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Fractures of the foot and ankle
ORTHOPAEDICS: LOWER LIMB
Fractures of the foot and ankle
degenerative changes. It has been shown that 1 mm of talar shift can lead to a 42% reduction in joint contact area.1
Mechanism of injury and classification It is essential to think of any ankle fracture not simply as a broken bone, but a complex twisting injury that also disrupts ligamentous balance. There are two classifications: the DaniseWeber system and the LaugeeHansen classification.
Olusegun Aiyenuro Andrew J Goldberg
Abstract Fractures of the foot and ankle are common in all age groups. Soft tissue swelling, smoking and co-morbidities such as diabetes mellitus and peripheral vascular disease should be considered when forming the management plan. Careful attention to neurovascular status and the soft tissue envelope of the foot and ankle is essential to the management of these injuries especially where crush injuries have occurred. Open fractures should be treated urgently with a combined approach with the plastic surgeons. A good understanding of surgical anatomy is key to managing these fractures. Good intra-articular involvement and ligamentous stability are crucial in predicting long-term prognosis. The core principles of management are: to maintain the soft tissue envelope (minimize disruption); to obtain appropriate alignment; restoration of joint surfaces; and rehabilitation to obtain optimum function.
The DaniseWeber system This was initially developed by Danis2 in 1949 and later modified and popularized by Weber in 1967.3 This classification relates to the location of the fibula fracture in relation to the syndesmosis (Figure 1). Although it is simple to remember and gives a clue to stability it is not that useful in identifying fractures with a poor prognosis (i.e. separating tigers from pussy cats).
The LaugeeHansen classification (1950) LaugeeHansen carried out experiments on the ankles of cadavers.4 Various forces were applied to specimens and he recorded the injuries sequentially. Two factors dictated the injury: the position of the foot (pronation or supination) and the direction of the deforming force (e.g. external rotation). The commonest type is the supinationeexternal rotation (SER), seen in a typical footballing inversion injury. In an SER injury as the deforming force continues to act a series of structures get injured. If the deforming force stops at any point (for example by holding onto something), then no further damage occurs. In sequence the first structure to be injured is the anterior inferior tibiofibular ligament (SER1), followed by a short spiral fracture of the fibula (SER2), followed by a tear of the posterior inferior tibiofibular ligament (or posterior malleolar fracture e SER 3), and finally a medial injury (either a medial malleolar fracture or deltoid tear (SER4)). Distinguishing between an SER2 and an SER4 is essential, however, as the latter is a grossly unstable injury whereas the former might be stable. Indeed understanding the concept of stability is complex, but a good rule of thumb is that if more than one bone and/or ligamentous structure are injured it most likely represents an unstable situation. All classifications have limitations. The LaugeeHansen classification is better than the DaniseWeber at understanding severity but has poor inter- and intra-observer reliability.5,6 For this reason we propose that you do not try and learn all of the various types of this classification, but just understand the principles.
Keywords Calcaneal; Lisfranc; metatarsal; midfoot; neck; pilon; talar; talus; tibial; syndesmosis
Ankle fractures Ankle fractures are the most common lower extremity injury and are increasing in frequency especially in young athletes and elderly osteoporotic women.
Pathoanatomy The ankle joint is formed by the distal articular surfaces of the tibia, fibula, and the talus. The supporting ligaments of the ankle joint are crucial in determining its stability. The ligament complexes of the ankle joint can be considered in three broad areas: the distal tibiofibular joint or syndesmosis (anterior and posterior inferior tibiofibular ligaments and the interosseous ligament), the medial ankle ligaments (deltoid) and the lateral ankle ligament complex. Motion at the ankle joint is complex with not only plantar- and dorsiflexion but also glide, rotation and slide of the talus. It is one of the most congruent joints in the body with low risk of osteoarthritis. However, small disruptions to this perfect symbiosis can lead to alterations of the normal kinetics and development of
Imaging Radiographic views should include a lateral and mortise view (15 degrees internal rotation of the tibia e so as to level the fibula which sits posteriorly). If there is tenderness over the proximal fibula the knee should also be X-rayed to rule out a Maisonneuve fracture. Aside from obvious fractures, the most important sign is an equal joint space all around the talus. If this is not the case then it suggests a bony or ligamentous disruption that has led to a widened mortise. You should also check for tibiofibula overlap at the level of the syndesmosis (you would expect to see a
Olusegun Aiyenuro FRCS(Tr & Orth) PG Dip(T&O) is a Locum Consultant Trauma and Orthopaedic Surgeon at the Royal Surrey County Hospital, Guildford, UK. Conflicts of interest: none declared. Andrew J Goldberg OBE MD FRCS(Tr&Orth) is a Clinical Senior Lecturer in Trauma and Orthopaedics and Honorary Consultant Orthopaedic Surgeon, UCL Institute of Orthopaedics, Royal National Orthopaedic Hospital, Stanmore, UK. Conflicts of interest: none declared.
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ORTHOPAEDICS: LOWER LIMB
Diabetic patients require special attention especially in the presence of neuropathy as they have much higher rates of complications including wound problems, delayed union and Charcot arthropathy. In diabetics it is essential that you examine for neuropathy using SemmeseWeinstein monofilaments and if present then you should consider treating the patient with 12 weeks of casting whether surgical or non-surgical treatment is used.
Danis–Weber classification of ankle fractures
Operative treatment Surgery is indicated in unstable injuries where the surgeon feels that an improved outcome can be achieved by operative reduction and fixation. Open anatomic reduction and restoration of joint surfaces are achieved using internal fixation commonly with interfragmentary lag screws, buttress or neutralization plates, or tension band wires. Syndesmosis stabilization is performed (with a screw or ankle TightropeÔ suture) when it appears unstable using the hook stress test intraoperatively. The foot must be in neutral dorsiflexion at the time of stabilization as the talus is wider anteriorly than posteriorly. Controversy exists as to whether the screw should be partially or fully threaded and cross three or four cortices. The truth is that it probably does not matter. If a screw is used, then it is recommended to be removed prior to full weight-bearing after 6e10 weeks. This is a controversial subject however as some stable injuries can bear weight quicker.
Type A Below the syndesmosis
Type B At the level of the syndesmosis
Complications
Type C Above the syndesmosis
The most frequently asked question after ankle fracture relates to the risk of developing post-traumatic osteoarthritis (OA). A systematic review performed by Gougoulias in 2010 suggested that stable injuries have a very good prognosis and more than 80% of patients will be symptom-free after 18 years. In contrast 60% of unstable injuries that were not operated upon went on to have radiographic signs of OA after 6 years. In those operated upon 20% went on to have radiographic signs of OA after 6 years.7 Although this was a retrospective review and the science therefore not robust, it does however suggest that in unstable ankles, surgery can reduce the chance of long-term OA by twothirds. The study points out that elderly females, smokers and low educational level are all negative prognostic indicators.
Figure 1
minimum of 1 mm measured 1 cm above the joint line). CT and MRI scans can be helpful in determining the presence of talar osteochondral lesions, posterior cortical comminution, and ligamentous injuries.
Treatment principles The principles of treatment are to: identify unstable injuries restore anatomical alignment and joint congruity restore stability where necessary avoid missing concomitant injuries (such as a fracture of the lateral process of the talus) rehabilitate the patient appropriately. In the emergency department, the neurovascular status of the limb must be assessed. Grossly displaced or dislocated joints should be reduced urgently documenting the neurovascular status before and after reduction. A well-padded plaster backslab is applied and a check X-ray obtained.
Lisfranc injuries Whilst there are a wealth of midfoot injuries that can occur, the most important one to understand is the Lisfranc injury. Jacques Lisfranc de Martin was a gynaecologist and field surgeon in Napoleon’s army. In 1815 he described the Lisfranc amputation at the tarsometatarsal joint to treat frostbite of the forefoot in soldiers on the Russian front. However he never described the Lisfranc ligament which is crucial in understanding Lisfranc injuries. The Lisfranc joint is the articulation between the three cuneiforms and cuboid (tarsus) and the bases of the five metatarsals. Osseous stability is provided by the Roman arch of the metatarsals and the recessed keystone of the second metatarsal base. One of the most important stabilizers of this complex is the Lisfranc ligament, which is a large oblique ligament from the plantar aspect of the medial cuneiform to the base of the second
Non-operative treatment This is indicated in stable fractures or in patients where surgery is contraindicated such as vascular insufficiency. A below-knee cast or ankle boot is worn, non-weight-bearing for 6 weeks, gradually introducing weight-bearing as comfortable. Some stable injuries can bear weight quicker.
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metatarsal. When this ligament is compromised the midfoot becomes unstable which can lead to pain, further instability and eventually degenerative change.
Treatment Undisplaced Lisfranc injuries can be treated by non-weightbearing in plaster for about 8 weeks to allow the ligaments to heal. However, since there is a risk of displacement most Lisfranc injuries are treated operatively. The key to managing this injury is to reduce the second tarsometatarsal joint which acts as the keystone. Methods of fixation range from K-wires to plates and screws. Some surgeons perform a primary fusion and others a temporary internal fixation where the metalwork is removed after 8e12 weeks creating a form of pseudoarthrosis. Long-term complications include degenerative arthritis.
Clinical presentation Recognition of such an injury is therefore essential in any foot injury. The commonest being an axial load or twisting force on a plantar flexed foot. Presentation is with a swollen and tender midfoot.
Imaging Non-weight-bearing X-rays may look normal. Weight-bearing views provide ‘stress’, and may demonstrate subtle diastasis but in the acute situation are impractical. A CT or MRI scan may be helpful but stress views in the X-ray department or in theatre are most useful.
Fifth metatarsal fractures Fractures of the fifth metatarsal are common and usually result from direct trauma. Concomitant lateral ankle ligament injuries and adjacent fractures require careful assessment. The key to understanding these fractures is a good knowledge of the anatomy, in particular that the peroneus brevis and the lateral band of plantar fascia insert onto the base of the fifth metatarsal. Also the area between the metaphyseal vessels and
Classification Quenu and Kuss8 (1909) created a classification which was later modified by Hardcastle9 (1982) and Myerson10 (1986). The principles are shown in Figure 2.
Classification of LisFranc Injuries a
Total incongruity – all five metatarsals displaced in the same direction
b
c
Partial incongruity – one or two metatarsals displaced from the others
Divergent – displacement of the metatarsals
Figure 2
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a shear fracture of the calcaneus occurs obliquely. This is known as the primary fracture line and creates two fragments: the tuberosity; and the anteromedial fragment which contains the sustentaculum tali and is also known as the constant fragment (Figure 4) The fractures can be divided into extra- or intra-articular depending on whether the primary fracture line extends into the posterior subtalar joint. As the compressive force continues additional energy results in secondary fracture lines and additional fragments. If the energy exits posteriorly by the Achilles tendon then it is known as a tongue type fracture (also described by EssexeLopresti) and if the energy comes out superiorly just behind the posterior facet then it creates a joint depression type of fracture. Figure 5 further illustrates the fracture lines. The primary fractures lines are the vertical and the secondary fracture lines exit posteriorly or superiorly. The horizontal red line indicates a tongue type of fracture whereas the blue angled line represents a joint depression fracture.
diaphyseal nutrient artery represents a vascular watershed, making fractures in this area prone to non-union.
Classification Fractures of the fifth metatarsal are divided into proximal fractures, midshaft fractures and fractures of the head and neck (Figure 3). Proximal fractures are often grouped together as ‘Jones’ fractures, after Sir Robert Jones, who sustained such a fracture while dancing and wrote it up in 1902. Since then these fractures have been further divided by the location of the fracture.11 Table 1 outlines the types and treatments of the varying types. The term ‘dancer’s fracture’ was used for fractures of the distal shaft of the fifth metatarsal usually caused by a twisting or rotational force and has been described in dancers.12
Calcaneal fractures Calcaneal fractures are the most frequently fractured tarsal bone typically caused by a fall from a height. Up to 15% are open injuries, 5e10% are bilateral and there is an association with fractures of the lumbar spine, pelvis, hip, tibia and ankle.
Imaging A CT scan is essential to plan the management of calcaneal fractures. You should also arrange an ankle and calcaneal series of plain X-rays. On the lateral radiograph, look for flattening of Bohler’s angle and the angle of Gissane (Figure 6).
Pathoanatomy The superior articular surface has three facets: posterior, middle and anterior, which articulate with the talus to form the subtalar joint. A high-energy axial load during a fall from a height can result in an intra-articular fracture as the talus acts as a wedge driving into the thin cortical shell of the calcaneus. In the coronal plane the tuberosity of the calcaneus is positioned slightly lateral to the talus and as a vertical force is applied
Classification Body fractures are divided into extra-articular (25e30%) and intra-articular. EssexeLopresti (an up-and-coming surgeon who died at the age of 35 the year before his seminal paper was published) further divided the latter into joint depression type and tongue types. The main CT classification is that of Sanders.13,21 The principle of this classification is that a high number indicates a high number of fragments: Type I e undisplaced fractures Type II e two-part or split fractures Type III e three-part or split depression fractures Type IV e four-part or highly comminuted articular fractures. Each type is then subdivided into A, B or C, depending on where the primary fracture line appears on the posterior facet on the coronal CT image. A is most lateral and C is most medial. A has the best prognosis.
Anatomical classification of proximal fifth metatarsal fractures
III II I
Principles of treatment Goals of treatment include: creating a relatively normal foot shape to allow use of normal footwear; ensuring correct alignment; and establishing articular congruity to promote pain-free function and prevent long-term degenerative change. Treatment begins in the emergency department. It is important not to miss associated significant injuries in seriously or multiply injured patients or where there has been a high-energy injury. The spine and entire lower limb must be carefully evaluated. The foot is then elevated and a backslab with ice packs applied to help reduce pain and swelling. Surgical intervention should only be considered when the skin wrinkles return (orange peel sign).
Tuberosity avulsion fracture Jones fracture Diaphyseal stress fracture
Figure 3
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Zones of a base of the fifth metatarsal fracture Zone
Description
Treatment
Zone 1
Proximal cancellous tuberosity (93%) C An avulsion fracture due to the lateral band of the plantar fascia, and contraction peroneus brevis C Non-union is uncommon but can occur Jones fracture (4%) C Commonly occurs in an inversion injury C Involves the articulation between fourth to fifth metatarsals C Risk of non-union Diaphyseal stress fracture (3%) C Distal to the fourth to fifth metatarsal articulation C Often a stress fracture in athletes C Association with cavovarus foot C Risk of non-union
Immobilize in a short leg cast or walker boot and crutches for 6 weeks
Zone 2
Zone 3
Non-operative: Immobilize in a short leg cast or walker boot and crutches for 6 weeks
Operative: Intramedullary screw fixation (usually percutaneous)
Table 1
designed calcaneal fixation plates. Percutaneous and arthroscopic techniques also exist but only in the hands of very experienced operators. In Type IV fractures primary subtalar joint fusion is sometimes considered. There is much controversy as to whether operative treatment produces better results than non-operative methods even for displaced intra-articular injuries. Clinical trials comparing the two seem to be equivocal but in general suggest that a subset of younger well-motivated patients, where anatomic reduction is achieved, do much better following surgery. There are of course complications of both operative and nonoperative treatment. These include malunion and a widened heel
Non-operative This is appropriate in non-displaced Type I fractures or in the elderly with multiple medical problems, heavy smokers, those with distal vascular insufficiency, or in patients with nondisplaced extra-articular fractures. The fractures are treated in a short leg non-weight-bearing cast until the fracture heals. At 6 weeks, progressive weightbearing can be started in or out of plaster depending on the radiographic appearances.
Operative treatment Treatment includes open reduction and rigid internal fixation through an extensile (L-shaped) lateral approach, using specially
a
Lateral side of the calcaneus shows the primary fracture line (solid black line) and secondary fracture lines of a joint depression (blue line) and tongue type (red line) fractures
b
Figure 4 (a) Shear fracture of the calcaneus. (b) Displacement of the lateral wall of the calcaneus.
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Figure 5
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Mechanism of injury a
The mechanism is usually axial loading with forced dorsiflexion of the foot against the anterior margin of the tibial plafond resulting from falls from a height or in motor vehicle accidents. It may be associated with disruption of the medial malleolus, deltoid ligament and ankle or subtalar joints.
Classification Talar body fractures occur less commonly than neck fractures (approximately half the incidence). There are classifications of body fractures but none have been that useful. Classification of neck fractures provides a useful tool in treatment and an indication of AVN. Do not forget that talar fractures also include talar osteochondral lesions, as well as lateral and posterior talar process fractures. Hawkins17 classified talar neck fractures into four types (Figure 7), on the basis of the displacement of the fracture and involvement of the associated joints. The definition of a neck fracture is one where the main fracture line exits the inferior cortex of the talus anterior to the posterior subtalar facet.
b
Imaging Ankle and foot series. Canale view18 provides the optimum view of the talar neck. A CT is required in most cases.
Hawkins’ classification of talar neck fractures
Radiograph (lateral view) of the os calcis showing (a) Bohler’s angle (20–40°) and (b) the angle of Gissane (95–105°).
Figure 6
and difficulty wearing shoes, impingement of the peroneal tendons, wound breakdown, heel pad atrophy, and subtalar osteoarthritis.
Type I Undisplaced
Type II Displaced with subtalar joint disruption
Talus fractures These are uncommon accounting for only 2% of all lower extremity injuries. In 1919 after World War I, Anderson coined the term ‘aviator’s astragalus’ to describe 19 cases seen in pilots who landed with their planes.14 The word astragalus has a Greek origin, being derived from the word for vertebrae due to its shape. Two-thirds of the talus is covered by articular cartilage and it has no muscular attachments. Its arterial supply was described by Wildenauer in 1950 as having branches off the posterior and anterior tibial arteries (dorsalis pedis) as well as off the perforating peroneal artery.15 The blood supply to the body is retrograde from the neck and disruption of these vessels in displaced fractures risks avascular necrosis (AVN) to the body of the talus.16
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Type III Displaced with subtalar and ankle disruption
Type IV Displaced with subtalar, ankle and talo-navicular disruption
Figure 7
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traumatic osteoarthritis of the ankle or subtalar joints is common especially following AVN. Hawkin’s sign (subchondral osteopenia) is a good prognostic sign and indicates vascularity and washout of mineral content. This should be checked on an anteroposterior radiograph at 6e8 weeks.
Treatment Non-displaced Hawkins Type I fractures, can be treated nonoperatively in a short leg non-weight-bearing cast for 10e12 weeks until fracture healing is evident. Displaced fractures (Hawkins IIeIV): Emergent closed or open reduction and internal fixation with screws or with bespoke mini-fragment plates. Often two incisions are used and the key is avoidance of further damage to the blood supply by the approaches. Surgery is best carried out by experienced surgeons.
Pilon fractures Described by Etionne Destot in 1911, a pilon is Latin for a mortar and pestle, and is the anatomical region 5 cm proximal to the distal tibial articulating surface (distal metaphasis). Later, Bonnin named these fractures, ‘Plafond’ or ‘ceiling’ fractures. Commonly they occur in two ways: (a) high energy e in young men as a result of axial compression or shear due to fall from a height or skiing; and (b) low energy e a twisting injury often seen in elderly osteoporotic patients. These are uncommon accounting for about 5% of all tibial fractures but clearly there is some overlap with the more severe malleolar fractures. Associated injuries to the calcaneus, tibial plateau, pelvis and vertebrae can also occur. Pre-tensioning of the Achilles plus the position of the foot at the time of impact will dictate the fracture pattern. For example if the foot was dorsiflexed then the anterior plafond is most likely to be disrupted, whereas a neutral foot position will most likely cause a central implosion.
Complications Malunion can lead to fixed varus deformity of the hindfoot which is very disabling. The risk of AVN is listed in Table 2. Post-
Hawkin’s classification Type
Description
Risk of avascular necrosis
I II
Undisplaced Displaced fracture with incongruent subtalar joint Displaced fracture with subtalar and ankle dislocation Displaced Type III plus talonavicular dislocation (added in 1978 by Canale & Kelly)
<10% 40%
III IV
90% 100%
Imaging Mortise and lateral plain X-rays are essential. A CT would best evaluate the fracture pattern and articular surfaces. If a two-stage
Table 2
Ruedi–Allgower classification of pilon fractures
I
II
Type I: Undisplaced Type II: Displaced Type III: Comminuted
III
Figure 8
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2 Danis R. Theorie et pratique de l’osteosynthese. Masson & Cie 1949. 3 Weber BG. Malleolar fractures. Schweiz Med Wochenschr 1967; 97: 790e2. 4 Lauge-Hansen N. Fractures of the ankle. II. Combined experimental-surgical and experimental-roentgenologic investigations. Arch Surg 1950; 60: 957e85. 5 Nielsen JO, Dons-Jensen H, Sùrensen HT. LaugeeHansen classification of malleolar fractures. An assessment of the reproducibility in 118 cases. Acta Orthop Scand 1990; 61: 385e7. 6 Michelson J, Solocoff D, Waldman B, Kendell K, Ahn U. Ankle fractures. The LaugeeHansen classification revisited. Clin Orthop Relat Res 1997; 345: 198e205. 7 Gougoulias N, Khanna A, Sakellariou A, Maffulli N. Supinationexternal rotation ankle fractures: stability a key issue. Clin Orthop Relat Res 2010; 468: 243e51. 8 Quenu E, Kuss G. Etude sur les luxations du metatarse (luxations metatarsotarsiennes) du diastasis entre le 1er et le 2e metatarsien. Rev Chir 1909; 39: 281e336. 9 Hardcastle PH, Reschauer R, Kutscha-Lissberg E, Schoffmann W. Injuries to the tarsometatarsal joint. Incidence, classification and treatment. J Bone Joint Surg Br 1982; 64: 349e56. 10 Myerson MS, Fisher RT, Burgess AR, Kenzora JE. Fracture dislocations of the tarsometatarsal joints: end results correlated with pathology and treatment. Foot Ankle 1986; 6: 225e42. 11 Torg JS, Balduini FC, Zelko RR, Pavlov H, Peff TC, Das M. Fractures of the base of the fifth metatarsal distal to the tuberosity. Classification and guidelines for non-surgical and surgical management. J Bone Joint Surg Am 1984; 66: 209e14. 12 O’Malley MJ, Hamilton WG, Munyak J. Fractures of the distal shaft of the fifth metatarsal. “Dancer’s fracture”. Am J Sports Med 1996; 24: 240e3. 13 Sanders R, Fortin P, DiPasquale T, Walling A. Operative treatment in 120 displaced intraarticular calcaneal fractures. Results using a prognostic computed tomography scan classification. Clin Orthop Relat Res 1993; 87e95. 14 Coltart WD. Aviator’s astragalus. J Bone Joint Surg Br 1952; 34B: 545e66. 15 Wildenauer E. Proceedings: discussion on the blood supply of the talus. Z Orthop Ihre Grenzgeb 1975; 113: 730. 16 Prasarn ML, Miller AN, Dyke JP, Helfet DL, Lorich DG. Arterial anatomy of the talus: a cadaver and gadolinium-enhanced MRI study. Foot Ankle Int 2010; 31: 987e93. 17 Hawkins LG. Fractures of the neck of the talus. J Bone Joint Surg Am 1970; 52: 991e1002. 18 Canale ST, Kelly FB. Fractures of the neck of the talus. Long-term evaluation of seventy-one cases. J Bone Joint Surg Am 1978; 60: 143e56. € wer M. The operative treatment of intra-articular € edi TP, Allgo 19 Ru fractures of the lower end of the tibia. Clin Orthop Relat Res 1979; 138: 105e10. 20 Volgas D, DeVries JG, Stannard JP. Short-term financial outcomes of pilon fractures. J Foot Ankle Surg 2010; 49: 47e51. 21 Sanders R. Intra-articular fractures of the calcaneus: present state of the art. J Orthop Trauma 1992; 6: 252e65.
€wer classification Ruedi & Allgo Type
Description
I
Intra-articular fracture of the distal tibia without significant displacement Intra-articular fracture of the distal tibia with significant displacement but minimal comminution Fracture of distal tibia with severe comminution and significant intra-articular displacement
II
III
Table 3
procedure is planned then this should take place after the external fixator has been put on and ligamentotaxis applied.
Classification In 1979, Ruedi and Allgower proposed a classification on the basis of involvement of the articular surface and comminution of the fracture (Figure 8),19 in which a higher classification indicates a more severe injury and worse prognosis (Table 3).
Treatment Because these fractures are often the result of high-energy trauma, associated injuries are common. Initial evaluation in the emergency department should include careful scrutiny of the entire patient as well as the affected limb. Type I injuries that are completely undisplaced could be treated non-operatively in a non-weight-bearing plaster for 6e10 weeks although often they are fixed percutaneously to prevent displacement. Displaced Type II injuries are best treated by open reduction and internal fixation. Type III injuries are best served by a twostaged approach to apply a bridging or spanning external fixator and stretch it out (ligamentotaxis), to allow the soft tissues to rest. This would then be followed by a CT scan to review the situation (often referred to as ‘span and scan’) and a planned second stage limited open reduction and internal fixation procedure after a week or two.
Prognosis There is a high rate of wound problems in these patients and by the nature of their injury a high risk of post-traumatic arthritis. Patients who sustain a pilon fracture have significantly poorer general health scores than the average population 2e5 years following the injury. A paper by Volgas et al. suggested that in the USA, college graduates and white collar workers did significantly better than uneducated and unemployed individuals.20A REFERENCES 1 Ramsey PL, Hamilton W. Changes in tibiotalar area of contact caused by lateral talar shift. J Bone Joint Surg Am 1976; 58: 356e7.
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Fractures of the foot and ankle
degenerative changes. It has been shown that 1 mm of talar shift can lead to a 42% reduction in joint contact area.1
Mechanism of injury and classification It is essential to think of any ankle fracture not simply as a broken bone, but a complex twisting injury that also disrupts ligamentous balance. There are two classifications: the DaniseWeber system and the LaugeeHansen classification.
Olusegun Aiyenuro Andrew J Goldberg
Abstract Fractures of the foot and ankle are common in all age groups. Soft tissue swelling, smoking and co-morbidities such as diabetes mellitus and peripheral vascular disease should be considered when forming the management plan. Careful attention to neurovascular status and the soft tissue envelope of the foot and ankle is essential to the management of these injuries especially where crush injuries have occurred. Open fractures should be treated urgently with a combined approach with the plastic surgeons. A good understanding of surgical anatomy is key to managing these fractures. Good intra-articular involvement and ligamentous stability are crucial in predicting long-term prognosis. The core principles of management are: to maintain the soft tissue envelope (minimize disruption); to obtain appropriate alignment; restoration of joint surfaces; and rehabilitation to obtain optimum function.
The DaniseWeber system This was initially developed by Danis2 in 1949 and later modified and popularized by Weber in 1967.3 This classification relates to the location of the fibula fracture in relation to the syndesmosis (Figure 1). Although it is simple to remember and gives a clue to stability it is not that useful in identifying fractures with a poor prognosis (i.e. separating tigers from pussy cats).
The LaugeeHansen classification (1950) LaugeeHansen carried out experiments on the ankles of cadavers.4 Various forces were applied to specimens and he recorded the injuries sequentially. Two factors dictated the injury: the position of the foot (pronation or supination) and the direction of the deforming force (e.g. external rotation). The commonest type is the supinationeexternal rotation (SER), seen in a typical footballing inversion injury. In an SER injury as the deforming force continues to act a series of structures get injured. If the deforming force stops at any point (for example by holding onto something), then no further damage occurs. In sequence the first structure to be injured is the anterior inferior tibiofibular ligament (SER1), followed by a short spiral fracture of the fibula (SER2), followed by a tear of the posterior inferior tibiofibular ligament (or posterior malleolar fracture e SER 3), and finally a medial injury (either a medial malleolar fracture or deltoid tear (SER4)). Distinguishing between an SER2 and an SER4 is essential, however, as the latter is a grossly unstable injury whereas the former might be stable. Indeed understanding the concept of stability is complex, but a good rule of thumb is that if more than one bone and/or ligamentous structure are injured it most likely represents an unstable situation. All classifications have limitations. The LaugeeHansen classification is better than the DaniseWeber at understanding severity but has poor inter- and intra-observer reliability.5,6 For this reason we propose that you do not try and learn all of the various types of this classification, but just understand the principles.
Keywords Calcaneal; Lisfranc; metatarsal; midfoot; neck; pilon; talar; talus; tibial; syndesmosis
Ankle fractures Ankle fractures are the most common lower extremity injury and are increasing in frequency especially in young athletes and elderly osteoporotic women.
Pathoanatomy The ankle joint is formed by the distal articular surfaces of the tibia, fibula, and the talus. The supporting ligaments of the ankle joint are crucial in determining its stability. The ligament complexes of the ankle joint can be considered in three broad areas: the distal tibiofibular joint or syndesmosis (anterior and posterior inferior tibiofibular ligaments and the interosseous ligament), the medial ankle ligaments (deltoid) and the lateral ankle ligament complex. Motion at the ankle joint is complex with not only plantar- and dorsiflexion but also glide, rotation and slide of the talus. It is one of the most congruent joints in the body with low risk of osteoarthritis. However, small disruptions to this perfect symbiosis can lead to alterations of the normal kinetics and development of
Imaging Radiographic views should include a lateral and mortise view (15 degrees internal rotation of the tibia e so as to level the fibula which sits posteriorly). If there is tenderness over the proximal fibula the knee should also be X-rayed to rule out a Maisonneuve fracture. Aside from obvious fractures, the most important sign is an equal joint space all around the talus. If this is not the case then it suggests a bony or ligamentous disruption that has led to a widened mortise. You should also check for tibiofibula overlap at the level of the syndesmosis (you would expect to see a
Olusegun Aiyenuro FRCS(Tr & Orth) PG Dip(T&O) is a Locum Consultant Trauma and Orthopaedic Surgeon at the Royal Surrey County Hospital, Guildford, UK. Conflicts of interest: none declared. Andrew J Goldberg OBE MD FRCS(Tr&Orth) is a Clinical Senior Lecturer in Trauma and Orthopaedics and Honorary Consultant Orthopaedic Surgeon, UCL Institute of Orthopaedics, Royal National Orthopaedic Hospital, Stanmore, UK. Conflicts of interest: none declared.
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Diabetic patients require special attention especially in the presence of neuropathy as they have much higher rates of complications including wound problems, delayed union and Charcot arthropathy. In diabetics it is essential that you examine for neuropathy using SemmeseWeinstein monofilaments and if present then you should consider treating the patient with 12 weeks of casting whether surgical or non-surgical treatment is used.
Danis–Weber classification of ankle fractures
Operative treatment Surgery is indicated in unstable injuries where the surgeon feels that an improved outcome can be achieved by operative reduction and fixation. Open anatomic reduction and restoration of joint surfaces are achieved using internal fixation commonly with interfragmentary lag screws, buttress or neutralization plates, or tension band wires. Syndesmosis stabilization is performed (with a screw or ankle TightropeÔ suture) when it appears unstable using the hook stress test intraoperatively. The foot must be in neutral dorsiflexion at the time of stabilization as the talus is wider anteriorly than posteriorly. Controversy exists as to whether the screw should be partially or fully threaded and cross three or four cortices. The truth is that it probably does not matter. If a screw is used, then it is recommended to be removed prior to full weight-bearing after 6e10 weeks. This is a controversial subject however as some stable injuries can bear weight quicker.
Type A Below the syndesmosis
Type B At the level of the syndesmosis
Complications
Type C Above the syndesmosis
The most frequently asked question after ankle fracture relates to the risk of developing post-traumatic osteoarthritis (OA). A systematic review performed by Gougoulias in 2010 suggested that stable injuries have a very good prognosis and more than 80% of patients will be symptom-free after 18 years. In contrast 60% of unstable injuries that were not operated upon went on to have radiographic signs of OA after 6 years. In those operated upon 20% went on to have radiographic signs of OA after 6 years.7 Although this was a retrospective review and the science therefore not robust, it does however suggest that in unstable ankles, surgery can reduce the chance of long-term OA by twothirds. The study points out that elderly females, smokers and low educational level are all negative prognostic indicators.
Figure 1
minimum of 1 mm measured 1 cm above the joint line). CT and MRI scans can be helpful in determining the presence of talar osteochondral lesions, posterior cortical comminution, and ligamentous injuries.
Treatment principles The principles of treatment are to: identify unstable injuries restore anatomical alignment and joint congruity restore stability where necessary avoid missing concomitant injuries (such as a fracture of the lateral process of the talus) rehabilitate the patient appropriately. In the emergency department, the neurovascular status of the limb must be assessed. Grossly displaced or dislocated joints should be reduced urgently documenting the neurovascular status before and after reduction. A well-padded plaster backslab is applied and a check X-ray obtained.
Lisfranc injuries Whilst there are a wealth of midfoot injuries that can occur, the most important one to understand is the Lisfranc injury. Jacques Lisfranc de Martin was a gynaecologist and field surgeon in Napoleon’s army. In 1815 he described the Lisfranc amputation at the tarsometatarsal joint to treat frostbite of the forefoot in soldiers on the Russian front. However he never described the Lisfranc ligament which is crucial in understanding Lisfranc injuries. The Lisfranc joint is the articulation between the three cuneiforms and cuboid (tarsus) and the bases of the five metatarsals. Osseous stability is provided by the Roman arch of the metatarsals and the recessed keystone of the second metatarsal base. One of the most important stabilizers of this complex is the Lisfranc ligament, which is a large oblique ligament from the plantar aspect of the medial cuneiform to the base of the second
Non-operative treatment This is indicated in stable fractures or in patients where surgery is contraindicated such as vascular insufficiency. A below-knee cast or ankle boot is worn, non-weight-bearing for 6 weeks, gradually introducing weight-bearing as comfortable. Some stable injuries can bear weight quicker.
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metatarsal. When this ligament is compromised the midfoot becomes unstable which can lead to pain, further instability and eventually degenerative change.
Treatment Undisplaced Lisfranc injuries can be treated by non-weightbearing in plaster for about 8 weeks to allow the ligaments to heal. However, since there is a risk of displacement most Lisfranc injuries are treated operatively. The key to managing this injury is to reduce the second tarsometatarsal joint which acts as the keystone. Methods of fixation range from K-wires to plates and screws. Some surgeons perform a primary fusion and others a temporary internal fixation where the metalwork is removed after 8e12 weeks creating a form of pseudoarthrosis. Long-term complications include degenerative arthritis.
Clinical presentation Recognition of such an injury is therefore essential in any foot injury. The commonest being an axial load or twisting force on a plantar flexed foot. Presentation is with a swollen and tender midfoot.
Imaging Non-weight-bearing X-rays may look normal. Weight-bearing views provide ‘stress’, and may demonstrate subtle diastasis but in the acute situation are impractical. A CT or MRI scan may be helpful but stress views in the X-ray department or in theatre are most useful.
Fifth metatarsal fractures Fractures of the fifth metatarsal are common and usually result from direct trauma. Concomitant lateral ankle ligament injuries and adjacent fractures require careful assessment. The key to understanding these fractures is a good knowledge of the anatomy, in particular that the peroneus brevis and the lateral band of plantar fascia insert onto the base of the fifth metatarsal. Also the area between the metaphyseal vessels and
Classification Quenu and Kuss8 (1909) created a classification which was later modified by Hardcastle9 (1982) and Myerson10 (1986). The principles are shown in Figure 2.
Classification of LisFranc Injuries a
Total incongruity – all five metatarsals displaced in the same direction
b
c
Partial incongruity – one or two metatarsals displaced from the others
Divergent – displacement of the metatarsals
Figure 2
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a shear fracture of the calcaneus occurs obliquely. This is known as the primary fracture line and creates two fragments: the tuberosity; and the anteromedial fragment which contains the sustentaculum tali and is also known as the constant fragment (Figure 4) The fractures can be divided into extra- or intra-articular depending on whether the primary fracture line extends into the posterior subtalar joint. As the compressive force continues additional energy results in secondary fracture lines and additional fragments. If the energy exits posteriorly by the Achilles tendon then it is known as a tongue type fracture (also described by EssexeLopresti) and if the energy comes out superiorly just behind the posterior facet then it creates a joint depression type of fracture. Figure 5 further illustrates the fracture lines. The primary fractures lines are the vertical and the secondary fracture lines exit posteriorly or superiorly. The horizontal red line indicates a tongue type of fracture whereas the blue angled line represents a joint depression fracture.
diaphyseal nutrient artery represents a vascular watershed, making fractures in this area prone to non-union.
Classification Fractures of the fifth metatarsal are divided into proximal fractures, midshaft fractures and fractures of the head and neck (Figure 3). Proximal fractures are often grouped together as ‘Jones’ fractures, after Sir Robert Jones, who sustained such a fracture while dancing and wrote it up in 1902. Since then these fractures have been further divided by the location of the fracture.11 Table 1 outlines the types and treatments of the varying types. The term ‘dancer’s fracture’ was used for fractures of the distal shaft of the fifth metatarsal usually caused by a twisting or rotational force and has been described in dancers.12
Calcaneal fractures Calcaneal fractures are the most frequently fractured tarsal bone typically caused by a fall from a height. Up to 15% are open injuries, 5e10% are bilateral and there is an association with fractures of the lumbar spine, pelvis, hip, tibia and ankle.
Imaging A CT scan is essential to plan the management of calcaneal fractures. You should also arrange an ankle and calcaneal series of plain X-rays. On the lateral radiograph, look for flattening of Bohler’s angle and the angle of Gissane (Figure 6).
Pathoanatomy The superior articular surface has three facets: posterior, middle and anterior, which articulate with the talus to form the subtalar joint. A high-energy axial load during a fall from a height can result in an intra-articular fracture as the talus acts as a wedge driving into the thin cortical shell of the calcaneus. In the coronal plane the tuberosity of the calcaneus is positioned slightly lateral to the talus and as a vertical force is applied
Classification Body fractures are divided into extra-articular (25e30%) and intra-articular. EssexeLopresti (an up-and-coming surgeon who died at the age of 35 the year before his seminal paper was published) further divided the latter into joint depression type and tongue types. The main CT classification is that of Sanders.13,21 The principle of this classification is that a high number indicates a high number of fragments: Type I e undisplaced fractures Type II e two-part or split fractures Type III e three-part or split depression fractures Type IV e four-part or highly comminuted articular fractures. Each type is then subdivided into A, B or C, depending on where the primary fracture line appears on the posterior facet on the coronal CT image. A is most lateral and C is most medial. A has the best prognosis.
Anatomical classification of proximal fifth metatarsal fractures
III II I
Principles of treatment Goals of treatment include: creating a relatively normal foot shape to allow use of normal footwear; ensuring correct alignment; and establishing articular congruity to promote pain-free function and prevent long-term degenerative change. Treatment begins in the emergency department. It is important not to miss associated significant injuries in seriously or multiply injured patients or where there has been a high-energy injury. The spine and entire lower limb must be carefully evaluated. The foot is then elevated and a backslab with ice packs applied to help reduce pain and swelling. Surgical intervention should only be considered when the skin wrinkles return (orange peel sign).
Tuberosity avulsion fracture Jones fracture Diaphyseal stress fracture
Figure 3
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Zones of a base of the fifth metatarsal fracture Zone
Description
Treatment
Zone 1
Proximal cancellous tuberosity (93%) C An avulsion fracture due to the lateral band of the plantar fascia, and contraction peroneus brevis C Non-union is uncommon but can occur Jones fracture (4%) C Commonly occurs in an inversion injury C Involves the articulation between fourth to fifth metatarsals C Risk of non-union Diaphyseal stress fracture (3%) C Distal to the fourth to fifth metatarsal articulation C Often a stress fracture in athletes C Association with cavovarus foot C Risk of non-union
Immobilize in a short leg cast or walker boot and crutches for 6 weeks
Zone 2
Zone 3
Non-operative: Immobilize in a short leg cast or walker boot and crutches for 6 weeks
Operative: Intramedullary screw fixation (usually percutaneous)
Table 1
designed calcaneal fixation plates. Percutaneous and arthroscopic techniques also exist but only in the hands of very experienced operators. In Type IV fractures primary subtalar joint fusion is sometimes considered. There is much controversy as to whether operative treatment produces better results than non-operative methods even for displaced intra-articular injuries. Clinical trials comparing the two seem to be equivocal but in general suggest that a subset of younger well-motivated patients, where anatomic reduction is achieved, do much better following surgery. There are of course complications of both operative and nonoperative treatment. These include malunion and a widened heel
Non-operative This is appropriate in non-displaced Type I fractures or in the elderly with multiple medical problems, heavy smokers, those with distal vascular insufficiency, or in patients with nondisplaced extra-articular fractures. The fractures are treated in a short leg non-weight-bearing cast until the fracture heals. At 6 weeks, progressive weightbearing can be started in or out of plaster depending on the radiographic appearances.
Operative treatment Treatment includes open reduction and rigid internal fixation through an extensile (L-shaped) lateral approach, using specially
a
Lateral side of the calcaneus shows the primary fracture line (solid black line) and secondary fracture lines of a joint depression (blue line) and tongue type (red line) fractures
b
Figure 4 (a) Shear fracture of the calcaneus. (b) Displacement of the lateral wall of the calcaneus.
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Figure 5
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Mechanism of injury a
The mechanism is usually axial loading with forced dorsiflexion of the foot against the anterior margin of the tibial plafond resulting from falls from a height or in motor vehicle accidents. It may be associated with disruption of the medial malleolus, deltoid ligament and ankle or subtalar joints.
Classification Talar body fractures occur less commonly than neck fractures (approximately half the incidence). There are classifications of body fractures but none have been that useful. Classification of neck fractures provides a useful tool in treatment and an indication of AVN. Do not forget that talar fractures also include talar osteochondral lesions, as well as lateral and posterior talar process fractures. Hawkins17 classified talar neck fractures into four types (Figure 7), on the basis of the displacement of the fracture and involvement of the associated joints. The definition of a neck fracture is one where the main fracture line exits the inferior cortex of the talus anterior to the posterior subtalar facet.
b
Imaging Ankle and foot series. Canale view18 provides the optimum view of the talar neck. A CT is required in most cases.
Hawkins’ classification of talar neck fractures
Radiograph (lateral view) of the os calcis showing (a) Bohler’s angle (20–40°) and (b) the angle of Gissane (95–105°).
Figure 6
and difficulty wearing shoes, impingement of the peroneal tendons, wound breakdown, heel pad atrophy, and subtalar osteoarthritis.
Type I Undisplaced
Type II Displaced with subtalar joint disruption
Talus fractures These are uncommon accounting for only 2% of all lower extremity injuries. In 1919 after World War I, Anderson coined the term ‘aviator’s astragalus’ to describe 19 cases seen in pilots who landed with their planes.14 The word astragalus has a Greek origin, being derived from the word for vertebrae due to its shape. Two-thirds of the talus is covered by articular cartilage and it has no muscular attachments. Its arterial supply was described by Wildenauer in 1950 as having branches off the posterior and anterior tibial arteries (dorsalis pedis) as well as off the perforating peroneal artery.15 The blood supply to the body is retrograde from the neck and disruption of these vessels in displaced fractures risks avascular necrosis (AVN) to the body of the talus.16
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Type III Displaced with subtalar and ankle disruption
Type IV Displaced with subtalar, ankle and talo-navicular disruption
Figure 7
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traumatic osteoarthritis of the ankle or subtalar joints is common especially following AVN. Hawkin’s sign (subchondral osteopenia) is a good prognostic sign and indicates vascularity and washout of mineral content. This should be checked on an anteroposterior radiograph at 6e8 weeks.
Treatment Non-displaced Hawkins Type I fractures, can be treated nonoperatively in a short leg non-weight-bearing cast for 10e12 weeks until fracture healing is evident. Displaced fractures (Hawkins IIeIV): Emergent closed or open reduction and internal fixation with screws or with bespoke mini-fragment plates. Often two incisions are used and the key is avoidance of further damage to the blood supply by the approaches. Surgery is best carried out by experienced surgeons.
Pilon fractures Described by Etionne Destot in 1911, a pilon is Latin for a mortar and pestle, and is the anatomical region 5 cm proximal to the distal tibial articulating surface (distal metaphasis). Later, Bonnin named these fractures, ‘Plafond’ or ‘ceiling’ fractures. Commonly they occur in two ways: (a) high energy e in young men as a result of axial compression or shear due to fall from a height or skiing; and (b) low energy e a twisting injury often seen in elderly osteoporotic patients. These are uncommon accounting for about 5% of all tibial fractures but clearly there is some overlap with the more severe malleolar fractures. Associated injuries to the calcaneus, tibial plateau, pelvis and vertebrae can also occur. Pre-tensioning of the Achilles plus the position of the foot at the time of impact will dictate the fracture pattern. For example if the foot was dorsiflexed then the anterior plafond is most likely to be disrupted, whereas a neutral foot position will most likely cause a central implosion.
Complications Malunion can lead to fixed varus deformity of the hindfoot which is very disabling. The risk of AVN is listed in Table 2. Post-
Hawkin’s classification Type
Description
Risk of avascular necrosis
I II
Undisplaced Displaced fracture with incongruent subtalar joint Displaced fracture with subtalar and ankle dislocation Displaced Type III plus talonavicular dislocation (added in 1978 by Canale & Kelly)
<10% 40%
III IV
90% 100%
Imaging Mortise and lateral plain X-rays are essential. A CT would best evaluate the fracture pattern and articular surfaces. If a two-stage
Table 2
Ruedi–Allgower classification of pilon fractures
I
II
Type I: Undisplaced Type II: Displaced Type III: Comminuted
III
Figure 8
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2 Danis R. Theorie et pratique de l’osteosynthese. Masson & Cie 1949. 3 Weber BG. Malleolar fractures. Schweiz Med Wochenschr 1967; 97: 790e2. 4 Lauge-Hansen N. Fractures of the ankle. II. Combined experimental-surgical and experimental-roentgenologic investigations. Arch Surg 1950; 60: 957e85. 5 Nielsen JO, Dons-Jensen H, Sùrensen HT. LaugeeHansen classification of malleolar fractures. An assessment of the reproducibility in 118 cases. Acta Orthop Scand 1990; 61: 385e7. 6 Michelson J, Solocoff D, Waldman B, Kendell K, Ahn U. Ankle fractures. The LaugeeHansen classification revisited. Clin Orthop Relat Res 1997; 345: 198e205. 7 Gougoulias N, Khanna A, Sakellariou A, Maffulli N. Supinationexternal rotation ankle fractures: stability a key issue. Clin Orthop Relat Res 2010; 468: 243e51. 8 Quenu E, Kuss G. Etude sur les luxations du metatarse (luxations metatarsotarsiennes) du diastasis entre le 1er et le 2e metatarsien. Rev Chir 1909; 39: 281e336. 9 Hardcastle PH, Reschauer R, Kutscha-Lissberg E, Schoffmann W. Injuries to the tarsometatarsal joint. Incidence, classification and treatment. J Bone Joint Surg Br 1982; 64: 349e56. 10 Myerson MS, Fisher RT, Burgess AR, Kenzora JE. Fracture dislocations of the tarsometatarsal joints: end results correlated with pathology and treatment. Foot Ankle 1986; 6: 225e42. 11 Torg JS, Balduini FC, Zelko RR, Pavlov H, Peff TC, Das M. Fractures of the base of the fifth metatarsal distal to the tuberosity. Classification and guidelines for non-surgical and surgical management. J Bone Joint Surg Am 1984; 66: 209e14. 12 O’Malley MJ, Hamilton WG, Munyak J. Fractures of the distal shaft of the fifth metatarsal. “Dancer’s fracture”. Am J Sports Med 1996; 24: 240e3. 13 Sanders R, Fortin P, DiPasquale T, Walling A. Operative treatment in 120 displaced intraarticular calcaneal fractures. Results using a prognostic computed tomography scan classification. Clin Orthop Relat Res 1993; 87e95. 14 Coltart WD. Aviator’s astragalus. J Bone Joint Surg Br 1952; 34B: 545e66. 15 Wildenauer E. Proceedings: discussion on the blood supply of the talus. Z Orthop Ihre Grenzgeb 1975; 113: 730. 16 Prasarn ML, Miller AN, Dyke JP, Helfet DL, Lorich DG. Arterial anatomy of the talus: a cadaver and gadolinium-enhanced MRI study. Foot Ankle Int 2010; 31: 987e93. 17 Hawkins LG. Fractures of the neck of the talus. J Bone Joint Surg Am 1970; 52: 991e1002. 18 Canale ST, Kelly FB. Fractures of the neck of the talus. Long-term evaluation of seventy-one cases. J Bone Joint Surg Am 1978; 60: 143e56. € wer M. The operative treatment of intra-articular € edi TP, Allgo 19 Ru fractures of the lower end of the tibia. Clin Orthop Relat Res 1979; 138: 105e10. 20 Volgas D, DeVries JG, Stannard JP. Short-term financial outcomes of pilon fractures. J Foot Ankle Surg 2010; 49: 47e51. 21 Sanders R. Intra-articular fractures of the calcaneus: present state of the art. J Orthop Trauma 1992; 6: 252e65.
€wer classification Ruedi & Allgo Type
Description
I
Intra-articular fracture of the distal tibia without significant displacement Intra-articular fracture of the distal tibia with significant displacement but minimal comminution Fracture of distal tibia with severe comminution and significant intra-articular displacement
II
III
Table 3
procedure is planned then this should take place after the external fixator has been put on and ligamentotaxis applied.
Classification In 1979, Ruedi and Allgower proposed a classification on the basis of involvement of the articular surface and comminution of the fracture (Figure 8),19 in which a higher classification indicates a more severe injury and worse prognosis (Table 3).
Treatment Because these fractures are often the result of high-energy trauma, associated injuries are common. Initial evaluation in the emergency department should include careful scrutiny of the entire patient as well as the affected limb. Type I injuries that are completely undisplaced could be treated non-operatively in a non-weight-bearing plaster for 6e10 weeks although often they are fixed percutaneously to prevent displacement. Displaced Type II injuries are best treated by open reduction and internal fixation. Type III injuries are best served by a twostaged approach to apply a bridging or spanning external fixator and stretch it out (ligamentotaxis), to allow the soft tissues to rest. This would then be followed by a CT scan to review the situation (often referred to as ‘span and scan’) and a planned second stage limited open reduction and internal fixation procedure after a week or two.
Prognosis There is a high rate of wound problems in these patients and by the nature of their injury a high risk of post-traumatic arthritis. Patients who sustain a pilon fracture have significantly poorer general health scores than the average population 2e5 years following the injury. A paper by Volgas et al. suggested that in the USA, college graduates and white collar workers did significantly better than uneducated and unemployed individuals.20A REFERENCES 1 Ramsey PL, Hamilton W. Changes in tibiotalar area of contact caused by lateral talar shift. J Bone Joint Surg Am 1976; 58: 356e7.
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