This document provides an overview and discussion of various foot and ankle fractures and their typical treatment approaches. It begins with an agenda for reviewing ankle x-rays, classifications, and foot and ankle fractures. Several case examples are presented and treatment options discussed, including immobilization with casting, referral to orthopedics, and potential surgical intervention depending on the location and severity of the fracture. Common fractures addressed include those of the ankle, talus, calcaneus, midfoot, metatarsals, and phalanges.

1. FFoooott aanndd AAnnkkllee FFrraaccttuurreess
Dr. Dave Dyck R3
Sept. 5/02

2. TTooddaayy’’ss AAggeennddaa::
• Review ankle x-rays (10min)
• Review ankle x-ray classification (5-
10min)
• Review various foot and ankle fractures
and their treatments (30min)

3. CCaassee 11::
• 32y male with R ankle pain and inability to
walk after jumping off trailer 8 feet high
and landing on both feet.

4. OOttttaawwaa aannkkllee rruulleess::
• Order ankle x-rays if there is pain in
malleolar zone + any one of:
– Inability to weight bear both immediately and
in ER (4 steps)
– Bony tenderness over posterior distal 6cm of
either malleoli
(consider sensorium, ETOH, other inj,
sensation,etc.)

5. OOttttaawwaa aannkkllee rruulleess::
• Sensitivity=99-100%
• Specificity=40%

6. AAnnkkllee XX--rraayyss::
• AP
• Lateral
• Mortise

7. AAPP

8. AAPP xx--rraayy::
• Medial clear space < 4mm (if not consider
lat talar shift and deltoid disruption)
• Space between medial fibular wall and
incisural surface of tibia < 5mm
• Anterior tibial tubercle should overlap
fibula by 6-10mm (or 42% fibular width)
(syndesmotic injury)

9. AAPP xxrraayy

10. MMoorrttiissee xx--rraayy::
• Tibiofibular overlap
>1mm
• Tibiofibular clear
space <5mm
(if abnormalconsider
syndesmotic inj)

11. MMoorrttiissee xx--rraayy::
• Medial clear space
<4mm and superior-medial
joint space
w/in 2mm of width
laterally (often AP
view better)

12. MMoorrttiissee xx--rraayy::
• Talar tilt (normal -1.5
to 1.5 degrees) ie.
parallel
• Can normally go up to
5 degrees in stress
views

13. MMoorrttiissee xx--rraayy::
• Tibiofibular line: distal
tibia and medial
aspect of fibula
should be continuous
• articular surface of
talus should be
congruent with that of
distal fibula

14. LLaatteerraall xx--rraayy::
• Tibia/fibula/talus/joint
space and os
trigonum

15. OOss ttrriiggoonnuumm::
• Common accessory
bone (8%) of foot
found just posterior to
lateral tubercle of
talus

16. SShheepphheerrdd’’ss FFrraaccttuurree::
• Extreme plantar
flexion injury

17. CCaassee 11::

18. HHooww wwoouulldd yyoouu ccllaassssiiffyy tthhiiss??

19. LLaauuggee--HHaannsseenn::
• Based on position of foot prior to injury
and the motion of the talus relative to the
leg once force is applied
• Eg supination-external rotation
• Further subdivided into worsening areas of
injury
• USELESS!

20. DDaanniiss--WWeebbeerr
• Based on level of fibular fracture
• A=below syndesmosis
• B=at level of syndesmosis
• C=above syndesmosis
• THE MORE PROXIMAL THE FIBULAR #
THE MORE SEVERE THE INJURY

21. AAOO ccllaassssiiffiiccaattiioonn::
• Similar to DW scheme but adds further
info based on medial malleolar
involvement
• ANY MEDIAL MALLEOLAR # =
UNSTABLE ANKLE

22. AAOO ccllaassssiiffiiccaattiioonn

23. HHeennddeerrssoonn sscchheemmee::
• Most common
• Unimalleolar vs bimalleolar vs trimalleolar

24. CCaassee 22::
Treatment?

25. TTrraannssvveerrssee ttyyppee AA11//aavvuullssiioonn ##
• Treat as stable ankle sprains if they are
minimally displaced, <3mm in diameter,
and no indication of medial ligament
damage. Otherwise treat in walking
cast/boot for 6-8 weeks

26. IIssoollaatteedd mmeeddiiaall mmaalllleeoollaarr ##
• Rare (have high index of suspicion for
other injuries)
• If min displaced treat with immobilization
and outpatient follow-up
• r/o Maisonneuve’s fracture

27. MMaaiissoonnnneeuuvvee’’ss ffrraaccttuurree::

28. TTrreeaattmmeenntt::
• Cast immobilization and refer to ortho for
possible ORIF vs. conservative tx (only if
mortise intact)

29. CCaassee 33::
Treatment?

30. BBiimmaalllleeoollaarr aanndd ttrriimmaalllleeoollaarr ##
• Usually involve syndesmosis
• Post slab and ortho referral (may try
closed reduction if ++displaced and
definitely if dislocation)

31. CCaassee 44::

32. TTiibbiiaall ppllaaffoonndd oorr PPiilloonn ffrraaccttuurree
• Due to axial load
• Very unstable
• Splint and refer to ortho for ORIF

33. HHiinnddffoooott FFrraaccttuurreess::
• Talus
• Calcaneus

34. CCaassee 55::

35. TTaallaarr ffrraaccttuurreess::
• Rare
• Poor blood supply  high incidence of
AVN
• Can be major or minor

36. MMaajjoorr TTaallaarr ffrraaccttuurreess::
• Neck, head, body (& lat process)
• Talar neck fractures = 50%
– Hawkins type1= non displaced + no joint inv.
– Type II = displaced with subluxation or
dislocation of the subtalar joint BUT ankle
joint is OK
– Type III = Type II +dislocation of ankle joint
– Type IV = Type III + talar head dislocation

37. TTaallaarr NNeecckk ##

38. TTrreeaattmmeenntt::
• Type I= NWB BK casting x 8-12 weeks
• Type II= closed reduction with traction +
plantar flexion and BK casting vs ORIF
• Type III/IV = immed. Ortho consult
• Ortho should be involved in all cases

39. TTrreeaattmmeenntt::
• Talar body # = if non-displaced  BK non-weight
bearing cast x 6-8 weeks
• Talar head # = if non-displaced  BK
walking cast X 6-8 weeks VS NWB
• ER ortho otherwise

40. MMiinnoorr ttaallaarr ffrraaccttuurreess::
• Minor avulsion fractures of neck, body,
and lateral process are treated with post
slab, crutches and ortho follow-up
• Osteochondral fractures of talar dome 
NWB BK cast x3mo w ortho f/u

41. Case 6: 8ft fall oonnttoo bbootthh ffeeeett.. RR>>LL
hheeeell ppaaiinn aanndd ccaann’’tt wwaallkk
• L calcaneus x-ray:

42. BBoohhlleerr’’ss aannggllee ((3300--4400 ddeegg))

43. RR ccaallccaanneeuuss xx--rraayy::

45. TTrreeaattmmeenntt??

46. TTrreeaattmmeenntt::
• Extraarticular=
– 25-35%
– Anterior process, tuberosity, medial process,
sustenaculum tali, and body
– If not displaced nor involving subtalar jt may
treat with compressive dressings/casting
* Intraarticular= post facet involved
- well padded post splint + ortho

47. CCaallccaanneeaall ffrraaccttuurreess::
• More than 50% are associated with other
extremity or spinal fractures

48. MMiiddffoooott FFrraaccttuurreess::
• Navicular
• Cuboid
• Lisfranc

49. CCaassee 77::

50. • r/o accessory bone

51. CCaassee 8::

52. NNaavviiccuullaarr ffrraaccttuurreess::
-Most common midfoot fracture but still rare
-treatment=
non-displaced=short-leg walking cast x6
wks
displaced= ortho

53. CCuubbooiidd FFrraaccttuurreess::
• Treat as per navicular
fractures
• r/o Lisfranc injury

54. CCaassee 99::

55. LLiissffrraanncc JJooiinntt::
• Formed by the articulations of metatarsals
1-3 with the cuneiforms and metatarsals 4
& 5 with the cuboid
• The metatarsal bases of digits 2-5 are
joined by strong ligaments

56. WWhhaatt ttoo llooookk ffoorr oonn xx--rraayy::
• Normally, medial aspect of metatarsals 1-3
should align with medial borders of cuneiforms
• Metatarsals should be aligned dorsally with
tarsals on lateral view
• Medial 4th metatarsal should align with medial
cuboid
• Any fracture or dislocation of the navicular or
cuneiforms or widening between metatarsals 1-3
• Proximal 2nd metatarsal # is pathogpneumonic

57. NNoorrmmaall LLiissffrraanncc jjooiinntt

58. TTrreeaattmmeenntt::
• Consult ortho
• May try closed reduction with traction but
post reduction displacement of >2mm or
tarso-metatarsal angle> 15 degrees
requires surgery

59. FFoorreeffoooott ffrraaccttuurreess::
• Metatarsal
• Phalangeal

60. CCaassee1100::

61. CCaassee 1111::

62. TTrreeaattmmeenntt::
• Nondisplaced or min displaced fractures of
metatarsal 2-4 stiff shoe, casting, or
fracture brace.
• Non displaced 1st metatarsal  NWB BK
walking cast
• Displaced 1st or 5th metatarsal  ER ortho
• Attempt closed reduction if >3mm
displacement or 10 degrees angulation

63. TTrreeaattmmeenntt ccoonntt..
• Metatarsal base #  r/o LF injury
• Jones Fracture=5th metatarsal base
fracture.
– Tx=non displaced  NWB BK cast x6-8 wks
– = displaced  surgery

64. JJoonneess ##

65. PPeeddss== ??aappoopphhyyssiiss

66. PPhhaallaannggeeaall ##
• Nondisplaced digits 2-5= buddy tape
• Can also buddy tape non-displaced
phalange1 but may need BK walking cast
for pain control
• Residual displacement, intraarticular,
comminution ortho