Category Archive Fracture of Bone A-Z

Wound Dressings can be present over different anatomical parts of the body. However, the basic principles of choosing a wound dressing remain the same. In the United States, chronic wounds affect more than six million people, and this will grow in numbers due to our elderly and diabetic populations. Choosing the correct dressing will lessen the time of healing, provide cost-effective care, and improve the patient’s quality of life.

The goal is to help the wound heal as soon as possible by using an appropriate dressing material to maintain the right amount of moisture. When the wound bed is dry, use a dressing to increase moisture and if too wet and the surrounding skin is macerated, use material that will absorb excess fluid and protect the surrounding healthy skin.

Important criteria to consider before choosing a specific wound dressing are cleaning, absorbing, regulating, and the need to add medication.

It is important to choose a dressing guided by the cost, ease of application, and clinician’s preference.[rx][rx][rx][rx]

Wound Types and Appropriate Treatment

• If too dry, use a hydrogel to hydrate. Dry eschar may also benefit from enzymatic debridement ointments such as collagenase.
• If the wound has minimal drainage, a hydrocolloid will keep it just right.
• If there is heavy drainage, absorb excess fluid using material like alginate, hydrofibers, cellulose, foam, ceramic fiber, or negative pressure wound therapy.
• If the surrounding skin shows maceration, use zinc oxide, protective films, or a negative pressure wound therapy.
• If the wound is infected and there is a lot of sloughs, which cannot be mechanically debrided, then a chemical debridement can be done with collagenase-based products.
• If the bioburden needs to be controlled, a silver-based or iodine-based product should be used.
• If the wound has an excessive odor, topical metronidazole or activated-charcoal dressing material will help.
• If the wound has healthy granulation tissue and needs to have faster healing and epithelialization, hydrocolloid, foams, collagen, or silver collagen will help.
• If the wound is superficial, occlusive semiocclusive dressings help to heal. Polymeric membrane dressings also are good to treat superficial abrasions.[rx][rx][rx]

Management

After following the principles of wound debridement (discussed in another article), the wound should be profusely irrigated with a neutral solution like normal saline to wash off any debris. Never use toxic or irritating solutions like hydrogen peroxide which are detrimental to wound healing.[rx][rx][rx][rx]

Next chose a dressing material that is easy to replace, stays in place with appropriate anchoring and does not cause harm to the wound bed or normal surrounding skin by shearing force or sticking to the skin. Patients can develop complications like contact or allergic reactions.

The ideal dressing should keep the wound moist but not macerated, limit bacterial overgrowth, keep odor to a minimum, and be comfortable to wear. Frequent inspection of the wound is necessary to optimize wound dressing selection.

Today there are many types of dressings and even techniques to manage wounds. For the most part, the majority of wounds that require special dressings are chronic wounds or surgical wounds.

The overall objective of a wound dressing include the following

• Decrease the pain
• Apply compression for hemostasis
• Protect the wound from the environment
• Protect the wound from soiling with body fluids or waste
• Immobilize the injured body part
• Promote wound healing

Before applying any type of wound dressing, it is important to assess the following

• Mechanism of injury
• Risk of contamination
• Injury to deeper structures
• Underlying nerve or tissue damage
• Any perfusion deficits
• Tetanus status
• Disability
• Amount of tissue loss

When there is a nonhealing or chronic wound or a wound caused by trauma, it is important to get an x-ray to ensure that there is no fracture or a foreign body left in the tissues. If the x-rays do not reveal a foreign body, then ultrasound is a useful technique to identify radiolucent foreign bodies like splinters or thorns.

Currently Available Dressing Options

• The semipermeable dressing allows for moisture to evaporate and also reduces pain. This dressing also acts as a barrier to prevent environmental contamination. The semipermeable dressing does not absorb moisture and requires regular inspection. It also requires a secondary dressing to hold the semipermeable dressing in place.
• Tulle is a non-adherent dressing impregnated with paraffin. It aids healing but doesn‘t absorb exudate. It also requires a secondary dressing to hold it in place. It is ideal for burns as one can add topical antibiotics to the dressing. It is known to cause allergies, and this limits its wider use.
• Plastic film dressings are known to absorb exudate and can be used for wounds with a moderate amount of exudate. They should not be used on dry wounds. They often require a secondary dressing to hold the plastic in place.
• Fixation sheets can conform to body contour and provide pain relief and also allow exudate to escape. These sheet dressings do need oil application before removal and can be used to manage low-intensity wounds that do not require regular check-ups. They should not be applied to infected wounds.
• Calcium alginate dressings keep the wound moist, reduce pain, and can be used to pack cavities. They also provide hemostasis and can absorb excess exudate. They should not be used in the presence of an infection or on dry wounds. Often another dressing is required to hold the alginate in place.
• Foam dressings keep the wound moist, can absorb fluid and can also protect the wound. They can be used on wounds with a moderate amount of exudate and should be avoided on dry wounds. They can be painful to remove if they dry out.
• Hydrocolloid dressings retain moisture and are painless to remove. They are ideal for small abrasions and not to be used on dry or infected wounds.
• Paper adhesive tape is useful for just approximating wound edges and ideal for small wounds. The tape is not useful on wounds with large exudates. [rx]

Wound dressings should provide the most optimum conditions for wound healing while protecting the wound from infection with microorganisms and further trauma. It is important that the dressings be removed atraumatically, to avoid further damage to the wound surface during dressing changes.

Certain special wounds will need more specialized wound dressings, for example, skin substitute, biological skin products, and other complex wound dressing products. Compression therapy is needed for venous leg ulcers. [rx][rx][rx]

• https://www.ncbi.nlm.nih.gov/books/NBK554465/
• https://www.ncbi.nlm.nih.gov/books/NBK532960/
• https://www.ncbi.nlm.nih.gov/books/NBK459283/
• https://www.ncbi.nlm.nih.gov/books/NBK470338/
• https://www.ncbi.nlm.nih.gov/books/NBK470199/
• https://www.ncbi.nlm.nih.gov/books/NBK470338/
• https://www.sciencedirect.com/topics/medicine-and-dentistry/abrasion
• https://en.wikipedia.org/wiki/Abrasion_(medical)

Lower extremity amputation is performed to remove ischemic, infected, necrotic tissue or locally unresectable tumor and, at times, is a life-saving procedure. Peripheral artery disease, alone or in combination with diabetes mellitus, contributes to more than one-half of all amputations; trauma is the second leading cause. The second Trans-Atlantic Inter-Society Consensus Working Group (TASC II) documented an incidence of major amputations due to peripheral artery disease ranging from 12 to 50 per 100,000 individuals per year . The aging population is expected to increase this number by 50 percent in the next 15 years

Over 150000 people undergo amputations of the lower extremity in the United States each year. This incidence is directly proportional to rates of peripheral arterial occlusive disease, neuropathy, and soft tissue sepsis.[rx] This correlation is due to the increased incidence of diabetes mellitus, which is present in eighty-two percent of all vascular-related lower extremity amputations in the United States. Patients with diabetes mellitus have an astounding 30 times greater lifetime risk of undergoing an amputation when compared to patients without diabetes mellitus, which translates to an economic strain in healthcare systems of over $4.3billion in annual costs in the USA alone.[rx] Trauma to the lower extremity can lead to amputation in over 20% of patients when associated with severe wound contamination and significant soft tissue loss.[rx] Battle-related explosive events can lead to amputation in 93% of cases and approximately 2% of combat casualties leat to limb amputation.[rx]

This activity will focus on amputations at the level of the femur and distally; it will cover above-knee, through-knee, and below-knee amputations. In addition, it will describe the technique for certain foot amputations (Syme, Chopart, Boyd), but the reader is encouraged to seek further in-depth text for review of these techniques. Amputations are procedures that are performed surgically although on rare occasions and limited settings can be performed employing cryoamputation.[rx]

Anatomy and Physiology

The lower extremity is subdivided into the thigh (between the hip and knee joints), lower leg (between knee and ankle), and the foot (calcaneus and distally).

The thigh compartments and its contents are the following:

• Anterior compartment:

  • Sartorius
  • Quadriceps, composed of rectus femoris, vastus lateralis, vastus medius, and vastus intermedius.
  • Superficial femoral artery and vein
• Medial compartment

  • Adductor magnus muscle
  • Gracilis muscle
  • Deep femoral artery and vein
  • Saphenous nerve
• Posterior compartment

  • Biceps femoris muscle
  • Semitendinosus muscle
  • Semimembranosus muscle
  • Sciatic nerve

*The great saphenous vein and nerve are located in the subcutaneous tissue of the medial thigh and run parallel to the intermuscular septum of the anterior and medial compartments.

The lower leg compartments and its contents are the following:

• Anterior compartment

  • Tibialis anterior muscle
  • Extensor hallucis longus muscle
  • Extensor digitorum longus muscle
  • Peroneus tertius muscle
  • Anterior Tibial artery
  • Anterior tibial vein
  • Deep peroneal nerve
• Lateral compartment

  • Peroneus brevis muscle
  • Peroneus longus muscle
• Deep posterior compartment

  • Tibialis posterior muscle
  • Flexor digitorum longus muscle
  • Flexor hallucis longus muscle
  • Posterior tibial artery
  • Posterior tibial vein
  • Peroneal artery
  • Peroneal vein
  • Tibial nerve
• Superficial posterior compartment

  • Soleus muscle
  • Gastrocnemius muscle
  • Plantaris muscle
  • Sural cutaneous nerve

* The lesser saphenous vein is located in the subcutaneous tissue of the posterior lower leg and runs parallel to the sural nerve.

The foot is composed of seven tarsal bones, five metatarsals, and fourteen phalanges. It is subdivided into hindfoot (talus and calcaneus bones), midfoot (cuboid, navicular, three cuneiform bones) and forefoot (metatarsals and phalanges). The muscles of the foot can be extrinsic, originating from the anterior or posterior aspect of the lower leg, and intrinsic muscles, originating from the foot.

Indications

Indications for amputation are related to the degree of tissue necrosis or viability, and it is performable in either a single operation or a staged manner (amputation followed by reconstruction). The decision to take on either approach depends largely on the clinical status of the patient and the quality of the soft tissues at the desired level of amputation with the primary goal being to excise the non-viable and infected tissue. In general, soft tissue quality and the ability to obtain bone coverage will guide the adequacy of the level of amputation. It is important to note that skin grafts are an acceptable option for patients where adequate muscle coverage is obtainable, where skin coverage is not possible.

Patients with diabetes mellitus can present along a spectrum of disease; from a non-healing foot wound with underlying osteomyelitis to a grossly infected wound leading to septic shock. In peripheral vascular disease, this decision to amputate is made with the appearance of non-healing wounds when there are no options for the restoration of flow. These patients can generally present in one of two ways: in the acute setting with infected necrosis (‘wet gangrene’) leading to sepsis or with ischemic necrosis (‘dry gangrene’) where the tissue is necrotic without signs of systemic compromise.

Before deciding to amputate, it is essential to optimize the patient from a medical standpoint. In patients with diabetes mellitus, all efforts should focus on achieving adequate glycemic control and early antibiotic treatment to minimize the risk of surgical site infection and to maximize the length of non-infected tissue, respectively. It is reasonable to consider these patients candidates for a single operation should the quality of the soft tissue allow it. In the patient presenting with septic shock, the decision to perform an open (guillotine) amputation with staged reconstruction versus a single operation depends on the clinical status of the patient and the primary goal should be to obtain adequate source control, leaving reconstruction for a later date. Patients presenting with signs of a systemic inflammatory response and extensive cellulitis may receive initial treatment with intravenous antibiotics. A decrease in cellulitis may allow for a more distal level of amputation than anticipated as well as allowing the operation to take place in a single stage.

High-energy traumatic injuries can lead to amputation at the moment of injury. Alternatively, patients can present to the hospital with a mangled extremity not amenable to reconstruction. Several scoring systems can be utilized to determine whether complex reconstruction options should be pursued. However, the primary focus should have its basis on employing the Advanced Trauma Life Support protocol since it is likely that patients present with concomitant life-threatening injuries. This includes assessment of bleeding from the wound, obtaining hemostasis, and performing adequate resuscitation. The level of amputation will depend on the viability of the soft tissues used to obtain bone coverage.[rx] It is important to note that victims of severe traumatic lower extremity injury who initially were candidates for limb salvage may become candidates for an amputation due to infection, inability to obtain bone or hardware coverage, persistently high pain levels or lack the desire to submit to lengthy reconstructive protocols for poor functional results.

Contraindications

Patients with advanced peripheral vascular disease often have diabetes, are elderly, and have multiple comorbidities with low physiologic reserve. It is therefore ideal to medically optimize these patients before a definitive operation. However, an emergency lower extremity amputation may be required to allow for clinical improvement, and the risks of surgery anesthesia must be discussed with the patient and/or designated advocates.

Certain patients are in the intensive care setting receiving vasoactive infusions and heavy sedation with low cardiopulmonary reserve. Amputation may be indicated, but their critically ill state does not allow for such. It is acceptable to wait for clinical optimization before performing an amputation. An alternative to this is cryoamputation, which is the concept of refrigeration of unsalvageable ischemic limb in critically ill patients. There are many described techniques which include the application of ice bags, ice water immersion, mechanical refrigeration, and utilizing dry ice. Although cumbersome, it can be employed successfully with appropriate training of nursing staff and the creation of institutional protocols. A subsequent formal amputation procedure can then follow once the metabolic derangements have resolved, and the benefits of the surgery have surpassed the risks.

Equipment

The procedure will occur in the operating theater in a sterile environment with the use of an appropriately sized tourniquet. The patient is in the supine position and under general anesthesia or regional blockade. Of note, some patients may have no vascular inflow, and therefore, a tourniquet is not necessary. However, careful consideration should focus the skin by covering it with a cotton roll or stockinette before application of a tourniquet.

A ruler and marking pen are used to demarcate the skin incision and the respective soft tissue flap. A large 15 or 20 blade can be used to incise the skin and soft tissues. Alternatively, electrocautery is an option for the soft tissues and the entire dissection with fresh blades reserved for nerve transection.

A Gigli saw or a power saw is used for transecting the bones. The power saw can also be utilized to soften the edges of the bone once transected. Alternatively, a bone rasper can be used and allows for more control and possibly smoother curvature of the anterior surface of the bone. A drill, a 2.0 mm drill bit and fiber wire suture are used if performing a myodesis. The tissue is closed in layers.

Dressing materials can include petroleum gauze, soft rolls, army battle dressings, and an elastic bandage for compression.

Personnel

Every team performing a lower extremity amputation must include an operating room nurse, a scrub technologist, a surgical assistant, and an anesthesiologist. Post-anesthetic care unit staff is usually comprised of nurses and anesthesiologist or intensivists and are vital in the care of the patient in the immediate post-operative period. Face-to-face communication from the surgery team is obligatory during patient hand-off. This is an opportunity to communicate a summary of the patient and the reason for the operation performed. It also allows the surgeon to communicate adversities encountered during the case, report on estimated blood loss and discuss resuscitative measures used intra-operatively that may need continuation in the immediate post-operative setting. It is also important to communicate the type of hospital unit the patient will go to thereafter and the need for post-operative laboratory values.

Preparation

The most important part of the preparation, after medical optimization, is determining the level of amputation. Transcutaneous oxygen tension (TcPO2) is a measure of oxygen tension in the skin derived from the local capillary blood perfusion. This has been utilized as a tool to determine the level of amputation in ischaemic limbs which demonstrated that patients with primary healing of postoperative wounds had significantly higher values of TcPO2 than patients with failure to heal (37 mmHg; range 15 to 56 mmHg vs. 18 mmHg; range 8 to 36 mmHg, p<0.01).[rx] Although useful in the setting of isolated peripheral vascular disease, this tool does not take into account the condition of the patient, the condition of the soft tissues, the presence of neuropathy or the functional status of the patient; all of which are also determinants in selecting amputation level. An accepted approach to amputation level determination in the patient with peripheral vascular disease is the presence of a femoral pulse; this indicates patency of the deep femoral artery which has general acceptance as appropriate for a transtibial (below-knee) amputation. On the other hand, efforts for revascularization must undergo an assessment before performing an above-knee amputation in the absence of a femoral pulse[rx].  Despite many available modalities for assessing healing potential, none has proven more useful than a good physical exam.  Pulse, temperature, and hair growth patterns are all useful and guide clinical intuition.

It is imperative to discuss the probability of independence after major lower extremity amputation with the patient. AMPREDICT is a user-friendly prediction tool of mobility outcomes in individuals undergoing major lower extremity amputation because of complications of diabetes or peripheral vascular disease.[rx] Informing the patient of their probability to achieve independence in the 12 months following amputation allows for shared-decision making and, more importantly, allows the patient to understand their mobility prognosis during the strenuous recovery period.  Rates of ambulation outside the home decrease drastically as the length of amputation decreases.  Energy expenditure for ambulation increases significantly as the amputation site moves higher.

More often than not, the level of amputation is determined by the degree of soft tissue compromise/infection despite optimal antibiotic therapy. In patients presenting with gangrene or necrotizing soft tissue infection, there is very little room for discussion, and the primary objective is to preserve life. A secondary objective in this setting is to preserve as much functional limb length as possible as this has a significant impact on the patients post-operative functionality.

Technique

The use of general anesthesia (GA) versus regional anesthesia (RA) for performing major lower extremity amputation is an area of ongoing debate. There is literature to support the use of RA for major lower extremity amputation with decreased blood loss, need for transfusion, postoperative pain medication, and faster time to oral intake when compared with the general anesthesia group.[rx] Another study showed there was no difference in postoperative myocardial infarction or mortality between GA and RA.[rx] More recently, the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) was utilized to determine the effect of anesthesia type on major lower extremity amputation outcomes in functionally impaired elderly patients.[rx] They reviewed over 3000 patients over eight years. Fifty-nine percent underwent above-the-knee amputations, and the remainder were below-the-knee. Patients undergoing GA were more apt to have impaired sensorium, be on anticoagulation, or have a bleeding disorder and had a prior operation within 30 days. GA correlated with shorter anesthesia time to surgery but equivalent operative times when compared to RA. There was no difference with regards to postoperative myocardial infarction/cardiac arrest, pulmonary complications, stroke, urinary tract infections, and wound complications. Therefore, the decision about which anesthesia type to use should be performed on a case by case basis and collectively between the patient, surgeon, and anesthesiologist.

There are several components in the preparation of the patient in the operating room which apply to all amputation levels. The patient should be in the supine position with appropriate use of tourniquet as this has shown to reduce blood loss during lower extremity amputation in the setting of peripheral artery disease.[rx] Preparation of the skin should be performed circumferentially and as proximal as the groin. Skin preparation products include those containing iodophors or chlorhexidine gluconate, both of which are acceptable options.[rx] In the setting of diabetic foot wounds or gangrene, we recommend maintaining the wound covered with a dry dressing as well as covering the affected foot with a sterile impermeable stockinette. An occlusive adhesive dressing can be utilized to create a seal and further isolate this from the incision site.

Principles of amputation surgery at any level includes: removal of diseased tissue, providing a residual limb that allows for prosthetic fit, tapering the ends of bone to avoid sharp edges, providing a conical shaped limb to allow better prosthetic fit, controlling postsurgical edema, avoiding hematoma formation, allowing for nerve retraction, preservation of length and optimized postoperative pain control.[rx]

The critical steps in surgical technique for several amputations levels will be discussed in order of proximal to distal.

Above-knee amputation

1. Syme amputation

   1. A weight-bearing amputation through the ankle that involves removal of all of the bones of the foot while preserving the heel pad for weight-bearing
2. Boyd  amputation

   1. A weight-bearing amputation through the ankle that preserves the calcaneus and heel pad for weight-bearing.
   2. The calcaneus gets fused to the tibia and is non-mobile
3. Chopart amputation

   1. A weight-bearing amputation at the midtarsal level preserving the additional length of the foot

Complications

Lower extremity amputations involve significant perioperative morbidity and mortality. Thirty-day postoperative mortality rates can range from 4% to 22%.[rx] Long term mortality rates at 1, 3, and 5 years can reach 15, 38, and 68%, respectively.[rx] Mortality rates in diabetic lower extremity amputation patients can be as high as 77% at 5 years.[rx] Risk factors for death in the perioperative setting include AKA, postoperative cardiac complications, age over 74 years, and acute renal failure.[rx] A review of 2879 amputees demonstrated the most common post-surgical complications included pneumonia (22%), acute kidney injury (15%), deep venous thrombosis (15%), acute lung injury/acute respiratory distress syndrome (13%), osteomyelitis  (3%) and flap failure (6%).[rx]

Wound complications, which include dehiscence, seroma, hematoma, can occur in 12% to 34% of BKA patients and 6% to 16% of AKA patients.[rx] Risk factors for wound complications include sepsis, compartment syndrome, end-stage renal disease, ongoing tobacco use, body mass index over 30 kg/m2, and BKA.[rx] A retrospective study showed that the use of incisional negative pressure wound therapy (NPWT) in major limb amputation and revision amputation had demonstrable benefit in decreasing the risk of wound complications.[rx]

Phantom limb pain (PLP) is the pain that persists after complete tissue healing and is characterized by dysesthesia at the level of the absent limb. Patients describe this pain as burning, throbbing, stabbing, sharp as well as the sensation that the amputated limb is in an abnormal position.[rx] This pain can be present in 67% of patients at six months and 50% of patients at five to seven years.[rx][rx] There are several risk factors for developing PLP, which include: the presence of pre-amputation pain, female gender, upper extremity amputations, and bilateral amputations of the upper and/or lower extremities.[rx] A multidisciplinary approach which includes surgical technique, regional analgesia, pharmacological agents, physical therapy and psychotherapy are all key components in the peri-operative care of an amputee that can have a strong impact in decreasing the risk of PLP.

Revision amputation procedures can occur in as many as 42% of patients who underwent a below-knee amputation secondary to trauma. Additionally, up to 13% of patients undergo revision to a higher level of amputation. Age, presence of a crush injury, compartment syndrome, and experiencing a major post-surgical complication were significant risk factors of revision amputation.[rx]

It is also important to include psychological trauma as a complication of limb loss. A recent review performed by Mckechnie et al. reveals that depression can occur in 20.6 to 63% of patients (3 times higher than the general population) and anxiety in 25% to 57% (approximately the same as the general population) with 83% of patients attending a psychiatric clinic at one point after their surgery.[rx] Darnall et al. demonstrated an increased risk of depressive symptoms in patients undergoing an amputation secondary to trauma versus vascular disease or cancer.[rx] Current research, such as “Amputees Unanimous: A 12-step program”, is focusing on a multimodal approach toward the care of an amputee which aims to provide encouragement, support, and optimism for the future.[rx] Further research is needed to determine their impact on this patient population.

Hand Extensor Tendon Lacerations are relatively common injuries and, when not treated appropriately, may result in a lasting impairment of hand function.[rx] Due to their superficial location and being adjacent to the bones, extensor tendons in the hand are more prone to injury than the flexors.[rx][rx]

Causes of  Extensor Tendon Lacerations

Extensor tendon lacerations are very common injuries within young manual workers.[rx] Laceration with a sharp object is the most common mechanism followed by saw injuries, both having a slightly different distribution anatomically. A saw is likely to be causing injury distal to the metacarpophalangeal joint (MCPJ) and be associated with fractures, while sharp object lacerations tend to be proximal to that.[rx] Accidental injuries in younger children are seen sometimes involving flexor and extensor injuries, while much more rarely they can happen in neonates as a result of iatrogenic injury during delivery – particularly during C-section.[rx]

Diagnosis of Extensor Tendon Lacerations

History and Physical

Accurate assessment and management are essential as it has a direct impact on livelihood and work of affected individuals.[rx] A detailed history is crucial and must include the mechanism of injury, position of the hand and fingers at the time, age, occupation, and handedness. Knowing whether a human bite was involved is vital as any contamination would need formal irrigation and debridement.[rx]

Both a systemic and an in-depth examination of both hands is crucial, comparing like for like.[rx] Unless the injury is part of a larger trauma, and the patient needs to be treated according to the ATLS protocol, hand examination should start with an inspection. Any open wound to the back of the hand should raise suspicion of extensor tendon injury. Neurovascular status should always be tested and documented before any local anesthetic is given.[rx]

Once that is done, open injuries should be explored with care under local anesthetic and with appropriate magnification.[rx] Additional injuries must be sought.[rx] Any suspicion of deep injury warrants a referral to the hand surgery team.[rx]

The radial nerve innervates all extrinsic extensor tendons of the hand. The clinician should look out for radial nerve injury but not forget also to assess median and ulnar nerves.[rx] Extrinsic tendons can be divided into superficial and deep groups as shown below:[rx]

Superficial extrinsic extensors

• Extensor carpi radialis longus (ECRL)
• Extensor carpi radialis brevis (ECRB)
• Extensor digitorum communis, (EDC)
• Extensor digiti minimi (EDM)
• Extensor carpi ulnaris (ECU)

Deep extrinsic extensors

• Abductor pollicis longus (APL)
• Extensor pollicis longus (EPL)
• Extensor indicis proprius (EIP)

The above can be grossly tested even in the case where the patient is unable or unwilling to cooperate by checking for normal tenodesis and digital cascade.[rx]

At the level of the wrist, they are divided into six compartments numbered from radial to ulnar side, as shown in figure 1.[rx] Fibroosseous sheaths separate them, and extensor retinaculum acts as a roof over them to prevent bowstringing. Within the compartments, the tendons are round, but they flatten the more distally they run.[rx] Loss of normal digital cascade with extension lag of any single digit should prompt assessment of all six components of the extensor compartment:[rx]

• Compartment 1 – APL and extensor pollicis brevis (EPB)
• Compartment 2 – ECRL and ECRB
• Compartment 3 – EPL
• Compartment 4 – EDC and EIP
• Compartment 5 – EDM
• Compartment 6 – ECU

In addition to the above divisions, extensor tendons have been classified into a zone system by Kleinert and Verdan. They have described 8 zones relating to underlying bones and joints. Doyle has later added on an additional 9 zone in the musculotendinous junction in the forearm, which is about 4 cm proximal to the wrist.[rx][rx] All can be seen in figure 2 and shows the odd number zones are over the joints broadly. Each zone differs in anatomy and properties of the extensor mechanism; therefore, all need to be assessed, and any treatment of a laceration will depend largely on its location.[rx]

Extension in each finger needs to be tested on a joint by a joint basis in isolation, looking at the active range of movement and movement against resistance. Some special considerations need to be taken depending on the zone affected by the injury as per their specialized anatomy and in cases where there is more than one tendon per digit (both EDM and EIP can be tested by extending the relevant finger with the hand flat on a surface). It is worth noting that the full extension of small joints is occasionally possible even after those tendons have been lacerated.[rx]

Junctura tendinae prevent independent extension of digits, and they allow for an ongoing extension of the metacarpophalangeal joint (MCPJ) even if one of the tendons is lacerated. Saggital bands are crucial for MCPJ extension without direct tendon attachment to the proximal phalanx. The extensor mechanism gets more complex past MCPJ (zone V).[rx] As shown in figure 3, extensor tendon divides into three parts over the proximal phalanx (zone IV) to form central slip and lateral bands (zone III). Elson test can be used to test central slip in zone III – it involves flexion of proximal interphalangeal joint (PIPJ) to 90 degrees and attempting to extend distal interphalangeal joint (DIPJ) in that position. Normally DIPJ remains lax unless central slip is damaged as lateral bands have increased pull.[rx]

Distally lateral bands join and insert into the base of the distal phalanx, just proximal to the nail germinal matrix.[rx] (Zone I). There are several stabilizing extensor mechanisms, including triangular ligament over the middle phalanx (zone II), oblique retinacular ligament running from proximal phalanx to distal phalanx, and transverse retinacular ligament anchoring lateral bands to the volar plates.[rx] All of these have the potential to be affected in the event of injury.

Evaluation

After the initial assessment is performed, further evaluation should take place. Radiographs must be taken to assess if there are any associated fractures. Glass and some other foreign bodies may also be discovered that way.[rx] Anteroposterior, true lateral, and oblique views should be taken of both the affected area and the neighboring joints.[rx]

Complex injuries such as those associated with significant tissue compromise (be that bone or soft tissue) may require reconstruction well beyond simple tendon repair, which is outside of the scope of this review. A thorough assessment must be conducted and documented, and basic reconstructive principles may be used to approach defects of any complexity[rx]:

• 1) Restore reliable vascular supply
• 2) Stabilize the wound bed (debridement)
• 3) Reestablish skeletal stability.

Once the above is fulfilled, the tendons themselves may be assessed for reconstruction as well as any potential requirement for graft coverage or fascial flaps may be considered.[rx]

Treatment  of Extensor Tendon Lacerations

GENERAL PRINCIPLES

There is not a clear gold standard for the treatment of extensor tendon lacerations.[rx] The important thing to note is that the term ‘laceration’ can be used quite widely and can hide more complex injuries associated with the laceration itself.[rx] Tetanus prophylaxis should be considered, and antibiotics are commonly used.[rx] Repair should take place soon after the laceration and certainly within two weeks from the injury (ideally within a week).[rx] Modern repair techniques and current protocols for rehabilitation may improve outcomes.[rx]

Tendon injury repair may include primary repair, secondary repair, immediate reconstruction with a tendon graft, staged tendon reconstruction, and tendon transfer. The greater the number of tissues involved in the injury, the more challenging it is to restore the hand function.[rx]

Preserving or restoring appropriate tendon length is crucial to the outcome of repair, as even seemingly minor changes in tension can have a detrimental effect on finger movement.[rx] Despite easy surgical access and the results being generally better than in flexor tendon injuries, it remains a challenge to maintain that correct length and normal function in extensors.[rx]

Miller’s criteria are used to evaluate extensor tendon injuries, and they have shown that laceration severity, the zone of injury, surgical technique used for repair, accompanying trauma to surrounding tissues, hand therapy, and patient compliance are all important to the outcome.[rx]

Surgery is indicated if[rx]:

• more than 25% of the tendon has been cut
• the patient is unable to extend the digit
• there is associated contamination requiring a formal washout and debridement
• the joint is unstable
• conservative approach trial has failed
• the patient can comply with the postoperative protocol.

The procedure can be performed under a local anesthetic or a nerve block, with the patient supine and the arm at their side on an arm table. A pneumatic tourniquet is very useful to control bleeding intraoperatively. Because of varying morphology depending on the zone of injury, treatment is best planned by anatomic classification.[rx]

Proximal zones (VI to IX) can take a 3-0 suture, but the size needs to be reduced the more distal the injury.[rx] The more distal repairs are less complicated in repair technique but are still more difficult to operate on because of their smaller size and lack of collagen bundle linkage. This means that there is little grip strength for the suture material. Equally, they are very flat distally to MCPJ, which means they cannot take a core suture and have a large surface area between the defect and surrounding tissues making it more prone to adhesions.[rx][rx]

Contaminated wounds may need to be washed out and left to repair at a later date when the wound bed is clean. If the cut is clear and both ends are seen, they can be repaired in an emergency setting. Alternatively, the skin may be loosely closed over the lacerated tendons as a temporary measure if a surgical repair is required in theatre. Extensor tendon injuries should be managed in extension splinting to avoid exacerbating the injury and tendon end separation.[rx]

Partial injuries can be managed with wound care and splinting, but most complete injuries require a primary repair. If not immediately possible patient may be a candidate for delayed treatment, two-stage reconstruction, tendon transfer, or graft, but these may result in subpar outcomes. Often that is due to stiffness and reduced range of motion (ROM). This is seen in both adult and pediatric populations, although it is much more pronounced in the former.[rx]

If immobilization in children is difficult due to small digit size, a K wire fixation may be considered. Alternatively, an alumifoam splint can be incorporated into the cast.[rx]

ZONE 1

Zone 1 lacerations are lacerations at or distal to DIPJ and can be referred to as open mallet finger.[rx] They can be treated using dermatotenodesis – full-thickness single layer closure of both the skin and the underlying tendon.[rx] If there is no underlying bony injury, these can be treated in the emergency department as long as the wound and joint can be thoroughly irrigated.[rx] The patient must continue to move PIPJ to avoid stiffness, and they must be warned that they may never regain a full DIPJ flexion as well as may have some extensor lag, even with a well-done repair.[rx]

ZONE 2

Zone two injuries are overlaying middle phalanx. Injures of over 50% of the tendon should be repaired.[rx] Injuries involving less than 50% of the tendon may be treated with 1 to 2 weeks of splinting provided there is no associated lag, and the DIPJ can be extended against resistance. Occasionally these are associated with significant soft tissue loss and need more complex reconstruction.[rx]. Just like in zone 1, the results can be poor in zone 2 – less normal movement is present there, and shortening can impact the ROM in the interphalangeal joints (IPJ).[rx]

ZONE 3

A zone three laceration is over the PIPJ and results in a boutonniere deformity. It disrupts the central slip. Absent or weak PIPJ extension is a positive finding. It can be either reconstructed directly, or a tendon flap can be raised from the proximal part of it.[rx] These injuries are often associated with traumatic arthrotomy of the PIPJ or bony injury and should, therefore, be thoroughly explored and managed accordingly.[rx] If a primary repair cannot be achieved, a turndown technique can be used, or the lateral bands can be sutured together to make up for the lack of central slip.[rx]

ZONE 4

The injuries are over the proximal phalanx and usually involve the broad extensor mechanism.[rx] Because of this broadness, they are often partial injuries.[rx] Partial lacerations have been shown to have good results with splinting only (for 3 to 4 weeks); however, complete lacerations require an operation.[rx] The methods used include modified Kessler, modified Bunnel, and modified Becker. Similar to zone 2 injuries, these can be associated with soft tissue injuries and defects, necessitating a more complex approach.[rx]

ZONE 5

These are over the MCPJ and must be assumed to be human bites until proven otherwise. They ought to be repaired, and care must be taken to ensure sagittal bands are intact or repaired to ensure central tendon position and a good clinical outcome. If there is a bite involved, the wound must be extended, washed out, left open, and the patient should be started on antibiotics after the cultures have been sent off from the theatre.[rx] Traumatic arthrotomies are common, and because these injuries often happen while the MCPJ is in a flexed position, the resulting injury can be more proximal than anticipated making the repair more difficult due to the proximal portion of the tendon retracting.[rx] Postoperatively splinting is done with the wrist in 30-45 extension and MCPJ in 20 to 30 flexion. PIPJ and DIPJ are left free.[rx]

ZONE 6

This area covers the dorsum of the hand over the metacarpals. There may not necessarily be a loss of extension at MCPJ in these injuries because of the presence of the junctures, even if the laceration involves the whole tendon. This makes diagnosis more difficult if not explored.[rx]. Tendons are becoming larger here and may need (and be able to accommodate) a core suture as well as a peripheral repair.[rx] The methods that can be used include running-interlocking horizontal mattress, modified Bunnel, augmented Becker, Halsted, or Silfverskiold.[rx] More complex degloving injuries may require grafting or a flap.[rx]

ZONE 7

These injuries happen underneath the extensor retinaculum, and it is unclear if releasing it to visualize the damage and repair it is necessary, and there’s no other way to repair the damage.[rx] The repair of tendons here can lead to an increased number of poor results because of injury to the extensor compartments or a bowstring effect if retinaculum is not repaired properly.[rx] It may also result in adhesions, particularly if splinted statically.[rx] If repaired too tightly, it can also impair tendon glide. What follows from both is a loss of motion. Additionally, repair itself may impact that, especially if too bulky. The retinaculum can be lengthened using step-cut or Z-plasty to prevent that. Early mobilization should also be considered, so repair must be strong enough to cope with it.[rx]

ZONE 8

This zone lies in the distal forearm, and lacerations are likely to involve more than just one tendon, as well as muscle bellies themselves and musculotendinous junction. Repair should start with thumb and wrist extensor and move from there.[rx] The repair is more likely to be difficult as the tissues are not as strong. The repair can be done using a figure of eight sutures. Care should be taken to assess the posterior interosseous nerve (PIN) beforehand and protect it intraoperatively. Both wrist and elbow splinting may need to be considered to protect the repair postoperatively.[rx]

THUMB

Mallet is less likely here as the tendon is broader, but if it occurs, it should be repaired primarily.[rx] It is often robust enough to take a dedicated tendon suture, but dermatotenodesis is also an option.[rx] EPB may be lacerated with no functional deficit, and the need for its repair is debatable, but EPL affects both IPJ and MCPJ in the thumb and requires reconstruction if lacerated.[rx] T4 and T5 zones may involve superficial radial nerve, and large branches may need repair (while smaller ones may need to be buried to avoid neuromas). Anything more proximal to this may be treated as zone 8 and 9 injuries.[rx]

Differential Diagnosis

The term laceration implies the mechanism of injury; however, other things may present with a similar clinical picture of a deficit in the extensor mechanism function:

• Mallet finger (avulsion of the extensor tendon insertion from the distal phalanx, with or without the involvement of a bony fragment)
• Arthritis (chronic irritation to the tendon may result in damage to the extensor mechanism causing a classical deformity like boutonniere, swan neck or a simple tendon rupture near the joint affected)
• Trigger finger (will result in loss of passive extension as well as active)
• Posterior interosseous nerve (PIN) syndrome (patient will be unable to extend actively, but tenodesis will remain normal)

Treatment Planning

Given that there is more than one way to manage these types of injuries, care must be taken when planning your treatment and adjustments have to made depending on several factors including anatomical location, concomitant injuries, and patient compliance, for example in case of young children.[rx]

Complications

Complications include:

• tendon rupture[rx]
• reduction in both active and passive ROM[rx]
• adhesions[rx]
• extension lag (especially in MCPJ)[rx]
• loss of flexion and reduced ability to grip[rx]
• finger deformities[rx]

The adhesions are the most common of the above and can result in a loss of flexion.[rx][\rx] Loss of flexion is a larger problem than extensor lag, especially in zones 3 and 4, as it has a higher effect on grip.[rx] When adhesions happen, additional treatments are required, including intense hand therapy, and sometimes re-operation may be required (rates of tenolysis is anywhere between 0 and 17%).[rx] To compare repair rupture rates are estimated to be between 0 and 8%.[rx]

Extensor tendon laceration outcomes can be measured using Miller’s criteria which divide them in to excellent (extension lag, 0 flexion loss), good (less than 10 extension lag, less than 20 flexion loss), fair (11 to 45 extension lag, 21 to 45 flexion loss) and poor (greater than 45 extension lag, greater than 45 flexion loss). Notably, all of the above is measured purely on the extent of complications.[rx]

Postoperative and Rehabilitation Care

Postoperative rehabilitation minimizes tendon gapping while reducing the chances of adhesions at the same time.[rx] Three main approaches are available when it comes to postoperative care of extensor tendon lacerations – immobilization, early passive motion (EPM), and early active motion (EAM).[rx]

Traditionally extensor tendon lacerations have been splinted statically for 4 to 6 weeks, which often resulted in a loss of flexion due to adhesion formation.[rx] Immobilization is most appropriate in a non-compliant patient but comes at a price of the highest complication rates.[rx] Only 64% of patients treated this way had good to excellent results, and they have reported an above-average loss of flexion.[rx] This can be somewhat offset by reducing the length of the immobilization period.[rx] Children should be immobilized statically as it doesn’t rely on patient cooperation, and children do not suffer from adhesions, contractures, bowstringing, and tenodesis as much as adults do. Most of the pediatric complications reported postoperative relate to damage at the repair site rather than immobility.[rx]

Studies of dynamic and static splinting have shown that the former results in much-improved outcomes in the context of extensor tendon injuries.[rx] However, some EPM splints are expensive and inconvenient to wear. They also require a motivated patient.[rx] Generally, EAM is encouraged post-op at present – this protocol seems to be more cost-effective and have a lower rate of complications than the other two protocols in extensor zones 3 to 6.[rx]

There are now splinting methods which allow a degree of movement – just enough to prevent stiffness, but not so much that it ruptures the repair. Relative motion splint (RM) is a compact splint where the injured tendon is placed in a 15 to 20 degree less relative motion than adjacent tendons from a common muscle. This means its particularly applicable in extensor tendons in zones IV to VII.[rx] Early protected motion lead to a recovery in 90% of patients in all thumb zones and finger ones 3 to 7, even in patients with suboptimal compliance.[rx]

Finger Dislocation is a joint injury in which the finger bones move apart or sideways so the ends of the bones are no longer aligned normally. Finger dislocations usually happen when the finger is bent backward beyond its normal limit of motion.

Finger joint dislocation is a common hand injury. Finger dislocation can occur at the proximal interphalangeal (PIP), distal interphalangeal (DIP), or metacarpophalangeal (MCP) joints. This paper discusses the epidemiology, anatomy, examination, imaging, treatment, and complications of finger dislocation.

Fingers have three joints – the metacarpophalangeal (MCP) joint, the proximal interphalangeal (PIP) joint, and the distal interphalangeal (DIP) joint. The MCP joint is between the metacarpals and proximal phalanges. The PIP joint is a hinge joint between proximal and middle phalanges. The DIP is also a hinge joint and is between the middle and distal phalanges. The range of motion of these joints allows for flexion and extension, which provides grasping, pinching, and clawing or reaching functions of the fingers. The middle phalanx range of motion at the PIP joint is 105 +/- 5-degrees and accounts for the majority of the flexion of the fingertip during grasping. Flexion and extension of the digit are also possible at the metacarpophalangeal joint; however, the MCP joint can also perform adduction, abduction, and circumduction.[rx]

The bones that make up the joints of the fingers are known by the medical terms phalanges and metacarpal bones. Any of these joints can be dislocated in an injury:

• Distal interphalangeal joints –  are in the finger joints closest to the fingernails. Most dislocations in these joints are caused by trauma, and there is often an open wound in the location of the dislocation.
• Proximal interphalangeal joints – are the middle joints of the fingers. A dislocation in one of these joints is also known as a jammed finger or coach’s finger. It is the most frequent hand injury in athletes, and it is especially common among those who play ball-handling sports, such as football, basketball and water polo. In most cases, the dislocation happens because the fingers are bent backward when an athlete tries to catch a ball or block a shot. Proximal interphalangeal joint dislocations also can happen when an athlete’s fingers are twisted or bent by an opponent, especially when two athletes wrestle or grab for control of a ball.
• Metacarpophalangeal joints – are in the knuckles, located where the fingers meet the rest of the hand. These joints connect the metacarpal bones in the palm with the first row of phalanges in the finger. Because these joints are very stable, metacarpophalangeal joint dislocations are less common than the other two types. When metacarpophalangeal dislocations do occur, they are usually dislocations of either the index finger or little finger (pinky).

The phalangeal joints have important stabilizers that provide necessary support during motion. Joint stabilizers are both static and dynamic. Static stabilizers consist of non-contractile tissue, including the collateral ligaments, volar plate, dorsal capsule, sagittal bands, and ulnar and radial collateral ligaments. The volar plate is an essential stabilizer as it reinforces the volar side of the joint capsule and maintains stability by preventing hyperextension of the finger joints.[rx] The collateral ligaments provide the stabilization against radial and ulnar deviation of the interphalangeal joints. Sagittal bands encircle the MCP joint to keep the extensor tendon centralized and to prevent bowstringing. Dynamic stabilizers include extrinsic and intrinsic tendons and muscles, and two important dynamic stabilizers are the central slip and lateral bands. The central slip tendon is found dorsally and provides for PIP joint extension, and the lateral bands provide DIP joint extension. Finally, digital arteries and nerves are found vulgarly and appear on both ulnar and radial sides of the digit.[rx][rx]

Causes of Finger Dislocation

Finger dislocations can involve the MCP, PIP or DIP joints and may occur in the dorsal, volar, or lateral planes. Dislocations categorize, according to the position of the distal bone relative to the more proximal bone.[rx]

Hyperextension or high-energy axial loads at the MCP joint can result in dislocation. MCP joint dislocation infrequently occurs because of the protection against hyperextension by the volar plate and radial and ulnar deviation by the collateral ligaments. The most common MCP joint dislocation is the index finger. MCP joint dislocation of the middle finger occurs more frequently when it is subjected to ulnar stress while in hyperextension.[rx] Most common MCP joints dislocate dorsally.[rx] The typical presentation of MCP joint dislocation is with the IP joint in flexion and the MCP joint in extension. A nonreducible dislocation with dimpling on the volar surface indicates volar plate interposition.[rx]

PIP joint dislocations are the most common dislocation due to sports and are also known as “coach’s finger.” The typical presentation of PIP joint dislocation is a deformity, decreased range of motion, and pain. PIP joint dislocations can classify into dorsal, volar, and lateral dislocations.  PIP joint dislocation is most commonly dorsal; however, volar dislocation correlates with a higher rate of complications and more difficult reductions.[rx][rx] Dorsal dislocation results result from longitudinal compression and hyperextension commonly by a ball hitting the fingertip.

Dorsal PIP joint dislocation most commonly occurs at the middle finger and is associated with volar plate, collateral ligament, and dorsal joint capsule injury. Swan neck deformity most often occurs in dorsal dislocations and results from volar plate injury. Trapping of the volar plate inside the joint may occur, causing malalignment and oblique rotation resulting under challenging reductions. Volar dislocation of the PIP joint can occur with and without rotation of the intermediate phalanx. Volar dislocation is infrequent and can be associated with injury to the central slip of the extensor tendon. Untreated rupture of the central slip after PIP joint dislocation is associated with pseudo-boutonniere (PIP flexion contracture). Pseudo-boutonniere is a chronic PIP joint flexion with the absence of DIP extension.

Lateral PIP dislocation can also occur and involves disruption of the collateral ligaments.  The patient presents with joint instability and the widening of the joint on radiographs. Finally, rotary volar dislocations may occur when the phalanx displaces and rotates around one collateral ligament, allowing the proximal phalanx to wedge itself between the lateral band and extensor tendon. The classic lateral radiographic finding has the description of “Chinese finger-trap.”[rx]

DIP joint dislocations typically present with deformity at the fingertip. Dorsal, lateral, and volar DIP joint dislocations are all possible.  Dorsal DIP joint dislocations occur most frequently and are associated with fractures and skin injuries. They are not always associated with flexor tendon avulsions but may have an interposed volar plate causing a non-reducible dislocation. Volar DIP joint dislocations are similar to dorsal PIP joint dislocations in that both are associated with extensor tendon injuries. The lateral DIP joint is more likely to have post-reduction instability than volar or dorsal dislocations. Isolated DIP joint dislocation without related injuries such as soft tissue or fractures is rare and is commonly managed with closed reduction and splinting in the emergency departments.[rx][rx]

Symptoms of Finger Dislocation

The following symptoms are common with any type of dislocation.^[rx]

• Intense pain
• Joint instability
• Deformity of the joint area
• Reduced muscle strength
• Bruising or redness of joint area
• Difficulty moving joint
• Stiffness

Diagnosis of Finger Dislocation

History and Physical

• Examiners must perform a complete history, which includes risk factors such as Ehlers-Danlos syndrome, mechanism of injury, handedness, previous finger injuries, occupation, and hobbies. Ample lighting should be used to examine the hand for skin integrity, ecchymosis, swelling, or bony deformity.
• If skin integrity becomes compromised due to laceration or abrasion, the goal of the examiner is to evaluate in a bloodless field if possible. Examiners may use finger tourniquets or, in a patient with adequate circulation, an anesthetic with epinephrine can be used.[rx] Finger examination must be through its complete active and passive range of motion.[rx]
• A thorough neurovascular exam is imperative in the evaluation of the injured hand. The injured digit should be compared to the same digit on the unaffected hand for light-touch, pinprick, and 2-point discrimination to identify any potential digital nerve injury. The digital artery can be evaluated by comparison to an unaffected digit on the opposite hand with the use of a capillary refill.
• If the examiner identifies a deformity, the examiner must also determine if there is any rotation or angulation. Hyperextension of the finger joint should be performed to asses the competency of the volar plate. Lateral stress of finger joint is performed to test the collateral ligaments. To evaluate the integrity of the central slip, the Elson test is preform.  To assess for rotation or angulation, the patient is asked to make a fist if possible, and all the fingertips should point toward the scaphoid. Overlapping or “scissoring” indicates a rotational component to the injury. Rotated or angulated fractures are also identifiable by comparison of the digital pulp and nails with the unaffected hand. Palpation can be used to determine the location of maximal tenderness.[rx]

Imaging

Standard plain radiographs, usually a minimum of 2 views

• Generally, pre- and post-reduction X-rays are recommended. Initial X-ray can confirm the diagnosis as well as evaluate for any concomitant fractures. Post-reduction radiographs confirm successful reduction alignment and can exclude any other bony injuries that may have been caused during the reduction procedure.^[rx]
• In certain instances if initial X-rays are normal but injury is suspected, there is possible benefit of stress/weight-bearing views to further assess for disruption of ligamentous structures and/or need for surgical intervention. This may be utilized with AC joint separations.^[rx]
• Nomenclature: Joint dislocations are named based on the distal component in relation to the proximal one.^[rx]

Ultrasound

• Ultrasound may be useful in an acute setting, particularly with suspected shoulder dislocations. Although it may not be as accurate in detecting any associated fractures, in one observational study ultrasonography identified 100% of shoulder dislocations, and was 100% sensitive in identifying successful reduction when compared to plain radiographs.^[rx] Ultrasound may also have utility in diagnosing AC joint dislocations.^[rx]
• In infants <6 months of age with suspected developmental dysplasia of the hip (congenital hip dislocation), ultrasound is the imaging study of choice as the proximal femoral epiphysis has not significantly ossified at this age.^[13]

Cross-sectional imaging (CT or MRI)

• Plain films are generally sufficient in making a joint dislocation diagnosis. However, cross-sectional imaging can subsequently be used to better define and evaluate abnormalities that may be missed or not clearly seen on plain X-rays. CT is useful in further analyzing any bony aberrations, and CT angiogram may be utilized if the vascular injury is suspected.^[rx] In addition to improved visualization of bony abnormalities, MRI permits for a more detailed inspection of the joint-supporting structures in order to assess for ligamentous and another soft tissue injury.

Evaluation

• The standard of care for evaluating injuries to the hand is plain film imaging. For each affected digit, true lateral, anterior-posterior, and oblique views are necessary. The films must demonstrate a clear view of the affected digit.  Unaffected fingers must not obscure the view of the affected digit.
• Examiners should keep in mind that rotational deformities are most commonly diagnosed on the physical exam rather than on plain films.[rx] In addition to plain films, ultrasound (US) continues to be an area of research regarding the identification of fractures and tendon ruptures.[rx]

Treatment / Management

Treatment of MCP, PIP, and DIP joint dislocation may be operative or nonoperative depending on the ease of reduction, post-reduction stability, or involvement of the volar plate or other stabilizing structures.  Before any reduction, a digital nerve block using lidocaine, bupivacaine, or tetracaine injected at the dorsal base of the dislocated finger will provide immediate anesthesia.[rx]

Medication

The Following medication may be considered to prescribe for mallet finger

• Analgesics – Prescription-strength drugs that relieve pain but not inflammation.
•  Antidepressants – A Drugs that block pain messages from your brain and boost the effects of dolphins.
• Medication – Common pain remedies such as aspirin, acetaminophen, ibuprofen, and naproxen can offer short-term relief. All are available in low doses without a prescription. Other medications, including muscle relaxants and anti-seizure medications, treat aspects of spinal stenosis, such as muscle spasms and damaged nerves.
• Corticosteroid injections – Your doctor will inject a steroid such as prednisone into your finger joints.  Steroids make the inflammation go down. However, because of side effects, they are used sparingly.
• Anesthetics – Used with precision, an injection of a “nerve block” can stop the pain for a time.
• Muscle Relaxants – These medications provide relief from post-operative muscle spasms.
• Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic pain management.
• Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
• Calcium & vitamin D3 – to improve bone health and healing fracture.
• Closed reduction and splinting – The clinician can achieve the closed reduction by extension and axial compression on the proximal phalanx with relocating pressure over the phalangeal base to glide it into position. This approach is different than the traction technique used in PIP joint dislocation. Multiple reduction attempts should be avoided as the inability to reduce may indicate volar plate interposition requiring open reduction.  Multiple attempts at MCP joint dislocation reduction have the potential complication of displacing the volar plate between articular surfaces, lumbricals, or flexor tendons. The finger should have to splint with the wrist extended 30 degrees and MCP joint in 30 to 60 degrees of slight flexion to prevent terminal extension for about 3 to 6 weeks, followed by an additional two weeks of buddy taping.

Surgery

Operative intervention – is indicated for nonreducible MCP joint dislocation as there is a high likelihood of volar plate involvement in these cases. Open reduction of MCP joint dislocation can be performed using either a dorsal or volar approach; however, the dorsal approach is preferable as it carries a lower risk of neurovascular injury. After surgery, the wrist is splinted in 30-degrees of extension with the MCP joint in slight flexion for two weeks to prevent terminal extension. The recommendation is that the PIP and DIP joints not be immobilized. Recovery to preinjury motion typically occurs between 4 to 6 weeks.[rx]

PIP joint dislocations – are also manageable with operative and nonoperative options, but unlike MCP joint dislocations, practitioners must determine if the PIP joint dislocation is dorsal, volar, lateral, or rotary as the treatment may differ. For closed reduction of dorsal PIP joint dislocation, the practitioner should apply slight extension and longitudinal traction, and with the other hand, apply pressure to the dorsal aspect of the proximal phalanx to relocate the displaced digit. After reduction, the examiner should evaluate the joint for instability in all planes and obtain radiographs. The normal contour of the dorsal aspect of the PIP joint on lateral plain film is “C” shaped.

If, after reduction, this contour takes on a “V” shape, it may indicate persistent dorsal subluxation, which can lead to severe stiffness.[rx] PIP joint dislocation is often stable after reduction and is treated by dorsal splinting in 30-degrees of flexion. Volar PIP dislocations are the least common, but the reduction of the volar PIP joint dislocation is generally successful. The reduction takes place by applying mild traction with the PIP and MCP joints held in slight flexion. After the reduction of the volar dislocation, apply extension splint for six weeks. Unlike volar PIP joint dislocation, lateral dislocations are more likely to require operative intervention. Closed reduction requires relaxation of the extensor tendon and lateral bands by wrist extension and MCP flexion, respectively. Then the middle phalanx is gently rotated back into position. If reduction of the lateral PIP joint dislocation provides a full range of motion without subluxation, then the joint is not grossly unstable. In these cases, splinting and reassessment in two or three weeks is recommended. All unstable dislocations require referral for orthopedic evaluation and possible open repair.  Indications for operative intervention regarding PIP joint dislocation include joint instability, significant ligament, soft tissue or tendon injury, or dislocations that are not reducible.

Splinting remains the mainstay of emergency treatment post-reduction. A recent randomized control trial compared buddy taping versus aluminum orthosis treatment of Eaton grades I and II hyperextension type injuries and found no difference in strength, pain, or function at three weeks. However, buddy tape did show an earlier range of motion and decreased edema.[11]

DIP joint dislocation management is less complex then PIP joint dislocation. The three types of DIP joint dislocation are dorsal, volar, and lateral. The most common type of DIP joint dislocation is dorsal. Dorsal DIP joint dislocation is reduced with longitudinal traction, relocating dorsal pressure on the distal phalanx with DIP joint in flexion. Often, the reduction occurs easily in the emergency room setting, followed by splinting of DIP in 10 to 20-degree flexion for two to three weeks.[4]  If there is persistent DIP joint instability, such as those found more commonly in lateral dislocation, then it is treated with four to six weeks of K-wire fixation after concentric reduction. Irreversible dislocation is typically due to volar plate interposition and requires surgical intervention.

Complications

• Chronic stiffness is common after DIP dislocation treatment.
• Overtreatment, such as prolonged splinting and multiple attempts of reduction of volar PIP joint dislocations, increases the likelihood of volar plate scarring and flexion contractures.
• Chronic pain
• Reduced mobility of MCP, PIP, and DIP joints.
• Missing or delayed volar plate injuries are associated with boutonniere deformity, swan neck deformity, laxity, and contractures.
• Swan neck deformity, PIP flexion contracture, mallet finger deformity may also occur if the dislocations of the finger are chronically unrecognized.

Epidemiology

• Each joint in the body can be dislocated, however, there are common sites where most dislocations occur. The following structures are the most common sites of joint dislocations:
• Dislocated shoulder
  • Shoulder dislocations account for 45% of all dislocation visits to the emergency room.^[rx] Anterior shoulder dislocation, the most common type of shoulder dislocation (96-98% of the time) occurs when the arm is in external rotation and abduction (away from the body) produces a force that displaces the humeral head anteriorly and downwardly.^[rx] Vessel and nerve injuries during a shoulder dislocation is rare, but can cause many impairments and requires a longer recovery process.^[rx] There is a 39% average rate of recurrence of anterior shoulder dislocation, with age, sex, hyperlaxity and greater tuberosity fractures being the key risk factors.^[rx]
• Knee: Patellar dislocation
  • Many different knee injuries can happen. Three percent of knee injuries are acute traumatic patellar dislocations.^[rx] Because dislocations make the knee unstable, 15% of patellas will re-dislocate.^[rdx]
  • Patellar dislocations occur when the knee is in full extension and sustains a trauma from the lateral to medial side.^[rx]
• Elbow: Posterior dislocation, 90% of all elbow dislocations^[rx]
• Wrist: Lunate and Perilunate dislocation most common^[rx]
• Finger: Interphalangeal (IP) or metacarpophalangeal (MCP) joint dislocations^[rx]
  • In the United States, men are most likely to sustain a finger dislocation with an incidence rate of 17.8 per 100,000 person-years.^[rx] Women have an incidence rate of 4.65 per 100,000 person-years.^[rx] The average age group that sustains a finger dislocation are between 15 and 19 years old.^[31]
• Hip: Posterior and anterior dislocation of hip
  • Anterior dislocations are less common than posterior dislocations. 10% of all dislocations are anterior and this is broken down into superior and inferior types.^[rx] Superior dislocations account for 10% of all anterior dislocations, and inferior dislocations account for 90%.^[rx] 16-40 year old males are more likely to receive dislocations due to a car accident.^[32] When an individual receives a hip dislocation, there is an incidence rate of 95% that they will receive an injury to another part of their body as well.^[rx] 46–84% of hip dislocations occur secondary to traffic accidents, the remaining percentage is due based on falls, industrial accidents or sporting injury.^[rx]
• Foot and Ankle:
  • Lisfranc injury is a dislocation or fracture-dislocation injury at the tarsometatarsal joints
  • Subtalar dislocation, or talocalcaneonavicular dislocation, is a simultaneous dislocation of the talar joints at the talocalcaneal and talonavicular levels.^[rx][]rx Subtalar dislocations without associated fractures represent about 1% of all traumatic injuries of the foot and 1-2 % of all dislocations, and they are associated with high energy trauma. Early closed reduction is recommended, otherwise open reduction without further delay.^[rx]
  • Total talar dislocation is very rare and has very high rates of complications.^[rx][rx]
  • Ankle Sprains primarily occur as a result of tearing the ATFL (anterior talofibular ligament) in the Talocrural Joint. The ATFL tears most easily when the foot is in plantarflexion and inversion.^[rx]
  • Ankle dislocation without fracture is rare.^[rx]

References

A Posterior Elbow Dislocation often occurs when a person falls on an outstretched hand, posteriorly directed force at the elbow joint causes dislocation at the ulnohumeral and radiocapitellar articulations. Valgus force may induce the commonly seen posterolateral elbow dislocation.  [rx][rx][rx] Anterior elbow dislocations occur when the elbow is flexed, and there is a direct blow on the posterior aspect of the elbow.

Pathophysiology

Considering elbow anatomy and the likely mechanism of injury causing an elbow dislocation can help one understand the pathophysiology associated with this particular injury. During a posterior elbow dislocation, the shearing forces causing the injury may cause associated radial head, radial neck or coronoid process fractures. The medial collateral and lateral collateral ligaments provide support to the elbow joint in addition to its bony anatomy. The LCL is often disrupted when an elbow dislocation occurs; the MCL is the last soft tissue structure injured as the ulna is displaced. Often, the flexor-pronator mass may be ruptured, and occasionally the brachialis may be injured.

The anterior compartment of the elbow encompasses the brachial artery and ulnar and median nerves. These structures are particularly vulnerable to injury because the anterior compartment is often disrupted during posterior dislocation. The ulnar nerve may become entrapped as it passes posteriorly around the medial epicondyle. The brachial artery and median nerve travel closely to one another and injuries are often seen in both these structures simultaneously.

Anterior dislocations are often associated with olecranon fractures.  These dislocations may also disrupt the posterior elbow compartment which contains the radial nerve and insertion of the triceps muscle.

Causes Of Posterior Elbow Dislocation

In general, elbow trauma can subdivide into the following categories:

Traumatic injuries

• Traumatic injuries range from simple contusions to more complex osseoligamentous fracture-dislocation patterns.  The latter is often seen following a fall on an outstretched hand while the forearm is supinated and the elbow is either partially flexed or fully extended

Attritional injuries

• Another form of elbow injuries consists of the subacute-to-chronic variety that occurs secondary to repetitive motions, eventually leading to various tendinosis conditions.  These can include but are not limited to, lateral epicondylitis (tennis elbow), and chronic partial UCL injuries or strains.[rx][rx]

Pediatric considerations

• Elbow trauma in children most commonly occurs via sport or following falls.  Moreover, careful attention during the assessment is necessary, given the characteristic sequence of ossification center appearance and fusion, which can make the radiographic assessment rather challenging.  Commonly encountered pediatric elbow fractures include (but are not limited to)[rx]

Another common elbow injury in children

• Subluxated radial head (nursemaid’s elbow)
• Accounts for 20% of all upper extremity injuries in children
• Peak age 1 to 4 years; occurs more frequently in females than males
• Mechanism of injury: sudden longitudinal pull on the forearm with forearm pronated

Signs And Symptoms Of Posterior Elbow Dislocation

Symptoms include:

• The child stops using the arm, which is held in extension (or slightly bent) and palm down.^[6]
• Minimal swelling.
• All movements are permitted except supination.
• Pain on the outer part of the elbow (lateral epicondyle)
• Point tenderness over the lateral epicondyle—a prominent part of the bone on the outside of the elbow
• Pain from gripping and movements of the wrist, especially wrist extension (e.g. turning a screwdriver) and lifting movements^[rx]
• Sudden intense pain at the back of the elbow will be felt at the time of injury.
• The patient will in most cases be unable to straighten the elbow.
• Rapid swelling and bruising may start to appear. Trying to move the elbow will be painful and the back of the elbow will be very tender to touch.
• Caused by longitudinal traction with the wrist in pronation, although in a series only 51% of people were reported to have this mechanism, with 22% reporting falls, and patients less than 6 months of age noted to have the injury after rolling over in bed.
• Symptoms include pain and tenderness on the inside of the elbow. Bruising and swelling may be present for more severe injuries.
• Impact injuries causing damage to the medial ligament usually involves a lateral force (towards the outside) being applied to the forearm, placing the medial (inner) joint under stress.
• The patient presents with swelling over the lateral elbow with a limited range of motion, particularly forearm rotation and elbow extension ± elbow effusion and bruising. Pain is increased with passive rotation.
• The most reliable clinical sign is point tenderness over the radial head.
• Needs careful assessment for nerve and vascular involvement, especially with brachial artery, median and ulnar nerves.
• It is important to detect crepitation or a mechanical blockage of motion from displaced fracture fragments. This often requires aspiration of a haemarthrosis with the installation of local anesthetic for pain relief.
• If there is significant wrist pain and/or central forearm pain, there may be acute longitudinal radioulnar dissociation with disruption of the distal radioulnar joint.
• Overuse injuries of the MCL may also occur. Repetitive motions that place a lot of stress on the inner elbow can cause damage to the ligament. For example, throwers (track and field and ball sports such as baseball) are prone to this injury. Especially if the technique is poor!

Diagnosis Of Posterior Elbow Dislocation

History

All patients experiencing traumatic injury should first be assessed head to toe for any life or limb threatening injuries first. Obvious bony deformities may distract both the patient and the practitioner from more serious traumatic injuries. After the patient has been cleared of other significant injuries, attention can be turned to the affected extremity.

The initial history should consist of the mechanism of injury and the duration of the injury until initial presentation. The patient should be asked if this is a first-time occurrence or if there have been previous elbow injuries in the past. A physician should review associated symptoms suggesting a neurovascular compromise and inquire about numbness, tingling or coolness of the distal extremity.

The physical examination should begin with an inspection of the elbow joint looking for swelling, deformity or bruising. Posterior elbow dislocations often present with an upper extremity that is flexed and appears shortened. Anterior elbow dislocations are held in extension, and the upper extremity appears elongated. Specific attention should be paid to looking for open wounds which would suggest a complex dislocation. The functionality of the elbow joint should be assessed by observing a range of motion. It is also important to evaluate the remainder of the affected extremity and nearby joints for associated injury. Particular attention should be paid to the distal radioulnar joint for tenderness which can indicate disruption of the intraosseous ligament, eponymously referred to as an Essex-Lopresti lesion.

Physical Examination

The examiner should perform and document relevant findings, including:

• Skin integrity

  • Critical when assessing for the presence of an open fracture and/or traumatic arthrotomy
• Presence of swelling or effusion
• Comprehensive neurovascular examination

How the patient carries their arm may give clues to the diagnosis.

Bony Injuries

• Supracondylar fracture

  • Flexion type

    • Patient supports injured forearm with other arm and elbow in 90º flexion
    • Loss of olecranon prominence

  • Extension type

    • Patient hold arm at side in S-type configuration

Soft Tissue Injuries

• Elbow dislocations:

  • Posterior: abnormal prominence of olecranon
  • Anterior: loss of olecranon prominence

• Radial head subluxation

  • Elbow slightly flexed and forearm pronated resists moving the arm at the elbow

Sensory And Motor Testing Of The Median And Ulnar Nerves

Median

• Test for sensory function

  • Two-point discrimination over the tip of the index finger.

• Test for motor function

  • “OK” sign with thumb and index finger and abduction of the thumb (recurrent branch)

Ulnar

• Test for sensory function

  • Two-point discrimination of the little finger

• Test for motor function

  • Abduct index finger against resistance

Compartment Syndrome

Acute compartment syndrome can usually develop over a few hours after a serious injury. Some symptoms of acute compartment syndrome are:

• A new persistent deep pain
• Pain that seems greater than expected for the severity of the injury
• Numbness and tingling in the limb
• Swelling, tightness and bruising

Radiological Test

Radiographic studies that are necessary for all patients presenting with varying degrees of elbow trauma include:

• Anteroposterior (AP) elbow
• Lateral elbow
• Oblique views (optional, depending on fracture/injury)
• Traction view (optional, can facilitate the assessment of comminuted fracture patterns)
• Ipsilateral shoulder to wrist orthogonal views
  • Especially in the setting of high energy trauma or when exam and evaluation are limited

• Fat pad sign
  • Seen with intra-articular injuries
  • Normally, anterior fat pad is a narrow radiolucent strip anterior to humerus
  • The posterior fat pad is normally not visible
  • Anterior fat pad sign indicates joint effusion/ injury when raised and becomes more perpendicular to the anterior humeral cortex (sail sign)
  • Posterior fat pad sign indicates effusion/injury
    • In adults, posterior fat pad sign without other obvious fracture implies radial head fracture
    • In children, it implies supracondylar fracture

Pediatric Considerations

• Fractures in children often occur through unossified cartilage, making radiographic interpretation confusing
• A line of mensuration drawn down the anterior surface of the humerus should always bisect the capitellum in lateral view.
• If any bony relationship appears questionable on radiographs, obtain a comparison view of uninvolved elbow.
• Suspect nonaccidental trauma if history does not tip injury.
• Ossification centers: 1 appear: (CRITOE)
  • Capitellum 3 to 6 months
  • Radial head 3 to 5 years
  • Medial (Internal) epicondyle 5 to 7 years
  • Trochlea 9 to 10 years
  • Olecranon 9 to 10 years
  • Lateral Epicondyle

• It is essential to do bilateral radiographic imaging in pediatric cases.
• A nurse’s elbow can reduce spontaneously when the patient supinates the arm.

Advanced Imaging Sequences

Computerized tomography (CT) scans are often a consideration in the setting of comminuted fracture patterns for pre-operative surgical planning.  Magnetic resonance imaging (MRI) can be an option in the setting of soft tissue and ligamentous injury evaluation, or when suspecting stress or occult fractures.[rx][rx][rx]

Treatment of Posterior Elbow Dislocation

Initial treatment of simple, closed posterior elbow dislocations is a closed reduction. Some complex elbow dislocations may initially be treated with closed reductions; however, associated fracture implies significant soft tissue damage and likely persistent instability which may require open reduction and internal fixation to improve outcomes. Open dislocations will require extensive washout during an open reduction. Any dislocation with signs of neurovascular compromise requires immediate closed reduction.[rx][rx]

Doctors sometimes recommend very different treatments for both tennis elbow and golfer’s elbow. According to the studies done so far, the following treatments can help:

• Rest, ice
• Physical therapy when appropriate – Eccentric exercises for lateral epicondylitis
• Braces/bandages – These are worn around the elbow or on the forearm to take the strain off the muscles.
• Injections – Injections into the elbow with various substances, such as Botox, hyaluronic acid or autologous blood (the body’s own blood).
• Extracorporeal shockwave therapy (ESWT) – A device generates shock or pressure waves that are transferred to the tissue through the skin. This is supposed to improve the circulation of blood in the tissue and speed up the healing process.
• Laser therapy – The tissue is treated with concentrated beams of light. This is supposed to stimulate the circulation of blood and the body’s cell metabolism.
• Stretching and strengthening exercises: Special exercises that stretch and strengthen the muscles of the arm and wrist.
• Manual therapy – This includes active and passive exercises, as well as massages.
• Ultrasound therapy – The arm is exposed to high-frequency sound waves. This warms the tissue, which improves the circulation of blood.
• Transcutaneous electrical nerve stimulation (TENS) – TENS devices transfer electrical impulses to the nervous system through the skin. These are supposed to keep the pain signals from reaching the brain.
• Acupuncture – The acupuncture needles are inserted into certain points on the surface of the arm. Here, too, the aim is to minimize the perception of pain.
• Cold – The elbow is regularly cooled with ice packs.
• Massages –A massage technique called “transverse friction massage” is often used to treat tennis elbow and golfer’s elbow. It is applied to the tendons and the muscles, using the tips of one or two fingers.

Medication

• Conscious sedation is often necessary to achieve reductions
• Painkillers – especially non-steroidal anti-inflammatory drugs (NSAIDs).
• Injections – Steroid injections.
• Ibuprofen – 600 to 800 mg (pediatric: 5 to 10 mg/kg) PO TID
• Naprosyn – 250 to 500 mg (pediatric: 10 to 20 mg/kg) PO BID
• Tylenol with codeine – 1 or 2 tabs (pediatric 0.5 to 1 mg/kg codeine) PO: do not exceed acetaminophen 4g/24 hours
• Morphine sulfate – 0.1 mg/kg IV
• Hydromorphone 5 mg/acetaminophen 300mg
• Hydrocodone/acetaminophen – 1 to 2 tabs PO

Attritional injuries management modalities

Most of these injections contain one of the following active ingredients. These include but are not limited to[rx][rx][rx]:

• Corticosteroid injection – when applicable
• Platelet-rich plasma (PRP) considerations – 2016 study noted efficacy in managing UCL insufficiency
• Steroids: reduce inflammation. Studies show that steroid injections can temporarily relieve pain. But there is also evidence that they can disrupt the healing process: People who were first given several steroid injections had more pain after a few months than people who didn’t receive any steroid injections. Frequent steroid injections carry the risk of tissue dying (atrophy), for instance, leaving a visible mark on the elbow.
• Hyaluronic acid – A substance made by the body, found in tissue and joints. It is typically used to treat osteoarthritis. One study suggests that hyaluronic acid might be effective in the treatment of tennis elbow. But further research is needed to assess its pros and cons.
• Botox – inhibits the sending of signals between the nerve cells. This has a paralyzing effect on the muscles. According to studies done on this so far, Botox can relieve the pain just a little at most. Also, Botox injections can have side effects like partial paralysis in the fingers that can last several weeks.
• Autologous blood injections – Blood is taken from a vein in the arm and then injected into the elbow. This blood may be treated in different ways before it is injected. One common form of treatment with autologous blood is called platelet-rich plasma (PRP) therapy. It involves separating the blood into its various elements in a centrifuge. Then a concentrated solution of blood platelets is injected into the elbow. There is no evidence that treatment using autologous blood is effective.

Surgery Technique or Approaches to the Reduction

There are two common approaches to the reduction of a posterior elbow dislocation. It is recommended the first technique is attempted in the prone position. With the patient laying down the affected arm is abducted with an elbow on the edge of the cart. The wrist is then grasped and the forearm placed in slight supination while gentle traction is applied. The coronoid process must be distracted and disengaged from the olecranon fossa. Once this has been accomplished downward pressure with the other hand on the olecranon should reduce the dislocation with the operator feeling a confirmatory clunk. A two-person technique is also described where one operator applies downward traction at the wrist, and other applies the downward force onto the olecranon with both their thumbs.

The alternative method is performed with the patient seated or lying supine on the cart. An assistant stabilizes the affected humerus while the operator flexes the elbow, supinates the wrist slightly and applies distal and downward traction at the wrist with one hand. The other hand is placed just distal to the elbow on the volar aspect of the forearm applying slow, gentle inline traction until the confirmatory clunk is appreciated.

Following reduction of the dislocation, a neurovascular examination should be performed to identify improvement in any previous neurovascular symptom or a new symptom that may have manifested following the reduction.  The elbow should be held in 90 degrees of flexion for 5 to 10 days followed by an active range of motion. Earlier range of motion has demonstrated better physical outcomes. Dislocations that appear more unstable may require up to 3 weeks of splinting and a specific range of motion plan. Post-reduction films should be obtained.

• https://www.ncbi.nlm.nih.gov/books/NBK532948/
• https://www.ncbi.nlm.nih.gov/books/NBK459250/
• https://www.ncbi.nlm.nih.gov/books/NBK470574/
• https://www.ncbi.nlm.nih.gov/books/NBK549817/
• https://www.ncbi.nlm.nih.gov/books/NBK549817/
• https://www.ncbi.nlm.nih.gov/books/NBK459268/
• https://www.ncbi.nlm.nih.gov/books/NBK549817/
• https://www.ncbi.nlm.nih.gov/books/NBK459268/
• https://www.ncbi.nlm.nih.gov/books/NBK448140/
• https://www.ncbi.nlm.nih.gov/books/NBK507002/
• https://www.ncbi.nlm.nih.gov/books/NBK534226/
• https://www.ncbi.nlm.nih.gov/books/NBK544370/
• https://www.ncbi.nlm.nih.gov/books/NBK430777/
• https://www.ncbi.nlm.nih.gov/books/NBK441976/
• https://www.ncbi.nlm.nih.gov/books/NBK431092/
• https://www.ncbi.nlm.nih.gov/books/NBK519000/
• https://www.ncbi.nlm.nih.gov/books/NBK507001/
• https://en.wikipedia.org/wiki/Olecranon_fracture
• https://en.wikipedia.org/wiki/Olecranon_bursitis
• https://en.wikipedia.org/wiki/Tennis_elbow
• https://www.uofmhealth.org/health-library/elbow
• https://www.sportsinjuryclinic.net/sport-injuries/elbow-pain/acute-elbow-injuries
• https://patient.info/doctor/elbow-injuries-and-fractures
• https://pubs.rsna.org/doi/full/10.1148/rg.333125176
• https://medlineplus.gov/elbowinjuriesanddisorders.html

Diagnosis of Metatarsal Stress Fractures

During an interview, patients indicate that there is an inciting activity or exercise subjecting the patient to repetitive stress. Activity-related, insidious onset of pain at the site of fracture is often elicited from history. Pain may improve transiently with rest but increases again with activity. Pain often is described as dull and aching. It is important to obtain a thorough medical history with particular attention to potential intrinsic risk factors. This may include an interview on a patient’s diet, endocrine disorders, and menstrual history in female patients.

Physical examination consists of palpation of the pain site, eliciting boney tenderness. If the fracture is in the proximity of a joint, the joint motion will aggravate the pain. Patients may have a limping gait with weight-bearing.

History and Physical

• These patients typically present with pain about the lateral aspect of the forefoot that is worse with weight-bearing activity. This pain may occur in the setting of acute trauma or repetitive microtrauma over weeks to months. One should be suspicious of stress fracture with antecedent pain or pain of worsening quality or duration over time. The examiner must obtain a thorough past medical history and social history to make treatment decisions and optimize patients with surgical indications. It is important to evaluate the skin for open injuries that may require more urgent debridement.
• Physical examination may reveal tenderness to palpation, swelling, and ecchymosis at the site of injury. Patients will also have pain with resisted foot eversion. It is critical to evaluate the patient for other injuries, including injury to the lateral ankle ligamentous structures and Lisfranc injury.
• An exam of the circulatory system, feeling for pulses, and assessing how quickly blood returns to the tip of a toe after it is pressed and the toe turns white (capillary refill).
• A neurologic exam, assessing sensation such as light touch and pinprick sensations
• Motor function, asking the patient to move the injured area. This assists in assessing muscle and tendon function. The ability to move the foot means only that the muscles and tendons work, and does not guarantee bone integrity or stability. The concept that “it can’t be broken because I can move it” is not correct.
• A range of motion exam of the foot may be helpful in assessing ligament stability. However, if the fracture is obvious, the health care practitioner may choose to keep the foot immobilized to prevent further pain.

Imaging

• X-rays – are often taken to evaluate the status of the bones in the foot and to check for a fracture. Usually, three views are taken to help the health care professional and radiologist adequately view the bones. Special views may be taken if there is a concern for a fracture of the calcaneus. X-rays may not be taken for simple toe injuries, since the result may not affect the treatment plan.
• For some foot fractures, X-rays – may not be adequate to visualize the injury. This is often true for metatarsal stress fractures, where bone scans may be used if the history and physical examination suggest a potential stress fracture, but the plain X-rays are normal.
• Computerized tomography (CT) – may be used to assess fractures of the calcaneus and talus, since it may better be able to illustrate the anatomy of the ankle and midfoot joint and potential associated injuries. Magnetic resonance imaging (MRI) may be used in some cases of foot fractures.
• The Lisfranc joint describes  – the connection between the first, second, and third metatarsals and the three cuneiform bones. A Lisfranc fracture-dislocation often requires a CT scan to evaluate this region of the foot. While X-rays may hint at the damage in this type of injury, the CT scan delineates the numerous bones and joints that may be damaged.
• Clinical tests – such as the use of therapeutic ultrasound and tuning forks are also useful in diagnostic investigations on stress fractures.[rx] When used directly on the site of the suspected lesion, they may trigger or worsen the pain because of the great local osteoclastic reabsorption, which results in injury to the periosteum.[rx, rx] In addition, the skipping rope test (hop test) can be used: this consists of asking the patient to hop on the spot while putting weight on the limb that is under investigation. The test is positive when it triggers strong or incapacitating pain in the region injured.[rx, rx]
• Some laboratory tests – may be useful in investigating stress fractures: serum levels of calcium, phosphorus, creatinine, and 25(OH)D3. Nutritional markers should be requested in the presence of clinical conditions of weight loss and anorexia. Hormonal levels (FSH and estradiol) should be investigated when there is a history of dysmenorrhea.[rx]
• Computed tomography (CT) – is used mainly when there is a contraindication against using magnetic resonance imaging.[rx, rx, rx, rx] Chronic and quiescent lesions may be more evident in this examination than on magnetic resonance imaging or bone scintigraphy because they present low bone turnover.[rx] Single-photon emission CT (SPECT) has been particularly more useful in investigating stress fractures involving the dorsal spine, and specifically in pars interarticularis (spondylolysis).[rx, rx, rx]
• Nuclear medicine using triple-phase scintigraphy – (technetium-99 m) presents significant sensitivity (74–100%) to bone remodeling and shows imaging alterations three to five days after the start of symptoms. [rx, rx, rx, rx] The radiopharmaceutical becomes concentrated in the regions affected and detects areas of bone remodeling, microfractures of the trabecular bone, periosteal reaction, and formation of bone callus.[rx]
• Magnetic resonance imaging (MRI) – is the most sensitive and specific imaging examination for diagnosing stress fractures. It is recommended by the American College of Radiology as the preferred examination in the absence of radiographic alterations.[rx] The abnormalities caused by the fracture can be identified one to two days after the start of the symptoms, with early detection of edema in the bone tissue and adjacent areas.rx[, rx, rx] This examination makes it possible to differentiate medullary damage from cortical, endosteal, and periosteal damage allows gradation of the lesions regarding their severity and prognosis. Intramedullary endosteal edema is one of the first signs of bone remodeling and may continue to be present for up to six months after the fracture has been diagnosed and treated, while the cortical maturation and remodeling take place.[rx, rx] Medullary edema or signs of bone stress may also be present in asymptomatic physically active patients, without any correlation with an increased incidence of stress fractures, especially in the tibia in marathon runners. The fracture line is less commonly visible. It presents sensitivity slightly greater than or equal to that of scintigraphy, but it is considered to be a more specific examination.[rx, rx, rx]

Treatment of Metatarsal Stress Fractures

Fractures of the toe bones are almost always traumatic fractures. Treatment for traumatic fractures depends on the break itself and may include these options:

Initial Treatment Includes

• Get medical help immediately – If you fall on an outstretched leg, get into a car accident or are hit while playing a sport and feel intense pain in your leg area, then get medical care immediately. Cause significant pain in the front part of your leg closer to the base of your leg. You’ll innately know that something is seriously wrong because you won’t be able to lift your leg up above the heart level. Cleaning and treating any wounds on the skin of the injured hand.
• Aggressive wound care – as needed for contaminated wounds. Clear with disinfectant material [rx]
• ICE and elevation – It help for prevention swelling, edema
• Rest – Sometimes rest is all that is needed to treat a traumatic fracture of the toe.mSometimes rest is the only treatment needed to promote healing of a stress or traumatic fracture of a metatarsal bone.
• Elevation – Elevation initially aims to limit and reduce any swelling. For example, keep the foot up on a chair to at least hip level when you are sitting. When you are in bed, put your foot on a pillow. Sometimes rest is the only treatment that is needed, even in traumatic fracture.
• Splinting – The toe may be fitted with a splint to keep it in a fixed position.
• Rigid or stiff-soled shoes – Wearing a stiff-soled shoe protects the toe and helps keep it properly positioned. Use of a postoperative shoe or boot walker is also helpful.
• Buddy taping the fractured toe to another toe is sometimes appropriate, but in other cases, it may be harmful.
• Avoid the offending activity – Because stress fractures result from repetitive stress, it is important to avoid the activity that led to the fracture. Crutches or a wheelchair are sometimes required to offload weight from the foot to give it time to heal.
• Immobilization, casting, or rigid shoe – A stiff-soled shoe or another form of immobilization may be used to protect the fractured bone while it is healing. The use of a postoperative shoe or boot walker is also helpful.
  
• Casting, or rigid shoe – A stiff-soled shoe or another form of immobilization may be used to protect the fractured bone while it is healing. The use of a postoperative shoe or boot walker is also helpful.
• Stop stressing the foot – If you’ve been diagnosed with a stress fracture, avoiding the activity that caused it is important for healing. This may mean using crutches or even a wheelchair.

Medication

The following medications may be considered doctor to relieve acute and immediate pain

• Antibiotic – Cefuroxime or Azithromycin, or  Flucloxacillin or any others cephalosporin/quinolone antibiotic must be used to prevent infection or clotted blood remove to prevent furthers swelling and edema
•  Antidepressants – A drug that blocks pain messages from your brain and boosts the effects of endorphins (your body’s natural painkillers).
• Corticosteroids – Also known as oral steroids, these medications reduce inflammation. To healing the nerve inflammation and clotted blood in the joints.
• Muscle Relaxants –  These medications provide relief from associated muscle spasms.
• Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, and tingling.
• Opioids – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
• Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
• NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include  and Ketorolac, Aceclofenac, naproxen
• Calcium & vitamin D3 – to improve bone health and healing fracture.
• Glucosamine & Diacerein, Chondroitin sulfate – can be used to tightening the loose tension, cartilage, ligament, and cartilage, ligament regenerate cartilage or inhabit the further degeneration of cartilage, ligament
• Dietary supplement -to remove general weakness & improved health

Surgery

Treatment decisions have their basis on the anatomic zone of injury, the social and medical history of the injured patient, and evidence of radiographic signs of healing.

• Nondisplaced zone 1 injuries – can be treated conservatively with protected weight-bearing in a hard-soled shoe, walking boot, or walking cast. Progression to weight-bearing as tolerated can initiate as pain and discomfort subside over 3 to 6 weeks. Fractures involving 30% of the articular surface or with an articular step off over 2 mm have treatment with open reduction and internal fixation, closed reduction, and percutaneous pinning, or excision of the fragment.[rx]
• Nondisplaced zone 2 injuries or Jones fractures – may also be treated conservatively with 6 to 8 weeks of non-weight bearing in a short leg cast. The physician may advance weight-bearing status as radiographic evidence of bone healing appears. Indications for surgical interventions include the high-performance athlete, the informed patient who elects to proceed with surgical treatment, or displaced fractures. There are many forms of surgical interventions, including intramedullary screw fixation, tension band constructs, and low profile plates and screws. Surgical management of high-performance athletes minimizes the risk of nonunion and prevents prolonged restriction from physical activity.
• Diaphyseal zone 3 stress fractures – paint a more complicated picture for the patient and physician. A trial of conservative management with non-weight bearing in a short leg cast may be the initial therapy, however, immobilization for up to 20 weeks may be necessary before there is observable radiographic union, and even then, nonunion development is not uncommon. High-performance athletes or individuals with Torg Type II or III fractures may require surgical interventions. Surgical options include intramedullary screw fixation, bone grafting procedures, or a combination of the two.[rx]
• The bone grafting inlay technique – requires removing a 0.7 by 2.0 cm rectangular section of bone at the fracture site and replacing it with an autogenous cortical cancellous bone graft of the same dimensions taken from the anteromedial distal tibia. The medullary cavity must be curetted or drilled until all of the sclerotic bone has been removed and the medullary canal reestablished prior to inserting the donor graft.
• Nondisplaced dancer’s fractures – and other fractures of the fifth metatarsal shaft and neck receive the same treatment as nondisplaced zone 1 injuries. Weight-bearing status can advance as tolerated by pain. If evidence of delayed union or nonunion exists, surgical interventions may be required. If there is more than 3 mm of displacement or angulation exceeds 10 degrees, the fracture should be reduced and splinted.[rx] If the fracture remains mal reduced or there is evidence of loss of reduction on follow-up radiographs, surgical interventions with percutaneous pinning or plate and screw fixation should be a consideration.

Patients treated with intramedullary screw fixation or bone graft inlay technique should remain non-weight bearing in a plaster splint or short leg cast for six weeks with a gradual return to sport or activity.[rx]

Other Treatments

Diagnosis of March Fractures

During an interview, patients indicate that there is an inciting activity or exercise subjecting the patient to repetitive stress. Activity-related, insidious onset of pain at the site of fracture is often elicited from history. Pain may improve transiently with rest but increases again with activity. Pain often is described as dull and aching. It is important to obtain a thorough medical history with particular attention to potential intrinsic risk factors. This may include an interview on a patient’s diet, endocrine disorders, and menstrual history in female patients.

Physical examination consists of palpation of the pain site, eliciting boney tenderness. If the fracture is in the proximity of a joint, the joint motion will aggravate the pain. Patients may have a limping gait with weight-bearing.

History and Physical

• These patients typically present with pain about the lateral aspect of the forefoot that is worse with weight-bearing activity. This pain may occur in the setting of acute trauma or repetitive microtrauma over weeks to months. One should be suspicious of stress fracture with antecedent pain or pain of worsening quality or duration over time. The examiner must obtain a thorough past medical history and social history to make treatment decisions and optimize patients with surgical indications. It is important to evaluate the skin for open injuries that may require more urgent debridement.
• Physical examination may reveal tenderness to palpation, swelling, and ecchymosis at the site of injury. Patients will also have pain with resisted foot eversion. It is critical to evaluate the patient for other injuries, including injury to the lateral ankle ligamentous structures and Lisfranc injury.
• An exam of the circulatory system, feeling for pulses, and assessing how quickly blood returns to the tip of a toe after it is pressed and the toe turns white (capillary refill).
• A neurologic exam, assessing sensation such as light touch and pin prick sensations
• Motor function, asking the patient to move the injured area. This assists in assessing muscle and tendon function. The ability to move the foot means only that the muscles and tendons work, and does not guarantee bone integrity or stability. The concept that “it can’t be broken because I can move it” is not correct.
• A range of motion exam of the foot may be helpful in assessing ligament stability. However, if the fracture is obvious, the health care practitioner may choose to keep the foot immobilized to prevent further pain.

Imaging

• X-rays – are often taken to evaluate the status of the bones in the foot and to check for a fracture. Usually, three views are taken to help the health care professional and radiologist adequately view the bones. Special views may be taken if there is a concern for a fracture of the calcaneus. X-rays may not be taken for simple toe injuries, since the result may not affect the treatment plan.
• For some foot fractures, X-rays – may not be adequate to visualize the injury. This is often true for metatarsal stress fractures, where bone scans may be used if the history and physical examination suggest a potential stress fracture, but the plain X-rays are normal.
• Computerized tomography (CT) – may be used to assess fractures of the calcaneus and talus, since it may better be able to illustrate the anatomy of the ankle and midfoot joint and potential associated injuries. Magnetic resonance imaging (MRI) may be used in some cases of foot fractures.
• The Lisfranc joint describes  – the connection between the first, second, and third metatarsals and the three cuneiform bones. A Lisfranc fracture-dislocation often requires a CT scan to evaluate this region of the foot. While X-rays may hint at the damage in this type of injury, the CT scan delineates the numerous bones and joints that may be damaged.

Treatment of March Fractures

Fractures of the toe bones are almost always traumatic fractures. Treatment for traumatic fractures depends on the break itself and may include these options:

Initial Treatment Includes

• Get medical help immediately – If you fall on an outstretched leg, get into a car accident or are hit while playing a sport and feel intense pain in your leg area, then get medical care immediately. Cause significant pain in the front part of your leg closer to the base of your leg. You’ll innately know that something is seriously wrong because you won’t be able to lift your leg up above the heart level. Cleaning and treating any wounds on the skin of the injured hand.
• Aggressive wound care – as needed for contaminated wounds. Clear with disinfectant material [rx]
• ICE and elevation – It help for prevention swelling, edema
• Rest – Sometimes rest is all that is needed to treat a traumatic fracture of the toe.mSometimes rest is the only treatment needed to promote healing of a stress or traumatic fracture of a metatarsal bone.
• Elevation – Elevation initially aims to limit and reduce any swelling. For example, keep the foot up on a chair to at least hip level when you are sitting. When you are in bed, put your foot on a pillow. Sometimes rest is the only treatment that is needed, even in traumatic fracture.
• Splinting – The toe may be fitted with a splint to keep it in a fixed position.
• Rigid or stiff-soled shoes – Wearing a stiff-soled shoe protects the toe and helps keep it properly positioned. Use of a postoperative shoe or boot walker is also helpful.
• Buddy taping the fractured toe to another toe is sometimes appropriate, but in other cases, it may be harmful.
• Avoid the offending activity – Because stress fractures result from repetitive stress, it is important to avoid the activity that led to the fracture. Crutches or a wheelchair are sometimes required to offload weight from the foot to give it time to heal.
• Immobilization, casting, or rigid shoe – A stiff-soled shoe or another form of immobilization may be used to protect the fractured bone while it is healing. The use of a postoperative shoe or boot walker is also helpful.
  
• Casting, or rigid shoe – A stiff-soled shoe or another form of immobilization may be used to protect the fractured bone while it is healing. The use of a postoperative shoe or boot walker is also helpful.
• Stop stressing the foot – If you’ve been diagnosed with a stress fracture, avoiding the activity that caused it is important for healing. This may mean using crutches or even a wheelchair.

Medication

The following medications may be considered doctor to relieve acute and immediate pain

• Antibiotic – Cefuroxime or Azithromycin, or  Flucloxacillin or any others cephalosporin/quinolone antibiotic must be used to prevent infection or clotted blood remove to prevent furthers swelling and edema
•  Antidepressants – A drug that blocks pain messages from your brain and boosts the effects of endorphins (your body’s natural painkillers).
• Corticosteroids – Also known as oral steroids, these medications reduce inflammation. To healing the nerve inflammation and clotted blood in the joints.
• Muscle Relaxants –  These medications provide relief from associated muscle spasms.
• Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, and tingling.
• Opioids – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
• Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
• NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include  and Ketorolac, Aceclofenac, naproxen
• Calcium & vitamin D3 – to improve bone health and healing fracture.
• Glucosamine & Diacerein, Chondroitin sulfate – can be used to tightening the loose tension, cartilage, ligament, and cartilage, ligament regenerate cartilage or inhabit the further degeneration of cartilage, ligament
• Dietary supplement -to remove general weakness & improved health

Surgery

Treatment decisions have their basis on the anatomic zone of injury, the social and medical history of the injured patient, and evidence of radiographic signs of healing.

• Nondisplaced zone 1 injuries – can be treated conservatively with protected weight-bearing in a hard-soled shoe, walking boot, or walking cast. Progression to weight-bearing as tolerated can initiate as pain and discomfort subside over 3 to 6 weeks. Fractures involving 30% of the articular surface or with an articular step off over 2 mm have treatment with open reduction and internal fixation, closed reduction, and percutaneous pinning, or excision of the fragment.[rx]
• Nondisplaced zone 2 injuries or Jones fractures – may also be treated conservatively with 6 to 8 weeks of non-weight bearing in a short leg cast. The physician may advance weight-bearing status as radiographic evidence of bone healing appears. Indications for surgical interventions include the high-performance athlete, the informed patient who elects to proceed with surgical treatment, or displaced fractures. There are many forms of surgical interventions, including intramedullary screw fixation, tension band constructs, and low profile plates and screws. Surgical management of high-performance athletes minimizes the risk of nonunion and prevents prolonged restriction from physical activity.
• Diaphyseal zone 3 stress fractures – paint a more complicated picture for the patient and physician. A trial of conservative management with non-weight bearing in a short leg cast may be the initial therapy, however, immobilization for up to 20 weeks may be necessary before there is observable radiographic union, and even then, nonunion development is not uncommon. High-performance athletes or individuals with Torg Type II or III fractures may require surgical interventions. Surgical options include intramedullary screw fixation, bone grafting procedures, or a combination of the two.[rx]
• The bone grafting inlay technique – requires removing a 0.7 by 2.0 cm rectangular section of bone at the fracture site and replacing it with an autogenous cortical cancellous bone graft of the same dimensions taken from the anteromedial distal tibia. The medullary cavity must be curetted or drilled until all of the sclerotic bone has been removed and the medullary canal reestablished prior to inserting the donor graft.
• Nondisplaced dancer’s fractures – and other fractures of the fifth metatarsal shaft and neck receive the same treatment as nondisplaced zone 1 injuries. Weight-bearing status can advance as tolerated by pain. If evidence of delayed union or nonunion exists, surgical interventions may be required. If there is more than 3 mm of displacement or angulation exceeds 10 degrees, the fracture should be reduced and splinted.[rx] If the fracture remains mal reduced or there is evidence of loss of reduction on follow-up radiographs, surgical interventions with percutaneous pinning or plate and screw fixation should be a consideration.

Patients treated with intramedullary screw fixation or bone graft inlay technique should remain non-weight bearing in a plaster splint or short leg cast for six weeks with a gradual return to sport or activity.[rx]

Other Treatments

Fifth Metatarsal Fracture are common injuries that must be recognized and treated appropriately to avoid poor clinical outcomes for the patient. Since orthopedic surgeon Sir Robert Jones first described these fractures in 1902, there has been an abundance of literature focused on the proximal aspect of the fifth metacarpal due to its tendency towards poor bone healing. Nevertheless, it is critical that the physician recognizes all injury patterns of the fifth metatarsal and initiate the appropriate treatment plan or referral process to avoid potential complications.

Types of Foot Metatarsal Bone Fractures

Classified by Lawrence and Bottle, the base, or proximal aspect, of the fifth metatarsal is broken up into three anatomical zones:

• zone 1 – the tuberosity;
• zone 2 – the metaphyseal-diaphyseal junction; and
• zone 3 – the diaphyseal area within 1.5 cm of the tuberosity.[rx] Fractures through zone 1 have the name to as pseudo-Jones fractures, and fractures through zone 2 are referred to as Jones fractures. Additionally, a patient may sustain a shaft fracture greater than 1.5 cm distal to the tuberosity, a long spiral fracture extending into the distal metaphyseal area, the so-called dancer’s fracture, or a stress fracture of the metatarsal.

Classification of these fractures is crucial to making management decisions. Metaphyseal arteries and diaphyseal nutrient arteries provide the blood supply to the fifth metatarsal base.[rx] The avascular watershed area exists in zone 2, contributing to the high nonunion rates seen with these fractures.

The radiographic appearance of fifth metatarsal base stress fractures classify into three types based on the Torg classification system[rx]

Are there different types of a break?

Breaks (fractures) can be acute or caused immediately by injury. They can also occur over a longer period of time, when they are called stress fractures.

• Acute metatarsal fracture – is usually caused by a sudden forceful injury to the foot, such as dropping a heavy object on to the foot, a fall, kicking against a hard object when tripping, or from a sporting injury.An acute metatarsal fracture may be open or closed, and displaced or not displaced:
  • Open or closed – an open fracture is one where the skin is broken over the fracture so that there is a route of possible infection from the outside into the broken bones. This is a more serious type of fracture, with more damage to the soft tissues around it making treatment and healing more complicated. A specialist assessment is needed.
  • Displaced or not displaced – a displaced fracture is one where, following the break, the bones have slipped out of line. A displaced fracture needs specialist care, as the bones will need to be properly lined up and stabilized. This may involve an anesthetic and some kind of metal pinning or plating to the bones.
• A stress fracture – is a hairline break in a bone, caused by repetitive stress. This is cracking which goes only partway through the bone. There may be a single split in the bone or multiple small splits. The hairline break or breaks do not go through the full thickness of the bone, so stress fractures are not generally displaced. However, several small stress fractures can develop around the same area, over time.
• Avulsion Fractures – The avulsion fracture is by far the most common fifth metatarsal fracture. They occur at the bottom-most portion of the bone. They are frequently confused with Jones fractures and are often referred to as pseudo-Jones fractures.
• Jones Fracture – The Jones fracture is the most notorious fifth metatarsal fracture because it is very difficult to heal. The Jones fracture occurs near the bottom of the bone at an anatomic location called the metaphyseal-diaphyseal junction. This area of bone is thought to have less blood supply than other bones, impeding the rate of healing (particularly if the fracture further impedes circulation).
• Dancer’s Fracture – The dancer’s fracture has become a universal term for any fifth metatarsal fracture, but foot surgeons generally reserve for fracture of a specific orientation. A true dancer’s fracture occurs mostly in the middle tissues of the long metatarsal bone and will be oriented obliquely in the shaft of the bone. The fracture line may even spiral and rotate throughout the bone. Sometimes the dancer’s fracture can cause the bone to chip into smaller pieces (called comminution).

Causes of Foot Metatarsal Bone Fractures

Zone 1 fractures are tuberosity avulsion fractures, also called pseudo-Jones fractures, and occur when the hindfoot gets forced into inversion during plantarflexion.[rx] This acute injury pattern may occur after an athlete lands awkwardly after a jump. These fractures rarely involved the fifth tarsometatarsal joint and lay proximal to the fourth and/or fifth intermetatarsal joint

• Zone 2 injuries – have the name Jones fractures. These acute injuries may occur with a significant adduction force to the foot with a lifted heel.[rx] This type of injury pattern can occur with a sudden change of direction by an athlete. These fractures usually involve the fourth and/or fifth metatarsal articulation and have nonunion rates as high as 15 to 30%.
• Zone 3 injuries – are chronic injuries of repetitive microtrauma, causing increasing pain with activity over months. There is an increased risk of nonunion with these fractures.
• The dancer’s fracture – or long spiral fracture of the distal metatarsal, is typically caused by the dancer rolling over their foot while in the demi-pointe position or sustained while landing a jump.

Symptoms of Foot Metatarsal Bone Fractures

Symptoms of stress fractures include

• Pain with or after normal activity
• Pain that goes away when resting and then returns when standing or during activity
• Pinpoint pain (pain at the site of the fracture) when touched
• Swelling but no bruising
• Bruising or discoloration that extends to nearby parts of the foot
• Pain with walking and weight-bearing
• Swelling in the heel area
• Pain at the site of the fracture, which in some cases can extend from the foot to the knee.
• Significant swelling, which may occur along the length of the leg or maybe more localized.
• Blisters may occur over the fracture site. These should be promptly treated by a foot and ankle surgeon.
• Bruising that develops soon after the injury.
• Inability to walk; however, it is possible to walk with less severe breaks, so never rely on walking as a test of whether or not a bone has been fractured.
• Change in the appearance of the ankle—it will look different from the other ankle.
• Bone protruding through the skin—a sign that immediate care is needed. Fractures that pierce the skin require immediate attention because they can lead to severe infection and prolonged recovery.

Diagnosis of Foot Metatarsal Bone Fractures

History and Physical

• These patients typically present with pain about the lateral aspect of the forefoot that is worse with weight-bearing activity. This pain may occur in the setting of acute trauma or repetitive microtrauma over weeks to months. One should be suspicious of stress fracture with antecedent pain or pain of worsening quality or duration over time. The examiner must obtain a thorough past medical history and social history to make treatment decisions and optimize patients with surgical indications. It is important to evaluate the skin for open injuries that may require more urgent debridement.
• Physical examination may reveal tenderness to palpation, swelling, and ecchymosis at the site of injury. Patients will also have pain with resisted foot eversion. It is critical to evaluate the patient for other injuries, including injury to the lateral ankle ligamentous structures and Lisfranc injury.
• An exam of the circulatory system, feeling for pulses, and assessing how quickly blood returns to the tip of a toe after it is pressed and the toe turns white (capillary refill).
• A neurologic exam, assessing sensation such as light touch and pin prick sensations
• Motor function, asking the patient to move the injured area. This assists in assessing muscle and tendon function. The ability to move the foot means only that the muscles and tendons work, and does not guarantee bone integrity or stability. The concept that “it can’t be broken because I can move it” is not correct.
• A range of motion exam of the foot may be helpful in assessing ligament stability. However, if the fracture is obvious, the health care practitioner may choose to keep the foot immobilized to prevent further pain.

Evaluation

Radiographs are the initial imaging of choice used to evaluate for these injuries. AP, lateral, and oblique images of the foot are essential to making the diagnosis. In zone 1 injuries, the medial fracture line lies proximal to the fourth to the fifth intermetatarsal joint. In zone 2 injuries, the medial fracture line extends towards or even into the fourth and/or fifth intermetatarsal joint. In zone 3 injuries, the medial fracture line will typically exit distal to the fourth and/or fifth intermetatarsal joint, but some may be more proximal.[rx] The usual fracture pattern seen in dancer fractures is an oblique spiral fracture beginning distal and lateral and extending proximal and medial.[rx] Other distal diaphyseal fractures are generally seen on radiographs running in the transverse plane.

Imaging

• X-rays – are often taken to evaluate the status of the bones in the foot and to check for a fracture. Usually, three views are taken to help the health care professional and radiologist adequately view the bones. Special views may be taken if there is a concern for a fracture of the calcaneus. X-rays may not be taken for simple toe injuries, since the result may not affect the treatment plan.
• For some foot fractures, X-rays – may not be adequate to visualize the injury. This is often true for metatarsal stress fractures, where bone scans may be used if the history and physical examination suggest a potential stress fracture, but the plain X-rays are normal.
• Computerized tomography (CT) – may be used to assess fractures of the calcaneus and talus, since it may better be able to illustrate the anatomy of the ankle and midfoot joint and potential associated injuries. Magnetic resonance imaging (MRI) may be used in some cases of foot fractures.
• The Lisfranc joint describes  – the connection between the first, second, and third metatarsals and the three cuneiform bones. A Lisfranc fracture-dislocation often requires a CT scan to evaluate this region of the foot. While X-rays may hint at the damage in this type of injury, the CT scan delineates the numerous bones and joints that may be damaged.

Treatment of Foot Metatarsal Bone Fractures

Fractures of the toe bones are almost always traumatic fractures. Treatment for traumatic fractures depends on the break itself and may include these options:

Initial Treatment Includes

• Get medical help immediately – If you fall on an outstretched leg, get into a car accident or are hit while playing a sport and feel intense pain in your leg area, then get medical care immediately. Cause significant pain in the front part of your leg closer to the base of your leg. You’ll innately know that something is seriously wrong because you won’t be able to lift your leg up above the heart level. Cleaning and treating any wounds on the skin of the injured hand.
• Aggressive wound care – as needed for contaminated wounds. Clear with disinfectant material [rx]
• ICE and elevation – It help for prevention swelling, edema
• Rest – Sometimes rest is all that is needed to treat a traumatic fracture of the toe.mSometimes rest is the only treatment needed to promote healing of a stress or traumatic fracture of a metatarsal bone.
• Elevation – Elevation initially aims to limit and reduce any swelling. For example, keep the foot up on a chair to at least hip level when you are sitting. When you are in bed, put your foot on a pillow. Sometimes rest is the only treatment that is needed, even in traumatic fracture.
• Splinting – The toe may be fitted with a splint to keep it in a fixed position.
• Rigid or stiff-soled shoes – Wearing a stiff-soled shoe protects the toe and helps keep it properly positioned. Use of a postoperative shoe or boot walker is also helpful.
• Buddy taping the fractured toe to another toe is sometimes appropriate, but in other cases, it may be harmful.
• Avoid the offending activity – Because stress fractures result from repetitive stress, it is important to avoid the activity that led to the fracture. Crutches or a wheelchair are sometimes required to offload weight from the foot to give it time to heal.
• Immobilization, casting, or rigid shoe – A stiff-soled shoe or another form of immobilization may be used to protect the fractured bone while it is healing. The use of a postoperative shoe or boot walker is also helpful.
  
• Casting, or rigid shoe – A stiff-soled shoe or another form of immobilization may be used to protect the fractured bone while it is healing. The use of a postoperative shoe or boot walker is also helpful.
• Stop stressing the foot – If you’ve been diagnosed with a stress fracture, avoiding the activity that caused it is important for healing. This may mean using crutches or even a wheelchair.

Medication

The following medications may be considered doctor to relieve acute and immediate pain

• Antibiotic – Cefuroxime or Azithromycin, or  Flucloxacillin or any others cephalosporin/quinolone antibiotic must be used to prevent infection or clotted blood remove to prevent furthers swelling and edema
•  Antidepressants – A drug that blocks pain messages from your brain and boosts the effects of endorphins (your body’s natural painkillers).
• Corticosteroids – Also known as oral steroids, these medications reduce inflammation. To healing the nerve inflammation and clotted blood in the joints.
• Muscle Relaxants –  These medications provide relief from associated muscle spasms.
• Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, and tingling.
• Opioids – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
• Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
• NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include  and Ketorolac, Aceclofenac, naproxen
• Calcium & vitamin D3 – to improve bone health and healing fracture.
• Glucosamine & Diacerein, Chondroitin sulfate – can be used to tightening the loose tension, cartilage, ligament, and cartilage, ligament regenerate cartilage or inhabit the further degeneration of cartilage, ligament
• Dietary supplement -to remove general weakness & improved health

Surgery

Treatment decisions have their basis on the anatomic zone of injury, the social and medical history of the injured patient, and evidence of radiographic signs of healing.

• Nondisplaced zone 1 injuries – can be treated conservatively with protected weight-bearing in a hard-soled shoe, walking boot, or walking cast. Progression to weight-bearing as tolerated can initiate as pain and discomfort subside over 3 to 6 weeks. Fractures involving 30% of the articular surface or with an articular step off over 2 mm have treatment with open reduction and internal fixation, closed reduction, and percutaneous pinning, or excision of the fragment.[rx]
• Nondisplaced zone 2 injuries or Jones fractures – may also be treated conservatively with 6 to 8 weeks of non-weight bearing in a short leg cast. The physician may advance weight-bearing status as radiographic evidence of bone healing appears. Indications for surgical interventions include the high-performance athlete, the informed patient who elects to proceed with surgical treatment, or displaced fractures. There are many forms of surgical interventions, including intramedullary screw fixation, tension band constructs, and low profile plates and screws. Surgical management of high-performance athletes minimizes the risk of nonunion and prevents prolonged restriction from physical activity.
• Diaphyseal zone 3 stress fractures – paint a more complicated picture for the patient and physician. A trial of conservative management with non-weight bearing in a short leg cast may be the initial therapy, however, immobilization for up to 20 weeks may be necessary before there is observable radiographic union, and even then, nonunion development is not uncommon. High-performance athletes or individuals with Torg Type II or III fractures may require surgical interventions. Surgical options include intramedullary screw fixation, bone grafting procedures, or a combination of the two.[rx]
• The bone grafting inlay technique – requires removing a 0.7 by 2.0 cm rectangular section of bone at the fracture site and replacing it with an autogenous corticocancellous bone graft of the same dimensions taken from the anteromedial distal tibia. The medullary cavity must be curetted or drilled until all of the sclerotic bone has been removed and the medullary canal reestablished prior to inserting the donor graft.
• Nondisplaced dancer’s fractures – and other fractures of the fifth metatarsal shaft and neck receive the same treatment as nondisplaced zone 1 injuries. Weight-bearing status can advance as tolerated by pain. If evidence of delayed union or nonunion exists, surgical interventions may be required. If there is more than 3 mm of displacement or angulation exceeds 10 degrees, the fracture should be reduced and splinted.[rx] If the fracture remains malreduced or there is evidence of loss of reduction on follow-up radiographs, surgical interventions with percutaneous pinning or plate and screw fixation should be a consideration.

Patients treated with intramedullary screw fixation or bone graft inlay technique should remain non-weight bearing in a plaster splint or short leg cast for six weeks with a gradual return to sport or activity.[rx]

Other Treatments

Treatment of Calcaneus Fractures/Calcaneus fractures are rare but potentially debilitating injuries. The calcaneus is one of seven tarsal bones and is part of the hind-foot which includes the calcaneus and the talus. The hindfoot articulates with the tibia and fibula creating the ankle joint. The subtalar or calcaneotalar joint accounts for at least some foot and ankle dorsal/plantar flexion. Historically a burst fracture of the calcaneus was coined a”Lovers Fracture” as the injury would occur as a suitor would jump off a lover’s balcony to avoid detection. [rx][rx][rx]

Calcaneus fractures often result in a varus deformity with heel widening, loss of calcaneal height, and subtalar joint incongruency. ORIF can be used to address deformities, restoring the anatomic morphology of the calcaneus, and thereby the biomechanics and function of the hindfoot. Restoring heel width prevents chronic peroneal tendonitis secondary to impingement from lateral wall blowout of the calcaneus, and restoring the length and alignment of the Achilles tendon maintains plantarflexion strength [rx, rx, rx]. ORIF also provides the opportunity for anatomic reduction and rigid internal fixation of the subtalar joint. Normal subtalar motion is integral for the foot to adapt on uneven surfaces with inversion and eversion [rx, rx, rx].

The epidemiology of tarsal fractures is as follows

• Tarsal fractures account for 2% of all fractures.
• Calcaneal fractures account for 50-60% of all fractured tarsal bones.
• Less than 10% present as open fractures.
• Traditionally, there is a male predominance of injuries due to the industrial nature of the accidents. Recent studies suggest regional variation in male/female predominance due to disparities in the types of regional accident occurrence.
• Most patients with calcaneus fractures are young, with the 20-39 age group the most common.
• Comorbidities such as diabetes and osteoporosis may increase the risk of all types of fractures.
• Calcaneal fractures are rare in children.

Pathophysiology

Falls from a height directly translate energy into the calcaneus on impact as the heel strikes a surface crushing the calcaneus against the talus. The talus acting as a wedge causes depression and the widening of the calcaneal body. [rx][rx]Similarly, a foot depressed against an accelerator, brake or floorboard translates a large amount of force through the calcaneus during high-speed automobile accidents. Fracture patterns are similar in either mechanism. Gunshot wounds and other ballistic injuries cause a more diffuse nonpredictable fracture pattern but remain uncommon. Avulsion fractures require a large amount of twisting or shearing force due to the strength of the ligamentous and tendinous attachments to the calcaneus. The tibial artery and nerve run along the medial aspect of the calcaneal body and are thought to be shielded by the sustentaculum tali thus neurovascular injuries are uncommon with calcaneal fractures.

Types of Calcaneus Fractures

There are two main classification systems of extraarticular fractures.

Essex-Lopresti

• Joint depression type with a single verticle fracture line through the angle of Gissane separating the anterior and posterior portions of the calcaneus.
• Tongue type which has the same verticle fracture line as a depression type with another horizontal fracture line running posteriorly, creating a superior posterior fragment. The tuberosity fragment may then rotate superiorly.

Sanders Classification: Based on reconstituted CT findings

• Type I fractures – 1 nondisplaced or minimally displaced bony fragment
• Type II fractures – 2 bony fragments involving the posterior facet. Subdivided into types A, B, and C depending on the medial or lateral location of the fracture line.
• Type III fractures – 3 bony fragments including an additional depressed middle fragment. Subdivided into types AB, AC, and BC, depending on the position and location of the fracture lines.
• Type IV fractures – 4 comminuted bony fragments.

The Sanders classification system is the most commonly used system for categorizing intra-articular fractures. There are 4 types:

1. Type I fractures are non-displaced fractures (displacement < 2 mm).
2. Type II fractures consist of a single intra-articular fracture that divides the calcaneus into 2 pieces.
   • Type IIA: fracture occurs on lateral aspect of calcaneus.
   • Type IIB: fracture occurs on central aspect of calcaneus.
   • Type IIC: fracture occurs on medial aspect of calcaneus.
3. Type III fractures consist of two intra-articular fractures that divide the calcaneus into 3 articular pieces.
   • Type IIIAB: two fracture lines are present, one lateral and one central.
   • Type IIIAC: two fracture lines are present, one lateral and one medial.
   • Type IIIBC: two fracture lines are present, one central and one medial.
4. Type IV fractures consist of fractures with more than three intra-articular fractures.

Extra-articular fractures include all fractures that do not involve the posterior facet of the subtalar joint.

• Type A involve the anterior calcaneus
• Type B involve the middle calcaneus. This includes the sustentaculum tali, trochlear process and lateral process.
• Type C involve the posterior calcaneus, the posterior tuberosity and medial tubercle included.

Causes of Calcaneus Fractures

Calcaneal fractures most commonly occur during high energy events leading to axial loading of the bone but can occur with any injury to the foot and ankle. [rx][rx]

• Falls from height and automobile accidents – are the predominant mechanisms of injury, although jumping onto hard surfaces, blunt or penetrating trauma and twisting/shearing events may also cause injury. Most of the injuries cause the bone to flatten, widen, and shorten. Stress fractures may occur with overuse or repetitive use, such as running.
• Trips and falls – Losing your balance may lead to trips and falls, which can place excessive weight on your ankle. This might happen if you walk on an uneven surface, wear ill-fitting shoes, or walk around without proper lighting.
• Heavy impact – The force of a jump or fall can result in a broken and causes of fracture. It can happen even if you jump from a low height.
• Missteps – You can break your ankle if you put your foot down awkwardly. Your ankle might twist or roll to the side as you put weight on it.
  Sports – High-impact sports involve intense movements that place stress on the joints, including the calcenious fructure. Examples of high-impact sports include soccer, football, and basketball.
• Car collisions – The sudden, heavy impact of a car accident can cause broken ankles. Often, these injuries need surgical repair. The crushing injuries common in car accidents may cause breaks that require surgical repair.
• Falls – Tripping, and falling can break bones in your ankles, as can landing on your feet after jumping down from just a slight height.
• Missteps – Sometimes just putting your foot down wrong can result in a twisting injury that can cause a broken bone.

Symptoms of Calcaneus Fractures

Calcaneal fractures produce different signs and symptoms, depending on whether they are traumatic or stress fractures. The signs and symptoms of traumatic fractures may include:

• Sudden pain in the heel and inability to bear weight on that foot
• Swelling in the heel area
• Bruising of the heel and ankle
• Generalized pain in the heel area that usually develops slowly (over several days to weeks)
• Swelling in the heel area
• Pain at the site of the fracture, which in some cases can extend from the foot to the knee.
• Significant swelling, which may occur along the length of the leg or may be more localized.
• Blisters may occur over the fracture site. These should be promptly treated by a foot and ankle surgeon.
• Bruising that develops soon after the injury.
• Inability to walk; however, it is possible to walk with less severe breaks, so never rely on walking as a test of whether or not a bone has been fractured.
• Change in the appearance of the ankle—it will look different from the other ankle.
• Bone protruding through the skin—a sign that immediate care is needed. Fractures that pierce the skin require immediate attention because they can lead to severe infection and prolonged recovery.

Diagnosis of Calcaneus Fractures

History and Physical

A traumatic event will almost invariably precede the presentation of calcaneal injury.

• Patients will present with diffuse pain, edema, and ecchymosis at the affected fracture site.
• The patient is not likely able to bear weight.
• Plantar ecchymosis extending through the plantar arch of the foot should raise suspicion significantly.
• There may be associated disability of the Achilles tendon, also raising the suspicion of a calcaneus injury.
• Skin quality around the heel must be evaluated for tenting and/or threatened skin.  This is especially important in the setting of Tongue-type calcaneus fractures.

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Evaluation

Evaluation of a potential calcaneus fracture should include the following:

• Complete neurovascular examination – as well as evaluation of all lower extremity tendon function. Loss of ipsilateral dorsal pedis or posterior tibial pulse compared to contralateral limb should raise suspicion of arterial injury and prompt further investigation with angiography or Doppler scanning.
• Initial bony evaluation – with AP, lateral, and oblique plain films of the foot and ankle is needed. A Harris View may be obtained which demonstrates the calcaneus in an axial orientation. [rx]
• Mondor’s Sign – is a hematoma identified on CT that extends along the sole and is considered pathognomic for calcaneal fracture.
• Stress fractures – such as those seen in runners would be best evaluated with a bone scan or MRI.
• Bohler’s Angle – may be depressed on plain radiographs. Defined as the angle between two lines drawn on plain film. The first line is between the highest point on the tuberosity and the highest point of posterior facet and the second is the highest point on the anterior process and the highest point on the posterior facet. The normal angle is between 20-40 degrees.
• The Critical Angle of Gissane – may be increased. Defined as the angle between two lines drawn on plain film. The first along the anterior downward slope of the calcaneus and the second along the superior upward slope. A normal angle is 130-145 degrees.
• Normal Bohlers and Gissane angles – do not rule out a fracture. Abnormalities of either of these findings should prompt a CT scan for further classification and evaluation of the fracture.
• Stress test – Depending on the type of ankle fracture, the doctor may put pressure on the ankle and take a special x-ray, called a stress test. This x-ray is done to see if certain ankle fractures require surgery.

Calcaneal fractures can be classified into two general categories.[rx][rx]

• Extraarticular fractures – account for 25 % of calcaneal fractures. These typically are avulsion injuries of either the calcaneal tuberosity from the Achilles tendon, the anterior process from the bifurcate ligament, or the sustentaculum tali.
• Intraarticular Fractures – account for the remaining 75%. The talus acts as a hammer or wedge compressing the calcaneus at the angle of Gissane causing the fracture.
• Noncontrast computed tomography – remains the gold standard for traumatic calcaneal injuries. CT scan is used for preoperative planning, classification of fracture severity, and in instances where the index of suspicion for a calcaneal fracture is high despite negative initial plain radiographs (2 to 3-mm cuts are recommended).
• X-rays – This test is the most common and widely available diagnostic imaging technique. X-rays create images of dense structures, such as bone. An x-ray can show if your calcaneus is broken and whether the bones are displaced.
• Computed tomography (CT) scans – Because of the complex anatomy of the calcaneus, a CT scan is routinely ordered after a fracture has been diagnosed on x-ray. A CT scan will produce a more detailed, cross-sectional image of your foot and can provide your doctor with valuable information about the severity of your fracture. This information will help your doctor recommend the best plan for treatment.

Treatment of Calcaneus Fractures

Initial treatment includes

• Get medical help immediately – If you fall on an outstretched arm, get into a car accident or are hit while playing a sport and feel intense pain in your leg area, then get medical care immediately. Cause significant pain in the front part of your leg closer to the base of your leg. You’ll innately know that something is seriously wrong because you won’t be able to lift your arm up above the heart level. Cleaning and treating any wounds on the skin of the injured hand.
• Aggressive wound care – as needed for contaminated wounds. Clear with disinfectant material [rx]
• ICE and elevation – It help for prevention swelling, edema
• Splinting – Bulky Jones type splints are commonly applied.
• Weight-bearing by others person or cratch – All patients who are candidates for outpatient treatment are non-weight bearing at discharge.
• Rest, compression, and elevation (RICE) – Rest (staying off the injured foot) is needed to allow the fracture to heal. Ice reduces swelling and pain; apply a bag of ice covered with a thin towel to the affected area. Compression (wrapping the foot in an elastic bandage or wearing a compression stocking) and elevation (keeping the foot even with or slightly above the heart level) also reduce the swelling.
• Immobilization – Sometimes the foot is placed in a cast or cast boot to keep the fractured bone from moving. Crutches may be needed to avoid weight-bearing. For traumatic fractures, treatment often involves surgery to reconstruct the joint, or in severe cases, to fuse the joint. The surgeon will choose the best surgical approach for the patient.
• Get a referral to physical therapy – Once you’ve recovered and able to remove your arm sling splint for good, you’ll likely notice that the muscles surrounding your ankle fracture look smaller and feel weaker. That’s because muscle tissue atrophies without movement. If this occurs, then you’ll need to get a referral for some physical rehabilitation. Rehab can start once you are cleared by your orthopedist, are pain-free, and can perform all the basic arm and phalanges movements. A physiotherapist or athletic trainer can show you specific rehabilitation exercises and stretches to restore your muscle strength, joint movements, and flexibility
• Taping the hand – as a type of soft splint, with the pinky and ring finger, taped together to help in healing correction of the dislocated bone, which may be done with anesthesia.
• Eat Nutritiously During Your Recovery – All bones and tissues in the body need certain nutrients in order to heal properly and in a timely manner. Eating a nutritious and balanced diet that includes lots of minerals and vitamins is proven to help heal broken bones of all types, including. Therefore, focus on eating lots of fresh produce (fruits and veggies), whole grains, lean meats, and fish to give your body the building blocks needed to properly repair your. In addition, drink plenty of purified water, milk, and other dairy-based beverages to augment what you eat.
  • Broken bones need ample minerals (calcium, phosphorus, magnesium, boron) and protein to become strong and healthy again.
  • Excellent sources of minerals/protein include dairy products, tofu, beans, broccoli, nuts and seeds, sardines, and salmon.
  • Important vitamins that are needed for bone healing include vitamin C (needed to make collagen), vitamin D (crucial for mineral absorption), and vitamin K (binds calcium to bones and triggers collagen formation).
  • Conversely, don’t consume food or drink that is known to impair bone/tissue healing, such as alcoholic beverages, sodas, most fast food items, and foods made with lots of refined sugars and preservatives.

Closed fractures

• All surgical treatment is aimed at restoration of heel height and width (i.e., reconstructing the anatomy to reapproximate Bohler and Gissane angles), repair and realignment of the subtalar joint, and returning the mechanical axis of the hindfoot to functionality.
• Most extraarticular fractures are treated conservatively with 10-12 weeks of casting (true extra-articular fractures only account for roughly 20% of all calcaneal fractures)
• Calcaneal tuberosity avulsion displaced sustentaculum tali, and large substantial calcaneal body fractures may require operative management.
• Some intraarticular injuries may be treated in a closed fashion depending upon severity. Many are treated with either open surgical reduction and internal fixation, percutaneous pinning, or sometimes arthrodesis.
• Nondisplaced Sanders type I fractures may be treated in a conservative, closed fashion.

Medication

The following medications may be considered doctor to relieve acute and immediate pain

• Antibiotic – Cefuroxime or Azithromycin, or  Flucloxacillin or any others cephalosporin/quinolone antibiotic must be used to prevent infection or clotted blood remove to prevent furthers swelling and edema
•  Antidepressants – A drug that blocks pain messages from your brain and boosts the effects of endorphins (your body’s natural painkillers).
• Corticosteroids – Also known as oral steroids, these medications reduce inflammation. To healing the nerve inflammation and clotted blood in the joints.
• Muscle Relaxants –  These medications provide relief from associated muscle spasms.
• Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, and tingling.
• Opioids – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
• Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
• NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include  and Ketorolac, Aceclofenac, naproxen
• Calcium & vitamin D3 – to improve bone health and healing fracture.
• Glucosamine & Diacerein, Chondroitin sulfate – can be used to tightening the loose tension, cartilage, ligament, and cartilage, ligament regenerate cartilage or inhabit the further degeneration of cartilage, ligament
• Dietary supplement -to remove general weakness & improved health

Surgical Treatment

When surgical management is recommended it is with the goal to restore calcaneal morphology and to restore articular congruency.  The decision to move forward with surgery must be based on fully informed consent of the abundant risks and expected benefits of surgery and must involve the patient in shared decision making as the operative intervention for calcaneal fractures is fraught with complications.

Surgical treatment must be delayed until the so-called, “wrinkle sign,” returns.  This will usually occur five to ten days following the injury. Furthermore, all serous and hemorrhagic blisters must be epithelialized.  [rx] Sanders et all describe that the soft tissue swelling may take up to 21 days to resolve and that surgery should not proceed until this has occurred. [rx]

Surgical intervention is typically recommended for the following indications: [rx]

• Displaced tongue type Fractures
• Joint depression with articular comminution or anterior process involvement
• Bohler’s angle of <5 degrees on initial presentation
• Fracture Dislocation
• Anterior process fractures with >25% of the calcaneocuboid articulation involved
• Calcaneal body fractures with significant varus or valgus malalignment, lateral impingement, loss of calcaneal height, or significant translation of the posterior tuberosity.

 Cast immobilization with non-weightbearing for 6 weeks

• techniques:standard short-leg cast for calcaneal stress fractures non weight bearing cast well-padded heel

Cast immobilization with non weightbearing for 10-12 weeks

• techniques:standard short-leg cast applied with mild equinus windowed over posterior heel to allow for frequent skin checks  requires close follow-up to determine if pull of gastrocnemius-soleus dispaces fracture weekly cast changes are necessary due to high incidence of skin complications high incidence of vascular insufficiency and diabetes in this population

Closed reduction and percutaneous pinning

• ideal for poor soft tissue coverage or patients with peripheral vascular disease
• Steinmann pin placed into the fracture site anteromedially-to-posterolateral to leverage fragments into place additional K-wires and Steinmann pins are placed from posterior-to-anterior and lateral-to-medial to secure remaining bone fragments
• calcaneal transfixing pin can be used to distract fracture
• percutaneous tamps and elevators can be used to raise the articular surface
• pins are cut flush with the skin and removed 8-10 weeks post-op
• can be combined with a distracting external fixator
  • pins placed in calcaneal tuberosity, cuboid, and distal tibia
  • restore calcaneal height, width, and alignment
  • can be combined with percutaneous cannulated screw

ORIF

Extensile lateral or medial approach

• full-thickness skin, soft tissue, and periosteal flaps are developed
  • flap supplied by lateral calcaneal branch of peroneal artery
  • superior flap contains the calcaneofibular ligaments and peroneal tendon sheath

• sural nerve and peroneal tendons are retracted superiorly
• lateral calcaneal wall visualized
• fracture opened and medial wall reduced going medial to lateral reduction confirmed indirectly via fluoroscopy
• tuberosity reduction is done under direct visualization
  • manual traction, Schanz pins, and minidistractors
    • pin in tuberosity aids with the reduction
  • height and length of tuberosity is recreated
  • quality of reduction affects outcomes

• provisional fixtaion was K-wires
• definitive fixation with plates and screws

Extensile lateral L-shaped incision is the most popular 

• vertical portion between posterio fibula and achilles tendon
• the horizontal portion in line with 5th metatarsal base
• a more inferior incision protects the sural nerve
• high rate of wound complications
• provides access to the calcaneocuboid and subtalar joints
• bone grafting provided no added benefit
  • restore congruity of subtalar joint
  • restore Böhler’s angle and calcaneal height
  • restore width
  • correct varus malalignment

Sinus tarsi approach

• minimally invasive incision that minimizes soft tissue dissesction
• reduces wound complications associated with extensile lateral incision
• allows direct visualization of the posterior facet, anterolateral fragment, and lateral wall
• lower incidence of sural nerve neuralgia
• same incision can be utilized for secondary subtalar arthrodesis or peroneal tendon debridement
• decreased surgical time
• patient placed in lateral decubitus position incision made in line with the tip of the fibula and the base of the 4th metatarsal

2-4 cm in length

• extensor digitorum brevis retracted cephalad to expose sinus tarsi and posterior facet
• peroneal tendons retracted posteriorly
• Schanz pin inserted percutaneously in posteroinferior tuberosity going from lateral to medial
• provides distraction and aids with reduction
• fibrous debris and fat removed from sinus tarsi
• small elevator or lamina spreader placed under posterior facet fragment to aid in reduction
• K-wires inserted for provisional fixation aimed towards the sustentaculum
• two screws are placed lateral-to-medial to engage sustentaculum and support facet
• one large fully threaded screw from posterior-to-anterior to support axial length of calcaneus
• the low-profile plate is applied underneath a well developed soft tissue envelope with screws engaging anterolateral and tuberosity fragments
• non weight bearing for 6-8 weeks post-op with ankle range-of-motion exercises beginning 2 weeks post-op

Essex-Lopresti manuever

• manipulate the heel to increase the calcaneal varus deformity
• plantarflex the forefoot
• manipulate the heel to correct the varus deformity with a valgus reduction

Stabilize the reduction with percutaneous K-wires or open fixation as described above arthroscopic-assisted reduction and internal fixation

• increased set-up increased swelling from fluid extravasation technically challenging
• can be combined with sinus tarsi approach
• fluoroscopy unit positioned posterior and oblique to patient
• allows for axial hindfoot views anterolateral and posterolateral portals are used to visualize posterior facet 2.4 mm 0° arthroscope
• patient positioned in the lateral decubitus position
• an interosseous ligament is preserved
• hematoma is irrigated
• loose bodies and cartilage fragments are removed with a shaver
• Freer elevator is introduced into one of the portal sites and used to elevate the posterior facet reduction can be visualized directly
• Schanz pin to control tuberosity fragment
• cannulated screws from the posterior aspect of the calcaneal tuberosity to the anterior aspect of the calcaneus
• restores and stabilizes length
• lateral-to-medial screws placed in sustentaculum
• buttress screw from the posterior aspect of the calcaneal tuberosity to the subchondral bone of the posterior facetposterior approach for calcaneal tuberosity fractures
  • patient positioned prone on table
  • posterior midline incision
  • fracture fragment is mobilized and debrided
  • plantar flexion of foot aids with reduction
    • presence of gastrocnemius tightness may preclude reduction
      • Strayer procedure may be performed to aid in the reduction
  • provisional fixation with K-wires
  • final fixation with either lag screws tension-band constructs figure-of-8 tension-band wire passed around ends of K-wires or cannulated screws suture fixation Krackow sutures passing through bone tunnels
  • restricted weight-bearing for 6 weeks followed by a progression of weight bearing an additional 6 weeks

• decreased soft-tissue dissection
• preservation of local blood supply
• removal of loose bone fragments
• improved visualization of the articular surface and cartilage lesions

Physical Therapy Management

After the surgery, active range of motion exercises may be practiced with small amounts of movement for all joints of the foot and ankle. These exercises are used to maintain and regain the ankle joint movement. When needed for the involved lower extremity, the patient may continue with elevation, icing and compression. During the therapy, the patient will progress to gradual weight-bearing. Patients may find this very difficult and painful. The physiotherapist conducts joint mobilization to all hypermobile joints.

During the treatment, progressive resisted strengthening of the gastrocnemius muscles is done by weighted exercises, toe-walking, ascending and descending stairs and plyometric exercises. When the fracture is healed, the physiotherapist will progress the weight-bearing in more stressful situations. This therapy consists of gait instruction and balance practice on different surfaces.

These are some outcome measures that can be used to measure the functional abilities of the patient to see the prognosis which can be used during the rehabilitation period.

• Lower Extremity Functional Scale (LEFS)
• Foot and Ankle Ability Measure (FAAM)

Pre-Surgery

Initial stability is essential for open reduction internal fixation of intraarticular calcaneal fractures.

Preoperative revalidation consist of:
• Immediate elevation of the affected foot to reduce swelling.
• Compression such as foot pump, intermittent compression devices, or compression wraps as tolerable.
• Instructions for using wheelchair, bed transfers, or crutch walking.

Post-Surgery

Both the progression of nonoperative and postoperative management of calcaneal fractures include traditional immobilization and early motion rehabilitation protocols. In fact, the traditional immobilization protocols of nonoperative and postoperative management are similar, and are thereby combined in the progression below. ^[2] Phases II and III of traditional and early motion rehabilitation protocols after nonoperative or postoperative care are comparable as well and are described together below. 

Phase I: Weeks 1-4

Goals:

• Control oedema and pain
• Prevent extension of fracture or loss of surgical stabilization
• Minimize loss of function and cardiovascular endurance

Intervention:

• Cast with the ankle in neutral and sometimes slight eversion,
• Elevation
• Toe curl and active ankle joint (dorsiflexion and plantarflexion)-encourage to do from the first post-operative day.
• After 2-4 days, instruct in non-weight bearing ambulation utilizing crutches or walker-crutch walking training
• Instruct in wheelchair use with an appropriate sitting schedule to limit time involved extremity spends in dependent-gravity position
• Instruct in comprehensive exercise and cardiovascular program utilizing upper extremities and uninvolved lower extremity
• Strengthening adjacent joint musculature ( hip and knee)

Phase II: Weeks 5-8

Goals:

• Control remaining or residual oedema and pain
• Prevent re-injury or complication of fracture by progressing weight-bearing safely
• Prevent contracture and regain motion at ankle/foot joints
• Minimize loss of function and cardiovascular endurance

Intervention:

• Continued elevation, icing, and compression as needed for involved lower extremity.
• After 6-8 weeks, instruct in partial-weight bearing ambulation utilizing crutches or walker
• Initiate vigorous exercise and range of motion to regain and maintain motion at all joints: tibiotalar, subtalar, midtarsal, and toe joints, including active range of motion in large amounts of movement and progressive isometric or resisted exercises
• Progress and monitor comprehensive upper extremity and cardiovascular program

Phase III: Weeks 9-12

Goals:

• Progress weight-bearing status
• Normal gait on all surfaces
• Restore full range of motion
• Restore full strength
• Allow return to previous work status

Intervention:

• After 9-12 weeks, instruct in normal full-weight bearing ambulation with the appropriate assistive device as needed
• Progress and monitor the subtalar joint’s ability to adapt for ambulation on all surfaces, including graded and uneven surfaces
• Joint mobilization to all hypomobile joints including: tibiotalar, subtalar, midtarsal, and to toe joints
• Soft tissue mobilization to hypomobile tissues of the gastrocnemius complex, plantar fascia, or other appropriate tissues
• Progressive resisted strengthening of gastrocnemius complex through the use of pulleys, weighted exercise, toe-walking ambulation, ascending/descending stairs, skipping or other plyometric exercise, pool exercises, and other climbing activities
• Work hardening program or activities to allow return to work between 13- 52 weeks.

Implant Removal:

Implant removal 1 year after plate fixation is only advocated in cases of protruding hardware or massive arthrofibrosis with limited range of motion, mostly after plate fixation through extensile approaches. Implant removal is combined with intraarticular arthrolysis and debridement employing subtalar arthroscopy

Complications

Due to the severe nature and the force required to sustain calcaneal fractures concomitant injuries must be considered.[rx][rx] Studies have shown greater than 70% of patients with calcaneus fractures have additional injuries.

• A thorough evaluation – of the entire spine should be performed anytime a calcaneal fracture is identified especially when a fall is a mechanism. The force from impacting the ground translates through the lower extremity and upward sometimes causing spinal compression fractures.
• Compartment syndrome – of the foot is a rare but severely debilitating complication of calcaneal fractures and can occur in up to 10% of the injuries. A high index of suspicion is needed in considering patients presenting with increased pain either after treatment or during the initial evaluation.
• Osteomyelitis, postoperative wound infection, malunion, and subtalar arthritis – are all potential complications of calcaneal fractures and repair.
• Infections and wound breakdown – are the most common and devastating complications of the extensile lateral approach.  Wound complications and infections can be as high as 37% and 20% respectively with operative intervention. [rx]
• Subtalar osteoarthritis – may result from surgical or nonsurgical treatment with an increasing number of patients with non-operatively treated displaced intra-articular calcaneus fractures requiring late subtalar fusion as a result of subtalar arthritis. [rx]  Another study found that non-operative measures were up to 6 times more likely to lead to a late subtalar fusion due to symptomatic subtalar arthritis. [rx]This is considered post-traumatic arthritis. Loss of subtalar motion is very common as well.
• Sural nerve injury – may result in up to 15% of cases treated operatively (more often with the extensile lateral approach). The risk is reduced with a more inferiorly based L-incision. [rx]
• Chronic pain – is also a common complication, in many cases owing to post-traumatic subtalar arthritis, malalignment or stiffness resulting from the injury.
• Wound Healing Problems – Although seen with any surgical procedure, wound healing complications are particularly concerning following calcaneal fracture surgery. The area around the outside of the heel has relatively thin skin and limited soft-tissue coverage. This can make wound healing problems more likely following calcaneal fracture surgery, and potentially more severe if they do develop. Wound healing problems are increased significantly for smokers and diabetics.
• Infection – Infections can create a major problem if they occur following a calcaneal fracture. As a result of the limited soft-tissue covering the outside of the heel, a superficial wound infection can quickly spread down to the underlying bone. If an infection develops, your surgeon may recommend the use of oral or intravenous antibiotics. A repeat trip to the operating room may be required.
• Subtalar Arthritis – Painful subtalar arthritis and stiffness of the hindfoot is common following calcaneal fractures. This occurs as a result of the damage to the cartilage at the time of the initial injury.
• Painful Hardware – Pain may be associated with the screws and plates used to align and secure the broken bone fragments. This occurs in about 10-20% of patients who have had surgical stabilization of a calcaneus fracture. Your doctor will help you determine if hardware removal is required.
• Peroneal tendon instability – may result from displaced, intra-articular calcaneus fractures.  [rx]  This may result from direct damage to the tendons themselves as a result of the injury or fracture fragments that may impinge on the tendons.  Up to a 40% displacement of the peroneal tendons has been appreciated on CT scans of calcaneus fractures. [rx].  Furthermore, with significant height loss, calcaneal widening and hindfoot varus subfibular impingement may result from soft tissue or osseous abnormalities.  Subfibular impingement may result in lateral heel pain, particularly with eversion of the hindfoot. Techniques have been described to perform percutaneous calcaneal osteotomy and peroneal tendon decompression to try to alleviate subfibular impingement after calcaneal malunion. [rx]

Postoperative and Rehabilitation Care

• Immediately post-operatively – the patient’s foot and ankle should be placed into an extremely well-padded posterior splint.
• Drains are typically removed–  on postoperative day 2 or even earlier based on surgeon preference.
• The patient should be adequately educated – on the need to elevate the extremity for the first several weeks after surgery to reduce swelling and the subsequent risk of wound complications.
• The splint – may be removed as early as 2-5 days based on some recommendations or left in place for 2 weeks in some cases, but after removing the splint the patient should begin his or her range of motion exercises for the subtalar joint and ankle joint as soon as possible.
• Weight-bearing – is often delayed 8-12 weeks (or more depending on the degree of comminution and progression of healing on radiographs).
• Routine serial radiographs – should be obtained to ensure the progression of healing.
• Early motion. Many doctors encourage motion of the foot and ankle early in the recovery period. For example, you may be instructed to begin moving the affected area as soon as your pain allows. If you have had surgery, you may be instructed to begin moving the affected area as soon as the wound heals to your doctor’s satisfaction.
• Physical therapy. Specific exercises can help improve the range of motion in your foot and ankle and strengthen supporting muscles. Although they are often painful at the beginning and progress may be difficult, exercises are required in order for you to resume normal activities.
• Weight-bearing. When you begin walking, you may need to use crutches, a cane, or a walker and/or wear a special boot. It is very important to follow your doctor’s instructions for walking on your foot. If you put weight on your foot too soon, the bone pieces may move out of place and you might require surgery. If you have had surgery, the screws might loosen or break and the bone may collapse. This may not occur the first time you walk on it but, if the bone is not healed and you continue to bear weight, the metal will eventually break.

References

What Is Calcaneus Fractures?/Calcaneus fractures are rare but potentially debilitating injuries. The calcaneus is one of seven tarsal bones and is part of the hind-foot which includes the calcaneus and the talus. The hindfoot articulates with the tibia and fibula creating the ankle joint. The subtalar or calcaneotalar joint accounts for at least some foot and ankle dorsal/plantar flexion. Calcaneal anatomy is demonstrated in Figure 1. Historically a burst fracture of the calcaneus was coined a”Lovers Fracture” as the injury would occur as a suitor would jump off a lover’s balcony to avoid detection. [rx][rx][rx]

Calcaneus fractures often results in a varus deformity with heel widening, loss of calcaneal height, and subtalar joint incongruency. ORIF can be used to address deformities, restoring the anatomic morphology of the calcaneus, and thereby the biomechanics and function of the hindfoot. Restoring heel width prevents chronic peroneal tendenitis secondary to impingement from lateral wall blowout of the calcaneus, and restoring the length and alignment of the Achilles tendon maintains plantar flexion strength [rx, rx, rx]. ORIF also provides the opportunity for anatomic reduction and rigid internal fixation of the subtalar joint. Normal subtalar motion is integral for the foot to adapt on uneven surfaces with inversion and eversion [6, 20, 29].

The epidemiology of tarsal fractures is as follows

• Tarsal fractures account for 2% of all fractures.
• Calcaneal fractures account for 50-60% of all fractured tarsal bones.
• Less than 10% present as open fractures.
• Traditionally, there is a male predominance of injuries due to the industrial nature of the accidents. Recent studies suggest regional variation in male/female predominance due to disparities in the types of regional accident occurrence.
• Most patients with calcaneus fractures are young, with the 20-39 age group the most common.
• Comorbidities such as diabetes and osteoporosis may increase the risk of all types of fractures.
• Calcaneal fractures are rare in children.

Pathophysiology

Falls from a height directly translate energy into the calcaneus on impact as the heel strikes a surface crushing the calcaneus against the talus. The talus acting as a wedge causes depression and the widening of the calcaneal body. [rx][rx]Similarly, a foot depressed against an accelerator, brake or floorboard translates a large amount of force through the calcaneus during high-speed automobile accidents. Fracture patterns are similar in either mechanism. Gunshot wounds and other ballistic injuries cause a more diffuse nonpredictable fracture pattern but remain uncommon. Avulsion fractures require a large amount of twisting or shearing force due to the strength of the ligamentous and tendinous attachments to the calcaneus. The tibial artery and nerve run along the medial aspect of the calcaneal body and are thought to be shielded by the sustentaculum tali thus neurovascular injuries are uncommon with calcaneal fractures.

Types of Calcaneus Fractures

There are two main classification systems of extraarticular fractures.

Essex-Lopresti

• Joint depression type with a single verticle fracture line through the angle of Gissane separating the anterior and posterior portions of the calcaneus.
• Tongue type which has the same verticle fracture line as a depression type with another horizontal fracture line running posteriorly, creating a superior posterior fragment. The tuberosity fragment may then rotate superiorly.

Sanders Classification: Based on reconstituted CT findings

• Type I fractures – 1 nondisplaced or minimally displaced bony fragment
• Type II fractures – 2 bony fragments involving the posterior facet. Subdivided into types A, B, and C depending on the medial or lateral location of the fracture line.
• Type III fractures – 3 bony fragments including an additional depressed middle fragment. Subdivided into types AB, AC, and BC, depending on the position and location of the fracture lines.
• Type IV fractures – 4 comminuted bony fragments.

The Sanders classification system is the most commonly used system for categorizing intra-articular fractures. There are 4 types:

1. Type I fractures are non-displaced fractures (displacement < 2 mm).
2. Type II fractures consist of a single intra-articular fracture that divides the calcaneus into 2 pieces.
   • Type IIA: fracture occurs on lateral aspect of calcaneus.
   • Type IIB: fracture occurs on central aspect of calcaneus.
   • Type IIC: fracture occurs on medial aspect of calcaneus.
3. Type III fractures consist of two intra-articular fractures that divide the calcaneus into 3 articular pieces.
   • Type IIIAB: two fracture lines are present, one lateral and one central.
   • Type IIIAC: two fracture lines are present, one lateral and one medial.
   • Type IIIBC: two fracture lines are present, one central and one medial.
4. Type IV fractures consist of fractures with more than three intra-articular fractures.

Extra-articular fractures include all fractures that do not involve the posterior facet of the subtalar joint.

• Type A involve the anterior calcaneus
• Type B involve the middle calcaneus. This includes the sustentaculum tali, trochlear process and lateral process.
• Type C involve the posterior calcaneus, the posterior tuberosity and medial tubercle included.

Causes of Calcaneus Fractures

Calcaneal fractures most commonly occur during high energy events leading to axial loading of the bone but can occur with any injury to the foot and ankle. [rx][rx]

• Falls from height and automobile accidents – are the predominant mechanisms of injury, although jumping onto hard surfaces, blunt or penetrating trauma and twisting/shearing events may also cause injury. Most of the injuries cause the bone to flatten, widen, and shorten. Stress fractures may occur with overuse or repetitive use, such as running.
• Trips and falls – Losing your balance may lead to trips and falls, which can place excessive weight on your ankle. This might happen if you walk on an uneven surface, wear ill-fitting shoes, or walk around without proper lighting.
• Heavy impact – The force of a jump or fall can result in a broken and causes of fracture. It can happen even if you jump from a low height.
• Missteps – You can break your ankle if you put your foot down awkwardly. Your ankle might twist or roll to the side as you put weight on it.
  Sports – High-impact sports involve intense movements that place stress on the joints, including the calcenious fructure. Examples of high-impact sports include soccer, football, and basketball.
• Car collisions – The sudden, heavy impact of a car accident can cause broken ankles. Often, these injuries need surgical repair. The crushing injuries common in car accidents may cause breaks that require surgical repair.
• Falls – Tripping, and falling can break bones in your ankles, as can landing on your feet after jumping down from just a slight height.
• Missteps – Sometimes just putting your foot down wrong can result in a twisting injury that can cause a broken bone.

Symptoms of Calcaneus Fractures

Calcaneal fractures produce different signs and symptoms, depending on whether they are traumatic or stress fractures. The signs and symptoms of traumatic fractures may include:

• Sudden pain in the heel and inability to bear weight on that foot
• Swelling in the heel area
• Bruising of the heel and ankle
• Generalized pain in the heel area that usually develops slowly (over several days to weeks)
• Swelling in the heel area
• Pain at the site of the fracture, which in some cases can extend from the foot to the knee.
• Significant swelling, which may occur along the length of the leg or may be more localized.
• Blisters may occur over the fracture site. These should be promptly treated by a foot and ankle surgeon.
• Bruising that develops soon after the injury.
• Inability to walk; however, it is possible to walk with less severe breaks, so never rely on walking as a test of whether or not a bone has been fractured.
• Change in the appearance of the ankle—it will look different from the other ankle.
• Bone protruding through the skin—a sign that immediate care is needed. Fractures that pierce the skin require immediate attention because they can lead to severe infection and prolonged recovery.

Diagnosis of Calcaneus Fractures

History and Physical

A traumatic event will almost invariably precede the presentation of calcaneal injury.

• Patients will present with diffuse pain, edema, and ecchymosis at the affected fracture site.
• The patient is not likely able to bear weight.
• Plantar ecchymosis extending through the plantar arch of the foot should raise suspicion significantly.
• There may be associated disability of the Achilles tendon, also raising the suspicion of a calcaneus injury.
• Skin quality around the heel must be evaluated for tenting and/or threatened skin.  This is especially important in the setting of Tongue-type calcaneus fractures.

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Evaluation

Evaluation of a potential calcaneus fracture should include the following:

• Complete neurovascular examination – as well as evaluation of all lower extremity tendon function. Loss of ipsilateral dorsal pedis or posterior tibial pulse compared to contralateral limb should raise suspicion of arterial injury and prompt further investigation with angiography or Doppler scanning.
• Initial bony evaluation – with AP, lateral, and oblique plain films of the foot and ankle is needed. A Harris View may be obtained which demonstrates the calcaneus in an axial orientation. [rx]
• Mondor’s Sign – is a hematoma identified on CT that extends along the sole and is considered pathognomic for calcaneal fracture.
• Stress fractures – such as those seen in runners would be best evaluated with a bone scan or MRI.
• Bohler’s Angle – may be depressed on plain radiographs. Defined as the angle between two lines drawn on plain film. The first line is between the highest point on the tuberosity and the highest point of posterior facet and the second is the highest point on the anterior process and the highest point on the posterior facet. The normal angle is between 20-40 degrees.
• The Critical Angle of Gissane – may be increased. Defined as the angle between two lines drawn on plain film. The first along the anterior downward slope of the calcaneus and the second along the superior upward slope. A normal angle is 130-145 degrees.
• Normal Bohlers and Gissane angles – do not rule out a fracture. Abnormalities of either of these findings should prompt a CT scan for further classification and evaluation of the fracture.
• Stress test – Depending on the type of ankle fracture, the doctor may put pressure on the ankle and take a special x-ray, called a stress test. This x-ray is done to see if certain ankle fractures require surgery.

Calcaneal fractures can be classified into two general categories.[rx][rx]

• Extraarticular fractures – account for 25 % of calcaneal fractures. These typically are avulsion injuries of either the calcaneal tuberosity from the Achilles tendon, the anterior process from the bifurcate ligament, or the sustentaculum tali.
• Intraarticular Fractures – account for the remaining 75%. The talus acts as a hammer or wedge compressing the calcaneus at the angle of Gissane causing the fracture.
• Noncontrast computed tomography – remains the gold standard for traumatic calcaneal injuries. CT scan is used for preoperative planning, classification of fracture severity, and in instances where the index of suspicion for a calcaneal fracture is high despite negative initial plain radiographs (2 to 3-mm cuts are recommended).
• X-rays – This test is the most common and widely available diagnostic imaging technique. X-rays create images of dense structures, such as bone. An x-ray can show if your calcaneus is broken and whether the bones are displaced.
• Computed tomography (CT) scans – Because of the complex anatomy of the calcaneus, a CT scan is routinely ordered after a fracture has been diagnosed on x-ray. A CT scan will produce a more detailed, cross-sectional image of your foot and can provide your doctor with valuable information about the severity of your fracture. This information will help your doctor recommend the best plan for treatment.

Treatment of Calcaneus Fractures

Initial treatment includes

• Get medical help immediately – If you fall on an outstretched arm, get into a car accident or are hit while playing a sport and feel intense pain in your leg area, then get medical care immediately. Cause significant pain in the front part of your leg closer to the base of your leg. You’ll innately know that something is seriously wrong because you won’t be able to lift your arm up above the heart level. Cleaning and treating any wounds on the skin of the injured hand.
• Aggressive wound care – as needed for contaminated wounds. Clear with disinfectant material [rx]
• ICE and elevation – It help for prevention swelling, edema
• Splinting – Bulky Jones type splints are commonly applied.
• Weight-bearing by others person or cratch – All patients who are candidates for outpatient treatment are non-weight bearing at discharge.
• Rest, compression, and elevation (RICE) – Rest (staying off the injured foot) is needed to allow the fracture to heal. Ice reduces swelling and pain; apply a bag of ice covered with a thin towel to the affected area. Compression (wrapping the foot in an elastic bandage or wearing a compression stocking) and elevation (keeping the foot even with or slightly above the heart level) also reduce the swelling.
• Immobilization – Sometimes the foot is placed in a cast or cast boot to keep the fractured bone from moving. Crutches may be needed to avoid weight-bearing. For traumatic fractures, treatment often involves surgery to reconstruct the joint, or in severe cases, to fuse the joint. The surgeon will choose the best surgical approach for the patient.
• Get a referral to physical therapy – Once you’ve recovered and able to remove your arm sling splint for good, you’ll likely notice that the muscles surrounding your ankle fracture look smaller and feel weaker. That’s because muscle tissue atrophies without movement. If this occurs, then you’ll need to get a referral for some physical rehabilitation. Rehab can start once you are cleared by your orthopedist, are pain-free, and can perform all the basic arm and phalanges movements. A physiotherapist or athletic trainer can show you specific rehabilitation exercises and stretches to restore your muscle strength, joint movements, and flexibility
• Taping the hand – as a type of soft splint, with the pinky and ring finger, taped together to help in healing correction of the dislocated bone, which may be done with anesthesia.
• Eat Nutritiously During Your Recovery – All bones and tissues in the body need certain nutrients in order to heal properly and in a timely manner. Eating a nutritious and balanced diet that includes lots of minerals and vitamins is proven to help heal broken bones of all types, including. Therefore, focus on eating lots of fresh produce (fruits and veggies), whole grains, lean meats, and fish to give your body the building blocks needed to properly repair your. In addition, drink plenty of purified water, milk, and other dairy-based beverages to augment what you eat.
  • Broken bones need ample minerals (calcium, phosphorus, magnesium, boron) and protein to become strong and healthy again.
  • Excellent sources of minerals/protein include dairy products, tofu, beans, broccoli, nuts and seeds, sardines, and salmon.
  • Important vitamins that are needed for bone healing include vitamin C (needed to make collagen), vitamin D (crucial for mineral absorption), and vitamin K (binds calcium to bones and triggers collagen formation).
  • Conversely, don’t consume food or drink that is known to impair bone/tissue healing, such as alcoholic beverages, sodas, most fast food items, and foods made with lots of refined sugars and preservatives.

Closed fractures

• All surgical treatment is aimed at restoration of heel height and width (i.e., reconstructing the anatomy to reapproximate Bohler and Gissane angles), repair and realignment of the subtalar joint, and returning the mechanical axis of the hindfoot to functionality.
• Most extraarticular fractures are treated conservatively with 10-12 weeks of casting (true extra-articular fractures only account for roughly 20% of all calcaneal fractures)
• Calcaneal tuberosity avulsion displaced sustentaculum tali, and large substantial calcaneal body fractures may require operative management.
• Some intraarticular injuries may be treated in a closed fashion depending upon severity. Many are treated with either open surgical reduction and internal fixation, percutaneous pinning, or sometimes arthrodesis.
• Nondisplaced Sanders type I fractures may be treated in a conservative, closed fashion.

Medication

The following medications may be considered doctor to relieve acute and immediate pain

• Antibiotic – Cefuroxime or Azithromycin, or  Flucloxacillin or any others cephalosporin/quinolone antibiotic must be used to prevent infection or clotted blood remove to prevent furthers swelling and edema
•  Antidepressants – A drug that blocks pain messages from your brain and boosts the effects of endorphins (your body’s natural painkillers).
• Corticosteroids – Also known as oral steroids, these medications reduce inflammation. To healing the nerve inflammation and clotted blood in the joints.
• Muscle Relaxants –  These medications provide relief from associated muscle spasms.
• Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, and tingling.
• Opioids – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
• Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
• NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include  and Ketorolac, Aceclofenac, naproxen
• Calcium & vitamin D3 – to improve bone health and healing fracture.
• Glucosamine & Diacerein, Chondroitin sulfate – can be used to tightening the loose tension, cartilage, ligament, and cartilage, ligament regenerate cartilage or inhabit the further degeneration of cartilage, ligament
• Dietary supplement -to remove general weakness & improved health

Surgical Treatment

When surgical management is recommended it is with the goal to restore calcaneal morphology and to restore articular congruency.  The decision to move forward with surgery must be based on fully informed consent of the abundant risks and expected benefits of surgery and must involve the patient in shared decision making as the operative intervention for calcaneal fractures is fraught with complications.

Surgical treatment must be delayed until the so-called, “wrinkle sign,” returns.  This will usually occur five to ten days following the injury. Furthermore, all serous and hemorrhagic blisters must be epithelialized.  [rx] Sanders et all describe that the soft tissue swelling may take up to 21 days to resolve and that surgery should not proceed until this has occurred. [rx]

Surgical intervention is typically recommended for the following indications: [rx]

• Displaced tongue type Fractures
• Joint depression with articular comminution or anterior process involvement
• Bohler’s angle of <5 degrees on initial presentation
• Fracture Dislocation
• Anterior process fractures with >25% of the calcaneocuboid articulation involved
• Calcaneal body fractures with significant varus or valgus malalignment, lateral impingement, loss of calcaneal height, or significant translation of the posterior tuberosity.

 Cast immobilization with non-weightbearing for 6 weeks

• techniques:standard short-leg cast for calcaneal stress fractures non weight bearing cast well-padded heel

Cast immobilization with non weightbearing for 10-12 weeks

• techniques:standard short-leg cast applied with mild equinus windowed over posterior heel to allow for frequent skin checks  requires close follow-up to determine if pull of gastrocnemius-soleus dispaces fracture weekly cast changes are necessary due to high incidence of skin complications high incidence of vascular insufficiency and diabetes in this population

Closed reduction and percutaneous pinning

• ideal for poor soft tissue coverage or patients with peripheral vascular disease
• Steinmann pin placed into the fracture site anteromedially-to-posterolateral to leverage fragments into place additional K-wires and Steinmann pins are placed from posterior-to-anterior and lateral-to-medial to secure remaining bone fragments
• calcaneal transfixing pin can be used to distract fracture
• percutaneous tamps and elevators can be used to raise the articular surface
• pins are cut flush with the skin and removed 8-10 weeks post-op
• can be combined with a distracting external fixator
  • pins placed in calcaneal tuberosity, cuboid, and distal tibia
  • restore calcaneal height, width, and alignment
  • can be combined with percutaneous cannulated screw

ORIF

Extensile lateral or medial approach

• full-thickness skin, soft tissue, and periosteal flaps are developed
  • flap supplied by lateral calcaneal branch of peroneal artery
  • superior flap contains the calcaneofibular ligaments and peroneal tendon sheath

• sural nerve and peroneal tendons are retracted superiorly
• lateral calcaneal wall visualized
• fracture opened and medial wall reduced going medial to lateral reduction confirmed indirectly via fluoroscopy
• tuberosity reduction is done under direct visualization
  • manual traction, Schanz pins, and minidistractors
    • pin in tuberosity aids with the reduction
  • height and length of tuberosity is recreated
  • quality of reduction affects outcomes

• provisional fixtaion was K-wires
• definitive fixation with plates and screws

Extensile lateral L-shaped incision is the most popular 

• vertical portion between posterio fibula and achilles tendon
• the horizontal portion in line with 5th metatarsal base
• a more inferior incision protects the sural nerve
• high rate of wound complications
• provides access to the calcaneocuboid and subtalar joints
• bone grafting provided no added benefit
  • restore congruity of subtalar joint
  • restore Böhler’s angle and calcaneal height
  • restore width
  • correct varus malalignment

Sinus tarsi approach

• minimally invasive incision that minimizes soft tissue dissesction
• reduces wound complications associated with extensile lateral incision
• allows direct visualization of the posterior facet, anterolateral fragment, and lateral wall
• lower incidence of sural nerve neuralgia
• same incision can be utilized for secondary subtalar arthrodesis or peroneal tendon debridement
• decreased surgical time
• patient placed in lateral decubitus position incision made in line with the tip of the fibula and the base of the 4th metatarsal

2-4 cm in length

• extensor digitorum brevis retracted cephalad to expose sinus tarsi and posterior facet
• peroneal tendons retracted posteriorly
• Schanz pin inserted percutaneously in posteroinferior tuberosity going from lateral to medial
• provides distraction and aids with reduction
• fibrous debris and fat removed from sinus tarsi
• small elevator or lamina spreader placed under posterior facet fragment to aid in reduction
• K-wires inserted for provisional fixation aimed towards the sustentaculum
• two screws are placed lateral-to-medial to engage sustentaculum and support facet
• one large fully threaded screw from posterior-to-anterior to support axial length of calcaneus
• the low-profile plate is applied underneath a well developed soft tissue envelope with screws engaging anterolateral and tuberosity fragments
• non weight bearing for 6-8 weeks post-op with ankle range-of-motion exercises beginning 2 weeks post-op

Essex-Lopresti manuever

• manipulate the heel to increase the calcaneal varus deformity
• plantarflex the forefoot
• manipulate the heel to correct the varus deformity with a valgus reduction

Stabilize the reduction with percutaneous K-wires or open fixation as described above arthroscopic-assisted reduction and internal fixation

• increased set-up increased swelling from fluid extravasation technically challenging
• can be combined with sinus tarsi approach
• fluoroscopy unit positioned posterior and oblique to patient
• allows for axial hindfoot views anterolateral and posterolateral portals are used to visualize posterior facet 2.4 mm 0° arthroscope
• patient positioned in the lateral decubitus position
• an interosseous ligament is preserved
• hematoma is irrigated
• loose bodies and cartilage fragments are removed with a shaver
• Freer elevator is introduced into one of the portal sites and used to elevate the posterior facet reduction can be visualized directly
• Schanz pin to control tuberosity fragment
• cannulated screws from the posterior aspect of the calcaneal tuberosity to the anterior aspect of the calcaneus
• restores and stabilizes length
• lateral-to-medial screws placed in sustentaculum
• buttress screw from the posterior aspect of the calcaneal tuberosity to the subchondral bone of the posterior facetposterior approach for calcaneal tuberosity fractures
  • patient positioned prone on table
  • posterior midline incision
  • fracture fragment is mobilized and debrided
  • plantar flexion of foot aids with reduction
    • presence of gastrocnemius tightness may preclude reduction
      • Strayer procedure may be performed to aid in the reduction
  • provisional fixation with K-wires
  • final fixation with either lag screws tension-band constructs figure-of-8 tension-band wire passed around ends of K-wires or cannulated screws suture fixation Krackow sutures passing through bone tunnels
  • restricted weight-bearing for 6 weeks followed by a progression of weight bearing an additional 6 weeks

• decreased soft-tissue dissection
• preservation of local blood supply
• removal of loose bone fragments
• improved visualization of the articular surface and cartilage lesions

Physical Therapy Management

After the surgery, active range of motion exercises may be practiced with small amounts of movement for all joints of the foot and ankle. These exercises are used to maintain and regain the ankle joint movement. When needed for the involved lower extremity, the patient may continue with elevation, icing and compression. During the therapy, the patient will progress to gradual weight-bearing. Patients may find this very difficult and painful. The physiotherapist conducts joint mobilization to all hypermobile joints.

During the treatment, progressive resisted strengthening of the gastrocnemius muscles is done by weighted exercises, toe-walking, ascending and descending stairs and plyometric exercises. When the fracture is healed, the physiotherapist will progress the weight-bearing in more stressful situations. This therapy consists of gait instruction and balance practice on different surfaces.

These are some outcome measures that can be used to measure the functional abilities of the patient to see the prognosis which can be used during the rehabilitation period.

• Lower Extremity Functional Scale (LEFS)
• Foot and Ankle Ability Measure (FAAM)

Pre-Surgery

Initial stability is essential for open reduction internal fixation of intraarticular calcaneal fractures.

Preoperative revalidation consist of:
• Immediate elevation of the affected foot to reduce swelling.
• Compression such as foot pump, intermittent compression devices, or compression wraps as tolerable.
• Instructions for using wheelchair, bed transfers, or crutch walking.

Post-Surgery

Both the progression of nonoperative and postoperative management of calcaneal fractures include traditional immobilization and early motion rehabilitation protocols. In fact, the traditional immobilization protocols of nonoperative and postoperative management are similar, and are thereby combined in the progression below. ^[2] Phases II and III of traditional and early motion rehabilitation protocols after nonoperative or postoperative care are comparable as well and are described together below. 

Phase I: Weeks 1-4

Goals:

• Control oedema and pain
• Prevent extension of fracture or loss of surgical stabilization
• Minimize loss of function and cardiovascular endurance

Intervention:

• Cast with the ankle in neutral and sometimes slight eversion,
• Elevation
• Toe curl and active ankle joint (dorsiflexion and plantarflexion)-encourage to do from the first post-operative day.
• After 2-4 days, instruct in non-weight bearing ambulation utilizing crutches or walker-crutch walking training
• Instruct in wheelchair use with an appropriate sitting schedule to limit time involved extremity spends in dependent-gravity position
• Instruct in comprehensive exercise and cardiovascular program utilizing upper extremities and uninvolved lower extremity
• Strengthening adjacent joint musculature ( hip and knee)

Phase II: Weeks 5-8

Goals:

• Control remaining or residual oedema and pain
• Prevent re-injury or complication of fracture by progressing weight-bearing safely
• Prevent contracture and regain motion at ankle/foot joints
• Minimize loss of function and cardiovascular endurance

Intervention:

• Continued elevation, icing, and compression as needed for involved lower extremity.
• After 6-8 weeks, instruct in partial-weight bearing ambulation utilizing crutches or walker
• Initiate vigorous exercise and range of motion to regain and maintain motion at all joints: tibiotalar, subtalar, midtarsal, and toe joints, including active range of motion in large amounts of movement and progressive isometric or resisted exercises
• Progress and monitor comprehensive upper extremity and cardiovascular program

Phase III: Weeks 9-12

Goals:

• Progress weight-bearing status
• Normal gait on all surfaces
• Restore full range of motion
• Restore full strength
• Allow return to previous work status

Intervention:

• After 9-12 weeks, instruct in normal full-weight bearing ambulation with the appropriate assistive device as needed
• Progress and monitor the subtalar joint’s ability to adapt for ambulation on all surfaces, including graded and uneven surfaces
• Joint mobilization to all hypomobile joints including: tibiotalar, subtalar, midtarsal, and to toe joints
• Soft tissue mobilization to hypomobile tissues of the gastrocnemius complex, plantar fascia, or other appropriate tissues
• Progressive resisted strengthening of gastrocnemius complex through the use of pulleys, weighted exercise, toe-walking ambulation, ascending/descending stairs, skipping or other plyometric exercise, pool exercises, and other climbing activities
• Work hardening program or activities to allow return to work between 13- 52 weeks.

Implant Removal:

Implant removal 1 year after plate fixation is only advocated in cases of protruding hardware or massive arthrofibrosis with limited range of motion, mostly after plate fixation through extensile approaches. Implant removal is combined with intraarticular arthrolysis and debridement employing subtalar arthroscopy

Complications

Due to the severe nature and the force required to sustain calcaneal fractures concomitant injuries must be considered.[rx][rx] Studies have shown greater than 70% of patients with calcaneus fractures have additional injuries.

• A thorough evaluation – of the entire spine should be performed anytime a calcaneal fracture is identified especially when a fall is a mechanism. The force from impacting the ground translates through the lower extremity and upward sometimes causing spinal compression fractures.
• Compartment syndrome – of the foot is a rare but severely debilitating complication of calcaneal fractures and can occur in up to 10% of the injuries. A high index of suspicion is needed in considering patients presenting with increased pain either after treatment or during the initial evaluation.
• Osteomyelitis, postoperative wound infection, malunion, and subtalar arthritis – are all potential complications of calcaneal fractures and repair.
• Infections and wound breakdown – are the most common and devastating complications of the extensile lateral approach.  Wound complications and infections can be as high as 37% and 20% respectively with operative intervention. [rx]
• Subtalar osteoarthritis – may result from surgical or nonsurgical treatment with an increasing number of patients with non-operatively treated displaced intra-articular calcaneus fractures requiring late subtalar fusion as a result of subtalar arthritis. [rx]  Another study found that non-operative measures were up to 6 times more likely to lead to a late subtalar fusion due to symptomatic subtalar arthritis. [rx]This is considered post-traumatic arthritis. Loss of subtalar motion is very common as well.
• Sural nerve injury – may result in up to 15% of cases treated operatively (more often with the extensile lateral approach). The risk is reduced with a more inferiorly based L-incision. [rx]
• Chronic pain – is also a common complication, in many cases owing to post-traumatic subtalar arthritis, malalignment or stiffness resulting from the injury.
• Wound Healing Problems – Although seen with any surgical procedure, wound healing complications are particularly concerning following calcaneal fracture surgery. The area around the outside of the heel has relatively thin skin and limited soft-tissue coverage. This can make wound healing problems more likely following calcaneal fracture surgery, and potentially more severe if they do develop. Wound healing problems are increased significantly for smokers and diabetics.
• Infection – Infections can create a major problem if they occur following a calcaneal fracture. As a result of the limited soft-tissue covering the outside of the heel, a superficial wound infection can quickly spread down to the underlying bone. If an infection develops, your surgeon may recommend the use of oral or intravenous antibiotics. A repeat trip to the operating room may be required.
• Subtalar Arthritis – Painful subtalar arthritis and stiffness of the hindfoot is common following calcaneal fractures. This occurs as a result of the damage to the cartilage at the time of the initial injury.
• Painful Hardware – Pain may be associated with the screws and plates used to align and secure the broken bone fragments. This occurs in about 10-20% of patients who have had surgical stabilization of a calcaneus fracture. Your doctor will help you determine if hardware removal is required.
• Peroneal tendon instability – may result from displaced, intra-articular calcaneus fractures.  [rx]  This may result from direct damage to the tendons themselves as a result of the injury or fracture fragments that may impinge on the tendons.  Up to a 40% displacement of the peroneal tendons has been appreciated on CT scans of calcaneus fractures. [rx].  Furthermore, with significant height loss, calcaneal widening and hindfoot varus subfibular impingement may result from soft tissue or osseous abnormalities.  Subfibular impingement may result in lateral heel pain, particularly with eversion of the hindfoot. Techniques have been described to perform percutaneous calcaneal osteotomy and peroneal tendon decompression to try to alleviate subfibular impingement after calcaneal malunion. [rx]

Postoperative and Rehabilitation Care

• Immediately post-operatively – the patient’s foot and ankle should be placed into an extremely well-padded posterior splint.
• Drains are typically removed–  on postoperative day 2 or even earlier based on surgeon preference.
• The patient should be adequately educated – on the need to elevate the extremity for the first several weeks after surgery to reduce swelling and the subsequent risk of wound complications.
• The splint – may be removed as early as 2-5 days based on some recommendations or left in place for 2 weeks in some cases, but after removing the splint the patient should begin his or her range of motion exercises for the subtalar joint and ankle joint as soon as possible.
• Weight-bearing – is often delayed 8-12 weeks (or more depending on the degree of comminution and progression of healing on radiographs).
• Routine serial radiographs – should be obtained to ensure the progression of healing.
• Early motion. Many doctors encourage motion of the foot and ankle early in the recovery period. For example, you may be instructed to begin moving the affected area as soon as your pain allows. If you have had surgery, you may be instructed to begin moving the affected area as soon as the wound heals to your doctor’s satisfaction.
• Physical therapy. Specific exercises can help improve the range of motion in your foot and ankle and strengthen supporting muscles. Although they are often painful at the beginning and progress may be difficult, exercises are required in order for you to resume normal activities.
• Weight-bearing. When you begin walking, you may need to use crutches, a cane, or a walker and/or wear a special boot. It is very important to follow your doctor’s instructions for walking on your foot. If you put weight on your foot too soon, the bone pieces may move out of place and you might require surgery. If you have had surgery, the screws might loosen or break and the bone may collapse. This may not occur the first time you walk on it but, if the bone is not healed and you continue to bear weight, the metal will eventually break.

References

Ankle Joint Fracture/An ankle fracture is a break of one or more ankle bones. Symptoms may include pain, swelling, bruising, and an inability to walk on the leg. Complications may include an associated high ankle sprain, compartment syndrome, decreased range of motion, and malunion.^[rx][rx]

Fractures of the ankle joint are among the commonest fractures in adults, with an incidence of up to 174 cases per 100 000 persons per year [rx]. For a good long-term functional outcome to be achieved, reliable early evaluation is crucial so that it can be determined whether the problem is a distortion (sprain), ligament rupture, bony ligament avulsion, or fracture of the talocrural joint. The proper treatment is chosen on the basis of the mechanism of the accident and the correct classification of the injury and accompanying soft-tissue damage. The goal of treatment is to enable the patient to put his or her full weight on the joint once again without pain and to prevent permanent damage.

The ankle joint is a highly complex joint. The ankle joint has multidirectional mobility for its complex role in supporting the weight of the body and fulfilling a myriad of daily functions. It is a combination of bones and ligaments structured around the talus. It includes the tibia, fibula, calcaneus, the tibiofibular ligament, the lateral ligament complex, and the medial ligament complex. The talocrural joint is the place where the distal tibia, distal fibula, and talus articulate. The tibia and fibula are anchored together via the syndesmosis. The syndesmosis consists of the interosseous membrane as well as the transverse, anterior, and posterior tibiofibular ligaments. There are both lateral and medial collateral ligament complexes which help to increase the stability of the ankle joint. The lateral collateral ligament forms from the fibulocalcanear ligament (FCL), the anterior fibulotalar ligament (AFTL), and the posterior fibulotalar ligament (PFTL). The medial collateral ligament consists of the deltoid ligament and the plantar calcaneonavicular ligament. The ankle joint moves in a unique way due to its structure. As the talus is asymmetric, the ankle is not purely a hinge joint. Instead, it acts as a rotary hinging movement. As many structures are involved in the ankle joint, in the context of an acute ankle fracture, it is easiest to think of it as a ring of structures situated around the talus. One break in the ring leads to a stable injury, while two or more breaks in the ring lead to an unstable injury.[rx][rx]

Relevant Anatomy of Ankle Joint Fracture

The talocrural joint is the junction of three bony structures: the distal ends of the tibia and fibula and the trochlea of the talus. The tibia and fibula are elastically bound in the fork of the ankle joint by the ligamentous structures of the syndesmosis (interosseous membrane; anterior, posterior, and transverse tibiofibular ligaments) [rx, rx]. Powerful collateral ligaments stabilize the joint against stress from the sides: laterally, the anterior tibiotalar ligament (AFTL), fibulocalcanear ligament (FCL), and posterior tibiotalar ligament (PFTL), and, medially, the broad fan of the deltoid ligament and the plantar calcaneonavicular ligament (spring ligament), whose medial border is blended with the forepart of the deltoid ligament. Because the talus is asymmetrically shaped, movement in the ankle joint is not a pure hinge movement, but rather a rotatory hinging movement around the helical axis of the joint [rx]. Precise congruence of the ankle joint is essential for its proper function, and thus malpositions of traumatic origin have major adverse effects, as they alter the biomechanics of the joint and cause pathological compressive stress [rx, rx].

Ankle fractures are generally to be regarded as joint fractures even if there is no fracture cleft in any of the articular surfaces of the joint. For the ankle joint in particular, non-anatomical reductions and restraints lead to premature degeneration of the joint. Thus, proper anatomical reconstruction—generally involving surgery—is needed to prevent post-traumatic degeneration over the long term.

Pathophysiology of Broken Ankle

There are various methods to classify ankle fractures.

Percival Pott described ankle fractures in terms of the number of malleoli involved (unimalleolar, bimalleolar, and trimalleolar).

The Danis-Weber classification system categorizes ankle fractures by assessing the location of the distal fibula fracture in its relation to the syndesmosis.

• A – Below syndesmosis
• B – At the syndesmosis level
• C – Above syndesmosis (i.e., Maisonneuve fracture)

Although this method describes the fracture relative to the syndesmosis, it does not accurately predict damage or injury to the syndesmosis. It also does not address damage to any medial ankle structure.

Type A is managed operatively with a closed repair. Type B & C require internal fixation.

The Lauge-Hansen classification system uses the mechanism of injury to determine the extent of injury to the ankle joint. By knowing the mechanism of injury or the deforming force, one can establish a sequence of injuries of the likely structures injured. Assessing the mechanism of injury can be valuable in deciding the appropriate treatment.

Supination-Adduction (SA)

• Distal fibula transverse fracture
• Medial malleolus vertical fracture

Supination-External Rotation (SER) – most common ankle injury (60% fractures)

• Anterior inferior tibiofibular ligament injury
• Spiral (or oblique) fracture of the distal fibula
• Posterior inferior tibiofibular ligament injury OR posterior malleolus avulsion
• Fracture of medial malleolus OR deltoid ligament injury

Pronation-External Rotation (PER)

• Fracture of medial malleolus OR deltoid ligament injury
• Anterior inferior tibiofibular ligament injury
• Spiral (or oblique) fracture of the fibula (aspect proximal to tibial plafond)
• Posterior inferior tibiofibular ligament injury OR posterior malleolus avulsion

Pronation-Abduction (PA)

• Fracture of medial malleolus OR deltoid ligament injury
• Anterior inferior tibiofibular ligament injury
• Comminuted or transverse fibular fracture (proximal to tibial plafond)

1st word (position of the foot during the time of injury)

• Pronation:  Eversion, abduction, dorsiflexion; medial ligaments stretched and prone to injury
• Supination: Inversion, adduction, plantarflexion; lateral ligaments stretched and prone to injury

2nd word (movement of talus in ankle mortise relative to the tibia)   Injuries always occur in a cumulative pattern; for example, a SER4 injury includes injuries of SER1, SER2, and SER3.

Pronation-dorsiflexion injuries are not classified in either the Danis-Weber or the Lauge-Hansen systems. Although uncommon, it is a unique mechanism in which injury results from axial loading. An example of this type of injury is a pilon fracture. In this type of injury, the sequence of events is as follows:

• Axial loading drives the talus into the tibia causing a medial malleolus fracture
• Another fracture occurs at the anterior tibial margin
• Supramalleolar fibular fracture
• Transverse fracture of the posterior tibia

Talar fractures often result from sudden hyperextension. Most often they are avulsion fractures on the anterior aspect of the talar neck. CT is the imaging of choice for these fractures. Talar fractures can also be due to pronation injury, plantar hyperflexion injury, or dorsiflexion injury.[rx][rx][rx]

Classification

There are several classification schemes for ankle fractures:

• The Lauge-Hansen classification categorizes fractures – based on the mechanism of the injury as it relates to the position of the foot and the deforming force (most common type is supination-external rotation)
• The Danis-Weber classification categorizes ankle fractures – by the level of the fracture of the distal fibula (type A = below the syndesmotic ligament, type B = at its level, type C = above the ligament), with use in assessing injury to the syndesmosis and the interosseous membrane
• The Herscovici classification categorizes medial malleolus fractures –  of the distal tibia based on level.
• The Ruedi-Allgower classification categorizes pilon – fractures of the distal tibia.

Fracture types

• Pilon fracture (Plafond fracture) –a fracture of the distal part of the tibia, involving its articular surface at the ankle joint.
• Wagstaffe-Le Fort avulsion fracture¨ –  a vertical fracture of the anteromedial part of the distal fibula with avulsion of the anterior tibiofibular ligament.
• Tillaux fracture, a Salter-Harris type III fracture – through the anterolateral aspect of the distal tibial epiphysis.^[rx]

Most common ankle fractures

• Lateral malleolus fracture – This is the most common type of ankle fracture. It is a break of the lateral malleolus, the knobby bump on the outside of the ankle (in the lower portion of the fibula).
• Bimalleolar ankle fracture – This second-most common type involves breaks of both the lateral malleolus and of the medial malleolus, the knobby bump on the inside of the ankle (in the lower portion of the tibia).
• Trimalleolar ankle fracture – This type involves breaks in three sides of the ankle: the medial malleolus of the tibia, as well as the lateral malleolus and posterior malleolus (in the lower portion of the fibula).
• Pilon fracture (also called a plafond fracture) – This is a fracture through the weight-bearing “roof” of the ankle (the central portion of the lower tibia). This is usually a higher energy traumatic injury resulting from a fall from a height.

As the number of fracture lines increase, so does the risk of long-term joint damage. Trimalleolar ankle fractures and pilon fractures have the most cartilage injury and, therefore, have a higher risk of arthritis in the future.

Causes of Ankle Joint Fracture

Ankle fractures can be caused by excessive strain to the ankle joint as well as by blunt trauma.[rx]

• Trips and falls – Losing your balance may lead to trips and falls, which can place excessive weight on your ankle. This might happen if you walk on an uneven surface, wear ill-fitting shoes, or walk around without proper lighting.
• Heavy impact – The force of a jump or fall can result in a broken ankle. It can happen even if you jump from a low height.
• Missteps – You can break your ankle if you put your foot down awkwardly. Your ankle might twist or roll to the side as you put weight on it.
  Sports – High-impact sports involve intense movements that place stress on the joints, including the ankle. Examples of high-impact sports include soccer, football, and basketball.
• Car collisions – The sudden, heavy impact of a car accident can cause broken ankles. Often, these injuries need surgical repair. The crushing injuries common in car accidents may cause breaks that require surgical repair.
• Falls – Tripping, and falling can break bones in your ankles, as can landing on your feet after jumping down from just a slight height.
• Missteps – Sometimes just putting your foot down wrong can result in a twisting injury that can cause a broken bone.

Symptoms of Ankle Joint Fracture

Symptoms of an ankle fracture can be similar to those of ankle sprains (pain), though typically they are often more severe by comparison. It is exceedingly rare for the ankle joint to dislocate in the presence of ligamentous injury alone. However, in the setting of an ankle fracture, the talus can become unstable and subluxate or dislocate. Patients may notice ecchymosis (“black and blue” coloration from bleeding under the skin), or there may be an abnormal position, alignment, gross instability, or lack of normal motion secondary to pain.

• Pain, swelling, tenderness and bruising at your ankle joint
• Inability to move your ankle through its normal range of motion
• Inability to bear weight on your injured ankle — However, if you can bear weight on the ankle, don’t assume there is no fracture.
• In some cases, a “crack” or “snap” in the ankle at the time of injury
• In open fractures, severe ankle deformity, with portions of the fractured bone visible through broken skin
• Pain at the site of the fracture, which in some cases can extend from the foot to the knee.
• Significant swelling, which may occur along the length of the leg or may be more localized.
• Blisters may occur over the fracture site. These should be promptly treated by a foot and ankle surgeon.
• Bruising that develops soon after the injury.
• Inability to walk; however, it is possible to walk with less severe breaks, so never rely on walking as a test of whether or not a bone has been fractured.
• Change in the appearance of the ankle—it will look different from the other ankle.
• Bone protruding through the skin—a sign that immediate care is needed. Fractures that pierce the skin require immediate attention because they can lead to severe infection and prolonged recovery.

Diagnosis of Ankle Joint Fracture

History and Physical

• History is an integral part of any medical evaluation. In addition to the standard history (setting, chronology, location, quality, quantity, aggravating/alleviating factors, associated symptoms), it is important to ask specific questions targeted toward an ankle injury.

Questions include

• Where is the pain? Is this an isolated injury or are there other injuries? Other injuries can be missed if there is a severely distracting injury such as an open ankle fracture-dislocation. Ankle fractures are usually the result of a twisting mechanism sustained as a result of a low-energy injury. A higher energy mechanism should raise the specter of compartment syndrome of the leg or a more grave injury such as a pilon fracture (axial loading). An ambulating patient is unlikely to have an unstable fracture.
• The ankle position at the time of injury and subsequent direction of force generally dictates the fracture pattern, as described by the Lauge-Hansen classification system. Past medical history can also be an important factor. Prior injuries/surgeries to the affected joint may affect the presentation. Comorbidities including diabetes, peripheral vascular disease, and smoking can complicate wound and fracture healing or increase the risk of a Charcot neuroarthropathy. A patient’s baseline/goals should be established through a social history including the patient’s level of mobility pre-injury, home situation, and regular activities as well as their future functional goals.

Physical Examination

• Always examines the contralateral un-injured ankle first, as it helps to establish a baseline ankle examination (what it looked like before injury). It is also vital to examine the tibia, fibula, knee, and foot as well. Some injury mechanisms can cause other injuries superior to the ankle (i.e., Maisonneuve fracture). Examine the ankle visually for swelling, pain, ecchymosis, and soft tissue injury, including abrasions and lacerations.  Palpate the ankle to localize the point of injury. To ensure full examination, work methodically. Starting at the proximal tibia/fibula and working down. Once palpation is complete, perform examinations to assess neurological and vascular integrity.  Assess for sensation, motor function, capillary refill, and pulses. It is important to test the passive and active range of motion, as well as weight-bearing status. It is imperative to assess and continue to monitor for signs of compartment syndrome.[rx][rx][rx]

Evaluation

Ottawa Ankle Rules

Ankle radiographs should only be needed if there is pain or tenderness in either malleolus AND one of the following

• Tenderness of the bone at the posterior edge or tip (within 6 cm) of either the lateral or medial malleolus
• Patient unable to bear weight at the time of injury AND on arrival to the emergency department. Weight-bearing is determined by the patient’s ability to take four steps.

It is important to recall that this set of rules was developed to reduce the number of unnecessary radiographs ordered.  The reported sensitivity of the Ottawa ankle rules are close to 100%, but the specificity is highly variable across all studies; this is believed to be caused by user interpretation of the rules and provider dependent techniques in assessing tenderness on exam. Therefore, although effective, even the correct application of this rule does not 100% rule out an ankle fracture.

Radiological Features

Ankle x-ray: 3 view

• AP view – assess for soft tissue swelling that may lead to the discovery of other more subtle fractures
• Mortise view – taken with the foot in 15 degrees of internal rotation, evaluates talus positioning and syndesmosis widening
• Lateral view – assess for anterior and/or posterior avulsion fractures assess for an effusion of ankle joint

If proximal leg tenderness is present or medial clear space widening with no obvious fibular fracture, radiographs of the tibia and fibula should be obtained to rule out the presence of a Maisonneuve injury. A Maisonneuve fracture is a proximal fibula spiral fracture with concomitant disruption of the distal fibular syndesmosis and interosseous membrane.

If your doctor suspects an ankle fracture, he or she will order additional tests to provide more information about your injury.

• X-rays – X-rays are the most common and widely available diagnostic imaging technique. X-rays can show if the bone is broken and whether there is displacement (the gap between broken bones). They can also show how many pieces of broken bone there are. X-rays may be taken of the leg, ankle, and foot to make sure nothing else is injured.
• Stress test – Depending on the type of ankle fracture, the doctor may put pressure on the ankle and take a special x-ray, called a stress test. This x-ray is done to see if certain ankle fractures require surgery.
• Computed tomography (CT) scan – This type of scan can create a cross-section image of the ankle and is sometimes done to further evaluate the ankle injury. It is especially useful when the fracture extends into the ankle joint.
• Magnetic resonance imaging (MRI) scan – These tests provide high-resolution images of both bones and soft tissues, like ligaments. For some ankle fractures, an MRI scan may be done to evaluate the ankle ligaments.
• More complex axial imaging – is rarely necessary; exceptions include triplane and pilon fractures.
• Posterior malleolus fractures usually require a CT – as the plain film underestimates the degree of impaction.
• Weight-bearing radiographs – not indicated in the acute ankle fracture in the emergency department, usually used for more stable injuries in outpatient settings
• MRI -although rarely emergently indicated is used to assess soft tissue, cartilaginous, or ligamentous injuries. It can also help to detect occult fractures.
• Ultrasound – can be used to assess for fractures as well a ligament and tendon injuries; however, results are user-dependent.[rx][rx]

Differential Diagnosis

• Rheumatoid arthritis
• Charcot joint
• Osteoid osteoma
• Ewing’s sarcoma
• Osteosarcoma
• Pathologic fracture
• Osteomyelitis
• Septic arthritis
• Osteoarthritis
• Gout
• Ankle sprain
• Achilles rupture
• Tendon dislocation

Treatment of Ankle Joint Fracture

Non-Surgical

Treatment available can be broadly

Medication

The following medications may be considered doctor to relieve acute and immediate pain

• Antibiotic – Cefuroxime or Azithromycin, or  Flucloxacillin or any others cephalosporin/quinolone antibiotic must be used to prevent infection or clotted blood remove to prevent furthers swelling and edema
•  Antidepressants – A drug that blocks pain messages from your brain and boosts the effects of endorphins (your body’s natural painkillers).
• Corticosteroids – Also known as oral steroids, these medications reduce inflammation. To healing the nerve inflammation and clotted blood in the joints.
• Muscle Relaxants –  These medications provide relief from associated muscle spasms.
• Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, and tingling.
• Opioids – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
• Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
• NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include  and Ketorolac, Aceclofenac, naproxen
• Calcium & vitamin D3 – to improve bone health and healing fracture.
• Glucosamine & Diacerein, Chondroitin sulfate – can be used to tightening the loose tension, cartilage, ligament, and cartilage, ligament regenerate cartilage or inhabit the further degeneration of cartilage, ligament
• Dietary supplement -to remove general weakness & improved health

Surgery

All other types require surgery, most often an open reduction and internal fixation (ORIF), which is usually performed with permanently implanted metal hardware that holds the bones in place while the natural healing process occurs. A cast or splint will be required to immobilize the ankle following surgery.

In children, recovery may be faster with an ankle brace rather than a full cast in those with otherwise stable fractures.^[rx]

Stable fractures are those that are non-displaced. These fractures receive conservative treatment. Patients with stable fractures can be discharged with unrestricted weight-bearing as tolerated. These patients can receive a walking boot and be discharged with a plan for X-ray in 1 week if stability is uncertain. It is essential to provide extensive ED return precautions in the case of a change in the status of the injury. Return precautions should include but not be limited to: uncontrolled pain, numbness, tingling, increased swelling, and decrease or change in their ability to bear weight.

Unstable fractures include those that are displaced, have talar shift, bimalleolar, and trimalleolar. These unstable fractures get treated with open reduction internal fixation (ORIF). If the patient has multiple comorbidities and is unable to tolerate surgical repair, there is the option for casting with 6 weeks of non-weight-bearing status. The ankle would need weekly ankle X-ray and the need for thromboprophylaxis needs to be assessed depending on other risk factors. This plan would require consultation with the orthopedic surgeon.[rx][rx]

Complications

Complications following ankle fractures can occur after both conservative nonoperative management and operative management.

• Nonoperative management complications may include – compartment syndrome, dislocation, complex regional pain syndrome, limited range of motion, or inner pressure ulceration.
• Operative management complications may include – compartment syndrome, wound hematoma, impaired wound healing, dislocation, mispositioned screws, inadequate reduction, complex regional pain syndrome, malunion, malposition, impingement syndrome, limited range of motion, or arthrosis.
• A complication of ankle fracture – seen in people with diabetes is Charcot arthropathy which is also known as neuropathic arthropathy. This condition occurs when there is a progressive degeneration of the ankle joint, which leads to the destruction of the bone, increased bone resorption, which ultimately leads to deformity. Long-term complications of this may lead to ulceration, infection, or eventual amputation.
• Thromboprophylaxis – is also essential in those with ankle fractures until full mobilization to prevent the development of DVT and pulmonary embolism.[rx][rx]
• Arthritis – Fractures that extend into the joint can cause arthritis years later. If your ankle starts to hurt long after a break, see your doctor for an evaluation.
• Bone infection (osteomyelitis) – If you have an open fracture, meaning one end of the bone protrudes through the skin, your bone may be exposed to bacteria that cause infection.
• Compartment syndrome – This condition can rarely occur with ankle fractures. It causes pain, swelling and sometimes disability in affected muscles of the legs.
• Nerve or blood vessel damage – Trauma to the ankle can injure nerves and blood vessels, sometimes actually tearing them. Seek immediate attention if you notice any numbness or circulation problems. Lack of blood flow can cause a bone to die and collapse.

Prevention

These basic sports and safety tips may help prevent a broken ankle:

• Wear proper shoes – Use hiking shoes on rough terrain. Choose appropriate athletic shoes for your sport.
• Replace athletic shoes regularly – Discard sneakers as soon as the tread or heel wears out or if the shoes are wearing unevenly. If you’re a runner, replace your sneakers every 300 to 400 miles.
• Start slowly – That applies to a new fitness program and each individual workout.
• Cross-train. Alternating activities can prevent stress fractures. Rotate running with swimming or biking.
• Build bone strength – Get enough calcium and vitamin D. Calcium-rich foods include milk, yogurt and cheese. Ask your doctor if you need to take vitamin D supplements.
• Declutter your house – Keeping clutter off the floor can help you to avoid trips and falls.
• Strengthen your ankle muscles – If you are prone to twisting your ankle, ask your doctor for exercises to help strengthen the supporting muscles of your ankle.

References