The ANKLE and the FOOT

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The ANKLE and the FOOT

  1. 1. The ANKLE and the FOOT TRAUMA MI Zucker, MD
  2. 2. A dr Z Lecture • On TRAUMA of the Ankle and Foot and some general concepts in musculoskeletal trauma evaluation
  3. 3. Rules for Success in Radiology • Know which exam to order • Know which films you need • Know good films from bad films, and don’t accept bad ones • Read methodically by check list • Know the common lesions • Know the commonly missed lesions
  4. 4. General Approach to Musculoskeletal Radiology • Soft tissues • Joints • Bones
  5. 5. The ANKLE
  6. 6. The Ankle Series • Anterior-posterior (AP) • Mortise (15 degree internal oblique) • Lateral
  7. 7. Anterior-Posterior: Adult
  8. 8. AP: Kid
  9. 9. Mortise: Adult
  10. 10. Lateral: Adult
  11. 11. Lateral: Kid
  12. 12. The INJURIES ANKLE
  13. 13. When Does the Patient NEED Radiography? The OTTAWA Rules Ankle and Foot
  14. 14. The OTTAWA ANKLE Rules • Unable to weight bear immediately • Unable to walk four steps in medical facility • Bone tenderness medial or lateral malleolus If “YES” to any, get ANKLE films
  15. 15. The OTTAWA FOOT Rules • Bone tenderness base of fifth metatarsal • Bone tenderness navicular If “YES” to either, get foot films
  16. 16. Some OTTAWA Rule caveats • Not valid if injury not acute • Some exclude patients under age 18 years or over 55 years These factors make the Rules less reliable, so we are more likely to do imaging in these circumstances.
  17. 17. OTTAWA Rules: Ankle Tenderness
  18. 18. OTTAWA Rules: Foot Tenderness
  19. 19. The Ankle Sprain • Grade I: Soft tissues swelling/joint effusion • Grades II and III: Soft tissue swelling/joint effusion but may also have “FLAKE” avulsion fractures of the dorsum of the talus or navicular bones. • Management differs, depending on grade
  20. 20. The Sprain: treatment • Grade I • Grades II/III • Ace wrap, crutches, limited time off weight bearing • Air or posterior splint, crutches, prolonged period off weight bearing, orthopedic consult
  21. 21. Soft Tissue Swelling
  22. 22. Joint Effusion
  23. 23. “FLAKE” Fracture
  24. 24. FRACTURES of the ANKLE
  25. 25. WEBER’S Classification • Based only on location of a FIBULA fracture. A fracture, or no fracture, of the medial malleolus (tibia) does NOT change the classification.
  26. 26. WEBER’S Classification • Weber A: Fracture below the joint margin • Weber B: Fracture begins at the joint margin • Weber C: Fracture begins above the joint margin
  27. 27. Weber A, B, and C injuries are ALL from INVERSION
  28. 28. WEBER’S Assumptions • Weber A: Anterior and posterior tibia- fibula and interosseous ligaments intact: STABLE • Weber B: Anterior and posterior tibia-fibula ligaments torn: Moderately UNSTABLE • Weber C: Interosseous ligament torn: Completely UNSTABLE
  29. 29. Management of WEBER Injuries • Weber A: Cast for 6 weeks • Weber B: Frequently ORIF • Weber C: Always ORIF ORIF: Open Reduction Internal Fixation
  30. 30. WEBER A
  31. 31. WEBER B
  32. 32. WEBER C
  33. 33. REMEMBER If the MEDIAL MALLEOLUS is also fractured, it does NOT change the Weber classification
  34. 34. What if ONLY the Medial Malleolus is Fractured?
  35. 35. Two possibilities • Weber A “equivalent” from INVERSION: The Lateral Collateral Ligament is torn but the Lateral Malleolus did not fail • EVERSION INJURY: an UNSTABLE Maisonneuve Fracture
  36. 36. Maisonneuve Fractures • These are EVERSION injuries that fracture the MEDIAL MALLEOLUS, tear the entire Interosseous Ligament and Membrane, and exit as a high FIBULA SHAFT fracture • They are all UNSTABLE and are treated by ORIF
  37. 37. Maisonneuve Fracture: Lower
  38. 38. Maisonneuve Fracture: Upper
  39. 39. Caveat • The high fibula fracture may be clinically occult • So, ALWAYS get AP/lateral films of the ENTIRE tibia and fibula if there is an “isolated” medial malleolus fracture on the ankle series
  40. 40. Bimalleolar Fracture • Medial and lateral malleolar fractures, but still use Weber, as medial malleolar fracture does NOT change classification • This is a Weber B
  41. 41. Trimalleolar Fracture • In addition to lateral and medial malleolar fractures, there is a fracture of the distal posterior tibia, called the POSTERIOR Malleolus. If large, extra ORIF needed.
  42. 42. “Ankle” Injuries that are really FOOT Injuries • Fractures of the base of the Fifth Metatarsal • Fractures of the Anterior Process of the Calcaneous • “Flake” fractures of the Talus or Navicular (we already did this, and they are components of an ankle injury)
  43. 43. Fractures of the Base of the Fifth Metatarsal
  44. 44. We will look at these again When we get to the FOOT
  45. 45. Fractures of the Anterior Process of the Calcaneous
  46. 46. Stress fractures: repetitive microtrauma
  47. 47. Salter-Harris Injuries Physis injuries, so KIDS ONLY!
  48. 48. Salter-Harris PHYSIS Injuries • SH I: Physis only • SH II: Physis and metaphysis • SH III: Physis and epiphysis • SH IV: Physis, metaphysis and epiphysis • SH V: Crush injury of physis • SH VI: Avulsed piece of metaphysis, physis, and epiphysis
  49. 49. Salter-Harris what?
  50. 50. Salter-Harris I and IV
  51. 51. Remember: KIDS ONLY! NO Salter-Harris injuries are possible after physis closes: “Salter-Harris Nothing”
  52. 52. And now…
  53. 53. The FOOT
  54. 54. FOOT: Views • AP • Oblique • Lateral
  55. 55. AP
  56. 56. AP
  57. 57. Oblique
  58. 58. Lateral
  59. 59. AP FOOT: Kid
  60. 60. Lateral FOOT: Kid
  61. 61. Talus • Avulsions of dorsal margin: Ankle ligament injury (we did it under ANKLE) • Osteochondral fracture: acute and stress • Body of talus
  62. 62. Talus Body fracture
  63. 63. Osteochondral Fracture
  64. 64. Calcaneous • Body: axial load • Stress: repetitive microtrauma • Anterior process: ankle injury
  65. 65. Axial Load Fracture
  66. 66. Stress Fracture • Initial film: pain one week • Follow-up film: pain three weeks
  67. 67. Fifth Metatarsal Base • DANCER’S: tubercle, inversion, heals well • Crepe support, walking boot or cast, on or off weight bearing: depends on extent of fracture • JONES: proximal shaft, inversion or direct blow or stress, sometimes delayed or non-union • Posterior cast or boot, off weight bearing • If non-union, ORIF
  68. 68. Dancer’s Fifth
  69. 69. Jones Fifth
  70. 70. Lisfranc Injuries • Severe dorsal or plantar flexion at midfoot- forefoot junction • Usually, very displaced and obvious • Can be subtle • ALL need surgery
  71. 71. Lisfranc: obvious
  72. 72. Lisfranc: subtle
  73. 73. Metatarsal fractures • Spiral • Stress
  74. 74. Spiral fracture
  75. 75. Stress fracture
  76. 76. Toe fractures • “Stub” • Crush
  77. 77. Toe fractures
  78. 78. GOODBYE • Copyright 2004 MI Zucker

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