10/09/2013

HR-6000L
Justification, Optimisation and
Interpretation in Medical
Imaging

Foot fractures
Toes
Rarely significant

Metatarsals
Base 5th
Lisfrancs fracture dislocation

Foot and ankle

Tarsals
Calcaneus
Talus
Gary Culpan

Toe fractures

Gary Culpan

Significance of toe fractures

Mechanism of injury

Great toe
May need treatment

Direct trauma

Lesser toes

Stubbing
Crush injury
Heavy object dropped

Not significant unless grossly displaced

Hyperextension
Stress

Often do not require radiography

Unlike finger injuries!
Hatch and Hacking (2003)

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Treatment of toe fractures

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Stress fractures of toes

Elevation, Ice, Rest

Rare
Affect proximal phalanx

Neighbour strapping

Particularly Great toe

Continued microtrauma

Maintain position

Manipulation
If widely displaced

Surgery
Open injuries
Gary Culpan

Gary Culpan

10/09/2013

Arthritis affecting Great toe

Hallus varus

Common site MTPJ

Primary OA
Secondary OA

big toe deviates away from midline of foot

most commonly develops after failure of bunion
surgery
other conditions include:

Hallux rigidus
Linked to repetitive trauma e.g. running

Hallux valgus (bunion)

Toe is deviated towards second toe
Metatarsal is deviated medially

trauma, removal of sesamoid from MTPJ, some arthritides

Hallus varus
Toe is deviated away from second toe
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Metatarsal fractures

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Fracture of little toe MT

Mechanism of injury

Mechanism
Inversion
Avulsion of base (peroneus brevis)
Transverse fracture base (Jones fracture)
Neck (dancers fracture)

Trauma
Great toe
Little toe

Often comminuted and displaced

Stress
Middle toes

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5MT fracture

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Stress fractures

Avulsion of base of 5th

metatarsal
Due to inversion stress on
peroneus brevis tendon
Important to distinguish
from secondary
ossification centre

Usual site
2nd MT
3rd MT less common
5th MT separate fracture type

Mechanism of injury
Repeated stress
Runners neck
Dancers proximal shaft
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Gary Culpan

10/09/2013

Friebergs
disease

Stress fractures
Often no history of trauma
Radiographs normal in first three weeks
Callus demonstrated later

Bone scintigraphy positive early

Treatment

Osteochondritis
MT head
Commonest 3MT
Repetitive trauma
e.g. dancing

Rest

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Gary Culpan

Chopart fracture dislocation

Dislocations of the foot

Hunter et al 2000

Less common than fractures

Most common in tarsometatarsal
(Lisfrancs) joint

Injury involves
mid tarsal joints
talonavicular &
calcaneocuboid

Fracture dislocation
Associated fractures of cuboid or navicula

Charcot joint
Neuropathic
Diabetes

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Mid foot tarsal fractures

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Hind foot tarsal fractures

Talus

Navicula

Second commonest fracture of foot

Compression fractures

Rare

Neck
Body
Posterior process

Direct trauma
Avulsion dorsal surface

Kohlers disease osteochondritis

Avulsion fractures
Osteochondral fracture

Cuneiform

Talar dome
Trauma sports related

Related to other fractures

e.g. Lisfranc injury

Calcaneus

Cuboid

Commonest fracture of foot

Axial load
Stress

Direct trauma
Related to other fractures

Gary Culpan

Gary Culpan

10/09/2013

Talar fractures

Calcaneal fractures

Often occurs from forced dorsiflexion of foot

Motor vehicle accidents

Complication

60% of major tarsal injuries

Mechanism of injury
Fall / jump from height
Bilateral in 10%
Associated with spinal fractures (thoraco-lumbar junction)

Dislocation of subtalar and talonavicular joints

Fracture

Important consideration

Vertically orientated involving neck of talus

Comminuted

Subtalar joint involvement

Osteochondral fracture

Stress fractures
Joggers & runners
Elderly osteoporosis
Sclerotic band

Chronic stress
Seen in athletes & ballet dancers
Lucency with separate fragment

Vertical or parallel to posterior contour of calcaneus

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Gary Culpan

Bohlers angle

Ankle

Lines drawn onto superior border of

calcaneus

Most frequently injured of all major

weight bearing joints
Usually young adults involved in sports
e.g. football, running, skiing
2 basic mechanisms of injury

One anterior
One posterior

Normal range of angle

20-40 degrees

Inversion
Eversion
Also internal / external rotation, hyperflexion,
hyperextension, vertical compression
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Projections

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Spotting ankle injuries

AP

Usually displaced
May only show on one projection

Foot dorsiflexed
Best shows tibio-talar joint

Overlap on lateral can be difficult

Medial or lateral?

Mortice
Internal rotation ~ 20

Soft tissue swelling

Effusion
Loss of symmetry of joint

Lateral
Superimposed malleoli
Include base 5MT
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Gary Culpan

10/09/2013

Effusion

Ankle fractures

More difficult
to see and
less useful
predictor of
injury than in
the knee joint

Unimalleolar
Bimalleolar
Trimalleolar
Complex

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Inversion injuries

Avulsion base 5MT

Most common
Injury types

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Review Jones fracture

To avoid X-ray foot and ankle requests
ensure base 5MT on all lateral ankle
projections

Avulsion base 5MT

Anterior process of calcaneus
Ligamentous tear
Avulsion lateral malleolus

Ottawa ankle rules

Pain in malleolar region, bony tenderness, unable to
weight bear
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Anterior process of calcaneus

Often missed
Mistaken for sprain
Treated with cast
Can take 6-9 months for
complete recovery

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Eversion injuries
Less common than inversion
Mechanism
Trips and falls

Injury types
Transverse fracture medial malleolus
Associated oblique fracture lateral malleolus

Weber classification
A, B, C
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Gary Culpan

10/09/2013

Weber classification

Posterior malleolus

Determines stability
Relates injury tibio-fibular syndesmosis
Weber A

Mechanism of injury
Severe inversion or eversion
Twisting of foot onto dorsal surface

Injury distal to syndesmosis

Fracture stable

Fracture posterior aspect of tibia

Weber B

Rarely seen in isolation

Tri-malleolar fracture

At level of syndesmosis
May be stable or unstable

Weber C

Above syndesmosis
Unstable
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Maisonneuve fracture

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Tillaux fracture
Common in adolescents

Eversion injury
Fracture in proximal half of fibula

12-15 years

Rare in adults
Clinical history

Junction of proximal & middle 1/3

Disruption of tibiofibular syndesmosis

Low-velocity trauma
Sporting activities

Tear of tibiofibular ligament

Fracture of medial malleolus

Skateboard
Sliding (football, baseball)

Interosseous membrane

External rotation of foot

Always damaged to level of fibular fracture

Gary Culpan

Gary Culpan

Pathophysiology

Tillaux fracture

Fusion of distal tibial epiphysis occurs in stages

Abduction & external rotation

Avulsion lateral margin tibia
If more than 2mm displacement or
irregularity of tibial articular surface
surgery is required
If medial portion of fibula is detached
this is Wagstaffe-LeFort fracture

Starts posteriorly; progresses anteriorly

Middle third first
Medial side next
Lateral aspect last
Takes 12-18 months in total

Tillaux fracture occurs after medial part of physis has

fused but before lateral part fuses
Fracture line
Vertical through epiphysis
Exits on lateral cortex of tibia

Displacement usually minimal

Salter-Harris type III
Fibula usually doesnt fracture
Gary Culpan

Gary Culpan

10/09/2013

Fibular fractures - Potts fracture

Triplanar (Marmor-Lynn)
fracture

Most common ankle fracture

Affects distal third of fibula

Involves lateral aspect of distal tibial

epiphysis with extension in 2 other
planes
Mechanism is plantar flexion with
external rotation
Salter-Harris type II fracture

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Gary Culpan

Dupuytrens fracture

Tibial shaft fractures

Eversion injury
2-7cm above distal tibiofibular
syndesmosis & includes disruption of
medial collateral ligament
Leads to instability

High velocity trauma

Severe displacement
Imaging difficulties
Open fractures
Treatment options
Cast
External fixator
Internal fixation

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References

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Eponyms and colloquialisms

Hatch RL and Hacking S (2003) Evaluation and Management of Toe

Fractures American Family Physician Vol. 68/No. 12 (December 15,
2003)
Hollis MH (2007) Hallux Rigidus eMedicine.com
http://www.emedicine.com/orthoped/topic125.htm last accessed 1009-13
Richardson ML, Hansen ST & Kilcoyne RF (1997) Radiographic
Evaluation of Hallux Valgus. University of Washington Department of
Radiology: Radiology Exhibits
http://www.rad.washington.edu/academics/academicsections/msk/teaching-materials/radiology-anatomy-teachingmodules/radiographic-evaluation-of-hallux-valgus last accessed 10-0913
University of Washington Radiology Online Classroom
http://courses.rad.washington.edu/

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Hunter et al 2000

http://radiographics.rsnajnls.org/cgi/reprint/20/3/819

Lee et al 2004
http://radiographics.rsnajnls.org/cgi/reprint/24/4/1009

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