058- Ankle and Foot

Describe three tests that can be done to stress the ankle in the setting of a suspected fracture/ligament injury.

1) anterior drawer test to assess anterior talofibular ligament: have patient in sitting position with knee bent at 90 degrees and ankle resting in neutral position; pull forwards on heel and push backwards on calf; look for abnormal forwards movement of heel, sensation of a "clunk," or formation of a sulcus in the skin over the joint to suggest partial or complete tear of the anterior talofibular ligament 2) talar tilt test (or inversion stress test) to assess both anterior talofibular ligament and calcaneofibular ligament: patient sitting with knees at 90 degrees and ankle neutral, invert the foot; feel for increased laxity compared to the normal side or for palpable anterior aspect of talus laterally to suggest ligament injury 3) external rotation stress test (same as above but external rotation)

What images make up the standard XR views of the ankle?

AP Lateral Internal rotation/mortise view

What 3 views make up a complete series of foot XRs?

AP, lateral, and internal oblique (45 degrees)

List 8 risk factors for Achilles Tendon Rupture.

-RA -SLE -gout -hyperparathyroidism -CRF -steroid use/injection -fluroquinolone antibiotic therapy -hx of Achilles tendon rupture

Which talar fractures may require operative management?

-any "major" talus fracture (fractures of the talar head, neck, or significant fractures through the body) -some "minor" talus fractures, including displaced lateral process #s

What findings on XR can be suggestive of a lisefranc joint disruption?

-check for alignment of the 1st 4 MTs with their respective tarsal (cuneiform or cuboid); the most consistent relationship is the medial aspect of the 2nd MT with it's cuneiform, always check this line -check for step-offs on the lateral view of the foot between the mid foot and forefoot -look for any widening between the metatarsal bases (especially the 1st and 2nd, or 2nd and 3rd) -look for fractures around the Lisefranc joint that raise suspicion for associated dislocation (any fracture of a MT base, ESPECIALLY the 2nd MT), cuboid #, or cuneiform # *fracture of the 2nd MT base is virtually pathognomonic for a Lisefranc injury; also any injury to the 1st or 2nd MT or their articulations with the 1st and 2nd cuneiforms is suspicious for a Lisfranc joint injury

Which navicular fractures require urgent ortho consultation?

-intra-articular and involving >20% of the articular surface -significantly displaced Otherwise, most can be managed with walking cast x 4-6 weeks and ortho follow up.

List 4 possible indications for orthopaedic consultation in the ED for an ankle sprain.

-ligament disruption with a coexisting fracture that results in instability -ligament sprain associated with displaced osteochondral lesions -tear of both anterior talofibular and calcaneofibular ligaments in a young athlete -severe sprain in the setting of a patient with recurrent severe sprains

List 8 potential complications of a severe ankle fracture.

-malunion -nonunion -osteopenia -traumatic arthritis -chronic instability -ossification of the interosseous membrane -avascular necrosis -complex regional pain syndrome -neurovascular complications

Describe the 3 categories of Lisfranc injuries.

1) homolateral - all 5 metatarsals are displaced in the same direction 2) isolated- one MT is displaced away from the rest 3) divergent- MTs are splayed outwards both laterally and medially; most commonly occurs between the 1st and 2nd MTs

Which posterior malleolus #s require urgent Orthopedics consult (in ED) and possible ORIF?

1) posterior malleolus # associated with other injury in the ankle ring (e.g. medial or lateral fracture or ligament disruption) 2) isolated posterior malleolus # that involves more than 25% of the tibial surface 3) intra-articular posterior malleolus # 4) open posterior malleolar #

Most stress fractures do not require any management except cessation of the triggering activity and re-evaluation of training routines/equipment. What are the 2 exceptions that require special treatment?

1) stress fractures of the navicular bone- tend to heal poorly due to relatively poor vascular supply, require NWB casting x 6-8 weeks 2) stress fracture of the base of the 5th MT (i.e. chronic Jones #)- require NWB casting, and like other 5th MT #s, can have delayed healing, requiring casting for up to 20 weeks Rarely, these require OR management and bone grafting.

Which metatarsal shaft fracture requires the most aggressive treatment, and why?

1st MT fractures require aggressive management, as they are the main load-bearing toe (carry twice the load of other MTs), and therefore fracture can affect the load-bearing integrity of the foot.

How should MT shaft fractures be managed?

2nd-5th MT shaft fractures tend to heal well, regardless of management (suggestions range from 2-4 weeks in short leg walking cast to just supportive footwear and WBAT); do not usually require Ortho F/U 1st MT shaft #: a) Nondisplaced- short leg cast x 4-6 weeks, NWB x at least the first 3 weeks b) Displaced (>3mm or 10 degrees angulation)- closed reduction and NWB cast x 4-6 weeks; rarely require open fixation

What is the subtalar joint?

3 points of articulation between the inferior aspect of the talus and the calcareous are collectively referred to as the subtalar joint.

What width of the medial mortise (medial clear space) is considered abnormal?

>4mm

Describe treatment of plantar fasciitis.

A combination of avoiding precipitating conditions, rest, padding, orthotics, nonsteroidal anti-inflammatory drugs, and occasionally steroid injections. Extracorporeal shock wave therapy can be beneficial in refractory cases. Very rarely, surgical release of the plantar fascia is required, a therapy that can be beneficial in either condition.

What is the ED management of a cuboid fracture?

All cuboid fractures require in-ED Ortho consultation. Relatively rare fractures, and often require OR management.

How should Lisefranc injuries be managed in the ED? What are complications of missed/delayed diagnosis?

All suspected or confirmed Lisefranc injuries should be referred to Ortho in the ED. These injuries require urgent management and reduction in order to reduce long-term complications. The Lisefranc joint complex is a critical structure in the biomechanics of walking. Complications from late diagnosis or missed Lisefranc injuries can include arthritis, compartment syndrome, chronic pain syndromes, loss of metatarsal arch, and biomechanical/ambulation problems.

How should flexor hallucis longus tendonitis be identified and managed?

Also called "dancer's tendonitis," can result from chronic overuse of tendon. Responsible for plantar flexion. Can have edema/tenderness posterior to the medial malleolus (where the tendon inserts), and pain with passive extension of the 1st toe. Tx with NSAIDS, rest, temporary immobilization. Should have F/U with ortho to ensure resolution.

What arteries supply the foot?

Anterior and posterior tibial arteries, and peroneal artery.

What ligament is most commonly involved in ankle sprains? What is the mechanism?

Anterior talofibular ligament Secondary to extreme inversion/plantarflexion, resulting in strain to lateral ligament complex.

How are isolated dislocations of the mid foot managed?

As mid-foot is essential for integrity of the foot and arch, any dislocation of the mid foot (navicular, cuboid, or cuneiforms) should have ED Ortho consult for possible open reduction.

What vascular complication are major talar fractures at risk of?

Avascular necrosis

Why can't bone scan imaging be used to follow up fractures for resolution?

Bone scan abnormalities may persist up to 1 year after the initial trauma, so not a good follow up test.

If Lisefranc injury is suspected clinically, but not apparent on plain radiographs, what diagnostic test may follow?

Can consider CT or MRI for definitive diagnosis Also can consider first getting stress-view XRs, as this may bring out Lisefranc fracture in many cases.

What are the most common locations for stress fractures to occur?

Can occur in the MT shaft, most commonly the 2nd or 3rd MT shaft. Calcaneus stress #s are also common. Midfoot stress #s are uncommon, but when they occur, they are usually in the navicular bone.

Why are initial radiographs often normal in the setting of a suspected stress fracture? What is the gold standard test for suspected stress fracture not visible on plain XR?

Can take 4-6 weeks from symptom onset for radiographic evidence of fracture to appear, and even then only appears in 50% of stress fractures. If unsure, follow up with MRI.

When should suspicion for osteochondral lesion of the ankle be raised? What are treatment options? What is the prognosis?

Commonly missed initially, but think about this in a patient who has had a previous ankle "sprain" and has persistent chronic ankle pain after. Can be treated with immobilization x 6 weeks or surgery; generally good prognosis as long as tx is initiated within 1 year of the symptom onset.

What are the 2 main classification schemes of ankle fractures? Which one is mainly used clinically, and why?

Danis-Weber system and Lauge-Hansen system Lauge-Hansen system classifies based on ligamentous injury, but is rarely used clinically anymore, due to inability to accurately predict severity of injury. Danis-Weber system is preferred, as it is more able to predict need for OR management.

What is the management of calcaneal fractures?

Depends on displaced vs. non-displaced. Non-displaced may be managed non-operatively, with 6-8 weeks immobilization. However, advanced imaging is usually required to be sure that a fracture is non-displaced, as plain XRs can underestimate the severity of a #. All require in-ED ortho consult.

Describe a subtalar dislocation injury. What are general management principles?

Dislocation of the talus from the mid foot. Occurs when there is complete disruption of the talonavicular and talocalcaneal ligaments, but preservation of the stronger calcaneonavicular ligament. Direction is described as the position of the foot relative to the talus. Management is urgent reduction of the dislocation (supine patient, knee flexed; apply longitudinal traction to the foot and reverse the deformity). Require in ED ortho consult. Usually immobilization x 6 weeks in below knee cast.

In addition to mortise measurements, what other 2 measurements can be used to assess the integrity of the tibulo-fibular syndesmosis?

Distance from the lateral border of the posterior tibial malleolus to the medial border of the fibula at the most distal part of the bone should be <5mm. Also, the distance from the medial border of the fibula to the lateral border of the anterior tibial tubercle (i.e. the amount of overlap between the fibula and tibia) should be AT LEAST 10mm.

What fracture is considered pathognomonic for a lisfranc injury?

Fracture at the base of the 2nd MT.

Describe management of 2-5th toe phalanx fractures.

Generally considered minor fractures. If non-displaced, buddy tape to adjacent toe (gauze in between). Often remain painful x 2-3 weeks. If displaced, closed reduction followed by buddy taping. Rarely, if cannot achieve adequate reduction or open #, may require OR fixation.

How are fractures of the base of the 1st-4th MT managed?

Generally non-operative if non-displaced, place in below knee cast (NWB); if displaced, or significantly intra-articular (>25% of articular surface involved), may require operative fixation. Consult Ortho.

How are metatarsal-phalangeal dislocations managed? Which ones may require OR fixation?

Generally, can manage with closed manual reduction, then walking air cast with toe plate x 3 weeks. Do not require Ortho follow up. More serious injuries that may require ortho include fracture-dislocations, dislocations that fail closed reduction, or complex dislocations (where ligaments or sesamoid bones have moved into the intra-articular space). These may require open reduction.

What additional XR view should be added when considering calcaneal fracture?

Harris (or axial) view Allows better assessment of the calcaneal tuberosity, subtalar joint, and sustenaculum tali.

Describe the classification scheme of talar neck fractures.

Hawkin's classification: Type 1: nondisplaced talar neck # Type 2: subtalar subluxation at the neck # Type 3: dislocation of the talar body from the subtalar joint/ankle Later addition to this classification: Type 4: associated navicular distraction injury Management: Type 1 = non-operative, Type 2/3/4 all typically require

How are trimalleolar fractures managed?

Highly unstable, require urgent ED Ortho assessment and ORIF.

Describe the basic bony anatomy of the foot, divided into 3 regions: Hindfoot Midfoot Forefoot

Hindfoot: talus + calcaneus Midfoot: Navicular bone, cuboid bone, and 3 cuneiform bones Forefoot: Metatarsals, proximal/middle/distal phalanges

Describe the 3 grades of ligamentous injury.

I- ligamentous stretch without tearing II- partial tear of ligament, moderate joint instability III- complete tear of the ligament, marked joint instability

What antibiotic prophylaxis is recommended for open lower extremity fractures?

In mild-moderately contaminated wounds, 1st generation cephalosporin is sufficient. If highly contaminated, add in amino glycoside for gram negative coverage. If farming or soil-related crush injury, require addition of 3rd antibiotic (PCN or Clinda) for coverage of Clostridium Perfringens. Also require early irrigation and debridement, as needed.

Describe Boehler's angle. What it it's clinical utility?

Intended for assessment of calcaneal fractures. Angle <20 degrees suggestive of compression #. Utility is questionable in latest evidence. Historically was more useful prognostically than diagnostically, as even normal fractures could have a normal Boehler's angle, and new evidence questions even it's prognostic value. Being largely replaced by advanced imaging of the calcaneous in the setting of suspected injury.

What other injuries should be considered in the setting of an isolated posterior malleolus #?

Isolated posterior malleolus fracture is rare. Usually indicates disruption of the posterior tibiofibular ligament. Also look for subtle fractures of the lateral/medial malleoli, disruptions of the medial/lateral collateral ligaments, or proximal fibular # (Maissoneuve).

What are the Lisfranc joints?

Joints between the mid foot and the forefoot.

What form of ankle compression dressing is shown to have the best functional outcomes in the setting of ankle sprain?

Lace-up or stirrup ankle braces have the best functional outcomes (improved functioning at 10 days and 1 month) when compared to tape, elastic bandaging, or semi-rigid ankle support.

Although isolated cuboid and cuneiform fractures are rare, what other injury should be considered if one is found?

Lisfranc injury should be considered Cuboid fracture often results from compression between displaced 4th and 5th metatarsals. Cuneiform fractures have similar mechanism with 1-3rd MTs.

What joint articulations make up the Lisfranc joint?

Lisfranc joint is made up of: -1st, 2nd, and 3rd MT articulations with their respective cuneiforms -4th and 5th MT articulations with the cuboid bone (i.e. tarso-metatarsal joint complex)

How are metatarsal head/neck fractures managed differently from MT shaft fractures, and why?

MT head/neck are more integral to the structure of the arch of the forefoot, therefore displaced fractures require adequate reduction. Nondisplaced #s can be managed with WBAT cast x 4-6 weeks. Displaced #s require urgent reduction- can attempt closed, but often unstable and require open fixation. Need to involve Ortho for these.

What are the major and minor fractures of the talus?

Major fractures: -talar head fracture -talar neck fracture -severe talar body fractures (most of the fractures listed below in "minor" are technically talar body fractures; severe fractures through the entire body of the talus are uncommon, but considered major when they occur) Minor fractures: -avulsion fractures -osteochondral lesions of the talar dome -lateral process fractures ("snowboarder's fracture")

What other injury must be looked for in the setting of a medial malleolar fracture?

Medial malleolar fractures are OFTEN associated with second fracture somewhere else in the ankle, due to the ring-like structure of the ankle. When a medial malleolus # is identified, must closely assess the lateral and posterior malleoli for fractures/ligamentous disruptions, as well as the entire length of the fibula for proximal fib fractures (i.e Maisonneuve fracture).

What structures make up the mortise of the ankle? What structure sits in the mortise?

Medial malleolus, lateral malleolus, and horizontal articulating surface of the tibia (i.e. the "plafond"). The talar dome sits in the mortise.

What is the difference between the mortise ankle view and the AP view? When evaluating the mortise (in the mortise view), what criteria should be assessed?

Mortise view = 15-20 degrees of internal rotation

What is the most common sesamoid bone in the foot? How is a sesamoid fracture managed?

Most common sesamoid = under the 5th MT head. Manage fracture with below knee walking cast x 3-4 weeks.

What is the most common fracture of the mid foot?

Navicular fracture

How are Achilles tendon ruptures managed?

No clear evidence to support operative vs. non-operative management. Typically operative management if younger, more active patient, or if if previously had non-op management and then re-ruptured. Operative management associated with less likelihood of re-rupture, but higher likelihood of complications (infection, abscess). Both routes of management encourage early mobilization.

How does a peroneal ligament dislocation or rupture present? How is it diagnosed clinically? How is it treated?

Occurs often with forced dorsiflexion of the ankle. Often accompanied by "snapping" sensation. Achilles tendon rupture would also be on the DDX for this presentation. Often have pain and swelling posterior to the lateral malleolus (an area that is typically spared in ankle fractures). Test by holding foot in a dorsiflexed position, and having the patient actively evert their foot. Inability to do this indicates likely dislocation or rupture. Should be referred to Orthopedics, as these injuries usually require operative repair.

How does a tibialis posterior tendon rupture present? How is it treated?

Often due to forced eversion of the foot. Will see swelling in the medial aspect of the ankle. Inability to fully INVERT the foot while the foot is in plantar flexed and everted position is classic. Results in flat-footedness of the affected foot. Requires orthopaedic referral due to need for operative management.

What is the clinical history usually associated with stress fractures?

Often gradual/insidious onset of localized pain, usually in the forefoot. Often in athletes, often associated with some change in training habit (new track, new footwear, etc.)

What is the clinical presentation of an Achilles tendon rupture?

Often middle aged male. Hx of forced dorsiflexion, followed by "pop" or "snap." After injury, will identify weakness in plantar flexion on exam. May have palpable defect in posterior aspect of ankle.

How should the syndesmosis of the tibia/fibula be evaluated on XR? In what view?

On an AP view, look for the width between the tibia + fibula at 2 key points:

Describe management of phalanx fractures involving the hallux.

Phalanx fractures that involve the 1st toe are managed similarly to other phalanx fractures, but with more time for immobilization. If non displaced, then buddy tape to adjacent toe (gauze in-between), and place in walking air cast x 2-3 weeks or as long as toe is painful. If displaced, then closed reduction and manage as above. If cannot achieve good reduction, or significantly intra-articular, then consider Ortho for operative fixation.

What is the fibular compression test, or "squeeze test," to assess for fibular fracture?

Place fingers on the fibula and thumb on the tibia and squeeze; pain elicited anywhere along the fibula is suspicious for fracture or interosseous membrane/syndesmotic ligament rupture.

What complication are navicular fractures particularly prone to, and why?

Prone to avascular necrosis. Similar to scaphoid in the wrist, the navicular bone has a large surface, and the blood supply only enters at the small waist of the bone, leaving the middle 1/3 of the bone relatively avascular. If this blood supply is interrupted by a fracture, high risk of avascular necrosis.

Describe the Ottawa Foot Rule. What is the sensitivity of the rule for detecting #?

Radiography if: -pain on palpation to base of 5th MT -pain over navicular bone -unable to weight bear for at least 4 steps at time of injury AND in ED 100% sensitivity for MIDFOOT fractures (does not apply to forefoot or hind foot injuries) Exclusion criteria: intoxicated, sensory deficits in the lower extremity, or other significant/distracting injury

What is a total talar dislocation? How is it different from a subtalar dislocation? What is the management/prognosis?

Rare injury. Means that the talus is completely dislocated at all 6 of its articulations, leaving an entirely free-floating talus. This is different from a subtalar dislocation, where the talonavicular and talocalcaneus ligaments are disrupted, but others are preserved. Devastating injury, requires urgent ED consultation. Prognosis is poor, with frequent complications and avascular necrosis. (This injury basically never happens).

Describe the Danis-Weber ankle fracture classification:

Refers to fractures of the lateral malleolus (i.e. FIBULA). Classifies based on location of # relative to the tibiotalar joint (and tibio-fibular syndesmosis). A= fracture line is below the level of the syndesmossis + tibiotalar joint; typically non-operative management B = fracture line is at the level of the tibio-talar joint (connects with the mortise); often a spiral fracture moving proximally; may be unstable, may require ORIF C = fracture line is above the level of the tibio-talar joint (entirely above the mortise); unstable, requires ORIF

How are interphalangeal joint dislocations generally managed?

Simple closed reduction is usually sufficient. If 1st toe is involved (most common), then after reduction place in short walking boot x 2-3 weeks. For 2nd-5th toes, buddy taping is sufficient. No ortho follow up required.

Which ankle fractures require Ortho consultation in the ED? (10)

Summary: any unimalleolar fractures with displacement, intra-arcticular involvement, or ligamentous injury in an adjacent malleolus region, OR all bi/trimalleolar #s, open #s, intra-articular #s, or pilon #s

What 3 sets of ligaments compose the ankle joint?

Syndesmotic ligaments (between the distal tibia and fibula), medial collateral ligaments, and lateral collateral ligaments.

What is a pilon fracture?

THIS IS A BAD FRACTURE!!! Pilon fracture = fracture of the distal tibia, resulting from a primarily axial, high impact force, driving the talus into the tibial plafond. Severe fracture, usually from significant impact or fall from height. Often results in shortening of the leg. Requires ER Ortho consult and ORIF. Often open fractures (25% of the time), and often associated with other injuries (of the lower extremity, lower spine, or other system injuries) due to high force of impact. The position of the foot at the time of impact determines the fracture pattern (see image).

What is the usual mechanism behind an Achilles tendon rupture?

Usually unexpected dorsiflexion, forced dorsiflexion of a plantar flexed foot, or push off from foot with an extended knee and leg contraction (like a runner exiting a starting block).

Describe the Ottawa Ankle Rule. What is the sensitivity of the rule for detecting #?

The OAR state that an ankle radiographic series is required if there is pain in the malleolar region with any of the following findings: • Bone tenderness at the posterior edge of the distal 6 cm or the tip of the lateral malleolus, or • Bone tenderness at the posterior edge of the distal 6 cm or the tip of the medial malleolus, or • Inability to bear weight (defined as the ability to transfer weight onto each leg regardless of limping) for at least four steps both immediately after the injury and at the time of evaluation 100% sensitivity Exclusion criteria: intoxicated, sensory deficits in the lower extremity, or other significant/distracting injury

What are accessory ossicles of the foot? How can these be differentiated from acute fracture fragments?

These are additional ossified lesions that exist frequently around the bones of the foot, and can look like acute fracture fragments at a glance. Can differentiate by obtaining bilateral foot XRs, as ossificles MAY be bilateral (although not always). Also, ossicles should be well corticated with smooth edges, while fracture fragments are often not.

How should stress fractures of the ankle be managed?

These are typically stable and non-operative. However, given that they tend to occur in high-functioning athletes, in whom recovery is essential, orthopaedic referral is often prudent.

What is the usual mechanism of calcaneal fractures? What other injury is associated with them?

Usually very strong axial load (i.e. landing on feet from a big height). Commonly associated with spinal fractures, especially vertebral compression injuries.

Describe the 2 types of 5th metatarsal base #s, and their respective management.

This is the "Jones" fracture, as it is commonly called. 2 different types of # can affect the base of the 5th MT: 1) Proximal tuberosity # (fracture of the bulbous tuberosity at the proximal end of the 5th MT) -these generally heal well and are benign #s -if EXTRAARTICULAR and NONDISPLACED, can manage with stiff footwear x 2-3 weeks, no follow up needed -if INTRAARTICULAR involving >30% of the articular surface, or displaced >2mm, may require OR fixation (should get Ortho referral) 2) Fracture through the base of the 5th MT at least 1.5cm distal to the proximal end of the bone (or through the diaphysis) -if NONDISPLACED, then can manage with NWB cast x 6-8 weeks and urgent ortho follow up -if displaced, then require OR fixation and NWB casting; may have delayed healing, requiring casting for 5-6 months!

What is the classic physical exam maneuver used to diagnose an Achilles tendon rupture?

Thompson test Have the patient kneel on a chair with their feet extended over the edge, or prone on a stretcher with feet hanging over the end of the stretcher, or knees flexed to 90 degrees while prone. Squeeze the posterior calf; should normally see passive plantar flexion of the ankle. Absence or weakness of this movement indicates possible Achilles tendon rupture.

How are bimalleolar fractures managed?

True bimalleolar fracture (2 fractured malleoli) are considered unstable injuries, therefore require urgent ED orthopaedic referral and often ORIF. In injuries of single malleolar # with a 2nd malleolar ligamentous injury, controversy as to whether open or closed management is better. In general, should still see Ortho in the ED.

Discuss the management of the different Weber classifications of lateral malleolus fractures.

Weber A: Does not require ED Ortho consult. Should be casted, with no WB x at least 3 weeks, and follow up with Ortho. Expected healing time 6-8 weeks. Weber B & C: require ED Ortho consult, often for ORIF *for Weber B, can consider doing squeeze test (mid-calf) for syndesmosis injury or gravity stress views; if the joint does not open up and there is no evidence of syndesmosis tenderness, then can go home with NWB cast + ortho follow up; the reason for this is because the only reason Bs need OR is if the syndesmosis is involved