Foot and Ankle Fractures

Ankle

Eponymous Types

Maisonneuve
either a med malleolus fracture or deltoid lig tear with a high fibular fracture
Le Fort - Wagstaffe
avulsion fracture of anterior margin of distal fibula at insertion of anterior tibio-fibular lig
Tillaux-Chaput
avulsion fracture of anterior tibial margin by the anterior tibio- fibular lig
Volkmanns triangle
the postero lat malleolar fracture

Classification: (Weber/ AO)

Type A
Transverse avulsion fracture of the fibula at the level of the ankle joint or below
Medial malleolus may be intact or sheared, and may be an associated compression fracture of the tibial edge
The tibio-fibular ligament complex is always intact
A1 isolated fibular fracture
A2 with fracture of med malleolus
A3 with a posteromedial fracture
Type B
Spiral fracture of the distal fibula beginning at the level of the syndesmosis
Part of the tibio-fibular syndesmotic ligament may be involved but the ankle mortise is stable following reduction of the fracture
B1 isolated fibular fracture
B2 with a med lesion ( malleolus or ligament)
B3 with a med lesion and fracture of posterolat tibia
Type C
Fracture of the fibula anywhere between the syndesmosis and the head of the fibula
The tibio-fibular ligament complex is always disrupted and diastasis screws should be inserted if it remains unstable after fixation of the fracture (ankle in neutral position when inserted)
C1 diaphyseal fracture of fibula- simple
C2 diaphyseal fracture of fibula- complex
C3 proximal fracture of fibula

Investigation

XRay
AP/lat/mortise views
stress views
Tomograms
CT
If X-Rays show a displaced malleolar fracture there must be a ligament injury somewhere around the mortice
Ramsey and Hamilton (1976) showed that lateral displacement of the talus in the mortice of 1mm an average 42% loss of articular contact and congruency

Treatment

Nonoperative

Indications
for undisplaced or stable fractures
for displaced fractures when anatomical reduction can be obtained and maintained without repeated manipulation
when pt general condition does not permit
when operative treatment delayed
obtained by reversing the mechanism of injury
maintained by AKPOP for rotationally unstable injuries, 3- point molding, ankle at 90
Undisplaced or stable fractures can be managed in BKPOP, WB PRN

Operative

Indications
failure of CR
when CR requires forced, abnormal positioning of the foot
for displaced or unstable fractures that result in displacement of the talus or
widening of the mortise of more than 1-2 mm
Aims
restore fibular length
anatomical jt surface reconstruction
close mortise: anatomic reconstruction of the fibula usually restores the mortise and restores stability to the syndesmosis
Syndesmotic fixation if: tibiofibular diastasis +/- high fibular fracture
instability post ORIF of fibula
Diastasis screws should be tri-cortical and not lagged
remove prior to WB
posterior malleolus- fix if more than 25% of artic surface and displaced more than 2mm most reduce with the fibular reduction
No significant benefit has been identified in the generally accepted regime of delayed application of plaster until after a reasonable range of movement has been achieved.

A paper from Nottingham suggests that females over 50 have higher incidence of complications of operative treatment- however this is a retrospective review and their overall figures are not very impressive ( Beauchamp etal "displaced ankle fractures in patients over 50 yrs of age" JBJS 65B: 329-332, 1983).
Their recommendation must be viewed with a degree of caution . A prospective trial from Chicago suggests that ORIF gives a better result in pts who are more than 50 yo ( Phillips etal JBJS 67A: 67, 1985)

Complications

Bone

nonunion
most of the med malleolus treated with CR- due to interposed tissue
treat if symptomatic with ORIF + BG
malunion

Wound

skin necrosis marginal necrosis in ~ 3%
care in handling tissue etc- treat with dressings

Infection

less than 2%, treat infection, leave fixation until fracture healed

Arthritis

incidence with severity of injury
degen changes in 10% of anatomically fixed , 85% if not adequately reduced - changes apparent within 18 mths
ref: Klossner "Late results of operative and nonoperative treatment of severe ankle fractures" Acta Chir Scand Suppl. 293: 1-93, 1962

Prognosis

There is a reduction in the incidence of arthrosis in patients where an anatomical reduction has been achieved
ref: Phillips etal JBJS 67A: 67-78, 1985 Prospective trial shows higher total ankle scores in those that are operatively treated- especially so in those pts more than 50 yrs old

Tillaux Fractures

Avulsion fracture of the anterolat distal tibia at site of attachment of the anterior tibio-fibular lig
= SH3 fracture

Triplane Fractures


Combine a Tillaux fracture with a type 2 S-H fracture
May be two or three part and fixation may cross the physis in these injuries as they occur when closure of the physis is imminent
Growth arrest occurs in 14% of all ankle fractures in the skeletally immature and appearance may be delayed for up to six months therefore need to check growth at one year

Treatment

ORIF

Prognosis

Residual displacement of 2mm or more after reduction is associated with a less than optimal result unless the epiphyseal fracture was outside the weight bearing area of the ankle

Talus

Anatomy

The talus has 7 articular facets and no muscular attachments
60% of the surface area is cartilage problems with the blood supply which is via an anastomosis between the anterior tibial, posterior tibial and the peroneal vessels
posterior tibial artery
deltoid branches- supply med 1/3 of body
artery of the tarsal canal- anastomoses with artery of sinus tarsi
beneath neck of talus
ant tibial artery(dorsalis pedis)
multiple branches to dorsal talar neck
branch to form artery of sinus tarsi
peroneal artery
branches to post process
branch to form artery of sinus tarsi
ref: Mulfinger and Trueta " The blood supply to the Talus" JBJS 52: 160-167, 1970
Undisplaced fractures disrupt the intraosseous vessels but leave the major vascular sling intact
Displaced fractures disrupt the vascular sling- ie the branches from the dorsalis pedis to the neck, the arteries of sinus tarsi and the tarsal canal
The wedge shape of the dome (in the AP plane) results in increased instability in plantar flexion
An Os Trigonum is present in 3 - 30% of people and 60% are bilateral

Talar neck fractures

mechanism

hyperdorsiflexion of foot on leg

Classification

Hawkins "Fractures of the neck of the talus" JBJS 52A:991-1002, 1970

Type I

Undisplaced vertical fracture of the neck
AVN occurs in 0 - 10%
90% good results with trabecular healing in 6 - 8 weeks

Type II

Displaced vertical fractures with subluxation or dislocation of the sub talar joint
AVN occurs in 20 - 50%
47% unsatisfactory result with healing usually in 8 - 12 weeks

Type III

Displaced fracture with subluxation or dislocation of the subtalar joint and dislocation of the ankle joint
AVN occurs in 80 - 100%
52% unsatisfactory results and healing occurs in upward of 16 weeks

Type IV

As for III but with subluxation/dislocation of the head of the talus from the talo-navicular joint (not initially described by Hawkins)

Treatment


Type 1 BKPOP 8-12 wks until signs of fracture healing present, NWB first 6/52
Type 2 Reduction - closed may be successful -try once. ORIF usually needed
Type 3 ~ 25% of these are open . ORIF required
Type 4 ORIF
protect from WB until healing is secure

Complications

Skin necrosis / infection

more significant with open injuries
prevent by immed reduction of displaced injuries
if infected - need to debride the sequestered talar body, combined withtibiocalcaneal fusion

delayed/ non union

delayed union = not healed in 6 mths- 5-10%
nonunion - v rare

malunion

varus malunion most common- leads to ST jt degeneration
best results correlate with anatomical reduction

AVN

Type 1~10% ; Type 2 ~20-50% ; Type 3 ~80-100%
Hawkins sign: Subchondral osteoporosis evident at 6 - 8 weeks which signifies vascularity and indicates a good prognosis
Bone scan and MRI both define AVN

Protect from WB until healed. If avascular will take up to 3 yrs to revascularise during which time collapse may occur. Some recommend protection in a weight relieving orthosis for this time, others say collapse will occur regardless If collapse with symptomatic ankle jt degeneration- Blair fusion- this maintains the shape of the foot

Post- traumatic OA of ankle or ST jts- can occur without AVN

Talar Body Fractures

uncommon
Mechanism
most commonly fall froma height axial compression of talus bw tibia and os calcis
Treatment
ORIF with early ROM
Prognosis
high incidence of AVN, OA ankle and ST jts

Talar Head Fractures

rare- is a compression fracture of the talar head
Treatment
undisplaced fracture - BKPOP 6/52
displaced fracture- ORIF
Prognosis
healing uneventful
OA talonavicular jt- treatment with firm longitudinal arch support
fusion if this fails

Lateral Talar Process Fractures

rare-involve the post talocalcaneal jt, may be difficult to see on routine films
mechanism
foot dorsiflexion and inversion
Treatment
the size of the fragment and the degree of displacement decide treatment
the larger the fragment the more likely it is to involve the ST jt and need ORIF
Undisplaced fracture- BKPOP 6/52
Displaced fracture- ORIF , if signif comminution excise
Prognosis
high proportion of pts will have ST jt pain regardless of treatment

Osteochondral Fractures of the Talus

occur on the med or lat talar dome

Classification

Stage I

Localised subchondral trabecular compression not evident on plane X-Rays bone scan & MRI

Stage II

Incomplete separation of the fragment which is usually missed on X-Ray bone scan if suspected

Stage IIA

when the development of a subchondral cyst

Stage III

Unattached and undisplaced fragment which is usually evident on X-Ray and is well displayed on CT no need for bone scan or MRI

Stage IV

Displaced fragment

Management

Stage I lesions is conservative.
Stage II and III lesions the osteochondral flap is arthroscopically excised and the base drilled to expose bleeding bone.
Stage IV lesions the separated fragment is removed and the bed drilled.

Subtalar Dislocation

is the simultaneous dislocation of the ST jt and Talonavicular jts

Classification

medial or lateral

Mechanism

Inversion med dislocation
Eversion lat dislocation
Assoc with osteochondral fractures in 45%

Treatment

Closed reduction- prompt, gentle under anaesthesia, knee flexed to relax tendo achilles, traction, accentuate the deformity, reduce by reversing the deformityclunk!
following reduction the injury is stableBK splint for 4 wks followed with ROM program. Do not prolong immobilisation
~ 10% of med dislocations + 15-20% lat dislocations not reducible closed- causes include-
medial
capsule of talonavicular jt blocks
EDB interposes
assoc fracture of either talus or navicular
lateral
interpositionof tib post tendon

Prognosis

good if prompt accurate reduction
often have some ST jt stiffnes
lateral dislocations tend to do worse than med- more force required for lat dislocation

Os calcis

Classification

Extra-articular 25-30% of all os calcis fractures
Include
anterior process- an avulsion fracture of the bifurcate lig or EDB
tuberosity (beak or avulsion)- avulsion of achilles tendon insertion
med process- is origin of Abd hallucis, med part FDB, med plantar fascia- due to shear force in fall on heel in a valgus position
sustentaculum - rare as isolated fracture- due to fall on heel in inversion
body
Intra-articular
70-75% of all os calcis fractures- 4 types
  1. undisplaced
  2. Tongue type ( involves a relative downturn of the single fragment associated with posterior articular facet and tuberosity )
  3. Joint depression type (depression of post facet separate articular bits)
  4. comminuted

Mechanism

fall from a height in 80-90%
10 % are associated with lumbar spine fractures
Fractures are bilateral in 5 - 10% and associated with other lower limb injuries in 25%

X-Rays

AP/Lat/axial views
Oblique views of subtalar jt- lat oblique shows ant facet of ST jt
med oblique shows middle and post facets ST jt
CT good for preop planning- sections semi-coronal (perp to post facet) and parallel to sole of foot (=transverse sections)
Bohlers angle usually 25 - 40o
Crucial angle of Gissane

Treatment

Extraarticular

anterior process
BKPOP 4/52
tuberosity
undisplaced - slight equinus POP 6/52
displaced- ORIF and equinus BKPOP 6-8/52
med process
undisplaced to mod displaced- rest +/- POP NWB 4/52, then WB prn
severe displaced- CR/BKPOP 6/52
sustentaculum
BKPOP 6/52
body
rest/ elevation to minimise swelling
ROM exs , NWB 6/52 if not grossly displaced
if grossly displaced eg heel very wide- CR/POP 6/52

Intraarticular

Undisplaced
elevation, active mobilisation, NWB 6-12/52
Displaced
controversial- Operative treatment not shown to be any better than conservative treatment
treat as for undisplaced with early ROM exs etc
-if the heel is grossly widened CR , then early ROM
Aim for a foot that can fit into a normal shoe
ref: Pozo et al JBJS 66B:386-391, 1984
21 pts, displaced intraarticular fractures 14.6 yr FU, 76% good results with nonop treatment
There have been no prospectively randomised trials of the treatment of these injuries

Prognosis

Various authors recommend closed treatment with and without manipulation, ORIF or early arthrodesis

When the results of different forms of treatment of this group of fractures are compared the results are strikingly similar with the average time off work in most series being 4 - 6 months and symptoms steadily improve up to 2 years with approximately 80% good results at that stage

Improvement has been reported in patients up to 6 years following the injury

If going to operate start with lateral approach enables freeing peroneal tendons and use a second incision on the medial side if difficulty reducing the fracture

-ref: Stevenson "Treatment of displaced intraarticular fractures of the calcaneus using medial and lateral approaches, internal fixation and early motion"
JBJS 69A:115-130, 1987
Eastwood etal "Intra articular fractures of the calcaneum" parts 1 and 2
JBJS 75B: 183-195, 1993
-gives excellent description of the operative technique
No method of treatment has been shown to be superior to functional treatment or early mobilisation of the joints with elevation then non weight bearing for 6 - 8 weeks
As there are none of the operative complications of the other methods of treatment this must be the treatment of choice

Complications

Malunion broad flat heel
Joint incongruity early degenerative arthritis
rare- nerve entrapment
theoretically the flattening of the tuber angle should reduce triceps surae power- this does not seem to be a clinical problem

Long term symptoms could be classified into 3 main groups

  1. Impingement of the peroneal tendons where good relief is obtained by removing the bony protrusion causing entrapment of the tendons
  2. Painful heel due to a disrupted fat pad
  3. Stiffness of the ankle, subtalar joint and mid-tarsal joints due to disrupted soft tissues

Tarso-metatarsal Joints; Lisfrancs Fracture

Mechanism

direct blow or crush
indirect force- eg windsurfer

Classification

(Quenu & Kuss 1909)
Isolated: eg 1st ray displaced while lat 4 rays stay in place
Homo-lateral displacement: ie all rays displace in the one direction
Divergent: eg 1st ray goes med, the rest displace lat

Xrays

AP/lat and 30 deg oblique
look for
widening of interMT space
lining up of MT's with their cuneiforms
assoc fractures

Treatment

There is no place for conservative management of fracture and fracture dislocations of the tarso- metatarsal joint complex
ref: Myerson "the diagnosis and treatment of injuries to the Lisfranc Joint Complex"
OCNA 20:655, 1989

Prognosis

Whatever the severity of the initial injury the prognosis depends on an accurate reduction and its maintenance

Jones Fracture

Transverse fracture through the proximal shaft of the fifth metatarsal just distal to the tarsometatarsal joint and the insertion of the peroneus brevis.

Dancers Fracture

Spiral fracture of the neck of the fifth metatarsal

Stress Fractures

May occur in any of the bones of the foot, most commonly the second or third metatarsal but also the distal fubula, calcaneum, the navicular, and even the sesamoids of the great toe.