Fractures

  • FRACTURES OF THE FOOT

    Fractures of the foot are fairly common. Falls at work, sport or and road traffic accidents account for the most cases load.

    Ankle fractures

    Ankle fractures : To the uninitiated, an ankle fracture can seem like a ‘sprain’. Ankle fractures are both common in low impact injuries like trip off of a step or foot getting caught in a manhole and the ankle twisting that follows. Injuries also occur during sport and high velocity injuries like road traffic accident.

    Swelling is a universal occurrence after ankle injuries. Bruising is also seen when there is more soft tissue injury. Typically walking and standing is painful. Rarely the sharp fragments from inside can protrude through the skin and cause bleeding.

    Anatomy ankle

    Treatment : The most important aspect of ankle fracture treatment for the first 48 hrs is rest, elevation and icing of the foot and ankle.

    Serial casting with visible improvement

    Ankle fractures require elevation

    Correct technique for manipulation on foot

    Icing will reduce swelling

    General Principles : Fractures of the ankle generally require operative fixation as each side of the ankle acts as a dynamic strut which supports and stabilizes the ankle by moving in sync with the other side during various movements occurring at the ankle. Fixation is usually with screws alone, plates and screws or wire with screws. Fixation of fracture restores anatomy, and joint continuity.

    Serial casting with visible improvement
    X rays of fracture on both sides of ankle
    Correct technique for manipulation on foot
    Before and after fracture fixation

    Initially patient walks with a crutch or walker without any weight on the involved side for 6 weeks. Later patient walks with a Plaster of Paris cast or boot.

    TALAR FRACTURES

    Fractures of the talus : Also known as astragalus fractures, due to early models of aircraft which required operation using clutches with the foot. Now-a- days these fractures are more common in falls from heights and in road traffic accidents

    Anatomy : The talus is the bone that makes up the lower part of the ankle joint (the tibia and fibula bones of the lower leg make up the upper part of the ankle joint). The talus sits above the heel bone (calcaneus). Together, the talus and calcaneus form the subtalar joint, which is important for walking, especially on uneven ground.

    Talus bone anatomy and relation to other bones in the foot

    Blood supply of Talus : Is critical, and disruptions results in delayed union or non-union. Also since a large part of the talar surface is covered in cartilage, disruption in blood supply result in permanent damage as cartilage does not heal. These two key anatomical facts plus the location of talus deep in the ankle joint makes it uniquely susceptible to injuries that result in poor outcomes if not identified and treated adequately.

    Serial casting with visible improvement
    Blood supply of the talus
    Correct technique for manipulation on foot
    Blood supply of the talus

    Consequent to it’s precarious blood supply, a fracture talus does not heal as efficiently as other bones, with the exception of scaphoid in the hand and neck of the femur in the hip. For this reason, many talus fractures require surgery.

    Mechanism : This type of fracture often occurs during a high-energy event, such as a car collision or a high-velocity fall, skiing injury or in the past, flying airplanes with car-like braking systems.

    Fracture patterns : Fractures occur in the body, neck, outside (lateral) and back (posterior) aspects of the talus. However it is the neck fractures which are fraught with the highest rates of non-union amongst all talar bone fractures. Fractures of the lateral process often occur when the ankle is forced out to the side and are commonly seen in snowboarders. Fractures are often classified according to the displacement of the fracture fragments.

    Serial casting with visible improvement
    X-ray showing talar body fracture
    Correct technique for manipulation on foot
    X-ray showing talar lateral process fracture

    a) Minimally displaced or stable fractures : In a minimally displaced fracture, the bones usually stay in place during healing, and surgery to fix the bones into position is not usually required.

    Serial casting with visible improvement
    Talar neck fracture
    Correct technique for manipulation on foot
    X ray showing talar neck fracture

    Displaced fracture : A fracture is displaced out of it’s anatomic position when there is a greater amount of energy involved in the injury. Fractures that are displaced are also more likely to be unstable. Displaced and unstable fractures of the talus often require surgery for restoring correct fracture alignment and the best chance for return to normal movement of the ankle.

    Presentation : Patients with talus fractures present with acute severe pain, inability to walk or bear weight on the foot, significant swelling & bruising. People with talus fractures will usually present themselves in casualty or emergency room for initial treatment because of the severity of their symptoms.

    Imaging Tests : Correct X-rays will not only help to diagnose the injury but will also help the doctor decide on the correct treatment. Both the type of fracture and displacement of fracture are seen on x rays

    with a splint for night wear

    X ray showing talar fracture
    • Computed Tomography (CT) scan : Sometimes when more information is required following an x-ray, a CT scan may also be ordered. A CT scan shows a cross-sectional image of the bone and fracture pattern. It can provide valuable information about the severity of the fracture by helping your doctor see the fracture lines more clearly.

      with a splint for night wear

      CT scan showing talar fracture

    Treatment : Immediate treatment for a talus fracture is to apply a well-padded splint to immobilize the limb and protect it. Elevating the foot above the level of the heart helps to minimize swelling and pain

    a) Nonsurgical Treatment : Only fractures that are well-aligned (stable) can be treated without surgery. This is very rare in a talus fracture; however, because of the high-energy force that causes the injury. Casting is used for a minimum of 6 to 8 weeks but sometimes to up to 3 months. The goal is for the bone to heal enough to bear weight fully.

    b) Surgical Treatment : Podiatric surgery is required more often than not to internally fix a fractured talus, to stabilize and help healing. Podiatric surgery also produces better results and reduces the risk of future complications. Fracture fragments are first held temporarily with k wires and then fixed with special screws or metal plates and screws.

    Extensive skin bruising

    Many times the condition of the skin in talar fractures is bad to warrant fixing these fractures with a frame external fixator.

    with a splint for night wear

    External fixator for treating talar fracture

    Recovery : Generally talar fractures can take from 6-12 weeks to heal, depending on the severity of displacement of the fracture fragments. Periodic x rays are done to gauge progression of healing.

    a) Early Motion : Early joint mobility is as much essential as healing of the fracture. Patients who are treated without surgery will work on regaining motion in the foot and ankle after the cast is removed. As patient recovers movements, gaining balance and strength in muscles is also a priority. This is achieved with:

    • Hydrotherapy
    • Wobble boards
    • Terabands
    • Tip toe exercises

    b) Weight-bearing : Partial weight bearing or full weight bearing is done either with a crutch or walker respectively. Also a rocker boot will help to transfer weight rather than transmit weight. Weight bearing is initially partial and gradually full weight bearing is allowed. The rehab process is best guided by the surgeon and be physio, to obtain optimum results.

    Complications after Talus Fractures :

    a) Avascular Necrosis (AVN) : With unstable talus fractures, the blood supply to the bone can be disrupted at the time of the injury. Since talus is one of the bones known to have a critical blood supply, an injury can lead to irreparable loss of blood supply, leading to collapse of the bone. This condition is called avascular necrosis (AVN) and leads to pain and arthritis. This complication is well known in talar fractures, and hence adequate and early treatment is paramount.

    The more severe the talus fracture, the more likely that AVN will occur

    b) Posttraumatic Arthritis : Posttraumatic arthritis is arthritis that develops after an injury. The cartilage surface on the bone is damaged due to injury. The majority of talus fractures result in some degree of posttraumatic arthritis. In cases of extreme arthritis that limits activity, additional surgery, such as a joint fusion or ankle replacement, may be the best option to relieve symptoms.

    CALCANEAL FRACTURES

    Calcaneal fracture, also known as lover's fracture is one of the worst fractures to have in the body, due to frequency of post-treatment complications. It is usually caused by a fall from height when one lands on their feet. The name lover's fracture is derived from the fact that a lover may jump from great heights while trying to escape from the lover's spouse.

    Mechanism of injury
    Mechanism of injury

    Anatomy & Patterns of Injury : The calcaneus, also known as the heel bone, is the largest of the tarsal bones and articulates with the cuboid bone in front and the talus bone superiorly. It is responsible for transmitting the majority of the body's weight from the talus bone to the ground.

    Calcaneal fractures are categorized into two types: Intra and Extra-articular fractures on the basis of involvement of the subtalar joint involvement (the joint above the calcaneus bone). Intra-articular fractures are more common. The Sanders classification groups these fractures into four types, based on the location of the fracture at the posterior articular surface.

    Extra-articular fractures are less common, and located outside the subtalar joint. Extra-articular fractures are categorized depending on whether the involvement of the calcaneus is anterior(front) (Type A), Middle (Type B) or Posterior(behind)

    X ray showing calcaneal fractures
    X ray showing calcaneal fractures

    The Angle of Gissane, is the angle formed by the downward and upward slopes of the calcaneal superior surface. On a lateral(side vies) x ray, an angle of Gissane of > 130° suggests fracture of the posterior subtalar joint surface. Bohler's angle, is another normal anatomic landmark seen in lateral x rays. An angle < 20° suggests a depression of posterior facet and possible calcaneal fracture.

    club foot

    Clinical Presentation : The most common symptom is pain over the heel area, especially when the heel is pressed. A history of recent trauma to the area or fall from a height is obtained. Inability to bear weight over the involved foot, limited mobility of the foot, and limping are other findings. Upon inspection, the examiner may notice swelling, redness, and bruising of the skin. The heel may also become widened with associated edema due to displacement of lateral calcaneal border.

    club foot

    Picture showing enormous swelling in calcaneal fractures

    Treatment :

    a) Non-surgical Treatment : Non-surgical treatment is indicated for extra-articular fractures and Sanders Type I intra-articular fractures, provided that the calcaneal weight-bearing surface and foot function are not compromised. The Orthopaedic surgeon may treat the fracture either by closed reduction with or without fixation (casting), or fixation alone (without reduction), depending on the individual case. Cast treatment and non-weight bearing for 2 months followed by range-of-motion exercises and progressive weight bearing.

    b) Surgical Treatment : Displaced intra-articular fractures require surgical intervention within 2 weeks of fracture, before bone consolidation has occurred. Currently, open reduction with internal fixation (ORIF) is usually the preferred surgical approach when dealing with displaced intra-articular fractures. Newer, more innovative surgical techniques and equipment have decreased the incidence of intra- and post-operative complications.

    Calcaneal fracture at operation
    Calcaneal fracture after operation

    Principles of calcaneal fracture treatment

    • Latest studies show better outcomes when operation is delayed by a few days till swelling settles down.
    • If operated early, skin break down can occur, with disastrous consequences.
    • Smokers generally have a poorer outcome.

    club foot

    Complications : Complications often occur with calcaneus fractures. Minor complications include: Small or temporary areas of delayed wound healing, nerve irritation around the incision, tendon irritation joint stiffness, chronic pain and chronic swelling.

    Major complications :

    a) Failure of the wound to heal and infection : Outcomes are generally poorer in smokers, So It is important to tell your surgeon if you are a smoker. With or without surgery, bone may take longer to heal if you smoke. Evaluating for soft-tissue involvement is the most important aspect of the clinical examination because of its association to overall outcome. Skin blisters may become infected if medical attention is delayed, which can lead to necrotizing fasciitis or osteomyelitis, causing irreparable muscle/bone damage. Ligament and tendon involvement should also be explored. Achilles tendon injury can be seen with posterior (Type C) fractures. Worth mentioning is the fact that, since calcaneal fractures are related to height falls, other concomitant injuries should be sought. Vertebral compression fractures occur in approximately 10% of these patients.

    b) Post-traumatic arthritis : This is a well-known complication of calcaneal fractures. Cartilage damage occurring during initial trauma, results in secondary arthritis giving rise to pain, limping and stiffness.

    A subtalar joint fusion is a good operation to reduce pain from post-injury arthritis. A pan talar fusion might also be necessary if both ankle and subtalar joints are involved in the arthritic process.