14 - T&O Ankle and Foot Flashcards
What is the definition of an ankle fracture?
Fracture of any malleolus (lateral, medial or posterior) with or without disruption to the syndesmosis
Tibial articular surface (plafond) fracture is not an ankle fracture this is a Pilon fracture
What is the ankle syndesmosis?
Fibrous structure consisiting of anterior inferior tibofibular ligament (AITFL) and posterior inferior tibiofibular ligament (PIFL) and interosseous mebrane
How are ankle fractures classified?
- Anatomically: e.g isolated lateral malleolar fracture, bimalleolar fracture, trimalleolar fracture
- Weber Classification (Classifies lateral malleolus fractures)
- Lague Hansen classification
How will an ankle fracture present?
- Ankle pain
- Associated deformity if fracture dislocation (urgent reduction)
- Check for neurovascular compromise and skin integrity for open fracture
What investigations should you do if you suspect an ankle fracture?
- Plain radiography AP and Lateral with ankle dorsiflexed as talus can look translated in mortise when plantarflxed
- If complex use CT scan
- Use Ottawa rules if diagnostic uncertainty
How are ankle fractures managed?
- Immediate reduction under sedation in A+E then put on below knee back slab
- Repeat post reduction neurovascular exam
- Repeat plain film radiography
Conservative
- If non-displaced medial malleolus fracture, Weber A, Weber B without talar shift, those for surgical intervention
- Below knee back slab for a week then bring back for x-ray and full cast
Surgical
- ORIF if displaced bi/trimalleolar, Weber C, Weber B with talar shift, open fractures
What are the complications with ankle fractures?
- Post traumatic arthritis (rare if appropriate reduction and fixation)
- ORIF: surgical site infection, DVT/PE, neurovascular injury, non-union, metalwork prominence
How are ankle sprains produced and how are they managed?
- High ankle sprain: to the syndesmosis
- Low ankle sprain: damage to ATFL and CFL
Usually due to inversion injury. Fingertip tenderness distal to malleoli, swelling and pain
Get plain film radiograph to rule out bony injury then RICE and early mobilisation
How are calcaneal fractures classified and how do they occur?
Most commonly fractured tarsal bone usually due to axial loading (fall from height). Associated with other fractures
Intrarticular (75%)
Articular surface of subtalar joint, further classified by Sanders Classification. Intra need definitive fixation
Extraarticular (25%)
Avulsion fractures, usually calcaneal tuberosity by Achilles tendon
How do calcaneal fractures present?
- Recent trauma
- Pain and tenderness around calcaneal region
- Inability to weight bear
- Swollen and bruised
- Shortened and widened heel
- Varus deformity
- Assess posterior heel skin integrity (any tenting or blanching needs emergency surgical intervention)
What investigations should you do if you suspect a calcaneal fracture?
- Gold standard MRI
- Plain film radiograph (AP, lateral, oblique): will show calcaneal shortening, varus tuberosity deformity, decreased Bohler’s angle
How are calcaneal fractures managed?
Conservative (<2mm displacement or normal Bohler’s angle)
- Cast immobilisation and no weight bearing for 10-12 weeks
Surgical
- Closed reduction with percutaneous pinning if large fracture but minimal displacement
- ORIF otherwise
- Emergency surgical fixation if any skin compromise
What are some complications with a calcaneal fracture?
Subtalar arthritis that can be treated with analgesia and physio. If unsuccessful with need subtalar arthrodesis
What is the pathophysiology of achilles tendonitis and achilles tendon rupture and what are some risk factors for this?
Repetitive action of tendon results in microtears leading to local inflammtion. Tendon becomes thickened, fibrotic and loses elasticity
Rupture occurs when substantial sudden force (e.g change in direction runnin) applied to tendon when already has tendonitis
Risk factors: unfit individual with sudden increase in exercise, poor footwear choice, male gender, obesity, fluoroquinolone use
How does achilles tendonitis and achilles rupture present?
Tendonitis
Gradual onset of pain and stiffness in posterior ankle that is worse with movement.
Tenderness 2-6cm above insertion site
Rupture
Sudden onset sever pain with audible popping sound. Loss of power of plantarflexion
Do Simmonds Thompson test and feel for palpable step in tendon
How is Achilles tendon rupture and tendonitis investigated and managed?
Ix
Usually clinical but can use US if not sure
Mx
Tendonitis: stop precipitating exercise, NSAIDs, if chronic physiotherapy
Rupture: Analgesia and immobilisation in a plasta full equinus with crutches and no weight bearing. Hold position for 2 weeks then semi-equinus for 4 weeks then neutral for 4 weeks
Delayed presentation (>2 weeks) or rerupture needs surgical fixation with end to end tendon repair
What is the pathophysiology of talar fractures?
Second most commont tarsal bone to fracture, usually in the neck
Usually due to high energy trauma when ankle forced into dorsiflexion causing talus to hit tibial plafond
Talus has retrograde blood supply so fracture causes high risk for AVN
How do talus fractures present and what are some differentials?
- Immediate pain and swelling around ankle
- If dislocation then unable to dorsiflex or plantarflex ankle
- Check if overlying skin is threatened
- Do distal neurovascular status
Differentials: ankle fracture, Pilon fracture
When is skin ‘threatened’? (close to becoming open fracture)
- White
- Non-blanching
- Tethered
How are talar fractures investigated and classified?
- AP and Lateral plain film radiographs in both dorsi and plantarflexion. Plantar reduces any subluxation present
- CT imaging if complex
- Hawkins Classification used for talar neck fractures to determine risk of AVN