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 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 -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
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
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 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 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 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
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
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 – 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
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
X-ray -Boehler’s angle (20-40 degrees) -suspect fracture if <20 degrees Treatment -ortho consult -?ORIF vs conservative management Calcaneus #’s
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 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