Download - Hindfoot Fractures Moritz Haager July 8, 2004. Jeez, I sure hope I don’t bust my hindfoot
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Hindfoot FracturesHindfoot Fractures
Moritz HaagerMoritz Haager
July 8, 2004July 8, 2004
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Jeez, I sure hope I don’t bust my hindfoot..
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What articulations comprise the What articulations comprise the ankle joint complex?ankle joint complex?
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What articulations comprise the What articulations comprise the ankle joint complex?ankle joint complex?
Talocrural jointsTalocrural joints1.1. Distal tibia – talusDistal tibia – talus2.2. Medial malleolus – talusMedial malleolus – talus3.3. Lateral malleolus – talusLateral malleolus – talus4.4. Distal tibia – distal fibula Distal tibia – distal fibula
(distal tibiofibular joint)(distal tibiofibular joint)Collectively allow dorsiflexion Collectively allow dorsiflexion and plantarflexion and plantarflexion
Subtalar jointsSubtalar joints5.5. Talus – CalcaneusTalus – Calcaneus
Contributes to inversion and Contributes to inversion and eversioneversion
Hence the talus & calcaneus Hence the talus & calcaneus are key to ankle functionare key to ankle function
1
23
4
5
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AP RadiographAP Radiograph
AdequacyAdequacy– Fibula & tibia above Fibula & tibia above
talustalus– Open medial clear Open medial clear
space space
> 10 mm
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Lateral RadiographLateral Radiograph
AdequacyAdequacy– Malleoli superimposedMalleoli superimposed– Joint space cleary Joint space cleary
visible w/o overlapvisible w/o overlap
Look for signs of Look for signs of ankle effusionankle effusion– Lucency anterior or Lucency anterior or
posterior to joint posterior to joint capsulecapsule
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Mortise ViewMortise ViewEvaluates articular surfaceEvaluates articular surfaceTechniqueTechnique– Leg is internally rotated 15 – 20Leg is internally rotated 15 – 20oo – X-ray beam perpendicular to X-ray beam perpendicular to
intermalleolar lineintermalleolar lineAdequacyAdequacy– No overlap of talar dome & joint No overlap of talar dome & joint
spacespace– Med. & lat. clear spaces openMed. & lat. clear spaces open
Articular surfaces should be parallel Articular surfaces should be parallel throughout i.e. uniform joint widththroughout i.e. uniform joint widthShould see mild (Should see mild (>>1 mm) overlap of 1 mm) overlap of tibia & fibulatibia & fibulaMedial clear space should not Medial clear space should not exceed 4 mm exceed 4 mm Lateral clear space should not Lateral clear space should not exceed 5.5 mmexceed 5.5 mm
medial clear space
lateral clear space(< 5.5 mm)
>1 mm
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Talus anatomyTalus anatomy
What is the risk with talar neck fractures? Why?What is the risk with talar neck fractures? Why?
Avascular necrosisAvascular necrosis– Most of the vascular supply to body via neckMost of the vascular supply to body via neck
Neck
Talar dome or trochlea
Midfoot(Chopart joint)
Subtalar joint
BodyHead
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Talar fracturesTalar fractures
Minor talar fractures Minor talar fractures – Chip and avulsion fractures of neck ,head, and body. Chip and avulsion fractures of neck ,head, and body. – Usually same mechanism as ankle sprains Usually same mechanism as ankle sprains
Talar neck fracturesTalar neck fractures– 50% of major talar injuries.50% of major talar injuries.– extreme dorsiflexion force (aviator’s astralagus)extreme dorsiflexion force (aviator’s astralagus)– Frequent associated fracturesFrequent associated fractures– Hawkins classificationHawkins classification
Talar body fractures Talar body fractures – 23% of all talar fractures (including minor fractures) 23% of all talar fractures (including minor fractures) – Major talar body fractures are uncommon Major talar body fractures are uncommon
usually axial loading (e.g. falls)usually axial loading (e.g. falls)
Talar head fracturesTalar head fractures– Uncommon (5-10%)Uncommon (5-10%)– compressive force transmitted up through the talonavicular joint compressive force transmitted up through the talonavicular joint
applied on a plantarflexed foot applied on a plantarflexed foot
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Hawkins Classification of Talar Hawkins Classification of Talar Neck FracturesNeck Fractures
Type 1: = nondisplaced; Type 1: = nondisplaced; Type 2: subtalar subluxationType 2: subtalar subluxationType 3: dislocation of the talar body (50% open #’s)Type 3: dislocation of the talar body (50% open #’s)Type 4: dislocation of the talar body & distraction of the Type 4: dislocation of the talar body & distraction of the talonavicular joint. talonavicular joint. – Fracture type influencesFracture type influences management & prognosis management & prognosis
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Calcaneal anatomyCalcaneal anatomy
Posteriortuberosity
Anteriorprocess
apex of posterior facet
Sustenaculum tali
Lateral malleolus
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Axial (Harris) ViewAxial (Harris) View
Sustenaculumtali
Lateral malleolus
Posteriortuberosity
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Bohlers AngleBohlers Angle
apex of posterior facet
Posteriortuberosity
apex ofanterior process
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Calcaneus FracturesCalcaneus Fractures
ClassificationClassification– Compression #’sCompression #’s– Posterior tuberosity #’sPosterior tuberosity #’s– Anterior process #’sAnterior process #’s– Sustenaculum tali #’sSustenaculum tali #’s
High energy mechanism High energy mechanism associated associated injuriesinjuries– 20% will have vertebral fractures20% will have vertebral fractures
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Chip (osteochondral) fracture
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Talus fracture
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Type 3 talar neck fracture
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Normal
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Type 2 talar fracture
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Oblique ViewOblique View
Anteriorprocess #
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Posterior tubercle #
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Key ConceptsKey Concepts
Plain films tend to underestimate hindfoot Plain films tend to underestimate hindfoot fractures fractures – often require CT or MRI for better evaluationoften require CT or MRI for better evaluation
Calcaneal fractures are Calcaneal fractures are – frequently bilateral frequently bilateral – associated with other injuriesassociated with other injuries
Abnormal Bohlers angle may be only clueAbnormal Bohlers angle may be only clue
Talus fractures are at risk for AVNTalus fractures are at risk for AVN
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QuestionsQuestions