ANKLE & LEG #

By:

YOSRA MOHAMED HUSSIEN (OPT)

 2 INTRODUCTION

– Most common weight-bearing skeletal injury

– Fractures of the ankle joint are common

amongst adults

– It is diagnosed by clinical examination and X-

Ray

– Fractures of the foot are less common.

YOSRA MOHAMMED HUSSIEN - HEAD OF ORTHOPEDIC DEPARTMENT/ AL-NEELAIN UNIVERSITY 08/14/2022

3 CLINICAL PRESENTATION

– Pain

– Swelling

– Bruising (soon after the injury)

– Difference in appearance.

– Observable differences compared to the unaffected side

– Ligamentous injury (deltoid, posterior tibiofibular)

YOSRA MOHAMMED HUSSIEN - HEAD OF ORTHOPEDIC DEPARTMENT/ AL-NEELAIN UNIVERSITY 08/14/2022
4 HISTORY

– Mechanism of injury

– Time elapsed since the injury

– Soft-tissue injury

– Has the patient ambulated on the ankle?

– Patient’s age / bone quality

– Associated injuries

– Comorbidities (DM, smoking)

YOSRA MOHAMMED HUSSIEN - HEAD OF ORTHOPEDIC DEPARTMENT/ AL-NEELAIN UNIVERSITY 08/14/2022

 5 PHYSICAL EXAMINATION

– Neurovascular exam (balance, proprioception. Sensory & motor)

– Note obvious deformities

– Pain over the medial or lateral malleoli

– Palpation of ligaments around the ankle

– Palpation of proximal fibula, lateral process of talus, base of 5th MT

– Examine the hindfoot and forefoot

YOSRA MOHAMMED HUSSIEN - HEAD OF ORTHOPEDIC DEPARTMENT/ AL-NEELAIN UNIVERSITY 08/14/2022
 6 RADIOGRAPHS

– AP, Lateral, Mortise of Ankle (Weight Bearing if possible)

– AP, Lateral of Knee

– AP, Lateral, Oblique of Foot

YOSRA MOHAMMED HUSSIEN - HEAD OF ORTHOPEDIC DEPARTMENT/ AL-NEELAIN UNIVERSITY 08/14/2022

 7 ANKLE AP VIEW

– Tibiofibular overlap
– <10mm is abnormal and implies syndesmotic injury

– Tibiofibular clear space

– >5mm is abnormal - implies syndesmotic injury

– Talar tilt
– >2mm is considered abnormal

YOSRA MOHAMMED HUSSIEN - HEAD OF ORTHOPEDIC DEPARTMENT/ AL-NEELAIN UNIVERSITY 08/14/2022

 8 ANKLE LATERAL VIEW

– Posterior malleolar fractures

– Anterior/posterior subluxation of the talus under

the tibia

– Displacement/Shortening of distal fibula

– Associated injuries

YOSRA MOHAMMED HUSSIEN - HEAD OF ORTHOPEDIC DEPARTMENT/ AL-NEELAIN UNIVERSITY 08/14/2022

9 CLASSIFICATION SYSTEMS

1. Weber-Danis is based on radiographic criteria

2. Lauge-Hansen classification is based on a rotational mechanism of

injury

3. AO classifies all long bone fractures with a systematic approach, based

on location, topography, and extent of bony lesion. It is based on
radiographic criteria and incorporates the mechanism of injury.

YOSRA MOHAMMED HUSSIEN - HEAD OF ORTHOPEDIC DEPARTMENT/ AL-NEELAIN UNIVERSITY 08/14/2022

 10 Weber-Danis

– A: Fibula Fracture distal to mortise, may be associated with oblique or

vertical medial malleolar fractures 

– B: Fibula Fracture at the level of the mortise, extend proximally in an oblique

fashion

– C: Fibula Fracture proximal to mortise, have an associated syndesmotic

injury. It can be associated with medial malleolus fractures or injury to the
deltoid ligament
YOSRA MOHAMMED HUSSIEN - HEAD OF ORTHOPEDIC DEPARTMENT/ AL-
08/14/2022
NEELAIN UNIVERSITY
11 INITIAL MANAGEMENT

– Closed reduction (conscious sedation may be necessary)

– Splint

– Delayed fixation until soft tissues stable

– Pain control

– Monitor for possible compartment syndrome in high energy injuries

YOSRA MOHAMMED HUSSIEN - HEAD OF ORTHOPEDIC DEPARTMENT/ AL-NEELAIN UNIVERSITY 08/14/2022

12 FIXATION

Undisplaced #
– Cast immobilization (boot POP) 3-6 weeks

Displaced # with or without subluxation

– Joint or loss of normal ankle mortise
– ORIF (fibular plating, screw fixation of medial
malleoli, syndesmotic screw)

YOSRA MOHAMMED HUSSIEN - HEAD OF ORTHOPEDIC DEPARTMENT/ AL-NEELAIN UNIVERSITY 08/14/2022

13 DIFFERENTIAL DIAGNOSIS

– Rheumatoid Arthritis – Deep Venous Thrombosis

– Gout and Pseudogout – Peroneal Tendinopathy
– Ankle Dislocation – Sinus Tarsi Syndrome
– Ankle Impingement
– Ankle ligament sprains
– Compartment Syndrome of the
Foot

YOSRA MOHAMMED HUSSIEN - HEAD OF ORTHOPEDIC DEPARTMENT/ AL-NEELAIN UNIVERSITY 08/14/2022

14 COMPLICATIONS

1. Dislocated or subluxated ankle joint

2. Stiffness
3. OA
4. Ankle instability
5. Nonunion (displaced medial malleolus)
6. Malunion

YOSRA MOHAMMED HUSSIEN - HEAD OF ORTHOPEDIC DEPARTMENT/ AL-NEELAIN UNIVERSITY 08/14/2022

15 PT MANAGEMENT

YOSRA MOHAMMED HUSSIEN - HEAD OF ORTHOPEDIC DEPARTMENT/ AL-NEELAIN UNIVERSITY 08/14/2022

16 CALCENEAL #

– Result from axial loading; fall from height

– Traction through Achilles tendon lead to avulsion fracture

– It can be very painful and may be accompanied by vertebral #

– Extra-articular or intra-articular fracture (referring to subtalar joint)

– Result in loss of foot arch lead to flat foot

YOSRA MOHAMMED HUSSIEN - HEAD OF ORTHOPEDIC DEPARTMENT/ AL-NEELAIN UNIVERSITY 08/14/2022

17 EXTRA-ARTICULAR CALCENEAL #

YOSRA MOHAMMED HUSSIEN - HEAD OF ORTHOPEDIC DEPARTMENT/ AL-NEELAIN UNIVERSITY 08/14/2022

18 COMPLICATIONS

1. Skin necrosis (intense swelling)

2. Malunion

3. Peroneal tendon impingement

4. Flat and broad foot (shoe fitting)

5. Subtalar arthrosis

YOSRA MOHAMMED HUSSIEN - HEAD OF ORTHOPEDIC DEPARTMENT/ AL-NEELAIN UNIVERSITY 08/14/2022

19 MEDICAL ANAGEMENT

 Extra-articular fractures or undisplaced intra-articular #

– Boot POP cast for 5 weeks

– No weight bearing is allowed

 Displaced intra-articular # or avulsion of Achilles insertion:

– ORIF screw or recon plate

YOSRA MOHAMMED HUSSIEN - HEAD OF ORTHOPEDIC DEPARTMENT/ AL-NEELAIN UNIVERSITY 08/14/2022

20 METATARSAL #

 The most common is # base of 5th metatarsal

– It is caused by an inversion strain of the foot so that the base

becomes avulsed by the peroneus brevis tendon.

– Treatment:

– Walking plaster cast or bandage for 3 – 6 weeks in the majority of

cases
YOSRA MOHAMMED HUSSIEN - HEAD OF ORTHOPEDIC DEPARTMENT/ AL-NEELAIN UNIVERSITY 08/14/2022
21

YOSRA MOHAMMED HUSSIEN - HEAD OF ORTHOPEDIC DEPARTMENT/ AL-NEELAIN UNIVERSITY 08/14/2022

22 METATARSAL #

 Metatarsal shaft # are common

– They are usually caused by crushing and are associated with

much soft tissue damage or swelling

– Treatment:

– Elevation of the foot, if swollen, is followed by a walking

(below knee) cast for 6 weeks
YOSRA MOHAMMED HUSSIEN - HEAD OF ORTHOPEDIC DEPARTMENT/ AL-NEELAIN UNIVERSITY 08/14/2022
23 METATARSAL #

 Stress #
– These are common fractures, usually at the neck of the 2nd
metatarsal
– Caused by repetitive stress due to long periods of walking
– Treatment:
– It is usually diagnosed while healing, with callus being visible
on the X - ray at 3 or 4 weeks

YOSRA MOHAMMED HUSSIEN - HEAD OF ORTHOPEDIC DEPARTMENT/ AL-NEELAIN UNIVERSITY 08/14/2022

24 TARSOMETATARSAL FRACTURE
DISLOCATION (LISFRANC)

– These are rare injuries to the tarsometatarsal joint, usually as a

result of rotation of the hindfoot about a fixed forefoot

– Early recognition by close inspection of X - rays in a patient with

a painful and swollen foot following such a mechanism will result
in a more favorable outcome

– Treatment  reduction and fixation

YOSRA MOHAMMED HUSSIEN - HEAD OF ORTHOPEDIC DEPARTMENT/ AL-NEELAIN UNIVERSITY 08/14/2022

25 COMPARTMENT SYNDROME

YOSRA MOHAMMED HUSSIEN - HEAD OF ORTHOPEDIC DEPARTMENT/ AL-

08/14/2022
NEELAIN UNIVERSITY
26 PHALANGEAL #

– These are common injuries and usually of little significance

– The # may interfere with the circulation, necessitating amputation

of the toe

– Treatment:

– They are usually treated by protective dressings, reassurance and

allowing the patient to continue walking

YOSRA MOHAMMED HUSSIEN - HEAD OF ORTHOPEDIC DEPARTMENT/ AL-NEELAIN UNIVERSITY 08/14/2022

27 PT MANAGEMENT

– TYPE A (stable non-displaced or slightly displaced #) treated conservatively as ruptured

ligament in a stabilizing ankle orthosis for early function with pain-adapted full weight-
bearing

– More significant # immobilized and require a rehabilitation program after cast removal.

– Impairments can be pain, swelling, stiffness, muscle atrophy and decreased muscle
torque, impaired ankle mobility, impaired balance capacity and increased ankle
circumference after cast removal

YOSRA MOHAMMED HUSSIEN - HEAD OF ORTHOPEDIC DEPARTMENT/ AL-NEELAIN UNIVERSITY 08/14/2022

28 PT MANAGEMENT

– Ankle ROM
– Strengthening exercise
– Mobilization exercise
– Weight bearing (CKC)
– Balancing exercise
– Patient education and advice
– Functional training
– Home exercise program

YOSRA MOHAMMED HUSSIEN - HEAD OF ORTHOPEDIC DEPARTMENT/ AL-NEELAIN UNIVERSITY 08/14/2022

 THANK YOU

YOSRA MOHAMMED HUSSIEN - HEAD OF

29 08/14/2022
ORTHOPEDIC DEPARTMENT/ AL-NEELAIN UNIVERSITY