Clinics in Family Practice
Volume 2 • Number 3 • September 2000
Copyright © 2000 W. B. Saunders Company






OFFICE MANAGEMENT OF TRAUMA

  _____


MANAGEMENT OF ACUTE FRACTURES AROUND THE KNEE, ANKLE, AND FOOT



Phillip M. Steele MD
Charles Bush-Joseph MD
Bernard Bach Jr. MD

  _____

Department of Family Practice, MacNeal Hospital, Berwyn, Illinois; and
Department of Orthopaedic Surgery, Rush Medical College, Chicago, Illinois
  _____

Address reprint requests to
Phillip M. Steele, MD
Gem City Bone and Joint
1909 Vista Drive
Laramie, WY 82070
Primary care physicians commonly see fractures to the lower extremity.
Isolated injuries to the metatarsals and phalanxes account for up to 15% of
all fractures presenting to emergency departments. Ankle injuries, including
sprains and fractures, account for 10% of all radiographs ordered in an
emergency room setting. With the advent of improved orthotic bracing and of
surgical and nonsurgical techniques, the management of lower extremity
fractures is evolving. This article reviews current concepts in the
evaluation and management of these injuries. Indications for radiographic
evaluation and treatment with splinting or casting are also reviewed.


ACUTE CARE

Acute care of the injured patient includes initial triage of the unstable
patient, identification of musculoskeletal injuries, and provisional
splinting of injured extremities. Initial evaluation requires evaluation for
closed head, cervical spine, intrathoracic, and intra-abdominal injuries.
Checking vital signs, symptoms of shock, and potential risks of bleeding
should be done immediately. Examination for the presence of gross deformity,
loss of pulses, or impaired neurologic function distal to the injury should
also be included in the initial evaluation. Provisional splinting of injured
extremities and sterile dressing of open wounds will ease the patient's
discomfort and allow a more detailed examination. A warm blanket for the
torso and a supine position will increase the patient's comfort and decrease
the risk for shock. Comfort care includes minimizing patient transfers and
early administration of analgesia, because radiologic positioning can be
very painful.
High-energy trauma, including motor vehicle injuries, falls from height, or
injuries with possible spine or pelvic fractures, have a greater potential
for internal bleeding. If a high-energy hip or pelvic fracture is suspected,
large-bore intravenous access may be necessary to control shock.
A padded fiberglass posterior or stirrup splint can be used for lower leg
injuries.[ 22
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661022> ] An elastic bandage or tape measure can
be used to determine the length of splint needed. For correct width sizing,
a 4- or 5-inch rolled elastic bandage can be used to estimate the splint
width size that provides the best fit. The choice of precut or rolled
splinting material is a matter of preference, because each has its own
merits. Using cool water will lengthen the setting time. Avoiding
oversaturation of the splint makes molding the splint more comfortable for
the patient and improves fit.[ 23
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661023> ] For stability, an assistant should hold
the extremity above and below the fracture site while an elastic bandage is
rolled with light tension and a 50% overlap. A 3-inch elastic bandage is
best for the ankle and foot area. Wrapping the tibia and fibula area with a
4-inch wrap while smoothing the cast padding will also improve comfort. The
toes should be left exposed to check for circulation. The patient should be
instructed to check the FACTS: Function, Arterial pulses, Capillary refill,
Temperature of the skin, and Sensation. Rest, Ice, Compression and Elevation
(RICE) instructions and the proper use of crutches should be reviewed with
the patient. The patient should be given clear instructions on recognizing
the symptoms of compartment syndrome and when to call with questions or
concerns that develop before the next scheduled visit.
For patients with fractures requiring urgent or possible surgical
management, an additional history of last meal, medical problems, and
medications should be sought. Patients should take nothing by mouth until
surgical consultation has established a definitive treatment.


OPEN FRACTURES

Although definitive treatment of closed fractures should be considered
urgent, all open fractures should be treated as a true medical emergency to
minimize the risk of infection. An open fracture is a fracture that
communicates with an open wound. Skin abrasions or simple lacerations not
communicating with the fracture hematoma are not considered open fractures
and are treated as closed injuries.
Although open fractures should ideally be graded under operative conditions
to minimize the risk for infection,[ 1
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661001> ] [ 26
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661026> ] [ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] communicating the type of open fracture
can help the surgical consultant assess the urgency of the situation. The
most common classification system for open fractures divides open fractures
into three main types based on the mechanism of injury, the vascular status
of the extremity, the extent of soft-tissue damage, the amount of
comminution and bone loss, and the degree of bacterial contamination. Type I
fractures are low-energy injuries with minimal soft-tissue damage and a
surface wound smaller than 1 cm. This type of open wound is created from an
inside-to-outside puncture from the underlying bone. A type II fracture
occurs with moderate energy forces and causes an associated soft-tissue
laceration of less than 10 cm. The most severe open fracture pattern is type
III, which results from highenergy forces causing extensive soft-tissue
damage. Extensive comminution or a segmental fracture pattern generally
occurs with this type of fracture, and bacterial contamination is often
suspected.[ 1
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661001> ] [ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ]
Medical management of open fractures should be oriented at preventing
additional contamination by rapid transport and by minimizing dressing
changes and the number of persons inspecting the wound outside the operating
room. The wound should be covered with moist sterile bandaging, and the
extremity should be splinted in place.
Acute management should not include routine wound cultures in the emergency
department, because in patients who have undergone repeated dressing changes
and cultures taken before surgery the risk of infection increases from 4.3%
to 19.2%.[ 1
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661001> ] [ 26
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661026> ] Initial cultures are generally not
effective in predicting sepsis. Early intravenous administration of
antibiotic should be routine for all open fractures. Antibiotic coverage for
a type I open fracture should be oriented towards gram-positive organisms,
using cefazolin. Combination therapy using an aminoglycoside for
gram-negative coverage plus cefazolin should be used for type II and III
open fractures.[ 1
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661001> ] [ 26
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661026> ] [ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] If Clostridium perfringens contamination
is suspected (e.g., from soil near farmlands), penicillin coverage should be
added.[ 26
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661026> ] If surgical delay is anticipated,
intravenous antibiotics should be started in the Emergency Department.
The speed and urgency of transportation to the hospital has a great effect
on prognosis. Helicopter transfer is associated with an infection rate of
about 3%, whereas the rate of infection following ground transport is
2%.[ 26
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661026> ] Primary care management should include
transport coordination to optimize patient prognosis.


COMPARTMENT SYNDROME

Although compartment syndrome (CS) may occur after any fracture, it is more
commonly associated with long-bone fractures. Compartment syndrome is
associated with about 20% of tibial fractures.[ 1
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661001> ] [ 26
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661026> ] [ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] The force required to fracture long
bones causes extensive muscular contusion, swelling, and hemorrhage. With
early cast immobilization, muscle expansion is limited, increasing the risks
for CS. As fascial compartment pressure increases, it may exceed capillary
blood pressures to the involved area. Although arterial pressure may be
sufficient for distal pulses, capillary flow is diminished, and muscular
ischemia may occur. The finding of diminished or absent pulses is a late
clinical sign of CS, and intervention should have already occurred. Clinical
signs of CS include increasing, disproportionate pain after casting or
splinting and pain incurred with passive motion of the involved
compartment.[ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] After the first 24 hours, there may also
be tenderness over the involved compartment, as well as at the site of the
fracture, and weakness of the musculature of the compartment involved (Table
1)
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#T066101>  . Immediate removal of constricting or
circumferential dressings or splints is the first intervention with
suspected CS. Orthopedic referral is indicated if symptoms are not promptly
relieved with splint and dressing removal. Evaluation and management include
compartment pressure measurement and surgical fasciotomies for pressures
above 30 mm Hg.

TABLE 1 -- Physical Examination Findings for Anterior and Posterior
Compartment Syndrome
Involved Compartment
Symptoms
Anterior Compartment
Decreased sensation 1st web space, weakness of toe extension, pain with
passive toe flexion
Posterior Compartment
Decreased sensation over sole of foot, pain with passive toe extension,
weakness of toe flexion




FOLLOW-UP

Patients with a suspected or confirmed fracture should be re-examined in 2
to 5 days. Repeat radiographs are recommended for injuries with a high index
of suspicion based on history and physical examination but an initially
negative radiographic study. Nondisplaced stable fractures usually do not
require re-imaging at the first follow-up appointment. For injuries that
require casting as a definitive treatment, evolving or resolving swelling
may interfere with adequate immobilization, and casting may require delay or
recasting to ensure proper fit. Lowerextremity fractures involving the tibia
above the level of the malleolus often require surgical management or the
use of a long leg cast and should be referred to a specialist.
As a general rule, the more complicated the fracture, the more frequent the
follow-up. Less compliant patients should also be seen more frequently.
Fractures with a poor blood supply may require radiographs every 2 weeks,
whereas stable, nondisplaced fractures can be evaluated radiographically for
healing at 4 to 6 weeks.[ 11
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661011> ] [ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] [ 32
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661032> ] [ 35
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661035> ]
Two weeks after casting, follow-up either by telephone or office visit is
advisable to check cast comfort, compliance, and pain. Most fractures heal
in 6 to 8 weeks but vary depending on location, type, blood supply, and the
age of the patient.[ 11
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661011> ] [ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] Once radiographic evidence of fracture
healing has occurred and there is no tenderness over the fracture site, the
cast can be safely discontinued. The patient can be referred to physical or
home therapy for a strengthening and range-of-motion program, depending on
age, motivation, and joint involvement.


EVIDENCE-BASED DIAGNOSTIC TESTING

To discourage the indiscriminate use of radiographs, Brand et al in 1980
developed a protocol for selecting patients with injuries who need
radiographic examination (Table 2).
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#T066102>  [ 6
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661006> ] Studying 848 patients, they found that
strict adherence to the protocol would have decreased unnecessary
radiographic procedures by 12% in upper-extremity injuries and by 19% in
lower-extremity injuries. By eliminating unnecessary radiographic
procedures, they concluded that $79 to $139 million annually could be saved
nationwide. Since this pioneering study, the use of radiographs to assess
ankle, knee, nursemaid's elbow, and shoulder injuries and for pediatric
comparison views has been extensively reviewed. Clinical decision rules
(CDRs) for determining the need for radiologic evaluation exist at many
institutions and should be familiar to primary care providers. In this
article, the specific CDRs for each joint are discussed with each specific
joint fracture.

TABLE 2 -- Evolution of the Ottawa Ankle Rules
Original Ottawa Ankle Rules
Refined Ankle/Foot Rules
Age > 55
No age limits
Unable to bear weight (4 steps) both immediately and in emergency department
Inability to bear weight (4 steps) both immediately and in the emergency
department
Bone tenderness (at the posterior edge or top of either malleolus)
Bone tenderness (at the posterior edge or top of either malleolus)
Bone tenderness of the navicular, the cuboid, base of the fifth metatarsal
Bone tenderness at the navicular or the base of the fifth metatarsal
Pain in the midfoot
Pain in the midfoot

In a recent meta-analysis by Kaufman et al, CDRs were evaluated based on
study type, power, sensitivity, specificity, and validity.[ 17
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661017> ] The goal was to determine whether CDRs
have been reliably developed and validated for plain radiography of
extremity trauma. They found that the existing literature supports the use
of CDRs to evaluate isolated blunt trauma in healthy adults and that CDRs
are designed to detect common fractures. They also found that patient
education and follow-up care are essential, because patients who were not
radiologically assessed could have an insignificant avulsion fracture.
Furthermore, patients who are sent home without a diagnosis and treated as
having "no significant fracture" must understand that they could have a
significant ligament injury, a rare fracture, or an occult fracture. Because
CDRs have not demonstrated 100% sensitivity, the obvious risk of using CDRs
is that some nonsignificant fractures may be missed.


FRACTURES AROUND THE KNEE

The need for selective radiographic evaluation of ankle injuries has been
well described with the Ottawa Ankle Rules (OAR). Guidelines for the use of
knee radiography have not met with widespread acceptance.[ 25
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661025> ] [ 31
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661031> ] [ 36
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661036> ] To establish guidelines that can be
considered the Ottawa Knee Rules, Stiell et al evaluated 1047 adults with
acute knee injuries.[ 25
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661025> ] [ 31
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661031> ] [ 36
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661036> ] They evaluated decision rules including
(1) patient age of 55 years and older, (2) tenderness at the head of the
fibula, (3) isolated tenderness of the patella, (4) inability to flex to
90°, and (5) inability to bear weight for four steps, both immediately and
in the emergency department. The presence of one or more of these findings
was found to have a 100% sensitivity and a 54% specificity.
Application of these decision rules reduced radiography of acute knee
injuries from 68.6% to 49.4% and reduced time in the emergency room by an
average of 39 minutes.[ 25
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661025> ] [ 31
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661031> ] Although decision rules were developed
for emergency department management, application of these decision rules in
primary care may prove to be equally beneficial.[ 31
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661031> ]

Imaging

Assessment of acute knee injuries should begin with anterior-posterior (AP)
and lateral views. If tenderness of the patella exists, a sunrise or
merchant view should be included.[ 30
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661030> ] For patients who are unable to bear
weight and in whom a plateau injury is suspected, oblique views or a plateau
view should be added to the routine knee series. If a tibial spine fracture
is suspected with an anterior cruciate ligament injury, a notch or tunnel
view can help visualize this area. Radiographically detected defects in the
knee include the ABCs: Alignment (varus or valgus joint space narrowing,
rotational defects of the femoral condyle and shaft, patella alta, or
patella baja [the normal length of the patella ligament is equal to the
patella length ±20%; Bone (cortical defects and defects of the tibial
plateau structure); and Cartilaginous (flattening of the condyles, reactive
sclerosis, or a radiolucent defect may represent an osteochondral defect).
Soft-tissue swelling and a hemarthrosis should increase the suspicion for a
fracture.[ 14
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661014> ] [ 30
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661030> ]


DISTAL FEMUR FRACTURES

Distal femur fractures are uncommon fractures that generally result from
high-velocity trauma involving direct forces, such as hyperabduction or
adduction, hyperextension, and axial loading. Significant knee pain and
notable hemarthrosis or swelling and deformity are frequently present.
External rotation and shortening of the thigh should increase suspicion of a
displaced supracondylar fracture, because the quadriceps muscle will pull
the proximal fragment forward while the gastrocnemius causes posterior
displacement of the distal fragment.[ 1
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661001> ] [ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] The considerable force necessary to
fracture the femur causes extensive muscular contusion to the quadriceps and
increases the risk for compartment syndrome. This extensive soft-tissue
injury makes fracture management, pain control, and rehabilitation more
difficult, and the extent of the injury should be included in the decision
process for nonoperative or operative management.

Imaging

Anterior-posterior and lateral radiographs of the distal femur are usually
sufficient to demonstrate most fractures. However, an AP pelvis and AP and
lateral hip radiographs should be included, because ipsilateral hip
fracture, dislocation, and multiple fractures are common with high-energy
trauma.[ 14
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661014> ] [ 30
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661030> ]

Acute Care

The proximity of the femoral artery to the popliteal fossa necessitates an
accurate assessment of distal pulses and palpation for a possible pulsitile
hematoma in the popliteal fossa. Any suspicion of vascular compromise should
be further evaluated with Doppler ultrasound imaging. Emergent consultation
with vascular or orthopedic surgeons is imperative when vascular compromise
exists. Injury to the peroneal and deep peroneal nerves can occur with
fractures to the distal femur; sensory integrity can be assessed at the
interspace between the first and second toe. Muscular testing is usually
difficult because of pain during the acute management of distal femoral
fractures. Adequate analgesia can contribute to the effectiveness of initial
assessment of these injuries.[ 1
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661001> ] [ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ]

Classification

In adults, distal femur fractures are divided into three main types (Fig. 1)
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#F066101>  . Supracondylar fractures include
fractures found in the area just above the femoral condyles (metaphysis) to
the junction of the femoral shaft (diaphysis). These fractures are
extra-articular and are not associated with a hemarthrosis. Intra-articular
fractures consist of intercondylar and condylar fractures. They are
associated with significant hemarthrosis and should be suspected in any
patient presenting with a history of trauma and intra-articular swelling.
Isolated condylar fractures are uncommon and can be associated with knee
dislocation and muscular or ligamentous attachment avulsion.[ 2
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661002> ] [ 14
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661014> ] [ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] [ 30
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661030> ]

<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/I41.fig#top>
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/I41.fig#top> Figure 1. Types of distal femur
fractures.

No universal classification system has been accepted, because surgical
management of distal femoral fractures is very individualized. The
evaluation of each fracture should be based on displacement, comminution,
associated soft-tissue injury, neurovascular status, osteoporosis, joint
involvement, and functional status. The fracture should be described as
either displaced or nondisplaced, and involvement of one or both condyles,
extension into the metaphysis or diaphysis, and neurovascular status should
be noted. Care must be taken to confirm whether the fracture is open or
closed, because open fractures require urgent irrigation and debridement.[ 2
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661002> ] [ 14
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661014> ] [ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] [ 30
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661030> ]

Treatment

Complications for distal femur fractures include deep vein thrombosis, fat
embolism, delayed union or malunion, valgus or varus angulation deformities,
chronic arthritis, compartment syndrome, and growth disturbances in
adolescents. Orthopedic management is generally required except for simple
nondisplaced fractures.[ 21
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661002> ] [ 65
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661002> ] Prompt early referral is important,
because definitive treatment of these fractures varies depending on type of
fracture. Alignment of the femoral condyles must be precise, and any
abnormalities will disrupt joint mechanics and increase wear of the
cartilaginous surfaces. Current strategies include cast-bracing
immobilization or open reduction with internal fixation (ORIF).[ 65
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661002> ] [ 68
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661002> ] Medical management involves prevention
of shock, immobilization, and pain control. Neurovascular deficits should
prompt urgent referral to a vascular surgeon or orthopedist.


PATELLAR FRACTURES

As the largest sesamoid bone, the patella has an important biomechanical
role in knee extension by increasing the length of lever arm. The principal
quadriceps insertion site is the superior edge of the patella. The inferior
edge acts as the site of attachment for the patellar tendon. Contraction of
the quadriceps muscle transmits force through the patella to the patellar
tendon and tibial tuberosity. Because cosiderable forces can be transmitted
across the knee during running and jumping, fractures of the patella are
common.[ 2
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661002> ] [ 14
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661014> ] [ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] [ 30
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661030> ]
Two main types of patellar fractures are caused by indirect and direct
trauma. Indirect trauma is the most frequent cause of patellar fracture and
occurs during unexpected, rapid, forceful flexion of the knee against a
fully contracted quadriceps. Horizontal or transverse fractures are the most
common fractures caused by indirect trauma. Fractures from direct trauma
occur as a result of a direct blow or a fall onto the knee. Generally,
direct trauma causes considerable comminution, because little soft tissue is
present to buffer the blow. Because many fractures result from a combination
of indirect and direct forces (it is difficult to remain completely relaxed
while falling), many fractures present multiple patterns.[ 2
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661002> ] [ 14
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661014> ] [ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] [ 30
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661030> ]
During the physical examination assessing patellar injury, it is essential
to check the ability to extend the knee completely against gravity. Loss of
knee extension may signify disruption of the quadriceps mechanism,
necessitating emergent referral.[ 2
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661002> ] [ 9
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661009> ] When the physical examination is limited
because of pain, aspiration of a hemarthrosis and instillation of a local
anesthetic may assist in determining the integrity of the quadriceps tendon.
The patient will generally complain of pain localized to the patella area
and exhibit notable prepatellar swelling. Joint hemarthrosis is frequently
present, and a defect or crepitus may be noted on palpitation of the
quadriceps and patella tendon.[ 2
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661002> ] [ 9
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661009> ]

Classification

The classification system for patellar fractures is based on fracture
descriptions, not on prognosis. They are classified as vertical, transverse,
marginal, comminuted (stellate), or osteochondral (Fig. 2)
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#F066102>  . Transverse fractures account for about
one half of all patellar fractures, followed next in frequency by comminuted
fracture. Marginal fractures are found along the edge of the patella and are
not associated with disruption of the extensor mechanism. Fractures found
with more than 2 mm of displacement or with any articular surface step-off
should be considered displaced and referred for orthopedic management.[ 2
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661002> ] [ 9
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661009> ] [ 11
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661011> ] [ 30
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661030> ] [ 38
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661038> ]

<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/I42.fig#top>
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/I42.fig#top> Figure 2. Types of patella fractures.

Osteochondral fractures result from either direct forces or from patellar
dislocation. Directed pressures around a point of contact cause separation
of the articular surface from the subchondral bone and from the supporting
trabecular bone. These osteochondral fragments usually heal without
complications but on occasion may become detached and form a loose body.[ 9
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661009> ]

Imaging

The patella is often difficult to evaluate in an AP knee radiograph because
of distal femur overlap. Therefore, special views of the patella are helpful
in identifying suspected fractures. Many physicians consider merchant and
sunrise views to be identical, but they are actually obtained with different
orientations. In the sunrise view, the patient is in a prone position, and
the knee flexed 115°. The x-ray beam is directed tangentially through the
patellofemoral joint with about 15° cephalad angulation.[ 14
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661014> ] The merchant view is imaged with the
patient supine and knee flexion at 45°. The central beam is caudally
directed with a 60° orientation through the patellofemoral joint.[ 14
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661014> ] Both views are adequate for assessing
vertical fractures and osteochondral defects. A sunrise view is better for
evaluating acute fractures, and a merchant view is better for assessing
cartilaginous changes to the patellofemoral joint. A lateral knee view is
best for identifying horizontal fractures and patella location.
Using the Insall-Salvati ratio, patella alta may be assessed for possible
quadriceps tendon rupture. The normal relationship is 0.8 to 1.2, measured
by comparing the length of the infrapatellar tendon (inferior pole of the
patella to the tibial tuberosity) to the length of the patella on a
lateral-view radiograph.[ 14
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661014> ] [ 30
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661030> ]
Vertically oriented grooves on the anterior surface of the patella are
normal findings and should not be considered evidence of a fracture.
Bipartite and multipartite patellae are unfused accessory ossification
centers and are normal variants.[ 14
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661014> ] They are generally found in the
superolateral corner and are often bilateral, smooth, or rounded. They
should not be confused with a fracture, and comparison views of the
contralateral knee are often helpful.

Treatment

After confirming an intact extensor mechanism, acute care consists of
controlling swelling and pain with a long straight-leg immobilizer in full
extension for 4 to 5 days, ice, compression and elevation. Initially a
non-weight bearing status is more comfortable, with advancement to toe touch
and full weight bearing as tolerated. Quadriceps strengthening should begin
during the acute phase with straight leg lifts.[ 2
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661002> ] After the acute period, patients with
nondisplaced fractures and good quadriceps control can be treated with
continuation of the straight-leg immobilizer or with above-the-knee
casting.[ 2
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661002> ] [ 9
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661009> ] [ 11
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661011> ] [ 32
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661032> ] Only persons experienced with long-leg
casting should apply a full-length cast.[ 2
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661002> ] [ 11
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661011> ] The knee should be in full extension for
a total of 4 to 6 weeks. Immobilization is generally required until evidence
of fracture healing is present on repeat radiographs. After initial
follow-up, displacement of the fragments should be checked at 2 weeks with
repeat radiographs.

Referral

A major portion of the blood supply to the patella enters from the central
portion of the distal pole. A transverse fracture through the midportion of
the patella with displacement can result in nonunion or avascular necrosis
(AVN) of the proximal portion of the patella. Referral is indicated for all
displaced fractures and with any evidence of articular surface displacement
of 2 mm or more.[ 11
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661011> ] [ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] [ 32
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661032> ]


PROXIMAL TIBIAL INJURIES

Tibial condylar injury ("car-bumper injury") is commonly found after
automobile/pedestrian accidents. Frequently the lateral plateau is injured,
because valgus force is the most common. Ligamentous injury is often
associated with tibial condylar injuries, because a varus or valgus force
causes a compressive force opposite the ligament being stressed until its
rupture. Thus, a valgus force applying stress to the medial collateral
ligament cantilevers a compressive force onto the lateral tibial condyle.[ 2
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661002> ] [ 11
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661011> ] [ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ]
Osteoporotic individuals may fracture the tibial plateau with relatively
minor trauma. Therefore any elderly person with a hemarthrosis should be
suspected of having a tibial plateau injury until proven otherwise.[ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] Patients will present with inability to
bear weight, a significant effusion, joint-line or proximal tibial pain, and
decreased range of motion. Complaints of instability are common, as is
ligament instability during physical examination. A patient presenting
acutely with an isolated anterior cruciate ligament (ACL) rupture generally
complains only of instability and can usually bear weight for at least four
steps. Conversely, those with a proximal tibial fracture will not be able to
bear weight (Ottawa Knee Rules), and this finding should prompt further
evaluation.
Complete assessment for ligament instability is crucial for management. A
simple nondisplaced lateral fracture with an associated ACL rupture should
be referred for surgical management,[ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] whereas a nondisplaced lateral fracture
with intact ligaments could be managed by an experienced primary care
physician.[ 1
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661001> ] Acutely, analgesia is often required
before ligament assessment can be undertaken. Arthrocentesis of a tense
hemarthrosis and instillation of long-acting local anesthetic can provide
adequate analgesia and improve ligament evaluation.[ 32
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661032> ] When laxity of the joint is found,
careful assessment for fracture stability must also be made. Because an
unstable fracture can mimic a collateral injury on stressing, careful
palpation of the fracture fragment during ligament testing is crucial.
Plain-film stress views, CT scanning, or MR imaging can clarify questionable
physical examination findings.[ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] Assessment of suspected proximal tibial
injuries includes a complete neurovascular examination with emphasis on
peroneal nerve testing. Therefore, evaluation of nerve and muscular function
should include ankle dorsiflexion and eversion as well as sensation in the
lateral lower leg.

Imaging

Radiographic evaluation of a suspected ligamentous knee injury includes an
AP and lateral view.[ 14
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661014> ] [ 30
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661030> ] Patients not able to ambulate at least
four steps (Ottawa Knee Rules) should have additional plain films taken to
evaluate the tibial plateau. Internal and external oblique views or tibial
plateau view (AP with 15° vertical orientation) are frequently used.[ 14
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661014> ] [ 30
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661030> ] The normal tibial plateau slopes
downward from anterior to posterior, thus making compression fractures very
subtle. In the lateral view, the normal medial tibial condyle is concave,
whereas the lateral tibial condyle is convex. A small avulsion fracture on
the lateral margin of the lateral tibial condyle near the insertion site of
the lateral capsular ligament is commonly found with internal rotation and
varus stress injuries. This type of fracture has been termed a Segond
fracture after Paul Segond who first described this injury.[ 2
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661002> ] [ 14
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661014> ] This fracture is significant, because
there is a 75% to 100% association with concurrent ACL rupture (Fig. 3)
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#F066103>  .[ 14
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661014> ] [ 30
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661030> ]

<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/I43.fig#top>
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/I43.fig#top> Figure 3. Segond fracture suggesting a
torn ACL.


Classification

The most widely accepted classification system for plateau fractures is the
Schatzker system (Fig. 4)
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#F066104>  .[ 14
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661014> ] [ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] [ 30
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661030> ] It is helpful to use a precise
description of the amount of displacement, angulation, and number of
fragments, and the classification type when describing a plateau injury to
an orthopedic consultant. Fracture types I through III are lateral plateau
fractures. Type I is a split fracture without articular depression of the
lateral plateau. With displacement, the lateral meniscus is usually torn or
detached. A split fracture with depression is a type II injury and usually
results from a combined axial and lateral force. Large compression areas
usually include meniscus entrapment and should be managed surgically. Type
III injuries occur as isolated areas of lateral plateau depression and, if
extensive, may also entrap the meniscus.[ 14
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661014> ] [ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] [ 30
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661030> ] A type IV fracture is isolated to the
medial plateau, whereas types V and VI are bicondylar and bicondylar plus
tibial shaft, respectively. Experienced primary care physicians can manage
simple, nondisplaced (3 mm) types I-III fractures with no associated
ligamentous injury.[ 11
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661011> ] [ 32
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661032> ] [ 35
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661035> ] Schatzker types IV through VI are medial
plateau and bicondylar fractures and should always be referred for
orthopedic management.[ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] Acute management includes long leg
immobilization, use of crutches, and RICE therapy.

<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/I44.fig#top>
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/I44.fig#top> Figure 4. Lateral plateau Schatzker
classification.


Treatment

The goal for management of tibial plateau fracture includes minimizing the
risk for posttraumatic osteoarthritis, restoring articular function, and
correcting malalignment.[ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] Because limited data are available on
the maximal acceptable area of articular depression that reduces the risk
for articular dysfunction and osteoarthritis, a conservative approach may be
warranted.[ 16
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661016> ] Factors that contribute to the choice of
operative or nonoperative management include ligament and fracture
stability, displacement greater than 3 mm, comminution, and fracture
location.[ 16
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661016> ] [ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] In general, all high-energy fractures
should be referred for orthopedic management.[ 4
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661004> ] [ 16
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661016> ] [ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] Additional factors to consider include
the patient's age and level of activity, associated medical conditions, and
osteoporosis.[ 4
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661004> ] [ 16
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661016> ] [ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] Many variables affect the long-term
functional outcome of tibial plateau fractures. The single most important is
knee instability. Ligamentous instability that goes undiagnosed during the
acute assessment can profoundly affect functional recovery. Tibial plateau
fractures are often associated with incarceration of the meniscus into the
fracture site. Split and compression fractures with more than 3 mm of
displacement are at increased risk for meniscus entrapment (Fig. 5)
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#F066105>  .[ 4
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661004> ] [ 16
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661016> ] [ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] Arthroscopic evaluation before ORIF may
identify incarceration of the meniscus and allow concurrent repair with the
plateau fracture. Evaluation by MR imaging should be considered when
uncertainty exists about open versus closed management.

<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/I45.fig#top>
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/I45.fig#top> Figure 5. Schatzker type II and proximal
fibular fracture.

Drainage of a significant hemarthrosis and instillation of local anesthetic
should be used to confirm ligament and fracture stability and to decrease
pain. After stability is assured, low-energy nondisplaced type I-III
fractures can be managed with a long leg compressive stocking and a hinged
knee brace locked in full extension.[ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] The patient should not bear weight for a
total of 4 to 6 weeks. Gradual passive range of motion exercises can begin
after 2 weeks, with a goal of passive flexion to 90° by 4 weeks.[ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] A total of 8 to 12 weeks of
immobilization is usually necessary. Radiographs should be taken weekly for
the first 3 to 4 weeks and then spaced every 3 to 4 weeks until fracture
healing.[ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ]


TIBIAL SPINE INJURIES

Although injuries of the tibial spine (intercondyle eminence) are uncommon,
they may be seen with an acute ACL rupture.[ 2
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661002> ] [ 4
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661004> ] [ 32
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661032> ] With the knee in a flexed position,
rotational forces can produce excessive tension of the ACL, causing either
ligament rupture or tibial spine avulsion. Because in younger pediatric
patients the ligament structure is relatively stronger than bone, tibial
spine injuries should be suspected with a positive Lachman test,
hemarthrosis, and painful ambulation.[ 4
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661004> ] Anterior-posterior and lateral
radiographs should be routinely scrutinized for a nondisplaced or hinged
tibial spine fracture when plain films of patients with acute ACL injury are
examined (Fig 6)
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#F066106>  .[ 30
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661030> ] Most isolated ACL ruptures will cause
symptoms of instability, painful range of motion, and intra-articular
swelling. Inability to bear weight is not always a typical finding with
cruciate injury. Tibial plateau or tibial spine fracture should be
considered in patients presenting with ACL rupture and inability to bear
weight. For suspected tibial spine injuries, the addition of a tunnel or
oblique view can increase the sensitivity and specificity of a radiographic
knee series.[ 14
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661014> ] [ 30
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661030> ]

<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/I46.fig#top>
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/I46.fig#top> Figure 6. Type II tibial spine avulsion
fracture.


Classification

Three types of intercondylar eminence fracture patterns have been described.
Type I injuries are nondisplaced or incomplete avulsions. Fractures that
have displacement of the anterior one third to one half of the avulsed
fragment and that are hinged on the posterior border are classified as type
II. In the most common pattern, type III, the avulsed fragment is completely
separated from the tibial plateau.[ 4
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661004> ] [ 32
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661032> ]

Acute Care and Treatment

Early treatment includes knee immobilization in a full-length knee
immobilizer and no weight bearing. Aspiration of a tense hemarthrosis and
standard RICE therapy can significantly help control pain. Type I and II
injuries can usually be managed with closed reduction using hyperextension
of the knee and cast immobilization at 10° to 15° of flexion for 4 to 6
weeks.[ 4
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661004> ] [ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] Because controversy exists over the
angle of immobilization that is recommended, orthopedic consultation is
usually indicated. All type III and irreducible type I and II fractures
should be referred for ORIF.[ 4
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661004> ]


TIBIAL TUBEROSITY FRACTURES

Sudden forced flexion of the knee against a contracted quadriceps muscle, as
occurs during a jump and forceful landing, may cause a tibial tuberosity
fracture. This injury is uncommon after apophysis closure, but may be seen
in younger patients, because their tendons can be stronger than bone.[ 2
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661002> ] [ 4
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661004> ] Care must be taken not to confuse this
injury with Osgood-Schlatter disease, which involves the anterior surface of
the tubercle.[ 2
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661002> ] [ 4
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661004> ] [ 32
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661032> ] The physical examination should include
assessment of the quadriceps extension mechanism, because its loss mandates
urgent referral. Although both types of injury can cause pain and tenderness
directly over the tuberosity, apophysis fracture will result in the knee's
being held in slight flexion (20°-40°) and in difficulty with knee extension
against resistance. Tuberosity fractures involve complete or incomplete
avulsion of the tibial tubercle, the insertion site of the patella tendon.

Classification and Imaging

Lateral radiographs allow visualization of these fractures and the amount of
displacement. In type I injuries, the distal fragment of the tibial
tuberosity is displaced proximally and anteriorly. The patient can usually
extend the knee against gravity but has difficulty extending the knee
against resistance. Patients with type II and III tibial tuberosity
fractures are unable to extend the knee against gravity. Type II fragments
are hinged at the proximal portion, with a larger fragment extending into
the physis of the tibia. Fractures with extension into the articular surface
are termed type III injuries.[ 2
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661002> ] [ 4
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661004> ]

Treatment

Type I injuries with minimal displacement can be treated with cast
immobilization in full extension for 6 weeks.[ 2
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661002> ] [ 4
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661004> ] Postreduction displacement greater than
5 mm requires orthopedic referral and surgical management. Displacement in
younger patients should be compared with radiographs of the contralateral
knee. All type II and III injuries should be referred for ORIF.[ 2
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661002> ] [ 4
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661004> ] Routine knee films adequately
demonstrate these fractures, but comparison views are useful for suspected
nondisplaced apophysis fractures (Fig. 7)
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#F066107>  .

<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/I47.fig#top>
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/I47.fig#top> Figure 7. Type II tibial tuberosity
fracture.



FRACTURES OF THE TIBIAL SHAFT

The tibia is the most commonly fractured long bone, and these fractures are
frequently associated with severe complications. Tibial fracture can be
challenging for both the orthopedist and primary care physician. Controversy
exists over the method of treatment, because there is a lack of adequate
randomized, controlled trials comparing closed management versus ORIF or
fixation with intramedullary rod. A recent meta-analysis found that time to
union was 20 weeks for intramedullary rod placement, 14.7 weeks for cast
immobilization, and 13 weeks for ORIF.[ 20
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661020> ] The difference between cast
immobilization and ORIF was not found to be significant. Differences in the
definitions of healing, union, and functional outcome make clinical
correlation difficult, however. The authors concluded that for most closed
fractures of the tibia time to union may be shorter after ORIF than after
cast immobilization; however, there may be a higher incidence of
complications with ORIF.
Although debate continues over surgical versus conservative management of
tibial shaft fractures, acute care and fracture stabilization principles are
the basis of primary care management.[ 5
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661005> ] [ 15
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661015> ] [ 20
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661020> ] Besides being the most commonly
fractured long bone, the tibia is also the most common open fracture.[ 1
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661001> ] [ 26
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661026> ] Initial evaluation should include a
thorough inspection for soft-tissue defects. Wounds to the surface of the
lower leg may communicate with an underlying fracture, which may have become
partially reduced. When in doubt the primary care physician should assume
that an open fracture is present and seek prompt orthopedic consultation.
Open fractures should be dressed with moist, sterile bandaging and splinted
in place. If the patient has absent distal pulses, an attempt at fracture
reduction may be warranted.[ 1
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661001> ] A long-leg, padded posterior splint with
the knee in about 10° of flexion should be placed with two assistants
holding above and below the fracture site. An elastic bandage should be
lightly wrapped around the limb.
Regular neurovascular checks should be carried out, because compartment
syndrome is a frequent sequela of lower-extremity injury.[ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] If the skin over the fracture site is
tented and ischemic, some gentle axial traction may lessen the risk for an
evolving open fracture. Acute care should include adequate analgesia,
because the process of splint immobilization and patient transfer can be
quite painful. Frequently, intravenous access is warranted for pain control,
administration of antiemetics, and fluid replacement.

Imaging and Classification

A cross-table lateral and AP view of the entire tibia is generally
sufficient for diagnosis (Fig. 8)
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#F066108>  .[ 14
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661014> ] [ 30
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661030> ] Fracture immobilization should take
place before radiologic studies, because moving patients with
lower-extremity trauma can cause unnecessary pain and increase the odds of
converting a closed fracture to an open one. For patients with gross
deformity, intravenous access and analgesia is preferable before splint
immobilization. Careful assessment of the knee and ankle is required before
imaging studies, because there is a high incidence of associated knee and
ankle injuries. Long-bone fractures are best described in terms of their
features, because no classification scheme has been universally
ccepted.[ 26
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661026> ] Table 3
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#T066103>  . lists the features of long-bone
fractures in the order in which they should be communicated to another
physician.

<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/I48.fig#top>
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/I48.fig#top> Figure 8. Closed distal third comminuted
fracture of the left tibia. The fracture is considered nondisplaced, as
there is less than 5° angulation in the AP plane and no rotation
abnormality.


TABLE 3 -- Descriptive Terminology For Long-Bone Fracture
Type
Open versus Closed
Location
Proximal, middle, and distal third

Proximal or dustal diaphyseal-metaphyseal junction
Configuration
Transverse, oblique, spiral, and comminuted
Displacement
25%, 50%, 75%, complete
Angulation
In degrees of distal fragment in relation to the proximal fragment. AP,
varus, or valgus (apex of the fracture points towards the force)
Length
Measured in mm of overlap or distraction
Rotation
Degrees
Associated
Fibula fracture and other injuries
Nondisplaced
5 mm of displacement AP and mediolateral; 10° angulation AP and 5°
angulation mediolateral; 10° rotation.
AP = anterior-posterior.


Treatment

Because no clear consensus exists for management of tibial shaft fractures,
assessment of a patient's likelihood for early weight bearing helps provide
indications for surgical versus conservative management.[ 29
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661029> ] [ 40
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661040> ] A retrospective, nonrandomized study
found earlier rates of healing with early weight bearing than with
non-weight bearing.[ 15
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661015> ] Multiple studies have corroborated this
finding and the correlation between delayed weight bearing and delayed union
and nonunion.[ 40
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661040> ] Therefore, patients who have comorbid
conditions that limit early ambulation should be considered for ORIF. When
making decisions about fracture management each fracture should be treated
as unique. All factors involved contribute to the management decision and
prognosis.
Primary care physicians experienced in plaster casting can manage lowenergy,
minimally displaced (<4 mm), stable, isolated shaft fractures with closed
reduction and long leg casting.[ 11
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661011> ] [ 35
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661035> ] After the acute swelling has stabilized
with elevation and ice, a walking long leg cast should be applied with the
knee in 0° to 5° of flexion.[ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] A walking boot should be placed over the
cast to assist with ambulation. Gradual weight bearing should be initiated
as tolerated, with the goal of full weight bearing by 2 weeks. Early
ambulation should be with assistance of crutches and heel pressure. Weekly
radiographs should be taken to confirm fracture stability.[ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] At 4 weeks, the plaster cast should be
removed, and the leg should be assessed for fracture healing. At this time,
reliable patients can be switched to a patellar tendon-bearing orthosis or a
long-leg fiberglass cast.[ 5
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661005> ] [ 15
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661015> ] [ 20
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661020> ] [ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] [ 29
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661029> ] A common complication of prolonged knee
immobilization is knee stiffness. Many studies have found that the rates of
union using a patellar tendon-bearing cast or orthosis that allows earlier
knee motion are comparable to those obtained with long-leg casting. [ 29
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661029> ]
Patients should be cautioned about compartment syndrome after casting and
given instructions for quadriceps-strengthening exercises. After weekly
evaluations for the first month, the patient can have follow-up visits
lengthened to every 3 to 4 weeks. Radiographs should be taken with each
re-examination; evidence of fracture healing should be present by 14 weeks.
The rate of healing is quite variable, and patients should be counseled that
low-energy, minimally displaced fractures heal by 21 weeks in 75% of
patients. About 90% of patients are clinically healed by 26 weeks.[ 29
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661029> ]

Referral

Indications for referral include combined tibial and fibular injuries,
floating knee injuries, unstable or displaced fractures greater than 4 mm,
and comminuted fractures. All high-energy fractures should be referred, as
should rotational or angulation abnormalities greater than 5°. Although
fractures are considered nondisplaced with less than 10° angulation in the
anterior/posterior plane, multiple planes and multiple factors are involved
with a tibial shaft injury, and most primary care physicians should seek
orthopedic consultation.[ 5
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661005> ] [ 15
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661015> ] [ 20
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661020> ] [ 26
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661026> ] [ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] [ 40
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661040> ]


PROXIMAL AND MIDSHAFT FIBULAR FRACTURES

Although the fibula is not significantly involved in weight bearing, it does
have a critical role in knee and ankle stability. The proximal fibula serves
as the attachment site for the lateral collateral ligament and biceps
femoris. It also acts to dissipate torsional stress of the ankle, so it must
be examined in ankle injuries to rule out a compensatory Maisonneuve
fracture. The distal portion helps form the lateral support of the ankle and
serves as the attachment point for the lateral ligaments. Primary care
physicians can manage isolated fibular fractures, with this caveat: proximal
fibular fractures indicate knee instability until proven otherwise.[ 32
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661032> ] Proximal fractures may also be
associated with common peroneal nerve injury. Therefore, testing for ankle
dorsiflexion and sensation of the first web space is essential.
Isolated fractures of the fibula can be caused by direct or indirect forces.
A direct blow to the lateral leg tends to cause a transverse or comminuted
fracture. Indirect rotational force tends to cause oblique fractures,
whereas varus stress causes avulsion injury. Most patients will be able to
walk with an isolated fibular fracture, but difficulty in walking should
prompt further evaluation for associated fracture or ligament
nstability.[ 11
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661011> ] [ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ]

Imaging and Classification

When ordering radiographic studies, it is advisable to obtain studies above
and below the joint if any ankle or knee tenderness is elicited on physical
examination. Identification of a spiral fibula fracture or a fracture that
occurs at the junction of the middle and distal thirds may warrant ankle
radiographs, because associated ligament and ankle injury are common with
these fracture patterns.[ 14
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661014> ] [ 30
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661030> ] Lateral and AP views are generally
sufficient for fracture identification. Descriptive terminology is best
used, as was discussed previously (Table 3)
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#T066103>  . Because proximal fibular fractures are
commonly associated with tibial plateau fractures (split and compression,
type II), a thorough inspection of the radiographs is warranted.

Treatment

As with any lower-extremity injury, elevation, ice, analgesics, and
immobilization with a posterior splint are the mainstays of acute care. The
patient should not bear weight until the initial follow-up visit. Management
of isolated proximal fibular head fractures should include careful
evaluation for common peroneal nerve injury and lateral collateral ligament
rupture.[ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] Small avulsion and nondisplaced
fractures to the fibula neck and head can be treated symptomatically with a
knee immobilizer and crutches for comfort.[ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] The patient can advance to a hinged knee
brace when able to bear weight comfortably. Four to 6 weeks of protection
from lateral motion and rotational forces is generally sufficient for
healing.
For unstable midshaft combination fractures, a dual posterior and stirrup
splint provides excellent stabilization. Application first of the
full-length posterior splint with a light elastic wrap (leaving the toes
exposed) followed by a full-length stirrup splint will provide excellent
fracture stabilization and pain relief. Leaving a small opening with the
elastic bandage near the medial malleolus (posterior tibial artery) and the
dorsalis pedis artery is helpful for future pulse checks. Excessive cast
molding and elastic bandage tension can increase the likelihood of
developing compartment syndrome.
Because the fibula is minimally involved with weight bearing, nondisplaced
midshaft fractures usually heal without complications. Casting, however, can
cause a serious complication related to inadequate padding near the peroneal
nerve. Injury to the peroneal nerve can cause long-term disability, and
additional cast padding near the proximal portion of the fibula is
advisable. After the acute period, in 4 to 5 days, a short leg walking cast
or cast walking boot should be applied for 4 to 6 weeks.[ 8
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661008> ] [ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] [ 32
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661032> ] Gradual progression to weight bearing
should be as tolerated, and healing of the fracture should be completed by 8
weeks. For reliable patients with minimal tenderness, assisted ambulation
with crutches and elastic wrap from the ankle to above the knee may be
adequate.[ 11
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661011> ] [ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ]
Referral is indicated for significant displacement and severe comminution.
Development of compartment syndrome or peroneal nerve involvement is also an
indication for orthopedic consultation.[ 11
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661011> ] [ 26
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661026> ] [ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] [ 40
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661040> ]


INJURIES TO THE ANKLE JOINT

Ankle injury is the most common lower-extremity injury seen in many primary
care practices.[ 10
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661010> ] Familiarity with a thorough ligamentous
examination and the OAR is essential for proper management. Approximately
15% of persons evaluated for acute ankle injury have a significant fracture.
Application of CDRs can benefit patient care by decreasing cost and time
spent waiting.[ 22
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661022> ] Multiple studies have validated the
original ankle rules, and attempts to refine these rules have not
significantly improved their sensitivity or specificity. Pooled analysis of
the OAR conducted at university and community hospital emergency departments
had a combined sensitivity of 97% or higher for ankle and foot injuries and
a negative predictive value of 99%.[ 22
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661022> ] Although the specificity is only 31% to
63% and the positive predictive value is 20%, the OAR have consistently been
shown to be effective in decreasing the number of radiologic studies needed
by 34%. Therefore, the OAR are more effective in ruling out fractures than
ruling them in.[ 22
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661022> ]
The clinical usefulness of the OAR in the primary care setting has been an
area of debate. Proponents argue that extrapolation of emergency room CDRs
are not valid, because the fracture frequency of the foot and ankle
approaches 20% in the emergency room, compared with only about 8.5% in the
primary care setting.[ 22
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661022> ] More recently, several studies involving
pediatric and primary care physician clinics found sensitivity and
specificity identical to emergency department CDRs, and similar time and
cost benefits.[ 22
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661022> ]
Successful management requires determination of a stable versus unstable
fracture. The bones and ligaments of the ankle form a ring around the ankle
mortise. For instability to occur, ligamentous injury or fracture must
include both medial and lateral sides of the ring. Generally, isolated
nondisplaced distal fibular or distal tibial fractures are stable when no
ligamentous instability is present on the opposite side of the ring. Careful
evaluation of the ankle for medial and lateral swelling and ecchymosis
should be routine, and their presence should increase suspicion of an
unstable injury.[ 10
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661010> ] [ 11
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661011> ] [ 21
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661021> ] [ 24
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661024> ] [ 39
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661039> ]
The three bones that make up the ankle joint (distal tibia, distal fibula,
and talus) are bound together by the joint capsule and surrounding
ligaments. The anatomic relationship of the tibial plafond (joint surface of
the distal tibia and fibula) to the talus is important for ankle stability.
The talus is broader anteriorly, and dorsiflexion increases bone surface
contact, thus improving stability. This relationship causes decreased
stability with plantarflexion and accounts for the vulnerability to
ligamentous injuries in this position.[ 10
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661010> ] [ 11
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661011> ] [ 21
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661021> ] [ 24
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661024> ] [ 39
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661039> ] [ 42
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661042> ]
Forces acting on the ankle lead to typical fracture or ligamentous patterns.
Determining the position of the ankle during injury can assist in assessment
of ligament stability. Although simple, unidirectional forces can be
involved in ankle injury, generally a multidirectional component is present,
making diagnosis challenging.[ 21
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661021> ] [ 24
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661024> ] [ 39
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661039> ]
Medial complex injuries typically occur from an eversion and abduction
force. The medial complex consists of the medial malleolus, the medial facet
of the talus, and the superficial and deep components of the deltoid
ligament. Eversion of the ankle causes injury to the superficial deltoid
ligaments and, if sufficient, to the deep deltoid ligament. Avulsion of the
distal medial malleolus tends to occur with younger and older patients,
because ligamentous strength may be relatively greater in these individuals.
With continuation of these forces, impaction of the distal lateral malleolus
occurs, resulting in either rupture of the syndesmosis or oblique fracture
of the distal fibula. When external rotation is combined with an eversion
force, a proximal fibula fracture (Maisonneuve fracture) may occur.[ 10
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661010> ] [ 11
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661011> ] [ 21
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661021> ] [ 24
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661024> ]
The lateral complex, which consists of the distal fibula, the lateral facet
of the talus, and the lateral collateral ligaments of the ankle and subtalar
joint, is the most common ankle injury. Lateral malleolus injury typically
occurs with inversion and adduction forces. The inversion force first
strains the lateral ligament complex or avulses (transverse fracture) the
lateral malleolus. With continuation of this force, the talus impacts the
medial malleolus, causing an oblique fracture of the distal tibia (Fig. 9)
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#F066109>  . Posterior malleolus injury is found with
a combination of forces (eversion, abduction, and vertical loading). When
high-energy impaction or axial compression is involved, a severely
comminuted fracture of the tibial plafond, called a pilon fracture, may
occur.[ 10
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661010> ] [ 11
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661011> ] [ 21
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661021> ] [ 24
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661024> ] [ 39
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661039> ]

<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/I49.fig#top>
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/I49.fig#top> Figure 9. Oblique fracture of the medial
malleolus fracture.

Physical examination of the ankle should assess for swelling and ecchymosis.
Swelling is, however, a function of time and is an unreliable indicator of
the presence or severity of injury. Fractures can easily be missed by
failure to check the joint above and below the area of chief complaint.
Squeezing the tibia or fibula at mid-calf allows assessment of a proximal
Maisonneuve fracture. The clinician should always remember to document
neurovascular function.

Imaging

Radiographs should include an AP, lateral, and mortise view, which is taken
with the foot externally rotated 15° to 20°.[ 14
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661014> ] [ 30
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661030> ] Important radiographic relationships are
listed in Tables 4
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#T066104>  and 5
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#T066105>  and Figure 10
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#F066110>  . Stress view radiographs have a limited
role in evaluation of the acute ankle injury. They should only be taken
under anesthesia before reconstructive surgery. A standing mortise view of
the ankle can help identify ligamentous instability in difficult-to-examine
patients.[ 30
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661030> ] Comparison of the normal radiographic
relationships from the mortise and standing mortise view will show loss of
the normal tibiofibular overlap and asymmetry of clear spaces. A comparison
view with the uninjured ankle can also be useful in difficult cases.[ 30
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661030> ]
TABLE 4 -- Radiographic Relationships of the Ankle Mortise View
Area
Normal Values
Lateral clear space
Greater than 2 mm is suspicious for a syndesmosis sprain
Tibiofibular overlap
Greater than 1 mm
Medial clear space
Symmetrical with lateral clear space

TABLE 5 -- Radiographic Relationships of the AP Ankle View
Area
Normal Values
Medial clear space
Greater than 3 mm can indicate deltoid ligament of syndesmosis
Tibiofibular clear
Normally less than 6 mm
Standing AP View
Syndesmotic widening greater than 3 mm from the AP view indicates an
syndesmotic sprain
AP = anterior-posterior.


<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/I50.fig#top>
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/I50.fig#top> Figure 10. Radiographic anatomy of the
ankle mortise. A = medial clear space; B = tibular/fibular clear space; C =
tibular/fibular overlap; D = lateral clear space.

In reviewing ankle radiographs, it should be remembered that transverse
fractures usually result from avulsion forces, whereas oblique fractures
usually result from impaction of the talus against the malleoli.[ 30
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661030> ] [ 32
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661032> ] Vertical malleolar fractures are caused
by impaction with the talus. Any displaced malleolar fracture should be
considered as unstable and is almost always associated with ligamentous
injury of the opposite side. In general, all oblique fractures of the medial
malleolus and oblique fractures 2 to 3 inches proximal to the joint line
should be assumed to have associated ligament injury and should be
considered unstable.[ 32
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661032> ]
In addition to using the radiographic ABCs to evaluate ankle films, checking
for the five most commonly missed foot and ankles fractures is
dvisable.[ 30
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661030> ] [ 35
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661035> ] The mnemonic FLOAT is helpful for recall
(Fig. 11)
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#F066111>  : close attention to the Fifth metatarsal
base, Lateral process of the talus, Os trigone or posterior malleolus,
Anterior process of the calcaneus, and Talar dome can help correlate
radiographic findings with tenderness on physical examination (Fig. 12)
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#F066112>  .

<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/I51.fig#top>
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/I51.fig#top> Figure 11. Five most commonly missed
ankle and foot fractures using the FLOAT mnemonic. (Adapted from Steinberg
GG, Akins CM: Orthopaedics in Primary Care, ed 3. Philadelphia, Lippincott
Williams & Wilkins, 1999; with permission.)


<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/I52.fig#top>
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/I52.fig#top> Figure 12. Os trigone fracture of the
right ankle.


Classification

The Danis-Weber system of classification for ankle fractures is the most
useful for primary care management. This classification system is simple and
helpful in deciding which fractures need referral.[ 14
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661014> ] [ 30
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661030> ] This classification scheme is based on
the level of the fracture in relationship to the joint mortise of the distal
fibula (Fig. 13)
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#F066113>  . [ 11
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661011> ] [ 14
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661014> ] [ 30
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661030> ] [ 35
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661035> ] Type A fractures are horizontal avulsion
fractures found below the mortise. They are stable and amenable to being
treated with closed reduction and casting unless accompanied with a medial
malleolus fracture. A spiral fracture that starts at the level of the
mortise is a type B fracture (Figs. 13
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#F066113>  , 14)
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#F066114>  , which occurs as the result of external
rotational forces. These fractures may be stable or unstable, depending on
ligamentous involvement and associated fractures. The type C fracture is
above the level of the mortise and disrupts the ligamentous attachment
between the fibula and tibia inferior to the fracture. These fractures are
considered very unstable and require open reduction and internal
ixation.[ 14
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661014> ] [ 24
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661024> ] [ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] [ 39
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661039> ]

<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/I53.fig#top>
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/I53.fig#top> Figure 13. Danis-Weber classification of
fibular fractures.


<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/I54.fig#top>
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/I54.fig#top> Figure 14. Danis-Weber class II
fracture.


Acute Care

As always, acute management involves analgesia for pain, immobilization,
keeping the patient comfortable, and preventing shock. Using either a
well-padded posterior or stirrup splint, the patient should not bear weight
until definitive treatment in 3 to 4 days. Small avulsion Danis-Weber type A
fractures can be treated symptomatically with an ankle stirrup brace and
with ambulation allowed as tolerated. The patient should apply ice to the
injured area over a compressive dressing for 20 minutes every 2 to 3 hours
for the first 24 hours, then every 4 to 6 hours until casting. Keeping the
limb elevated above the level of the heart will also significantly reduce
swelling.

Treatment

Isolated lateral malleolus fractures are the most common fractures involving
the ankle. Most inversion injuries result in an isolated sprain of the
anterior talofibular ligament. A small avulsion fracture, however, can
occasionally be seen near the distal portion of the lateral malleolus.
Barely visible osseous chip fractures should not alter the routine active
management of grade 1 and grade 2 ankle sprains.[ 11
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661011> ] [ 32
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661032> ]
Most primary care physicians can manage isolated nondisplaced type A
Danis-Weber fractures.[ 11
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661011> ] [ 32
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661032> ] [ 37
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661037> ] More experienced providers can treat
stable, nondisplaced fractures to the medial or posterior malleolus with
involvement of less than 25% of the articular surface. Instability is
probable with vertical medial malleolar fractures, displaced medial or
lateral fractures, and inversion medial malleolar fractures.[ 10
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661010> ] [ 11
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661011> ] [ 32
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661032> ] [ 37
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661037> ] Cast immobilization can be accomplished
after the acute period with either a short leg walking cast or a walking
cast fracture boot for a reliable patient. The ankle should be casted in a
neutral position to avoid shortening of the Achilles tendon. Generally, 4 to
6 weeks are required for evidence of radiographic healing.[ 11
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661011> ] [ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] [ 37
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661037> ] If the fracture site is not tender,
gradual weight bearing and ankle rehabilitation can begin. If no evidence of
fracture healing is present, an additional 2 to 4 weeks may be required. If
there is no evidence of fracture healing by 8 weeks, orthopedic referral is
mandatory.[ 11
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661011> ] [ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] [ 37
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661037> ]
After the immobilization period, the patient should begin ankle
rehabilitation. Range of motion and strength return quickly in young
patients, and referral to physical therapy may not be needed. Calf
stretching and strengthening exercises and with range-of-motion exercises
can be performed at home by the motivated patient. Patients with premorbid
conditions and increased age usually require formal physical therapy.

Referral

Orthopedic consultation is advisable for all fractures displaced greater
than 2 mm, because minor changes involving the joint mortise can cause
chronic pain and early osteoarthritis.[ 11
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661011> ] [ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] [ 32
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661032> ] [ 42
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661042> ] Any suspected unstable injury
(Danis-Weber classification type B or C) should be referred, as should all
bimalleolar fractures. Referral is also indicated for all trimalleolar
fractures, which involve fracture to both the medial and lateral malleoli
and a fracture to the posterior lip of the tibial plafond (Fig. 15)
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#F066115>  . This fracture usually results from an
avulsion of the posterior tibiofibular ligament at its insertion site. In
the presence of medial malleolar tenderness and more than 5 mm of medial
clear space on the mortise view, a presumptive diagnosis of deltoid ligament
rupture should be made.[ 30
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661030> ] [ 32
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661032> ] Such an injury should be treated as
bimalleolar fracture and referred for management.[ 24
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661024> ] Fractures that show no radiographic
evidence of healing after 8 weeks should also be evaluated for ORIF.[ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ]

<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/I55.fig#top>
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/I55.fig#top> Figure 15. Bimalleolar fracture,
posterior and lateral malleolus.



TARSAL INJURIES

Foot injuries are frequently seen by primary care physicians and can provide
ample frustration to those who are not familiar with the anatomy and
function of the foot. The tarsal bones make up the hindfoot (calcaneus and
talus) and midfoot (navicular, cuneiforms, and cuboid); the forefoot
comprises the metatarsals. Injuries to the tarsal bones are infrequent but
should be treated cautiously when present. These bones are crucial for
walking, and injuries often have a poor prognosis.[ 10
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661010> ] [ 18
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661018> ] [ 37
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661037> ] A calcaneus body fracture should prompt
a thorough thoracolumbar examination and imaging because a significant fall
is the most common cause.[ 30
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661030> ]
The mainstay of foot injury diagnosis is a careful, complete physical
examination, because evaluation of plain films of the foot can be
challenging. A systematic evaluation should include a stepwise review of the
bones found in the hindfoot, midfoot, and forefoot. The calcaneus is the
most commonly fractured tarsal bone; injury usually results from compressive
forces from a fall or motor vehicle accident. Talus fractures are usually
minor, involving an avulsion injury after an ankle sprain. Talar neck
fractures and dislocations require emergent referral, however, because the
tenuous blood supply to the body of the talus arrives through the neck.[ 11
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661011> ] [ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] [ 32
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661032> ] Avascular necrosis is a serious sequela
of failure to identify or appropriately refer talus injuries.[ 11
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661011> ] [ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] [ 32
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661032> ] [ 37
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661037> ]
Midfoot fractures are uncommon except as the result of blunt or severe
trauma. Because the midfoot bones are the least mobile bones of the foot,
fractures to this area usually involve multiple bones. Crush injuries to the
midfoot result in multiple comminuted fractures, and identification of one
fracture necessitates a more detailed evaluation of the surrounding
midfoot.[ 7
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661007> ] [ 10
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661010> ] Navicular fractures are mostly eversion
injuries resulting in dorsal avulsion fractures. Stress fractures to the
navicular are common among runners, and point tenderness to this area with
no evidence of fracture on normal plain films should prompt additional
studies (bone scan or CT scan).[ 10
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661010> ] [ 38
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661038> ]

Imaging of the Tarsal Bones

The standard foot radiographic series includes AP, lateral, and internal
(medial) oblique views.[ 14
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661014> ] [ 30
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661030> ] When dealing with the varying densities
between the forefoot and hindfoot, additional views are useful for certain
fractures. Suspected fractures to the calcaneus are best visualized with a
standard foot lateral view and an axial calcaneus projection.[ 30
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661030> ] Because intra-articular fractures have
poor outcomes, a clear understanding of fracture extension is critical. The
addition of a calcaneus lateromedial oblique view can improve visualization
of the anterior aspect of the subtalar joint. If questions still exist about
the presence of intra-articular extension, a CT scan should be ordered.[ 14
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661014> ] [ 30
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661030> ] Bohler's angle is measured to evaluate
the magnitude of calcaneus compression.[ 11
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661011> ] [ 30
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661030> ] Bohler's angle can be determined by
measuring the angle formed between two lines, one of which is drawn along
the superior surface of the posterior tuberosity and the other connecting
the superior tip of the subtalar articular surface and the superior tip of
the anterior process (Fig. 16)
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#F066116>  . Although a normal Bohler's angle does
not exclude a calcaneal fracture, angles less than 20° are found with
compressive injuries.[ 30
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661030> ] Bilateral calcaneus fractures are
common; therefore, radiographic examination of the uninjured foot should be
considered.[ 30
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661030> ]

<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/I56.fig#top>
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/I56.fig#top> Figure 16. Bohler's angle.

The talus is evaluated with a standard ankle series (AP, mortise, and
lateral) and a 45° internal oblique view to see the body of the talus, if
needed.[ 14
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661014> ] [ 30
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661030> ] Because radiographic evaluation of the
talar neck can be difficult, CT examination may be needed when there is
strong suspicion of a talar neck injury.[ 30
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661030> ] [ 37
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661037> ] Talar neck fractures occur after
forcible dorsiflexion of the talar neck against the tibial plafond, as
occurs when the foot is slammed on the brake during a motor vehicle
accident.

Acute Care

After evaluation for distal pulses and nerve function, application of a
padded posterior splint, compressive dressing, elevation, and ice are the
mainstays of care. The patient should be instructed not to bear weight until
radiographic evaluation has taken place. Fractures that require casting
should be re-evaluated in 3 to 4 days for definitive care.[ 32
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661032> ]

Calcaneus Fractures

Primary care management of calcaneus fractures is based on distinguishing
between intra-articular and extra-articular fractures. Because 70% of
calcaneus fractures involve the subtalar joint, the finding of an isolated
extra-articular fracture should prompt close inspection of the subtalar
joint.[ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] [ 30
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661030> ] [ 37
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661037> ] Extra-articular fractures generally
result from twisting injuries, such as an avulsion of the anterior process
(bifurcate ligament rupture). Some of the common extra-articular fractures
that can be managed by primary care physicians include simple nondisplaced
(less than 2 mm) fractures involving the posterior tuberosity, anterior
process, or lateral process and body fractures with no subtalar joint
involvement.[ 10
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661010> ] [ 11
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661011> ] [ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] [ 37
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661037> ] Most intra-articular calcaneus injuries
present with significant heel pain, difficulty with walking, plantarflexion
pain, and ecchymosis after an axial load from jumping or falling. These
injuries merit orthopedic referral.

Treatment

Acute care consists of RICE therapy with a bulky compressive dressing to
help control swelling.[ 10
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661010> ] [ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] [ 37
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661037> ] Fracture blisters are a common
complication with calcaneus fractures, and many physicians advocate bed rest
and elevation to help minimize their formation. The patient should not bear
weight until follow-up in 4 to 5 days. Generally, nondisplaced
extra-articular fractures can be managed with either a short leg cast or
walking boot for 4 to 6 weeks.[ 3
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661003> ] [ 10
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661010> ] [ 11
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661011> ] [ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] [ 37
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661037> ] Small minimally displaced avulsion
fractures do well, but larger displaced avulsion and intra-articular
fractures should be referred promptly for ORIF.[ 3
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661003> ] [ 10
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661010> ] [ 11
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661011> ] [ 13
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661013> ] [ 18
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661018> ] [ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] [ 37
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661037> ] Healing time for most fractures is
between 6 and 12 weeks, but pain and stiffness in the area may continue for
months. Follow-up visits should be made every 3 to 4 weeks, and repeat
radiographs should be done after immobilization.
Tuberosity fractures usually result from an Achilles tendon avulsion injury.
Patients present with pain, swelling, ecchymosis, and weakness with stair
climbing. Small, nondisplaced fractures may be treated with a short leg cast
(5° to 10° of plantarflexion) for 6 weeks.[ 11
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661011> ] [ 26
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661026> ] [ 30
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661030> ] [ 37
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661037> ] Fracture stabilization should be
confirmed radiographically in 1 week. A small avulsion of the distal
Achilles tendon insertion can occur and, if nondisplaced with a negative
(intact) Thompson test, can be managed with a short leg cast in
plantarflexion.[ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] Larger displaced fragments should be
referred for ORIF. After 6 to 8 weeks, physical therapy is initiated,
because a progressive stretching program is needed.[ 11
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661011> ] [ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ]
Inversion and axial forces may cause tenderness over the posterolateral
heel. The axial calcaneal view is the best for evaluation of medial or
lateral process injuries. Nondisplaced fractures of the lateral process can
be treated with a short leg walking cast for 4 weeks.[ 11
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661011> ] [ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] [ 37
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661037> ]
Ankle sprains with planterflexion and inversion forces may cause avulsion of
the anterior process at the insertion site of the bifurcate ligament.[ 11
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661011> ] [ 13
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661013> ] [ 18
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661018> ] [ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] [ 37
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661037> ] Localized swelling and tenderness are
present about 1.5 to 2.5 cm distal and slightly inferior to the lateral
malleolus (anterior and inferior to the anterior talofibular ligament
insertion). This fracture is best viewed on the lateral radiograph and is
easily missed unless the anterior process is specifically examined.[ 30
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661030> ] Small avulsion fractures with minimal
displacement can be treated with a walking cast boot for 2 to 4 weeks.[ 10
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661010> ] Larger fragments or significant
displacement should be referred for ORIF.[ 13
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661013> ] [ 18
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661018> ]
Nondisplaced fractures to the body of the calcaneus without subtalar joint
involvement tend to do well regardless of the method of treatment.[ 11
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661011> ] [ 13
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661013> ] [ 18
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661018> ] [ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] [ 37
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661037> ] When uncertainly exists concerning
subtalar joint involvement, oblique radiographic views or CT scans should be
considered. Fractures that show loss of Bohler's angle, widening of the
heel, or displacement should be referred for orthopedic management.[ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] After the acute phase, range-of-motion
exercises should begin, and toe-touch ambulation should be used for 4 to 6
weeks.[ 11
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661011> ] [ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] Gradual progression to full weight
bearing should start with clinical and radiographic evidence of healing.

Fractures of the Talus

The talus is a unique bone, because about 60% of it is covered by cartilage,
and it acts as the distribution point for the body's weight to the foot. The
tenuous blood supply enters distally and flows in a posterior direction. The
talus articulates with the tibial plafond above, the calcaneus below, and
the navicular anteriorly.[ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] [ 38
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661038> ] The posterior and lateral processes of
the talus are prone to injury with eversion and inversion.[ 10
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661010> ] [ 37
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661037> ] [ 38
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661038> ] Although most fractures to the talus are
small chip or avulsion fractures, osteochondral fractures can occur with
severe ankle sprains, when the talar head impacts against either the medial
or lateral malleolus, resulting in cartilage injury.
It is important to recognize talar neck injuries, because displacement
should be managed with urgent surgical intervention. Avascular necrosis is a
serious complication, and controversy exists over the best management.[ 3
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661003> ] [ 8
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661008> ] [ 11
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661011> ] [ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] Although nondisplaced vertical fractures
can be managed with a short leg non-weight bearing cast, it is best to refer
these patients' management. [ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] When questions exist about whether the
fracture is displaced, a CT evaluation should be done. All displaced
fractures of the talar neck and minimal displacements of the subtalar joint
should be referred promptly.[ 8
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661008> ] [ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ]
Fractures of the lateral process of the talus occur after severe inversion
and dorsiflexion injury.[ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] [ 37
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661037> ] Patients will present with minimal
tenderness over the anterior talofibular ligament (ATF) and have a normal
anterior drawer test and pain with inversion. Localized tenderness below the
fibula is common, and careful attention to this area on plain film should
help localize the fracture.[ 37
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661037> ] Small nondisplaced fractures with joint
involvement of less than 10% can be treated symptomatically with a cast boot
or short leg walking cast for 6 weeks.[ 10
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661010> ] [ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] [ 37
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661037> ] Displaced fractures greater than 3 mm
and those involving the subtalar articulation should be referred. CT
scanning may be necessary, because joint involvement can be difficult to
determine on radiographs.
A fracture to the os trigonum or posterior process of the talus occurs
primarily from repeated forceful plantarflexion.[ 10
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661010> ] This injury is more common in athletes
such as ballet dancers assuming pointe or demipointe positions and ice
skaters. They present with pain localized to the posterior ankle and
anterior to the Achilles tendon. Because most of these injuries are a form
of impingement, conservative management should be tried initially with
nonsteroidal anti-inflammatory drugs (NSAIDs), limiting plantarflexion,
taping, or bracing.[ 10
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661010> ] CT scan or bone scan is often needed
when conservative care fails. Use of a short leg walking cast for 4 to 6
weeks should be considered for recalcitrant cases.
Acute osteochondral fractures generally result from inversion injury during
sports. The patient will have significant pain with weight bearing and
complain of pain inside the ankle rather than instability symptoms. A joint
effusion may be seen on physical examination. The examiner should palpate
the lateral talar dome in plantarflexion and the medial aspect in
dorsiflexion, because most lesions are either posteromedial or
anterolateral.[ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] [ 37
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661037> ] It is common for the initial radiographs
to be negative, and the patient should be instructed about the importance of
follow-up should pain continue. Patients with chronic pain should have
repeat radiographs, and if these radiographs are negative, a bone scan or CT
scan is appropriate. Osteochondral lesions are classified into four stages.
Stage I is a small area of compression of the subchondral bone. Stage II
lesions are partially attached but nondisplaced osteochondral fragments,
whereas stage III lesions are completely detached but nondisplaced
fragments. Stage IV lesions are completely displaced fragments.[ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] Acute stage I and II fractures can be
treated with a non-weightbearing short leg cast for 6 weeks, but referral is
indicated for all stage III and IV injuries.[ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] [ 37
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661037> ] [ 38
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661038> ] [ 41
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661041> ]


MIDFOOT

Fractures to the midfoot are uncommon and generally are found only in the
setting of local trauma or eversion plantarflexion injury. The midfoot is
made up of the navicular, cuboid, and cuneiforms bones, which articulate
with the metatarsals anteriorly and with the talus and calcaneus
posteriorly.

Imaging

Midfoot fractures are best evaluated with a standard three-view foot series
with the addition of an external oblique foot view.[ 14
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661014> ] [ 30
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661030> ] Because navicular fractures can be
complicated by AVN and nonunion, CT evaluation is often necessary when there
is significant comminution or displacement. Care must be taken when
evaluating midfoot radiographs, because accessory bones are a common
finding, and more than one accessory navicular bone has been diagnosed as a
fracture. The os tibiale externum is frequently confused with a dorsal
avulsion fracture. Accessory bones are usually bilateral, smooth with
rounded edges, and nontender, whereas avulsion fractures are tender and have
sharp, irregular edges.[ 14
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661014> ] [ 37
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661037> ]

Acute Care

Early RICE therapy with a compressive dressing and posterior splint for
comfort is appropriate for the acute injury. Stress fractures can be casted
at the initial office visit. Compartment syndrome can occur with crush or
trauma midfoot injuries, so patients should be appropriately educated about
its signs and symptoms.

Navicular Fractures

Minimally displaced dorsal avulsion fractures usually do not involve a
significant portion of the articular surface. They can be treated with a
short leg walking cast or cast boot for 4 to 6 weeks. Fragments that involve
more than 20% of the talonavicular joint should be referred for orthopedic
management, because they should be reduced acutely to restore the articular
surface. Persistent pain after casting should be evaluated for surgical
excision.[ 10
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661010> ] [ 11
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661011> ] [ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] [ 38
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661038> ]
Eversion injury may result in significant tension to the insertion sites for
the posterior tibial tendon and the anterior fibers of the deltoid ligament,
causing an avulsion injury to the navicular tuberosity. Passive eversion or
active inversion of the foot will cause tenderness to this area and is
characteristic of this injury. An associated fracture to the cuboid is
common with midfoot trauma, and the finding of a navicular fracture should
prompt the examiner to inspect the radiographs closely. With minimally
displaced fractures, a short leg walking cast with the foot in neutral
position can be used for 4 to 6 weeks.[ 10
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661010> ] [ 11
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661011> ] [ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] [ 38
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661038> ] During casting, particular attention
should be paid to molding an adequate longitudinal arch. Nonunion may occur
and can be managed with additional immobilization for 2 to 4 weeks.
Continued, symptomatic nonunion requires referral for possible surgical
excision.[ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ]
Fractures to the body of the navicular are usually associated with other
midfoot injuries. Nondisplaced fractures can be treated with a
below-the-knee walking cast with a well-molded longitudinal arch.[ 10
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661010> ] [ 11
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661011> ] [ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] [ 38
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661038> ] Between 6 and 8 weeks are needed for
union, at which time the patient can be advanced to a molded arch support
for ambulation. All displaced fractures should be referred for orthopedic
management, because recurrent displacement can occur.

Cuboid Fracture

This classic nutcracker fracture results from a compressive force between
the calcaneus and the fifth metatarsal.[ 32
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661032> ] Crush injury to the Lisfranc joint
should also be suspected with the findings of distal cuboid or cuneiform
fractures. Cuboid fractures cause considerable pain, and patients have
difficulty walking. Treatment for nondisplaced cuboid fractures is 6 weeks
in a short leg walking cast that is well-molded and with an adequate arch
support.[ 11
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661011> ] [ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] [ 32
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661032> ] After the immobilization period, a
molded hard plastic foot orthotic should be used to maintain adequate arch
support for up to 6 months. Displaced and dislocated cuboid injuries should
be referred for orthopedic management.

Cuneiform Fracture

Injury to the cuneiform bones is uncommon except with direct trauma or
crushing injury. Pain and swelling are localized to the involved area, and
weight bearing is difficult. Comparison radiograph views are frequently
needed, because these fractures are often subtle. Nondisplaced fractures can
be treated with a well-molded short leg walking cast for 6 weeks.[ 32
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661032> ] [ 37
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661037> ] Displaced fractures and
fracture-dislocation injuries should be considered unstable and referred
promptly for orthopedic management.

Lisfranc Injury

The tarsometatarsal joint or the Lisfranc joint is made up of the five
metatarsal bases and the articulation with the bones of the midfoot. Most
injuries to this area are subtle, and a high index of suspicion must be
present for diagnosis. Up to 20% of Lisfranc injuries are missed on
radiographic evaluation.[ 7
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661007> ] [ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] [ 30
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661030> ] The classical Lisfranc injury was first
described during the Napoleonic Wars when a rider was thrown from his horse
and was dragged with his foot caught in the stirrup. Today's version is an
axial force to the metatarsals when the toes are dorsiflexed and the ankle
plantarflexed (kneeling position).[ 7
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661007> ] [ 10
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661010> ] [ 30
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661030> ] The axial force causes the metatarsal
base to be displaced dorsally and laterally, resulting in ligamentous injury
and fracture dislocation. The most common radiographic finding is disruption
of the normal anatomic relationship between the first and second
metatarsals. Occasionally, small avulsion fragments from the medial
cuneiform can be seen between the bases of the first and second
metatarsals.[ 30
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661030> ]

Imaging

A standard foot series (weight-bearing if possible) is usually adequate for
identification of a Lisfranc injury. The AP view should be inspected closely
for malalignment of the medial border of the second metatarsal and the
medial border of the medial cuneiform. On the oblique view, the medial
border of the fourth metatarsal forms a continuous line with the medial
border of the cuboid and the third metatarsal forms a continuous line with
the lateral borders of the third metatarsal and lateral cuneiform.[ 7
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661007> ] [ 10
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661010> ] [ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] [ 30
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661030> ] [ 38
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661038> ] If the patient is able to stand,
weight-bearing views should be used. The lateral view should be inspected
for dorsal displacement of the proximal base of the second metatarsal and
flattening of longitudinal arch (during weight bearing).[ 30
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661030> ] Comparison views are often helpful, and
for questionable cases CT evaluation is necessary.[ 7
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661007> ] [ 30
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661030> ]

Treatment

The key to treatment is early recognition, because Lisfranc injuries can be
difficult to treat. If suspected, each metatarsal and each bone of the
midfoot should be palpated. Pain localized to the tarsometatarsal joints
should prompt careful radiologic evaluation. Inability to bear weight
standing on tiptoes is another diagnostic clue. Considerable controversy
exists over open versus closed management of a Lisfranc fracture or
dislocation. Treatment largely depends on the magnitude of injury, and any
displacement greater than 1 mm should be referred for ORIF.[ 7
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661007> ] [ 10
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661010> ] [ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] Patients with mild to moderate trauma
and no tarsometatarsal ligament instability on weight-bearing radiographs
can be managed with immobilization. Most primary care physicians, however,
should refer these patients for orthopedic management.


FOREFOOT

Fractures of the forefoot, which is composed of the metatarsal and
phalanges, are among the fractures most commonly seen by primary care
physicians.[ 11
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661011> ] [ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] [ 38
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661038> ] [ 41
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661041> ] Most isolated forefoot fractures are
treated conservatively. Fractures to the base of the fifth metatarsal,
however, must be accurately diagnosed to avoid nonunion with a Jones
fracture. Most metatarsal fractures result from trauma or from an inversion
ankle injury that causes an avulsion fracture to the base of the fifth
metatarsal. Generally, metatarsal fractures are isolated and minimally
displaced, because the surrounding supporting ligaments tend to splint the
fractured bone in place.[ 11
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661011> ] [ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] [ 38
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661038> ] [ 41
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661041> ] Localized pain and tenderness are
usually present, as is difficulty with weight bearing. Swelling can be
severe, and the potential for compartment syndrome exists.

Imaging

Metatarsal and phalanges fractures are usually well visualized with the
standard foot series; however, distal phalanx fractures may be difficult to
visualize, as the central ray of the x-ray beam is focused near the midfoot.
As a coned down AP view may be beneficial in some situations.[ 30
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661030> ] Fractures are described as transverse,
oblique, spiral, comminuted, intra-articular, or extra-articular to the
base, shaft, or head of the metatarsal.[ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ]

Acute Care

Initial management of a metatarsal fracture should focus on reducing
swelling and immobilization with a posterior splint. Patients should not
bear weight until follow-up examination. Initial follow-up should be in 3 to
5 days for casting or a postoperative wooden shoe.

Fractures of the Fifth Metatarsal

The most common fracture to the base of the fifth metatarsal results from an
inversion ankle injury. The peroneus brevis tendon insertion causes an
avulsion of the proximal portion of the metatarsal base.[ 10
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661010> ] [ 11
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661011> ] [ 38
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661038> ] [ 41
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661041> ] Confusion exists for some primary care
physicians, because this tuberosity avulsion fracture has been
inappropriately called a "pseudo-Jones fracture" (Fig. 17)
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#F066117>  . Properly designated, a Jone's fracture
is a transverse fracture through the proximal fifth metatarsal shaft and has
a considerable incidence of nonunion because it is in a watershed area of
blood supply.[ 10
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661010> ] [ 11
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661011> ] [ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] [ 30
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661030> ] [ 38
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661038> ] [ 41
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661041> ]

<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/I57.fig#top>
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/I57.fig#top> Figure 17. Types of fifth metatarsal
fractures.

Avulsion injury to the base of the fifth metatarsal is commonly missed,
because it is frequently not included in a routine ankle series or palpated
during physical examination.[ 30
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661030> ] An unfused apophysis is frequently
confused in children and adolescents as a fifth metatarsal avulsion injury.
Tuberosity avulsion fractures are transverse, whereas the unfused apophysis
is oriented along the long axis of the metatarsal.[ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] [ 38
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661038> ] [ 41
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661041> ] Also, the os vesalianum is an accessory
bone that is often mistaken for a fracture. Accessory bones have smooth
cortical margins and are usually bilateral.[ 30
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661030> ]
Nondisplaced tuberosity fractures can be managed with a wooden postoperative
shoe or cast fracture boot, with weight bearing as tolerated for 2 to 4
weeks.[ 10
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661010> ] [ 11
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661011> ] [ 38
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661038> ] [ 41
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661041> ] For those with a displaced fragment
greater than 3 mm, or- thopedic referral should be considered. Fractures to
the metaphysealdiaphyseal junction (Jone's fractures) result from a vertical
load placed on the lateral foot. Jones fractures can be managed with 6 to 8
weeks in a non-weight-bearing short-leg cast if nondisplaced but are best
referred.[ 11
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661011> ] [ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] Frequent follow-up is essen-tial, and
nonunion after 3 months of therapy should be referred for ORIF. Because a
high rate of delayed union and nonunion occurs with this fracture,
consultation for ORIF should be considered.[ 10
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661010> ] [ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] [ 38
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661038> ] [ 41
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661041> ] All displaced Jones fractures and
intraarticular tuberosity fractures should be referred for orthopedic
management.

Fractures of the First to Fourth Metatarsal

Fractures to the metatarsal bones are usually caused by direct impact from
falling objects or indirect forces such as a twisting fall. Crushing
injuries to the foot are frequently associated with compartment syndrome,
neurovascular dysfunction, and decreased tissue viability.[ 10
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661010> ] [ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] [ 38
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661038> ] [ 41
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661041> ] Initial inspection should focus on a
thorough musculoskeletal examination and documentation of neurovascular
function. Because the first metatarsal has important weight-bearing
function, suspected fractures to this area should be carefully evaluated for
any displacement on the radiograph.[ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] [ 41
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661041> ] Fracture to the metatarsals from direct
trauma usually causes displacement in the sagittal or AP plane. Therefore,
the lateral radiograph should be thoroughly inspected for angular
deformity.[ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] [ 41
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661041> ]
Fractures to the metatarsal bases are rare and should increase suspicion for
a Lisfranc injury. Most nondisplaced metatarsal shaft fractures heal well
and can be treated by primary care physicians.[ 11
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661011> ] [ 38
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661038> ] All displaced fractures to the first or
fifth metatarsal should be referred for possible ORIF.[ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] [ 41
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661041> ] Nondisplaced or minimally displaced
second through fourth metatarsal shaft and neck fractures can be treated
with a stiff shoe, short-leg cast, or walking fracture boot for 2 to 4
weeks.[ 10
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661010> ] [ 11
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661011> ] [ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] [ 38
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661038> ] [ 41
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661041> ] Early ambulation as tolerated should be
the goal, because reflex sympathetic dystrophy is associated with prolonged
immobilization.[ 38
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661038> ] [ 41
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661041> ] Medial or lateral displacement of the
second, third, and fourth metatarsals in the frontal plane is generally well
tolerated and heals without risk of any long-term disability.[ 41
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661041> ] Dorsal or sagittal plane angulation is
poorly tolerated, however, and should be referred for closed reduction.[ 28
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661028> ] [ 41
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661041> ] Nondisplaced fractures to the first
metatarsal are best treated with a non-weight-bearing short leg cast for 2
to 3 weeks. After initial immobilization, a wooden postoperative shoe can be
used for comfort.

Phalangeal Fractures

Toe fractures are often trivialized, but they can be quite painful. Phalanx
fracture to the second through fifth toes can be managed with buddy taping,
a small piece of gauze to prevent maceration of the skin, and a wooden
postoperative shoe for comfort.[ 32
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661032> ] [ 37
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661037> ] [ 41
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661041> ]
Most fractures to the great toe are caused by trauma from a direct blow or
an axial compression. Nondisplaced fractures can be treated with a wooden
postoperative shoe or a walking cast with a toe plate.[ 10
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661010> ] [ 11
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661011> ] [ 32
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661032> ] [ 38
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#R0661038> ] Fractures that are displaced or have an
intra-articular component may require surgical fixation. Usually 2 to 4
weeks is adequate for treatment. A subungual hematoma is often indicative of
a phalanx fracture.


SUMMARY

This review of acute fracture management is designed to provide a quick
reference for many common fractures but is not all inclusive. The referral
guidelines depend on physician experience; when questions exist concerning
fracture management, consultation is generally advisable. The enclosed
fracture management summary tables will hopefully provide a quick reference
for which radiologic views to order, treatment pearls, basic management, and
when to refer (Tables 6
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#T066101>  , 7
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#T066101>  , and 8)
<http://home.mdconsult.com/das/article/body/jorg=journal&source=&sp=11549820
&sid=61087292/N/216720/#T066101>  . Finally, inspection of radiographs
whenever possible should not only include the radiologist interpretation,
but evaluation by the physician as well. The benefit of knowing the location
of point tenderness, swelling, and ecchymosis gives the primary care
physician the advantage in making the correct diagnosis.

TABLE 6 -- Fracture Management Summary: Knee
Fracture Type
Radiographic View
Landmarks
Acute Treatment Maxims
Definitive Treatment
Follow-up
Repeat Radiographs
Referral
Femoral condylar
AP, lateral knee, and sunrise (AP pelvis; AP and lateral hip)
Medial femoral condyle is usually larger than lateral condyle on lateral
radiograph
Check the popliteal fossa for hematoma
ORIF
Orthopedic
Orthopedic
Always




Cast bracing



Patella
Sunrise, AP and lateral knee or merchant view
Patella ratio (0.8-1.2)
Check extensor mechanism knee immobilizer
Long leg immobilizer or cylinder cast for 4-6 weeks
4-5 days, then every 3-4 weeks
At 2 weeks, then 4-6 weeks
Displaced 2 mm or midportion transverse fracture. Any articular step-off
Tibial plateau
AP and lateral knee, oblique or tunnel view ± sunrise view
ACL rupture is suggested with Segond fracture
Arthrocentesis for tense hemarthrosis. Long leg splint (NWB)
Low-energy types 1-3 nondisplaced
Weekly for 3-4 weeks then every 3 weeks until brace d/c
Weeks 1, 2, 3, then every 2-3 weeks
Displaced fractures and fractures with 2 mm of articular surface involvement




Hinged knee brace at full ext. for 2 weeks (NWB). Then gradual passive
flexion to 90° by 4 weeks. Total immobilization 8-12 weeks





Ottawa Knee rules > 55 years of age, fibula head tenderness, isolated
patella tenderness, inability to flex > 90° or bear weight for 4 steps












All medial condyle fractures, types V & VI.
Tibial spine
Standard knee + tunnel view
Suspect ACL rupture
Straight-leg knee immobilizer
Full-length cast with 10°-15° flexion for 4-6 weeks.
Week 1 and then every 3-4 weeks.
After reduction, week 1 then week 4-6
Displaced or irreducible fracture; all type 3 and ACL ruptures.



Arthrocentesis for pain control




Tibial tuberosity
Lateral knee
Type 2 extends to physis; type 3 extends to joint
Check extension mechanism
Full-length cast at 0° for 6 weeks
Week 1 then every 3-4 weeks
After reduction, then week 1 and week 4-6
Displacement 5 mm







Types 2 and 3
AP = anterior-posterior; NWB = non-weight bearing; RICE = rest, ice,
compression, elevation; d/c = discontinued.

TABLE 7 -- Fracture Management Summary: Ankle
Fracture Type
Radiographic View
Landmarks
Acute Treatment Maxims
Definitive Treatment
Follow-up
Repeat Radiographs
Referral
Tibia shaft
AP and lateral lower leg
Location, configuration, displacement, angulation, length, rotation,
associated injuries
Compartment syndrome 20%
Plaster cast (0°-5°) for 4 weeks. Gradual weight bearing to full by 2 weeks.
Then short leg walking brace until clinical and radiographic healing.
After acute swelling for casting, then weekly for 4 weeks, then every 2-3
weeks.
Weeks 1, 2, 3, and 4 and then every 2-3 weeks
All high-energy fractures. Combined tibiafibula 4 mm displacement comminuted
fractures Angulation > 5° and floating knee



Full-length posterior splint or stirrup splint











Should refer unless experienced in long leg casting.
Fibula
AP and lateral
Proximal fibular fractures indicate knee instability until proven
other-wise. Check peroneal nerve.
Knee immobilizer or hinged knee brace locked in extension (small avulsion
fracture). NWB acutely
Short leg walking cast or cast walking boot for nondisplaced midshaft
fracture, 4-6 weeks. Advance weight bearing as tolerated.
Acutely 3-4 days, then every 3-4 weeks until healed
To confirm fracture healing 4-6 weeks
Significant displacement, comminution, peroneal nerve involvement, or
unstable knee
Ankle
AP, lateral, and mortise view (Include 3 views of foot if midfoot pain or
fifth metatarsal pain)
AP: tibiofibular overlap  10 mm
Ottawa Ankle Rule: Inability to bear weight, malleolus tenderness (posterior
edge to 6 cm proximal), bone tender-ness of navicular, fifth metatarsal, or
midfoot pain
Weber Type A: Acute: posterior or stirrup splint.
Casting 3-5 days after acute injury
Assess fracture healing at 4 weeks
Displacement greater than 2 mm or unstable Danis-Weber type B or C fractures
trimalleolar and bimalleolar fractures


Mortise: medial clear space <4 mm, tibiofibular overlap 14;1 mm


Evaluate healing at 4-6 weeks






Short-leg walking cast or walking fracture boot for 4-6 weeks



Talus
AP, mortise, lateral ankle, and 45° internal oblique
Talar neck injuries are at risk for AVN; therefore CT scan for suspected
injury
5 most commonly missed ankle fractures:
Lateral Process Avulsion (10% of joint) nondisplaced: cast boot for 4-6
weeks
In 2-4 weeks
4 weeks
All displaced fractures with >3 mm or 10% of jont space



Fifth metatarsal







Lateral process talus



All talar neck fractures unless experienced



Os trigone







Anterior process calcaeus







Talar dome




AP = anterior-posterior; ACL = anterior cruciate ligament; ORIF = open
reduction with internal fixation; NWB = non-weight bearing.

TABLE 8 -- Fracture Management Summary: Foot
Fracture Type
Radiograpic View
Landmarks
Acute Treatment Maxims
Definitive Treatment
Follow-up
Repeat Radiographs
Referral
Calcaneous
AP and lateral foot, axial projection
Bohler's angle (20°-40°)
Elevation, ice, compression, and NWB to prevent fracture blisters
Anterior process: Small avulsion fracture with minimal displace-ment-use
walking cast boot for 2-4 weeks
2-4 weeks
4 weeks
Displaced fractures, subtalar joint involvement, delayed union or nonunion


Less than 20° suggests fracture





Midfoot
AP, lateral, and internal oblique
AP view: second and third metatarsal aligns with medial and lateral second
and third cuneiforms
Posterior splint acutely and NWB
Dorsal avulsion fracture of the navicular (< 20% of joint)
2-4 weeks
4 weeks
Displacement, nonunion or delayed union

CT scan for navicular body fractures

Watch for compartment syndrome with crush injuries.








Cast walking boot for 4-6 weeks





Oblique view: fourth medial metatarsal aligns with medial edge of cuboid





First Metatarsal
AP, lateral oblique foot and coned down view for first metatarsal
No dorsal or sagittal angulation
Posterior splint and RICE
Non-weight bearing short leg cast for 2-3 weeks. Postoperative wooden shoe
for comfort for 2-3 weeks
2-3 weeks
4 weeks
Intra-articular or displaced
Second- Fourth Metatarsal
AP, lateral and oblique foot
Frontal plane displacement is OK. Dorsal or Sagittal displacement refers
RICE therapy and posterior splint 2-4 days
Wooden post-operative shoe, cast walking boot, or short leg cast for 2-3
weeks if significant pain
2-3 weeks
4 weeks
Displacement greater than 10° in the dorsal or sagittal plane,
intra-articular, or multiple
Fifth Metatarsal
AP, lateral and oblique foot
Apophysis = long axis Tuberosity = transverse Jones = Metaphysis/shaft
Weight bearing as tolerated
Nondisplaced tuberosity Fracture: postoperative wooden shoe 2-4 weeks
2-4 weeks
4 weeks
Jone's fractures, displaced tuberosity fracture > 3 mm
AP = anterior-posterior; NWB = non-weight bearing; RICE = rest, ice,
compression, elevation.



Key Points
Always review the radiographs yourself.
When in doubt, refer or consult.
Treat the patient first, then the fracture.
High energy fractures mandate above and below joint inspection.
Increasing pain after immobilization is compactment syndrome until proven
otherwise.





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Edward E. Rylander, M.D.
Diplomat American Board of Family Practice.
Diplomat American Board of Palliative Medicine.