Fracture and Dislocation of the Ankle and Foot

Definition | Aetiology | Pathophysiology | Risk Factors | Signs and Symptoms | Investigations | Management | Ottawa Ankle Rule | References

Definition

Fractures and dislocations of the ankle and foot involve breaks in the bones or displacement of the joints within the ankle or foot. These injuries are often due to trauma, such as falls, twists, or direct impacts.

Aetiology

Fractures and dislocations of the ankle and foot can be caused by:

• High-impact trauma, such as falls, car accidents, or sports injuries
• Twisting injuries, commonly seen in sports or uneven surfaces
• Direct blows or crush injuries to the foot or ankle
• Repetitive stress or overuse, particularly in athletes
• Osteoporosis or other bone-weakening conditions

Pathophysiology

The pathophysiology of ankle and foot fractures and dislocations involves:

• Disruption of bone continuity, leading to fractures
• Displacement of joints, resulting in dislocations
• Damage to surrounding ligaments, tendons, and muscles
• Potential compromise of blood vessels and nerves, especially in severe injuries
• Inflammation, swelling, and bleeding within the affected area

Risk Factors

• Participation in high-impact sports such as football, basketball, and running
• Advanced age
• Osteoporosis or other conditions that weaken bones
• High-risk occupations involving heavy lifting or machinery
• History of previous fractures or dislocations

Signs and Symptoms

The signs and symptoms of ankle and foot fractures and dislocations include:

• Severe pain in the ankle or foot
• Swelling and bruising around the affected area
• Inability to bear weight on the injured foot
• Visible deformity or misalignment of the foot or ankle
• Numbness or tingling if nerves are affected
• Instability or a feeling that the ankle might give way (in dislocations)

Investigations

Specific investigations to diagnose ankle and foot fractures and dislocations include:

• Clinical examination: Physical assessment of pain, deformity, and range of motion.
• Imaging studies:
  • X-rays: To confirm the presence and type of fracture or dislocation.
  • CT scan: For detailed images of complex fractures or associated injuries.
  • MRI: To evaluate soft tissue damage and ligament injuries.

Management

Primary Care Management

• Initial assessment and stabilisation: Prompt referral to emergency services for further evaluation and treatment.
• Pain management: Analgesics such as paracetamol or NSAIDs to relieve pain.
• Immobilisation: Splinting or using a brace to stabilise the ankle or foot temporarily.

Specialist Management

• Closed reduction: Manipulative reduction of dislocated joints under sedation or anaesthesia.
• Surgical intervention:
  • Internal fixation: Using screws, plates, or rods to stabilise fractures.
  • Ligament repair or reconstruction: For associated ligament injuries.
• Postoperative care: Pain management, physiotherapy, and rehabilitation to restore function.
• Monitoring for complications: Regular follow-up to detect and manage potential complications such as non-union, malunion, or chronic instability.

Ottawa Ankle Rule

The Ottawa Ankle Rule is a clinical decision-making tool used to determine the need for X-rays in the case of an ankle or foot injury. It is designed to reduce unnecessary radiographs and involves the following criteria:

• X-rays are indicated if there is pain in the malleolar zone and any of the following:
  • Bony tenderness at the posterior edge or tip of the lateral malleolus
  • Bony tenderness at the posterior edge or tip of the medial malleolus
  • Inability to bear weight immediately after the injury and in the emergency department for four steps
• For foot injuries, X-rays are indicated if there is pain in the midfoot zone and any of the following:
  • Bony tenderness at the base of the fifth metatarsal
  • Bony tenderness at the navicular bone
  • Inability to bear weight immediately after the injury and in the emergency department for four steps

References

1. NHS (2024) Ankle Fracture and Dislocation. Available at: https://www.nhs.uk/conditions/ankle-fracture/ (Accessed: 24 June 2024).
2. National Institute for Health and Care Excellence (2024) Ankle and Foot Injuries. Available at: https://cks.nice.org.uk/topics/ankle-and-foot-injuries/ (Accessed: 24 June 2024).
3. British Medical Journal (2024) Ankle and Foot Fractures: Clinical Features, Diagnosis, and Management. Available at: https://www.bmj.com/content/350/bmj.h2748 (Accessed: 24 June 2024).
4. American Academy of Orthopaedic Surgeons (2024) Ankle and Foot Fractures. Available at: https://orthoinfo.aaos.org/en/diseases--conditions/ankle-and-foot-fractures/ (Accessed: 24 June 2024).
5. Stiell, I.G., et al. (1992) 'Ottawa Ankle Rules for the use of radiography in acute ankle injuries', *Journal of the American Medical Association*, 268(14), pp. 1927-1930.

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