Easily Missed Fractures of the Ankle & Foot

Home , March fracture

Easily Missed Fractures of the Ankle & Foot page 1 of 18 Easily Missed Fractures Search for on EVERY Ankle view: Easily Missed 1) MM & LM (Weber) 2) OLT (OCD) Previous Fractures 3) 5th MT (Jones, Avulsion) Talk 4) LPT Foot & Ankle Search for on EVERY Foot view: 5) APC This but first… 6) MT Talk Anatomy: Tarsal 7) Lisfranc Bones & Joints ©Ken L Schreibman, PhD/MD 2008 schreibman.info ©Ken L Schreibman, PhD/MD 2008 schreibman.info

Anatomy: Tarsal Bones & Joints Anatomy: Tarsal Bones & Joints Talus Talus Dome Latin: “Ankle” Center of Ankle Joint Body

Head ©Ken L Schreibman, PhD/MD 2008 schreibman.info ©Ken L Schreibman, PhD/MD 2008 schreibman.info

Anatomy: Tarsal Bones & Joints Mortise: Woodworking Term Ankle Joint Dome pla·fond\plà-fōn\ n [fr. plat flat + fond bottom] MORTISE ceiling formed by the underside of a floor TENON

Plafond Mortise

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©Ken L Schreibman, PhD/MD 11/10/08 www.schreibman.info Easily Missed Fractures of the Ankle & Foot page 2 of 18 Anatomy: Tarsal Bones & Joints Anatomy: Tarsal Bones & Joints Talus Tibia Talo-Navicular Joint Navicular sits on Head like a hat

Navicular Navicular Head of Head Navicular Talus of Talus

Talo-Navicular  Calcaneus subluxation Posterior Tibial Tendon  (PTT) Disfunction ©Ken L Schreibman, PhD/MD 2008 schreibman.info ©Ken L Schreibman, PhD/MD 2008 schreibman.info

Anatomy: Tarsal Bones & Joints Anatomy: Tarsal Bones & Joints Sub-Talar Sub-Talar Sustentaculum* Tali Joint Joint Anterior 3 Facets Middle Talus

Calcaneus Posterior * Latin: “a supporting structure”

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Anatomy: Tarsal Bones & Joints Anatomy: Tarsal Bones & Joints Sub-Talar Calcaneus Joint

Talus

Cuboid

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©Ken L Schreibman, PhD/MD 11/10/08 www.schreibman.info Easily Missed Fractures of the Ankle & Foot page 3 of 18 Anatomy: Tarsal Bones & Joints Anatomy: Tarsal Bones & Joints Calcaneo-Cuboid Joint Chopart Joint Lateral Process Talus

Anterior Process Cuboid Calcaneus Cuboid Calcaneus

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Anatomy: Tarsal Bones & Joints Anatomy: Tarsal Bones & Joints IV 2 V 1 3

Navicular Cuboid I Navicular Cuboid II The Navicular III Talus IV V Talus DOES NOT 1 2 3 articulate with Cuboid the Calcaneus Navicular

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Anatomic Divisions Anatomy: 3D

META- FORE- TARSALS FOOT LISFRANC 1 2 3 MID- CHOPART N Cu FOOT Ta Ca TARSALS HIND- FOOT

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©Ken L Schreibman, PhD/MD 11/10/08 www.schreibman.info Easily Missed Fractures of the Ankle & Foot page 4 of 18 Anatomy: Cross-Sectional Anatomy: Cross-Sectional CT: Axial Plane CT: Axial Plane

MM Syndesmosis Ti Ta Fi LM

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Anatomy: Cross-Sectional Anatomy: Cross-Sectional CT: Axial Plane CT: Axial Plane

2 1 N 3 N TNJ Ta Cu M-STJ P-STJ Ca

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Anatomy: Cross-Sectional Anatomy: Cross-Sectional CT: Axial Plane CT: Axial Plane GOOD FOR: Syndesmosis Talonavicular Joint Calcaneocuboid Joint Cu Navicular-cuneiform Joints CCJ Ca Tarsal-metatarsal Joints NOT GOOD FOR: Ankle Joint Subtalar Joint ©Ken L Schreibman, PhD/MD 2008 schreibman.info ©Ken L Schreibman, PhD/MD 2008 schreibman.info

©Ken L Schreibman, PhD/MD 11/10/08 www.schreibman.info Easily Missed Fractures of the Ankle & Foot page 5 of 18 Anatomy: Cross-Sectional Anatomy: Cross-Sectional CT: Sagittal Plane CT: Sagittal Plane Reformatted off Axial reference image Reformatted off Axial reference image Medial Slice Middle Slice Ti Ti TNJ TNJ Ta Ta P-STJ N ST N Ca 1 I

M-STJ M-STJ ©Ken L Schreibman, PhD/MD 2008 schreibman.info ©Ken L Schreibman, PhD/MD 2008 schreibman.info

Anatomy: Cross-Sectional Anatomy: Cross-Sectional CT: Sagittal Plane CT: Sagittal Plane Reformatted off Axial reference image SECONDARY PLANE FOR: Lateral Slice Ankle Joint Ti Sub-Talar Joint AJ P-STJ Talo-Navicular Joint Ta LPT Calcaneo-Cuboid Joint APC Ca Navicular-Cuneiform Joints Cu Tarsal-Metatarsal Joints NOT GOOD FOR: CCJ Syndesmosis ©Ken L Schreibman, PhD/MD 2008 schreibman.info ©Ken L Schreibman, PhD/MD 2008 schreibman.info

Anatomy: Cross-Sectional Anatomy: Cross-Sectional CT: Coronal Plane (2 schemes) CT: Coronal Plane (2 schemes) 1) Mortise Coronal: Reformatted off Axial 2) Oblique Coronal: Reformat off Sagittal Aligned between Malleoli Perpendicular to P-STJ GOOD FOR: GOOD FOR: Distal Tibial Fractures Hindfoot Fxs Malleoli MM Sub-Talar Joint Tillaux, Triplane Talus Pilon LM Calcaneus Talar Dome Fxs (OLT) Tarsal (Mortise Sagittal, perpendicular to this) Coalitions ©Ken L Schreibman, PhD/MD 2008 schreibman.info ©Ken L Schreibman, PhD/MD 2008 schreibman.info

©Ken L Schreibman, PhD/MD 11/10/08 www.schreibman.info Easily Missed Fractures of the Ankle & Foot page 6 of 18 UW 2-Page CT Protocol Sheets Anatomy: Cross-Sectional CT: Oblique Coronal Plane Sagittal ref image perpendic to P-STJ

Ti AJ Fi Ta P-STJ  Ca

©Ken L Schreibman, PhD/MD 2008 www.radiology.wisc.eduschreibman.info ©Ken L Schreibman, PhD/MD 2008 schreibman.info

Anatomy: Cross-Sectional Anatomy: Cross-Sectional CT: Oblique Coronal Plane CT: Oblique Coronal Plane Sagittal ref image perpendic to P-STJ Sagittal ref image perpendic to P-STJ

P-STJ ST M-STJ

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Anatomy: Cross-Sectional Anatomy: Cross-Sectional CT: Oblique Coronal Plane CT: Oblique Coronal Plane Sagittal ref image perpendic to P-STJ GOOD FOR: Sub-Talar Joint Ankle Joint NOT GOOD FOR: Talo-Navicular Joint A-STJ Calcaneo-Cuboid Joint Navicular-Cuneiform Joints Tarsal-Metatarsal Joints

©Ken L Schreibman, PhD/MD 2008 schreibman.info ©Ken L Schreibman, PhD/MD 2008 schreibman.info

©Ken L Schreibman, PhD/MD 11/10/08 www.schreibman.info Easily Missed Fractures of the Ankle & Foot page 7 of 18 Easily Missed Fractures Lateral Process Talus Search for on EVERY Ankle view: 1) MM & LM (Weber, Adolescent) 2) OLT (OCD) 3) 5th MT (Jones & Avulsion) 4) LPT

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Lateral Process Talus Fracture Lateral Process Talus Fracture 17 yo F gymnast, 29 yo F, landed wrong s/p MVA after vault Lateral View Lateral View

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Lateral Process Talus Fracture Lateral Process Talus Fracture 40 yo M, s/p 24 yo M, construction motorcycle worker fell 15 feet accident Lateral View Lateral View AP View AP View

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©Ken L Schreibman, PhD/MD 11/10/08 www.schreibman.info Easily Missed Fractures of the Ankle & Foot page 8 of 18

Fracture of the lateral process of the talus is a common, yet frequently missed, injury. It is the second most common fracture of the talar body, accounting for 24% of these injuries, yet it has been documented that 40% of fractures of the lateral process of the talus are missed at initial presentation.

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Mechanism of foot/ankle injuries related to snowboarding

Twisting Collision 12% with Tree Falling 8% Getting 75% off Lift 4% Collision with Skier 1% Getting on Lift 1%

The Snowboarder’s Foot and Ankle Kirkpatrick, et al Am J Sports Med 1998: 26 271-277

Lateral Process Talus Fracture Ankle Injuries 29 yo snow boarder  5-6% of all alpine skiing injuries CT: Axial  12-38% of all snowboarding injuries

LPT Fractures CT: Coronal CT: Sagittal  15% of snowboarding ankle injuries  2% of all snowboarding injuries

The Snowboarder’s Foot and Ankle Kirkpatrick, et al Courtesy of Paul Hsieh, Colorado Am J Sports Med 1998: 26 271-277 ©Ken L Schreibman, PhD/MD 2008 schreibman.info

©Ken L Schreibman, PhD/MD 11/10/08 www.schreibman.info Easily Missed Fractures of the Ankle & Foot page 9 of 18 Easily Missed Fractures Anterior Process Calcaneus Search for on EVERY Ankle view: 1) MM & LM (Weber) 2) OLT (OCD) 3) 5th MT (Jones, Avulsion) 4) LPT Search for on EVERY Foot view: 5) APC

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Anterior Process Calcaneus Fx APC FxFx: Search for on every foot view 29 yo F, tripped down some steps Obl AP

6 months later…

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APC Fx: Best seen on CT APC Fx: May require fixation 29 yo F, tripped down some steps 29 yo F, tripped down some steps CT day of injury CT 6-months after injury 9-months post-surgery

RIGHT LEFT RIGHT LEFT

Acute margins Sclerotic margins

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©Ken L Schreibman, PhD/MD 11/10/08 www.schreibman.info Easily Missed Fractures of the Ankle & Foot page 10 of 18 Elongated APC:APC “Anteater sign” Elongated APC: “Anteater sign” Unlike the normal triangular APC. 1) More easily fractured Elongated APC has blunt tip Even from minor trauma like an anteater’s snout.

51 yo M, Jumping with child ©Ken L Schreibman, PhD/MD 2008 schreibman.info ©Ken L Schreibman, PhD/MD 2008 schreibman.info

Elongated APC: “Anteater sign” Tarsal Coalitions 2) Tarsal Coalition Axial CT Cause of foot pain in adolescent i) Calcaneo-Navicular “Rigid (peroneal) flat foot” Abnormal hindfoot biomechanics Sagittal CT “Talar Beak”, seen on lateral

51 yo M, Jumping with child 12 yo M ©Ken L Schreibman, PhD/MD 2008 schreibman.info ©Ken L Schreibman, PhD/MD 2008 schreibman.info

Tarsal Coalitions Tarsal Coalitions Occur at 2 sites Occur at 2 sites i) Calcaneo-Navicular ii)Middle Facet Sub-Talar Joint Can be seen on C Best seen on Oblique Coronal CT oblique view N Osseous Non-osseous Coalition Coalition

RIGHT LEFT 12 yo M 29 yo F, long h/o Bilateral foot pain, worse on Right ©Ken L Schreibman, PhD/MD 2008 schreibman.info ©Ken L Schreibman, PhD/MD 2008 schreibman.info

©Ken L Schreibman, PhD/MD 11/10/08 www.schreibman.info Easily Missed Fractures of the Ankle & Foot page 11 of 18 APC: Fx vs Os Calcaneus Secondarius APC: Fx vs Os Calcaneus Secondarius

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APC: Fx vs Os Calcaneus Secondarius APC: Fx vs Os Calcaneus Secondarius

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APC: Fx vs Os Calcaneus Secondarius APC: Fx vs Os Calcaneus Secondarius

O APC C S RIGHT LEFT

11 yo F with R foot pain ©Ken L Schreibman, PhD/MD 2008 schreibman.info ©Ken L Schreibman, PhD/MD 2008 schreibman.info

©Ken L Schreibman, PhD/MD 11/10/08 www.schreibman.info Easily Missed Fractures of the Ankle & Foot page 12 of 18 Easily Missed Fractures Metatarsal Fractures Search for on EVERY Ankle view: CAN BE VERY SUBTLE 1) MM & LM (Weber, Adolescent) Need AP & Oblique Views 2) OLT (OCD) Magnification Helps 3) 5th MT (Jones & Avulsion) 4) LPT Search for on EVERY Foot view: 5) APC 6) MT

©Ken L Schreibman, PhD/MD 2008 schreibman.info ©Ken L Schreibman, PhD/MD 2008 schreibman.info

Metatarsal Fractures Metatarsal Fractures CAN BE VERY SUBTLE Need AP & Oblique Views Magnification Helps FATIGUE FRACTURES ARE COMMON “March Fracture” 2nd/3rd/4th MTs Look Closely for Periosteal Reaction Suggest Follow-Up Radiographs

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Metatarsal“March Fracture” Fractures “March Fracture” 40 yo F 3 weeks later 21 yo M

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©Ken L Schreibman, PhD/MD 11/10/08 www.schreibman.info Easily Missed Fractures of the Ankle & Foot page 13 of 18 Metatarsal Fractures Metatarsal Fractures - Occult CAN BE VERY SUBTLE 14 yo M Need AP & Oblique Views Magnification Helps FATIGUE FRACTURES ARE COMMON “March Fracture” 2nd/3rd/4th MTs Look Closely for Periosteal Reaction Suggest Follow-Up Radiographs CHRONIC PAIN w/NEG RADIOGRAPHS… …MRI

Metatarsal Fractures - Occult Metatarsal Fractures - Occult 14 yo M 6 weeks later 14 yo M T1 T2 FS

Metatarsal Stress Fracture Metatarsal Stress Fracture 22 yo F, pain during 1 week vacation wearing sandals 22 yo F, pain during 1 week vacation wearing sandals IR

©Ken L Schreibman, PhD/MD 11/10/08 www.schreibman.info Easily Missed Fractures of the Ankle & Foot page 14 of 18 Metatarsal-Phalangeal Joint Dislocation Metatarsal-Phalangeal Joint Dislocation 47 yo M, in ER Priors 2 years earlier… normal 47 yo M, in ER with “Pain” with “Pain”

        Parallelism: Parallel Articular Surfaces

Easily Missed Fractures Lisfranc Fx/Dislocation Search for on EVERY Ankle view: 1) MM & LM (Weber, Adolescent) 2) OLT (OCD) 3) 5th MT (Jones & Avulsion) 4) LPT Metatarsals Search for on EVERY Foot view: 5) APC Lisfranc 6) MT 1 2 3 Tarsal Bones CUB 7) Lisfranc OID ©Ken L Schreibman, PhD/MD 2008 schreibman.info ©Ken L Schreibman, PhD/MD 2008 schreibman.info

Lisfranc Fx/Dislocation Lisfranc Fx/Dislocation Lack of Parallelism

©Ken L Schreibman, PhD/MD 11/10/08 www.schreibman.info Easily Missed Fractures of the Ankle & Foot page 15 of 18 Lisfranc Fx/Dislocation Lisfranc Fx/Dislocation AP Obl HOMOLATERAL

I II 1 2

1 2 3 CUB OID

Lisfranc Fx/Dislocation Lisfranc Fx/Dislocation Lisfranc Joint DIVERGENT Lisfranc Ligament

Lisfranc 1 2 3 CUB 1 2 3 CUB OID OID

Lisfranc Fx/Dislocation Lisfranc Fx/Dislocation: Diabetes Lisfranc Joint CommonNormal site Neuropathic66 yo M h/o Diabetes destruction Lisfranc Ligament neuropathicLisfranc joint Presentsof the Lisfrancin Sept swollen joint foot collapse MR is requested to “r/o Osteo” Can occur rapidly Are there radiographs? Yes …3 months ago

Repeat radiographs obtained now, prior to MR, reveal… June September

©Ken L Schreibman, PhD/MD 11/10/08 www.schreibman.info Easily Missed Fractures of the Ankle & Foot page 16 of 18 LisfrancLisfranc: Fx/Dislocation The Man Lisfranc: The Man  Very Aggressive Surgeon  Very Aggressive Surgeon  Wrote Extensively  Never Described  Described New Procedures T-MT Fx/Dislocation  Disarticulation of the Shoulder  Described T-MT Amputation  Excision of the Rectum  1815: 50 pages to describe  Amputation of the Cervix  only 1 minute to perform! Jacques Lisfranc Jacques Lisfranc 1790-1847 1790-1847  Never Described T-MT Fx/Dislocation

Thanks to Micaela Sullivan-Fowler UW History of Medicine Librarian ©Ken L Schreibman, PhD/MD 2008 schreibman.info ©Ken L Schreibman, PhD/MD 2008 schreibman.info

Lisfranc:Timeline: The19th ManCentury Lisfranc:Timeline: The19th ManCentury  Very Aggressive Surgeon  Described T-MT Amputation  Never Described “Military surgeons were not given the calm T-MT Fx/Dislocation and unhurried atmosphere necessary for  Described T-MT Amputation the task of laboriously picking out bone splinters and bits of clothing from gaping  1815: 50 pages to describe wounds.”  only 1 minute to perform! Medical Revolution in France Jacques Lisfranc Jacques Lisfranc Vess 1975 Univ. Press of Fla. 1790-1847 23yo Joined Napoleon‟s Army 1790-1847 1800 1900 1800 1900 1796-1815 1895 1796-1815 1895 NapoleonicWars Roentgen Rays NapoleonicWars Roentgen Rays

Lisfranc:Timeline: The19th ManCentury Lisfranc:Timeline: The19th ManCentury  Described T-MT Amputation  Described T-MT Amputation “Locating the open ends of severed “Although some wounds did not arteries and tying them off in the smoke of themselves dictate amputation, it often had battle or by flickering candlelight was an to be done because the patient could not enormous problem.” otherwise survive the rigors of transport to the rear” Medical Revolution in France Medical Revolution in France Jacques Lisfranc Vess 1975 Univ. Press of Fla. Jacques Lisfranc Vess 1975 Univ. Press of Fla. 1790-1847 1790-1847

1800 1900 1800 1900 1796-1815 1895 1796-1815 1895 NapoleonicWars Roentgen Rays NapoleonicWars Roentgen Rays

©Ken L Schreibman, PhD/MD 11/10/08 www.schreibman.info Easily Missed Fractures of the Ankle & Foot page 17 of 18 Lisfranc:Timeline: The19th ManCentury Lisfranc:Timeline: The19th ManCentury  Described T-MT Amputation “The mind did not have time to reason. Percy, surgeon-in-chief, complained of Experience and coldbloodedness counted having too many “pseudosurgeons who for more than talent. Everything had to be counted their battle actions only by the done with prompt and decisive action.” number of arms and legs they had cut off.”

Medical Revolution in France Medical Revolution in France Jacques Lisfranc Vess 1975 Univ. Press of Fla. Jacques Lisfranc Vess 1975 Univ. Press of Fla. 1790-1847 1790-1847

1800 1900 1800 1900 1796-1815 1846 1895 1796-1815 1846 1895 NapoleonicWars Ether Roentgen Rays NapoleonicWars Ether Roentgen Rays

Lisfranc:Timeline: The19th ManCentury Lisfranc:Timeline: The19th ManCentury Dr Oliver Wendell Homes (US physician, poet, Percy called Lisfranc, “so obsessive a humorist, Dean of Harvard Medical School): scalpel-wielder that he (Lisfranc) lamented the passing of the Napoleonic age that had “As for Lisfranc, I can say little more of him provided him with so many splendid than he was a great drawer of opportunities for amputations” blood…ordering a wholesale bleeding of his patients, right and left, whatever might Medical Revolution in France be the matter with them.” Jacques Lisfranc Vess 1975 Univ. Press of Fla. Jacques Lisfranc Guillaume Dupuytren: A Surgeon in His 1790-1847 1790-1847 Place and Time Barsky. Vantage Press

1800 1900 1800 1900 1796-1815 1846 1895 1796-1815 1846 1895 NapoleonicWars Ether Roentgen Rays NapoleonicWars Ether Roentgen Rays

Lisfranc:Timeline: The19th ManCentury Timeline: 19th &Century 20th Centuries Dr Oliver Wendell Homes (US physician, poet,  Born 1857, N. Wales humorist, Dean of Harvard Medical School):  Died 1933, age 76 [quoting Lisfranc]:  1887 (age 30) “the splendid guardsmen of the old Empire Apprenticed w/uncle, had such magnificent thighs to amputate.” Hugh Owen Thomas  1888 – Appointed chief Jacques Lisfranc Guillaume Dupuytren: A Surgeon in His Jacques Lisfranc Sir Robert Jones surgeon for the 1790-1847 Place and Time Barsky. Vantage Press 1790-1847 1857-1933 Manchester Ship Canal 1800 1900 1800 1900 2000 1796-1815 1846 1895 1796-1815 1846 1895 Napoleonic Wars NapoleonicWars Ether Roentgen Rays Ether Roentgen Rays –Established a chain of small hospitals along the length of the canal construction –This was the first organized fracture and injury service in England ©Ken L Schreibman, PhD/MD 2008 schreibman.info ©Ken L Schreibman, PhD/MD 2008 schreibman.info

©Ken L Schreibman, PhD/MD 11/10/08 www.schreibman.info Easily Missed Fractures of the Ankle & Foot page 18 of 18 Timeline: 19th & 20th Centuries Timeline: 19th & 20th Centuries  During WWI, revolutionized the care of wounded soldiers – Established network of field hospitals – Rehab hospitals Jacques Lisfranc Sir Robert Jones – Mortality rate for Jacques Lisfranc Sir Robert Jones 1790-1847 open fractures was 1790-1847 1857-1933 reduced from 1857-1933 80% to 20% 1800 1900 2000 1800 1900 2000 1796-1815 1846 1895 1914-1919 1796-1815 1846 1895 1914-1919 Napoleonic Wars Ether Roentgen Rays WW I 1925-“To him and his Napoleonic Wars Ether Roentgen Rays WW I Pioneer in the care of practical teaching and crippling diseases of influence we owe it children. Established that our streets today the first long-stay show relatively so few orthopœdic hospitals war cripples” for children. ©Ken L Schreibman, PhD/MD 2008 schreibman.info ©Ken L Schreibman, PhD/MD 2008 schreibman.info

Jones: Early X-Ray Proponent Jones: Early X-Ray Proponent Dec 28 1895: Feb 22 1896: Jones “In 1896 we were all dancing in a circle round the tentpole. Röntgen publishes publishes in Lancet, Robert Jones‟ ankle seemed to give…he said he had strained “On a New Kind “The Discovery of a such and such a muscle or tendon, exclaiming: of Rays” Bullet Lost in the Wrist ‘Most interesting, most painful. I had no idea it by Mean of the could be so painful. Most interesting!’ Roentgen Ray” “At that time he (Jones) had what might almost be described Sir Robert Jones as a new toy – an X-ray apparatus, the first in England. 1857-1933 “He wondered whether it would not be possible for the X-ray to show the torn or swollen muscle, and on experimenting the plate 1800 1900 2000 showed to his amazement that a small bone was fractured. 1895 Roentgen Rays “This disability gave him immense satisfaction. To one patient Arguably the first published who came to him with mysterious symptoms he said, after a case history in which x-rays brief examination, were used as a diagnostic tool ‘Madam, you could have paid me no greater compliment – this is a genuine Jones fracture.’” Frederick Waston: “The Life of ©Ken L Schreibman, PhD/MD 2008 schreibman.info Sir Robert Jones” p98, 1934

Jones: Early X-Ray Proponent Jones: The Inspiration “Radiography here, as in all Memorial Tablet: branches of medicine, is an essential aid to diagnosis. No “Great surgeon: matter how experienced we may be, greater man” we cannot afford to dispense with it, even in the apparently simple and Obituary: obvious case. Not only should we “As a teacher he was pre- insist upon procuring a film, but it is equally important that we should eminent, not in the role of welcome the radiologist‟s reading of didactic pedagogue, but in the it. Some surgeons resent this and role of leader able to enthuse say, „Give me the film so that I can men, and through them he read it myself,‟ but this is an arrogant advanced the art and science of Peltier: “Eponymic fractures: and stupid attitude, and not the Jones: Manipulation as a his specialty” Robert Jones and Jones’s therapeutic measure, Proc fracture”Surgery1972 v71 p522 Roy Soc Med 24: 1405, 1931-2 patient‟s advantage.” ©Ken L Schreibman, PhD/MD 2008 schreibman.info