Foot and Ankle Fractures

1. Foot and Ankle Fractures Dr. Dave Dyck R3 Sept. 5/02

2. 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)

3. Case 1: • 32y male with R ankle pain and inability to walk after jumping off trailer 8 feet high and landing on both feet.

4. 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.)

5. Ottawa ankle rules: • Sensitivity=99-100% • Specificity=40%

6. Ankle X-rays: • AP • Lateral • Mortise

7. AP

8. 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)

9. AP xray

10. Mortise x-ray: • Tibiofibular overlap >1mm • Tibiofibular clear space <5mm (if abnormalconsider syndesmotic inj)

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

12. Mortise x-ray: • Talar tilt (normal -1.5 to 1.5 degrees) ie. parallel • Can normally go up to 5 degrees in stress views

13. 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

14. Lateral x-ray: • Tibia/fibula/talus/joint space and os trigonum

15. Os trigonum: • Common accessory bone (8%) of foot found just posterior to lateral tubercle of talus

16. Shepherd’s Fracture: • Extreme plantar flexion injury

17. Case 1:

18. How would you classify this?

19. 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!

20. Danis-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

21. AO classification: • Similar to DW scheme but adds further info based on medial malleolar involvement • ANY MEDIAL MALLEOLAR # = UNSTABLE ANKLE

22. AO classification

23. Henderson scheme: • Most common • Unimalleolar vs bimalleolar vs trimalleolar

24. Case 2: Treatment?

25. 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

26. 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

27. Maisonneuve’s fracture:

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

29. Case 3: Treatment?

30. Bimalleolar and trimalleolar # • Usually involve syndesmosis • Post slab and ortho referral (may try closed reduction if ++displaced and definitely if dislocation)

31. Case 4:

32. Tibial plafond or Pilon fracture • Due to axial load • Very unstable • Splint and refer to ortho for ORIF

33. Hindfoot Fractures: • Talus • Calcaneus

34. Case 5:

35. Talar fractures: • Rare • Poor blood supply  high incidence of AVN • Can be major or minor

36. 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

37. Talar Neck #

38. 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

39. 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

40. 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

41. Case 6: 8ft fall onto both feet. R>L heel pain and can’t walk • L calcaneus x-ray:

42. Bohler’s angle (30-40 deg)

43. R calcaneus x-ray:

45. Treatment?

46. 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

47. Calcaneal fractures: • More than 50% are associated with other extremity or spinal fractures

48. Midfoot Fractures: • Navicular • Cuboid • Lisfranc

49. Case 7:

50. r/o accessory bone