The ANKLE and the FOOT TRAUMA MI Zucker, MD

A dr Z Lecture On TRAUMA of the Ankle and Foot and some general concepts in musculoskeletal trauma evaluation

Rules for Success in Radiology Know which exam to order Know which films you need Know good films from bad films, and don’t accept bad ones Read methodically by check list Know the common lesions Know the commonly missed lesions

General Approach to Musculoskeletal Radiology Soft tissues Joints Bones

The ANKLE

The Ankle Series Anterior-posterior (AP) Mortise (15 degree internal oblique) Lateral

Anterior-Posterior: Adult

AP: Kid

Mortise: Adult

Lateral: Adult

Lateral: Kid

The INJURIES ANKLE

When Does the Patient NEED Radiography? The OTTAWA Rules Ankle and Foot

The OTTAWA ANKLE Rules Unable to weight bear immediately Unable to walk four steps in medical facility Bone tenderness medial or lateral malleolus If “YES” to any, get ANKLE films

The OTTAWA FOOT Rules Bone tenderness base of fifth metatarsal Bone tenderness navicular If “YES” to either, get foot films

Some OTTAWA Rule caveats Not valid if injury not acute Some exclude patients under age 18 years or over 55 years These factors make the Rules less reliable, so we are more likely to do imaging in these circumstances.

OTTAWA Rules: Ankle Tenderness

OTTAWA Rules: Foot Tenderness

The Ankle Sprain Grade I: Soft tissues swelling/joint effusion Grades II and III: Soft tissue swelling/joint effusion but may also have “FLAKE” avulsion fractures of the dorsum of the talus or navicular bones. Management differs, depending on grade

The Sprain: treatment Grade I Grades II/III Ace wrap, crutches, limited time off weight bearing Air or posterior splint, crutches, prolonged period off weight bearing, orthopedic consult

Soft Tissue Swelling

Joint Effusion

“FLAKE” Fracture

FRACTURES of the ANKLE

WEBER’S Classification Based only on location of a FIBULA fracture. A fracture, or no fracture, of the medial malleolus (tibia) does NOT change the classification.

WEBER’S Classification Weber A: Fracture below the joint margin Weber B: Fracture begins at the joint margin Weber C: Fracture begins above the joint margin

Weber A, B, and C injuries are ALL from INVERSION

WEBER’S Assumptions Weber A: Anterior and posterior tibia-fibula and interosseous ligaments intact: STABLE Weber B: Anterior and posterior tibia-fibula ligaments torn: Moderately UNSTABLE Weber C: Interosseous ligament torn: Completely UNSTABLE

Management of WEBER Injuries Weber A: Cast for 6 weeks Weber B: Frequently ORIF Weber C: Always ORIF ORIF: Open Reduction Internal Fixation

WEBER A

WEBER B

WEBER C

REMEMBER If the MEDIAL MALLEOLUS is also fractured, it does NOT change the Weber classification

What if ONLY the Medial Malleolus is Fractured?

Two possibilities Weber A “equivalent” from INVERSION: The Lateral Collateral Ligament is torn but the Lateral Malleolus did not fail EVERSION INJURY: an UNSTABLE Maisonneuve Fracture

Maisonneuve Fractures These are EVERSION injuries that fracture the MEDIAL MALLEOLUS, tear the entire Interosseous Ligament and Membrane, and exit as a high FIBULA SHAFT fracture They are all UNSTABLE and are treated by ORIF

Maisonneuve Fracture: Lower

Maisonneuve Fracture: Upper

Caveat The high fibula fracture may be clinically occult So, ALWAYS get AP/lateral films of the ENTIRE tibia and fibula if there is an “isolated” medial malleolus fracture on the ankle series

Bimalleolar Fracture Medial and lateral malleolar fractures, but still use Weber, as medial malleolar fracture does NOT change classification This is a Weber B

Trimalleolar Fracture In addition to lateral and medial malleolar fractures, there is a fracture of the distal posterior tibia, called the POSTERIOR Malleolus. If large, extra ORIF needed.

“Ankle” Injuries that are really FOOT Injuries Fractures of the base of the Fifth Metatarsal Fractures of the Anterior Process of the Calcaneous “Flake” fractures of the Talus or Navicular (we already did this, and they are components of an ankle injury)

Fractures of the Base of the Fifth Metatarsal

We will look at these again When we get to the FOOT

Fractures of the Anterior Process of the Calcaneous

Stress fractures: repetitive microtrauma

Salter-Harris Injuries Physis injuries, so KIDS ONLY!

Salter-Harris PHYSIS Injuries SH I: Physis only SH II: Physis and metaphysis SH III: Physis and epiphysis SH IV: Physis, metaphysis and epiphysis SH V: Crush injury of physis SH VI: Avulsed piece of metaphysis, physis, and epiphysis

Salter-Harris what?

Salter-Harris I and IV

Remember: KIDS ONLY! NO Salter-Harris injuries are possible after physis closes: “Salter-Harris Nothing”

And now…

The FOOT

FOOT: Views AP Oblique Lateral

AP

AP

Oblique

Lateral

AP FOOT: Kid

Lateral FOOT: Kid

Talus Avulsions of dorsal margin: Ankle ligament injury (we did it under ANKLE) Osteochondral fracture: acute and stress Body of talus

Talus Body fracture

Osteochondral Fracture

Calcaneous Body: axial load Stress: repetitive microtrauma Anterior process: ankle injury

Axial Load Fracture

Stress Fracture Initial film: pain one week Follow-up film: pain three weeks

Fifth Metatarsal Base DANCER’S: tubercle, inversion, heals well Crepe support, walking boot or cast, on or off weight bearing: depends on extent of fracture JONES: proximal shaft, inversion or direct blow or stress, sometimes delayed or non-union Posterior cast or boot, off weight bearing If non-union, ORIF

Dancer’s Fifth

Jones Fifth

Lisfranc Injuries Severe dorsal or plantar flexion at midfoot-forefoot junction Usually, very displaced and obvious Can be subtle ALL need surgery

Lisfranc: obvious

Lisfranc: subtle

Metatarsal fractures Spiral Stress

Spiral fracture

Stress fracture

Toe fractures “Stub” Crush

Toe fractures

GOODBYE Copyright 2004 MI Zucker