The Powdrell Injury

Updated and cleaned up. This is a part of a larger series on Sports Injuries - Paragon

For any of you that saw Ryan Powdrell's twisted leg in the first quarter of last night's game I'm sure you will agree that it was pretty horrific stuff. It reminded me of Joe Theisman's fractured Tibia and Fibula that he suffered at the hand of Lawrence Taylor all those years ago. When I initially saw he injury I thought it might have been a Tibial shaft fracture. But because the network only briefly showed the injury I wasn't able to get a real good look at it.

Needless to say this is a significant injury. A fractured ankle is bad enough but when coupled with a dislocation thing can be a bit more complicated because the neuro-vascular structures can be torn or disrupted so it is imperative to get the ankle reduced back into place.

Powdrell will have surgery today and will miss the rest of the season. Provided that the ankle is reduced in a timely manner the surgery is pretty routine and there really shouldn't be any reason why he couldn't play again.

For those who are interested there are three x-rays below that show the injury.


The Normal Ankle
The ankle is a complex mechanism. What we normally think of as the ankle is actually made up of two joints: the subtalar joint, and the true ankle joint.

The true ankle joint is composed of 3 bones, seen above from a front, or anterior, view: the tibia which forms the inside, or medial, portion of the ankle; the fibula which forms the lateral, or outside portion of the ankle; and the talus underneath. The true ankle joint is responsible for up and down motion of the foot.

Beneath the true ankle joint is the second part of the ankle, the subtalar joint, which consists of the talus on top and calcaneus on the bottom. The subtalar joint allows side-to-side motion of the foot. The ends of the bones in these joints are covered by articular cartilage. The major ligaments of the ankle are: the anterior tibiofibular ligament, which connects the tibia to the fibula.

The lateral collateral ligaments, which attach the fibula to the calcaneus and gives the ankle lateral stability; and, on the medial side of the ankle, the deltoid ligaments, which connect the tibia to the talus and calcaneus and provide medial stability.

These components of your ankle, along with the muscles and tendons of your lower leg, work together to handle the stress your ankle receives as you walk, run and jump.

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The fractured-dislocated ankle
Fractures of the ankle range from relatively minor twisting injuries to those that are associated with violent disruption of the ankle. There are two different mechanisms of injury which have different effects on the structure of the ankle.

The first one is where there is a twisting mechanism and the body rotates around the foot. The other is where there is a crushing type mechanism that impacts the foot. The twisting type of injuries are far more common, and although there is less likelihood of damage to the cartilage, the bones that make up the ankle joint must nonetheless be carefully re-aligned. The second type of injury which occurs from a fall from a height, or in a motor vehicle accident is usually far more serious and is often associated with cartilage damage.

There are many different varieties and grades of severity of ankle fractures. These may involve only the medial malleolus, only the fibula, or both bones (which is called a bi-malleolar fracture). At times the talus may completely pop out of the ankle joint associated with the fracture. We call this a fracture dislocation.

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The repaired ankle (ORIF- Open Reduction Internal Fixation)
If the shape and anatomy of the ankle are not accurately restored, the cartilage lining of the ankle will be disturbed. This will inevitably lead to arthritis. Think of arthritis as a wearing away of the grisel lining of the bone. Imagine the end of a chicken bone which is lined with cartilage. Every joint in the body is lined with cartilage, and loss of the cartilage leads to the development of arthritis.

Therefore, the goal of treating all ankle fractures is to re-position the bones to prevent the occurrence of arthritis. Some minor ankle fractures can be treated in a boot or a cast without surgery. The majority of ankle fractures, however, do require operative treatment. Surgery is performed with incision(s) on one or both sides of the ankle. Screws and/or a metal plate are inserted into the medial malleolus and the fibula in order to accurately restore or reduce the fracture alignment.

Following surgery, a bandage with plaster is applied to the ankle. The bandage remains until the stitches are removed (usually about two weeks). At that time exercise activities are initiated. No walking on the ankle is permitted for approximately six weeks. At that time protective walking (with a removable boot or brace) may be allowed. Physical therapy exercises, swimming and biking are important parts of the recovery process. They strengthen the leg and develop movement of the ankle.

If the ankle is not repaired correctly or does not heal well, arthritis and deformity of the ankle can occur. Some of these patients will have no other option but to have the ankle surgery re-done. Dr Myerson has developed techniques for salvaging very severe deformities of the ankle after unsuccessful fracture treatment.

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