Fractures of the Foot and Ankle

Fractures of the Foot and Ankle

Foot

Although foot fractures commonly occur in sports, they are rarely severe enough to be considered a true medical emergency. Conservative management usually consists of appropriately splinting the injured area and advising the use of crutches until definitive diagnosis. One exception is the Lisfranc fracture. Although rarely encountered in sports, Lisfranc fractures are serious orthopedic traumatic emergencies. This injury usually is the result of substantial torsional stress, and physical examination reveals significant swelling and pain at the tarsometatarsal joint. Point tenderness is also prominent at the base of the third metatarsal. Displaced Lisfranc fractures are clinically evident, thereby facilitating definitive diagnosis. However, this pathology is typically misdiagnosed as minimally or nondisplaced fractures on clinical examination. This unique fracture is sometimes deemed catastrophic because of the high incidence of complications and warrants immediate transportation of the injured athlete to the nearest emergency medical facility because surgical intervention is typically required. The role of athletic trainers in correctly managing this fracture should include immobilizing the foot in a posterior ankle splint or walking boot and advising the use of crutches for nonweight-bearing ambulation. Failure to promptly recognize this significant injury may delay adequate care and yield unsuccessful outcomes. Common complications secondary to improper management of Lisfranc fractures include post-traumatic arthritis and reflex sympathetic dystrophy.

Ankle

The ankle is the most commonly injured joint in the human skeletal system. Ankle fractures typically refer to pathology of the distal tibia and fibula and the talus and calcaneus. The most common mechanism of injury is hyperinversion of the joint. Although the ankle joint is less susceptible

to hypereversion mechanisms of injury, pathology subsequent to this specific mode tends to produce significant damage. Ankle injuries frequently result in loss of playing time throughout sports. However, rarely do these fractures

rise to the level of a true medical emergency unless an open fracture occurs. The Ottawa rules are a useful guide to athletic trainers for quickly establishing the potential severity of ankle pathology. Any athlete presenting

with significant posterior ankle pain or the failure to bear body weight should be immediately removed from athletic activity and referred to a physician. When assessing a potential ankle fracture, the inability to bear weight on the affected extremity should raise suspicion of significant ankle injury. Careful inspection for any open wounds is of utmost importance. Unrecognized open fractures are a risk for serious infection. Common findings specifi to ankle fractures typically include obvious deformity, edema or effusion, ecchymosis, and point tenderness along the injured bone. Principal management of ankle fractures is dependent on multiple factors, with the preservation of anatomical integrity and correct physiological joint function being critically important in preserving later gait and weightbearing function. As such, immediate activation of EMS or transport of the athlete to the nearest emergency medical facility is mandated with severe cases of injury for comprehensive care. Furthermore, when caring for ankle fractures, it

is extremely important that the athletic trainer periodically monitor neurovascular functions of the foot and ankle. Immobilization of the ankle joint in the position of presentation with a posterior ankle splint, sugar tong/short-leg stirrup splint, or walking boot will assist in pain control and

limit displacement of fragments, thereby sustaining soft tissue integrity. The use of crutches may also be advised for nonweight-bearing ambulation to further protect the affected area.

X-rays are only required if there is bony pain in the malleolar or midfoot area and any one of the following:

■ Bone tenderness along the distal 6 cm of the posterior edge of the tibia or tip of the medial malleolus

■ Bone tenderness along the distal 6 cm of the posterior edge of the fibula or tip of the lateral malleolus

■ Bone tenderness at the base of the fifth metatarsal (for foot injuries)

■ Bone tenderness at the navicular bone (for foot injuries)

■ An inability to bear weight both immediately and in the emergency department for four consecutive steps

*The Ottawa rules are not applied to those younger than age 18 years.

Fundamentals of Joint Dislocations

Dislocations of the shoulder, elbow, hip, knee, ankle, and sternoclavicular

joints constitute traumatic orthopedic emergencies as a result of the potential for neurovascular compromise and resultant disability if not treated immediately. Definitive  treatment for dislocated joints comprises reducing the injury to correct anatomical position. Whether this occurs on-site

or in a hospital depends on the competency of the athletic trainer. A properly trained athletic trainer may attempt joint reduction with prior approval of the team physician; this approval should be written and should clearly refer to specific joints and types of dislocations. This is especially indicated if the arrival of EMS or transport to a hospital will be prolonged.

Early reduction following joint dislocation is less difficult than prolonged reduction. This is because of muscle spasms and guarding from pain, which will increase over time and hinder such efforts. Reduction attempts should be performed only after a thorough examination of the joint. Furthermore, neurovascular status must be monitored before, during, and after any attempts.As a general rule, most EMS providers are not specifically trained nor permitted to reduce joint dislocations. Significant resistance or greatly

increased pain are reasons to abort reduction attempts and may indicate an associated fracture. Dislocations that are not reduced should be splinted in the position found and the athlete should be transported to a hospital immediately. If reduction is successful, distal neurovascular function should

be rechecked, followed by careful application of ice and splinting the area in a position of function. The athlete should be seen as soon as possible by an orthopedic surgeon for further evaluation of joint function. In most cases only dislocations of the patella, shoulder, fingers, or toes should be reduced on the field if required immediately. Reductions of the elbow, hip, or knee joints are regarded as difficult and should only be attempted by an appropriate medical specialist. This difficulty is attributed to challenging reduction techniques, the high likelihood of concomitant fractures, and severe complications from incompetent attempts. The athletic trainer covering sports without a physician present should obtain or develop written

clinical standards and field protocols pertaining to the management of joint dislocations. In any event, all dislocations, whether reduced in the field or not,must be evaluated by an orthopedic surgeon as soon as possible.