عادل الهنداوي .دInjuries of the ankle &foot:
the ankle is formed by lower tibia & fibula forming the ankle
mortise + the talus lying in the mortise.
The ankle is stabilized by 3 groups of ligaments:
1-lateral collateral ligament → anterior &posterior talofibular (TFL) &
calcaneofibular ligaments (CFL) .
2-medial collateral(deltoid) ligament→ superficial &deep.
3-inferior tibiofibular ligaments→ anterior & posterior .(syndesmosis)
A nkle ligament s injuries:>90% invo lve the lateral lig aments.
Injuries of the lateral ligaments:
MOI : twisted ankle with inversion &plantar flexion→ partial or complete tear of
ATFL→ CFL→ PTFL.
CF: swollen bruised ankle with tender lateral side &painful i nversion.
X -ray: AP, Lateral &oblique views: may show avulsion of tip of lat. malleolus .
Stress view shows talar tilt(unstable ankle) if the tear is complete. *Exclude foot
injury &ankle # or tibiofibular (syndesmosis) diastasis.
Partial tear(sp rain &strain): elastic bandage until swelling subsided, active
exercise, correct heel -toe gait &avoid dangling the foot.
Complete tear: 6weeks below -knee cast→ 4weeks ankle brace &physiotherapy.
Surgical repair is advisable in top class athletes.
Complication: Recurrent lateral instability: occurs in 20% after complete lat
lig tear. CF: attacks of giving way &instability; O/E: excessive in version & +ve
anterior drawer test. X -ray: show talar tilt on inversion stress. Ŗ : conservative →
raise lateral side of heel &extend it laterally, peroneal muscles exercise &brace.
If all these fail→ operative : lig repair or peroneus brevis ten odesis.
Deltoid ligament tear: usually associated with fibula # or diastasis.X -ray: widening of medial joint space.
Treatment: CR→ 8 weeks below -knee cast. If CR fails→ OR(soft tissue
interposition). *the AP view of the ankle should be in 30˚internal ankle
rotati on(mortise view) to see the lateral joint space.
Inferior tibiofibular ligament s tear: usually asso ciated with otherinjuries(e.g. # fibula or deltoid lig tear ). If both ant &post TFL are torn
→ complete tibiofibular joint separation(TF diastasis).
If only anterior TFL is torn→ partial diastasis.
MOI: ankle external rotation or abduction force.
CF: tender swelling over front of ankle. Squeeze test→ pain overthe syndesmosis.
X -ray: with complete tear→ wide ankle mortise.
Treatment: Partial tear→ 3wee ks elastic bandage.
Complete tear → urgent ORIF with transverse screw→ 8weeks cast.
Complication: if operation is delayed→ persistent pain &instability.
Fractures of the ankle (Pott's #): is common.MOI: the patient stumble &fall(foot is anchored whi le body go forward)→
talus rotate&/or tilt in the mortise→ # of one or both malleoli ± ligament tear.
The pattern of injury depends on foot position (supinated or pronated) & force
direction on talus(external rotation, adduction, ab duction or combination) .
Danis -Weber classification : according to level of fibula #:A → transverse fibula # below syndesmosis ± vertical # of
medial malleolus(adduction injury).
B→ oblique fibula # at syndesmosis ± transverse medial
malleolus # or deltoid lig tear (external r otation injury) .
C → fibula # above synd esmosis(TFL &interosseous lig tear)
± diastasis, medial injury, posterior malleolus # (abduction &
external rotation injury).
CF: swollen deformed ankle.
X -ra y: AP view→ joint space;
Lat view→ fibula #;
Mort ise view→ diastasis.
Treatment: there are 4 principles: 1 -don’t delay(rapid severe swelling)
2-treat the entire injury(# &lig tear). 3 -accurate reduction(intraarticular).
4-check &maintain reduction.
Undisplaced type A&B #→ 2weeks split below -knee cast→ checking x -ray→8weeks complete cast.
Undisplaced type C #→ can be the same Ŗ but better ORIF.
Displaced type A&B #→ CR &casting; if failed or displaced later → ORIF.
Displaced type C #→ ORIF.
X -ray signs of lig ament tear (# instability &need of ORIF) are:
1-wide medial joint space >4mm; 2 -wide TF space >6mm ;
3-talar tilt; 4 -asymmetry of talotibial space.
Methods of fixation: fibula #→ plate &screw; medial malleolus→
malleolar screw or tension band wiring; TF diastasis→ transverse TF screw.Compli cations: malunion, nonunion &ankle stiffness.
Open ankle #: most can be Ŗ by ORIF except severe cases→ external fixation.
Pilon fractures:MOI: axial force like FFH will drive the talus up striking tibial plafond.
CF: severe swelling with # blis ters &ankle deformity.
X -ray: comminuted distal tibia # extending into the ankle.
CT is better & 3D CT is the best.
Rüedi classification: І: undisplaced;
П: minimally displaced;
Ш: markedly displaced.
Treatment: first treat the soft tissue
swelling by 2 -3weeks elevation then:
І→ 12weeks below -knee cast(NWB).
П→ ORIF using plate &screws(wound breakdown &infection).
Or skeletal traction through calcaneal pin for 12weeks.
Ш→ skeletal traction or external fixation(indirect reduction
through ligamentotax is).
Complication: infection, nonunion & OA.
Foot injuriesInjuries of the talus: are uncommon.
MOI: severe violence like FFH, RTA or severe twisting injury.
*the blood supply of talar body comes mainly from neck vessels running from
anterior to post erior; if these are torn(by neck #)→ talar body avascular necrosis.
CF: swollen foot &ankle; deformity; skin split or tented→ slough later.
X -ray: AP, Lat &oblique views; CT for body #.
Look for # of talar head, neck, body, talar processes, or osteochond ral #
&for ≠ of midtarsal, subtalar &ankle joint.
Fractures of talus head→ are rare.
Fractures of talus neck→ Hawkins:
І: undisplaced #; П : displaced # with subtalar joint ≠;
Ш: displaced with ankle joint ≠; ІV: with talonavicular ≠.
Fractures of ta lus body→ are rare.
Fractures of lat &post processes → occur with ankle lig injury.
Osteochondral #→ often missed; needs CT for diagnosis.Treatment:
Type І→ 8weeks below -knee cast(4weeks NWB).
Type П→ MUA & 12weeks NWB cast. If fail→ ORIF.
Type Ш & ІV→ ORIF b y k -wires or lag screws.
Complications: early → skin damage: debridement &delayed closure.
→ talar detachment: clean &reduce.
late→ malunion; avascular necrosis of talus body(50% in displaced neck #).
→ OA of subtal ar or ankle joints due to malunion, avascul ar necrosis or
cartilage damage; Ŗ→ arthrodesis of the affected joint.
Fractures of the calcaneum: are common.MOI: usually FFH e.g. ladder(20% have also spine, pelvis, or hip injury);
Traction injury cau ses avulsion #; direct blow is rare.
Calcaneal # are either extra -articular or intra -articular(involve the subtalar joint).
Extra articular # (25%) : are easy to Ŗ with good prognosis like:
Anterior process #, body (behind talocalcaneal joint ), calcaneal tub erosity
(avulsion by Achilles tendon ), Sustentaculum tali &inferomedial process.
Intra articular fractures (75%) : either: 2parts # or 3parts #: joint depressiontype or tongue type.
CF: swollen bruised foot with short broad heel;ankle movements are no rmal.
X -ray: AP, Lat, oblique &axial (Harris) views.Measure tuber -joint
(Böhler's)angle on lat view: 20˚ -40˚ is normal. If # is displaced→ <20˚.
CT( especially coronal image) is the best for accurate diagnosis.
*calc # in 10% is bilateral & 10% have spine #.
Extra articular #→ 2weeks elevation, exercise &
crepe bandage→ 4weeks NWB→ 4weeks PWB.
For displaced tuberosity #→ ORIF by cancellous screw.
Intra articular # :
Undisplaced → the same conservative Ŗ.
Displaced → ORIF: screws (±bone graft to fill de fects)&lateral buttress plate.
Early→ swelling &blistering &even compartment syndrome.
Late: 1- malunion→ short, wide &valgus heel.
2-Peroneal tendon impingement . 3-subtalar OA.
Mid -tarsal injuries→ sprain of midtarsal joint;#(nav icular, cuboid, cuneiforms) ; # - ≠ (talonavicular, calcaneocuboid joints).
MOI: twisting force, FFH, crushing injury.
CF: swollen bruised foot; compartment syndrome.
X -ray: all tarsal bones should be clearly seen.
Treatment: sprain→ crepe bandage. *often # -≠ are missed .
undisplaecd #→ 1week elevation→ 6weeks cast.
displaced #→ may needs ORIF : screw or k -wire .
fracture -dislocation→ CR or OR &k -wire fixation.
Tarso -metatarsal injuries: sprains or # -≠ of the 5 joints.MOI: high velocity injury.
X -ray: is not easy to interpret, take multiple views &compare with normal .
Concentrate on 2 nd &3 rd metatarsal. *
Treatment: sprain→ 4weeks cast.
# - ≠→ CR or ORKF &8wk cast .
Metatarsal fractures: are common. 4 types:
MOI: direct blow→ crush #.
Twisting injury→ spiral #.
Traction injury→ avulsion #.
Repetitive stress→ stress #.
Undisplaced #→ few days elevation &exercise→ 6weeks cast.
Displaced #→ the same Ŗ but significant displacement in the sagittal plane
especially of 1st metatarsal→ CR or open RKF.
Traction injury :
forced foot inversion may avulse (by peroneus brevis) the base of 5th metatarsal.
x-ray: transverse #. A peroneal ossicle may be mistaken for a #(it is bilateral).
Treatment: fe w days elevation &crepe bandage .
if pain is severe→ cast.
Severe displacement→ ORIF by screw.