the ankle and the foot
Post on 19-Oct-2014
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The ANKLE and the FOOT
TRAUMA
MI Zucker, MD
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A dr Z Lecture
• On TRAUMA of the Ankle and Foot and some general concepts in musculoskeletal trauma evaluation
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Rules for Success in Radiology
• Know which exam to order
• Know which films you need
• Know good films from bad films, and don’t accept bad ones
• Read methodically by check list
• Know the common lesions
• Know the commonly missed lesions
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General Approach to Musculoskeletal Radiology
• Soft tissues
• Joints
• Bones
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The ANKLE
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The Ankle Series
• Anterior-posterior (AP)
• Mortise (15 degree internal oblique)
• Lateral
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Anterior-Posterior: Adult
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AP: Kid
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Mortise: Adult
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Lateral: Adult
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Lateral: Kid
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The INJURIES
ANKLE
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When Does the Patient NEED Radiography?
The OTTAWA Rules
Ankle and Foot
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The OTTAWA ANKLE Rules
• Unable to weight bear immediately
• Unable to walk four steps in medical facility
• Bone tenderness medial or lateral malleolus
If “YES” to any, get ANKLE films
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The OTTAWA FOOT Rules
• Bone tenderness base of fifth metatarsal
• Bone tenderness navicular
If “YES” to either, get foot films
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Some OTTAWA Rule caveats
• Not valid if injury not acute
• Some exclude patients under age 18 years or over 55 years
These factors make the Rules less reliable, so we are more likely to do imaging in these circumstances.
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OTTAWA Rules: Ankle Tenderness
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OTTAWA Rules: Foot Tenderness
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The Ankle Sprain
• Grade I: Soft tissues swelling/joint effusion
• Grades II and III: Soft tissue swelling/joint effusion but may also have “FLAKE” avulsion fractures of the dorsum of the talus or navicular bones.
• Management differs, depending on grade
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The Sprain: treatment
• Grade I
• Grades II/III
• Ace wrap, crutches, limited time off weight bearing
• Air or posterior splint, crutches, prolonged period off weight bearing, orthopedic consult
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Soft Tissue Swelling
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Joint Effusion
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“FLAKE” Fracture
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FRACTURES of the ANKLE
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WEBER’S Classification
• Based only on location of a FIBULA fracture. A fracture, or no fracture, of the medial malleolus (tibia) does NOT change the classification.
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WEBER’S Classification
• Weber A: Fracture below the joint margin
• Weber B: Fracture begins at the joint margin
• Weber C: Fracture begins above the joint margin
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Weber A, B, and C injuries are ALL from INVERSION
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WEBER’S Assumptions
• Weber A: Anterior and posterior tibia-fibula and interosseous ligaments intact: STABLE
• Weber B: Anterior and posterior tibia-fibula ligaments torn: Moderately UNSTABLE
• Weber C: Interosseous ligament torn: Completely UNSTABLE
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Management of WEBER Injuries
• Weber A: Cast for 6 weeks
• Weber B: Frequently ORIF
• Weber C: Always ORIF
ORIF: Open Reduction Internal Fixation
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WEBER A
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WEBER B
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WEBER C
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REMEMBER
If the MEDIAL MALLEOLUS is also fractured, it does NOT change
the Weber classification
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What if ONLY the Medial Malleolus is Fractured?
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Two possibilities
• Weber A “equivalent” from INVERSION: The Lateral Collateral Ligament is torn but the Lateral Malleolus did not fail
• EVERSION INJURY: an UNSTABLE Maisonneuve Fracture
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Maisonneuve Fractures
• These are EVERSION injuries that fracture the MEDIAL MALLEOLUS, tear the entire Interosseous Ligament and Membrane, and exit as a high FIBULA SHAFT fracture
• They are all UNSTABLE and are treated by ORIF
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Maisonneuve Fracture: Lower
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Maisonneuve Fracture: Upper
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Caveat
• The high fibula fracture may be clinically occult
• So, ALWAYS get AP/lateral films of the ENTIRE tibia and fibula if there is an “isolated” medial malleolus fracture on the ankle series
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Bimalleolar Fracture
• Medial and lateral malleolar fractures, but still use Weber, as medial malleolar fracture does NOT change classification
• This is a Weber B
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Trimalleolar Fracture
• In addition to lateral and medial malleolar fractures, there is a fracture of the distal posterior tibia, called the POSTERIOR Malleolus. If large, extra ORIF needed.
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“Ankle” Injuries that are really FOOT Injuries
• Fractures of the base of the Fifth Metatarsal
• Fractures of the Anterior Process of the Calcaneous
• “Flake” fractures of the Talus or Navicular (we already did this, and they are components of an ankle injury)
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Fractures of the Base of the Fifth Metatarsal
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We will look at these again
When we get to the FOOT
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Fractures of the Anterior Process of the Calcaneous
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Stress fractures: repetitive microtrauma
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Salter-Harris Injuries
Physis injuries, so KIDS ONLY!
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Salter-Harris PHYSIS Injuries
• SH I: Physis only• SH II: Physis and
metaphysis• SH III: Physis and
epiphysis• SH IV: Physis, metaphysis
and epiphysis• SH V: Crush injury of
physis• SH VI: Avulsed piece of
metaphysis, physis, and epiphysis
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Salter-Harris what?
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Salter-Harris I and IV
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Remember: KIDS ONLY!
NO Salter-Harris injuries are possible after physis closes:
“Salter-Harris Nothing”
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And now…
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The FOOT
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FOOT: Views
• AP
• Oblique
• Lateral
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AP
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AP
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Oblique
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Lateral
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AP FOOT: Kid
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Lateral FOOT: Kid
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Talus
• Avulsions of dorsal margin: Ankle ligament injury (we did it under ANKLE)
• Osteochondral fracture: acute and stress
• Body of talus
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Talus Body fracture
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Osteochondral Fracture
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Calcaneous
• Body: axial load
• Stress: repetitive microtrauma
• Anterior process: ankle injury
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Axial Load Fracture
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Stress Fracture
• Initial film: pain one week
• Follow-up film: pain three weeks
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Fifth Metatarsal Base
• DANCER’S: tubercle, inversion, heals well
• Crepe support, walking boot or cast, on or off weight bearing: depends on extent of fracture
• JONES: proximal shaft, inversion or direct blow or stress, sometimes delayed or non-union
• Posterior cast or boot, off weight bearing
• If non-union, ORIF
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Dancer’s Fifth
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Jones Fifth
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Lisfranc Injuries
• Severe dorsal or plantar flexion at midfoot-forefoot junction
• Usually, very displaced and obvious
• Can be subtle
• ALL need surgery
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Lisfranc: obvious
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Lisfranc: subtle
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Metatarsal fractures
• Spiral
• Stress
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Spiral fracture
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Stress fracture
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Toe fractures
• “Stub”
• Crush
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Toe fractures
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GOODBYE
• Copyright 2004
MI Zucker