Injuries to the foot and ankle are among the most frequently occurring musculoskeletal injuries. This slideshow takes a look at the three of the most common foot and ankle injuries that may require surgical intervention.

Acute ankle sprains involve disruption of fibers of the lateral ankle ligaments, usually from a twisting injury.^[1] The anterior talofibular and the calcaneofibular ligaments are often affected.

The immediate appearance of swelling in the region is due to internal bleeding. The blue arrow in the photograph points to the swelling in the anterolateral aspect of the right ankle; the green arrow points to the normal appearance of fossae between prominent tendons and skeletal outlines.

NOTE: All images courtesy of V. K. Panchbhavi MD, FACS.

Most ankle sprains can be managed conservatively. Rest, ice, compression, and elevation (RICE) therapy is instituted as soon as possible following an acute sprain.^[1]

The image is from the same patient as in the previous slide, approximately 3 weeks later. The blue arrow points to the resolution of the swelling with physical therapy.

Chronic Ankle Sprain

Ankle sprains that do not heal well or resolve result in instability of the ankle.^[1-3] The drawer test (shown) is one of the techniques used to evaluate ankle instability; a positive drawer test demonstrates excessive motion in the anteroposterior direction at the ankle joint.^[1]

The red arrows in the image show the direction of force applied by the clinician's hands on the patient's leg and foot when using the drawer test. The blue arrow shows a depression in the region of the anterolateral aspect of the ankle; the appearance of this depression is called the suction sign, and it indicates compromise of the anterior talofibular ligament.^[1]

Lateral ankle ligament repair/reconstruction is a common surgical procedure undertaken in patients with chronic lateral ankle instability.^[3,4] To restore stability, the anterior talofibular ligament and the calcaneofibular ligaments are tightened by double breasting (overlapping the layers) or by advancing their attachment on the fibula.

The blue arrow indicates the calcaneofibular ligament, and the green arrow indicates the anterior talofibular ligament.

In this image, the anterior talofibular and calcaneofibular ligaments are advanced and sutured.

Achilles Tendon Rupture

Acute Achilles tendon rupture occurs just proximal to the site of its insertion in the calcaneus.^[5] When affected patients are placed in the prone position, the loss of plantar flexion tone is evident on comparison of both sides (shown).

In this image, the left foot is less plantar flexed than the right foot. In addition, the left foot shows loss of the prominent contours made by an intact, taut Achilles tendon, which can be seen in the uninjured right foot.

Achilles tendon rupture in young individuals can either be managed conservatively in a cast, or it can be repaired surgically.^[5-7] The candidates best suited for operative repair included healthy, active individuals who wish to return to sports activities.^[7]

There are many different surgical techniques used to repair the Achilles tendon, but they usually involve reapproximating the torn ends of the tendon, sometimes reinforced by the gastrocsoleus aponeurosis or plantaris tendon.^[5] Among different surgical options is a minimally invasive repair (shown).^[8] A transverse incision is placed at the site of the Achilles tendon rupture to expose and rejoin the torn ends.

The proximal end of the Achilles tendon is secured with suture threads.

The distal end of the Achilles tendon is also secured with suture threads.

The ends of the Achilles tendon have been repaired, with sutures restoring the plantar flexion tension.

Repair of the Achilles tendon of the left foot (right side of image) has restored the plantar flexion tension to be equal to that of the right foot (left side of image).

Ankle Fracture

Ankle fractures are common injuries around the ankle joint and occur when the malleoli are broken.^[9] Affected individuals experience sudden severe pain and swelling, followed by difficulty and inability in bearing weight on the injured foot. The swelling (shown), bruising (shown), and tenderness are maximal over the injured malleoli.

These radiographs are from the same patient as in the previous slide. The images of the injured ankle reveal fractures that involve all three malleoli.

The blue arrow indicates the medial malleolar fracture, the green arrow points to the fracture in the fibula, or the lateral malleolus, and the yellow arrow demonstrates the fracture in the posterior aspect of the tibia, or the posterior malleolus.

Open reduction and internal fixation (ORIF) is the most frequently used procedure to repair ankle fractures.^[9,10] Open reduction refers to operative realignment of the fractured bones, and internal fixation refers to the use of metal plates and/or screws to secure the bones in the correct position.^[9]

The intraoperative image shows the outline of the fibula as well as hatch marks that indicate the surgical incision and approach to fix the fractures in the fibula and the posterior malleolus.

Metal plates have been placed in position on the back of the fibula and the posterior malleolus. These plates are used to secure the fractures.

Incision hatch marks are clearly shown over the medial malleolus of the ankle.

The medial malleolar fracture is exposed so it can be reduced and fixed with screws.

These radiographs show that all the fractures have been reduced and stabilized with plates and screws.