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Foot and Ankle Fractures. Foot and Ankle Fractures. Anatomy. Three groups of stabilizing ligaments : 1)Lateral -anterior talofibular ligament (ATFL) -calcaneofibular ligament (CFL) -posterior talofibular ligament (PTFL).

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Foot and ankle fractures l.jpg

Foot and Ankle Fractures

Foot and Ankle Fractures


Anatomy l.jpg
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


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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


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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.


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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").


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Special Tests

Anterior Drawer

-integrity of the ATFL

-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


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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




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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

Classification


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Unimalleolar Fractures

Lateral

-any avulsion <3mm in size can be treated as an ankle sprain


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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


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Unimalleolar Fractures- Lateral

Type B and C (at or above the tibiotalar

joint)

-orthopedic consult ?ORIF

-type B : 50% associated with tibiofibular disruption


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Unimalleolar Fractures-Medial

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!!!


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Bimalleolar Fractures

Management

-disruption of two elements of the ring

-ortho consult

-management controversial (ORIF vs closed reduction and close f/u)


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Trimalleolar Fractures (Cotton’s fracture)

Management

-disruption of three parts of the ring (medial/lateral/posterior)

-ortho consult

-ORIF



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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



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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



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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


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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


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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



Talar l.jpg
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


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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


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Fractures – TalusClassification

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


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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


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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


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X-ray

-Boehler’s angle (20-40 degrees)

-suspect fracture if <20 degrees

Treatment

-ortho consult

-?ORIF vs conservative management

Calcaneus #’s


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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


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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



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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


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Classification

Classification

1)Total Incongruity

2)Partial Incongruity

3)Divergent

(Homolateral/Divergent, Type A,B,C)


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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.


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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


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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


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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