Ankle and Foot Fractures

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26 Ankle and Foot Fractures

Anatomy of the Ankle and Foot

image

Bones of the Foot

Malleoli

• Articulate with trochlea of talus
• Medial malleolus: distal tibia
• Lateral malleolus: distal fibula

Tarsal Bones

• Talus

image Only bone articulating with tibia and fibula
image Parts and landmarks

image Head, neck, body, trochlea, lateral process, posterior process (medial, lateral tubercles)
image Lateral tubercle may be unfused.

image No muscular attachments
image Flexor hallucis longus tendon runs between medial and lateral tubercles.

• Calcaneus

image Has multiple facets, posterior largest
image Sustentaculum tali

image Supports talar neck, attached to spring ligament
image Overlies flexor hallucis longus tendon

image Calcaneal tendon (Achilles) attached to posterior superior tuberosity

• Navicular: boat-shaped, with medial tuberosity for tibialis posterior insertion
• Cuboid

image Tuberosity and cuboid groove inferior
image Most lateral tarsal bone
image Articulates with metatarsals IV and V
image Inferior groove for peroneus longus tendon

• Medial cuneiform

image Largest of 3, for metatarsal I
image Bears partial insertion of peroneus longus

• Intermediate cuneiform

image Shortest
image Metatarsal II base is recessed, fracturable

• Lateral cuneiform: articulates with both navicular and cuboid, as well as metatarsal III

Metatarsal Bones

• Anterior support of longitudinal arch
• 5, numbered I-V, 1-5
• Base, body, head; characteristics of long bone
• Peroneus brevis inserts on base of metatarsal V

Phalanges

• Digit 1 (hallux): proximal and distal (2), 2 sesamoid bones
• Digits 2-5: proximal, medial, distal (3)

Ankle and Foot Joints

• Ankle joint

image Synovial hinge (ginglymus)
image Mortise-and-tenon structure with talus between malleoli

• Numerous complex synovial joints exist between individual tarsals and between tarsals and metatarsals.
• Transverse tarsal joint (Chopart)

image Calcaneus with cuboid + talus with navicular
image Allows inversion and eversion

• Transverse metatarsal joint (Lisfranc): between cuneiforms, cuboid, and metatarsal bases
image

Ankle Joints and Ligaments

Ankle and Foot Ligaments

• Inferior tibiofibular (syndesmosis)

image Complex support of distal tibia and fibula
image Anterior inferior tibiofibular (AITFL)
image Posterior inferior tibiofibular (PITFL)
image Inferior transverse
image Interosseus ligament

• Ankle ligaments (collateral)

image Medial: deltoid (4 parts): tibionavicular, tibiocalcaneal, posterior and anterior tibiotalar
image Lateral: anterior and posterior talofibular (ATFL, PTFL), calcaneofibular (CFL)

• Intertarsal ligaments (named for paired bones)
• Tarsometatarsal ligaments
• Transverse tarsal ligaments
• Interphalangeal and collateral ligaments

Compartments of the Foot

• Foot does not have muscular compartments comparable to leg and thigh.
• Blood and fluid retention tend to be confined to dorsal or plantar spaces.
• Dorsal: dorsalis pedis vessels lie subcutaneously and dorsal to interossei and bones of foot
• Plantar: spaces occur between layers of foot muscles and tendons

image Layer 1: abductors of digits 1 and 5
image Layer 2: flexor digitorum longus tendons and quadratus plantae
image Layer 3: flexor digitorum brevis
image Layer 4: interossei, adductors of digits 1 and 5, opponens

• Medial and lateral plantar neurovascular bundles lie in space between layers 2 and 3.
• Plantar neurovascular bundles enter foot by passing posterior to medial malleolus: fluid extravasation in posterior inferior leg can follow this route into foot.

Vessels and Nerves

image

Arteries and Nerves of the Sole

Arterial Supply

• Posterior tibial artery (from tibial) gives rise to medial and lateral plantar branches above and below ankle joint.

image Medial plantar artery supplies medial aspect of plantar foot.
image Lateral plantar artery supplies lateral aspect of plantar foot.

• Anterior tibial artery typically gives rise to dorsalis pedis artery.
• Terminal, perforating branch of peroneal (fibular) artery typically anastomoses with dorsalis pedis artery.
• Peroneal (fibular) artery occasionally emerges through uppermost interosseus membrane to give rise to dorsalis pedis artery.

Venous Drainage

• Runs parallel to anterior and posterior tibial arteries and their major branches
• Deep plantar and dorsal tributaries drain into posterior and anterior tibial veins; tributaries of popliteal drain to femoral.
• Surface drainage along greater and lesser saphenous veins, into femoral and popliteal, resp.

Nerves

• Hilton’s law: nerves supplying a joint also innervate muscles acting across it, as well as skin over distal insertions of those muscles

Sciatic Nerve (L4-S1)

• Dominant nerve supply for lower extremity
• Tibial (anterior) divisions: plantar flexors of foot

image Medial plantar nerve: to abductor and short flexor hallucis, flexor digitorum brevis, 1 medial lumbrical
image Lateral plantar nerve: quadratus plantae, interossei, and 3 lateral lumbricals; adductor hallucis; abductor and flexor digiti minimi brevis

• Peroneal (fibular, posterior) divisions

image Deep peroneal (fibular): anterior compartment extensors of ankle/foot: extensors hallucis brevis and digitorum brevis
image Superficial peroneal (fibular): lateral compartment extensor/evertor

Clinical Correlates

image

Classification of Ankle Fractures

image

Rotational Fractures

Ankle Fractures

• Typically involve malleolar prominences of tibia and fibula, along with avulsion and rupture of supporting ligaments
• Characteristic patterns of fractures accompany injuries caused by extreme forced movements in specific directions.

image Supination and adduction
image Supination and external rotation
image Pronation and abduction
image Pronation and external rotation

Tarsal Fractures

image

Fractures of the Talar Neck

image

Fractures of the Calcaneus

image

Metatarsal and Phalangeal Injuries

Talus Fractures

• Neck is most common site for talar fractures.
• Usually result from direct trauma or landing on foot after a fall
• Hyperdorsiflexion impacts neck on distal tibia.
• Three types of talar fractures

image Type I: nondisplaced
image Type II: neck fracture with subtalar subluxation or dislocation
image Type III: neck fracture with dislocation of tibiotalar and subtalar joints

• Neck fractures can lead to avascular necrosis because most of blood supply passes through here.

Calcaneus Fractures

• Most common tarsal fractures
• Intraarticular

image 75% of all calcaneal fractures
image From forceful landing on a heel
image Talus driven down on cancellous calcaneus

• Extraarticular

image Anterior process: avulsion caused by landing on plantar-flexed, adducted foot
image Calcaneal tuberosity: avulsion due to sudden forceful contraction of gastrocnemius/soleus
image Sustentaculum tali fracture: landing on inverted foot
image Body fracture: jumping and landing on heel

Metatarsal and Phalangeal Fractures

• Please see p. 388.

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