ankle anatomy. and structure. and mechanisms of fracture

1. Ankle and
foot fracture
DR : Ghazi Al-Areqi
DONE BY : MOHANNAD AHMED

2. Ankle Anatomy :
• ankle joint is a hinged synovial joint .
• Is formed by the articulation of 3 bones that
are the talus, tibia, and fibula.
• distal ends of the tibia and fibula in the lower
limb articulates with the proximal end of the
talus.
• The talus articulates inferiorly with the
calcaneus and anteriorly with the navicular.
• bones are covered by articular cartilage .
• three malleoli in ankle joint [ lateral , medial ,
posterior or 3rd malleolus ].

3. Ankle joint is supported by :
• Fibrous capsule.
• Medial ligaments [Deltoid ligament]:-
A- Superficial :
- Tibionavicular lig.
- Tibiocalcaneal lig.
- Posterior tibiotalar part lig.
B- Deep:-
- Anterior tibiotalar part lig.
• Lateral ligament:-
- Anterior talofibular lig.
- Posterior talofibular lig.
- Calcaneofibular lig.
• Ligaments that connect
the lower end of the tibia and fibula :-
- Anterior and posterior tibiofibular lig.
- Interosseous lig.

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6. Muscles of the ankle:
1.Gastrocnemius muscle.
2. Soleus muscle.
•Both connect to the calcaneus by the
Achilles tendon.
•Both are involved in planter flexion.

7. 3. Tibialis anterior .
4. Tibialis posterior.
• Both are inserted in
the inner arch of the foot .
• Both are involved in INVERSION .

8. 5. Fibularis longus.
6. Fibularis brevis.
• Both inserted into
the outer arch of the foot.
• Both are involved in EVERSION.

9. Tendons:
1- Achilles Tendon: attaches the calf muscles (Gastrocnemius and Soleus) to the heel bone
(calcaneus). Help in Lifts the heel off the ground during activity
2- Posterior Tibial Tendon: attaches one of the calf muscles (the tibialis
posterior muscle) to the bones on the inside arch of the foot. It acts to
plantarflex and and invert the foot
3- Anterior tibial tendon : attach the anterior tibialis muscle to the foot. It acts to
dorsiflex and invert the foot.
4- Two peroneal tendon : pass behind the lateral malleolus and turn the foot
down and out [ peroneous longus and peroneous brevis].

10. Nerve and blood supply:
By nerves that pass through the ankle
on their way to the foot :
1- posterior tibial nerve
2- deep peroneal nerve
3- superficial peroneal nerve
By arteries that pass through the ankle
on their way to the foot :
1- Dorsalis pedis artery
2- posterior tibial artery

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posterior tibial nerve : divided into lateral ana medial
planter and calcaneus branch .

12. ANKLE
FRACTURE :

13. Definition : All fractures of the lower ends of the tibia and fibula involving the
ankle joint .
Incidence: ankle fracture are among the most common injuries.
Aetiology :
1. External rotation fracture [ pott’s fracture] : Commonest type , occurs due to forcible
external ( lateral ) rotation of the foot.
2. Internal rotation fracture : very RARE , occurs due to forcible internal ( medial ) rotation
of the foot .
3. Abduction fracture : occurs due to fall on EVERTED foot.
4. Adduction fracture : occurs due to fall on INVERTED foot.
5. Vertical compression fracture : occurs due to fall from a height on the foot.

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15. [ lague-Hansen classification ]

19. 2)- According to level of fibular fracture [ Weber classification ] :
Type A :
•Fracture of fibula below the tibiofibular syndesmosis .
•It may be associated with a fracture of the medial malleolus or tear of the medial
ligament.
Type B :
•Fibular fracture at the level of syndesmosis .
•It may be associated with tear of the anterior tibiofibular ligament or fractures of the
medial malleolus or the posterior malleolus .
Type C :
•Fibular fracture above the level of syndesmosis , which leads to disruption of the
syndesmosis, a part of the interosseous membrane and wide separation of the
tibiofibular joint.
•There may be associated fracture of the medial and third malleolus.

21. Clinical picture:
• History of trauma
• immediate pain and severe pain
• deformity
• inability to move ( cannot put weight on the injured foot )
• swelling & edema
• tenderness
• bruising

22. Complications:
Commonest complications are :-
• joint complications , osteoarthritis, ankle stiffness.
• Malunion & nonunion.
• Injury of anterior & posterior tibial nerves & vessels or long & short
saphenous.
• Injury of surrounding tendons.

23. Investigation:
✓ Plain x-ray that shows :
1. Absence of the normal overlap of the lower ends of the tibia
and fibula .
2. Widening of the space between the medial malleolus and the
talus.
3. Incongruity of the saddle-shaped surface of the talus and the
tibia.

24. X-ray of ankle fracture
Normal x-ray of the ankle

25. A. Fracture of one malleolus without displacement :
•External fixation in a below knee cast for 6 weeks ( fixation of a joint above
and a joint below the ankle ) .
B. Fracture of 2 or 3 malleoli with displacement :
•Open reduction and internal fixation are necessary to restore normal
anatomical position and to achieve normal load distribution .
•Surgery should be done within 6 hours after trauma before development of
edema or 6 days after edema subside.
•First, fibular fracture ( lateral malleolus ) should be reduced anatomically to
restore its length & fixed by plate and screws
•Then the medial malleolus is reduced and fixed with screws .
•The third malleolus is fixed by screws .
•Collateral ligaments may need surgical repair
•Tibia-fibular syndesmosis reconstruction by protection screw which
removed after 6 weeks
Treatment:

26. Below knee cast

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28. •` Tibial plafond : is the distal end of the
tibia including the articular surface.
•` Mechanism of injury :
High energy axial loads as the tibial
plafond is injured by the talus punching up
into it.
•` clinical picture:
- Immediate and sever pain
- Swelling
- Bruising
- Tender to the touch
- Cannot put any weight on the injured foot
- Deformity ( out of place)
pilon fracture

29. Investigation:
X-RAY :
Appears as a comminuted distal tibial
fracture extendeing into the tibial
plafond ( ankle joint )
Usually it’s not obvious by x-ray .
CT-scan :
Gives accurate definition of the
fragments.

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31. Treatment :
1- Control of swelling by elevation.
2- Apply external fixation or circular
frame fixation so the blisters can be
treated.
3- Once the skin has recovered,
open reduction and fixation with
plates and screws may be done.
4- Early movement help to reduce
the oedema and prevent stiffness.

33. Ligamentous injuries of the ankle :
•Mechanism of injury : Twisting of the foot.
•Pathology : Sprain or tear of the ligaments.
An inversion twist of the foot is a frequent injury which results usually in
sprain or tear of the lateral ligaments of the ankle.
Injury to the deltoid ligament by eversion twist of the foot is rare.
•Clinically : tenderness and swelling anterior and below the lateral malleolus.
Pain which is made worse by inversion of the foot.
•X-RAY : may show subluxation of the talus.
•Treatment :
A. Sprained ankle : novocaine , hydrocortisone and elastoplast strapping of the
ankle
The patient is encouraged to resume his activities
B. Torn ligaments : below knee plaster cast for 6 weeks and an Elastoplast
bandage is then applied for one month.

34. Foot fracture

35. Anatomy of the foot :
IA)- Bones:
Divided into three regions..
(I) Hindfoot [talus and calcaneus]
( tarsals bones)
(II) Midfoot [ navicular, cuboid ,
cuneiforms]
( tarsals bones)
(III) forefoot [ metatarsals and
phalanges ]

36. A• Tarsals :
A set of seven irregularly shaped
bones .
They are situated proximally in
the foot in the ankle area.
Divided into :-
•Proximal bones: talus ,
calcaneus.
•Intermediate bones : Navicular
bone.
•Distal bones: 3 cuneiform bones
“ medial – intermediate- lateral”
and cuboid bone.

37. B• Metatarsals:
There are five in
number, each bone is
formed of 3 parts :
- Base
- Shaft
- Head

38. C• Phalanges:
The bones of the toes .
Each toe has three phalanges [
Proximal , intermediate , distal
] .
Except the big toe , which only
has two phalanges
[ proximal and distal ].

39. IB)- joint :
`• Subtalar joint : between talus and
calcaneus .
`• Talonavicular joint : between distal
talus and navicular .
`• Metatarsophalangeal joint :
articulations between the heads of the
metatarsals and the proximal
phalanges.
`• interphalangeal joint : [ proximal &
distal ]
- Proximal: between proximal phalanx
and Middle phalanx .
- Distal: Between middle phalanx and
distal phalanx .

40. IC ) – muscle :
`•Dorsal group :
- Extensor Digitorum brevis.
- Extensor Hallucis brevis.
`•Lateral group :
- Flexor digiti minimi brevis.
- Opponens digiti minimi.
- Abductor digiti minimi.
`• Planter group :
- Adductor Hallucis.
- Flexor hallucis brevis.
- Abductor Hallucis.
`• Middle group :
- Flexor digitorum brevis .
- Quadratus plantae.
`• Interossei group :
- Planter Interossei.
- Dorsal interossei.
`• lumbrical muscles

45. Calcaneus

46. `• calcaneus is a large and strong bone that forms the
back of the foot.
`• Articulates above with talus and anteriorly with
cuboid forming subtalar joint and calcaneocuboid joints.
`• Calcaneus articulate with talus by 3 facets : anterior ,
posterior and middle.
`• It has 4 processes : anterior , posterior , medial and
lateral.
`• Its main functions is : weight bearing and stability.

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48. Böhler’s angle:
It Used in the assessment of intra-
articular calcaneal fractures.
Measure by used of two
intersecting lines: one drawn from
anterior process of the calcaneus
to the highest part of posterior
articular surface and a second
drawn parallel to superior point of
tuberosity.

49. Calcaneus fracture:
Ateiology : usually by trauma .
Mechanism of injury:
`• The patient falls from a height, often from a ladder, onto one or both heels.
`• The calcaneum is driven up against the talus and is split or crushed.
`• More than 20% of these patients suffer associated injuries of the spine,
pelvis or hip.
`• It may be bilateral.

50. Classification:
I) Extra-articular fractures
involve the calcaneal processes
or the posterior part of the bone
They are easy to manage and have
a good prognosis.
II) Intra-articular fractures
cleave the bone obliquely and run
into the superior articular surface
of the Subtalar joint and it’s an
indication of open reduction and
internal fixation.

51. Clinical picture:
1` The foot is painful, swollen and bruised.
2` The heel may look broad and squat.
3` Tenderness
4` Absence of normal concavity below the lateral malleolus [
BULGE BELOW THE LATERAL MALLEOLUS]
5` The subtalar joint cannot be moved but ankle movement is
possible.
6` check for signs of a compartment syndrome of the foot
(intense pain, very extensive swelling and bruising and
diminished sensation).

52. Investigation:
Plain x-ray:-
Extra-articular fractures are usually fairly obvious, Intra-articular fractures,
also, can often be identified in the plain films .
if there is displacement of the fragments, the lateral view may show
flattening of Böhler’s angle.
However, for accurate definition of intra-articular fractures, CT is essential.
With severe injuries – and especially with
bilateral fractures – it is essential to assess the knees,
the spine and the pelvis as well.

53. Complications:
I) Broadening of the heel:
This is quite common and may cause problems
with shoe fitting and walking
II) Talocalcaneal stiffness and osteoarthritis:
Displaced intra-articular fractures may lead to joint
stiffness and, eventually, osteoarthritis.

54. Treatment:
Undisplaced fractures :-
`• Leg and foot are elevatedand treated
with ice-packs until the swelling subsides .
`• The calcaneus is compressed from side
to side to correct Broadening of the heal .
`• Firm bandage is applied and the patient
is allowed on non-weightbearing crutches
for 6 weeks.

55. Displaced intra-articular fractures :
are best treated by open reduction and internal fixation with plates
and screws.

56. Postoperatively:
- The foot is lightly splinted and elevated.
- Exercises are begun as soon as pain subsides.
- After 2–3 weeks, the patient can be allowed up on non-
weightbearing crutches.

57. Talus fracture

58. Talus is formed of

61. Talus is the most
cartilaginous surface and
articulate with:
1` Tibia to form tibiotalar joint.
2` Calcaneus to form Subtalar
joint.
3` Navicular to form
Talonavicular joint.

62. Talus fracture:
Ateiology : usually by trauma.
Mechanism of injury:
• falls from a height lead to compressing the talus between
the tibia and calcaneus .
• Hyper dorsiflexion and axial loading.

63. Clinical picture:
1• Pain in foot and ankle.
2• Swelling in foot and ankle.
3• if there’s displaced, there may be
an obvious deformity
4• inability to move.

64. Complications:
Avascular necrosis :
Fractures of the neck of the talus
often result in avascular necrosis
(AVN) of the body (the posterior
fragment).

65. Classification of talus fracture:
Hawkin’s classification:
Type I : non-displaced fracture
In type I fractures AVN is
less than 10%.

66. Type II :
Displaced (however little)
and associated
with subluxation or
dislocation of the subtalar
joint.
In type II AVN is about 30–
40%.

67. Type III :
Displaced, with dislocation of
the body of the talus from the
ankle joint ( tibiotalar
dislocation or subluxation).
In type III AVN more than 90%.

68. Type IV :
Fracture with Subtalar and
tibiotalar dislocation and
Talonavicular subluxation.
In type IV AVN more than
90%.

69. Investigation:
X-Ray :-
Is not easy to see the
fracture by x-ray
because of
unfamiliarity with the
normal appearance in
various x-ray
projections.
CT-scan is essential

71. Treatment:
Undisplaced fracture:-
1` no need for reduction.
2` split plaster is done until
swelling subsides then is
replaced by complete plaster.
3` remains in plantigrade
position for 6-8 weeks .

72. Displaced fracture:
1` reduction is required : closed
reduction should be tried first , if
this fails an open reduction must be
done.
2` below knee plaster is needed for
6-12 weeks.
3` weightbearing isn’t allowed until
healing occurs.

73. Tarsometatarsal injury:
•They may be :
`- Sprains : common
`- dislocation : rare
• Mechanism of injury:
Twisting or crushing injuries.
• A fracture dislocation should always
be suspected if the patient has pain,
swelling and bruising of the foot after
an accident, even if there is no
obvious deformity.

74. Investigation :
X-ray:-
- Fracture dislocation is clear
and can’t be missed.
- Full extent of the injury is not
clear.
CT-Scan :-
Is the investigation of choice
for bony and articular injury.
MRI :-
Used to see ligamentous injury.

75. Treatment:
Undisplaced sprains: require cast immobilization
for 4–6 weeks.
Subluxation or dislocation:
-requires reduction usually closed reduction by Traction
and manipulation under anaesthesia (open
reduction is rarely needed).
-the position is then held with K-wires or screws and cast
immobilization.
-The patient is instructed to remain nonweightbearing for
6–12 weeks.

77. Metatarsals fracture:
Mechanism of injury:-
1` Direct blow
2` severe twisting
3` Repetitive stress
Clinical picture:-
1` History of injury
2` pain
3` swelling
Investigation:-
X-RAY can show the fracture.

78. Treatment:
- In undisplaced or slightly
displaced fracture: A walking
plaster may be applied, and is
retained for 3 weeks
- In the severe displacement :
reduction and fixation may be
done. weightbearing is
avoided for 3 weeks and this is
followed by a further 3 weeks
in a weightbearing cast.

79. Stress injury ( march fracture) :
It’s a very tiny fracture of the metatarsal bones due to repeated
loads on the foot .
Occurs in young adults particularly army member or sport person .

80. Clinical picture:
1` painful foot after overuse.
2` tenderness.
3` tender lump is palpable in the metatarsal bone.
4` swelling.
Investigation:
- Not diagnosed by x-ray as it is normal
- A radio-isotope scan will show an area of intense
activity in the bone .
- MRI also may show stress changes in the bone.

81. Treatment:
No displacement occurs so neither reduction nor
splintage is necessary.
The forefoot may be supported and normal walking is
encouraged.

82. Fracture of phalanges:
Mechanism of injury:
A heavy object falling on the toes causing
fracture of the phalanges.
Management:
- No specific treatment and the patient
encouraged To walk in a suitably adapted boot.
- If pain is marked , the toe can be splinted by
strapping it to its neighbor for 2-3 weeks.
- If the skin is broken, it must be covered with a
sterile dressing .

83. Thank you.