EASILY MISSED FOOT AND ANKLE FRACTURES NORDIC TRAUMA COURSE 2016, AARHUS
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1 EASILY MISSED FOOT AND ANKLE FRACTURES NORDIC TRAUMA COURSE 2016, AARHUS Ken F. Linnau, MD, MS Emergency Radiology Harborview Medical Center University of Washington Seattle, WA
2 Thanks to Claire K Sandstrom Harborview Medical Center Seattle, WA
3 How many of these radiographs are normal?
4 Metatarsal stress fractures Metatarsals are most common site of stress fracture Occur with activity done in excess: hiking, running, marching May occur after foot surgery Often not evident on initial radiographs
5 Metatarsal stress fractures: options Re-image with radiographs in 7-10 days: cheap Bone scan: sensitive MRI: fancy, not cheap, sensitive
6 45 YOF W FOOT PAIN AFTER RUNNING Sag T1 Ax T1 Sag STIR Ax T2 FS
7 34 yom calcaneus fx pinned 2 wks ago, continued pain
8 Stress fractures in the foot: Any bone except phalanges. Metatarsal (2 nd and 3 rd ): fluffy periosteal reaction. Calcaneus: narrow bands of tuberosity. Talus: notoriously missed: consider MRI. Navicular: fracture is typically sagittal in orientation: External oblique view or CT or MRI.
9 22 yo bicyclist who crashed How many fractures do you see?
10 22 yo bicyclist who crashed
11 22 yo bicyclist who crashed
12 The same bicyclist 10 days later
13 The same bicyclist 10 months later
14 Tarso-metatarsal (TMT) fracture - dislocation (Lisfranc) Due to forced plantar flexion, twist or crush. Transverse metatarsal ligaments II V. Skip MT I-II (arrow). Oblique Lisfranc ligament (yellow). Base of MT II locked in mortise between medial and lateral cuneiform
15 25 yof car vs. bulldozer Lisfranc fracture-dislocation: Unique osseous and ligamentous anatomy Predisposition for MT I- II separation More disruption with high-energy Divergent Homolateral Radiographic clues
16 22 yof jumped from 9ft Click to add text Stress views!
17 Every year in July..
18 22 yof jumped from 9ft Stress views: Warranted if tender or swollen Early diagnosis improves outcomes of Lisfranc fx Ankle block or anesthetic Forefoot abduction with fulcrum at calcaneo-cuboid joint Operative indication if TMT joint displacement > 2 mm
19 22 yof jumped from 9ft
20 45 yof fall from standing height Lisfranc injury? No Lisfranc on CT! Click to add text
21 Metadiaphyseal fracture of the 5 th MT (Jones) cm from base of MT V Extra-articular Propensity for non-union Distinguish from avulsion Os vesalianum Sesamoid of peroneus tendon Common in running athletes Inversion or stress-related
22 46 yo man persistent pain 6 weeks after fall What o clock is the important abnormality?
23
24 46 yom, ankle pain 6 weeks post fall
25 46 yom, ankle pain 6 weeks post fall
26 46 yom, ankle pain, post op
27 Lateral process of the talus Always inspect carefully, if swelling inferior to lat. malleolus Fractures usually only seen on AP view Contains the lateral portion of posterior facet If untreated: premature subtalar osteoarthritis Snowboarder fracture
28 24 yom, basketball injury
29 Weber C Fibula Fx High Fibula Fx 6 cm above malleolus tip Weber B Low Fibula Fx at or below tibial plafond Weber A Post mal Fx Spiral (Low ant/high post) Oblique (Low med/high lat) Transverse Pron-Ext Rotation Stage IV Med mal Fx or deltoid lig tear NO med mal fx or deltoid lig tear Pron- Abduction Stage III Med mal Fx (vertical) NO med mal Fx NO post mal Fx Sup-Ext Rotation Stage IV Post mal Fx Sup-Adduction Stage II Sup-Adduction Stage I Pron-Ext Rotation Stage III Sup-Ext Rotation Stage III NO post mal Fx Sup-Ext Rotation Stage II Modified from Arimoto HK and Forrester DM. Classification of Ankle Fractures: An Algorithm. AJR 135: (1980)
30 Joseph Yu s checklist for low-energy ankle trauma: Medial malleolus (1) Lateral malleolus (2) Anterior tibial tubercle (3) Posterior tibial malleolus (4) Talar dome (5) Lateral talar process (6) Posterior talar process (7) Dorsal to talonavicular joint (8) Anterior calcaneus process (9) Calcaneal insertion of ext dig brev (10) Base of 5 th MT (11) Emergency Radiology (2009) 16:
31 24 yof rock climber: fall Click to add text Which side is abnormal?
32 24 yof rock climber: fall Click to add text
33 Joseph Yu s checklist for low-energy ankle trauma: Medial malleolus (1) Lateral malleolus (2) Anterior tibial tubercle (3) Posterior tibial malleolus (4) Talar dome (5) Lateral talar process (6) Posterior talar process (7) Dorsal to talonavicular joint (8) Anterior calcaneus process (9) Calcaneal insertion of ext dig brev (10) Base of 5 th MT (11) Emergency Radiology (2009) 16:
34 24 yof rock climber: fall
35 Osteochondral defects: Talar dome (5) Most common talus fracture ¼ lateral, ¾ medial MRI can be helpful to assess stage of injury
36 24 yof rock climber: fall
37 Posterior process of the talus (7): Medial and lateral tubercles form groove for flexor hallucis tendon. Injury presents with posteromedial pain. Os trigonum = unfused lat tubercle. Completely corticated Synchondrosis anteriorly Differentiating os from fracture: CT, MR.
38 27 yof rolled her ankle How many fractures do you see?
39 27 yof rolled her ankle
40 Anterior process of the calcaneus (9): Insertion of the bifurcate ligament Stabilizer of plantar and dorsal flexion. Avulsion fractures uncommon Often initially missed. Oblique views, CT, MR may help. DDX: os calcaneus secundarius
41 Joseph Yu s checklist for low-energy ankle trauma: Medial malleolus (1) Lateral malleolus (2) Anterior tibial tubercle (3) Posterior tibial malleolus (4) Talar dome (5) Lateral talar process (6) Posterior talar process (7) Dorsal to talonavicular joint (8) Anterior calcaneus process (9) Calcaneal insertion of ext dig brev (10) Base of 5 th MT (11) Emergency Radiology (2009) 16:
42 Summary: Stress fractures are often initially radiographically inapparent Lisfranc fracture dislocations can be subtle, but require surgery Talar fractures: lateral process fractures are often subtle, scrutinize the AP view. Joe s ankle check list: try it, you may like it.
43 Selected references: 1. Digiovanni CW, Benirschke SK, Hansen ST. Foot Injuries. In: Browner BD, Jupiter JB, Levine AM, editors. Skeletal Trauma: WB Saunders; p Nathan R, Ingraham C. Lower Extremity Trauma. In: Bittle MM, Gunn ML, Gross JA, Stern EJ, editors. Trauma Radiology Companion. 2nd ed: Lippincott Williams & Wilkins; p Rogers LF. The Foot. Radiology of Skeletal Trauma: Churchill Livingston; p Yu JS, Cody ME. A template approach for detecting fractures in adults sustaining low-energy ankle trauma. Emerg Radiol. 2009;16(4): Epub 2009/02/19. klinnau@uw.edu
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