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h. If patient still hypotensive insert arterial line to monitor BP and blood gases
i. Initiate EKG monitoring
j. Assess neurologic status by Glasgow coma scale
i. Check pupillary response, extremity posturing, and response to commands
ii. Evaluate motor function of all extremities and trunk
iii. If sensory and/or motor deficit, establish spinal cord level of functional
changes
k. Obtain admission blood work (CBC and coagulation profile, arterial blood
gases, urinalysis, and venous blood chemistries)
2. Second priorities:
a. Obtain a H&P if possible
b. Secondary examination of the head, chest, abdomen, pelvis, and
extremities with attention paid to life threatening injuries
c. Obtain appropriate x-rays (cervical, chest, etc.)
d. Place a Foley catheter and check for occult blood in the urine
e. Place a NG tube and check for occult blood in the GI tract
f. Splint extremity fractures
g. Complete neurologic examination
h. Tetanus prophylaxis
i. Culture and sensitivity of open wounds
j. No antibiosis unless specific indication is apparent
k. Perform emergency surgery if required
3. Third priorities:
a. Systematic evaluation of the body
b. Specialty radiology (CT, angiograms)
c. Specialty consultations
d. Invasive monitoring (Swan-Ganz)
e. Urgent Surgery
NOTE* Lower extremity injuries are of low initial priority unless there is frank
bleeding. With an arterial injury, there is a pulsatile flow or spurt of bright
red blood. if present exert manual pressure initially, surgical repair later
Calcaneal Fractures
A disabling injury of the foot. There are a number of associated injuries when
dealing with a calcaneal fracture including: compression fracture of the
lumbar vertebrae, laceration of the kidney-renal damage, fractures of the
lower extremity, and compartment syndrome
1. Anatomical considerations:
a. The largest tarsal bone that has a thin cortical shell enclosing cancellous
bone that contains traction trabeculae radiating from the inferior cortex and
pressure lamellae converging to support the posterior and anterior facets.
b. The calcaneus articulates with the talus through 3 facets, the largest being
the posterior
c. The middle and anterior facet have a common joint cavity with the TN joint
and are separated from the larger posterior facet by the sulcus calcaneus.
d. The lateral end of the tarsal canal gives attachment to the bifurcate
ligament, the EDB, and the inferior extensor retinaculum.
e. Boehler's tuber joint angle overlies the posterior articular facet and is a
measurement of the sagittal plane between the anterior and posterior aspect
of the calcaneus (normal 20-400)
f. Gissane's critical angle is the position that abuts with the lateral process of
the talus and which under compression force acts as a wedge creating the
primary fracture line in the calcaneus
2. Radiological Examination
a. Plain film x-rays
i. A-P NOTE* Evaluating integrity of the bone plus Boehler's angle and the Critical
view angle of Gissane is essential in the diagnosis
ii.
Lateral view
iii. Anthensen's view (demonstrates medial and posterior facets of the STJ)
iv. Isherwood views:
Oblique lateral (anterior process and calcaneocuboid)
Medial oblique axial (medial and posterior facet)
Lateral oblique axial (posterior facet) v. Broden's projections
Broden 1 (shows the posterior facet from anterior)
Broden 2 (shows the sinus tarsi to posterior)
b. Tomography
c. CT scanning (The Gold Standard)
3. Classification: Due to the fact that two types of fractures exist (intra-
articular and extra-articular) the classification that is best used is a
combination of the Rowe (inclusive for extra-articular) and Essex-Lopresti
(inclusive for intra-articular, replacing Rowe 4 8 5)
a. Rowe:
i. Type 1a: Fracture of the tuberosity
ii. Type 1b: Fracture of the sustentaculum tali
iii. Type 1c: Fracture of the anterior process (most common; female
patients predominate, mostly related to wearing high heeled shoes)
iv. Type 2a: Beak fracture
v. Type 2b: Avulsion fracture involving the tendo Achilles insertion
vi. Type 3: Oblique body fracture not involving the STJ
vii. Type 4: Body fracture involving the STJ
viii. Type 5: Joint depression fracture with comminution
b. Essex-Lopresti:
i. Fractures not involving the STJ: Tuberosity fractures
Beak type
Avulsion medial border -Vertical
Horizontal
ii. Fractures involving the calcaneal-cuboid joint:
Parrot-nose type
Various
iii. Fractures involving the STJ:
Without displacement
Tongue-type with displacement
Centro-lateral depression of the joint
Sustentaculum tali fracture alone
Comminuted
NOTE* The primary fracture line is vertical from the vertex of the critical angle of
Gissane to the plantar aspect. The secondary fracture line is determined by the
direction of the force
4. Mechanism of injuries:
a. Torque injuries (extra-articular fractures)
i. Anterior process fx
ii. Avulsion fx
iii. Sustentacular fx
6. Treatment:
a. Anterior process fractures:
i. Small fragment fractures
Soft cast NWB for 2-4 weeks (early mobilization important)
ii. Large displacement fragment
RIF or excision (it is recommended to wait 1 year before excision)
b. A plate stabilizing the lateral wall (the plate is the key in preventing the
posterior heel from drifting into varus)
c. A transverse K-wire or Schanz screw is inserted into the posterior body and
helps reduce the Medial wall indirectly to pull the heel out of varus, and lock
in the medial cortices before the lateral-to-medial lag screws are inserted
2. Blood supply:
a. Extraosseous blood supply comes from:
i. Posterior tibial (#1)
ii. Anterior tibial (#2)
iii. Perforating peroneal (#3)
b. The talar neck is supplied by an anastamosis of 2 vessels:
i. Artery of the tarsal sinus
ii. Artery of the tarsal canal
3. Classification:
a. Chips and avulsions
b. Compression fractures
c. Fractures of the body:
i. Non displaced
ii. Displaced
iii. Comminuted
d. Fractures of the neck (Hawkins' classification): All caused by some fall
or
accident resulting in a severe dorsiflexory force to the foot
i. Group 1: Vertical fracture of the neck that is undisplaced
One of the three sources of the blood supply is disrupted (a 13% chance
of avascular necrosis has been reported)
ii. Group 2: Vertical fracture of the neck that is displaced, the STJ is
subluxed or dislocated, and the ankle joint is WNL
Two main sources of blood supply are interrupted (a 42% chance of
avascular necrosis has been reported)
Prognosis is related to the development of avascular necrosis
iii. Group 3: A vertical fracture of the neck that must be displaced and the
body of the talus must be dislocated from both the ankle and subtalar joints
All three sources of blood supply are disrupted (91 % chance of avascular
necrosis)
iv. Group 4: The fracture of the talar neck is associated with dislocation of the
body from the ankle and the subtalar joints with an additional dislocation or
subluxation of the head of the talus from the T-N joint
Avascular necrosis reported in 100% of cases
4. Treatment:
a. Talar neck:
i. Group 1:
BK/NWB cast for 6-12 weeks, followed by NWB with no cast for an
additional 2-5 months with ROM ankle excercises (prognosis is excellent)
ii. Group 2:
Closed reduction with BK/NWB cast until evidence of union
Early ORIF when and if closed reduction fails or the original reduction is
unstable (prognosis related to the development of avascular necrosis)
iii. Group 3:
ORIF with accurate anatomical reduction must be achieved followed by
BK/NWB cast for 3-4 months (prognosis is poor)
iv. Group 4:
As per Group 3
c. Total talar dislocations (out of the ankle mortise and STJ, anterior to the
fibula, head directed medially, talus rotated on the longitudinal axis so its
inferior aspect points posteriorly):
i. Manipulation:
Usually not successful but should be attempted
ii. Skeletal traction:
Steinmann pin through calcaneus attached to traction apparatus to
achieve an open space between the tibia and calcaneus. The assistant
inverts and plantarflexes the foot, as the surgeon presses both thumbs on
the posterior aspect of the talus by inward and backward movement to
rotate the talus. Afterward, the pin is removed and the foot is immobilized
in an anterior and posterior splint for 7 days with the knee bent to 300 and
ankle at 90°. This is followed by a BK cast for 6-8 weeks. Avascular
necrosis is inevitable.
If there is an open wound treat appropriately.
Osteochondral Fractures
1. Classification (Berndt and Harty):
a. Stage 1: A small area of compression of subchondral bone
b. Stage 2: A partially detached osteochondral fragment
c. Stage 3: A completely detached osteochondral fragment remaining in the
defect.
d. Stage 4: A displaced osteochondral fragment
2. NOTE* It has been found that 44% are lateral and anterior, and 56% are
Mechanism medial and posterior. Lateral lesions are shallow wafer shaped and
of injury: medial lesions are deep cup shaped
a. Lateral
lesions: Inversion and dorsiflexion
b. Medial lesions: Inversion, plantarflexion and lateral rotation of the tibia on
the talus
3. Diagnosis:
a. Stage 1:
i. Usually no symptoms, and has been diagnosed as an ankle sprain
ii. ROM of the ankle is WNL and painless
b. Stage 2:
i. Painful with associated collateral ligament damage
Lateral dome lesions have pain over the lateral collateral ligaments
Medial dome lesions have pain over the deltoid
ii. Ankle ROM may be limited due to traumatic synovitis
c. Stage 3 8 4:
i. Pain is more severe
ii. Decreased ROM of the ankle, joint locking or crepitus, and/or instability of
the collateral ligaments
Note* The diagnosis can be made on x-ray (the A-P view shows the medial
talar dome clearly, the lateral dome is obscured but can be visualized in
the medial oblique), but the use of tomograms or CT are best
4. Treatment:
a. Conservative: For stage 1, 2, 3 medial lesions via NWB BK cast for 6 weeks
followed by a patellar-bearing brace until the fracture heals
b. Surgical: For stage 3 lateral and 4, surgery to remove fragment, or
stabilize fragment using K -wire or Herbert screw
NOTE* Review of the literature reveals that surgically treated patients have
better results in preventing post-traumatic arthritis. However, conservative
vs. surgical treatment depends upon the size/location/stage of the fracture
fragment
Fractures of the navicular are easily missed,, and are important to diagnosis
quickly as a delay in treatment could lead to traumatic arthrosis of
Lisfranc's joint as well as the T-N joint. Isolated fractures are uncommon,
and usually occur in conjunction with Lisfranc's dislocations and fractures of
the rearfoot. Stress fractures of the navicular have been seen in runners
but more frequently in basketball players, and this problem is often
misdiagnosed as anterior tibial tendonitis
1. Anatomy:
a. Cancellous bone which is convex distally where it articulates with the three
cuneiforms and is concave proximally to accomodate the talar head
b. The dorsal navicular surface is roughened and serves as an attachment for
the dorsal talonavicular ligament, cuneonavicular ligaments and the
cubonavicular ligament
c. The plantar surface is so roughened and is invested by the plantar
calcaneonavicular ligament (spring ligament)
d. The lateral surface serves the attachment for the navicular portion of the
bifurcate ligament
e. The navicular tuberosity provides the major attachment site for the
posterior tibial tendon
f. The blood supply is from the dorsalis pedis and the medial plantar artery
which form an arcade of 6-8 randomly arranged vessels that penetrate the
navicular surface (the central 1 /3 is relatively avascular)
iv. Can be confused with 2 accessory ossicles in the same area, the os
supratalare and os supranaviculare
v. Treatment is with a BK partially weight-bearing cast for 4-6 weeks
vi. If late problems such as a painful dorsal prominence occurs, excision of
the fragment is recommended
2. Classification system:
a. Type 1: Stress fracture
b. Type 2: Avulsion fractures
(a) Bifurcate ligament area
(b) Tarsometatarsal ligament area
c. Type 3: Body fracture, nondisplaced
d. Type 4: Indirect crush fracture or nutcracker fracture
e. Type 5: Plantar dislocation
f. Type 6: Direct crush
3. Avulsion Fractures:
a. Most common on the lateral aspect at the calcaneocuboid joint and the 5th
met-cuboid articulation.
b. Avulsion fracture of the tuberosity due to tension on inferior
calcaneocuboid ligament.
c. Adduction of the cuboid on the calcaneus will result in avulsion due to
tension on lateral calcaneocuboid ligament.
5. Stress fractures:
a. Should be suspected if concerned about peroneus longus tendonitis,
calcaneocuboid arthritis, dropped cuboid, and capsulo-ligamentous strain in
the cavus foot type.
b. Treatment: BK cast 6-8 weeks (first 2 weeks NWB)
NOTE* In general, treatment for type 1, 2, and 3 injuries is usually NWB BK
cast for 6-8 weeks. Avulsion fractures are sometimes opened if the
dislodged fragment is felt to be intraarticular or will cause impingement
on the peroneal tendons. Type 5 dislocations must be reduced, with
closed reduction under general anesthesia attempted first with an
inversion-adduction force on the forefoot while pushing the cuboid up
from the arch. If this fails, open reduction is advised. Type 4 fractures
usually require autogenous bone grafting for anatomic alignment of the
calcaneocuboid and tarsometatarsal joints
Cuneiform Fractures
1. Avulsion fractures:
a. Usually located on the medial aspect of the internal cuneiform as an
avulsion due to pull of the tibialis anterior
3. Stress fractures:
a. Diagnosed by bone scans, CT, or tomography b. Treated with BK WB cast
NOTE*
a. Cuneiform fractures are usually associated with Lisfranc dislocations
b. The mechanism of the dislocation and fractures of the cuneiforms involves
the forefoot and rearfoot acting as levers, with the lesser metatarsals
displaced laterally and dorsally
c. Fracture of the 2nd metatarsal base is an important factor in causing
dislocation or fracture of the middle cuneiform
d. Lisfranc's ligament interruption has an effect on a middle cuneiform
fracture/dislocation
2. Type 2: Intraarticular fracture of the 5th metatarsal base with one or two
fracture lines
a. A result of shearing force caused by the internal twisting of the forefoot
while the peroneus brevis is contracted
b. Displacement of the fragments depends upon the extent of the damage to
the capsule and ligaments
c. Treatment is with an Unna-type boot or BK non-weightbearing cast for 4-6
weeks, or if nonreducible, then ORIF
NOTE* If, wound is open treat accordingly :(check blood loss, shock etc)
tetanus prophylaxis,
NOTE*antibiotic
Salter devised
therapy,
a classification
skin coveragesystem
as necessary,
describing fractures of long
rigid reductionbones
of fracture, and fluid replacement as necessary
1. Location of the fracture: diaphysis, metaphysis, physis, epiphysis,
intraarticular
2. Extent of the fracture: complete or incomplete
2. 3. Arrangement of the fracture: transverse, spiral, oblique, compression,
Treatment: comminuted
a. Closed
reduction with BK NWB cast 4-6 weeks
b. Open reduction:
i. Monofilament wire
ii. K-wires
iii. AO technique
b. Classification:
a. Salter classification is based on 6 categories
i. Site: anatomical location
ii. Configuration: transverse, oblique, spiral, etc.
iii. Open or closed
iv. Location
v. Extent: complete or incomplete
vi. Relationship of the fracture fragments to each other: displaced, angulated,
rotated, etc.
c. Treatment:
i. Simple fractures with no displacement are treated NWB BK cast for 6-8
weeks
ii. Displaced fractures should be anatomically reduced (usually open
reduction ORIF)
iii. Open fractures: treated as per open fracture classification
4. External fixator device for metatarsal fractures: A miniature
external fixation device can be utilized in the treatment of metatarsals.
Maintains the normal metatarsal parabola pattern
a. Indications: When a metatarsal fracture is severely comminuted or when a
significant loss of bone stock is present (gunshot)
b. This supplies rigid fixation giving stability to the fracture and can be
combined with other forms of fixation
c. It is capable of both compression and lengthening the metatarsal
fragments and can be combined with bone grafting as needed
d. Should be reserved for patients for whom reduction by any other means
cannot be obtained
2. Lauge-Hansen:
a.
NOTE* The hallmark of this injury is an avulsion fibular fracture at the level of
the ankle or below.
Supination-Adduction:
i. Stage 1: Transverse fracture of the lateral malleolus usually below or at the
level of the ankle mortise or lateral collateral ligamentous rupture (pulloff)
ii. Stage 11: Stage I plus an oblique fracture of the medial malleolus (pushoff)
c. Supination-External Rotation:
NOTE* This is the most common fracture of the ankle, and its hallmark is a
spiral
fracture of the fibula i. Stage
I: Rupture of the anteroinferior tibiofibular ligament, sometimes with
avulsion of the bony fragment between the tibia and fibula. (tibia:
Chaput, fibula: Wagstaff)
ii. Stage II: Stage I plus a spiral oblique fracture of the lateral malleolus.
iii. Stage III: Stage 11 plus a fracture of the posterior lip of the tibia
(Volkmann's fracture)
iv. Stage IV: Stage III plus a fracture of the medial malleolus
d. Pronation-External Rotation:
4. Other fractures:
a. Tillaux fracture: Fracture of the anterior tubercle of the tibia due to
tension of the IATF ligament. Also a type 3 epiphyseal injury of the
anterolateral distal tibia.
b. Wagstaff-Lefort fracture: Vertical fracture of the anterior margin of the
lateral malleolus due to an avulsion of either the anteroinferior tibiofibular or
anterior talofibular ligaments.
c. Maisonneuve fracture: Fracture of the proximal fibula , associated with
tibiofibular diastasis.
d. Pankovich classification of Wagstaff fractures:
i. Type l: Avulsion fracture and fibular fragments remaining attached to the
anterior talofibular ligament and IATF ligament
ii. Type Il: Oblique fracture with fragment remaining attached to the IATF
ligament
iii. Type III: Oblique fracture of the fibula in addition to a fracture of the
anterior tibial tubercle
e. Bosworth fracture: Fibular oblique fracture caused by external rotation
but the fracture occurs after posterior dislocation of the fibula. This causes
closed reduction to be impossible.
f. Frost. fracture: A triplane fracture which is a combination of Tillaux and
Salter-Harris Type 2 occurring at the distal tibia
g. Pott's Fracture: A fracture of the distal fibula and disruption of the
deltoid ligament (or medial malleolar fracture)
h. Cooperman's fracture: This is a Salter-Harris triplane type 4 epiphyseal
ankle fracture which consists of 2 fragments: the first is composed of the
tibial shaft, medial malleolus, and the anteromedial portion of the epiphysis;
the second consists of the remainder of the metaphysis, epiphysis, and
attached fibula.
i. Chaput's tubercle: The anterolateral tubercle of the distal tibia
j. Shepherd's fracture: Fracture of the posterolateral tubercle of the talus.
k. Volkmann's fracture: A fracture of the posterolateral corner of the distal
tibia (Volkmann's triangle), medial malleolus, fibular shaft, and tibiofibular
diastasis.
l. Ashurst's sign: The overlap of the anterior tibial tubercle and the medial
2/3 of the distal fibula normally is found on the A-P x-ray of the ankle.
Ashurst's sign is present with a lessening of this overlap due to widening of
the ankle mortise due to disruption of the anterior tibiofibular ligament
m. Thurston-Holland sign: The spike of metaphyseal bone attached to the
fractured epiphysis seen with Salter-Harris 2 fractures.
NOTE* ORIF is indicated for all ankle fractures with a greater than 2 mm.
lateral or posterior displacement of the lateral or medial malleolus
b. Absolute criteria:
i. Fractures and dislocations must be reduced immediately
ii. All joint surfaces of the ankle must be anatomically reduced iii. Reduction
must be maintained while the fractures are healing iv. Motion of the joints
should be started as soon as possible
c. Other criteria:
i. ORIF of the fibula should precede fixation of the medial malleolus because
it provides a buttress to the talus, which tends to displace laterally and pull
along the medial malleolus. Shortening of the fibula must be prevented (see
chapter 29: Ankle Conditions, Nonunion of Malleoli)
ii. Repair of the deltoid is difficult and rarely necessary, and should be
reserved for more severe injuries in which soft tissues around the ankle are
damaged.
iii. Large displaced fragments of the anterior and posterior processes of the
tibia, which are present in some indirect ankle fractures, should be
anatomically reduced (if at least 1 /4th the weight-bearing surface) in order
to restore congruity of the articular surface (reduction of these fragments
prevents subluxation of the talus)
iv. Fracture of Chaput tubercle and Wagstaff fractures should always be
reduced and fixed
v. A displaced yet essentially intact fibula requires syndesmotic screws for
proper reduction
NOTE* Stability of the syndesmosis is tested by pulling the fibula laterally
with a bone hook.
NOTE*When
Observe
thereforistendon
more than
dislocations,
2-3 mm of i.e.
lateral
posterior tibial tendon into the
displacementankle
of thejoint
fibula, instability is present and the use of a
syndesmotic screw(s) is indicated. It is desirable to insert this screw 2-3
cm above the tibial plafond. When there is a plate attached to the fibula,
one cortical screw can be removed and replaced with a syndesmotic
screw. When drilling for a syndesmotic screw, the direction must be
anteromedial to avoid inserting the screw posterior to the tibia
d. Fixation of the fibula: Should be fixed prior to the medial malleolus
i. AO Technique:
Interfragmentary screws are inserted most often from the anterior edge in a
posteroinferior direction
Overdrilling is unnecessary and may cause comminution of the fragment
3.5 mm cortical screws are most often used
ii. Cerclage Wiring:
It is useful in comminuted fractures while a plate is being applied to the
lateral side of the fibula
Can be used as an adjunctive device for an oblique fracture of the fibula
while an intramedullary nail is being used
iii. Inyo Nails:
Excellent for transverse fractures of the distal fibula
Useful in osteoporotic bone but requiring cerclage wiring of an oblique
fracture of the fibula prior to insertion
When inserting the nail, it is critical to reduce the fracture anatomically in
order to avoid penetration outside the bone
f. Closed reduction:
i. The main advantage of closed reduction is lack of postoperative wound
complications
ii. Closed reduction is contraindicated in unstable ankle fractures in which
both malleoli are fractured
iii. Closed reduction is acceptable in fractures when open reduction is
contraindicated (vascular compromise, neglected open fractures, pyoderma,
skin necrosis or contusion)
iv. Gravity is utilized by positioning the leg horizontally and in external
rotation while holding the foot in one hand with the heel resting in the palm.
This effectively produces internal rotation and adduction of the talus and in
that way reduces the fibula and brings in position the medial malleolus
A short leg cast is first applied while the fracture is being reduced, then is
extended to a long leg cast with the knee in 30° of flexion. A minimum of
6 weeks of immobilization is required
5. Factors that result in irreducible fractures:
a. Interpositon of the deltoid ligament
b. Trapping of the tibialis posterior tendon
c. Trapping of the medial tendon(s)
d. Dislocation and fracture-dislocation of the fibula behind the tibia
6. Soft tissue complications of fractures and dislocations of the ankle:
a. Skin: Blistering, decubitus breakdown, slow wound healing
b. Massive Edema: Treat with compression immediately, cold application,
elevation, rigid internal fixation and early ROM
c. Fracture blisters: Direct result of edema. ORIF must be delayed for 3-7
days
d. DVT's: Due to plaster immobilization, venous insufficiency, sickle-cell.
Treat casted patients with sub-Q heparin 2500-5000 units Q 8-12 hours if
they are at risk
e. Chondrolysis of the ankle (cartilage necrosis): Leads to posttraumatic
arthritis
f. Avascular necrosis of the talus
g. Infection following open fractures (5-30%)
h. Nerve injuries
i. Nerve disruptions (complete and incomplete)
ii. Reflex sympathetic dystrophy syndrome
i. Arterial injuries
j. Tendon injuries
k. Ligament injuries
i. Medial deltoid
ii. Lateral ligament (chronic thickening, local tenderness, inversion
instability, anterior subluxation)
2. Treatment:
a. Medial force injuries: reduced by traction and reversal of the mechanism of
injury with casting (WB or NWB)
b. Lateral force injuries: closed reduction first. C-C fusion is recommended for
persistent symptoms. Triple arthrodesis has been the traditionally
recommended treatment if conservative care has failed
2. Classifications:
a. Hardcastle et. al.
i. Type A: Total incongruity (the metatarsals displace in a unit in one plane
ii. Type B; Partial incongruity ( at least one of the tarso-metatarsal joints is
not displaced)
iii. Type C: Divergent (the 1 st metatarsal is displaced medially and the other
metatarsals are displaced laterally)
b. Quenu and Kuss
c. Myerson: Further subdivided Hardcastle's classification
i. Type A: Total incongruity
ii. Type 131: Partial incongruity, medial metatarsals
iii. Type B2: Partial incongruity, lateral metatarsals
iv. Type C: Divergent patterns
v. Type Cl: Partial displacement
vi. Type C2: Total displacement
NOTE* Due to the spontaneous relocation that this fracture dislocation can
produce, x-rays do not usually show the true magnitude of the severity of
this injury
5. Complications:
a. Amputation
b. Sepsis
c. Thrombophlebitis
d. Compartment syndrome
e. Neuroma formation (either traumatic or postsurgical “amputation” type)
f. Post-traumatic arthritis
NOTE* Angular relationships between the ATFL and the CFL is 100° in the
frontal plane and 105° in the sagittal plane. This sagittal plane angle
decreases with STJ supination and increases with STJ pronation. The
angular relationship between these two lateral ligaments is very d cult to
attain during reconstructive ankle stabilization repair tending to cause a
decrease in allowable STJ supination at the expense of attaining stability
against inversion stress.
2. Ligament composition:
a. 67% water
b. Remaining 33%: 90% collagen type 1, elastin, and glycosaminoglycans
3. Causative Factors:
a. Tibial varum
b. Calcaneal varum
c. Plantarflexed -1st ray
d. Rigid forefoot valgus
e. STJ varum
f. Uncompensated equinus
g: Muscle imbalance (peroneal insufficiency)
h. Previous sprains (elongated ligaments no longer restrain inversion)
i. Torsional abnormalities
j. Short leg syndrome
k. Ankle varus
4. Mechanism of injury:
a. Internal rotation, plantarflexion, and adduction of the talus beyond normal
physiologic limits
6. Diagnosis:
a. Scout films
b. Stress views (local anesthesia: peroneal block + local ankle infiltration):
Can use a Telos® apparatus for better quality control
i. Inversion stress: A 5-6° difference between the injured and uninjured ankle
signifies ligamentous rupture
NOTE* Always take bilateral inversion stress films when examining a patient
radiographically with potential grade III ruptures
NOTE* Degree of talar tilt is not a true indication of which ligament is ii.
ruptured
Push-pull stress (anterior draw sign): The ability to pull the ankle out of the
mortise more than 4 mm. usually indicates a rupture of the anterior
talofibular ligament
NOTE* There are certain situations where the stress test may be invalid:
genetic ligamentous
NOTE* Thelaxity,
main history
indication
of chronic
for ankle
ankle
arthrography
instability,ininability
a soft tissue injury is to
to achieve evaluate
adequateaanesthesia,
possible ankle
or inability
diastasis
toand
properly
to confirm
maneuver
ligamentthe tears
uninjured ankle. In these cases, ankle arthrography would be indicated
c. Ankle arthrography: In performing this test you must consider the following
i. The patient must have no allergy to iodine
ii. The injection should be administered at the anterior-medial aspect of
the ankle (to prevent confusion from the actual injury)
iii. The test must be performed within the first 5-7 days following the
injury
iv. Dye that is found within the normal anatomical confines of adjacent
tendon sheaths and not within the surrounding soft tissue should be
considered a normal anatomical variant
d. Peroneal tenography: A diagnostic technique for evaluation of the
calcaneo-fibular ligament. If dye is injected into the peroneal tendon sheath
and is found to enter the ankle joint but no dye is seen in the soft tissue
surrounding the ankle, a negative test.
ii. Surgical treatment 2-3 days following injury (must be young and athletic
who need complete stability):
Single ligament rupture:
Watson-Jones*: This uses the peroneus brevis, which passes through the
fibula from posterior to anterior, through the neck of the talus from dorsal to
plantar, back through the fibula, from anterior to posterior, and sutured
back onto itself.
Lee Procedure (modified Watson-Jones)*: This uses the peroneus brevis
tendon, which is then passed through the fibula, from posterior to anterior,
and then sutured back onto itself.
Evans*: This utilizes the peroneus brevis through an oblique hole through
the fibula sutured back onto the belly of the peroneus brevis.
Storren
Nilsonne
Pouzet
Haig
Castaing and Meunier
Dockery and Suppan
Lateral Medial
Common Rare
Adduction (inversion) Rarely alone
Type I (Anterior Talofibular Ligament) palpable tenderness Abduction or External Rotation
Talus Stable - Anterior drawer sign Edema
- Inversion stress (occhymosis in deltoid area)
- X-Ray (Bilateral)
Deltoid ligament ruptured to variable
degree
Treatment 1 strap assesment made as per
2 physical therapy Close (1956)
1. Mortise view
Type II Anterior Talofibular Ligament Palpable tenderness 2. If lateral displacement of
Calcaneal Fibular Ligament diffuse ankle pain talus
If plantar flexion • possible anterior deltoid ligament 2mm + Type I
rupture 3mm + Type II
Talar stability 4mm + Type III
+ Anterior drawer Treatment 1. Type I strap
- Inversion stress 2. Type II
- X-Ray 3. Type III -cast B, K., W. B.
Treatment 1. strap (occ. B. K.. W.B. cast)
2. physical therapy
3. youth - possible ligament
NOTE* Most common are fractures of the fibula and ruptures of the
tibiofibular ligaments a.
Types
of injuries:
i. Supination-external rotation
ii. Pronation-external rotation
iii. Pronation-abduction
4. Diagnosis:
a. Scout films (with pronation injuries a high fibular x-ray)
b. Stress x-ray (local anesthesia): Can be done by hand or using a Telos®
apparatus
i. Mortise view of the ankle where the foot is abducted and everted in relation
to the leg
ii. Lateral view where the foot is anteriorly displaced in relation to the leg
NOTE* Stress views are done bilaterally and the clear space is what is
compared Note* A clear space of 1 cm. or greater is diagnostic of a complete rupture,
and a displacement of 3mm. or more means tearing of part of the deltoid
5. Treatment:
a. Usually closed reduction and with BK NWB cast with the foot in inversion is
sufficient for 3-6 weeks, followed by a BK weight-bearing cast for another 3-6
weeks.
b. Surgical repair is indicated if closed reduction does not replace the talus to
its proper position.
NOTE* This can occur if the deltoid gets rolled up or inverted, or if the
posterior tibial tendon gets trapped.
Compartment Syndrome
Usually diagnosed in the arm and leg, also occurs in the foot, and can follow
several types of injuries, most commonly multiple fractures or crushing
injuries. This entity should be considered in the differential diagnosis in
patients presenting with a painful swollen foot post trauma
1. Definition: Increased compartmental pressure resulting in decreased
perfusion and ultimate ischemic changes to the tissues on the compartment.
This can eventually result in contractures and poorly functioning limbs,
a. Physiology: At rest the intramuscular pressure is approximately 5 mm Hg.
During a muscular contracture the pressure can increase up to 150 mm Hg or
more. At relaxation, the compartment pressure rapidly drops, and within 5-10
minutes, has returned to baseline. With a compartment syndrome, there is
no drop of pressure
Two criteria must be fulfilled for this diagnosis to be made: a space that is limited by
fascia, skin, or bone must be present; second increased compartment pressure
caused by a decrease in compartment size or an increase in the size of the contents
within that compartment must be present
Any injury with a pressure greater than 30 mm Hg should undergo an
immediate fasciotomy
Note* The patient might still present with a pulse because the vascular
collapse occurs first at the arteriolar level 4.
Compartments of the foot:
a. Medial compartment: Its borders are the medial and lateral intermuscular
septum, the medial portion of the plantar aponeurosis, the tarsus
(proximally) and shaft of the first metatarsal (distally). It contains the
abductor hallucis flexor hallucis brevis, and the FDL tendon
b. Central compartment: Its borders are the medial and lateral intermuscular
septum, the central portion of. the plantar aponeurosis, the tarsus
(proximally) and interosseous fascia (distally). It contains the flexor digitorum
brevis, FDL tendon with lumbricals, quadratus plantae, adductor hallucis, PT
and peroneal tendons
c. Lateral compartment: Its borders are the lateral intermuscular septum,
lateral portion of the plantar aponeurosis, and the associated osseous
components. It contains the abductor digiti minimi, flexor digiti minimi, and
opponens digiti
d. Interosseous compartment: Its borders are the metatarsals and the
interossei fascia. It contains the interossei
5. Clinical Findings:
a. Pain out of proportion to the clinical findings b. Paresthesias
c. Pulselessness
d. Or none of the above
6. Treatment:
a. Fasciotomy
i. Double dorsal technique:
Midfoot and forefoot: 2 dorsal longitudinal incisions, one over the 2nd
metatarsal and the other over the 4th (deepened down to the metatarsal
shaft) where a hemostat is passed into each adjacent interosseous space.
The wound is closed secondarily in 5 days.
ii. Extensile medial incision
iii. Combined approach
7. Associated complications:
a. Comminuted fractures
b. Severe soft tissue injuries
c. Post-ischemia swelling
d. Intramuscular hematomas associated with bleeding diasthesis
e. Crush injuries
j. For type 1, 2, and 3A open fractures delayed primary closure, using skin
grafts within 5-7 days
k. For type 3B and 3C open fractures, the soft tissue loss is so great that the
use of skin flaps is necessary and a delay in using them becomes apparent
because of the repeated debridements
l. External fixation should be used for all type 3 and unstable type 2 fractures
m. Internal fixation (screws, plates, pins, etc.) should be used for articular
and metaphyseal open fractures. This is done preferably within 8 hours of the
NOTE* An open fracture untreated in the initial 7-8 hours (golden period) is
generally considered to convert from a contaminated wound to an infected
wound
injury
4. Antibiotic considerations:
a. Limiting the duration of the initial antibiotic therapy is important to
minimize the emergence of resistant nosocomial bacteria
b. Type 1 fractures are treated with Cefazolin 2 gm STAT followed by 2 gm Q
8 h for 48 to 72 hours
c. Type 2 and 3 are treated with combined therapy, using cefazolin as above,
plus an aminoglycoside (Gentamycin or Tobramycin) dosed at 1.51.7 mg per
kg on admission, followed by 3.0 to 5.0 mg per kg per day in divided doses.
The duration of therapy is 3 days unless overt infection develops
d. Administer 10 million units of Pen G if the injury was sustained on a farm,
to cover for Clostridium sp.
Soft Tissue Injuries
1. Classification:
a. Tidy wound: Surgical incision, laceration
b. Untidy wound: Crush, avulsion, abrasion
c. Wound with tissue loss: Excision, burn, ulcer, avulsion
d. Infected wound: Established (cellulitis, lymphangitis, abscess, bum, or
vasculitis) or Incipient (bum, contaminated wound, abrasion)
2. Treatment (general):
a. Tetanus prophylaxis
b. Antibiotic prophylaxis
c. H 8 P, including vascular, neurological, musculoskeletal and integumentary
status
d. Inspection of the wound under local or regional anesthesia
e. Initial gentle cleansing of the wound with a mild soap (no strong
antiseptics that can cause tissue damage)
f. X-rays, CBC, and urinalysis as necessary
g. Primary wound care: remove all foreign and devitalized material
copious flushing, atraumatic tissue handling, avoid tourniquet
h. Skin closure when appropriate
3. Treatment (specific):
a. Tidy wound: Once debrided, can be closed after appropriate skin cleansing
(skin edges may be freshened)
b. Untidy wound: Deep damage must be repaired and skin closure should be
delayed until wound demarcation has progressed to the point where viability
is reasonably assured. Secondary or delayed primary closure may be
indicated. Swelling within closed compartments may indicate the need for the
release of damaged fascia or skin
c. Wound with tissue loss: Must prevent the wound from drying out and must
cover exposed vital structures using biological dressings, porcine xenografts,
or appropriate autograft
f. Infected wound: Prior to closure the wound must be debrided and
converted to a contaminated wound, and then a clean wound (check with
C&S and colony counts: less than 105 bacteria per millimeter means
contamination)
NOTE* The most important criterion is the clinical appearance of the wound
in the decision to close a wound. The number 105 bacteria present in the
wound is mentioned as a criteria of active infection, as it has been seen on
the board exams (this is unreliable)
Puncture Wounds
1. General protocols:
a. Tetanus prophylaxis
b. Remove all foreign material, leave wound open, do C&S
c. Start broad spectrum antibiotics
d. If no improvement in 3 days suspect a gram (-) infection
e. If bone or joint is penetrated or if wound is deep, surgical exploration
and debridement are necessary
f. If pain persists after 4 days of treatment use bone/gallium scans, sed rate,
WBC to follow patient progress
4. Growth plate injuries: Problems after injury are rare, but when growth is
disturbed, the reason is from avascular necrosis of the plate, crushing or
infection of the plate, formation of a bone callus bridge between the bony
epiphysis and metaphysis, and hyperemia producing local overgrowth. There
are 2 types of growth plates, epiphyseal (those that form under pressure)
and apophyseal (those that form under traction)
6. Classification: Salter-Harris
a. Type 1: A complete separation of the growth plate at the zone of
transformation, no disruption of growth, treated with closed reduction and
immobilization for 3 weeks
b. Type 2: Separation of the growth plate with extention of the fracture line
into the metaphysis. This extension creates the 'Thurston Holland Sign'.
There is usually no growth disturbance and it is treated the same way as type
1
c. Type 3: Separation of the growth plate with extension of the fracture line
into the epiphysis so that it is intraarticular. Potential for growth disturbance
as the fracture line crosses the entire growth plate, and must not be left
displaced by ORIF
d. Type 4: A fracture from the metaphysis through the growth plate and into
the epiphysis, and can result in growth disturbance. This fracture is unstable
and requires ORIF
e. Type 5: A crush type injury usually with subsequent growth disturbance.
Treated with closed reduction (if displaced) and immobilization 3-6 weeks
NWB
f. Type 6: A scooping out of a portion of the growth plate, via some type of
projectile causing osseous and soft tissue damage. Any large fragments
of bone are reduced. Bony bridging causing growth disturbances can be a
complication here. Treat the bony bridge with resection and interposition of
fat or silicone rubber
g. Type 7: An intraarticular fracture that does not involve the physis. Very
difficult to diagnosis in the very young. Treat with immobilization if
nondisplaced and ORIF if the fragment is large and displaced (or excision of
the fragment if too small to reduce)
3. Treatment:
a. Type 1: Open reduction
NOTE* Closed reduction can be tried under anesthesia as follows: traction
and increase dorsiflexion, then push the proximal phalanx into contact
with the metatarsal head, then push (don't pull) the proximal phalanx
into the reduced position, maintaining contact with the metatarsal head
b. Type 2A: Closed reduction followed by Reece shoe or BK walking cast
c. Type 2B: Closed reduction followed by Reece shoe or BK NWB cast
(sesamoid may have to be excised at a later date prn symptoms) or open
reduction with excision of the fractured sesamoid
3. Sesamoid fractures:
a. Mechanism: Fall from a height, repetitive direct trauma (dancing), and
repetitive indirect trauma (traction of the intrinsics)
b. Presentation:
i. Sesamoid involved: Tibial more than fibular (tibial is larger), rarely both
injuried, almost never bilateral
ii. Clinical presentation: Pain on direct palpation and pain on hallux
dorsiflexion
iii. Differential diagnosis of pain in the sesamoid area: Joplins neuroma,
sesamoiditis, osteochondritis dissecans, osteochondrosis, ruptured bipartite
sesamoid, turf toe, DJD/eroded crista, hypertrophic sesamoid, and fractured
sesamoid
c. X-ray evaluation: Order bilateral AP, lateral and plantar axial (MO for tibial
and LO for fibular sesamoid) 75% of bipartite sesamoids are unilateral. Bone
scan if in doubt
d. Normal sesamoids:
Ossification appears at 8-10 years
Bipartite sesamoids more common in tibial than in fibular
Sesamoids may be multipartite
2. Complications:
a. Split nail
b. Adhesions of the skin fold to the nail root
c. Chronic ingrown nails
d. Widening of the nail
e. Narrowing of the nail
f. Protruding or non-adherent nail
g. Malaligned nail
2. Treatment:
a. Zone 1:
i. Flush, debridment and appropriate wound closure (usually secondary
intention)
ii. Occasionally skin graft large defects (split thickness less durable, full
thickness more durable)
b. Zone 2:
i. Reduction of bone with debridement of necrotic tissue
ii. Coverage of nail bed and phalanx tip usually achieved by local
neurovascular advancement flap
c. Zone 3:
i. Not suitable to initial treatment in ER or office
ii. Usually complete nail bed loss
iii. OR debridement of necrotic tissue and matrix
iv. Delayed revision of the digit
v. Attempt to maintain tendon function
v. Terminal Symes may be necessary
2. Some authors believe that the culture of the bite wound offers little
information because of the multiplicity of organisms found and the absence
of an established infection
5. Elevation and immobilization with the ankle at 900, and after 72 hours
improvement occurs, then initiate ROM and adjunctive PT
6. Leave any potentially contaminated wound open for 4-6 days, and at that
time, if the wound is clean, without redness or swelling, it is reasonably safe
to perform primary closure