This document provides information on ankle and foot fractures. It begins by describing ankle anatomy including the bones and ligaments. It then discusses common types of ankle fractures like Pott's fractures and classifications like the Weber system. Foot anatomy and fractures of bones like the calcaneus and talus are also outlined. Treatment approaches including casting, splinting, and surgery are described for different types and severities of ankle and foot fractures. Complications are noted. The document is a comprehensive overview of ankle and foot fracture anatomy, mechanisms of injury, classifications, clinical presentation, investigations, and management.

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.