Foot and Ankle - Ankle Fractures and Sprains

Lecture 13

What are the core themes of ankle fx treatment?

• control swelling

• restore ROM, especially DF

• control pain

• WB progression

• restore gait and running

• proximal strength, then distal and intrinsic strength

• balance and proprioception

What is the most common kind of LE fx?

ankle fx

Describe the Weber ankle fx classifications.

Weber A = below the TCJ

• syndesmosis is intact

• usually stable

Weber B = in line with TCJ

• 50% will have syndesmosis disruption

• variable stability

Weber C = above the TCJ

• syndesmosis is disrupted

• ORIF required

• likely injury to medial malleolus and/or deltoid ligament

**all refer to lateral ankle fx

What special precautions must be in place when a syndesmosis screw is used?

• NWB for 6-8 weeks

• screw gets removed at 10-12 weeks

• pt is FWB after screw is removed and PT can begin

When should a pt who received a syndesmosis screw start using a lace-up ankle brace?

once OKC, active ankle motions and increasing intensity can be tolderated

Describe the benefits of using flexible fixation.

• implant fracture is not a concern

• early WB protocols are safe and effective

What can cause a trimalleolar fracture?

• rotational forces

• high energy forces

What is broken in a trimalleolar fracture?

both malleoli and the posterior tibia

What is a Maisonneuve fracture?

a spiral fracture of the proximal fibular shaft and medial malleolus

• deltoid ligament is frequently disrupted

• tibiofibular syndesmosis and interosseus membrane also disrupted

**sometimes misdiagnosed deltoid rupture!

What is usually the cause of a Maisonneuve fracture?

excessive pronation and ER on the deltoid and syndesmotic ligaments

Why is a Maisonneuve fracture considered a “sneaky ankle fracture?”

it is often misdiagnosed as an ankle sprain, as the proximal fibular fx is often missed

If a pt presents with pain at the syndesmosis, what is the most important thing you should do to rule out serious issues?

order X-ray

What is the most common cause of calcaneal fractures?

axial load

• MVA

• fall from a great height

Describe calcaneal fractures and what commonly occurs in conjunction with them.

• fx itself is commonly comminuted without displacement

• ST joint may be involved

• ORIF is indicated when:

  • intra-articular fx with displacement greater than 1mm

  • extra-articular fx with soft tissue involvement and/or significant varus/valgus malalignment

What are common complications that may result post-ORIF for a calcaneal fx?

• poor wound healing

• non-union

• lingering pain

• additional surgeries

What is the key characteristic of post-calcaneal fx rehab?

restoring STJ mobility

When might ROM start for pts with non-operative calcaneal fx?

7 days post-injury

Describe return-to-work for those with calcaneal fx.

• may take up to 3 months in those who are sedentary

• light duty for 4 months

• full duty after 6 months

Is there a long waiting period for pts who undergo surgery for calcaneal fx to safely begin rehab?

no

What is the 2nd most common type of LE fx?

metatarsal fractures

Describe what a pt may experience after a metatarsal fracture.

• treated with immobilization or internal fixation

• commonly caused by direct trauma, excessive rotation, stress

What is a Jones fx?

fx of the proximal 5th metatarsal

What is a pseudo-Jones fx?

an avulsion fx at the base of the 5th metatarsal

What is a March fx?

a fracture of the distal 1/3 of the 2nd or 3rd metatarsal

• these pts would need to be NWB for quite some time

What are the most common areas for a stress fracture in the ankle and foot?

• navicular

• proximal 5th metatarsal

• anterior tibia

• medial malleolus

• sesamoids

• metatarsal shafts

What are common causes for stress fractures in the ankle and foot?

• overtraining

• possible psychological components

• BMD (RED-S) ← may take up to 8 months to return to sport

Describe Lisfranc injury.

• varies from mild sprains to fracture

• AKA flip-flop fx (due to location)

• <1% of fx

• often misdiagnosed bc it is missed on X-ray

• signs: pain, swelling, inability to WB

  • swelling is commonly in the midfoot

  • point tenderness

  • force applied to this area may elicit medial or lateral pain

Where is the Lisfranc joint complex located?

the Lisfranc joint complex is all of the points where a metatarsal meets a tarsal bone at the midfoot

How is Lisfranc injury diagnosed?

• X-ray may or may not catch; can’t rule out grade 1-2 sprains

• re-eval is necessary if pain and swelling persist past 10 days from the injury

• MOI: commonly high energy forces, falls, industrial accidents, MVA

What would rehab for a Lisfranc injury look like?

• proper treatment is ESSENTIAL for minimizing risk of disability

  • Lisfranc joints are stressed during gait

• fx and fx-dislocations require surgery

• NWB for 6-8 weeks

• walking initiated with removable boot

• swimming and biking are permitted early

• Boot d/c after 10 weeks

What might surgery for Lisfranc injury include?

• ORIF with screw placement after reduction of fx

• screws are often left in for 4-5 months then removed

• cast or short-leg splint after surgery

What complications may arise from surgery for Lisfranc injury?

• non-union

• development of arthritis particularly with malalignment

• may need eventual fusion

How long might surgery for a foot/ankle fx be delayed due to swelling?

up to 14 days

What factors may affect wound healing after surgery for a foot/ankle fx? What about factors that might increase risk of infection?

poor wound healing:

• osteoporosis

• DM2

• alcoholism

• tobacco use

infection risk:

• male sex

• DM

• immunosuppressant meds

• smoking

What are the post-operative considerations for pts after foot/ankle fx?

• well-padded short leg cast splint allows for swallow to occur

• procedure may be outpatient or pt may spend 1-2 days in the hospital

• pain levels dictate care

• pt may have an in-dwelling catheter for pain meds

• D/C from hospital on crutches, NWB on surgical LE

• cast gets changed about a week after surgery

What are important milestones for post-op ankle fx?

2 weeks: stitches come out and new cast is applied for another 2 weeks

4 weeks: possible 3rd recasting, PWB, start progressing to FWB

healed fx: supportive brace and progress from aquatic PT to on land

stable, reliable fixation: possible early motion at 3-4 weeks

When would a PT normally evaluate an ankle fracture post-operatively?

after 6 weeks

What factors influence WB, immobilization, and referral time to PT?

surgeon's preference, fracture itself, and fixation strength

What does current evidence suggest in regards to early motion for ankle fxs post-operatively?

early motion increases risk of infection and fixation failure

What is a Pilon fx?

distal tibia comminutes into talus

• typically caused by axial load driving the talus into the tibial plafond

What factors make ankle fx outcomes hard to compare and study?

• area is highly susceptible to CRPS

• preexisting arthritis

• patient health

• type of fx and severity

• associated intra-articular issues

• pt age and reliability

• bone quality

Describe the typical timeline for recovery for surgical ankle fracture.

many adults experience a period of rapid initial recovery (80% in 6 months) before plateau, but on average the injury remains not fully healed even after 2 years

• worse for older and male pts

When would an ankle arthroscopy be indicated?

to identify and treatment of intra-articular issues

What things could be identified with an ankle arthroscopy?

• osteochondral lesions

  • can occur with ankle fx or sprains

• impingement

• loose bodies

• adhesions

• osteophytes

Describe treatment for ankle OA/RA.

may require surgery once conservative options have been exhausted

conservative tx:

• ROM

• MMTs

• balance

• possible foot posture improvement

• ADLs and functional tasks

• gait training

subsequent ankle fusion surgery may require:

• shoes with rocker soles (like Kim K shape-ups)

• ROM will be limited

Describe ankle arthroplasty.

• relieves pain without sacrificing ROM

• not first choice for younger pts

• replaced ankle fusions

What are the contraindications for ankle arthroplasty?

• evidence of infection or poor blood supply

• un-repairable ligaments

• severe deformity

• muscle damage

• obesity (over 250lbs)

• significant knee valgus or varus

Describe the rehab timeline for ankle arthroplasty.

• pt may spend a night in the hospital

• casted for 6 weeks post-op

• PT can begin after cast is removed

• rehab will take about 3-4 months

  • modalities to manage pain and swelling

  • may be NWB for a spell, progress to gait training

  • FWB may take a few months

  • ROM

  • aquatic therapy!!

  • routine annual follow-up

How can you diagnose lateral ankle sprain?

• pt history/subjective

• anterior drawer test

• reverse anterolateral drawer test

• anterolateral talar palpation

What outcome measures can be utilized to track progress in a pt with lateral ankle sprain?

• LEFS

• FAAAM (foot and ankle ability measure)

• ROM

• talar translations

• hopping

• SL balance

• WB

• star excursion balance test

How is acuity staged for lateral ankle sprain?

acute: 1-2 weeks

subacute: up to 12 months

chronic: 60% resolved after a year, pt reports of ankle “giving way”

Describe ankle sprain prevention training.

• chronic sprainers need proprioception and balance training

• taping can be preventative

• prophylactic bracing

• acute sprains may use braces and taping

• severe injuries may require immobilization for up to 10 days

Which forms of ther ex are indicated for pts with lateral ankle sprain?

• protected AROM

• stretching (usually gastroc/soleus)

• neuromuscular re-education

• postural retraining

• balance training, especially for landing and push-off mechanics

• early bracing and RTW/RTS

What forms of manual therapy should be used for pts with lateral ankle sprain?

• manual lymph drainage

• active and passive soft tissue

• joint mobs (especially A-P)

Should US be used for lateral ankle sprains?

no, evidence shows it just does not work for this kind of injury

Which modalities can be used for lateral ankle sprains?

• ice

• laser

• dry needling if pt likes it, weak evidence

• NSAIDs

• pulsed shortwave diathermy

• electrotherapy has weak evidence

What are important things to keep in mind for chronic lateral ankle sprains?

• wean off external supports and braces

• heavy emphasis on proprioceptive training

• manual therapy should be done in WB and NWB

• needling fibularis muscles may help

• psychologically informed techniques

Why would someone get a lateral ankle strain repair?

if they have an occupation requiring full or excessive ROM that necessitates repair of CF and ATF ligaments

• ex. dancers

Describe the 3 types of lateral ankle sprain repair techniques.

1. Brostrom: direct ATF and CF repair

2. Modified Brostrom/Gould: augment of repair with extensor retinaculum

3. Allograft Biotenodesis Brostrom: anterior tibial tendon or hamstring if tissue is viable to be used as a graft

What is meant by “pants-over-vest” imbrication?

one end of the ligament is sewn over top of the other end

What is the goal of lateral ankle sprain repair surgery?

• restore ROM of ankle and STJ

• integrity of anatomy

• restore joint mechanics

What are the primary post-operative precautions for the Brostrom approach?

no adduction or inversion for 6 weeks

When is RTS indicated after a lateral ankle sprain repair?

when fibularis muscles is symmetrical in strength to nonsurgical side

What kind of ther ex is indicated for post-operative lateral ankle sprains 4 weeks post-op?

• aquatic therapy

• isometric fibularis strengthening

• stationary bike

• gentle ROM

Describe the treatment indicated for syndesmosis strain.

• grades 1 and 2 are generally non-operative

• immediate NWB with crutches or walker

  • prevents further talar and fibular rotation that may irritate soft tissues

• 3 phase rehab, highly individualized

• some may RTS in as little as 2 weeks

• generally, recovery takes double the time as a grade 3 lateral ankle sprain

• significant disruption may require surgery

  • focus on regaining ROM and ADL completion