Foot and Ankle fractures

FOOT & ANKLE FRACTURES

Dr José PM Leal & Dr Kieran Kitchener

Clinical Education Fellows

George Eliot Hospital

LEARNING OUTCOMES

• Identification of common ankle and foot fractures

• Anatomy of ankle and foot

• Radiology interpretation

• Management of fractures

• Paediatric fractures

ANKLE FRACTURES

What four bones make up the ankle joint?

What four bones make up the ankle joint?

Fibula
Tibia
Talus
Calcaneus

• Mortise joint: tibial plafond, medial malleolus

(tibia), lateral malleolus (fibula)

• Tibia and fibula joined at syndesmosis

(AITFL + PITFL + intra-osseous membrane)

• Stability of ankle:

• Deltoid ligament

• Syndesmosis

• Lateral ligament complex

• ATFL

• PTFL

• CFL

ANKLE ANATOMY

• Ankle fracture = fracture of any malleolus ±

disruption to syndesmosis

• Typically twisting mechanism

• Demographics:

• young, active (15-24, M>F)

• elderly (75-84, F>M)

• What are the two common methods of classifying fractures of the ankle?

ANKLE FRACTURES

• Ankle fracture = fracture of any malleolus ±

disruption to syndesmosis

• Typically twisting mechanism

• Demographics:

• young, active (15-24, M>F)

• elderly (75-84, F>M)

• Weber classification

• Lateral malleolus fractures

• Lauge-Hansen classification

• Based on combination of foot position and direction

of force applied at the time of injury

ANKLE FRACTURES

WEBER CLASSIFICATION:

CLASSIFICATION OF LATERAL MALLEOLAR FRACTURES

• Inferior to

syndesmosis

• Syndesmosis intact
• Usually stable
• Reduction and back

slab or CAM boot

• ORIF occasionally

needed

• At level of

syndesmosis

• Syndesmosis intact

or partially torn

• Possible medial #

or deltoid injury

• Stability variable
• ORIF may be

needed

• Superior to

syndesmosis

• Syndesmosis

damaged =
widening of joint

• Usually medial # or

deltoid injury

• Unstable
• ORIF required

WEBER CLASSIFICATION

WEBER A

• Below the level of the syndesmosis (infrasyndesmotic)

• Usually transverse

• Tibiofibular syndesmosis intact

• Deltoid ligament intact

• Medial malleolus occasionally fractured

• Usually stable if medial malleolus intact; treat with CAM

walker or moon boot with crutches and weight bear as
tolerated with them for 6 weeks

WEBER B

•Distal extent at the level of the syndesmosis (trans-syndesmotic); may
extend some distance proximally

•Usually spiral

•Tibiofibular syndesmosis usually intact, but widening of the distal tibiofibular
joint (especially on stressed views) indicates syndesmotic injury

•Medial malleolus may be fractured

•Deltoid ligament may be torn, indicated by widening of the space between
the medial malleolus and talar dome

•Variable stability, dependent on the status of medial structures
(malleolus/deltoid ligament) and syndesmosis; may require open reduction
and internal fixation (ORIF)

•Weber B fractures could be further subclassified as

•B1: isolated

•B2: associated with a medial lesion (malleolus or ligament)

•B3: associated with a medial lesion and fracture of posterolateral tibia

WEBER C

•Above the level of the syndesmosis (suprasyndesmotic)

•Tibiofibular syndesmosis disruption with widening of the distal tibiofibular
articulation

•Medial malleolus fracture or deltoid ligament injury often present

•Fracture may arise as proximally as the level of fibular neck and not visualised on
ankle films, requiring knee or full-length tibia-fibula radiographs (maisonneuve
fracture)

•Unstable: usually requires ORIF

•Weber C fractures can be further subclassified as

•C1: diaphyseal fracture of the fibula, simple

•C2: diaphyseal fracture of the fibula, complex

•C3: proximal fracture of the fibula

•A fracture above the syndesmosis results from external rotation or abduction
forces that also disrupt the joint

•Usually associated with an injury to the medial side

LAUGE-HANSEN

1. Supination-Adduction (SA) injuries: These occur when the foot is in a supinated

(turned inward) position and a force is applied in an adduction (inward) direction.
This typically results in a fracture of the lateral malleolus (fibula) and possible
rupture of the deltoid ligament on the medial side of the ankle.

2. Supination-External Rotation (SER) injuries: These occur when the foot is in a

supinated position and a force is applied in an external rotation (outward) direction.
This can result in a fracture of the fibula, followed by a rupture of the anterior
talofibular ligament and the calcaneofibular ligament.

3. Pronation-Abduction (PA) injuries: These occur when the foot is in a pronated

(turned outward) position and a force is applied in an abduction (outward) direction.
This can lead to a fracture of the medial malleolus (tibia) and possible rupture of the
lateral ligaments.

4. Pronation-External Rotation (PER) injuries: These occur when the foot is in a

pronated position and a force is applied in an external rotation direction. This can
result in a fracture of the medial malleolus, followed by rupture of the deltoid
ligament and the syndesmosis (the ligaments that hold the tibia and fibula together).

OTTAWA RULES

• An Ankle X-ray is only required if:

•There is any pain in the malleolar zone; and,

•Any one of the following:

•Bone tenderness along the distal 6 cm of the posterior edge of the tibia or tip of the medial malleolus
(ZONE B), OR

•Bone tenderness along the distal 6 cm of the posterior edge of the fibula or tip of the lateral
malleolus (ZONE A), OR

•An inability to bear weight both immediately and in the emergency department for four steps.

• A foot X-ray series is indicated if:

•There is any pain in the midfoot zone; and,

•Any one of the following:

•Bone tenderness at the navicular bone (C), OR

•Bone tenderness at the base of the fifth metatarsal (D), OR

•An inability to bear weight both immediately and in the emergency department for four steps.

OTTAWA RULES

WHAT IS SEEN HERE?

TRIMALLEOLAR FRACTURES

• Three-part ankle fracture

• Medial malleolus

• Posterior malleolus

• Lateral malleolus

• Unstable fracture

• Ligamentous injury highly likely

• CT scan required

• Operative planning

• Posterior malleolus assessment

PAEDIATRIC FRACTURES –

SALTER HARRIS

TRIPLANE FRACTURES

• Traumatic paediatric ankle fractures

• Complex Salter-Harris IV fracture pattern in multiple planes

• Diagnosed on plain XR

• CT scan may be required

• Management:

• Closed reduction & casting

• <2mm displacement

• ORIF

• >2mm displacement

• Complications

• Growth arrest

• Ankle pain & degeneration

FOOT FRACTURES

FOOT FRACTURES

• Toe fractures

• Proximal phalanx most likely (longest)

• Conservative management, WB as able

• +/- haematoma block and manipulation

• Metatarsal fracture

• Direct blow, twisting injury

• Stress fractures

• Conservative management, WB as able

5TH METATARSAL FRACTURE

• Most common fracture of foot

• Predisposed to poor healing due to the limited blood

supply to 5th metatarsal base

• Jones fracture

LISFRANC FRACTURE

• Midfoot fracture-dislocation

• Twist and fall, direct trauma

• Weight bearing XR required

• Conservative Mx: NWB cast/boot

• Operative Mx: displaced/unstable #,

ORIF/fusion

LISFRANC FRACTURE

LISFRANC FRACTURE

LISFRANC FRACTURE

LISFRANC FRACTURE

CHARCOT ARTHROPATHY

• Progressive degenerative/destructive joint disorder in patients

with abnormal pain sensation and proprioception.

• Present either insidiously or as incidental findings

• Charcot joints although swollen are of normal temperature

without elevated inflammatory markers. Importantly, they are
painless.

• Management:

•Conservative – cast or boot, weight off of foot.

•Surgical – May need removal of areas of bone or fixation. Surgery if
severe and affecting mobility, or if fractures are unstable.

CHARCOT ARTHROPATHY

• Progressive degenerative/destructive joint disorder in patients

with abnormal pain sensation and proprioception.

• Present either insidiously or as incidental findings

• Charcot joints although swollen are of normal temperature

without elevated inflammatory markers. Importantly, they are
painless.

• Management:

•Conservative – cast or boot, weight off of foot.

•Surgical – May need removal of areas of bone or fixation. Surgery if
severe and affecting mobility, or if fractures are unstable.

ANY QUESTIONS?

Multiple Choice

Which ligament is torn here?

• Deltoid

• Spring

• Anterior Talofibular

• Posterior Talofibular

Open Ended

What type of fracture is seen on this x-ray?

Open Ended

A patient presents with an ankle injury. Given this x-ray, what is the usual treatment modality?

• What is seen on this xray?

• What is seen on this xray?

​Os trigonum – accessory bone within the flexor hallicus longus bone. Can be normal variant or develop from trauma

Open Ended

How would you classify this fracture?

Multiple Choice

What is the fracture seen here?

• No fracture seen

• Charcot's foot

• 5th metatarsal fracture

• 1st metatarsal fracture

• Lis Franc Fracture

• https://teachmesurgery.com/orthopaedi

c/ankle-and-foot/ankle-
fracture/#:~:text=The%20most%20com
mon%20classification%20used,the%20le
vel%20of%20the%20syndesmosis

• https://radiopaedia.org/articles/weber-

classification-of-ankle-fractures?lang=gb

• https://gpnotebook.com/en-

GB/pages/musculoskeletal-
medicine/ottawa-rules-regarding-
requirement-for-ankle-x-ray

• https://www.123rf.com/photo_7826177

3_four-major-pulse-points-of-the-foot-
the-pedal-pulses.html

• https://www.orthobullets.com/trauma/1

047/ankle-fractures

• https://orthoinfo.aaos.org/en/diseases--

conditions/toe-and-forefoot-fractures/

• https://www.orthobullets.com/foot-

and-ankle/7031/5th-metatarsal-base-
fracture

• https://orthoinfo.aaos.org/en/diseases--

conditions/lisfranc-midfoot-injury

• https://www.msdmanuals.com/en-

gb/home/injuries-and-
poisoning/fractures/metatarsal-
fractures#Treatment_v13967406

REFERENCES