Ankle ligament injuries

By Dr. : ANAS B. AHMED

Movement
Ankle ligament injuries
• Ankle sprains are the most common of all sports related injuries,
accounting for over 25 per cent of cases.
• They are probably even more common in pedestrians and country
walkers who stumble on stairways, pavements and potholes.
• In more than 75 per cent of cases it is the lateral ligament complex
that is injured, in particular the anterior talofibular and
calcaneofibular ligaments.
• Medial ligament injuries are usually associated with a fracture or
joint injury.
Ankle ligament injuries
Ankle ligament injuries
• A sudden twist of the ankle momentarily tenses the structures around the
joint.
• This may amount to no more than a painful wrenching of the soft tissues –
what is commonly called a sprained ankle.
• If more severe force is applied, the ligaments may be strained to the point
of rupture.
• With a partial tear, some of the ligament remains intact and, once it has
healed, it is able to stabilize the joint.
• With a complete tear, the ligament may still heal but it might not regain its
original form and length; the joint will potentially be unstable.
Lateral collateral ligaments
• The lateral collateral ligaments consist of the anterior talofibular, the posterior
talofibular and (between them) the calcaneofibular ligaments.
• The anterior talofibular ligament (ATFL) runs almost horizontally from the anterior edge
of the lateral malleolus to the neck of the talus; it is relaxed in dorsiflexion and tense in
plantarflexion.
• In plantarflexion the ligament essentially changes its orientation from horizontal with
respect to the floor, to almost vertical.
• Thus the ligament at greatest stretch, and most vulnerable, with the foot plantar-flexed
is the ATFL – hence the propensity for ATFL injury with the plantar-flexed, inverting, foot.
• The calcaneofibular ligament stretches from the tip of the lateral malleolus to the
posterolateral part of the calcaneum, thus it helps also to stabilize the subtalar joint.
Maximum tension is produced by inversion and dorsiflexion of the ankle.
• The posterior talofibular ligament runs from the posterior border of the lateral
malleolus to the posterior part of the talus.
Lateral collateral ligaments
Medial collateral (deltoid) ligament
• The medial collateral (deltoid) ligament consists of superficial and deep portions.
• The superficial fibres spread like a fan from the medial malleolus as far anteriorly
as the navicular and inferiorly to the calcaneum and talus. Its chief function is to
resist eversion of the hindfoot.
• The deep portion is intra-articular, running directly from the medial malleolus to
the medial surface of the talus. Its principal effect is to prevent external rotation
of the talus.
• The combined action of restraining eversion and external rotation makes the
deltoid ligament a major stabilizer of the ankle.
• The distal tibiofibular joint is held by four ligaments: the anterior, posterior,
inferior transverse and interosseous ‘ligament’, which is really a thickened part of
the interosseous membrane. This strong ligament complex still permits some
movement at the tibiofibular joint during flexion and extension of the ankle.
Medial collateral (deltoid) ligament
Mechanism of injury
• The common ‘twisted ankle’ is due to unbalanced loading with the
ankle inverted and plantarflexed.
• First the anterior talofibular and then the calcaneofibular ligament is
strained; sometimes the talocalcaneal ligaments also are injured.
• If fibres are torn there is bleeding into the soft tissues.
• The tip of the malleolus may be avulsed and in some cases the
peroneal tendons are injured.
• There may be a small fracture of an adjacent tarsal bone or (on the
lateral side) the base of the fifth metatarsal.
Mechanism of injury
Acute injury of lateral ligaments
• Clinical features
• A history of a twisting injury followed by pain and swelling could
suggest anything from a minor sprain to a fracture.
• If the patient is able to walk, and bruising is only faint and slow to
appear, it is probably a sprain; if bruising is marked and the patient
unable to put any weight on the foot, this suggests a more severe
injury.
• Tenderness is maximal just distal and slightly anterior to the lateral
malleolus.
• The slightest attempt at passive inversion of the ankle is extremely
painful.
• It is impossible to test for abnormal mobility without using local or
general anaesthesia.
Acute injury of lateral ligaments
• With all ankle injuries it is essential to examine the entire leg and
foot; undisplaced fractures of the fibula or the tarsal bones, or even
the fifth metatarsal bone are easily missed and injuries of the distal
tibiofibular joint and the peroneal tendon sheath cause features that
mimic those of a lateral ligament strain.
Acute injury of lateral ligaments
• Imaging
• About 15 per cent of ankle sprains reaching the Emergency
Department are associated with an ankle fracture.
• This complication can be excluded by obtaining an x-ray, but there are
doubts as to whether all patients with ankle injuries should be
subjected to x-ray examination.
• X-ray examination is called for if there is:
• Pain around the malleolus;
• Inability to take weight on the ankle immediately after the injury;
• Inability to take four steps in the Emergency Department;
• Bone tenderness at the posterior edge or tip of the medial or lateral malleolus or
the base of the fifth metatarsal bone.
Acute injury of lateral ligaments
• Imaging
• If x-ray examination is considered necessary, anteroposterior,
lateral and ‘mortise’ (30-degree oblique views of the ankle) should
be obtained.
• Localized soft tissue swelling and, in some cases, a small avulsion
fracture of the tip of the lateral malleolus or the anterolateral
surface of the talus may be the only corroborative signs of a lateral
ligament injury.
• However, it is important to exclude other injuries, such as an
undisplaced fibular fracture or diastasis of the tibiofibular
syndesmosis.
Acute injury of lateral ligaments
• Imaging
• Persistent inability to weightbear over 1 week or longer should call
for re-examination and review of all the initial ‘negative’ x-rays.
• For patients who have had persistent pain, swelling, instability and
impaired function over 6 weeks or longer, despite appropriate
early treatment, magnetic resonance imaging (MRI) or computed
tomography (CT) will be required to assess the extent of soft
tissue injury or subtle bony changes.
Acute injury of lateral ligaments
Acute injury of lateral ligaments
Ankle ligament injuries
(a) Schematic diagram
showing the mortise-and-
tenon articulation and main
ligaments of the ankle.
(b) The three components of
the lateral collateral ligament.
(c) The commonest injury is a
partial tear of one or other
component of the lateral
ligament. Following a
complete tear, the talus may
be displaced in the ankle
mortise; the tibiofibular
ligament may have ruptured
as well, shown here in
somewhat exaggerated form.
Acute injury of lateral ligaments

Ankle ligament injuries

(d) Stress x-ray showing
talar tilt.
(e,f) X-rays demonstrating
anteroposterior instability.
Pulling the foot forward
under the tibia causes the
talus to shift appreciably
at the ankle joint; this is
usually seen after recurrent
sprains.
Acute injury of lateral ligaments
• Treatment
• Initial treatment consists of rest, ice, compression and elevation (RICE),
which is continued for 1–3 weeks depending on the severity of the
injury and the response to treatment.
• Cold compresses should be applied for about 20 minutes every 2 hours,
and after any activity that exacerbates the symptoms.
• More recently the acronym has been extended to ‘PRICE’ by adding
protection (crutches, splint or brace) and still further to ‘PRICER’,
adding rehabilitation (supported return to function).
• There is evidence that in acute injuries topical non-steroidal anti-
inflammatory (NSAI) gels or creams might be as beneficial as oral
preparations, probably with a better risk profile.
Acute injury of lateral ligaments
• Operative treatment
• If the ankle does not start to settle within 1–2 weeks of starting
RICE, further review and investigation are called for.
• Persistent problems at 12 weeks after injury, despite
physiotherapy, may signal the need for operative treatment.
• Residual complaints of ankle pain and stiffness, a sensation of
instability or giving way and intermittent swelling are suggestive of
cartilage damage or impinging scar tissue within the ankle.
• Arthroscopic repair or ligament substitution is now effective in
many cases, allowing a return to full function and sports.
Deltoid ligament tear
• Rupture of the deltoid ligament is usually associated with either a fracture
of the distal end of the fibula or tearing of the distal tibiofibular
ligaments (or both).
• The effect is to destabilize the talus and allow it to move into eversion and
external rotation.
• The diagnosis is made by x-ray: there is widening of the medial joint
space in the mortise view; sometimes the talus is tilted, and diastasis of
the tibiofibular joint may be obvious.
• When there is a deltoid ligament or medial malleolar injury but no
apparent lateral disruption at the ankle, it is important to look for a
fracture or dislocation of the proximal fibula.
Deltoid ligament tear
Deltoid ligament tear
Deltoid ligament tear
Deltoid ligament tear
• Treatment
• Provided the medial joint space is completely reduced, the
ligament will heal.
• The fibular fracture or diastasis must be accurately reduced, if
necessary by open operation and internal fixation.
• Occasionally the medial joint space cannot be reduced; it should
then be explored in order to free any soft tissue trapped in the
joint.
• A below-knee cast is applied with the foot plantigrade and is
retained for 8 weeks.
Malleolar fractures in the
ankle
Malleolar fractures in the ankle
• Also referred to as Pott’s fracture.
• The most obvious injury is a fracture of one or both malleoli; often,
though, the ‘invisible’ part of the injury – rupture of one or more
ligaments – is just as serious.
• Fractures and fracture dislocations of the ankle are common.
Malleolar fractures in the ankle
• Most are low-energy fractures of one or both malleoli, usually caused
by a twisting mechanism.
• Less common are the more severe fractures involving the tibial
plafond, the pilon fractures, which are high-energy injuries often
caused by a fall from a height.
• The patient usually presents with a history of a twisting injury, usually
with the ankle going into inversion, followed by immediate pain,
swelling and difficulty weightbearing.
• Bruising often comes out soon after injury.
Ligaments of the tibiofibular syndesmosis

The ligaments of the tibiofibular syndesmosis

include the anterior and posterior tibiofibular
ligaments (AIFTL and PIFTL), the interosseous
ligament (IOL), and the transverse ligament (TL)
Mechanism of injury
• The patient stumbles and falls.
• Usually the foot is anchored to the ground while the body lunges
forward.
• The ankle is twisted and the talus tilts and/or rotates forcibly in the
mortise, causing a low-energy fracture of one or both malleoli, with
or without associated injuries of the ligaments.
• If a malleolus is pushed off, it usually fractures obliquely; if it is
pulled off, it fractures transversely.
Mechanism of injury
Mechanism of injury
Mechanism of injury
• The precise fracture pattern is determined by:
• The position of the foot;
• The direction of force at the moment of injury.
• The foot may be either pronated or supinated and the force upon the
talus is towards adduction, abduction or external rotation, or a
combination of these.
Mechanism of injury
Mechanism of injury
Pathological anatomy
• A simpler (perhaps too simple) classification is that of Danis and Weber, which
focuses on the fibular fracture.
• Type A
• Is a transverse fracture of the fibula below the tibiofibular syndesmosis,
• Perhaps associated with an oblique or vertical fracture of the medial malleolus;
• This is almost certainly an adduction (or adduction and internal rotation) injury.
• Type B
• Is an oblique fracture of the fibula in the sagittal plane at the level of the
syndesmosis;
• Often there is also an avulsion injury on the medial side (a torn deltoid ligament or
fracture of the medial malleolus).
• This is probably an external rotation injury and it may be associated with a tear of
the anterior tibiofibular ligament.
Pathological anatomy
• Type C
• Is a more severe injury, above the level of the syndesmosis, which
means that the tibiofibular ligament and part of the interosseous
membrane must have been torn.
• Associated injuries are an avulsion fracture of the medial malleolus (or
rupture of the medial collateral ligament), a posterior malleolar fracture
and diastasis of the tibiofibular joint.
• This is due to severe abduction or a combination of abduction and
external rotation.
Pathological anatomy
Pathological anatomy
Pathological anatomy
Pathological anatomy

Ankle fractures – classification The

Danis–Weber classification is based on the
level of the fibular fracture.
(a)
Type A – a fibular fracture below the
syndesmosis and an oblique fracture of the
medial malleolus (caused by forced
supination and adduction of the foot).
Pathological anatomy

Type B – fracture at the

syndesmosis, often associated with
disruption of the anterior fibres of the
tibiofibular ligament and fracture of
the posterior and/or medial malleolus,
or disruption of the
medial ligament (caused by forced
supination and external rotation).
Pathological anatomy

(c) Type C – a fibular fracture

above the syndesmosis;
the tibiofibular ligament must be
torn, or else
Pathological anatomy

the ligament avulses a small piece

of the tibia.
Here, again, there must also be
disruption on the medial side of
the joint – either a medial
malleolar fracture or rupture of
the deltoid ligament.
Clinical features
• Ankle fractures are seen in sportsmen and sportswomen, as well as
those who catch their foot, twist and fall in day-to-day activities; an
older group includes women with postmenopausal osteoporosis who
trip and fall.
• A history of a twisting injury, followed by intense pain and inability to
stand on the leg suggests something more serious than a simple
sprain.
• The ankle is swollen and deformity may be obvious.
• The site of tenderness is important; if both the medial and lateral
sides are tender, a double injury (bony or ligamentous) must be
suspected.
X-rays
• At least three views are needed: anteroposterior, lateral and a 30-
degree oblique ‘mortise’ view.
• The level of the fibular fracture is often best seen in the lateral view;
diastasis may not be appreciated without the mortise view.
• Further X-rays may be needed to exclude a proximal fibular fracture,
up as high as the knee.
Treatment
• Swelling is usually rapid and severe, particularly in the higher-energy
injuries.
• If the injury is not dealt with within a few hours, definitive treatment
may have to be deferred for several days while the leg is elevated so
that the swelling can subside; this can be hastened by using a foot
pump (which also reduces the risk of deep-vein thrombosis) and cold
compression.
Treatment
• Fractures are visible on X-ray; ligament injuries are not.
• Always look for clues to the invisible ligament injury
1. Widening of the tibiofibular space,
2. Asymmetry of the talotibial space,
3. Widening of the medial joint space,
4. Tilting of the talus.
Treatment
Treatment
(a) Stable fracture: In this Danis–Weber
type B fracture the tibiofibular syndesmosis
has held; the surfaces of the tibia and talus
are precisely parallel and the width of the
joint space is regular both superiorly and
medially.
(b) Slight subluxation: The syndesmosis is
intact but the talus has moved laterally with
the distal fibular fragment; the medial joint
space is too wide, signifying a deltoid
ligament rupture.
It is vital, after reduction of the fibular
fracture, to check that the medial joint
space is normal;
if it is not, the ligament has probably been
trapped in the joint and it must be freed so as to
allow perfect repositioning of the talus.
Treatment
(c) Fracture dislocation: In this high
fibular fracture the syndesmosis has
given way, the medial collatoral
ligament has been torn and the talus is
displaced and tilted. The fibula must be
fixed to full length and the tibiofibular
joint secured before the ankle can be
stabilized.
(d) Posterior fracture-dislocation:
If the posterior margin of the tibia is
fractured, the talus may be displaced
upwards.
The fragment must
be replaced and fixed securely.
Treatment
• Like other intra-articular injuries, ankle fractures must be accurately
reduced and held if later mechanical dysfunction is to be prevented.
• Persistent displacement of the talus, or a step in the articular
surface, leads to increased stress and predisposes to secondary
osteoarthritis.
• Ankle fractures are often unstable.
• Whatever the method of reduction and fixation, the position must
be checked by x-ray during the period of healing.
Treatment
• In assessing the accuracy of reduction, four objectives must
be met:
1. The fibula must be restored to its full length;
2. The talus must sit squarely in the mortise, with the talar and
tibial articular surfaces parallel;
3. The medial joint space must be restored to its normal width, i.e.
the same width as the tibio-talar space (about 4 mm);
4. Oblique x-rays must show that there is no tibiofibular diastasis.
Treatment
• Undisplaced fractures
• An isolated, undisplaced type A fracture is stable and will need minimal
splintage: a firm bandage or stirrup brace is applied mainly for comfort until
the fracture heals.
• Undisplaced type B fractures are potentially unstable only if the tibiofibular
ligament is torn or avulsed, or if there is a significant medial-sided injury.
• X-rays will show if the syndesmosis or mortise is intact; if it is (stable), a below-knee cast
is applied with the ankle in the neutral (anatomical) position.
• A check x-ray is taken at 2 weeks to confirm that the fracture remains undisplaced.
• The cast can usually be discarded after 6–8 weeks.
• Ankle and foot movements are regained by active exercises when the plaster is removed.
• If it is not stable then operation is needed
• Undisplaced type C fractures are better fixed from the outset.
Treatment
• Displaced Weber type A fractures
• Open reduction and internal fixation
• Postoperatively a ‘walking cast’ or removable splintage boot is applied for 6 weeks; the
advantage of removable splintage is that early physiotherapy can be commenced.
• Displaced Weber type B fractures
• Closed reduction needs traction (to disimpact the fracture) and then internal rotation
of the foot.
• If closed reduction succeeds, a cast is applied, following the same routine as for undisplaced
fractures.
• Failure of closed reduction (sometimes a torn medial ligament is caught in between the talus
and medial malleolus) or late redisplacement calls for operative treatment.
• Displaced Weber type C fractures
• Almost all type C fractures are unstable and will need open reduction and internal
fixation.
Treatment

(a,b) Danis–Weber type A fractures can often be

treated conservatively but, if the medial
malleolar fragment involves a large segment of
the articular surface, it is best treated by
accurate open reduction and internal fixation
with one or two screws.
Treatment
(c,d) An unstable fracture-
dislocation such as this almost
always needs open reduction and
internal fixation.
The fibula should be restored to full
length and fixed securely; in this
case the medial malleolus also
needed internal fixation;
Treatment

(a) In this type B fracture there is partial disruption of

the distal tibiofibular syndesmosis.
Treatment (b) required medial and lateral fixation as
well a tibiofibular screw.
Treatment
(c) A type C fracture must, inevitably, disrupt the
tibiofibular ligament; in this case the medial malleolus
was intact but the deltoid ligament
was torn (look at the wider than normal medial joint
space).
(d) By fixing the fibular fracture and using a tibiofibular
screw, the ankle was completely reduced and it was
therefore unnecessary to explore the deltoid ligament.
Complications
• Early
• Vascular injury
• With a severe fracture-subluxation the pulses may be obliterated.
• The ankle should be immediately reduced and held in a splint until definitive treatment
has been initiated.
• Wound breakdown and infection
• Diabetic patients are at greater than usual risk of developing wound-edge necrosis and
deep infection.
• In dealing with displaced fractures, these risks should be carefully weighed against the
disadvantages of conservative treatment; casts may also cause skin problems if not well
padded and are less effective in preventing malunion.
Complications
• Late
• Incomplete reduction
• Incomplete reduction is common and, unless the talus fits the mortise accurately,
degenerative changes may occur.
• Non-union
• The medial malleolus occasionally fails to unite because a flap of periosteum is
interposed between it and the tibia. It should be prevented by operative reduction and
screw fixation.
• Joint stiffness
• Swelling and stiffness of the ankle are usually the result of neglect in treatment of the
soft tissues.
• The patient must walk correctly in plaster and, when the plaster is removed, he or she
must, until circulatory control is regained, wear a crepe bandage and elevate the leg
whenever it is not being used actively. Physiotherapy is always helpful.
Complications
• Late
• Algodystrophy
• This often follows fractures of the ankle.
• The patient complains of pain in the foot; there may be swelling and diffuse tenderness,
with gradual development of trophic changes and severe osteoporosis
• Osteoarthritis
• Malunion and/or incomplete reduction may lead to secondary osteoarthritis of the ankle
in later years.
Pilon fractures
Pilon fractures
• Unlike the twisting injuries that cause the common ankle fractures,
this injury to the ankle joint occurs when a large force drives the
talus upwards against the tibial plafond, like a pestle (pilon) being
struck into a mortar.
• There is considerable damage to the articular cartilage and the
subchondral bone may be broken into several pieces; in severe cases,
the comminution extends some way up the shaft of the tibia.
Pilon fractures

Influence of the position of the foot upon the pattern of fracture.

A Plantar flexion results in posterior injury.
B Dorsal flexion results in anterior injury.
C Neutral position results in anterior and posterior impaction.
Clinical features
• There may be little swelling initially but this rapidly changes and
fracture blisters are common.
• The ankle may be deformed or even dislocated; prompt approximate
reduction is mandatory.
X-rays
• This is a comminuted fracture of the distal end of the tibia,
extending into the ankle joint.
• The fracture may be classified according to the amount of
displacement and comminution (Rüedi and Allgöwer, 1979), though
this will usually require accurate definition by CT.
• In all cases, assessment is far better with CT scanning (preferably
including three-dimensional reconstruction) than with plain x-ray
examination.
Classification
• Rüedi type 1 is an intra-articular fracture with little or no
displacement of the fragments;
• Type 2 there is more severe disruption of the articular surface but
without very marked comminution.
• Type 3 is a severely comminuted fracture with displacement of the
fragments and gross articular irregularity.
Classification

(a) undisplaced (type 1),

(b) minimally displaced (type 2);
(c) markedly displaced (type 3).
Treatment
• The three points of early management of these injuries are: span,
scan, plan.
• Staged treatment has reduced the complication rate in these injuries.
• Control of soft tissue swelling is a priority; this is best achieved by
elevation and applying an external fixator across the ankle joint (the
spanning external fixator, or travelling traction).
• It may take 2– 3 weeks before the soft tissues improve, and
fracture blisters can be actively managed rather than hidden under
plaster.
• Surgery can be planned, based on the CT scan.
Treatment
A 43-year-old man suffered a
high- energy comminuted
fracture of the distal end of the
tibia.
(a) Swelling and fracture
blisters around the ankle.
(b,c) X-rays showing disruption
of the metaphyseal–diaphyseal
junction in this pilon fracture.
Treatment

Fracture held in an
external fixator
Treatment

At 3 months after minimal approach reduction and

fixation with distal locking plates the fractures
have healed and the joint is congruent and
normally aligned.
Outcome
• Pilon fractures usually take several months to heal.
• Postoperatively, physiotherapy is focused on joint movement and
reduction of swelling.
• Although bony union may be achieved, the fate of the joint is
decided by the degree of cartilage injury – the ‘invisible’ factor on x-
rays.
• Secondary osteoarthritis, stiffness and pain are still frequent late
complications.
Injuries to talus
Anatomy
Anatomy
Anatomy
Injuries to talus
• Talar fractures and dislocations are relatively uncommon.
• They usually involve considerable violence, such as:
• Car accidents in which the occupants are thrown against the
resistant frame of the vehicle,
• Falls from a height,
• Severe wrenching of the ankle.
Injuries to talus
• The injuries include:
• Fractures of the neck, body, head or bony processes of the talus,
• Dislocations of the talus or the joints around the talus,
• Osteochondral fractures of the superior articular surface,
• Variety of chip or avulsion fractures.
Injuries to talus
• The significance of the more serious injuries is enhanced by two
important facts:
1. The talus is a major weightbearing structure (the superior
articular surface carries a greater load per unit area than any
other bone in the body);
2. It has a vulnerable blood supply and is a relatively common site
for post-traumatic ischaemic necrosis.
Injuries to talus
Injuries to talus
• Blood vessels enter the bone from the anterior tibial, posterior tibial
and peroneal arteries, as well as anastomotic vessels from the
surrounding capsule and ligaments.
• The head of the talus is richly supplied by intraosseous vessels.
• However, the body of the talus is supplied mainly by vessels that
enter the talar neck from the tarsal canal and then run retrograde
from distal to proximal.
• In fractures of the talar neck these vessels are divided; if the fracture
is displaced, the extraosseous plexus too may be damaged and the
body of the talus is at risk of ischaemia.
Mechanism of injury
• Fracture of the talar neck is produced by violent hyperextension of the
ankle.
• The neck of the talus is forced against the anterior edge of the tibia, which
acts like a cleaver.
• If the force continues, the fracture is displaced and the surrounding joints
may sublux or dislocate.
• Fracture of the body is usually a compression injury due to a fall from a
height, or an everting force across the body, fracturing the lateral process
(the snowboarders’ fracture).
• Avulsion fractures are associated with ligament strains around the ankle
and hindfoot.
Clinical features
• The patient has most commonly been involved in a motor vehicle
accident or has fallen from a height.
• The foot and ankle are painful and swollen; if the fracture is
displaced, there may be an obvious deformity, or the skin may be
tented or split.
• Tenting is a dangerous sign; if the fracture or dislocation is not
promptly reduced, the skin may slough and become infected.
• The pulses should be checked and compared with those in the
opposite foot.
X-ray
• Anteroposterior, lateral and oblique views are essential; CT scanning
helps to identify associated injuries of the ankle and foot.
• Both malleoli, the ankle mortise, the talus and all the adjacent tarsal
bones should be carefully assessed.
• Undisplaced fractures are not always easy to see, and sometimes
even severely displaced fractures are missed in the initial assessment.
X-ray
(a) Talocalcaneal fracture–dislocation.
(b) Undisplaced fracture of the talar
neck.
(c) Type III fracture of the neck.
X-ray

(d) Displaced fracture of the

body of the talus.
(e) This fracture of the body
was thought to be well
reduced; however, in the AP
view
(f) it is possible to see two
overlapping outlines,
indicating that the fragments
are malrotated.
Classification
• Fractures of the neck of the talus These fractures are classified
according to the system devised by Hawkins (1970) and modified by
Canale (1978):
• Group I – undisplaced
• Group II – displaced (however little) and associated with
subluxation or dislocation of the subtalar joint
• Group III – displaced, with dislocation of the body of the talus from
the ankle joint
• Type IV – displaced vertical talar neck fracture with associated
talonavicular joint disruption.
Treatment
• Undisplaced fractures
• A split below-knee plaster is applied and, when the swelling has
subsided, is replaced by a complete cast with the foot
plantarflexed.
• Weightbearing is not permitted for the first 4 weeks; thereafter, At
8-12 weeks the splintage is discarded.
• Displaced fractures of the neck
• Type II fractures open reduction and internal fixation.
• Type III fracture- dislocations need urgent open reduction and
internal fixation.
Treatment

Fractures of the talus – treatment (a) This

displaced fracture of the body was reduced and
fixed with a countersunk screw (b), giving a perfect
result.
Fractures of the neck, even if well reduced (c) are
still at risk of developing ischaemic necrosis (d).
Complications
• Malunion
• The importance of accurate reduction has been stressed.
• Malunion may lead to distortion of the joint surface, limitation of movement and
pain on weightbearing.
• If early follow-up x-rays show redisplacement of the fragments, a further attempt at
reduction is justified.
• Persistent malunion predisposes to osteoarthritis.
• Avascular necrosis
• Avascular necrosis of the body of the talus occurs in displaced fractures of the talar
neck.
• The incidence varies with the severity of displacement: in type 1 fractures it is less
than 10 per cent; in type 2 about 30–40 per cent; and in type 3 more than 90 per
cent.
Complications
• Secondary osteoarthritis
• Osteoarthritis of the ankle and/or subtalar joints occurs some years after
injury in over 50 per cent of patients with talar neck fractures.
• There are a number of causes:
• (1) articular damage due to the initial trauma;
• (2) malunion and distortion of the articular surface;
• (3) avascular necrosis of the talus.
Fractures of calcaneum
Anatomy
Anatomy
Mechanism of injury
• The calcaneum is the most commonly fractured tarsal bone, and in 5-
10 per cent of cases both heels are injured simultaneously.
• In most cases the patient falls from a height, often from a ladder, onto
one or both heels.
• The calcaneum is driven up against the talus and is split or crushed.
• Over 20 per cent of these patients suffer associated injuries of the
spine, pelvis or hip.
• Avulsion fractures sometimes follow traction injuries of the tendo
Achillis.
Pathological anatomy
• Essex-Lopresti divide calcaneal fractures into:
• Extra -articular fractures (those involving the various calcaneal
processes or the body posterior to the talocalcaneal joint)
• Intraarticular fractures (those that split the talocalcaneal articular
facet).
Pathological anatomy
• Extra-articular fractures
• These account for 25 per cent of calcaneal injuries.
• Avulsion of the anterior process, the sustentaculum tali, the
tuberosity or the inferomedial process.
• Fractures of the posterior (extra-articular) part of the body are
caused by compression.
• Extra-articular fractures are usually easy to manage and have a
good prognosis by closed method unless the fragment is large and
badly displaced, in which case it will need to be fixed back in
position.
Pathological anatomy
Extra-articular fractures of the
calcaneum
Fractures may occur through
(A) the anterior process,
(B) the body,
(C) the tuberosity,
(D) the sustentaculum tali or
(E)the medial tubercle.
Treatment is closed unless the
fragment is large and badly displaced,
in which case it will need to be fixed
back in position.
Pathological anatomy
• Intra-articular fractures
• These injuries are much more complex and unpredictable in their
outcome.
• The impaction of the talus cleaving the bone from above to produce a
primary fracture line that runs obliquely across the posterior articular
facet and the body from posteromedial to anterolateral.
• Where it splits, the posterior articular facet depends upon the position
of the foot at impact: if the heel is in valgus (abducted), the fracture is
in the lateral part of the facet; if the heel is in varus (adducted), the
fracture is more medial.
• The upward displacement of the body of the calcaneum produces one
of the classic x-ray signs of a 'depressed' fracture: flattening of the
angle subtended by the posterior articular surface and the upper
surface of the body posterior to the joint (Bohler's angle).
Pathological anatomy
Pathological anatomy

Intra-articular fractures of the calcaneum The primary fracture line (a,b) is created by the impact of the
talus on the calcaneum – it runs from posteromedial to anterolateral.
Secondary fracture lines may create ‘tongue’ (c) or ‘joint depression’ (d) variants to the fracture pattern.
Pathological anatomy

Intra-articular fractures of the calcaneum CT scans have allowed a better understanding of the fracture anatomy.
A coronal CT scan enables the identification of three major fragments in most intra-articular fractures: the lateral joint fragment (L),
the sustentaculum tali (S) and the body fragment (B).
In type 1 fractures (a) the lateral joint fragment is in valgus whereas the body is in varus.
In type 2 fractures (b), the sustentaculum tali is in varus and the lateral joint is elevated in relation to it.
In type 3 fractures (c) the lateral joint fragment is impacted and buried within the body fragment
Clinical features
• There is usually a history of a fall from a height, or a road traffic accident; in
elderly osteoporotic people even a comparatively minor injury may
fracture the calcaneum.
• The foot is painful and swollen and a large bruise appears on the lateral
aspect of the heel.
• The heel may look broad and squat.
• The surrounding tissues are thick and tender, and the normal concavity
below the lateral malleolus is lacking.
• The subtalar joint cannot be moved but ankle movement is possible.
• Always check for signs of a compartment syndrome of the foot (intense
pain, very extensive bruising and diminished sensation, with pain on
passive toe movement).
Clinical features
X-ray
• Plain x-rays should include lateral, oblique and axial views.
• Extra-articular fractures are usually fairly obvious.
• Intra-articular fractures, also, can often be identified in the plain
films and if there is displacement of the fragments the lateral view
may show flattening of the tuber-joint angle (Böhler’s angle).
• For accurate definition of intra-articular fractures, CT is essential and
three-dimensional reconstruction views even better.
• With severe injuries – and especially with bilateral fractures or in the
unconscious patient – it is essential to assess the knees, spine and
pelvis as well.
Treatment
• Extra-articular fractures
• The mobility and function are more important than anatomical
repositioning'.
• The vast majority are treated closed:
• Compression bandaging, ice packs and elevation until the
swelling subsides;
• Exercises as soon as pain permits;
• No weightbearing for 4 weeks and partial weightbearing for
another 4 weeks.
Treatment
• Extra-articular fractures
• Fractures of the anterior process; Fractures involves the
calcaneocuboid joint. If there is a large displaced fragment,
internal fixation may be needed
• Fractures of the tuberosity These are usually due to avulsion by
the tendo Achillis; if the fragment is displaced, it should be
reduced and fixed with cancellous screws; the foot is then
immobilized in slight equinus to relieve tension on the tendo
Achillis.
Treatment
Extra-articular
calcaneal fractures –
treatment (a) Avulsion
fracture of
posterosuperior corner
(b) fixed by a screw.
Treatment
• Intra-articular fractures
• Undisplaced fractures are treated in much the same way as extra-
articular fractures:
• Displaced intra-articular fractures are best treated by open
reduction and internal fixation as soon as the swelling subsides.
• Postoperatively the foot is lightly splinted and elevated.
• Exercises are begun as soon as pain subsides.
• Restoration of function may take 6-12 months.
Treatment
Intra-articular calcaneal fracture
– treatment
X-ray gives limited information, (a)
but the CT (b) shows the
severe depression of the
posterior calcaneal facet.
This was treated operatively (b)
with a calcaneal locking plate,
to reconstitute the posterior
facet (arrow) and restore the
height of the calcaneum (c,d).
Complications
• Early
• Swelling and blistering
• Intense swelling and blistering may jeopardize operative treatment.
• The limb should be elevated with the minimum of delay.
• Compartment syndrome
• About 10 per cent of patients develop intense pressure symptoms.
• The risk of a fullblown compartment syndrome can be minimized by
starting treatment early.
• If operative decompression is carried out, this will delay any definitive
procedure for the fracture.
Complications
• Late
• Malunion
• Closed treatment of displaced fractures, or injudicious weightbearing
after open reduction, may result in malunion.
• The heel is broad and squat, and the patient has a problem fitting shoes.
• Usually the foot is in valgus and walking may be impaired.
• Peroneal tendon impingement
• Lateral displacement of the body of the calcaneum may cause painful
compression of the peroneal tendons against the lateral malleolus.
Complications
• Late
• Insufficiency of the tendo Achillis
• The loss of heel height may result in diminished tendo Achillis action.
• Talocalcaneal stiffness and osteoarthritis
• Displaced intraarticular fractures may lead to joint stiffness and,
eventually, osteoarthritis.
Metatarsal fractures
Metatarsal fractures
• Metatarsal fractures are relatively common and are of four types:
1. Crush fractures due to a direct blow;
2. Spiral fracture of the shaft due to a twisting injury;
3. Avulsion fractures due to ligament strains;
4. Insufficiency fractures due to repetitive stress.
Fractures of fifth metatarsal base (Jones
fracture)
• Forced inversion of the foot (the ‘pot-hole injury’) may cause avulsion
of the base of the fifth metatarsal, with pull-off by the peroneus
brevis tendon or the lateral band of the plantar fascia.
• Pain due to a sprained ankle may overshadow pain in the foot.
• Examination will disclose a point of tenderness directly over the
prominence at the base of the fifth metatarsal bone.
• The proximal avulsion fractures can usually be treated
symptomatically, with initial rest and support, but with early
mobilization and return to function. Surgery may be needed in intra-
articular fractures
Fractures of fifth metatarsal base (Jones
fracture)
Fractures of fifth metatarsal base (Jones
fracture)
Stress injury (March fracture)
• In a young adult (often a military recruit or a nurse) the foot may become
painful and slightly swollen after overuse.
• A tender lump is palpable just distal to the midshaft of a metatarsal bone.
• Usually the second metatarsal is affected, especially if it is much longer
than an ‘atavistic’ first metatarsal.
• The x-ray appearance may at first be normal but a radioisotope scan will
show an area of intense activity in the bone.
• Later a hairline crack may be visible and later still (4–6 weeks) a mass of
callus is seen.
• No displacement occurs and neither reduction nor splintage is necessary.
The forefoot may be supported with an elastic bandage and normal
walking is encouraged.
Stress injury (March fracture)
Stress injury (March fracture)

March fracture (fatigue fracture).

(a, b) Frontal radiographs of the right
foot in a college gymnast show the
early (a) and late (b) radiographic
findings of a second metatarsal
fatigue fracture (arrow).
The fracture completely healed with
rest.
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