Foot and ankle Injury

Ankle sprain

-Lateral ankle sprain

-                   Lateral ligament complex

  • anterior talofibular ligament (ATFL)
  • calcaneofibular ligament (CFL)
  • posterior talofibular ligament (PTFL)

-                   Cause

  • forceful inversion

-                   Pathology

-                   Clinical presentation

  • Pain
  • swelling
  • Ecchymosis

-                   Investigation

  • X ray : Ankle(AP, Lat, mortise)
  • MRI
  • Computerized Tomography

-                   Treatment

  • Conservative treatment
    • RICE method (Rest, Ice, Compression & Elevation)
  • Operative treatment
    • Ligament repair

Medial ankle sprain

-                   Cause

-                   Pathology

  • Superficial deltoid ligament 
  • Deep deltoid (tibiotalar) ligament 

-                   Clinical presentation

  • Pain, swelling
  • Ecchymosis

-                   Investigation : X ray, MRI,Computerized Tomography

-                   Treatment

  • Conservative treatment
    • short-leg walking cast (plantigrade)
  • Operative treatment
    • Surgical exploration and repair

Ankle fracture

-       Anatomy

-       Mechanism

  • Rotational force
  • Axial compression

-       Clinical Feature

  • low VS high-energy injury
  • Pain, swelling
  • Ecchymosis
  • Tenderness

-       Classification

  • Lauge-Hansen, Danis-Weber
    • Supination-Adduction (SA)
    • Supination-External Rotation (SER)
    • Pronation-Abduction (PA)
    • Pronation-External Rotation (PER)
    • Danis-Weber
      • Type A (infrasyndesmotic) เกิดจากsupination-adduction force
      • Type B (transsyndesmotic) เกิดจากsupination-external rotation force
      • Type C (suprasyndesmotic) เกิดจากpronation-external rotation force

-       Investigation

  • X ray : Ankle(AP, Lat, mortise)
    • Medial clear space 
    • Tibiofibular clear space
    • MRI
    • Computerized Tomography

-       Treatment

  • Isolated fracture of medial malleolus
    • Non-displaced และminimally displaced fracture
      • SLC
      • Displaced fracture(> 2 mms.)
        • ORIF
        • Isolated fracture of lateral malleolus
          • Non-displaced และminimally displaced fracture
            • SLC
            • Displaced fracture(> 2 mms.)
              • ORIF

Bimalleolar fracture

-           ORIF

Trimalleolar fracture

-           ORIF

-           Posterior malleolus fixation when More than 25% fragment with displacement

Pilon fractures

-       Non-displaced fracture

  • closed reduction & casting

-       Displaced fracture

  • ORIF
  • External fixation when severe soft tissue injury

 

Foot fractures

-       Talus Fracture

  • MCM: neck of talus
  • Mechanism: ankle hyperextension injury
  • Clinical
    • Beware Skin necrosis
  • Investigation
    • X ray : Ankle(AP, Lat, Oblique)
    • CT scan
      • fracture displacement , osteochondral fragment
      • MRI
        • chondral fracture ,osteonecrosis
  • Classifications: Hawkin’s classification
    • Type I: non-displaced fracture
    • Type II: displaced fracture with subtalar subluxation or dislocation
    • Type III: displaced fracture with subtalar and ankle dislocation
    • Type IV: displaced fracture with talonavicular dislocation
    • Treatment
      • Type I: SLC 8-12 wks
      • Type II: CR with SLC8-12 wks
      • Type III, IV: urgent ORIF with K-wire , lag screws
  • Complications
    • avascular necrosis, malunion, post-traumatic osteoarthritis

Calcaneus fracture

-       Anatomy : Largest tarsal bone

-       Mechanism

  • Axial compression force
  • Avulsion force

-       Clinical Feature

  • low VS high-energy injury
  • Pain, swelling
  • Ecchymosis
  • Tenderness

-       Investigation

  • Plain film
    • Lateral: Bohler’s angle
    • axial views : width
    • CT scan : Intraarticular fracture

-       Classification

  • Intra-articular fracture
    • joint depression type
    • tongue type
    • Extra-articular fracture
      • anterior process
      • sustentaculum tali
      • calcaneal tuberosity
      • inferomedial process

-       Treatment

  • Extraarticular fracture 
    • non
    • Intra-articular fracture
      • Non displace : non operative
      • Displace: ORIF
        • Tongue type : close reduction with large pin fixation (Essex-Lopresti technique)
        • Joint depression type : ORIF with plate and screw fixation

-       Complications 

  • Early complications
    • compartment syndrome, infection
    • Late complications
      • malunion, peroneal tendon impingement, Achilles tendon insufficiency

Metatarsal fractures

-       Mechanism of injury 

  • Direct blow เกิดcomminuted fracture
  • Twisting injury เกิดspiral fracture
  • Avulsion fractures : 5 metatarsal base
  • Repetitive trauma ทำาให้เกิดinsufficiency fractures

-       Treatment

  • Non-displaced fractures
    • short leg cast
    • Displaced fractures
      • 1st metatarsal : ORIF
      • 2nd-5th metatarsal : close reduction withshort leg cast
      • Multiple metatarsal fractures : ORIF

Fracture of Fifth metatarsal base (Jones’ fracture)

-       Insertion of Peroneus brevis

-       Mechanism

  • Forceful inversion

-       Treatment

  • Non-displaced fracture : short walking cast
  • Displaced fracture : ORIF with TBW or screw fixation

งานวิชาการ