Foot and Ankle Injury Analysis in Emergency Settings

Foot and ankle injuries are a common cause of emergency department (ED) visits.

The foot is a key component for the human weight-bearing function. In foot consultations, determining the exact mechanism of the injury is a key factor to reach an accurate diagnosis. Additionally, one should ask about injuries or symptoms in all areas along the lower extremity.

The complete physical examination of any foot consultation is a 6-step process: inspection, palpation, range of motion, strength, neurovascular function, and special tests such as midfoot stress testing.

The Ottawa Foot Rules have a sensitivity of almost 100% in determining the value of plain radiographs in the diagnosis of fractures, this requires 4 steps at the time of injury and at presentation and no sensitivity over the navicular or head of the fifth metatarsal to avoid x-rays.

Implementing these rules reduces the number of x-rays ordered by 30% to 40%. If a plain radiograph is ordered, a weight-bearing view should be obtained whenever possible as this helps evaluate ligamentous injuries.

Common normal variants on standing radiographs include the accessory navicular, os peroneum, and os trigonum. Computed tomography (CT) should be considered in case of clinical suspicion of fracture of the talus, calcaneus or navicular and in the presence of a normal plain radiograph.

The unique anatomical characteristic of the talus (a small area for arterial vascular supply) predisposes it to nonunion and avascular necrosis. Talar neck fractures account for half of major talar injuries; These are best observed on radiography with the Canale projection.

Lateral process fractures, although rare, are associated with snowboarding and are frequently misdiagnosed as ankle sprains. Physical examination may demonstrate tenderness over the lateral process.

Closed talar and peritalar dislocations are extremely rare and require emergency reduction; Most of these injuries are open and require surgical reduction. Treatment of all talus fractures includes immobilization, the use of crutches, and urgent consultation with a specialist.

The calcaneus is the tarsal bone that is most frequently fractured and its fracture usually coexists with vertebral injuries. Diagnosis of the fracture begins with standard radiographs of the calcaneus, which include measurement of the Böhler angle, which should measure between 25 and 40 degrees.

According to studies, a Böhler angle of less than 25º would have a sensitivity and specificity of 100% and 82%, respectively, for calcaneal fractures.

After identifying the fracture, CT should be considered to rule out intra-articular involvement; these have a worse diagnosis than extra-articular fractures and require surgical intervention.

Treatment of calcaneal fractures includes detailed evaluation of associated injuries, orthopedic consultation, immobilization, use of crutches, and foot compartment syndrome should be considered in all cases before discharge, as it has a frequency of 10%.

Fractures of the navicular bone can be traumatic or stress-related. Traumatic injuries can cause avulsion, tuberosity, or tarsal navicular body fractures. CT is the imaging study of choice for traumatic navicular injury.

Navicular stress fractures have a higher risk of delayed union or nonunion and the study of choice is magnetic resonance imaging (MRI). The treatment of navicular injuries includes immobilization, the use of crutches, follow-up with a specialist and, in case of displacement, associated dislocation or open fracture, urgent care in the ED.

Cuboid fractures are frequently associated with fractures of the heel, calcaneus, or tarsometatarsal region, and occur from falls from a height or crushing. Cuboid compression injury is associated with horse riding. These fractures should be treated with splinting, use of crutches and discussed with the specialist.

Lisfranc joint injuries present with significant pain and inability to bear weight. Examination will demonstrate tenderness to palpation around the midfoot and pain with midfoot stress testing.

Weight-bearing views are essential for diagnostic imaging, and the most consistent radiographic finding of a Lisfranc injury is malalignment of the medial edges of the second metatarsal and medial cuneiform. CT may be useful to evaluate the severity or joint involvement of the fracture.

Moderate sprains should be treated conservatively, but in some cases Lisfranc injuries require surgical reduction and fixation.

Lisfranc injuries must be immobilized, they must not bear weight, and a specialist must monitor them. In cases of displacement, associated dislocation or evidence of compartment syndrome, emergency intervention is necessary.

Traumatic metatarsal fractures are the most common foot fractures; Sometimes on examination it is difficult to define the location of the lesion. In case of tense swelling, pain disproportionate to the examination findings, and significant symptoms with passive movement of the fingers, compartment syndrome should be suspected.

Displacements greater than 4 mm or angles of more than 10º require reduction and in cases of displacement or angulation of the first metatarsal fracture, intervention is always necessary.

Metatarsal fractures should be immobilized and non-weight bearing, then monitored by the foot specialist within 3 to 5 days. Any evidence of significant fracture displacement, compartment syndrome, or open fracture necessitates emergency consultation.

Flat feet, a dorsi/plantarflexed metatarsal, and tight gastrocnemius muscles predispose an individual to metatarsal stress fractures. Physical examination demonstrates swelling, tenderness, and pain with walking.

These types of fractures are treated by correcting or modifying the offensive activity and protecting the metatarsal. Nonsteroidal anti-inflammatories should be used with caution due to controversial use in stress fractures. The follow-up must be carried out by a specialist.

Fractures of the fifth metatarsal are separated into tuberosity avulsion fractures, proximal shaft fractures (Jones fracture), and shaft stress fractures.

Non-displaced tuberosity avulsion fractures can be treated symptomatically, and in cases of displacements greater than 3 mm or a separation of more than 2 mm on the articular surface of the cuboid, referral is made to a specialist.

Otherwise, these patients should use a hard-soled shoe or walking boot and in more severe cases use crutches. Acute proximal diaphyseal fractures have a higher risk of nonunion or delayed union and are treated with immobilization, the use of crutches, and referral to a specialist for follow-up.

Shaft stress fractures, although rare, are prone to delayed union or nonunion. Radiographically, they are differentiated from acute fractures by the presence of cortical thickening around the fracture site. These are treated through immobilization, the use of crutches and referral to a specialist.

In phalangeal injuries, the physical examination should focus on evidence of an open fracture, deformity, or subungual hematoma.

In case of angulation or deformity, reduction is necessary. These injuries are treated with splinting, subungual hematomas should be evacuated if they have been present for less than 48 hours and are symptomatic, and it is not always necessary to remove the nail.

These patients should wear hard-soled shoes if they experience pain when walking, otherwise it is recommended to wear closed shoes. Antibiotic prophylaxis for open fractures depends on wound contamination and comorbidities.

Open toe fractures that do not involve the distal phalanx should be referred to a specialist. Significant toe fractures should be referred to a specialist.

Closed toe dislocations that do not involve the first metotarsophalangeal joint are usually reduced with longitudinal traction. While open toe dislocations require specialist consultation. Dislocations of the first metatarsophalangeal joint can be complicated, are usually mostly dorsal, and often require surgical reduction.

Ankle injuries are one of the most common sports injuries of the extremities most common in the ED. Although the majority are benign, more than 20% of these lesions may have prolonged associated morbidity.

The ankle is made up of the tibia, fibula and talus, with 3 groups of stabilizing ligaments located laterally, medially and anteroposteriorly. Among these, the anterior talofibular ligament (ATL) is the most frequently injured. The medial ligaments are 20% to 50% stronger than the lateral ones.

The history should determine the type and extent of the injury. Ask about the mechanism of injury, the position of the foot and ankle during the injury, whether any sounds were heard at the time of the injury, previous history of injury. of the ankle, the presence of associated pain and the degree of function after the event.

The physical examination includes inspection, range of motion, and palpation. It is necessary to evaluate the joint above and below, as well as palpate the fibula in its entirety.

Specific ligamentous tests should not be performed until the x-rays have been examined or if these have been considered unnecessary. These tests may be difficult to perform initially and should be repeated once the pain and swelling have resolved.

The anterior drawer test evaluates the integrity of the LTFA; subluxation of 2 mm or more compared to the opposite side or “sucking sign” indicates significant injury to the LTFA. Talar inclination evaluates the integrity of the LTFA and the calcaneofibular ligament (CFL); It is particularly painful in acute injury.

The compression test tests the integrity of the syndesmotic ligaments; Ankle pain indicates an injury to these ligaments and has a high specificity for syndesmotic injury. The Thompson test analyzes the integrity of the Achilles tendon, a positive test indicates the absence of plantar flexion and rupture of the Achilles tendon.

The Ottawa Ankle Rules  (OAR) limit unnecessary radiographs, stating that images should be obtained in patients who cannot walk more than 4 steps after injury and in those with bone tenderness at the tip of the ankle or along the posterior edge. of the distal 6 cm of the malleoli, the base of the fifth metatarsal or the navicular.

Negative OAR does not mean absence of fracture, but suggests that clinically important fractures requiring prolonged immobilization, casting, or surgical fixation are not present. Stress views of the ankle allow evaluation for significant instability or syndesmotic injury.

Ultrasound can significantly reduce unnecessary imaging without missing a clinically important fracture compared to the use of OAR and allows evaluation of other soft tissue injuries. CT and MRI have limited utility in the ED.

The most used classifications for ankle fractures are the Lauge-Hansen (LH) and Danis-Weber (DW) classifications. The 4 mechanisms of the LH system are: supination-adduction, supination-external rotation, pronation-adduction and pronation-lateral rotation. In turn, each mechanism is classified by the degree of force applied. The DW system, which has 3 defined fracture types based on their location on the fibula, is often preferred.

Treatment of ankle fractures includes evaluation of the neurovascular status of the foot and immediate reduction of fractures with neurovascular compromise or fracture-dislocations; Obtaining x-rays should not delay reduction. A complete reduction should be attempted.

Open fractures require emergency orthopedic consultation as do significant, unstable displacements or fractures involving the intra-articular surface; Stable nondisplaced fractures should be splinted or cast with outpatient follow-up, and avulsion fractures less than 3 mm can be treated as sprains.

Lateral fractures of the malleolus are the most common fractures of the ankle and their stability depends on their location. Stable fractures can be splinted or cast and referred for outpatient consultation with a specialist. Fractures in the tibiotalar joint without ligamentous rupture can heal without surgical fixation.

Medial fractures of the malleolus are frequently seen together with other fractures, but if they are isolated they are treated with immobilization and outpatient follow-up if they are not displaced. Posterior fractures of the malleolus almost always have other associated injuries and these patients should receive orthopedic consultation in the ED.

Treatment of bimalleolar fractures is controversial, but it is possible to reduce these fractures. Trimalleolar fractures always require open reduction and internal fixation.

In tibial pilon fractures the tibia and fibula are frequently fragmented. These types of fractures require orthopedic consultation in the ED due to joint involvement. These are often open fractures and are associated with long-term morbidity. Fractures of the talar dome are the most common chondral fractures.

These fractures are often overlooked and present later as “a sprained ankle that didn’t heal.” These patients should be referred for outpatient evaluation for further imaging studies. Generally, the treatment of these fractures is conservative.

Maissonneuve fracture accounts for 1 in 20 ankle fractures. In this fracture, a complete physical examination, particularly of the proximal fibula, is very important. Most of these fractures require open reduction with internal fixation due to instability.

Ligamentous injuries are extremely common in the ED and are mostly lateral ligament injuries. The most common mechanism is foot inversion. Ankle sprains usually heal well and it is estimated that 20% to 40% of these progress to chronic ankle instability.

All sprains are treated with rest, ice, compression and elevation; This RICE therapy is considered standard. Non-steroidal anti-inflammatories are also used, the use of crutches depends on the degree of the injury and the patient’s symptoms.

Grade I lateral sprains are treated functionally and grade II sprains require specialist follow-up. While the treatment of grade III is controversial, some support the surgical approach while others recommend non-surgical therapy initially. Medial sprains are rare and their treatment is similar to lateral sprains.

Syndesmotic injuries account for 20% to 25% of ankle injuries. They are associated with long-term disability and a much higher likelihood of chronic pain and instability. The positive compression test in the absence of fibular fracture has a high specificity for syndesmotic injury. The ankle should be splinted until the patient receives an outpatient consultation with the specialist.

The best clinical test to evaluate Achilles tendon rupture is the Thompson test. In case of doubt, ultrasound or MRI can facilitate the diagnosis. The optimal therapy is still controversial, the ankle should be splinted and the patient referred to a specialist.

Peroneus tendon injuries are often misdiagnosed as ankle sprains. Physical examination demonstrates tenderness along the posterior border of the lateral malleolus, and the dislocated tendon can occasionally be palpated. These lesions are evaluated with ultrasound and treatment is controversial. In the ED this injury is splinted and the patient is referred to a specialist.

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