Orthopaedic Trauma

An ankle fractures refer to a break in the fibula, tibia, or talus bones, or a combination of these. The injuries typically result from a twisting injury and can result from low or high velocity force. Some ankle fractures are related to dislocation of the ankle joint, and these will typically require reduction in the emergency department. The correct treatment for ankle fractures is crucial to ensure the highest chance of return to function, reduce pain, and prevent long-term arthritis. X-rays will diagnose the majority of injuries; however, a CT and/or MRI scan may be required for further assessment as well as assistance with surgical planning.

Treatment

Simple, undisplaced ankle fractures can typically be treated non-operatively in either plaster or a moon boot. The length of immobilisation will often be dictated by the severity of the injury and any associated injuries. Fractures with significant displacement or deemed to be unstable will usually require surgical fixation. This will usually involve a combination of plates and screws with or without fixation of associated ligamentous injuries (Syndesmosis). The recovery for these fractures will be dictated by the significance of the fracture/s and associated ligament injuries, typically taking at least three months to regain most function in the ankle. Risks of ankle fracture surgery include deep vein thrombosis, infection, damage to neurovascular structures, and post-traumatic ankle arthritis.

Achilles rupture refers to a tear in the Achilles tendon, one of the major tendons contributing to push-off strength within the ankle. Such ruptures usually occur during sporting activities but can also happen in everyday activities, particularly in individuals with an already weakened tendon. The majority of injuries can be confirmed on ultrasound, but occasionally an MRI scan is required.

Treatment

Treatment for Achilles tendon rupture is typically non-surgical, especially for injuries that are identified and treated within 24 to 48 hours of the injury. Current literature suggests that patients managed through an accelerated physiotherapy programme tend to have good functional outcomes. The typical treatment involves the patient being placed into a cam boot with some wedges to help bring the tendon ends together. This is followed by physical therapy to aid the repair and then gradual strengthening of the tendon.

In some circumstances, surgical intervention is warranted, in the form of a surgical repair of the torn tendon. This is typically reserved for patients with delayed presentations of injuries or delay in treatment. Certain athletes may also prefer to have a surgical repair of their Achilles tendon. Regardless of whether the management is surgical or non-surgical, recovery typically takes up to six months, depending on the circumstances.

Risks associated with surgical intervention include infection, deep vein thrombosis, nerve damage, and re-rupture of the tendon.

Lisfranc injuries refers to a serious injury of the midfoot. These can include both bony injuries as well as ligamentous injuries, all of which help to stabilise the midfoot region. Typically, Lisfranc injuries occur with the foot in a flexed position but can have various other mechanisms of injury. They can be related to both low and high velocity injuries. Lisfranc injuries are important to diagnose as they have a high chance of progressing to arthritis when missed. Usually, patients will present with significant swelling and bruising within the foot. Most Lisfranc injuries can be identified on plain x-rays and CT scans but, in some circumstances, an MRI scan will need to be performed. 

Treatment for Lisfranc injuries depends upon the stability of the injury as well as any dislocation or malalignment of the joints. Theepan will be able to go through your scans with you and determine the best course of action. Patients who are deemed suitable for non-operative treatments are typically non-weight-bearing for six weeks, during which time they will start physical therapy. It is likely they will use arch support orthoses throughout the rest of their life. Patients with unstable Lisfranc injuries deemed suitable for surgical intervention, will typically involve the use of either plates and screws (which usually will need to be removed) to stabilise the affected joints or an internal brace device which usually does not need to be removed. Recovery from Lisfranc surgery can take between four and six months. Patients with severe Lisfranc injuries may be best suited to primary fusion surgery, particularly in those with significant joint destruction and those of an older age demographic. The risks of Lisfranc surgery include deep vein thrombosis, infection, damage to the neurovascular structures in the area, as well as development of post-traumatic arthritis.

Each knee has two menisci, the medial (inside) and the lateral (outside) meniscus. Tears usually result from a twisting motion to the knee. The symptoms of meniscal injuries usually include pain, as well as mechanical symptoms of clicking, locking, and sometimes the feeling of instability within the knee. The meniscus provides a shock absorber for the knee between the femur and tibia bones. Blood supply for the meniscus can be tenuous in parts and, as such, the healing of meniscus injuries is often guarded. Meniscus injuries can occur in conjunction with other injuries such as ACL tears or ACL ruptures.

Treatment

Treatment for meniscus injuries depends on several factors including the acuity of the injury, the patient's age, and the presence of any arthritic changes. In the presence of severe arthritic joint changes within the compartment of the meniscus injury, current evidence would suggest that non-operative interventions would be beneficial in the first instance. This includes, but is not limited to, physiotherapy, as well as potentially the use of corticosteroid injections to help manage the pain.

Where the injury is more acute or with certain types of meniscal injuries, consideration can be given to meniscal repair versus meniscal debridement. Meniscal repair is usually reserved only for those tears in which there is a higher chance of healing possible, often in younger patients. The recovery from meniscal repair usually takes three to four months, and there is at least a six week period of using crutches. Deep bending is also avoided for a six week period.

Patients who have an irreparable tear, usually a debridement, a procedure may be performed whereby a portion of the meniscus causing issues is 'trimmed out'. This procedure is done by keyhole incisions and usually the recovery is much quicker, with most people walking comfortably without any gait aids at three to four weeks after the surgery.

The risks of meniscal surgery include deep vein thrombosis, infection, failure of repair, and potential post-traumatic arthritis later on in life.