Foot and Ankle FracturesFoot and Ankle Fractures

Dr. Dave Dyck R3

Sept. 5/02

Today’s Agenda:Today’s Agenda:

• Review ankle x-rays (10min)

• Review ankle x-ray classification (5-10min)

• Review various foot and ankle fractures and their treatments (30min)

Case 1:Case 1:

• 32y male with R ankle pain and inability to walk after jumping off trailer 8 feet high and landing on both feet.

Ottawa ankle rules:Ottawa ankle rules:

• Order ankle x-rays if there is pain in malleolar zone + any one of:– Inability to weight bear both immediately and

in ER (4 steps)– Bony tenderness over posterior distal 6cm of

either malleoli

(consider sensorium, ETOH, other inj, sensation,etc.)

Ottawa ankle rules:Ottawa ankle rules:

• Sensitivity=99-100%

• Specificity=40%

Ankle X-rays:Ankle X-rays:

• AP

• Lateral

• Mortise

APAP

AP x-ray:AP x-ray:

• Medial clear space < 4mm (if not consider lat talar shift and deltoid disruption)

• Space between medial fibular wall and incisural surface of tibia < 5mm

• Anterior tibial tubercle should overlap fibula by 6-10mm (or 42% fibular width)

(syndesmotic injury)

AP xrayAP xray

Mortise x-ray:Mortise x-ray:

• Tibiofibular overlap >1mm

• Tibiofibular clear space <5mm

(if abnormalconsider syndesmotic inj)

Mortise x-ray:Mortise x-ray:

• Medial clear space <4mm and superior-medial joint space w/in 2mm of width laterally (often AP view better)

Mortise x-ray:Mortise x-ray:

• Talar tilt (normal -1.5 to 1.5 degrees) ie. parallel

• Can normally go up to 5 degrees in stress views

Mortise x-ray:Mortise x-ray:

• Tibiofibular line: distal tibia and medial aspect of fibula should be continuous

• articular surface of talus should be congruent with that of distal fibula

Lateral x-ray:Lateral x-ray:

• Tibia/fibula/talus/joint space and os trigonum

Os trigonum:Os trigonum:

• Common accessory bone (8%) of foot found just posterior to lateral tubercle of talus

Shepherd’s Fracture:Shepherd’s Fracture:

• Extreme plantar flexion injury

Case 1:Case 1:

How would you classify this?How would you classify this?

Lauge-Hansen:Lauge-Hansen:

• Based on position of foot prior to injury and the motion of the talus relative to the leg once force is applied

• Eg supination-external rotation

• Further subdivided into worsening areas of injury

• USELESS!

Danis-WeberDanis-Weber

• Based on level of fibular fracture

• A=below syndesmosis

• B=at level of syndesmosis

• C=above syndesmosis

• THE MORE PROXIMAL THE FIBULAR # THE MORE SEVERE THE INJURY

AO classification:AO classification:

• Similar to DW scheme but adds further info based on medial malleolar involvement

• ANY MEDIAL MALLEOLAR # = UNSTABLE ANKLE

AO classificationAO classification

Henderson scheme:Henderson scheme:

• Most common

• Unimalleolar vs bimalleolar vs trimalleolar

Case 2:Case 2:

Treatment?

Transverse type A1/avulsion #Transverse type A1/avulsion #

• Treat as stable ankle sprains if they are minimally displaced, <3mm in diameter, and no indication of medial ligament damage. Otherwise treat in walking cast/boot for 6-8 weeks

Isolated medial malleolar #Isolated medial malleolar #

• Rare (have high index of suspicion for other injuries)

• If min displaced treat with immobilization and outpatient follow-up

• r/o Maisonneuve’s fracture

Maisonneuve’s fracture:Maisonneuve’s fracture:

Treatment:Treatment:

• Cast immobilization and refer to ortho for possible ORIF vs. conservative tx (only if mortise intact)

Case 3:Case 3:

Treatment?

Bimalleolar and trimalleolar #Bimalleolar and trimalleolar #

• Usually involve syndesmosis

• Post slab and ortho referral (may try closed reduction if ++displaced and definitely if dislocation)

Case 4:Case 4:

Tibial plafond or Pilon fractureTibial plafond or Pilon fracture

• Due to axial load

• Very unstable

• Splint and refer to ortho for ORIF

Hindfoot Fractures:Hindfoot Fractures:

• Talus

• Calcaneus

Case 5:Case 5:

Talar fractures:Talar fractures:

• Rare

• Poor blood supply high incidence of AVN

• Can be major or minor

Major Talar fractures:Major Talar fractures:

• Neck, head, body (& lat process)

• Talar neck fractures = 50%– Hawkins type1= non displaced + no joint inv.– Type II = displaced with subluxation or

dislocation of the subtalar joint BUT ankle joint is OK

– Type III = Type II +dislocation of ankle joint– Type IV = Type III + talar head dislocation

Talar Neck #Talar Neck #

Treatment:Treatment:

• Type I= NWB BK casting x 8-12 weeks

• Type II= closed reduction with traction + plantar flexion and BK casting vs ORIF

• Type III/IV = immed. Ortho consult

• Ortho should be involved in all cases

Treatment:Treatment:

• Talar body # = if non-displaced BK non-weight bearing cast x 6-8 weeks

• Talar head # = if non-displaced BK walking cast X 6-8 weeks VS NWB

• ER ortho otherwise

Minor talar fractures:Minor talar fractures:

• Minor avulsion fractures of neck, body, and lateral process are treated with post slab, crutches and ortho follow-up

• Osteochondral fractures of talar dome NWB BK cast x3mo w ortho f/u

Case 6: 8ft fall onto both feet. R>L Case 6: 8ft fall onto both feet. R>L heel pain and can’t walkheel pain and can’t walk

• L calcaneus x-ray:

Bohler’s angle (30-40 deg)Bohler’s angle (30-40 deg)

R calcaneus x-ray:R calcaneus x-ray:

Treatment?Treatment?

Treatment:Treatment:

• Extraarticular= – 25-35%– Anterior process, tuberosity, medial process,

sustenaculum tali, and body– If not displaced nor involving subtalar jt may

treat with compressive dressings/casting * Intraarticular= post facet involved

- well padded post splint + ortho

Calcaneal fractures:Calcaneal fractures:

• More than 50% are associated with other extremity or spinal fractures

Midfoot Fractures:Midfoot Fractures:

• Navicular

• Cuboid

• Lisfranc

Case 7:Case 7:

• r/o accessory bone

Case 8:Case 8:

Navicular fractures:Navicular fractures:

-Most common midfoot fracture but still rare

-treatment=

non-displaced=short-leg walking cast x6 wks

displaced= ortho

Cuboid Fractures:Cuboid Fractures:

• Treat as per navicular fractures

• r/o Lisfranc injury

Case 9:Case 9:

Lisfranc Joint:Lisfranc Joint:

• Formed by the articulations of metatarsals 1-3 with the cuneiforms and metatarsals 4 & 5 with the cuboid

• The metatarsal bases of digits 2-5 are joined by strong ligaments

What to look for on x-ray:What to look for on x-ray:

• Normally, medial aspect of metatarsals 1-3 should align with medial borders of cuneiforms

• Metatarsals should be aligned dorsally with tarsals on lateral view

• Medial 4th metatarsal should align with medial cuboid

• Any fracture or dislocation of the navicular or cuneiforms or widening between metatarsals 1-3

• Proximal 2nd metatarsal # is pathogpneumonic

Normal Lisfranc jointNormal Lisfranc joint

Treatment:Treatment:

• Consult ortho

• May try closed reduction with traction but post reduction displacement of >2mm or tarso-metatarsal angle> 15 degrees requires surgery

Forefoot fractures:Forefoot fractures:

• Metatarsal

• Phalangeal

Case10:Case10:

Case 11:Case 11:

Treatment:Treatment:

• Nondisplaced or min displaced fractures of metatarsal 2-4 stiff shoe, casting, or fracture brace.

• Non displaced 1st metatarsal NWB BK walking cast

• Displaced 1st or 5th metatarsal ER ortho

• Attempt closed reduction if >3mm displacement or 10 degrees angulation

Treatment cont.Treatment cont.

• Metatarsal base # r/o LF injury

• Jones Fracture=5th metatarsal base fracture. – Tx=non displaced NWB BK cast x6-8 wks– = displaced surgery

Jones #Jones #

Peds= ?apophysisPeds= ?apophysis

Phalangeal #Phalangeal #

• Nondisplaced digits 2-5= buddy tape

• Can also buddy tape non-displaced phalange1 but may need BK walking cast for pain control

• Residual displacement, intraarticular, comminution ortho