Ankle & Foot injuries

Calcaneal fracture

Ankle(Ottawa Rules)

Achilles tendon

Remember analgesia.Always assess and record the patient’s ability to bear weight

Ankle sprains - Ottawa Ankle Rules

Ankle x-rays are required if only if criteria beloware fulfilled.

With apparent ankle injuries, check other sites of trauma which are easily missed (i.e. tendo-achilles, os calcis, base of 5th metatarsal, whole of fibula (and tibia)
Remember to x-ray the foot if there is bony tenderness over the navicular or base of 5th metatarsal.
Check for AP instability.
Treat by ice (if recent), elevation and active exercises when elevated.
Encourage weight bearing, [BestBets] give stick/crutches if necessary
Do not routinely refer to ED clinic
In the case of a bad sprain, the above treatment is best supervised by direct referral to physiotherapy.

Malleolar fractures

If undisplaced, treat with below-knee POP and refer to the Fracture Clinic (CUH Fracture Clinic Referral form)
If displaced or tibio-fibular diastasis, refer to the on-call Orthopaedic Team
If diastasis, obtain X-ray of whole leg.

Reminder of normal foot anatomy

For more normal anatomy and x-rays, please see the x-ray section

Fracture calcaneum (os calcis)

May occur from a fall onto the heels or with "simple" inversion ankle injuries.
If in doubt - request axial X-ray.
If the sub-talar articular surface is involved, refer to the on-call Orthopaedic Team for admission.
Gross disruption of the subtalar joint is indicated by a flattening in Bohler's angle (should be 30⁰ - 40⁰).
If there is no sub-talar involvement apply a well padded POP backslab, advice, no weight bearing and provide crutches. Elevate.
Arrange a Fracture Clinic appointment.
Warn patient to return immediately if pain increases

Rupture of the tendon-Achilles

Confirm by local tenderness and a gap and positive Simmond's test (lie prone and calf squeeze produces plantar flexion in normal individuals).

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Cinical

Observe # foot may not rest in natural plantar-flexionflexion
Palpable step in Achilles Tendon

Management

Refer to on call orthopaedic team
Operative repair is preferable to conservative management [Bestbets].(NNT=10, NNH=21 [Bandolier])

Sub-talar and forefoot dislocation

Reduce immediately under Entonox +/- IV Morphine and Midazolam (sedation sheet)
(urgency = prevent skin overlying head of talus becomes ischaemic
Refer to the on-call Orthopaedic Team Referral form

Lis-Franc fractures

Clinically:

Suspect injury if point tenderness over midfoot, or laxity between 1st and 2nd MT’s

Radiology:

> 1mm gap between adjacent bases of 1st and 2nd MT’s
The six bone tarsometatarsal complex is known as the lis franc joint.
Injuries uncommon, but up to 20% are missed.
Force of injury variable and can be minor rotational to severe axial load.
In most injuries involve disruption of the joint and associated fractures of metatarsals, cuneiforms and cuboids.
A fracture at the base of the 2nd metatarsal is pathogmonic of disruption of the ligament complex.

Types of Lis-Franc fractures:

Divergent: metatarsals splayed both medially and laterally - usually between 1st and 2nd MT's
Isolated - one or more MT's are displaced from the rest
Homolateral - all 5 MT's are displaced in the same direction either laterally or medially

Isolated fractures of the cuboid and cuneiform bones are rare and an associated injury to the lis franc joint should be sought

Management

(thus why important to identify)

Frequently require open reduction and internal fixation or Kirschner wires
In interim, whilst waiting on orthopaedic opinion, should be immobilized in a below knee back slab and have hourly neurovascular obs due to the risk of swelling and compartment syndrome – (especially if crush type injury)

Complications

Early can have dorsalis pedis artery injury therefore always double check pulse and perfusion

Navicular fracture

Navicular is involved in both longitudinal and medial foot arches. 3 # types:

Avulsion #
# Body
Stress #

Stress fractures

Sports related insideous onset midfot pain
Point tender over dorsum navicular ("N spot")
Tender or medial plantar arch (less specific)
Pain with passive eversion and active inversion
Difficult to see on plain views (? bone scan or CT)
Strict non-weight bearing POP and # clinic Referral form
Analgesia, physio rehab back to sports

Fractures of the body

Commonly associated with other midtarsal injuries
Beware associated forfoot displacement
> 1mm displacement needs ORIF

Avulsion #

Twisting forces on the mid foot
Beware avulsion of the posterior tibial tendon insertion (tuberosity fracture) which may need fixation
Should be differentiated from Os Tibiale Exterior Naviculare

Avulsion Fracture of the base of the 5th metatarsal

Tubigrip [Bestbets] rather than plaster
Elevation when not walking on it, exercises.
Stick or crutches.
Review in clinic only if difficulty mobilising.
POP only if patient unable to weight bear at all.

Jones Fracture

$Jones fracture (proximal shaft) 5MT, not base MT$

Transverse fracture of shaft of little metatarsal.
Very different to pull off fracture as above.
Unstable as peroneus (brevis) tendons distract fracture and mal/non union likely.
Treat in POP and refer fracture clinic (CUH Fracture Clinic Referral form)

Other metatarsal fractures

ice, elevation and exercises. POP may be helpful if multiple fractures.

Toe fractures

If compound treat as for compound fractures plus soft footwear.
Fractures of the Hallux involving the articular surfaces require Fracture Clinic (CUH # Clinic Referral form)
Otherwise follow-up in the ED clinic or by GP