- Pain and deformity of femur
- May lose large amount of blood in thigh
- Anteroposterior and lateral X-rays of femur are confirmatory
Fractures of the femoral shaft occur most commonly with high-energy trauma. Fractures occurring with minimal trauma should alert the emergency physician to the possibility of a pathologic fracture.
As noted earlier, significant bleeding may occur secondary to femoral shaft fractures and up to 3L of blood can be lost in the thigh (see Table 28–1). The patient typically presents with tenderness and deformity of the thigh. Evaluate and document the neurovascular status. Although not as common as with lower leg fractures, significant soft tissue swelling can occur; therefore, frequent reexaminations should be performed to assess for the development of compartment syndrome.
Anteroposterior and lateral views should confirm the diagnosis. Adequate visualization of the knee and hip on these films is important because associated fractures are common.
Adequate pain control and fluid resuscitation is indicated. In-line traction, either skeletal traction or an external traction device, should be applied to the leg.
Obtain orthopedic consultation for admission and ORIF (usually with an intramedullary rod).
The knee is a large synovial hinge joint and is the most commonly involved joint in orthopedic injuries seen in the emergency department. The knee has a complex architecture of bone, muscle, ligament, and cartilage. The bones of the knee joint include the distal femur, proximal tibia, and patella. The fibula is not a part of the knee joint but serves as the attachment point for the lateral collateral ligament. The bones offer little stability to the joint, and the knee relies on the soft tissue components for proper function.
The medial collateral ligament originates from the medial femoral epicondyle and inserts on the medial aspect of the tibia just distal to the tibiofemoral joint. The medial collateral ligament provides stability to valgus stresses (Figure 28–15A) and helps stabilize the medial meniscus. The lateral collateral ligament originates from the lateral femoral epicondyle and inserts onto the proximal fibula, providing resistance to varus forces (Figure 28–15B). The cruciate ligaments are located within the intercondylar notch and are named anterior and posterior by their attachment to the tibia at the tibial spines. The cruciate ligaments protect against anterior and posterior displacement of the knee.
Varus (A) and valgus (B) stress tests for rupture of the medial and lateral collateral ligaments of the knee. More laxity than in the uninjured knee or lack of a firm end point constitutes a positive test. Pain and muscle guarding may make interpretation difficult.
The menisci are cartilages positioned on the tibia. The menisci help dissipate forces within the knee joint and help prevent abnormal movement of the tibia and femur. The hamstring muscles (semitendinous, semimembranous, and the two heads of the biceps femoris) are the main flexors of the knee. The quadriceps muscles (vastus medialis, vastus lateralis, vastus intermedius, rectus femoris) combine to form the quadriceps tendon, which inserts onto the superior patella and the retinaculum of the joint capsule and functions in extension of the knee joint.
It is important to assess neurovascular status for knee injuries. The collateral circulation is tenuous, and the popliteal artery is responsible for the blood supply to the lower leg. The popliteal artery is tethered above at the hiatus of the adductor magnus and below at the soleus muscle. This tethering makes the popliteal artery susceptible to injury from traction forces as seen with dislocations as well as disruption from fractures or penetrating wounds.
The emergency department evaluation of an acute knee injury frequently involves obtaining plain X-rays, with anteroposterior, lateral, and sunrise view. Several clinical decision rules exist to aid the emergency physician in determining which patients need X-rays acutely. The Pittsburgh rules note that mechanism of injury (such as blunt trauma and falls), patient age (older than 55 years or younger than 12 years), and inability to walk at least four weight-bearing steps are predictors of fractures that require radiographic evaluation. The Ottawa rules identify five indications for radiographs of the knee: age greater than 55 years, isolated tenderness of the patella, tenderness of the head of the fibula, inability to flex the knee to 90°, and inability to transfer weight for four steps. Both sets of rules have demonstrated high sensitivity in predicting injuries and may be helpful to the emergency physician in the evaluation of the acutely injured knee.
- May be secondary to direct blow or traction injury
- Pain and tenderness are commonly seen
- May disrupt extensor mechanism
- Plain X-rays are usually sufficient
- Bipartite patella may be misinterpreted as fracture
The patella is the largest sesamoid bone in the body and may be fractured by direct forces such as falls and by indirect forces. Significant fractures of the patella may disrupt the extensor mechanism of the knee. The most common pattern of patellar fracture is the transverse fracture, and can be caused by a direct blow or a powerful contractile force from the quadriceps.
The patella may be dislocated or subluxed by direct forces or a hyperflexion injury, and it almost always displaces laterally. The patella is held in place by the quadriceps tendon, the patellar ligament and the medial and lateral retinacula. This injury occurs most commonly in adolescents. Often the patient gives a history of prior subluxations that resolved spontaneously.
Examination of the patient reveals pain and tenderness over the patella. A joint effusion may be present. If the patella is displaced significantly, a patellar defect may be palpable.
Plain radiographs including anteroposterior, lateral, and sunrise views are usually sufficient to identify the fracture; however, CT scanning or MRI may be necessary to identify occult injuries. Bipartite or multipartite patellae are congenital findings that may be confused with acute fracture.
Obtain orthopedic consultation. Simple fractures may be treated with immobilization of the knee in extension.
Patients with simple fractures may be discharged with outpatient follow-up. Open and displaced fractures require surgical repair.
- Common in adolescents
- Almost always displaces laterally
- Obvious deformity, restriction of motion
- Plain X-rays are usually sufficient for diagnosis
Tenderness is present on physical examination, and a deformity is usually easily seen. A joint effusion may be present.
Plain radiographs are usually sufficient to confirm the injury.
Management consists of closed reduction with appropriate sedation if needed for muscle relaxation, although some dislocations can be easily reduced without sedation. This is accomplished by applying medial force to the patella while the knee is being extended.
Discharge the patient with immobilization, crutches, and orthopedic referral for follow-up. Recurrent subluxations or dislocations may require surgical repair.
- Generally represent high-energy injuries
- Associated hip and patella injuries are common
- Plain X-rays are usually sufficient
- Obtain arteriogramif vascular injury is suspected
Fractures in the distal one-third of the femur are typically described by the relationship of the fracture line to the femoral condyles. Distal femur fractures generally represent high-energy injuries.
Pain, deformity, swelling, and inability to bear weight are usually present. Associated patella and hip injuries sometimes occur and acute hemarthrosis is common and can signify intra-articular extension of the fracture or ligamentous injury.
Diagnosis can usually be made with standard anteroposterior and lateral views. Oblique views and CT scanning may also be needed. If vascular compromise is suspected, obtain an arteriogram.
Distal femur fractures are significant injuries that require orthopedic consultation in the emergency department. Skeletal traction and surgical repair are frequently required.
- Usually occur to lateral aspect
- May be associated with peroneal nerve and popliteal artery injuries
- CT scan is helpful in planning treatment
- High suspicion for compartment syndrome
Tibial plateau fractures are intra-articular fractures and may result from axial loading and varus or valgus forces. The lateral portion of the tibia is most commonly involved. The fracture significantly impairs the function of the knee joint. Popliteal artery and peroneal nerve injuries may be seen, and the neurovascular status should be monitored continuously and documented. A Segond fracture is an avulsion fracture of the lateral tibial plateau and is a marker of ACL disruption.
Pain and tenderness are usually easily elicited. A hemarthrosis or effusion may be present, and the incidence of associated ligamentous injuries is significant.
Diagnosis is usually made on anteroposterior and lateral X-rays, but can be difficult to identify on routine radiographs. CT scanning is often used to delineate the extent of the injury. Tomograms and MRI may also be used. If vascular injury is suspected, obtain an arteriogram.
Treatment and Disposition
Immobilize the knee, keep the patient nonweight bearing, and obtain orthopedic consultation. A compartment syndrome may accompany tibial plateau fractures, and compartment pressures should be measured if indicated.
Tibial Tuberosity Fractures and Osgood-Schlatter Disease
- Usually avulsion fracture of patella tendon
- Obtain orthopedic consultation to determine treatment
The tibial tubercle is proximal at the anterior border of the shaft and is the attachment for the ligamentum patella. These fractures generally occur secondary to strong flexion or extension of the knee against resistance. Fractures usually occur prior to closure of the epiphysis and represent an avulsion fracture caused by the patella tendon. Osgood-Schlatter disease (or tibial tubercle apophysitis) represents a chronic traction injury to the tibial tuberosity and commonly occurs in adolescents engaging in sporting activities.
Tenderness and painful swelling over the tibial tubercle is present and, based on the mechanism of injury, an effusion may be seen. Diagnosis is confirmed with plain radiographs. In adolescents, Osgood-Schlatter disease must be in the differential diagnosis. Osgood-Schlatter disease is most commonly seen in males aged 10–13 years. Its radiographic findings may be difficult to differentiate from an acute fracture. A careful history and examination will help delineate an acute injury. A hemarthrosis is not associated with Osgood-Schlatter.
Treatment and Disposition
Orthopedic consultation is necessary because tibial tuberosity fractures may require open reduction. Osgood-Schlatter disease is treated conservatively with rest, ice and analgesics, and can be treated with immobilization and, in rare cases, surgery.
- Not common; usually seen in children
- Usually avulsion injury from cruciate ligament
- Suspect associate ligament injury
Fractures of the tibial spines (intercondylar eminence) are not commonly seen. These fractures usually represent an avulsion injury by one of the cruciate ligaments. They are more commonly seen in children and most often involve the anterior tibial spine.
Localized pain and a hemarthrosis may be present. If a significant ligamentous injury has occurred, instability of the knee may be seen.
The presentation may be subtle and may be noted only as an incidental finding on the X-ray. Plain films will usually identify the injury. In addition, as with other intra-articular fractures of the knee, a lipohemarthrosis is often demonstrated (Figure 28–16). This finding on the lateral views of the knee is produced by the layering of different density fluids (blood and marrow fat) present within the joint. CT scanning, MRI, or arthroscopy may be needed to identify associated injuries such as cruciate ligament ruptures.
A lipohemarthrosis noted on lateral radiograph of the knee in a supine patient is a specific sign of an intra-articular fracture although a fracture is not visualized. Just as oil and water separate, blood and fat from the marrow form the straight lines visualized in this radiograph.
Simple fractures are usually treated with immobilization.
If significant ligamentous injury is present, surgery may be necessary.
- May be seen with high- or low-velocity injuries
- Tenderness and joint effusion are usually present
- Assess for associated popliteal artery injury
Dislocations involving the tibiofemoral joint (as opposed to patellar dislocations) are an orthopedic emergency and may represent a limb-threatening injury. They are commonly seen in high-energy trauma but may also be seen with low-velocity injuries such as from falls or sports injuries. The presence of a dislocation represents significant trauma to the soft tissues (ie, ligaments, menisci, and joint capsule). As noted above, the location and anatomy of the neurovascular bundle, including the popliteal artery, popliteal vein, and common peroneal nerve places it at significant risk of injury, particularly with posterior dislocations. Tenderness and joint effusion are generally present.
Visual deformity may be obvious, but some dislocations may reduce prior to evaluation. Careful attention to the neurovascular status is indicated, and the presence of a pulse does not rule out an arterial injury. Knee dislocation is also associated with damage to the surrounding ligaments and menisci.
Plain radiographs help confirm the diagnosis. Traditionally, arteriography was recommended in all cases to identify arterial injuries, such as intimal tears, which may be clinically subtle but progress to occlusion and ischemia. Some authors recommend that serial examinations including ankle-brachial indices may be sufficient to exclude a clinically significant arterial injury. All authors agree, however, that if the arterial examination is abnormal, arteriography or Doppler studies should be obtained.
Management includes emergent reduction by in-line longitudinal traction. The neurovascular status should be monitored continuously and reassessed frequently.
Orthopedic consultation is necessary, and vascular surgical consultation may be needed. Patients for whom arteriography has not been obtained should be admitted for observation.
Gholve PA, Scher DM, Khakharia S et al: Osgood Schlatter syndrome. Curr Opin Pediatr 2007;19(1): 44–50
Hollis JD, Daley BJ: 10-year review of knee dislocations: is angiography always necessary? J Trauma 2005;59(3):652–655
Kleneberg EO, Crites BM, Flinn WR et al: The role of angiography in assessing popliteal artery injury in knee dislocations. J Trauma 2005;56(4):786–790
Knee Ligament Injuries: General Considerations
- Guarding and joint effusions may make diagnosis difficult in acute setting
- Patient may need immobilization and follow-up examination
Knee ligament injuries may range from minor sprains to complete disruptions. The more subtle injuries may be difficult to assess acutely because guarding and joint effusions may make determination of joint instability problematic. If possible, the unaffected knee should be examined before the injured knee in order to determine the patient's baseline, because some degree of laxity may be normal for an individual. After initial clinical and radiographic assessment, it is often prudent to treat the injury with a period of immobilization and crutches and to arrange for a follow-up examination. Depending on the patient's clinical situation and associated injuries, it is sometimes helpful to have the orthopedic consultant examine the patient under general anesthesia. If the patient has a grossly unstable knee with injury to multiple ligaments, consider the possibility of a spontaneously reduced knee dislocation. Serial vascular examinations including ankle-brachial indices are warranted to avoid missing an associated limb-threatening popliteal artery injury. If the vascular examination is abnormal, obtain angiography or Doppler studies for further evaluation.
Knee Ligament Injuries: Collateral Ligaments
The medial collateral ligament is the most commonly injured ligament in the knee and is associated with ACL injury. The mechanism of injury often involves a direct blow and sports injuries. The lateral collateral ligament is less commonly involved and occurs more often in high-energy trauma such as motor vehicle collisions.
The patient usually presents with tenderness along the distribution of the ligament. Evaluate the ligament's stability by placing varus and valgus stresses (see Figure 28–15) with the knee in extension and with 30° flexion.
Plain radiography is of limited use but should be obtained initially to rule out associated fractures. MRI has emerged as a useful modality to evaluate these injuries but is rarely indicated in the emergency department. Orthopedic follow-up should be arranged.
Simple strains may be treated conservatively with immobilization and follow-up examination.
Patients can be discharged with immobilization and follow-up. Unstable joints will need further evaluation (eg, MRI, arthroscopy) and eventual surgical repair.
Knee Ligament Injuries: Cruciate Ligaments
Injuries to the cruciate ligaments usually result from direct anterior or posterior forces to the knee. Rotational forces may also injure the cruciate ligaments and are usually associated with other injuries (ie, menisci, collateral ligaments). Injuries may be associated with high- or low-energy trauma. The anterior cruciate ligament is the most commonly injured.
Joint effusions are common, and hemarthrosis may be seen particularly with anterior cruciate ligament injuries. Stability of the anterior cruciate ligament is assessed clinically by the Lachman's test (to determine the endpoint of the tibia when pulled anteriorly with the thigh stabilized) (Figure 28–17), pivot shift (“jerk” test to detect anterolateral rotatory instability), and anterior drawer tests (to detect forward movement of the tibia relative to the femur compared to the other side). Stability of the posterior cruciate ligament is evaluated by the posterior drawer sign or the posterior sag sign (positive when the tibia sags backward with the knee flexed with muscle relaxation) (Figure 28–18).
The Lachman test for rupture of the anterior cruciate ligament. Attempt to pull the tibia forward relative to the femur while the knee is slightly flexed. Any increase in laxity compared with the uninjured knee signifies injury.
Rupture of the posterior cruciate ligament is a likely diagnosis when the tibia of the injured knee sags posteriorly below the distal femur when the legs are held flexed 90° at the hip and knee.
Plain radiography may be unrevealing. Avulsion fractures of the tibial spines suggest a cruciate ligament tear. If the clinical examination does not reveal significant instability, outpatient follow-up examination may include MRI.
Immobilize the knee and give the patient crutches and nonweight-bearing status instructions.
Orthopedic follow-up is indicated for all significant injuries, and arthroscopy may be performed for both diagnosis and treatment.
- Medial meniscus most commonly affected
- Patient may complain of knee locking
- MRI or arthroscopy may be necessary for diagnosis
The menisci provide a gliding surface for the femoral condyles and aid in distributing stress across the joint. Meniscal tears usually occur when a rotational force is applied to the knee while the foot is planted. Because of degenerative processes, the injury producing the acute tear may not be significant. The medial meniscus is most commonly affected.
The patient may complain of hearing a pop, but this finding is not specific. Joint line tenderness is usually present, and the patient may complain that the knee “locks.” This locking is usually seen with a “bucket-handle” tear of the meniscus when the free central portion becomes lodged in the intercondylar notch. Clinical diagnosis is evaluated by use of the McMurray and Apley tests.
Plain films will not identify the tear but may be useful if associated bony injuries are suspected.
Treatment involves knee immobilization, crutches, and pain control.
Patients may be discharged from the emergency department with immobilization and orthopedic follow-up. Outpatient MRI is commonly used to make the diagnosis. Arthroscopy may be diagnostic and used to perform meniscectomy.
Roberts DM, Stallard TC
: Emergency department evaluation and treatment of knee and leg injuries. Emerg Med Clin North Am 2000;18(1):67
Swenson TM: Physical diagnosis of the multiple-ligament-injured knee. Clin Sports Med 2000;19(3):415
- May disrupt extensor mechanism
- Quadriceps tendon is more commonly affected
- CT scan or MRI may be needed to confirm diagnosis
Complete rupture of the quadriceps or patella tendon will disrupt the extensor mechanism of the knee. Injuries can occur with high-energy injuries or may be seen with low-energy trauma, particularly in the elderly, but are also classically associated with steroid use. The quadriceps tendon is more commonly ruptured compared to the patella tendon.
The patient presents with a swollen and tender knee and is unable to extend the knee against resistance. A palpable defect may be appreciated.
Plain films may demonstrate an abnormal position of the patella. CT scanning and MRI confirm the diagnosis.
Place the patient in a knee immobilizer until consultation is obtained.
Management depends on the extent of the injury. Complete ruptures require surgical repair.
- Most common long bone fracture
- Open fractures sometimes occur
- Plain X-rays are usually sufficient for diagnosis
- Assess for compartment syndrome
The tibia is the most common site of long bone fractures. The majority of these fractures will occur with associated fracture of the fibula. The tibia can be injured by a variety of forces.
Because little soft tissue is found around the tibia anteriorly, open fractures are common. Pain, swelling, and deformity are usually present. Compartment syndrome sometimes occurs with tibial injuries, and frequent reassessments should be performed.
Plain films are usually adequate to identify the fracture. As with all suspected long bone injuries, the joints above and below should be adequately visualized on the radiographs.
Measure compartment pressure if a compartment syndrome is suspected clinically. Simple nondisplaced fractures may be treated with a long leg posterior splint and crutches with orthopedic follow-up.
Open, displaced, and comminuted fractures require orthopedic consultation because they require operative management.
- Isolated fibula fractures are uncommon
- Patient may be able to bear weight
- Assess for Maisonneuve fracture
Isolated fibular fractures are uncommon because they are usually seen with an associated tibia fracture. They may occur by direct blow or with rotational forces. Of particular importance is a Maisonneuve fracture, which is a fracture of the proximal fibula with an associated medial malleolus ankle fracture or ligamentous disruption of the ankle without a fracture.
The patient usually complains of pain and tenderness, and a deformity can usually be palpated. Since the fibula is a nonweight bearing bone, a patient with an isolated fibular shaft fracture may be able to walk.
Plain X-rays should be sufficient for the diagnosis.
Splints or compressive dressing may be applied for comfort. A Maisonneuve fracture represents an unstable ankle injury, and requires immobilization and orthopedic consultation to determine definitive management.
With isolated, uncomplicated fibula fractures, the patient may be discharged with instructions to advance from nonweight-bearing status to weight-bearing status as tolerated.
The bones of the ankle include the distal tibia, distal fibula, and the talus. The ankle mortise is formed by the medial and lateral malleoli and the plafond (the articular surface of the distal tibia). As with the knee, the ankle relies on articular cartilage, joint capsule, and ligaments to provide joint stability. Management of ankle injuries is based on the joint's stability.
The ligaments are divided into three sets: the syndesmotic (anterior and posterior tibiofibular ligaments); the lateral collateral (calcaneofibular, anterior talofibular, and lateral tibiocalcaneal ligaments); and the medial collateral or deltoid ligaments, which are further divided into four parts (posterior tibiotalar, tibiocalcaneal, anterior tibiotalar, and tibionavicular). Ankle injuries are common and often involve a combination of bony and ligamentous injuries.
Clinical decision rules aid the emergency physician in determining whether plain radiography is needed in the evaluation of ankle or foot injuries. The Ottawa ankle rules state that ankle X-rays should be obtained if there is pain at the malleoli, inability to bear weight for four steps, and tenderness posteriorly or inferiorly at the malleoli. Ottawa foot rules recommend that X-rays be obtained if there is inability to bear weight for four steps and tenderness at the base of the fifth metatarsal or over the navicular bone. The sensitivities of the Ottawa ankle and foot rules are 98–100%.
Lateral Malleolar Fractures
- Inversion injury
- May include minor avulsion fractures to complete joint disruption
- Plain X-rays are usually sufficient for diagnosis
Lateral malleolar fractures may range from simple avulsion fractures seen with inversion to displaced fractures with mortise disruption.
The patient usually presents with point tenderness, swelling, and difficulty ambulating.
Plain radiographs are usually sufficient to make the diagnosis.
Simple fractures may be treated with a posterior short leg splint with stirrups (Figure 28–19), crutches with no weight bearing, and orthopedic follow-up.
Combined sugar-tong splint and posterior-plantar plaster slab with padding for ambulatory (nonweight-bearing) patient with foot injuries.
Open or displaced fractures require orthopedic consultation for operative management.
Medial Malleolar Fractures
- Eversion injury
- Often associated with deltoid ligament injury
- Plain X-rays are usually sufficient for diagnosis
Medial malleolar fractures result from eversion injuries or external rotation. These fractures are frequently associated with injuries to the deltoid ligament.
Pain, swelling, and difficulty in ambulating are usually present. Palpate the proximal fibula to determine whether a Maisonneuve fracture is present.
Plain films are usually sufficient for the diagnosis.
Management is similar to that for lateral malleolar fractures; however, if significant injury to the deltoid ligament has occurred, the rehabilitation period will be longer.
Patients with closed injuries may be discharged with a posterior short leg splint with stirrups (Figure 28–19), crutches with no weight bearing, and orthopedic follow-up in 2–3 days.
Posterior Malleolar Fractures
- Rare injury
- Usually avulsion from posterior talofibular ligament
- May represent significant joint instability
Fractures involving only the posterior malleoli are rare and usually result from an avulsion injury involving the posterior tibiofibular ligament. If isolated they may be managed conservatively as above. If these fractures are associated with other injuries or joint instability, orthopedic consultation is indicated. Bimalleolar and trimalleolar fractures should be considered unstable and mandate orthopedic consultation for surgical management.
- May occur from direct or indirect forces
- Use Thompson test
- Orthopedic consultation is necessary
Rupture of the Achilles tendon is often seen in middle-aged individuals participating in sporting activities. It may be secondary to a direct blow or can occur with indirect forces as with forced dorsiflexion. The patient frequently reports hearing a pop.
Localized pain and weakness in plantarflexion are present, and a deformity may be appreciated. The diagnosis is mainly clinical. To determine if the tendon has been ruptured, the emergency physician can squeeze the calf muscles with the patient prone and the knee flexed to 90° (Thompson test) or alternatively squeeze the calf muscles with the patient kneeling on a chair with both knees flexed (Figure 28–20). Absence of plantarflexion or decreased plantarflexion compared to the unaffected side suggests rupture.
Test for Achilles tendon continuity. Squeeze the relaxed calf while observing the amount of ankle plantarflexion thus produced. If the tendon is ruptured, less motion occurs compared with that on the uninjured side.
X-rays may show thickening of the tendon. MRI will confirm the diagnosis.
A temporary long leg or stirrup splint may be placed until consultation with orthopedics.
Orthopedic consultation should be obtained because Achilles tendon injuries may be managed surgically or nonoperatively.
- Usually results from forced dorsiflexion
- Tenderness posterior to lateral malleolus
- CT scan or MRI may be needed to confirm diagnosis
The peroneal tendons function in eversion, pronation, and plantarflexion. These tendons can become subluxed or dislocated by tearing of the superior retinaculum attachment on the fibula. The injury usually results from forced dorsiflexion.
The patient presents with pain, swelling, and weakness on eversion. Tenderness posterior to the lateral malleolus is present.
A small avulsion fracture of the lateral malleolus is pathognomonic of this injury. A CT or MRI scan may be needed to confirm the diagnosis.
Treatment involves use of a posterior splint, crutches with no weight bearing, and analgesics.
Orthopedic consultation is necessary to determine appropriate management. Patients with these injuries may be discharged with appropriate follow-up, but peroneal tendon injuries often need surgical repair.
- Associated fracture often present
- Assess neurovascular status
- Dislocation may require reduction before X-rays are obtained
An ankle dislocation represents displacement of the talus and foot from the tibia. Dislocations are described by the relationship of the talus to the tibia. They may be open or closed, and an associated fracture frequently occurs. Dislocations occur from axial loading to the foot in plantarflexion and are seen in sporting injuries and in high-energy trauma such as motor vehicle collisions.
The neurovascular status should be determined quickly along with rapid reduction. The patient will have gross deformity of the ankle joint.
Radiographs can be used for diagnosis, but should not be delayed when skin tenting or neurovascular compromise is present.
Once the dislocation has been reduced, reassess the neurovascular status, splint the ankle, and obtain radiographs and orthopedic consultation.
These patients will frequently be admitted and should not be discharged without consultation from an orthopedist.
- Anterior talofibular ligament is affected most commonly
- Swelling, ecchymosis, point tenderness
- Assess for instability of ligaments
- Ankle rules may help in determining need for X-rays
- Most are managed conservatively
Ankle sprains most often occur secondary to significant force applied as inversion and plantarflexion. The ligament most commonly affected is the anterior talofibular ligament, accounting for approximately two-thirds of ankle sprains. The next most commonly affected ligament is the calcaneofibular ligament, and in 20% of cases both the calcaneofibular and anterior talofibular are involved. The deltoid ligament located medially is injured less often (approximately 5% of sprains). Eversion forces may initiate this injury, and sprains of the deltoid ligament typically require extended rehabilitation periods compared to the more common anterior talofibular or calcaneofibular ligament sprains. Deltoid ligament ruptures may be seen with medial malleolar fractures.
The patient typically presents with a history of a fall or twisting injury. Often swelling, ecchymosis, and point tenderness are present. Grading of sprains is described earlier in this chapter. Always assess for associated injuries such as a Maisonneuve fracture or Achilles tendon rupture.
Physical examination may include the anterior drawer test. With the patient seated, the knee flexed to 90°, and the ankle in neutral position or 10° of plantarflexion, gently pull forward on the heel while pushing the lower leg posteriorly. Visualize for any deformity or feel for a clunk. This test examines the integrity of the anterior talofibular ligament. The talar tilt-test assesses the anterior talofibular and calcaneofibular ligaments. With the knee flexed to 90° and the ankle in a neutral position, invert the heel and assess for displacement of the talar head or laxity. The external rotation test is used to evaluate the distal talar syndesmotic ligaments. With the foot in neutral position and the knee flexed to 90°, rotate the foot and assess for laxity and pain laterally.
Use history, physical findings, and Ottawa ankle rules to determine whether radiographs are necessary. X-rays will be negative for fracture but may demonstrate soft tissue swelling. In significant ligament sprains and ruptures, the mortise may be affected.
Most ankle sprains may be treated conservatively on an outpatient basis. The RICE (rest, ice, crutches, and immobilization elevation) treatment is usually indicated. For minor injuries, immobilization with an elastic bandage and crutches may be all that is necessary. For more significant injuries, a sugar-tong or posterior plaster splint may be applied. A plaster cast should never be applied acutely because of the risk of further swelling leading to increased pain and vascular compromise. Aircasts and other commercial devices may be useful. Crutches should be used with no weight bearing initially and progressing to weight-bearing status as tolerated. Prescribe appropriate analgesics. Depending on the severity of injury, the patient may return to normal function in as little as a few days; however, it may be several weeks until proper function is restored.
For minor injuries, treatment should be initiated as above. If symptoms resolve quickly, follow-up may not be necessary. Patients may consider follow-up with a primary-care provider for further evaluation in minor cases. Patients with significant sprains should receive treatment with immobilization and crutches as above and should be referred to an orthopedist within 1 week.
Perry JJ, Stiell IG: Impact of clinical decision rules on clinical care of traumatic injuries to the foot and ankle, knee, cervical spine, and head. Injury 2006;37(12):1157–1165
et al: Radiography in acute ankle injuries: the Ottawa ankle rules versus local diagnostic decision rules. Ann Emerg Med 2007;39:599
- Most common tarsal bone fracture
- Axial loading, often associated with vertebral fractures
- The Boehler angle may detect subtle fractures
- Orthopedic consultation is necessary
The calcaneus is the largest of the tarsal bones and the one most commonly fractured. The most common mechanism is axial loading from a fall. A high association exists between calcaneal fractures and other lower-extremity and vertebral fractures.
The patient complains of severe pain in the heel and inability to bear weight. Ecchymosis and deformity may be present.
Obtain plain radiographs including anteroposterior, lateral, and axial views. Measurement of the Boehler angle on the lateral view may help to identify subtle fractures. The Boehler angle is formed by the intersection of lines drawn from the anterior and posterior elements of the superior portion of the calcaneus (Figure 28–21). The normal angle is 20–40°; an angle of less than 20° suggests a calcaneal fracture.
Because calcaneal fracture lines are often subtle to visualize on foot radiographs, Boehler's Angle is used to determine if the normal anatomic relationships of the calcaneal bony prominences have been disrupted. The normal angle is 28–40° and with fracture from an axial load, the angle is reduced to less than 20°.
A posterior leg splint or bulky Jones splint should be applied. The patient should be given crutches and nonweight-bearing status instructions.
Orthopedic consultation is necessary to determine operative versus nonoperative management.
- No muscle attachment on talus
- Tenuous blood supply
- CT scan or MRI may be necessary to detect subtle fractures
The talus is the second largest tarsal bone and is the second most commonly injured bone after the calcaneus. The talus is the only bone in the foot with no muscle attachment; it is held in place by the malleoli and ligaments. The talus has a somewhat tenuous blood supply, and avascular necrosis is a potential with significant fractures. Other complications include infection, posttraumatic arthritis, malunion, and nonunion. Fractures may result from plantarflexion, dorsiflexion, or inversion forces. Talus fractures usually result from high-energy trauma, and associated injuries are common.
Pain and swelling are common. Inversion and eversion are usually quite painful.
Plain radiographs may miss subtle fractures, and CT scanning or MRI may be necessary.
Simple fractures are treated conservatively with splinting, nonweight bearing and analgesics. Major fractures often require open reduction or prolonged nonweight-bearing immobilization.
Talar fractures require orthopedic consultation and many require ORIF.
- Uncommon injury
- Associated with talocalcaneal and talonavicular ligament ruptures
- Plain X-rays should be sufficient for diagnosis
- Rapid reduction is indicated
Subtalar dislocations are rare injuries and occur secondary to severe rotational forces that rupture the talocalcaneal and talonavicular ligaments, while the calcaneonavicular ligament remains intact. The dislocation is usually lateral or medial, although anterior and posterior dislocations may occur.
An obvious deformity is usually visible and neurovascular status should be carefully assessed, but compromise is rare.
Plain radiographs including an anteroposterior view of the foot should determine the diagnosis.
The dislocation should be reduced quickly, usually via closed reduction under adequate sedation. In-line longitudinal traction should be applied to the foot and then appropriate directional force applied to correct the deformity. Direct pressure on the head of the talus can be helpful. Buttonholing of the talus through the extensor retinaculum can make reduction impossible.
After reduction, immobilization in a splint and orthopedic referral are indicated.
Tarsometatarsal Injuries (Lisfranc Injuries)
- Uncommon injury; large amount of force is required
- Lisfranc joint
- Plain X-rays are usually sufficient for diagnosis
The tarsometatarsal joint comprises the articulation of the first three metatarsals with the medial, middle, and lateral cuneiform bones, as well as the articulation of the fourth and fifth metatarsals with the cuboid. The tarsometatarsal joint separates the forefoot from the mid-foot and is commonly referred to as the Lisfranc joint. It functions in supination and pronation of the foot. Injuries to this joint are uncommon and generally the result of a large force applied to the foot. Dislocations can occur in part or all of this joint and are frequently associated with metatarsal and tarsal fractures.
Pain and obvious deformity over the joint are generally present.
Plain films usually suffice; a lateral weight-bearing view may detect subtle injuries but is not indicated in the emergency department. Fractures at the base of the second metatarsal or the dorsal aspect of the cuboid are often associated with Lisfranc fracture dislocations.
These injuries are often managed with closed reduction and percutaneous wires.
Orthopedic consultation is necessary.
Perron AD, Brady WJ, Keats TE: Orthopedic pitfalls in the ED: lisfranc fracture-dislocation. Am J Emerg Med 2001;19:71
- Common; result from crush or twisting injuries
- Most common at base of fifth metatarsal (Jones fracture)
- Treat with posterior splint
Metatarsal fractures are common, accounting for approximately one-third of foot fractures. They may occur as a result of crush injuries or twisting forces.
A visible deformity may be present, along with tenderness and swelling.
A fracture involving the base of the fifth metatarsal is the most common fracture. Plain radiographs should be sufficient to make the diagnosis. Care should be taken to examine the X-rays for subtle abnormalities in the Lisfranc joint.
Avulsion fractures involving the tuberosity of the proximal fifth metatarsal can be splinted for comfort, or the patient may be allowed to bear weight in a hard-soled shoe. Fractures involving the metaphysis of the proximal fifth metatarsal (also known as a Jones fracture) are more prone to complication, such as nonunion, and should be immobilized in a posterior splint (see Figure 28–18).
Discharge the patient with orthopedic follow-up within a few days.
- Fractures and dislocations are common
- Pain, obvious deformity
- X-rays may be bypassed in minor injuries
- Treatment involves buddy taping
Injuries to the toes are common and include both fractures and dislocations. Fractures of the phalanges are the most common fractures in the foot and frequently involve the fifth phalanx. Dislocations are rare; when seen, they most commonly occur in the metatarsophalangeal joint of the great toe.
Pain, swelling, and deformity are usually seen.
X-rays usually reveal the injury. Radiographs may not be obtained for minor injuries.
Conservative management and immobilization by taping to the adjacent toe (buddy taping) are instituted. Dislocations are usually easily reduced with adequate sedation or a digital nerve block.
Patients with simple fractures do not require orthopedic follow-up. Complicated fractures and dislocations should be immobilized with buddy taping; patients with complicated fractures and dislocations should be referred for outpatient orthopedic follow-up.