Foot and Ankle Fractures2

Foot and Ankle Fractures
Foot and Ankle
Fractures
Anatomy
Three groups of stabilizing ligaments :

1)Lateral
-anterior talofibular ligament (ATFL)
-calcaneofibular ligament (CFL)
-posterior talofibular ligament (PTFL).
-limit ankle inversion and prevent anterior and
lateral subluxation of the talus
Anatomy
2)Medial
-deltoid ligament (group of four ligaments)
-anterior and posterior tibiotalar
-tibionavicular
-tibiocalcaneal
-stabilize the joint during eversion and
prevent talar subluxation
-20-50% stronger than lateral ligaments
History
• History
-mechanism of injury
-ankle and foot position during the injury
-any sounds heard at the time injury
-previous history of ankle injury, any knee
or foot pain
-degree of function after the event.
Physical Exam
Inspection
-deformity, ecchymosis, swelling, perfusion
ROM (normal)
-30 to 50 degrees plantar flexion
-20 degrees dorsiflexion
-25 degrees inversion and eversion
-15 degrees of adduction
-30 degrees of abduction
Palpation
-individual ligaments (MCL,LCL, syndesmotic) and tendons
-the joints above and below the ankle
-important: proximal fibula (“Maisonneuve fracture”) and the
base of the fifth metatarsal ("dancer's fracture").
Special Tests
Anterior Drawer
-integrity of the ATFL
-grasp the heel with one hand and apply a posterior force to the tibia
with the other hand, while drawing the heel forward.
-laxity is compared with the opposite (uninjured) ankle.
-positive test: a difference of 2 mm subluxation compared with the
opposite side or a visible dimpling of the anterior skin of the affected
ankle (suction sign)
Squeeze Test
-tests the integrity of the syndesmotic ligaments
-examiner places his hand 6 to 8 inches below the knee and squeezes
the tibia and fibula together
-positive test: results in pain in the ankle, which indicates injury of the
syndesmotic ligament
X-rays
X-rays
-approx. 10-15% of all traumatic radiographs are of the ankle
-80% of all ankle injuries get an x-ray, fewer than 15% have a
significant fracture
Views
-AP, lateral, mortise view (15-20 degrees of internal rotation)
-AP : malleoli, plafond, talar dome, lateral process of the talus
-Lateral : ant/post tibial margins, talar neck, post, talar process
and calcaneus
-Mortise : most important view, medial clear space should not
exceed 4mm
Xray Measurments
Ankle Fractures
Classification
Danis-Weber
-based on mechanism of injury
-three fracture types (i.e., A, B, C ),
defined by the location of the fibular
fracture
-A - below the tibiotalar joint
-B - at the level of the tibiotalar joint
-C - above the tibiotalar joint
Unimalleolar Fractures
Lateral
-any avulsion <3mm in size can be treated
as an ankle sprain
Unimalleolar Fractures- Lateral
Stability depends on the location of the fracture
-Type A (below tibiotalar joint)
-no medial tenderness
-BN walking cast
-f/u 1wk to ensure no displacement
-non-wt bearing x3wks then wt bearing for
another 3-5 wks
-medial tenderness (check mortise for
displacement)
-ortho consult
Unimalleolar Fractures- Lateral
Type B and C (at or above the tibiotalar

joint)
-orthopedic consult ?ORIF
-type B : 50% associated with
tibiofibular disruption
Unimalleolar Fractures-Medial
Medial
-commonly associated with lateral and posterior
malleolar disruption
-need to examine entire length of the fibula
(Maisonneuve #)
Isolated medial fracture (nondisplaced)
-non wt bearing x3 wks, f/u after 1 wk
-wt bearing another 3-5 wks
-if very active can ORIF initially!!!
Bimalleolar Fractures
Management
-disruption of two elements of the ring
-ortho consult
-management controversial (ORIF vs closed
reduction and close f/u)
Trimalleolar Fractures (Cotton’s
fracture)
Management
-disruption of three parts of the ring
(medial/lateral/posterior)
-ortho consult
-ORIF
Pilon #?
Pilon Fractures (Bad!)
Mechanism
-axial compression
-talus driven into the plafond
-usually comminuted and displaced with extensive
soft tissue swelling
-look for associated injuries
-calcaneus, femoral neck, acetabulum, lumbar
vertebrae
Management
-emergent ortho consult
Tillaux #?
Tillaux fracture (Pediatric)
SH type III of the lateral tibial epiphysis

-extreme eversion and lateral rotation
-adolescence
-medial aspect of epiphysis is closed
-fracture of the lateral aspect and into joint
Management
-ortho consult ORIF
Foot Fractures
Anatomy
Anatomy
-27 bones, 57 articulations
-Hindfoot : calcaneus and talus
-Midfoot : cuboid, navicular, and three cuneiforms
-Forefoot : metatarsals, phalanges, and sesamoids
-Subtalar joint
-formed by three articulations between the inferior talus
and calcaneus
-Inversion and eversion of the hindfoot through the
subtalar joint
Anatomy
-Tarsometatarsal, or Lisfranc's joint

-connects the midfoot and the forefoot
-Blood supply
- anterior and posterior tibial arteries
-Nerve supply
-peroneal (deep and superficial), posterior
tibial, saphenous and sural nerves
X-rays
Xrays
-AP, lateral, oblique(45 degrees of internal
rotation)
-AP and oblique
-best image for the forefoot and midfoot
-Lateral
-best image for the hindfoot and soft tissues
Foot Fractures
Talar #
Talus
General
-second most common fractured tarsal
-3 parts : head, neck, body
-prone to dislocation with foot in plantar
flexion
-tenuous blood supply – risk of avascular
necrosis
Fractures - Talus
Minor
-chip #’s treated like sprains
Treatment
-as above tx as sprain
-fragments >5mm may need excision
Major
-involve head (5-10% of all talar #’s), neck (50%
of all major #’s) and body (23% of all talar #’s)
-high energy mechanism
Fractures – Talus
Classification
Classification (Hawkins)
Type I fractures
-nondisplaced and lack joint involvement
risk AVN : approx. 10%
Type II fractures
-displacement of the talar neck with subluxation or dislocation of the
subtalar joint and preservation of the ankle joint
Type III fractures
-displaced with dislocation of the talus from both the subtalar and
ankle joints
-risk AVN : >70%
Type IV fracture
-type II injury with associated talar head dislocation
Fractures - Talus
Treatment
-all require ortho consult
-any significant displacement/dislocation,
attempt closed reduction in the ED
-grasp midfoot and apply longitudinal
traction while plantar flexing the foot
Calcaneus (Lover’s #)
General
-5x more common in men
-largest and most frequently fractured tarsal bone
-falls (axial load) or twisting mechanisms
-extra-articular (25-35%) – good prognosis
-intra-articular (70-75%) – not so good prognosis!
-look for associated fractures
->50 % cases have associated other extremity or
spinal fractures
-7% bilateral
-50% will have long-term disability
Calcaneus #’s
X-ray
-Boehler’s angle (20-40
degrees)
-suspect fracture if <20
degrees
Treatment
-ortho consult
-?ORIF vs conservative
management
Navicular
General
-most common midfoot #
-blood supply tenuous, risk AVN
-classification: dorsal avulsion # (47% all
navicular #’s), tuberosity and body #’s
-mechanism usually eversion injury
-pain over the dorsal and medial aspect of
foot with swelling
Navicular
Treatment
Avulsion
-walking cast 4-6wks and ortho f/u
Tuberosity and body
-not displaced, cast (non wt bearing
initially) with close f/u
-if displaced or >20% articular surface
area will require ORIF
LisFranc ?
Lisfranc Injury (tarsometatarsal
fractures/dislocations)
General
-damage to the tarsometatarsal joint (any # or dislocation
to this area is termed a Lisfranc injury)
-commonly missed injury
-4% incidence per year of tarsometatarsal injuries in
collegiate football players
-early recognition and anatomical alignment with internal
fixation is necessary for satisfactory results
-mechanism : high-energy needed to disrupt ligament,
rotational force( e.g MVA)
-clinical: severe midfoot pain, significant swelling and
ecchymosis, inability to wt bear
Classification
Classification
1)Total Incongruity
2)Partial Incongruity
3)Divergent
(Homolateral/Divergent, Type A,B,C)

X-ray Findings
• 1. The medial shaft of the second metatarsal should be aligned
with the medial aspect of the middle cuneiform on the
anteroposterior view.
• 2. The medial shaft of the fourth metatarsal should be aligned
with the medial aspect of the cuboid on the oblique view.
• 3. The first metatarsal cuneiform articulation should have no
incongruency.
• 4. A "fleck sign" should be sought in the medial cuneiform-
second metatarsal space. This represents an avulsion of the
Lisfranc ligament.
• 5. The naviculocuneiform articulation should be evaluated for
subluxation.
6. A compression fracture of the cuboid should be sought.
Lisfranc - Treatment
Treatment
The key to successful outcome in the Lisfranc
injuries is anatomical alignment
-Nondisplaced
-treated with a non-weight-bearing cast for 6
weeks followed by a weight-bearing cast for
an additional 4 to 6 weeks.
-Displaced fractures (>2mm) – ORIF
Metatarsal #’s
Treatment
-2nd – 4th – conservative with well padded
shoe
-1st - ORIF
Exception
-displaced (>3mm or angulated-plantar direction
>10 degrees)
-closed reduction
-+/- pinning if unstable
-non wt bearing cast 4-6 wks
Jones #
Jones #
-transverse # >15mm from the proximal end
of the bone (high rate delayed/nonunion)
-occur in >50% pts with conservative
therapy)
Treatment
-ortho f/u
-non-wt bearing cast 6-8 weeks or ORIF
X-Rays

Foot and Ankle Fractures2

Uploaded by

Copyright:

Available Formats

Foot and Ankle Fractures2

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Foot and Ankle Fractures2

Uploaded by

Copyright:

Available Formats

Foot and Ankle Fractures

Foot and Ankle

Three groups of stabilizing ligaments :

Type B and C (at or above the tibiotalar

SH type III of the lateral tibial epiphysis

-Tarsometatarsal, or Lisfranc's joint

(Homolateral/Divergent, Type A,B,C)

You might also like