Gözden kaçan izole posterior malleol kırıkları

Yıl 2014, Cilt: 48 Sayı: 3, 249 - 252, 30.05.2014

Turhan Ozler Melih Guven Ayberk Onal Cagatay Ulucay Tahsin Beyzadeoglu Faik Altintas

https://doi.org/10.3944/AOTT.2014.14.0033

Öz

Amaç:Bu çalışmada tanısı atlanmış izole posterior malleol kırıklı hastaların yaralanma mekanizması ve klinik ve radyolojik sonuçlar açısından değerlendirilmesi amaçlandı.

Çalışma planı: Atlanmış izole posterior malleol kırığı olan 7 hasta (5 erkek, 2 kadın, ortalama yaş 32 (23-40)) çalışmaya alındı. Ayak bileği burkulması nedeniyle acil servise başvuran ve standart ayak bilek grafileri ile kırık saptanmayan bu 7 hastada şikayetlerin devam etmesi nedeniyle 3. haftada çekilen ayak bileği MR görüntülemesi ile izole posterior malleol kırığı tanısı koyuldu. Hastalar 3 hafta boyunca yük kısıtlaması ve ayak bilekliği ile tedavi edildiler. Kırık kaynamasının ve olası dejeneratif değişikliklerin değerlendirilmesinde ayak bileğinin ön-arka, yan ve 50° dış rotasyonda çekilen grafileri kullanıldı. Bütün hastalar 1 yıl takip edildi.

Bulgular: Altıncı hafta sonunda 7 hastanın 6’sında kırık kaynaması görüldü. Bir hastanın ise 6. ayda hala kırığı kaynamamıştı. Hastaların ortalama AOFAS ayak bileği ardayak skorları tedavi öncesi ve tedavi sonrası 3. ayda sırası ile 20 (11-31) ve 86 (43-96) idi. Birinci yıl takiplerinde hiçbir hastada dejeneratif değişiklik veya instabilite saptanmadı.

Çıkarımlar: Ayak bileği arkasında ağrı yakınması olan ve plantar fleksiyon ve/veya aksiyel kompresyon mekanizması ile ayak bileği burkulması tarif eden hastalarda izole posterior malleol kırığı akla getirilmelidir. Tanıda 50° dış rotasyonda çekilen yan grafi kırığın saptanmasına yardımcı olabilir.

Anahtar Kelimeler

Posterior malleol kırığı; ayak bileği burkulması; izole.

Missed isolated posterior malleolar fractures

Öz

Objective:The aim of this study was to evaluate the injury mechanism and clinical and radiological results of the patients with isolated posterior malleolar fracture.

Methods: Seven patients (5 male, 2 female; mean age: 32 years; range: 23-40) with a missed isolated posterior malleolar fracture were included in the study. All patients had initially been examined for an ankle sprain in the emergency room, where the initial plain radiographs did not show any abnormality. Due to the long lasting symptoms all patients underwent an MRI scan by the 3rd week which revealed a posterior malleolar fracture. Patients were treated with an ankle brace for 3 weeks. All patients were followed up for 1 year. Bone healing and degenerative changes were evaluated with plain Radiographs, including a 50° external rotation lateral. Clinical outcome was evaluated with American Orthopedic Foot and Ankle Society ankle hindfoot scale.

Results: Fracture healing was seen in 6 of the 7 patients by the 6th week. There was no radiographic healing by 6th month in the remaining patient. Mean AOFAS ankle hindfoot scores at the beginning of the treatment and at 3rd month were 20 (11-31) and 86 (43-96), respectively. There was no instability or degenerative changes at one-year follow-up.

Conclusion: Isolated posterior malleolar fracture should be kept in mind in patients who present with pain at the posterior part of the ankle following a forced plantar flexion and/or axial compression injury. A 50° external rotation lateral radiograph can be useful in detecting the fracture.

Anahtar Kelimeler

Posterior malleolar fracture, ankle sprain, isolated

Kaynakça

• Lauge-Hansen N. Fractures of the ankle. II. Combined experimental-surgical and experimental-roentgenologic investigations. Arch Surg 1950;60:957-85. CrossRef
• Jaskulka RA, Ittner G, Schedl R. Fractures of the posterior tibial margin: their role in the prognosis of malleolar fractures. J Trauma 1989;29:1565-70. CrossRef
• Boggs LR. Isolated posterior malleolar fractures. Am J Emerg Med 1986;4:334-6. CrossRef
• Koval KJ, Lurie J, Zhou W, Sparks MB, Cantu RV, Sporer SM, et al. Ankle fractures in the elderly: what you get depends on where you live and who you see. J Orthop Trauma 2005;19:635-9. CrossRef
• McDaniel WJ, Wilson FC. Trimalleolar fractures of the ankle. An end result study. Clin Orthop Relat Res 1977;122:37-45.
• Macko VW, Matthews LS, Zwirkoski P, Goldstein SA. The joint-contact area of the ankle. The contribution of the posterior malleolus. J Bone Joint Surg Am 1991;73:347
• De Vries JS, Wijgman AJ, Sierevelt IN, Schaap GR. Longterm results of ankle fractures with a posterior malleolar fragment. J Foot Ankle Surg 2005;44:211-7. CrossRef
• Wei SY, Okereke E, Winiarsky R, Lotke PA. Nonoperatively treated displaced bimalleolar and trimalleolar fractures: a 20-year follow-up. Foot Ankle Int 1999;20:404-7.
• Heim UF. Trimalleolar fractures: late results after fixation of the posterior fragment. Orthopedics 1989;12:1053-9.
• Harper MC, Hardin G. Posterior malleolar fractures of the ankle associated with external rotation-abduction injuries. Results with and without internal fixation. J Bone Joint Surg Am 1988;70:1348-56.
• Lindsjö U. Operative treatment of ankle fracture-dislocations. A follow-up study of 306/321 consecutive cases. Clin Orthop Relat Res 1985;199:28-38.
• Stiell IG, Greenberg GH, McKnight RD, Nair RC, McDowell I, Worthington JR. A study to develop clinical decision rules for the use of radiography in acute ankle injuries. Ann Emerg Med 1992;21:384-90. CrossRef
• Haraguchi N, Haruyama H, Toga H, Kato F. Pathoanatomy of posterior malleolar fractures of the ankle. J Bone Joint Surg Am 2006;88:1085-92. CrossRef
• Kitaoka HB, Alexander IJ, Adelaar RS, Nunley JA, Myerson MS, Sanders M. Clinical rating systems for the anklehindfoot, midfoot, hallux, and lesser toes. Foot Ankle Int 1994;15:349-53. CrossRef
• Knudsen R, Vijdea R, Damborg F. Validation of the Ottawa ankle rules in a Danish emergency department. Dan Med Bull 2010;57:A4142.
• Pijnenburg AC, Glas AS, De Roos MA, Bogaard K, Lijmer JG, Bossuyt PM, et al. Radiography in acute ankle injuries: the Ottawa Ankle Rules versus local diagnostic decision rules. Ann Emerg Med 2002;39:599-604. CrossRef
• Ebraheim NA, Mekhail AO, Haman SP. External rotation-lateral view of the ankle in the assessment of the posterior malleolus. Foot Ankle Int 1999;20:379-83. CrossRef
• Gardner MJ, Brodsky A, Briggs SM, Nielson JH, Lorich DG. Fixation of posterior malleolar fractures provides greater syndesmotic stability. Clin Orthop Relat Res 2006;447:165-71. CrossRef
• Donken CC, Goorden AJ, Verhofstad MH, Edwards MJ, van Laarhoven CJ. The outcome at 20 years of conservatively treated ‘isolated’ posterior malleolar fractures of the ankle: a case series. J Bone Joint Surg Br 2011;93:1621-5.