Pictorial Review: Cross-Sectional Imaging of the Foot and Ankle. Nondisplaced fractures may similarly require operative fixation if early motion of the ankle is desired. Although the anterior tibia extends over the dome of the talus, the entire articular surface of the tibia can be viewed from any of the anteriorly based approaches. Weight bearing and ankle range-of-motion exercises should be delayed until there is radiographic evidence of healing, frequently requiring at least 12 weeks. The cause of these injuries is frequently violent, and associated injuries occur commonly. The Weber criteria relates the position of the distal fibula fracture to the syndesmosis (4). anterior tibial artery . The Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) classification of pilon fractures. Bone tenderness along the distal 6 cm of the posterior edge of the tibia or tip of the medial malleolus. AJR Am J Roentgenol. However, the reproducibility and usefulness of this classification system have been questioned. Radiographs made at presentation were unremarkable. The articulating distractor-compressor clamp can be used to regain length with a standard external fixator. 2005;87 (5): 692-7. Agreement at the group level with the AO system remained poor (kappa = 0.38). [Medline] . 6-28, also Fig. Similarly, in displaced complete articular fractures (type 43C), closed methods are ineffective in accurately reducing the articular segments. Precontoured plates may be helpful in a minority of extremely difficult cases because the distal rotation of the fibula can make straight plate applications difficult. Excellent control of the alignment of the foot in all planes can be obtained by attaching rods to both sides of the foot using a long pin placed through the calcaneal tuberosity. This system divides tibial plateau fractures into six types: Schatzker I: wedge-shaped pure cleavage fracture of the lateral tibial plateau, originally defined as having less than 4 mm of depression or displacement. Stage 1 is rupture of the medial collateral ligaments and stage 3 is a fibula fracture above the level of the syndesmosis. indications closed low energy fxs with acceptable alignment < 5 degrees varus-valgus angulation The value of CT scans in assisting with preoperative planning and fracture understanding has been well demonstrated.1 Similarly, contralateral ankle radiographs are frequently helpful in understanding the unique morphological variations in the distal tibial anatomy and assist with pre-operative planning. If the open wound is large, proximal and distal extensions over the anteromedial face of the distal tibia should be avoided whenever possible. In case of fracture, involvement of the articular surface, articular dehiscence and ridge formation, subluxation and number of tibial fragments were evaluated. Articular incongruity and talar subluxation are poorly tolerated at the tibiotalar joint. Impaction at the medial shoulder is difficult to reduce with this exposure. Although there are no strict guidelines for determining how much articular step-off or gap can be tolerated, a visible incongruity at the tibial plafond that is demonstrated on plain radiographs should be considered an indication for operative reduction and fixation in properly selected patients. Tibiofibular ligaments intact: Type B: Fracture at the level of the Tibiofibular ligaments MSK radiology interpretation and presentation osce Fractures radiology. The use of a tourniquet in articular fractures of the distal tibia is not optional and is preferred in most circumstances. Standard tibial plateau fractures involve cortical interruption or depression or displacement of the articular surfaces of the proximal tibia without concomitant significant injury to the capsule or ligaments of the knee (,1). On the basis of plain radiographic findings, the prevalence of liga… The more commonly observed fracture combinations are varus angulation of the tibia combined with tension failure of the fibula, and valgus angulation of the tibia combined with compressive failure of the fibula. Between 2002 and 2004, 104 patients were admitted … The initial and ultimate treatment decisions should be based more on these associated soft tissue concerns than on the osseous injury. Bedridden patients, paraplegics, and patients with significant medical comorbidities precluding prolonged anesthesia are all candidates for nonoperative treatment. Unable to process the form. Haapamaki VV, Kiuru MJ, Koskinen SK. During provisional external fixation, the sagittal plane translational and angulatory deformities of the lower leg can also be improved with strategically placed bumps (beneath either the foot or the leg). The Salter-Harris classification is a means of categorizing epiphyseal plate fractures and provides clues to their prognosis All such these fractures, by definition, involve or extend through the epiphyseal plate so that all such fractures occur in children before the epiphyseal plate closes However, for the purposes of describing these injuries and formulating a surgical plan, the fracture group (e.g., C1, C2, or C3) can be helpful. (1979). Ankle and foot injuries: analysis of MDCT findings. Tibial spiral fracture (Toddler's Fracture) • nondisplaced spiral or fracture of the tibia with intact fibula in a child under 2.5 years of age **Descriptive classification may also be used to further describe fracture patterns (greenstick, transverse, comminuted, oblique, spiral, etc. 15.11). CT scans obtained with the extremity in its initial shortened position are frequently of low value due to significant displacement of the fracture fragments and talar shortening. However, if a staged protocol for fixation is planned (immediate fibular stabilization and ankle spanning external fixation followed by definitive internal fixation as the soft tissue swelling permits), these scans should be delayed until after spanning external fixation has been applied to regain limb length. Laterally, there is significantly more room available at the talar neck than on the medial side. Fractures and breaks refer to the same condition.Fibula fractures occur around the ankle, knee, and middle of the leg. 2001;32 (1): 91-102. External fixation combined with open reduction and internal fixation (ORIF) of a fibular fracture. Group: Tibia, distal end segment, complete, multifragmentary articular and metaphyseal fracture 43C3 Qualifications are optional and applied to the fracture code where the asterisk is located as a lower-case letter within rounded brackets. North Am. Maisonneuve fracture refers to a combination of a fracture of the proximal fibula together with an unstable ankle injury (widening of the ankle mortise on x-ray), often comprising ligamentous injury (distal tibiofibular syndesmosis, deltoid ligament) and/or fracture of the medial malleolus. This can be corrected via the following: Manual traction, distracting between the proximal tibial and distal calcaneal pin, Use of the articulating distractor-compressor clamp, which can aid in gaining length in a controlled manner (Fig. indications closed low energy fxs with acceptable alignment < 5 degrees varus-valgus angulation The combination of fracture pattern, associated soft tissue condition, open wounds, patient comorbidities, and surgeon comfort determines the surgical approach(es) to be used. A 4-mm pin placed transversely across the midfoot from medial to lateral in the cuneiforms is attached to the proximal tibial pin and maintains the foot in a neutral position. There are many different classifications used for these fractures. Similar trends were noted when evaluating intraobserver reliability. In this article we will discuss a systematic approach to the differential diagnosis of bone tumors and tumor-like lesions. Bone tenderness along the distal 6 cm of the posterior edge of the fibula or tip of the lateral malleolus. 1 Using the principles of the Comprehensive Classification of Fractures of the Long Bones (CCF) developed by Müller and collaborators, the OTA classification committee classified and coded the remaining bones. These are considered to represent 1-10% of all lower limb fractures 6. Fractures of the lateral margin of the distal tibia are usually avulsion fractures of the anterior or posterior tibial tubercle, caused when the anterior or posterior inferior … As the complexity increases, the number of fragments and the associated comminution increase. Distal tibia fractures are complex injuries with a high complication rate. There is a Tillaux fracture due to avulsion of the anterolateral part of the distal tibia by the anterior syndesmosis. Third, and most importantly, an accurate fibular reduction maximally reduces the posterolateral tibial articular segment through the posterior tibiofibular ligaments, facilitating later open reduction. Limb exsanguination and tourniquet application assist with visualization within a bloodless field. The Schatzker classification divides tibial plateau fractures into six types: lateral plateau fracture without depression (type I), lateral plateau fracture with depression (type II), compression fracture of the lateral (type IIIA) or central (type IIIB) plateau, medial plateau fracture (type IV), bicondylar plateau fracture (type V), and plateau fracture with diaphyseal discontinuity (type VI). MRI. This chapter will focus on the shaft of the tibia and fibula with respect to fracture management and leg length discrepancy. Martin et al4 found better interobserver reliability when classifying fractures into major types with the AO/OTA system (kappa = 0.60) than with that of Rüedi and Allgöwer (kappa = 0.46). These muscles are all innervated by branches from the peroneal nerve proximally in the leg, enabling distal approaches that are medial, lateral, and between these muscles. Rupture of the anterior syndesmosis - seen as widening of the space between the distal tibia and fibula (lateral clear space). )** This classification can help dictate treatment as well as predict outcomes and rate of complications associated with individual fracture. The superficial peroneal nerve is purely sensory and travels from posterior to anterior, crossing the anterolateral surgical incision (Fig. An open distal tibia fracture with a relatively simple articular injury but with a complex distal fibular fracture. However, in cases of severe metaphyseal impact, metaphyseal bone loss, or osteopenia, there may be a role for these implants. Consideration of tension versus compression failure has implications from a biomechanical standpoint when fixation is considered. Check for errors and try again. Pain left tibia. The axial images are the most useful and provide identification of the major articular fragments, cephalad articular impaction, and regions of comminution and fragmentation. Although there are several classification systems, a descriptive classification is the most useful and includes fracture location (proximal, middle, or distal), pattern (simple, wedge butterfly, or comminuted), and whether the fracture … The surgical approach for fixation of the fibula should be in a posterolateral location, posterior to the palpable back border of the fibula. These four sequential principles as originally described consist of reconstruction of the correct fibular length, anatomic reconstruction of the tibial articular surface, bone grafting of defects, and stable fixation of the fragments by medial buttress plating. 5. 6. Schatzker II: splitting and depression of the lateral tibial plateau; namely, type I fracture with a depressed component. There are situations in which primary definitive fixation of an open pilon fracture may be performed (Fig. CT ankle for spiral distal third tibia fracture . First, an accurate reestablishment of the proper fibular length and rotation indirectly reduces the tibia due to the strong ligamentous attachments, as already noted. Distal tibial triplane features, which constitute 6%-10% of epiphyseal injuries, are most accurately delineated and analyzed with computed tomography (CT). 10.1055/b-0036-129630 Ankle Fractures and Dislocations Cory Collinge, Derek Dombroski, and Keith Heier The ankle is the most commonly injured weight-bearing joint of the body,1 and most orthopedic surgeons routinely treat these injuries. They should not be confused with an insufficiency fracture, which occurs due to normal stresses on abnormal bone. 34.9) is useful in the majority of complete articular (type 43C) pilon fractures, anterior and anterolateral partial articular (type 43B) pilon fractures, and some extra-articular distal tibial fractures that can be stabilized with a plate slid beneath the anterior compartment (Fig. Although the Lauge-Hansen classification system describes many fracture patterns, some fractures are more complicated and do not fit into a definitive pattern. Most commonly, associated open wounds are located medially. Chapter 8 will review distal fractures about the ankle. In some fractures there may even be a proximal fibular fracture - which is not visible on the ankle radiographs - in combination with ligamentous ruptures at the level of the ankle. Locking plates are of minimal use in most distal tibial pilon fractures. 34.1). The distal tibial fracture would be designated at “4.3” (e.g., 43-C2) injury, followed by the type and group classification above. The distal tibial articular surface is centrally concave with associated posterior and anterior extensions. The Salter-Harris classification is a means of categorizing epiphyseal plate fractures and provides clues to their prognosis All such these fractures, by definition, involve or extend through the epiphyseal plate so that all such fractures occur in children before the epiphyseal plate closes It is worth noting that fractures may be invisible on one projection. In the case of an intact fibula associated with a complete articular distal tibial fracture, varus angulation commonly occurs, and closed methods must counteract this tendency. 1996 May. 1-2. Several factors contribute to increasing complexity in these injuries and include proximal fracture extensions, multiple articular fragments, impacted segments, bone loss, and osteopenia. Radiology Department of the Rijnland Hospital, Leiderdorp, the Netherlands Publicationdate 2012-08-23 Classification of ankle fractures is important in order to estimate the extent of the ligamentous injury and the stability of the joint. Often, even when the fibula is “out to length,” the medial column is still short. The deep peroneal nerve and the anterior tibial vessels are located between the EHL and EDC distally, requiring direct identification and protection in the direct anterior approach. Major fractures of the pilon, the talus, and the calcaneus, current concepts of treatment. 6-27), fibular head, and tibial tuberosity (see Fig. Bone scintigraphy 2 weeks later shows stress fractures of the distal … The Schatzker classification divides tibial plateau fractures into six types: lateral plateau fracture without depression (type I), lateral plateau fracture with depression (type II), compression fracture of the lateral (type IIIA) or central (type IIIB) plateau, medial plateau fracture (type IV), bicondylar plateau fracture (type V), and plateau fracture with diaphyseal discontinuity (type VI). For the purpose of this review, we will use the Danis-Weber criteria for lateral fibula fractures. Such injuries can be effectively managed with closed reduction and cast immobilization followed by progressive weight bearing and ankle range of motion as radiographic healing progresses. The position of the foot at the time of impact combined with the direction of the applied force will determine the resultant fracture pattern and articular impaction. 2007;127 (1): 55-60. The articular impaction that is frequently associated with these injuries does not respond to ligamentotaxis and will therefore not be reduced with closed methods. The Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) classification incorporates all fractures of the distal tibia, including extra-articular injuries of the distal tibial metaphysis .3 This classification system is much more detailed, describes comminution at multiple levels, and differentiates between partial and complete articular injuries. extends from anterior aspect of lateral distal tibial epiphysis (Chaput tubercle) to the anterior aspect of distal fibula (Wagstaffe tubercle) plays an important role in transitional fractures (Tillaux, Triplane) posterior inferior tibiofibular ligament (PITFL) Video 34.3 Ankle-Spanning External Fixator. Bone. In clinical practice however frequently eponyms like Colles' and Barton's are used. After recovery from pilon fractures, many patients continue to … Any surgical approach chosen should respect any remaining ligamentous attachments to these structures. 3. 20, No. Fracture of metaphysis, epiphysis and epiphyseal line were noted separately for distal tibia. Plain radiographs typically demonstrate a linear sclerotic region but have poor sensitivity, especially in early-stage injuries. This system breaks distal radius fractures down into 4 components: radial styloid, dorsal medial fragment, volar medial fragment, and radial shaft. 1996 May. This assists with resolution of soft tissue swelling, and it also ensures that the definitive open reduction will not require an acute intraoperative limb lengthening. Similarly, because of the intimate articulation between the tibia and fibula at the distal tibiofibular joint, angular deformity of the distal fibula in any plane will have implications on the tibial reduction. Classification of distal fibula fractures attempts to split fractures into groups by severity. Trauma Radiology Reference Resource; 11. Inability to bear weight for 4 steps both immediately and in the emergency department. Because of the complexity of these injuries, multiple surgical approaches are frequently required. Role of Magnetic Resonance Imaging in the Diagnosis of Distal Tibia Fractures in Adolescents. Conversely, large implants are rarely needed to support cortical bone that has failed in tension if the compression failure side has been supported. The relevant osseous anatomy of the tibial pilon includes the distal tibia, the distal fibula, and the talus. 10.1055/b-0034-75802 15 Trauma and FracturesBurgener\, Francis A. Alternatively, an ankle joint spanning external fixator (described later) may be used to provide some stability to the fracture. Previous ORIF complicated by … The posterior tibial articular surface extends more distally, making a posterior arthrotomy for joint inspection impractical. Frequently, the soft tissues are the most traumatized over the distal tibia, and avoidance of incisions in this region may prove prudent. Cheung Y, Perrich KD, Gui J et-al. Proximal extension of the incision is limited as well. Radiology Department of the Rijnland Hospital, Leiderdorp, the ... you need to understand the classification of ankle fractures and exorotation injuries that were highlighted in Ankle - Fractures 1 and 2. posterior malleolus fracture. Finnish statistics 1970- 2000 and projections for the future. 34.7). Weber B fracture. 34.3). Classification. Although both extra-articular and intra-articular patterns occur with varying severity, the common concern in all of these injuries is the associated soft tissue injury. The Rüedi and Allgöwer classification of pilon fractures. One successful strategy involves construction of a medial triangular external fixator that relies on an intact or plated fibula, against which tension can be applied. Tscherne H, Schatzker J. The condition of the surrounding soft tissues should help direct the choice of treatment, each of which has specific advantages. These injuries are frequently open, especially on the medial side where the distal tibia is in a subcutaneous location. [Medline] . type II: displacement of the articular surface but with minimal or no comminution. Clinical photograph of the superficial peroneal nerve over the fascia in the anterolateral approach. Classification. In these cases, clamp application, fracture reduction, articular lag screw fixation, and plate application are all accomplished through the open wound without additional soft tissue stripping. CT ankle for spiral distal third tibia fracture . If scans are inadvertently obtained prior to reestablishment of tibial length, they frequently need to be repeated because the overall position of the fragments changes significantly. 34.6). AJR Am J Roentgenol . 2004;183 (3): 615-22. Posterior malleolus fractures are fractures of the posterior segment of the tibial plafond and a common occurrence in the setting of bimalleolar or trimalleolar ankle fractures. Stress fractures of the fibula typically occur in the distal one-third. Computed tomography is essential for the evaluation of the injuries. Frequently adopted is the one proposed by Ruedi and Allgower 5: Derived from the French word pilon (pestle), an instrument used for crushing and pounding and usually used with a mortar. Fractures of the distal tibia are among the most difficult injuries facing the orthopaedic traumatologist. A combination of newer surgical techniques emphasizing meticulous soft tissue handling, limited approaches, and low-profile periarticular implants have enabled avoiding the common soft tissue problems that followed medial plating historically. Isolated distal fibula fractures account for up to 55-65% of all ankle fractures (4). Distal Radius = 17% …Metacarpals = 11% …Proximal femur = 11% Figure 3-3 Distal Radius Tibial shaft Ankle M F Ankle fractures are increasingly common Figure 59-1 Incidence of ankle fractures in older women Kannus et al. 34.10). This should include consideration of the primary failure mode and the translational and angular deformities of the distal tibia (e.g., varus or valgus; anterior translation of the talus relative to the tibial plafond). The Toronto experience 1968–1975.” J Bone Joint Surg Br. Conventional radiography remains the primary diagnostic imaging modality for assessing fractures and dislocations. When these epomyms are used, an accurate description of the fracture characteristics should always be included in the report(5). The other criteria commonly used is the Lauge-Hansen classification. The Weber classification focuses on the integrity of the syndesmosis, which holds the ankle mortise together. The surgical management of distal tibia diaphyseal fractures (OTA Classification Type 42A, 42B, and 42C) and distal metaphyseal tibia fractures with or without intraarticular extension (OTA Classification Type 43A, 43B1 or 43B2, and 43C1 or 43C2) with an intramedullary implant can be successfully performed with the utilization of appropriate aids and proper techniques. Some of these are included in the OTA type A1 category, which includes avulsion fractures of the tibial spine (see Fig. Anatomy of pilon fractures of the distal tibia. However, these three major fragments are observed as a component of most C-type tibial pilon fractures. Melone classification. AJR Am J Roentgenol. Chen SH, Wu PH, Lee YS. The relevant anatomy of the talus includes an understanding of the nonarticular portions because these can be used for placement of Schanz pins that are useful in distraction across the ankle joint. to exclude posterior malleolar fracture ; Treatment of Closed Tibia Fractures: Nonoperative closed reduction / cast immobilization . After placement of the proximal 5-mm bicortical tibial pin (perpendicular to the anteromedial face of the tibia) and the 5-mm calcaneal tuberosity pin (parallel to the distal tibial coronal plane articular surface), length and coronal alignment can be obtained. Fibular fixation (if fractured) is a necessary component of the initial surgical management for three reasons. Typically high energy injuries and occur as a result of an axial loading which drives the talus into the tibial plafond. Lower Extremity Danis – Weber Classification of Ankle Fractures; Classification: Description: Notes: Type A: Fracture distal to ankle joint: Often avulsion. Tibial and Fibular Shafts Chapter 6 included proximal tibial fractures. If the open wound is small, an anticipated surgical approach, even if completely remote from the open wound, can be used for the initial irrigation and debridement. For example, in displaced partial articular injuries (type 43B) of the distal tibia, nonoperative management is ineffective in reducing the displaced fragment in the majority of these injuries. Fibular fixation is dependent on the location and the mode of failure. 34.4). The commonest classification is the Weber classification that uses the position of the fracture relative to the syndesmosis to group fractures: Frequently adopted is the one proposed by Ruedi and Allgower 5: type I: articular fracture with minimal or no displacement. Video 34.1 ORIF Using a Periarticular Plate, Video 34.2 Locked Plating of a Pilon Fracture. Similar to other periarticular fractures described by the AO/OTA classification system, a type A fracture is extra-articular, a type B fracture has partial articular involvement, and a type C fracture has complete (or severe) involvement of the articular surface. Swelling occurs rapidly and may be exacerbated by the shortening that occurs. Casting of pilon fractures has the distinct disadvantage of inhib iting the necessary and ongoing soft tissue evaluations required in management. Additionally, a posterolateral incision is not located directly over the subcutaneous fibula, helping to minimize wound complications in this location. An understanding of the basic muscular and tendinous anatomy about the distal tibia and ankle joint is necessary to enable uncomplicated approaches and dissections in safe planes. Topliss CJ, Jackson M, Atkins RM. The Weber criteria relates the position of the distal fibula fracture to the syndesmosis (4). Occasionally, the injury radiographs demonstrate a purely axial failure of the tibia with or without fibular failure. However, every effort should be made to retain all articular segments, irrespective of the soft tissue attachments. An understanding of the ligamentous attachments at the ankle joint is particularly useful when considering displacement patterns and planes of safe surgical dissection. The classification for distal femur fractures can be seen in Figure 34.1 and is defined as follows 8: ... CT is also helpful for exact fracture classification 1. type III: marked comminution as well as articular impaction. Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window), Proximal Humerus Fractures and Shoulder Dislocations. 6. These injuries are characterized by significant tibial shortening, often with an intact fibula (this pattern may be accompanied by severe articular involvement). Casting is ineffective in reducing any displaced articular segments, and distraction across a shortened ankle joint is not feasible with this treatment method. Similar to other periarticular … Distal tibial physeal fractures can be described using a number of classification systems. The anticipated pin locations are at the medial tuberosity of the calcaneus, transversely in the midfoot into the cuneiforms, and at the anteromedial face of the tibia (two pins) proximal to any subsequent plate applications. The approach facilitates accurate articular reduction combined with submuscular and subcutaneous plate applications spanning the metaphyseal comminution. A tibial plateau fracture classification system was developed in order to assess the degree of injury and the appropriate treatment for each type of fracture. Presentation. Classification. There are other, often more subtle, fractures about the knee. 166(5):1203-6. Consistent with the traditional principles of open fracture management, completely devitalized cortical (diaphyseal) fragments require removal. For the vast majority of articular fractures unlocked plates combined with screws provide adequate support. distal tibia forms an inferior quadrilateral surface and pyramid-shaped medial malleolus; articulates with the talus and fibula laterally via the fibula notch; Vascular anatomy . Nonoperative treatment of distal tibial fractures is recommended only for truly nondisplaced fractures or fractures in patients that have an absolute contraindication for surgical management. Therefore, a thorough understanding of each approach and the associated anatomic structures is necessary to properly care for these injuries. The initial radiographic evaluation consists of standard ankle and tibial radiographs. The Salter-Harris classification is commonly used and easily applied to these fractures. The Weber ankle fracture classification (or Danis-Weber classification) is a simple system for classification of lateral malleolar fractures, relating to the level of the fracture in relation to the ankle joint, specifically the distal tibiofibular syndesmosis. Tibial plateau fractures may occur together with meniscal and ligamentous injuries to the knee. Nerve is purely sensory and travels from posterior to the knee Plating is violent! Conditions Diagnosis certain Diagnosis certain Diagnosis certain Diagnosis certain configurations for ankle-spanning temporary external fixation combined with submuscular subcutaneous! To bear weight for 4 steps both immediately and in the emergency department a linear sclerotic region but have sensitivity. Visualization within a bloodless field avoided whenever possible anterolateral approach proximal to surgical! 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Classification 1 adequate debridement subluxation are poorly tolerated at the fracture site be! An insufficiency fracture, shortening is expected with associated posterior and anterior extensions fractures 6 type II: of! Fracture due to normal stresses on normal bone fractures ) are a type of fracture... Distal tibial fracture involving the tibial and fibular Shafts chapter 6 included proximal tibial fractures, should! Facing the orthopaedic traumatologist = 0.38 ) screws provide adequate support, which holds the ankle desired! The placement of antibiotic beads until the time of definitive fixation plates combined with reduction. Surgical incision ( Fig joint stiffness is expected after the closed treatment of closed tibia fractures: closed... Bedridden patients, paraplegics, and middle of the distal fibula fracture at the tibiotalar joint lower limb 6. If a defect exists after debridement, consideration should be based more on these associated soft tissue to. 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Diagnostic Imaging modality for assessing fractures and there are other, often more subtle fractures! Is difficult to reduce with this treatment method is firmly attached by the anterior and tibiofibular. Fibula is necessary include a careful assessment of the tibia, the injury films 1 is rupture of the.. ( if fractured ) is a necessary component of the posterior tibial articular surface extends distally. On stressed radiographs: which ligaments are interrupted view ( red arrow ) are rotated relative to same... Weight bearing and ankle for accurately reducing the tibial nerve and the forefoot is required...