Foot pain:Stress fractures are very common and show up on ray around 10-14 days after the injury in many patients. Generally 3 views of the hand are needed to accurately assess the presence or absence of a fracture.
A rule of thumb generally used is that if you can bear weight or Wei ... Read More. There is probably no significant displacement and natural healing has started.
Make sure you're using firm fitting supportive footwear with good heels and arches. Months after their episode of trauma they still have pain and swelling and have been unable to get back to their sporting activity.
Athletes do need to be aware that x-rays, particularly at the time of the injury and particularly in joints such as the ankle, frequently miss fractures. A bone scan is often used these days to make the diagnosis of bony injury where x-rays are normal but the history and examination findings suggest otherwise.
This requires an injection of a radio isotope dye into the arm which is then taken around the body by the blood stream. Sometimes specific types of imaging (CAT or MRI scans) of the particular area are performed to assess the extent of the damage to the bony and cartilaginous surfaces.
This may allow us to see bony fractures which have become unstable and formed loose bodies in the past. This usually means temporarily removing the athlete from their provocative activity and embarking on an appropriate rehabilitation program before the stress “crack” in the bone becomes anything more major.
Ultrasound scans are also used more and more these days to help determine the nature of soft tissue injuries such as acute or chronic Achilles (bottom of calf), patella (front of knee), tendon injuries and rotator cuff tears in the shoulder. These are a relatively inexpensive form of investigation but can provide very useful information with regard to diagnosis and severity of injury.
The most advanced (and expensive) form of imaging used in sports medicine is the MRI scan. MRI (Magnetic Resonance Imaging) gives the best pictures of the soft tissues available and allows us to see the precise anatomy of muscles and tendons, nerves and blood vessels, amount of fluid in joints as well as bony architecture.
X-rays only show four out of 10 cases (40 percent) where the lateral process of the talus is broken off. When this fracture goes unnoticed, patients may be treated for an ankle sprain.
They don't get better and end up back in the doctor's office with chronic pain and swelling. Further, imaging is needed to get to the bottom of the problem.
Vincent A. Foible, MD, et al. Fracture of the Lateral Process of the Talus: A Report of 2 Cases. In The American Journal of Orthopedics.
Author: Jeremy Kim, MD (EM Resident Physician, Icahn School of Medicine at Mount Sinai) // Edited by: Alex Hoffman, MD (@EMHighAK, EM Attending Physician, UT SW / Parkland Memorial Hospital) & Justin Bright, MD (@JBright2021) A 25-year-old male presents with a left ankle injury while playing basketball.
There is swelling and ecchymosis diffusely with tenderness at the tip of the lateral malleolus. Traumatic ankle pain is a common presenting problem to emergency departments.
When x-rays are ordered based on the Ottawa ankle rules, multiple studies have shown sensitivity at nearly 100% in adult populations while decreasing the number of x-rays ordered by 20-40%. 3,4 Similar sensitivity results are seen in pediatric populations, with near 100% sensitivity when categorizing Salter-Harris Type I as clinically insignificant due to low complication rate.
One of the original multi-center validation studies for Ottawa ankle rules in 1995 revealed a 0.5% fracture miss rate, mostly because providers misused the clinical decision rule or in one case had difficulty assessing the grossly swollen ankle. 3 However, at a similar rate, patients who underwent imaging had the x-rays initially read as negative.
The mortise view is taken in 15-20 degrees of internal rotation with x-ray beams projecting perpendicular to the intermalleolar line. In an effort to save time and resources, some institutions use a two-view approach (lateral PLUS either AP or mortise), but this has a sensitivity of only 85-98%.
Thorough physical exam Palpate posterior edge of distal 6 cm of both lateral and medial malleoli Assess for associated proximal fibular fracture (Maisonette fracture): palpate the proximal fibula Assess for syndetic ligament injury. Squeeze test (squeeze at mid-calf causes pain just proximal to ankle) or external rotation of foot (with tibia stabilized, causes pain at level of syndesmosis) 11 Assess for open fracture.
You have the advantage of having examined the patient and have additional localization clues to detect fractures. Consider CT imaging if concerning mechanism or if needed for surgical considerations by orthopedic colleagues (e.g.
Erbium KS et al. Impact of clinical history on radiographic detection of fractures: a comparison of radiologists and orthopedists. Posterior Tatar process fractures are often associated with tenderness to deep palpation anterior to the Achilles tendon over the anterolateral talus, and plantar flexion may exacerbate the pain.
These fractures can often be managed nonsurgically with weight-bearing status and a short leg cast worn for approximately four weeks. Computed tomographic scans or magnetic resonance imaging may be required because these fractures are difficult to detect on plain films.
Ankle injuries are commonly evaluated by primary care and emergency physicians. Most of these injuries do not pose a diagnostic dilemma and can be managed nonsurgically without a prolonged or costly work-up.
However, the clinical presentation of some subtle fractures can be similar to that of routine ankle sprains, and they are commonly misdiagnosed as such. AP view: deep, cup-shaped lesion; initial radiograph can be normal because changes in chondral bone may not develop for weeks.
Tenderness to deep palpation anterior to the Achilles tendon over anterolateral talusPlantar flexion may reproduce pain. Difficult with standard views; an oblique ankle radiograph taken with the foot placed in 40 degrees of external rotation has been successful.
AP view: deep, cup-shaped lesion; initial radiograph can be normal because changes in chondral bone may not develop for weeks. Tenderness to deep palpation anterior to the Achilles tendon over anterolateral talusPlantar flexion may reproduce pain.
Difficult with standard views; an oblique ankle radiograph taken with the foot placed in 40 degrees of external rotation has been successful. This article features subtle fractures to facilitate timely diagnosis and treatment of these less-common injuries.
The dome of the talus articulates with the tibia and fibula, and has a key role in ankle motion and in supporting the axial load during weight-bearing 1 – 4 (Figures 1 and 2). Fractures of the Tatar dome are generally the result of inversion injuries of the ankle.
Although the etiology in atraumatic lesions is unclear, osteochondral fragments can separate from the surrounding cartilage surface and dissect into the joint space. Clinical diagnosis of Tatar dome fractures can be highly challenging because there are no pathognomonic signs or symptoms.
5 The patient may have sustained a fall or a twisting injury to the ankle and may generally ambulate with an antalgic gait. In the acute setting, the symptoms of a Tatar dome fracture are similar to and often occur with an ankle sprain.
Diagnosis of Tatar dome lesions can often be made with standard anteroposterior (AP), lateral, and mortise ankle radiographs. Secondary changes in the chondral bone (visible on plain radiographs) caused by a compression fracture of the articular osteochondral surface may take weeks to appear.
2, 4 In addition, small chondral fragments are radiolucent and not evident on standard radiographs. If suggested by the clinical scenario, fractures not visualized with plain radiographs may require magnetic resonance imaging (MRI) or computed tomography (CT).
6 The fracture classification developed by Bernat and Party is widely used to stage Tatar dome lesions (Table 3). Mortise view of the ankle showing an atraumatic osteochondral lesion (arrow) of the medial Tatar dome.
TABLE 3 Bernat and Party Classification of Osteochondral Lesions of the Tatar Dome Compression fracture of chondral bone Stage I, II, and III medial lesions can usually be treated nonsurgically with six weeks in a weight-bearing cast.
Treatment options fragment excision range from arthroscopy with or without chondral bone drilling to open reduction internal fixation. The lateral Tatar process is an osseous protuberance that articulates supernaturally with the fibula, helping to stabilize the ankle mortise, and inferomedially with the calcaneus, forming the lateral portion of the subtler joint 7 (Figures 1 and 2).
8 – 11 Traditionally, the causative injuries are falls, motor vehicle crashes, or direct trauma. Physical examination findings are similar to those in lateral ankle ligamentous injuries.
Pain with plantar flexion, dorsiflexion, and subtler joint movement is generally present. 7 Although the normal anatomy of the ankle may be obscured by soft tissue swelling, a helpful diagnostic indicator is point tenderness over the lateral process.
13 A CT scan can clearly show this injury and may be required to confirm a suspected fracture. Anteroposterior view of the ankle showing a fracture (arrow) of the lateral process of the talus.
Anteroposterior view of the ankle showing a fracture (arrow) of the lateral process of the talus. A weight-bearing, short leg cast can be used if anatomic position with less than 2 mm displacement can be maintained.
7 For large and displaced fragments, the treatment of choice is usually surgical reduction and fixation. The posterior process of the talus is composed of two tubercles, the lateral and medial (Figures 1 and 2).
Diagnosis Clinically, patients with a fracture of the lateral tubercle present with pain and swelling in the anterolateral area of the ankle. The pain is often reproduced with plantar flexion and occasionally accentuated with dorsiflexion of the great toe.
This is caused by compression of the fracture fragment as the flexor halls longs tendon passes between the medial and lateral tubercle. Careful physical examination and correlation with radiographic findings may be necessary to differentiate a fracture of the lateral tubercle, a fracture of a fused OS trigonal, a tear in the fibrous attachment of the ostrigonum to the lateral tubercle, or a normal OS trigonal.
When the diagnosis is unclear and clinical suspicion is present, an MRI or CT will clearly demonstrate this fracture. Treatment Nondisplaced or minimally displaced fractures can be treated with a non-weight-bearing, short leg cast for four to six weeks.
6 If the fracture site continues to be symptomatic after six months, fragment excision is usually curative. 6, 9 Larger and more displaced fractures may require open reduction internal fixation.
17, 18 They were first described by Ce dell, 18 who presented four cases of medial tubercle fractures that had originally been treated as ankle sprains. Visualization of the medial tubercle fracture on plain radiograph may be challenging, but the fracture can generally be seen on an oblique projection with the foot and ankle externally rotated 40 degrees and the beam centered 1 cm posterior and inferior to the medial malleolus 16, 17 (Figure 7).
Special oblique view of the ankle showing a medial tubercle fracture (arrow) of the posterior process of the talus. Special oblique view of the ankle showing a medial tubercle fracture (arrow) of the posterior process of the talus.
Computed tomographic scan demonstrating a medial tubercle fracture (arrow) of the posterior process of the talus. Computed tomographic scan demonstrating a medial tubercle fracture (arrow) of the posterior process of the talus.
Inversion plantar flexion can cause avulsion fractures of the anterior process. This injury tends to be extra-articular and accounts for most of the anterior process fractures that are initially diagnosed as ankle sprains.
Patients with anterior process fractures generally have a history of a previous inversion injury or involvement in a motor vehicle crash. 21 Clinically, patients generally show signs and symptoms similar to those of a lateral ankle sprain.
21, 23 An important diagnostic feature is point tenderness over the calca-neocuboid joint that is localized approximately 1 cm inferior and 3 to 4 cm anterior to the lateral malleolus, just distal to the anterior talofibular ligament insertion. 21, 22, 23 Careful assessment of the point of maximal tenderness may help differentiate this fracture from a lateral ligament sprain.
Although this fracture can be difficult to assess on routine radiographs of the foot and ankle, a careful inspection of the lateral view of the calcaneus often reveals this subtle fracture 21, 24 (Figure 9). 9, 21, 23 In addition, an accessory ossicles (calcaneus secondaries) maybe located near the anterior process and could be misinterpreted as a fracture.
Lateral view of the foot and ankle showing a fracture (arrow) of the anterior process of the calcaneus. Lateral view of the foot and ankle showing a fracture (arrow) of the anterior process of the calcaneus.
For small, nondisplaced fractures, early immobilization in a weight-bearing, short leg cast or compressive dressing for four to six weeks followed by range-of-motion exercises and a gradual return to weight-bearing has been successful. Although fracture healing may appear radiographically to be complete, approximately 25 percent of patients require more than a year before becoming asymptomatic.
21 Following nonsurgical management, most patients report satisfactory results and a return to pre-injury activity levels. 21, 23, 24 Symptomatic nonunion or large, displaced fractures may require surgical intervention.
However, intra-articular fractures require special attention to ensure that the articular surface is restored to anatomic congruity and that the correct mechanical alignment is maintained. This step optimizes the chance for a full recovery and decreases the incidence of post-traumatic arthritis and associated comorbidities.
The Ottawa ankle rules (Figure 1025) offer the physician clinical guidance as to which injuries require radiographs. Prospective studies have validated the effectiveness of these guidelines and shown the rules to be 100 percent sensitive for clinically significant fractures.
An ankle radiographic series is only required if there is pain in the alveolar zone and any of the following findings are present: bone tenderness at point A or B, or inability to bear weight immediately following the injury and during examination. A foot radiographic series is only required if there is pain in the midfoot zone and any of the following findings are present: bone tenderness at point C or D, or inability to bear weight immediately following the injury and during examination.
Adapted with permission from Rubin A, Wallis R. Evaluation and diagnosis of ankle injuries. An ankle radiographic series is only required if there is pain in the alveolar zone and any of the following findings are present: bone tenderness at point A or B, or inability to bear weight immediately following the injury and during examination.
A foot radiographic series is only required if there is pain in the midfoot zone and any of the following findings are present: bone tenderness at point C or D, or inability to bear weight immediately following the injury and during examination. Adapted with permission from Rubin A, Wallis R. Evaluation and diagnosis of ankle injuries.
Although fractures of the talus where varied rarely encountered in the Ottawa ankle trials, the fractures discussed in this article would likely be identified using the Ottawa ankle rules, because of the inability of the patient to bear weight after the injury and during the examination. Nevertheless, some patients with these fractures are able to ambulate and, because patients with these fractures generally do not present with tenderness along the posterior border of the lateral or medial malleolus, radiographic evaluation may not be indicated under the Ottawa guidelines.
However, as with all guidelines, clinical judgment and experience may be grounds for radiographic analysis in unique cases. Furthermore, in the case of a suspected ankle sprain that does not improve as expected or is accompanied by tenderness over a potential fracture site, radiographic analysis at a follow-up evaluation may be indicated.