Common fractures and injuries of the ankle and foot: functional anatomy, imaging, classification and management.
The ankle joint can be viewed functionally as the mortise and tenon joint found in woodwork with the tibia and fibula forming a mortise-like cavity that receives the tenon like talus (Figure 1). Stability of the joint is due to the congruity of the osseous structures and associated ligaments. The tibial plafond articulates with the talus and forms the roof of the mortise. The medial malleolus articulates with the medial talus and the lateral malleolus binds the lateral aspect of the joint. The medial malleolus is supported by the strong deltoid ligament that consists of a superficial and deep portion. The lateral aspect of the joint is reinforced by the lateral complex which consists of lateral collateral ligaments and a syndesmosis. The ankle syndesmosis consists of an anterior and posterior tibiofibular ligament at the level of the plafond and an interosseous ligament located 1cm above the tibial plafond and is a condensation of the interosseous membrane (Lundberg et al 1989).
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Pain, bruising, swelling and an inability to weight bear suggest a fracture or ligamentous injury. Lateral and mortise view radiographs should be performed.
Classification systems of ankle injuries Different classification methods have been devised to characterise ankle injuries; the two most common being the Lauge-Hansen (Lauge-Hansen 1950) and Danis-Weber (Weber 1972) systems.
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The Lauge-Hansen classification resulted from work on cadavers in which forces were applied to a rigid foot and the resultant pattern of injuries observed. Failure is either a bony fracture or ligamentous disruption. Lauge-Hansen uses a two-word nomenclature where the first word describes the position of the foot at the time of injury and the second word describes the direction of the deforming force. There are five types of Lauge-Hansen fracture each with progressive stages of injury, supination adduction, supination external rotation, pronation external rotation, pronation abduction and pronation dorsiflexion. This classification was initially proposed to guide the closed reduction of ankle fractures by reversing the injury mechanism. It is useful in describing the pathomechanics of ankle injuries and inferring their stability (Michelson et al 2007).
The Weber classification system is based on the belief that the lateral structures are the main stabilising structures of the ankle joint and the degree of the disruption of these structures determines the need for and degree of operative correction (Michelson et al 1996). In Weber type A injuries the level of lateral malleolar injury is distal to tibial plafond (Figure 2). The injury is at level of tibial plafond in type B injuries (Figure 3), and proximal to tibial plafond in type C injuries (Figure 4).
Management of ankle fractures
Stability of the fractured ankle is the main determinant of prognosis and management. Stable fractures can be managed nonoperatively and unstable fractures fare better with operative stabilisation (Micheslon 1995). Stable fractures are immobilised with a below-knee back slab and elevated. The plaster is completed once the swelling has subsided and is left for approximately six weeks with the patient non-weight bearing. The patient is followed up in clinic with repeat radiographs to ensure satisfactory healing.
Displaced bimalleoler or trimalleolar fractures, talar shift and syndesmotic widening are indications for operative fixation (See Case study 1). The various operative treatment modalities are discussed by the authors in a previous review paper (Al-Rashid et al 2010). Lateral malleolar fractures are managed with an inter-fragmentary lag screw and a third tubular plate used as a neutralisation plate as shown in Figure 5 and Figure 6. A bridging plate with locking screws may be used in severely comminuted fractures (Micheslon 1995). Proximal fibular fractures without shortening can be managed with a syndesmosis screw alone, where the screw holds the tibiofibular joint stable while the sysndesmosis heals. Medial malleolar fractures are usually fixed with one or two 3.5mm partially threaded cancellous screws (Baird & Jackson 1987) as shown in Figure 6. Medial deltoid ligament injuries are usually only repaired if they prevent reduction of the joint, although this is rare. Posterior malleolar fractures that involve less than 25% of the joint surface, as shown in Figure 2, can be left alone (van den Bekerom et al 2009). Those involving greater than 25%, should be reduced and fixed with lag screws through a posterolateral or anterior approach.
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Where there is a suspicion of a syndesmotic injury, the proximal fibula fracture should be fixed and the stability of the mortise tested. Any instability requires insertion of a 4.5mm syndesmotic screw from lateral to medial and should purchase three or four cortices (Micheslon 1995) as shown in Figure 6.
Following surgery, patients are immobilised in a below knee back-slab which is converted to a full cast once the swelling subsides. The patient is non-weight bearing for approximately six weeks, or longer if there are concerns about bone quality or fracture fixation. Removal of metalwork is not routinely performed unless indicated by infection or pain from prominent metalwork. Removal of syndesmosis screws is controversial with some surgeons removing them before weight bearing and others leaving them unless they cause symptoms.
Delayed surgery for an old fracture dislocation is a difficult undertaking due to soft-tissue contractures and malunited fractures. Previous studies have shown that if anatomic reduction is achieved, results with delayed surgery can be as good as those obtained with immediate surgery (Khan et al 2007).
Achilles Tendon Ruptures
The Achilles tendon attaches the gastrocnemius and soleus muscles to the calcaneum. Injury to the tendon may result in a partial or complete tear usually occurring two inches above the calcaneum. The mechanism of injury usually involves eccentric loading on a dorsiflexed ankle with the knee extended, such as when jumping or running.
Complete tears usually occurs in middle-aged patients often during the performance of sport or activity they are unaccustomed to, whereas partial tears are much less common and typically occur in the younger competitive athlete. Systemic conditions such as gout and the use of medications such as steroids and certain antibiotics are risk factors. Diagnosis is made by history and examination findings which may include the presence of a defect over the area and a positive Simmond's test where squeezing of the calf does not result in plantar flexion of the foot. An ultrasound or magnetic resonance scan may help in cases of ambiguity.
Management of Achilles tendon injuries
Bhandari et al (2002) performed a systematic review and meta-analysis of literature and found that operative fixation is associated with a lower re-rupture rate of 4% compared with 13% for non-operative management. Operative repair of the tendon is generally performed in active patients with a complete rupture. Although operative fixation is also associated with an earlier return to sport and activity, the incidence of complications including wound infection and breakdown because of the tenuous blood supply is significant at 26% for open procedures and 8% for minimally invasive procedures (Bhandari et al 2002). Minimally invasive surgical repair techniques are associated with reduced perioperative morbidity, faster recovery times, shorter hospital stays and improve functional outcomes when compared with open procedures (Maffuli et al 2009).
Case study 1
Mr DT, a 57 year old painter decorator fell off his ladder at work and was brought to A&E by ambulance with a closed fracture subluxation of his right ankle. He had not sustained any other injuries and had a past medical history of ischemic heart disease and chronic obstructive airways disease. On examination he had no distal neurovascular compromise. He had radiographs of his ankle performed to determine the exact nature of his injury and showing a Weber C fracture subluxation (Figure 4). In view of the unstable nature of the ankle injury a decision was made to treat the injury operatively following informed consent. The patient was operated on later that day under general anaesthetic, six hours after he had last eaten and drank. He had open reduction and internal fixation of his ankle (Figure 6) under tourniquet control at 300 mmHg and using an image intensifier. The patient was placed supine on the operating table with a sandbag under the ipsilateral buttock.
A lateral incision was made and the fibula fracture was identified. The fracture was held reduced with a lag screw applied across the fracture site. An eight-hole dynamic compression plate was applied across the fracture site acting as a neutralisation plate with three proximal and three distal bicortical screws. A medial incision was then made and the medial malleolus fracture was reduced. In view of the small size of the fragment, it was stabilised with one partially threaded cancellous screw. As the ankle remained unstable on stressing the syndesmosis, a syndesmosis screw was inserted from the fibula engaging the tibia. The wounds were then washed and closed. The skin was closed with non-absorbable sutures and a plaster backslab applied.
Postoperatively the patient was advised to continue with elevation to help reduce the swelling and allowed to partially weight bear. At one week follow-up, the plaster backslab was completed as the swelling had subsided and a check x-ray performed. At two weeks follow-up, the sutures were removed, the plaster reapplied and a further check x-ray performed. At six weeks follow-up, the patient had the syndesmosis screw removed under local anaesthetic and was allowed to commence full weight bearing mobilisation. In view of the restricted range of movement in his ankle he was referred for physiotherapy. At final follow-up six months following surgery, the patient had resumed a full range of movement in his ankle and had resumed his occupation. His metalwork was not causing him any problems and there are no plans to remove it.
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Conservative management may be indicated in all other cases of complete rupture and for partial ruptures (see Case study 2). An equinus cast is applied with the foot in extreme plantar-flexed position, and is changed serially over six to eight weeks with the foot gradually brought out of equinus. Weight bearing is usually commenced at six weeks. Gradual strengthening by physiotherapy is recommended for optimal results. The rehabilitation protocol is determined by a number of factors including the injury, the quality of the repair, the patient's age, medical and social history, and sporting endeavours (Strom & Casillas 2009).
Lisfranc Joint Injuries
Jacques Lisfranc de St Martin (1790-1847) was a French surgeon in the Napoleonic army who developed a method of quick amputation through the taros-metatarsal joint that did not involve any osteotomy. The eponymous name Lisfranc injury was later given to describe any injury that occurred at this joint. The Lisfranc ligament is a thick ligament arising from the medial aspect of the first cuneiform and attaching to the base of the second metatarsal (Figure 7 and Figure 8). The Lisfranc ligament is the only significant attachment between the first and second ray at the mid-tarsal level, therefore dysfunction leads to an unstable joint with severe pain and instability.
The mechanism of injury is usually a direct blow or axial loading of the metatarsal with rotation in a hyper-flexed foot. Low energy injuries occur in athletes and higher energy injuries occur in road traffic and industrial accidents (Vuori & Aro 1993). A relevant mechanism of injury, and findings of swelling and erythema over the medial aspect of the mid-foot aide diagnosis. Instability on abduction and pronation stress testing of the forefoot may be evident.
Case study 2
Mrs GT, a 37 year old retail manager experienced sudden pain in the back of her right ankle when playing badminton and fell to the ground. She attended A&E and was diagnosed with a right sided achilles tendon rupture; she had a palpable gap in her achilles tendon and a positive Simmond's sign. She was otherwise fit and well and not on any medication. A radiograph of the ankle showed no fractures. Following a detailed discussion regarding the pros and cons of operative and nonoperative management, the patient opted for nonoperative management of her injury. This was because the patient was not a keen sportsperson and had only just started playing badminton. Her decision was also determined by the fact that she would have to stay in a plaster for the same length of time whether she was operated on or not.
The patient was placed in an equinus cast that was changed every two weeks. After eight weeks the plaster was removed and the patient allowed to commence mobilisation unaided. She was referred for physiotherapy and was doing well at six months follow-up. She had not resumed any sporting activities due to a change in her employment and social circumstances.
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Imaging of the Lisfranc joint
Greater than 2mm spacing between the second metatarsal and medial cuneiform or the second and first metatarsal on anteroposterior radiographs suggests instability (Figure 8). A positive 'Fleck sign', avulsion of the lateral aspect of the medial cuneiform or medial aspect of the base of the second metatarsal suggests a Lisfranc injury. Any dorsal displacement of the taros-metatarsal joints or plantar displacement of greater than 1mm on lateral radiographs suggests an unstable Lisfranc injury (Hatem 2008). If the diagnosis is uncertain abduction stress testing under fluoroscopic control (Coss et al 1998) or a CT of the foot will clinch the diagnosis.
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Management of Lisfranc joint injuries
Injuries with no radiographic evidence of instability can be treated conservatively with closed reduction. Operative stabilisation is indicated if there is evidence of instability, neurovascular compromise, open fracture or compartment syndrome. Closed reduction and percutaneous pinning is suitable for injuries with greater than 2mm of displacement but less than 15 degrees of talo-metatarsal angulation. Open reduction is required for displacement of greater than 2mm and 15 degrees of talo-metatarsal angulation (Kuo et al 2000). It may also be indicated in the young competitive athlete with lesser degrees of displacement. The principles of treatment involve stabilising or debriding osteochondral defects, reducing medial joints and stabilising the rays from a medial to a lateral direction. Stabilisation involves any combination of screws, plates and Kwires (Figure 9). Open fractures are usually treated with external fixation. Post-operative rehabilitation of all Lisfranc injuries involves non-weight bearing in a cast for six weeks followed by weight bearing in a cast for a further six weeks.
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Delayed presentation of unstable injuries manifests as severe pain, instability or early onset arthritis. Treatment is symptomatic but may require a taros-metatarsal joint fusion.
These infrequent injuries create a major socioeconomic burden. In 1945, Bankart noted that 'the results of crush fractures of the os calcis are rotten' and the results have not improved significantly since then (Gougoulias et al 2009).
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The calcaneum is important in maintaining vertical posture and normal walking. Its tough outer cortical bone is surrounded by softer cancellous bone, allowing it to resist bending, tensile and compressive forces. The superior surface articulates with the talus via a posterior, middle and anterior facet, whereas its anterior surface articulates with the cuboid bone. The Achilles tendon inserts into the posterior tuberosity. Below the middle talar facet is the sustentaculum tali which serves as attachment of several other ligaments and laterally the peroneus longus tendon attaches to a tubercle called the peroneal trochlea. Intra-articular fractures are usually the result of axial loading of the calcaneum following a fall from a height or a motor vehicle accident. Extra-articular fractures usually result from twisting injuries or may be the result of a direct blow. There is a relevant history and the patient complains of a painful and swollen ankle and inability to weight bear.
Imaging of calaneo fractures
Radiographs form the principle diagnostic tool. Antero-posterior images may show a lateral wall bulge of the calcaneus. On the lateral view a reduction in Bohler's angle (Bohler 1931) or an increase in Gissane's angle (Gissane 1947) is highly suggestive of an intra-articular fracture with displacement. Bohler's angle subtends two lines drawn from the superior margin of the posterior facet to the superior margin of the anterior process, and the superior margin on the posterior facet to the superior margin of the tuberosity. A reduction from the normal angle of 20-40 degrees suggests an intra-articular fracture. The crucial angle of Gissane subtends a line drawn along the border of the posterior facet and a line drawn along the anterior process. It is normally 100-130 degrees and an increase in the angle suggests depression of the posterior facet.
Classification of calcaneo fractures
A number of classification systems based on the radiographic appearance have been devised. The Essex-Lopresti classification (Essex-Lopresti 1993) distinguishes extra-articular fractures from intra-articular ones. For intra-articular fractures the calcaneum impacts the ground and a primary fracture line develops and runs from plantar-medial to dorso-lateral. This results in an anteromedial sustentacular fragment and a postero-lateral tuberosity fragment. A secondary fracture line may then develop. If this extends posterior a large 'tongue-type' postero-lateral fragment results, whereas if it begins at the crucial angle of Gissane and extends postero-dorsally, a depressed fragment containing the majority of the posterior facet results (Figure 10).
The Sanders classification is a prognostic classification system based on CT appearances of the posterior facet (Sanders 1993). The coronal CT image that shows the posterior facet in widest profile is chosen and the posterior facet is divided into three equal portions by two vertical lines. A third line marks the border of the sustentaculum. The lines are labelled A to C from lateral to medial. Fractures in the more medial zones are more difficult to visualize and subsequently more difficult to repair. Type I fractures are non-displaced and Type II are two-part fractures. Type III are three-part or split depression fractures and Type 4 are comminuted fractures.
Management of calcaneo fractures
In a recent systematic review of randomised trials, the results of operative and nonoperative treatment showed no difference in residual pain, but favoured surgical management on ability to return to the same work and to wear the same shoes as before the fracture. Surgery reduced the need for subsequent subtalar fusion, but it is unclear whether general health outcome measures, injury specific scores and radiographic parameters improved after operative treatment, and whether the benefits of surgery outweigh the risks that include deep infection and subtalar arthritis (Gougoulias et al 2009).
Undisplaced extra-articular fractures make up a third of these fractures and can generally be treated non-operatively with elevation, cast immobilisation and early range of movement exercises (Schepers et al 2008). Sanders type I fractures do well with non-operative management. Displaced fragments may be amenable to closed or semi-open reduction with Steinman pins. Surgery can be performed within the first 24 hours if swelling has been controlled or after a week or so once the swelling subsides. Exceptions include large displace fragments and those that involve the Achilles tendon which should be treated by open reduction and internal fixation. Displaced intra-articular fractures are generally treated by operative stabilisation (Potter & Nunley 2009). A lateral, medial or combined approach can be used. Sanders type II and III fractures should be treated with open reduction and internal fixation. The principles are to achieve congruency of the posterior facet, restore the normal height and width of the calcanuem, free any enclosed peroneal tendon, reduce the calcaneo-cuboid joint and neutralise any varus deformity. Outcomes of Sanders type IV injuries are poor and some clinicians manage them conservatively whilst others opt for primary fusion of all or some of the calcaneal joints (Sanders et al 1993). Surgery should be avoided in diabetic patients, smokers who refuse to stop immediately, those with limited ambulation and repeat 'jumpers' such as those with psychiatric issues
Case study 3
Mr AK, a 22 year old student sustained a crush injury to his left foot when a car wheel drove over it at slow speed. He presented to A&E with a painful swollen foot. He had not sustained any other injuries and had no significant past medical history. On examination he had a swollen foot with no wounds and no distal neurovascular compromise. Radiographs of his foot showed fractures of the first, second and third metatarsals (Figure 11). In view of the unstable nature of the foot injury a descision was made to manage the fractures with manipulation under anaesthetic and K-wire fixation (Figure 12) following informed consent. As the foot was swollen, he was admitted for elevation, analgesia and observation. The swelling subsided five days following admission and he was operated on under general anaesthetic, using a tourniquet at 300 mmHg and an image intensifier. The patient was placed supine on the operating table.
Fractures of the first second and third metatarsals were manipulated to a satisfactory position. Stab incisions were made at the medial aspect of the foot proximal and distal to the first metatarsal fracture, and at the plantar aspect of the foot at the site of the second and third metatarsal heads. Blunt dissection was performed to bone to avoid injury to neurovascular structures. Two K-wires of 1.8mm diameter were used to stabilise the first metatarsal fracture by engaging into the second and third metatarsals. Two further retrograde K-wires were then used to stabilise the second and third metatarsal fractures. The K-wires were then cut, dressings applied and the patient placed in a plaster backslab.
Postoperatively the patient was advised to continue with elevation to help reduce the swelling and advised to non-weight bear. At one week follow-up, the plaster backslab was completed as the swelling had subsided and a check x-ray performed. At six weeks follow-up, the patient had the plaster and K-wires removed in the fracture clinic and was allowed to commence full weight bearing mobilisation. He was referred for physiotherapy. At final follow-up six months following surgery, the patient was not limited in his activities of daily living and had made a complete recovery.
Metatarsal And Phalangeal Fractures
Fractures to the metatarsal bones and phalanges of the foot are common injuries and are due to direct trauma, excessive rotational forces or repetitive stress. They are usually minimally displaced and respond well to conservative treatment either by splint age or a walker boot with early mobilisation (Schenck & Heckman 1995). If displaced or unstable they are stabilised with K-wires (Figure 11 and Figure 12) as seen in Case study 3.
Fractures of the fifth metatarsal are common injuries worthy of special mention. It is important that a distinction is made between the more benign proximal tuberosity fractures (Figure 13) and Jones' fractures that occur at the metaphyseal-diaphyseal junction (Figure 14). The lateral cord of the plantar fascia and the peroneus brevis tendon attach to the plantar and lateral aspect of the tuberosity respectively.
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Avulsion fractures of the tuberosity are due to the pull of the lateral cord and peroneus brevis tendon following a twisting injury. The tuberosity receives blood from multiple metaphyseal vessels and branches of the nutrient artery and healing occurs easily with conservative management. In a large series of 288 tuberosity fractures, we have previously shown that these fractures heal well if managed symptomatically and none of them required surgery (Khan et al 2006).
Jones' fractures were first described by Sir Robert Jones (1857-1933), an orthopaedic surgeon from London who himself sustained this injury while dancing and these fractures have taken the eponymous name (Jones 1902). These fractures at the metaphyseal-diaphyseal junction occur within 1.5 cm of the tuberosity and can be acute fractures or stress fractures. A review of Jones' original case examples shows that the some radiographs meet the criteria of stress fractures. These fractures require prolong immobilisation and have a high propensity for delayed union and non-union. The treatment of choice for acute fractures is immobilisation of the limb in a below knee non-weight bearing plaster for six to eight weeks. Fractures with delayed union may eventually heal if treated nonoperatively, although this may take up to 20 weeks. An active athlete will benefit from early surgery. Fractures with symptomatic non-union require surgery. Surgical procedures fall into two categories, medullary curettage and inlay grafting, and axial closed intra-medullary screw fixation (Khan et al 2005).
The ankle and foot are functionally important and complex joints. The spectrum of injuries seen vary from stable injuries that can be managed non-operatively to unstable injuries that require surgical fixation. It is important to appreciate the functional anatomy and have an understanding of the imaging and classification systems used to decide on the appropriate management.
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Provenance and Peer review: Commissioned by Editor, Peer reviewed, Accepted for publication May 2010.
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MBChB, MSc, MRCS, PhD
Academic Orthopaedic Registrar, Royal National Orthopaedic Hospital, London.
MBBS, MA, MRCS
Surgical Trainee Registrar (Year 2) in Trauma and Orthopaedics, West Middlesex University Hospital
Staff Grade in Trauma and Orthopaedic Surgery, West Middlesex University Hospital
No competing interests declared
Correspondence address: Mr W Khan, UCL Institute of Orthopaedics, Royal Orthopaedic Hospital, Stanmore, HA7 4LP. Email: firstname.lastname@example.org
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|Title Annotation:||CLINICAL FEATURE|
|Author:||Khan, Wasim; Oragui, Emeka; Akagha, Edwin|
|Publication:||Journal of Perioperative Practice|
|Date:||Jul 1, 2010|
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