The ANKLE and the FOOT

TRAUMA

MI Zucker, MD

A dr Z Lecture

• On TRAUMA of the Ankle and Foot and some general concepts in musculoskeletal trauma evaluation

Rules for Success in Radiology

• Know which exam to order

• Know which films you need

• Know good films from bad films, and don’t accept bad ones

• Read methodically by check list

• Know the common lesions

• Know the commonly missed lesions

General Approach to Musculoskeletal Radiology

• Soft tissues

• Joints

• Bones

The ANKLE

The Ankle Series

• Anterior-posterior (AP)

• Mortise (15 degree internal oblique)

• Lateral

Anterior-Posterior: Adult

AP: Kid

Mortise: Adult

Lateral: Adult

Lateral: Kid

The INJURIES

ANKLE

When Does the Patient NEED Radiography?

The OTTAWA Rules

Ankle and Foot

The OTTAWA ANKLE Rules

• Unable to weight bear immediately

• Unable to walk four steps in medical facility

• Bone tenderness medial or lateral malleolus

If “YES” to any, get ANKLE films

The OTTAWA FOOT Rules

• Bone tenderness base of fifth metatarsal

• Bone tenderness navicular

If “YES” to either, get foot films

Some OTTAWA Rule caveats

• Not valid if injury not acute

• Some exclude patients under age 18 years or over 55 years

These factors make the Rules less reliable, so we are more likely to do imaging in these circumstances.

OTTAWA Rules: Ankle Tenderness

OTTAWA Rules: Foot Tenderness

The Ankle Sprain

• Grade I: Soft tissues swelling/joint effusion

• Grades II and III: Soft tissue swelling/joint effusion but may also have “FLAKE” avulsion fractures of the dorsum of the talus or navicular bones.

• Management differs, depending on grade

The Sprain: treatment

• Grade I

• Grades II/III

• Ace wrap, crutches, limited time off weight bearing

• Air or posterior splint, crutches, prolonged period off weight bearing, orthopedic consult

Soft Tissue Swelling

Joint Effusion

“FLAKE” Fracture

FRACTURES of the ANKLE

WEBER’S Classification

• Based only on location of a FIBULA fracture. A fracture, or no fracture, of the medial malleolus (tibia) does NOT change the classification.

WEBER’S Classification

• Weber A: Fracture below the joint margin

• Weber B: Fracture begins at the joint margin

• Weber C: Fracture begins above the joint margin

Weber A, B, and C injuries are ALL from INVERSION

WEBER’S Assumptions

• Weber A: Anterior and posterior tibia-fibula and interosseous ligaments intact: STABLE

• Weber B: Anterior and posterior tibia-fibula ligaments torn: Moderately UNSTABLE

• Weber C: Interosseous ligament torn: Completely UNSTABLE

Management of WEBER Injuries

• Weber A: Cast for 6 weeks

• Weber B: Frequently ORIF

• Weber C: Always ORIF

ORIF: Open Reduction Internal Fixation

WEBER A

WEBER B

WEBER C

REMEMBER

If the MEDIAL MALLEOLUS is also fractured, it does NOT change

the Weber classification

What if ONLY the Medial Malleolus is Fractured?

Two possibilities

• Weber A “equivalent” from INVERSION: The Lateral Collateral Ligament is torn but the Lateral Malleolus did not fail

• EVERSION INJURY: an UNSTABLE Maisonneuve Fracture

Maisonneuve Fractures

• These are EVERSION injuries that fracture the MEDIAL MALLEOLUS, tear the entire Interosseous Ligament and Membrane, and exit as a high FIBULA SHAFT fracture

• They are all UNSTABLE and are treated by ORIF

Maisonneuve Fracture: Lower

Maisonneuve Fracture: Upper

Caveat

• The high fibula fracture may be clinically occult

• So, ALWAYS get AP/lateral films of the ENTIRE tibia and fibula if there is an “isolated” medial malleolus fracture on the ankle series

Bimalleolar Fracture

• Medial and lateral malleolar fractures, but still use Weber, as medial malleolar fracture does NOT change classification

• This is a Weber B

Trimalleolar Fracture

• In addition to lateral and medial malleolar fractures, there is a fracture of the distal posterior tibia, called the POSTERIOR Malleolus. If large, extra ORIF needed.

“Ankle” Injuries that are really FOOT Injuries

• Fractures of the base of the Fifth Metatarsal

• Fractures of the Anterior Process of the Calcaneous

• “Flake” fractures of the Talus or Navicular (we already did this, and they are components of an ankle injury)

Fractures of the Base of the Fifth Metatarsal

We will look at these again

When we get to the FOOT

Fractures of the Anterior Process of the Calcaneous

Stress fractures: repetitive microtrauma

Salter-Harris Injuries

Physis injuries, so KIDS ONLY!

Salter-Harris PHYSIS Injuries

• SH I: Physis only• SH II: Physis and

metaphysis• SH III: Physis and

epiphysis• SH IV: Physis, metaphysis

and epiphysis• SH V: Crush injury of

physis• SH VI: Avulsed piece of

metaphysis, physis, and epiphysis

Salter-Harris what?

Salter-Harris I and IV

Remember: KIDS ONLY!

NO Salter-Harris injuries are possible after physis closes:

“Salter-Harris Nothing”

And now…

The FOOT

FOOT: Views

• AP

• Oblique

• Lateral

AP

AP

Oblique

Lateral

AP FOOT: Kid

Lateral FOOT: Kid

Talus

• Avulsions of dorsal margin: Ankle ligament injury (we did it under ANKLE)

• Osteochondral fracture: acute and stress

• Body of talus

Talus Body fracture

Osteochondral Fracture

Calcaneous

• Body: axial load

• Stress: repetitive microtrauma

• Anterior process: ankle injury

Axial Load Fracture

Stress Fracture

• Initial film: pain one week

• Follow-up film: pain three weeks

Fifth Metatarsal Base

• DANCER’S: tubercle, inversion, heals well

• Crepe support, walking boot or cast, on or off weight bearing: depends on extent of fracture

• JONES: proximal shaft, inversion or direct blow or stress, sometimes delayed or non-union

• Posterior cast or boot, off weight bearing

• If non-union, ORIF

Dancer’s Fifth

Jones Fifth

Lisfranc Injuries

• Severe dorsal or plantar flexion at midfoot-forefoot junction

• Usually, very displaced and obvious

• Can be subtle

• ALL need surgery

Lisfranc: obvious

Lisfranc: subtle

Metatarsal fractures

• Spiral

• Stress

Spiral fracture

Stress fracture

Toe fractures

• “Stub”

• Crush

Toe fractures

GOODBYE

• Copyright 2004

MI Zucker