Traumatic Injuries to the Ankle and Foot

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Traumatic Injuries to the Ankle and Foot

• Thad Barkdull, MD
• MAJ, MC, USA
• Sports Medicine Fellow

Adapted from presentations by Leggit, OConnor,
Williams, Ho (yes, Ho), and well thats about
enough
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Goals

• Anatomy
• History
• Examination
• Diagnosis
• Surgical Referrals
• Treatment

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SUBTALAR JOINT AND LIGAMENTS
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Evaluation

• History
• Mechanism of Injury
• Location of Pain
• Continued activity
• Weight Bearing
• Previous Injuries

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Physical Examination

• Observation
• Palpation
• ROM
• Strength Testing
• Special Tests
• Radiography

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Observation Swelling, Ecchymosis, Deformity
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PalpationNeuro/Vascular Status, Ligaments,
Tendons, Bones
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ROM

• Plantarflexion
• Dorsiflexion
• Inversion
• Eversion
• (Active Passive)

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• Special Tests
• Anterior Drawer
• Talar Tilt
• Side to Side
• Thompsons
• Squeeze
• External Rotation

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Anterior Drawer-Test ATFL
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Talar Tilt - ATFL/CFL
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Side to Side Widening of Mortise to Test Tibfib
Lig
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Thompsons Test Integrity of Achilles Tendon
is no movement
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SQUEEZE TEST- Syndesmosis Injury
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External Rotation Test- Syndesmosis Injuries
Cotton Test
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OTTAWA Ankle Rules
Or inability to bear weight
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CASES
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Case

• 21 yo female volleyball player presents with
  lateral ankle pain after landing on teammates
  foot
• Ankle inverted
• Negative Ottawa criteria

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Lateral Ankle Sprain
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Epidemiology

• Estimated 1 million present to physicians with
  acute ankle injuries each year
• Sprains account for 25 of all sports-related
  injuries and 75 of all ankle injuries
• Lateral ankle ligaments are the most commonly
  injured structures in young athletes
• More than 40 of ankle sprains have potential to
  cause chronic problems

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Mechanism of Injury

• Inversion of ankle
• Typically when unexpectedly landing on uneven
  surface (ground, others)

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Clinical Presentation

• Lateral Pain
• Weight Bearing
• /- Swelling
• /- Ecchymosis

Ottawa Rules negative
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Diagnosis

• Clinical diagnosis
• Point tender over ATFL, CFL
• ? talar tilt, anterior drawer
• When will you get an x-ray?

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Indications for Ankle Radiographs

• Ottawa Ankle Rules
• Age 55 years or older

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Indications for Ankle Radiographs

• How good are the Ottawa Rules?
• When originally published
• 100 sensitivity 40 specificity for detecting
  malleolar fractures
• Subsequent studies
• Lower sensitivity (93 to 95) and specificity
  (6 to 11) than originally thought
• Not perfect, but still a good tool
• Other indications
• The patient cannot communicate (altered mental
  status, alcohol intoxication, or other)
• Pain and swelling do not resolve within 7-10 days
  after injury
• Anytime your history and physical dont give you
  enough information

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Classification of Lateral Ankle Sprainsby
Special Testing
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Classification of Lateral Ankle Sprains by
History/Exam
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Chronic Pain after Ankle Sprain
Inadequate Rehab ( Top 3) Slow Rehab Instability T
alar Dome OCD Peroneal Tendon Injury Synovial
Impingement Complex Regional Pain Syndrome
Subtalar Injury Tarsal Coalition Osteoarthritis T
arsal Tunnel Stress Fracture Interosseous
Membrane Injury
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Medial Ankle Sprains

• Isolated deltoid ligament sprain
• Rare, usually accompanied by lateral malleolar fx
  and/or syndesmotic injury
• Rehabilitation similar to lateral sprains but
  more likely to require immobilization and have
  residual symptoms

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Case

• Pt is an 18 y/o football player who presents with
  an ankle sprain.
• Pt has considerable swelling and demonstrates
  more tenderness proximal to the ATFL.
• Radiographs are negative for fracture.

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Syndesmotic Ankle Sprain
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Epidemiology

• Ankle sprains are the most common lower extremity
  injury in sports medicine, constituting 25 of
  all sports injuries.
• In one series, syndesmotic injuries constituted
  17 of ankle sprains.
• Syndesmotic injuries result in longer periods of
  disability than standard lateral ankle sprains.
• Syndesmotic injuries are commonly associated with
  ankle fractures and deltoid ligament sprains.

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Mechanism of Injury

• Forced external rotation of the foot
• Internal rotation of the tibia on a planted foot.
• Common in soccer, skiing, motocross and football

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Clinical Presentation

• Non-weight bearing
• Pain is located anteriorly along the syndesmosis
• Active external rotation of the foot is painful
  (Cotton Test)

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Diagnosis

• Clinical diagnosis
• Positive Squeeze Test
• Positive External Rotation Stress Test
• When will you get an x-ray?

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Imaging

• Ottawa Ankle Rules

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AP View Widened medial clear space Mortise
View Open mortise (decreased tib-fib overlap)
Syndesmotic injury Surgical referral (needs a
screw)
mm
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Diagnosis

• Radiographic imaging assists in stratifying
  severity of injury.

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• Syndesmosis Radiographic Criterion
• Mortise medial clear space gt 4mm
• AP tibiofibular overlap
• lt 10 mm or compare to opposite side

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Syndesmotic injuries are commonly associated with
what fracture?
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Maisonneuve
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Treatment

• Syndesmotic injuries without fracture or gross
  widening can be treated conservatively
• Fractures or radiographic evidence of syndesmotic
  widening warrant orthopedic consultation for
  operative repair.

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Case

• 45 yo male playing recreational basketball
• Landed, gunshot calf
• Minimal pain, but unable to bear weight or point
  toes

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Achilles Tendon Rupture
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Epidemiology

• Poorly conditioned 30-45 yo males (weekend
  warriors)
• 1 per 1000 athlete-years
• History of tendinitis/degenerative changes
• Steroids?

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Mechanism of Injury

• Sudden DF of PFd foot
• Sudden unexpected DF of ankle
• Pushing off WB foot with knee locked and extended
• Direct blow

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Clinical Presentation

• /- calf pain
• Antalgia
• Difficulty with tiptoe walk
• Possible visible or palpable defect superior to
  calcaneus

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Diagnosis

• History
• Thompson Test
• MRI

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Treatment

• To cut or not to cut
• Probably should be surgerized
• Newer therapy modalities may make non-surgical
  intervention more viable option

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Case

• 19 yo soldier carried into clinic in obvious pain
• Poor PLF, felt snap in right ankle
• Swelling, inversion deformity noted
• Unable to bear weight

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Ankle Fractures and Dislocations
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Epidemiology

• High velocity, high impact sports
• Stress fractures
• Running
• Gymnastics
• Dancing
• Salter Harris children

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Mechanism of Injury

• Type A lateral displacement of talus
• Eversion force supination ankle (50 of all
  fxs)
• Eversion force pronated ankle
• Abduction force pronated ankle

From Birrer RB, OConnor FC. Sports Medicine for
the Primary Care Physician. CRC Press 2004.
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Mechanism of Injury

• Type B medial displacement of talus
• Adduction force supinated ankle
• Adduction force dorsiflexed/plantarflexed ankle
• Type C axial compression of talus
• Type D repetitive microtrauma

From Birrer RB, OConnor FC. Sports Medicine for
the Primary Care Physician. CRC Press 2004.
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Clinical Presentation

• Looks like a sprain
• Big bone sticking out
• Remember Ottawa

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Indications for Ankle Radiographs

• Ottawa Ankle Rules
• Age 55 years or older

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Normal ankle (AP view)
Normal ankle (Lateral view)
Normal ankle (Mortise view)
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AP View of the Ankle
D E
DE Talar Tilt lt 2 degrees of angulation is Nl
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AP View of the Ankle
Talar Tilt gt 2 degrees angulation may indicate
medial or lateral disruption
Tib-fib Clear Space gt 5mm or Tib-fib Overlap
lt 10mm may indicate syndesmotic
injury
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Lateral View of the Ankle
Dome of the talus centered under and congruous
with tibial plafond
Posterior tibial tuberosity fractures direction
of fibular injuries can be identified
Avulsion fractures of the talus by the anterior
capsule can be identified
Any deformity to the talus, calcaneus or subtalar
joint
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Mortise View of the Ankle

• AP view taken with the foot in 15-20 degrees of
  internal rotation to offset the intermalleolar
  axis
• Medial clear space
• gt 4mm may indicate lateral talar shift
• Talar tilt, Tib-fib Overlap, Tib-fib clearspace
  (see AP view)
• Talocrural angle (angle b/w plafond parallel and
  intermalleolar line)
• Normal is 8-15 degrees (where the lines
  intersect)
• Smaller angle may indicate fibular shortening

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Mortise View of the Ankle
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Normal AP lateral right ankle X Ray
mm
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Ankle Fracture Classification

• Danis-Weber Classification
• Defined by location of the fracture line
• Type A below the tibiotalar joint
• Type B at the level of the tibiotalar joint
• Type C above the tibiotalar joint
• Syndesmotic ligament compromise
• Lauge-Hansen Classification
• Infrequently used, clinically mostly academic

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Weber Type A lateral malleolar fracture Treat
conservatively
mm
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Danis-Weber Type B fibular ankle fracture
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Weber Type B lateral malleolar fracture with
widened mortise Treat conservatively if fibular
displacement lt 3mm gt 3mm ORIF
mm
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Mortise view Weber C fracture with open mortise
and widened medial clear space deltoid
syndesmotic ligament tears, with fracture
surgical referral
mm
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Open mortise with high fibular fracture Name? Ma
issoneuve fracture surgical referral
mm
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Medial malleolar Fx Widened medial clear space
talar dislocation Open mortise syndesmotic
injury Maissoneurve Fx Surgery
mm
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Maisonneuve Fracture

• Proximal fibula fx
• Ankle external rotation
• Transmission of force through interosseous
  membrane to fibula
• Stable fxs can be casted (long leg)
• ORIF with 6 weeks non WB cast
• Only fix syndesmosis

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Exam with positive anterior drawer sign
Dislocation, secondary to complete ATFL disruption
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Radiographic Stress Tests of the Ankle

• Talar Tilt Stress Test
• Stabilize the leg with one hand while inverting
  plantar flexed heel with the other
• Contralateral ankle used for comparison
• Line is drawn across the talar dome and tibial
  vault
• Degree of lateral opening angle is measured
• Normal tilt is less than 5 deg
• Standing Talar Tilt Stress Test
• may be more sensitive
• Patient stands on an inversion stress platform
  with the foot and ankle in 40 deg of plantar
  flexion and 50 deg of inversion

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Exam with positive talar tilt

• Lateral ligament tears
• ATFL
• -CFL

mm
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Positive talar tilt stress test Surgery
mm
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Radiographic Stress Tests of the Ankle

• Anterior Drawer Test
• Abnormal anterior translation is between 5 to 10
  mm, or 3 mm more than other side
• External Rotation Stress Test
• Evaluates syndesmotic deep Deltoid ligaments
• Difference in width of superior clear space
  between medial and lateral side of the joint
  should be lt 2 mm

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Lateral ligamentous injury Medial malleolar
avulsion fracture Surgical referral
mm
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Nondisplaced spiral fibular fracture CR
immobilization
mm
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Posterior malleolar avulsion fracture
mm
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Medial malleolar fracture refer for screw
fixation
mm
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Bimalleolar fractures Osteopenic appearing
bone Surgical referral Tx osteoporosis prn
mm
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Mortise view
Pilon fracture (Comminuted tibial plafond
compression fracture) Management?
AP view
Lateral view
mm
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Anterolateral tibial epiphyseal fracture aka
Tillaux fracture
mm
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Tillaux Fracture

• Fracture of the anterolateral tibial epiphysis
• Mechanism
• Avulsion of epiphyseal fragment due to the strong
  anterior tibiofibular ligament
• External rotational force across the ankle
• Commonly seen in adolescents
• Treatment ORIF

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Treatment

• ORIF
• Non-Weight Bearing Cast x 3 weeks
• Progressive Weight Bearing in Short Leg Walking
  Cast x 3 weeks
• Physical Therapy program for strengthening and
  motion

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Salter-Harris fracture, type II Refer for ORIF
mm
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S A L T ER
Straight Above beLow Through CERush
1 2 3 4 5
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Case

• Pt is a 23 y/o active duty special operations
  soldier who presents with persistent dorsal foot
  pain.
• He stepped in a hole over a week ago, and has not
  improved with self-care.

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Lisfranc Fracture

• The articulation between the tarsal and
  metatarsal bones in the foot is named after
  Jaques Lisfranc, a field surgeon in Napoleon's
  Army.

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Epidemiology

• Lisfranc injuries may represent 1 of all
  orthopedic trauma, but 20 are missed on initial
  presentation.

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Clinical anatomy

• The second metatarsal is the keystone to the
  Lisfranc joint.
• Transverse ligaments join the metatarsals,
  excluding the first and second.
• Soft tissue support is abundant on the plantar
  surface, leaving the dorsal surface relatively
  vulnerable.

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L I S F R A N C
I N J U R Y
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Mechanism of Injury

• Indirect injuries account for the majority of
  injuries
• either a rotational force to the forefoot
• or axial loading on a plantar flexed, fixed foot

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Mechanism of Injury

• Common source of trauma
• falls from a height
• motor vehicle accidents
• equestrian accidents
• athletic injuries

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Clinical Presentation

• Presentation varies from a mild undetectable
  subluxation to an obvious fracture dislocation
• Midfoot pain, swelling and difficulty bearing
  weight are clinical clues
• Tense swelling may indicate a CS

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Diagnosis

• High index of suspicion in ankle and foot
  injuries
• Pain with passive pronation and abduction of the
  forefoot with the hindfoot supported
• Proper radiographic interpretation

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Imaging

• AP, lateral and oblique views
• On AP and obliques the 2nd met medial border
  should align with the middle cuneiform

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Fleck Sign
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Imaging

• AP, lateral and oblique views
• On the lateral the metatarsal shaft should not be
  more dorsal than the respective tarsal bone
• Contralateral foot films
• Weight-bearing views

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Treatment

• Orthopedic consultation for possible ORIF
• Identify and manage compartment syndrome

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Case

• Pt is a 35 y/o anesthesiologist who while running
  up the stairs, noted a painful pop involving the
  lateral foot.
• On palpation, she has considerable tenderness
  over the proximal fifth metatarsal.

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Fifth Metatarsal Fracture
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Epidemiology

• The most commonly fractured metatarsal
• These fractures may result from direct or
  indirect trauma.
• Proximal fifth metatarsal fractures have been the
  subject of considerable debate and controversy.

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Clinical Anatomy

• The proximal fifth metatarsal consists of the
  tuberosity, base, and proximal shaft.
• Tuberosity is the site of attachment of the
  peroneus brevis and lateral band of the plantar
  fascia.
• The metaphyseal-diaphyseal junction is a vascular
  watershed
• The metaphyseal-diaphyseal junction includes the
  joint between the base of the 4th and 5th
  metatarsals.

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Mechanism of Injury

• Tuberosity fractures have a mechanism of injury
  comparable to an ankle sprain
• An acute fracture of the metaphyseal-diaphyseal
  junction (Jones) occurs with a forceful adduction
  force while the foot is plantarflexed e.g.
  stumbling and catching oneself

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Clinical Presentation

• Pain, swelling and an inability to bear weight
  similar to a moderate ankle sprain.
• In a tuberosity fracture there is pinpoint pain
  over the base of the fifth metatarsal
• In an acute Jones fracture the pain is distal to
  the tuberosity at the fracture site
• History of prodromal symptoms is important to r/o
  stress fracture

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Imaging

• AP, lateral and oblique radiographs
• Avulsion fractures are almost always transverse

• In a Jones fracture, the fracture line is
  transverse and extends into the joint between the
  bases of the 4th and 5th metatarsals

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Treatment

• Tuberosity fractures rarely need referral, unless
  displaced over 3mm
• Initially treated in a firm-soled shoe, and
  transitioned to a SLWC or fracture boot as needed
• Jones fracture treated in a posterior splint and
  referred for either a SLNWBC or operative fixation

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Case

• 24 yo male rugby player presents with posterior
  foot pain after fall during line out
• Immediate pain
• Unable to bear weight
• Pain over heel

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Calcaneal Fractures
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Epidemiology

• Most commonly fractured tarsal bone

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Mechanism of Injury

• Axial load onto foot
• Tibia driven into talus and thus into calcaneus
• Force foot dorsiflexion may also cause fracture

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Clinical Presentation

• Pain, swelling, ecchymosis over heel

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Abnormal Bohlers angle Calcaneal
Fx Surgerize!
mm
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Calcaneal fracture ORIF
mm
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Case

• 20 yo male, wide receiver experiences pain when
  starting pattern
• Able to bear weight, but painful
• Ottawa negative

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Turf Toe
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Epidemiology

• Ranked third in collegiate athletes after knee
  and ankle injuries

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Mechanism of Injury

• Forced hyperextension
• Sometimes with varus or valgus stresses
• Also with forced flexion

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Clinical Presentation

• Pain, swelling, ecchymosis over 1st MTP joint

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Grading

• Grade I minor swelling, ecchymosis
• Grade II partial tear of the capsule
• Pain, swelling, ecchymosis, restricted motion
• Difficulty with sport specific function
• Grade III complete capsuloligamentous tears
• Possible occult MP subluxation
• Difficulty with ADLs

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Diagnosis

• Based on history and tenderness on examination at
  1st MTP joint, as well as painful ROM

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Imaging

• Plain films may show sesamoid fracture,
  diastasis, periarticular fracture
• Should get plain films with Grade II and III
  injuries

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Treatment

• RICE
• Taping
• Buddy taping
• Rigid orthoses
• Refractory cases may require surgery
• Osteochondral fx
• Unstable MPJ
• Proximal migration of sesamoids

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Case

• 22 yo female sprinter experiences pain when
  coming out of blocks
• Able to bear weight, but painful
• No improvement with rest
• Ottawa negative

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Navicular Stress Fracture
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Epidemiology

• 0.7-2.4 of all stress fractures (1980)
• More recent reports 14-35
• Track athletes at elite level 59

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Mechanism of Injury

• Repetitive weight-bearing exercises that involve
  antagonistic muscular load

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Clinical Presentation

• Vague, aching pain
• Dorsal foot, radiating along medial arch
• Increase with activity and progress to
  post-activity
• Rarely bilateral

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Diagnosis

• Normal ROM
• Normal strength
• Usually no swelling or ecchymosis
• Localized pain with inverting-everting forefoot
• Tender over dorsal navicular area
• Pain with hopping, standing on toes

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Imaging

• Plain films (consider 20 deg pronation) may show
  fx, but may be negative early
• Bone scan almost 100 sensitive
• Should f/u with CT to better delineate injury
  (ie. surgery?)
• MRI also reasonable choice

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Treatment

• Six weeks in well-molded NWB cast
• Rehab when no tenderness
• Continue to f/u at 2 weeks
• Surgery
• Displaced
• Fragmentation
• Delayed union or nonunion
• RTP usually 4-5 months (longer with conservative
  therapy)

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Conclusion

• Lots of different potential injuries
• Lots of anatomy to know
• If you dont know the diagnosis, you wont find
  the injury
• Know what to surgerize
• And dont hurt your patient

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Questions??
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