1. The ANKLE and the FOOT
TRAUMA
MI Zucker, MD

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

3. 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

4. General Approach to Musculoskeletal Radiology
Soft tissues
Joints
Bones

5. The ANKLE

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

7. Anterior-Posterior: Adult

8. AP: Kid

9. Mortise: Adult

10. Lateral: Adult

11. Lateral: Kid

12. The INJURIES
ANKLE

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

14. 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

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

16. 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.

17. OTTAWA Rules: Ankle Tenderness

18. OTTAWA Rules: Foot Tenderness

19. 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

20. 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

21. Soft Tissue Swelling

22. Joint Effusion

23. “FLAKE” Fracture

24. FRACTURES of the ANKLE

25. 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.

26. 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

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

28. 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

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

30. WEBER A

31. WEBER B

32. WEBER C

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

34. What if ONLY the Medial Malleolus is Fractured?

35. 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

36. 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

37. Maisonneuve Fracture: Lower

38. Maisonneuve Fracture: Upper

39. 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

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

41. 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.

42. “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)

43. Fractures of the Base of the Fifth Metatarsal

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

45. Fractures of the Anterior Process of the Calcaneous

46. Stress fractures: repetitive microtrauma

47. Salter-Harris Injuries
Physis injuries, so KIDS ONLY!

48. 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

49. Salter-Harris what?

50. Salter-Harris I and IV

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

52. And now…

53. The FOOT

54. FOOT: Views AP
Oblique
Lateral

55. AP

56. AP

57. Oblique

58. Lateral

59. AP FOOT: Kid

60. Lateral FOOT: Kid

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

62. Talus Body fracture

63. Osteochondral Fracture

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

65. Axial Load Fracture

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

67. 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

68. Dancer’s Fifth

69. Jones Fifth

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

71. Lisfranc: obvious

72. Lisfranc: subtle

73. Metatarsal fractures
Spiral
Stress

74. Spiral fracture

75. Stress fracture

76. Toe fractures
“Stub”
Crush

77. Toe fractures

78. GOODBYE
Copyright 2004
MI Zucker