Foot and Ankle Fractures2.Ppt 0

8/6/2019 Foot and Ankle Fractures2.Ppt 0

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Foot and Ankle Fractures

Foot and AnkleFoot and Ankle

FracturesFractures


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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


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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 kneeor foot pain

-degree of function after the event.


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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").


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Special Tests

Anterior Drawer

-integrity of the ATFL

-grasp the heel with one hand and apply a posterior force to the tibia with theother 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 tibiaand fibula together

-positive test: results in pain in the ankle, which indicates injury of thesyndesmotic ligament


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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 andcalcaneus

-Mortise : most important view, medial clear space should not

exceed 4mm


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Xray Measurments


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Ankle Fractures


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Classification

Danis-Weber

-based on mechanism of injury

-three fracture types (i.e., A, B, C ),

defined by the location of the fibularfracture

-A - below the tibiotalar joint

-B - at the level of the tibiotalar joint

-C - above the tibiotalar joint


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Unimalleolar Fractures

Lateral

-any avulsion


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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


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Unimalleolar Fractures- Lateral

Type B and C (at or above the tibiotalar

joint)

-orthopedic consult ?ORIF

-type B : 50% associated with

tibiofibular disruption


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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!!!


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Bimalleolar Fractures

Management

-disruption of two elements of the ring

-ortho consult

-management controversial (ORIF vs closed

reduction and close f/u)


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Trimalleolar Fractures

(Cottons fracture)

Management

-disruption of three parts of the ring

(medial/lateral/posterior)

-ortho consult

-ORIF


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Pilon #?


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Pilon Fractures (Bad!)

Mechanism

-axial compression

-talus driven into the plafond-usually comminuted and displaced with extensive softtissue swelling

-look for associated injuries

-calcaneus, femoral neck, acetabulum, lumbar vertebraeManagement

-emergent ortho consult


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Tillaux #?


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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 jointManagement

-ortho consult ORIF


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Foot Fractures


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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


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Foot Fractures


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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 ofavascular necrosis


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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


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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 subtalarjoint 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


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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


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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

->50 % cases have associated other extremity or spinal fractures

-7% bilateral

-50% will have long-term disability


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Calcaneus #s

X-ray

-Boehlers angle (20-40

degrees)

-suspect fracture if


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Navicular

General

-most common midfoot #

-blood supply tenuous, risk AVN

-classification: dorsal avulsion # (47% allnavicular #s), tuberosity and body #s

-mechanism usually eversion injury-pain over the dorsal and medial aspect offoot with swelling


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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


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LisFranc ?


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Lisfranc Injury (tarsometatarsal

fractures/dislocations)

General

-damage to the tarsometatarsal joint (any # or dislocation to this area istermed a Lisfranc injury)

-commonly missed injury-4% incidence per year of tarsometatarsal injuries in collegiate footballplayers

-early recognition and anatomical alignment with internal fixation isnecessary for satisfactory results

-mechanism : high-energy needed to disrupt ligament, rotationalforce( e.g MVA)

-clinical: severe midfoot pain, significant swelling and ecchymosis,inability to wt bear


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Classification

Classification

1)Total Incongruity

2)Partial Incongruity

3)Divergent

(Homolateral/Divergent, Type A,B,C)


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X-ray Findings

1. The medial shaft of the second metatarsal should be aligned withthe medial aspect of the middle cuneiform on the anteroposteriorview.

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 noincongruency.

4. A "fleck sign" should be sought in the medial cuneiform-secondmetatarsal space. This represents an avulsion of the Lisfranc ligament.

5. The naviculocuneiform articulation should be evaluated forsubluxation.

6. A compression fracture of the cuboid should be sought.


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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


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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


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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


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X-Rays


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Foot and Ankle Fractures2.Ppt 0