Ankle & Foot Fracture/Dislocations

1. Ankle & Foot Fracture/Dislocations Shawn Dowling

2. ANKLE 3 Primary Joints Medial malleolus w/medial talus Tibial plafond w/talar dome Lat malleolus w/lat talus 3 Bones: Tibia, Fibula and Talus 3 sets of Ligaments: Lateral collaterals (ATFL, CFL, PTFL) Syndesmotic Ligaments Medial collaterals (Deltoid) ANATOMY 101

3. BONES Fibula Tibia Talus

4. LIGAMENTS Syndesmotic Ligaments Medial Collateral Ligaments Lateral Collateral Ligaments

5. JOINTS Fibulotalar Tibiotalar (mid) Tibia Fibula Tibiotalar (lateral) Talus

6. Complicated (28 bones, 57 articulations) Subdivided in 3 segments & mvts Hindfoot - inv/ever Midfoot - abd/add Forefoot – flex/ext Joints Talo-crural jnt Inversion/eversion Hindfoot – mid foot (Choparts) Inversion/eversion Midfoot – forefoot (Lisfranc’s)* Abd/adduction MTP-IP Flex/extension FOOT

7. HINDFOOT talus calcaneus navicular cuboid MIDFOOT Medial cuneiforms metatarsals sesamoids FOREFOOT phalanges

8. Choparts Lisfrancs MTP IP

9. C E B A F D

11. What are stable fractures? • Ankle forms a ring • Disruption of only 1 structure is stable • Disruption of > 1 is unstable

12. Approach to Ankle/Foot X-rays • 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

13. 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

14. Diagnosis?Classification?Treatment? Does it change you mgmt if they have a tender deltoid ligament?

15. 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

16. Stable ? • Is the location significant? • Management? • What measurements/lines do you look at in the ankle? • What do they signify?

18. Syndesmosis injury 1 >10 mm B A Medial clear Space <5mm 2 3 4 A-B = talar tilt <3 is normal

19. Point out 3 abnormalities.Diagnosis? Stable? Treatment?

20. Maisonneuve

21. Diagnosis? Treatment?

22. 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

23. Mechanism of injury? Associated injuries?Management?

24. PILON #Mechanism of injury- axial load? Associated injuries- calcaneus, C,T & L spine, pelvis, intra-abdominal.Management- OR, approx 50% are open fractures

25. Description? What do you want to know/assess?What do you want to do? How?

26. 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

27. 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

29. 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 #”)

30. 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

31. 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

32. 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

33. Describe fracture? Classification? Management? SH-2 LLC x 3 wks, then SLC X 1-3 wks

34. Describe fracture? Classification? Management? SH2 Reduction/immbolize (air cast)

35. SALTR Lower (epiphysis) Ram (Crush) Straight Thru the Physis Above (metaphysis)

36. 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

37. Acute Skin necrosis NV injury Compartment syndrome # Blisters Wound infection/osteo Chronic Mal-union Non-union Post-traumatic arthritis AVN Chronic pain Chronic instability Ankle # Complications

38. Describe # Do you need to speak to Ortho? ?ottawa ankle rules Talar Dome # Yes – Ortho to see in cast clinic

39. 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?

40. Talus Neck Body Head Chopart’s joint

41. 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

42. 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

43. Describe injury. • Name this injury.v • Management?

44. Describe injury. • Name this injury • Lisfranc • Management? • OR

46. 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

47. Normal Lisfranc joint alignment • Tx: • Need to speak to ortho • May try closed reduction

48. Describe. • Management • NWB cast • # usu from direct trauma

49. Describe. • Management • Walking cast x 2-3 weeks • Avulsion type #

50. 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