of the Ankle and Foot

Fig. 24.1

(a) Malunion of a fracture/subluxation of the left ankle with lateral subluxation of the talus and valgus deformity. (b) Clinical appearance of the foot with a chronic wound on the dorsum secondary to ill-fitting shoes

If the position cannot be held by external splinting, casting, or cast modification by wedging or serial casting, open reduction and internal fixation (ORIF) should be considered after swelling has subsided and the skin shows fine wrinkles over the foot dorsum, fracture blisters have dried, and the soft tissue envelope has reached its optimal post-injury condition. The time until these changes occur depends on the time from injury to first hospital treatment, previous traditional treatments, the energy of the injury, and patient and nursing compliance. Wound dehiscence and infections around the foot and ankle are poorly tolerated in any environment, making it safer to wait. In less-resourced locales, lack of plastic surgeons and many antibiotics preclude effective management of wound complications (Box 24.1).

Box 24.1 Principles for Foot/Ankle Trauma

Early/timely reduction of fractures and dislocations
Immobilization with POP/cast
Ultimate goal
- Plantigrade foot
- Stable ankle mortise
Consider traction, ex-fix, or percutaneous pins

If ORIF is not possible in the face of uncontrolled instability, percutaneous pinning, especially in an attempt to hold alignment, can be considered. Its major drawback is the requirement of C-arm.

Intra-articular Distal Tibia Fractures (Pilon or Plafond Fractures)

By definition, intra-articular distal tibia fractures or pilon fractures infer a high-energy mechanism of injury, with soft tissue compromise and the potential for significant soft tissue and joint complications and long-term disability. The prudent approach in less-resourced environments should be avoidance of complications while addressing the basic principles of ending with a stable, plantigrade foot, and acceptable alignment. Calcaneal pin traction with elevation on a Bohler-Braun frame provides a safe and effective treatment without the unacceptably high soft tissue complications of open reduction and internal fixation with nonspecific plates. This technique, while relieving the deforming force of the Achilles tendon, utilizes ligamentotaxis to realign the major fragments and restore an acceptable ankle mortise. Direct access to blisters, open wounds, or other soft tissue injury allows observation and dressings. Take care to protect the heel from excessive pressure by a sponge under the Achilles or a glove partially filled with water.

After 2–4 weeks, this approach can be converted to pins and plaster or a spanning external fixator (Fig. 24.2). In certain fracture patterns or clinical situations, small incision approaches may be used with the addition of K-wires, Rush rods, or small plates in order to optimize the position or stability of major fracture fragments or malleoli (Fig. 24.3). The decision to proceed with more rigid fixation and larger soft tissue exposures to achieve anatomic reduction should be taken with trepidation, but the results of neglected displaced pilon fractures are also well known [2] (https://www2.aofoundation.org/wps/portal/surgery?showPage=diagnosis&bone=Tibia&segment=Distal).

../images/270913_2_En_24_Chapter/270913_2_En_24_Fig2_HTML.png — Fig. 24.2

Typical spanning external fixator , with a trans-calcaneal pin and a pin in the first metatarsal, maintaining the foot and ankle in neutral alignment

../images/270913_2_En_24_Chapter/270913_2_En_24_Fig3_HTML.png — Fig. 24.3

Fracture of distal tibia and fibula fixed with Rush rods

Ankle Fractures and Dislocations

Low-energy rotational ankle fractures and fracture-dislocations are common, and the majority can be adequately treated with closed methods (Fig. 24.4). Conversely, malalignment and mismanagement of these fractures result in pain, stiffness, or deformity, leading to severe functional disability. There are multiple classification systems (Lauge-Hansen, Weber), but the majority of displaced ankle fractures can be divided into (1) abduction-external rotation and less commonly (2) supination-adduction. Early reduction maneuvers are based on reversing the mechanism of injury and deformity. A prompt reduction will significantly reduce the pain, relieve neurovascular compromise, restore the plafond, and markedly reduce soft tissue swelling. Early reduction has a higher likelihood of success (https://www.vumedi.com/video/ankle-anatomy-and-radiology/).

../images/270913_2_En_24_Chapter/270913_2_En_24_Fig4a_HTML.png — Fig. 24.4

(a) X-ray of closed bimalleolar fracture-dislocation after RTC. (b) Postreduction X-ray. (c) The appearance of the plaster cast showing molding distal to the lateral malleolus, proximal to the medial malleolus, and proximally around the fibula to produce three-point fixation (*arrowheads*). The heel is molded by lifting it in a plantar and forward motion to prevent equinus and maintain talotibial alignment (*arrowheads*)

../images/270913_2_En_24_Chapter/270913_2_En_24_Fig4b_HTML.png — Fig. 24.4

(a) X-ray of closed bimalleolar fracture-dislocation after RTC. (b) Postreduction X-ray. (c) The appearance of the plaster cast showing molding distal to the lateral malleolus, proximal to the medial malleolus, and proximally around the fibula to produce three-point fixation (*arrowheads*). The heel is molded by lifting it in a plantar and forward motion to prevent equinus and maintain talotibial alignment (*arrowheads*)

In less-resourced countries, many of these injuries will present in a delayed fashion with significant swelling. An excellent approach to this problem is Quigley stockinette traction for those fracture deformities that arise from abduction-external rotation forces (the vast majority). The elevation and stockinette traction allow the swelling to resolve, and while in the stockinette, the foot and ankle fall into adduction, internal rotation, and supination by simple gravity (Fig. 24.5). After 5–7 days, this technique can be followed by a more securely molded cast for the maintenance of reduction after the swelling has subsided.

../images/270913_2_En_24_Chapter/270913_2_En_24_Fig5_HTML.png — Fig. 24.5

Quigley stockinette technique for reduction and suspension of ankle injuries. Definitive operative or nonoperative management can be done when the swelling is reduced

The reduction of malleolar fractures is eloquently described by Sir John Charnley in The Closed Treatment of Common Fractures, and we recommend that surgeons, especially those who haven’t treated ankle fracture-dislocations by other than open means, review his chapter on Pott’s fracture. He lists three common sources of error when attempting a reduction:

Keeping the foot at right angles to the leg by dorsiflexing the forefoot in order to secure a plantigrade foot. This simply pushes the talus posteriorly, especially if the Achilles tendon is tight. Lifting the heel and bringing the hindfoot into a plantigrade position will correct this error (Fig. 24.6).
Compressing the mortise in an attempt to reduce the diastasis and realign the talus will simply put pressure on the soft tissues. To reduce a bimalleolar fracture-dislocation, lateral pressure must be applied distal to the lateral malleolus, and medial pressure must be directed proximal to the medial malleolus, forcing the talus medially (Fig. 24.7).
Incorrect rotation of the foot. The fracture forces produce external rotation, making it essential to keep the foot internally rotated to achieve a good reduction. Clinically check the alignment of the line connecting the patella with the second ray.