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 Squeeze Test -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 Medial clear space not >4mm if so disruption of integraty A-B clear space if >5mm disruption of the syndesmotic ligaments

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 -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