Foot And Ankle Injuries

Ankle sprains General principles Ankle sprains are very common. Inversion injuries cause about 85% of all ankle injuries, with the lateral collateral ligamentous complex as the most frequently injured structure (Cardone et al. 1993). Key points •

Ankle sprains, especially of the lateral collateral ligamentous complex, are one of the most common sportsrelated musculoskeletal injury.

Anatomy/biomechanics The ankle joint is a mortise joint that is made of the distal tibia and fibula and the talus. The lateral collateral ligamentous structure consists of the anterior talofibular (ATF), calcaneofibular (CF), and the posterior talofibular (PTF) ligaments. The medial collateral ligament is made of the superficial and deep portions of the deltoid ligament. Mechanism of injury The ATF ligament is taut in plantar flexion, and it is the most commonly injured ligament. The mechanism of injury is inversion while the foot is plantar flexed. The CF ligament is taut in dorsiflexion, and can be injured with the ATF ligament. Less commonly injured is the deltoid ligament. Jumping and cutting increase the risk of an ankle sprain while participating in sports, such as basketball, tennis, and soccer. Key points •

The ATF ligament is taut in plantar flexion, and it is the most commonly injured ligament.

Presentation Signs and symptoms The most common complaint is acute onset of pain after an injury. Associated symptoms are swelling, difficulty with weight bearing, and instability.

Classification of injury Sprains of the ankle can be classified by the degree of injury to the lateral collateral ligamentous structures. A grade I injury is stretching of the ATF without laxity, grade II injury is partial tear of the ATF ligament and CF ligament with mild laxity, and grade III injury is a complete rupture of the ATF, CF, and PTF ligaments with gross laxity. In the study by Gerber et al. (1998) the vast majority of sprains were classified grade I or grade II sprains. By 6 weeks following injury, 95% of the patients had returned to full activity in the military academy. Key points Sprains of the ankle classified (by the degree of the lateral collateral ligamentous structures) are:

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Grade I injury = stretching of the ATF without laxity,

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Grade II = partial tear of the ATF ligament and CF ligament with mild laxity,

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Grade III = complete tear of the ATF, CF, and PTF ligaments with gross laxity

Possible associated injuries Radiographs will help with the diagnosis of other injuries which may occur with ankle sprains, which include talar dome fractures, avulsion fractures of the lateral or medial malleolus, and other bony injuries. Diagnosis Examination findings The examination of a patient with an ankle injury should begin with the patient uncovering both legs from the knee. The skin is checked for lacerations or abrasions, swelling, blisters. Generally, the patient will have point tenderness at the area of injury, over the lateral and medial ankle. The anterior drawer test may be positive with an injury to the ATF ligament, and an increased talar tilt indicates an injury to the CF ligament.

Key points There is: •

point tenderness at the area of injury (over the lateral and medial ankle),

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the anterior drawer test may be positive with an injury to the ATF ligament,

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an increased talar tilt indicates an injury to the CF ligament

Diagnostic techniques The routine use of radiographs for the evaluation of the acutely injured patient to exclude fractures is questionable. The introduction of the Ottawa ankle rules has shown that the number of unnecessary ankle radiographs can be enormously reduced. If needed, then antero-posterior, lateral and mortise view of the ankle should be taken, together with at least antero-posterior and oblique views of the foot. MRI can help to demonstrate soft tissue and bony injury, and is sensitive to show acute or chronic tears, but is not required for diagnosis. Cardone et al showed good correlation between MRI and surgical findings (Chrisman and Snook, 1969). As the management of acute ankle sprains is mainly functional, and because treatment does not depend on the degree of ankle laxity on stress views, talar tilt and anterior drawer stress radiographs have no clinical relevance in the acute situation. In patients with chronic instability, the large variability in talar tilt and anterior drawer values in both injured and non-injured ankles precludes their routine use (Frost and Amendola, 1999). An ankle radiograph series is needed if there is any pain over the medial and/or lateral malleolus and bony tenderness over the medial and/or lateral malleolus, and inability to bear weight both immediately after the injury and in the Accident and Emergency Department.

A foot radiograph series is needed if there is any pain in the midfoot and bone tenderness over the base of the fifth metatarsal and/or the navicular, and inability to bear weight both immediately after the injury and in the Accident and Emergency Department.

Key points •

Although traditionally stress radiographs are taken, and MRI depicts very well the presence and extent of the ligamentous injury, they are not necessary in planning the management of acute or chronic ankle ligament injuries, unless there is a definite clinical indication for them.

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Ottawa Ankle Rules:

1. An ankle radiograph series is needed if there is any pain in medial and/or lateral malleolus and bony tenderness over the medial and/or lateral malleolus, and inability to bear weight both immediately after the injury and in the Accident and Emergency Department. 2. A foot radiograph series is needed if there is any pain in the midfoot and bone tenderness over the base of the fifth metatarsal and/or the navicular, and inability to bear weight both immediately after the injury and in the Accident and Emergency Department.

Management Initial Acute injuries are treated with the RICE (rest, ice, compression, and elevation) regimen. In moderate to severe injuries, a short course of immobilization (up to five days) in a splint or cast with the ankle in neutral position is helpful to allow the symptoms to improve and bearing weight. Once the pain and swelling decrease, active and passive range of motion exercises can be initiated. Physical therapy is helpful for recovery of strength and motion, particularly peroneal strength. An ankle stirrup may be used for additional support until strength is regained and symptoms are resolved. Great stress should be placed on proprioception exercises.

Key points •

Acute injuries are treated with the regimen RICE: rest, ice, compression, and elevation.

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Moderate to severe injuries-a short course of immobilization in a splint or cast in neutral.

Surgical indications The majority of ankle sprains are treated non-operatively. In cases of chronic recurrent injuries with failure of nonoperative management and recurrent ankle injuries or instability, surgical reconstruction should be considered.

Key points •

The majority of ankle sprains are treated non-operatively.

Surgical techniques available

There are over 80 surgical techniques described for the reconstruction of the lateral collateral ligaments. These procedures involve anatomic repair of the torn ligaments or reconstructive procedures with tendon transfers, such as with use of the peroneus brevis tendon. The most commonly used techniques include the modified Brostrom repair and the Chrisman-Snook procedure. The Brostrom repair is an anatomic repair of the torn ATF ligament, whereas the Chrisman-Snook procedure incorporates half of the peroneus brevis tendon to reconstruct the ATF and CF ligaments (Chrisman and Snook 1969). The Evans repair also uses the peroneus brevis tendon, but in this procedure half of the tendon is brought through a drill hole through the fibula and then inserted into the base of the fifth metatarsal (Rosenbaum et al, 1997). Nonanatomic repairs can lead to reduced mobility of the subtalar joint and cause impaired eversion, with the possibility of increased development of arthrosis of the subtalar joint.

Author’s preferred technique The Brostrom procedure was described as a surgical treatment of chronic ligament ruptures by repairing the ATF ligament (Brostrom 1966). The procedure was modified by Gould that included mobilization and repair of the lateral extensor retinaculum to the fibula to reinforce the ligament repair (Hamilton et al. 1993). This procedure provides the most anatomic repair and avoids complications associated with other repairs, such as loss of peroneal function, a long scar, and limitation of subtalar motion. The procedure is undertaken with the patient supine and a sand bag under the hip. Under tourniquet control, a curvilinear incision is made just distal to the lateral malleolus, taking care to identify and protect the lateral branch of the superficial peroneal nerve (the intermediate dorsal cutaneous nerve) and the sural nerve. The lateral aspect of the extensor retinaculum is mobilized and then the capsule is incised identifying the scarred ATF ligament. The CF ligament is also identified. The ATF and CF are repaired with the vest over pants technique or with drill holes into the fibula. The extensor retinaculum is then repaired with absorbable suture with the ankle held in neutral. The skin is repaired with a running subcuticular suture.

Key points •

An anatomic repair of the torn ATF is the surgical technique of choice

Post-operative care The patient is immobilized in a short leg cast for 4 weeks, weight-bearing as able. Gentle range of motion exercises can be initiated once the cast is removed. More aggressive mobilisation regimes can be instituted in selected patients.

Complications and management Complications from surgical repair include wound healing problems, surgical neuromas, continued instability, and stiffness. Taking care to protect the sensory nerves and gentle handling of soft tissue will help to avoid these complications.

Prognosis

Patients have good relief of pain and instability in most cases. However, up to 40% of patients may continue to experience ankle dysfunction (Gerber et al, 1998). Following a modified Brostrom procedure, there were 26 excellent results, one good, and one fair in 28 ankles in 27 patients (Hamilton et al. 1993). There were no failures, stretch-outs, re-dos, or complications. This procedure is an excellent choice for the dancers, athletes, or nonathletes alike. A

Achilles tendon tears

B

General principles

Rupture of the Achilles tendon is a common injury in men, usually in the 4th to 5th decade (Maffulli 1999). In athletes, acute ruptures may be associated with low grade symptoms from underlying tendinopathy (Novecheck 1998).

Anatomy/biomechanics The Achilles tendon is made of the gastrocnemius-soleus complex, the largest muscle in the leg. The gastrocnemiussoleus spans two in its joints, contracts eccentrically and concentrically, and it twists 90 course from its origin to its insertion. The area of hypovascularity 4 to 6 cm from the insertion (Saltzman and Tearse 1998) is where most of the acute subcutaneous tears take place. Advanced intra-tendinous degeneration is a feature of acute ruptures (Maffulli et al 2000). Mechanism of injury The aetiology of a rupture is usually multifactorial, and the patient is usually engaged in an acceleration-deceleration sport, the most common being squash or badminton. Key points •

Most patients sustain a tear when engaged in an acceleration-deceleration sport

Presentation Patients complain of sudden onset of pain in the posterior aspect of the lower leg. Frequently, patients describe that they felt a “kick” in the affected ankle. Patients may not be able to bear weight, and may find it difficult to walk. There is associated swelling and ecchymosis. Diagnosis The diagnosis can reliably be made by history and physical examination (Maffulli, 1998). Examination findings

The patient has localized swelling of the involved foot and ankle, and the area of rupture manifests as a palpable defect. The patient may be able to plantar flex the foot through the action of the long flexors, but the calf squeeze test will show no plantar flexion of the affected ankle.

Key points •

Diagnosis: The calf squeeze test is performed with the patient prone. The calf is squeezed, and plantar flexion of the foot is absent in a complete rupture of the Achilles tendon.

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A ‘no touch’ technique to diagnose an Achilles tendon tear is performed asking the patients, who is lying prone on an examination couch, to actively flex their knees to 90°. The position of the ankles and feet is observed during flexion of the knee. If the foot on the affected side falls into neutral or in dorsiflexion, an Achilles tendon tear is diagnosed.

Imaging techniques MRI scanning and ultrasonography have been used in dubious cases. It should be stressed that if the two clinical tests described above indicate a rupture, additional imaging is not warranted (Maffulli, 1998).

Management Initial The patient should be treated with ice, elevation, splinting and crutches. These measures will help with the acute symptom of pain and inability to bear weight.

Options With a complete rupture, the patient can be treated with a course of immobilization, with a short leg cast in gravity equinus for 6 to 8 weeks, gradually decreasing the amount of equinus changing the cast every two weeks, with the last cast with the foot plantigrade. Weight bearing should be allowed during the last two weeks in the cast.

Surgical indications For the healthy, active patient, most surgeons recommend surgery. Although there are definite surgical risks, the risk of rerupture is approximately one tenth of that of conservative management, and return to sport is faster and more predictable.

Key points •

For the healthy, active patient, most surgeons recommend surgical treatment

Surgical techniques available End to end suture is recommended, using a large absorbable suture in a Kessler-type fashion. Percutaneous repair is an option, but the results may be variable, and there can be complications with sural nerve entrapment with the Ma

and Griffith (1978) technique. A more modern technique (Webb & Bannister, 1999) involves only three transverse wounds, and can be performed under local anaesthetic with no risks to the sural nerve.

Author’s preferred technique Without a tourniquet, the Achilles tendon is exposed through a curved longitudinal medial incision, thus avoiding a scar directly over the tendon, and the sural nerve. The ends of the tendon are debrided if necessary and then reapproximated with an absorbable suture in a modified Kessler technique. A finer absorbable circumferential suture is used as a tidying stitch. If possible, the paratenon is repaired with absorbable suture, followed by the subcutaneous tissue, the skin edges juxtaposed, and steristripped. The foot and ankle are maintained in physiological equinus. A compression dressing is applied, and the leg immobilised in a below knee weightbearing cast for two weeks.

Post-operative care Patients are encouraged to undertake toe-touch weight bearing as soon as able. At two weeks, the cast is removed, and the wound inspected. By that time, the skin should be healed, but patients are invited not to get that part wet for another two weeks. A synthetic anterior leg, ankle and foot slab is applied, with velcro straps keeping it in place at the leg, ankle (without interfering with the incision), and foot. Full weight bearing is allowed, encouraging the patients to discard the crutches over the course of the next two weeks. The straps around the foot are removed several times a day to perform active mobilisation of the ankle. Progressive resistance exercises under physiotherapist supervision are encouraged from the fourth post-operative week. The anterior slab is discarded six weeks after the operation.

Complications and management Complications of surgical repair include wound infection, skin healing problems, sural nerve injury or neuroma, rerupture, and weakness. The soft tissues should be handled gently with non-tooth forceps and hand-held retractors. If a wound healing complication develops, local wound care with normal saline wet to dry dressings generally allow the wound to heal by secondary intention. Rarely is a plastic surgery consultation required. Neural injuries can be avoided by using a medial approach. The patient is instructed to return to pre-injury activities gradually over the course of 4 to 6 months after removal of the cast. Prognosis The prognosis following surgical repair is good, and usually the maximum strength is achieved 8 to 12 months following the procedure. Normally, the tendon remains significantly thicker than the contralateral, and there may be persistent weakness of which the patient may not be aware. Ankle fractures General principles

Fractures of the ankle are common. If fractures are displaced, they require either manipulation under anaesthetic and an above knee cast with weekly or fortnightly follow-up, or open reduction and internal fixation, which has become more common. Open reduction and internal fixation is recommended in overweight patients. Key points •

If fractures are displaced, they require either work-intensive follow-up or open reduction and internal fixation.

Anatomy/biomechanics The ankle joint consists of the distal tibia and fibula and the talus, which are held together with ligaments. The tibiofibular syndesmosis is made of the anterior tibiofibular ligament, posterior tibiofibular ligament, transverse tibiofibular ligament, and the interosseous membrane. Approximately 70% of dorsiflexion and plantar flexion takes place at the ankle joint. With displacement in a fracture, the weight-bearing portion of the talus can change dramatically. Therefore, anatomic reduction is crucial for regaining function and prevention of early secondary osteoarthritis. Key points Anatomic reduction is necessary for regaining function and prevention of early secondary osteoarthritis. Mechanism of injury Frequently, an ankle fracture occurs from a fall, with an inversion and rotation injury, and is associated with sport. The mechanism determines involvement of the lateral, medial, or posterior malleolus of the ankle joint. Presentation Patients present with acute onset of pain and inability to bear weight. Swelling usually develops rapidly. Signs and symptoms Most patients have moderate to severe pain and localised tenderness at and around the fracture site. There can be a more or less evident deformity of the ankle. The swelling is local in the foot and ankle, but can extend proximally, and fracture blisters can easily develop. Ankle motion is limited by pain and swelling.

Classification of injury The most common classification is the Danis-Weber scheme. It describes the position of the fracture of the lateral malleolus. A type A injury is a fracture of the lateral malleolus below the syndesmosis, a type B fracture is at the level of the syndesmosis, and a type C fracture is above the syndesmosis. This is a simple classification, is reproducible, and has some bearing to management.

The other well known classification is the Lauge-Hansen classification, the first one based on the mechanism of injury. It was determined from the results of a cadaver study, and the first term indicates the position of the foot and the second term describes the direction of the deforming force. There are four types: supination-adduction injury, supination-external rotation injury, pronation-abduction injury and pronation-external rotation injury. Each type has stages of the mechanism of injury. It is comprehensive, but difficult to use in clinical practice as it results in a total of 64 different types of fractures. Key points •

Classification of injury: the most commonly used classification is the Danis-Weber scheme

Possible associated injuries The syndesmosis may be injured with an ankle fracture. Fixation with a syndesmosis screw is necessary if the fracture lies 3 to 4.5 cm proximal to the mortise (Boden et al. 1989).

Diagnosis The diagnosis of an ankle fracture can be made with history of the mechanism of injury, physical examination, and radiographic examination. Examination findings The skin is examined for lacerations, abrasions, swelling and fracture blisters. Gentle palpation of the malleoli, medial and lateral collateral ligaments, syndesmosis, and proximal fibula will help determine the structures involved. Tenderness of the deltoid ligament indicates a deltoid tear, and this may require treatment if there is an associated displaced lateral malleolus fracture.

Diagnostic techniques Following history taking and physical examination, radiographs are taken (anteroposterior, lateral, and mortise views of the ankle joint). Further diagnostic studies are generally not required unless there is a suspicion of a stress fracture or occult injury, in which case a bone scan may be helpful.

Management Initial The initial treatment for a displaced fracture is immediate reduction. Post-reduction radiographs are obtained to confirm adequate reduction. Generally, any ankle fracture is to be immobilization, preferably with a splint. Ice and elevation should be used to control the swelling, and help with pain control.

Options

Cast immobilization, initially with a long leg cast, may be used once the swelling has diminished. Non-surgical treatment is used with undisplaced fractures or minimally displaced isolated medial or lateral malleolus fractures. Also, patients with significant co-morbidities and limited activity level may be candidates for non-operative treatment.

Key points •

The initial treatment for a displaced fracture is immediate reduction

Surgical indications Open reduction and internal fixation of ankle fractures is indicated in bimalleolar fractures (Fig. 20.1) or displaced isolated medial or lateral malleolus fractures. More than 2 mm of displacement significantly affects the function of the ankle joint and induces faster development of post traumatic arthritis. If a deltoid ligament tear is detected either clinically or at operation, and prevents reduction, the deltoid ligament should be explored, and flipped out of the medial aspect of the ankle joint and repaired.

Key points •

More than 2 mm of displacement significantly affects the function of the ankle joint

Surgical techniques available The lateral malleolus is anatomically reduced to ensure normal function of the ankle joint, and lag screws may be used if the fracture pattern is a spiral or long oblique. Frequently, a one third semi-tubular is placed on the lateral aspect of the lateral malleolus, especially if the fracture has a short oblique configuration or if comminution is present. The medial malleolus is treated with one to two partially threaded screws. If the fragment is too small to accommodate two screws, then a Kirschner wire may be used to help control rotation. Fractures that have injury of the syndesmosis (Danis-Weber type C or a Lauge-Hansen pronation external rotation injury), should be evaluated for the need of a syndesmosis screw. Boden et al. (1989) recommend that one be used if the lateral malleolus fracture is 3.0 to 4.5 cm from the level of the plafond with instability following fixation of the medial fracture. The reduction of the mortise should be confirmed with intra-operative radiographs. Wuest (1997) recommends the use of a fully threaded 4.5 mm screw that is inserted through four cortices for ease of removal from the lateral aspect. If the screw should fail, the screw can easily be removed from the medial cortex of the tibia. McBryde et al. (1997) reported on 17 cadavers subjected to loading following syndesmosis fixation at 2 cm and 3.5 cm above the tibiotalar joint. They found that fixation at 2 cm resulted in less syndesmotic widening. The posterior malleolus requires reduction and internal fixation if it involves a portion of the articular surface greater than 25%. This fragment is reduced through a posterolateral incision, and the screws penetrate the anterior cortex to gain compression at the fracture site. An attempt at closed reduction should be made by dorsiflexing the ankle maximally under image intensifier control. If successful, an antero-posterior partially threaded cancellous screw can be inserted through the anterior stab wound.

Author’s preferred technique

All surgery is performed without tourniquet. For the syndesmosis screw, I prefer to use a 3.5 or 4.5 mm cortical screw, placed approximately 2 cm above the plafond. I only include 3 cortices, and the foot is held in maximum dorsiflexion while the screw is inserted at a 25 to 30 degree angle from posterolateral to anteromedial. The screw is removed 12 weeks from the time of surgery, and the patient is informed that there is a possibility of screw breakage. If the posterior malleolus fragment is greater than 25% of the articular surface, it should be anatomically reduced. This is achieved using a posterolateral incision that will also allow access to the lateral malleolus. The posterior fragment is reduced and the guide wire of the 4.0 mm cannulated screw provides initial fixation. Intraoperative image intensification is used to confirm reduction, and then the screw is placed from posterior to anterior, approximately 1 to 1.5 cm from the joint. Two screws can be used, but one is often sufficient. We use subcuticular absorbable sutures to the skin .

Post-operative care The patient is placed in a bulky compression dressing with a back slab with the ankle in neutral. A short leg synthetic cast is applied, but weight bearing is not allowed for the first two post-operative weeks, when the patient is reviewed in the Fracture clinic. The patient is then allowed to bear weight in a walking cast for an additional month. The time of protected weight-bearing is increased with cases of severe comminution.

Complications and management Infection and wound healing problems are rare in healthy patients, but surgical neuromas, stiffness, and posttraumatic arthritis are seen with some frequency, depending on the initial injury and surgical reduction. Fracturedislocations are associated with many more complications especially when there is a delay in surgical treatment. Fracture blisters are seen more frequently with fracture-dislocations, because of the greater extent of soft-tissue injury. Immediate reduction, even before radiographs are taken, is recommended and surgical fixation will decrease the severity of this occurrence. Once blisters occur, it is generally recommended to wait until these resolve before proceeding with open reduction. If early surgery is absolutely necessary, remember not to incise the skin through a bloody blister (Giordano et al 1994). Special considerations Patients treated with a syndesmosis screw should maintain protected weight bearing until the screw has been removed, generally around the 6th or 8th post-operative week. This may be difficult to achieve if the surgeon elects to maintain the screw for 12 weeks. Physical activities should be avoided during this time. With highly comminuted fibular fractures, the sydesmosis screw should be maintained until there is evidence of healing of the fracture (Ebraheim et al. 1997). Prognosis

With anatomic reduction and stable fixation, the patient has a good chance of returning to most pre-injury activities. Post traumatic arthritis may result from an ankle fracture, is more commonly seen with displaced bimalleolar fractures, and usually occurs within the first 2 years after the injury (Ebraheim et al. 1997). Key points •

Post traumatic arthritis may result from an ankle fracture, is more commonly seen with displaced bimalleolar fractures, and usually occurs within the first 2 years after the injury

Osteochondral defects of the talus General principles

These lesions of the talus are also known as osteochondral fractures and osteochondral lesions. The diagnosis may be difficult to make, and it is not uncommon for the injury to be misdiagnosed as an ankle sprain. Osteochondritis dissecans can also be present in the talar dome, and is not an acute injury. Key points •

The diagnosis may be difficult to make

Anatomy/biomechanics The area of involvement is the chondral surface of the talar dome. On the lateral aspect, the anterior portion is usually involved. The posterior aspect is affected with a medial injury. Mechanism of injury The most common mode of injury is inversion of the ankle. Other mechanisms include fall from a height and motor vehicle accidents. Presentation The patient complains of pain of the ankle, and can have difficulty with weight-bearing and associated swelling. If the diagnosis is not made initially, the patient may develop chronic pain, swelling, instability, stiffness, and possibly locking with a loose fragment. Signs and symptoms Clinical examination may show localized tenderness over the lesion. There may be swelling and decreased motion compared to the uninjured ankle. Attempted motion of the ankle may reproduce symptoms.

Classification of injury

These injuries are classified according to Berndt and Harty (1959) system. Stage I is a compression lesion, Stage II is fragment that is still attached to the talus, Stage III is a fragment without attachment, but is undisplaced, and Stage IV is a displaced fragment. Possible associated injuries Other injuries that can be concurrent include lateral collateral ligament injury, peroneal tendon injury, and fracture of the ankle. Diagnosis. A high index of suspicion should be maintained. Diagnostic techniques

Most lesions can be seen on radiographs of the ankle, anteroposterior, mortise, and lateral views (Fig. 20.2). An MRI scan will reveal lesions not found on plain radiographs. This study will also delineate associated injuries, especially of the surrounding soft-tissues.

Key points •

An MRI scan will reveal lesions not found on plain radiographs

Management Initial In Stage I, II, and III injuries, it is important to immobilize and initiate protected weight-bearing to help prevent detachment or displacement of the lesion. Splinting and use of crutches can be used until the fragment begins to heal, at about 4 to 6 weeks. At that time, gentle range of motion can be included in the treatment. This is followed by a short leg weight bearing in a cast for an additional month.

Surgical indications The most important indication for surgical treatment is a displaced fragment, stage IV. Occasionally, a stage III lesion will not heal with immobilization, and then surgical treatment is warranted. Key points •

If the fragment is displaced, surgery is indicated.

Surgical techniques available These lesions can be treated with arthroscopic or open techniques.

Author’s preferred technique

My preference is to treat unhealed stage III lesions and stage IV lesions arthroscopically. Large fragments should be fixed with mini or small fragment screws, absorbable pins, or Herbert screws. Smaller fragments may be removed and the osteochondral base drilled. Some posterior fragments may require an osteotomy of the medial malleolus to gain access for fixation or debridement. Some authors recommend to bring the drill bit through the medial malleolus into the joint, and then to the medial talar dome. Intraoperative image intensification is required to confirm positioning of the drill.

Key points •

We treat stage III and stage IV lesions arthroscopically

Post-operative care After arthroscopic debridement, the patient is placed in a short leg splint and crutches for two weeks. If the lesion is large, non-weight-bearing is continued for about 6 weeks to allow for fibrocartilage ingrowth. After healing is seen on postoperative radiographs, the patient can be progressed to weight-bearing in a removable cast. Range of motion exercises can also be performed.

Complications and management The most common complication is the development of secondary arthritis, usually determined by the extent of the initial injury. Other complications include nonunion, malunion, symptoms from the fixation means used, and surgical neuroma. Nonunion and malunion of the fragment should be treated surgically if the patient is symptomatic. Removal of hardware might help decrease some symptoms. Surgical neuromas can be treated symptomatically. Exploration and resection is sometimes warranted. Prognosis Undisplaced lesions generally heal with little consequence. Displaced and stage III nonunions may result in post traumatic arthritis, and progress with time. These patients should be followed, and treatment may include bracing, or possibly ankle fusion in the severe cases.

Fractures of the talus Anatomy/biomechanics The talus articulates with the distal tibia and fibula, forming the ankle joint. It also articulates with the calcaneus in the subtalar joint, and with the navicular in the talonavicular joint. Injury to the talus may involve one or more of these joints, and may affect motion of the foot or the ankle. Mechanism of injury Common causes of talus fractures include sports injuries, such as inversion or eversion injuries. Other causes include motor vehicle accidents or fall from a height.

Presentation Signs and symptoms Generally, patients with a fracture of the talus will present with acute onset of pain and swelling. They will have difficulty with weight bearing.

Classification of injury Hawkins (1970) classified talar neck fractures. Type 1 fractures are nondisplaced, type 2 are displaced with subtalar joint subluxation or dislocation, and type 3 fractures are displaced and involve the subtalar and ankle joint with subluxation or dislocation. A type 4 fracture has been added to the system to include subluxation or dislocation of the talonavicular joint. Key points •

The classification system developed by Hawkins (1970) is still commonly used

Diagnosis Examination findings There is diffuse swelling around the ankle and foot. There is also significant tenderness to gentle palpation. Vascular and neurologic examination should always be included, as these systems can be injured with displacement or dislocations.

Diagnostic techniques The diagnosis is made with plain radiographs of the foot and ankle. The displacement and dislocation is obvious. Sometimes, a CT scan may be helpful to define the nature of the fracture if there is significant comminution.

Management Initial The patient should be placed in a splint and prompted to partial weight-bearing. Ice and elevation will help with swelling and pain. A subluxation or dislocation requires immediate reduction and splinting. If reduction is not achieved, then emergency open reduction is indicated.

Options Type 1 injuries do not require surgical treatment. The patient is placed in a non-weight-bearing cast for 6 weeks, followed by radiographic examination. If fracture consolidation is seen, weight-bearing may be allowed in a short leg cast. Range of motion exercises may be initiated once the swelling and pain allow.

Surgical indications

Displaced types 2 and 3 fractures of the talar neck require open reduction and internal fixation to try and prevent avascular necrosis.

Author’s preferred technique Surgical reconstruction can be accomplished through a dorsomedial incision, and partially threaded screws are used. Once the fracture is reduced, the guide wire from the cannulated 4.0 mm screw system is used to maintain the reduction while the screw is introduced. Intraoperative image intensification is necessary to confirm reduction and placement of the hardware. Intraoperative plain radiographs of the foot and ankle should be obtained before completion of the procedure to assure that anatomical reduction has been achieved.

Key points •

Displaced types 2 and 3 fractures of the talar neck require open reduction and internal fixation to try and prevent avascular necrosis.

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Surgery is undertaken through a dorsomedial incision, and partially threaded screws are used.

Post-operative care Following surgery, the patient is placed in a compression dressing with splints. The sutures are removed at two weeks, and a short leg cast is placed. Non-weight-bearing is continued until six weeks following surgery, at which time radiographs are taken. If there is evidence of healing, the patient may begin weight-bearing in a short leg walking cast. This may be removed for range of motion exercises.

Complications and management The most important complication is avascular necrosis. In most patients, this is evident by six weeks following the injury. The Hawkins’ sign is a radiolucency of the talar dome from hypervascularization of the fracture, and absence of this indicates avascular necrosis. Avascular necrosis is managed by prolonged non-weight-bearing in a cast until there is evidence of revascularization. MRI can be used to monitor the healing process. Other complications include malunion and nonunion. Malunion can be avoided by obtaining anatomic reduction at surgery. Key points •

The most important complication is avascular necrosis. This can be seen by 6 weeks following the injury.

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The Hawkins’ sign is a radiolucency of the talar dome from hypervascularization of the fracture

Prognosis

The prognosis depends on the severity of the initial injury. Type I injuries heal without complications and return of function occurs. Patients with type II or III injuries usually have residual pain, stiffness and swelling. Fractures of the calcaneus General principles The calcaneus is the most commonly fractured tarsal bone. A fracture of the calcaneus may be intra-articular or extraarticular. Most extra-articular injuries can be treated nonoperatively, whereas intra-articular fractures frequently may require open reduction and internal fixation. However, it should be kept in mind that, despite many advocates of surgical management, even where there is some evidence of benefit of operative compared with non-operative treatment, it remains unclear whether the possible advantages of surgery are worth its risks (Bridgman et al 2001). While waiting for a decision to undertake surgery, beware of compartment syndrome of the foot. Key points •

Most extra-articular injuries can be treated nonoperatively.

Anatomy/biomechanics The calcaneus is an important component of the gait cycle, especially with heel strike, foot flat, and toe off. The subtalar joint allows inversion and eversion, both necessary for walking on uneven surfaces. Restoration of the anatomy of the calcaneus is important to maintain the lever arm of the gastrocnemius-soleus complex. Mechanism of injury Most intra-articular fractures occur from axial loading following a fall from a height or motor vehicle accident. Presentation Most patients with calcaneus fractures will have severe pain and swelling, causing difficulty with weight bearing.

Signs and symptoms On physical examination, the patient will have obvious swelling and bruising, possibly with fracture blisters present. The hind foot and ankle may be diffusely tender, with most of the tenderness at the heel.

Possible associated injuries Depending on the mechanism of injury, a calcaneal fracture may be associated with other skeletal injuries, including, a fracture of the contralateral calcaneus, of the pelvis and of the lumbar spine. Therefore, a careful clinical examination is necessary, and radiographs of the other areas should be obtained if clinical examination warrants them.

Key points

•

A calcaneal fracture may have associated skeletal injuries, including fracture of the contralateral calcaneus, of the pelvis and of the lumbar spine

Classification of injury Extra-articular fractures can involve the body, posterior tuberosity, anterior process, medial process, and lateral process. Intra-articular fractures are classified by a primary and secondary fracture lines. The primary fracture line is a constant finding in displaced calcaneal fractures, caused by the talus wedging into the calcaneus. The sustentaculum tali fragment maintains its attachment to the talus by the interosseous ligament. A secondary fracture line usually occurs, producing a tongue-type or joint depression fracture. The tongue-type fracture is produced when the fracture line continues to the posterior facet and then completes through the posterior tuberosity. In the jointdepression type fracture, the fracture line continues into the posterior facet only. Sanders’ classification is based on CT coronal views of the comminution involvement of the posterior facet (Sanders et al. 1993). Type I injury is undisplaced or extra-articular, type II is one fracture line with displacement, type III has two fracture lines, and type IV has three fracture lines or more, creating four or more fragments. The type IV is associated with poor results. Diagnosis Examination findings Moderate to severe swelling is usually seen. With severe injuries, fracture blisters may develop. Also, bruising and loss of motion are commonly found. Paraesthesiae may develop in conjunction with swelling.

Key points •

With severe injuries, fracture blisters may develop

Diagnostic techniques Plain radiographs will reveal the fracture. If there is intra-articular extension, then Broden’s views will help visualize the posterior facet. These views are obtained by placing the foot in internal rotation, 45 degrees, and angling the beam from cephalad from 10 to 40 degrees. If operative management is planned, then a CT scan with coronal views of the posterior facet is helpful in planning the surgical reconstruction. Key points •

A CT scan with coronal views of the posterior facet is helpful in planning the surgical reconstruction

Management Initial

As with other fractures of the foot and ankle, immediate splinting, elevation, and intermittent compression using a foot pump will help decrease further swelling and possibly soft-tissue damage.

Key points •

A foot pump can be used to try and reduce the marked swelling that occurs with calcaneal fractures

Options The spectrum of treatment options for calcaneal fractures remains broad, and includes elevation, compression dressing, early motion, closed manipulation, placement of a percutaneous pin, open reduction and internal fixation, and primary subtalar fusion. Extra-articular fractures that are minimally displaced can be treated with a non-weight-bearing cast for 4 weeks, followed by a weight-bearing cast for an additional 4 to 6 weeks. Fractures that involve the articular surface can be treated nonoperatively provided they have little displacement, less than 2 mm. There is still little evidence that surgery is beneficial (Bridgman et al 2001).

Key points •

The spectrum of treatment options for calcaneal fractures remains broad

Surgical indications Any extra-articular fracture with significant displacement or causes subluxation of the subtalar or calcaneocuboid joint, or an intra-articular fracture with greater than 2 mm of incongruity warrants open reduction (Fig. 20.3). Other important considerations are widening of the calcaneus or loss of calcaneal height.

Surgical techniques available Open reduction can be achieved through medial or lateral incisions. The medial incision allows for exposure of the sustentaculum tali, but visualization of the posterior facet requires a lateral exposure. Generally, the medial fragment can be reduced indirectly through the lateral exposure.

Author’s preferred technique My preference for exposure is through an extended lateral approach. The patient is placed supine with a sand bag under the hip of the injured side, and the table is tilted to the contralateral side. A tourniquet is used, and a L-shaped incision is made just posterior to the peroneal tendons and sural nerve. A full thickness soft-tissue flap is raised, and two Kirschner wires are placed into the talus for retraction. The lateral wall is removed, and the posterior facet fragments are reduced through the exposure. The sustentaculum tali is reduced with the guide wire of a 4.0 mm

cannulated system. Kirschner wires may be used for provisional fixation, then the lateral wall is replaced. Bone graft can be placed if the cancellous defect is large. A Y or H-shaped calcaneal plate is contoured to the lateral surface of the calcaneus, and 3.5 mm cortical screws are used for fixation. Image intensification is used to confirm the reduction and screw placement, and plain radiographs should be obtained prior to completion of the procedure. A drain is placed for 24 to 48 hours. A bulky compression dressing is placed with splints. The patient is maintained on elevation and ice until discharge, approximately 2 to 3 days following surgery.

Key points •

An extended lateral approach can be used to manage operatively most calcaneal fractures.

Post-operative care The sutures are removed after 3 weeks. No weight is placed on the foot for 3 months. Radiographs are obtained to determine the extent of healing. Once consolidation is satisfactory, then partial weight-bearing can be initiated, in a walking cast. Range of motion exercises can be started once the sutures have been removed.

Complications and management The most common complication is residual pain, swelling and stiffness. Post-traumatic arthritis is common, and is dependent on the amount of comminution of the posterior facet. Therefore, anatomic reduction is important to help restore as much function as possible. Another important complication is wound healing problems, occurring in about 10% of patients (Macey et al. 1994). This can be minimized by waiting for the swelling to resolve, and by not using a tourniquet. If a wound dehiscence or infection occurs, it can usually be treated with oral antibiotics and local wound care. Approximately 20% of patients develop peroneal tendinopathy that requires removal of the hardware (Macey et al. 1994). Special considerations While operative versus nonoperative treatment remains controversial, the general trend is for open reduction, as this allows for restoration of calcaneal height, width, and joint surface. In the case of a severely comminuted fracture, operative management may not provide a better outcome, especially if performed by the occasional operator. Although primary subtalar fusion should be considered, we suggest to try conservative management first.

Prognosis The prognosis for an intra-articular fracture depends on the amount of comminution of the joint surface and the restoration of congruity. Most patients can return to weight-bearing activities with some limitations. Shoewear also may be limited to wide flat shoes. Macey et al (1994) reported preliminary results of surgical treatment of calcaneal fractures in over 100 displaced intra-articular calcaneal fractures (Macey et al. 1994). Sixty-five percent of patients were limited only in their ability to participate in vigorous activities and sports, and 70% of patients have been completely satisfied with their surgical outcome.

Key points •

The prognosis for an intra-articular fracture depends on the amount of comminution of joint surface and the restoration of congruity. However, it is surprising the high level of function that can be maintained despite radiographic evidence of gross joint incongruity and degenerative joint disease.

Lisfranc fracture dislocations General principles Injuries involving the tarsometatarsal articulation, or Lisfranc joint, can be misdiagnosed as a foot or ankle sprain, with potentially disastrous consequences. A Lisfranc fracture dislocation is usually misdiagnosed and frequently apporpriate management is instituted late. It is important to suspect the injury, and confirm its presence by radiographs. Key points •

Can be misdiagnosed as a foot or ankle sprain

Anatomy/biomechanics The Lisfranc ligament is a strong structure spanning the medial cuneiform to the base of the second metatarsal base. Injury to this ligament can allow for subluxation of the Lisfranc joint. Since the tarsometatarsal joint is an important component of the arch of the foot, disruption of the ligaments can lead to collapse of the arch and post-traumatic arthritis. Mechanism of injury The mechanism of injury is direct trauma to the Lisfranc joint, or axial force onto a plantar flexed foot, such as in a sports activity or motor vehicle accident. Presentation Signs and symptoms The patient will present with pain around the midfoot. There can be mild to marked swelling, depending on the extent of the injury. Neurovascular examination is usually normal, but the possibility of a compartment syndrome of the foot should be kept in mind. Key points The presenting complaint following a Lisfranc joint injury may be •

Pain, which may be diffuse about the midfoot

Possible associated injuries

Frequently, a fracture of a metatarsal can be associated with a dislocation. The most common such fracture is at the medial aspect of the base of the second metatarsal from an avulsion injury of the Lisfranc ligament. Other metatarsals can be involved, with fracture patterns involving the base or the diaphysis of the metatarsals.

Classification of injury A classification system was described by Quenu and Kuss that describes the displaced components. A type 1 is ipsilateral direction of displacement, type 2 is isolated with only one or two of the metatarsals displaced, and type 3 is divergent, where there is displacement of all of the metatarsals and separation between the first and second metatarsals. Diagnosis Examination findings Patients have swelling, tenderness and bruising of the foot. The swelling is generally diffuse, and can be moderate to severe. The risk of compartment syndrome should be kept in mind.

Diagnostic techniques Plain radiography is usually sufficient. Antero-posterior views may show disruption of the medial border of the second metatarsal in relation to the medial border of the middle cuneiform. An oblique view may show loss of congruity of the medial border of the fourth metatarsal to that of the cuboid. A true lateral radiograph can show loss of the normal curvature of the arch of the midfoot, particularly when in a weight-bearing position. A CT scan is helpful in subtle injuries. Widening will be seen between the first and second metatarsal bases as compared to the uninjured foot. Also, a bone scan will show increase uptake at the involved joint.

Key points •

Plain radiography is usually sufficient to diagnose an injury to the Lisfranc joint.

Management Initial Following clinical and radiographic examination, the patient should be placed in a splint and kept non-weight bearing until surgery is undertaken.

Surgical indications Closed reduction with anatomic restoration of the alignment of the Lisfranc joint and percutaneous fixation with a combination of wires and screws is the most common surgical treatment. If closed reduction is not possible because of haematoma or scar formation, then open reduction and internal fixation with screws allows optimal management of the injury.

Key points •

Anatomical reduction, either closed with percutaneous wiring, or open, with percutaneous and/or internal fixation, is the current recommended treatment for these potentially devastating injuries

Surgical techniques available The procedure is performed through multiple longitudinal incisions, depending on the metatarsals involved. The first tarsometatarsal joint is exposed through a dorsal incision. The second and third are approached through a second intermetatarsal incision, and the fourth and fifth through a fourth intermetatarsal incision. Pins or screws can be used for fixation (Fig. 20.4).

Author’s preferred technique Once reduction is achieved, a guide wire is inserted. I prefer to use cannulated 4.0 mm screws. The screw pattern and number depends on the type of injury. One screw is usually placed from the medial cuneiform into the base of the second metatarsal, to stabilize the Lisfranc ligament. An additional screw can be placed between the bases of the first and second metatarsals. The other metatarsals can be fixed with longitudinal screws.

Post-operative care The limb is placed in a bulky dressing with splints, while non-weight-bearing and elevation are continued. The staples are removed after 2 weeks, at which time range of motion exercises can be commenced in a removeable cast. Following 4 to 6 weeks, partial weight-bearing is begun and then progressed to full weight-bearing in a cast. The screws are maintained for 3 to 6 months.

Complications and management Patients usually experience prolonged stiffness and swelling with limitation of their weight-bearing activities. The long term complication is post traumatic arthritis, which is determined by the initial injury and the adequacy of reduction. Some patients benefit from an arch support, orthotic device, or possibly tarsometatarsal arthrodesis for severe arthritis.

Prognosis The patient should be advised as to the possibility of developing arthritis of the Lisfranc joint, as most patients will suffer some form of this. Most patients can return to many pre-injury activities, however, the rehabilitation may be prolonged with limitation of shoewear to wide flat shoes. Posttraumatic arthritis and planovalgus deformity may occur in up to 50% of patients. However, radiographic findings do not necessarily correlate with clinical findings. In patients with symptomatic post-traumatic osteoarthritis, arthrodesis should be considered.

Jones fractures General principles The true Jones fracture is an acute fracture of the fifth metatarsal involving the fourth-fifth intermetatarsal facet. The importance of the Jones fracture is that a delayed union, nonunion, or re-fracture may occur. The correct diagnosis is critical in proper treatment of a Jones fracture: it should be differentiated from an avulsion fracture of the base of the fifth metatarsal, and from diaphyseal stress fractures. Key points •

The importance of the Jones fracture is that a delayed union, nonunion, or re-fracture may occur.

Anatomy/biomechanics There is an area of hypovascularity between the diaphysis and the tuberosity, exactly in the region where Jones fractures occur. This lack of blood supply affects healing potential. Mechanism of injury The cause of this fracture is usually an inversion injury. It can also be caused by a direct blow or result from overuse as in a stress fracture.

Presentation Signs and symptoms The patient has complaints of lateral forefoot pain. There may be associated swelling and a limp. With stress fractures, the complaints may be minimal.

Classification of injury There are at least three distinct fracture patterns that occur in the proximal fifth metatarsal: avulsion fracture, acute Jones fractures, and diaphyseal stress fractures. Diagnosis Examination findings Physical examination reveals localized tenderness at the base of the fifth metatarsal. In an acute injury, there is usually swelling and bruising.

Diagnostic techniques The diagnosis is made with plain radiographs of the foot (Fig. 20.5). If a stress fracture is suspected but not seen on the radiograph, a bone scan may be obtained.

Management Initial Jones fractures should be treated with immediate immobilization in a non-weight-bearing cast (Torg et al. 1984) for 6 to 8 weeks until there is evidence of radiographic healing. This is followed by a short leg walking cast for an additional 4 weeks. Key points •

Jones fractures should be treated with immediate immobilization and non-weight-bearing for 6 to 8 weeks until there is evidence of radiographic healing

Surgical indications For the high-performance athlete with an acute Jones fracture, early intramedullary-screw fixation is an accepted option (Rosenberg and Sferra 2000; Torg et al. 1994).

Surgical techniques available An intramedullary screw is placed percutaneously through a small dorsolateral incision, using a 4.5 mm AO/ASIF malleolar screw with protected weight-bearing until radiographic union is evident (Torg, 1994).

Post-operative care Following internal fixation, the patient is treated with immobilization in a non-weightbearing cast for 4-6 weeks followed by another period of 4-6 weeks in a weightbearing cast.

Complications and management A delayed union can be diagnosed by the radiographic finding of intramedullary sclerosis and absence of callus with widening of a sclerotic fracture line. If these develop, then surgical treatment is recommended. Even following surgical treatment, failures can occur. Glasgow et al (1996) reported surgical failures in 11 patients who were treated with intramedullary screw fixation or inlaid corticocancellous bone graft. These included delayed union in 3 patients, re-fracture in 7 patients, and nonunion in one patient. Prognosis The prognosis for surgical treatment is good so that the athlete can return to sports activities once the fracture has healed. Compartment syndrome of the foot General principles

With fractures or crush injuries, swelling and haematoma can ensue and cause compromise of vascularity of the foot. Anatomy/biomechanics There are nine compartments that have been identified in the foot by gelatin dye injection studies: medial, superficial, lateral, adductor, four interossei, and calcaneal compartments (Manoli and Weber 1990, Shereff 1990). Each are contained in a fibro-osseous space and must be released individually. Presentation Signs and symptoms The patient will complain of severe pain of the foot, with inability to bear weight or move the foot and ankle.

Possible associated injuries Frequently, there are fractures associated with this syndrome. Most common are multiple metatarsal fractures, fractures of the calcaneus and fractures of the talus. A severe crush injury to the foot can also result in a compartment syndrome without a fracture.

Diagnosis Examination findings The foot is diffusely tender and the swelling may not be marked. Peripheral pulses may not be palpable. The most important factor in making the diagnosis of a compartment syndrome of the foot is clinical suspicion in the presence of unremitting pain. If this syndrome is suspected, then compartment pressure should be measured and plans made for surgical release. Key points •

The foot is diffusely tender and the swelling may not be marked. Peripheral pulses may or may not be palpable. The most important factor in making the diagnosis of a compartment syndrome of the foot is clinical suspicion.

Diagnostic techniques Most trauma centres have compartment pressure monitors. The clinician should be familiar with the anatomy of the compartments, so that they can be measured accurately. If the pressure is greater than 30 mm Hg or is less than 30 mm Hg below the diastolic blood pressure, then the diagnosis is confirmed. If a compartment pressure monitor is not available, and the suspicion of a compartment syndrome is high, surgical decompression should be advised. Do not delay intervention to obtain evidence of increased intra-compartmental pressure.

Management

Initial The injured foot should be splinted and closely monitored. Elevation should not be above the heart level, as this may further diminish blood flow to the extremity.

Surgical indications Once the diagnosis is made, it is a surgical emergency to release all of the compartments of the foot.

Surgical techniques available There are two common approaches to release. The medial approach utilizes one incision, and the dorsal approach has two incisions. The dorsal incisions are generally used when fixation of metatarsal fractures is performed.

Author’s preferred technique My preferred approach is through two dorsal incisions. All the compartments can be released, and then the wounds can be repaired with split thickness skin grafts several days later. Occasionally, the wounds can be closed without skin graft. Key points •

Author’s preferred approach is through two dorsal incisions

Post-operative care The patient can be treated in a splint to protect the associated fractures. If there are no fractures, then weight bearing may begin once the soft-tissues have healed.

Complications and management Prompt treatment of compartment syndrome of the foot will usually prevent complications. If there is a delay in diagnosis and treatment, a claw foot deformity may result. It is important to release the calcaneal compartment, as this can be associated with calcaneal fractures. Prognosis If the syndrome is treated promptly, there should be little residual deficit. Patients should be advised that persistent swelling may be present, and that long term paraesthesiae in the toes and in the sole of the foot may result.

References

Berndt AL, Harty M: Transchondral fractures (osteochondritis dissecans) of the talus. J. Bone Joint Surg., 41A:988-1020, 1959. Boden SD, Labropoulos PA, McCowin P, et al.: Mechanical considerations for the syndesmosis screw: A cadaver study. J. Bone Joint Surg., 71A:1548-1555, 1989.

Bridgman SA, Dunn KM, McBride DJ, Richards PJ: Interventions for treating calcaneal fractures (Cochrane Review). The Cochrane Library Issue 1, 2001 http://www.cochrane.de/cochrane/revabstr/ab001161.htm Brostrom L: Sprained ankle. Acta Chir. Scand., 132:551-565, 1966. Cardone BW, Erickson SC, Den Hartog BD, Carrera GF: MRI of injury to the lateral collateral ligamentous complex of the ankle. J. Computer Assisted Tomography, 17:102-107, 1993. Chrisman OD, Snook GA: Reconstruction of lateral ligament tears of the ankle: an experimental study and clinical evaluation of seven patients treated by a new modification of the Elmslie procedure. J. Bone Joint Surg., 51A:904-912, 1969. Ebraheim NA, Mekhail AO, Gargasz SS: Ankle fractures involving the fibula proximal to the distal tibiofibular syndesmosis. Foot Ankle International, 18:513-521, 1997. Frost SC, Amendola A: Is stress radiography necessary in the diagnosis of acute or chronic ankle instability? Clin J Sport Med 9: 40-45, 1999. Gerber JP, Williams GN, Scoville CR, Arciero RA, Taylor DC: Persistent disability associated with ankle sprains: a prospective examination of an athletic population. Foot Ankle International, 19:653-660, 1998. Giordano CP, Koval KJ, Zuckerman JD, Desai P: Fracture blisters. Clin Orthop 307: 214-221, 1994. Glasgow MT, Naranja RJ, Glasgow SG, Torg JS: Analysis of failed surgical management of fractures of the base of the fifth metatarsal distal to the tuberosity: the Jones fracture. Foot Ankle International, 17:449-457, 1996. Hamilton WG, Thompson FM, Snow SW: The modified Brostrom procedure for lateral ankle instability. Foot Ankle, 14:1-7, 1993. Hawkins LF: Fractures of the neck of the talus. J. Bone Joint Surg., 52A:991-1002, 1970. Lauge-Hansen N: Fractures of the ankle, II. Combined experimental-surgical and experimental roentgenologic investigations. Arch. Surg., 60:957-985, 1950. Ma GW, Griffith TG: Percutaneous repair of acute closed ruptured achilles tendon: a new technique. Clin Orthop 128: 247-255, 1978. Macey LR, Benirschke SK, Sangeorzan BJ, Hansen ST: Acute calcaneal fractures: treatment options and results. J. Amer. Acad. Orthopaedic Surgeons, 2:36-43, 1994. Maffulli N: The clinical diagnosis of subcutaneous tear of the Achilles tendon. A prospective study in 174 patients. Am J Sports Med 26: 266270, 1998. Maffulli N: Rupture of the Achilles tendon. J Bone Joint Surg Am 81: 1019-1036, 1999. Maffulli N, Barrass V, Ewen SW: Light microscopic histology of achilles tendon ruptures. A comparison with unruptured tendons. Am J Sports Med 28: 857-863, 2000. Manoli A II, Weber TG: Fasciotomy of the foot: An anatomical study with special reference to release of the calcaneal compartment. Foot Ankle, 10:267-275, 1990. McBryde A, Chiasson B, Wilhelm A, Donovan F, Ray T, Bacilla P: Syndesmotic screw placement: a biomechanical analysis. Foot Ankle International, 18:262-266, 1997. Novacheck TF: Running injuries: a biomechanical approach. J. Bone Joint Surg., 80A:1220-1233, 1998. Rosenbaum D, Becker J, Sterk J, Gerngross H, Claes L: Functional evaluation of the 10-year outcome after modified Evans repair for chronic ankle instability. Foot Ankle International, 18:765-771, 1997. Rosenberg GA, Sferra JJ: Treatment strategies for acute fractures and nonunions of the proximal fifth metatarsal. J Am Acad Orthop Surg 8: 332-338, 2000. Saltzman CL, Tearse DS: Achilles tendon injuries. J. Amer. Acad. Orthopaedic Surgeons, 6:316-325, 1998. Sanders R, Fortin P, Dipasquale T, et al.: Operative treatment in 120 displaced intra-articular calcaneal fractures: Results using a prognostic computed tomography scan classification. Clin. Orthop., 290:87-95, 1993. Shereff MJ: Compartment syndromes of the foot. In Greene WB (ed): American Academy of Orthopaedic Surgeons Instructional Course

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Figures Figure 1. A.

Preoperative mortise radiograph demonstrating a displaced bimalleolar ankle fracture in a 43 year old man following an inversion injury

while playing softball. B.

Postoperative mortise radiograph shows anatomic reduction with internal fixation.

Figure 2.

A mortise radiograph of a 26 year old woman who fell and twisted her right ankle. A small osteochondral defect is seen in the

lateral talar dome.

Figure 3. A.

Preoperative lateral radiograph of a 33 year old woman who jumped off a 12 foot cliff and sustained an intra-articular calcaneus

fracture. B.

Preoperative CT scan demonstrates a large depressed fragment of the posterior facet.

C.

Postoperative lateral radiograph shows anatomical restoration of the posterior facet joint surface.

Figure 4. A.

Preoperative oblique radiograph of a 26 year old man who sustained an open left Lisfranc fracture dislocation.

B.

Postoperative oblique radiograph demonstrates satisfactory alignment following internal fixation.

Figure 5. Oblique radiograph of a 21 year old man demonstrates an undisplaced Jones fracture.