Fracture Classification Review DPM 2026

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Questions and Answers

Which of the following are main patterns of injury in Lauge-Hansen classification?

Supination-adduction

Pronation-abduction

Supination-external rotation

All of the above (correct)

What is the first word in Lauge-Hansen classification?

Position of foot at time of injury

What type of fracture occurs at stage 1 of the Supination-adduction pattern?

Rupture of lateral collateral ligaments or transverse fracture of fibula below ankle joint

The Danis-Weber classification indicates that 'A' corresponds to fibular fracture at the ankle level.

False Signup and view all the answers

What type of injury is classified as SH II?

Partially splits through physis and out through metaphysis with a metphyseal triangular shaped piece of bone Signup and view all the answers

What does the Rowe classification primarily deal with?

Calcaneal fractures Signup and view all the answers

What type of fracture does Sanders Type II refer to?

Two part fractures of the posterior facet Signup and view all the answers

What is the Hawkins 3 classification associated with?

Subtalar and ankle joint dislocated Signup and view all the answers

SH V refers to __________.

compression or crush injuries that are difficult to diagnose Signup and view all the answers

What are the four types categorized under Sanders classification?

Type I, Type II, Type III, Type IV Signup and view all the answers

In the Watson-Jones classification, what type of fracture is indicated as 'II'?

Dorsal chip fracture Signup and view all the answers

What does the first word in the Lauge-Hansen classification refer to?

Position of foot at time of injury Signup and view all the answers

Which of the following is NOT a pattern of injury in Lauge-Hansen classification?

Pronation-internal rotation Signup and view all the answers

What is the first stage of a supination-adduction fracture?

Rupture of lateral collateral ligaments or transverse fracture of fibula below ankle joint Signup and view all the answers

What are the stages of a Pilon fracture according to Ruedi/Allgower classification?

Stage I: No comminution or displacement; Stage II: Some displacement but not comminution or impaction; Stage III: Comminution and/or impaction of the joint surface Signup and view all the answers

In the Danis-Weber classification, what does type C represent?

Fibular fracture above level of the ankle Signup and view all the answers

What does the Sanders classification primarily assess?

Calcaneal fractures Signup and view all the answers

The Hawkins classification is used for talar neck fractures.

True Signup and view all the answers

Describe a Type II fracture in the Berndt & Harty classification.

Partially detached osteochondral lesion (OCD) Signup and view all the answers

What is the primary feature of a Type 1 fracture in the Stewart classification?

Fracture at the metaphyseal-diaphyseal junction Signup and view all the answers

Which of the following classifications includes a Type B2?

Hardcastle Signup and view all the answers

What does the first word in Lauge-Hansen classification indicate?

Position of foot at time of injury Signup and view all the answers

Which stage involves a rupture of the lateral collateral ligaments in Supination-Adduction injuries?

Stage 1 Signup and view all the answers

In Pronation-Abduction injuries, what occurs during Stage 1?

Rupture of deltoid ligament Signup and view all the answers

What type of fracture involves a deltoid ligament rupture and a transverse fracture of the medial malleolus in Pronation-External Rotation?

Stage 1 Signup and view all the answers

In Danis-Weber classification, what does Type A signify?

Fibular fracture below the level of the ankle Signup and view all the answers

What is the prognosis for Stage I of Ruedi/Allgower pilon fractures?

Excellent prognosis Signup and view all the answers

What does the Hawkins classification predict?

AVN rate Signup and view all the answers

Stage II of Sanders classification includes two-part fractures of the posterior facet.

True Signup and view all the answers

Match the following Hawkins classifications with their descriptions:

Hawkins 1 = Non displaced neck fracture, AVN 0 – 13 % Hawkins 2 = Displaced neck fracture, AVN 20 – 50 % Hawkins 3 = Subtalar and ankle joint dislocated, AVN 83 – 100 % Hawkins 4 = Includes talonavicular subluxation, rare variant Signup and view all the answers

What type of fracture does the Watson-Jones classification categorize?

Navicular fractures Signup and view all the answers

What does the Stewart classification relate to?

Fifth Metatarsal fractures Signup and view all the answers

Which type of open fracture has minimal soft tissue damage?

Type 1 Signup and view all the answers

What is the primary mechanism of injury (MOI) for a talar head fracture?

Violent dorsiflexion of plantarflexed foot Signup and view all the answers

Stage 4 of Hawkins classification indicates the best prognosis.

False Signup and view all the answers

What does 'Nutcracker sign' indicate in relation to Shepherd's fracture?

Pain with plantarflexion of the ankle Signup and view all the answers

What does the term 'AVN' stand for?

Avascular necrosis Signup and view all the answers

What type of fracture classification is the Sanders classification used for?

Calcaneal fractures Signup and view all the answers

What type of fracture occurs in the medial or lateral tubercle due to a fall with the heel inverted or everted?

Rowe 1a Signup and view all the answers

What is the prognosis for a Stage 1 Berndt and Harty fracture?

Conservative RX Signup and view all the answers

In terms of severity, which Navicular fracture has the highest likelihood of occurring due to the watershed area?

Type 4 Signup and view all the answers

Wagstaff fracture is an AITFL avulsion of the anteromedial fibula.

True Signup and view all the answers

Which type of open fracture is characterized by clean puncture and little soft tissue damage?

Type 1 Signup and view all the answers

What is the mechanism of injury (MOI) for a talar neck fracture?

Violent dorsiflexion of the plantarflex foot Signup and view all the answers

Match the following classifications to their corresponding fractures:

Gustillo and Anderson = Open fractures Hawkins = Talar fractures Rowe = Calcaneal fractures Watson Jones = Navicular fractures Signup and view all the answers

In the Hawkins classification, Stage 4 indicates surgical treatment due to AVN being greater than 91%.

True Signup and view all the answers

What does the 'piano key test' indicate?

Pain caused by pressing on the dorsal metatarsal head Signup and view all the answers

What is a common treatment approach for Lisfranc Grade 1 injuries?

Conservative treatment Signup and view all the answers

A ______ fracture of the calcaneal tubercle is classified as Rowe 1a.

fracture Signup and view all the answers

The Sanders classification only contains Type 1 fractures with no displacement.

False Signup and view all the answers

What is the MOI for a Shepherd's fracture?

Forced plantarflexion Signup and view all the answers

What injury type is associated with a Tillaux-Chaput fracture?

AITFL avulsion fracture from anterolateral tibia Signup and view all the answers

Which navicular fracture type involves the dorsal lip?

Type 2 Signup and view all the answers

What is acute compartment syndrome (ACS)?

A complication of trauma that leads to increased pressure in a muscle compartment, interrupting blood flow and causing tissue necrosis. Signup and view all the answers

What are some potential causes of acute compartment syndrome?

All of the above Signup and view all the answers

Acute compartment syndrome is caused solely by crushing injuries.

False Signup and view all the answers

Match the following compartments with their locations in the lower leg:

Anterior compartment = Front of the leg Lateral compartment = Outside of the leg Deep Posterior compartment = Back of the leg Superficial Posterior compartment = Back of the leg Signup and view all the answers

The classic signs of acute compartment syndrome are known as the ___ P's.

six Signup and view all the answers

What is the significance of intra-compartmental pressure measurement in diagnosing ACS?

It helps confirm the diagnosis by measuring pressure within a muscle compartment to assess for elevated levels indicative of ACS. Signup and view all the answers

Which surgical technique is recommended for addressing compartment syndrome?

Fasciotomy Signup and view all the answers

What is Volkmann's contracture?

Ischemic contracture of the muscles in the forearm due to prolonged compartment syndrome. Signup and view all the answers

Delayed treatment of acute compartment syndrome can lead to permanent damage.

True Signup and view all the answers

What is the best course of action for a patient with a calcaneal fracture and suspected compartment syndrome with an intra-compartment pressure reading of 40 mmHg?

Perform an emergency fasciotomy of the foot Signup and view all the answers

Which pedal compartment was not released, leading to unilateral claw toe deformity and numbness of the lateral foot in a patient post-fasciotomy?

Lateral compartment Signup and view all the answers

How many compartments are there in the foot?

There are 9 compartments in the foot. Signup and view all the answers

What are the '6 P's associated with acute compartment syndrome?

Pain, Pressure, Paresthesia, Pallor, Paralysis, Pulselessness. Signup and view all the answers

What complications are associated with acute compartment syndrome?

Muscle necrosis, nerve damage, functional impairment. Signup and view all the answers

How many compartments are in the foot?

There are 4 compartments in the foot. Signup and view all the answers

How many compartments are in the leg?

There are 4 compartments in the leg. Signup and view all the answers

What is the best course of action for a patient with a calcaneal fracture and suspected compartment syndrome with a pressure reading of 40 mmHg?

Perform an emergency fasciotomy of the foot Signup and view all the answers

Which pedal compartment was not released if a patient presents with a unilateral claw toe deformity after a fasciotomy?

Deep posterior compartment Signup and view all the answers

ACR is associated with the clinical symptoms known as the '6 P's', which include _ and _?

Pain, Pallor Signup and view all the answers

True or False: The absolute pressure in an compartment reading of 30 mmHg is an indication for an emergency fasciotomy.

False Signup and view all the answers

What is acute compartment syndrome (ACS)?

A complication of trauma or other factors causing increased pressure within a muscle compartment that can lead to tissue necrosis. Signup and view all the answers

Which of the following are potential causes of acute compartment syndrome?

External pressure Signup and view all the answers

What is the historical significance of Dr. Richard Von Volkmann in relation to ACS?

He described 'Volkmann’s contractures' in 1881, which are associated with ischemic muscle damage. Signup and view all the answers

Acute compartment syndrome is often a complication of __________ injuries.

crush Signup and view all the answers

ACS can lead to a positive feedback loop of increased tissue damage.

True Signup and view all the answers

What are the 6 P's used to assess for ACS?

Pallor Signup and view all the answers

What diagnostic method is used to measure intra-compartmental pressures?

Wick-catheter system Signup and view all the answers

Match the compartments of the lower leg with their corresponding areas:

Anterior = Dorsiflexion of the foot Lateral = Eversion of the foot Deep Posterior = Plantarflexion Superficial Posterior = Flexion of toes Signup and view all the answers

What is the recommended treatment for compartment pressures above 40 mmHg?

Fasciotomy Signup and view all the answers

Increased capillary permeability in ACS can lead to __________.

inflammation Signup and view all the answers

What is the most common metatarsal fracture?

Fifth metatarsal Signup and view all the answers

What are the typical mechanisms of injury (MOI) for metatarsal fractures? (Select all that apply)

Crush Signup and view all the answers

A fracture of the first metatarsal requires a low amount of force.

False Signup and view all the answers

What is the recommended non-operative management for a non-displaced first metatarsal fracture?

4-6 weeks non-weight bearing in cast or boot, followed by 6-8 weeks protected weight bearing. Signup and view all the answers

What is the surgical intervention for greater than 3-4 mm displacement of a metatarsal fracture?

Operative management is required. Signup and view all the answers

Which of the following is a common complication of a Jones fracture?

Malunion Signup and view all the answers

Match the type of metatarsal fracture with its description.

Transverse = Horizontal fracture line Oblique = Angled fracture line Spiral = Fracture caused by twisting forces Comminuted = Multiple fracture lines Signup and view all the answers

A fracture at the level of the diaphyseal-metaphyseal junction of the fifth metatarsal is known as a ________ fracture.

Jones Signup and view all the answers

Avulsion fractures of the fifth metatarsal are uncommon.

False Signup and view all the answers

What is the typical healing time for a non-operative treatment of a Jones fracture?

Average 24 weeks. Signup and view all the answers

What is the goal of open fracture treatment?

Convert contaminated wounds to clean wounds, early soft tissue healing, stabilize fractures Signup and view all the answers

Which of the following is NOT a type of Gustillo and Anderson classification?

Type IV Signup and view all the answers

What are the antibiotics recommended for Type I open fractures?

Cefazolin (Ancef) 2 gm IV Q 8h Signup and view all the answers

What is the percentage of infection for Type IIIB fractures?

10-50% Signup and view all the answers

What does the Mangled Extremity Severity Score (MESS) predict?

Amputation Signup and view all the answers

In infection considerations, Type I has a percentage of infection of ______

0-2% Signup and view all the answers

What is a surgical emergency treatment plan for open fractures?

Irrigation and debridement Signup and view all the answers

Type II open fractures have moderate contamination and no extensive soft tissue damage.

True Signup and view all the answers

What are the indications for amputation?

Massive uncontrolled sepsis, necrosis and gangrene, primary amputation Signup and view all the answers

What is the primary goal of open fracture treatment?

Convert contaminated wounds to clean wounds, early soft tissue healing, stabilize fractures Signup and view all the answers

Which type of open fracture has clean puncture less than 1 cm?

Type I Signup and view all the answers

What characterizes a Type II open fracture?

Laceration > 1 cm with moderate contamination Signup and view all the answers

What would be prescribed for Type I open fractures as antibiotic therapy?

Cefazolin (Ancef) 2 gm IV Q 8h Signup and view all the answers

Type IIIC open fractures are characterized by arterial injury.

True Signup and view all the answers

The ___ score predicts amputation with 100% accuracy if the value is greater than or equal to 7.

Mangled Extremity Severity Score (MESS) Signup and view all the answers

What is the infection rate for Type IIIA open fractures?

7% Signup and view all the answers

What are the recommendations for antibiotic therapy for Grade III open fractures?

First generation cephalosporin and aminoglycoside within 3 hours and continued for 48-72 hours Signup and view all the answers

Which mechanisms of injury are associated with talar fractures? (Select all that apply)

Motor Vehicle Accidents Signup and view all the answers

What is the classification system associated with talar neck fractures?

Hawkins Signup and view all the answers

What is the mechanism of injury for a talar head fracture?

Violent dorsiflexion of a fully plantarflexed foot Signup and view all the answers

Talar fractures are not common and account for 3-8% of all foot fractures.

True Signup and view all the answers

What is the common treatment for non-displaced talar body fractures?

Immobilization for 6-8 weeks Signup and view all the answers

A talar fracture characterized by forced plantarflexion compressing the posterior talar process is known as a ______.

Shepherd's fracture Signup and view all the answers

What percentage of talar head fractures develop avascular necrosis (AVN)?

10% Signup and view all the answers

What type of fractures account for 20% of talar fractures?

Fractures of the lateral process Signup and view all the answers

Match the following talar fracture classifications with their corresponding types:

Hawkins = Talar neck fractures Sneppen = Talar body fractures Berndt and Harty = Talar dome fractures Signup and view all the answers

What is osteochondral autologous transplantation?

Osteochondral autologous transplantation is a surgical procedure that involves transplanting cartilage and bone from one area of the body to repair damaged areas, typically used for joint issues. Signup and view all the answers

What is en bloc talar shoulder transplantation?

En bloc talar shoulder transplantation is a surgical technique where the talus is transplanted along with its surrounding soft tissue in a single unit. Signup and view all the answers

Which of the following journals published studies related to fractures of the talus?

The Journal of Bone and Joint Surgery American Volume Signup and view all the answers

Which surgical technique is mentioned for treating osteochondral lesions of the talus?

Mosaicplasty Signup and view all the answers

Osteochondral lesions of the talus are commonly treated with total ankle arthroplasty.

False Signup and view all the answers

The DMU Integrity Code prohibits unauthorized use of copyrighted material.

True Signup and view all the answers

What is the ideal method for immediate reduction of dislocated joints in Talar Body Management?

Closed reduction in the ER Signup and view all the answers

Talar neck fractures are classified by ____ (year).

Hawkins (1970) Signup and view all the answers

What is the AVN rate of a Hawkins I fracture?

0-13% Signup and view all the answers

What treatment is typically recommended for a Hawkins I fracture?

Conservative Signup and view all the answers

Hawkins III fractures have an AVN rate of 100%.

True Signup and view all the answers

Which of the following is a hallmark sign of Avascular Necrosis (AVN)?

Sclerosis of the talus Signup and view all the answers

What can be a pre-collapse surgical treatment option for AVN?

Core decompression Signup and view all the answers

What is the treatment for Stage I and Stage II lesions of Talar Dome fractures?

Conservative treatment Signup and view all the answers

The mechanism of injury for anterolateral lesions involves _____.

dorsiflexion/inversion Signup and view all the answers

What does the Hawkins sign indicate?

Absence of AVN Signup and view all the answers

Which of the following is NOT a post-collapse surgical treatment option?

Total Ankle Replacement Signup and view all the answers

What are Lisfranc injuries?

Injuries involving the tarsometatarsal joints, ranging from sprain to fracture-dislocation. Signup and view all the answers

Who originally described the amputation at the level of the tarsometatarsal joint?

Jacques Lisfranc de St. Martin Signup and view all the answers

Lisfranc injuries are common in the general population.

False Signup and view all the answers

Which classification was further classified based on displacement and incongruity?

Hardcastle Signup and view all the answers

What provides intrinsic stability in the foot anatomy?

The arch and intermetatarsal ligaments. Signup and view all the answers

What types of injuries can lead to Lisfranc injuries?

High energy incidents (e.g., MVA) and low energy incidents (e.g., missed step, sports). Signup and view all the answers

Which imaging technique provides the most useful view of osseous structures in high-energy injuries?

CT Signup and view all the answers

MRI is the most useful imaging technique for low-energy injuries.

True Signup and view all the answers

What is one of the first steps in managing Lisfranc injuries?

Non-operative care for sprains Signup and view all the answers

What is the reported rate of post-traumatic arthritis following ORIF for Lisfranc dislocation?

40-90% Signup and view all the answers

What does the term 'pilon' refer to?

A pestle Signup and view all the answers

Which of these is NOT considered a pilon fracture?

Pilon fractures Signup and view all the answers

What are the two primary mechanisms of injury for pilon fractures?

Rotational and axial loading forces. Signup and view all the answers

What are the three main fragments observed in axial compression fractures?

Medial fragment, anterior fragment, and posterior fragment. Signup and view all the answers

What type of fracture is classified as Type I in the Ruedi and Allgower classification?

Non-displaced fractures Signup and view all the answers

The main goal of operative treatment for pilon fractures is to restore the _______.

articular surface Signup and view all the answers

High-energy pilon fractures generally have better outcomes than low-energy fractures.

False Signup and view all the answers

What does the primary arthrodesis technique involve?

Fusing bones together to stabilize the joint. Signup and view all the answers

Match the following classification systems with their fracture types:

Ruedi and Allgower Classification = Type I: Non-displaced, Type II: Displaced, Type III: Severely comminuted AO Classification = 43A: Extra-articular, 43B: Partial intra-articular, 43C: Completely intra-articular Signup and view all the answers

What does the term 'pilon' refer to in pilon fractures?

A pestle, which is a club-shaped tool. Signup and view all the answers

Which of the following fractures are considered pilon fractures?

Intra-articular fractures of the tibial plafond Signup and view all the answers

Grossly displaced fractures of the distal tibia can lead to soft tissue necrosis.

True Signup and view all the answers

The Ruedi and Allgower classification categorizes fractures into Type I, Type II, and Type ______.

III Signup and view all the answers

What are the three main fracture fragments observed in axial compression?

Medial fragment, Anterior or Anterior-lateral fragment, Posterior or Posterior-lateral fragment. Signup and view all the answers

What is one of the goals of applying an external fixator for pilon fractures?

To provide stability as the soft tissue calms down Signup and view all the answers

Why is fixation of the fibula considered key in pilon fractures?

Accurate fibular length, alignment, and rotation indirectly reduce the majority of tibial deformity. Signup and view all the answers

Open wounds with significant devitalization are common with low-energy trauma in pilon fractures.

False Signup and view all the answers

Match the following types of pilon fractures with their characteristics:

Type I = Non-displaced fractures Type II = Displaced fractures with loss of articular congruency Type III = Displaced and severely comminuted fractures with impaction Signup and view all the answers

What is the typical prognosis for fractures resulting from high-energy trauma?

Poor Signup and view all the answers

What is a primary method for non-operative treatment of pilon fractures?

Reserved for truly nondisplaced fractures. Signup and view all the answers

What are isolated sustentaculum fractures primarily caused by?

Axial load and forced inversion of the hindfoot Signup and view all the answers

Is it true that sustained sustentaculum fractures are classically regarded as intra-articular fractures?

False Signup and view all the answers

What type of treatment is recommended for nondisplaced or minimally displaced sustentaculum fractures?

Immobilization in a fracture boot and early range-of-motion exercises. Signup and view all the answers

What condition typically requires operative treatment with more than 2 mm of displacement?

Sustentaculum fractures Signup and view all the answers

What mechanism causes an anterior process fracture?

Forced inversion and plantar flexion of the foot. Signup and view all the answers

What classification is used for anterior process fractures?

Degan Classification Signup and view all the answers

True or False: Tuberosity avulsion fractures are caused by the violent pull of the gastrocnemius-soleus complex.

True Signup and view all the answers

What is a common complication of calcaneal fractures?

Subtalar arthrosis. Signup and view all the answers

Match the following types of treatment for calcaneal fractures with their purposes:

In Situ = Common salvage procedure for subtalar arthrosis Aggressive Wound Care = Treatment for wound dehiscence Aggressive Debridement = Treatment for osteomyelitis ORIF = Operative treatment for larger, displaced fragments Signup and view all the answers

What is the most commonly fractured tarsal bone?

Calcaneus Signup and view all the answers

Calcaneal fractures make up 2% of all fractures.

True Signup and view all the answers

What type of calcaneal fractures are most commonly observed?

Displaced intra-articular fractures Signup and view all the answers

What age group is most affected by calcaneal fractures?

21-45 Signup and view all the answers

What are common implications of calcaneal fractures?

All of the above Signup and view all the answers

What anatomical structure provides support to the talar neck?

Sustentaculum tali Signup and view all the answers

Which imaging technique is primarily used to classify calcaneal fractures?

X-rays Signup and view all the answers

What is the purpose of Böhler’s angle in imaging?

To assess displacement of the weightbearing posterior facet Signup and view all the answers

What surgical technique is used for displaced intra-articular fractures involving the posterior facet?

All of the above Signup and view all the answers

Patient's preference for minimally invasive procedures is increasing.

True Signup and view all the answers

What does the ROWE classification categorize?

Calcaneal fractures Signup and view all the answers

What is the mechanism of injury for isolated sustentaculum fractures?

Axial load and forced inversion of the hindfoot. Signup and view all the answers

What is the recommended non-operative treatment for nondisplaced or minimally displaced sustentaculum fractures?

Immobilization in a fracture boot Signup and view all the answers

Sustentaculum fractures are classically regarded as ______ fractures.

extraarticular Signup and view all the answers

All sustentaculum fractures require operative treatment.

False Signup and view all the answers

What are the types in Degan Classification of anterior process fractures?

Type I: Non-displaced, extra-articular; Type II: Displaced, extra-articular; Type III: Displaced, intra-articular. Signup and view all the answers

What is a common cause of tuberosity avulsion fractures?

Forced ankle dorsiflexion after a stumble Signup and view all the answers

Calcaneal body fractures involve the subtalar joint.

False Signup and view all the answers

What are some complications of calcaneal fractures?

Subtalar arthrosis, wound dehiscence, osteomyelitis, loss of fixation, malalignment. Signup and view all the answers

Which treatment option is associated with wound dehiscence?

Aggressive wound care Signup and view all the answers

What surgical procedure may be considered for subtalar arthrosis?

Distraction arthrodesis. Signup and view all the answers

What is the most commonly fractured tarsal bone?

calcaneus Signup and view all the answers

What percentage of calcaneal fractures are displaced intra-articular fractures?

75% Signup and view all the answers

Calcaneal fractures are typically associated with high risk for disability.

True Signup and view all the answers

Which of the following factors is a mechanism of injury for calcaneal fractures?

High-velocity motor vehicle accidents Signup and view all the answers

What type of imaging is essential for assessing calcaneal fractures?

X-rays Signup and view all the answers

What is the typical range for Böhler’s Angle in degrees?

20 to 40 degrees Signup and view all the answers

The calcaneus has four articulations with its adjacent _______ bones.

tarsal Signup and view all the answers

What is one of the consistent features of displaced intra-articular fractures?

The sustentaculum tali remains attached to the talus Signup and view all the answers

Match the Rowe classification with the type of fracture:

I a = Fracture of the calcaneal tubercle I b = Fracture of the sustentaculum tali II a = Beak fracture of the tuberosity III = Oblique body fracture not involving the STJ Signup and view all the answers

What does the Essex-Lopresti classification utilize?

CT imaging for fractures Signup and view all the answers

Non-operative treatment has shown good long-term outcomes for calcaneal fractures.

False Signup and view all the answers

Which type of fixation is recommended for Sanders type II fractures?

Sinus tarsi approach Signup and view all the answers

What are the three osseous structures that make up the ankle joint?

Tibia, fibula, talus Signup and view all the answers

What classification system is based on the foot position and direction of deforming forces?

Lauge-Hansen Signup and view all the answers

What is the first stage of the Lauge-Hansen classification for Supination-Adduction?

Transverse avulsion type fracture of distal fibula Signup and view all the answers

What are the four components of syndesmotic ligaments?

Anterior inferior tibiofibular ligament, posterior inferior tibiofibular ligament, inferior transverse tibiofibular ligament, interosseous ligament Signup and view all the answers

Which type of Danis-Weber classification defines a fracture of the lateral malleolus distal to the syndesmosis?

Type A Signup and view all the answers

What is a Tillaux-Chaput fracture?

AITFL avulsion fracture from anterolateral tibia Signup and view all the answers

In the Lauge-Hansen classification, what does the first word of the classification indicate?

Foot position (supination or pronation) Signup and view all the answers

Match the following named ankle fractures with their descriptions:

Tillaux-Chaput = AITFL avulsion fracture from anterolateral tibia Wagstaff = AITFL avulsion fracture of anteromedial fibula Volkmann = PITFL avulsion fracture from posterior lateral tibia Bosworth = PITFL avulsion fracture from posterior medial fibula Maisonneuve = Proximal fibular fracture near fibular neck Signup and view all the answers

What are the three osseous structures that make up the ankle joint?

Tibia, Fibula, Talus Signup and view all the answers

Match the ligament to its classification:

Superficial Deltoid = Medial Ligaments Anterior talofibular ligament = Lateral Ligaments Posterior inferior tibiofibular ligament = Syndesmotic Ligaments Interosseous ligament = Syndesmotic Ligaments Signup and view all the answers

Which classification system is based on foot position and direction of deforming forces?

Lauge-Hansen Signup and view all the answers

What is the first word in the Lauge-Hansen classification describing?

Foot position (either supination or pronation) Signup and view all the answers

What type of fracture is classified as Type A in the Danis-Weber classification?

Fracture below the syndesmosis Signup and view all the answers

The ______ is an avulsion fracture from the anterolateral tibia.

Tillaux-Chaput fracture Signup and view all the answers

Which stage of the Supination-Adduction Lauge-Hansen classification includes a distal fibula transverse avulsion?

Stage 1 Signup and view all the answers

What are the objectives for learning about ankle fractures?

Identify mechanisms of injury, classification schemes, management principles, specific concepts of fracture fixation devices, and criteria for evaluating fixation devices. Signup and view all the answers

What is evaluated in the clinical examination for ankle fractures?

All of the above Signup and view all the answers

The medial clear space widening of greater than 4 mm indicates a deltoid ligament injury.

True Signup and view all the answers

What advantage does closed reduction have over open reduction?

Lower infection risk Signup and view all the answers

Which technique involves exaggerating the deformity before reducing it?

Charnley Maneuver Signup and view all the answers

What is the goal of fracture reduction?

Anatomical reduction Signup and view all the answers

Which type of healing is characterized by significant callus formation?

Secondary Bone Healing Signup and view all the answers

Interfragmentary screws can be used in spiral fibular fractures.

True Signup and view all the answers

What is the purpose of a neutralization plate in plating techniques?

Protects lag screw from deforming forces. Signup and view all the answers

What is a major advantage of open reduction internal fixation?

Anatomic reduction Signup and view all the answers

In the Tension Band Wire technique, a ______ of 8 application is used to apply compression.

figure Signup and view all the answers

What are the two main types of fracture blisters?

Clear fluid-filled and hemorrhagic-filled Signup and view all the answers

What is the average healing time for clear fluid-filled blisters?

12 days Signup and view all the answers

Hemorrhagic blisters heal faster than clear fluid-filled blisters.

False Signup and view all the answers

What test is used to evaluate syndesmosis after fractures are fixated?

Cotton hook test Signup and view all the answers

Which method is recommended for inserting screws in syndesmotic fixation?

Posterior to anterior Signup and view all the answers

What are some characteristics of super construct hardware designs?

Extends hardware beyond the immediate injury site Signup and view all the answers

What is the main benefit of using internal fixation in diabetic ankle fractures?

Reduces wound complications and improves recovery times Signup and view all the answers

Intramedullary nail fixation is the primary choice for most patients with ankle fractures.

False Signup and view all the answers

Which of the following is a contraindication for IM nail fixation?

Active lifestyle in young patients without criteria Signup and view all the answers

What is one of the goals of using external fixation with delta frames?

To stabilize soft tissue structures Signup and view all the answers

What was the initial treatment plan for the 53 year old male with a right ankle fracture?

Conservative treatment with reduction and casting, non-weight bearing Signup and view all the answers

What bones are included in the midfoot?

Navicular, Cuneiforms, Cuboid Signup and view all the answers

Midfoot fractures are relatively common, accounting for 25% of all foot fractures.

False Signup and view all the answers

What is the most common type of midfoot fracture?

Navicular fractures Signup and view all the answers

The initial evaluation of trauma patients includes a neurovascular exam to rule out __________.

compartment syndrome Signup and view all the answers

What imaging method is often required for traumatic injuries to the midfoot?

CT scan Signup and view all the answers

What are the treatment options for non-displaced midfoot fractures?

NWB SLC for 6-8 weeks Signup and view all the answers

What type of fracture occurs when the foot moves in the opposite direction of tendon and/or ligament pull?

Avulsion fractures Signup and view all the answers

What percentages of navicular fractures are dorsal lip avulsion fractures?

47% Signup and view all the answers

What is a common complication of untreated navicular stress fractures in athletes?

Chronic pain Signup and view all the answers

The medial column shortening of more than 3 mm will require surgical intervention.

True Signup and view all the answers

What is the treatment for comminuted midfoot fractures?

ORIF, External fixation, Bridge plating Signup and view all the answers

Cuboid fractures are often a component of __________ injuries.

medial column Signup and view all the answers

Which classification describes types of navicular stress fractures?

Saxena Classification Signup and view all the answers

What are the primary topics covered in 'Master Techniques in Podiatric Surgery'?

The foot and ankle. Signup and view all the answers

Who authored the article on ankle sprains and instability published in Med Clin North Am?

Czajka CM, Tran E, Cai AN, DiPreta JA. Signup and view all the answers

The Dockery procedure is related to knee surgery.

False Signup and view all the answers

What is the focus of Chapter 62 in 'The Podiatry Institute Update'?

Radiographic Analysis of Ankle Ligamentous Injuries. Signup and view all the answers

What significant contribution did Stiell IG make in 1994?

Implementation of the Ottawa ankle rules. Signup and view all the answers

Which of the following publications focuses on comprehensive aspects of foot and ankle surgery? (Select all that apply)

McGlamry’s Comprehensive Textbook of Foot & Ankle Surgery, 3rd Ed. Signup and view all the answers

What does the copyright notice in the presentation imply?

Reproduction or distribution is prohibited. Signup and view all the answers

What is the diagnosis made by for Acute Lateral Ankle Sprains?

Physical examination Signup and view all the answers

What imaging may be necessary depending on physical exam findings? (Select all that apply)

MRI Signup and view all the answers

Functional rehabilitation is curative for grade 3 syndesmotic injuries.

False Signup and view all the answers

The ligament healing time for ankle sprains can range from _ to _ weeks depending on the injury grade.

6, 12 Signup and view all the answers

What does the abbreviation PRICE stand for in the treatment of acute lateral ankle sprains?

Protection, Rest, Ice, Compression, Elevation Signup and view all the answers

What is the position called where articulating bones have their maximum area of contact?

Close-Packed Position Signup and view all the answers

Acute ankle sprains can lead to chronic ankle instability.

True Signup and view all the answers

What is a common biomechanical cause of chronic ankle instability? (Select all that apply)

Connective soft tissue disorder Signup and view all the answers

What treatment helps improve strength and balance in patients with chronic ankle instability?

Neuromuscular training Signup and view all the answers

What type of surgical treatment is a Brostrom procedure?

Direct Repair Signup and view all the answers

What can often occur after acute ankle sprains?

Peroneal tendon pathology Signup and view all the answers

What is the most common injured ankle ligament?

Anterior talofibular ligament (ATFL) Signup and view all the answers

Which of the following ligaments is considered the second most common injured ankle ligament?

Calcaneofibular ligament (CFL) Signup and view all the answers

The posterior talofibular ligament is the strongest ankle ligament.

True Signup and view all the answers

Syndesmosis injury occurs with forced ______ and eversion.

dorsiflexion Signup and view all the answers

What percentage of ankle sprains are lateral ankle sprains?

85% Signup and view all the answers

Which grade of ankle sprain involves complete tearing of the affected ligament?

Grade 3 (Severe) Signup and view all the answers

What clinical test is used to evaluate the anterior talofibular ligament (ATFL)?

Anterior drawer test Signup and view all the answers

What impact did the Ottawa Ankle Rules have on radiographs?

Decreased ankle radiographs by 28% Signup and view all the answers

It is common for acute lateral ankle sprains to result in complete loss of function.

False Signup and view all the answers

What is the primary role of the calcaneofibular ligament (CFL)?

Resists ankle and subtalar inversion Signup and view all the answers

What is a common consequence of repeated ankle sprains?

Chronic ankle instability Signup and view all the answers

What year was the book 'Master Techniques in Podiatric Surgery: The Foot and Ankle' published?

2005 Signup and view all the answers

Which of these papers discusses ankle sprains and instability?

Ankle sprains and instability by Czajka CM et al. Signup and view all the answers

The Ottawa ankle rules were implemented in 1994.

True Signup and view all the answers

Which chapter discusses radiographic analysis of ankle ligamentous injuries?

Chapter 62 of The Podiatry Institute Update Signup and view all the answers

What is prohibited according to the copyright notice?

Reproduction or distribution Signup and view all the answers

What is the most common injured ankle ligament?

Anterior talofibular ligament (ATFL) Signup and view all the answers

Repeated ankle sprains can lead to chronic ankle instability.

True Signup and view all the answers

How many ankle sprains occur in the USA annually?

Approximately 2 million Signup and view all the answers

What percentage of ankle sprains are lateral ankle sprains?

85% Signup and view all the answers

The calcaneofibular ligament (CFL) resists ankle and subtalar ______.

inversion Signup and view all the answers

Which of the following is not a part of the syndesmosis structure?

Calcaneofibular ligament (CFL) Signup and view all the answers

What is the most severe classification of ankle sprain?

Grade 3 (Severe) Signup and view all the answers

Complete rupture of the deltoid ligament is common.

False Signup and view all the answers

What are the Ottawa Ankle Rules designed to reduce?

Unnecessary ankle radiographs Signup and view all the answers

What is the initial method for diagnosing acute lateral ankle sprains?

Physical examination Signup and view all the answers

What imaging may be required depending on physical exam findings in acute lateral ankle sprains?

Radiographs or MRI Signup and view all the answers

Which test is used to evaluate the anterior talofibular ligament (ATFL)?

Anterior Drawer Signup and view all the answers

What is the typical ligament healing time for acute lateral ankle sprains?

6 weeks to 3 months Signup and view all the answers

Match the following ligament with its characteristic:

Anterior talofibular ligament (ATFL) = Most commonly injured ankle ligament Calcaneofibular ligament (CFL) = Resists ankle and subtalar inversion Posterior talofibular ligament (PTFL) = Strongest ankle ligament Deltoid ligament = Rarely ruptures but can cause medial malleolus fracture Signup and view all the answers

Conservative treatment is successful up to 90% of the time for acute lateral ankle sprains.

True Signup and view all the answers

What does the acronym PRICE stand for in the treatment of acute lateral ankle sprains?

Protection, Rest, Ice, Compression, Elevation Signup and view all the answers

What is the function of the close-packed position in treating acute ankle sprains?

Joint stability Signup and view all the answers

What is the first step in the treatment of acute lateral ankle sprains?

Rest Signup and view all the answers

What is a key factor that can lead to chronic ankle instability following acute ankle sprains?

Recurrent ankle sprains Signup and view all the answers

The peroneal tendons reside in the __ compartment of the leg.

lateral Signup and view all the answers

What is the primary surgical treatment option for repairing peroneal tendon pathology?

All of the above Signup and view all the answers

What is the postoperative protocol for foot and ankle surgery regarding weight bearing?

NWB for 2 - 4 weeks Signup and view all the answers

Study Notes

Ankle Fracture Classification

Lauge-Hansen classification focuses on foot position at the time of injury and motion of the talus during the injury.
Four main patterns of ankle injuries: Supination-adduction, Pronation-abduction, Supination-external rotation, Pronation-external rotation.

Supination-Adduction

Stage 1: Trauma leads to a rupture of the lateral collateral ligaments or a transverse fracture of the fibula below the ankle joint.
Stage 2: Characterized by a vertical fracture of the medial malleolus.

Pronation-Abduction

Stage 1: Injury involves rupture of the deltoid ligament or transverse fracture of the medial malleolus.
Stage 2: Disruption of anterior and posterior inferior tibiofibular ligaments or specific fractures (Tillaux Chaput, Wagstaffe, Volkmann).
Stage 3: Short oblique fracture of the fibula at the ankle joint.

Supination-External Rotation

Stage 1: Involves disruption of anterior inferior tibiofibular ligament or fractures (Tillaux Chaput/Wagstaffe).
Stage 2: Spiral fracture of fibula at the ankle joint.
Stage 3: Disruption of posterior inferior tibiofibular ligament or Volkmann fracture.
Stage 4: Rupture of deltoid ligament along with a transverse fracture of the medial malleolus.

Pronation-External Rotation

Stage 1: Characterized by rupture of the deltoid ligament or transverse fracture of the medial malleolus.
Stage 2: Disruption of anterior inferior tibiofibular ligament or specific fractures along with potential rupture of interosseous membrane.
Stage 3: Fibular fracture proximal to syndesmosis.
Stage 4: Disruption of posterior inferior tibiofibular ligament or Volkmann fracture.

Danis-Weber Classification

Classifies fibular fractures based on their relationship to the ankle joint.
Type A: Fracture below the ankle level; linked with Supination-Adduction.
Type B: Fracture at the ankle level; associated with Supination-External Rotation and Pronation-Abduction.
Type C: Fracture above the ankle level; connected to Pronation-External Rotation.

Pilon Fractures (Ruedi/Allgower Classification)

Stage I: No joint fragment displacement or comminution.
Stage II: Some displacement present, but no comminution or impaction.
Stage III: Comminution and/or impaction of the joint surface.

Growth Plate Injuries

Salter-Harris type I: Injury without x-ray evidence, closed reduction leads to excellent prognosis.
Type II: Extends partially through the physis with specific bone fragments present; good prognosis.
Type III: Involves the joint surface requiring ORIF.
Type IV: Extends through metaphysis, physis, and epiphysis requiring ORIF.
Type V: Compression injuries with difficult diagnosis but treatment possible if growth potential remains.

Calcaneal Fractures

Classified into extra-articular and intra-articular types.
Rowe classification details various specific fractures including tubercle and joint depression fractures.
Sanders classification utilizes CT imaging to categorize fractures based on involvement of posterior facets.

Talar and Navicular Fractures

Sneppen classification categorizes talar fractures based on anatomical location including shear and crush types.
Hawkins classification evaluates talar neck fractures, correlating with avascular necrosis (AVN) risks.

Fifth Metatarsal Fractures (Stewart Classification)

Type 1: Jones fracture at the metaphyseal-diaphyseal junction.
Type 2: Intra-articular tuberosity fracture without comminution.
Types dictate treatment choices based on the athlete’s activity level and fracture characteristics.

Ankle Fracture Classification

Lauge-Hansen classification focuses on foot position at the time of injury and motion of the talus during the injury.
Four main patterns of ankle injuries: Supination-adduction, Pronation-abduction, Supination-external rotation, Pronation-external rotation.

Supination-Adduction

Stage 1: Trauma leads to a rupture of the lateral collateral ligaments or a transverse fracture of the fibula below the ankle joint.
Stage 2: Characterized by a vertical fracture of the medial malleolus.

Pronation-Abduction

Stage 1: Injury involves rupture of the deltoid ligament or transverse fracture of the medial malleolus.
Stage 2: Disruption of anterior and posterior inferior tibiofibular ligaments or specific fractures (Tillaux Chaput, Wagstaffe, Volkmann).
Stage 3: Short oblique fracture of the fibula at the ankle joint.

Supination-External Rotation

Stage 1: Involves disruption of anterior inferior tibiofibular ligament or fractures (Tillaux Chaput/Wagstaffe).
Stage 2: Spiral fracture of fibula at the ankle joint.
Stage 3: Disruption of posterior inferior tibiofibular ligament or Volkmann fracture.
Stage 4: Rupture of deltoid ligament along with a transverse fracture of the medial malleolus.

Pronation-External Rotation

Stage 1: Characterized by rupture of the deltoid ligament or transverse fracture of the medial malleolus.
Stage 2: Disruption of anterior inferior tibiofibular ligament or specific fractures along with potential rupture of interosseous membrane.
Stage 3: Fibular fracture proximal to syndesmosis.
Stage 4: Disruption of posterior inferior tibiofibular ligament or Volkmann fracture.

Danis-Weber Classification

Classifies fibular fractures based on their relationship to the ankle joint.
Type A: Fracture below the ankle level; linked with Supination-Adduction.
Type B: Fracture at the ankle level; associated with Supination-External Rotation and Pronation-Abduction.
Type C: Fracture above the ankle level; connected to Pronation-External Rotation.

Pilon Fractures (Ruedi/Allgower Classification)

Stage I: No joint fragment displacement or comminution.
Stage II: Some displacement present, but no comminution or impaction.
Stage III: Comminution and/or impaction of the joint surface.

Growth Plate Injuries

Salter-Harris type I: Injury without x-ray evidence, closed reduction leads to excellent prognosis.
Type II: Extends partially through the physis with specific bone fragments present; good prognosis.
Type III: Involves the joint surface requiring ORIF.
Type IV: Extends through metaphysis, physis, and epiphysis requiring ORIF.
Type V: Compression injuries with difficult diagnosis but treatment possible if growth potential remains.

Calcaneal Fractures

Classified into extra-articular and intra-articular types.
Rowe classification details various specific fractures including tubercle and joint depression fractures.
Sanders classification utilizes CT imaging to categorize fractures based on involvement of posterior facets.

Talar and Navicular Fractures

Sneppen classification categorizes talar fractures based on anatomical location including shear and crush types.
Hawkins classification evaluates talar neck fractures, correlating with avascular necrosis (AVN) risks.

Fifth Metatarsal Fractures (Stewart Classification)

Type 1: Jones fracture at the metaphyseal-diaphyseal junction.
Type 2: Intra-articular tuberosity fracture without comminution.
Types dictate treatment choices based on the athlete’s activity level and fracture characteristics.

Ankle Fracture Classification

Lauge-Hansen classification focuses on foot position at the time of injury and motion of the talus during the injury.
Four main patterns of ankle injuries: Supination-adduction, Pronation-abduction, Supination-external rotation, Pronation-external rotation.

Supination-Adduction

Stage 1: Trauma leads to a rupture of the lateral collateral ligaments or a transverse fracture of the fibula below the ankle joint.
Stage 2: Characterized by a vertical fracture of the medial malleolus.

Pronation-Abduction

Stage 1: Injury involves rupture of the deltoid ligament or transverse fracture of the medial malleolus.
Stage 2: Disruption of anterior and posterior inferior tibiofibular ligaments or specific fractures (Tillaux Chaput, Wagstaffe, Volkmann).
Stage 3: Short oblique fracture of the fibula at the ankle joint.

Supination-External Rotation

Stage 1: Involves disruption of anterior inferior tibiofibular ligament or fractures (Tillaux Chaput/Wagstaffe).
Stage 2: Spiral fracture of fibula at the ankle joint.
Stage 3: Disruption of posterior inferior tibiofibular ligament or Volkmann fracture.
Stage 4: Rupture of deltoid ligament along with a transverse fracture of the medial malleolus.

Pronation-External Rotation

Stage 1: Characterized by rupture of the deltoid ligament or transverse fracture of the medial malleolus.
Stage 2: Disruption of anterior inferior tibiofibular ligament or specific fractures along with potential rupture of interosseous membrane.
Stage 3: Fibular fracture proximal to syndesmosis.
Stage 4: Disruption of posterior inferior tibiofibular ligament or Volkmann fracture.

Danis-Weber Classification

Classifies fibular fractures based on their relationship to the ankle joint.
Type A: Fracture below the ankle level; linked with Supination-Adduction.
Type B: Fracture at the ankle level; associated with Supination-External Rotation and Pronation-Abduction.
Type C: Fracture above the ankle level; connected to Pronation-External Rotation.

Pilon Fractures (Ruedi/Allgower Classification)

Stage I: No joint fragment displacement or comminution.
Stage II: Some displacement present, but no comminution or impaction.
Stage III: Comminution and/or impaction of the joint surface.

Growth Plate Injuries

Salter-Harris type I: Injury without x-ray evidence, closed reduction leads to excellent prognosis.
Type II: Extends partially through the physis with specific bone fragments present; good prognosis.
Type III: Involves the joint surface requiring ORIF.
Type IV: Extends through metaphysis, physis, and epiphysis requiring ORIF.
Type V: Compression injuries with difficult diagnosis but treatment possible if growth potential remains.

Calcaneal Fractures

Classified into extra-articular and intra-articular types.
Rowe classification details various specific fractures including tubercle and joint depression fractures.
Sanders classification utilizes CT imaging to categorize fractures based on involvement of posterior facets.

Talar and Navicular Fractures

Sneppen classification categorizes talar fractures based on anatomical location including shear and crush types.
Hawkins classification evaluates talar neck fractures, correlating with avascular necrosis (AVN) risks.

Fifth Metatarsal Fractures (Stewart Classification)

Type 1: Jones fracture at the metaphyseal-diaphyseal junction.
Type 2: Intra-articular tuberosity fracture without comminution.
Types dictate treatment choices based on the athlete’s activity level and fracture characteristics.

Open Fractures Classification (Gustilo and Anderson)

Type 1: Clean puncture wound (<1cm), simple fracture, minimal contamination, little soft tissue damage.
Type 2: Extensive laceration with moderate contamination, no significant soft tissue loss, moderate comminution.
Type 3a: Open fracture with adequate soft tissue coverage, severe comminution, periosteal stripping, increased risk of infection.
Type 3b: Extensive soft tissue loss with bone exposure, high risk of amputation.
Type 3c: Open fracture with associated arterial injury, significant risk of complications.

Mechanism of Injury (MOI) for Talar Fractures

Talar Head: Violent dorsiflexion or plantarflexion divides the head into medial and lateral fragments.
Talar Neck: Forced axial load through the tibia shears off the talar head, leading to injury.

Hawkins Classification of Talar Neck Fractures

Stage 1: Nondisplaced talar neck fracture, best prognosis (AVN 0-13%).
Stage 2: Displaced talar neck fracture with subtalar joint (STJ) dislocation (AVN 20-50%).
Stage 3: Displaced talar neck fracture with STJ and ankle dislocation (AVN 83-100%).
Stage 4: Displaced talar neck fracture involving STJ, ankle, and talonavicular joint (AVN >91%).

Talar Fractures Characteristics

Lateral Process: Associated with snowboarder's fracture due to compression during inversion and dorsiflexion.
Posterior Process: Injuries like Shepherd's fracture from forced plantarflexion, leading to compression between tibia and calcaneus.
Cedell Fracture: Occurs from forced dorsiflexion and pronation, resulting in avulsion of the tubercle.
Talar Body: Injured via axial compression with plantarflexion upon impact.

Berndt and Harty Classification

Stage 1: Small area of subchondral compression, treated conservatively.
Stage 2: Partially detached osteochondral fragment, conservative treatment recommended.
Stage 3: Fully detached osteochondral fragment without displacement, conservative treatment.
Stage 4: Fully detached with displacement, requires surgical intervention.
Stage 5: Radiolucent defect with underlying lesion, indicative of severe injury.

Lisfranc Injuries (Nunley and Vertullo Classification)

Grade 1: Low-grade sprain, normal X-ray but positive bone scan.
Grade 2: Disruption of Lisfranc ligament complex with minimal diastasis (1-5 mm).
Grade 3: Complete disruption with more than 5 mm diastasis and loss of arch height on lateral weight-bearing X-ray.

Assessment Signs for Lisfranc Injuries

Mondor's sign: Plantar ecchymosis indicating injury.
Piano Key Test: Pain assessment by pressing on dorsal metatarsal head.
Tenting: Pressure necrosis in the soft tissue envelope.

Sanders Classification for Calcaneal Fractures

Evaluated via coronal CT, classifies fractures into types based on displacement and location within the posterior facet.
Type 1: No displacement.
Type 2: Single fracture line (two fragments).
Type 3: Two fracture lines (three fragments).
Type 4: Three or more fracture lines (four fragments).

Rowe Classification for Calcaneal Fractures

Types 1a, 1b, 1c: Extraarticular fractures of specific calcaneal areas (tubercle, sustentaculum, anterior process).
Type 4: Involves the subtalar joint, indicating intraarticular involvement.
Type 5: Joint depression with comminution classified as intraarticular joint depression fracture.

Named Ankle Fractures

Tillaux-Chaput Fracture: Anterolateral tibial avulsion fracture of the anterior inferior tibiofibular ligament (AITFL).
Wagstaff Fracture: Anteromedial fibular avulsion involving AITFL.
Volkmann Fracture: Posterior lateral fibular avulsion (PITFL).
Bosworth Fracture: Posterior medial fibular avulsion (PITFL).
Maisonneuve Fracture: Proximal fibular fracture near neck indicative of syndesmotic injury.

Midfoot Fractures and Navicular Fracture Classifications

Navicular Fractures: Commonly associated with plantarflexed foot position.
Watson-Jones Classification: Distinguishes types based on fracture mechanism (eversion, dorsal lip avulsion, body fracture, stress fracture).
Sangeorzan Classification: Classifies navicular body fractures based on orientation of the fracture line (transverse, oblique, comminuted).

Open Fractures Classification (Gustilo and Anderson)

Type 1: Clean puncture wound (<1cm), simple fracture, minimal contamination, little soft tissue damage.
Type 2: Extensive laceration with moderate contamination, no significant soft tissue loss, moderate comminution.
Type 3a: Open fracture with adequate soft tissue coverage, severe comminution, periosteal stripping, increased risk of infection.
Type 3b: Extensive soft tissue loss with bone exposure, high risk of amputation.
Type 3c: Open fracture with associated arterial injury, significant risk of complications.

Mechanism of Injury (MOI) for Talar Fractures

Talar Head: Violent dorsiflexion or plantarflexion divides the head into medial and lateral fragments.
Talar Neck: Forced axial load through the tibia shears off the talar head, leading to injury.

Hawkins Classification of Talar Neck Fractures

Stage 1: Nondisplaced talar neck fracture, best prognosis (AVN 0-13%).
Stage 2: Displaced talar neck fracture with subtalar joint (STJ) dislocation (AVN 20-50%).
Stage 3: Displaced talar neck fracture with STJ and ankle dislocation (AVN 83-100%).
Stage 4: Displaced talar neck fracture involving STJ, ankle, and talonavicular joint (AVN >91%).

Talar Fractures Characteristics

Lateral Process: Associated with snowboarder's fracture due to compression during inversion and dorsiflexion.
Posterior Process: Injuries like Shepherd's fracture from forced plantarflexion, leading to compression between tibia and calcaneus.
Cedell Fracture: Occurs from forced dorsiflexion and pronation, resulting in avulsion of the tubercle.
Talar Body: Injured via axial compression with plantarflexion upon impact.

Berndt and Harty Classification

Stage 1: Small area of subchondral compression, treated conservatively.
Stage 2: Partially detached osteochondral fragment, conservative treatment recommended.
Stage 3: Fully detached osteochondral fragment without displacement, conservative treatment.
Stage 4: Fully detached with displacement, requires surgical intervention.
Stage 5: Radiolucent defect with underlying lesion, indicative of severe injury.

Lisfranc Injuries (Nunley and Vertullo Classification)

Grade 1: Low-grade sprain, normal X-ray but positive bone scan.
Grade 2: Disruption of Lisfranc ligament complex with minimal diastasis (1-5 mm).
Grade 3: Complete disruption with more than 5 mm diastasis and loss of arch height on lateral weight-bearing X-ray.

Assessment Signs for Lisfranc Injuries

Mondor's sign: Plantar ecchymosis indicating injury.
Piano Key Test: Pain assessment by pressing on dorsal metatarsal head.
Tenting: Pressure necrosis in the soft tissue envelope.

Sanders Classification for Calcaneal Fractures

Evaluated via coronal CT, classifies fractures into types based on displacement and location within the posterior facet.
Type 1: No displacement.
Type 2: Single fracture line (two fragments).
Type 3: Two fracture lines (three fragments).
Type 4: Three or more fracture lines (four fragments).

Rowe Classification for Calcaneal Fractures

Types 1a, 1b, 1c: Extraarticular fractures of specific calcaneal areas (tubercle, sustentaculum, anterior process).
Type 4: Involves the subtalar joint, indicating intraarticular involvement.
Type 5: Joint depression with comminution classified as intraarticular joint depression fracture.

Named Ankle Fractures

Tillaux-Chaput Fracture: Anterolateral tibial avulsion fracture of the anterior inferior tibiofibular ligament (AITFL).
Wagstaff Fracture: Anteromedial fibular avulsion involving AITFL.
Volkmann Fracture: Posterior lateral fibular avulsion (PITFL).
Bosworth Fracture: Posterior medial fibular avulsion (PITFL).
Maisonneuve Fracture: Proximal fibular fracture near neck indicative of syndesmotic injury.

Midfoot Fractures and Navicular Fracture Classifications

Navicular Fractures: Commonly associated with plantarflexed foot position.
Watson-Jones Classification: Distinguishes types based on fracture mechanism (eversion, dorsal lip avulsion, body fracture, stress fracture).
Sangeorzan Classification: Classifies navicular body fractures based on orientation of the fracture line (transverse, oblique, comminuted).

Overview of Acute Compartment Syndrome (ACS)

ACS is a critical condition resulting from trauma, often linked to crush injuries or other significant damage.
Prompt diagnosis is essential to prevent loss of limb function; it is considered a surgical emergency.
Anatomy knowledge of the lower leg is vital for effective treatment.

Etiology of ACS

Common causes include:
- Exertional and major vascular injuries
- Trauma, hemorrhage, surgical closure, external pressure
- Burns, snake bites, infiltration, infection, frostbite

Pathophysiology of ACS

Injury leads to bleeding and edema, causing increased pressure.
Elevated pressure hampers arterial-venous flow, ultimately resulting in collapse of capillary blood flow.
Tissues can die, causing nerve damage and muscle death; untreated ACS may lead to death.

Compartment Anatomy of the Lower Leg

Divided into four compartments:
- Anterior, lateral, deep posterior, and superficial posterior
Septa separate these compartments, which are crucial for surgical decompression.

Compartment Anatomy of the Foot

Two classification systems exist: Myerson (4 compartments) and Manoli-Weber (9 compartments).
The Myerson study identifies key muscles and tendons in each compartment that could be affected during ACS.

Diagnosis of ACS

Utilize the NLDOCAT framework to assess the History of Present Illness (HPI), focusing on injury nature, pain location, duration, onset, characteristics, aggravating factors, and previous treatments.
The six clinical signs - the "6 P's":
- Pain, Paresthesia, Pallor, Pulselessness, Poikilothermia, Paralysis
Emphasize a thorough physical examination, including vascular, musculoskeletal, neurological, and dermatological assessments.

Diagnostic Tests

Confirm diagnosis using intra-compartmental pressure measurement through devices like wick-catheter systems.
Radiological imaging such as X-ray and CT scans can help assess the extent of injuries and rule out fractures.

Surgical Management

Incision techniques vary:
- Lateral and medial incisions allow access to different compartments of the leg for fasciotomy.
Special precautions during surgery include protecting nerves and ensuring complete compartment release.

Postoperative Care

Options for surgical closure include primary closure, delayed primary closure, or packing open.
Essential to monitor for complications like Volkmann’s contracture and ensure proper limb positioning to prevent contractures.

Complications of ACS

High risk for neurological deficits and wound healing complications post-injury.
Importance of early recognition and treatment to reduce the incidence of long-term disabilities.

Conclusion

ACS should be considered for all high-energy injuries to the leg and foot.
Gaining expertise in compartment anatomy and intervention strategies is critical for effective management and patient care.

Practice Questions

Example scenarios provided focus on recognizing ACS symptoms, determining appropriate interventions based on intra-compartment pressure readings, and identifying improperly released compartments leading to complications.### Compartment Syndrome Overview
Compartment syndrome occurs when pressure increases within a muscle compartment, compromising blood flow and leading to tissue damage.
Symptoms include intense pain, cold insensate extremities, pale discoloration, and absent pulses.

Clinical Case Example

An 18-year-old female with a calcaneal fracture shows signs of compartment syndrome: BP at 110/75, intense pain, cold insensate foot, pale discoloration, and absent pulses.
Intra-compartment pressure reading shows 40 mmHg, indicating the need for immediate intervention.

Management Protocols

Immediate emergency fasciotomy is indicated when intra-compartment pressure is elevated (≥30 mmHg) and accompanied by clinical symptoms.
Delayed surgical intervention can lead to permanent muscle damage and disability.

Diagnosis and Complications

A patient who suffered a crush injury underwent a forefoot fasciotomy but later developed a unilateral claw toe deformity and numbness due to severe atrophy of the quadratus plantae muscle.
Complications arose from the omission of the deep calcaneal compartment during the fasciotomy.

Anatomic Considerations

The deep calcaneal compartment is located posteriorly and may be missed if only intermetatarsal, medial, and lateral compartments are addressed.
Understanding the anatomy of foot compartments is crucial for surgery to minimize complications.

Key Facts about Fasciotomy

Five-incision fascia release strategies aim to relieve pressure in specific compartments, particularly useful in trauma cases.
Necessary to thoroughly evaluate all compartments to prevent long-term muscle atrophy and dysfunction.

Importance of Timely Intervention

Immediate surgical intervention is critical in preventing irreversible damage to muscle and nerves.
Prolonged compartment syndrome can lead to significant post-operative complications, requiring extensive rehabilitation.

Overview of Acute Compartment Syndrome (ACS)

ACS is a critical condition resulting from trauma, often linked to crush injuries or other significant damage.
Prompt diagnosis is essential to prevent loss of limb function; it is considered a surgical emergency.
Anatomy knowledge of the lower leg is vital for effective treatment.

Etiology of ACS

Common causes include:
- Exertional and major vascular injuries
- Trauma, hemorrhage, surgical closure, external pressure
- Burns, snake bites, infiltration, infection, frostbite

Pathophysiology of ACS

Injury leads to bleeding and edema, causing increased pressure.
Elevated pressure hampers arterial-venous flow, ultimately resulting in collapse of capillary blood flow.
Tissues can die, causing nerve damage and muscle death; untreated ACS may lead to death.

Compartment Anatomy of the Lower Leg

Divided into four compartments:
- Anterior, lateral, deep posterior, and superficial posterior
Septa separate these compartments, which are crucial for surgical decompression.

Compartment Anatomy of the Foot

Two classification systems exist: Myerson (4 compartments) and Manoli-Weber (9 compartments).
The Myerson study identifies key muscles and tendons in each compartment that could be affected during ACS.

Diagnosis of ACS

Utilize the NLDOCAT framework to assess the History of Present Illness (HPI), focusing on injury nature, pain location, duration, onset, characteristics, aggravating factors, and previous treatments.
The six clinical signs - the "6 P's":
- Pain, Paresthesia, Pallor, Pulselessness, Poikilothermia, Paralysis
Emphasize a thorough physical examination, including vascular, musculoskeletal, neurological, and dermatological assessments.

Diagnostic Tests

Confirm diagnosis using intra-compartmental pressure measurement through devices like wick-catheter systems.
Radiological imaging such as X-ray and CT scans can help assess the extent of injuries and rule out fractures.

Surgical Management

Incision techniques vary:
- Lateral and medial incisions allow access to different compartments of the leg for fasciotomy.
Special precautions during surgery include protecting nerves and ensuring complete compartment release.

Postoperative Care

Options for surgical closure include primary closure, delayed primary closure, or packing open.
Essential to monitor for complications like Volkmann’s contracture and ensure proper limb positioning to prevent contractures.

Complications of ACS

High risk for neurological deficits and wound healing complications post-injury.
Importance of early recognition and treatment to reduce the incidence of long-term disabilities.

Conclusion

ACS should be considered for all high-energy injuries to the leg and foot.
Gaining expertise in compartment anatomy and intervention strategies is critical for effective management and patient care.

Practice Questions

Example scenarios provided focus on recognizing ACS symptoms, determining appropriate interventions based on intra-compartment pressure readings, and identifying improperly released compartments leading to complications.### Compartment Syndrome Overview
Compartment syndrome occurs when pressure increases within a muscle compartment, compromising blood flow and leading to tissue damage.
Symptoms include intense pain, cold insensate extremities, pale discoloration, and absent pulses.

Clinical Case Example

An 18-year-old female with a calcaneal fracture shows signs of compartment syndrome: BP at 110/75, intense pain, cold insensate foot, pale discoloration, and absent pulses.
Intra-compartment pressure reading shows 40 mmHg, indicating the need for immediate intervention.

Management Protocols

Immediate emergency fasciotomy is indicated when intra-compartment pressure is elevated (≥30 mmHg) and accompanied by clinical symptoms.
Delayed surgical intervention can lead to permanent muscle damage and disability.

Diagnosis and Complications

A patient who suffered a crush injury underwent a forefoot fasciotomy but later developed a unilateral claw toe deformity and numbness due to severe atrophy of the quadratus plantae muscle.
Complications arose from the omission of the deep calcaneal compartment during the fasciotomy.

Anatomic Considerations

The deep calcaneal compartment is located posteriorly and may be missed if only intermetatarsal, medial, and lateral compartments are addressed.
Understanding the anatomy of foot compartments is crucial for surgery to minimize complications.

Key Facts about Fasciotomy

Five-incision fascia release strategies aim to relieve pressure in specific compartments, particularly useful in trauma cases.
Necessary to thoroughly evaluate all compartments to prevent long-term muscle atrophy and dysfunction.

Importance of Timely Intervention

Immediate surgical intervention is critical in preventing irreversible damage to muscle and nerves.
Prolonged compartment syndrome can lead to significant post-operative complications, requiring extensive rehabilitation.

Anatomy Overview

Metatarsals consist of five bones: head (distal), neck, diaphysis (shaft), metaphysis (proximal), and base (proximal).
The base of each metatarsal is broad, composed mainly of cancellous bone.
First metatarsal connects weakly to the second, bearing significant weight during gait.

Introduction to Metatarsal Fractures

Account for 35-88% of all foot and ankle fractures and nearly 7% of total fractures.
Fifth metatarsal is the most commonly fractured; first metatarsal is the least common.

Mechanisms of Injury (MOI)

Direct Blow: Immediate impact to the metatarsals.
Twisting Injury: Rotation causing stress on the bone structure.
Crush Injury: Pressure leading to fracturing.
High forces are necessary to fracture the first metatarsal.

Fracture Patterns

Common types: Transverse, Oblique, Spiral, Comminuted/Crush, Avulsion, Fracture-Dislocation.
Fractures can be classified as displaced/nondisplaced, angulated, translated, complete/incomplete, intraarticular/extraarticular.

Physical Examination

Indicators include antalgic gait, edema, ecchymosis, and palpable pain.
Assess neurovascular status and soft tissue envelope.
High suspicion for secondary injuries like Lisfranc injury or compartment syndrome.

Imaging Techniques

Traditional 3-view X-rays are standard to assess fractures.
CT/MRI recommended for first metatarsal base fractures and cases of delayed healing.
Bone scans (Tech-99) are used for stress fractures but have limited application.

Management Approaches

Non-Operative

Non-displaced fractures: Generally managed with nonoperative care, allowing for healing without surgical intervention.
Central metatarsal fractures: Typically require 6-8 weeks of weight-bearing as tolerated (WBAT) with gradual transition to regular shoes once healing is evident.

Operative

Indicated for fractures with severe displacement (>3-4 mm) or angulation (>10 degrees).
Surgical methods include Open Reduction and Internal Fixation (ORIF), percutaneous fixation, and external fixation for comminuted cases.

Special Considerations

Malunion, particularly with the first metatarsal, can lead to complications like dorsal angulation and shortening.
Treatments may involve cheilectomy, plantarflexory osteotomy, or arthrodesis for persistent issues.

Fifth Metatarsal Fractures

Most common metatarsal fracture, often seen in athletes.
Types include:
- Dancer’s fracture: Distal diaphyseal fracture from forced dorsiflexion.
- Jones fracture: Involves the diaphyseal-metaphyseal junction, susceptible to delayed healing due to poor blood supply.

Management of Fifth Metatarsal Fractures

Non-operative care recommended for avulsion fractures and distal diaphyseal fractures with some displacement.
Operative treatment may involve bicortical screws, intramedullary screws, or plate fixation for cases of nonunion or severe displacement.

Summary

Healing dynamics of metatarsal fractures depend heavily on displacement and angulation.
Specific conditions like the Jones fracture require tailored management strategies and patient education.
Most fractures heal well with appropriate treatment.

Management of Open Fractures

Goals: Convert contaminated wounds to clean, promote early soft tissue healing, stabilize fractures.
Essential to recognize history and physical findings in crush and degloving injuries.

Gustillo and Anderson Classification

Classifies open fractures based on mechanism of injury, contamination level, fracture configuration, and soft tissue damage.

Types of Open Fractures

Type I: Clean puncture < 1 cm, simple fracture, minimal soft tissue damage.
Type II: Laceration > 1 cm, moderate contamination, no extensive soft tissue damage, moderate comminution.
Type IIIA: Extensive laceration, adequate soft tissue coverage, severe comminution.
Type IIIB: Massive contamination, extensive soft tissue loss, periosteal stripping, bone exposure, severe comminution.
Type IIIC: Open fracture with arterial injury.

Open Fracture Treatment Plan

Considered a surgical emergency; crucial to adhere to the "golden period."
Perform multi-system evaluations, antibiotic therapy, irrigation, and debridement.
Stabilize fractures and monitor for compartment syndrome.
Consider delayed closure and bone grafting for healing.
Distinguish between contaminated and infected wounds.

Antibiotic Protocols

Limited duration (48-72 hours) is recommended.
Type I fractures: Cefazolin (Ancef) 2 gm IV Q 8h.
Types II and III fractures: Combined therapy with Cefazolin and aminoglycoside (3-5 mg/kg/day).
Initiate antibiotics within 3 hours post-injury and continue as specified based on fracture type.

Infection Considerations

Infection rates: Type I (0-2%), Type II (2-7%), Type IIIA (7%), Type IIIB (10-50%), Type IIIC (25-50%).
Over 50% of Type IIIC cases may result in amputation.

Surgical Principles

Initial debridement and pulse lavage essential, with repeat as necessary.
Early wound coverage with delayed primary closure, grafts, or flaps is optimal.

Stabilization of Fractures

Consider risks versus benefits for intra-articular fractures; complications may outweigh infection risks.
Types of fixation include internal vs. external, each with specific healing advantages.

Indications for Amputation

Indicative in cases of massive uncontrolled sepsis, necrosis, and gangrene.

Mangled Extremity Severity Score (MESS)

A MESS value ≥ 7 has 100% accuracy in predicting amputation following lower extremity trauma.

Bone Grafting

Applicable for Type I, II, and III fractures, aiding in the healing process.

Management of Open Fractures

Goals: Convert contaminated wounds to clean, promote early soft tissue healing, stabilize fractures.
Essential to recognize history and physical findings in crush and degloving injuries.

Gustillo and Anderson Classification

Classifies open fractures based on mechanism of injury, contamination level, fracture configuration, and soft tissue damage.

Types of Open Fractures

Type I: Clean puncture < 1 cm, simple fracture, minimal soft tissue damage.
Type II: Laceration > 1 cm, moderate contamination, no extensive soft tissue damage, moderate comminution.
Type IIIA: Extensive laceration, adequate soft tissue coverage, severe comminution.
Type IIIB: Massive contamination, extensive soft tissue loss, periosteal stripping, bone exposure, severe comminution.
Type IIIC: Open fracture with arterial injury.

Open Fracture Treatment Plan

Considered a surgical emergency; crucial to adhere to the "golden period."
Perform multi-system evaluations, antibiotic therapy, irrigation, and debridement.
Stabilize fractures and monitor for compartment syndrome.
Consider delayed closure and bone grafting for healing.
Distinguish between contaminated and infected wounds.

Antibiotic Protocols

Limited duration (48-72 hours) is recommended.
Type I fractures: Cefazolin (Ancef) 2 gm IV Q 8h.
Types II and III fractures: Combined therapy with Cefazolin and aminoglycoside (3-5 mg/kg/day).
Initiate antibiotics within 3 hours post-injury and continue as specified based on fracture type.

Infection Considerations

Infection rates: Type I (0-2%), Type II (2-7%), Type IIIA (7%), Type IIIB (10-50%), Type IIIC (25-50%).
Over 50% of Type IIIC cases may result in amputation.

Surgical Principles

Initial debridement and pulse lavage essential, with repeat as necessary.
Early wound coverage with delayed primary closure, grafts, or flaps is optimal.

Stabilization of Fractures

Consider risks versus benefits for intra-articular fractures; complications may outweigh infection risks.
Types of fixation include internal vs. external, each with specific healing advantages.

Indications for Amputation

Indicative in cases of massive uncontrolled sepsis, necrosis, and gangrene.

Mangled Extremity Severity Score (MESS)

A MESS value ≥ 7 has 100% accuracy in predicting amputation following lower extremity trauma.

Bone Grafting

Applicable for Type I, II, and III fractures, aiding in the healing process.

Mechanisms of Injury for Talar Fractures

Talar fractures occur from high-energy injuries, commonly seen in motor vehicle accidents and falls from heights.
Specific fracture types include:
- Talar head: Often caused by violent dorsiflexion of a plantarflexed foot.
- Lateral process: Known as "snowboarder’s fracture," results from compression during inversion and dorsiflexion.
- Posterior process: Fractures occur due to forced plantarflexion.
- Talar neck, body, and dome are also critical sites for injury.

Classification Systems and Treatment Correlation

Talar neck fractures are classified by Hawkins, correlating with avascular necrosis (AVN) risk.
Talar body fractures are categorized by Sneppen, which relates treatment to fracture displacement and joint involvement.
Talar dome fractures follow the Berndt and Harty classification, assisting in treatment decisions.

Management Principles

Comprehensive patient work-up includes:
- Detailed medical history and mechanism of injury.
- Physical examination for accompanying injuries (e.g., vertebral compression fractures).
- Radiographic assessment using AP, lateral views, and Canale & Kelly view.
Treatment approaches:
- Conservative management includes non-weight bearing (NWB) with a short leg cast for 4-8 weeks.
- Surgical interventions such as open reduction internal fixation (ORIF) for displaced fractures.

Talar Anatomy

The talus serves as a critical structural link between the leg and foot and is involved in three joints: ankle, subtalar, and talonavicular.
60% of the talar surface consists of cartilage, making injuries likely to be intra-articular.
The blood supply is tenuous due to limited soft tissue attachment; major vascular sources include:
- Posterior tibial artery via the tarsal canal.
- Dorsalis pedis for the head and neck.
- Peroneal artery providing blood flow to the sinus.

Specific Fracture Types

Talar head fractures:
- Rare (<10% of talar fractures), treated based on joint involvement and comminution; displaced fractures need ORIF.
Fractures of the lateral process:
- Comprise 20% of talar fractures; treatment varies from conservative management to ORIF based on displacement.
Posterior talar process fractures:
- Notably termed "Shepherd’s fracture" and treated conservatively unless problematic.
Talar body fractures:
- Account for 13-23% of injuries, often associated with high-energy mechanisms and potentially requiring surgical intervention.
Talar neck fractures, the second most common type, correlate with Hawkins classification; treatment varies based on the extent of displacement.

Goals of Management for Talar Injuries

Thorough evaluation using imaging techniques (radiographs, CT scans).
Immediate closed reduction of any dislocated joints.
Achieve anatomical reductions with stable fixation.
Promote fracture union and minimize AVN occurrences.
Ensure effective postoperative care to reduce complications.### Hawkins Classification of Talar Fractures
Hawkins I: Nondisplaced talar neck fracture; associated with an AVN (Avascular Necrosis) rate of 0-13%; best prognosis; typically managed conservatively with non-weight bearing (NWB) short leg cast (SLC) for 6-8 weeks.
Hawkins II: Displaced talar neck fracture with subtalar joint dislocation; AVN rate ranges from 20-50%; requires surgical intervention with Open Reduction Internal Fixation (ORIF); NWB SLC for 8 weeks post-surgery.
Hawkins III: Displaced talar neck fracture accompanied by subtalar and ankle joint dislocations; AVN risk is 83-100%; surgical treatment with ORIF is necessary; NWB SLC for 8 weeks; talar body is restrained by deltoid ligament.
Hawkins IV: Displaced talar neck fracture involving subtalar, ankle, and talonavicular joint dislocations; AVN rate exceeds 91%; surgical treatment with ORIF required; very rare occurrence; NWB SLC for 8 weeks.

Hawkins Sign and AVN

Hawkins Sign: Subchondral radiolucency visible on AP/Mortise view indicating potential non-vascularity. Seen 6 weeks to 3 months post-injury; has 100% sensitivity for the absence of AVN but only 57.7% specificity.
Goals of Talar Neck Fracture Management:
- Assessment of injury extent through radiographs and CT scans.
- Immediate closed reduction of dislocated joints.
- Aim for anatomic reduction and stable fixation of fractures to promote union and reduce AVN occurrence.

Avascular Necrosis (AVN) of the Talus

AVN arises from arterial injury leading to tissue ischemia; hallmark signs include sclerosis of talus and signal changes detectable via MRI (gadolinium enhances accuracy).
Collapse of the talar dome may also occur, influencing treatment approaches.
Pre-collapse treatments:
- Conservative: Includes Patellar Tendon Bearing (PTB) Brace; compliance can be problematic; Hyperbaric Oxygen Therapy (HBOT) evidence remains anecdotal.
- Surgical: Core decompression to alleviate internal pressure allowing revascularization; can occur with intact cartilage.
Post-collapse treatments:
- Conservative: Observation, symptom management, and bracing until surgery becomes necessary.
- Surgical: Options include Tibiotalocalcaneal (TTC) fusion and Tibiocalcaneal (Blair) fusion; total ankle replacement contraindicated due to AVN.

Fractures of the Talar Dome

Talar dome lesions represent 1% of all talar fractures involving articular cartilage and subchondral bone damage.
Patients often present with a history of ankle fractures or inversions; symptoms may delay despite initial improvement post-injury.
Injury mechanisms vary by lesion location:
- Anterolateral lesions: caused by dorsiflexion/inversion.
- Posteromedial lesions: arise from plantarflexion/inversion.
Morphology:
- Posteromedial lesions: deep, cup-shaped, often asymptomatic.
- Anterolateral lesions: shallow, wafer-shaped, frequently symptomatic.

Classification by Berndt & Harty

Stage I: Small subchondral compression.
Stage II: Partially detached osteochondral fragment.
Stage III: Fully detached, not displaced.
Stage IV: Detached and displaced.
Stage V: Radiolucent defect underneath the lesion.
Treatment varies based on lesion stage and symptoms:
- Stage I & II: conservative treatment (WB SLC).
- Stage III medial lesions: conservative; lateral lesions may need surgery.
- Stage IV: requires surgical intervention.

Surgical Options

Ankle Arthroscopy: Involves debridement of OCD, microfracture, or chondrocyte implantation.
Ankle Arthrotomy: Similar to arthroscopy but involves direct access; can include Osteochondral Autologous Transplantation like mosaicplasty or en bloc talar shoulder transplantation.

Overview of Lisfranc Injuries

Involves injuries to the tarsometatarsal joints, varying from sprains to fracture-dislocations.
Rare in the general population (0.2%), but more common in athletes, affecting 4% of football players.
Without proper treatment, can result in long-term morbidity.

Historical Context

Named after Jacques Lisfranc de St. Martin, a French surgeon who described surgical amputations at the tarsometatarsal joint.
Quenu and Kuss in 1909 established the initial classification; Hardcastle (1982) and Myerson (1999) expanded categories based on injury characteristics.

Anatomical Insights

The medial cuneiform to the base of the second metatarsal connects via the Lisfranc ligament.
The second metatarsal serves as the keystone, supported by intrinsic stability from the arch and intermetatarsal ligaments.

Mechanisms of Injury

High-energy mechanisms include motor vehicle accidents; low-energy impacts involve missed steps or sports activities.
Injuries can occur through direct force (crush injuries usually leading to dislocation) or indirect forces applied to a plantarflexed and inverted foot.

Classifications

Classifications include:
- Quenu & Kuss: Isolated, Homolateral, Divergent.
- Hardcastle classification based on displacement.
- Myerson classification focuses on dislocation direction.

Physical Examination

Common complaints include diffuse pain; diagnosis ideally within 6 weeks post-injury.
Indicators of severity: plantar ecchymosis, tender palpation, and soft tissue envelope “tenting.”
Consideration for compartment syndrome in trauma cases.

Imaging Techniques

X-ray findings: diastasis between the first and second metatarsal, displacement in lateral views, and potential "fleck" fragments.
MRI is best for low-energy injuries, highlighting soft tissue and ligament injuries.
CT scans provide comprehensive views of osseous structures, crucial for identifying metatarsal and tarsal fractures.

Management Strategies

Non-operative care is suitable for minor sprains and patients unfit for surgery but may carry risks of complications if not stabilized.
Operative care options:
- Closed reduction, percutaneous fixation, or arthrodesis for severe injuries.
- Operative fixation often involves multiple techniques (K-wires, external fixation, ORIF).
- Primary arthrodesis recommended for non-essential joints, yielding lower reoperation rates compared to ORIF.

Recovery and Return to Activity

Recovery times post-surgery vary by injury severity and management approach, notably impacting athletes' return to sports.
High rates of return to play documented (~90% NFL, ~94% soccer players) but caution for decreased performance in high-impact activities.

Conclusion

There is no universal treatment approach for Lisfranc injuries; effective management necessitates consideration of injury specifics and timely diagnosis to minimize risks of chronic issues like degenerative joint disease (DJD).

Introduction to Pilon Fractures

"Pilon" refers to a pestle; coined by Destot in 1911, it highlights the role of the talus in these fractures.
Also known as tibial plafond fractures, involving intra-articular fractures of the tibial plafond.

Anatomy

The distal tibia is a subcutaneous bone, making it susceptible to soft-tissue complications.
Severe displacement of fractures can lead to soft-tissue necrosis.

Mechanisms of Injury

Rotational (Torsion) Injury:
- Low-energy trauma with spiral fractures and minimal soft-tissue damage.
- Results in mildly or moderately displaced large articular fragments, often having a favorable prognosis.
Axial Compression:
- Caused by high-energy trauma with marked articular damage and soft-tissue envelope compromise.
- Results in significant fragmentation and worse prognosis.

Physical Examination

Assess the soft tissue envelope:
- Look for swelling, contusions, and signs of compartment syndrome.

Imaging

X-ray and CT scans are crucial for evaluation.
Classifications include Ruedi and Allgower, and AO Classification for fracture assessment.

Ruedi and Allgower Classification

Type I: Non-displaced fractures.
Type II: Displaced fractures with loss of articular congruency.
Type III: Displaced, severely comminuted fractures with impaction.

AO Classification

Categorizes fractures based on their relationship to the joint:
- 43A: Extra-articular.
- 43B: Partial intra-articular.
- 43C: Completely intra-articular.

Treatment Approaches

Non-Operative: Extremely limited to truly nondisplaced fractures or patients with contraindications to surgery.
Operative Options:
- Includes external fixation, open reduction and internal fixation (ORIF), minimally invasive plate fixation, medullary nailing, and arthrodesis.
- Key principles involve restoring anatomic fibular length and distal tibial articular surface.

Fixation Techniques

Accurate fibular alignment is essential for reducing tibial deformity.
Use of external fixators provides stability and aids in soft tissue healing.

Surgical Procedures

Stage 1: Focuses on stabilizing the soft tissue and may include debridement and external fixation of the tibial plafond fracture.
Stage 2: Definitive surgical management aims to restore the articular surface with stable fixation.

Post-Operative Care

Well-padded splinting is maintained in a neutral position for 2–3 weeks.
Gradual physical therapy and progressive weight-bearing are initiated after approximately 12 weeks.

Outcomes

Functional outcomes are generally poor post-injury when compared to age-matched populations.
Increased incidence of post-traumatic arthritis over time and higher unemployment rates among previously employed patients following injury.

Introduction to Pilon Fractures

"Pilon" refers to a pestle; coined by Destot in 1911, it highlights the role of the talus in these fractures.
Also known as tibial plafond fractures, involving intra-articular fractures of the tibial plafond.

Anatomy

The distal tibia is a subcutaneous bone, making it susceptible to soft-tissue complications.
Severe displacement of fractures can lead to soft-tissue necrosis.

Mechanisms of Injury

Rotational (Torsion) Injury:
- Low-energy trauma with spiral fractures and minimal soft-tissue damage.
- Results in mildly or moderately displaced large articular fragments, often having a favorable prognosis.
Axial Compression:
- Caused by high-energy trauma with marked articular damage and soft-tissue envelope compromise.
- Results in significant fragmentation and worse prognosis.

Physical Examination

Assess the soft tissue envelope:
- Look for swelling, contusions, and signs of compartment syndrome.

Imaging

X-ray and CT scans are crucial for evaluation.
Classifications include Ruedi and Allgower, and AO Classification for fracture assessment.

Ruedi and Allgower Classification

Type I: Non-displaced fractures.
Type II: Displaced fractures with loss of articular congruency.
Type III: Displaced, severely comminuted fractures with impaction.

AO Classification

Categorizes fractures based on their relationship to the joint:
- 43A: Extra-articular.
- 43B: Partial intra-articular.
- 43C: Completely intra-articular.

Treatment Approaches

Non-Operative: Extremely limited to truly nondisplaced fractures or patients with contraindications to surgery.
Operative Options:
- Includes external fixation, open reduction and internal fixation (ORIF), minimally invasive plate fixation, medullary nailing, and arthrodesis.
- Key principles involve restoring anatomic fibular length and distal tibial articular surface.

Fixation Techniques

Accurate fibular alignment is essential for reducing tibial deformity.
Use of external fixators provides stability and aids in soft tissue healing.

Surgical Procedures

Stage 1: Focuses on stabilizing the soft tissue and may include debridement and external fixation of the tibial plafond fracture.
Stage 2: Definitive surgical management aims to restore the articular surface with stable fixation.

Post-Operative Care

Well-padded splinting is maintained in a neutral position for 2–3 weeks.
Gradual physical therapy and progressive weight-bearing are initiated after approximately 12 weeks.

Outcomes

Functional outcomes are generally poor post-injury when compared to age-matched populations.
Increased incidence of post-traumatic arthritis over time and higher unemployment rates among previously employed patients following injury.

Calcaneal Fractures Overview

Calcaneal fractures represent 2% of all fractures, being the most frequently fractured tarsal bone.
Roughly 60% of tarsal fractures are calcaneal, with 75% being displaced intra-articular fractures.

Significance of Calcaneal Fractures

Serious and debilitating, often leading to long-term disability and chronic pain.
Common among male laborers aged 21-45, impacting workforce and economy.

Anatomy of the Calcaneus

Counteracts compressive forces during weight-bearing and serves as the lever arm for the triceps surae.
Contains key structures like the sustentaculum tali, important for ligament insertion and tendon function.
Four articulations with tarsal bones: anterior facet, middle facet, posterior facet (primary load-bearing).

Mechanism of Injury

Commonly caused by high-velocity motor vehicle accidents or falls from heights.
Intra-articular injuries often involve complex fracture patterns.

Imaging Techniques

Essential imaging includes X-rays (AP, lateral, and mortise views).
Böhler’s Angle and the critical angle of Gissane are critical for assessing fracture severity.
CT scans assist in classifying fracture types according to the Sanders classification.

Non-Operative Management

Focused on elevation, splinting, and immobilization.
Gait issues persist in 53% of patients at 20-year follow-up.

Operative Management

Indicated for specific fractures, such as displaced intra-articular ones.
Techniques include ORIF (Open Reduction Internal Fixation), percutaneous fixation, and external fixation.
Timing of surgery is critical; delay may be necessary for swelling reduction.

Surgery Goals

Achieve anatomic reduction, restore function, and enable immediate weight-bearing when possible.
Soft tissue preservation is crucial for better outcomes.

Rowe Classification

A classification system identifying various types of calcaneal fractures focuses on location and mechanism:
- Type I: Fractures of tubercle and sustentaculum.
- Type III: Common extra-articular fractures without subtalar joint involvement.
- Type V: Intra-articular fractures with joint depression.

Post-operative Protocol

Initial non-weight bearing for 2-3 weeks, followed by a gradual increase in mobility.
Emphasis on rehabilitation and monitoring for complications, such as stiffness.

Important Considerations

High risk of associated injuries.
Patient preferences for minimally invasive techniques may improve outcomes and recovery time.
The management protocol should adapt based on fracture type and surgical outcome.### Sustentaculum Fractures
Result from axial load and forced inversion of the hindfoot.
Classified as extraarticular fractures.
Often associated with medial facet incongruity in the subtalar joint and subtalar dislocations based on CT analysis.

Non-operative Treatment for Sustentaculum Fractures

Applicable for nondisplaced or minimally displaced fractures.
Involves immobilization in a fracture boot.
Early range-of-motion exercises are encouraged.
Nonweight-bearing is recommended for 10 to 12 weeks.

Operative Treatment for Sustentaculum Fractures

Recommended for fractures with more than 2 mm displacement.
Indicated for medial facet depression or extension into the posterior facet.

Anterior Process Fracture

Caused by forced inversion and plantar flexion, leading to an avulsion fracture.
Fracture line exits in the calcaneocuboid joint and typically affects a minimal portion of the articular surface.

Degan Classification of Anterior Process Fractures

Type I: Non-displaced, extra-articular.
Type II: Displaced, extra-articular.
Type III: Displaced, intra-articular.

Non-operative Treatment for Anterior Process Fractures

Suitable for smaller fragments with minimal intraarticular involvement.
Nondisplaced or minimally displaced fractures treated with a fracture boot and weight-bearing as tolerated.
Range-of-motion exercises begin once acute swelling decreases.

Operative Treatment for Anterior Process Fractures

Involves excision of fragments, particularly for painful nonunion.
Recommended for larger or displaced fragments as well as significant intraarticular involvement.
Critically indicated for fractures associated with unstable midfoot injuries.

Tuberosity Avulsion Fracture

Occurs due to violent pull from the gastrocnemius–soleus complex, often from forced ankle dorsiflexion.
Avulsed fragment varies in size and includes the entire Achilles tendon insertion.
Displacement poses risk to surrounding skin due to limited soft tissue coverage over the tuberosity.

Calcaneal Body Fracture

Comprises 20% of calcaneal fractures and are true extraarticular fractures with no subtalar joint involvement.
Injury mechanisms are similar to those in intraarticular fractures but involve lower energy, preventing extension into the posterior facet.

Complications of Calcaneal Fractures

Subtalar arthrosis resulting in decreased range of motion (ROM).
Risk of wound dehiscence which can lead to osteomyelitis.
Potential for loss of fixation and malalignment, causing subfibular impingement.

Salvage Procedures for Calcaneal Fractures

Common issue of subtalar arthrosis managed with options such as In Situ or distraction arthrodesis.
Wound dehiscence requires aggressive wound care protocols.
Osteomyelitis treated through aggressive debridement for effective management.

Calcaneal Fractures Overview

Calcaneal fractures represent 2% of all fractures, being the most frequently fractured tarsal bone.
Roughly 60% of tarsal fractures are calcaneal, with 75% being displaced intra-articular fractures.

Significance of Calcaneal Fractures

Serious and debilitating, often leading to long-term disability and chronic pain.
Common among male laborers aged 21-45, impacting workforce and economy.

Anatomy of the Calcaneus

Counteracts compressive forces during weight-bearing and serves as the lever arm for the triceps surae.
Contains key structures like the sustentaculum tali, important for ligament insertion and tendon function.
Four articulations with tarsal bones: anterior facet, middle facet, posterior facet (primary load-bearing).

Mechanism of Injury

Commonly caused by high-velocity motor vehicle accidents or falls from heights.
Intra-articular injuries often involve complex fracture patterns.

Imaging Techniques

Essential imaging includes X-rays (AP, lateral, and mortise views).
Böhler’s Angle and the critical angle of Gissane are critical for assessing fracture severity.
CT scans assist in classifying fracture types according to the Sanders classification.

Non-Operative Management

Focused on elevation, splinting, and immobilization.
Gait issues persist in 53% of patients at 20-year follow-up.

Operative Management

Indicated for specific fractures, such as displaced intra-articular ones.
Techniques include ORIF (Open Reduction Internal Fixation), percutaneous fixation, and external fixation.
Timing of surgery is critical; delay may be necessary for swelling reduction.

Surgery Goals

Achieve anatomic reduction, restore function, and enable immediate weight-bearing when possible.
Soft tissue preservation is crucial for better outcomes.

Rowe Classification

A classification system identifying various types of calcaneal fractures focuses on location and mechanism:
- Type I: Fractures of tubercle and sustentaculum.
- Type III: Common extra-articular fractures without subtalar joint involvement.
- Type V: Intra-articular fractures with joint depression.

Post-operative Protocol

Initial non-weight bearing for 2-3 weeks, followed by a gradual increase in mobility.
Emphasis on rehabilitation and monitoring for complications, such as stiffness.

Important Considerations

High risk of associated injuries.
Patient preferences for minimally invasive techniques may improve outcomes and recovery time.
The management protocol should adapt based on fracture type and surgical outcome.### Sustentaculum Fractures
Result from axial load and forced inversion of the hindfoot.
Classified as extraarticular fractures.
Often associated with medial facet incongruity in the subtalar joint and subtalar dislocations based on CT analysis.

Non-operative Treatment for Sustentaculum Fractures

Applicable for nondisplaced or minimally displaced fractures.
Involves immobilization in a fracture boot.
Early range-of-motion exercises are encouraged.
Nonweight-bearing is recommended for 10 to 12 weeks.

Operative Treatment for Sustentaculum Fractures

Recommended for fractures with more than 2 mm displacement.
Indicated for medial facet depression or extension into the posterior facet.

Anterior Process Fracture

Caused by forced inversion and plantar flexion, leading to an avulsion fracture.
Fracture line exits in the calcaneocuboid joint and typically affects a minimal portion of the articular surface.

Degan Classification of Anterior Process Fractures

Type I: Non-displaced, extra-articular.
Type II: Displaced, extra-articular.
Type III: Displaced, intra-articular.

Non-operative Treatment for Anterior Process Fractures

Suitable for smaller fragments with minimal intraarticular involvement.
Nondisplaced or minimally displaced fractures treated with a fracture boot and weight-bearing as tolerated.
Range-of-motion exercises begin once acute swelling decreases.

Operative Treatment for Anterior Process Fractures

Involves excision of fragments, particularly for painful nonunion.
Recommended for larger or displaced fragments as well as significant intraarticular involvement.
Critically indicated for fractures associated with unstable midfoot injuries.

Tuberosity Avulsion Fracture

Occurs due to violent pull from the gastrocnemius–soleus complex, often from forced ankle dorsiflexion.
Avulsed fragment varies in size and includes the entire Achilles tendon insertion.
Displacement poses risk to surrounding skin due to limited soft tissue coverage over the tuberosity.

Calcaneal Body Fracture

Comprises 20% of calcaneal fractures and are true extraarticular fractures with no subtalar joint involvement.
Injury mechanisms are similar to those in intraarticular fractures but involve lower energy, preventing extension into the posterior facet.

Complications of Calcaneal Fractures

Subtalar arthrosis resulting in decreased range of motion (ROM).
Risk of wound dehiscence which can lead to osteomyelitis.
Potential for loss of fixation and malalignment, causing subfibular impingement.

Salvage Procedures for Calcaneal Fractures

Common issue of subtalar arthrosis managed with options such as In Situ or distraction arthrodesis.
Wound dehiscence requires aggressive wound care protocols.
Osteomyelitis treated through aggressive debridement for effective management.

Objectives

Identify mechanisms of ankle fracture injuries and classification schemes.
Understand management principles for open reduction internal fixation (ORIF) of ankle fractures.
Recognize specifics of ankle fracture fixation devices.
Evaluate criteria for assessing ankle fracture internal fixation devices.

Anatomy - Osseous Structures

Ankle joint consists of three main osseous structures: tibia, fibula, and talus.
Functions as a hinge or ginglymus type synovial joint.
Allows complex triplane motion.

Anatomy - Ligamentous Structures

Medial Ligaments:
- Superficial Deltoid (posterior tibiotalar, tibionavicular, tibiocalcaneal)
- Deep Deltoid (anterior tibiotalar)
Lateral Ligaments:
- Anterior talofibular
- Posterior talofibular
- Calcaneofibular

Anatomy - Syndesmotic Ligaments

Four main components:
- Anterior inferior tibiofibular ligament (AITFL)
- Posterior inferior tibiofibular ligament (PITFL)
- Inferior transverse tibiofibular ligament
- Interosseous ligament

Ankle Fracture Classification Systems

Lauge-Hansen Classification: Based on foot position and direction of deforming forces with four main groups:
- Supination-Adduction
- Pronation-Abduction
- Supination-External Rotation
- Pronation-External Rotation
Danis-Weber Classification: Based on radiographic appearance of fibular fracture relative to syndesmosis, categorized into three types:
- Type A: Fracture distal to syndesmosis
- Type B: Fracture at the syndesmosis level
- Type C: Fracture above the syndesmosis

Lauge-Hansen Classification Details

Supination-Adduction:
- Stage 1: Transverse avulsion of distal fibula or lateral collateral ligament tear.
- Stage 2: Vertical medial malleolar fracture.
Pronation-Abduction:
- Stage 1: Transverse fracture of medial malleolus or deltoid ligament tear.
- Stage 2: Posterior malleolar fracture or AITFL/PITFL avulsion.
Supination-External Rotation:
- Stage 1: Injury/avulsion of AITFL.
- Stage 4: Fracture of medial malleolus or deltoid ligament.
Pronation-External Rotation:
- Stage 1: Transverse medial malleolar fracture.
- Stage 3: Oblique/spiral fracture of fibula above syndesmosis.

Danis-Weber Classification Specifics

Type A: Lateral malleolus fracture below the syndesmosis.
Type B: Lateral malleolus fracture at the syndesmosis.
Type C: Lateral malleolus fracture above the syndesmosis.

Named Ankle Fractures

Tillaux-Chaput: AITFL avulsion from anterolateral tibia.
Wagstaff: AITFL avulsion of anteromedial fibula.
Volkmann: PITFL avulsion from posterior lateral tibia.
Bosworth: PITFL avulsion from posterior medial fibula.
Maisonneuve: Proximal fibular fracture near fibular neck.

Objectives

Identify mechanisms of ankle fracture injuries and classification schemes.
Understand management principles for open reduction internal fixation (ORIF) of ankle fractures.
Recognize specifics of ankle fracture fixation devices.
Evaluate criteria for assessing ankle fracture internal fixation devices.

Anatomy - Osseous Structures

Ankle joint consists of three main osseous structures: tibia, fibula, and talus.
Functions as a hinge or ginglymus type synovial joint.
Allows complex triplane motion.

Anatomy - Ligamentous Structures

Medial Ligaments:
- Superficial Deltoid (posterior tibiotalar, tibionavicular, tibiocalcaneal)
- Deep Deltoid (anterior tibiotalar)
Lateral Ligaments:
- Anterior talofibular
- Posterior talofibular
- Calcaneofibular

Anatomy - Syndesmotic Ligaments

Four main components:
- Anterior inferior tibiofibular ligament (AITFL)
- Posterior inferior tibiofibular ligament (PITFL)
- Inferior transverse tibiofibular ligament
- Interosseous ligament

Ankle Fracture Classification Systems

Lauge-Hansen Classification: Based on foot position and direction of deforming forces with four main groups:
- Supination-Adduction
- Pronation-Abduction
- Supination-External Rotation
- Pronation-External Rotation
Danis-Weber Classification: Based on radiographic appearance of fibular fracture relative to syndesmosis, categorized into three types:
- Type A: Fracture distal to syndesmosis
- Type B: Fracture at the syndesmosis level
- Type C: Fracture above the syndesmosis

Lauge-Hansen Classification Details

Supination-Adduction:
- Stage 1: Transverse avulsion of distal fibula or lateral collateral ligament tear.
- Stage 2: Vertical medial malleolar fracture.
Pronation-Abduction:
- Stage 1: Transverse fracture of medial malleolus or deltoid ligament tear.
- Stage 2: Posterior malleolar fracture or AITFL/PITFL avulsion.
Supination-External Rotation:
- Stage 1: Injury/avulsion of AITFL.
- Stage 4: Fracture of medial malleolus or deltoid ligament.
Pronation-External Rotation:
- Stage 1: Transverse medial malleolar fracture.
- Stage 3: Oblique/spiral fracture of fibula above syndesmosis.

Danis-Weber Classification Specifics

Type A: Lateral malleolus fracture below the syndesmosis.
Type B: Lateral malleolus fracture at the syndesmosis.
Type C: Lateral malleolus fracture above the syndesmosis.

Named Ankle Fractures

Tillaux-Chaput: AITFL avulsion from anterolateral tibia.
Wagstaff: AITFL avulsion of anteromedial fibula.
Volkmann: PITFL avulsion from posterior lateral tibia.
Bosworth: PITFL avulsion from posterior medial fibula.
Maisonneuve: Proximal fibular fracture near fibular neck.

Objectives

Identify mechanisms of injury and classification schemes for ankle fractures.
Understand management principles for open reduction internal fixation (ORIF) of ankle fractures.
Recognize specific concepts and details of ankle fracture fixation devices.
Evaluate criteria for ankle fracture internal fixation devices.

Clinical Evaluation

Assess patient distress level, pain intensity, and perform airway, breathing, and circulation (ABC) checks.
Check gross limb appearance: look for foot positioning, significant deformity, open wounds, and swelling.
Evaluate vascular status through dorsalis pedis and posterior tibial pulse, skin temperature, and capillary refill time.
Neurological status: check sensation, baseline activity, and ability to move actively.
Conduct a musculoskeletal examination to determine stability, palpate for pain, and assess ankle ligament and syndesmosis integrity.

Radiographic Evaluation

Obtain three standard views: anteroposterior (AP), mortise, and lateral.
Assess medial clear space; widening > 4 mm indicates deltoid ligament injury and lateral translation of the talus.
Tibio-fibular overlap should be < 10 mm for proper syndesmotic integrity evaluation.
Talar tilt assesses lateral ankle instability; normal distance between lines is < 2 mm.
Evaluate fibular shortening with Shenton line and dime sign.

Ankle Fracture Evaluation

Investigate for additional injuries and neurovascular compromise.
Determine if the fracture is stable or unstable and classify it as open or closed.
Categorize cases as urgent/emergent or delayed treatment.

Closed Reduction vs Open Reduction with Internal Fixation

Closed Reduction:
- Advantages: lower infection and anesthesia complication risk, potentially less downtime.
- Disadvantages: risk of imperfect reduction, loss of correction, and cast complications.
Common techniques include Charnley and Quigly maneuvers; both involve manipulating the limb for anatomical alignment.

Open Reduction Internal Fixation (ORIF)

Advantages: allows for precise anatomical reduction, earlier weight bearing, and increased stability.
Disadvantages: requires soft tissue incision, risk of hardware complications, potential for infection, and loss of correction.

Bone Healing

Primary Bone Healing: involves anatomical reduction, rigid fixation, and no callus formation.
Secondary Bone Healing: involves stable reduction, significant callus formation, and endochondral healing.

Fracture Patterns

Focus treatment on fracture patterns rather than classification.
Types of fractures include transverse, vertical, spiral, and oblique.

Open Reduction Internal Fixation Techniques

Utilize various plate techniques including neutralization plates, bridge plates, and buttress plates to provide stability.
Medial malleolar fractures typically use cancellous screws, while tension band wire technique applies compression.

Post-Operative Course

Apply posterior splint, short leg cast, and maintain non-weight bearing for 6-8 weeks.
Transition to protected weight bearing with CAM boot; assess need for physical therapy.
Manage post-operative pain and consider DVT prophylaxis for 2-3 weeks.

Mechanisms and Management of Ankle Fractures

Ankle fractures classified based on mechanisms of injury and established classification schemes.
Open reduction internal fixation (ORIF) is the primary management approach for ankle fractures.
Understanding and evaluating fixation devices is critical for effective repair and stabilization.

Fracture Blisters

Fracture blisters typically develop 24-48 hours post-injury, often in high-energy trauma cases.
Two types of fracture blisters:
- Clear fluid-filled blisters, healing on average in 12 days.
- Hemorrhagic-filled blisters, healing around 16 days, indicating more serious soft tissue damage.
Surgical timing related to blister type remains unclear; surgery may be attempted prior to blister formation to minimize complications.
Blisters can be incised if necessary during surgical procedures.

Syndesmotic Injuries

Syndesmotic injuries lead to ankle joint instability and require careful evaluation using AP X-rays.
The "Cotton hook test" is performed post-fixation to assess syndesmosis stability.
If instability is present, fixation of the syndesmotic ligament is mandatory to restore ankle joint stability.

Syndesmotic Fixation Techniques

Screw Fixation:
- Utilizes fully threaded cortical screws, inserted in a posterior to anterior direction at approximately 30 degrees between fibula and tibia.
- Screws should not compress the syndesmosis, with their placement ~1.5-2 cm proximal to the ankle joint.
Suture Button Fixation:
- Involves synthetic sutures linking two metallic buttons, allowing for stable fixation while permitting dynamic motion similar to natural ligament behavior.

Challenges in Diabetic Ankle Fractures

Patients with diabetic ankle fractures face difficulties due to comorbid conditions and peripheral neuropathy affecting sensation and weight-bearing capacity.
Complications include wound healing issues and a heightened risk of Charcot neuroarthropathy, occurring with or without fixation.
Traditional fixation methods have evolved to include:
- Minimally invasive plate osteosynthesis (MIPO) to reduce tissue disruption.
- Super construct hardware that extends beyond the injury site for enhanced stabilization.
- Intramedullary nailing as a minimally invasive option.

Delta Frames in External Fixation

External fixation using delta frames stabilizes unstable or open ankle fractures and supports soft tissue integrity.
They maintain reduction and prevent equinus, remaining in place until swelling subsides before transitioning to traditional internal fixation methods.

Intramedullary Nail Fixation

Indicated for elderly patients and those with acute trauma or multiple injuries, particularly in cases of comorbid conditions like diabetes or peripheral vascular disease.
Benefits:
- Reduced wound complications due to less invasive insertion.
- Lower symptomatic metal reaction rates and shorter recovery times.
- Load-sharing mechanism minimizes stress shielding and allows earlier weight-bearing.

Case Study Overview

Case of a 53-year-old male presenting with a closed tri-malleolar ankle fracture following an unwitnessed fall.
Previous medical history includes intellectual disability, seizure disorder, and CHF among other issues, complicating traditional treatment compliance.
Initial treatment involved conservative management, with eventual plans for open reduction and internal fixation.
Following the potential need for revision surgery, an intramedullary nail was considered, emphasizing its role as a minimally invasive stabilization option for hindfoot injuries.

Midfoot Fractures Overview

Midfoot consists of bones located between Chopart’s and Lisfranc joint lines: Navicular, Cuneiforms, and Cuboid.
Midfoot fractures account for approximately 5% of all foot fractures.
Isolated midfoot fractures are rare; they usually occur with other injuries.

Evaluation and Diagnosis

Initial trauma evaluation includes neurovascular, dermatological, and musculoskeletal examinations.
Up to 30% of midfoot fractures may be missed on radiographs due to bony overlap.
CT scans are often necessary for accurate assessment of traumatic injuries.
MRI is useful for diagnosing stress fractures.

Treatment Approaches

Treatment depends on fracture characteristics: displacement, joint involvement, comminution, and column shortening.
Non-displaced fractures are typically managed conservatively (NWB SLC for 6-8 weeks).
Displaced or comminuted fractures often require surgical intervention (ORIF, external fixation, bridge plating).
Significant shortening of the medial or lateral column (>3 mm) necessitates surgical correction.

Mechanisms of Injury

Common injuries include avulsion fractures, body fractures, and fracture-dislocations resulting from high-energy trauma.
Injuries may occur from plantarflexed foot positions or direct trauma.

Navicular Fractures

Navicular fractures are the most common midfoot fractures, comprising 62% of midfoot injuries.
Four classification types include tuberosity, dorsal avulsion, body, and stress fractures.
Tuberosity fractures are the second most common (24% of navicular fractures) and typically result from eversion injuries.

Dorsal Lip Avulsion Fracture

Represents 47% of navicular fractures, caused by plantar flexion combined with inversion or eversion.
Treatment generally involves conservative management, but surgery may be warranted for significant symptomatic fragments.

Navicular Body Fractures

Account for 29% of navicular fractures. Can be classified as displaced or non-displaced.
Displaced fractures are categorized into three types based on fracture line orientation (transverse, oblique, comminuted).

Navicular Stress Fractures

Constitute up to 15% of pedal stress fractures in athletes.
More common in athletes engaged in track and field and basketball.
Often misdiagnosed; initial radiographs can be negative, leading to the necessity for advanced imaging.

Cuboid Fractures

Rarely occur in isolation and are often associated with medial column injuries.
Three fracture types: avulsion, simple body fractures, and compression (nutcracker fractures).
Treatment goals focus on restoring joint surfaces and lateral column length.

Cuneiform Fractures

Rarely isolated, typically part of a complex injury involving midtarsal and tarsometatarsal dislocations.
Treatment varies based on displacement and injury severity, with conservative management for non-displaced fractures.

General Treatment Principles

Non-displaced fractures generally treated conservatively (weight-bearing splinting).
Surgical options include closed reduction with percutaneous pinning, ORIF, or bridge plating for displaced fractures.

Conclusion

A comprehensive understanding of midfoot fracture mechanisms, evaluation, and treatment options is critical for optimal patient outcomes. Timely diagnosis and appropriate management are key to preventing long-term complications.

Overview of Lateral Ankle Injuries

Most prevalent injuries seen in primary care and emergency settings.
Approximately 2 million ankle sprains occur annually in the USA.
Ankle sprains can lead to substantial time off due to disability, with potential for chronic instability and pain.

Lateral Ankle Anatomy

Anterior Talofibular Ligament (ATFL)
- Most commonly injured ligament.
- Functions to prevent anterior translation of the talus; tight in plantarflexion and inversion.
Calcaneofibular Ligament (CFL)
- Second most commonly injured; resists ankle and subtalar inversion.
- Lies outside of the joint capsule, with peroneal tendons located above it.
Posterior Talofibular Ligament (PTFL)
- Strongest but least commonly injured; primarily involved in fractures or dislocations.
- Prevents posterior translation of the talus; tight in dorsiflexed inversion.

Syndesmosis Anatomy

Comprises various ligaments including:
- Anterior and Posterior Inferior Tibiofibular Ligaments (AITFL & PITFL).
- Transverse Tibiofibular Ligament and Interosseous Tibiofibular Ligament.
Injury typically occurs with forced dorsiflexion and eversion.

Deltoid Ligament

Contains superficial and deep structures, including the tibionavicular and posterior tibiotalar ligaments.
Complete ruptures are rare; usually associated with medial malleolus avulsion fractures.

Acute Ankle Sprains

Lateral ankle sprains account for up to 85% of all ankle sprains.
Syndesmotic sprains represent about 10% of lateral sprains, while deltoid sprains account for approximately 15%.

Classification of Sprains

Grade 1 (Mild)
- Stretching of ligaments with mild pain and no instability.
Grade 2 (Moderate)
- Partial tearing; moderate edema and some instability noted.
Grade 3 (Severe)
- Complete ligament tears; significant instability, pain, and inability to bear weight.

Ottawa Ankle Rules

Designed to reduce unnecessary radiographs, indicating:
- Pain on palpation of specific bony structures necessitates imaging.
- Inability to bear weight also indicates the need for radiographic evaluation.

Physical Examination Protocol

Involves a thorough proximal to distal evaluation to assess for fractures and ligament injuries.
Key examinations include palpation of various ligaments and performing specific tests like the anterior drawer and talar tilt for stability assessment.

Radiographic Evaluation

Common imaging views include Mortise and AP Views to assess the integrity of involved ligaments.
Medial clear space >6mm or tibiofibular overlap <10mm suggest possible ruptures.

Treatment Approaches

Initial management employs PRICE (Protection, Rest, Ice, Compression, Elevation).
Conservative treatment successful in 90% of cases; severe syndesmotic injuries may require surgical intervention.
Ligament healing can take 6 weeks to 3 months, depending on injury severity.

Conclusion

Knowledge of lateral anatomy, biomechanics, and appropriate clinical evaluation is crucial for effective management of ankle injuries, with various treatment options tailored to the severity of the injury.### Treatment of Acute Lateral Ankle Sprains
PRICEMMMS protocol includes Protection, Rest, Ice, Compression, Elevation, and Medications such as NSAIDs to alleviate pain and swelling.
Modalities like electrical stimulation, ultrasound, and contrast baths can aid recovery.
Mobilization strategies are debated; some suggest active dorsiflexion and plantarflexion on the day of injury to reduce edema.
Close-packed position maximizes joint contact and stability, recommended for 3 weeks, followed by physical therapy.
Grade III syndesmotic injuries require surgical reduction and stabilization; immobilization followed by therapy is contraindicated.

Chronic Ankle Instability

Acute sprains can progress to chronic instability primarily due to biomechanical causes like pathologic laxity and anatomic variances such as rearfoot varus and forefoot valgus.
Functional causes include proprioceptive abnormalities, neuromuscular control loss, and strength deficits.
Treatment options include neuromuscular training and bracing for conservative management, while surgical options involve direct repairs like the Brostrom procedure.

Peroneal Tendon Anatomy

Peroneal tendons reside in the lateral compartment, held by the superior peroneal retinaculum, with a common sheath that splits at the peroneal tubercle.
The peroneus brevis tendon inserts at the 5th metatarsal known as the styloid process, while the peroneus longus wraps around the cuboid to insert at the base of the 1st metatarsal cuneiform joint.
The os peroneum is a variant sesamoid bone located within the peroneus longus tendon.

Peroneal Tendon Pathology

Issues can arise following acute sprains and are often associated with low-lying muscle bellies, peroneus quartus presence, or hypertrophic peroneal tubercles.
Physical examination reveals pain on palpation, strength testing of eversion, and potential clicking/popping during ankle circumduction.
Imaging techniques include radiographs for fractures and MRI for tenosynovitis and tendon tears.

Treatment Strategies

Conservative care comprises immobilization, NSAIDs, and localized treatment options like valgus wedges.
Surgical interventions may include tenosynovectomy, tendon repair, or excision procedures to address specific conditions of the peroneal tendons and retinaculum.
Always assess for biomechanical contributors, adjusting surgical approaches if necessary.

Case Study Insights

A young female with a recent ankle sprain exhibits significant pain, swelling, and limitations in range of motion on examination.
Key assessments include vascular, dermatological, neurological, and musculoskeletal evaluations, determining the need for imaging or surgical intervention based on findings.

Learning Objectives

Understand lateral ankle anatomy and its functions.
Recognize biomechanical factors and anatomical variations related to lateral ankle pathology.
Conduct clinical evaluations for ankle instability.
Identify radiographic findings associated with lateral ankle injuries.
Explore various treatment options for acute and chronic lateral ankle injuries.

Ankle Injuries

Ankle injuries are prevalent, with approximately 2 million sprains occurring annually in the USA.
Ankle sprains can lead to considerable time loss due to disability.
Chronic ankle instability can develop from repeated sprains, leading to joint degeneration and persistent pain.

Anatomy: Lateral Ankle Ligaments

Anterior Talofibular Ligament (ATFL)
- Most frequently injured ligament; serves as the primary stabilizer.
- Tightens in plantarflexed inversion; prevents anterior translation of the talus.
Calcaneofibular Ligament (CFL)
- Second most commonly injured ligament; resists inversion at the ankle and subtalar joints.
- Lies superficial to peroneal tendons and is tight during dorsiflexed inversion.
Posterior Talofibular Ligament (PTFL)
- Strongest and least frequently injured ligament, often injured in fractures or dislocations.
- Tightens in dorsiflexed inversion; prevents posterior translation of the talus.

Anatomy: Syndesmosis

Distal Tibiofibular Ligament Complex
- Includes the Anterior and Posterior Inferior Tibiofibular Ligaments and Interosseous Membrane.
- Injuries can occur due to forced dorsiflexion and eversion.

Anatomy: Deltoid Ligament

Comprises superficial structures (tibionavicular, tibiocalcaneal, superficial posterior tibiotalar) and deep structures (anterior and deep posterior tibiotalar).
Complete ruptures are rare, often associated with medial malleolus avulsion fractures.

Acute Ankle Sprains

Lateral ankle sprains make up about 85% of all sprains.
Syndesmotic sprains account for approximately 10% of lateral sprains.
Deltoid sprains represent about 15% of ankle injuries.

Classification of Acute Ankle Sprains

Grade 1 (Mild)
- Ligament stretching, mild edema, no instability or loss of function.
Grade 2 (Moderate)
- Incomplete ligament tearing, moderate edema, mild instability, and some loss of function.
Grade 3 (Severe)
- Complete ligament tearing, significant swelling and instability, inability to bear weight.

Ottawa Ankle Rules

Utilized to guide the need for radiographs in ankle injuries.
Focus on specific palpation areas: posterior fibula, posterior tibia, base of the 5th metatarsal, and navicular.
A palpable pain or inability to bear weight mandates X-rays.

Clinical Examination

Conduct a structured 15-step exam from proximal to distal.
Include palpation of relevant anatomical structures and special tests for ligaments.

Diagnosis and Imaging

Diagnosis relies on physical examination results.
Radiographs and possibly MRI may be required for suspected fractures or ligamentous injuries.

Treatment for Acute Ankle Sprains

Initial treatment involves the PRICE protocol: Protection, Rest, Ice, Compression, and Elevation.
Conservative treatments are effective for up to 90% of cases, with recovery times between 6 weeks to 3 months.

Advanced Management

Functional rehabilitation is generally ineffective for grade 3 syndesmotic injuries, which often require surgical intervention for stabilization.### Treatment of Acute Lateral Ankle Sprains
PRICEMMMS approach includes Protection, Rest, Ice, Compression, Elevation, Medications (NSAIDs for pain and swelling), Modalities (e.g., electrical stimulation, ultrasound), and Mobilization (active movements advised to reduce edema).
Early mobilization, often recommended, may be avoided in certain cases, especially with plantarflexion concerns for the ATFL.
Close-packed position maximizes joint stability, with the foot at 90 degrees for dorsiflexion, while open-packed position leads to increased instability.
Grade III syndesmotic injuries necessitate surgical intervention for stabilization; conservative management is contraindicated.

Chronic Ankle Instability

Acute ankle injuries can lead to chronic instability characterized by biomechanical causes such as pathologic laxity and connective tissue disorders.
Anatomic variances like rearfoot varus and forefoot valgus may contribute to chronic instability.
Functional causes include proprioceptive abnormalities, neuromuscular control loss, and strength deficits.

Treatment of Chronic Ankle Instability

Conservative treatment includes neuromuscular training (e.g., wobble board and single-leg exercises) and taping/bracing to enhance stability.
Surgical options encompass direct repair techniques like the Brostrom procedure, which enhances strength by approximately 60%.
Indirect repairs include several historical techniques (e.g., Watson-Jones, Evans, and Chrisman-Snook) focusing on different methods of ligamentous reattachment.

Peroneal Tendon Anatomy and Pathology

Peroneal tendons (longus and brevis) are positioned in the lateral compartment and share a common sheath before reaching the calcaneus.
Common pathologies arise after ankle sprains, including tendinitis, tears, and dislocations, often associated with anatomical anomalies like low-lying musculature or hypertrophic structures.
Clinical examinations emphasize pain locations, muscle strength, and stability assessments, including anterior drawer and talar tilt tests.

Imaging and Surgical Treatment for Peroneal Pathologies

Radiographs may detect abnormalities like os peroneum or fibular fractures, while MRI is the primary tool for diagnosing tenosynovitis or tendon tears.
Conservative management entails immobilization, NSAIDs, and therapeutic wedges.
Surgical interventions can include tenosynovectomy, tendon repair, and addressing any anatomical variances contributing to instability.

Case Study Overview

A 23-year-old female with a recent ankle sprain displayed significant pain and limited mobility, indicating an acute injury.
Musculoskeletal examinations highlighted tenderness in the ATFL area with a positive anterior drawer test suggesting potential instability.
Treatment plans revolve around conservative measures initially, with careful monitoring to assess recovery and the likelihood of a positive outcome.

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This quiz focuses on the classification of ankle fractures, particularly the Lauge-Hansen system. Participants will learn about the key patterns of injury and the mechanics involved in different types of fractures. Ideal for podiatric health professionals, this assessment ensures a comprehensive understanding of fracture classifications.

Fracture Classification Review DPM 2026

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Questions and Answers

Which of the following are main patterns of injury in Lauge-Hansen classification?

What is the first word in Lauge-Hansen classification?

What type of fracture occurs at stage 1 of the Supination-adduction pattern?

The Danis-Weber classification indicates that 'A' corresponds to fibular fracture at the ankle level.

What type of injury is classified as SH II?

What does the Rowe classification primarily deal with?

What type of fracture does Sanders Type II refer to?

What is the Hawkins 3 classification associated with?

SH V refers to __________.

What are the four types categorized under Sanders classification?

In the Watson-Jones classification, what type of fracture is indicated as 'II'?

What does the first word in the Lauge-Hansen classification refer to?

Which of the following is NOT a pattern of injury in Lauge-Hansen classification?

What is the first stage of a supination-adduction fracture?

What are the stages of a Pilon fracture according to Ruedi/Allgower classification?

In the Danis-Weber classification, what does type C represent?

What does the Sanders classification primarily assess?

The Hawkins classification is used for talar neck fractures.

Describe a Type II fracture in the Berndt & Harty classification.

What is the primary feature of a Type 1 fracture in the Stewart classification?

Which of the following classifications includes a Type B2?

What does the first word in Lauge-Hansen classification indicate?

Which stage involves a rupture of the lateral collateral ligaments in Supination-Adduction injuries?

In Pronation-Abduction injuries, what occurs during Stage 1?

What type of fracture involves a deltoid ligament rupture and a transverse fracture of the medial malleolus in Pronation-External Rotation?

In Danis-Weber classification, what does Type A signify?

What is the prognosis for Stage I of Ruedi/Allgower pilon fractures?

What does the Hawkins classification predict?

Stage II of Sanders classification includes two-part fractures of the posterior facet.

Match the following Hawkins classifications with their descriptions:

What type of fracture does the Watson-Jones classification categorize?

What does the Stewart classification relate to?

Which type of open fracture has minimal soft tissue damage?

What is the primary mechanism of injury (MOI) for a talar head fracture?

Stage 4 of Hawkins classification indicates the best prognosis.

What does 'Nutcracker sign' indicate in relation to Shepherd's fracture?

What does the term 'AVN' stand for?

What type of fracture classification is the Sanders classification used for?

What type of fracture occurs in the medial or lateral tubercle due to a fall with the heel inverted or everted?

What is the prognosis for a Stage 1 Berndt and Harty fracture?

In terms of severity, which Navicular fracture has the highest likelihood of occurring due to the watershed area?

Wagstaff fracture is an AITFL avulsion of the anteromedial fibula.

Which type of open fracture is characterized by clean puncture and little soft tissue damage?

What is the mechanism of injury (MOI) for a talar neck fracture?

Match the following classifications to their corresponding fractures:

In the Hawkins classification, Stage 4 indicates surgical treatment due to AVN being greater than 91%.

What does the 'piano key test' indicate?

What is a common treatment approach for Lisfranc Grade 1 injuries?

A ______ fracture of the calcaneal tubercle is classified as Rowe 1a.

The Sanders classification only contains Type 1 fractures with no displacement.

What is the MOI for a Shepherd's fracture?

What injury type is associated with a Tillaux-Chaput fracture?

Which navicular fracture type involves the dorsal lip?

What is acute compartment syndrome (ACS)?

What are some potential causes of acute compartment syndrome?

Acute compartment syndrome is caused solely by crushing injuries.

Match the following compartments with their locations in the lower leg:

The classic signs of acute compartment syndrome are known as the ___ P's.

What is the significance of intra-compartmental pressure measurement in diagnosing ACS?

Which surgical technique is recommended for addressing compartment syndrome?

What is Volkmann's contracture?

Delayed treatment of acute compartment syndrome can lead to permanent damage.

What is the best course of action for a patient with a calcaneal fracture and suspected compartment syndrome with an intra-compartment pressure reading of 40 mmHg?

Which pedal compartment was not released, leading to unilateral claw toe deformity and numbness of the lateral foot in a patient post-fasciotomy?

How many compartments are there in the foot?

What are the '6 P's associated with acute compartment syndrome?

What complications are associated with acute compartment syndrome?

How many compartments are in the foot?

How many compartments are in the leg?

What is the best course of action for a patient with a calcaneal fracture and suspected compartment syndrome with a pressure reading of 40 mmHg?

Which pedal compartment was not released if a patient presents with a unilateral claw toe deformity after a fasciotomy?

ACR is associated with the clinical symptoms known as the '6 P's', which include _____ and _____?

True or False: The absolute pressure in an compartment reading of 30 mmHg is an indication for an emergency fasciotomy.

What is acute compartment syndrome (ACS)?

Which of the following are potential causes of acute compartment syndrome?

What is the historical significance of Dr. Richard Von Volkmann in relation to ACS?

ACR is associated with the clinical symptoms known as the '6 P's', which include _ and _?