Der Unfallchirurg
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Fractures to the anterior process of the calcaneus (PAC) have long been considered rare injuries and have received little attention in clinical research. On the contrary, recent studies have reported a distinct higher incidence, especially following ankle sprains. Decisive reasons are that fractures of the PAC are regularly missed on plain radiographs and that a clinical differentiation from injuries to the lateral ankle ligaments is difficult. ⋯ For both, non-operative and operative treatment, the case reports and case series report satisfactory outcomes for the majority of patients. Nevertheless, comparative studies and patient-rated outcome measures are missing. Therefore, evidence-based recommendations cannot be given.
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The medial collateral ligament (MCL) complex is characterized by a complex anatomical arrangement of the individual ligamentous structures including three joints and the spring ligament complex. Biomechanically it serves as the main stabilizing structure in the ankle region against rotational and pronating forces. Lesions in the region of the MCL complex are more frequent than previously thought and like lesions of the spring ligament complex can lead to pain and instability. ⋯ Various options for treatment of acute and chronic lesions of the MCL and spring ligament complex are available including the use of free tendon grafts. Controversy exists regarding the operative treatment of MCL lesions in the case of ankle fractures. It is recommended for cases with impinging tissue in the medial gutter serving as a barrier to adequate reduction of the joint and in cases of unstable fractures after reduction.
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Fractures of the lateral tubercle of the talus (PLT) are rare. With the increasing popularity of the trend sport snowboarding, the incidence of PLT fractures has increased. The most common classification of PLT fractures is the Hawkins classification. ⋯ A reason for the inconsistent treatment results could be the observed concomitant injuries, including dislocation of the tendons of the peroneus muscles (46%), calcaneal chondral injuries (48%) and subluxation of the subtalar joint (7%). Based on the limited evidence available, the authors recommend the application of CT and MRI for PLT fractures to assess concomitant injuries, which are the primary indication for surgery. Dislocated type I and II fractures (>2 mm) should be treated operatively, type III and non-dislocated type I and II fractures can be treated conservatively by immobilization and partial weight-bearing for 6 weeks.
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Due to the frequency and potentially complicated course distortion of the upper angle joint represents an important entity in the orthopedic patient clientele. The initial diagnosis includes a detailed anamnesis of the injury mechanism and an accurate clinical examination. To exclude bony, ligamentous and chondral lesions, besides basic diagnostics consisting of X‑rays and ultrasound, magnetic resonance imaging (MRI) is considered the most important tool. ⋯ If conservative therapy fails and thus chronic instability develops the indications for operative treatment are given. Meanwhile, surgical techniques have been established with satisfactory results. Inadequate rehabilitation could be identified as a major risk factor for re-injury, therefore phase-adapted aftercare has gained significant importance.
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Injuries to the distal tibiofibular syndesmosis are frequent and continue to generate controversy due to an extensive range of diagnostic techniques and therapeutic options. ⋯ The single most important prognostic factor after unstable injury of the distal tibiofibular syndesmosis with or without fracture is the anatomic reduction of the distal fibula and fitting into the tibial incisura.