ankle fractures and Lisfranc injury clinical cases

• Leave the backslab on and re-image
• Take the backslab off and examine the lower leg before planning imaging
• Apply a boot and encourage weight bearing
• Offer a tubigrip and tell him to stop being a wuss.
• Plan for surgery

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• Standard ankle X-rays (including full-length tibia XR)
• CT ankle (including full-length tibia xr)
• Weight bearing views (including full-length tibia XR)

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• Get going in a walking boot
• Moulded cast in the plaster room and re-xray
• Moulded cast in the operating room with II
• ORIF – Syndesmotic screw/s +/- medial repair
• ORIF – Syndesmotic suture button/s +/- medial repair
• ORIF – Syndesmotic suture button and screw +/- medial repair
• ORIF – Plate fibular fracture + syndesmotic suture button/screw +/- medial repair

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• Mobilise in a boot, weight bear as tolerated and see in 1-week with repeat X-ray
• Clinical assessment of medial ecchymosis/swelling/pain
• Clinical assessment (as above) + gravity/manual stress view
• MRI to look at deltoid ligament
• Weight bearing X-ray
• Weight bearing CT (if they'll do it)
• Book for theatre - EUA +/- ORIF

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• Treat in a cast/Boot, Non WB and follow up with weekly x-rays for first 2-3 wks before referring to physio (PT)
• Treat in a cast/Boot, Full WB and follow up with weekly x-rays for first 2-3 wks before referring to PT
• Treat in a cast/Boot, Full WB and x-ray @ 1wk. If no talar shift @1 wk, refer to PT.
• Treat in a cast/boot, Full WB and no further x-rays. Refer PT right away
• Treat with ORIF

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• ORIF lateral mall only
• ORIF lateral mall and assess the syndesmosis intra-op (fix if it widens)
• ORIF lateral mall and syndesmosis routinely, regardless of stress test.

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• The medial side always closes with anatomical fibula ORIF. If not this means the fibula is mal-reduced (or the syndesmosis), so I'd revisit my fixation rather than go medial.
• The medial side does sometimes fail to close up, in which case I'd explore it and fish out any bits of debris.
• If the medial side was still wide, I'd do an open repair of deltoid, plus removal of debris.
• In these cases with ruptured deltoid (no med mall fracture) I routinely repair the deltoid as part of ORIF.

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• The wt bearing view confirms this to be a stable injury. Put patient in a boot, mobilise Wt bearing as tolerated. X-ray in a week to be safe and if no talar shift at that point, continue non-op
• Looks nice on this X-ray, the ankle may be unstable because both lateral and posterior malls fractured. I'd apply a moulded cast to prevent any lateral subluxation. X-ray in 1 week
• Looks like it's probably unstable but in a nice position. I'd carry out manipulation and a nice, moulded or total contact cast under GA or sedation
• I'd get a CT to look at the posterior malleolus and the rest of the ankle - I'm worried there may be a hidden injury I'm not appreciating on the plain X-rays
• Clearly unstable, with bony injuries to lateral and posterior aspects. The deltoid has almost certainly gone as well. This is getting ORIF and early mobilisation - no need for CT, adds nothiing

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• This has made me rather cross; you gotta be nuts to want a CT. I'd firmly berate the SHO, explaining that a CT gives us no additional, useful information; total waste of precious NHS resources.
• No - The CT changes nothing for a small posterior mall like this one. The ankle is demonstrated to be stable on the stress view, I'd go non-op, weight bearing in a boot. No change
• No - I'm still gunning for manipulation and a nice, moulded or total contact cast
• No - I'm doing ORIF anyway
• Yes - the CT is very reassuring. Everything undisplaced. I'd go non-op, weight bearing in a boot.
• Yes - I'm now doing manipulation and a nice, moulded or total contact cast
• Yes - CT has pushed me to doing ORIF - thank god for the SHO!

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• Routine lateral approach to fix fibular and no fixation of posterior malleolus
• Routine lateral approach to fix fibular and AP screw to the posterior malleolus
• Routine lateral approach and percutaneous posterior malleolus fixation, back to front.
• Posterolateral approach and fixation of fibular and posterior malleolus with plates/screws

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• OMFG, WTFFF, FFS, NO!  All these pointless CT's are doing my head in. These BOFAS guys have gone completely rogue, suggesting we need to be getting CTs on every tiny PM avulsion
• No - CT changes nothing for a small posterior mall like this.  It extends posteromedially but it remains a very small proportion of the joint. I'd go non-op, weight bearing in a boot. No change
• No - I'm still gunning for manipulation and a nice, moulded or total contact cast
• No - I'm still doing ORIF anyway
• Yes - the CT is very reassuring. Everything undisplaced. I'd go non-op, weight bearing in a boot.
• Yes - I'm now doing manipulation and a nice, moulded or total contact cast
• Yes - I had no idea the posterior mall was so comminuted and extensive. Clearly this is a bigger injury than the plain x-rays suggested. CT has pushed me to doing ORIF.

View Results

• Routine lateral approach to fix fibular and no fixation of posterior malleolus
• Routine lateral approach to fix fibular and AP screw(s) to the posterior malleolus
• Routine lateral approach and percutaneous posterior malleolus fixation, back to front.
• Posterolateral approach and fixation of fibular and posterior malleolus with plates/screws
• Dual approaches to fibular (lateral) and the posterior mall (postero-medial)

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• I can’t see anything obviously abnormal
• There appears to be dorsal subluxation of the 2nd TMTJ
• The intermetatarsal gap between 1 and 2 is abnormally widened
• The inter-cuneiform gap between medial and intermediate is abnormally widened
• I think I can see a metatarsal base fracture or 'fleck avulsion'

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• I would advise conservative treatment with a non-weight bearing plaster
• Obtain weightbearing X-rays, AP/Lat/Oblique, of the injured foot
• Obtain contralateral X-rays for comparison
• Plan for stress test/EUA
• Proceed to CT or MRI (if so why did you select the modality? please post in the comments section)

View Results

• The stress views look absolutely fine - continue with conservative treatment with a plaster
• The stress views look absolutely fine - continue with conservative treatment in a Boot
• I'd get a CT at this point - I think the stress view is equivocal
• I would carry out EUA and then proceed to ORIF if obviously unstable under GA
• It is definitely an unstable injury and I would advise surgical stabilisation

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• This looks absolutely fine - no injury seen
• There is clearly an unstable Lisfranc injury with dorsal displacement of the 2nd TMTJ
• There is a fleck sign with no displacement
• There is a fleck sign with subtle displacement
• I do not have enough evidence to be able to advise the patient on the best treatment option. I'd arrange an MRI to look at the midfoot ligaments

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• Non-op treatment
• EUA and proceed
• I would definitely have it fixed

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• Tubigrip (or nothing) and Wt bear as tolerated
• Boot and Wt bear as tolerated
• Walking cast and Wt bear as tolerated
• Non-wt bearing in cast 6-8 weeks and then into a boot with incremental WB
• Non-wt bearing in cast 8-12 weeks and then into a boot with incremental WB
• Non-wt bearing in boot 6-8 weeks and then incremental WB
• Non-wt bearing in boot 8-12 weeks and then into a boot with incremental WB

View Results

• Percutaneous screw fixation
• Open reduction and screw fixation
• Dorsal plating
• K-wire fixation
• Neoligament stabilisation (Tightrope/Internal Brace)

View Results