If there is a small avulsion fracture off the tip of the fibula, these can often be treated by weightbearing cast immobilization followed by Cam Walker and physical therapy. When the diagnosis is unclear and clinical suspicion is present, an MRI or CT will clearly demonstrate this fracture.16, Nondisplaced or minimally displaced fractures can be treated with a non-weight-bearing, short leg cast for four to six weeks.9,15 After this period of immobilization, weight bearing is allowed as tolerated. The other two are the lateral and the posterior malleolus. [1] Fractures of the foot are less common. This page will discuss ankle and foot fractures and the role that physiotherapists play in the rehabilitation of such injuries. Reddit and its partners use cookies and similar technologies to provide you with a better experience. Case 1 - Avulsion Fracture of the Superior Peroneal Retinaculum. Frontal. Anterior process fractures result . Then a Cam Walker and physical therapy is initiated. Age: 32 Sex: male Height: 511 Weight: 160lbs Race: cacausian Duration of complaint: 1 week Location: ankle (lateral malleolus) Any existing relevant medical issues: no Current medications: None. Avulsion fractures are breaks or splits in the bone. Posterior talar process fractures are often associated with tenderness to deep palpation anterior to the Achilles tendon over the posterolateral talus, and plantar flexion may exacerbate the pain. Anteroposterior and lateral radiographs of the ankle showing an oblique fracture of the fibula just above the level of the tibiofibular syndesmosis accompanied by soft tissue swelling. As the clinical scenario dictates, a CT scan or MRI may be necessary.9,21,23 In addition, an accessory ossicle (calcaneus secondarium) maybe located near the anterior process and could be misinterpreted as a fracture.21,24, For small, nondisplaced fractures, early immobilization in a nonweight-bearing, short leg cast or compressive dressing for four to six weeks followed by range-of-motion exercises and a gradual return to weight bearing has been successful.21,23, Although fracture healing may appear radiographically to be complete, approximately 25 percent of patients require more than a year before becoming asymptomatic.21 Following nonsurgical management, most patients report satisfactory results and a return to preinjury activity levels.21,23,24 Symptomatic nonunions or large, displaced fractures may require surgical intervention.21,24. A broken ankle is also known as an ankle fracture. These fractures can often be managed nonsurgically with nonweight-bearing status and a short leg cast worn for approximately four weeks. The lateral malleolus is at the end of the fibula, a smaller bone in the leg. The pain is often reproduced with plantar flexion and occasionally accentuated with dorsiflexion of the great toe. The pain is often exacerbated by activities requiring plantar flexion.15 Physical examination findings in lateral tubercle fractures of the posterior process are highly consistent for tenderness to deep palpation anterior to the Achilles tendon over the posterior talus. Soft tissue swelling over the lateral malleolus. Usually, 4-8 weeks nonweightbearing followed by protected weightbearing with a cast. Computed tomographic scans or magnetic resonance imaging may be required because these fractures are difficult to detect on plain films. See permissionsforcopyrightquestions and/or permission requests. 65 year old man, had a fall 2 weeks ago. This occurs as tendons can bear more load than the bone. Pain with plantar flexion, dorsiflexion, and subtalar joint movement is generally present.7 Although the normal anatomy of the ankle may be obscured by soft tissue swelling, a helpful diagnostic indicator is point tenderness over the lateral process. Avulsion fractures can occur on any part of the body, but they are most common in the ankles, hips, and elbows. Often a fracture of the lateral malleolus occurs in combination with a sprained ankle or other fractures of the foot, ankle or lower leg (such as following trauma). However, as with all guidelines, clinical judgment and experience may be grounds for radiographic analysis in unique cases. Introduction:Traumatic rupture of posterior tibialis tendon in association with medial malleolus fracture is extremely rare.Case Presentation:We demonstrate our experience in the management of a co. Thin bony fragments adjacent to the lateral aspect of tip of the lateral malleolus and cortical irregularity at the lateral talus, likely representing avulsion fractures. Diagnosis of talar dome lesions can often be made with standard anteroposterior (AP), lateral, and mortise ankle radiographs. He said I would be "good to go" in 4-6 weeks. Point your toes down as far as they go, then use the other foot on top to apply some pressure to create a stretch on the top of your foot. Unable to process the form. One of the first stages in this injury is rupture of the anterior tibiofibular ligament (or anterior syndesmosis). An avulsion fracture is where a fragment of bone is pulled away at the ligamentous or tendinous attachment. Inversion plantar flexion can cause avulsion fractures of the anterior process. 1. Inversion with plantar flexion can lead to an avulsion fracture. It can be caused by traumatic traction (repetitive long-term or a single high impact traumatic traction) of the ligament or tendon. 84th Avenue, Suite 102, Plantation FL, 33324, (954) 430-9901 - Pembroke Pines-Silver Lakes, Foot, Ankle, & Leg Specialists Insurance Accepted, ACUTE AND CHRONIC CARE OF MUSCULOSKELETAL INJURIES JOINT SURGERY, SOFT TISSUE INJURIES (TENDON, LIGAMENT, MUSCLE). By rejecting non-essential cookies, Reddit may still use certain cookies to ensure the proper functionality of our platform. This guy twisted his ankle. Fractures of the talar dome are generally the result of inversion injuries of the ankle. However, CT (Figure 8) or MRI may be necessary if the diagnosis is unclear.16,17, Medial tubercle fractures are treated in a manner similar to that for lateral tubercle fractures.17,18,20, The anterior process of the calcaneus is a saddle-shaped bony protuberance that articulates with the cuboid. Most common ankle fractures. Lateral process fractures are the second most common talar fractures. Tenderness anterior to the lateral malleolus, along the anterior border of the talus, Mortise view: shallow, wafer-shaped lesion, Inversion with plantar flexion or atraumatic, Tenderness posterior to the medial malleolus, along the posterior border of the talus. The fracture may then be diagnosed and treated soon enough after the injury to avoid an adverse prognosis. SURGICAL CARE: If unstable, and/or displaced, these fractures need to be brought to the OR to have open reduction and internal fixation (ORIF). Although the etiology in atraumatic lesions is unclear, osteochondral fragments can separate from the surrounding cartilage surface and dissect into the joint space. Typically, the secondary center of ossification of the lateral malleolus appears during the first year of life and fuses with the shaft at 15 years. Skinner H. Current Diagnosis & Treatment in Orthopedics, Fourth Edition. The patient usually has a history of a rapid inversion and dorsiflexion injury.79 Fractures of the lateral process range from avulsion fractures of the capsular ligaments to intra-articular injuries involving the ankle and subtalar joints.9, Physical examination findings are similar to those in lateral ankle ligamentous injuries. However, the clinical presentation of subtle fractures can be similar to that of ankle sprains, and these fractures are frequently missed on initial examination. Lateral lesions are best visualized on a mortise view and are generally thin and wafer-shaped.1,4 (Figure 4). 2. A fractured ankle can range from: A simple break in one bone, which may not stop you from walking, to. Pre and Postop Fibula Fracture ORIF (Below), Plate and Screws are placed as well as a syndesmotic screw after reductionto give stability due to theligamentous injury. Isolated nondisplaced lateral malleolar fractures have a low risk of complications and have good clinical results regardless of treatment. Typical findings include crepitance, stiffness, and recurrent swelling with activity.5. It is very difficult to tell the difference without an X-ray or MRI scan. -If I were to have surgery, is there a time window that I should have it done post accident to guarantee it heals correctly. 17842 NW 2nd St., Pembroke Pines, FL 33029 (954) 430-9901 Then, you can gradually progress to putting weight on the ankle again. Post-surgical repair with open reduction of the fracture with internal fixation involving screws and plate (right) allow re-alignment of the fracture fragments will allow the bones to heal correctly and in a timely fashion. Ice application: Apply ice to help reduce pain and swelling. Overall, optimal results are achieved with early diagnosis and treatment of these fractures. Ankle Fractures are very common fractures in the pediatric population that are usually caused by direct trauma or a twisting injury. There are two parts involved in the treatment of a stable lateral malleolus fracture. In the acute setting, the symptoms of a talar dome fracture are similar to and often occur with an ankle sprain.3,5, In lateral talar dome lesions, tenderness is generally found anterior to the lateral malle-oli, along the anterior lateral border of the talus.3,6 In medial talar dome lesions, tenderness is usually located posterior to the medial malleolus, along the posterior medial border of the talar dome.3,6 Chronic talar dome lesionstraumatic and atraumatic osteo-chondritis dissecans lesionsmay have a clinical presentation similar to that of arthritis. However, intra-articular fractures require special attention to ensure that the articular surface is restored to anatomic congruity and that the correct mechanical alignment is maintained. An avulsion fracture, also known as a sprain fracture, is a detachment of bone fragment that occurs when a ligament, tendon or joint capsule pulls away from its point of attachment. As these osteochondral fragments (often referred to as osteochondritis dissecans lesions) become loose in the joint, they can cause pain, locking, crepitance, and swelling.1,4,5, Clinical diagnosis of talar dome fractures can be highly challenging because there are no pathognomonic signs or symptoms.5 The patient may have sustained a fall or a twisting injury to the ankle and may generally ambulate with an antalgic gait. Incidental note of os subfibulare and os trigonum. Anyone can suffer an avulsion fracture of the ankle, but athletes and children are more prone to them than the rest of us. 8,9 Small nondisplaced avulsion fractures of the tip of the lateral malleolus (Figure 13-4) are best treated with early mobilization similar to . Less frequently it leads to an avulsion of the anterolateral tibial epiphysis. Now, the ankle joint is anatomic and symmetrical. A posterior subtalar effusion seen on the lateral view is highly suggestive of an occult lateral process fracture.13 A CT scan can clearly show this injury and may be required to confirm a suspected fracture.11, A nonweight-bearing, short leg cast can be used if anatomic position with less than 2 mm displacement can be maintained.7,11 A nonweight-bearing cast should be maintained for four to six weeks, followed by two weeks in a walking cast and initiation of rehabilitation exercises.7 For large and displaced fragments, the treatment of choice is usually surgical reduction and fixation.7,8, The posterior process of the talus is composed of two tubercles, the lateral and medial (Figures 1 and 2). April 21 - Visit ER. Difficult with standard views; an oblique ankle radiograph taken with the foot placed in 40 degrees of external rotation has been successful. An unfused accessory ossification center. 1600 Town Center Blvd, Weston FL, 33326 (954) 389-5900 This condition is known as a lateral malleolus fracture. Displaced filbular fracture with ankle dislocation. Lateral malleolus fracture: This is the most common type of ankle fracture. X-ray showed a small loose body at the tip of lateral malleolus. The x-ray image below is that of a non-displaced lateral malleolar fracture that will heal well without surgery (RED ARROW). Tells me it is a small undisplaced fracture of lateral malleolus. Frontal. He c/o pain and swelling over his left ankle. Most avulsion fractures heal very well without surgical intervention. They can be distal, at or proximal to the joint line of the ankle. Ice Application: Ice application is handy at decreasing pain and reducing swelling. The medial malleolus is the largest of the three bone segments that form your ankle. Etiology. Frontal. Delays in treatment can result in long-term disability and surgery. All Rights Reserved. Age: 32 Sex: male Height: 5'11" Weight: 160lbs Race: cacausian Duration of complaint: 1 week Location: ankle (lateral malleolus) Any existing relevant medical issues: no Current medications: None. Medial malleolus-distal end of tibia that forms the medial ankle bone.Hallux-meaning 'big toe', digit 1.Foot and ankle bones Tibia-medial malleolus Fibula-lateral malleolus Tarsals Talus Calcaneus Cuboid Cuneiforms (medial, middle, lateral) Navicular . Fractures of the anterior process account for approximately 15 percent of all calcaneal fractures and are commonly misdiagnosed as ankle sprains.6,21,23,24, Anterior process fractures result from avulsion or compression. A CT scan may be required to further characterize the fracture pattern and for surgical planning. Ankle Fractures - Pediatric. He c/o pain and swelling over his left ankle. Elevation: Elevation is important to keep swelling restricted. Can it cause issues like abrasion to surrounding areas? Put a towel/bandage around your foot and pull it towards you. Usually, a plate and screws is utilized. DANIEL B. JUDD, M.D., AND DAVID H. KIM, M.D. The patient has an ORIF Fibula fracture and a temporary screw (RED ARROWS)placed across the syndesmosis for 12-16 weeks and then permanently implanted an Arthrex Tightrope (GREEN ARROWS)to maintain stability but allow physiologic motion. Usually, 4-8 weeks nonweightbearing followed by protected weightbearing with a cast. Foot/ ankle and lower leg bone and ligaments terminology Lateral malleolus-distal end of fibula that forms the lateral ankle bone. Check for errors and try again. The patient must be either immobolized and kept non-weightbearing in a cast depending on various factors including age of patient and pain level. This is consistent with an avulsion fracture involving the superior peroneal retinaculum. 3. Stress placed on the bone by a tendon or ligament causes the fracture. Alignment has been maintained. Hold both stretches for up to 30 seconds and repeat 3 times. In a different patient, after conservative care,a patient with a healed high fibular fracture with fracture callus surrounding the fracture site is seen on the X ray (GREEN ARROW). When treatment is delayed, patients tend to have a more complex clinical course. If symptoms persist, an additional four to six weeks of immobilization would be recommended.6 If the fracture site continues to be symptomatic after six months, fragment excision is usually curative.6,9 Larger and more displaced fractures may require open reduction internal fixation.6,16. By accepting all cookies, you agree to our use of cookies to deliver and maintain our services and site, improve the quality of Reddit, personalize Reddit content and advertising, and measure the effectiveness of advertising. Case study, Radiopaedia.org (Accessed on 11 Dec 2022) https://doi.org/10.53347/rID-21949. Multiple loose bodies are seen just below medial malleolus. There are two theories regarding the origin of os subfibulare 2: An avulsion fracture attributable to pull of the anterior talofibular ligament. The lateral talar process is an osseous protuberance that articulates superolaterally with the fibula, helping to stabilize the ankle mortise, and inferomedially with the calcaneus, forming the lateral portion of the subtalar joint7 (Figures 1 and 2). report an incidence of up to 174 cases per 100 000 persons per year in a Finish population. -Should this be surgically re-attached? Alignment has been maintained. However, the clinical presentation of some subtle fractures can be similar to that of routine ankle sprains, and they are commonly misdiagnosed as such. However, repeated radiographs may be necessary because initial films may appear normal. April 20 rolled ankle. 84th Avenue, Suite 102, Plantation FL, 33324 (954) 720-1530, fter conservative care,a patient with a healed high fibular fracture with fracture callus surrounding the fracture site is seen on the X ray, shows the increased clear space which is abnormal and exemplifies a syndesmosis tear, 1600 Town Center Blvd Ste C Weston, FL 33326-3635, 17842 NW 2nd St Pembroke Pines, FL 33029-2806, 220 S.W. Treatment of an avulsion fracture typically includes resting and icing the affected area. Preop and Postop Fibula Fracture ORIF with Syndesmotic Rupture. CONSERVATIVE CARE: If non-displaced and stable, these fractures can be treated non-operatively with cast immobilization. Ankle views showed grossly swollen soft tissue over lateral malleolus. Ankle injuries are commonly evaluated by primary care and emergency physicians. LATERAL MALLEOLAR FRACTURES. Fractures of the lateral tubercle can be caused by hyperplantar flexion or inversion.1,2,15 Hyperplantar flexion injuries tend to cause compression fractures, while inversion injuries tend to produce avulsion fractures.1,2,15 Both of these injuries have been described after falls and have been associated with football and rugby kicking injuries, which place the ankle in a forced plantar flexed position.19 If present, an os trigonum can be injured by the same mechanisms described above.2,19, Clinically, patients with a fracture of the lateral tubercle present with pain and swelling in the posterolateral area of the ankle. C/o pain left ankle since then. Info: I've been told that the bone is likely to not re-attach itself naturally due to the distance, but . This young boy allegedly twisted his left ankle 3 days ago. Syndesmosis or medial malleolar injury not evident in this patient. Fractures of the anterior process account for approximately 15 percent of all calcaneal fractures and are commonly misdiagnosed as ankle sprains. (OBQ20.15) Figure A is the radiograph of a 55-year-old female who is a poorly-controlled diabetic with neuropathy and peripheral vascular disease (PVD) that underwent ankle open reduction internal fixation (ORIF) two years ago at an outside facility. 2 weeks later follow up with family Dr. She tells me to have to x-rayed again . Symptoms of an ankle avulsion fracture are very similar to an ankle sprain. As the bone breaks, the part of the bone that is attached to the tendon or ligament pulls away from the rest of the bone. It is a break of the lateral malleolus, the knobby bump on the outside of the ankle (in the lower portion of the fibula). When the . When a medial malleolus fracture occurs by itself . 6, 21, 23, 24. Thecircleshows the increased clear space which is abnormal and exemplifies a syndesmosis tear. This article features subtle fractures to facilitate timely diagnosis and treatment of these less-common injuries. Furthermore, in the case of a suspected ankle sprain that does not improve as expected or is accompanied by tenderness over a potential fracture site, radiographic analysis at a follow-up evaluation may be indicated. Prospective studies have validated the effectiveness of these guidelines and shown the rules to be 100 percent sensitive for clinically significant fractures.25,26. Spondylosis Spondylolysis Spondylolisthesis. X-ray. This step optimizes the chance for a full recovery and decreases the incidence of post-traumatic arthritis and associated morbidities. It is attached to the cuboid by an interosseous ligament and to the cuboid and navicular bones by the strong bifurcate ligament21,22 (Figures 1 and 2). Isolated Nondisplaced Lateral Malleolar Fractures. Stage I, II, and III medial lesions can usually be treated nonsurgically with six weeks in a nonweight-bearing cast.1,3,5 Adequate reduction and immobilization are crucial for fracture healing and to avoid avascular necrosis of the fracture fragment.5, Patients with stage III lateral lesions, stage IV lesions, and persistent symptoms are generally treated surgically. Lateral. There is a small loose body (arrow) indicating an avulsion injury. The dome of the talus articulates with the tibia and fibula, and has a key role in ankle motion and in supporting the axial load during weight bearing14 (Figures 1 and 2). 220 S.W. Posterior process fractures can occur at either or both tubercles.1418 Lateral and medial tubercle fractures are discussed separately. Cookie Notice Fracture was repaired with plate and screws with a syndesomotic screw. Go get aircast, use crutches (NWB) and follow up with family Dr in 2 weeks. In Fracture Management for Primary Care (Third Edition), 2012. (2006) ISBN:0071438335. At first, the patient may think they have sprained their ankle with symptoms of immediate pain and swelling. CONSERVATIVE CARE: If non-displaced and stable,these fractures can be treated non-operatively with cast immobilization. Incidental note of os subfibulare and os trigonum. 84th Avenue, Suite 102 Plantation, FL 33324, 17842 NW 2nd St., Pembroke Pines, FL 33029, 220 S.W. Non-surgical and surgical options exist to treat medial malleolus fractures, but the choice often comes down to the extent of the fracture. This young boy allegedly twisted his left ankle 3 days ago. Fractures of the ankle joint are common amongst adults. Medial tubercle fractures are relatively rare.17,18 They were first described by Cedell,18 who presented four cases of medial tubercle fractures that had originally been treated as ankle sprains. Fibula Fracture ORIF with Syndesmotic and Deltoid Rupture. Thin bony fragments adjacent to the lateral aspect of tip of the lateral malleolus and cortical irregularity at the lateral talus, likely representing avulsion fractures. and our OVERVIEW: Lateral malleolar fractures are fractures that occur in the distal aspect of the fibula. Appropriate radiographs are essential to the diagnosis of these fractures but, in the work-up of an ankle injury, radiographs are not always required. Some recent reports79,12 implicate snowboarding accidents in these fractures. Elevation: Lie down and keep your ankle elevated above . Copyright 2002 by the American Academy of Family Physicians. This means that one or more of the bones that make up the ankle joint are broken. Ankle avulsion fracture opinions needed. In general, extra-articular fractures of the talus and calcaneus can be managed with nonsurgical treatment. The Ottawa ankle rules (Figure 1025 ) offer the physician clinical guidance as to which injuries require radiographs. A plate and screws is placed on the fibula after reduction and 2 Arthrex Tightrope is placed across the syndesmosistomaintain reduction. ADVERTISEMENT: Supporters see fewer/no ads. {"url":"/signup-modal-props.json?lang=us\u0026email="}, Benoudina S, Lateral malleolar fracture. This content is owned by the AAFP. In this case, the avulsion involves the peroneal retinaculum, which is a fibrous retaining band that binds down the tendons of the peroneus longus and brevis as they run across the side of the ankle. Generally, medial tubercle fractures are secondary to dorsiflexion, pronationtype injuries, because the medial tubercle is avulsed by the deltoid ligament.17,18, On clinical assessment, there may be only slight pain with ambulation and range-of-motion testing.6,18 Patients with medial tubercle fractures typically have swelling and pain posterior to the medial malleolus and anterior to the Achilles tendon.17,18,20, Visualization of the medial tubercle fracture on plain radiograph may be challenging, but the fracture can generally be seen on an oblique projection with the foot and ankle externally rotated 40 degrees and the beam centered 1 cm posterior and inferior to the medial malleolus16,17 (Figure 7). McGraw-Hill Medical. Percutaneous FIxation of Displaced Fibula Fracture in Diabetic Patient, South Florida Institute of Sports Medicine Treatment options fragment excision range from arthroscopy with or without subchondral bone drilling to open reduction internal fixation.4,5. Soft tissue swelling over the lateral malleolus. OVERVIEW: Lateral malleolar fractures are fractures that occur in the distal aspect of the fibula. Several fractures, which may require surgery. In acute injuries, this rough irregular surface may help distinguish a fracture from a normal os trigonum, which generally has a smooth, rounded cortical surface.15 In chronic cases, these differences may be less distinct, making the distinction between a fracture and a normal os trigonum difficult. Bimalleolar ankle fracture: This second-most common type involves breaks of both the lateral malleolus and of the . These are avulsion fractures of the medial ankle ligaments. This is consistent with an avulsion fracture involving the superior peroneal retinaculum. Dr. has x-ray completed. The findings are consistent with isolated lateral malleolar fracture. If suggested by the clinical scenario, fractures not visualized with plain radiographs may require magnetic resonance imaging (MRI) or computed tomography (CT).6 The fracture classification developed by Berndt and Harty is widely used to stage talar dome lesions (Table 3).5, An orthopedic surgeon should be consulted for treatment of talar dome lesions because of the high functional demands of for the talar dome and the potential for complications. Generally, the AP ankle view is best for visualizing deep, cup-shaped medial lesions,1,4 although the lesions are often appreciated on the mortise view as well (Figure 3). Lateral. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. Treatment of a stable lateral malleolus fracture need to include efforts to minimize swelling following by a gradual development in weight-bearing. She was noncompliant with her immediate postoperative weight-bearing instructions and went on to fixation failure. Fractures of the talar dome may be medial or lateral, and they are usually the result of inversion injuries, although medial injuries may be atraumatic. A fracture can be caused by a fall, a blow to the . A fracture is a break or crack in a bone that often results from an injury. A lateral malleolus fracture is relatively common among the elderly, but can also occur in the younger patient. Studies have shown a fibular fracture displaced by 1 mm can decrease the contact area of the ankle joint by 42%. Annotated image. Six to eight weeks of nonweightbearing cast followed by Cam Walker and physical therapy. Syndesmosis or medial malleolar injury not evident in this patient. [1] [2] It can occur at numerous sites in the . Nevertheless, some patients with these fractures are able to ambulate and, because patients with these fractures generally do not present with tenderness along the posterior border of the lateral or medial malleolus, radiographic evaluation may not be indicated under the Ottawa guidelines. Treatment of Lateral Malleolus Fractures. A common spot for avulsion fractures is at the lateral malleolus or outside ankle bone. The fractures discussed here can be serious injuries and cause prolonged disability. From 33 to 41 percent of these fractures are missed on initial presentation.811 Traditionally, the causative injuries are falls, motor vehicle crashes, or direct trauma. Many of these injuries, if left without a definitive diagnosis, result in long-term disability (Table 1). Most of these injuries do not pose a diagnostic dilemma and can be managed nonsurgically without a prolonged or costly work-up. The lateral tubercle is the larger of the two and serves as the attachment of the posterior talocalcaneal and posterior talofibular ligaments.9,14,15 The medial tubercle serves as the attachment for the posterior third of the deltoid ligament.9,14,15 The under-surface of both tubercles forms the posterior fourth of the subtalar joint.9,14, An accessory bone known as the ostrigonum is relatively common, posterior to the lateral tubercle.6,15 The os trigonum can be a source of pathology, and a normal os trigonum may be confused with a fracture of the lateral tubercle.2,9,14. Secondary changes in the subchondral bone (visible on plain radiographs) caused by a compression fracture of the articular osteochondral surface may take weeks to appear.2,4 In addition, small chondral fragments are radiolucent and not evident on standard radiographs. Info: I've been told that the bone is likely to not re-attach itself naturally due to the distance, but that surgery is not needed so l'm seeking additional opinions. They are located medially or laterally with equal frequency and occasionally through both.35 Lateral talar dome fractures are almost always associated with trauma, while medial talar dome lesions can be traumatic or atraumatic in origin. The patient had a temporary screw (RED ARROWS) placed across the syndesmosis for 12-16 weeks and then permanently implanted an Arthrex Tightrope (GREEN ARROWS) to maintain stability but allow physiologic motion. This is caused by compression of the fracture fragment as the flexor hallucis longus tendon passes between the medial and lateral tubercle.15, Careful physical examination and correlation with radiographic findings may be necessary to differentiate a fracture of the lateral tubercle, a fracture of a fused os trigonum, a tear in the fibrous attachment of the ostrigonum to the lateral tubercle, or a normal os trigonum.2,6,19, A lateral radiograph of the foot usually best visualizes the lateral tubercle and, if present, the os trigonum.6,9 When evaluating the fracture line, a rough, irregular cortical surface suggests the presence of an acute fracture (Figure 6). These types of fractures can be very disabling. Privacy Policy. This injury tends to be extra-articular and accounts for most of the anterior process fractures that are initially diagnosed as ankle sprains.2123, Anterior process fractures secondary to compression generally occur when the foot is forcefully dorsiflexed and the anterior process is pressed against the cuboid.22 Because of the energy involved with this mechanism, anterior process fractures secondary to compression are often intra-articular and are commonly associated with other fractures.7,23, Patients with anterior process fractures generally have a history of a previous inversion injury or involvement in a motor vehicle crash.21 Clinically, patients generally show signs and symptoms similar to those of a lateral ankle sprain.21,23 The pain may be minimal with standing but increases substantially with ambulation.21,23 An important diagnostic feature is point tenderness over the calca-neocuboid joint that is localized approximately 1 cm inferior and 3 to 4 cm anterior to the lateral malleolus, just distal to the anterior talofibular ligament insertion.21,22,23 Careful assessment of the point of maximal tenderness may help differentiate this fracture from a lateral ligament sprain.21,23, Although this fracture can be difficult to assess on routine radiographs of the foot and ankle, a careful inspection of the lateral view of the calcaneus often reveals this subtle fracture21,24 (Figure 9). Kannus et al. Although fractures of the talus were vary rarely encountered in the Ottawa ankle trials, the fractures discussed in this article would likely be identified using the Ottawa ankle rules, because of the inability of the patient to bear weight after the injury and during the examination. Diagnosis is made with plain radiographs of the ankle. Copyright 2022 American Academy of Family Physicians. Lateral talar process fractures are characterized by point tenderness over the lateral process. Point tenderness over the calcanealcuboid joint (approximately 1 cm inferior and 3 to 4 cm anterior to the lateral malleolus), Lateral radiograph (an accessory ossicle, the calcaneus secondarium, may be present), Small nondisplaced fracture: nonweight-bearing with compressive dressing or NWBSLC for four to six weeks, Joint rest, ice, compression, and elevation (RICE), Progressive range-of-motion and proprioceptive exercises, Protection from further ankle injury with a wrap or brace, Completely detached fragment without displacement, Completely detached fragment with displacement. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. External rotation injury of the ankle is the most common ankle injury and can lead to a Weber B or Weber C fracture. Most ankle injuries are straightforward ligamentous injuries. An avulsion fracture occurs when a muscle or tendon is pulled so hard at the spot where it attaches to the bone that it tears a small piece of bone away. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. The lateral process can be palpated anteriorly and inferiorly to the tip of the lateral malleolus.8,11, Fractures can usually be visualized on a standard ankle series9 (Figure 5). For more information, please see our Point tenderness over the lateral process (anterior and inferior to the lateral malleolus), Mortise view; lateral view may show subtalar effusion, Small fragment with <2 mm Displacement: NWBSLC for four to six weeks, Posterior talar Process (lateral tubercle), Tenderness to deep palpation anterior to the Achilles tendon over posterolateral talus, Lateral radiograph (an accessory ossicle, the os trigonum, may be present), Minimally displaced fracture: NWBSLC for four to six weeks, Posterior talar process (medial tubercle), Tenderness to deep palpation between the medial malleolus and the Achilles tendon. The symptoms of a medial malleolus fracture are fairly predictable: Pain on the inner side of the ankle, swelling and bruising, and difficulty walking. You can use Radiopaedia cases in a variety of ways to help you learn and teach. The x-rays below demonstrate a lateral malleolar fracture that is displaced and has shortening which requires surgical repair (left). X-ray. Again, these fractures have been commonly misdiagnosed as ankle sprains.2,9,15,16 In one case series,15 17 of 20 patients with fractures were misdiagnosed with ankle sprains. AP view: deep, cup-shaped lesion; initial radiograph can be normal because changes in subchondral bone may not develop for weeks. After the deltoid and syndesomosis is healed, we replace the long screw (RED ARROW) with a Arthrex Tightrope (GREEN ARROW)that allows physiologic motion but maintains stability. Bruising may develop later and the athlete will most likely have difficulty moving the . Pre and Postop Pics of ORIF Fibula Fracture with Deltoid Rupture, Pre and Post-op X-rays status post ORIF Lateral Malleolar Fracture (Below), Pre and Postop X-rays of Lateral Malleolar Fracture, Seriesof 15 y/o Displaced Fibular Fracture with syndesmosis and deltoid rupture, Note displacement of fracture and increase space at medial ankle, Intraop, stress of the ankle reveals even more widening of ankle joint (RED ARROWS). Feel a stretch in the back of your calf. X-ray showed a small loose body at the tip of lateral malleolus. When part of this bone fractures, the ankle can become unstable. With an avulsion fracture, an injury to the bone occurs near where the bone attaches to a tendon or ligament. They can be distal, at or proximal to the joint line of the ankle. The injury occurs at the site where a tendon or ligament attaches and happens because the tendon or ligament pulls abruptly and breaks a piece of bone away. The button on the right of the bone is what holds the strong suture like material connected between the 2 bones. Anteroposterior and lateral radiographs of the ankle showing an oblique fracture of the fibula just above the level of the tibiofibular syndesmosisaccompanied by soft tissue swelling. Some patients do well with weightbearing protected immobilization in a cast boot. This is indicative of calcaneo-fibular ligament tear. This can be seen as the two "buttons" on the right side of the xrays on the tibia. These fractures should be considered in the differential diagnosis of any acute ankle sprain, as well as any suspected sprain that does not improve with routine treatment (Table 2). First, you need to focus on resting and getting the swelling to go down. -If it doesn't get re-attached, what happens to the floating bone fragment? 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