Foot & Ankle Fractures

Question 1

What is a mortise?

Answer 1

The mortise bones, the distal ends of the tibia and fibula, are held together as a syndesmosis by the distal tibiofibular and interosseous ligaments.

Question 2

What is the ankles range of movement?

Answer 2

The ankle moves in only one plane (flexion/extension) but has a complex axis of rotation

Question 3

What is found beneath the medial malleolus

Answer 3

Structures posterior to medial malleolus 
-	Tibialis Posterior
-	Flexor Digitorum Longus
-	Tibial Artery
-	Tibial Nerve
-	Flexor Hallucis Longus 
Ligament
Deltoid ligament – resists eversion of the hind foot.

Question 4

What is found beneath the lateral malleolus (include ligaments not technically found below)

Answer 4

Structures inferior to lateral malleolus
- Peroneus brevis
- Peroneus longus
Lateral collateral ligaments – Anterior talofibular, posterior talofibular and the calcaneofibular ligaments.

Question 5

What is the most commonly damaged ligament in the foot

Answer 5

Anterior talofibular ligament runs horizontally from the anterior edge of the lateral malleolus to the neck of the talus. ATFL is the most vulnerable to stretch and most likely to rupture in inversion injury

Question 6

What is the classification system for ankle fractures?

Answer 6

Weber A B C

Question 7

What is Weber classified on the basis of?

Answer 7

The Weber classification system classifies ankle fractures on the basis of lateral malleolar fractures and syndesmosal involvement in an ABC fashion.

Question 8

What is Weber A?

Answer 8

• Usually transverse fracture of lateral malleolus – usually stable if medial malleolus intact

Question 9

What is Weber B?

Answer 9

• Usually spiral fracture of lateral malleolus at the level of the syndesmoses. Medial malleolus may be fracture and deltoid ligament may be torn.

Question 10

What is Weber C?

Answer 10

• Above the level of the syndesmoses, and fracture may arise as far up as the fibular neck.

Question 11

What is the usual history of patient with ankle sprain?

Answer 11

A history of a twisting injury followed by pain and swelling

Question 12

How do you differentiate between sprain and break?

Answer 12

if the patient is able to walk, bruising is faint and slow to appear it is probably a sprain. If bruising is marked and the patient is unable to weight bear then the injury is probably more severe.

Question 13

What is an important rule of ankle fractures

Answer 13

It is vitally important to image the whole leg as there may be occult fractures of the fibular.

Question 14

What views should be taken on imaging of ankle inuries?

Answer 14

Anteror-posterior, lateral and mortise views of the ankle should be taken.

Question 15

When should patient be recalled after being sent home with sprained ankle?

Answer 15

Persistent inability to weight bear over 1 week or longer should call for re-examination and review of all initially negative x-rays.

Question 16

How is ankle sprain treated?

Answer 16

Treatment for lateral ligament damage should be PRICE – Protection (crutches, splint or brace), Rest, Ice, Compression and Elevation. NSAIDS in the acute phase should be used.

Question 17

What is recurrent lateral instability? Why are they worrying?

Answer 17

Recurrent sprains are associated with added cartilage damage and should be investigated by MRI.

Question 18

How do you test and treat recurrent lateral instability?

Answer 18

Stress tests and examinations for ligament instability (talar tilt test/Anterior draw test) can be used.
Modifying shoe wear or surgical intervention is usually required.

Question 19

What are deltoid ligament sprains usually associated with?

Answer 19

Rupture of the deltoid ligament is usually associated with distal fibular fracture or tearing of the distal tibiofibular ligaments. This destabilizes the talus and allows it to move into eversion and external rotation.

Question 20

How is diagnosis of deltoid ligament injury made?

Answer 20

The diagnosis is usually made on x-ray by widening o fhte medial joint space in the mortise view.

Question 21

What is a maissoneuve injury?

Answer 21

An unpronounceable Maissoneuve injury is a rupture of the deltoid ligament but no apparent lateral disruption at the ankle – due to fracture of the proximal fibular. Takes those knee x-rays people!

Question 22

How do malleolar fractures happen?

Answer 22

Malleolar fractures of the ankle usually come about as a result of low-energy twisting, when the foot is anchored in the ground while the body lunges forward. This causes fractures of one or both malleoli with possible ligament involvement.

Question 23

What x-rays are needed in malleolar fractures?

Answer 23

Three views are needed – AP, lateral and a 30 degree oblique “mortise view”. The level of the fibular fracture is often best seen in lateral view. You must request a more proximal x-ray of the fibular to rule out injury higher up.

Question 24

How do you assess ligament injury in ankle injury? (4)

Answer 24

widening of the tibiofibular space, asymmetry of the talotibial space, widening of the medial joint space or tilting of the talus.

Question 25

How do you treat malleolar fractures?

Answer 25

Swelling is rapid and severe and if the injury is not dealt with immediately surgery will have to be put off until the swelling can subside.
Reduce any fractures not in place already and consider ORIF(open reduction, internal fixation) with plate and screws/nails.

Question 26

How do you manage malleolar fractures post-op?

Answer 26

After open reduction and fixation of ankle fracture movements should be regained before applying a below-knee plaster cast.
Patient is allowed partial weightbearing with crutches and support is retained until fracture consolidation (6-12 weeks).

Question 27

Give four complications of malleolar fractures

Answer 27

• Vascular injury
• Wound infection
• Non-union
• Joint stiffness

Question 28

What is apilon injury?

Answer 28

A pilon injury occurs when a large force drives the talus upwards against the tibial plafond, like a pestile (pilon) being struct into a mortar. Considerable damage occurs to the articular cartilage.

Question 29

What happens in child ankle fracturesd?

Answer 29

Physeal injuries are quite common in children and almost a third happen around the ankle.

Question 30

What is the usual salter harris classification of child ankle fractures?

Answer 30

Salter Harris type 1/2 fracture.

Question 31

What is treatment for salter harris 1/2 ankle fractures?

Answer 31

Salter Harris Type 1 & 2 are generally treated closed. If it is displaced then the fracture is usually gently reduced under anaresthetic. More serious Salter Harris fractures must be followed up with x-ray within five days of treatment.

Question 32

Give three child specific complications of ankle fractures

Answer 32

Assymetrical growth – In fractures through the epiphysis (SH 3/4) there may be localized fusion of the physis. This can be corrected through surgery.
Shortening – Early physeal closure occurs in 2% of children with distal tibial injuries.
Malunion – Usually as a result of imperfect reduction, and may result in angular deformity of the ankle (usually valgus). In younger children this may simply be corrected by remodelling.

Question 33

Why must you worry about foot injuries?

Answer 33

Injuries of the foot are often followed by loss of function – this is especially the case in high energy impact, in which large open fractures may distract from a more disabling foot injury.

Question 34

How must foot injuries be assessed?

Answer 34

Entire foot must be assessed for pinpoint tenderness, and the circulation and nerve supply of the appendage must be tested. Imaging usually begins with AP, lateral and oblique views of the foot, although CT may be more useful.

Question 35

How do talar fractures happen?

Answer 35

Talar fractures usually occur as a result of high energy trauma. This is significant as the talus is the major weightbearing structure of the body (more than any other bone) and it has a vulnerable blood supply and is sensitive to ischaemic necrosis.

Question 36

Why are talar fractures prone to avascular necrosis?

Answer 36

Blood vessels enter the talus from the anterior tibial, posterior tibial and peroneal arteries, as well as anastomotic vessels of the ankle joint capsule. The head of the talus has a rich blood supply, but the body is supplied mainly by vessels that run retrograde from distal to proximal. In fractures of the talar neck the vessels to the body can be divided and it can undergo ischaemic necrosis.

Question 37

What is the MOA of talar fracture?

Answer 37

Fracture of the talar neck is produced by violent hyperextension of the ankle.

Question 38

How common are calcaneal fractures and in what weird way do they sometimes present>?

Answer 38

Most commonly fracture tarsal bone and in 5-10% of cases both heels are injured simultaneously

Question 39

Why should we be worried about calcaneal fractures?

Answer 39

Dangerous as can be intraricular, complex and unpredictable.

Question 40

How are calcaneal fractures treated?

Answer 40

Vast majority are treated closed with RICE and exercises as soon as pain permits. No weightbearing is allowed for 4 weeks, and only partial weight bearing 4 weeks after that.

Question 41

Give four other potential fractures of the foot

Answer 41

• Tarsal
• Metatarsal
• Metatarsophalangeal joint injuries
• Fractures toes