Achilles injuries often present as a sudden onset of pain in the posterior aspect of the ankle, without direct trauma

The typical patient is male, 30–40 years old who has begun new activities such as jumping sports, known colloquially as a “Weekend Warrior”

Often patients can ambulate, but with poor balance and with pain

The rupture typically occurs 2 to 5 cm proximal to the insertion of the Achilles within the calcaneus. This is the “watershed zone” of diminished vascularity

These injuries have been associated with recent fluoroquinolone use

The physical examination is the key to diagnosis

The patient will often maintain the ability to plantar flex their ankle because of the continuity of the flexor hallux longus and the flexor digitorum longus

There will often be weakness of plantar-flexion and tenderness with resisted plantar-flexion

Palpation in the posterior aspect of the ankle and Achilles may reveal a palpable gap

Ecchymosis and swelling in this area is common

Positive Thompson test

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  Lie the patient prone on the examination table with shoes and socks removed from both feet

  
  
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  With the knee bent to 90° on the uninvolved extremity, the ankle should have a resting plantar-flexion posture

  
  
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  When the calf is squeezed, the ankle will plantar flex

  
  
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  On the side with an Achilles tendon rupture, the ankle will stay bent essentially to 90° when the knee is bent. In addition, when the calf is squeezed, the ankle will not move

  
  
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  This failure of the ankle to move when the calf is squeezed is what constitutes a positive Thompson test

Plain radiographs of the foot or ankle are necessary to ensure there is not an avulsion fracture of the calcaneus

Place the patient in a posterior slab splint with the ankle in resting plantar-flexion

A “CAM” boot with 15° of plantar-flexion can also be used if available

Crutches and non-weight-bearing status are required

The long-term outcome of Achilles ruptures is quite good

Historically, patients were operatively repaired within 1 to 2 weeks. However, newer literature indicates equally good outcomes in eligible patients who undergo non-operative treatment with progressive casting and functional rehabilitation

In general, patients are able to return to sporting activities in 4–6 months after an Achilles rupture

Ankle fractures can have a variety of histories, from a simple twist and fall to a violent motor vehicle collision

For most ankle fractures, patients present with the inability to weight-bear

They will often complain of pain over the medial or lateral malleolus

Ankle fractures can be the result of rotational injuries or of axial loads

In a rotational injury, often the injury will be the result of an inversion or eversion stress to the ankle

During an inversion event, the injury will often start over the distal tip of the fibula (the lateral malleolus), and progress in a circular fashion to the posterior aspect of the ankle (posterior malleolus) and then to the medial distal portion of the ankle (medial malleolus) or deltoid ligament (Figure 5.1 A, B, C)

Similarly, an eversion event will often start with an injury over the medial malleolus or deltoid ligament, then progress to the posterior malleolus and then the lateral malleolus

Conversely, a pilon fracture results from an axial load being placed upon the foot. This can occur either from a sudden deceleration (fall from height) or from a direct impact (head on motor vehicle collison). The talus is essentially forced into the distal tibial plafond, resulting in a fracture of the entire distal tibia

Obtain plain radiographs of the joint

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  These should include PA, lateral, and mortise views

  
  
  
  
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    The mortise view is an AP view with the ankle internally rotated approximately 20° such that the medial and lateral malleolus are in the same frontal plane

  
  

Especially in cases of fractures with dislocation, the diagnosis is often immediately evident

The physical examination should focus on skin breaks, motor function, and vascular status

The vascular examination is important on the initial evaluation but even more important after reduction of any dislocation or manipulation

Similarly, sensation to light touch often can improve after the reduction of a fracture

In cases of open fractures, an orthopedic consult is emergent

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  The wound should be irrigated and dressed by the ED provider to help reduce the risk of infection

  
  
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  Consider starting antibiotics (i.e., cefazolin) to reduce the risk of infection

Dislocation of an ankle fracture should be promptly managed. Often the talus will sublux or dislocate laterally, which compromises the integrity of the skin medially. The goal of the reduction is to get the talus to sit under the distal tibia (ankle mortise) and to relieve pressure over the skin

Reduction can be accomplished with procedural sedation, intra-articular injection of a local anesthetic (without epinephrine), or with a forceful and longitudinal traction of quick duration

In cases of intra-articular injection, there is often a large space just medial to the talus, assuming a lateral dislocation of the talus within the ankle mortise

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  The surface landmark is the tibialis anterior tendon

  
  
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  The injection can be done just medial to this landmark

  
  
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  A soft spot is often palpable to help guide the proper area to start

To reduce the fracture:

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  Over-exaggerate the fracture

  
  
  
  
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    In cases of a lateral dislocation, this would involve tipping the ankle into greater valgus after shifting the ankle laterally

    
    
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    Having the knee flexed is often helpful as this will help relax the gastrocnemius muscle

  
  
  
  
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  Apply longitudinal traction and restore the bone to its normal position

  
  
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  An assistant can hold counter-traction to the proximal tibia or distal femur

Post reduction, immobilize the joint

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  A fracture–dislocation should be placed in a posterior split plus a stirrup splint for medial and lateral stability

  
  
  
  
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    This combination prevents dorsiflexion, plantar flexion, inversion, and eversion

  
  
  
  
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  A stable fracture should be placed in a simple posterior splint

  
  
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  Distal fibular fractures (Weber A) can be immobilized with a posterior splint or CAM walking boot and most are immediately weight-bearing as tolerated by the patient

Post-reduction radiographs are a necessity to ensure the ankle is reduced and aligned properly

Fibular fractures above the malleolus (Weber B and C) will require operative repair

Discharge instructions should include elevation, ice, and non-weight-bearing status

The outcome of ankle fractures is as varied as the presentations, and depends on both the amount of energy involved and the presence of any associated soft-tissue injuries

Some fractures require surgical intervention with open reduction and internal fixation, while other fractures are treated conservatively with splinting and casting

In general, ankle fractures that require surgical intervention require 6–12 weeks of non-weight-bearing

Injuries in this group entail a variety of injuries, including:

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  Calcaneus fractures

  
  
  
  
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    Result from axial load injuries, similar to ankle pilon fractures

    
    
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    With any axial load injury, it is important to evaluate for injuries at the knee, hip, pelvis, and lumbar spine

    
    
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    Patients will be unable to bear weight on the heel

  
  
  
  
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  Talus fractures (Figure 5.4)

  
  
  
  
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    Result from an axial load with forced dorsiflexion of the ankle

    
    
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    These are often the result of high-energy trauma and must be recognized promptly for optimal management because of the tenuous blood supply of the talar neck

    
    
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    Avascular necrosis of the talus is a common long-term complication even if properly managed

  
  
  
  
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  Lisfranc injuries

  
  
  
  
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    The result of an axial load placed on to the heel of a foot that is plantar flexed

    
    
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    A common example is a football player whose toes are planted into the ground but whose heel is off the ground. Often another player rolls on to the heel, causing an injury to the Lisfranc joint

    
    
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    The Lisfranc joint is located between the cuneiforms and the first and second metatarsal bases

    
    
    
    
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      The Lisfranc ligament connects the medial cuneiform with the base of the second metatarsal

    
    
    
    
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    This injury is often missed in the ED and failure to diagnose is one of the most common reasons for litigation later

  
  
  
  
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  Metatarsal injuries (Figure 5.5 A, B)

  
  
  
  
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    Commonly caused by inversion/eversion injuries or direct trauma

    
    
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    Fifth metatarsal fractures are the most common

    
    
    
    
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      Can be divided into avulsion or “pseudo Jones” and distal or “Jones” fractures

      
      
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      Jones fractures require more aggressive follow-up and management because of the increased risk of malunion, non-union, and avascular necrosis