Ankle and foot injuries

Question 1

what cause ankle (soft tissue) sprains?

Answer 1

trauma
usually twisting forces (usually inversion/twisting forced on a planted foot)
high energy or osteoporotic bone
Elastic limit of ligaments - usually lateral ligaments (A/PTFL - anterior/posterior talofibular
ligaments, calcaneofibular ligaments CFL)

Question 2

presentation of ankle sprian?

Answer 2

takes longer to resolve than a fracture
pain 
bruising 
tenderness 
severity graded (1-3, 3 being complete rupture)

Question 3

what is the management of an ankle sprain?

Answer 3

non-surgical: RICE (rest, ice, compression and elevation) 
physiotherapy 
surgical 
- Brostrum Gould 
- Chrisman Snook

Question 4

What is the cause of ankle fracture?

Answer 4

common

usually a result of twisting forces (usually inversion or twisting on a planted foot)

Question 5

what determines need for x-ray in ankle injury?

Answer 5

Ottawa criteria is used in A&E to determine whether an X-ray is needed:
severe localised
tenderness (bony tenderness) of the distal tibia/fibula, or inability to weight bear for four steps

Question 6

what is the classification of ankle fractures?

Answer 6

weber classification
A - fracture of the lateral malleolus distal to the syndesmosis/tibial plafond (connection between the distal ends of the tibia and fibula) - usually stable
B - fracture at the level of the syndesmosis, can be stable or unstable (e.g. distal fibula fracture
WITHOUT medial malleolus fracture/deltoid ligament rupture would be stable, but WITH these
impairments it would be unstable)
C - fracture proximal to the level of the syndesmosis, usually unstable
• If unstable, need ORIF with plates and screws

Question 7

what does talar shift/ tilt on AP x-ray mean?

Answer 7

deltoid ligament must be ruptured if there is no medial lammelar fracture
gross talar shift causes fracture-dislocation

Question 8

what is the prognosis of talar shift?

Answer 8

Ankle joint contact pressures greatly increase with subsequent risk of post-traumatic OA whit
even 1mm of talar shift - SO anatomic reduction and rigid internal fixation is required to
minimise this risk with any taller shift

Question 9

what is a bimalleolar ankle fracture?

Answer 9

(both medial and lateral malleoli fractured)
are unstable, usually do ORIF
(ORIF may be delayed by 1-2 weeks if there is associated soft tissue swelling and fracture
blisters, this is to reduce the risk of wound healing problems and infection)

Question 10

what is a calcaneal fracture?

Answer 10

usually caused by fall from height onto heal

prognosis dependent on the extent of the involvement of the subtalar joint and the degree of comminution

Question 11

what is a talar fracture?

Answer 11

usually because of forced dorsiflexion from rapid deceleration (RTA/ aircraft crash)
with dislocation/subluxation of the talus or displacement of the fracture
high risk of AVN
reduction

Question 12

what is a midfoot (lisfranc) fracture/dislocation?

Answer 12

uncommon and often overlooked
Fracture of the base of the 2nd metatarsal is associated with the dislocation of the base of the
2nd metatarsal, with/without dislocation of the other metatarsals at the tarso-metatarsal joints
the ligament from the medial cuneiform to the base of the 2nd metatarsal not longer holds the
metatarsal in joint

Question 13

what is the investigation of a midfoot (lisfranc) fracture/dislocation?

Answer 13

can be missed on x-ray

if in doubt CT

Question 14

how does midfoot (lisfranc) fracture/ dislocation presenT?

Answer 14

grossly swollen
bruised foot
unable to weight bear (be wary if x-ray looks normal)

Question 15

how is a midfoot (lisfranc) fracture/ dislocation managed?

Answer 15

closed/open reduction with fixation using screws

Question 16

what is a 5th metatarsal fracture?

Answer 16

a fracture of the base of the 5th metatarsal

normally due to an inversion injury with an avulsion fracture at the insertion of the peroneus brevis tendon

Question 17

how should 5th metatarsal fractures be managed?

Answer 17

heal - need walking cast/supportive bandage/ stout boot for 4-6 weeks
even if it fails to achieve bony union may have stable fibrous non-union (usually asymptomatic)

Question 18

who gets 1st metatarsal fractures?

Answer 18

they are uncommon because it is strong and thick

important so normally fixed

Question 19

what is a lesser metatarsal fracture?

Answer 19

common - often with multiple fractures
if minimal displacement then can be conservatively treated with a cast
if multiple displaced fractures - stabilised with K-wires to reduce the risk of chronic pain

Question 20

what is a 2nd metatarsal fracture?

Answer 20

a common site for stress fracture
can occur spontaneously
or
after period of increased exercise/activity

Question 21

how is a 2nd metatarsal fracture managed?

Answer 21

May not be seen on X-ray until healing/callus appears (can take several weeks)
Diagnosis: may use bone scan
Treatment: cast until pain subsides

Question 22

what is the management for a toe fracture?

Answer 22

Rarely need anything except protection in a stout boot
Intra-articular fractures of the base of the proximal phalanx at the hallux: can do reduction and
fixation (if fragments are sizeable)
Open fractures: debridement, may be stabilised with wires• Dislocations: closed reduction and either neighbour strapping or wiring