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Categorias
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SER
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Supination-external rotation
Supination-External Rotation: foot supinated (inverted) with an external rotational force. Four progressive stages: (1) anterior tibiofibular (anterior inferior tibiofibular) ligament sprain/rupture; (2) lateral short oblique fracture of the distal fibula running anteroinferior to posterosuperior; (3) posterior tibiofibular ligament rupture or posterior malleolus avulsion; (4) transverse medial malleolus fracture or deltoid ligament disruption.
CondutaManagement is stage- and stability-driven: early stages with an intact medial side (e.g. SER-II, isolated distal fibula) are stable and treated nonoperatively in a cast/boot, whereas the late stage with medial malleolus fracture or deltoid disruption (SER-IV, bimalleolar-equivalent) is unstable and treated with open reduction and internal fixation to restore the mortise.
RiscoMost common ankle-fracture mechanism. Stability tracks with stage: SER-II is generally stable; SER-IV is inherently unstable because the disrupted medial restraint no longer stabilizes the mortise, predicting poor outcome if the talus is not anatomically reduced.
Supination-Adduction: foot supinated (inverted) with an adductive force. Two progressive stages: (1) anterior talofibular ligament sprain or transverse/avulsion fracture of the distal fibula below the joint line; (2) vertical (near-vertical) fracture of the medial malleolus with impaction of the anteromedial distal tibial plafond.
CondutaStage 1 (isolated low fibular/lateral injury) is generally stable and treated nonoperatively. Stage 2 adds a vertical medial malleolus fracture with possible plafond impaction - this is unstable and typically requires ORIF, with attention to buttressing the vertical fragment and elevating any impacted plafond.
RiscoStability tracks with stage: the medial-side vertical fracture and articular impaction of stage 2 make it unstable and at risk for malreduction and post-traumatic arthritis if the joint surface and mortise are not restored.
Pronation-External Rotation: foot pronated (everted) with an external rotational force. Four progressive stages: (1) medial malleolus transverse fracture or deltoid ligament disruption; (2) anterior tibiofibular ligament disruption; (3) lateral fibular fracture above the level of the joint (high/spiral fibular fracture); (4) posterior tibiofibular ligament rupture or posterior malleolus avulsion.
CondutaPER injuries start with medial-side failure, so they are unstable from an early stage and usually need surgery: ORIF of the high (suprasyndesmotic) fibular fracture and medial malleolus, with syndesmotic fixation when the distal tibiofibular ligaments are disrupted (high Maisonneuve-type fractures).
RiscoHigher instability profile than SER: the early medial injury plus high fibular fracture and syndesmotic disruption produce a mortise-unstable ankle; missed syndesmotic injury risks chronic instability and arthritis.
Pronation-Abduction: foot pronated (everted) with an abductive force. Three progressive stages: (1) medial malleolus fracture or deltoid ligament disruption; (2) anterior inferior tibiofibular ligament sprain/rupture; (3) transverse, often comminuted, fracture of the fibula above the level of the syndesmosis.
CondutaLike PER, the medial side fails first, so PAD injuries are typically unstable and treated operatively: ORIF of the medial malleolus and the comminuted suprasyndesmotic fibular fracture, with syndesmotic fixation when the distal tibiofibular ligaments are disrupted.
RiscoUnstable pattern: combined medial-side injury, syndesmotic involvement, and a comminuted high fibular fracture compromise the mortise and increase the risk of malunion and post-traumatic arthritis if not anatomically fixed.