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CHAPTER 58 Ankle and Foot
Riyad B. Abu-Laban and Nicholas G.W. Rose
To him whose feet hurt, everything hurts.
Socrates
The ankle and foot are highly evolved structures designed to
support the body’s weight and to facilitate locomotion over varied
terrain. Findings related to ankle and foot injuries are often subtle,
and diagnoses may be delayed or missed, particularly in cases of
multiple trauma.
The ankle and foot are best approached clinically as a single
functional unit. Although they are discussed sequentially in this
chapter, mechanisms of injury overlap, and a pathologic condition
in one location may accompany an associated pathologic condition in another.
ANKLE
PRINCIPLES OF DISEASE
Anatomy
The ankle joint is the articulation of the tibia and fibula with the
talus. The dome of the talus fits into the “mortise” formed by
the medial malleolus, the horizontal articular surface of the tibia
(the plafond), and the lateral malleolus. The stability of the ankle
depends on the bony and ligamentous integrity of the mortise.
The calcaneus is also important to the motion and stability of
the ankle.
The ankle is composed of three primary articulations: the inner
surface of the medial malleolus with the medial surface of the
talus, the distal tibial plafond with the talar dome, and the medial
surface of the lateral malleolus with the lateral process of the talus.
These three articular surfaces are contiguous, lined with cartilage,
and enclosed by a single joint capsule. The distal tibia also articulates with the distal fibula just proximal to the talus, forming the
distal tibiofibular joint. Collectively, these articulations are called
the talocrural joints.
Three sets of ligaments—the syndesmotic ligaments, the
lateral collateral ligaments, and the medial collateral ligaments—
support the ankle joint and are essential to its stability (Figs. 58-1
and 58-2).
Tendons course through the ankle in four geographic groups.
The flexor retinaculum tethers the tendons of the tibialis posterior, the flexor digitorum longus, and the flexor hallucis muscles
behind the medial malleolus. The peroneal retinaculum and
tendon sheath tether the peroneus longus and brevis tendons
behind the lateral malleolus. The extensor retinaculum tethers
the tendons of the tibialis anterior, extensor digitorum longus,
extensor hallucis longus, and peroneus tertius over the anterior
aspect of the ankle. Posteriorly, in the midline, lie the Achilles
and plantaris tendons.
Pathophysiology
Ankle movements are complex and often involve more than one
joint. It is best to consider the group of joints about the ankle as
one unit, the ankle joint complex. This complex, which is made
up of the talocrural joints and the talocalcaneal (subtalar) joints,
allows movements along several axes of motion.1 Dorsiflexion and
plantar flexion of the ankle joint complex occur primarily at the
talocrural joints, rotating about the horizontal axis that passes
through the medial and lateral malleoli (Fig. 58-3; see also Fig.
58-5). Motions of the ankle joint complex in conjunction with the
midtarsal joints include inversion and eversion, which are rotational movements about the oblique subtalar axis involving the
subtalar joint (see Fig. 58-3A), and abduction (external rotation)
and adduction (internal rotation), which are rotational movements about the longitudinal axis of the tibia (see Fig. 58-3B).
The components providing stability to the ankle are best conceptualized as a ringlike structure surrounding the talus2 (Fig.
58-4). Disruption of one element of this ring does not, by itself,
induce instability. Injury to one ring element, however, should
prompt careful scrutiny for a second injury. Any disruption of two
or more elements causes ankle instability and can significantly
affect joint function.2
Clinical Features
The presence of immediate swelling and severe pain in the ankle
region suggests serious ligament disruption, hemarthrosis, or fracture, and rapid progression of symptoms may represent more
severe injury. Inability to bear weight immediately after an injury
often implies a significant pathologic condition.3 Patient recollection of a “pop” sound should prompt consideration of ligament,
tendon, or retinacular rupture but does not necessarily increase
the probability of a fracture. Finally, the inciting event causing the
ankle injury should be determined and, when necessary, further
investigated.
Patients with a subacute or chronic ankle problem may be
unable to correlate symptom onset with a particular traumatic
event. Inquiry should elicit the type and extent of physical activities and whether the ankle “gave way.” In elderly patients ankle
injuries or fractures may manifest as subacute problems reflecting
either misdiagnosis of a serious condition as a simple sprain or
neglect by the patient or caregiver.
723
724 PART II ◆ Trauma / Section Three • Orthopedic Lesions
Interosseous
(syndesmotic)
ligament
Posterior
tibiofibular
ligament
Calcaneofibular
ligament
Anterior inferior
tibiofibular ligament
Posterior
tibiotalar part
Anterior
tibiotalar part
Anterior talofibular
ligament
Tibiocalcaneal
part
Tibionavicular
part
Lateral talocalcaneal
ligament
Figure 58-1. Anatomy of the lateral collateral and the syndesmotic
ligaments of the ankle. (From Nicholas JA, Hershman EB [eds]: The
Lower Extremity and Spine in Sports Medicine, 2nd ed. St Louis, Mosby,
1994.)
Figure 58-2. Anatomy of the medial collateral ligaments of the ankle.
(Adapted from Nicholas JA, Hershman EB [eds]: The Lower Extremity
and Spine in Sports Medicine, 2nd ed. St Louis, Mosby, 1994.)
x axis
w axis
Dorsi flexors
Evertors
lar
bta
Su
Invertors
Inversion
x axis
s
axi
Lateral
z axis
Plantarflexion
Dorsiflexion
z axis
Medial
Eversion
y axis
A
Plantar flexors
B
Figure 58-3. Four axes of the ankle joint complex. A, The horizontal axis passing through the two malleoli (z axis); the longitudinal axis of the
foot (x axis); the oblique subtalar axis (w axis). B, The longitudinal axis of the tibia (y axis) and two additional views of the x and z axes. (A, From
the American Academy of Orthopedic Surgeons: Atlas of Orthotics. St Louis, Mosby, 1975. B, Adapted from the Department of Orthopedics, Mayo
Clinic and Mayo Foundation, Rochester, Minn. Reproduced in Stormont DM, Morrey BF, An KN, Cass JR: Am J Sports Med 13:295, 1985.)
Chapter 58 / Ankle and Foot 725
suspicion of a fracture is low, the location of tenderness does not
indicate the need for plain radiography, or radiographs have ruled
out a fracture.3 Specific clinical examination tests are discussed
elsewhere in the appropriate sections.
Physical Examination
The examination of the ankle starts with an assessment of deformity, ecchymosis, edema, and perfusion, followed by active and
passive range of motion. Assessment of point tenderness may
localize ligament, bone, or tendon injuries, particularly when the
patient is seen early. Palpation should include the medial and
lateral collateral ligaments, the syndesmotic ligaments, the inferior
and posterior edges of the medial and lateral malleoli, the entire
length of the fibula and tibia, the anterior plafond, the medial and
lateral dome of the talus (palpable with the ankle in plantar
flexion), the base of the fifth metatarsal, the calcaneus, the Achilles
tendon, and the peroneal tendons behind the lateral malleolus.
Stress testing of the ankle joint, which is discussed later, should
not be performed until a fracture has been excluded. An evaluation of weight-bearing ability should proceed only if clinical
DIAGNOSTIC STRATEGIES
Radiology
The anteroposterior, lateral, and mortise views make up the standard three-view radiographic series of the ankle. Although twoview ankle series have been studied, the likelihood of missing
a subtle fracture is reduced with three views.4 Subtle fractures
can be easily missed on ankle radiographs,5 and a standardized
approach to radiograph interpretation can reduce the likelihood
of missing low-energy ankle fractures6 (Fig. 58-5). The anter­
oposterior view identifies fractures of the medial and lateral malleoli, anterior tibial tubercle, distal tibia or fibula, talar dome, body
and lateral and posterior process of the talus, and calcaneus. The
lateral view identifies fractures of the anterior and posterior tibial
margins, talar neck, posterior talar process, calcaneus, and any
anterior or posterior displacement of the talus or pathology
involving the talonavicular joint. On this view, any incongruity of
the articular space between the talar dome and the distal tibia
suggests ankle instability, particularly if narrowing of the anterior
joint space is present. The lateral view is also useful in identifying
an ankle effusion, which appears as a teardrop-shaped density
displacing the normal fat adjacent to the anterior or posterior
margin of the joint capsule. The presence of an effusion suggests
the possibility of a subtle intra-articular injury, such as an osteochondral lesion of the talar dome.7
The mortise view, which is taken with the ankle in 15 to 25
degrees of internal rotation, is most important for evaluating
the congruity of the articular surface between the dome of the
talus and the mortise. The lines formed between the articular
surfaces should be parallel, the joint space should appear uniform
throughout the tibiotalar and talofibular components of the
joint, and the medial clear space should not exceed 4  mm8
(Fig. 58-6).
In most cases of isolated blunt ankle trauma evaluated within
48 hours of injury, the Ottawa Ankle Rules (OAR) should be used
Figure 58-4. The ring structure surrounding the talus is made up
of the tibial plafond, medial malleolus, deltoid ligaments, calcaneus,
lateral collateral ligaments, and syndesmotic ligaments. The integrity of this ring determines the stability of the ankle. (From Simon RR,
Koenigsknecht SJ: Emergency Orthopedics: The Extremities, 2nd ed.
Norwalk, Conn, Appleton & Lange, 1987.)
4
1
3
2
7
1
2
5
8
6
9
11
A
10
B
C
Figure 58-5. Approach to reviewing ankle radiographs. A to C, A standard radiographic series of the ankle has three views: an anteroposterior
view (A), an internal rotation or mortise view (B), and a lateral view (C). The following 11 locations should be carefully scrutinized, as they are
areas where fractures frequently occur: the medial (1) and lateral (2) malleoli, anterior tibial tubercle (3) and posterior tibial malleolus (4), talar
dome (5), lateral talar process (6), tubercles of the posterior talus process (7), dorsal to the talonavicular joint (8), anterior calcaneus process
(9), calcaneal insertion of the extensor digitorum brevis (10), and the base of the fifth metatarsal bone (11). (From Yu JS, Cody ME: A template
approach for detecting fractures in adults sustaining low-energy ankle trauma. Emerg Radiol 16:309, 2009.)
726 PART II ◆ Trauma / Section Three • Orthopedic Lesions
Mortise view
≤4 mm
Talocrural angle
(83° ± 4°)
Medial clear space
(≤4 mm)
Talar tilt
(≤2 mm)
Anteroposterior view
A
B
C
B
A
A = Lateral border of
posterior tibial malleolus
B = Medial border of fibula
C = Lateral border of anterior
tibial tubercle
B
B
C
Syndesmosis A
(<5 mm)
Syndesmosis B
(≥10 mm)
Talar
subluxation
Figure 58-6. Radiologic criteria for evaluating the syndesmosis. (From Stiehl JB: Ankle fractures with diasthesis. Instr Course Lect 39[III]:79, 1990.)
to determine whether ankle or foot radiographs are necessary.3,9
The OAR state that an ankle radiographic series is required if
there is pain in the malleolar region with any of the following
findings:
• Bone tenderness at the posterior edge of the distal 6 cm or
the tip of the lateral malleolus, or
• Bone tenderness at the posterior edge of the distal 6 cm or
the tip of the medial malleolus, or
• Inability to bear weight (defined as the ability to transfer
weight onto each leg regardless of limping) for at least four
steps both immediately after the injury and at the time of
evaluation
The OAR further state that a foot radiographic series is required
if there is pain in the midfoot region with any of the following
findings:
• Bone tenderness at the navicular bone, or
• Bone tenderness at the base of the fifth metatarsal, or
• Inability to bear weight for at least four steps both
immediately after the injury and at the time of evaluation
The OAR have a sensitivity approaching 100% in detecting malleolar zone ankle fractures and midfoot zone fractures.3,9 The OAR
were derived in an adult population and are not applicable in
subacute or chronic injuries. The OAR appear to perform well in
pediatric patients older than 5 years; however, results have varied,
leading some researchers to propose alternative rules to address
the unique aspects of this population.10-18
The decision rules for foot radiography, although applicable to
blunt ankle trauma, apply only to the midfoot zone. The OAR
were not designed to be general guidelines for foot radiography
and certainly do not apply to the hindfoot or forefoot. Finally, the
OAR are not applicable to intoxicated patients or those who are
difficult to assess because of head injuries, multiple injuries, or
diminished sensation related to neurologic deficits. Use of the
OAR by specialized emergency and triage nurses has been found
to have efficacy in application comparable to that for use by
physicians.19-21 Although the OAR are well validated, their adoption and clinical impact remains variable.22,23
Other Imaging Techniques
Although plain radiography is the initial imaging modality of
choice for ankle injuries, it can miss subtle ankle fractures, osteochondral lesions, stress fractures, or ligamentous injuries. When
unexplained symptoms persist after negative or inconclusive findings on plain radiography, other imaging modalities or orthopedic
consultation may be advisable.24
Radionuclide imaging (bone scanning) can detect soft tissue
injuries, such as distal syndesmotic disruptions, stress fractures,
and osteochondral lesions.25 Bone scan abnormalities are present
once a patient is symptomatic and typically appear 1 to 2 weeks
before radiographic evidence of a stress fracture. Because of its
high sensitivity, a negative bone scan effectively rules out the
diagnosis. Bone scan abnormalities are nonspecific, however,
because infections and tumors also can lead to positive results
(see further discussion on stress fracture imaging in the “Foot”
section of this chapter), and bone scanning is not useful for
follow-up because abnormalities can persist for up to 1 year after
recovery.25 Radionuclide imaging is virtually always ordered on
an outpatient basis and has been largely supplanted by computed
tomography (CT) and magnetic resonance imaging (MRI). CT
scanning provides superior bone imaging and is an excellent
modality to delineate abnormalities not identified or incompletely characterized by other imaging techniques.24,25 CT can
detect small fractures, subtle stress fractures, and ligamentous
injuries and can facilitate surgical planning.24,25 Newer CT image
reformatting techniques can be extremely helpful, including
two-dimensional multiplanar reformatting to identify small fractures, three-dimensional volume rendering to show relationships
Chapter 58 / Ankle and Foot 727
General
Ankle
Figure 58-7. The mechanics of bone failure in tension and types of
A
B
tension ankle fractures. Arrows indicate the direction of distracting
forces. (From Dahners LE: The pathogenesis and treatment of
bimalleolar ankle fractures. Instr Course Lect 39[III]:85, 1990.)
between tendons and underlying bones, and shaded surface
display to provide disarticulated views of joint surfaces and
enhance diagnostic accuracy.26,27 MRI, although not typically performed emergently, provides unprecedented clarity in depicting
soft tissue structures such as ligaments and tendons and can also
delineate bone marrow changes associated with stress fractures
before radiographic abnormalities appear.25 MRI can be helpful
both in guiding management decisions and in following the
patient’s response to therapy.28
Additional imaging techniques such as magnetic resonance or
CT arthrography can be useful in the evaluation of chronic ankle
pain to detect loose bodies, ligamentous injuries, cartilaginous
abnormalities, impingements, or osteochondral lesions.29 CT/
SPECT, which combines CT and radionuclide scanning with
single photon emission computed tomography (SPECT), has been
shown to significantly increase the diagnostic ability of imaging
in osteochondral lesions, stress fractures, impingement syndromes, and osteomyelitis.30 The decision to perform specialized
imaging of this nature is typically made through orthopedic or
radiologic consultation; such studies are not performed in the
emergency department (ED).
SPECIFIC PATHOLOGIC
CONDITIONS
Ankle Fractures
Pathophysiology
Fractures occur when a deforming force is sufficient to overcome
the structural strength of a bone. A bone under tension breaks
transversely along the axis of the deforming force31 (Fig. 58-7).
Alternatively, ligamentous rupture or an avulsion fracture can
occur at either end of a stressed ligament or tendon.
Management
The management of ankle fractures consists of identification and
classification, assessment of stability, immediate reduction of
fracture-dislocations that threaten soft tissues or neurovascular
status, and specific treatment and disposition.
To date, no ideal system has been developed for the classification of ankle fractures. The classic Danis-Weber (Fig. 58-8) and
Lauge-Hansen classification systems are based on fracture location and mechanism of injury, respectively.32 The Danis-Weber
C
Figure 58-8. The Danis-Weber classification of ankle fractures focuses
on the location of the fibular fracture in relation to the tibiotalar joint
and syndesmosis. See text for explanation. (From Wilson FC: The
pathogenesis and treatment of ankle fractures: Classification. Instr
Course Lect 39[III]:79, 1990.)
classification has predictive value for operative repair in isolated
lateral malleolar fractures, as the location of the fibular fracture is
related to the integrity of the syndesmosis, and is thus more useful
to emergency physicians than the more complex Lauge-Hansen
classification. Both systems have limitations, however, and neither
accurately predicts management or clinical outcome in all situations. The Danis-Weber system does not adequately classify
isolated medial malleolar fractures, bimalleolar, trimalleolar, or
pilon fractures.33 By contrast, the Lauge-Hansen classification was
intended to characterize ligamentous injury patterns based on
the radiographic appearance of ankle fractures.34 According to a
recent MRI study of 49 ankle fractures, however, this system was
unable to predict patterns of ligamentous injuries in 53% of cases,
and 17% of cases were unclassifiable.35 This study also found that
more than 65% of cases had a complete ligamentous disruption
associated with a related malleolar fracture, calling into question
the stability of the fractures. It is clear that the Lauge-Hansen
system in isolation is inadequate for classifying all fractures and
has particular limitations in predicting soft tissue injuries. Modifications to these two classification schemes have been proposed
to better describe ankle fractures and, more important, to predict
outcome; however, because of their complex nature, most modified classification schemes are relegated to research applications
and trauma registries.33-35
728 PART II ◆ Trauma / Section Three • Orthopedic Lesions
The injured ankle should be promptly immobilized, elevated,
and iced to minimize swelling and further soft tissue damage. The
presence of gross deformity with neurovascular compromise or
skin tenting necessitates immediate intervention.36,37 Plain radiography before reduction can be helpful but should not delay reduction in injuries with obvious vascular compromise.
Appropriate procedural sedation and analgesia techniques
should be used for reduction. The fundamental principle of closed
reduction is to reverse the deforming forces. For example, reduction of a fracture-dislocation caused by an adduction injury would
require an abduction force. The initial application of a distracting
force, sometimes combined with slightly increasing the deformity,
is often helpful in achieving reduction. After reduction, neurovascular status should be reassessed, the leg should be immobilized
and elevated, and postreduction radiographs should be obtained.
The overarching goal in the definitive treatment of ankle fractures
is to achieve anatomic reduction.
Disposition
In general, all displaced or potentially unstable ankle fractures
require orthopedic consultation in the ED (Box 58-1). These injuries include all bimalleolar and trimalleolar fractures and unimalleolar fractures with contralateral ligamentous injuries (e.g., a
lateral malleolar fracture with deltoid ligament disruption or a
medial malleolar fracture with lateral collateral ligament disruption).38 In addition, all intra-articular fractures, especially those
with step deformity of the articular surface, require early orthopedic involvement.
Extra-articular fractures that disrupt only one ring element
generally can be treated with casting for 6 to 8 weeks. Orthopedic
follow-up on an outpatient basis within 1 to 2 weeks of the injury
is ideal in case operative intervention is required. The presence of
any abnormal measurement on the mortise view (see Fig. 58-6)
suggests instability and the need for orthopedic consultation in
the ED. Avulsion fractures, in which the avulsed fragment is less
than 3 mm in diameter and minimally displaced, can be treated
in an identical manner to an ankle sprain.
The outcome of ankle fractures depends on the extent of injuries, the number of malleoli fractured, ankle stability, and patient
age.32,33 For ankle fractures that require surgery, outcome is better
in unimalleolar fractures over trimalleolar fractures, in isolated
lateral malleolar fracture over isolated medial malleolar fractures,
in multimalleolar fractures without medial malleolar fracture over
BOX 58-1
Ankle Fractures for Which Orthopedic
Consultation in the Emergency Department
Is Recommended
Unimalleolar fractures
Displaced medial malleolar fracture
Medial malleolar fracture with lateral collateral ligament
rupture
Displaced lateral malleolar fracture
Lateral malleolar fracture with deltoid ligament rupture
Lateral malleolar fracture with widened medial clear space
Unimalleolar fracture with syndesmotic diastasis
Fibula fracture at or proximal to the tibiotalar joint line
Displaced posterior malleolar fracture
Posterior malleolar fracture involving more than 25% of
articular surface
All bimalleolar fractures
All trimalleolar fractures
All intra-articular fractures with step deformity
All open fractures
All pilon fractures
those with malleolar fractures, and in cases with posterior fragments involving less than one third of the articular surface over
larger fragments.39
Unimalleolar Fractures
Lateral Malleolar Fractures. The stability of an isolated lateral malleolar fracture depends on the location of the fracture in relation
to the level of the tibiotalar joint, which defines the distal portion
of the syndesmotic ligament and the stability it provides to the
ankle joint. The Danis-Weber classification (see Fig. 58-8) is
useful and predictive of outcome in these types of unimalleolar
fractures.33 This classification groups fractures into three groups
(A, B, and C), each of which has three subgroups. Lateral malleolar fractures below the tibiotalar joint (Danis-Weber type A)
rarely disrupt other bony or ligamentous structures, and in the
absence of injury to the medial structures such fractures are
unlikely to affect the dynamic congruity of the ankle joint.38 The
management of uncomplicated lateral malleolar fractures involves
casting for 6 to 8 weeks, with no weightbearing for at least the
first 3 weeks, and ongoing follow-up to ensure proper union.
Concomitant tenderness over the deltoid ligament may suggest
a biomechanical disruption of both malleoli, an associated fracture of the medial malleolus, or an associated fracture of the
posterior malleolus and warrants orthopedic consultation in the
ED, especially if the medial clear space on the mortise view is
widened (see Fig. 58-6).38 CT imaging can be useful in such situations as it may identify occult medial or posterior malleolar
fractures.
Fibular fractures proximal to the tibiotalar joint line (a DanisWeber type C injury; see Fig. 58-8) frequently, but not always,
disrupt the distal tibiotalar syndesmosis and the medial structures
and commonly require orthopedic consultation in the ED and
operative intervention. Treatment of an isolated fracture at the
level of the tibiotalar joint (a Danis-Weber type B injury; see Fig.
58-8) is controversial because 50% of these injuries are accompanied by an injury to the distal tibiofibular syndesmosis that may
require operative intervention.40 Distal tibiofibular space measurements on plain radiography have a sensitivity of only 31% and a
specificity of 83%, compared with CT scan, in detecting tibiofibular syndesmosis injuries.41 Tenderness on palpation of the syndesmotic ligament or a widening of the medial joint space on the
mortise view adds further support to the need for emergency
consultation.
Medial Malleolar Fractures. Medial malleolar fractures are
usually the result of eversion or external rotation. These two forces
exert tension on the deltoid ligament, causing an avulsion of
the tip of the medial malleolus or a rupture of the deltoid ligament. Although they can occur in isolation, medial malleolar
fractures are commonly associated with lateral or posterior malleolar disruption. Because of this, the identification of a medial
malleolar fracture warrants a careful examination of the entire
length of the fibula for tenderness, the presence of which warrants
radiographic evaluation to rule out a proximal fibular fracture
(Fig. 58-9).
An isolated nondisplaced medial malleolar fracture can be
treated with casting for 6 to 8 weeks, with no weightbearing for at
least the first 3 weeks and close orthopedic follow-up. Any displacement or concomitant disruption of the lateral components
of the ankle warrants orthopedic consultation in the ED for consideration of operative management.38
Posterior Malleolar Fractures. Isolated fractures of the posterior
malleolus are rare and imply an avulsion of the posterior tibiofibular ligament. These injuries can be associated with proximal
fibular fractures and medial and lateral collateral ligament sprains.
Treatment usually consists of casting for 6 weeks, provided that
no associated injury or ankle instability is present.42 Fractures
Chapter 58 / Ankle and Foot 729
Figure 58-9. Maisonneuve fracture.
A
B
A, Anteroposterior view shows a slight widening
(arrows) of the ankle mortise and the medial
clear space. B, Anteroposterior view shows an
oblique fracture at the proximal shaft of the fibula.
(From Nicholas JA, Hershman EB [eds]: The Lower
Extremity and Spine in Sports Medicine, 2nd ed. St Louis, Mosby, 1994.)
involving more than 25% of the tibial surface usually require open
reduction and internal fixation.38
Trimalleolar Fractures
Bimalleolar Fractures
Trimalleolar fractures involve fractures of the medial, lateral, and
posterior malleoli. Closed treatment of trimalleolar fractures often
leads to unsatisfactory results, so operative reduction and internal
fixation is the treatment of choice.46
Bimalleolar fractures involve the disruption of at least two elements of the ankle ring and are therefore unstable. These fractures
result from adduction or abduction forces, the latter being more
common.31 Rotational injuries also can cause bimalleolar fractures, as well as trimalleolar fractures if the posterior malleolus is
involved.
The mechanism of injury often can be deduced from the
appearance of the fractures.31 An abduction injury exerts tension
on the medial malleolus, causing a horizontal fracture, and compresses the lateral malleolus, causing an oblique shear or a comminuted fracture (see Fig. 58-7). An adduction injury causes the
reverse, leading to a horizontal fracture of the fibula and an
oblique shear fracture of the medial malleolus. A rotational injury
causes oblique or spiral fractures of the fibula or medial malleolus.
Associated damage to other soft tissue structures (e.g., the syndesmosis) is common with bimalleolar fractures.
Controversy exists about whether such injuries should be
treated closed or surgically.31,43 Unstable bimalleolar fractures
require surgical intervention, however, and one study found that
outcomes at 1 year after surgery were worse with bimalleolar fractures than with lateral malleolar fractures with deltoid ligament
disruption.44
Rarely, stress fractures of the medial malleolus or distal fibula
can be seen, particularly in athletes and runners. Plain radiographs
may be nondiagnostic, but radionuclide bone scanning, CT,
or MRI—the choice of which is often influenced by local
availability—can establish the diagnosis.45 Most such injuries
can be treated nonoperatively, but orthopedic consultation and
follow-up are prudent.
Open Fractures
Open ankle fractures usually occur from severe isolated ankle
injuries or multiple trauma and require immediate orthopedic
consultation. After documentation of the neurovascular status and
the extent of soft tissue trauma, gross contaminants should be
removed from the wound, saline-soaked sterile gauze should be
applied, and the injured leg should be splinted.36 Swabbing an
open wound for bacterial culture and sensitivity testing is unnecessary. If significant deformity is present, immediate reduction
before splinting is indicated.36 Tetanus immunoprophylaxis should
be administered as appropriate. Because open fractures are invariably contaminated with bacteria, patients with these injuries
should receive intravenous antibiotics.47,48 For low-energy injuries
with mild to moderate contamination, a first-generation cephalosporin is usually sufficient.36,47,48 Heavily contaminated wounds
require the addition of gram-negative bacterial coverage, typically
an aminoglycoside.47,48 Adding either penicillin G or clindamycin
(if penicillin allergic) as a third antibiotic is necessary for farmor soil-related crush injuries, in which contamination with Clostridium perfringens can be present.47,48 In addition to the ankle
radiographs, radiographs of the foot, tibia, and fibula should be
obtained.
All open fractures benefit from early surgical intervention for
débridement and irrigation.36 Therefore identification is crucial,
and emergency orthopedic consultation must be sought for such
injuries.
730 PART II ◆ Trauma / Section Three • Orthopedic Lesions
A
B
C
Figure 58-10. Anteroposterior (A) and lateral (B) radiographic views showing a pilon fracture with computed tomographic (C) three-dimensional
reconstruction providing important preoperative information about joint congruity. (From Hanlon DP: Leg, ankle, and foot injuries. Emerg Med Clin
North Am 28:885, 2010.)
Complications
Early operative complications of closed and open ankle fractures
include pin site infection, delayed skin necrosis, skin graft rejection, and osteomyelitis. Delayed complications of both operative
and nonoperative treatment include malunion, nonunion, osteopenia, traumatic arthritis, chronic instability, ossification of the
interosseous membrane, avascular necrosis, and complex regional
pain syndrome.2,49
Pilon Fractures
Pilon fractures involve the distal tibial metaphysis and usually are
the result of high-energy mechanisms, such as falls from a significant height. These injuries often are comminuted and associated
with significant soft tissue trauma, devastation of joint architecture, and leg shortening (Fig. 58-10). Other, higher-priority injuries can be present in such situations.
Pathophysiology
Destot first coined the term hammer fracture to describe the way
the head of the talus drives itself into the tibial plafond and causes
a pilon fracture. The primary deforming force is one of axial
compression, and the position of the foot at the time of injury
determines the fracture location and pattern50 (Fig. 58-11). Secondary rotational or shear forces may cause increased comminution and fragment displacement with more extensive soft tissue
injuries. One fourth of pilon fractures are open, and associated
injuries include fractures of the calcaneus, tibial plateau, femoral
neck, acetabulum, or lumbar vertebrae, as well as trauma to other
major systems.
Management
Radiographic examination should include the entire tibia and
fibula, as well as the ankle. The emergency management principles
for open fractures, as outlined previously, should be applied.
Treatment involves restoration of the articular surface and fibular
length, combined with meticulous management of soft tissue
Figure 58-11. Schematic diagram of the pathophysiology of pilon
fractures. The position of the foot at the time of impact determines the fracture pattern. (From Gustilo RB, et al [eds]: Fractures and
Dislocations. St Louis, Mosby, 1993.)
injuries.50,51 Because surgical management is required, orthopedic
consultation in the ED is necessary. Pilon fractures with low-grade
soft tissue damage are managed with primary open reduction
and internal fixation.51,52 In severe pilon fractures with extensive
soft tissue damage, however, results are better with a two-stage
approach involving initial length restoration and external fixation
followed by anatomic reduction and internal fixation after soft
tissue swelling has subsided.52-54
Complications
Complications of pilon fractures are common, particularly
in more severe cases.51 Early complications include wound infection, skin sloughing, pin site infection, and wound dehiscence.
Delayed and late complications include malunion, nonunion, leg
Chapter 58 / Ankle and Foot 731
shortening, post-traumatic arthritis, avascular necrosis, and protracted pain. Some patients with severe pilon fractures ultimately
require arthrodesis.
Soft Tissue Injuries
Ligament Injuries
Ankle sprains are commonly seen in EDs, with a recent series
estimating an annual incidence of 52.7 to 60.9 cases per 10,000
population.55 Ankle sprains also are one of the most common
injuries in young athletes, and 40% of patients experience dysfunction for up to 6 months postinjury.56,57 The term ankle sprain
refers to a potpourri of ligamentous and nonligamentous injuries.58 Even when ligamentous injury is certain, the ideal treatment
approach remains controversial, and significant variation in clinical practice exists.55,59,60
Pathophysiology. Most ankle sprains occur from extreme inversion and plantar flexion causing symptoms on the lateral aspect
of the ankle. Usually the anterior talofibular ligament is injured
first, followed by the calcaneofibular ligament if the deforming
forces are sufficiently strong (see Fig. 58-1). Approximately two
thirds of ankle sprains are isolated anterior talofibular ligament
injuries, whereas 20% involve both anterior talofibular and calcaneofibular ligament injuries. In addition, the lateral talocalcaneal
ligament may be stressed with an inversion injury, leading to avulsion fractures at either end of the attachment sites.61 Isolated calcaneofibular or posterior talofibular ligament injuries are rare.
Isolated injury of the deltoid ligament occurs in less than 5%
of ankle sprains. Rupture of this ligament occurs most commonly
in conjunction with lateral malleolar fractures, especially when an
external rotational force is involved.
Injuries of the distal tibiofibular syndesmotic ligaments are
uncommon in the general population but may represent 10 to
20% of injuries in competitive athletes.62 Dorsiflexion and external
rotation forces are usually responsible for this injury, the presence
of which may significantly prolong the recovery time from lateral
collateral ligament sprains.62
Ligamentous injuries are classified into three grades based on
functional and presumed pathologic findings. A grade I injury
involves ligamentous stretching without grossly evident tearing or
joint instability. A grade II injury involves a partial tear of the ligament with moderate joint instability, often accompanied by significant localized swelling and pain. A grade III injury involves a
complete tear of the ligament with marked joint instability, severe
edema, and ecchymosis. This classification system, although commonly used, fails to characterize ankle injuries involving two or
more ligaments, and it does not consider nonligamentous injuries.
Although more comprehensive classification systems have been
proposed,61 there is a strong association with increased gradation
of ankle sprain and long-term risk of chronic instability, early
osteoarthritis, chronic pain, and permanent disability.63,64
Clinical Features. Although desirable, an accurate history of
ankle position and injury mechanism is often unavailable. Inversion followed by external rotation of the ankle suggests the potential for deltoid or syndesmotic injury. Forced dorsiflexion with
snapping may indicate peroneal tendon displacement. Previous
injuries to the same ankle or symptoms of recurrent ankle instability or pain suggest the presence of a subacute or chronic pathologic process.
On physical examination, the presence of edema, ecchymosis,
and point tenderness over the medial or lateral collateral ligaments
or the syndesmotic ligaments suggests a ligamentous injury.
Inability to bear weight in the absence of a fracture suggests the
presence of a grade II or III ankle sprain.65 With inversion injuries,
point tenderness may also be present along the distal fibula, the
lateral aspect of the talus, the lateral aspect or anterior process of
the calcaneus, or the base of the fifth metatarsal. Deltoid ligament
tenderness necessitates palpation of the full length of the fibula to
rule out a proximal fibular fracture (a type C Danis-Weber or
Maisonneuve fracture; see Figs. 58-8 and 58-9) and a low threshold for imaging the entire tibia and fibula should exist. The fibular
compression test, also known as the squeeze test, reveals fibular and
syndesmotic injuries.62 To perform this test, the examiner places
the fingers over the fibula and the thumb over the tibia at midcalf
and squeezes the two bones. Pain anywhere along the length of the
fibula suggests a fibular fracture or an interosseous membrane or
syndesmotic ligament disruption at that location.62 Finally, the
Achilles tendon should be assessed.
Stress testing is the application of a deforming force to assess
joint motion beyond the physiologic range, the presence of which
suggests ligament disruption or mechanical instability. Although
rarely required, stress testing is safe to perform and can be helpful
for acute and severe ankle injury in which rupture of two or more
ligaments is suspected, a fracture suspected to be isolated in which
the presence of an additional ligament rupture would influence
management, the possibility of a concomitant syndesmotic injury,
follow-up evaluation of an acute ankle injury after pain and swelling have subsided, and a chronically symptomatic ankle. With the
exception of these scenarios, stress testing is not indicated because
it is painful and does not alter management. The normal ranges
for stress tests are controversial, so the uninjured side should be
examined for comparison.
Common ankle stress tests include the anterior drawer test, the
inversion stress test, and the external rotation test. The anterior
drawer test primarily assesses the integrity of the anterior talofibular ligament. For this test to be performed, the patient is seated
with the knee in 90 degrees of flexion and the ankle in a neutral
position or 10 degrees of plantar flexion. The examiner then pulls
on the heel with one hand and pushes the leg posteriorly with the
other. Anterior displacement of the talus, the perception of a
“clunk,” and the induction of a sulcus anteromedially over the
joint indicate partial or complete tear of the anterior talofibular
ligament.
The inversion stress test, or talar tilt test, evaluates both the
anterior talofibular ligament and the calcaneofibular ligament. It
is performed by inverting the heel with the knee in 90 degrees of
flexion and the ankle in neutral position. Palpation of the head of
the talus laterally or a finding of increased laxity compared with
the uninjured side suggests partial or complete tear of these
ligaments.
The external rotation stress test is indicated when injury to the
distal tibiofibular syndesmotic ligaments is suspected. It is performed by externally rotating the foot with the knee in 90 degrees
flexion and the ankle in a neutral position. Pain at the syndesmosis
or the sensation of lateral talar motion suggests partial or complete tear of the ligaments.
Diagnostic Strategies: Radiology. Standard ankle radiographic
views are useful to exclude fractures and to detect instability by
the measurement of joint spaces (see earlier discussion and Fig.
58-6).8 Presence of avulsion fractures, which can be located at the
bases of the malleoli, the lateral process of the talus, the lateral
aspect of the calcaneus, the posterior malleolus, the lateral aspect
of the distal tibia, or the base of the fifth metatarsal, constitute an
important clue to the location of ligamentous injuries.
In addition to the standard mortise measurements previously
discussed, two measurements on the anteroposterior radiograph
further evaluate the distal tibiofibular syndesmosis (see Fig. 58-6).8
At the distal overlap between the fibula and the tibia, the distance
between the posterior edge of the lateral tibial groove and the
medial fibular cortex (syndesmosis A) should not exceed 5 mm.8
Furthermore, the amount of tibiofibular bony overlap (syndesmosis B) should be at least 10 mm.8 Measurements outside of
these values suggest a syndesmotic diastasis. Stress radiographs,
732 PART II ◆ Trauma / Section Three • Orthopedic Lesions
BOX 58-2
Differential Diagnosis for Presumed
Ankle Sprain
Lateral collateral ligament sprain
Peroneal tendon dislocation
Osteochondral lesion of the talar dome
Fracture of the posterior process of the talus
Fracture of the lateral process of the talus
Fracture of the anterior process of the calcaneus
Midtarsal joint injury
Fracture of the base of the fifth metatarsal
Figure 58-12. Locations of common fractures in or near the ankle
that should be considered in the differential diagnosis of a presumed
ankle sprain. (From Gustilo RB, et al [eds]: Fractures and Dislocations. St Louis, Mosby, 1993.)
accomplished by taking radiographs during stress testing of the
ankle, generally do not influence the emergency management of
ankle sprains and are not recommended.66
Many injuries can masquerade as ankle sprains.58 Box 58-2 lists
conditions to be considered in the differential diagnosis; Figure
58-12 shows locations of common fractures in or near the ankle
that can be misdiagnosed as an ankle sprain.
Management. Most ligament sprains, regardless of severity,
heal well and result in a satisfactory outcome. To date, compelling
evidence for a significant difference in outcomes between surgical
and functional (nonsurgical) treatment is lacking. Limited data
suggest that recovery times may be longer and complications
more frequent with surgical treatment.67 Most patients with acute
sprains of the ankle should start with functional treatment.68
For the minority who fail to respond, delayed operative repair of
ruptured ligaments, sometimes years after the injury, has been
shown to yield results equivalent to those with primary repair.68,69
Functional treatment, which is defined as a form of therapy in
which the ankle is not fully immobilized, allowing either complete
or partial joint function, starts in the ED with RICE therapy (rest,
ice, compression, and elevation); however, significant variability
exists in how this combination is applied, and the optimal methods
remain unclear.60,61,70 The evidence to date suggests that lace-up
ankle support is more effective in short-term edema reduction
than semirigid ankle support, elastic bandaging, and taping.
Elastic bandaging causes fewer complications than taping but
appears to correlate with slower return to work and sports.60 One
study suggests that compared with elastic bandaging, ankle bracing
with a lace-up brace such as the Air-Stirrup Ankle Brace (Aircast,
DJO Inc., Vista, Calif.) leads to improved functioning at both 10
days and 1 month.71
For grade I or II injuries, short-term protection with a tensor
bandage, taping, a laced-up support, or a commercial walking
boot or brace, with the optional use of crutches for a few days, is
appropriate.68,70 For patients with first-time ankle sprains, treatment with a lace-up stirrup brace combined with elastic wrapping
results in an earlier return to function compared with use of
a brace alone, elastic wrap alone, or a walking cast.72 For severe
grade II or grade III injuries, there is currently equipoise regarding
the merit of immobilization compared with functional rehabilitation, with little high-quality evidence to guide therapy.73,74 A recent
study supports a 10-day period of immobilization with a belowknee cast or Aircast ankle brace to speed recovery from ankle
sprains, with immobilization leading to reduced symptoms and
faster recovery compared with tubular compression bandages.75
However, a weakness in this study was the lack of a control group
incorporating an active ankle physiotherapy program, known to
be important for improved recovery. An accelerated functional
rehabilitation program carried out over the first week of injury
has also recently been shown to improve function in grade I and
II ankle sprains in the short term.76
Because there is little evidence for a more favorable outcome
with complete immobilization over functional treatment incorporating a removable brace, the use of a lace-up support or air cast
that permits some ankle motion is generally preferable.68,74,77 Such
patients should also use crutches to avoid weightbearing until
they can stand and walk a few steps on the injured ankle without
pain. How long crutches will be required varies significantly,
ranging from a few days to 2 or 3 weeks. Follow-up care with the
patient’s primary physician within the first 2 weeks is appropriate
for minor sprains, whereas orthopedic or sports medicine referral
on an outpatient basis is prudent for severe sprains.
Analgesics are often necessary for pain management in ankle
injuries, and studies suggest that nonsteroidal anti-inflammatory
agents, acetaminophen, or oral opioids for severe cases are
efficacious.78-80 Topical diclofenac gel also has been shown to have
efficacy in pain reduction and allowing early mobilization.67,81,82
After the acute management phase, the next two phases of
functional treatment involve appropriate early rehabilitation and
occur outside the ED.83 Phase two, which begins after swelling has
subsided and the patient is able to bear weight easily, involves
strengthening the peroneal and dorsiflexor muscles by isometric,
concentric, and eccentric exercises. The final phase begins when
full range of motion has been reestablished and the patient can
exercise painlessly. This starts with exercises to rebuild motor
coordination and proprioception, recondition the muscles, and
increase endurance. The patient uses an ankle tilt board or disk
to develop coordination and performs increasingly demanding
functional activities (e.g., brisk walking, running, and figure-ofeight running to hopping, jumping, and cutting) to build up the
muscle groups.83,84 With severe sprains the patient may benefit
from the use of air casts, braces, or taping during the latter two
phases of functional treatment and in the initial period of return
to sports.83 The entire treatment program usually lasts 4 to 6
weeks, depending on the injury’s severity.61,70,85
Disposition. Rarely, orthopedic consultation in the ED is indicated for an acute ligament sprain. Primary surgical repair of
acute ligament rupture is controversial, and possible indications
include sprains with displaced osteochondral lesions, complete
tears of both the anterior talofibular and calcaneofibular ligaments
in a young athlete, a ligament sprain associated with a fracture
causing instability (e.g., a deltoid ligament rupture with a lateral
malleolar fracture), and an acute severe sprain in a patient with a
history of recurrent and severe sprains.61 Failure of nonoperative
treatment also constitutes an indication for surgical repair;
however, an orthopedic referral on an outpatient basis is adequate
ED management.69
Small avulsion fractures of the fibula with minimal or no
displacement can be treated in the same manner as an ankle
sprain. If the avulsed fragment is larger than 3 mm or significantly
Chapter 58 / Ankle and Foot 733
displaced, splinting and referral for orthopedic follow-up on an
outpatient basis are justified.
Despite appropriate treatment, chronic problems develop in
10 to 30% of patients with ankle sprains.70 These include functional instability, mechanical instability, chronic pain, stiffness,
and recurrent swelling and occur more often in grade III ankle
sprains.
Functional instability refers to the patient’s subjective sensation
that the ankle gives way during activity. Although this may be a
minor nuisance for some people, it can be devastating and debilitating for persons whose activities demand a high degree of ankle
stability. Mechanical instability results from ligamentous laxity,
which allows ankle joint movements beyond the physiologic
range. In contrast to functional instability, mechanical instability
can often be demonstrated clinically by the anterior drawer or
talar tilt test and stress radiographs.61
Soft tissue abnormalities that cause chronic pain include synovial impingement, peroneal tendon subluxation or dislocation,
intra-articular loose bodies, anterior tibiofibular syndesmotic
ligament injuries, and degenerative arthritis. Bone-related causes
of chronic pain include osteochondral lesions, fractures of the
anterior process of the calcaneus, fractures of the lateral process
of the talus, and anterior and posterior impingement.58,86
Patients with any of these chronic conditions should be referred
for orthopedic follow-up care because they may require further
imaging or arthroscopy for diagnosis or definitive treatment.
Tendon Injuries
Achilles Tendon Rupture. Achilles tendon rupture is most common
in middle-aged men, and its causes are multifactorial. This con­
dition is easily misdiagnosed, leading to a delay in therapy, a
worse prognosis, and increased morbidity, including chronic
weakness and loss of function. In the great majority of cases, a
complete transection of the tendon is present; however, partial
tears of the Achilles tendon can occur and may be more prone to
misdiagnosis.
Achilles tendon rupture results from direct trauma or indirectly
transmitted forces, including sudden unexpected dorsiflexion,
forced dorsiflexion of a plantar-flexed foot, and strong push-off
of the foot with simultaneous knee extension and calf contraction
(as in a runner accelerating from the starting position). Factors
predisposing to Achilles tendon rupture include preexisting
disease such as rheumatoid arthritis, systemic lupus erythematosus, gout, hyperparathyroidism, or chronic renal failure, steroid
use or injection, fluoroquinolone antibiotic therapy, and previous
Achilles tendon rupture.87
The diagnosis of Achilles tendon rupture is primarily clinical.
Patients usually describe a sudden onset of pain at the back of the
ankle associated with an audible “pop” or “snap.” Although the
pain can resolve rapidly, weakness in plantar flexion persists. On
examination, a visible and palpable tendon defect may be noted 2
to 6 cm proximal to the calcaneal insertion in acute presentations
but will be less apparent in delayed presentations because of
hematoma or edema. Even in cases of complete Achilles tendon
rupture, weak plantar flexion may still be possible because of the
actions of the tibialis posterior, toe flexors, and peroneal muscles.
This retained ability for plantar flexion often leads to the misdiagnosis of complete ruptures as ankle strains or partial tears in as
many as 25% of cases.88 The classic maneuver to assess the integrity of the Achilles tendon is the Thompson test.89 This is performed with the patient prone and the knee flexed at 90 degrees
or the feet hanging over the end of the stretcher. Alternatively, the
patient kneels on a chair with both knees flexed at 90 degrees and
the feet hanging over the edge. Squeezing the calf muscles in these
two positions should cause passive plantar flexion of the foot.
Absence of this motion, or a markedly weakened response
compared with the uninjured side, suggests complete rupture.
Another recently described diagnostic test, the reverse Silfverskiöld test, compares dorsiflexion of the injured ankle with that in
the uninjured ankle while the patient is in the supine position.
Achilles tendon rupture results in a notably increased degree of
dorsiflexion compared with the uninjured side.90
Lateral radiographic views of the ankle may suggest rupture by
showing opacification of the fatty tissue–filled space anterior to
the Achilles tendon (Kager’s triangle) or an irregular contour and
thickening of the tendon.88 Ultrasonography or MRI can demonstrate partial or complete tendon ruptures, but these studies are
indicated only in cases in which diagnostic uncertainty exists.88
A lack of consensus exists regarding the choice between operative and nonoperative management in the treatment of Achilles
tendon rupture.91-93 Surgical repair is routinely performed in
active individuals owing to its lower incidence of rerupture.
However, surgery carries higher rates of other complications, such
as superficial or deep wound infections, in comparison with nonoperative management.91,94 In both types of management, early
mobilization improves functional recovery without increasing
rerupture rates.91,93 Minimally invasive surgery combined with
early rehabilitation with postoperative functional bracing may
further improve outcome.95,96 Achilles tendon rerupture after
initial nonoperative treatment usually necessitates surgical repair,
with substandard results compared with primary repair.97 ED
orthopedic referral of patients with Achilles tendon rupture is
necessary to determine the appropriate management.
Peroneal Tendon Dislocation or Tear. The peroneal muscles are
the primary evertors and pronators of the foot and also participate
in plantar flexion. The peroneus longus and brevis tendons use
the posterior peroneal sulcus (the fibular groove), located behind
and underneath the lateral malleolus, as a pulley for their midfoot
insertions. The peroneus brevis tendon inserts onto the tuberosity
of the fifth metatarsal, and the peroneus longus tendon courses
beneath the cuboid to insert onto the medial cuneiform and base
of the first metatarsal. The superior peroneal retinaculum (Fig.
58-13), a fibrous structure running from the distal fibula to the
posterolateral aspect of the calcaneus, maintains the peroneal
tendons against the fibular groove.
Anterior subluxation or dislocation of the peroneal tendons
occurs as a result of a tear of the superior peroneal retinaculum
attachment from the fibula.98,99 This infrequent injury is commonly misdiagnosed as an ankle sprain and can occur in isolation
or concomitant with other sprains or fractures. The mechanism
of injury usually is forced dorsiflexion with reflex contraction of
the peroneal muscles, resulting in avulsion of the retinaculum and
anterior displacement of the peroneal tendons.98
Patients with a peroneal tendon dislocation complain of sudden
pain and a snapping sensation over the posterolateral ankle associated with weakness of eversion. Tenderness and swelling over the
lateral retromalleolar area (a location not typically involved in
ankle sprains) are characteristic. When accurate examination is
not precluded by swelling, the dislocated tendons also may be
palpable near the inferior tip of the lateral malleolus. Inability to
actively evert the foot when it is held in dorsiflexion or frank
subluxation of the tendons with this maneuver confirms the diagnosis. Findings on plain radiography are often normal; however,
15 to 50% of patients will be found to have an associated avulsion
fracture of the lateral ridge of the distal fibula. An MRI study or
ultrasound can be helpful in confirming the diagnosis. All patients
with a suspected or confirmed peroneal tendon dislocation should
be referred for orthopedic follow-up because these injuries require
surgical repair.99,100 Spontaneous healing is rare in untreated cases,
and chronic ankle instability and pain are common sequelae. Peroneal tendons also can tear longitudinally; such injuries manifest
either acutely or subacutely with recurrent pain and swelling
during activities.100,101
734 PART II ◆ Trauma / Section Three • Orthopedic Lesions
course of immobilization. Orthopedic follow-up on an outpatient
basis should be arranged to ensure proper resolution. Rarely, surgical intervention may be necessary.103
Ankle Dislocations
Figure 58-13. The locations of the superior (arrow) and inferior
peroneal retinaculum in relation to the fibula and the peroneal tendons.
(From Arrowsmith SR, et al: Traumatic dislocations of the peroneal
tendons. Am J Sports Med 11:142, 1983.)
Tibialis Posterior Tendon Rupture. The tibialis posterior is
primarily responsible for plantar flexion and inversion along
the subtalar joint. Its tendon uses the posteroinferior surface of
the medial malleolus as a pulley and inserts onto the navicular, the
medial cuneiforms, and the bases of the second through the fifth
metatarsals. The peroneus brevis opposes the action of the tibialis
posterior. With rupture of the tibialis posterior tendon, the peroneus brevis becomes unopposed and the medial longitudinal arch
loses its muscular support, leading to valgus deformity of the
hindfoot and a unilateral flatfoot.102
The mechanism of traumatic tibialis posterior rupture involves
forced eversion.102 In addition to a unilateral flatfoot, pain and
swelling on the medial aspect of the ankle are seen. Tenderness is
present over the navicular, and the patient cannot perform a toe
raise on the affected side. In addition, the patient with a tibialis
posterior tendon rupture is unable to invert the foot when it is in
plantar flexion and eversion. With a unilateral flatfoot, an observer
standing behind the patient can see “more toes” on the lateral
aspect of the affected side—a classic sign.102 Plain radiography can
exclude other bone abnormalities. Ultrasonography and MRI are
useful imaging modalities to diagnose this condition.102 Orthopedic consultation is indicated for tibialis posterior tendon ruptures,
because surgical repair often is necessary.
Other Tendon Injuries. The tibialis anterior is the primary dorsiflexor of the foot. Its tendon courses under the superior extensor
retinaculum and inserts onto the navicular, the medial cuneiform,
and the base of the first metatarsal. Tenosynovitis of the tibialis
anterior tendon is associated with overuse and characterized by
swelling, tenderness, and crepitus along the tendon. Treatment
involves RICE therapy, analgesia, and close follow-up. Rupture of
the tibialis anterior is rare and often is misdiagnosed as lumbosacral radiculopathy or peroneal nerve palsy because of the footdrop
it produces. This condition requires orthopedic consultation in
the ED because surgical repair is usually necessary.
The flexor hallucis longus is responsible for flexion of the great
toe and participates in plantar flexion of the foot. Its tendon
courses behind the medial malleolus through a fibro-osseous canal
and inserts onto the distal phalanx of the great toe. Flexor hallucis
longus tendinitis, also called dancer’s tendinitis, most often occurs
at the fibro-osseous canal.103 On examination, tenderness and
edema posterior to the medial malleolus are noted, and passive
extension of the first metatarsophalangeal (MTP) joint causes significant pain when the foot is in neutral position. Initial treatment
involves rest, nonsteroidal anti-inflammatory drugs, and a short
Ankle dislocations are described according to the direction
of displacement of the talus and foot in relation to the tibia.
Thus dislocation may be upward, posterior, medial, lateral, posteromedial, or anterior. Medial dislocation is the most common.
Most dislocations involve associated ankle fractures; rarely,
however, dislocations can occur without fracture. The mechanism
in all dislocations begins with axial loading of a plantar-flexed
foot, which forces the talus either anteriorly or posteriorly from
the ankle mortise. The eventual position of the dislocation depends
on the position of the foot at the time of injury and the direction
of the displacing force. Ankle dislocations can be closed or open
and most commonly result from significant falls, motor vehicle
collisions (MVCs), or high-speed sports.37 The neurovascular
supply to the foot usually is intact but may be compromised in
open dislocations.104
ED management involves the assessment of neurovascular
status and tendon function, followed by rapid reduction. Radiographs are helpful but should not delay reduction in cases when
vascular compromise or skin tenting is present.37 After appropriate
procedural sedation and analgesia, the patient is placed supine
and the knee is flexed to 90 degrees. Distraction of the foot, followed by a gentle force to reverse the direction of the dislocation,
usually accomplishes the reduction.105 Reassessment of the neurovascular status, splint immobilization, ankle elevation, and postreduction radiography should follow. Open dislocations require
the same management as previously discussed for open fractures.
The prognosis with an ankle dislocation is usually good, although
open fractures are associated with an increased incidence of
complications.104,105
FOOT
PRINCIPLES OF DISEASE
Anatomy
The foot is composed of 28 bones and 57 articulations (Fig.
58-14). It can be divided into three anatomic and functional
regions: the hindfoot, which contains the talus and calcaneus; the
midfoot, which contains the navicular, cuboid, and cuneiforms;
and the forefoot, which contains the metatarsals, phalanges, and
sesamoids. The midtarsal joints (Chopart’s joint) join the hindfoot
and midfoot, and the tarsometatarsal joints (Lisfranc’s joint) join
the midfoot and forefoot. The inferior aspect of the talus has three
articulations with the calcaneus that are collectively known as the
subtalar joint.
The bones of the foot interlock in a manner similar to the blocks
and keystones of a bridge, forming a complex system of arches
and beams tethered by ligaments and intrinsic muscles. Extrinsic
muscles originating in the lower leg are responsible for most of
the foot’s movements, as well as for maintenance of the arch and
beam structure. The course and insertion of these extrinsic
muscles are important in their actions and in their association
with specific avulsions and injuries. The arterial supply to the foot
is from the anterior and posterior tibial arteries and the peroneal
artery, a proximal branch of the posterior tibial artery. Motor and
sensory innervation comes from branches of the deep and superficial peroneal, posterior tibial, saphenous, and sural nerves.
The foot is capable of numerous weight-bearing and non–
weight-bearing motions (see Fig. 58-3), which vary at each articulation. Inversion and eversion of the hindfoot occur primarily
Chapter 58 / Ankle and Foot 735
Distal (3rd) phalanx
Middle (2nd) phalanx
Proximal (1st) phalanx
Forefoot
Metatarsal bones
Medial (1st) cuneiform bone
Middle (2nd) cuneiform bone
Lateral (3rd) cuneiform bone
Navicular bone
Cuboid bone
Talus
1
1
2 3
2 3
4
5
Lisfranc’s
joint
Midfoot
Chopart’s
joint
Hindfoot
Calcaneus (os calcaneum)
Figure 58-14. Bones and joints of the foot. (From Rockwood CA,
et al [eds]: Rockwood and Green’s Fractures in Adults, 3rd ed. New York, JB Lippincott, 1991.)
through the subtalar joint, adduction and abduction of the forefoot through the midtarsal joints, and flexion and extension
through the MTP and interphalangeal (IP) joints. The relative
importance of specific bones in supporting the body’s weight
varies with changes from the static to the mobile state. The biomechanics of walking and running are extremely complex, and
significant forces are imparted to the foot’s structures during these
precisely coordinated activities.106
Clinical Features
An accurate history is essential in the setting of foot trauma
because many mechanisms are associated with specific injury patterns. Mechanisms can be broadly divided into direct and indirect
(torsional) forces. Falls and axial loads, twisting injuries, dropped
objects, overuse injuries, crush injuries, burns, and penetrating
wounds each suggest different potential pathologic conditions.
Patient complaints may involve any combination of pain, swelling,
deformity, reduced function, or altered sensation. The location of
pain, along with a description of its quality, duration, and precipitants, focuses the differential diagnosis. The combination of
increasing pain with decreasing sensation is particularly compelling because this may indicate neurovascular compromise requiring immediate intervention. Along with general information
obtained when the history is taken, underlying pertinent medical
conditions, medications, and previous foot problems should be
identified.
The structures of the foot are uniquely accessible to palpation
and assessment. A directed examination, specific for the patient’s
complaint, is most useful in the ED.107
If the patient is ambulatory, observation of the gait provides
information on the degree of disability and pain and the potential
for serious injury. Formal examination begins with observation
of the foot in its position of rest, normally one of slight plantar
flexion and inversion. Swelling, deformity, ecchymosis, open
wounds, color, and temperature should be noted. The use of
ecchymosis to localize injuries can be misleading because of
pooling of blood in dependent areas after tracking through tissue
planes. All patients should have a neurovascular examination with
assessment of the dorsalis pedis and posterior tibial pulses,
sensation, and motor function. Precise localization of pain or
crepitus, when not precluded by swelling, is extremely valuable
and facilitates appropriate use of further diagnostic tools. An
awareness of anatomic landmarks, which some research suggests
may be suboptimal among clinicians,108 is important in this
process. The entire foot should be gently palpated over both the
dorsal and the plantar surfaces, methodically progressing from the
heel to the toes. Particular attention should be paid to areas in
which injuries commonly occur, such as the base of the fifth
metatarsal.
In some situations, an evaluation of range of motion is indicated. This begins with an assessment of active motion with the
foot in a dependent position. Next, if active motion is well tolerated, passive motion is assessed, beginning with the subtalar joint
in the hindfoot and moving distally to the midtarsal and forefoot
joints. Subtalar motion is evaluated by holding the lower leg with
one hand and the heel with the other. Then, with the foot in a
neutral position, the heel is inverted and everted. Normally,
there should be at least 25 degrees of mobility in each direction.
Midtarsal motion is evaluated by stabilizing the heel with one
hand while the other hand grasps the forefoot at the bases of
the metatarsals. The forefoot can then be pronated, supinated,
abducted, and adducted. Normally there should be at least 20
degrees of adduction and 10 degrees of abduction.
Forefoot motion is evaluated by flexing and extending the MTP
and IP joints individually. The first MTP joint has a particularly
wide passive range of motion, with 45 degrees of flexion and 70
to 90 degrees of extension. Throughout the physical examination,
findings can be compared with those of the opposite foot.
Diagnostic Strategies: Radiology
Plain radiography of the foot may be indicated by history, physical
examination, or both. Standard three-view radiographs of the
foot consist of anteroposterior, lateral, and 45-degree internal
oblique projections.109 The lateral projection gives the best imaging
of the hindfoot and soft tissues, whereas the anteroposterior and
oblique projections give the best imaging of the midfoot and
forefoot. The numerous overlapping bones of the foot demand
this complete radiographic series in all patients for whom radiographic examination is indicated.110 Injuries to the hindfoot also
warrant the addition of standard ankle projections and, when
indicated, calcaneus views.
Foot radiographs can be difficult to interpret.111 Moreover, foot
fractures are often minimally displaced or nondisplaced, increasing the challenge of radiographic diagnosis. Several additional
views improve the imaging of specific areas of the foot. Coned
views, weight-bearing radiographs, or a 45-degree external oblique
projection can be useful, particularly for detection of midfoot and
forefoot pathology. The most commonly obtained atypical view is
the Harris (axial) view for visualizing the calcaneus and subtalar
joints. Special magnification radiographs or stress radiographs
also may be useful in selected cases.
Interpretation of plain radiographs can be complicated by the
numerous accessory centers of ossification and the presence of
sesamoid bones (unipartite and multipartite) that exist as normal
variants in up to 30% of the population (Fig. 58-15). The most
commonly seen accessory bones are the os trigonum, os tibiale
externum (also called an accessory navicular bone), os peroneum,
and os vesalianum.112 These can be differentiated from fractures
by their smooth corticated surfaces. Comparison radiographs of
the opposite foot may be helpful, although such variants are not
inevitably bilateral. Accessory bones themselves can also fracture
or cause pain syndromes.113
Because of the limitations of plain radiography, other imaging
techniques have gained importance for specific foot injuries.
736 PART II ◆ Trauma / Section Three • Orthopedic Lesions
Os cuboideum
secundarium
Accessory
navicular
Os peroneum
Os tibiale
externum
Os vesalianum
pedis
Processus
uncinatus
Os trigonum
tarsi
Talus
accessorius
Sustentaculum tali
Accessory navicular
Os tibiale externum
Os intercuneiforme
Os intermetatarseum
Pars peronea
metatarsalia
Anomalous os
talocalcaneum
Calcaneus
secundarius
Os intercuneiforme
Processus uncinatus
Os intermetatarseum
Os peroneum
Sesamoids
Sesamoids
Os vesalianum pedis
Figure 58-15. Accessory ossicles of the foot. (From Berquist TH [ed]: Radiology of the Foot and Ankle. New York, Raven Press, 1989.)
Radionuclide imaging (bone scanning) can be useful for evaluating unexplained foot pain or pain in athletic injuries.114 In the
setting of acute foot trauma, this modality often can demonstrate
subtle fractures not visible with plain radiography. Historically,
bone scanning has been the standard modality for the diagnosis
of stress fractures; however, MRI has comparable sensitivity and
better specificity and has emerged as the imaging modality of
choice for this diagnosis.25,115
The CT scan can be valuable when complex articulations and
overlapping bones make standard radiographs difficult to interpret, particularly in the midfoot and hindfoot.116,117 As a result of
the wide availability and superiority of CT scanning, plain film
tomography is now virtually obsolete. CT is an excellent modality
for imaging complex anatomy, including the subtalar joint, the
calcaneus, and the tarsometatarsal (Lisfranc) joint complex.
Three-dimensional CT images provide unprecedented clarity
and detail.27
MRI has been used to investigate many of the same fractures
and dislocations imaged by CT, and the two modalities can be used
in a complementary manner.24,28,118,119 As in the ankle, the most
significant role of MRI is in the delineation of soft tissue conditions, such as athletic injuries and tendon ruptures, where it has
become the imaging modality of choice. In some conditions
involving the ankle joint, magnetic resonance arthrography on an
outpatient basis can be useful.120
SPECIFIC PATHOLOGIC
CONDITIONS
This section covers the major fractures and dislocations seen in
the foot, progressing anatomically from the hindfoot through to
the forefoot. This order corresponds with the sequence of physical
examination in patients with foot trauma. Any of these fractures
or dislocations may be open, necessitating appropriate wound
management.
Hindfoot Injuries
The hindfoot is commonly involved in foot injuries and is a difficult area to image. Fractures or dislocations in this region can
masquerade as ankle sprains and, if not considered in the differential diagnosis, can be missed.
Talar Fractures
Principles of Disease: Anatomy. The word talus is related to the
Latin taxillus, meaning “a small die or cube,” and dates back to the
time of the Roman Empire, when soldiers made dice out of
the ankle bones of horses. An appreciation of the unique anatomy
of the talus is crucial to an understanding of the pathophysiology
and treatment of talar fractures and dislocations. The talus is the
second largest tarsal bone and has seven articulations making up
60% of its surface. It is divided into three regions: the head, which
articulates with the navicular and calcaneus; the body, which
articulates with the tibia, fibula, and calcaneus; and the neck,
which joins the head and body and is the only portion of the talus
that is predominantly extra-articular. The talus is the only bone
in the lower extremity with no muscular attachments and is held
in position by the malleoli and ligamentous attachments. The
anterior width of the talus is greater than the posterior, causing it
to be less stable and more prone to dislocation when the foot is
plantar-flexed.
The blood supply to the talus is from a vascular ring formed by
branches of the anterior and posterior tibial arteries and the perforating branch of the peroneal artery. Vessels enter the talus from
three main sites, any or all of which can be disrupted by fractures
or dislocations. Because of the tenuous nature of these vessels and
the inconsistency of collateral circulation, the risk of avascular
necrosis is significant with many talar fractures.
Pathophysiology. Talar fractures are the second most common
tarsal fracture after fractures of the calcaneus. They are best
grouped into minor and major fractures, with minor fractures
being the more common.121 Stress fractures of the talus also can
occur. Minor talar fractures include avulsion fractures of the superior neck and head, and the lateral, medial, and posterior aspects
of the body.122 These fractures often involve the same mechanism
as that for ankle sprains (see Fig. 58-12 and Box 58-2): a combination of plantar flexion or dorsiflexion and an inversion force.
Lateral process fractures, previously uncommon, have been
described with snowboarding and can be occult on plain radiographs.123 Osteochondral lesions of the talar dome also fall into
the minor fracture category.
Major talar fractures usually are produced by significant forces
and occur in the head, neck, or body. Talar head fractures are
uncommon, making up 5 to 10% of all talar fractures. Their
Chapter 58 / Ankle and Foot 737
A
B
C
D
Figure 58-16. A, B, and C, Hawkins’s type 1, 2, and 3 fractures, respectively. D, Canale and Kelly’s type 4 fracture of the talar neck. Purple
shading indicates the articular surface of the talar dome. (From Gustilo RB, et al [eds]: Fractures and Dislocations. St Louis, Mosby, 1993.)
mechanism is a compressive force applied on a plantar-flexed foot
and transmitted up through the talonavicular joint. Comminution
is common, and associated navicular fractures can occur, further
disrupting the talonavicular articulation.
Talar neck fractures account for 50% of major talar injuries.
Their mechanism usually is an extreme dorsiflexion force, as generated in falls or MVCs. Associated fractures are common; the
most common is an oblique or vertical fracture of the medial
malleolus, which is seen in up to one fourth of cases. Other associated injuries include calcaneal fractures and vertebral compression
fractures.
Hawkins classified talar neck fractures into three categories
(Fig. 58-16): Type 1 fractures are nondisplaced; type 2 fractures
show subtalar subluxation; and type 3 fractures, 50% of which
are open, involve a dislocation of the talar body from the ankle
and subtalar joint. A fourth type that has been added to this
classification involves the additional distraction of the talonavicular joint. This classification is important descriptively and because
the type of fracture influences both treatment and outcome. Longterm complications, including avascular necrosis and arthritis, are
common with talar neck fractures and more likely with increasing
displacement.124
Talar body fractures include many of the minor talar fractures
previously listed.125 Major talar body fractures are uncommon and
usually result from falls with axial compression of the talus
between the tibial plafond and the calcaneus.
Clinical Features. Talar fractures range from obvious open
fractures to subtle fractures requiring special imaging techniques
to diagnose. Typically, a history of a twisting injury, fall, or highenergy impact can be elicited. Dorsal swelling and tenderness
over the talus are characteristic findings. Although ankle motion
may be preserved, inversion and eversion of the hindfoot often
are painful.
Diagnostic Strategies: Radiology. With minor talar fractures,
radiographs can be misinterpreted as normal in appearance. Even
when supplemental views are obtained, CT or MRI may be
required for visualization. Standard foot and ankle radiographic
views usually demonstrate major talar fractures (Figs. 58-17 and
58-18), with the anterior and oblique projections showing talar
alignment within the mortise and the lateral projection showing
the talar neck and alignment of the posterior aspect of the subtalar
joint. Normal variants, such as an os trigonum or os supratalare
(see Fig. 58-15), are occasionally encountered and should be differentiated from fractures. Specialized imaging by CT or MRI is
often required for complete assessment of talar fractures.
Management. Major talar fractures require precise reduction
because more weight per unit area is borne by the superior surface
of the talus than by any other bone. Most talar fractures involve
multiple articular surfaces, and adequate repair often necessitates
open reduction and internal fixation. Many minor talar fractures
heal with casting, and the initial treatment should be with a
Figure 58-17. Comminuted fracture of the talar body (arrows). (From
Rosen P, et al [eds]: Diagnostic Radiology in Emergency Medicine. St
Louis, Mosby, 1992.)
non–weight-bearing below-knee cast or posterior plaster slab.
Fragments larger than 5 mm in diameter may require excision.
Other minor fractures, such as displaced lateral process fractures,
require operative fixation because of their articular involvement.
The treatment of major talar fractures is controversial. Any
significantly displaced fracture, particularly if associated with neurovascular or cutaneous compromise, requires an early attempt at
closed reduction in the ED. Even if nonoperative reduction is
impossible, as is common in type 3 and type 4 neck fractures with
an intact medial malleolus, alignment often can be improved.
With neurovascular or cutaneous compromise, reduction should
not be delayed by waiting for radiography or consultation. After
appropriate procedural sedation and analgesia, reduction is performed by grasping the hindfoot and midfoot and applying
longitudinal traction with plantar flexion. This is followed by
realignment of the foot as reduction is achieved. Reevaluation of
the neurovascular status, posterior slab immobilization, and postreduction radiographs should then follow.
Displaced talar head fractures or those involving more than
50% of the articular surface usually require open reduction and
internal fixation, followed by non–weight-bearing casting. Smaller
fragments may require excision. Type 1 fractures of the talar neck
usually are treated with non–weight-bearing casting for 8 to 12
weeks. Most type 2 and all type 3 and type 4 fractures require open
reduction and internal fixation. The management of talar body
fractures varies with anatomic location.
738 PART II ◆ Trauma / Section Three • Orthopedic Lesions
Standing
A
Figure 58-18. Fracture of the talar neck (arrow). (From Rosen P, et al
[eds]: Diagnostic Radiology in Emergency Medicine. St Louis, Mosby,
1992.)
B
Disposition. All patients with talar fractures require orthopedic
consultation in the ED or referral for early orthopedic follow-up
on an outpatient basis. Most minor talar fractures are suitable for
outpatient follow-up and heal well, although some result in posttraumatic arthritis. Major talar fractures have a high incidence of
complications, the most significant of which is avascular necrosis.126 Outcome depends on the degree of anatomic reduction
attained and preservation of the vascular supply. The risk of avascular necrosis increases with delay to reduction and with increasing talar displacement, ranging from 10% for type 1 neck fractures
to 70% or more for type 3 neck fractures. Major fractures of the
talar body are also prone to avascular necrosis, the risk of which
doubles if an associated dislocation is present. Other potential
complications include skin infection, skin necrosis, post-traumatic
arthritis, malunion, delayed union, nonunion, and predisposition
to peroneal tendon dislocation. The incidence of each complication varies with the type of fracture and the aggressiveness of ED
and operative management.
Osteochondral Lesions
Osteochondral fractures of the talar dome account for 1% of talar
fractures and are usually diagnosed late in the clinical course after
ankle trauma.127 The broader term “osteochondral lesion” is preferable, as it describes injuries of any origin involving the articular
surface and/or subchondral region of the talus or tibial plafond
and can thus involve cartilage, subchondral bone, or both.128 These
injuries are now thought to be more common than previously
appreciated.128-130 Many synonyms for this entity, including transchondral fracture and dome fracture of the talus, exist. Mechanisms
identical to those causing ankle sprains are the most common
cause; however, a significant number of these injuries cannot be
ascribed to an acute traumatic event.
An osteochondral lesion should be considered in any patient
with ligamentous ankle injury accompanied by gross edema and
an effusion on plain radiographs.7 The diagnosis is often missed
Figure 58-19. A, Anteroposterior view of an ankle showing an
osteochondral fracture over the medial dome of the talus. B, Magnetic
resonance imaging of the same lesion, showing improved sensitivity
and detail from this modality. (From Frost A, Roach R: Osteochondral
injuries of the foot and ankle. Sports Med Arthrosc Rev 17:187, 2009.)
initially and not made until the patient returns with chronic ankle
pain.131 Physical findings usually are nonspecific, although localized tenderness over the posteromedial aspect of the talus and
increasing pain with exertion, weightbearing, or passive plantar
flexion may be noted. Standard-view radiographs are commonly
normal in appearance or show subtle and easily overlooked abnormalities, although specialized views may be helpful to assess the
subchondral surfaces.128 Bone scanning has been advocated as a
nonspecific screening modality129; however, its role is becoming
increasingly historic as CT or MRI studies are often required for
identification and classification (Fig. 58-19). MRI is emerging as
the imaging modality of choice for osteochondral lesions, owing
to its ability to detect bone marrow edema and cartilage, and MRI
classification schemes exist.128-131
When an osteochondral lesion is diagnosed or suspected, outpatient orthopedic referral is advised. The natural history of
osteochondral lesions is poorly defined and variable132; however,
chronic ankle discomfort and osteoarthritis are potential sequelae.
Osteochondritis dissecans, a subacute or chronic defect, may
develop in the talar dome after inadequate treatment of an osteochondral lesion. In general, however, with appropriate care, either
by cast immobilization for up to 6 weeks or operative management, the prognosis is good, particularly if treatment begins
within 12 months of symptom onset. The benefit of operative
management, often done arthroscopically, varies with the type of
lesion and its anatomic location.133 The previous discussion
underscores the necessity for orthopedic evaluation when a patient
has persistent unexplained ankle pain after a previous “sprain.”
Chapter 58 / Ankle and Foot 739
A
B
C
D
Figure 58-20. The forces that produce a subtalar dislocation can, when more extreme, produce a total talar dislocation. A, Medical subtalar
dislocation. B, Total lateral dislocation of the talus from more extreme inversion forces. C, Lateral subtalar dislocation. D, Total medial dislocation of
the talus from more extreme eversion forces. (Adapted from Sanders DW: Talus fractures. In Bucholz RW, Court-Brown CM, Heckman JD, Tornetta
P [eds]: Rockwood and Green’s Fractures in Adults, 7th ed. Philadelphia, Lippincott, Williams & Wilkins, 2010, pp 2022-2064.)
Subtalar Dislocations
Principles of Disease: Pathophysiology. Subtalar dislocation, also
called peritalar dislocation, is the simultaneous disruption of both
the talocalcaneal and talonavicular joints without disruption of
the tibiotalar joint (Fig. 58-20). This occurs when the talonavicular
and talocalcaneal ligaments rupture while the stronger calcaneonavicular ligament remains intact. Subtalar dislocations are rare
and are classified by the direction the foot takes in relation to the
talus.134 Anterior and posterior dislocations occasionally occur;
however, most subtalar dislocations are either medial or lateral,
with medial dislocations accounting for a majority of cases. Dislocation of the calcaneus is an exceptionally rare event that is
distinct from subtalar dislocation and involves disruption of the
talocalcaneal and calcaneocuboid articulations.
Subtalar dislocations are caused by severe torsional forces such
as those generated in MVCs or falls. Medial dislocations result
from inversion and plantar flexion, whereas lateral dislocations
arise from the combination of eversion and plantar flexion. Ten
percent of subtalar dislocations are open, and associated fractures
are present in one half of the cases, particularly those with lateral
dislocations.
Clinical Features. Obvious deformity typically is present, often
with tension of the skin on the side opposite the direction of
dislocation. Neurovascular status should be carefully assessed,
although it is rarely compromised. Swelling can mask the extent
of the injury, thus diagnosis can be delayed or missed if only ankle
radiographs are obtained.
Diagnostic Strategies: Radiology. Although standard foot radiographic views are diagnostic, properly positioning the patient for
these may be difficult. Inadequate films can delay diagnosis and
treatment. The single most helpful radiograph is an anteroposterior view of the foot, which will demonstrate the talonavicular
dislocation.
Management. Subtalar dislocations require expeditious reduction.135 More than 80% of closed subtalar dislocations can be
treated with closed reduction, either with procedural sedation and
analgesia in the ED or with general anesthesia. Closed reduction
is performed by flexing the knee and applying longitudinal traction to the foot with initial accentuation, followed by reversal of
the deformity (with use of eversion for medial dislocations and
inversion for lateral dislocations). Sometimes direct pressure over
the head of the talus aids in reduction. Closed reduction may
be impossible because of buttonholing of the talus through the
extensor retinaculum, entrapment in the peroneal tendons, or
associated fractures. After reduction, immobilization in a belowknee cast for 4 to 6 weeks is indicated.
Disposition. Urgent ED orthopedic consultation is indicated for
subtalar dislocations. Although serious complications are uncommon in cases of closed subtalar dislocation, most patients have
long-term limitation of subtalar motion, a sequela that can affect
gait. Avascular necrosis is uncommon.
Total Talar Dislocation
Total talar dislocation is an extremely rare and devastating
injury requiring orthopedic consultation in the ED. In these injuries, which are the end result of the same forces that produce
subtalar dislocation, the entire talus is distracted from all of its
articulations (see Fig. 58-20). Most are open, and infection and
avascular necrosis are common complications.136
Calcaneal Fractures
Principles of Disease: Anatomy. The calcaneus is the largest bone in
the foot and the most commonly fractured tarsal bone.137 It articulates with the talus superiorly (forming the subtalar joint) and
with the cuboid anterolaterally.
Pathophysiology. Falls with direct axial compression cause most
calcaneal fractures. Because of this high-energy mechanism, associated injuries are common: 7% of calcaneal fractures are bilateral,
25% are associated with other lower extremity injuries, and 10%
are associated with spinal injuries, typically vertebral compression
fractures.
Numerous classification schemes have been developed for calcaneal fractures. Perhaps the most intuitive is simple categorization of the fracture as either extra-articular or intra-articular.
Extra-articular fractures usually involve the addition of a rotatory
mechanism and include fractures of the sustentaculum tali and
the calcaneal tuberosity and oblique fractures of the calcaneal
body. Avulsion fractures of the anterior process by the bifurcate
ligament (which joins the calcaneus, navicular, and cuboid) also
are included in this category. Isolated calcaneal tuberosity fractures are rare but may require more expeditious treatment when
displaced owing to compromise of the skin overlying the Achilles
tendon.138 Up to 75% of calcaneal fractures are intra-articular,
ranging in severity from nondisplaced single fractures to severely
crushed, comminuted fractures. Because of the cancellous nature
of the calcaneus, fractures are frequently comminuted. Calcaneal
stress fractures may also occur.
740 PART II ◆ Trauma / Section Three • Orthopedic Lesions
20°-40°
B
A
C
Figure 58-22. Boehler’s angle is obtained by measuring the angle
Figure 58-21. Comminuted body fracture of the calcaneus with
subtalar involvement (arrows). (From Rosen P, et al [eds]: Diagnostic
Radiology in Emergency Medicine. St Louis, Mosby, 1992.)
Clinical Features. The typical history is one of a fall resulting
in a direct impact on the heel or heels. Physical examination
reveals pain, swelling, and tenderness over the affected heel, and
weightbearing on the hindfoot is usually impossible. In cases
of significant fracture, the heel may be deformed when viewed
from behind, appearing short, wide, and tilted. Ecchymoses may
extend over the entire sole, a finding not seen in isolated malleolar
fractures. The presence of compartment syndrome or associated
injuries such as vertebral compression fractures should be
considered.
Diagnostic Strategies: Radiology. Standard radiographic views of
the foot and ankle should be obtained. The anteroposterior view
of the foot shows the calcaneocuboid joint and the anterosuperior
calcaneus, whereas the lateral view shows the posterior facet and
can demonstrate compression of the calcaneal body (Fig. 58-21).
In addition, a Harris (axial) view, when not precluded by pain,
should be obtained to image the calcaneal tuberosity, subtalar
joint, and sustentaculum tali. Anterior process fractures require
differentiation from a calcaneus secundarius accessory ossification
center (see Fig. 58-15).139
Two assessments are critical to the management of calcaneal
fractures: whether the fracture involves the subtalar joint, and
the degree of depression of the posterior facet.140 Compression
fractures are not always obvious, and measurement of Boehler’s
angle (Fig. 58-22) can be helpful. Because Boehler’s angle may
be normal even in the presence of severely comminuted calcaneal
fractures, it has been considered more useful prognostically
than diagnostically, although recent findings raise questions
regarding the prognostic utility of this measurement as well.141
Boehler’s angle is measured on the lateral view as the angle between
two lines, one between the posterior tuberosity and the apex of
the posterior facet and the other between the apex of the posterior
facet and the apex of the anterior process. Although several values
for this measurement have been cited, an angle of 20 to 40 degrees
defines a normal range with the best diagnostic performance.142
An angle of less than 20 degrees suggests a compression fracture.
Comparison measurement of the uninjured side may be helpful
in questionable cases; however, the degree of variability between
feet in the same individual is poorly defined, and advanced
imaging is preferable in such situations.
Imaging of the calcaneus can be difficult because of the
complex three-dimensional nature of its articulations. Plain radiography can underestimate injury severity, and the CT scan has
formed by two lines, one between the posterior tuberosity (A) and the
apex of the posterior facet (B) and the other between the apex of the
posterior facet (B) and the apex of the anterior process (C). A value less
than 20 degrees suggests a calcaneal compression fracture. (From
Rosen P, et al [eds]: Diagnostic Radiology in Emergency Medicine. St. Louis, Mosby, 1992.)
revolutionized the assessment of calcaneal fractures, with good
correlation of findings with outcome.140,143 MRI is also an excellent
modality for imaging the hindfoot and has a role in assessment of
selected calcaneal fractures.
Management. The management of intra-articular or displaced
calcaneal fractures is controversial, with many operative and
nonoperative approaches described.140 Minimally invasive surgical
approaches and new technologies are changing the surgical
approach to these injuries.144 A recently published 15-year followup of a randomized trial comparing operative and nonoperative
management of displaced intra-articular calcaneal fractures found
no differences in clinical outcomes between the treatment
groups.141 The treatment of nondisplaced extra-articular fractures
usually involves casting for 6 to 8 weeks.
Disposition. Intra-articular or displaced calcaneal fractures
require orthopedic consultation in the ED. Outpatient orthopedic
follow-up care can be arranged for more innocuous injuries, provided that this approach is consistent with local practice and no
associated injuries that warrant hospitalization are present. In
considering outpatient follow-up, it is important to bear in mind
that plain radiographs often significantly underestimate the extent
and severity of calcaneal fractures. Minor extra-articular fractures
usually heal uneventfully; however, with significant calcaneal fractures, complications, including compartment syndrome, are frequent. In both conservatively and surgically treated patients, the
incidence of long-term pain, loss of joint mobility, and functional
disability approaches 50%.145
Midtarsal Joint Injuries
The midtarsal joint (Chopart’s joint) is composed of the talonavicular and calcaneocuboid joints. Injury in this area, although
rare, can occur with any ankle, hindfoot, or midfoot trauma.
Midtarsal joint injuries usually result from forced dorsiflexion
and often are associated with other significant fractures. Sprains,
fracture-subluxations and fracture-dislocations, and an isolated
“swivel dislocation” (a variant of a subtalar dislocation) all can
occur at the midtarsal joint. Pain, swelling, inability to bear weight,
and tenderness over the midtarsal joint are usual findings.
Although standard radiographs often are abnormal in appearance,
the diagnosis frequently is overlooked or delayed, with symptoms
ascribed to an ankle sprain (see Fig. 58-12 and Box 58-2). The
possibility of a midtarsal joint injury should be considered with
any isolated midfoot fracture,146 particularly those of the navicular
tuberosity. MRI can be helpful in the evaluation of midfoot tendon
Chapter 58 / Ankle and Foot 741
147
and ligamentous injuries. Undisplaced injuries may heal with
casting, but operative fixation is often required and management
can be difficult.148 Complications are common and include persistent pain, arthritis, and long-term disability.
Cuboid Fractures
The midfoot is an inherently stable region of the foot and is not
commonly injured. Fractures and relationships of the midfoot
tarsals often are difficult to visualize on standard radiographic
views because of underpenetration and the oblique orientation of
the bones and joints. A compounding factor is that pain associated
with midfoot injuries often is ill-defined and poorly localized.
Delay in diagnosis is frequent with midfoot injuries. Although
isolated fractures of the midfoot tarsals occur, associated injuries,
including significant sprains, subluxations, and spontaneously
reduced dislocations, are often present.
Isolated cuboid fractures are uncommon and usually result from
lateral subluxation of the midtarsal joint in Lisfranc’s injury.
Cuboid fracture has been termed a nutcracker fracture because the
cuboid is crushed between the bases of the fourth and fifth metatarsals and the anterior calcaneus.150 These fractures are also associated with fractures of the posterior malleolus.
The cuboid is best evaluated by the oblique view of a standard
foot radiographic series because this demonstrates both the calcaneocuboid and the cuboid-metatarsal relationship. The possibility
of Lisfranc’s injury should be considered with any cuboid fracture.
Treatment of isolated injuries ranges from casting for minor nondisplaced fractures to operative fixation.151 Extra-articular cuboid
fractures can lead to serious disability from dysfunction of the
peroneus longus tendon at the level of the peroneal groove. All
cuboid fractures warrant orthopedic assessment.
Navicular Fractures
Cuneiform Fractures
Principles of Disease: Anatomy. The navicular has a curved
shape—hence the derivation of its name from the Latin word
navis, meaning “ship.” Because of the navicular’s extensive
articular surface, its blood supply can enter only through a small
waist of cortex, and the middle third is relatively avascular. As a
result, the navicular is at particular risk for avascular necrosis
after fractures, analogous to its counterpart in the wrist, the
scaphoid bone.149
Pathophysiology. Navicular fractures, although relatively rare,
are the most common midfoot fracture and are classified into
dorsal avulsion fractures, tuberosity fractures, and body fractures.
Dorsal avulsion fractures account for one half of navicular fractures and usually occur when an eversion stress causes bony
avulsion from either the talonavicular capsule or the deltoid ligament. These fractures usually do not involve a significant amount
of articular surface. Tuberosity fractures also occur from eversion
forces, leading to an avulsion at the insertion of the posterior
tibial tendon. A tuberosity fracture may be the only clue to the
presence of a midtarsal joint injury. Body fractures are uncommon and result from an axial loading mechanism. They often
are comminuted, intra-articular, and associated with other midtarsal pathologic conditions. Stress fractures of the navicular can
also occur.
Clinical Features. Navicular fractures cause localized tenderness
over the dorsal and medial aspects of the midfoot. The navicular
tuberosity may be tender and is located by first identifying the
sustentaculum tali, a shelf of bone on the medial aspect of the
ankle approximately 2.5 cm below the tip of the medial malleolus.
The tuberosity is then easily palpable just anterior to this landmark. In the case of tuberosity fractures, pain may be exacerbated
by passive eversion or active inversion of the foot.
Diagnostic Strategies: Radiology. Standard foot radiographs
usually demonstrate navicular fractures; however, CT or MRI may
be required. Care is taken not to confuse the commonly occurring
os tibiale externum, also called an accessory navicular bone, with
an acute fracture (see Fig. 58-15).
Management. Dorsal avulsion and tuberosity fractures not
involving a significant amount of articular surface are usually
treated with a walking cast for 4 to 6 weeks. Body fractures and
displaced fractures involving more than 20% of the articular
surface often require operative fixation.
Disposition. Most navicular fractures are suitable for outpatient
orthopedic follow-up; however, significant fractures, particularly
if intra-articular, warrant orthopedic consultation in the ED.
Navicular tuberosity fractures can be complicated by nonunion.
Avascular necrosis and arthritis, particularly in body or other
intra-articular fractures, are potential late sequelae.
Fractures of the cuneiforms are extremely uncommon and usually
result from direct trauma. As with cuboid fractures, the patient
should be assessed carefully for the presence of Lisfranc’s injury.
Treatment usually is by casting; however, displaced fractures
require orthopedic assessment.
Midfoot Injuries
Dislocations of the Navicular, Cuboid,
and Cuneiforms
Isolated dislocations of each of the midfoot bones have been
described. These are uncommon injuries that often require open
reduction. Orthopedic consultation in the ED is required for any
of these injuries.
Lisfranc (Tarsometatarsal) Fractures
and Dislocations
Principles of Disease: Anatomy. Collectively, the tarsometatarsal
joints (see Fig. 58-14) are commonly called Lisfranc’s joint. Any
injury to this area, whether sprain, dislocation, or fracturedislocation, is termed a Lisfranc injury. Knowledge of the anatomy
of the Lisfranc joint complex is central to an understanding of
these injuries.
Lisfranc’s joint is composed of the articulations of the bases of
the first three metatarsals with their respective cuneiforms and the
fourth and fifth metatarsals with the cuboid. In concert, the tarsometatarsal joints act to allow supination and pronation of the
forefoot. The intrinsic stability of Lisfranc’s joint is provided by
the bone architecture and associated ligaments. When viewed end
on, the metatarsals have a trapezoidal shape and combine to form
a transverse arch with the second metatarsal acting as the “keystone.” The second metatarsal is essential for the stability of the
entire complex and is further buttressed by its snug articulation
in a recess created by the three cuneiforms. Strong transverse
intermetatarsal ligaments join the bases of the second through
fifth metatarsals, and Lisfranc’s ligament joins the medial cuneiform with the second metatarsal base. Lisfranc’s joint is further
supported by dorsal and plantar ligaments, the plantar fascia, and
the insertions of the tibialis anterior and peroneus longus tendons
at the first metatarsal base.
Pathophysiology. Lisfranc injuries are uncommon, in part
because tremendous energy is often required to disrupt this
complex. Such injuries arise from three mechanisms: rotational
forces, whereby the body twists around a fixed forefoot; axial
loads, whereby the weight of the body drives the hindfoot into
the bases of the metatarsals; and crush injuries. Because of the
mechanisms involved, associated injuries, such as MTP joint
742 PART II ◆ Trauma / Section Three • Orthopedic Lesions
dislocations, can occur. Most Lisfranc injuries are incurred in
MVCs. Sports involving fixation of the forefoot (e.g., equestrian
activities and windsurfing) also are associated with these injuries.
Of note, one third of Lisfranc ligamentous injuries arise from
seemingly trivial mechanisms such as stumbles or falls. Most Lisfranc injuries are closed.
Numerous classifications for displaced Lisfranc injuries exist,
none of which aids in determining appropriate treatment or
outcome.152 The most intuitive classification categorizes the direction of the dislocation in the horizontal plane (Fig. 58-23).153-155
In homolateral injuries, all five metatarsals are displaced in the
same direction. In isolated injuries, one or more metatarsals are
displaced away from the others. In divergent injuries, the metatarsals are splayed outward in both the medial and the lateral directions. These injuries usually occur between the first and second
metatarsals because of their lack of an intermetatarsal connection.
A component of dorsal displacement also is commonly present in
displaced Lisfranc injuries, whereas plantar displacement is
uncommon because of the joint’s bone architecture and the
strength of the plantar ligaments and fascia.
Because of ligamentous attachments, Lisfranc injuries almost
invariably involve associated metatarsal fractures, usually of the
second metatarsal base. Fractures of the cuboid, cuneiforms, and
navicular also are common, occurring in more than one third of
cases. Lisfranc injuries may be complicated by vascular injury
because a critical branch of the dorsalis pedis artery dives between
the first and second metatarsals to form the plantar arch. Trauma
to this vessel can cause significant hemorrhage and, uncommonly,
vascular compromise.
Clinical Features. Most Lisfranc injuries are clinically obvious;
however, findings may be subtle, and the true extent of the pathologic condition can easily be missed or misdiagnosed.156 Apparently trivial fractures, if viewed in isolation, fail to reflect the
serious soft tissue disruption that can be present. Some estimate
that the diagnosis is missed on initial ED presentation in up to
20% of cases.157-159
The clinical presentation varies with the extent of injury and
displacement. Severe pain in the midfoot and inability to bear
Homolateral
weight, particularly on the toes, are usual features. Paresthesias are
occasionally present, and examination usually reveals edema and
ecchymosis. In severe injuries, obvious deformity with forefoot
abduction, equinus (a plantar-flexed position of the forefoot), and
prominence of the medial tarsal area can be present. In addition,
anteroposterior shortening and transverse broadening may be
found. The dorsalis pedis pulse can be absent, or evidence of
vascular compromise of the forefoot may be present. Typically,
tenderness along the affected tarsometatarsal joints and pain with
passive abduction and pronation of the forefoot are present,
sometimes with pathologic mobility.
Diagnostic Strategies: Radiology. Standard radiographic views
of the foot usually are sufficient to diagnose injuries to the Lisfranc complex, although findings may be subtle (Fig. 58-24). The
anteroposterior view identifies fractures and alignment, with the
oblique view greatly aiding this assessment by eliminating overlap
at the metatarsal bases. The lateral view shows the soft tissues and
identifies any dorsal or plantar displacement. Weight-bearing
(stress) radiographs may be helpful in uncertain cases,157 and,
although poorly studied, it has been suggested that up to 10% of
Lisfranc injuries are undetectable without stress views.160 In
situations in which pain precludes weightbearing, regional anesthesia may facilitate obtaining weight-bearing radiographs. Comparison views are extremely helpful, and a 30-degree oblique
view, in addition to the standard 45-degree oblique view, also
may be of value. As is the case elsewhere in the hindfoot and
midfoot, CT scanning has revolutionized the diagnosis and evaluation of Lisfranc injuries.161 Because of its ability to image ligamentous structures, MRI may be useful to predict Lisfranc joint
complex instability.162
An appreciation of normal radiographic anatomy is essential
to assess Lisfranc injuries. Radiographs should be methodically
examined, with assessment of alignment, bones, and soft tissues.
The first four metatarsals should each line up with the respective
tarsal articulation along the medial edge on anteroposterior and
oblique radiographic views. The most consistent relationship is
the alignment of the medial edge of the base of the second metatarsal with the medial edge of the middle cuneiform. Dorsal
Isolated
Divergent
Figure 58-23. Classification of Lisfranc injuries. The ligamentous anatomy of the Lisfranc complex also is depicted. (From Hardcastle PH, et al:
Injuries to the tarsometatarsal joint: Incidence, classification and treatment. J Bone Joint Surg Br 64:349, 1982.)
Chapter 58 / Ankle and Foot 743
B
A
C
Figure 58-24. A, Anteroposterior radiograph showing a Lisfranc injury with fractures of the bases of the second through fourth metatarsals,
including a fragment suspicious for an avulsion from the Lisfranc ligament at the second metatarsal base. B, Lateral radiograph showing a step-off
at the tarsometatarsal joints (arrow). C, Computed tomography scan of the same patient showing increased detail, including lateral displacement
of the first metatarsal relative to the first cuneiform (arrow). (From Gupta RT, et al: Lisfranc injury: Imaging findings for this important but
often-missed diagnosis. Curr Probl Diagn Radiol 37:115, 2008.)
744 PART II ◆ Trauma / Section Three • Orthopedic Lesions
alignment of the tarsals with their respective metatarsals should
be assessed on the lateral view.
Findings suggestive of a Lisfranc injury include widening
between the first and second or second and third metatarsal bases
and any fracture around Lisfranc’s joint. Fracture of the second
metatarsal base (called a fleck sign), cuboid fractures, and cuneiform fractures are particularly common. A fracture of the second
metatarsal base is virtually pathognomonic for occult tarsometatarsal joint disruption.
If a suspicious fracture is present and alignment appears normal,
a spontaneously reduced dislocation may be present. In addition,
plain radiographs may be normal in appearance in the setting of
a typical history and tenderness over the tarsometatarsal joints,
suggesting a sprain of the Lisfranc complex that may or may not
be unstable. In either case, stress radiographs may be diagnostic.
Management. Lisfranc injuries usually are treated with closed
reduction and internal fixation with percutaneous Kirschner
wires. This is followed by non–weight-bearing casting for 12 weeks
and wearing of an orthotic for 1 year. Treatment of a sprain of the
Lisfranc complex usually involves immobilization for 6 weeks in
a below-knee walking cast.
Disposition. Any obvious or suspected Lisfranc injury requires
orthopedic consultation in the ED. Patients suspected of having a
sprain of the Lisfranc complex require casting and orthopedic
assessment on an outpatient basis, because operative fixation
can be required. The incidence of complications with a Lisfranc
injury depends on the timing of diagnosis and the degree of anatomic reduction achieved. Aggressive surgical management clearly
improves outcome.
Delayed treatment or missed diagnosis of Lisfranc injuries
can result in significant complications.163 Degenerative arthritis
is a common complication. Other potential complications include
compartment syndrome, residual pain, unequal metatarsal pressure, loss of the metatarsal arch, and complex regional pain
syndrome. Unstable sprains of the Lisfranc complex can result
in biomechanical problems if untreated, and delayed presen­
tations pose management challenges and often result in
complications.164
Forefoot Injuries
Traumatic forefoot conditions are commonly underdiagnosed and
often consist of more than one fracture or dislocation occurring
simultaneously. As occurs elsewhere in the foot, forefoot trauma
may lead to prolonged disability and dysfunction.
Metatarsal Fractures
Metatarsal fractures are common and account for one third of foot
fractures. The best approach is first to classify the injury anatomically as occurring in the shaft, the head and neck, or the base.
Management is then dictated by the metatarsal involved, the specific location and type of fracture, and the nature of any associated
injuries.165,166
Metatarsal Shaft Fractures Principles of Disease: Pathophysiology. Metatarsal shaft fractures
arise from either direct trauma (e.g., a crush injury from a heavy
object) or indirect trauma (e.g., a twisting force applied to a fixed
forefoot). Because of the nature of the mechanism of injury, associated phalangeal fractures often occur. Direct trauma may be
highly disruptive, resulting in multiple metatarsal fractures and
severe complications. The third metatarsal is the most commonly
fractured, and metatarsal shaft stress fractures are common.
Biomechanics are an important consideration in the approach
to metatarsal shaft fractures. During stance, weight is distributed
equally between the heel and forefoot, where it is spread across the
metatarsals, with the first metatarsal carrying twice its share of the
load. Great toe metatarsal fractures, although uncommon, require
more aggressive management because of this load-bearing function. Alignment of fractured metatarsals is important because
dorsal or plantar displacement can lead to pain or functional disability by altering the transverse arch and load distribution. Dorsal
angulation commonly occurs at the site of metatarsal fractures
from the action of intrinsic muscles and toe flexors. Medial or
lateral displacement, although less critical, can lead to the development of painful bony prominences or neuromas.
Clinical Features. Metatarsal shaft fractures cause weightbearing difficulty and tenderness, which usually is maximal on the
plantar surface and can be difficult to localize if swelling is significant. Axial compression of the involved toe often is painful, and
ecchymosis usually appears within 12 hours of injury. Rotational
alignment should be assessed by evaluating the position and plane
of the involved digit.
Diagnostic Strategies: Radiology. Standard radiographs are sufficient to diagnose most metatarsal shaft fractures; however, radiographs usually are exposed for visualization of the talar bones, and
the forefoot may be overpenetrated. Adjustment of penetration or
coned views may be required for visualization of subtle fractures.
Displacement and angulation, in both the sagittal and mediolateral planes, should be assessed.
Management. Most undisplaced metatarsal shaft fractures of
the second through fifth metatarsals are treated with a below-knee
walking cast for 2 to 4 weeks. Early casted ambulation may be
beneficial to healing and may reduce the incidence of complex
regional pain syndrome. Although some practitioners recommend
a non–weight-bearing cast for 4 to 6 weeks for these fractures,
others suggest that a metatarsal pad, stiff shoes, and crutches, if
needed, are sufficient. These various approaches attest to the fact
that most nondisplaced metatarsal shaft fractures heal well regardless of the treatment.
The great toe metatarsal requires more aggressive management
because of its biomechanical role and the stresses imposed on it
during gait. Nondisplaced first metatarsal fractures should be
treated with casting for 4 to 6 weeks.167 For at least the first 3 weeks
of this immobilization, if not the entire period, the patient should
not bear weight.
Reduction should be considered in any metatarsal shaft fracture
with more than 3 mm of displacement or 10 degrees of angulation. Closed reduction, with toe traps and countertraction at the
ankle, is often successful. Non–weight-bearing casting for 4 to 6
weeks should follow. The indications for open reduction are controversial but generally include the presence of compartment syndrome, unstable fractures, open fractures, fractures that have
failed closed reduction, and multiple fractures. These are treated
with fixation with either Kirschner wires or plates.167 In particular,
displaced first and fifth metatarsal shaft fractures are commonly
treated operatively. Major forefoot trauma, with crushing and
multiple open metatarsal fractures, requires an aggressive approach
with staged operative management.
Disposition. Most undisplaced metatarsal shaft fractures are
suitable for management without orthopedic referral. Orthopedic
consultation in the ED should be obtained for patients with multiple or displaced fractures. Complications are rare in nondisplaced or minimally displaced metatarsal shaft fractures. Complex
regional pain syndrome can occur and may be related to the
unnecessary use of non–weight-bearing casting. Inadequate
reduction, particularly in the sagittal plane, can lead to biomechanical problems and formation of painful callosities or metatarsalgia. Malunion in the mediolateral plane, particularly if involving
the first or fifth metatarsal, can lead to development of pressure
points, neuromas, or biomechanical problems. Delayed union,
nonunion, compartment syndrome, and soft tissue complications
occur uncommonly.
Chapter 58 / Ankle and Foot 745
Metatarsal Head and Neck Fractures Metatarsal head and neck fractures, although similar in their
pathophysiology and assessment to shaft fractures, commonly are
multiple and often result from direct trauma. Nondisplaced fractures may be treated with a walking cast for 4 to 6 weeks. Often
these fractures are displaced, with the distal fragment pulled in a
plantar and lateral direction by the flexor tendons, a finding best
appreciated on oblique and lateral radiographic views. Precise
realignment of neck and head fractures is important to maintain
the transverse arch. Although reduction may be successful with
toe traps, instability is common, and operative fixation is required
more commonly than with shaft fractures. Most of these fractures
warrant orthopedic consultation in the ED, particularly if they are
displaced or intra-articular. Complications are similar to those
seen with shaft fractures.
Metatarsal Base Fractures Principles of Disease: Pathophysiology. Isolated fractures of the
first through fourth metatarsal bases are uncommon. Most are
nondisplaced transverse fractures within 1 cm of the tarsometatarsal articulation and arise as a result of direct trauma. An indirect mechanism is more suggestive of the presence of an occult
Lisfranc injury. The most commonly encountered metatarsal base
fractures occur at the fifth metatarsal.
Fifth Metatarsal. Jones fracture is a term often erroneously
applied to any fracture of the fifth metatarsal base. The eponym
is in reference to Sir Robert Jones, a physician who in 1902
described a fracture he sustained while dancing and a series of
similar injuries. In reality, two distinct acute fractures can occur
in the region of the fifth metatarsal base, and debate continues
regarding which one Jones actually described.168 More important
than the terminology, these two fractures differ dramatically in
their mechanism, treatment, and prognosis.169
The more common, and benign, fracture at the fifth metatarsal
base is of the tuberosity. Also called the styloid, the tuberosity
is the bulge of the fifth metatarsal that is easily palpated over
the lateral edge of the foot. It is fractured by a sudden inversion
of a plantar-flexed foot. For decades, this fracture was thought
to be caused by an avulsion at the insertion of the peroneus
brevis tendon; however, it is now known that the plantar
aponeurosis is responsible for the location and nature of this
fracture.170
Tuberosity fractures range from tiny flecks to lesions involving
the entire tuberosity and usually are extra-articular, although they
may extend into the cubometatarsal joint. Often these injuries
masquerade as ankle sprains (see Fig. 58-12 and Box 58-2), making
the fifth metatarsal base an important area to palpate in any twisting injury.
The more serious acute fracture at the base of the fifth metatarsal is a transverse fracture occurring at least 15 mm distal to the
proximal end of the bone.169 This diaphyseal fracture probably
is a true Jones fracture and involves the fourth and fifth inter­
metatarsal articulations but not the cubometatarsal articulation.
Diaphyseal fractures result from a complex combination of forces
generated when a load is applied to the lateral forefoot in the
absence of inversion.169 Typically these occur in running and
jumping sports. Further subclassification schemes of proximal
diaphyseal fractures exist and can be helpful in determining management.152 Fifth metatarsal diaphyseal stress fractures can also
occur and should be considered when a seemingly acute injury is
preceded by a prodrome of pain in the region over weeks to
months.152,166
Clinical Features. The assessment of metatarsal base fractures
is similar to that described for fractures of the metatarsal shaft.
Pain often is diffuse and difficult to localize in these injuries, with
the exception of the easily palpable fifth metatarsal tuberosity.
Passive inversion also may be painful with a fifth metatarsal base
fracture.
Diagnostic Strategies: Radiology. Standard radiographic views
easily demonstrate most metatarsal base fractures. Radiographs
should be carefully assessed for fracture angulation, displacement,
and articular extension. If the fracture is intra-articular, an estimation of the percentage of articular surface involved is essential in
determining management. In difficult cases, CT studies may be
helpful.
With fractures of the first through fourth metatarsal bases, it is
important to search for other radiologic clues to a Lisfranc injury.
A fracture of the second metatarsal base is virtually pathognomonic for occult tarsometatarsal joint disruption. In assessment
for a fifth metatarsal base fracture, differentiation between the
tuberosity and diaphysis is essential (Fig. 58-25). Care should be
taken not to misinterpret an os vesalianum or os peroneum for a
fifth metatarsal base fracture (see Fig. 58-15). Standard ankle
radiographs also demonstrate the fifth metatarsal base, and this
area should be routinely scrutinized.
Management. Nondisplaced extra-articular fractures of the first
through fourth metatarsal bases usually are managed with a
below-knee cast. Displaced fractures should be reduced and often
require fixation. Intra-articular fractures, especially those of the
first metatarsal, often lead to complications. Operative fixation
may be required, even in nondisplaced intra-articular first metatarsal base fractures, if more than 25% of the articular surface is
involved.
The management of fifth metatarsal base fractures depends on
the type of fracture. Extra-articular tuberosity fractures, regardless
of their size or degree of displacement, heal well and are managed
symptomatically with a walking cast for 2 to 3 weeks, compression
wrap, or stiff shoes.168 Intra-articular tuberosity fractures involving more than 30% of the articular surface, or with more than
2 mm of displacement, may require fixation.168 Nondisplaced
intra-articular fractures usually are treated initially with non–
weight-bearing casting for 6 to 8 weeks, followed by radiographic
reassessment.168 Immobilization for up to 6 months may be
required for complete healing, and immediate fixation may be
advisable in athletes.169 Displaced fifth metatarsal diaphyseal fractures usually are managed operatively,171 and prolonged treatment
may be necessary particularly for diaphyseal stress fractures.
Disposition. Because they are rare and treatment varies, most
first through fourth metatarsal base fractures require orthopedic
assessment. Nondisplaced extra-articular fractures of the first
through fourth metatarsal bases are suitable for orthopedic
follow-up on an outpatient basis. Orthopedic consultation in the
ED should be obtained in any other first through fourth metatarsal base fracture or if Lisfranc’s injury is suspected. Significant or
displaced intra-articular fifth metatarsal tuberosity fractures or
diaphyseal fractures warrant orthopedic evaluation in the ED.
Intra-articular metatarsal base fractures involving the first
through fourth metatarsals can lead to post-traumatic arthritis
requiring arthrodesis. Complications are rare in cases of fifth
metatarsal tuberosity fractures, although fibrous nonunion of the
fracture fragment can occur. Fifth metatarsal diaphyseal fractures
are often complicated by delayed union, nonunion, or fracture
recurrence, owing to poor healing subsequent to disruption of the
metatarsal vascular supply. These complications occur in more
than 50% of patients treated conservatively and often require
aggressive surgical therapy and have prolonged healing times.
Phalangeal Fractures
Principles of Disease: Pathophysiology. Phalangeal fractures are the
most common forefoot fracture. They usually arise from direct
trauma, often the result of dropped heavy objects or stubbing the
toe. Less commonly, indirect mechanisms involving twisting of the
forefoot can lead to phalangeal fractures. Proximal phalanges are
more commonly fractured than middle or distal phalanges, and
746 PART II ◆ Trauma / Section Three • Orthopedic Lesions
A
Figure 58-25. A, Diaphyseal fracture of the fifth
B
the proximal phalanx of the fifth toe is most commonly injured.
Fractures of the hallux often are displaced, whereas fractures of
the lesser phalanges are often comminuted but less commonly
displaced.
Clinical Features. Although phalangeal fractures generally are
considered minor injuries, they can lead to disabling sequelae and
merit careful assessment.172 The patient with a phalangeal fracture
has acute pain and swelling of the affected toe, often with difficulty
ambulating or wearing shoes. Examination may reveal tenderness,
crepitus, and reduced range of motion. A subungual hematoma
metatarsal (arrow). This is the more serious of the
two fractures occurring at the fifth metatarsal base.
B, Tuberosity fracture of the fifth metatarsal base
(arrow). This is the more benign of the two
fractures occurring at the fifth metatarsal base. (A, From Rosen P, et al [eds]: Diagnostic Radiology
in Emergency Medicine. St. Louis, Mosby, 1992.)
often is present if the distal phalanx is involved, and open fractures
are common.
Diagnostic Strategies: Radiology. Standard radiographic views
usually are sufficient to demonstrate phalangeal fractures, with the
lateral view being most sensitive. Often the uninjured toes must
be positioned out of the way for adequate radiographs to be
obtained, and magnification radiographs occasionally are required.
Angulation and joint involvement should be assessed.
Management. Most phalangeal fractures are easily managed
and heal well. Large and symptomatic subungual hematomas
Chapter 58 / Ankle and Foot 747
should be evacuated, and, on rare occasions, nail bed repair may
be required. Nondisplaced lesser phalangeal fractures should be
stabilized by “buddy-taping”—splinting the injured toe to an adjacent, ideally longer, toe with adhesive tape. Placement of gauze
between the splinted toes is advisable to prevent skin maceration.
Phalangeal fractures often remain painful for 2 to 3 weeks until
stabilized by callus.
If significant displacement or angulation is present, reduction
should be performed with manual traction or toe traps after
digital block anesthesia. Moderate persistent angulation or displacement is acceptable if the clinical appearance of the toe
remains satisfactory. Rarely, operative fixation of lesser phalangeal
fractures is indicated, particularly in cases with severe rotatory
deformity or in open fractures requiring débridement.
Nondisplaced phalangeal fractures involving the hallux are
treated by buddy-taping, with a walking cast worn for 2 to 3 weeks
if the toe is painful. Alternatives to standard casting techniques,
such as the slipper cast, have also been described for phalangeal
fractures.173 Displaced phalangeal fractures of the hallux require
reduction. If the reduction is inadequate or unstable, operative
fixation may be indicated. Unless completely nondisplaced, most
intra-articular fractures involving the hallux are treated with
operative fixation, although this is an area of controversy.
Disposition. Most phalangeal fractures do not require orthopedic evaluation; however, if displacement persists or causes cosmetic or functional concern, consultation is advised. Orthopedic
consultation in the ED is advised for poorly reduced or intraarticular hallux fractures.
Complications of phalangeal fractures are uncommon. With
intra-articular phalangeal fractures, particularly those involving
the hallux, arthritis may be a late sequela, or fragments may
require operative removal. Symptomatic angular malunion and
osseous deformity can occur with phalangeal fractures, and exostectomy is sometimes required.
Sesamoid Fractures
The sesamoids are two flat oval bones found within the tendon of
the flexor hallucis brevis, under the head of the first metatarsal.
Their name comes from the Greek word sesamoeides, meaning
“resembling a sesame seed.” Ten percent of the population has
sesamoid bones under the fifth metatarsal head, and uncommonly,
sesamoids are found under the second, third, or fourth metatarsal
(see Fig. 58-15). Sesamoid fractures are uncommon and usually
are caused by direct trauma from falls. Hyperextension of the
great toe can indirectly lead to a sesamoid fracture.174 Sesamoid
fractures also can be found in association with MTP joint dislocations. The medial sesamoid of the great toe is more commonly
fractured than the lateral, and a suspected fracture should be differentiated from a bipartite sesamoid, which occurs in up to one
third of the population and also is more common on the medial
aspect. Stress fractures of the sesamoids also occur. Sesamoid fractures generally require a below-knee walking cast for 3 to 4 weeks.
Most heal without complications and do not require orthopedic
consultation.
Metatarsophalangeal Dislocations
Principles of Disease: Pathophysiology. Dislocations of the MTP
joint are uncommon injuries because of the protection footwear
provides and the inherent stability of MTP and IP joints. MTP
joint dislocations can occur in any joint and in any direction. First
MTP joint dislocations require large forces and usually result from
MVCs. These injuries often are open and typically involve dorsal
dislocations of the distal component caused by hyperextension of
the MTP joint. Associated sesamoid fractures may be present.
Complex dislocations, in which the sesamoids or local tendons
prevent closed reduction, can occur. Second through fifth MTP
dislocations usually are medial or lateral displacements that occur
when the toe strikes or hooks an object. The most common is a
lateral dislocation of the fifth MTP joint.
Clinical Features. Dislocations of the MTP joint cause pain,
swelling, and difficulty bearing weight on the ball of the foot. First
MTP joint dislocations usually are obvious on clinical examination because the toe is angled upward with dorsal and proximal
displacement of the proximal phalanx. This deformity leads to a
striking prominence of the metatarsal head over the plantar
surface. Skin tenting or a dimple may be present. Rarely the sesamoids are palpable dorsal to the metatarsal, indicating a complex
dislocation. Dislocations of the lesser toes often are more subtle
in presentation, and comparison with the uninjured foot may be
helpful. Neurovascular compromise is rare.
Diagnostic Strategies: Radiology. Dislocations of the MTP joint
are well visualized on standard radiographic views of the foot.
In first MTP joint dislocations, a double density often is present,
caused by superimposition of the base of the proximal phalanx
over the metatarsal head. Radiographs should be scrutinized
for signs suggesting complex dislocation, such as the sesamoids
lying between the two articular surfaces or dorsal to the metatarsal head.
Management. Most MTP joint dislocations, particularly of the
lesser toes, are easily reduced with longitudinal traction. Appropriate analgesia or local anesthesia should be administered before
reduction is attempted. Dorsal dislocations of the first MTP joint
can be more challenging and may require initial accentuation
of the deformity in addition to longitudinal traction for reduction.
Joint stability should be assessed and repeat radiographs obtained
after reduction of an MTP joint dislocation. After reduction,
a walking cast with a toe plate is worn for 3 weeks, followed
by physiotherapy to ensure adequate range of motion. Alternatively, buddy-taping and an aluminum splint can be used for
immobilization.
Disposition. Most MTP joint dislocations can be managed
without orthopedic consultation. If crepitus or obvious instability
is present or postreduction radiographs show joint incongruity or
an intra-articular fracture, orthopedic consultation should be
obtained for possible fixation. First MTP joint dislocations that
are open, show radiographic evidence of complexity, or do not
easily reduce require orthopedic consultation in the ED, because
open reduction may be required. Very rarely, MTP joint dislocations of the lesser toes require open reduction.
Complications are uncommon after MTP dislocations. Arthritis
and reduced range of motion, particularly of the hallux, may
occur. Dislocations for which the diagnosis is delayed for more
than 3 weeks often are not amenable to closed reduction and may
require metatarsal head excision.
Interphalangeal Joint Dislocations
IP joint dislocations are much less common than MTP joint dislocations and are sometimes overlooked. Most IP joint dislocations occur in the great toe and are a result of axial loading. IP
joint dislocations usually involve dorsal displacement of the distal
component and are easily managed without orthopedic consultation. Reduction is performed with longitudinal traction after
digital block anesthesia is achieved. Initial accentuation of the
deformity may be necessary if reduction is unsuccessful with
simple traction. If the dislocation involves the great toe, a walking
cast with a toe plate for 3 weeks is indicated after reduction. Lesser
toes require only buddy-taping. As with the MTP joint, complex
dislocations involving the first IP joint can occur, and orthopedic
consultation in the ED for open reduction may be necessary. Very
rarely, lesser toe IP joint dislocations are irreducible with closed
methods and will require open reduction.
748 PART II ◆ Trauma / Section Three • Orthopedic Lesions
Foot Pain
Perspective. Foot pain, particularly in the absence of obvious
trauma, poses a diagnostic and therapeutic challenge. Plain radiographs commonly are normal in appearance, so the history and
physical examination assume increased importance. Although a
definitive diagnosis often is difficult to obtain in the ED, a structured approach aids in appropriate patient management and disposition. Most causes of foot pain are minor and self-limited, but
the possibility of serious pathologic conditions (e.g., infection,
arthritis, tumor) should be considered. Although orthopedic consultation in the ED is rarely required, orthopedic or sports medicine follow-up on an outpatient basis is indicated for selected cases.
Foot pain can be classified as acute, acute on chronic, or chronic
and is best approached anatomically by localizing symptoms to
the hindfoot, midfoot, or forefoot. Three conditions warrant
specific mention.
Complex regional pain syndrome is a condition involving pain
in the presence of trophic changes and vasomotor instability from
inappropriate sympathetic nervous system activity and was previously termed “reflex sympathetic dystrophy.” Complex regional
pain syndrome occurs months after trauma, which may be major,
as in a Lisfranc injury, or relatively innocuous. It has many synonyms, including causalgia and Sudeck’s atrophy, and produces
pain of a diffuse burning, aching, or searing nature, together with
evidence of vasomotor instability. Complex regional pain syndrome should be considered in the differential diagnosis for foot
pain after trauma.
Another important consideration in patients with previous
penetrating trauma is a retained foreign body. Foreign bodies can
be a source of chronic drainage or chronic pain. The inciting
trauma may have occurred years previously, and a history of the
event may be difficult to extract, or such an event may be unknown
to the patient.
Finally, stress fractures are an important consideration in the
differential diagnosis for foot pain, particularly in athletes.
Hindfoot Pain. Hindfoot pain is a common complaint that
usually is the result of overuse rather than acute trauma.175 Bone
pain in the hindfoot necessitates consideration of talar or calcaneal stress fractures. A calcaneal stress fracture may be suspected
when pain is elicited on squeezing the calcaneus mediolaterally.
Another cause of bone pain is impingement by an os trigonum
(see Fig. 58-15) or prominent lateral posterior talar process. The
os trigonum syndrome involves pain during plantar flexion of
the foot and is particularly common in ballet dancers. A bone
scan may be required for diagnosis, and treatment is surgical.
Most patients with hindfoot pain describe subcalcaneal heel
pain, a complaint with an extensive differential diagnosis.176 The
literature on this topic is conflicting and fraught with inconsistent
terminology. The most common causes of subcalcaneal pain are
plantar fasciitis, subcalcaneal bursitis, acute rupture of the plantar
fascia, and nerve compression.
The plantar fascia is a tough layer of the sole that is functionally
significant during foot strike and the early stance phase of walking.
Plantar fasciitis, an overuse injury of insidious onset, usually
begins with pain on first weightbearing in the morning or after
prolonged sitting.177 This progresses to persistent pain during gait.
Pain and tenderness are localized to the medial aspect of the heel.
Plantar fasciitis is particularly common in cavus feet, although the
nature of this association is unclear.178 Plain radiography is not
diagnostic but shows a calcaneal spur in 50% of patients with
plantar fasciitis. This is a stress-related ossification with a 16%
incidence in asymptomatic persons and is not considered the
primary cause of pain in plantar fasciitis. Rarely, fascial ossification (an os subcalcis) may be seen.
Plantar fasciitis is distinct from subcalcaneal bursitis, a
condition with an identical presentation in which the pain is
localized to the bursa directly below the calcaneus. Differentiating
these two conditions can be difficult and usually is academic,
because initial treatment is identical: a combination of avoiding
pre­cipitating conditions, rest, padding, orthotics, nonsteroidal
anti-inflammatory drugs, and occasionally steroid injections.
Extracorporeal shock wave therapy can be beneficial in refractory
cases.179 Very rarely, surgical release of the plantar fascia is required,
a therapy that can be beneficial in either condition.
Plantar fascial rupture is a tear of the origin of the plantar fascia
at the calcaneus. This injury usually occurs during the push-off
phase of gait. Swelling may be noted, and typically pain is elicited
by passive dorsiflexion of the hallux. Treatment is nonsurgical,
often with a period of cast immobilization for symptomatic relief.
Compression of either the abductor digiti quinti nerve or the
posterior tibial nerve (the so-called “tarsal tunnel syndrome”) can
cause subcalcaneal heel pain.180 Diagnosis of these conditions is
difficult and is sometimes facilitated by assessing the impact of
selective nerve block with local anesthesia. Initial treatment of
these conditions is similar to that for plantar fasciitis, although
local steroid injections or surgical release may be required. Other
nerve entrapments also can occur in the hindfoot area.
Many tendons course through the hindfoot, particularly the
anteromedial aspect, and tendinitis can occur. Other tendon
pathologic conditions (e.g., ruptures, dislocations, retinacular
injuries) should be considered because they can result in significant functional disability.
Midfoot Pain. Isolated midfoot pain is less common than forefoot or hindfoot pain. Stress fractures are uncommon in the
midfoot and most commonly involve the navicular. Other causes
of midfoot pain include symptomatic accessory bones, particularly the accessory navicular, os tibiale externum, and os peroneum (see Fig. 58-15). An os tibiale externum is present in up to
14% of the normal population and is asymptomatic in most cases.
This accessory bone can produce debilitating pain on the medial
aspect of the midfoot. A bone scan facilitates diagnosis, and surgical excision may be necessary. An os peroneum is one of several
conditions that can cause lateral plantar pain in the midfoot
region. Localization of tenderness is aided by resisted plantar
flexion, and treatment ranges from immobilization to surgical
excision.
Forefoot Pain. The forefoot is the site for a myriad of painful
problems. Bunions, painful bursae, blisters, corns, calluses, hammertoes, and ingrown toenails all are diagnostically obvious but
can pose therapeutic challenges. Many are the result of poor footwear or a biomechanical problem with the foot and respond to
appropriate padding, avoidance of precipitants, and occasionally
surgical intervention.
Metatarsalgia is an often used, although loosely defined, term
referring to pain in the region of the metatarsal heads.181 This is a
common presenting complaint with many potential causes. Metatarsal stress fractures are extremely common and should be considered in the differential diagnosis for any unexplained forefoot
pain. Flexor or extensor tendinitis also can produce metatarsal
area pain and is suggested when plain radiographs show areas of
tendinous calcification. Arthritis, sesamoiditis, or a sesamoid
stress fracture should be considered when pain occurs in the
area of the hallux. “Turf toe” is MTP joint inflammation of the
hallux resulting from repeated hyperextension stress.117 It usually
responds to symptomatic measures but can be a significant and
debilitating injury in some athletes, such as football players.
An important cause of unilateral metatarsalgia is a perineural
fibrosis of the intermetatarsal plantar digital nerve, more
commonly known as Morton’s neuroma.181 This neuropathy of
unknown cause was first described in 1876 and usually involves
the second-third or third-fourth intermetatarsal space, causing
lancinating pain with weightbearing. The pain may be associated
with paresthesias and can radiate into the toes. In addition,
Chapter 58 / Ankle and Foot 749
“afterburn” pain can persist during rest. The pain of Morton’s
neuroma is reproduced when structures of the affected interspace
are pinched or when the metatarsal heads are compressed together.
Hence, pain may occur intermittently with tight-fitting footwear
(e.g., rock-climbing shoes, ski boots). Crepitus or a nodule may
be palpable. Initial treatment usually involves a metatarsal pad and
the use of shoes with a widened toe box. Surgical excision or
neurolysis may be required if conservative management is
unsuccessful.182
Freiberg’s disease is an osteochondrosis of the metatarsal head,
usually involving the second metatarsal, and is another cause of
pain in this area. Ingrown toenails are a common affliction that can
occur in any toe, most commonly the hallux. Often the abnormality is perpetuated by short nail trimming, which affords the
opportunity for a spicule of nail to grow under the nail fold.183
Allowing the nail to grow out and providing local care usually will
lead to resolution of the condition. Antibiotics are indicated if
infection is present. Chronic or recurring ingrowth necessitates
partial or complete excision of the nail and germinal ablation.183
SPECIAL CONSIDERATIONS
Stress Fractures
Principles of Disease: Pathophysiology
Stress fractures can occur anywhere in the appendicular skeleton
but are particularly common in the lower extremity. Athletic
activities, particularly running, account for most stress fractures.
Predisposing factors include training errors, poor footwear, a
previous period of inactivity, change in running surface, and
the “female athlete triad” of disordered eating, menstrual
disturbances, and low bone mineral density.184 Anatomic variations may play a role, with cavus feet being more prone to stress
fractures than flat feet.
Pedal stress fractures may occur anywhere but are most common
in the second or third metatarsal shaft. It is not generally appreciated that calcaneal stress fractures occur almost as often as metatarsal stress fractures. Midfoot stress fractures are uncommon and
usually occur in the navicular. The type of sport or activity is
related to the location of stress fractures, with navicular stress
fractures most often seen in basketball, metatarsal shaft stress
fractures in running, and fifth metatarsal diaphyseal stress fractures in football.
Clinical Features
Although the history is variable, most stress fractures produce
localized pain of insidious onset, usually with aching over a period
of weeks.185 The pain may be anywhere in the hindfoot, midfoot,
or forefoot but is most common along a metatarsal. Initially symptoms occur after athletic activities, but later they limit such activities. Often a predisposing factor, such as a training regimen change,
is present. A menstrual history should be obtained in female
patients because amenorrhea, often a result of training, can predispose to stress fractures.185-187
Physical examination may reveal swelling, point tenderness, or
percussion tenderness. In most patients, however, these findings
are absent, and the diagnosis is suspected by history alone.
Diagnostic Strategies: Radiology
Initial plain radiographs are commonly normal because bone
reaction in stress fractures depends on the length of time from
symptom onset. Radiographic abnormalities in the metaphyses
can take up to 4 weeks to develop, and those in the diaphyses can
take 6 weeks.25 Although plain radiographs have low sensitivity for
stress fractures, their specificity is high. The three important findings are periosteal new bone, endosteal thickening, or a radiolucent line. Radiographic findings vary with location: Metatarsal
fractures usually show callus or periosteal reaction, whereas navicular fractures show a lucent line, and calcaneal fractures show
curvilinear sclerosis.
The diagnosis of a stress fracture is easily missed because only
50% of patients develop plain radiographic abnormalities. Until
recently, radionuclide bone scanning was the imaging modality of
choice for stress fractures. Bone scans are nonspecific but extremely
sensitive for stress fractures, usually showing abnormal uptake
within 24 hours of injury. Rarely, a bone scan may be falsely negative if pain occurs before the onset of a demonstrable pathologic
condition. MRI scanning has been found to be equally sensitive
and more specific and has emerged as the imaging modality of
choice for the outpatient evaluation of this condition.25,115
Management
Athletic stress fractures are overuse injuries and necessitate an
evaluation of training habits, equipment, and techniques. Most
pedal stress fractures resolve in 4 to 6 weeks simply with limitation
of impact activities and do not require immobilization unless
symptoms are severe. Two locations, however, are unique and
deserve specific discussion.
Navicular stress fractures are uncommon and often delayed in
diagnosis. Healing is hampered by the relative avascularity of the
middle third of the bone, and initial treatment is with non–
weight-bearing casting for 6 to 8 weeks. Stress fractures of the fifth
metatarsal base are also problematic. Fifth metatarsal diaphyseal
stress fractures (also called chronic Jones fractures) are usually initially treated with non–weight-bearing status and casting. As with
acute diaphyseal fractures, delayed healing is common, and casting
for up to 20 weeks may be required.168
Disposition
Any patient diagnosed with or suspected of having a stress fracture
should undergo orthopedic or sports medicine follow-up on an
outpatient basis. Delayed union or nonunion can occur with stress
fractures, particularly those of the navicular or fifth metatarsal
base. Bone grafting or hardware fixation may be required. Most
other pedal stress fractures heal without complications.
Contusions and Sprains
Contusions of the foot, usually from dropped objects, are a
common injury. Sprains can occur in the foot, particularly with
athletic injuries. The calcaneocuboid and intermetatarsal ligaments are common sites of injury. Localizing such injuries is difficult, and these are often diagnoses of exclusion made after
appropriate clinical and radiographic assessment. Both contusions
and sprains usually respond rapidly to symptomatic therapy.
Sprains of the Lisfranc joint complex are unique and require
orthopedic consultation in the ED.
Tendon Injuries
Acute tendon ruptures in the foot, apart from the Achilles and
posterior tibial tendons, are rare. Although isolated ruptures of the
flexor hallucis longus and anterior tibial tendons have been
described, most tendon transections are the result of lacerations.
These typically arise from one of two mechanisms: penetrating
wounds to the sole of the foot or major trauma from such sources
as dropped objects, lawn mowers, or MVCs. Plantar penetrating
trauma usually results in flexor tendon injuries, whereas most
major mechanisms involve extensor tendons.
750 PART II ◆ Trauma / Section Three • Orthopedic Lesions
Orthopedic or plastic surgery consultation in the ED is indicated for any patient known or suspected to have a tendon injury
in the foot. It is clear that flexor and extensor hallucis longus
tendons should be repaired primarily; however, the need to repair
other tendons is controversial. In general, an attempt should be
made to repair any tendon transection, because apparently minor
injuries can lead to complications such as claw deformity. Tendon
injuries associated with innocuous lacerations are easily missed if
not carefully sought. Splinting for 2 to 6 weeks is required after
tendon repair.
Crush Injuries, Amputations, and Major
Vascular Injuries
Rapid assessment, stabilization, and immediate consultation are
priorities in the ED management of a major crush injury, amputation, or vascular injury of the foot. The injured limb is handled
gently and can be irrigated with sterile saline solution to remove
debris. Use of other irrigating solutions, exploration, or débridement, even if done carefully, is contraindicated.188 Antibiotics
should be administered, as with any open fracture. Compartment
syndrome should be considered in crush injuries. Many factors
enter into surgical decision-making for patients with such injuries,189 and objective measures, such as the “mangled extremity
score,” have been developed to predict the need for amputation.190
Local crush injuries often heal better than diffuse crush injuries.188
A surgical goal is preservation of as much length as possible to
maintain a longitudinal arch, and care plans are typically individualized.191 In the presence of a major vascular injury, the likelihood
of permanent disability is high.
present. Presence of an open wound does not guarantee that all
compartments are decompressed.
Diagnostic Strategies: Special Procedures
The only way to diagnose a compartment syndrome is to measure
intracompartmental pressure. The decision to perform this
maneuver relies on appropriate clinical suspicion. Techniques of
pressure measurement are well described, with a pressure greater
than 30 mm Hg generally considered diagnostic.193,194 Compartment syndrome can occur at lower pressures in hypotensive
patients. More details on the pathophysiology and diagnosis of
this condition can be found in Chapter 49. The needle localization
and distinguishing of foot compartments is challenging because
of their small size. For this reason and because of its importance
in surgical decision-making, measurement of pedal compartment
pressures usually should be left to an orthopedic surgeon.
Management
Early identification and prevention of further tissue damage are
important considerations in any patient with a mechanism consistent with the development of compartment syndrome. Circumferential bandages and casts should be avoided during early
management. In diagnosed or suspected cases of compartment
syndrome, the limb should be positioned at the level of the heart.
Limb elevation beyond this point is contraindicated because it
would decrease arterial flow, thereby narrowing the arterialvenous pressure gradient.
Disposition
Compartment Syndrome
Principles of Disease: Pathophysiology
Compartment syndrome is defined as an increase in pressure
within a confined osseofascial space that impedes neurovascular
function, resulting in tissue damage.188 Compartment syndrome
in the foot, as elsewhere in the body, constitutes a medical emergency. Classically, four foot compartments—medial, central,
lateral, and interosseous—are described, although studies using
dye injection have suggested that there may be as many as nine
foot compartments.188
Pedal compartment syndrome is most commonly caused
by significant crush injuries, fractures, or dislocations. Other
causes include bleeding disorders, burns, electrical injury, postischemic swelling after arterial injury or thrombosis, drug or
alcohol overdose, excessive exercise, and venous obstruction.37
Pedal compartment syndrome after an ankle sprain has also been
reported.192 Damage is related to the duration and magnitude of
compartment pressure rise and the arteriovenous gradient. Compartment syndrome can develop anywhere from 2 hours to
6 days after an insult, although the peak incidence is at 15 to
30 hours.
Clinical Features
Compartment syndrome typically causes pain out of proportion
to that expected for the injury. The pain is not decreased by immobilization and can be described as a feeling of tautness within the
foot.193 In the case of calcaneal fractures, the pain often is a relentless burning involving the entire foot. Physical examination may
reveal tense swelling and sensory deficits. Pain is exacerbated by
any movement (active or passive) that stretches the muscles of the
involved compartment. Passive dorsiflexion of the toes often is
painful. Peripheral pulses and capillary refill usually are normal in
compartment syndrome and thus offer no reassurance when
If compartment syndrome is suspected, immediate orthopedic
consultation is indicated because the only treatment is decompressive fasciotomy.
ACKNOWLEDGMENT
The authors gratefully acknowledge the authorship and contributions of Dr. Kendall Ho on four previous editions of this chapter.
KEY CONCEPTS
■ Ankle dislocations with obvious vascular compromise should
be reduced promptly, before radiographs are obtained.
■ The entire fibula should be examined if an isolated medial
malleolar fracture is present, to rule out a proximal fibular
(Danis-Weber type C or Maisonneuve) fracture.
■ Before diagnosis of an ankle sprain, other injuries that may
mimic an ankle sprain should be considered.
■ Patients with Achilles tendon rupture are still capable of
weak plantar flexion. The Thompson test should be
performed if an Achilles tendon rupture is suspected.
■ The presence of accessory ossicles may explain unexpected
radiologic “lesions” in the foot.
■ The possibility of a Lisfranc injury should be considered with
any fracture or dislocation in the tarsometatarsal region,
particularly fractures of the second metatarsal base.
■ The tuberosity should be carefully differentiated from the
diaphysis in all fifth metatarsal base fractures.
■ The possibility of a stress fracture should be considered in
patients with long-standing foot pain, particularly if
symptoms are in the metatarsal region.
■ Compartment syndrome of the foot can occur, with
potentially devastating results if it is not diagnosed early.
The references for this chapter can be found online by
accessing the accompanying Expert Consult website.
Chapter 58 / Ankle and Foot 750.e1
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