1. Foot and Ankle Fractures Dr. Dave Dyck R3 Sept. 5/02

2. Today’s Agenda: Review ankle x-rays (10min) Review ankle x-ray classification (5-10min) Review various foot and ankle fractures and their treatments (30min)

3. Case 1: 32y male with R ankle pain and inability to walk after jumping off trailer 8 feet high and landing on both feet.

4. Ottawa ankle rules: Order ankle x-rays if there is pain in malleolar zone + any one of: –Inability to weight bear both immediately and in ER (4 steps) –Bony tenderness over posterior distal 6cm of either malleoli (consider sensorium, ETOH, other inj, sensation,etc.)

5. Ottawa ankle rules: Sensitivity=99-100% Specificity=40%

6. Ankle X-rays: AP Lateral Mortise

7. AP

8. AP x-ray: Medial clear space < 4mm (if not consider lat talar shift and deltoid disruption) Space between medial fibular wall and incisural surface of tibia < 5mm Anterior tibial tubercle should overlap fibula by 6-10mm (or 42% fibular width) (syndesmotic injury)

9. AP xray

10. Mortise x-ray: Tibiofibular overlap >1mm Tibiofibular clear space <5mm (if abnormal  consider syndesmotic inj)

11. Mortise x-ray: Medial clear space <4mm and superior- medial joint space w/in 2mm of width laterally (often AP view better)

12. Mortise x-ray: Talar tilt (normal -1.5 to 1.5 degrees) ie. parallel Can normally go up to 5 degrees in stress views

13. Mortise x-ray: Tibiofibular line: distal tibia and medial aspect of fibula should be continuous articular surface of talus should be congruent with that of distal fibula

14. Lateral x-ray: Tibia/fibula/talus/joint space and os trigonum

15. Os trigonum: Common accessory bone (8%) of foot found just posterior to lateral tubercle of talus

16. Shepherd’s Fracture: Extreme plantar flexion injury

17. Case 1:

18. How would you classify this?

19. Lauge-Hansen: Based on position of foot prior to injury and the motion of the talus relative to the leg once force is applied Eg supination-external rotation Further subdivided into worsening areas of injury USELESS!

20. Danis-Weber Based on level of fibular fracture A=below syndesmosis B=at level of syndesmosis C=above syndesmosis THE MORE PROXIMAL THE FIBULAR # THE MORE SEVERE THE INJURY

21. AO classification: Similar to DW scheme but adds further info based on medial malleolar involvement ANY MEDIAL MALLEOLAR # = UNSTABLE ANKLE

22. AO classification

23. Henderson scheme: Most common Unimalleolar vs bimalleolar vs trimalleolar

24. Case 2: Treatment?

25. Transverse type A1/avulsion # Treat as stable ankle sprains if they are minimally displaced, <3mm in diameter, and no indication of medial ligament damage. Otherwise treat in walking cast/boot for 6-8 weeks

26. Isolated medial malleolar # Rare (have high index of suspicion for other injuries) If min displaced treat with immobilization and outpatient follow-up r/o Maisonneuve’s fracture

27. Maisonneuve’s fracture:

28. Treatment: Cast immobilization and refer to ortho for possible ORIF vs. conservative tx (only if mortise intact)

29. Case 3: Treatment?

30. Bimalleolar and trimalleolar # Usually involve syndesmosis Post slab and ortho referral (may try closed reduction if ++displaced and definitely if dislocation)

31. Case 4:

32. Tibial plafond or Pilon fracture Due to axial load Very unstable Splint and refer to ortho for ORIF

33. Hindfoot Fractures: Talus Calcaneus

34. Case 5:

35. Talar fractures: Rare Poor blood supply  high incidence of AVN Can be major or minor

36. Major Talar fractures: Neck, head, body (& lat process) Talar neck fractures = 50% –Hawkins type1= non displaced + no joint inv. –Type II = displaced with subluxation or dislocation of the subtalar joint BUT ankle joint is OK –Type III = Type II +dislocation of ankle joint –Type IV = Type III + talar head dislocation

37. Talar Neck #

38. Treatment: Type I= NWB BK casting x 8-12 weeks Type II= closed reduction with traction + plantar flexion and BK casting vs ORIF Type III/IV = immed. Ortho consult Ortho should be involved in all cases

39. Treatment: Talar body # = if non-displaced  BK non- weight bearing cast x 6-8 weeks Talar head # = if non-displaced  BK walking cast X 6-8 weeks VS NWB ER ortho otherwise

40. Minor talar fractures: Minor avulsion fractures of neck, body, and lateral process are treated with post slab, crutches and ortho follow-up Osteochondral fractures of talar dome  NWB BK cast x3mo w ortho f/u

41. Case 6: 8ft fall onto both feet. R>L heel pain and can’t walk L calcaneus x-ray:

42. Bohler’s angle (30-40 deg)

43. R calcaneus x-ray:

45. Treatment?

46. Treatment: Extraarticular= –25-35% –Anterior process, tuberosity, medial process, sustenaculum tali, and body –If not displaced nor involving subtalar jt may treat with compressive dressings/casting * Intraarticular= post facet involved - well padded post splint + ortho

47. Calcaneal fractures: More than 50% are associated with other extremity or spinal fractures

48. Midfoot Fractures: Navicular Cuboid Lisfranc

49. Case 7:

50. r/o accessory bone

51. Case 8:

52. Navicular fractures: -Most common midfoot fracture but still rare -treatment= non-displaced=short-leg walking cast x6 wks displaced= ortho

53. Cuboid Fractures: Treat as per navicular fractures r/o Lisfranc injury

54. Case 9:

55. Lisfranc Joint: Formed by the articulations of metatarsals 1-3 with the cuneiforms and metatarsals 4 & 5 with the cuboid The metatarsal bases of digits 2-5 are joined by strong ligaments

56. 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 pathogpneumonic

57. Normal Lisfranc joint

58. Treatment: Consult ortho May try closed reduction with traction but post reduction displacement of >2mm or tarso-metatarsal angle> 15 degrees requires surgery

59. Forefoot fractures: Metatarsal Phalangeal

60. Case10:

61. Case 11:

62. 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 Displaced 1 st or 5 th metatarsal  ER ortho Attempt closed reduction if >3mm displacement or 10 degrees angulation

63. Treatment cont. Metatarsal base #  r/o LF injury Jones Fracture=5 th metatarsal base fracture. –Tx=non displaced  NWB BK cast x6-8 wks – = displaced  surgery

64. Jones #

65. Peds= ?apophysis

66. Phalangeal # Nondisplaced digits 2-5= buddy tape Can also buddy tape non-displaced phalange1 but may need BK walking cast for pain control Residual displacement, intraarticular, comminution  ortho