Dr. Tyler Nathe joined Shannon O’Kelley from IRG Physical Therapy on KOMO Health Talk to discuss the compound ankle fracture and dislocation. Together, the two discuss the traumatic injury to Dak Prescott, treatment pathways, and rehabilitation.



It’s a northwest lifestyle weekend on KOMO News, IRG’s Health Talk continues.

Tom Hunter: All right. Our next guest is Dr. Tyler, Nathe. He’s an orthopedic surgeon with Proliance. He treats both sports medicine and general orthopedic patients. And we’re talking about the ankle and boy, what a gruesome ankle injury last Sunday, a week ago, Dak Prescott of the Cowboys suffered.

Shannon O’Kelley: Yeah. Compound fracture, fracture dislocation of the ankle, and a pretty significant injury for anybody, but particularly an athlete. And Dr. Nathe’s going to talk about how they look at this, how they put it back together and the outcomes. So I’m excited to talk to Dr. Nathe.

Tom Hunter: Here we go, Shannon O’Kelley and Dr. Nathe.

Shannon O’Kelley: Dr. Tyler Nathe, how are you?

Dr. Nathe: I’m doing great, Shannon. How are you?

Shannon O’Kelley: Doing wonderful. Welcome to Health Talk. Hey, we’ve had you on before talking a little bit about some sports medicine-type injuries. That’s your special area in your orthopedic practice. You practice up there in Issaquah. We’re going to talk about your practice in a little bit, but we want to talk about, most importantly, the recent injury, significant injury to Dak Prescott, an ankle fracture dislocation. But before we get there, tell our listeners about your practice, your area of interest, your training. Again, I like to say, give us the day in the life of Dr. Tyler Nathe.

Dr. Nathe: Okay. Thanks, Shannon. I’m an orthopedic surgeon practicing with Proliance Orthopaedics & Sports Medicine in Bellevue and Issaquah, specializing in sports medicine, which means I like taking care of people that get injured playing sports, or being active, and my goal is always get them back to that active, healthy lifestyle. Training at University of Washington, undergraduate and medical school, and I did my residency at University of California, Davis, Sacramento. I did a fellowship in sports medicine there as well.

Shannon O’Kelley: Nice, nice. Let’s talk about the ankle joint. Let’s do a little anatomy 101, particularly as it relates to a fracture dislocation. I’m going to question you on the bimalleolar, all that stuff, all that neat anatomical language. Tell us about the ankle joint. We know everybody probably saw it, or if he did not see it, Dak Prescott rolled his ankle, it rolled out. You could see that it dislocated, a pretty significant injury, but let’s talk a little anatomy. Can we?

Dr. Nathe: Yeah. So, the ankle joints made up of three bones, the tibia, the fibula, and the talus. The tibia is the big bone, that’s your shinbone. The fibula is the smaller bone on the side, and those two bones are connected with a strong ligament that we named syndesmosis. And then the talus sits below those, and the talus moves up and down and allows your ankle to dorsiflex and plantarflex.  There are smaller ligaments on the side of the ankle that keep the talus attached to the tibia and the fibula.

Shannon O’Kelley: And so in this talus, in this fracture dislocation, you get aggressive force, that talus actually pops out of its mortis, and it can fracture those bones at the end of the tibia and fibula, those are called the malleoli. Maybe describe the mechanism of injury and how that happens.

Dr. Nathe: So the ankle’s a constrained joint, so the malleoli are the tips of the bones on the inside and the outside of your ankle, your ankle bones if you look down at your ankle, and the talus sits between those within those. And so, in order for the talus to come out or dislocate, those things have to give way. And so you saw in Dak Prescott’s injury where his ankle rolled out to the outside, his fibula or lateral malleolus broke away, and then his talus came out from underneath his tibia. That’s what an ankle dislocation is, is where the talus comes up out from underneath the tibia. His injury was actually an open fracture, per report, where the skin broke and the bone was exposed.

Shannon O’Kelley: Yeah, yeah. Kind of a nasty injury. If the talus comes out to the lateral side, which is the fibula and it rolls back in, can it roll back over and knock off the malleoli of the tibia? Describe the fracture terms that sometimes people will hear.

Dr. Nathe: Typically when an ankle breaks in the way his did, as the talus starts to move laterally towards the outside, the first thing that’s stopping that from happening is the buttress of lateral malleolus of the fibula. That breaks way, and then as the energy continues, the talus continues to want to go out from underneath the tibia. The deltoid ligament, which attaches the talus to the medial malleolus, will either tear, or it will break the medial malleolus off as it goes, and that’s what’s considered a bimalleolar ankle fracture. So, the lateral malleolus broke at the talus, went out, and pushed against it and broke free, and then the medial malleolus broke in tension at the strong deltoid ligament, which attaches the medial malleolus to the talus, pulled it off and broke it. And then sometimes as well, a piece of bone can break off the back of the tibia and that’s called the posterior malleolus, and that also occurs from ligaments pulling on that. This happens when the syndesmosis ligaments break that off, and that indicates that the syndesmosis ligaments were also injured.

Tom Hunter: Back with Dr. Nathe and more after this time out on KOMO.

Speaker 1: It’s a northwest lifestyle weekend on KOMO News. Here’s Tom Hunter and Shannon O’Kelley with more IRG Health Talk.

Tom Hunter: We continue our conversation with Dr. Tyler Nathe and Shannon O’Kelley on KOMO.

Shannon O’Kelley: Dr. Nathe, again, thank you for joining us here on Health Talk. Thank you for sharing your information regarding an ankle fracture dislocation we all saw, or some of us may have seen, Dak Prescott sustained this. How do you put this back together? That’s your job as an orthopedic surgeon. You’re talking about a lot of trauma. You’re knocking bones off, you’re tearing ligaments. I’m sure there’s blood vessels and nerves that you have to be aware of. How do you put this back together so an athlete like Dak Prescott, who’s highly functional, is going to come back and play?

Dr. Nathe: Well, the first thing that needs to be done is, his ankle needs to be reduced, and I believe that was done on the sideline, that just stabilizes it temporarily. And then, per report, this was an open fracture, which means that his bone came out through the skin, so we’d consider this an emergency that he’s going to need to get surgery today to wash out the wound, to try to reduce the risk of infection. In these athletes, the risk of infection is significant, and that would be pretty substantial as far as effecting his career and long-term prospects. Most likely what happened was he broke the lateral malleolus and then the medial malleolus.

Dr. Nathe: We’d make an incision over the outside of the ankle and then we’d put the bone back together. Typically, it breaks in a jagged fashion.  It’s almost like putting a puzzle back together and the pieces fit in perfectly. We’d hold them together with a clamp and then we’d put a metal plate on the bone with screws going through the plate into the bone to hold it together, and that’s called open reduction and internal fixation. We put the broken bones back together and hold it with hardware. And then, most likely, additionally, he tore the ligaments between the two bones, the syndesmosis ligaments, and so we would put a little washer on the inside of the tibia and the outside of the fibula, and run a cable across to hold that together to provide that an internal strut, so those ligaments can heal.

Shannon O’Kelley: Then when you put all those bones back together and bring those ligaments back, let’s talk about that deltoid and those lateral ligaments, if it’s a trauma like that, are those going to be completely ripped apart? And are you going to have to suture those ligaments or put a graft on those ligaments for stability? Because ligaments are so important in joint stability post-op.

Dr. Nathe: Well, typically when you break the lateral malleolus and the medial malleolus, instead of the ligament tearing in those situations, it’s actually the bone that breaks. So that’s a good thing, because bone heals much more reliably than the ligament. But the syndesmosis ligaments can get torn, and we do repair that by cabling those two bones together. We don’t need to actually sew the ligament together, just by getting it back together and holding it in the right spot, it will heal together.

Shannon O’Kelley: And what is this healing time? And when you’re doing this surgery you’re anticipating, you got to mechanically, you got to be thinking and visualizing this mortis moving around, and you don’t want to disrupt that articular surface too much to create maybe some future arthritis potentially.

Dr. Nathe: Right.

Shannon O’Kelley: You’ve got a lot going on here.

Dr. Nathe: Yeah. This is a substantial injury, and this is an injury that an NFL athlete has a 25% chance of preventing him from coming back to play. Being a quarterback, he’s not going to need that same level of agility and change of direction as maybe a wide receiver or a cornerback, so I think his chances are better than that. But we’re looking at six weeks on crutches and then beginning to weight bear at six weeks. He’s probably already in physical therapy doing aggressive rehab on his ankle, working on range of motion, trying to prevent scar tissue from anything that’s going to reduce motion.

Shannon O’Kelley: Yeah. Just wishing him just the best. He seems like a great person and he’s a great athlete and seems like he has a lot of respect with his team. Dr. Nathe, thank you so much for your information. I’m sure our listeners are very appreciative of your insight and your expertise. Thank you again.

Dr. Nathe: It’s my pleasure, Shannon. Thanks for having me.

Tom Hunter: All right. Our conversation with Dr. Tyler Nathe talking about the ankle. And Shannon, we’ve talked about hips. We’ve talked about ankles, and I imagine you treat a lot of both, but the ankle injuries at this time of the year, especially with people starting to slip and slide a little bit, like we mentioned in the opening segment.

Shannon O’Kelley: Well slip and slide, and then a lot of people are getting out on the basketball court, because the weather’s bad going indoors, potentially playing those pick-up basketball games, and that ankle is unstable or weak, you’re going to roll it, you’re going to have an ankle sprain and then you’re going to be curtailed in your activities for a little while as that heals.

Tom Hunter: All right. Dr. Tyler Nathe, he can be reached at Tylernathemd.com. Final segment coming up next on KOMO.