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F o an Ak o t d n le F res ractu
Anatomy
Three groups of stabilizing ligaments:
1)Lateral -anterior talofibular ligament (ATFL) -calcaneofibular ligament (CFL) -posterior talofibular ligament (PTFL). -limit ankle inversion and prevent anterior and lateral subluxation of the talus
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
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 knee or foot pain -degree of function after the event.
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").
Special Tests
Anterior Drawer
-integrity of the ATFL -grasp the heel with one hand and apply a posterior force to the tibia with the other 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 tibia and fibula together -positive test: results in pain in the ankle, which indicates injury of the syndesmotic ligament
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 and calcaneus -Mortise : most important view, medial clear space should not exceed 4mm
Xray Measurments
Ankle Fractures
Classification
Danis-Weber -based on mechanism of injury -three fracture types (i.e., A, B, C ), defined by the location of the fibular fracture -A - below the tibiotalar joint -B - at the level of the tibiotalar joint -C - above the tibiotalar joint
Unimalleolar Fractures
Lateral -any avulsion <3mm in size can be treated as an ankle sprain
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!!!
Bimalleolar Fractures
Management -disruption of two elements of the ring -ortho consult -management controversial (ORIF vs closed reduction and close f/u)
Pilon #?
Tillaux #?
Foot Fractures
Anatomy
Anatomy
-27 bones, 57 articulations -Hindfoot : calcaneus and talus -Midfoot : cuboid, navicular, and three cuneiforms -Forefoot : metatarsals, phalanges, and sesamoids -Subtalar joint -formed by three articulations between the inferior talus and calcaneus -Inversion and eversion of the hindfoot through the subtalar joint
Anatomy
-Tarsometatarsal, or Lisfranc's joint -connects the midfoot and the forefoot -Blood supply - anterior and posterior tibial arteries -Nerve supply -peroneal (deep and superficial), posterior tibial, saphenous and sural nerves
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
Foot Fractures
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 of avascular necrosis
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
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
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
Calcaneus #s
X-ray -Boehlers angle (20-40 degrees) -suspect fracture if <20 degrees Treatment -ortho consult -?ORIF vs conservative management
Navicular
General -most common midfoot # -blood supply tenuous, risk AVN -classification: dorsal avulsion # (47% all navicular #s), tuberosity and body #s -mechanism usually eversion injury -pain over the dorsal and medial aspect of foot with swelling
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
LisFranc ?
Classification
Classification 1)Total Incongruity 2)Partial Incongruity 3)Divergent
(Homolateral/Divergent, Type A,B,C)
X-ray Findings
1. The medial shaft of the second metatarsal should be aligned with the medial aspect of the middle cuneiform on the anteroposterior view. 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 no incongruency. 4. A "fleck sign" should be sought in the medial cuneiform-second metatarsal space. This represents an avulsion of the Lisfranc ligament. 5. The naviculocuneiform articulation should be evaluated for subluxation. 6. A compression fracture of the cuboid should be sought.
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
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
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
X-Rays