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Orthopedic Trauma
Orthopedic Trauma

Common Foot and Ankle Injuries


Broken Ankle

During the past 30 years, doctors have noted an increase in the number and severity of broken ankles, due in part to an active, older population of "baby boomers." In 2003, nearly 1.2 million people visited emergency rooms because of ankle problems. The ankle actually involves two joints, one on top of the other. A broken ankle can involve one or more bones, as well as injuring the surrounding connecting tissues (ligaments).

Anatomy of the ankle

The top ankle joint is composed of three bones:

  • the shinbone (tibia).
  • the other bone of the lower leg (fibula).
  • the anklebone (talus).

The leg bones form a scooped pocket around the top of the anklebone. This lets the foot bend up and down.

Right below the ankle joint is another joint (subtalar), where the anklebone connects to the heelbone (calcaneus). This joint enables the foot to rock from side to side. Three sets of fibrous tissues connect the bones and provide stability to both joints. The knobby bumps you can feel on either side of your ankle are the very ends of the lower leg bones. The bump on the outside of the ankle (lateral malleolus) is part of the fibula; the smaller bump on the inside of the ankle (medial malleolus) is part of the shinbone.

When a break occurs

Any one of the three bones that make up the ankle joint could break as the result of a fall, an automobile accident or some other trauma to the ankle.

Because a severe sprain can often mask the symptoms of a broken ankle, every injury to the ankle should be examined by a physician. Symptoms of a broken ankle include:

  • Immediate and severe pain.
  • Swelling.
  • Bruising.
  • Tender to the touch.
  • Inability to put any weight on the injured foot.
  • Deformity, particularly if there is a dislocation as well as a fracture.

A broken ankle may also involve damage to the ligaments. Your physician will order X-rays to find the exact location of the break. Sometimes, a CT (computed tomography) scan or a bone scan will also be needed.

Treatment and rehabilitation

If the fracture is stable (without damage to the ligament or the mortise joint), it can be treated with a leg cast or brace. Initially, a long leg cast may be applied, which can later be replaced by a short walking cast. It takes at least 6 weeks for a broken ankle to heal, and it may be several months before you can return to sports at your previous competitive level. Your physician will probably schedule additional X-rays while the bones heal, to make sure that changes or pressures on the ankle don't cause the bones to shift. If the ligaments are also torn, or if the fracture created a loose fragment of bone that could irritate the joint, surgery may be required to "fix" the bones together so they will heal properly. The surgeon may use a plate, metal or absorbable screws, staples or tension bands to hold the bones in place. Usually, there are few complications, although there is a higher risk among diabetic patients and those who smoke. Afterwards, the surgeon will prescribe a program of rehabilitation and strengthening. Range of motion exercises are important, but keeping weight off the ankle is just as important. A child who breaks an ankle should be checked regularly for up to 2 years to make sure that growth proceeds properly, without deformity or uneven leg length.

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Fracture of the Talus

The talus (TAY-lus) is a small bone that sits between the heelbone (calcaneus) and the two bones of the lower leg (tibia and fibula). It has an odd humped shape, somewhat like a turtle. The bones of the lower leg "ride" on top and around the sides to form the ankle joint. Where the talus meets the bones of the foot, it forms the subtalar joint, which is important for walking on uneven ground. The talus is an important connector between the foot and the leg and body, helping to transfer weight and pressure forces across the ankle joint.

Most injuries to the talus result from motor vehicle accidents, although falls from heights also can injure the talus. These injuries are often associated with injuries to the lower back. An increasing number of talar fractures results from snowboarding, which uses a soft boot that is not rigid enough to prevent ankle injuries.

Signs and symptoms

Most talar fractures are marked by:

  • Acute pain.
  • An inability to bear weight.
  • Considerable swelling and tenderness.

A fracture that breaks through the skin has an increased risk of infection. Talar fractures that result from snowboarding injuries may be mistaken for ankle sprains because of the tenderness on the outer side of the ankle and severe bruising.

Diagnosis

Your doctor will examine your foot and ankle and ask you to describe how the injury occurred. He or she will order X-rays of your foot and ankle. In some cases, the X-ray will not show the fractures, so a computed tomography (CT) scan may be needed. These diagnostic tests will help pinpoint the location of the fracture. They also will show whether the bones are still aligned (nondisplaced fracture) or have shifted out of place (displaced fracture). Any loose bits of bone that may need to be removed also can be identified.

Your doctor will check the functioning of the nerves to the foot to ensure that there is no damage. He or she also will make sure that an adequate supply of blood is flowing to the toes and that pressure is not building in the muscles of the foot (compartment syndrome).

Treatment

A talar fracture that is left untreated or that doesn't heal properly will create problems for you later. Your foot function will be impaired, you will develop arthritis and chronic pain, and the bone may collapse.

Immediate first aid treatment for a talar fracture is to apply a well-padded splint around the back of the foot and leg from the toe to the upper calf. Elevate the foot above the level of the heart and apply ice for 20 minutes every hour or two until you can see a doctor. Don't put any weight on the foot.

In rare cases, a talar fracture can be treated without surgery if X-rays show that the bones have not moved out of alignment. You will have to wear a cast for at least 6 to 8 weeks and will not be able to put any weight on the foot during that time. Afterwards, your doctor will give you some exercises to help restore the range of motion and strength to your foot and ankle. Most fractures of the talus require surgery to minimize later complications. The orthopedic surgeon will realign the bones and use metal screws to hold the pieces in place. If there are small fragments of bone, they may be removed and bone grafts used to restore the structural integrity of the joint.

After the surgery, your foot will be put in a cast for 6 to 8 weeks and you will not be able to put any weight on the foot for at least 3 months. As the bones begin to heal, your orthopaedist may order X-rays or a magnetic resonance image (MRI) to see whether blood supply to the bone is returning. If the blood supply is disrupted, the bone tissue could die, a condition called avascular necrosis or osteonecrosis. This could cause the bone to collapse. Even if the bones heal properly, you may still experience arthritis in later years. Most of the talus is covered with articular cartilage, which enables bones to move smoothly against each other. If the cartilage is damaged, the bones will rub against each other, resulting in pain and stiffness. Treatments for arthritis include activity modifications, ankle-foot orthoses, joint fusion, bone grafting and ankle replacement.

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Fractures of the Heel

It's not easy to break your heelbone (calcaneus). Because it takes a lot of force, such as that sustained in a motor vehicle accident or a fall from a height, you may also incur other injuries as well, particularly to the back.

Signs and symptoms

  • Pain.
  • An inability to bear weight.

The pain may be centered on the outer side of the ankle, just below the lower leg bone (fibula). Or, it may be focused in the heel pad, particularly when you try to put weight on the foot. Your foot may become swollen and stiff. See your doctor right away, because if the bone heals improperly, severe problems may result later.

Diagnosing a heel fracture

Your doctor will try to pinpoint the area of pain and tenderness. You will probably need to get several X-rays of the heel and ankle area. A computed tomography (CT) scan may also be helpful. If you are also experiencing back pain, your doctor will recommend X-rays of the lower back as well to see if there is a fracture there.

The nerves that bring sensation and movement to the foot pass close to the heelbone. Your doctor will check their functioning to ensure that there is no damage. He or she will also make sure that an adequate supply of blood is flowing to the toes and that pressure is not building in the muscles of the foot (compartment syndrome).

Treating heel fractures

If the pieces of broken bone have not been pushed out of place by the force of the injury, you may not need surgery:

  • Your foot will need to be elevated above the level of your heart and wrapped in a bulky, compressive dressing to keep the bones from shifting.
  • Ice packs, applied for 20 minutes every hour or two, can help reduce swelling and pain.
  • Your doctor may apply a splint until the swelling goes down, which can take 1 to 3 weeks. Then the doctor may give you a removable splint and prescribe some exercises to maintain flexibility and movement.

You won't be able to put any weight on your foot until the bone is completely healed, which takes at least 6 to 8 weeks, and perhaps longer.

Surgical treatment

If the bones have shifted out of place (a displaced fracture), you will most likely need surgery. A metal plate and small screws are used to hold the bones in place. A bone graft may be used to aid in the healing of the fractures. The incision will be bandaged and a splint applied until it is healed. Then, you'll get a removable splint so that you can begin exercising the joint. You won't be able to put any weight on your foot for approximately 10 weeks after surgery. When you begin walking, you may need to use a cane and wear a special boot. It may take up to a year for the injury to heal completely. Depending on the type of job you have, you may not be able to return to the same type of work. Because of the amount of force needed to break the heel bone initially, even if your fracture heals properly, your foot may never be the same as it was before the injury. You may continue to experience stiffness and you may need to wear a heel pad, lift, or cup as well as special shoes with extra depth in the toe compartment.

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Lisfranc (Midfoot) Fracture

Have you ever dropped a heavy box on the top of your foot? Or accidentally stepped in a small hole and fallen, twisting your foot? These two common accidents can result in a Lisfranc fracture-dislocation of the midfoot. This fracture gets its name from the French doctor who first described the injury.

Lisfranc injuries occur at the midfoot, where a cluster of small bones form an arch on top of the foot between the ankle and the toes. From this cluster, 5 long bones (metatarsals) extend to the toes. The second metatarsal also extends down into the row of small bones and acts as a stabilizing force. The bones are held in place by connective tissues (ligaments) that stretch both across and down the foot. However, there is no connective tissue holding the first metatarsal to the second metatarsal. A twisting fall can break or shift (dislocate) these bones out of place.

Signs and symptoms

Lisfranc fracture-dislocations are often mistaken for sprains. The top of the foot may be swollen and painful. There may be some bruising. If the injury is severe, you may not be able to put any weight on the foot. Lisfranc injuries are often difficult to see on X-rays. Unrecognized Lisfranc injuries can have serious complications such as joint degeneration and compartment syndrome, a build-up of pressure within muscles that can damage nerve cells and blood vessels. If the standard treatment for a sprain (rest, ice and elevation) doesn't reduce the pain and swelling within a day or two, ask your doctor for a referral to an orthopedic specialist.

Diagnosis

The orthopaedist will examine your foot for signs of injury. He may hold your heel steady and move your foot around in a circle. This motion produces minimal pain with a sprain, but severe pain with a Lisfranc injury. If your initial X-ray did not show an injury, the orthopaedist may request several other views, including comparison views of the uninjured foot and stress or weightbearing X-rays. In some cases, a computed tomography (CT) scan or magnetic resonance image (MRI) may be necessary to confirm the diagnosis.

Treatment

Treatment for a Lisfranc injury depends on the severity of the injury. If the bones have not been forced out of position, you will probably have to wear a cast and refrain from putting weight on the foot for about 6 weeks. When the cast is removed, you may have to wear a rigid arch support. Your orthopaedist will also recommend foot exercises to build strength and help restore full range of motion.

Often, operative treatment is needed to stabilize the bones and hold them in place until healing is complete. Pins, wires or screws may be used. Afterwards, you will have to wear a cast and limit weightbearing on the foot for 6 to 8 weeks. A walking brace may be prescribed when the fixation devices are removed. You may also have to wear an arch support and a rigid soled shoe until all symptoms have disappeared. In some cases, if arthritis develops in these joints, the bones may have to be fused together.

It is important to follow your doctor's orders and refrain from activities until you are given the go-ahead. If you return to activities too quickly, you may easily suffer another injury, resulting in damage to the blood vessels, the development of painful arthritis, and an even longer healing time.

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Stress Fractures of the Foot and Ankle

Stress fractures are a type of overuse injury. These tiny cracks in your bones develop when your muscles become overtired (fatigued) and can no longer absorb the shock of repeated impacts. When this happens, the muscles transfer the stress to the bones, creating a small crack or fracture.

Stress fractures also can occur with normal usage if osteoporosis or some other disease weakens your bones and leaves them vulnerable. These fractures are often called "insufficiency fractures" because there isn't enough bone to withstand the normal stress of daily use.

Most stress fractures occur in the weight-bearing bones of the foot and lower leg. The most commonly affected site is the second or third of the long bones (metatarsals) between the toes and the midfoot. Stress fractures also can occur in the heel, the outer bone of the lower leg (fibula) and the navicular, a bone on the top of the midfoot.

Who's at risk?

  • Athletes who participate in high-impact sports such as track and field, basketball, gymnastics, ballet or tennis.
  • Adolescents whose bones have not yet fully hardened.
  • Women, particularly female athletes, who have abnormal or absent menstrual cycles that can result in decreasing bone mass.
  • Military recruits who suddenly must shift from a sedentary civilian life to a more active training regime.

Causes of stress fractures

Doing too much too soon is a common cause of stress fractures. Runners who have been confined indoors for most of the winter may want to pick up where they left off at the end of the previous season. Instead of starting slowly, they try to match their previous mileage. The result could be stress fractures in the foot and ankle.

Improper sports equipment, such as shoes that are too worn or stiff, also can contribute to stress fractures. A change of surface, such as going from a grass tennis court to one of clay or from an indoor to an outdoor running track, can increase the risk of stress fractures. Errors in training or technique are another cause of stress fractures. Some conditions, such as flatfoot or bunions, can change the mechanics of your foot and make stress fractures more likely to develop.

Insufficiency stress fractures result when the bone itself is weak. Conditions such as osteoporosis reduce the density and quality of bone matter, thus increasing the risk of fracture. Female athletes who experience irregular or absent menstrual periods may also have decreased bone density and an increased risk of stress fractures.

Signs and symptoms

  • Pain that develops gradually, increases with weight-bearing activity, and diminishes with rest.
  • Swelling on the top of the foot or the outside ankle.
  • Tenderness to touch at the site of the fracture.
  • Possible bruising.

Diagnosing a stress fracture

If you suspect a stress fracture in your foot or ankle, stop the activity and rest the foot. Ignoring the pain can have serious consequences, and the bone may break completely. Apply an ice pack and elevate the foot above the level of your heart. Try not to put weight on the foot until after you see a doctor.

Stress fractures are difficult to see on X-rays until they've actually started to heal. Your orthopaedist may recommend a bone scan, which is more sensitive than an X-ray and can detect stress fractures early.

Treating stress fractures

Treatment will depend on the location of the stress fracture. Most stress fractures will heal if you reduce your level of activity and wear protective footwear for 2 to 4 weeks. Your orthopaedist may recommend that you wear a stiff-soled shoe, a wooden-soled sandal, or a removable short leg fracture brace shoe. Athletes should switch to a sport that puts less stress on the foot and leg. Swimming and bicycle riding are good alternative activities.

Stress fractures in the fifth metatarsal bone (on the outer side of the foot) or in the navicular or talus bones take longer to heal, perhaps as long as 6 to 8 weeks. Your orthopaedist may apply a cast to your foot or recommend that you use crutches until the bone heals. In some cases, you may need surgery so that the orthopaedist can insert a screw in the bone to ensure proper healing.

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Toe and Forefoot Fractures

Nearly one-fourth of all the bones in your body are in your feet, which provide you with both support and movement. A broken (fractured) bone in your forefoot (metatarsals) or in one of your toes (phalanges) is often painful but rarely disabling. Most of the time, these injuries heal without operative treatment.

Types of fractures

Stress fractures frequently occur in the bones of the forefoot that extend from your toes to the middle of your foot. Stress fractures are like tiny cracks in the bone surface. They can occur with sudden increases in training (such as running or walking for longer distances or times), improper training techniques or changes in training surfaces. Most other types of fractures extend through the bone. They may be stable (no shift in bone alignment) or displaced (bone ends no longer line up). These fractures usually result from trauma, such as dropping a heavy object on your foot, or from a twisting injury. If the fractured bone does not break through the skin, it is called a closed fracture.

Several types of fractures occur to the forefoot bone on the side of the little toe (fifth metatarsal). Ballet dancers may break this bone during a misstep or fall from a pointe position. An ankle-twisting injury may tear the tendon that attaches to this bone and pull a small piece of the bone away. A more serious injury in the same area is a Jones fracture, which occurs near the base of the bone and disrupts the blood supply to the bone. This injury may take longer to heal or require surgery.

Signs and symptoms

Pain, swelling, and sometimes bruising are the most common signs of a fracture in the foot. If you have a broken toe, you may be able to walk, but this usually aggravates the pain. If the pain, swelling, and discoloration continue for more than 2 or 3 days, or if pain interferes with walking, something could be seriously wrong; see a doctor as soon as possible. If you delay getting treatment, you could develop persistent foot pain and arthritis. You could also change the way you walk (your gait), which could lead to the formation of painful calluses on the bottom of your foot or other injuries.

Diagnosis

The doctor will examine your foot to pinpoint the central area of tenderness and compare the injured foot to the normal foot. You should tell the doctor when the pain started, what you were doing at the time, and if there was any injury to the foot. X-rays will show most fractures, although a bone scan may occasionally be needed to identify stress fractures. Usually, the doctor will be able to realign the bone without surgery, although in severe fractures, pins or screws may be required to hold the bones in place while they heal.

Treatment

See a doctor as soon as possible if you think that you have a broken bone in your foot or toe. Until your appointment, keep weight off the leg and apply ice to reduce swelling. Use an ice pack or wrap the ice in a towel so it does not come into direct contact with the skin. Apply the ice for no more than 20 minutes at a time. Take an analgesic such as aspirin or ibuprofen to help relieve the pain. Wear a wider shoe with a stiff sole.

Rest is the primary treatment for stress fractures in the foot. Stay away from the activity that triggered the injury, or any activity that causes pain at the fracture site, for 3 to 4 weeks. Substitute another activity that puts less pressure on the foot, such as swimming. Gradually, you will be able to return to activity. Your doctor or coach may be able to help you pinpoint the training errors that caused the initial problem so you can avoid a recurrence.

The bone ends of a displaced fracture must be realigned and the bone kept immobile until healing takes place. If you have a broken toe, the doctor will "buddy-tape" the broken toe to an adjacent toe, with a gauze pad between the toes to absorb moisture. You should replace the gauze and tape as often as needed. Remove or replace the tape if swelling increases and the toes feel numb or look pale. If you are diabetic or have peripheral neuropathy (numbness of the toes), do not tape the toes together. You may need to wear a rigid flat-bottom orthopedic shoe for 2 to 3 weeks.

If you have a broken bone in your forefoot, you may have to wear a short-leg walking cast, a brace, or a rigid, flat-bottom shoe. It could take 6 to 8 weeks for the bone to heal, depending on the location and extent of the injury. After a week or so, the doctor may request another set of X-rays to ensure that the bones remain properly aligned. As symptoms subside, you can put some weight on the leg. Stop if the pain returns.

Surgery is rarely required to treat fractures in the toes or forefoot. However, when it is necessary, it has a high degree of success.

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