Ankle and foot fractures

1. AN K L E AN D F O O T
IN JU R IE S

2. • Injuries of the ankle and foot con be divided
into:
• Ligamentous injuries of the ankle.
• Ankle fracture (malleolar F. or Pott’s F).
• Tibial Plafond fractures
• Fracture of the talus.
• Fracture of the calcaneus.
• Fracture of metatarsals and phalanges

3. AN ATO M Y
• 1) Distal end of tibia
• : ankle mortise
• Distal end of fibula
• 2) Talus – trochlea of talus dome
• 3) Ligaments – a) lateral ligament
complex b) medial ( deltoid
ligament )
• c) syndesmosis

5. AN K L E S PR AIN S
• - The most common acute sport
injuries, 25% in every running or
jumping sport
• - Mechanism of injury: inversion and
plantar flexion of the foot when
landing off balance or clipping
another player’s foot

6. AN K L E S PR AIN S
• Sequence of injury: anterior
talofibular ligament, calcaneofibular
ligament, posterior talofibular
ligament, musculotendinous units
supporting the ankle joint

7. AN K L E S PR AIN S
• Incidence increased in :
• - individuals with varus
malalignment of lower limbs
• - calf muscle tightness
• - previous incompletely rehabilitated
ankle sprains

8. • Medial Ankle Sprain
– MOI: Eversion
– S/S: Pain and swelling around medial malleolus, pop,
pain with eversion or external rotation, inability to bear
weight
– Structures Injured: Deltoid Ligament
– Tx: Rule out fracture, RICE, ROM exercises, gradual
return to activity (longer than LAS), taping
– Special Tests: Talar Tilt (Eversion), Kleiger Test

10. • Inversion ( Lateral ) Ankle Sprain
• Mechanism of Injury - Inversion
• Typical presentation
– Pain on or near lateral malleolus
– Swelling around lateral malleolus
– Pain increases with lateral movements

11. • Lateral Ankle Sprain
– MOI: Inversion, Plantarflexion
– S/S: Pain and swelling around lateral malleolus, Pop
(repeatable c movement), Pain with MOI motions,
Inability to bear weight
– Structures Injured: Lateral Ankle Ligaments (anterior
talofibular & calcaneofibular most commonly)
– Tx: Rule out fracture, RICE, ROM exercises, gradual
return to activity, taping

16. AN K L E S PR AIN S
• - Diagnosis: x-rays, stress x-rays
• ( inversion stress, anterior drawer
test), ? MRI scan
• - acute phase ( first 72 hours ):
• RICE, then varies according to the
severity of injury

18. G R AD E 1 ( M ild )
S PR AIN S
• - The anterior talofibular ligament
affected
• - stress: minimal change on inversion,
normal anterior drawer
• - treatment by encouraging early active
movement:
• a) stationary cycling
• b) walking with protective taping or semi-
rigid brace ( Aircast splint )

19. G R AD E 1 ( M ild )
S PR AIN S
• c) NSAIDS (anti-inflammatory medication)
• d) physiotherapy: electrotherapy,
strengthening exercises, propreoception
(1 legged stand )
• e) functional progression to running,
jumping, hopping, swerving and cutting,
recovery into 6 weeks

20. G R AD E 2 (M od e rate )
S PR AIN S
• - Complete tear of anterior talofibular
ligament with some damage of the
calcaneofibular ligament
• - laxity when inversion, anterior drawer
present
• - treatment: a) 1 week crutches, joint
taped or in aircast splint
• b) follow grade 1 rehabilitation

21. G R AD E 3 ( S e ve re )
S PR AIN S
• - Uncommon severe injuries,
associated with fractures
• - treatment: 10 days NWB in aircast
brace or POP, then PWB with the
brace up to 6 weeks. Aggressive
rehabilitation follows
• - surgical reconstruction must be
considered

22. PE R O N E AL TE N D O N
IN JU R IE S
• - Strong everters and weak plantar flexors
of the foot
• - mechanism of injury:
• a) associated with lateral ligament
injuries
• b) forced dorsiflexion with slight
inversion and reflex contraction of the
tendons ( sprinting, uneven ground,
ballet)

23. PE R O N E AL TE N D O N
IN JU R IE S
• - O/E: Behind lat.malleolus discomfort or
swelling. Subluxation on resisting
dorsiflexion with eversion
• - treatment: a) acute phase – well-
moulded short NWB cast with pad over
lat.malleolus b) chronic phase – surgical
correction, POP 4 weeks c) rupture of
peroneal tendons – surgical correction

24. PE R O N E AL TE N D O N
IN JU R IE S
• TENDINITIS:
• - occurs in dancers, basketball,
volleyball
• - combined cause of the
lat.malleolus pulley action and foot
malalignment

25. PE R O N E AL TE N D O N
IN JU R IE S
• TENDINITIS:
• - TREATMENT – a) rest from sport,
temporary use of heel wedge
• b) physiotherapy, extreme cases: local
injection into the sheath
• c) gradual coaching programme, avoid
rapid direction changes or sprinting – 6
weeks
• d) failure of conservative treatment:
tenolysis of peroneal tendons

26. AC H IL L E S TE N D O N
IN JU R IE S
• - Common tendon of gastrocnemius
and soleus muscles
• - tendon twists laterally from 15cm
above insertion becoming more
pronounced at 2-5cm above
insertion. Blood supply reduced at
this level

27. AC H IL L E S TE N D O N
IN JU R IE S
• - Aetiology factors: lack of rear foot
support in shoes, terrain, excessive
training loads, biomechanical
factors of foot: over pronation, rear
foot varus or valgus, pes cavus,
tight calf muscles

29. – MOI: Forced ankle dorsiflexion while weight
bearing
– S/S: Pop, Feeling of being kicked in tendon,
Inability to plantarflex foot, Gross deformity
(observe and palpate), swelling, Lots of pain
– Special Tests: Thompson Test
– Treatment: Surgical Intervention to repair tear
in tendon, Long rehab to restore ankle function

32. Ankle fractures
• Fractures and fractures dislocation of the
ankle are common.
• It is also referred as Pott’s fractures.
• The most obvious injury is fracture of one
or both malleoli.
• The invisible injury is rupture of one or
more ligaments.

33. Ankle fractures
• Mechanism
• The patient stumbles and falls.
• The foot anchored to the ground and the
body lunges forwards.
• The ankle is twisted and talus is tilted
and/or rotates focibly in the mortise,
causing low energy fracture in one or both
malleoli.

34. Ankle fractures
• Associated ligamental injuries may
associated with such fractures.
• If the malleolus is pushed off, it is usually
fractures obliquely.
• If the malleolus pulled off, it is usually
fractures transversely.

35. Classification
• Danis and Weber (1991) which depends on
the fibullar fracture

36. Classification
• Type A
– Transverse Fracture lateral malleolus Below
syndesmosis, it associated with oblique or
vertical fracture of medial malleolus.
Mechanism
– Internal rotation and adduction

37. Classification
• Type B
– Oblique fracture of lateral malleolus At level of
syndesmosis, may associated with avalsion
fracture of medial malleolus or torn deltoid
ligament.
Mechanism
– External rotation leads to oblique fracture

38. Classification
• Type C
– Fibula fracture Above syndesmosis leading to
torn tibiofibular ligament (Syndesmotic injury)
– Mechanism
– Abduction and external rotation.

41. • Medial and posterior malleolar fractures,
deltoid ruptures may occur with any of
these

42. Clinical features
1. Common in skier, footballer and climbers.
2. H/O severe twisting, abduction or
adduction injuries.
3. Severe pain.
4. Inability to stand on the affected limb.
5. Swelling and deformity.
6. Tenderness on one or both malleoli.

43. X-Ray
• At least three views
3. Ap.
4. Lateral.
5. Mortise view ( 30° oblique view).

45. Initial Managment
• Closed reduction
– Hematoma block
– Conscious sedation
• Compression dressing, splint, and
elevation
• Early OR treatment
– Unstable fracture
– No soft tissue compromise (blisters,
severe swelling)
– Open fractures
• Delayed treatment
– Stable in splint
– Soft tissues need to recover
• Pain control

46. Medial Malleolar Fractures
• Nondisplaced fractures may be treated
nonoperatively
• Displaced fractures require anatomic
reduction and fixation.
• High nonuion rate

47. Lateral Malleolus Fractures
• Nonoperative managmement
– 2-3 mm displacement
– NO medial widening or
syndesmotic injury
– Cast or boot immobilization 6
wks
– Follow closely!
– Superior results

48. Surgical Indications
• Bimalleolar /
trimalleolar fractures
• Syndesmotic
disruption
• Talar subluxation
• Joint incongruity /
articular stepoff

49. Posterior Malleolus
May associated with
bimalleolar fracture
and called trimalleolar
fracture and it is
always need open
reduction and internal
fixation.

50. Complications
• Early
• Vascular injury.
• Wound breakdown and infection.

51. Complications
• Late
• Malunion with varus or
valgus deformity–
corrective osteotomy.
• Non union more
common of medial
malleolus.
• Degenerative arthritis.
• Joint stiffness,
• Algodystrophy.

52. Fracture of the tibial Plafond
• Fall from highet,
fracture depends on
position of talus on
impact: Comminuted
fracture of tibial
plafond.
• Management: IF
usually difficult:
Skeletal traction,
External fixator,
Minimal internal
fixation And plaster.

53. Injuries of talus
• Anatomy of talus: 60%
covered by
cartilage.B.supply
critical( dorsal neck, artery
of tarsal canal deltoid
branch). So fracture talar
neck will lead to avascular
necrosis of the body.
• Injuries include: Fracture
neck, Fracture body,
Dislocations

54. A-Fracture neck of talus
• Due to forcible
dorsiflexion.
Classified according to
Hawkins into:
a-Undisplaced fracture.
Blood supply intact,
avascular necrosis
rare. Treated by below
knee plaster for 2
months

55. A-Fracture neck of talus
• b- Displaced fracture
neck with subtalar
subluxation or
dislocation: B.supply
affected (30% AVN).
• Treatment: Early,
trial of Closed
reduction, If failed
OR and IF

56. A-Fracture neck of talus
• C:Fracture neck of
talus with total
dislocation of the body
of talus. AVN more
common, skin
sloughing.
• Treatment:Urgent,
usually closed
reduction fail and OR
and IF ,followed by
cast

57. Type D fracture
-type II injury with associated talar head
dislocation

58. Complications of Injuries around
talus include
• avascular necrosis of the
body.
• Osteoarthritis.
• sloughing of the skin.

59. Fracture Calcaneus
-5x more common in men
-largest and most frequently fractured tarsal bone
-falls (axial load) or twisting mechanisms ( fall from
a height).
-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

61. Types of Fracture calcaneus
• Types:
• 1- Isolated fractures:
Fracture of
sustentaculum tali,
posterior or anterior
process. Treatment:
Elevation, Ice bags ,
bandage and active
exercises
• 2-Avulsion fracture:
Tendoachilis--IF

62. Types of Fracture calcaneus
• 3-Extra-articular fr.
Compressed fr.
Outside the joint—
Below knee plaster.
• 4- Intra-articular:
Should he reduced
accurately– Closed
reduction and
percutenous fixation,
Or and plate fixation.

63. Complication of Fracture
Oscalcis
• OA of subtalar joint—
Arthrodesis
• Widening of heel:
impingement of
peroneal tendon or
sural nerve.
• Spur formation of
plantar aspect –
Shaving.
• Chronic pain and
swelling

64. Metatarsal fractures
• Fracture base 5th
metatarsal: common,
inversion, below
knee cast.
• Fracture shaft of
metatarsal: Direct
trauma- below knee
cast

65. Metatarsal and Phalangeal fractures
• March fracture :
Stress fr. Neck 2nd
less commonly 3rd
metatarsal, common
in new soldiers,
sclerotic ends, heel
by rest in below knee
cast
• Phalangeal fractures.
Direct trauma,
adhesive tapping