Description
A fracture is a break in the continuity of a bone. This page discusses ankle and foot fractures and the role of the physical therapist in the rehabilitation of such injuries. Ankle fractures are common in adults. Cannus et al. Reported incidence as high as 174 There are 100,000 Finns a year. [1] Foot fractures are less common.
Fractures of the ankle
Ankle fractures are most commonly diagnosed by clinical examination and x-rays. The Ottawa Rules provide clinicians with a tool to decide whether joints should be imaged. Several classifications exist and are used to determine the severity of injury and treatment. examples include Danis-Weber classification to determine extent of injury; Lauge-Hansen classification based on injury mechanism with predictable pattern and radiographic findings.
Complications of ankle fractures may include decreased range of motion in the ankle and foot joints due to periarticular and intraarticular adhesions or disruption of the articular surfaces. Destruction of the articular surfaces may lead to the development of osteoarthritis.
Fractures that are not displaced can be immobilized with a below-knee cast for 3-6 weeks. If displaced, the surgeon should reset the fragment to the normal anatomical position of the joint. If this cannot be achieved through manipulation and plaster casts, one may have to accept Open reduction and internal fixation (ORIF) followed by a plaster cast. [2]
Common ankle fractures include:
- Potts Fracture
- Avulsion Fractures
Fractures in the foot
The bony anatomy of the foot means that various fractures can occur. Calcaneal fractures are usually caused by a fall from a height. This fracture can be very painful and may be accompanied by a broken vertebrae. The phalanges and metatarsals are usually injured by heavy objects The object falls on the feet. These fractures do not require reduction or immobilization. Stress fractures of the metatarsal bones are known as “marching” fractures. These are caused by repeated trauma from prolonged walking. [2]
Common fractures of the foot include:
- Calcaneal Fractures
- Chopart fracture-dislocation
- Metatarsal Fractures
Stress Fractures
Stress fractures occur in bones that experience mechanical fatigue. [3] They are the result of exceeding repetitive submaximal loads, creating an imbalance between bone resorption and bone formation. [4] Fractures usually start at locations that are under great stress; this is called a “crack Enlightenment”. [4] If this microscopic crack fails to heal and is subjected to further loading, the microdamage will increase and the crack will grow. This increase in damage will cause the bone to fracture on a macroscopic level. [4]
- Leg and Foot Stress Fractures
Clinically Relevant Anatomy
The ankle joint
The ankle joint, also known as the talocrural joint, consists of three bony structures: the tibia (tibia) at the proximal end, the fibula at the distal end, and the talus at the distal end. The tibia and fibula have specific parts that make up the ankle:
- Medial malleolus – inner part of the tibia
- Posterior malleolus – the back of the tibia
- Lateral malleolus – end of fibula
The tibia and fibula form the ankle joint, whose structure and stability are provided by the following connective tissues:
- Interosseous membrane
- anteroposterior and transverse tibiofibular ligament
The collateral ligaments stabilize the joint against abduction and adduction forces. Laterally, the anterior talofibular ligaments (ATFL), calcaneous ligaments (CFL), and posterior talofibular ligaments (PTFL), and medially, the wide fan of the deltoid ligament and the plantar calcaneous ligament ligament whose medial border fuses with the anterior part of the deltoid ligament. [5]
The foot
The foot contains 26 bones. The foot is divided into three main parts: the hindfoot, the midfoot, and the forefoot.
- The hind foot is made up of two bones: the calcaneus and the talus. They form the subtalar joint.
- The midfoot is made up of 5 bones: the navicular cuboid and 3 cuneiform bones (medial medial and lateral). The bones are connected to the forefoot and rearfoot by muscles and the plantar fascia (arch ligament).
- The forefoot is made up of 19 bones: 5 metatarsals and 14 phalanges.
The Chopart joint is the connection between the rear foot and the midfoot, involving the Tanarovicular and Calcanoid joints; the Lisfranc joint connects the forefoot to the midfoot.
Epidemiology /Etiology
Ankle fractures result from trauma such as falls, sprains, and sports-related injuries [6]. It occurs in the elderly as well as the young.
There are a number of risk factors associated with an increased risk of persistent foot and ankle fractures. These are: smoking diabetes obesity previous falls and/or fractures very high or low levels of physical activity and low bone density (BMD). For seniors over 50 Other risk factors include female sex comorbidity and polypharmacy.
Younger males have higher activity levels, especially with regard to risk-taking and sports activities, which may explain the higher incidence of ankle and foot fractures in this age group [7]. Young women under age 50, while less active than men, are more likely to fall later in life, suggesting Occurs with postmenopausal bone loss; this can lead to an increased risk of fractures. [7]
Characteristics/Clinical Presentation
- Difficulty or inability to walk/weight-bearing ankles (can walk in less severe cases so relying on walking to test for broken bones is unreliable)
- Pain
- Swelling
- Bruising (soon after the injury)
- Difference in appearance
- Observable differences compared to the unaffected side
When the ankle is fractured, there is not only structural damage to the bone structure, but also damage to the ligaments (deltoid and anterior-posterior tibiofibular ligaments) and the nerve and musculoskeletal tissues surrounding the ankle complex. This may cause a loss of balance Reduced sense of joint position slows nerve conduction velocity impairs skin sensation and reduces back extension range of motion. [6]
Fracture Classifications
Ankle fractures can be classified according to the AO/OTA Danis-Weber or Lauge-Hansen classification systems.
The Lauge-Hansen classification is based on the rotational mechanism of the lesion. The table below details the 4 categories and 13 subgroups of ankle fractures.
Category stage (subgroup) supination external rotation (SER) 1. 2. Injury to the anterior inferior tibiofibular ligament. Oblique/spiral fracture of distal fibula3. Posterior tibiofibular ligament injury or posterior ankle avulsion4. Medial malleolus fracture or injury To the deltoid ligament supination and adduction (SA)1. Transverse fracture of distal fibula 2. Pronation and external rotation of the medial malleolus vertical fracture (PER) 1. Medial malleolus fracture or deltoid ligament injury2. Injury to the anterior inferior tibiofibular ligament 3 . Oblique/spiral fracture of the fibula proximal to the tibial plateau4. Posterior tibiofibular ligament injury or posterior ankle avulsion Pronation and abduction (PA)1. Medial malleolus fracture or deltoid ligament injury2. Inferior Tibialis Injury ligament3. Transverse or comminuted fracture of proximal fibula of tibial plateau
The Danis-Weber classification is based on radiographic criteria. It takes into account the location of the distal fibular fracture in relation to the syndesmosis of the ankle. Three categories are created:
- Type A fractures: below the level of the tibial plateau (syndesmosis), may be associated with an oblique or vertical medial malleolus fracture
- Type B fractures: at the level of the tibial plateau (syndesmosis) and extend proximally in an oblique fashion
- Type C fractures: Near the level of the tibial plateau, usually with syndesmosis injury. It may be associated with a fracture of the medial malleolus or an injury to the deltoid ligament. [5] [8]
The AO classification/OTA system classifies all long bone fractures using a systematic approach based on site topography and extent of bone injury. It is based on radiographic standards and incorporates damage mechanisms. Fractures are classified as subligamentous ligament fractures and Syndesmosis has further subcategories based on the presence or absence of medial or posterior ankle injury.
The AO and Lauge-Hansen classification systems are widely used in the clinical diagnosis of ankle injuries. The AO classification system is simple and easy to understand, emphasizing the coordination of the fibula and ankle ligamentous syndesmosis. The Lauge-Hansen classification system emphasizes The different stages of pathological injury adhere to the knowledge of the injury of the ankle ligament system in addition to the fracture pattern. It can provide a broad assessment of ankle injuries.
Compared with the Lauge-Hansen classification, the AO classification system is more reliable and reproducible and therefore more valuable in clinical practice. Nonetheless, the Lauge-Hansen classification system remains the basis for understanding the mechanism of ankle fractures. [9]
The table below compares the Danis-Weber Lauge-Hansen and AO/OTA classification systems.
Fibular Fracture Location Danis-Weber Classification Lauge-Hansen Classification SAD I IIAO/OTA Classification Subtibial Syndesmosis Type ASAD I II 44-A1 (isolated lateral) 44-A2 (lateral and medial) 44-A3 (lateral and medial) 44-A3 (lateral and medial) Posterior) Transsyndesmotic type BSER I II III IV44 -B1 (isolated lateral) 44-B2 (lateral and medial) 44-B3 (lateral medial and Volkmann fracture) syndesmotic CPER I II III IVPA I II III 44-C1 (simple diaphysis) 44-C2 (multiple fractures) 44-C3 ( proximal)
OTA = Orthopedic Trauma Association; SAD = supination adduction; SER = external rotation external; PER = internal rotation external; PA = pronation abduction. [8]
Differential Diagnosis
- Rheumatoid Arthritis
- Gout and Pseudogout
- Ankle Dislocation
- Ankle Impingement
- Compartment Syndrome of the Foot
- Deep Venous Thrombosis
- Peroneal Tendinopathy
- Sinus Tarsi Syndrome
- Ankle ligament sprains
Some subtle ankle fractures may present clinically similar to ankle sprains. This similarity makes ankle fractures often mistaken for ankle sprains. These injuries are very different and require accurate and early diagnosis. [10]
Diagnostic Procedures
Ottawa rules
Ankle x-rays are only needed if there is any pain in the ankle area and any of the following:
- Bone tenderness along the posterior tibial border or 6 cm distal to the tip of the medial malleolus or
- Bone tenderness along the posterior border of the fibula or 6 cm distal to the tip of the lateral malleolus or
- Unable to bear weight for four steps immediately and in the emergency room.
Additionally, the Ottawa Ankle Rules indicate whether a foot x-ray is required. It states that it is indicated if there is any pain in the midfoot area and any of the following:
- bony tenderness at the base of the fifth metatarsal (foot injury) or
- Bone tenderness at the navicular (foot injury) or
- Unable to bear weight for four steps immediately and in the emergency room.
Ankle fractures are evaluated initially with a physical examination and then with x-rays. [5]
To reduce the use of X-rays, infrasound equipment can be used to detect ankle fractures, although it cannot be relied on alone due to sensitivities of 85% and 52%. [11]
Ultrasound has good sensitivity and specificity for diagnosing lateral and medial malleolus fractures of the fifth metatarsal in patients with foot and/or ankle sprains. However, ultrasound has low sensitivity and specificity for scaphoid fractures. [8]
Imaging
Outcomes Measures
- The SF-36 includes 8 categories: Physical Functioning Physical Functioning Physical Pain General Health Vitality Social Functioning Emotional Functioning and Mental Health)[12]
- The Kerr-Atkins scale for pain and function after calcaneal fractures reaches an optimal score of 100. [6]
- EuroQol (EQ-5D) measures quality of life and general health status[6]
- The American Foot and Ankle Orthopedic Association score is based on 9 items: pain, limitation of motion and function, difficulty walking distance on various terrains, gait abnormalities, sagittal range of motion, ankle range of motion, and subtalar joint range of motion stability and alignment [13]
- The Olerud-Molander Ankle Scale (OMAS) is an ordinal rating scale from 0 (completely impaired function) to 100 (completely unimpaired function) involving 9 different items with different scores: Pain, stiffness, swelling, climbing stairs, running, jumping, squatting, bracing, and work/activity Level. [14]
- The FAOS is also a self-administered patient questionnaire consisting of 42 items divided into five subscales: Pain, Other Symptoms, Functions of Daily Living (ADL), Sports and Recreational Functions, and Foot and Ankle-Related Quality of Life. [14]
- The Global Self-Rating Ankle (GSRF) assessed their current ankle function[14]
- The American Orthopedic Foot and Ankle Society Hindfoot Scale (AOFAS) score has 3 components: pain (40 points) function and alignment on a scale of 0-100 with 100 being the best score[7]
- The Foot Function Index (FFI) consists of 23 questions that measure the impact of foot pathology on functions such as pain disability and limited mobility. The lower the score, the better the result [7]
Medical Management
Most patients with ankle fractures require immobilization for 6 weeks. Patients with initially nondisplaced fractures or who have undergone surgery typically require 4 weeks of non-weight bearing in a short leg cast or removable walking boot, followed by 2 weeks in a walking cast or guide. A removable boot will allow for earlier range-of-motion exercises.
Many types of ankle fractures require surgery. While surgery isn’t always necessary for ankle fractures, it’s not uncommon. Whether surgery is needed depends on how the ankle looks on x-rays and the type of ankle fracture.
The goal of surgery is to achieve smooth anatomical reconstruction of the articular surface and protection of the damaged ligament structure, so as to achieve early functional treatment of the joint. Adequate reduction of joint consistency is reported to be one of the most effective Great indicator of a good end result. Inadequate reduction may lead to osteoarthritis.
The timing of definitive surgical treatment depends primarily on soft tissue findings and is only possible if the soft tissue is not extremely fragile (hours after trauma). Whether surgery is needed depends on how the ankle looks on x-rays and the type of ankle fracture.
While ankle fracture surgery is not always required, it can be accomplished using 3 metal plates and multiple screws: one-third tubular plate; locking compression (LCP) metaphyseal plate for lateral malleolus and Weber B fractures; LCP Distal Fibula Plate Weber A Fracture and Weber B fracture.[5][15]
Plate Types – Left to Right: Conventional One-Third Tube Plate; LCP Metaphyseal Plate; LCP Distal Fibula Plate
Physical Therapy Management
Fractures with stable and nondisplaced or only slightly displaced fragments can be treated conservatively. Type A fractures do not need to be immobilized in a cast, but can be treated in a stable ankle orthosis like an external ligament rupture for early function and pain adaptation Full Weight [5]
Passive joint mobilization
More severe fractures require immobilization and a rehabilitation program after the cast is removed. Plans should be patient-centered and take into account the patient’s goals and wishes. Programs often include exercise weights and balance exercises to enhance ankle mobility. Physiotherapists should empower patients to perform home exercises and provide education and advice. [6]
Patients often complain of difficulty with activities involving the lower extremities, such as stair climbing and reduced participation in work and recreational activities. Injury may be pain, swelling, stiffness, muscle atrophy, and decreased muscle torque [9] Impaired ankle mobility, impaired balance Ankle volume and ankle girth [6] increase after removal of plaster cast.
Passive joint mobilization can be used to address pain and joint stiffness to allow for an early return to mobility. For this technique, a physical therapist manually slides the articular surfaces of the joint to create an oscillatory motion [16]. Manual techniques should be Complementary to programs that include active exercise.
Strength training may be beneficial after a fracture and should be considered an important rehabilitation option with physical therapy. Because loss of strength is one of the most common complications of a foot or ankle fracture. [17]
Home exercise program
Key Research
- Ankle fractures: investigation and treatment options. [5]
- Accuracy of the Ottawa ankle rule for excluding ankle and midfoot fractures: a systematic review. [18]
Resources
- Orthopedic Surgery UCSF. Ankle physical examination. http://orthosurg.ucsf.edu/oti/patient-care/divisions/sports-medicine/physical-examination-info/ankle-physical-examination/ (accessed 24 August 2014).
References
- ↑ Kannus P, Palvanen M, Niemi S, Parkkari J, Jrvinen M. Increasing number and incidence of low-trauma ankle fractures in elderly people: Finnish statistics during 1970–2000 and projections for the future. Bone. 2002 Sep 1;31(3):430-3.
- ↑ Jump up to:2.0 2.1 Tidy N, Porter S. Tidy’s physiotherapy. 13th ed. Edinburgh: Elsevier; 2013.
- ↑ Edwards WB, Taylor D, Rudolphi TJ, Gillette JC, Derrick TR. Effects of running speed on a probabilistic stress fracture model. Clinical Biomechanics. 2010 May 1;25(4):372-7.
- ↑ Jump up to:4.0 4.1 4.2 Maffulli N, Longo UG, Denaro V. Femoral Neck Stress Fractures. Operative Techniques in Sports Medicine. 2009;17:90-93.
- ↑ Jump up to:5.0 5.1 5.2 5.3 5.4 5.5 Goost H, Wimmer MD, Barg A, Kabir K, Valderrabano V, Burger C. Fractures of the ankle joint: investigation and treatment options. Deutsches Ärzteblatt International. 2014 May;111(21):377.
- ↑ Jump up to:6.0 6.1 6.2 6.3 6.4 6.5 Daly PJ, Fitzgerald RH, Melton LJ, Llstrup DM. Epidemiology of ankle fractures in Rochester, Minnesota. Acta Orthopaedica Scandinavica. 1987 Jan 1;58(5):539-44.
- ↑ Jump up to:7.0 7.1 7.2 7.3 Holloway KL et al. Foot and Ankle Fracture Incidence in South-Eastern Australia: An Epidemiological Study. Clin Res Foot Ankle 2014, 2:4
- ↑ Jump up to:8.0 8.1 8.2 Tartaglione JP, Rosenbaum AJ, Abousayed M, DiPreta JA. Classifications in brief: Lauge-Hansen classification of ankle fractures.
- ↑ Jump up to:9.0 9.1 Yin MC, Yuan XF, Ma JM, Xia Y, Wang T, Xu XL, Yan YJ, Xu JH, Ye J, Tong ZY, Feng YQ. Evaluating the reliability and reproducibility of the AO and Lauge-Hansen classification systems for ankle injuries. Orthopedics. 2015 Jul 1;38(7):e626-30.
- ↑ Judd D, Kim D. Foot Fractures That Are Frequently Misdiagnosed As Ankle Sprains. American family physician. 2002 Sep 1;66(5):785.
- ↑ Dancocks A, Rouse A, Hiscox J. A pilot study to assess the sensitivity and specificity of an intrasound device in the diagnosis of ankle fractures. Emergency Medicine Journal. 1997 Jul 1;14(4):230-2.
- ↑ Westphal T, Piatek S, Halm JP, Schubert S, Winckler S. Outcome of surgically treated intraarticular calcaneus fractures—SF-36 compared with AOFAS and MFS. Acta orthopaedica Scandinavica. 2004 Jan 1;75(6):750-5.
- ↑ Schie-Van der Weert V, Van Lieshout EM, De Vries MR, Van der Elst M, Schepers T. Determinants of outcome in operatively and non-operatively treated Weber-B ankle fractures. Archives of orthopaedic and trauma surgery. 2012 Feb;132(2):257-63.
- ↑ Jump up to:14.0 14.1 14.2 Nilsson GM, Eneroth M, Ekdahl CS. The Swedish version of OMAS is a reliable and valid outcome measure for patients with ankle fractures. BMC musculoskeletal disorders. 2013 Dec;14(1):1-8.
- ↑ Huang Z, Liu L, Tu C, Zhang H, Fang Y, Yang T, Pei F. Comparison of three plate system for lateral malleolar fixation. BMC Musculoskeletal Disorders. 2014 Dec;15(1):1-9.
- ↑ Lin CC, Moseley AM, Refshauge KM, Haas M, Herbert RD. Effectiveness of joint mobilisation after cast immobilisation for ankle fracture: a protocol for a randomised controlled trial [ACTRN012605000143628]. BMC Musculoskeletal Disorders. 2006 Dec;7(1):1-0.
- ↑ Murdoch A, Taylor N, Dodd K. Physical therapists should consider including strength training as part of fracture rehabilitation. Physical therapy reviews. 2004 Mar 1;9(1):51-9.
- ↑ Bachmann LM, Kolb E, Koller MT, Steurer J, ter Riet G. Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review. Bmj. 2003 Feb 22;326(7386):417.
