Foot and Ankle Fractures Dr. Dave Dyck R3 Sept. 5/02.
-
Upload
blaise-sherman -
Category
Documents
-
view
219 -
download
1
Transcript of Foot and Ankle Fractures Dr. Dave Dyck R3 Sept. 5/02.
Foot and Ankle FracturesFoot and Ankle Fractures
Dr. Dave Dyck R3
Sept. 5/02
Today’s Agenda:Today’s Agenda:
• Review ankle x-rays (10min)
• Review ankle x-ray classification (5-10min)
• Review various foot and ankle fractures and their treatments (30min)
Case 1:Case 1:
• 32y male with R ankle pain and inability to walk after jumping off trailer 8 feet high and landing on both feet.
Ottawa ankle rules:Ottawa ankle rules:
• 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.)
Ottawa ankle rules:Ottawa ankle rules:
• Sensitivity=99-100%
• Specificity=40%
Ankle X-rays:Ankle X-rays:
• AP
• Lateral
• Mortise
APAP
AP x-ray:AP x-ray:
• 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)
AP xrayAP xray
Mortise x-ray:Mortise x-ray:
• Tibiofibular overlap >1mm
• Tibiofibular clear space <5mm
(if abnormalconsider syndesmotic inj)
Mortise x-ray:Mortise x-ray:
• Medial clear space <4mm and superior-medial joint space w/in 2mm of width laterally (often AP view better)
Mortise x-ray:Mortise x-ray:
• Talar tilt (normal -1.5 to 1.5 degrees) ie. parallel
• Can normally go up to 5 degrees in stress views
Mortise x-ray:Mortise x-ray:
• Tibiofibular line: distal tibia and medial aspect of fibula should be continuous
• articular surface of talus should be congruent with that of distal fibula
Lateral x-ray:Lateral x-ray:
• Tibia/fibula/talus/joint space and os trigonum
Os trigonum:Os trigonum:
• Common accessory bone (8%) of foot found just posterior to lateral tubercle of talus
Shepherd’s Fracture:Shepherd’s Fracture:
• Extreme plantar flexion injury
Case 1:Case 1:
How would you classify this?How would you classify this?
Lauge-Hansen:Lauge-Hansen:
• 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!
Danis-WeberDanis-Weber
• 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
AO classification:AO classification:
• Similar to DW scheme but adds further info based on medial malleolar involvement
• ANY MEDIAL MALLEOLAR # = UNSTABLE ANKLE
AO classificationAO classification
Henderson scheme:Henderson scheme:
• Most common
• Unimalleolar vs bimalleolar vs trimalleolar
Case 2:Case 2:
Treatment?
Transverse type A1/avulsion #Transverse type A1/avulsion #
• 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
Isolated medial malleolar #Isolated medial malleolar #
• Rare (have high index of suspicion for other injuries)
• If min displaced treat with immobilization and outpatient follow-up
• r/o Maisonneuve’s fracture
Maisonneuve’s fracture:Maisonneuve’s fracture:
Treatment:Treatment:
• Cast immobilization and refer to ortho for possible ORIF vs. conservative tx (only if mortise intact)
Case 3:Case 3:
Treatment?
Bimalleolar and trimalleolar #Bimalleolar and trimalleolar #
• Usually involve syndesmosis
• Post slab and ortho referral (may try closed reduction if ++displaced and definitely if dislocation)
Case 4:Case 4:
Tibial plafond or Pilon fractureTibial plafond or Pilon fracture
• Due to axial load
• Very unstable
• Splint and refer to ortho for ORIF
Hindfoot Fractures:Hindfoot Fractures:
• Talus
• Calcaneus
Case 5:Case 5:
Talar fractures:Talar fractures:
• Rare
• Poor blood supply high incidence of AVN
• Can be major or minor
Major Talar fractures:Major Talar fractures:
• 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
Talar Neck #Talar Neck #
Treatment:Treatment:
• 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
Treatment:Treatment:
• 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
Minor talar fractures:Minor talar fractures:
• 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
Case 6: 8ft fall onto both feet. R>L Case 6: 8ft fall onto both feet. R>L heel pain and can’t walkheel pain and can’t walk
• L calcaneus x-ray:
Bohler’s angle (30-40 deg)Bohler’s angle (30-40 deg)
R calcaneus x-ray:R calcaneus x-ray:
Treatment?Treatment?
Treatment:Treatment:
• 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
Calcaneal fractures:Calcaneal fractures:
• More than 50% are associated with other extremity or spinal fractures
Midfoot Fractures:Midfoot Fractures:
• Navicular
• Cuboid
• Lisfranc
Case 7:Case 7:
• r/o accessory bone
Case 8:Case 8:
Navicular fractures:Navicular fractures:
-Most common midfoot fracture but still rare
-treatment=
non-displaced=short-leg walking cast x6 wks
displaced= ortho
Cuboid Fractures:Cuboid Fractures:
• Treat as per navicular fractures
• r/o Lisfranc injury
Case 9:Case 9:
Lisfranc Joint:Lisfranc Joint:
• 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
What to look for on x-ray:What to look for on x-ray:
• 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
Normal Lisfranc jointNormal Lisfranc joint
Treatment:Treatment:
• Consult ortho
• May try closed reduction with traction but post reduction displacement of >2mm or tarso-metatarsal angle> 15 degrees requires surgery
Forefoot fractures:Forefoot fractures:
• Metatarsal
• Phalangeal
Case10:Case10:
Case 11:Case 11:
Treatment:Treatment:
• 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
Treatment cont.Treatment cont.
• Metatarsal base # r/o LF injury
• Jones Fracture=5th metatarsal base fracture. – Tx=non displaced NWB BK cast x6-8 wks– = displaced surgery
Jones #Jones #
Peds= ?apophysisPeds= ?apophysis
Phalangeal #Phalangeal #
• 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