Ankle & Foot Fracture/Dislocations Shawn Dowling

ANATOMY 101 ANKLE 3 Primary Joints  Medial malleolus w/medial talus  Tibial plafond w/talar dome  Lat malleolus w/lat talus 3 Bones:  Tibia, Fibula and Talus 3 sets of Ligaments: Lateral collaterals (ATFL, CFL, PTFL) Syndesmotic Ligaments Medial collaterals (Deltoid)

Tibia Fibula Talus BONES

Medial Collateral Ligaments Lateral Collateral Ligaments Syndesmotic Ligaments LIGAMENTS

Tibia Fibula Talus JOINTS Fibulotalar Tibiotalar (mid) Tibiotalar (lateral)

FOOT Complicated (28 bones, 57 articulations) Subdivided in 3 segments & mvts Hindfoot - inv/ever Midfoot - abd/add Forefoot – flex/ext Joints Talo-crural jnt  Inversion/eversion Hindfoot – mid foot (Choparts)  Inversion/eversion Midfoot – forefoot (Lisfranc’s)*  Abd/adduction MTP-IP  Flex/extension

HINDFOOT MIDFOOT FOREFOOT calcaneus talus Medial navicular cuneiforms cuboid metatarsals phalanges sesamoids

Choparts Lisfrancs MTP IP

A B C D F E

What are stable fractures? Ankle forms a ring Disruption of only 1 structure is stable Disruption of > 1 is unstable

Approach to Ankle/Foot X- rays Go through complete approach (ABC’s) 3 views- AP, lat, Mortise (15-20° int rot) ankle, Direct evidence of injury: assess bones Indirect evidence of injuries: are all ankle measurements normal? Joint effusion? Describe x-ray, rather than simply naming it

Management In general Chip/avulsion #’s <3mm = Tx as sprain Non-displaced, non-intra-articular, stable #’s  3 wks NWB cast, 3-5 wks WB cast, f/u with cast clinic Unstable #’s, intra-articular # - speak with Ortho Open – saline soaked dsg, IV ABx, Td, Ortho urgently NV compromise – reduce and call Ortho Urgently

Diagnosis?Classification?Treatment? Does it change you mgmt if they have a tender deltoid ligament?

Lateral Malleoli #’s MC ankle #, MOI: usu inversion injury Weber classification – used to determine risk of syndesmosis injury and therefore need for operative repair Management NWB x 3wks, WB x 3-5wks* Refer B’s or C’s, Functional bimalleolar’s to ortho

Stable ? Is the location significant? Management? What measurements/lines do you look at in the ankle? What do they signify?

Medial clear Space <5mm A B A-B = talar tilt <3 is normal Syndesmosis injury >10 mm

Point out 3 abnormalities. Diagnosis? Stable? Treatment?

Maisonneuve

Diagnosis? Treatment?

Bimalleolar/Trimalleolar #’s Involve the medial, lateral and/or posterior malleoli Splint, pain control, NPO Need to speak to ortho as they will likely need OR

Mechanism of injury? Associated injuries? Management?

PILON # Mechanism of injury- axial load? Associated injuries- calcaneus, C,T & L spine, pelvis, intra-abdominal. Management- OR, approx 50% are open fractures

Description? What do you want to know/assess? What do you want to do? How?

Ankle Dislocations Relatively common, usually assoc w/# Describe the position of foot/talus to tibia If open, Tx as such X-rays should not delay reduction if NV compromise or skin tenting present Analgesia/PS, Reduce, splint, post-red films

Pediatric Ankle Injuries Not just little adult # The ligament attachments are stronger than the physis therefore more #’s, less sprains Overall management is similar to adults Although with fractures you can accept more angulation (little to no displacement) LLC casts are the initial choice for most #’s

Can we apply OAR/OFR in children? Six studies looked at validating OAR in peds Different age groups (2-18, 6-16) Sens 85*-100*% Considered all # Some considered all #, others only “significant #”)

BMJ Accuracy of OAR to exclude fractures of the ankle and mid-foot: A systematic review This study references all of the OAR done in children as well as adults

Problems with the studies Haven’t come up with a common definition of significant # Unsure of what to do with SH-1, inconsistent Dx Local practice (and Edmonton) – variable some apply it, some use rule + discretion, others use clinical judgement

Conclusion This needs to be further studied Need to determine which #’s are significant But I think they will likely be validated Although I think they’ll have to Tx SH1 as distinct injuries

Describe fracture? Classification? Management? SH-2 LLC x 3 wks, then SLC X 1-3 wks

Describe fracture? Classification? Management? SH2 Reduction/immbolize (air cast)

SALTR S traight A bove (metaphysis) L ower (epiphysis) T hru the Physis R am (Crush)

Non-operative management for SH 1-2 Attempt closed reduction, can accept more angulation Long leg cast x 3wks, followed by SLC x 3wks SH 3-4 -> OR SH 5 ->poor fx prognosis Complications for SH 3-5 include growth arrest, limb length discrepancy

Ankle # Complications Acute Skin necrosis NV injury Compartment syndrome # Blisters Wound infection/osteo Chronic Mal-union Non-union Post-traumatic arthritis AVN Chronic pain Chronic instability

Describe # Do you need to speak to Ortho? ?ottawa ankle rules Talar Dome # Yes – Ortho to see in cast clinic

Describe # Anything special about this bone? Blood flow distal to proximal like scaphoid and proximal femur, therefore inc AVN risk Is there a classification system for these #’s?

Talus Body Neck Head Chopart’s joint

Talar fractures Minor talar fractures Chip and avulsion fractures of neck,head, and body. Usually same mechanism as ankle sprains Talar neck fractures 50% of major talar injuries. extreme dorsiflexion force Hawkins classification Talar body fractures 23% of all talar fractures (including minor fractures) Major talar body fractures are uncommon  usually axial loading (e.g. falls) Talar head fractures Uncommon (5-10%) compressive force transmitted up through the talonavicular joint applied on a plantarflexed foot

Hawkins Classification of Talar Neck Fractures Type 1: = nondisplaced; Type 2: subtalar subluxation Type 3: dislocation of the talar body (50% open #’s) Type 4: dislocation of the talar body & distraction of the talonavicular joint. Fracture type influences management & prognosis Thanks Moby

Describe injury. Name this injury.v Management?

Describe injury. Name this injury Lisfranc Management? OR

What to look for on x-ray: Normally, medial aspect of metatarsals 1-3 should align with medial borders of cuneiforms Metatarsals should be aligned dorsally with tarsals on lateral view Medial 4 th metatarsal should align with medial cuboid Any fracture or dislocation of the navicular or cuneiforms or widening between metatarsals 1-3 Proximal 2 nd metatarsal # is pathognomonic Thanks Dave

Normal Lisfranc joint alignment Tx: Need to speak to ortho May try closed reduction

Describe. Management NWB cast # usu from direct trauma

Describe. Management Walking cast x 2-3 weeks Avulsion type #

Metatarsal # Treatment: Nondisplaced or min displaced fractures of metatarsal 2-4  stiff shoe, casting, or fracture brace. Non displaced 1 st metatarsal  NWB BK walking cast (cuz it’s a major WB surface) Displaced 1 st or 5 th metatarsal  ER ortho Attempt closed reduction if >3mm displacement or 10 degrees angulation Thanks Dave

Phalangeal #’s Non-displaced: buddy tape, (air cast if hallux involved as they are painful) Significant displacement/angulation: closed reduction -> speak with ortho if reduction is inadequate (esp w/hallux) If subungal hematoma is present with tuft # - evacuate hematoma and repair nail bed

10°

apex of anterior process apex of posterior facet Posterior tuberosity

Calcaneus # Management Order Harris (axial view), may need CT Probably should speak to Ortho for all since x-rays under-estimate extent of injury But…non-displaced, extra-articular – NWB cast x 6-8 wks Otherwise, Tx varies considerably and is best determined by Ortho

Summary Ankle #’s If #/injury disturbs>1 structure in ring = unstable or if intra-articular – ortho Otherwise: NWB cast x 3wks Foot Stable, extra-articular, wgt bearing surface  NWB cast Unstable, or intra-articular – ORTHO Stable, extra-articular, non-wgt bearing surface: conservative mgmt (rigid shoe, walking cast, buddy tape) If in doubt, Look up management of # - too many particularities to memorize

References Emergency Medicine Reports Management of Acute Foot and Ankle Disorders in the Emergency Department: Part I—The Ankle. Management of Acute Foot and Ankle Disorders in the Emergency Department: Part II—The Foot. Rosens Moritz and Dave Dyck’s Rounds Google Images