Ankle & Foot
Fracture/Dislocations
Shawn Dowling
ANATOMY 101
ANKLE
3 Primary Joints
3 sets of Ligaments:

 Medial malleolus
w/medial talus
 Tibial plafond w/talar
dome
 Lat malleolus w/lat
talus
3 Bones:
 Tibia, Fibula and
Talus


Lateral collaterals
(ATFL, CFL, PTFL)
Syndesmotic
Ligaments
Medial collaterals
(Deltoid)
BONES
Fibula
Tibia
Talus
LIGAMENTS
Syndesmotic
Ligaments
Medial
Collateral
Ligaments
Lateral
Collateral
Ligaments
JOINTS
Fibulotalar
Tibiotalar
(mid)
Tibiotalar
(lateral)
Tibia
Fibula
Talus
FOOT
Complicated (28
bones, 57
articulations)
Joints

 Inversion/eversion

Subdivided in 3
segments & mvts



Hindfoot - inv/ever
Midfoot - abd/add
Forefoot – flex/ext
Talo-crural jnt
Hindfoot – mid foot
(Choparts)
 Inversion/eversion

Midfoot – forefoot
(Lisfranc’s)*
 Abd/adduction

MTP-IP
 Flex/extension
HINDFOOT
talus
calcaneus
Medial
navicular cuboid
cuneiforms
metatarsals
FOREFOOT
sesamoids
phalanges
MIDFOOT
Choparts
Lisfrancs
MTP
IP
C
E
B
A
D
F
What are stable fractures?
Ankle forms a ring


Disruption of only 1
structure is stable
Disruption of > 1 is
unstable
Approach to Ankle/Foot Xrays
Go through complete approach (ABC’s)
3 views- AP, lat, Mortise (15-20° int rot)
ankle,
Direct evidence of injury: assess bones
Indirect evidence of injuries: are all ankle
measurements normal? Joint effusion?
Describe x-ray, rather than simply naming it
Management
In general


Chip/avulsion #’s <3mm = Tx as sprain
Non-displaced, non-intra-articular, stable #’s
 3 wks NWB cast, 3-5 wks WB cast, f/u with cast clinic



Unstable #’s, intra-articular # - speak with Ortho
Open – saline soaked dsg, IV ABx, Td, Ortho
urgently
NV compromise – reduce and call Ortho Urgently
Diagnosis?Classification?Treatment?
Does it change you mgmt if they
have a tender deltoid ligament?
Lateral Malleoli #’s
MC ankle #, MOI: usu
inversion injury
Weber classification – used to
determine risk of syndesmosis
injury and therefore need for
operative repair
Management


NWB x 3wks, WB x 3-5wks*
Refer B’s or C’s, Functional
bimalleolar’s to ortho
Stable ?
Is the location
significant?
Management?
What
measurements/lines do
you look at in the ankle?
What do they signify?
Syndesmosis injury
1
>10 mm A
2
B
3
4
A-B = talar tilt
<3 is normal
Medial clear
Space <5mm
Point out 3 abnormalities.
Diagnosis? Stable? Treatment?
Maisonneuve
Diagnosis? Treatment?
Bimalleolar/Trimalleolar
#’s
Involve the medial, lateral and/or
posterior malleoli
Splint, pain control, NPO
Need to speak to ortho as they will
likely need OR
Mechanism of injury? Associated injuries?
Management?
PILON #
Mechanism of injury- axial load? Associated injuriescalcaneus, C,T & L spine, pelvis, intra-abdominal.
Management- OR, approx 50% are open fractures
Description? What do you want to know/assess?
What do you want to do? How?
Ankle Dislocations
Relatively common, usually assoc w/#
Describe the position of foot/talus to
tibia
If open, Tx as such
X-rays should not delay reduction if NV
compromise or skin tenting present
Analgesia/PS, Reduce, splint, post-red
films
Pediatric Ankle Injuries
Not just little adult #
The ligament attachments are stronger
than the physis
therefore more #’s,
less sprains
Overall management is similar to adults


Although with fractures you can accept more
angulation (little to no displacement)
LLC casts are the initial choice for most #’s
Can we apply OAR/OFR in
children?
Six studies looked at validating OAR in
peds
Different age groups (2-18, 6-16)
Sens 85*-100*%


Considered all #
Some considered all #, others only
“significant #”)
BMJ 2003. Accuracy of OAR to exclude
fractures of the ankle and mid-foot: A
systematic review

This study references all of the OAR done
in children as well as adults
Problems with the studies


Haven’t come up with a common definition
of significant #
Unsure of what to do with SH-1,
inconsistent Dx
Local practice (and Edmonton) –
variable some apply it, some use rule +
discretion, others use clinical judgement
Conclusion
This needs to be further studied

Need to determine which #’s are significant
But I think they will likely be validated

Although I think they’ll have to Tx SH1 as
distinct injuries
Describe fracture?
Classification?
Management?
SH-2
LLC x 3 wks, then SLC
X 1-3 wks
Describe fracture?
Classification?
Management?
SH2
Reduction/immbolize (air cast)
Straight
SALTR
Lower
Above
(epiphysis)
(metaphysis)
Ram
Thru the (Crush)
Physis
Non-operative management for SH 1-2


Attempt closed reduction, can accept more
angulation
Long leg cast x 3wks, followed by SLC x 3wks
SH 3-4 -> OR
SH 5 ->poor fx prognosis

Complications for SH 3-5 include growth arrest,
limb length discrepancy
Ankle # Complications
Acute





Skin necrosis
NV injury
Compartment
syndrome
# Blisters
Wound infection/osteo
Chronic






Mal-union
Non-union
Post-traumatic
arthritis
AVN
Chronic pain
Chronic instability
Describe #
Do you need to
speak to Ortho?
?ottawa ankle rules
Talar Dome #
Yes – Ortho to see
in cast clinic
Describe #
Anything special
about this bone?

Blood flow distal to
proximal like
scaphoid and
proximal femur,
therefore inc AVN
risk
Is there a
classification system
for these #’s?
Talus
Body
Neck
Head
Chopart’s joint
Talar fractures
Minor talar fractures


Chip and avulsion fractures of neck ,head, and body.
Usually same mechanism as ankle sprains
Talar neck fractures



50% of major talar injuries.
extreme dorsiflexion force
Hawkins classification
Talar body fractures


23% of all talar fractures (including minor fractures)
Major talar body fractures are uncommon
 usually axial loading (e.g. falls)
Talar head fractures


Uncommon (5-10%)
compressive force transmitted up through the talonavicular
joint applied on a plantarflexed foot
Hawkins Classification of Talar
Neck Fractures
Type 1: = nondisplaced;
Type 2: subtalar subluxation
Type 3: dislocation of the talar body (50% open #’s)
Type 4: dislocation of the talar body & distraction of the
talonavicular joint.

Fracture type influences management & prognosis
Thanks Moby
Describe injury.
Name this injury.v
Management?
Describe injury.
Name this injury

Lisfranc
Management?

OR
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 pathognomonic
Thanks Dave
Normal Lisfranc
joint alignment
Tx:
Need to speak to
ortho
May try closed
reduction
Describe.
Management
NWB cast
# usu from direct
trauma
Describe.
Management
Walking cast x
2-3 weeks
Avulsion type #
Metatarsal # Treatment:
Nondisplaced or min displaced fractures of
metatarsal 2-4 stiff shoe, casting, or
fracture brace.
Non displaced 1st metatarsal  NWB BK
walking cast (cuz it’s a major WB surface)
Displaced 1st or 5th metatarsal  ER ortho
Attempt closed reduction if >3mm
displacement or 10 degrees angulation
Thanks Dave
Phalangeal #’s
Non-displaced: buddy tape, (air cast if
hallux involved as they are painful)
Significant displacement/angulation:
closed reduction -> speak with ortho if
reduction is inadequate (esp w/hallux)
If subungal hematoma is present with
tuft # - evacuate hematoma and repair
nail bed
10°
apex of
anterior process
Posterior
tuberosity
apex of
posterior facet
Calcaneus # Management
Order Harris (axial view), may need CT
Probably should speak to Ortho for all
since x-rays under-estimate extent of
injury
But…non-displaced, extra-articular –
NWB cast x 6-8 wks
Otherwise, Tx varies considerably and is
best determined by Ortho
Summary
Ankle #’s


If #/injury disturbs>1 structure in ring = unstable or if
intra-articular – ortho
Otherwise: NWB cast x 3wks
Foot

Stable, extra-articular, wgt bearing surface
 NWB cast


Unstable, or intra-articular – ORTHO
Stable, extra-articular, non-wgt bearing surface: conservative
mgmt (rigid shoe, walking cast, buddy tape)
If in doubt, Look up management of # - too many
particularities to memorize
References
Emergency Medicine Reports


Management of Acute Foot and Ankle Disorders in the
Emergency Department: Part I—The Ankle.
Management of Acute Foot and Ankle Disorders in the
Emergency Department: Part II—The Foot.
Rosens
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