#anklefoot

A trimalleolar fracture is a fracture of the ankle that involves the lateral malleolus, the medial malleolus, and the distal posterior aspect of the tibia, which can be termed the posterior malleolus. Necessary XR views include an AP, lateral and mortise view. Similar to bimalleolar fractures, these are often unstable and surgery is typically recommended. Non-operative management ED management includes a short leg walking cast or boot with weight bearing as tolerated. For isolated posteiror malleolus injuries, operative management is indicated of >25% of the articular surface in involved, >2mm articular step off or there is associated syndesmotic injury. If operative management is indicated, place the patient in a short leg posterior splint with stir-up and make them non-weight bearing. They should follow up with an orthopedist in 1-2 weeks although operative injuries may need to be seen sooner. 

A "bimalleolar equivalent" fracture means that in addition to one of the malleoli being fractured, the ligaments on the inside (medial) side of the ankle are injured. Usually, this means that the fibula is broken along with injury to the medial ligaments, making the ankle unstable.

Certain regions of the 5th metatarsal has a poor blood supply so it will have difficulty healing so treatment depends on where the break occurred. The blood supply worsens as you move distally along the metatarsal. These patient’s should be placed in a splint, made non-weight bearing and referred to an orthopedist for ORIF evaluation. 

Occurs when one or more of the metatarsal bones are displaced from the midfoot bones secondary to a lisfranc ligament tear. The lisfranc joint complex consists of the 5 metatarsal bones and their adjoining tarsal ones (3 cuneiforms and 2 lateral cuboid). Suspect a Lisfranc injury if there is greater than 1 mm gap between the base of the first and second or second and third metatarsals or any fractures around the Lisfranc joint complex. Fleck sign is an avulsion fracture of the base of the second metatarsal on the medial side, which is pathognomonic of a Lisfranc fracture. The only time surgery is not required is if the metatarsal bones don’t move during a weight bearing X-ray.

Secondary to high impact blunt trauma to the heel. Necessary XR views include AP, lateral and oblique however CT is the gold standard for characterization. Emergent orthopedic consultation is necessary if compartment syndrome or a calcaneal tuberosity fracture is suspected (due to skin necrosis risk). Immobilize these paitents in a bulky jones splint and make them non-weight bearing. Operative indications include any displacement, extra-articular involvement or achilles tendon injury.  Bohler’s angle can help assess the degree of calcaneal injury. These fractures have a high rate of chronic arthritis and high risk patients (diabetics, smokers) have frequent post-operative complications. 

This fracture occurs which forceful flexion of the ankle joint where the talus contacts the tibia. The talar neck is the most common fracture site. Necessary XR views include an AP, lateral and canale view (also known as the talar neck view). The patient should undergo emergent reduction if there is evidence of displacement due to avascular necrosis risk. Immobilize with a well padded, short leg posterior splint. Surgery is almost always indicated since the talus interacts with three separate joints, particularly the ankle joint. Surgery is only held for hairline cracks without displacement (Hawkins Type I) . Talar fractures are associated with high rates of avascular necrosis and post-traumatic arthritis. 

Clayton is back to review the new sensation, Hot Jewels metallic temporary body tattoos. Oh boy...

oh and the entirety of chapter 39