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International J. of Healthcare and Biomedical Research, Volume: 03, Issue: 03, April 2015, Pages 156-160
Case report:
Post traumatic non-union of lateral malleolus with severe ankle valgus
deformity - A single case report
Abhishek Patil1, Vaibhav Aterkar2, Damodhar Panda3,Pratik Patil4
1Junior Resident-II,2Assistant Professor,3Professor
Dept. of Orthopaedics, Rural Medical College,Loni, Maharashtra, India
4Junior Resident-I,
Dept. of Orthopaedics
JNMC, Sawangi (Meghe), Wardha, Maharashtra, India
Corresponding Author:-Dr.Patil Abhishek, Dept. of Orthopaedics, RMC Loni , India
Abstract:
Post traumatic non-union of lateral malleolus is extremely rare with a very few cases reported till date.We present a case of 50
year old female with 6 month old post traumatic non-union lateral malleolus with valgus deformity of right ankle. Patients chief
complains were dull aching pain with deformity of right ankle and difficulty in walking. She was managed with open reduction
and internal fixation with locking plate and autogenous bone grafting.
Keywords: Non-union of lateral malleolus, ankle valgus deformity, operative management
Introduction:
to a nearby hospital where she did not undergo any
Non-union of the lateral malleolus is a very rare
radiological investigation and a posterior splint was
entity.1Metaphyseal fracture non-union is rare in
applied as conservative management perceiving the
2
comparison to diaphyseal fracture non-union. Lateral
trauma as just an ankle sprain. The acute pain
malleolus is the key to anatomical reduction of
gradually subsided but soon she started having
bimalleolar
fracture,
because
persistent dull aching pain and difficulty in walking.
dislocation
of
talus
subluxation
or
follows
On examination there was a gross valgus deformity
displacement of the lateral malleolus. Fibular fixation
of ankle with no signs of arthritis of ankle joint.
plays a positive role in reducing tibial displacement
Range of movement around ankle joint was near
and improving mechanical stability of the entire
normal. No tenderness was present on lateral aspect
the
faithfully
3
lesion. We present a rare case of post traumatic non-
of ankle. Radiologically ankle mortise was not
union lateral malleolus with severe valgus deformity
maintained with severe valgus deformity (shown in
of the ankle.
figure 1).
Case report:
50 years old patient presented to the outpatient
department with chief complaints of
dull aching
pain, deformity of right ankle and difficulty in
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walking since 6 months. She gave a history of fall 6
months ago sustaining injury to right ankle. She went
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International J. of Healthcare and Biomedical Research, Volume: 03, Issue: 03, April 2015, Pages 156-160
On the mortise view, the distance between the lateral
border of the medial malleolus and the medial border
of the talus (the medial clear space) should be equal
to the superior clear space between the talus and the
distal tibia (shown in figure 2). A space greater than 4
mm is considered abnormal and indicates a lateral
shift of the talus.
Figure 1: AP &Lat view of Right Ankle
Figure 2: Showing ankle Mortise view
An alteration in the talar tilt with decrease in tibio-
Edges were sclerosed with clear cut fracture gap seen
fibular gap was seen in the radiograph. Varus stress
which was suggestive of non-union
view clearly showed non-union of lateral malleolus.
(shown in Figure 3).
Figure 3: Showing Right ankle AP with varus stress view
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ISSN: 2319-7072
International J. of Healthcare and Biomedical Research, Volume: 03, Issue: 03, April 2015, Pages 156-160
Considering the patients significant symptoms, x ray
Post-operative radiograph showed maintenance of
findings,
conservative
ankle mortise, with complete correction of deformity,
management the decision was made to bring the
with tibio-fibular gap less than 5mm with a normal
patient to the operating room to revise the area of
talar tilt (Figure 5)
a
previous
failure
of
nonunion distal fibula.
Through
anterolateral approach
dissection
was
performed down to the level of the nonunion site of
the lateral malleollus. Fracture site was exposed,
fibrous tissue removed and fracture edges were
freshened. A distractor was used to achieve fibular
length4 (shown in figure 4). The nonunion site was
identified and all nonviable bone was removed. There
was a void of about 1.8 centimeters between the
fracture fragments after the fibular length was
achieved, which was filled by strut autologous bone
graft from iliac crest.5 Iliac crest auto-graft was
fashioned to fit the defect, and was combined with
cancellous fillings from iliac crest and placed into the
defect to provide both an osteoinductive and
osteoconductive construct.4 This graft construct was
then held in position utilizing 3.5 mm locking plate
over the distractor acting as a bridge. A syndesmotic
screw was placed, distractor frame removed and the
final overall construct was assessed and noted to be
appropriately stable.
Figure 5: Showing maintained ankle mortise with
correction of deformity
Post-operatively, the patient was placed into a
Robert-Jones compression dressing with the ankle
immobilized in a below knee splint.Sutures were
removed at two weeks post-operatively, and she was
transitioned to a short leg, non-weight bearing cast.
She was kept non-weight bearing for approximately 6
weeks.
Follow up radiographs at 6 weeks and 12 weeks show
progressive union of the operated non-union site
(shown in figure 6 & 7). We allowed the patient to
start weight bearing after 12 weeks with full ankle
range of motion (shown in figure 8).
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Figure 4: Intra operative photograph showing
distraction of fracture site with help of distractor
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ISSN: 2319-7072
International J. of Healthcare and Biomedical Research, Volume: 03, Issue: 03, April 2015, Pages 156-160
Figure 6: Radiograph at 6 weeks
Figure 7: Radiograph at 12 weeks
Postoperative clinical photo:
Neutral
Plantar flexion
Dorsi-flexion
Figure 8: Showing full ankle range of movement
Discussion:
metaphyseal region has good blood supply, hence
Ankle fractures are most commonly treated injuries
less is the chance of them going into non-union.
by orthopaedic surgeons. The ankle joint is a
Possible
complex, three-bone joint. It consists of the tibial
conservative management are comminution, severe
plafond
malleolus
ankle displacement due to syndesmotic injury and
articulating with the body of the talus), the medial
other comorbidities such as diabetes, peripheral
(including
the
posterior
6
factors
favoring
non-union
after
malleolus, and the lateral malleolus. The joint is
vascular diseases etc. Diagnosis is based on
considered
larger
persistence of pain with radiographic evidence such
circumference of the talar dome circumference
as increased medial clear space, persistence of
laterally than medially. The dome itself is wider
fracture line.
anteriorly than posteriorly, and as the ankle dorsiflex,
Conclusion:
the fibula rotates externally through the tibio-fibular
Non-union of lateral malleolus fracture is a rare
syndesmosis, to accommodate this widened anterior
entity and its fixation is of paramount importance to
surface of the talar dome.
maintain the normal kinematics of the ankle
saddle-shaped,
with
a
Out of different fractures in the ankle joint, nonunion lateral malleolus is a rare entity.
1,2
As the
joint.Operative treatment of non-union of distal
fibular fracture in this case leads to reliable bone
healing and return of function to pre injury levels.
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ISSN: 2319-7072
International J. of Healthcare and Biomedical Research, Volume: 03, Issue: 03, April 2015, Pages 156-160
References:
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6th Edition; Philadelphia Lippincott Williams & Wilkins 2006:2147-2149
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