Transcript The ANKLE and the FOOT

The ANKLE and the FOOT
TRAUMA
MI Zucker, MD
A dr Z Lecture
• On TRAUMA of the
Ankle and Foot and
some general concepts
in musculoskeletal
trauma evaluation
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
General Approach to
Musculoskeletal Radiology
• Soft tissues
• Joints
• Bones
The ANKLE
The Ankle Series
• Anterior-posterior (AP)
• Mortise (15 degree internal oblique)
• Lateral
Anterior-Posterior: Adult
AP: Kid
Mortise: Adult
Lateral: Adult
Lateral: Kid
The INJURIES
ANKLE
When Does the Patient NEED
Radiography?
The OTTAWA Rules
Ankle and Foot
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
The OTTAWA FOOT Rules
• Bone tenderness base of fifth metatarsal
• Bone tenderness navicular
If “YES” to either, get foot films
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.
OTTAWA Rules: Ankle
Tenderness
OTTAWA Rules: Foot
Tenderness
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
The Sprain: treatment
• Grade I
• Ace wrap, crutches,
limited time off weight
bearing
• Grades II/III
• Air or posterior splint,
crutches, prolonged
period off weight
bearing, orthopedic
consult
Soft Tissue Swelling
Joint Effusion
“FLAKE” Fracture
FRACTURES of the ANKLE
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.
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
Weber A, B, and C injuries are
ALL from INVERSION
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
Management of WEBER Injuries
• Weber A: Cast for 6 weeks
• Weber B: Frequently ORIF
• Weber C: Always ORIF
ORIF: Open Reduction Internal Fixation
WEBER A
WEBER B
WEBER C
REMEMBER
If the MEDIAL MALLEOLUS is
also fractured, it does NOT change
the Weber classification
What if ONLY the Medial
Malleolus is Fractured?
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
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
Maisonneuve Fracture: Lower
Maisonneuve Fracture: Upper
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
Bimalleolar Fracture
• Medial and lateral
malleolar fractures,
but still use Weber, as
medial malleolar
fracture does NOT
change classification
• This is a Weber B
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.
“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)
Fractures of the Base of the Fifth
Metatarsal
We will look at these again
When we get to the FOOT
Fractures of the Anterior Process
of the Calcaneous
Stress fractures: repetitive
microtrauma
Salter-Harris Injuries
Physis injuries, so KIDS ONLY!
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
Salter-Harris what?
Salter-Harris I and IV
Remember: KIDS ONLY!
NO Salter-Harris injuries are
possible after physis closes:
“Salter-Harris Nothing”
And now…
The FOOT
FOOT: Views
• AP
• Oblique
• Lateral
AP
AP
Oblique
Lateral
AP FOOT: Kid
Lateral FOOT: Kid
Talus
• Avulsions of dorsal margin: Ankle ligament
injury (we did it under ANKLE)
• Osteochondral fracture: acute and stress
• Body of talus
Talus Body fracture
Osteochondral Fracture
Calcaneous
• Body: axial load
• Stress: repetitive microtrauma
• Anterior process: ankle injury
Axial Load Fracture
Stress Fracture
• Initial film: pain one
week
• Follow-up film: pain
three weeks
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
Dancer’s Fifth
Jones Fifth
Lisfranc Injuries
• Severe dorsal or plantar flexion at midfootforefoot junction
• Usually, very displaced and obvious
• Can be subtle
• ALL need surgery
Lisfranc: obvious
Lisfranc: subtle
Metatarsal fractures
• Spiral
• Stress
Spiral fracture
Stress fracture
Toe fractures
• “Stub”
• Crush
Toe fractures
GOODBYE
• Copyright 2004
MI Zucker