ANKLE and. foot FRACTURES 2021 (2).pptx

ANKLE FRACTURES

1. Ankle A nd Foot Fractrues Dr.Ghazi Ariki

2. Ankle joint The ankle is a complex joint consisting of functional articulations between the tibia and fibula, tibia and talus, and the fibula and talus, each supported by a group of ligaments.

3. The tibia and fibula form a mortise, providing a constrained articulation for the talus or tenon The articular surface of the distal tibia ( tibial plafond) and the mortise is wider superiorly and anteriorly to accommodate the wedge-shaped talus. The shape of the joint alone provides some intrinsic stability, especially in weight bearing

4. Ankle joint Anatomy

5. Ankle joint Anatomy

6. Bony and ligaments structures of the ankle joints

7. Mechanism of ankle injury The pattern of injury to the ankle depends on many factors, Age of the patient, Quality of the bone, Position of the foot at the time of injury, The direction, magnitude, and rate of the loading forces. of Lauge -Hansen. He emphasized the influence that the position of the foot had on the injury pattern and correlated this position with the direction of the deforming forces. In his system, the position of the foot (pronation or supination) at the time of injury is described first and the direction of the deforming force is described second. The common deforming forces acting on the ankle are (adduction, abduction, external rotation, and vertical loading).

8. Basic mechanism of injury

9. Danis -Weber System of classification AO Weber- Danis classification is based on location of the fibular fracture Weber A –Avulsion fracture below the tibiofibular joint line. Weber type B – Is an oblique fracture arising from the joint line. Weber C- is more proximal fracture of the fibula associated with syndesmotic injury

10. Sings and symptoms History Vertical loading from falls or high-speed deceleration may result in axial compression injuries to the foot, ankle, and spine, while twisting usually results in an external rotation injury. A history of prior ankle problems or injury may be important. Recurrent injuries, particularly ligament sprains, are common, and preexisting laxity, instability, or radiographic abnormalities can be misinterpreted as an acute injury. The patient's medical history should be reviewed because systemic problems such as diabetes, peripheral vascular disease, or metabolic bone disease may affect treatment planning.

11. Physical Examination Careful examination is needed to determine the status of the skin, soft tissues, and neurovascular structures, as well as the bones and ligaments. The entire lower leg, including the fibula, should be examined. Combinations of tenderness, swelling, or ecchymosis over the bone, ligaments, or joint line suggest an injury. The stability of the joint should be assessed, especially when these findings are associated with normal x-rays. Based on the physical findings, an anterior drawer, inversion, eversion, or external rotation stress test may be helpful.

12. Radiographic finding The standard radiographic evaluation of the ankle includes AP, lateral, and mortise views. The AP x-ray is taken in line with the long axis of the foot. The lateral view is obtained with the limb perpendicular to the long axis of the foot. The dome of the talus should be centered under the tibia and congruous with the distal tibial articular.

13. Radiographic finding The mortise view is obtained with the leg internally rotated 15° to 20° so that the x-ray beam is nearly perpendicular to the intermalleolar line. Mortise view of the ankle A-x-ray of the normal ankle, B- Parameters measured from mortise view A-B tibiofibular overlap

14. Specialized Evaluation Stress X-Rays Are used to confirm suspected ligamentous instability. Stress views of the opposite ankle must be obtained for comparison. To evaluate the lateral ligaments , an AP and mortise view is taken with an inversion (supination) stress on the ankle. Stress views with the foot in plantarflexion isolate the anterior talofibular ligament, while views in neutral evaluate both the anterior talofibular and calcaneofibular ligaments. There is normally less than 5° of talar tilt in the normal ankle. A difference in tilt of twice the uninjured ankle or a talar tilt of more than 10° to 15° indicates a tear of the anterior talofibular and calcaneofibular ligaments .

15. The external rotation stress x-rays evaluate the syndesmosis , and good views of the mortise are needed to make accurate measurements of syndesmotic integrity. A lateral x-ray during an anterior or posterior drawer stress may show subluxation of the talus. An anterior shift of greater than 8 to 10 mm compared with the uninjured ankle indicates a tear of the anterior talofibular ligament. The measurements obtained from the stress views may be influenced by the degree of patient relaxation, the position of the ankle, the amount of force used in testing, and the laxity of the contralateral ankle.

16. STRESS X-RAY Inversion stress x-ray showing talar tilt Anterior drawer stress x-ray showing anterior subluxation of the talus

17. Arthrography Arthrography has been used to evaluate the integrity of the capsule and ligaments of the ankle. Tomography Computed Tomography Magnetic Resonance Imaging: Magnetic resonance imaging allows multiplanar imaging without radiation. MRI is a useful diagnostic tool in the assessment of acute and chronic tendon and ligament injuries about the ankle. Bone Scan Arthroscopy

18. TREATMENT The goals of treatment are to obtain an anatomical reduction, maintain this reduction until the fracture heals, and return the patient to his or her preinjury level of function with a painless, mobile ankle. Nonoperative Treatment: Closed reduction is indicated for Nondisplaced or stable fractures. Displaced fractures when an anatomical reduction is obtained and maintained without repeated manipulation. When operative treatment is not indicated because of the general condition of the patient or the leg. When operative treatment is planned but will be delayed.

19. Operative Treatment The goals of operative treatment are to obtain an anatomical reduction that is maintained by stable fixation, resulting in a healed fracture and recovery of normal function. Indication for Operative treatment: Failure of closed reduction When closed reduction requires forced. Abnormal positioning of the foot, such as forced plantarflexion and inversion. Displaced or unstable fractures of either or both malleoli that result in displacement of the talus or widening of the mortise greater than 1 to 2 mm. Open fractures. The current trend is toward recommending open reduction and internal fixation for any displaced fracture that involves the articular surface. However, each patient must be individualized and the presence of systemic disease, such as diabetes mellitus, physiologic age, activity level, and particularly osteoporosis, must be evaluated before recommending operative treatment.

20. Type of internal fixation

21. Medial malleolar fracture Pt. present with medial ankle pain, swilling, ecchymosis and decreased range of motion the may unable to bear weight. Isolated fractures involving the medial articulation need consultation with an orthopedic. When no evidence of joint instability should have short leg splint and treated with RICE analgesics. Bi- and trimalleolar fracture: Medial malleolar fractures often present one component of a bi or trimalleolar fracture. In trimalleolar fracture all malleoli (Lateral, medial, posterior) are fractured. Clinical picture:Sever pain, swilling, ecchymosis. If there is dislocation with fracture joint deformity noted. Should be reduced immediately in the ER prior to hospitalization for ORIF .

22. Closed injury are typically unaccompanied by vascular compromise, and traction with appropriate manipulation to correct deformity is usually successful. Open fractures are common and more likely to have associated vascular compromise. Reduction in emergency department after surgical cleaning and copious irrigation is necessary unless immediate orthopedic operative care is available. In both closed and open fracture and fracture dislocation, a long leg posterior splint is placed followed by postreduction x-ray and vascular checks and Ortho. follow-up.

23. Posterior marginal fracture: Isolated posterior marginal tibial fractures are rare – nondisplaced fractures involving less than 25% of articular surface cane be treated closed and more than 25% displaced fracture need open reduction and internal fixation. Plafond fracture : Are also known an anterior marginal tibial fracture do to a high-energy dorsiflexion force this fracture need Ortho consultation. Maisonneuve Fracture : is an oblique fracture of proximal fibula with either disruption of the deltoid ligament or fracture of the medial malleolus . Treatment depending on if the medial malleolus displeased. To need ORIF

24. Tillaux fracture Is an avulsion fracture of the bone element by ATFL fracture of an anterior aspect of the distal tibia. The fracture line started and the joint line and extends vertically exiting or distal to the fused physis . If closed reduction is unsuccessful,ORIF is used.

25. PILON FRACTURE Definition: it is distal tibial metaphyseal fracture with extension in to the joint surface, usually with extensive comminution . The pilon fracture is among the most challenging problems faced by the orthopaedic surgeon. This fracture involved the tibial plafond of the ankle joint. As more experience with this fracture has been gained, the large compressive forces with the resulting crush injury and the significant disruption of the articular surface have been recognized. Mechanism of Injury The primary component of force is vertically directed through the talus into the distal tibia.The severity of bone, cartilage, and soft-tissue damage is directly proportional to the amount of energy involved in the traumatic event.

26. Classification Type I fractures are cleavage fractures of the articular surface with minimal displacement of the intra-articular fracture fragments. Type II fractures involve significant displacement of the intra-articular fractures without comminution but moderate intra-articular incongruity. Type III fractures are similar to type II fractures but have significant comminution with impaction of the distal tibia and gross incongruity of the articular surface.

27. Signs and Symptoms Meticulous examination of the skin. Soft tissues. Neurovascular structures, including pulses, should be performed. The tibia is mostly subcutaneous in this area; fracture displacement or excess pressure on the skin may convert a closed fracture into an open one. Swelling is often rapid and massive, and the fracture should be reduced and splinted as soon as the examination is complete. Subsequent edema, fracture blisters, and skin necrosis from the original injury may still convert closed fractures to open injuries, and continued soft-tissue monitoring is important. In addition, since many patients are victims of multitrauma , associated injuries are common and must be treated appropriately.

28. Diagnosis The standard three views of the ankle and a 45° external rotation view to delineate the anteromedial and posterolateral surfaces of the tibia should obtained. Computed tomography with coronal and sagittal reconstructions or conventional tomography may be considered to better evaluate the fracture pattern. A radiograph of the normal contralateral ankle may be used as a template guide for preoperative planning.

29. Conclusion Ankle injuries are commonplace in the ER. An understanding of ankle anatomy is integral to the accurate assessment and care of this injury. A systemic approach in the history and phys. Exam. And selective use of x-ray will prevent the clinician from overlooking commonly missed injuries. Appropriate splinting and timely consultation and referral will help reduce the morbidity associated with many ankle injuries

30. The Foot Function of the foot includes weight bearing, balance, and leverage for walking and running. Anatomy : the foot contain 28bons 57joints

31. Mechanism of injury Foot injury are result of direct trauma indirect trauma and overuse injury Fall from height on the heel. Axial compression on plantar flexed foot . Sudden increase in training Physical examination Phys.exam it includes assessment for ligamentous and joint stability, neurovascular compromise, soft tissue injury exam and documentation should include the following Inspection Inspect for swilling, ecchymosis, deformity, color and skin integrity. Palpation. Palpate for tenderness and Crepitus at site remote from the injury Range of motion Neurovascular examination

32. Radiography Radiographic interpretation of the foot is difficult because of overlapping shadows, secondary ossification centers, and sesamoid bones . Foot x-ray usually includes AP, Lt,Oblique view. An oblique view is often necessary to sort out the shadows of the overlapping small bones. Calcaneous view are ordered when evaluating calcaneal injury. Toes x-ray suffice in injuries limited to the toes Bone scan can aid in diagnosis of occult or stress fractures that are not radiograhically apparent.

33. Hand foot TALUS FRACTURES Associated with serious complications,including : Skin necrosis. Infection. Avascular necrosis. Malunion,and nonunion. Ankle and subtalar arthrofibrosis . Posttraumatic arthritis Blood supply of the talus.The three main arterial contributions are shown, in addition to the deltoid branch to the medial talar body .

34. Talus fractures Osteochondral fracture are common after inversion or eversion injury of the ankle. Body fractures are typically the result of high-impact injuries causing compression of the talus between the tibia and calcaneus.there is considerable displacement of fracture fragments with dislocation of the ankle and subtalar joints. This injuries should be evaluated by an orthopedic and often require ORIF nondisplaced fracture cane be treated by cast for 6-8weeks. Neck fracture the most common mechanism of talar neck fracture is hyperdorsiflexion of the foot on leg .

35. RADIOGRAPHIC EVALUATION High-quality anteroposterior (AP). Lateral. Oblique radiographs of the ankle and foot. Pronated oblique view of the midfoot to better visualize the talar neck and head. Tomograms or computed tomography (CT) scans are occasionally required to assess the fracture configuration and displacement. Pronated oblique view of midfoot to better visualize the talar neck. Ankle is in maximal equinus , with foot pronated 15°. Direct the roentgen tube 75° from the horizontal.

36. Classification of talus fracture The progressive displacement of the body of the talus produced one of three basic fracture configuration, with correlate with the three fracture types by Hawkins type : Nondisplaced vertical fracture of the talar neck. Displaced fracture of the talar neck with subluxation or dislocation of the subtalar joint (the ankle joint remains aligned) Displaced fracture of the talar neck with dislocation of the body of the talus from both the subtalar and ankle joints.

37. Treatment Should be designed to minimize these complications as osteonecrosis which most common and depend on severity of initial injury, all recent reviews of subject conclude that the best results occur when prompt, perfectly anatomical reduction of the neck fracture is achieved and maintained. Open dislocated fractures are orthopedic emergencies requiring: Irrigation Broad spectrum antibiotic Operative debridement Immobilization Closed type I fracture require immobilization with cast for 8-12 weeks Type II and III need prompt ORIF

38. Calcaneus The calcaneous ( os calcis ) is the tarsal bone most often fractured. Despite extensive clinical experience with this injury. Its major socioeconomic impact in regard to the time lost from work and recreation, the attention given it for many years by surgeons throughout the world and recent advances in imaging and operative treatment, often the result of this fracture are poor.pointed out that fracture of the calcaneous is one injury that has not increased in frequency with the advent of mechanized industry, automobile travel, or war. It has been common, often disabling injury since humans assumed the erect posture and began to defy gravity.

39. The calcaneous is the largest bone in the foot and absorbs most of the body weight with walking. It the most commonly fractured tarsal bone. It articulate with cuboid anteriorly and the talus superiorly. The medial and lateral processes on its plantar aspect severe as insertion points for muscle and plantar fascia. The calcaneous has a thin cortex and contains trabeculae that sometimes make radiographic interpretation of the subtle fractures difficult.

40. Calcaneal fracture occur with falls from height and are associated with compression fractures of the lumbar spine. The treatment of calcaneal fracture is challenging because often treatment result are not optimal. Symptoms and signs: Pain Swilling Deformity Skin blistering occur during first 36hour as result of sever damage to surrounding of soft tissues. Imaging X-ray AP and lateral view,axial calcaneal view . Tomography, CT scanning will further delineated fracture patterns and occult injury, bone scan may be useful to diagnose a stress fracture.

41. Classification The primary importance of classification is to separate those fractures that tend to have a good prognosis from that do poorly or require more aggressive treatment to ensure a satisfactory outcome. Essex- Loprestiwas : One of the first to emphasize the difference between extra-articular fractures, which tend to do well, and fracture involving the subtalar joint, which generally have a poorer prognosis. Various subtypes and configuration exist within each group of fractures. Extra-articular fractures occur infrequently (25% to30% of all calcaneal fractures ) and are divided anatomically in to the following: Anterior process Tuberosity (beak or avulsion) Medial process, sustentaculum tali Body

42. Intera -articular fractures (which comprise the remaining 70% to 75% of calcaneal fractures ) Type of intera -articular fractures Nondisplaced fractures Tongue type Joint depression Comminuted fracture Treatment Displaced intera -articular fracture need orthopedic consultation as a significant percentage of Pt have a poor outcome with this injury. Extra –articular fractures all nondisplaced fracture can be treated by RICE for 1-2weeks and subsequent treatment with walking cast and partial weight bearing for at lest 8weeks Displaced fracture need Ortho consultation

43. Dislocation Subtalar dislocation also known as peritalar dislocation, involves dislocation of the talocalcaneal and talonavicular joints with intact tibiotalar and calcaneocuboid joints, medial dislocation are the most common, than lateral dislocaation . Treatment of the dislocation is closed reduction and immobilization. Open talar dislocation needs irrigation, broad-spectrum antibiotic, and operative reduction

44. Midfoot Fractures is rarely happened. Usually result from crush injury. Cuboid and cuneiform fractures usually occur in combination and have associated subluxation or dislocation . Physical examination Reveals tenderness and swilling over the fractured bone. Treatment : for most nondisplaced fractures is short leg cast isolated fractures of the navicular , cuboid or cuneiforms are best immobilization in short leg posterior splint, with prompt orthopedic attention. As in all foot fractures elevation and ice to prevent excessive swilling are important. Multiple fractures or open injury need hospitalization.

45. Tarsometatarsal dislocation Lisfranc A fracture dislocation is rare but commonly missed injury.the recessed base of second metatarsal is the locking keystone of the joint and is held in place by an oblique ligament between the medial cuneiform and the second metatarsal . Transverse ligaments connect the bases of the second to fifth metatarsals but not the first metatarsal. During injury there is dislocation at the site of lowest resistance, usually the dorsal aspect of the Lisfrancs joint at the base of the second metatarsal. The usual mechanism of action is an axial load. May result from auto accidents when the foot is braced against the floorboard in extreme plantarflexion . Direct crushing blows can also cause this injury.

46. Physical examination Extreme swilling and tenderness over the Lisfrancs joint. Paresthesias may be described overlying the midfoot . Because the extreme forces involved in these joints,open wound with associated tissue damage and vascular impairment are typical. Radiography : X-ray diagnosis cane be difficult. The injury may be seen only on an oblique view. Treatment: Hospitalization and immediate orthopedic consultation for reduction and fixation under anesthesia. Complications such as acute vascular compromise from artery compression or spasm as well as residual pain and osteoarthritis can occur.

47. Forefoot Metatarsal: most metatarsal fracture are transverse resulting from direct trauma. Nondisplaced neck and shaft fractures should placed in short leg splint. Fracture with neurovascular and skin injury need checks and orthopedic follow up The fracture best seen on the AP and lateral views. Marsh fracture : the second and third metatarsal fracture thy are susceptible to stress marsh fracture. Diagnosis : by history and examination and bone scan that shows increased activity in areas of stress may allow for an early diagnosis. Treatment cessation of activity 4-6 weeks is curative.

48. Base of the fifth metatarsal : Peroneus brevis tendon avulses the tuberosity of the base of the V metatarsal in longitudinal fashion. Jones fracture : Transverse fracture at the proximal diaphysis of the fifth metatarsal Phalangeal and sesamoid fracture& dislocation: Usually occur with direct trauma or forced hyperextension, comminuted fractures of the great toe may require a walking cast