractura del peroné distal en una radiografía de tobillo es muy sencillo, probablemente se ha sobrestimado su utilidad para proporcionar elementos de juicio necesarios para decidir el método de tratamiento adecuado para la fractura. El objetivo del estudio es evaluar la utilidad diagnóstica de las radiografías de tobillo y su concordancia interobservador para la toma de decisiones de tratamiento en fracturas de tobillo Weber B. Materiales y Métodos Se realizó un experimento, prospectivo, aleatorizado, doble ciego, multicéntrico, mediante la aplicación de encuestas en tres países a Ortopedistas, residentes de ortopedia y Cirujanos de pie y Tobillo, en las cuales se les presentaban cuatro casos de fracturas de tobillo Webber B de características quirúrgicas en proyecciones unilaterales y comparativas, midiendo la variabilidad de las decisiones quirúrgicas. Resultados Se recolectaron 152 encuestas que respondieron 110 ortopedistas (72.37%), 24 cirujanos de pie y tobillo (15.79%), 4 cirujanos de otras subespecialidades ortopédicas (2.63%) y 14 residentes de ortopedia (9.21%). Se encontró una concordancia interobservador en las proyecciones comparativas del 70.83% (p<0.05) y en las unilaterales del 55.31%, (p<0.05), al realizar regresión lineal entre la respuesta el grado de entrenamiento, los años de experiencia y el país de procedencia no se encontró causalidad (poder de ?? <95%). El 100% de los encuestados diagnosticó la fractura del peroné distal. Discusión La serie radiográfica unilateral y comparativa no se recomiendan para la toma de una adecuada decisión quirúrgica en las fracturas de tobillo Weber B, dada su muy baja concordancia inter-observador. Para la toma de decisiones en fracturas de tobillo Weber B es necesaria la toma de otros exámenes complementarios como la Tomografía axial Computarizada.
Subject(s)
Humans , Ankle Fractures , Radiography , Diagnostic Tests, RoutineABSTRACT
Introducción Las fracturas de tobillo constituyen una de las principales causas de consulta a los servicios de urgencias alrededor del mundo, con una incidencia de 187/100.000 habitantes año. La más frecuente es la tipo B en la clasificación de Weber, con una evolución hacia la artrosis a largo plazo del 14%. Aunque el diagnostico de la fractura del peroné distal en una radiografía de tobillo es muy sencillo, probablemente se ha sobrestimado su utilidad para proporcionar elementos de juicio necesarios para decidir el método de tratamiento adecuado para la fractura. El objetivo del estudio es evaluar la utilidad diagnóstica de las radiografías de tobillo y su concordancia interobservador para la toma de decisiones de tratamiento en fracturas de tobillo Weber B. Materiales y Métodos Se realizó un experimento, prospectivo, aleatorizado, doble ciego, multicéntrico, mediante la aplicación de encuestas en tres países a Ortopedistas, residentes de ortopedia y Cirujanos de pie y Tobillo, en las cuales se les presentaban cuatro casos de fracturas de tobillo Webber B de características quirúrgicas en proyecciones unilaterales y comparativas, midiendo la variabilidad de las decisiones quirúrgicas. Resultados Se recolectaron 152 encuestas que respondieron 110 ortopedistas (72.37%), 24 cirujanos de pie y tobillo (15.79%), 4 cirujanos de otras subespecialidades ortopédicas (2.63%) y 14 residentes de ortopedia (9.21%). Se encontró una concordancia interobservador en las proyecciones comparativas del 70.83% (p<0.05) y en las unilaterales del 55.31%, (p<0.05), al realizar regresión lineal entre la respuesta el grado de entrenamiento, los años de experiencia y el país de procedencia no se encontró causalidad (poder de ?? <95%). El 100% de los encuestados diagnosticó la fractura del peroné distal. Discusión La serie radiográfica unilateral y comparativa no se recomiendan para la toma de una adecuada decisión quirúrgica en las fracturas de tobillo Weber B, dada su muy baja concordancia inter-observador. Para la toma de decisiones en fracturas de tobillo Weber B es necesaria la toma de otros exámenes complementarios como la Tomografía axial Computarizada.
Background Ankle fractures are one of the main causes of consultation with emergency services around the world, with an incidence of 187 / 100,000 inhabitants per year. The most common is type B in the Weber classification, with a long-term evolution towards osteoarthritis of 14%. Although the diagnosis of distal fibular fracture on an ankle radiograph is very simple, its usefulness has probably been overestimated to provide the necessary insights to decide the appropriate treatment method for the fracture. The objective of the study is to evaluate the diagnostic utility of ankle radiographs and their inter-observer agreement for the treatment decision making in Weber B fractures. Methods A prospective, randomized, double-blind, multicenter trial using three-country surveys of orthopedic surgeons was conducted; orthopedic surgeons and foot and ankle surgeons, were exposed to four Weber B ankle fractures x-ray series where surgery was actually required as the only treatment option. Unilateral and comparative projections, where presented in different time and order to each surgeon, measuring the variability of surgical decisions. Results Fifty-one orthopedic surgeons (72.37%), 24 foot and ankle surgeons (15.79%), 4 surgeons of other orthopedic subspecialties (2.63%) and 14 orthopedic surgery residents (9.21%) were surveyed. An inter-observer agreement of 70.83% (p <0.05) was found in the comparative projections series and 55.31% (p <0.05) in the unilateral ones. When performing linear regression between the training degree, years of experience and the provenance country of the surgeons, no causality was found (power of ß <95%). Nevertheless, 100% of the respondents diagnosed the fracture of the distal fibula as a Weber B fracture. Discussion The unilateral and comparative radiographic series are not recommended for making an adequate surgical decision in Weber B ankle fractures, given their very low inter-observer agreement. For decision making in Weber B ankle fractures it is necessary to take other complementary examinations such as Computed Axial Tomography.
Subject(s)
Humans , Ankle Fractures , Radiography , Diagnostic Tests, Routine , Fractures, BoneABSTRACT
Introducción: El manejo terapéutico de las fracturas de maléolo posterior en las fracturas trimaleolares de tobillo continúa en debate. Nuestro objetivo fue realizar una búsqueda de la evidencia científica sobre los aspectos terapéuticos de las fracturas de maléolo posterior en el contexto de las fracturas trimaleolares. Materiales y métodos: Se realizó una revisión de la bibliografía sistematizada por dos revisores, centrados en el manejo terapéutico del maléolo posterior. Resultados: Se obtuvieron 16 artículos clínicos de un total de 1029 pacientes, 8 estudios nivel de evidencia II y 8 de nivel IV. Se sistematizaron las indicaciones quirúrgicas y se analizaron los resultados funcionales y las complicaciones. Conclusiones: La comprensión pato-anatómica de estas fracturas es cada día mayor, principalmente por la utilización habitual de tomografías computarizadas (TC). El tratamiento quirúrgico sobre el maléolo posterior está evidenciando buenos y excelentes resultados funcionales. Para una adecuada decisión terapéutica se debería tener en cuenta ciertos factores: inestabilidad tibiotalar y sindesmótica, congruencia articular y características morfológicas del maléolo posterior. La reducción abierta (RA) y fijación interna con placa de sostén es el tratamiento que ha demostrado mejores resultados a corto y mediano plazo, no encontrando estudios con seguimiento a largo plazo.
Introduction: The therapeutic management of posterior malleolus fractures in trimaleolar ankle fractures continues in debate. Our objective was to conduct a search for scientific evidence on the therapeutic aspects of posterior malleolus fractures in the context of trimaleolar fractures. Materials and methods: A review systematic of the literature was carried out by two reviewers, focusing on the therapeutic management of the posterior malleolus. Results: 16 clinical articles were obtained with a total of 1029 patients, 8 studies level of evidence II and 8 studies level IV. The surgical indications were systematized, and the functional results and complications were analyzed. Conclusions: The patho-anatomical understanding of these fractures is increasing every day, mainly due to the usual use of CT scans. Surgical treatment on the posterior malleolus shows good and excellent functional results. For an adequate therapeutic decision certain factors should be taken into account: tibiotalar and syndesmotic instability, joint congruence and morphological characteristics of the posterior malleolus. Open reduction and internal fixation with support plate is the treatment that has shown better results in the short and medium term, not finding studies with long-term follow-up.
Introdução: O tratamento terapêutico das fraturas do maléolo posterior nas fraturas do tornozelo trimaleolar continua em debate. Nosso objetivo foi realizar uma pesquisa de evidências científicas sobre os aspectos terapêuticos das fraturas do maléolo posterior no contexto das fraturas trimaleolares. Materiais e métodos : Uma revisão sistemática da literatura foi realizada por dois revisores, com foco no manejo terapêutico do maléolo posterior. Resultados: foram obtidos 16 artigos clínicos com um total de 1029 pacientes, 8 estudos com nível de evidência II e 8 estudos com nível IV. As indicações cirúrgicas foram sistematizadas e os resultados e complicações funcionais foram analisados. Conclusões: O entendimento anatomopatológico dessas fraturas está aumentando a cada dia, principalmente devido ao uso habitual de tomografias computadorizadas. O tratamento cirúrgico do maléolo posterior mostra bons e excelentes resultados funcionais. Para uma decisão terapêutica adequada, certos fatores devem ser levados em consideração: instabilidade tibiotalar e sindesmótica, congruência articular e características morfológicas do maléolo posterior. A redução aberta e a fixação interna com placa de suporte é o tratamento que apresenta melhores resultados no curto e médio prazo, não encontrando estudos com acompanhamento a longo prazo.
Subject(s)
Humans , Ankle Fractures/surgery , Open Fracture Reduction , Fracture Fixation, InternalABSTRACT
Introducción Las fracturas de tobillo representan el 12% de las fracturas en la edad pediátrica. Planteamos la hipótesis que los pacientes con fracturas intraarticulares de tobillo tendrán un excelente resultado funcional y no presentarán cambios degenerativos articulares a los 6 meses post cirugía. El objetivo del estudio es realizar un analisis del resultado funcional, así como la presencia de cambios radiologicos degenerativos precoces en el seguimiento de pacientes con fracturas intra-articulares de tobillo tratadas en nuestro centro. Materiales y Métodos Estudio de Cohorte retrospectivo, se recolectaron datos de pacientes con fracturas intra-articulares de tobillo entre 2012 y 2016. Se clasificaron y evaluaron mediante score AOFAS y radiografías para clasificar según Van Dijk. Resultados La diferencia promedio de edad entre las fracturas triplanares y tillaux es de 17 meses (p: 0.038). La media de Score AOFAS fue de 85,2%. El 88.8% refiere dolor en relación a actividades cotidianas, a pesar de tener excelentes o buenos resultados funcionales. No hay correlación significativa entre los resultados de AOFAS en pacientes con fracturas transicionales y no transicionales., 43,4% presentaron estadio 0, 43,4% estadio I y 13% estadio II de Van Dijk. Ningún caso presento estadio III. Discusión En base a los hallazgos de este estudio, y al contrario de lo hipotetizado, la mayoría de los pacientes tienen un buen resultado funcional tras el manejo de las fracturas intraarticulares de tobillo y no excelente como se pensaba. Existe un grupo de pacientes que mostró cambios degenerativos precoces demostrables por radiografía.
Background Ankle fractures represent 12% of fractures in pediatric age. We hypothesized that patients with intra-articular ankle fractures will have an excellent functional result and will not present degenerative joint changes 6 months after surgery. The objective of the study is to carry out an analysis of the functional result, as well as the presence of early degenerative radiological changes in the follow-up of patients with intra-articular ankle fractures treated in our center. Methods Retrospective cohort study, data were collected from patients with intra-articular ankle fractures between 2012 and 2016. They were classified and evaluated using AOFAS score and radiographs to classify according to Van Dijk. Results The average age difference between triplanar and tillaux fractures is 17 months (p: 0.038). The mean AOFAS Score was 85.2%. 88.8% reported pain in relation to daily activities, despite having excellent or good functional results. There is no significant correlation between the AOFAS results in patients with transitional and non-transitional fractures. 43.4% had stage 0, 43.4% stage I, and 13% stage II Van Dijk. No case presented stage III. Discussion Based on the findings of this study, and contrary to the hypothesized, most patients have a good functional result after the management of intra-articular ankle fractures and not excellent as previously thought. There is a group of patients who showed early degenerative changes demonstrable by radiography.
Subject(s)
Humans , Infant , Child, Preschool , Child , Ankle Fractures , Tibial FracturesABSTRACT
Introduction:Ankle injuries comprise a major group of lower limb trauma. Many of these injuries can be treated by manipulative reduction and conservative treatment and some of these yield satisfactory results, so present study was undertaken to know the effectiveness of surgical management of ankle fractures. Method:42 surgically treated dis-placed fractures are included and studied in detail of age, sex, occupation, type of fracture, mode of injury, type of treatment, Clinical evidence of fracture union, Radiological evidence of fracture union, Relation of talus in the ankle mortise, Range of mobility of the ankle, Residual disability and pain, Ability to walk and time of return to duty and complications were noted. Result:42 cases were surgically treated, most of the patients were operated on an emer-gency basis within 24 hours of injury. Based on the mechanism of injury Pronation-External Rotation (30.9%) and Based on Ao Classification Type B -B2 (53.3%) were the major type of fractures. In the majority of cases, Malleolar screws type of implants used.In overall the final status of patients is good (ability to walk).Conclusion:Displaced ankle fractures need accurate open reduction and internal fixation and postoperative immobilization for 6 weeks. This will suffice to get good results. Post-operative rigid immobilization and protected weight bearing for 12 weeks is mini-mal to achieve good union followed by physiotherapy to restore the maximum range of movements
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<p><b>PURPOSE</b>To investigate the early and mid-term results of open reduction and internal fixation (ORIF) with transarticular external fixation (TEF) but no deltoid ligament repair (DLR) in the treatment of supination-external rotation type IV equivalent (SER IV E) ankle fractures (AO/OTA classification 44-B 3.1) and provide evidence for clinical practice.</p><p><b>METHODS</b>This study cohort consisted of 22 patients with SER IV E ankle fractures that underwent ORIF with TEF but no DLR between December 2011 and December 2014. There were 13 males and 9 females, mean age 38.9 years (range, 17-73 years). Eight cases involved the left side and 14 the right side. The causes of fractures included road traffic accidents (11 cases), falling from height (6 cases) and sports injuries (5 cases). The mean period of hospitalization was 9.8 days (range, 6-14 days). For all the patients, MRI and three-dimensional CT were done before surgery and X-rays done preoperatively and during follow-ups. The external frame was kept for 8-10 weeks. The preoperative American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score was 56.86 ± 4.400, the Medical Outcomes Short Form 36-item (SF-36) questionnaire score was 57.41 ± 4.102 and the visual analog score (VAS) was 5.50 ± 1.058. Patients' main complaints about inconvenience of daily life were also recorded.</p><p><b>RESULTS</b>All the 22 patients were followed up for 24-63 months (mean, 33.6 months). None of them developed nonunion during the follow-up; pin site infection was observed in one patient and posttraumatic osteoarthritis in another. At the final follow-up, the average AOFAS score, SF-36 score and VAS score were respectively 90.59 ± 5.096, 79.59 ± 5.394 and 1.82 ± 1.181, which were significantly improved compared with the preoperative data (t = 26.221, p < 0.001; t = 11.910, p < 0.001; t = 11.571, p < 0.001). The therapeutic effect was excellent in 13 cases, good in 7 cases and fair in 2 cases, with a good-excellent rate of 90.9%. Patients' main complaints were inconvenience of clothing (17 cases) and extremity cleaning (5 cases).</p><p><b>CONCLUSION</b>In the treatment of SER IV E ankle fractures, ORIF with TEF but no DLR can achieve satisfactory outcome, but long-term effect should be confirmed by large sample randomized controlled trials.</p>
Subject(s)
Adolescent , Adult , Aged , Ankle Fractures , General Surgery , Female , Fracture Fixation , Methods , Humans , Ligaments, Articular , General Surgery , Male , Middle Aged , Open Fracture Reduction , Methods , Postoperative Care , Retrospective Studies , Rotation , Supination , Young AdultABSTRACT
ABSTRACT OBJECTIVE: To evaluate the postoperative results of patients with supination-external rotation ankle fractures who underwent syndesmotic screw (SS) removal. METHODS: Retrospective cohort study assessing the late postoperative results of 35 patients operated from January 2013 to June 2015. Patients undergoing treatment of rupture of the distal tibiofibular syndesmosis with SS fixation and who did not have any concomitant surgical injuries in sites other than the ankle were included. Patients who did not complete appropriate follow-up after surgery were excluded from the study. RESULTS: There was no statistical significant difference in the evaluated outcomes among the patients who had their SS removed and those who remained with the SS. CONCLUSION: SS removal did not significantly alter the clinical results of patients surgically treated with SS for supination-external rotation fractures.
RESUMO OBJETIVO: Avaliar o resultado pós-operatório dos pacientes com fratura do tornozelo pelo mecanismo de supinação-rotação externa que foram submetidos a retirada do parafuso transindesmoidal (PT). MÉTODOS: Estudo de coorte retrospectivo que avaliou os resultados pós-operatórios tardios de 35 pacientes operados entre janeiro de 2013 e junho de 2015. Foram incluídos pacientes submetidos ao tratamento da ruptura da sindesmose tibiofibular distal com fixação com PT e que não apresentavam lesões cirúrgicas concomitantes em outros sítios que não o tornozelo. Pacientes que não foram devidamente acompanhados no pós-operatório foram excluídos. RESULTADOS: Não houve diferença estatisticamente significativa nos desfechos avaliados entre os pacientes que tiveram o PT removido e os que permaneceram com o PT. CONCLUSÃO: A retirada do PT não alterou significativamente o resultado clínico dos pacientes tratados cirurgicamente com PT por fraturas do tipo supinação-rotação externa.
Subject(s)
Humans , Male , Female , Adult , Middle Aged , Ankle Fractures , Ankle Injuries , Fracture Fixation, Internal , OrthopedicsABSTRACT
INTRODUCCIÓN: Las fracturas de tobillo representan un motivo frecuente de visita a los servicios de emergencias, constituyen el 25 % de las fracturas de miembro inferior. Al manejarse inadecuadamente pueden generar artrosis, por lo que adquiere importancia el manejo adecuado y oportuno que permita recuperar la movilidad temprana. CASO CLÍNICO: Paciente femenino de 17 años de edad, deportista (danza profesional), sinantecedentes patológicos de importancia, acudió al servicio de emergencias por sufrir caída de 2 metros de altura, mientras practicaba deporte, sufriendo trauma directo en miembro inferior izquierdo. Al examen físico el tobillo izquierdo se evidenció deformidad, dolor a la digitopresión, imposibilidad de apoyar el pie, inestabilidad de la articulación tibioperónea indicando lesión de la sindesmosis, tumefacción, equimosis, pulso pedio y tibial posterior presente, llenado capilar normal, y sensibilidad distal conservada. El diagnóstico fue fractura de tobillo tipo B de Weber. EVOLUCIÓN: Se realizó una reducción con osteosíntesis «tercio de caña¼ y fijación interna mediante doble sistema Tightrope®, luego del procedimiento permaneció 4 semanas con yeso cerrado, evidenciándose un adecuado proceso consolidativo en los controles radiográficos posteriores. Luego de un mes de terapia física presentó recuperación de la movilidad y negó presentar dolor o sensación de disconfort; el resultado funcional fue satisfactorio y luego de dos meses retomó su actividad regular. CONCLUSIÓN: El manejo activo con cirugía y fijación mediante sistema Tightrope® en fracturas de tobillo constituye una opción de tratamiento alternativa y eficaz en lugar de clavos sindesmales. En pacientes deportistas o con alta demanda de actividad física evita una reintervención quirúrgica y permite un retorno precoz a las actividades habituales.(AU)
BACKGROUND: Ankle fractures are a frequent reason of consult at emergency services. They represent 25 % of lower limb fractures. If are not handled properly it may lead to arthrosis, so the proper and timely treatment are important for early recovery of mobility. CASE REPORT: A 17-year old female patient, athlete and with no important medical precedents who attended to emergency department after suffering a 2-meter fall, she suffered direct trauma in lower left limb. Left ankle was painful and had swelling, ecchymosis and functional impotence. Diagnosis was Weber B ankle fracture. EVOLUTION: An open reduction with double Tightrope® fixation system was performed. She stood with a closed plaster for 4 weeks after procedure. Subsequent radiographic controls showed an adequate consolidation process. Mobility was recovered after one month of physical therapy, she did not refer pain or discomfort so the functional outcome was satisfactory. CONCLUSION: Active surgical management and fixation with Tightrope® system on ankle fractures is a fair option of treatment. It avoids reoperation and allows an early return to regular activities in athletes or in those patients with a high demand of physical activity./AU)
Subject(s)
Humans , Male , Ankle Fractures/therapy , Fracture Fixation, Internal , Bone NailsABSTRACT
ABSTRACT Objective: To evaluate the frequency of deltoid ligament injury in bimalleolar supination-external rotation type fractures and whether there is a correlation between the size of the fractured medial malleolus and deltoid ligament injury . Methods: Twenty six consecutive patients underwent magnetic resonance exams after clinical and radiographic diagnosis of bimalleolar supination-external rotation type ankle fractures . Results: Thirteen patients (50%) presented deltoid ligament injury associated to bimalleolar ankle fracture. Partial injury was present in seven (26.9%) patients and total injury in six (23.1%). Regarding medial fragment size, the average was 2.88 cm in the absence of deltoid ligament injury. Partial injuries presented 1.93 cm and total 2.1 cm on average . Conclusion: Deltoid ligament injury was present in 50% of bimalleolar ankle fractures. Smaller medial malleolus fragments, especially concerning the anterior colliculus, presented greater association with partial deltoid ligament injuries. Level of Evidence IV, Cross Sectional Study.
RESUMO Objetivo: Avaliar a frequência da lesão do ligamento deltóide nas fraturas bimaleolares do tornozelo tipo supinação-rotação externa e se existe correlação entre o tamanho do fragmento do maléolo medial fraturado e o tipo de lesão do ligamento deltóide. Métodos: Vinte e seis pacientes consecutivos com diagnóstico clínico e radiográfico de fratura bimaleolar do tornozelo tipo supinação-rotação externa (Lauge-Hansen), foram submetidos ao exame de ressonância magnética do tornozelo para avaliar a presença de lesão ligamentar associada à fratura bimaleolar. Resultados: Treze pacientes (50%) apresentaram lesão do ligamento deltóide associada à fratura bimaleolar do tornozelo, sendo sete (26,9%) lesões parciais e seis (23,1%) totais. Com relação ao tamanho do fragmento do maléolo medial, na ausência de lesão do ligamento deltóide, o tamanho médio foi de 2,88 cm. Nas lesões parciais, a média foi de 1,93 cm e, nas lesões totais do ligamento deltóide, de 2,1 cm. Conclusões: A lesão do ligamento deltóide esteve presente em metade das fraturas bimaleolares do tornozelo do tipo supinação-rotação externa. Fragmentos menores do maléolo medial, especialmente do colículo anterior, tem maior associação com lesões parciais do ligamento deltóide. Nível de Evidência IV, Estudo Transversal.
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OBJECTIVES: There remains controversy over osteoporotic feature of the ankle. Therefore, we investigated the possibility of the existence of a relationship between axial bone mineral density (BMD) in patients with ankle fracture group with that of the normal population in Korea under control of other confounding factors such as body mass index (BMI). METHODS: This study retrospectively reviewed medical records of patients who were treated in our institution from 2005 to 2015. A comparative analysis was carried out between 116 patients with ankle fracture (ankle fracture group) and 113 patients admitted with other orthopedic reasons (control group). Sex, age, energy level of trauma, and BMI were analyzed as variables affecting axial BMD. RESULTS: Age and sex of ankle fracture group were not different from them of control group (P = 0.968 and P = 0.870, respectively). BMI of ankle fracture group was higher than that of control (P = 0.029). The other variables showed no differences between the 2 groups. The energy level of trauma in ankle fracture group was related to only BMI (P = 0.013). CONCLUSIONS: Axial BMD of ankle fracture patients showed no difference from that of a control group in Korean population. The occurrence of ankle fracture is affected by only BMI rather than axial BMD. Evaluation of osteoporosis for patients with ankle fracture should be considered separately.
Subject(s)
Ankle Fractures , Ankle , Body Mass Index , Bone Density , Humans , Korea , Medical Records , Orthopedics , Osteoporosis , Retrospective Studies , Risk FactorsABSTRACT
PURPOSE: To introduce reliable and newly developed radiographic measures based on a lateral ankle radiograph to assess a syndesmotic reduction after screw fixation and to compare with the radiographic measures based on the anteroposterior (AP) and mortise radiographs. MATERIALS AND METHODS: The postoperative ankle radiographs of 34 ankle fracture cases after screw fixation for concurrent syndesmosis injury were reviewed. Two radiographic parameters were measured on each AP and mortise radiograph; tibiofibular clear space (TFCS) and tibiofibular overlap (TFO). Five radiographic parameters were measured on the true lateral radiographs; the anteroposterior tibiofibular (APTF) ratio, anterior tibiofibular ratio (ATFR), posterior tibiofibular ratio (PTFR), distances of intersection of the anterior fibular border and the tibial plafond to anterior cortex of the tibia (AA′), and the intersection of posterior fibular border and tibial plafond to the tip of the posterior malleolus (BB′). In addition, the distance (XP) between the fibular posterior margin (X) crossing tibial plafond or the posterior malleolus and posterior articular margin (P) of the tibial plafond was measured on the lateral view. RESULTS: Using TFCS and TFO in the AP and mortise radiographs, malreductions of syndesmosis were estimated in 17 of 34 cases (50.0%). Using the introduced and developed radiographic measures in the lateral radiographs, syndesmotic malreductions were estimated in 16 out of 34 cases (47.1%). Seventeen cases (50.0%) showed no evidence of postoperative diastasis using the radiographic criteria on the AP and mortise view, 10 cases (58.8%) of whom showed evidence of a malreduction on the lateral radiograph. The newly developed measurements, XP, were measured 0 in 11 out of 34 cases (32.4%). CONCLUSION: The reduction of syndemosis after screw fixation can be accurately assessed intraoperatively with a combination of several reliable radiographic measurements of the lateral radiograph and traditional radiographic measurements of the AP and mortise radiograph.