Ankle and foot fractures

Measured angle is from 20-40 degrees Bohler’s Angle Measured angle is from 20-40 degrees Calcaneal fracture from Angle is measured by posterior to middle part of calcanues. Cross with anterior line to midpoint of calcaneus

Calcaneal fractures Best diagnostic clue: Fracture line & Flat Bohler’s Angle Land from 75% height/ high-impact Don Juan fracture lover's fracture Low Bohler angle, suspect a lumbar fracture as well

Complications Possible AVN due to high amount of blood supply running through the area

First & second metatarsals Medial & middle cuneiforms Lisfranc Joint First & second metatarsals Medial & middle cuneiforms Pain in midfoot Inability to weight bear, especially on toes Lisfranc injury 20% Missed high risk of chronic pain and functional disability if goes unrecognized Always a Lisfranc injury of the joint Plantarflexed foot w/ axial loading will have midfoot compression

transverse ligaments connect lateral four metatarsal bases no ligament between 1st & 2nd metatarsal bases joint capsule & dorsal ligament… minimal support ……..prone to injury Almost invariably involve metatarsal fractures…………… 39%2nd metatarsal, cuboid, cuneiform, navicular

Signs of a Lisfranc injury 1st MT …no incongruency 2nd MTAP view 3rd MToblique view "fleck sign” medial cuneiform-2nd MT space No Subluxation at naviculocuneiform No "step-off”…..MT shaft never more dorsal than its tarsal bone When you fx lisfranc ligament, all the other metatarsals will go lateral

Jones fracture base of 5th metatarsal ….metaphyseal-diaphyseal junction Not IntraArticular Roy Jones – boxer 5th metacarpal is a boxer’s fx so jones is a 5th metatarsal fx At tubercle, you have ligament attaching, would be called avulsion fx if it happened there Within 1.5 cm distal to tuberosity of 5th metatarsal Don’t confuse with avulsion fracture of 5th metatarsal tuberosity (lateral band plantar aponeurosis) An oblique radiograph is essential to accurately assess this fracture

Jones Fracture proximal diaphysis 5th MT …risk for nonunion Trauma between insertion of fibularis(peroneus) brevis and fibularis(peroneus)tertius tendons plantar flex and strong adduction force at forefoot proximal diaphysis 5th MT …risk for nonunion Left – avulsion fx caused by plantar aponeurosis Right – Jones fx

Talar Fractures Neck & Body Retrograde blood supply from sinus tarsi arteries entering at the neck (most common) ........risk of AVN of body Hawkins' sign: Thin zone of subcortical lucency of the talar dome Hawkins' sign indicates an intact talar body blood supply AVN of body is of concern, look for Hawkin’s sign (Stephen Hawkin’s can’t use his body)

Maisonneuve fracture Ankle Mortise injuries …Medial Malleolar or Mortise…. ……..Entire Fibula needs X-Ray views Fibular fracture not seen in ankle X-Ray film (it’s too proximal) UNSTABLE FRACTURE

Tillaux fracture Salter-Harris III lateral distal tibia. Unique to early adolescents….12-14 yrs old Distal tibial physis fuses medial to lateral…. lateral physis relatively weak/prone to fracture

Pilon Fracture Comminuted fracture of the distal tibia with intraarticular extension into the plafond Type I: Nondisplaced Type II: Same as type I, but with displacement Type III: Multifragmented Plafond – ankle roof – pilon Pilon = big pile of mess

Weber C Weber B Weber A Widening at Weber C – need a full fibular view to get a better idea if there is a fracture C – above sea level B – baseline A - below

Cuboid Fracture Entrapment between the calcaneus and 4th and 5th metatarsals AKA nutcracker’s fracture.

Navicular Fracture Navicular tuberosity avulsion Posterior tibial tendon avulsion StressPartial or complete fracture in sagittal plane

Navicular Fractures Avulsion fractures most common…47-67% Body fractures commonly associated with other midfoot injuries Navicular stress fractures….59% are track and field athletes Uncommon in general population BodyType III has worst prognosis 86% of non-displaced stress fractures heal Up to 14% treated correctly do not return to previous activities

Köhler Disease Self limiting avascular necrosis of navicular in child < 6 years Collapsed navicular or normal navicular with increased density + fragmentation K – kohler – kid - kollapse

Freiberg Infraction Best diagnostic clueSclerosis and flattening of “2nd metatarsal head”…Long 2nd metatarsal susceptible to increased stresses…Involved 85% Trauma is primary event Vascular damage/compression subchondral marrow change with hyperintense edema

Metatarsal Stress Fractures March fracture/fatigue fractureDistal 3rd of metatarsal Due to recurrent stress….On feet prolonged periods…..soldiers/hikers/organists/doctors most commonly occur in the 2nd & 3rd metatarsals