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 ใ
      • 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
    • 1^st metatarsal : ORIF
    • 2^nd-5^th 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