Week 6 - H - Regional Adult Trauma (7) - Ankle injuries/fractures, foot injuries/fractures

Question 1

What are the bones that make up the knee and ankle joint?

Answer 1

Knee joint - 2 tibiofemoral articulations and 1 patellofemoral articulation

Ankle joint - formed by the tibia, fibula and talus

Question 2

What is the common way to get an ankle injury?

Answer 2

Inversion of the ankle or rotational force on a planted foot

Question 3

Which muscles cause inversion of the foot? Which cause eversion? What compartments do the muscle lie in?

Answer 3

Muscles causing inversion - tibialis anterior (anterior) and posterior (posterior)

Muscles causing eversion - fibularis longus& brevis (lateral) and tertius (anterior)

Question 4

Where do the tibialis posterior and anterior insert?

Answer 4

Tibialis anterior - base of the 1st metatarsal

Tibialis posterior - navicular

Question 5

Does the navicular or medial cuneiform attach to the 1st metatarsal?

Answer 5

The medial cuneiform articulates with the 1st metatarsal

Question 6

Where do the fibularis longus, tertius and brevis insert?

Answer 6

Fibularis longus (long so reaches far) - base of 1st metatarsal

Fibularis brevis and tertius - base of fifth metatarsal

Question 7

What are soft tissue sprains of the ankle characterised by?

Answer 7

Characterized by pain, bruising and mild to moderate pain over the ligaments

Question 8

What is the criteria used to identify a suspected ankle fracture?

Answer 8

THe ottawa criteria

Question 9

In A&E the Ottawa criteria are used to identify a suspected ankle fracture and give guidance as to which ankle injuries require an Xray. According to Ottawa criteria, which ankle injuries require an xray?

Answer 9

Any severe localised tenderness (known as bony tenderness) of the distal tibia or fibula or Inability to weight bear for four steps merits an xray

Question 10

With ankle fractures a distinction needs to be made between stable and unstable fractures. What ankle fractures are said to be stable?

Answer 10

Isolated distal fibular fractures with no medial fracture or rupture of the deltoid ligament are common and said to be stable

Question 11

What is the treatment of stable ankle fractures? Also state one more time what a stable ankle fracture is?

Answer 11

Treatment - walking cast or splint for 6 weeks (conservative)

Stable ankle fracture is an isolated distal fibula fracture with no medial fracture of rupture of the deltoid ligament

Question 12

What is the deltoid ligament of the ankle?

Answer 12

The deltoid ligament stablises the nakle joint by attaching to tibia, calcaneus and navicular

Question 13

Distal fibular fractures with rupture of the deltoid ligament are unstable What is the treatment of this unstable fracture?

Answer 13

Open reduction and internal fixation (with plates and screws)

Question 14

How is rupture of the deltoid ligament suspected?

Answer 14

If there is any brusing and tenderness medially

Question 15

Any talar shift/tilt = deltoid is ruptured (the foot would be slightly internally rotated) What is the treatment of this?

Answer 15

Anatomic reduction and internal fixation

Question 16

Bimalleolar fractures (fracture to both the medial and lateral malleoli) are unstable How are they treated?

Answer 16

Treated with open reduction and internal fixation

Ankle fractures can be associated with substantial soft tissue swelling and fracture blisters.

ORIF may be delayed by 1‐2 weeks to allow the soft tissues to settle and reduced the risk of wound healing problems and infection.

Question 17

How do calcaneal fracture occur and what should be ruled out?

Answer 17

Calcaneal fractures occur due to fall from height onto the heel (eg fall from ladder).

Other injuries associated with a fall from height should be excluded (especially spinal injuries).

Question 18

Fractures of the talar neck usually occur with forced dorsiflexion from rapid deceleration (RTA, aircraft crash). The talar can be displaced and what may this cause due to the blood supplying being around the talar neck?

Answer 18

This may cause avascular necrosis of the talus

Question 19

How is a displaced talar fracture treated?

Answer 19

Displaced talar fracture is treated with open or closed reduction and screw fixation

Question 20

AVN of the talus is not always symptomatic but secondary symptomatic OA may require what treatment?

Answer 20

Ankle fusion through arthrodesis

Question 21

What is the name given to the tarsometatarsal joints of the foot? What are the tarsal bones?

Answer 21

These are lisfranc joints

Tarsal bones - calcaneus, talus, navicular, medial, intermideiate and lateral cuneiform, cuboid

Question 22

A midfoot fracture/dislocation is often overlooked It is eeasily missed on xray so if there is clinical suspicion, what should be carried out?

Answer 22

Carry out a CT

Question 23

The patient typically presents with a grossly swollen, bruised foot upon which they’re unable to weight bear. In these patients, be very wary of a normal looking xray. What is the treatment of a midfoot fracture/dislocation?

Answer 23

Open reduction with internal fixation

Question 24

What tendon causes avulsion fracture of the 5th metatarsal? It attaches to the base of the metatarsal

Answer 24

This would be the fibularis brevis

Question 25

The first metatarsal is uncommonly fractured (due to its thickness and strength) but such is the importance of the first ray to foot function that fractures of the first metatarsal are usually fixed. What is the commonest metatarsal for a stress fracture?

Answer 25

This would be the 2nd metatarsal

Question 26

The fracture may not be visible on plain x‐ray until a healing / callus response has started (can take several weeks). What can generally be used to viw a metatarsal stress fracture? What is the treatment?

Answer 26

Techentium bone scan can view

Usually 6-12 weeks in a rigid soled boot

Question 27

Toe fractures rarely require anything other than protection in a stout boot If it is an open fracture, what is done?

Answer 27

If it is an open fracture of the toe - carry out debridement followed by fixation