Chapter
6

Tips, Tricks, and Management Algorithm for Foot and Ankle Injuries

Success mantra for foot and ankle trauma management: Ten commandments of foot and ankle trauma management!

Ankle Fractures

Till date, ankle fractures are one of the most controversial fractures in foot and ankle!

Algorithm of management with respect to timing of patient presentation is described in Flowchart 6.1.

Flowchart 6.1 Algorithm of management as per the timing of presentation of ankle fractures.

Ankle fractures are treated with typical ladder of fixation. Flowchart 6.2 enumerates that ladder.

Flowchart 6.2 Ankle fracture fixation ladder.

Ankle fractures associated with deltoid ligament injury are treated differently (Flowchart 6.3).

Flowchart 6.3 Treatment of ankle fracture with associated deltoid injury.

Tips and Tricks

♦ Early fixation of fractures (within 24 hours of injury) gives better outcome.

♦ Late-presenting injuries need protocol of span, scan, and plan with waiting up to 1 week.

♦ For late presentations, temporary joint spanning external fixator is used for a few days.

♦ Presence of wrinkles on the skin is a sign for safe intervention.

♦ Early surgical intervention prevents blister formation.

♦ For all isolated fibular fractures, gravity stress X-ray is a must to assess syndesmotic integrity and need for syndesmotic fixation (Fig. 6.1).

Fig. 6.1 Positioning of patient for taking gravity stress view.

♦ Antiglide plate (plate put on the posterior surface of the fibula) gives strongest fixation and is preferred in osteoporotic situations.

♦ Use of intramedullary nailing should be reserved for selected transverse, suprasyndesmotic fibula fractures only.

♦ Anteriorly taken medial incision provides the opportunity of looking inside the ankle joint to identify osteochondral lesion and is a must (Fig. 6.2).

Fig. 6.2 Anteriorly placed medial incision helps in visualizing ankle joint.

♦ Routine repair of deltoid ligament is not indicated.

♦ Explore deltoid ligament to remove its unfolding in cases where either after fibular reduction medial clear joint space remains wide or fibular reduction is difficult to maintain.

♦ Large medial malleolar fragment should be buttressed with a plate (Fig. 6.3).

Fig. 6.3 Postoperative X-ray image of a case where large medial fragment was fixed up with buttress plate.

♦ Always fix posterior malleolar fragment irrespective of its size for better reconstruction of incisura. Such a fixation often obviates the need for syndesmotic screw fixation (Fig. 6.4).

Fig. 6.4 Axial CT image of ankle showing the posterior malleolar fracture extending up to incisura of fibula.

♦ Posterior malleolar fractures are better stabilized by a biomechanically strong screw put from posterior to anterior.

♦ For a large posterior malleolar fragment, use of buttress plate is a must (Fig. 6.5).

Fig. 6.5 Postoperative radiograph of a case where large posterior malleolus fracture was stabilized with buttress plate.

♦ Ankle fracture protocols:

Preoperative: prepare and drape both the limbs.

Intraoperative: Follow six-step ankle protocol.

• Comparative image-assisted mortise view to look for medial clear space, dime sign, and ankle instability sign

• Hook test: It is done by putting a bone hook in the interosseous membrane of the fibula and the fibula is pulled outward to look for instability at syndesmosis (Fig. 6.6)

Fig. 6.6 Hook test.

• Tap test: It is performed by pushing tap through one of the screw holes of the fibular plate and separation of fibula from tibia is noted, which is suggestive of syndesmotic instability (Fig. 6.7)

Fig. 6.7 Tap test.

• Anteroposterior ballottement test (Fig. 6.8). In this test fibula is rolled anteroposteriorly over tibia and amount of instability at syndesmosis is noted.

Fig. 6.8 Anteroposterior ballottement test.

• Gravity stress test

♦ When in doubt, it is better to fix syndesmosis.

♦ Author’s preference is use of two 3.5 mm syndesmotic screws with purchase of four cotices and removal only if at the end of three post-operative months ankle dorsiflexion is limited.

♦ Use two screws with four cortices for syndesmotic fixation in unstable situations, diabetics, revision fixation, and osteoporosis for better stability.

♦ Foot should be in neutral position during syndesmotic screw fixation.

♦ In osteoporotic ankle fractures, use of antiglide fibula plate, bicortical screw fixation, and combination fixations are preferred.

♦ Use intramedullary K-wires supported with plate, locking plate, bone substitutes, and cement augmentation for osteoporotic cases.

♦ In neuropathic fractures, stronger, longer, combination, and spanning fixations are preferred. Use of fibula pro tibia screws is advised (Fig. 6.9).

Fig. 6.9 Radiograph showing fibula pro tibia screws.

Ankle Sprain

Flowcharts 6.4 and 6.5 demonstrate the management of acute and chronic lateral ligament injury.

Flowchart 6.4 Management of acute lateral ligament injury. ATFL, anterior talofibular ligament; CFL, calcaneofibular ligament, RICE, rest, ice, compression and elevation; BKPOP, below knee plaster.

Flowchart 6.5 Management of chronic lateral ligament injury.

Tips and Tricks

♦ Follow five-phase protocols for ankle sprain management (Flowchart 6.6).

Flowchart 6.6 Protocols for ankle sprain management. RICE, rest, ice, compression and elevation.

Fully activated and strong peronei are the best protection against instability!

♦ Use balanced board, proprioception exercises, and theraband judiciously for rehabilitation of ankle sprain cases.

♦ Reassess every ankle sprain case at the end of 6 weeks because 20% of properly treated ankle sprain cases progress to functional ankle instability.

♦ Get MRI images if symptoms persist beyond 10 weeks.

♦ Anatomical reconstruction of lateral ligament should always be preferred over nonanatomical reconstruction.

♦ At reconstructive lateral ligament surgery, correct bony malalignments like hindfoot varus or forefoot varus.

Syndesmotic Injuries

♦ Where: Between 2 and 5 cm above plafond (Fig. 6.10).

Fig. 6.10 Direction of syndesmotic screw.

♦ Number and size: 2 × 3.5 vs. 1 × 4.5 screws. Early results are good with 3.5 screws, but no difference visible at 1 year.

♦ No difference in outcomes between tricortical or quadricortical screws, but quadricortical screws can be removed easily if they break and are symptomatic.

Diagnosis of Syndesmotic Injury

♦ Four clinical tests:

• Direct palpation causing pain on syndesmosis

• External rotation of foot causing pain

• Calf squeeze causing pain

• Dorsiflexion with syndesmotic squeeze/taping relieving pain after taping than before

♦ External rotation test is most sensitive.

No single test is reliable to demonstrate syndesmotic instability. In case of clinical suspicion in symptomatic patient, MRI scan with high sensitivity and high specificity is recommended.

♦ Latest method of CT-based assessment: Tibiofibular line can be checked preoperatively/postoperatively/posttreatment (Fig. 6.11).

Fig. 6.11 CT image showing the tibiofibular line for diagnosis of syndesmotic injuries.

♦ Line from flat anterolateral surface of fibula to anterior tubercle of tibia measured 1 cm above tibial plafond on axial cut of CT scan. Must be within 2 mm from the anterior surface of tibia.

Tips and Tricks for Syndesmotic Screws

♦ Put a clamp at the same horizontal level. If the clamp is put obliquely, it can pull the fibula out of its anatomical groove

♦ Aim the drill posterior to anterior from the fibula, otherwise one may miss the tibia

♦ Position of the foot is immaterial. Let it stay in the resting position

♦ May allow the syndesmosis to fall back into its original position and allow for the natural movement of distal fibula during ankle movement

♦ Recent studies show no difference in symptoms and functional scores at 1 year between removal of screws or not

Flowcharts 6.7 and 6.8 demonstrate various types of closed pilon fractures and their respective treatment options.

Flowchart 6.7 Types of closed pilon fractures and their respective treatment options. ORIF, open reduction internal fixation; MIPO, minimally invasive plate osteosynthesis

Flowchart 6.8 Approach selection in the case of pilon fractures.

♦ At least one stiff implant is a must

Flowchart 6.9 shows the management of extra-articular calcaneal fractures.

Flowchart 6.9 Management of extra-calcaneal fractures. ORIF, open reduction internal fixation; MIS, minimal invasive surgery.

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Ten Commandments of Foot and Ankle Trauma Management Rational Prescription of Foot and Ankle Orthotics In the Foot and Ankle Operation Theater Lucid Approach and Simplistic Management of Diabetic Foot Foot and Ankle Examination Radiology in Foot and Ankle

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