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