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Foot and Ankle Fractures

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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 ... – PowerPoint PPT presentation

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Title: Foot and Ankle Fractures


1
Foot and Ankle Fractures
  • Foot and Ankle Fractures

2
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

3
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4
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

5
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.

6
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").

7
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

8
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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10
Xray Measurments
11
Ankle Fractures
12
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

13
Unimalleolar Fractures
  • Lateral
  • -any avulsion lt3mm in size can be treated as an
    ankle sprain

14
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

15
Unimalleolar Fractures- Lateral
  • Type B and C (at or above the tibiotalar
  • joint)
  • -orthopedic consult ?ORIF
  • -type B 50 associated with tibiofibular
    disruption

16
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!!!

17
Bimalleolar Fractures
  • Management
  • -disruption of two elements of the ring
  • -ortho consult
  • -management controversial (ORIF vs closed
    reduction and close f/u)

18
Trimalleolar Fractures (Cottons fracture)
  • Management
  • -disruption of three parts of the ring
    (medial/lateral/posterior)
  • -ortho consult
  • -ORIF

19
Pilon ?
20
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

21
Tillaux ?
22
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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24
Foot Fractures
25
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

26
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

27
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

28
Foot Fractures
29
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

30
Fractures - Talus
  • Minor
  • -chip s treated like sprains
  • Treatment
  • -as above tx as sprain
  • -fragments gt5mm 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

31
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 gt70
  • Type IV fracture
  • -type II injury with associated talar head
    dislocation

32
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

33
Calcaneus (Lovers )
  • 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
  • -gt50 cases have associated other extremity or
    spinal fractures
  • -7 bilateral
  • -50 will have long-term disability

34
Calcaneus s
  • X-ray
  • -Boehlers angle (20-40 degrees)
  • -suspect fracture if lt20 degrees
  • Treatment
  • -ortho consult
  • -?ORIF vs conservative management

35
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

36
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 gt20 articular surface area
    will require ORIF

37
LisFranc ?
38
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

39
Classification
  • Classification
  • 1)Total Incongruity
  • 2)Partial Incongruity
  • 3)Divergent
  • (Homolateral/Divergent, Type A,B,C)

40
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.

41
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 (gt2mm) ORIF

42
Metatarsal s
  • Treatment
  • -2nd 4th conservative with well padded
  • shoe
  • -1st - ORIF
  • Exception
  • -displaced (gt3mm or angulated-plantar direction
    gt10 degrees)
  • -closed reduction
  • -/- pinning if unstable
  • -non wt bearing cast 4-6 wks

43
Jones
  • Jones
  • -transverse gt15mm from the proximal end of the
    bone (high rate delayed/nonunion)
  • -occur in gt50 pts with conservative therapy)
  • Treatment
  • -ortho f/u
  • -non-wt bearing cast 6-8 weeks or ORIF

44
X-Rays
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