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] 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] 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] [26] [28] 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] [28]

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] [26] 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] [26] [28] If Clostridium perfringens contamination is suspected (e.g., from soil near farmlands), penicillin coverage should be added.[26] 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 12%.[26] 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] [26] [28] 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] 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) . 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] [28] [32] [35]

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] [28] 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). [6] 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] 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] [31] [36] To establish guidelines that can be considered the Ottawa Knee Rules, Stiell et al evaluated 1047 adults with acute knee injuries.[25] [31] [36] 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] [31] Although decision rules were developed for emergency department management, application of these decision rules in primary care may prove to be equally beneficial.[31]

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] 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] [30]

 

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] [28] 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] [30]

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] [28]

Classification

In adults, distal femur fractures are divided into three main types (Fig. 1) . 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] [14] [28] [30]


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] [14] [28] [30]

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] [65] 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] [68] 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] [14] [28] [30]

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] [14] [28] [30]

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] [9] 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] [9]

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) . 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] [9] [11] [30] [38]


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]

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] 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] 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] [30]

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] 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] 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] [9] [11] [32] Only persons experienced with long-leg casting should apply a full-length cast.[2] [11] 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] [28] [32]

 

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] [11] [28]

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] 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] whereas a nondisplaced lateral fracture with intact ligaments could be managed by an experienced primary care physician.[1] 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] 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] 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] [30] 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] [30] 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] [14] This fracture is significant, because there is a 75% to 100% association with concurrent ACL rupture (Fig. 3) .[14] [30]


Figure 3. Segond fracture suggesting a torn ACL.

Classification

The most widely accepted classification system for plateau fractures is the Schatzker system (Fig. 4) .[14] [28] [30] 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] [28] [30] 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] [32] [35] Schatzker types IV through VI are medial plateau and bicondylar fractures and should always be referred for orthopedic management.[28] Acute management includes long leg immobilization, use of crutches, and RICE therapy.


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] 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] 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] [28] In general, all high-energy fractures should be referred for orthopedic management.[4] [16] [28] Additional factors to consider include the patient's age and level of activity, associated medical conditions, and osteoporosis.[4] [16] [28] 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) .[4] [16] [28] 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.


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] 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] 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]

 

TIBIAL SPINE INJURIES

Although injuries of the tibial spine (intercondyle eminence) are uncommon, they may be seen with an acute ACL rupture.[2] [4] [32] 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] 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) .[30] 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] [30]


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] [32]

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] [28] 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]

 

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] [4] Care must be taken not to confuse this injury with Osgood-Schlatter disease, which involves the anterior surface of the tubercle.[2] [4] [32] 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] [4]

Treatment

Type I injuries with minimal displacement can be treated with cast immobilization in full extension for 6 weeks.[2] [4] 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] [4] Routine knee films adequately demonstrate these fractures, but comparison views are useful for suspected nondisplaced apophysis fractures (Fig. 7) .


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] 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] [15] [20] Besides being the most commonly fractured long bone, the tibia is also the most common open fracture.[1] [26] 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] 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] 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) .[14] [30] 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 accepted.[26] Table 3 . lists the features of long-bone fractures in the order in which they should be communicated to another physician.


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] [40] A retrospective, nonrandomized study found earlier rates of healing with early weight bearing than with non-weight bearing.[15] Multiple studies have corroborated this finding and the correlation between delayed weight bearing and delayed union and nonunion.[40] 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] [35] 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] 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] 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] [15] [20] [28] [29] 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]

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]

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] [15] [20] [26] [28] [40]

 

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] 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 instability.[11] [28]

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] [30] Lateral and AP views are generally sufficient for fracture identification. Descriptive terminology is best used, as was discussed previously (Table 3) . 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] Small avulsion and nondisplaced fractures to the fibula neck and head can be treated symptomatically with a knee immobilizer and crutches for comfort.[28] 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] [28] [32] 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] [28]

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] [26] [28] [40]

 

INJURIES TO THE ANKLE JOINT

Ankle injury is the most common lower-extremity injury seen in many primary care practices.[10] 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] 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] 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]

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] 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]

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] [11] [21] [24] [39]

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] [11] [21] [24] [39] [42]

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] [24] [39]

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] [11] [21] [24]

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) . 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] [11] [21] [24] [39]


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] [30] Important radiographic relationships are listed in Tables 4 and 5 and Figure 10 . 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] 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]

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.

 


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] [32] 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]

In addition to using the radiographic ABCs to evaluate ankle films, checking for the five most commonly missed foot and ankles fractures is advisable.[30] [35] The mnemonic FLOAT is helpful for recall (Fig. 11) : 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) .


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.)


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] [30] This classification scheme is based on the level of the fracture in relationship to the joint mortise of the distal fibula (Fig. 13) . [11] [14] [30] [35] 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 , 14) , 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 fixation.[14] [24] [28] [39]


Figure 13. Danis-Weber classification of fibular fractures.


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] [32]

Most primary care physicians can manage isolated nondisplaced type A Danis-Weber fractures.[11] [32] [37] 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] [11] [32] [37] 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] [28] [37] 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] [28] [37]

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] [28] [32] [42] 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) . 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] [32] Such an injury should be treated as bimalleolar fracture and referred for management.[24] Fractures that show no radiographic evidence of healing after 8 weeks should also be evaluated for ORIF.[28]


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] [18] [37] A calcaneus body fracture should prompt a thorough thoracolumbar examination and imaging because a significant fall is the most common cause.[30]

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] [28] [32] Avascular necrosis is a serious sequela of failure to identify or appropriately refer talus injuries.[11] [28] [32] [37]

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] [10] 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] [38]

Imaging of the Tarsal Bones

The standard foot radiographic series includes AP, lateral, and internal (medial) oblique views.[14] [30] 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] 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] [30] Bohler's angle is measured to evaluate the magnitude of calcaneus compression.[11] [30] 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) . Although a normal Bohler's angle does not exclude a calcaneal fracture, angles less than 20° are found with compressive injuries.[30] Bilateral calcaneus fractures are common; therefore, radiographic examination of the uninjured foot should be considered.[30]


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] [30] 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] [37] 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]

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] [30] [37] 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] [11] [28] [37] 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] [28] [37] 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] [10] [11] [28] [37] Small minimally displaced avulsion fractures do well, but larger displaced avulsion and intra-articular fractures should be referred promptly for ORIF.[3] [10] [11] [13] [18] [28] [37] 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] [26] [30] [37] 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] 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] [28]

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] [28] [37]

Ankle sprains with planterflexion and inversion forces may cause avulsion of the anterior process at the insertion site of the bifurcate ligament.[11] [13] [18] [28] [37] 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] Small avulsion fractures with minimal displacement can be treated with a walking cast boot for 2 to 4 weeks.[10] Larger fragments or significant displacement should be referred for ORIF.[13] [18]

Nondisplaced fractures to the body of the calcaneus without subtalar joint involvement tend to do well regardless of the method of treatment.[11] [13] [18] [28] [37] 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] After the acute phase, range-of-motion exercises should begin, and toe-touch ambulation should be used for 4 to 6 weeks.[11] [28] 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] [38] The posterior and lateral processes of the talus are prone to injury with eversion and inversion.[10] [37] [38] 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] [8] [11] [28] Although nondisplaced vertical fractures can be managed with a short leg non-weight bearing cast, it is best to refer these patients' management. [28] 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] [28]

Fractures of the lateral process of the talus occur after severe inversion and dorsiflexion injury.[28] [37] 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] 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] [28] [37] 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] 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] 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] [37] 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] 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] [37] [38] [41]

 

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] [30] 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] [37]

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] [11] [28] [38]

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] [11] [28] [38] 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]

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] [11] [28] [38] 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] 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] [28] [32] 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] [37] 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] [28] [30] 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] [10] [30] 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]

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] [10] [28] [30] [38] 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] Comparison views are often helpful, and for questionable cases CT evaluation is necessary.[7] [30]

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] [10] [28] 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] [28] [38] [41] 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] [28] [38] [41] 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] Fractures are described as transverse, oblique, spiral, comminuted, intra-articular, or extra-articular to the base, shaft, or head of the metatarsal.[28]

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] [11] [38] [41] Confusion exists for some primary care physicians, because this tuberosity avulsion fracture has been inappropriately called a "pseudo-Jones fracture" (Fig. 17) . 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] [11] [28] [30] [38] [41]


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] 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] [38] [41] 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]

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] [11] [38] [41] 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] [28] 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] [28] [38] [41] 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] [28] [38] [41] 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] [41] 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] [41]

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] [38] All displaced fractures to the first or fifth metatarsal should be referred for possible ORIF.[28] [41] 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] [11] [28] [38] [41] Early ambulation as tolerated should be the goal, because reflex sympathetic dystrophy is associated with prolonged immobilization.[38] [41] 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] Dorsal or sagittal plane angulation is poorly tolerated, however, and should be referred for closed reduction.[28] [41] 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] [37] [41]

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] [11] [32] [38] 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 , 7 , and 8) . 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.