Transcript Foot and Ankle Fractures

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
Xray Measurments
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
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 cuneiformsecond 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