ANKLE AND FOOT INJURIES

• Injuries of the ankle and foot con be divided into:

1. Ligamentous injuries of the ankle.

2. Ankle fracture (malleolar F. or Pott’s F).

3. Tibial Plafond fractures

4. Fracture of the talus.

5. Fracture of the calcaneus.

6. Fracture of metatarsals and phalanges

ANATOMY

• 1) Distal end of tibia• : ankle mortise• Distal end of fibula • 2) Talus – trochlea of talus dome• 3) Ligaments – a) lateral ligament complex b) medial ( deltoid ligament )• c) syndesmosis

ANKLE SPRAINS

• - The most common acute sport injuries, 25% in every running or jumping sport

• - Mechanism of injury: inversion and plantar flexion of the foot when landing off balance or clipping another player’s foot

ANKLE SPRAINS

• Sequence of injury: anterior talofibular ligament, calcaneofibular ligament, posterior talofibular ligament, musculotendinous units supporting the ankle joint

ANKLE SPRAINS

• Incidence increased in :• - individuals with varus

malalignment of lower limbs• - calf muscle tightness• - previous incompletely

rehabilitated ankle sprains

• Medial Ankle Sprain– MOI: Eversion

– S/S: Pain and swelling around medial malleolus, pop, pain with eversion or external rotation, inability to bear weight

– Structures Injured: Deltoid Ligament

– Tx: Rule out fracture, RICE, ROM exercises, gradual return to activity (longer than LAS), taping

– Special Tests: Talar Tilt (Eversion), Kleiger Test

• Inversion ( Lateral ) Ankle Sprain• Mechanism of Injury - Inversion• Typical presentation

– Pain on or near lateral malleolus– Swelling around lateral malleolus– Pain increases with lateral movements

• Lateral Ankle Sprain– MOI: Inversion, Plantarflexion

– S/S: Pain and swelling around lateral malleolus, Pop (repeatable c movement), Pain with MOI motions, Inability to bear weight

– Structures Injured: Lateral Ankle Ligaments (anterior talofibular & calcaneofibular most commonly)

– Tx: Rule out fracture, RICE, ROM exercises, gradual return to activity, taping

ANKLE SPRAINS

• - Diagnosis: x-rays, stress x-rays • ( inversion stress, anterior drawer

test), ? MRI scan• - acute phase ( first 72 hours ):• RICE, then varies according to the

severity of injury

GRADE 1 ( Mild ) SPRAINS

• - The anterior talofibular ligament affected

• - stress: minimal change on inversion, normal anterior drawer

• - treatment by encouraging early active movement:

• a) stationary cycling• b) walking with protective taping or

semi-rigid brace ( Aircast splint )

GRADE 1 ( Mild ) SPRAINS

• c) NSAIDS (anti-inflammatory medication)

• d) physiotherapy: electrotherapy, strengthening exercises, propreoception (1 legged stand )

• e) functional progression to running, jumping, hopping, swerving and cutting, recovery into 6 weeks

GRADE 2 (Moderate) SPRAINS

• - Complete tear of anterior talofibular ligament with some damage of the calcaneofibular ligament

• - laxity when inversion, anterior drawer present

• - treatment: a) 1 week crutches, joint taped or in aircast splint

• b) follow grade 1 rehabilitation

GRADE 3 ( Severe ) SPRAINS

• - Uncommon severe injuries, associated with fractures

• - treatment: 10 days NWB in aircast brace or POP, then PWB with the brace up to 6 weeks. Aggressive rehabilitation follows

• - surgical reconstruction must be considered

PERONEAL TENDON INJURIES

• - Strong everters and weak plantar flexors of the foot

• - mechanism of injury:• a) associated with lateral ligament

injuries• b) forced dorsiflexion with slight

inversion and reflex contraction of the tendons ( sprinting, uneven ground, ballet)

PERONEAL TENDON INJURIES

• - O/E: Behind lat.malleolus discomfort or swelling. Subluxation on resisting dorsiflexion with eversion

• - treatment: a) acute phase – well-moulded short NWB cast with pad over lat.malleolus b) chronic phase – surgical correction, POP 4 weeks c) rupture of peroneal tendons – surgical correction

PERONEAL TENDON INJURIES

• TENDINITIS:• - occurs in dancers, basketball,

volleyball• - combined cause of the

lat.malleolus pulley action and foot malalignment

PERONEAL TENDON INJURIES

• TENDINITIS:• - TREATMENT – a) rest from sport,

temporary use of heel wedge• b) physiotherapy, extreme cases: local

injection into the sheath• c) gradual coaching programme, avoid

rapid direction changes or sprinting – 6 weeks

• d) failure of conservative treatment: tenolysis of peroneal tendons

ACHILLES TENDON INJURIES

• - Common tendon of gastrocnemius and soleus muscles

• - tendon twists laterally from 15cm above insertion becoming more pronounced at 2-5cm above insertion. Blood supply reduced at this level

ACHILLES TENDON INJURIES

• - Aetiology factors: lack of rear foot support in shoes, terrain, excessive training loads, biomechanical factors of foot: over pronation, rear foot varus or valgus, pes cavus, tight calf muscles

– MOI: Forced ankle dorsiflexion while weight bearing

– S/S: Pop, Feeling of being kicked in tendon, Inability to plantarflex foot, Gross deformity (observe and palpate), swelling, Lots of pain

– Special Tests: Thompson Test– Treatment: Surgical Intervention to repair tear

in tendon, Long rehab to restore ankle function

Ankle fractures

• Fractures and fractures dislocation of the ankle are common.

• It is also referred as Pott’s fractures.

• The most obvious injury is fracture of one or both malleoli.

• The invisible injury is rupture of one or more ligaments.

Ankle fractures

• Mechanism• The patient stumbles and falls.• The foot anchored to the ground and the

body lunges forwards.• The ankle is twisted and talus is tilted

and/or rotates focibly in the mortise, causing low energy fracture in one or both malleoli.

Ankle fractures

• Associated ligamental injuries may associated with such fractures.

• If the malleolus is pushed off, it is usually fractures obliquely.

• If the malleolus pulled off, it is usually fractures transversely.

Classification

• Danis and Weber (1991) which depends on the fibullar fracture

Classification

• Type A– Transverse Fracture lateral malleolus Below

syndesmosis, it associated with oblique or vertical fracture of medial malleolus.

Mechanism – Internal rotation and adduction

Classification

• Type B– Oblique fracture of lateral malleolus At level of

syndesmosis, may associated with avalsion fracture of medial malleolus or torn deltoid ligament.

Mechanism – External rotation leads to oblique fracture

Classification

• Type C– Fibula fracture Above syndesmosis leading to

torn tibiofibular ligament (Syndesmotic injury)– Mechanism – Abduction and external rotation.

• Medial and posterior malleolar fractures, deltoid ruptures may occur with any of these

Clinical features

1. Common in skier, footballer and climbers.

2. H/O severe twisting, abduction or adduction injuries.

3. Severe pain.

4. Inability to stand on the affected limb.

5. Swelling and deformity.

6. Tenderness on one or both malleoli.

X-Ray

• At least three views

1. Ap.

2. Lateral.

3. Mortise view ( 30° oblique view).

Initial Managment

• Closed reduction – Hematoma block– Conscious sedation

• Compression dressing, splint, and elevation

• Early OR treatment– Unstable fracture– No soft tissue compromise (blisters,

severe swelling)– Open fractures

• Delayed treatment– Stable in splint– Soft tissues need to recover

• Pain control

Medial Malleolar Fractures

• Nondisplaced fractures may be treated nonoperatively

• Displaced fractures require anatomic reduction and fixation.

• High nonuion rate

Lateral Malleolus Fractures

• Nonoperative managmement– 2-3 mm displacement

– NO medial widening or syndesmotic injury

– Cast or boot immobilization 6 wks

– Follow closely!

– Superior results

Surgical Indications

• Bimalleolar / trimalleolar fractures

• Syndesmotic disruption

• Talar subluxation• Joint incongruity /

articular stepoff

Posterior Malleolus

May associated with bimalleolar fracture and called trimalleolar fracture and it is always need open reduction and internal fixation.

Complications

• Early

• Vascular injury.

• Wound breakdown and infection.

Complications

• Late

• Malunion with varus or valgus deformity– corrective osteotomy.

• Non union more common of medial malleolus.

• Degenerative arthritis.

• Joint stiffness,

• Algodystrophy.

Fracture of the tibial Plafond

• Fall from highet, fracture depends on position of talus on impact: Comminuted fracture of tibial plafond.

• Management: IF usually difficult: Skeletal traction, External fixator, Minimal internal fixation And plaster.

Injuries of talus • Anatomy of talus: 60%

covered by cartilage.B.supply critical( dorsal neck, artery of tarsal canal deltoid branch). So fracture talar neck will lead to avascular necrosis of the body.

• Injuries include: Fracture neck, Fracture body, Dislocations

A-Fracture neck of talus

• Due to forcible dorsiflexion. Classified according to Hawkins into:

a-Undisplaced fracture.

Blood supply intact, avascular necrosis rare. Treated by below knee plaster for 2 months

A-Fracture neck of talus

• b- Displaced fracture neck with subtalar subluxation or dislocation: B.supply affected (30% AVN).

• Treatment: Early, trial of Closed reduction, If failed OR and IF

A-Fracture neck of talus

• C:Fracture neck of talus with total dislocation of the body of talus. AVN more common, skin sloughing.

• Treatment:Urgent, usually closed reduction fail and OR and IF ,followed by cast

Type D fracture

-type II injury with associated talar head

dislocation

Complications of Injuries around talus include

• avascular necrosis of the body.

• Osteoarthritis.

• sloughing of the skin.

Fracture Calcaneus -5x more common in men-largest and most frequently fractured tarsal bone-falls (axial load) or twisting mechanisms ( fall from a height).-extra-articular (25-35%) – good prognosis-intra-articular (70-75%) – not so good prognosis!-look for associated fractures->50 % cases have associated other extremity or spinal

fractures-7% bilateral-50% will have long-term disability

Types of Fracture calcaneus

• Types:• 1- Isolated fractures:

Fracture of sustentaculum tali, posterior or anterior process. Treatment: Elevation, Ice bags , bandage and active exercises

• 2-Avulsion fracture: Tendoachilis--IF

Types of Fracture calcaneus

• 3-Extra-articular fr. Compressed fr. Outside the joint—Below knee plaster.

• 4- Intra-articular: Should he reduced accurately– Closed reduction and percutenous fixation, Or and plate fixation.

Complication of Fracture Oscalcis

• OA of subtalar joint—Arthrodesis

• Widening of heel: impingement of peroneal tendon or sural nerve.

• Spur formation of plantar aspect –Shaving.

• Chronic pain and swelling

Metatarsal fractures

• Fracture base 5th metatarsal: common, inversion, below knee cast.

• Fracture shaft of metatarsal: Direct trauma- below knee cast

Metatarsal and Phalangeal fractures

• March fracture : Stress fr. Neck 2nd less commonly 3rd metatarsal, common in new soldiers, sclerotic ends, heel by rest in below knee cast

• Phalangeal fractures. Direct trauma, adhesive tapping

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