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Project: Ghana Emergency Medicine Collaborative
Document Title: Plain Films of the Ankle and Foot, 2013
Author(s): Brian M...
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Plain Films of the
Ankle and Foot
Brian M. Fuller, MD

3
Objectives
­ 

Review Ottawa Ankle Rules

­ 

Go over some general considerations about
radiographs of the ankle and foo...
Ottawa Ankle Rules
­ 
­ 

­ 

­ 

­ 

Ankle Xray Series
Required only if there is pain in malleolar zone and any one
...
Ottawa Ankle Rules
­ 
­ 

­ 
­ 
­ 

Foot Xray Series
Required only if there is pain in the midfoot zone and any one
o...
The Ankle: General Considerations
­ 

­ 

­ 

­ 

Consists of: articulations between distal tibia, distal
fibula, and ...
Gray, Wikimedia Commons

8
Gray, Wikimedia Commons

9
10
Source undetermined
Source undetermined

11
12
Source undetermined
13
Source undetermined
Targeted Approach to
Analysis
Examine the Malleoli – 90% of fractures
involve the Malleoli. Distal fibula most
common
­  ...
Common Injuries to the Ankle

BarneyStinson13, Wikimedia Commons

15
Ankle Effusion

16
Source undetermined
Single and Bimalleolar
Fractures
­  Single

Malleolar fracture is considered

stable
­  Bimalleolar fractures are unstab...
Bimalleolar Fracture

18
Source undetermined
Maisonneuve Fracture
Due to strong eversion at ankle
Commonly causes fx of proximal ½ of fibula; also fx
of medial malleol...
Maisonneuve
Fracture

20
Source undetermined
Maisonneuve Fracture

21
Source undetermined
Pilon Fracture
­  Fracture

of the Tibial Plafond
(intraarticular distal tibial fx)
­  Mechanism is axial loading (fall ...
Pilon Fracture

23
Source undetermined
Common Injuries to the Ankle
­  Inversion/Eversion Injuries
­ 

­ 

­ 

Malleolar Fx due to: avulsion forces and impac...
The Foot
­ 

“Man’s foot is all his own. It is unlike any other foot.
It is the most distinctly human part of his whole
a...
The Foot: General Considerations
­ 

­ 
­ 
­ 
­ 

­ 

Consists of: all of the tarsal bones, metatarsals,
and the pha...
Clinical Decision
Making - Foot
No Specific Guidelines for ordering films of
the entire foot
­  Midfoot Guidelines are pa...
Source undetermined

28
29
Source undetermined
Common Injuries to the Foot

30
Bohlers Angle

31
Source undetermined
Calcaneal Fx
Most commonly fractured tarsal bone,
usually by fall or axial loading
­  Calcaneal Compression Fx can be det...
Calcaneal Compression
Fracture

Source undetermined

33
Source undetermined
Jones vs. PseudoJones
­  Jones

fracture – Transverse fracture
through proximal shaft of 5th
Metatarsal – often complicat...
Jones vs. Pseudojones

e-radiography.net

35
Jones Fracture

36
Source undetermined
PseudoJones Fracture

37
Source undetermined
Lisfranc Fracture/
Dislocation

Tarsometatarsal joint is Lisfranc
­  Associated with high energy
trauma (MVA or Fall) or ...
Lisfranc Homolateral
Type
­ 

Lateral
Displacement
of 1st and 2nd
– 5th
Metatarsals

39
Source undetermined
Lisfranc – Divergent
Type
­ 

1st and possibly 2nd
Metatarsal
dislocates medially
or stays fixed and
more lateral
metatar...
Metatarsal Fx

41
Source undetermined
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GEMC - Plain Films of the Foot and Ankle - Resident Training

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Transcript of "GEMC - Plain Films of the Foot and Ankle - Resident Training"

  1. 1. Project: Ghana Emergency Medicine Collaborative Document Title: Plain Films of the Ankle and Foot, 2013 Author(s): Brian M. Fuller MD, Maine Medical Center License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1
  2. 2. Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt { Content the copyright holder, author, or law permits you to use, share and adapt. } Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Creative Commons – Zero Waiver Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Make Your Own Assessment { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ { Content Open.Michigan has used under a Fair Use determination. } Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. 2
  3. 3. Plain Films of the Ankle and Foot Brian M. Fuller, MD 3
  4. 4. Objectives ­  Review Ottawa Ankle Rules ­  Go over some general considerations about radiographs of the ankle and foot ­  Review the normal bony and ligamentous anatomy ­  View some of the more common fractures/injuries to the ankle and foot 4
  5. 5. Ottawa Ankle Rules ­  ­  ­  ­  ­  Ankle Xray Series Required only if there is pain in malleolar zone and any one of: 1) tenderness along the distal 6cm of the posterior edge of the fibula or tip of the lateral malleolus 2) tenderness along the distal 6cm of the posterior edge of the tibia or tip of medial malleolus 3) inability to bear weight for 4 steps both immediately and in the ED 5
  6. 6. Ottawa Ankle Rules ­  ­  ­  ­  ­  Foot Xray Series Required only if there is pain in the midfoot zone and any one of: 1) tenderness at the base of the 5th metatarsal 2) tenderness at the navicular bone 3) inability to bear weight for 4 steps both immediately and in the ED 6
  7. 7. The Ankle: General Considerations ­  ­  ­  ­  Consists of: articulations between distal tibia, distal fibula, and talus Ankle Mortise: combo of the medial and lateral malleoli, together with the horizontal plate of the distal articulating surface of the tibia Radiographic Exam: consists of AP view, mortise view, externally rotated oblique, and lateral projections Ligamentous Anatomy: 7
  8. 8. Gray, Wikimedia Commons 8
  9. 9. Gray, Wikimedia Commons 9
  10. 10. 10 Source undetermined
  11. 11. Source undetermined 11
  12. 12. 12 Source undetermined
  13. 13. 13 Source undetermined
  14. 14. Targeted Approach to Analysis Examine the Malleoli – 90% of fractures involve the Malleoli. Distal fibula most common ­  Examine the Mortise – Uniformity. Small bone fragment may represent Talar dome fx – significant morbidity ­  Examine Peripheral Areas – Base of 5th Metatarsal, Soft tissues (Joint Effusion) ­  Order more films – Proximal fibular fx suspected when no fibular fx at ankle despite medial malleolar fx or joint space 14 widening. ­ 
  15. 15. Common Injuries to the Ankle BarneyStinson13, Wikimedia Commons 15
  16. 16. Ankle Effusion 16 Source undetermined
  17. 17. Single and Bimalleolar Fractures ­  Single Malleolar fracture is considered stable ­  Bimalleolar fractures are unstable and require operative repair 17
  18. 18. Bimalleolar Fracture 18 Source undetermined
  19. 19. Maisonneuve Fracture Due to strong eversion at ankle Commonly causes fx of proximal ½ of fibula; also fx of medial malleolus, tearing of tibiofibular lig, and disruption of tibiofibular syndesmosis Radiographic clues – Widening of medial jointspace,medial or posterior malleolar fx without lateral malleolar fx 19
  20. 20. Maisonneuve Fracture 20 Source undetermined
  21. 21. Maisonneuve Fracture 21 Source undetermined
  22. 22. Pilon Fracture ­  Fracture of the Tibial Plafond (intraarticular distal tibial fx) ­  Mechanism is axial loading (fall from height or MVA) ­  a/w injuries to calcaneus, tibial plateau, hip, pelvis and spine 22
  23. 23. Pilon Fracture 23 Source undetermined
  24. 24. Common Injuries to the Ankle ­  Inversion/Eversion Injuries ­  ­  ­  Malleolar Fx due to: avulsion forces and impaction forces Avulsion force created by intact ligaments; create horizontal fx lines Impaction force due to forced talar shift striking appropriate malleolus; create oblique fx line 24
  25. 25. The Foot ­  “Man’s foot is all his own. It is unlike any other foot. It is the most distinctly human part of his whole anatomical make up. It is a human specialization and, whether he be proud of it or not, it is his hallmark and so long as Man has been man, and so long as he remains Man, it is by his feet that he will be known from all other members of the animal kingdom.” Frederick W. Jones ­  Dude has a serious fetish!! 25
  26. 26. The Foot: General Considerations ­  ­  ­  ­  ­  ­  Consists of: all of the tarsal bones, metatarsals, and the phalanges Forefoot: metatarsals and phalanges Midfoot: navicular, cuboid, and three cuneiforms Hindfoot: talus and calcaneous Radiographic Exam: consists of anteroposteror, internally rotated oblique, and lateral views The heel is routinely examined in the lateral and axial projection 26
  27. 27. Clinical Decision Making - Foot No Specific Guidelines for ordering films of the entire foot ­  Midfoot Guidelines are part of Ottawa Ankle Rules ­  Soft tissue swelling and ecchymosis – poor indicators of skeletal injury ­  Localized bone tenderness and inability to bear weight are more specific signs of fx ­  Isolated injury of distal phalanx – radiography can be deferred, however injuries of the Great Toe should be 27 evaluated ­ 
  28. 28. Source undetermined 28
  29. 29. 29 Source undetermined
  30. 30. Common Injuries to the Foot 30
  31. 31. Bohlers Angle 31 Source undetermined
  32. 32. Calcaneal Fx Most commonly fractured tarsal bone, usually by fall or axial loading ­  Calcaneal Compression Fx can be detected by measuring Bohler’s angle ­  Bifurcate ligament stress can cause subtle anterior process avulsion fx ­  Vertebral fx occur in over 20% of calcaneal fx (also a/w fx of hip and knees ­  32
  33. 33. Calcaneal Compression Fracture Source undetermined 33 Source undetermined
  34. 34. Jones vs. PseudoJones ­  Jones fracture – Transverse fracture through proximal shaft of 5th Metatarsal – often complicated by nonunion and requires full cast ­  PseudoJones – avulsion fracture of tuberosity of 5th Metatarsal at insertion of Peroneus Brevis tendon (sprain) – Heals quickly without sequelae 34
  35. 35. Jones vs. Pseudojones e-radiography.net 35
  36. 36. Jones Fracture 36 Source undetermined
  37. 37. PseudoJones Fracture 37 Source undetermined
  38. 38. Lisfranc Fracture/ Dislocation Tarsometatarsal joint is Lisfranc ­  Associated with high energy trauma (MVA or Fall) or Diabetic Neuropathy ­  Lisfranc dislocation detected by malalignment of medial edge of 2nd metatarsal and medial edge of 2nd cuneiform ­  A/W fx of Cuneiforms, Metatarsal shafts and bases ­  2 Types – Homolateral and 38 Divergent ­ 
  39. 39. Lisfranc Homolateral Type ­  Lateral Displacement of 1st and 2nd – 5th Metatarsals 39 Source undetermined
  40. 40. Lisfranc – Divergent Type ­  1st and possibly 2nd Metatarsal dislocates medially or stays fixed and more lateral metatarsals are displaced laterally. 40 Source undetermined
  41. 41. Metatarsal Fx 41 Source undetermined
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