Orthopaedic Emergencies 313INJURIES TO THE LOWER TIBIA, ANKLE AND FOOT2 Inju r ies resu lt f rom fa l ls f rom a heig ht or sudden v iolence to t he foot, a s f rom
the pedal of a car being forced upwards in a car crash.
3 There is pain and swelling. Request an X-ray to define the injuries.
4 Complications of talar injuries include avascular necrosis and persistent
pain and disabilit y from osteoart hrosis, particularly if t he injur y is missed.
MANAGEMENT1 Refer all fractures including the osteochondral dome fracture immediately
to the orthopaedic team.
2 The only exception is an avulsion f lake fracture of the neck of the talus from
a ligamentous or capsular insertion.
(i) Treat this in a below-knee plaster and refer to the next fracture
clinic.
3 Occasionally, the talus dislocates completely and lies laterally in front of the
ankle joint.
(i) Refer the patient for urgent manipulation to avoid overlying skin
necrosis, similar to the dislocated ankle.
Fractures of the calcaneus
DIAGNOSIS AND MANAGEMENT
1 These are usually due to a fall from a height, and are bilateral in 20% of cases.
2 Falls from a height are associated with a typical constellation of injuries,
which includes fractures to the:
(i) Calcaneus.
(ii) Ankle.
(iii) Tibial plateau.
(iv) Femoral head or hip.
(v) Thoracolumbar vertebrae.
(vi) Atlas and base of the skull.
3 Look specifically for each of these in turn, and X-ray any tender area found.
4 The heel tends to f latten following a calcaneal fracture, and is locally tender
with bruising spreading to the sole and even up the calf.
5 Request an anteroposterior and lateral ankle X-ray with an additional
tangential (axial) calcaneal view to avoid missing a vertical calcaneal
fracture.
6 Arrange a CT scan in a complex fracture, particularly to demonstrate
involvement of the subtalar joint.
7 Elevate the foot and give analgesia.
8 Refer all fractures to the orthopaedic team.