Fractures of the foot and ankle

Ankle Fractures
Ankle fractures are an extremely common injury that may occur secondary to relatively low mechanisms of injury (i.e. slip on the ice) or major trauma (i.e. fall from a height or motor vehicle accident). Certain ankle fracture patterns maintain the overall stability of the ankle joint, while others are significantly unstable and require surgery to realign the bones and joints appropriately. Many of these injuries often also have a significant soft tissue component to the injury and in some scenarios, the cartilage lining of the joint may also be injured. These additional factors often have a major implication on outcomes if not treated appropriately initially.

The major problems following an ankle fracture are stiffness, chronic pain, and arthritis of the ankle joint, particularly following inappropriate realignment of the bones and the joint surface. Even a few millimeters of misstep of the joint can lead to arthritis and subsequent disability as the ankle is unable to tolerate even the most minimal amount of malalignment well.

When surgery is necessary, rigid plates and screws are utilized to fix the inside and outside of the ankle joint to provide maximal stability. After surgery, immobilization in a splint is required until the incisions have healed. After healing of the incisions, early motion of the ankle is initiated to maximize function and outcome while minimizing stiffness. Patients are generally to remain non-weight bearing for these first 4 to 6 weeks. At 6 weeks weight bearing is allowed in a protected walking boot for an additional 6 weeks and then patients are transitioned into a regular shoe with a gradual increase in activity allowed. During the recovery, physical therapy, low-impact strengthening, and aquatic exercise is encouraged and initiated as soon as possible. Continued improvement occurs for up to 6 to 12 months. In general, the outcomes after ankle fracture surgery are quite good, particularly in the short term. In the long term, arthritis may occur but with a lower likelihood if appropriately realigned surgically initially.

Dr. Vora treats ankle fractures with an aggressive rehabilitation method to maximize outcomes. He has published and lectured locally and nationally on the treatment of ankle fractures. In addition, the use of arthroscopy (minimally-invasive pokes holes in the skin to place a camera in the ankle joint) to additionally treat other conditions of the cartilage that may not be visible with otherwise is often utilized in attempt to maximize outcomes for patients with this condition.

For more on this condition, also see:
Reconstruction after ankle fractures
Arthritis of the foot and ankle
Total ankle replacement
Arthroscopic minimally invasive ankle fusion (arthrodesis)
Arthroscopy of the foot and ankle
 

Talus Fractures
Injuries of the talus are often surgical emergencies due to the tenuous blood supply to this bone. These fractures often require urgent treatment to realign the bone to maximize the body’s ability to heal the bone and prevent dead bone (avascular necrosis) from developing. Other types of talus fractures are simpler and do not compromise the blood supply and can be treated in a non-emergent fashion. The talus is a key bone of the foot and ankle is critical in the normal mechanics of both the foot and the ankle. The development of problems of the talus can thus cause significant pain and limitations of both the ankle joint and the hindfoot joints. In addition, when the fracture is not appropriately aligned, continued pain can occur because of the associated increased weight placed on the outside or inside part of the foot.

The treatment of talus fractures is individualized based upon the location of the fracture, degree of involvement of the joints, and other parameters. Some patterns require no surgical treatment and immobilization only, others urgent surgical treatment, and yet others with complex surgical procedures to realign the ankle or hindfoot joints and minimize the risk of arthritis.

Depending upon the type of talus fracture, recovery can be quite minimal from immediate weight bearing to extremely prolonged with up to 12 weeks of non-weight bearing. Whenever possible, once skin incisions have healed, patients are immobilized in a boot that can be removed to begin early range-of-motion exercise in order to minimize stiffness of the foot and ankle regions. The long-term prognosis after these types of injuries can also be guarded but can be reasonably predicted and individualized for patients based upon the initial x-ray findings and mechanism of injury initially.

Because of the complex nature of talus fractures and the many potential complications that may occur after this severe injury, treatment with an orthopaedic specialist experienced in these types of treatments should be considered.

For more on this condition, also see:
Arthritis of the foot and ankle
Reconstruction after hindfoot and heel bone fractures (talus, calcaneus)
Subtalar arthrodesis
Total ankle replacement
Arthroscopic minimally invasive ankle arthrodesis (fusion)
 

Calcaneus Fractures
Fractures of the heel bone are often severe, debilitating injuries that require extensive and complex treatment. When the heel bone breaks, it often “shatters” into multiple small pieces and the bony relationships become extremely distorted. The heel often widens and the height of the heel shortens significantly. The subtalar joint (the joint under the ankle joint) is also often severely stepped-off and irregular. This abnormality of the opposing surfaces of the joints can lead to severe pain, stiffness, and limitations. The ankle joint is usually unaffected (up and down movement) but side-to-side movement provided mainly by this joint can be dramatically reduced. In addition, the normal tendons, nerves, and other tissues surrounding the heel bone may be affected.

Some types of calcaneus fractures can be treated non-surgically. Many fractures do however benefit from surgical intervention to reduce the risks of arthritis of the subtalar joint, realign the height and width of the heel, and to facilitate recovery. Many fracture patterns are treated with a large incision on the outside of the ankle to piece together the fracture pieces which often are realigned similar to how a jigsaw puzzle is pieced together. Some fractures can also be treated utilizing a more minimally-invasive technique with the joint surfaces evaluated through a small incision and the screws for securing the fractures placed through small poke holes in the skin. This technique minimizes the potential soft tissue healing complications with major large incisions. Dr. Vora specializes in the treatment of calcaneus fractures, when appropriate, with this minimally-invasive technique.

The fracture is usually stabilized with plates and screws and immobilization is utilized until sufficient healing of the incision and soft tissues have occurred (usually 2 to 3 weeks). At this point, early mobilization of the joints, with particular attention to side-to-side movement of the subtalar joint, is begun to maximize motion. Weight bearing is usually restricted for the first 8 weeks, after which weight bearing is begun for an additional 4 to 6 weeks. At approximately 12 weeks, patients are able to return to regular shoe wear, although often times requiring a slightly larger shoe then before surgery.

Because of the complex nature of calcaneus fractures and the many potential complications that may occur after this severe injury, treatment with an orthopaedic specialist experienced in these types of treatments should be considered.

For more on this condition, also see:
Arthritis of the foot and ankle
Reconstruction after hindfoot and heel bone fractures (talus, calcaneus)
Subtalar arthrodesis
 

Midfoot Fractures
Fractures of the midfoot can be mild and require minimal aggressive intervention, or can be severe and require extensive stabilization of the foot. The midfoot bones have a very complex relationship and are held together by a complex group of strong ligaments that stabilize these joints. Once the ligaments or the bones are disrupted, significant disability may ensue. Pain, disability, swelling, and arthritis may result from incomplete treatment. These injuries may be obvious and secondary to a severe injury (i.e. motor vehicle accident) or may be very subtle and may go undiagnosed if appropriate testing has not been performed. If clinically suspected, special stress x-rays or MRI imaging may be necessary to confirm the diagnosis.

Mild injuries with stable ligament and bony relationships can be treated with protected weight bearing and gradual increase in activity. Any fracture or ligament injury pattern however that demonstrates even the smallest amount of disruption of the normal relationships of the midfoot requires open reduction and internal fixation (surgical stabilization of the midfoot with screws) in order to obtain perfect alignment. The risk of long-term arthritis and chronic pain significantly increases if perfect surgical alignment is not obtained.

This is injury which is commonly unrecognized in patients with chronic foot pain with subtle damage to these joints. For patients with severe injury and displacement to these joints, surgery by an experienced specialist in treating such disorders since outcomes are directly related to the ability of the surgeon to realign the joints appropriately initially to prevent long-term pain.

For more on this condition, also see:
Arthritis of the foot and ankle
Reconstruction after midfoot fractures (Lisfranc injury)
 

Fifth metatarsal fractures / forefoot fractures
Fractures of the metatarsals (bone in the front of the foot) and phalanges (toe bones) generally do not require surgical treatment. Some fracture patterns, particularly those with multiple fractured metatarsal bones or severe deformity, may require surgical stabilization to realign the bones appropriately.

The 5th metatarsal, the foot bone on the furthest outside part of the foot, may break in multiple locations. Based upon the location of the fracture, the blood flow may be tenuous and require surgical stabilization. Many of the fractures do not require surgery and can be treated with gradual protected increase weight bearing. The “Jones” fracture is an injury that occurs to the bone in a location where non-surgical treatment may not lead to adequate healing and thus surgical stabilization may considered. This can often be done without any large incisions through a percutaneous technique (stab hole technique) utilizing a minimally-invasive fashion.

With non-surgical treatment of Jones fractures, non-weight bearing is necessary for 6 to 8 weeks in a cast. With surgical stabilization, immediate weight bearing is permitted.

Many advances in the treatment of these fractures, including the use of supplemental bone grafts, stimulators, specialized surgical screws, and other techniques may improve outcomes. Appropriate screw selection and placement is critical in optimizing healing as well and treatment by an orthopaedic surgeon specializing in such problems should be considered.
 

Crush injuries of the foot
With significant trauma or crushing of the foot, severe long-term injuries to both the bones and soft-tissues may occur. The soft tissues, muscles and tendons, nerves, and arteries of the foot are all encompassed by a soft-tissue lining called fascia (a thin stretchy layer of tissue similar to a stretched balloon). This fascia can only expand to certain amount, similar to a balloon. When a muscle undergoes trauma, it can swell to the point of causing significant compression against this outer fascia lining, causing severe potential compression of the nerves and arteries in this area. The resultant artery damage can cause loss of blood flow to the foot and the nerve damage can cause severe long-term pain and limitations. In addition, the muscles may lose their blood flow causing further abnormalities.

When such injuries occur, evaluation by a specialist able to recognize these disorders and appropriately measure for these elevated pressures by a special device, called a compartment pressure monitor, is critical to promptly recognize and initiate treatment. If recognized in a timely fashion, this surrounding fascia layer can be released surgically to allow for the muscles to expand without risk of further damage to the nerves and arteries. This area can then be closed later once the swelling has resolved using special skin transferring techniques. This treatment can help preserve blood flow and prevent long-term nerve related pain, as well as other secondary foot deformities related to the dead muscle that may develop without intervention.

Dr. Vora has published extensively on the contribution of a crush injury to the foot and the effect outcomes and potential minor and major complications which may occur after such an injury. These injuries require prompt recognition of the disorder and urgent treatment to maximize outcome and to prevent long-term disabilities.