ANKLE AND FOOT INJURIES // Treatment .pptx

This presentation covers common ankle and foot injuries, their causes, diagnosis, and Treatment strategies.

1. ANKLE AND FOOT INJURIES PREPARED BY PENUBALA SAI DHARANI PT MSK & SPORTS

2. ANKLE JOINT The ankle joint is a hinged  synovial joint  that is formed by the articulation of the  talus ,  tibia , and  fibula   bone s. The articular facet of the lateral malleolus (bony prominence on the lower fibula) forms the lateral border of the ankle joint The articular facet of the medial malleolus (bony prominence on the lower tibia) forms the medial border of the joint The superior portion of the ankle joint forms from the inferior articular surface of the tibia and the superior margin of the talus. The talus articulates inferiorly with the  calcaneus   and anteriorly with the  navicular .

3. ANKLE INJURIES The bones forming the ankle joint are a frequent site of injury. A large variety of bending and twisting forces result in a number of fractures and fracture-dislocation at this joint. All these injuries are sometimes grouped under a general title ‘Pott’s fracture’. Some terms used in relation to ankle injuries:

4. The Lauge -Hansen classification of ankle injuries is most widely used. It is based on the mechanism of injury. It is believed that a specific pattern of bending and twisting forces results in specific fracture pattern. These are as follows: Adduction injuries. Abduction injuries. Pronation-external rotation injuries. Supination-external rotation injuries. Vertical compression injuries.

5. Adduction injuries (inversion): An inversion force with the foot in plantarfexion results in a sprain of the lateral ligament of the ankle. It may be either a partial or complete rupture. A partial rupture is limited to the anterior fasciculus of the lateral ligament ( talo -fibular component). In a complete rupture, the tear extends backwards to involve the whole of the lateral ligament complex. As complete rupture occurs, the talus tends to subluxate out of the ankle-mortise. The inversion force on an ankle in neutral or dorsiflexed position results in a fracture of the medial malleolus, typically, a fracture with the fracture line running obliquely upwards from the medial angle of the ankle-mortise. On the lateral side, this may be associated with a low transverse avulsion fracture of the lateral malleolus, or a lateral ligament rupture.

6. ABDUCTION INJURY Abduction injuries (eversion): In this type, the medial structures are subjected to a distracting force and the lateral structures to compressive force. This results in rupture of the deltoid ligament or a low-lying transverse fracture of the medial malleolus (avulsion fracture) on the medial side. On the lateral side, a fracture of the lateral malleolus at the level of the ankle-mortise with comminution of the outer cortex occurs. The talus, with both malleoli fractured, subluxates laterally.

7. Pronation-external rotation injuries When a pronated foot rotates externally, the talus also rotates outwards along its vertical axis. The first structures to give way are those on the medial side. There may occur a transverse fracture of the medial malleolus at the level of the ankle-mortise, or a rupture of the medial collateral ligament. With further rotation of the talus, the anterior tibiofibular ligament is torn. This is followed by a spiral fracture of the lower end of the fibula as the rotating talus hits the lateral malleolus.

8. In a case, where the tibio -fibular syndesmosis is completely disrupted, the fracture occurs above the syndesmosis i.e., in the lower-third of the fibula. At times the fracture may occur as high as the neck of the fibula ( Massonaie's fracture).

9. Supination-external rotation injuries With the foot supinated, the talus twists externally within the mortise. As the medial structures are lax, the first structure to give way is that on the lateral side, the head of the talus striking against the lateral malleolus, producing a spiral fracture at the level of the ankle-mortise. The next structure to break is the posterior malleolus. As the talus rotates further, it hits against the medial malleolus resulting in a transverse fracture

10. Vertical compression injuries All the above injuries may become complex due to a component of vertical compression force. It may be primarily a vertical compression injury resulting in either an anterior marginal fracture of the tibia or a comminuted fracture of the tibial articular surface with a fracture of the fibula— Pilon fracture

11. CLINICAL FEATURES There is history of a twisting injury to the ankle followed by pain and swelling. Often the patient is able to describe exactly the way the ankle got twisted. On examination, the ankle is found to be swollen. Swelling and tenderness may be localised to the area of injury. Crepitus may be noticed if there is a fracture.

12. RADIOLOGICAL FINDINGS Fracture line of the medial and lateral malleoli should be studied in order to evaluate the type of ankle injury. Small avulsion fractures from the malleoli a Tibio -fibular syndesmosis: All ankle injuries where the fibular fracture is above the mortice, the syndesmosis is bound to have been disrupted. are sometimes missed. Posterior subluxation of the talus should be looked for, on the lateral X-ray. Soft tissue swelling on the medial or lateral side in the absence of a fracture, must arouse suspicion of a ligament injury.

13. TREATMENT Principles of treatment: The complexity of the forces involved produce a variety of combinations of fractures and fracture-dislocations around the ankle. The basic principle of treatment is to achieve anatomical reconstruction of the ankle-mortise. This helps in regaining good function and reducing the possibility of osteoarthritis developing later. Fractures without displacement: It is usually sufficient to protect the ankle in a below-knee plaster for 3-6 weeks. Good, ready-made braces can be used in place of rather uncomfortable plaster cast.

14. Fractures with displacement: Aim of treatment is to ensure anatomical reduction of the ankle-mortise. This means, ensuring anatomical reduction of medial and lateral malleoli, and reduction of the talus acurately within the mortise. Following modes of treatment may be useful: Operative methods: More and more surgeons are now resorting to internal fixation for all displaced fractures of ankle without attempting closed reduction. This is done because by operative reduction, it is possible to achieve perfect alignment as well as stable fixation of fragments.

15. Internal fixation: In general, operative reduction and internal fixation may be used in cases where closed reduction has not been successful, or the reduction has slipped during the course of conservative treatment. The following techniques of internal fixation are used depending upon the type of fracture. Medial Malleolus Fracture Transverse fracture – compression screw, tension-band wiring Oblique fracture – compression screws Avulsion fracture – tension-band wiring lateral Malleolus Fracture s

16. Lateral Malleolus Fracture Transverse fracture – tension-band wiring Spiral fracture – compression screws Comminuted fracture – buttress plating Fracture of the lower third of fibula – 4-hole plate Posterior Malleolus Involving less than one-third of the articulating surface of the tibia – no additional treatment Involving more than one-third of the articulating surface of the tibia – internal fixation with compression screws Tibio -fibular syndesmosis disruption – needs to be stabilised by inserting a long screw from the fibula into the tibia.

17. Conservative methods: It is often possible to achieve a good reduction by manipulation under general anaesthesia . The essential feature of the reduction is to concentrate on restoring the alignment of the foot to the leg. By doing so the fragments automatically fall into place. Once reduced, a below-knee plaster cast is applied. If the check X-ray shows a satisfactory position, the plaster cast is continued for 8-10 weeks. The patient is not allowed to bear any weight on the leg during this period. Check X-rays are taken frequently to make sure the fracture does not get displaced. If everything goes well, the plaster is removed after 8-10 weeks and the patient taught physiotherapy to regain movement at the ankle.

18. External fixation: This may be required in cases where closed methods cannot be used e.g., open fractures with bad crushing of the muscles and tendons, with skin loss around the ankle. COMPLICATIONS Stiffness of ankle joint Osteoarthritis

19. SPRAINED ANKLE It is the term used for ligament injuries of the ankle. Commonly, it is an inversion injury, and the lateral collateral ligament is sprained. Sometimes, an eversion force may result in a sprain of the medial collateral ligament of the ankle. The patient gives history of a twisting injury to the ankle followed by pain and swelling over the injured ligament. Weight bearing gives rise to excruciating pain. In cases with complete tears, patient gives a history of feeling of 'something tearing' at the time of the injury.

20. There may be swelling and tenderness localised to the site of the torn ligament. If a torn ligament is subjected to stress by the following manoeuvres , the patient experiences severe pain: Inversion of a plantar-flexed foot for anterior talo -fibular ligament sprain. Inversion in neutral position for complete lateral collateral ligament sprain. Eversion in neutral position for medial collateral ligament sprain. Treatment: It depends upon the grade of sprain: Grade I: Below-knee plaster cast for 2 weeks followed by mobilisation . Grade II: Below-knee cast for 4 weeks followed by mobilisation . Grade III: Below-knee cast for 6 weeks followed by mobilisation . Current trend is to treat ligament injuries, in general, by ‘functional’ method i.e., without immobilisation . Treatment consists of rest, ice packs, compression, and elevation (RICE) for the first 2-3 days. The patient begins early protected range of motion exercises. For grade III ligament injury to the ankle, especially in young athletic individuals, operative repair is preferred by some surgeons.

21. CHRONIC ANKLE SPRAIN Chronic recurrent sprain ankle is a disabling condition. If a course of physiotherapy and modification in shoe has not helped, a detailed evaluation with MRI and arthroscopy may be necessary. Pain in a number of these so-called chronic ankle sprains is in fact due to impingement of the scarred capsule or chondromalacia of the talus. Arthroscopy is a good technique for diagnosis and treatment of such cases.

22. FRACTURES OF THE CALCANEUM Fractures of the calcaneum are caused by fall from height onto the heels, thus both heels may be injured at the same time. The fracture may be: An isolated crack fracture, usually in the region of the tuberosity; or More often a compression injury where the bone is shattered like an egg shell. The degree of displacement varies according to the severity of trauma. The fracture may be of one of the following types

23. CLINICAL FEATURES The patient often gives a history of a fall from height, landing on their heels. There is pain and swelling in the region of the heel. The patient is not able to bear weight on the affected foot. On examination, there is marked swelling and broadening of the heel. Many cases of compression fractures of the calcaneum are associated with a compression fracture of a vertebral body, fractures of the pubic rami, or an atlanto -axial injury. One must look for these injuries in a case of a fracture of the calcaneum.

24. TREATMENT Undisplaced fracture: Below-knee plaster cast for 4 weeks followed by mobilisation exercises. Compression fracture: This is a serious injury which inevitably leads to permanent impairment of functions. The foot is elevated in a well padded below-knee plaster slab for 2-3 weeks. Once pain and swelling subside, the slab is removed and ankle and foot mobilisation begun. Leg elevation is continued, and a compression bandage applied for a period of 4-6 weeks in order to avoid gravitational oedema. Weight bearing is not permitted for a period of 12 weeks.

25. FRACTURES OF THE TALUS Minor fractures in the form of a small chip from the margins of one of the articular surfaces of the talus are more common than the more serious fracture i.e. fracture of the neck of the talus. MECHANISM Fracture of the neck of the talus results from forced dorsiflexion of the ankle. Typically, this injury is sustained in an aircraft crash where the rudder bar is driven forcibly against the middle of the sole of the foot (Aviator's fracture), resulting in forced dorsiflexion of the ankle; the neck, being a weak area, gives way. This may be associated with dislocation of the body of the talus backwards, out of the ankle-mortise. Vascularity of the body of the talus may be compromised.

26. TREATMENT It depends upon the displacement. If undisplaced , a below-knee plaster cast for 8-10 weeks is sufficient. In a displaced fracture, open reduction and internal fixation of the fracture with a screw is required. COMPLICATIONS Avascular necrosis Non union Osteoarthritis

27. FRACTURES OF THE METATARSAL BONES Most metatarsal fractures are caused by direct violence from a heavy object falling onto the foot. A metatarsal fracture may be caused by repeated stress without any specific injury. FRACTURE OF THE BASE OF 5TH METATARSAL This is a fracture at the base of the 5th metatarsal, caused by the pull exerted by the tendon of the peroneus brevis muscle inserted on it. Clinically, there is pain, swelling and tenderness at the outer border of the foot, most marked at the base of the 5th metatarsal. Treatment is by a below-knee walking plaster cast for 3 weeks.

28. FRACTURE OF THE METATARSAL SHAFTS One or more metatarsal shafts may be fractured, mostly following a crush injury. Treatment is by below-knee plaster cast for 3-4 weeks. MARCH FRACTURE It is a ‘fatigue’ fracture of third metatarsal, resulting from long continued or often repeated stress, particularly from prolonged walking or running in those not accustomed to it. Thus, it may occur in army recruits freshly committed to marching – hence the term ‘March fracture’. The fracture heals spontaneously, so treatment is purely symptomatic. FRACTURES OF PHALANGES OF THE TOES These are common injuries, most often resulting from fall of a heavy object, or twisting of the toes. The great toe is injured most commonly. Satisfactory general alignment is maintained in most cases and little or no treatment is required. The injured toe is covered with a soft woolly dressing and strapped to the toe adjacent to it.