This appears to be a typical ankle sprain. RICE and functional immobilization is appropriate initial management.

1. 2/3/2010
Ahmed Alhubaishi
Ankle and foot
Define the following terms:
◦Tibial plafond
◦Mortise
◦Posterior malleolus
◦Sprain/strain
◦Ankle ring
1

2. 2/3/2010
 An emergency physician who applies the Ottawa
Ankle Rules correctly would send which of the
following ambulatory patients with a chief
complaint of “ankle pain” for x-ray?
 a. A 40-year-old male with tenderness upon
palpation of the posterior edge of the medial
malleolar tip
 b. A 25-year-old female with edema,
ecchymosis,and tenderness just anterior to the
lateral malleolus
 c. A 60-year-old male with lateral edema,
ecchymosis, and a positive anterior drawer test
 d. A 16-year-old male with posterior ankle
tenderness and a positive Thompson test
 An emergency physician who applies the Ottawa
Ankle Rules correctly would send which of the
following ambulatory patients with a chief
complaint of “ankle pain” for x-ray?
 a. A 40-year-old male with tenderness upon
palpation of the posterior edge of the medial
malleolar tip
 b. A 25-year-old female with edema,
ecchymosis,and tenderness just anterior to the
lateral malleolus
 c. A 60-year-old male with lateral edema,
ecchymosis, and a positive anterior drawer test
 d. A 16-year-old male with posterior ankle
tenderness and a positive Thompson test
2

3. 2/3/2010
Using OAR which of the
following not for X-ray:
 Bone tenderness at med. Malleolus
 Bone tenderness at lat. Malleolus
 Bone tenderness of the posterior
edge distal 6 cm to the ankle
 Inability to bear wt on ankle now and
immediately after the injury
 Soft tissue swelling over med. And
lat. malleolus
Using OAR which of the
following not for X-ray:
 Bone tenderness at med. Malleolus
 Bone tenderness at lat. Malleolus
 Bone tenderness of the posterior
edge distal 6 cm to the ankle
 Inability to bear wt on ankle now and
immediately after the injury
 Soft tissue swelling over med. And
lat. malleolus
3

4. 2/3/2010
Ottawa rules
When OAR cannot
be applied???
4

5. 2/3/2010
When OAR cannot be
applied???
1. Altered level of consciousness
2. Subacute or chronic injuries
3. Injuries to hindfoot or forefoot
4. Not designed to pick up # < 3 mm
One of the following ankle # can
be Rx as OPD with close ortho.
FU:
 Fibular # proximal to tibiotalar ( t-t)
joint line
 Lat. Malleolus # below the T-T joint
line
 Lat. Malleolus # with deltoid lig.
Rupture
 Unimalleolar # with syndesmotic
diastasis
5

6. 2/3/2010
One of the following ankle # can
be Rx as OPD with close ortho.
FU:
 Fibular # proximal to tibiotalar ( t-t)
joint line
 Lat. Malleolus # below the T-T joint
line
 Lat. Malleolus # with deltoid lig.
Rupture
 Unimalleolar # with syndesmotic
diastasis
What is this?
6

7. 2/3/2010
The ankle ring consists of the
following:
tibial plafond,
medial malleolus,
deltoid ligaments,
calcaneus,
lateral collateral
ligaments,
lateral malleolus
syndesmotic ligaments.
The integrity of this
ring determines
the stability of the
ankle
7

8. 2/3/2010
 Which of the following is the most
commonly injured soft-tissue
structure(s) of the ankle?
 a. Lateral collateral ligaments
 b. Medial collateral ligaments
 c. Inferior tibiofibular ligaments
 d. Achilles tendon
 Which of the following is the most
commonly injured soft-tissue
structure(s) of the ankle?
 a. Lateral collateral ligaments
 b. Medial collateral ligaments
 c. Inferior tibiofibular ligaments
 d. Achilles tendon
8

9. 2/3/2010
 Each of the following ligaments are
part of the ankle syndesmosis
except:
 a. Anterior inferior tibiofibular ligament
(AITFL)
 b. Posterior inferior tibiofibular
ligament (PITFL)
 c. Interosseous ligament (IOL)
 d. Calcaneofibular ligament (CFL)
 Each of the following ligaments are
part of the ankle syndesmosis
except:
 a. Anterior inferior tibiofibular ligament
(AITFL)
 b. Posterior inferior tibiofibular
ligament (PITFL)
 c. Interosseous ligament (IOL)
 d. Calcaneofibular ligament (CFL)
9

10. 2/3/2010
Ankle ligaments- lateral
Ankle ligaments – medial
(deltoid)
10

11. 2/3/2010
 All of the following terms describe
a motion of the talus within the
mortise except:
 a. adduction.
 b. external rotation.
 c. supination.
 d. plantar flexion.
 All of the following terms describe
a motion of the talus within the
mortise except:
 a. adduction.
 b. external rotation.
 c. supination.
 d. plantar flexion.
11

12. 2/3/2010
 Widening of the medial clear space
on ankle radiographs suggests
injury to each of the following
structures except:
 a. lateral ligament complex.
 b. deltoid ligament.
 c. anterior inferior tibiofibular ligament
(AITFL).
 d. posterior inferior tibiofibular
ligament (PITFL).
 Widening of the medial clear space
on ankle radiographs suggests
injury to each of the following
structures except:
 a. lateral ligament complex.
 b. deltoid ligament.
 c. anterior inferior tibiofibular ligament
(AITFL).
 d. posterior inferior tibiofibular
ligament (PITFL).
12

13. 2/3/2010
 Pain at the ankle during squeeze
testing is suggestive of injury to
which structure(s)?
 a. Medial collateral ligaments
 b. Inferior tibiofibular ligaments
 c. Lateral collateral ligaments
 d. Peroneal tendons
 Pain at the ankle during squeeze
testing is suggestive of injury to
which structure(s)?
 a. Medial collateral ligaments
 b. Inferior tibiofibular ligaments
 c. Lateral collateral ligaments
 d. Peroneal tendons
13

14. 2/3/2010
 On a normal AP ankle x-ray, the
amount of tibiofibular overlap
should be at least:
 a. 2 mm.
 b. 4 mm.
 c. 6 mm.
 d. 8 mm.
 On a normal AP ankle x-ray, the
amount of tibiofibular overlap
should be at least:
 a. 2 mm.
 b. 4 mm.
 c. 6 mm.
 d. 8 mm.
14

15. 2/3/2010
15

16. 2/3/2010
-Malleoli
superimposed
each other
-- body of
calcaneous
visible
-Base of 5 th
m.t
16

17. 2/3/2010
-entire joint space
-talar dome
No overlap
between the
previous two
-symmetrical joint
space
-Width of medial
space 2-3 mm
--T-F ovelap not
less than 1-2 mm
17

18. 2/3/2010
 Widening of the medial clear space or
a lesser degree of tibulofibular overlap
suggests
injury to to the medial
ligament,syndesmosis or
both
18

19. 2/3/2010
 The Lauge-Hansen classification of
ankle fractures is based on:
 a. the anatomic location of the fibular
fracture with respect to the mortise.
 b. the mechanism of injury.
 c. the degree of articular involvement.
 d. the presence or absence of
syndesmotic disruption.
 The Lauge-Hansen classification of
ankle fractures is based on:
 a. the anatomic location of the fibular
fracture with respect to the mortise.
 b. the mechanism of injury.
 c. the degree of articular involvement.
 d. the presence or absence of
syndesmotic disruption.
19

20. 2/3/2010
 Inversion injury. There is a transverse
avulsion fracture of the lateral
malleolus below the mortise caused
by supination-adduction forces
(arrow).The lateral ligaments remain
intact. This injury is classified as
Lauge-Hansen SA grade 1 or Danis-
Weber type A.
20

21. 2/3/2010
 The medial clear space is widened,
suggesting deltoid and/or syndesmotic
ligament disruption (arrowhead).
There is an isolated spiral fracture of
the fibula occurring at the level of the
mortise caused by supination-external
rotation forces.This injury is classified
as Lauge-Hansen SE grade 2 or
Danis-Weber type B.
21

22. 2/3/2010
What is this?
What is this?
MAISONNEUVE’S
FRACTURE
22

23. 2/3/2010
 Characteristics of a Maisonneuve
fracture include all of the following
except:
 a. It occurs in the setting of forceful
external rotation.
 b. It is frequently associated with
medial ligament and/or syndesmosis
disruption.
 c. It is highly unstable.
 d. The diagnosis is readily made on
routine ankle x-ray series.
 Characteristics of a Maisonneuve
fracture include all of the following
except:
 a. It occurs in the setting of forceful
external rotation.
 b. It is frequently associated with
medial ligament and/or syndesmosis
disruption.
 c. It is highly unstable.
 d. The diagnosis is readily made on
routine ankle x-ray series.
23

24. 2/3/2010
What is this?
Pilon
fracture
 # of distal tibial metaphysis
 Due to high energy mechanism
 Usually comminuted, 20% open
 Significant soft tissue loss
 Talus derive into tibial plafond
 Associated with: # of calcaneus,tibial
platue, femoral neck, acetabulum,
vertebrae
24

25. 2/3/2010
Tillaux Fracture:
 • Lateral tibia, involving articular
surface
 • Salter-Harris III fracture, mostly in
adolescents
 • Usually requires surgical fixation
 The best test for Achilles tendon
rupture is:
 a. ability to pronate the foot.
 b. ability to dorsiflex the foot.
 c. the Thompson squeeze test.
 d. the ―wiggle test.‖
25

26. 2/3/2010
 The best test for Achilles tendon
rupture is:
 a. ability to pronate the foot.
 b. ability to dorsiflex the foot.
 c. the Thompson squeeze test.
 d. the ―wiggle test.‖
 All of the following fractures
warrant orthopedic consultation in
the ED except:
 a. unimalleolar fracture.
 b. bimalleolar fracture.
 c. trimalleolar fracture.
 d. triplane fracture.
26

27. 2/3/2010
 All of the following fractures
warrant orthopedic consultation in
the ED except:
 a. unimalleolar fracture.
 b. bimalleolar fracture.
 c. trimalleolar fracture.
 d. triplane fracture.
When to consult ortho people to
come and see pt with ankle
pain
?
27

28. 2/3/2010
 Unimalleolar Fractures
 Displaced medial malleolar fracture
 Medial malleolar fracture with lateral collateral ligament rupture
 Displaced lateral malleolar fracture
 Lateral malleolar fracture with deltoid ligament rupture
 Lateral malleolar fracture with widened medial clear space
 Unimalleolar fracture with syndesmotic diastasis
 Fibula fracture at or proximal to the tibiotalar joint line
 Displaced posterior malleolar fracture
 Posterior malleolar fracture involving more than 25% of joint surface
 All Bimalleolar Fractures
 All Trimalleolar Fractures
 All Intraarticular Fractures With Step Deformity
 All Open Fractures
 All Pilon Fractures
Clinical Pathway: Evaluation
Of Ankle Injuries
28

29. 2/3/2010
29

30. 2/3/2010
Clinical Pathway: Management
Of Ankle Injuries
30

31. 2/3/2010
31

32. 2/3/2010
CASE
• 24 yo M football player
• Another player rolled over his ankle from behind
• ANKLE DISLOCATION:
• • Usually posterior
• • Often associated with fracture and ligamentous injury
• Reduction:
• • Place one hand behind heel, with other over dorsum of foot.
• • Downward and anterior traction, with foot plantar-flexed initially.
• • Finally bring ankle back to 90 degrees flexion.
• Clinical Pearl:
• Put the knee in a slightly flexed position (20-30 degrees) during
the
reduction to reduce tension at the ankle.
• Post-reduction:
• • Immobilize in short leg, 3-sided splint, ankle at 90 degrees
• • Follow up with Orthopedic surgeon
32

33. 2/3/2010
case
• 20 year old male twisted his ankle while ―snowboarding‖
• Exam: Ankle is swollen, diffusely tender, and plain films are
negative.
• Ankle Sprain:
• • R.I.C.E. (rest, ice, compression, elevation)
• • Functional immobilization
• o ACE, AirCast, taping, etc
• • Crutches
• o Weight-bearing as tolerated
• • Follow up exam
• o Approximately two weeks after injury
• o Repeat physical exam for ligamentous damage
• o Most patients will be much improved
• o A few may have persistent pain, swelling, and joint effusion,
• suggesting the possibility of occult fracture.
• When should I consider CT or MRI for
occult ankle fracture?
• Consider CT or MRI in the setting of negative
plain films, and:
• o High clinical suspicion
• o Persistent pain, swelling, effusion at follow-
up
• Important occult fractures of the ankle/foot:
• o Talar dome
• o Tillaux (lateral tibia)
• o Calcaneus, Navicular
• o Lateral process of the talus
33

34. 2/3/2010
• Haapamaki, American Journal of
Roentgenology, 2004
• Retrospective study, over 3 years
• 344 patients with a fracture on ankle / foot CT
• CT’s ordered to delineate fracture, or to r/o
occult fracture
• Most common occult fx in ankle (not
visualized on plain films):
• Calcaneus (20)
• Talus (15)
• Tillaux (7)
• Pearls:
• 1) CT helpful for:
• a. High suspicion (mechanism, exam)
• b. Poor recovery
• 2) High risk situations:
• a. Fall from height—Calcaneus
• b. Adolescent—Tillaux
• c. Snowboarding—Lat. process of
Talus
34

35. 2/3/2010
foot
Q
 What is CHOPART’S AND
LISFRANCE’S JOINTS?
 CHOPART: between midfoot and
hindfoot
 LISFRANCE: between midfoot and
metatarsals
35

36. 2/3/2010
foot
What are the foot # need
ortho consult in ED
?
36

37. 2/3/2010
 All talus fractures
 All calcaneus fractures
 Significant navicular fractures,
especially if intraarticular
 All cuboid fractures
 Lisfranc injuries
 Metatarsal shaft fractures with > 3 mm
displacement or 10 degrees angulation
 Metatarsal head and neck fractures
 Jones fractures
When BOEHLER’S angle < 20
degree means:
 Navicular fracture
 Cuboid fracture
 Lisfrance’s fracture
 Calcaneal fracture
 First metatarsal fracture
37

38. 2/3/2010
When BOEHLER’S angle < 20
degree means:
 Navicular fracture
 Cuboid fracture
 Lisfrance’s fracture
 Calcaneal fracture
 First metatarsal fracture
Boehler’s angle
38

39. 2/3/2010
What is this?
Calcaneus fracture:
 • Calcaneus fractures most often
occur in males (male:female = 5:1)
 • Peak age: between 30 and 50 years.
 • Associated injuries (Lumbar spine
vertebral compression fractures)
 • Treatment: Operative vs Casting
39

40. 2/3/2010
What is this?
 Talar body fracture
 Risk of AVN
40

41. 2/3/2010
What is this?
 Talar neck #
 50% of all talar #
 Extreme dorsiflexion
 Hawkin’s classification 1-4
41

42. 2/3/2010
Talar Dome Fracture:
 • Osteochondral lesion, articular
surface
 • CT and MRI both excellent to
visualize lesion
 • May be managed by cast (non-
weight bearing), or by arthroscopic
 surgery if loose fragments in joint
What is this?
42

43. 2/3/2010
Lisfrance’s fracture
 AP view :
◦ medial margin of the base of the second
metatarsal lines up with the medial margin
of the middle cuneiform
 oblique view:
◦ medial margin of the base of the third
metatarsal lines up with the medial margin
of the lateral cuneiform, and
◦ medial margin of the base of the fourth
metatarsal lines up with the medial margin
of the cuboid
Types of lisfrance’s #
43

44. 2/3/2010
What fracture is virtually
pathognomonic for a
Lisfranc injury?
Fracture the base of
second metatarsal
What are these?
44

45. 2/3/2010
What are these?
Jones #
Pseudojones #
45

46. 2/3/2010
 Jones’ fracture: transverse fracture at
least 15 mm distal to proximal end of
5th metatarsal; high rate of malunion
so call ortho
 Pseudo-Jones’ fracture: avulsion
fracture of tuberosity at 5th metatarsal
base; treat symptomatically
 Nonunion and chronic disability
may result from inadequate
immobilization of:
 a. lateral malleolar avulsion fractures.
 b. avulsion fractures of the tuberosity
of the fifth metatarsal (pseudo-Jones).
 c. fifth metatarsal shaft fractures
(Jones).
 d. lateral ligament tears with lateral
malleolar avulsion fractures.
46

47. 2/3/2010
 Nonunion and chronic disability
may result from inadequate
immobilization of:
 a. lateral malleolar avulsion fractures.
 b. avulsion fractures of the tuberosity
of the fifth metatarsal (pseudo-Jones).
 c. fifth metatarsal shaft fractures
(Jones).
 d. lateral ligament tears with lateral
malleolar avulsion fractures.
What are the
indications for
reduction of a
metatarsal
fracture?
47

48. 2/3/2010
Greater than 10
degrees angulation
or
3 mm displacement
Thank you
48