1. 2/3/2010
Ahmed Alhubaishi
Ankle and foot
Define the following terms:
◦Tibial plafond
◦Mortise
◦Posterior malleolus
◦Sprain/strain
◦Ankle ring
1
2. 2/3/2010
An emergency physician who applies the Ottawa
Ankle Rules correctly would send which of the
following ambulatory patients with a chief
complaint of “ankle pain” for x-ray?
a. A 40-year-old male with tenderness upon
palpation of the posterior edge of the medial
malleolar tip
b. A 25-year-old female with edema,
ecchymosis,and tenderness just anterior to the
lateral malleolus
c. A 60-year-old male with lateral edema,
ecchymosis, and a positive anterior drawer test
d. A 16-year-old male with posterior ankle
tenderness and a positive Thompson test
An emergency physician who applies the Ottawa
Ankle Rules correctly would send which of the
following ambulatory patients with a chief
complaint of “ankle pain” for x-ray?
a. A 40-year-old male with tenderness upon
palpation of the posterior edge of the medial
malleolar tip
b. A 25-year-old female with edema,
ecchymosis,and tenderness just anterior to the
lateral malleolus
c. A 60-year-old male with lateral edema,
ecchymosis, and a positive anterior drawer test
d. A 16-year-old male with posterior ankle
tenderness and a positive Thompson test
2
3. 2/3/2010
Using OAR which of the
following not for X-ray:
Bone tenderness at med. Malleolus
Bone tenderness at lat. Malleolus
Bone tenderness of the posterior
edge distal 6 cm to the ankle
Inability to bear wt on ankle now and
immediately after the injury
Soft tissue swelling over med. And
lat. malleolus
Using OAR which of the
following not for X-ray:
Bone tenderness at med. Malleolus
Bone tenderness at lat. Malleolus
Bone tenderness of the posterior
edge distal 6 cm to the ankle
Inability to bear wt on ankle now and
immediately after the injury
Soft tissue swelling over med. And
lat. malleolus
3
5. 2/3/2010
When OAR cannot be
applied???
1. Altered level of consciousness
2. Subacute or chronic injuries
3. Injuries to hindfoot or forefoot
4. Not designed to pick up # < 3 mm
One of the following ankle # can
be Rx as OPD with close ortho.
FU:
Fibular # proximal to tibiotalar ( t-t)
joint line
Lat. Malleolus # below the T-T joint
line
Lat. Malleolus # with deltoid lig.
Rupture
Unimalleolar # with syndesmotic
diastasis
5
6. 2/3/2010
One of the following ankle # can
be Rx as OPD with close ortho.
FU:
Fibular # proximal to tibiotalar ( t-t)
joint line
Lat. Malleolus # below the T-T joint
line
Lat. Malleolus # with deltoid lig.
Rupture
Unimalleolar # with syndesmotic
diastasis
What is this?
6
7. 2/3/2010
The ankle ring consists of the
following:
tibial plafond,
medial malleolus,
deltoid ligaments,
calcaneus,
lateral collateral
ligaments,
lateral malleolus
syndesmotic ligaments.
The integrity of this
ring determines
the stability of the
ankle
7
8. 2/3/2010
Which of the following is the most
commonly injured soft-tissue
structure(s) of the ankle?
a. Lateral collateral ligaments
b. Medial collateral ligaments
c. Inferior tibiofibular ligaments
d. Achilles tendon
Which of the following is the most
commonly injured soft-tissue
structure(s) of the ankle?
a. Lateral collateral ligaments
b. Medial collateral ligaments
c. Inferior tibiofibular ligaments
d. Achilles tendon
8
9. 2/3/2010
Each of the following ligaments are
part of the ankle syndesmosis
except:
a. Anterior inferior tibiofibular ligament
(AITFL)
b. Posterior inferior tibiofibular
ligament (PITFL)
c. Interosseous ligament (IOL)
d. Calcaneofibular ligament (CFL)
Each of the following ligaments are
part of the ankle syndesmosis
except:
a. Anterior inferior tibiofibular ligament
(AITFL)
b. Posterior inferior tibiofibular
ligament (PITFL)
c. Interosseous ligament (IOL)
d. Calcaneofibular ligament (CFL)
9
11. 2/3/2010
All of the following terms describe
a motion of the talus within the
mortise except:
a. adduction.
b. external rotation.
c. supination.
d. plantar flexion.
All of the following terms describe
a motion of the talus within the
mortise except:
a. adduction.
b. external rotation.
c. supination.
d. plantar flexion.
11
12. 2/3/2010
Widening of the medial clear space
on ankle radiographs suggests
injury to each of the following
structures except:
a. lateral ligament complex.
b. deltoid ligament.
c. anterior inferior tibiofibular ligament
(AITFL).
d. posterior inferior tibiofibular
ligament (PITFL).
Widening of the medial clear space
on ankle radiographs suggests
injury to each of the following
structures except:
a. lateral ligament complex.
b. deltoid ligament.
c. anterior inferior tibiofibular ligament
(AITFL).
d. posterior inferior tibiofibular
ligament (PITFL).
12
13. 2/3/2010
Pain at the ankle during squeeze
testing is suggestive of injury to
which structure(s)?
a. Medial collateral ligaments
b. Inferior tibiofibular ligaments
c. Lateral collateral ligaments
d. Peroneal tendons
Pain at the ankle during squeeze
testing is suggestive of injury to
which structure(s)?
a. Medial collateral ligaments
b. Inferior tibiofibular ligaments
c. Lateral collateral ligaments
d. Peroneal tendons
13
14. 2/3/2010
On a normal AP ankle x-ray, the
amount of tibiofibular overlap
should be at least:
a. 2 mm.
b. 4 mm.
c. 6 mm.
d. 8 mm.
On a normal AP ankle x-ray, the
amount of tibiofibular overlap
should be at least:
a. 2 mm.
b. 4 mm.
c. 6 mm.
d. 8 mm.
14
17. 2/3/2010
-entire joint space
-talar dome
No overlap
between the
previous two
-symmetrical joint
space
-Width of medial
space 2-3 mm
--T-F ovelap not
less than 1-2 mm
17
18. 2/3/2010
Widening of the medial clear space or
a lesser degree of tibulofibular overlap
suggests
injury to to the medial
ligament,syndesmosis or
both
18
19. 2/3/2010
The Lauge-Hansen classification of
ankle fractures is based on:
a. the anatomic location of the fibular
fracture with respect to the mortise.
b. the mechanism of injury.
c. the degree of articular involvement.
d. the presence or absence of
syndesmotic disruption.
The Lauge-Hansen classification of
ankle fractures is based on:
a. the anatomic location of the fibular
fracture with respect to the mortise.
b. the mechanism of injury.
c. the degree of articular involvement.
d. the presence or absence of
syndesmotic disruption.
19
20. 2/3/2010
Inversion injury. There is a transverse
avulsion fracture of the lateral
malleolus below the mortise caused
by supination-adduction forces
(arrow).The lateral ligaments remain
intact. This injury is classified as
Lauge-Hansen SA grade 1 or Danis-
Weber type A.
20
21. 2/3/2010
The medial clear space is widened,
suggesting deltoid and/or syndesmotic
ligament disruption (arrowhead).
There is an isolated spiral fracture of
the fibula occurring at the level of the
mortise caused by supination-external
rotation forces.This injury is classified
as Lauge-Hansen SE grade 2 or
Danis-Weber type B.
21
23. 2/3/2010
Characteristics of a Maisonneuve
fracture include all of the following
except:
a. It occurs in the setting of forceful
external rotation.
b. It is frequently associated with
medial ligament and/or syndesmosis
disruption.
c. It is highly unstable.
d. The diagnosis is readily made on
routine ankle x-ray series.
Characteristics of a Maisonneuve
fracture include all of the following
except:
a. It occurs in the setting of forceful
external rotation.
b. It is frequently associated with
medial ligament and/or syndesmosis
disruption.
c. It is highly unstable.
d. The diagnosis is readily made on
routine ankle x-ray series.
23
24. 2/3/2010
What is this?
Pilon
fracture
# of distal tibial metaphysis
Due to high energy mechanism
Usually comminuted, 20% open
Significant soft tissue loss
Talus derive into tibial plafond
Associated with: # of calcaneus,tibial
platue, femoral neck, acetabulum,
vertebrae
24
25. 2/3/2010
Tillaux Fracture:
• Lateral tibia, involving articular
surface
• Salter-Harris III fracture, mostly in
adolescents
• Usually requires surgical fixation
The best test for Achilles tendon
rupture is:
a. ability to pronate the foot.
b. ability to dorsiflex the foot.
c. the Thompson squeeze test.
d. the ―wiggle test.‖
25
26. 2/3/2010
The best test for Achilles tendon
rupture is:
a. ability to pronate the foot.
b. ability to dorsiflex the foot.
c. the Thompson squeeze test.
d. the ―wiggle test.‖
All of the following fractures
warrant orthopedic consultation in
the ED except:
a. unimalleolar fracture.
b. bimalleolar fracture.
c. trimalleolar fracture.
d. triplane fracture.
26
27. 2/3/2010
All of the following fractures
warrant orthopedic consultation in
the ED except:
a. unimalleolar fracture.
b. bimalleolar fracture.
c. trimalleolar fracture.
d. triplane fracture.
When to consult ortho people to
come and see pt with ankle
pain
?
27
28. 2/3/2010
Unimalleolar Fractures
Displaced medial malleolar fracture
Medial malleolar fracture with lateral collateral ligament rupture
Displaced lateral malleolar fracture
Lateral malleolar fracture with deltoid ligament rupture
Lateral malleolar fracture with widened medial clear space
Unimalleolar fracture with syndesmotic diastasis
Fibula fracture at or proximal to the tibiotalar joint line
Displaced posterior malleolar fracture
Posterior malleolar fracture involving more than 25% of joint surface
All Bimalleolar Fractures
All Trimalleolar Fractures
All Intraarticular Fractures With Step Deformity
All Open Fractures
All Pilon Fractures
Clinical Pathway: Evaluation
Of Ankle Injuries
28
32. 2/3/2010
CASE
• 24 yo M football player
• Another player rolled over his ankle from behind
• ANKLE DISLOCATION:
• • Usually posterior
• • Often associated with fracture and ligamentous injury
• Reduction:
• • Place one hand behind heel, with other over dorsum of foot.
• • Downward and anterior traction, with foot plantar-flexed initially.
• • Finally bring ankle back to 90 degrees flexion.
• Clinical Pearl:
• Put the knee in a slightly flexed position (20-30 degrees) during
the
reduction to reduce tension at the ankle.
• Post-reduction:
• • Immobilize in short leg, 3-sided splint, ankle at 90 degrees
• • Follow up with Orthopedic surgeon
32
33. 2/3/2010
case
• 20 year old male twisted his ankle while ―snowboarding‖
• Exam: Ankle is swollen, diffusely tender, and plain films are
negative.
• Ankle Sprain:
• • R.I.C.E. (rest, ice, compression, elevation)
• • Functional immobilization
• o ACE, AirCast, taping, etc
• • Crutches
• o Weight-bearing as tolerated
• • Follow up exam
• o Approximately two weeks after injury
• o Repeat physical exam for ligamentous damage
• o Most patients will be much improved
• o A few may have persistent pain, swelling, and joint effusion,
• suggesting the possibility of occult fracture.
• When should I consider CT or MRI for
occult ankle fracture?
• Consider CT or MRI in the setting of negative
plain films, and:
• o High clinical suspicion
• o Persistent pain, swelling, effusion at follow-
up
• Important occult fractures of the ankle/foot:
• o Talar dome
• o Tillaux (lateral tibia)
• o Calcaneus, Navicular
• o Lateral process of the talus
33
34. 2/3/2010
• Haapamaki, American Journal of
Roentgenology, 2004
• Retrospective study, over 3 years
• 344 patients with a fracture on ankle / foot CT
• CT’s ordered to delineate fracture, or to r/o
occult fracture
• Most common occult fx in ankle (not
visualized on plain films):
• Calcaneus (20)
• Talus (15)
• Tillaux (7)
• Pearls:
• 1) CT helpful for:
• a. High suspicion (mechanism, exam)
• b. Poor recovery
• 2) High risk situations:
• a. Fall from height—Calcaneus
• b. Adolescent—Tillaux
• c. Snowboarding—Lat. process of
Talus
34
35. 2/3/2010
foot
Q
What is CHOPART’S AND
LISFRANCE’S JOINTS?
CHOPART: between midfoot and
hindfoot
LISFRANCE: between midfoot and
metatarsals
35
39. 2/3/2010
What is this?
Calcaneus fracture:
• Calcaneus fractures most often
occur in males (male:female = 5:1)
• Peak age: between 30 and 50 years.
• Associated injuries (Lumbar spine
vertebral compression fractures)
• Treatment: Operative vs Casting
39
41. 2/3/2010
What is this?
Talar neck #
50% of all talar #
Extreme dorsiflexion
Hawkin’s classification 1-4
41
42. 2/3/2010
Talar Dome Fracture:
• Osteochondral lesion, articular
surface
• CT and MRI both excellent to
visualize lesion
• May be managed by cast (non-
weight bearing), or by arthroscopic
surgery if loose fragments in joint
What is this?
42
43. 2/3/2010
Lisfrance’s fracture
AP view :
◦ medial margin of the base of the second
metatarsal lines up with the medial margin
of the middle cuneiform
oblique view:
◦ medial margin of the base of the third
metatarsal lines up with the medial margin
of the lateral cuneiform, and
◦ medial margin of the base of the fourth
metatarsal lines up with the medial margin
of the cuboid
Types of lisfrance’s #
43
44. 2/3/2010
What fracture is virtually
pathognomonic for a
Lisfranc injury?
Fracture the base of
second metatarsal
What are these?
44
46. 2/3/2010
Jones’ fracture: transverse fracture at
least 15 mm distal to proximal end of
5th metatarsal; high rate of malunion
so call ortho
Pseudo-Jones’ fracture: avulsion
fracture of tuberosity at 5th metatarsal
base; treat symptomatically
Nonunion and chronic disability
may result from inadequate
immobilization of:
a. lateral malleolar avulsion fractures.
b. avulsion fractures of the tuberosity
of the fifth metatarsal (pseudo-Jones).
c. fifth metatarsal shaft fractures
(Jones).
d. lateral ligament tears with lateral
malleolar avulsion fractures.
46
47. 2/3/2010
Nonunion and chronic disability
may result from inadequate
immobilization of:
a. lateral malleolar avulsion fractures.
b. avulsion fractures of the tuberosity
of the fifth metatarsal (pseudo-Jones).
c. fifth metatarsal shaft fractures
(Jones).
d. lateral ligament tears with lateral
malleolar avulsion fractures.
What are the
indications for
reduction of a
metatarsal
fracture?
47