1. Trauma: Knee/Foot

Question 1

Casanova Fracture

Answer 1

Bilateral Calcaneal + T12-L2 compression/burst fracture

Peroneal tendons can become entrapped with lateral calcaneal fractures.

Question 2

The most common Tarsal Bone Fx

Answer 2

Calcaneal fractures are the most common (60%) Tarsal Bone Fx

Question 3

Intra-articular fractures will have a fracture line through

Answer 3

Question 4

Bohler s Angle

Answer 4

The line drawn between the anterior and posterior borders o f the calcaneus on a lateral view. An angle less than 20 degrees, is concerning for a fracture.

Question 5

Jones Fracture

Answer 5

This is a fracture at the base of the fifth metatarsal, 1.5cm distal to the tuberosity.

These are placed in a non-weight bearing cast (may require internal fixation- because o f risk of non-union.

Question 6

Avulsion Fracture of the S*’’ M etatarsal

Answer 6

This is more common than a j ones fracture. The classic history is a dancer.

It may be secondary to tug from the lateral cord of the plantar aponeurosis or peroneus brevis (this is controversial).

Question 7

Painful Os Peroneus Syndrome (POPS)

Answer 7

Os Peroneus (accessory ossicle) is within the Peroneus LONGUS

This ossicle is seen in about 10% of gen pop

Stress reaction and pain can progress to tendon disruption = POPS

MR Key Findings: Edema in the os peroneus just before the peroneus longus tendon enters the cuboid tunnel

Question 8

most common dislocation of the foot.

Answer 8

Lisfranc Injury

Question 9

Lisfranc Injury

Answer 9

The Lisfranc ligament connects the medial cuneiform to
the 2nd metatarsal base on the plantar aspect.

Fracture non-union and post traumatic arthritis are gonna occur if you miss it (plus a lawsuit).

Question 10

Answer 10

Lisfranc Injury

Associated fractures are most common at the base of the 2nd MT

“Fleck Sign”

This is a small bony fragment in the Lisfranc Space (between 1st MT and 2nd MT) - that is associated with an avulsion of the LF ligament

Question 11

Lisfranc Injury mechanism

Answer 11

Question 12

3 Ligaments make up the complex between the medial cuneiform and 2nd MT

Answer 12

The plantar band is the strongest

Question 13

Anatomic Trivia

Answer 13

Question 14

Achilles Tendon

Answer 14

This is the largest tendon in the body.

fused tendons of the gastrocnemius and the soleus muscles.

It does NOT have a tendon sheath, so it cannot have a tenosynovitis (fluid in the sheath).

Instead inflammatory change around the tendon is referred to as a “paratendinitis.”

Question 15

The Mythical

Master Knot of Henry

Answer 15

This is where Dick (FDL) crosses over Harry (FHL) at the medial ankle.

What is the Master Knot ofHenry? It’s a “Harry Dick”

Question 16

Ligamentous Injury

Answer 16

highest yield fact is that the anterior talofibular ligament is the weakest ligament and the most frequently injured (usually from inversion).

Question 17

Posterior Tibiai Tendon injury / Dysfunction

Answer 17

This results in a progressive flat foot deformity, as the PTT is the primary stabilizer of the longitudinal arch.

When chronic, the tear is most common = behind the medial malleolus (this is where the most friction is).

When acute, the tear is most common = at the insertion into the navicular bone.

You will also have a hindfoot valgus deformity (from unopposed peroneal brevis action).

Question 18

Acute Flat Arch should make you think of

Answer 18

Posterior Tibiai Tendon Tear

Question 19

I Say Acute Flat Foot,

Answer 19

You Say Posterior Tihial Tendon Injury

Question 20

Sinus Tarsi Syndrome

Answer 20

Never make this diagnosis in the setting ofacute trauma

Question 21

Sinus Tarsi

Answer 21

The space between the lateral talus and calcaneus.

It is an important source of proprioception and balance.

Fucking it up has consequences (if your goal is to make prima ballerina assoluta).

Question 22

Sinus Tarsi Syndrome

Answer 22

The “syndrome” is caused by hemorrhage or inflammation of the synovial recess with or without tears of the associated ligaments (talocalcaneal ligaments, inferior extensor retinaculum).

There are associations with rheumatologic disorders and abnormal loading (flat foot in the setting o f a posterior tibiai tendon tear)

Question 23

Answer 23

Sinus Tarsi Syndrome

MRI finding is obliteration of fat in the sinus tarsi space, and replacement with scar.

Question 24

Plantar Fasciitis

Answer 24

This is an inflammation of the fascia secondary to either repetitive trauma (overuse via endless rounding on fat diabetic, smokers as a medicine intern), abnormal mechanics (pes cavus, etc), or arthritis (Reiters, etc…).

The pain is localized to the origin of the plantar fascia, and worsened by dorsiflexion of the toes. This is usually a clinical diagnosis.

Question 25

The plantar fascia consists of 3 band

Answer 25

the central / lateral part normally thicker than the medial part the thinnest. Coronal T1 diagram through the heel

Question 26

Answer 26

Plantar Fasciitis a thickened fascia (> 4mm), most often the central band with increased T2 signal, most significant near its insertion at the heel.

Question 27

CLASSIC- FLAT FOOT PROGRESSION of Plantar Fascitis

Answer 27

Question 28

Split Peroneus Brevis

Answer 28

The history is usually “chronic ankle pain”. The tendon will be C shaped or boomerang shaped with central thinning and partial envelopment of the peroneus longus. Alternatively, there may be 3 instead of 2 tendons. The tear occurs at the lateral malleolus. There is a strong (80%) association with lateral ligament injury.

Question 29

Anterolateral impingement Syndrome

Answer 29

Injury to the anterior talofibular ligaments and tibiofibular ligaments (usually fi-om an inversion injury) can cause lateral instability, and chronic synovial inflammation. You can eventually produce a “mass” of hypertrophic synovial tissue in the lateral gutter

Question 30

Answer 30

Anterolateral impingement Syndrome The MRI finding is a “meniscoid mass” in the lateral gutter of the ankle, which is a balled up scar (T1 and T2 dark).

Question 31

Tarsal Tunnel Syndrome

Answer 31

Pain in the distribution of the posterior tibial nerve (first 3 toes) from compression as it passes through the tarsal tunnel (behind the medial malleolus). Unilateral (unlike carpal tunnel which is usually bilateral), Idiopathic Having said that, any mass lesion (ganglion cysts, neurogenic tumors, varicosities, lipomas, severe tenosynovitis, and accessory muscles) can cause compression of the nerve in the tunnel.

Question 32

Morton’s Neuroma

Answer 32

Soft tissue mass (tear drop shaped) shown between the and 4‘t' metatarsal heads (third intermetatarsal space) from compression / entrapment of the plantar digital nerve in this location by the intermetatarsal ligament. Over time this results in thickening and development of perineural fibrosis.

Question 33

is a physical exam (a sonographic sign) where you squeeze the patients foot and reproduce the pain (or see the scar pop out under ultrasound).

Answer 33

“Mulder’s Sign ”

Question 34

Morton’s Neuroma is NOT a Neuroma (a tumor). What is it?

Answer 34

Its a Scar!

Question 35

Morton’s Neuroma Classic look

Answer 35

It is a scar, so it’s gonna be dark on T1 and T2 (usually). It is tear drop shaped and projects downward.

Question 36

Primary Ddx of Morton's Neuroma

Answer 36

The reason is that your primary differential is intermetatarsal bursitis - which will extend above the transverse ligament, be fluid signal, and have a more cystic look. Small bursa in this location can be normal as long as the stay smaller than 3mm.

Question 37

Haglund’s Syndrome / Deformity

Answer 37

This is also called the “Mulholland deformity” for the purpose of fucking with you. Depending on what you read there are either 3 or 4 classic features: * Retro-Achilles bursitis, * Retrocalcaneal bursitis, * Thickening of the distal Achilles tendon (insertional portion) * Calcaneal Bony Prominence “prominent posterior superior os calcis” The deformitv is the “bump.” The “syndrome” is the bursitis and Achilles tendon thickening. They call this thing the “pump bumps,” because wearing high- heeled shoes is supposedly a predisposing factor

Question 38

Os Trigonum Syndrome

Answer 38

Os Trigonum (accessory ossicle) puts the smash on the FHL (“Harry”) during extreme ankle flexion — toe pointing shit (“Pointe technique”) that ballet dancers do... or other repetitive micro trauma.

Question 39

What is this “Synchondrosis ” ?

Answer 39

This is a joint that has essentially no movement and is lined with cartilage.

Question 40

Os Trigonum Syndrome classic findings

Answer 40

(1) “Stenosing” tenosynovitis / collection of fluid around the FHL (2) edema within the Os Trigonum and across the synchondrosis between the Os and the Posterior Talus.

Question 41

Classic Hx of Os Trigonum Syndrome

Answer 41

"Ballet Dancer"

Question 42

Achilles Tendon injury

Answer 42

Acute rupture is usually obvious with a fluid filled gap. The gap size will determine treatment (big gaps need surgery). 4 cm above teh calcaneal insertion

Question 43

Achilles Tendon Injury Vs Xanthoma

Answer 43

Without a large gap these things can be very hard to tell apart from a Xantlioma

Question 44

Plantaris Rupture

Answer 44

“Tennis Leg” “Achilles tendon ruptured but can still plantar flex.” focal fluid collection between the soleus and the medial head of the gastrocnemius. There is an association with ACL tears.

Question 45

Avulsions of the Calcaneal Tuberosity

Answer 45

Avulsions of the Calcaneal Tuberosity This is sort of an Aunt Minnie with the back of the bone totally ripped off via the Achilles. The classic association is diabetes. When you see this you have to think diabetes.

Question 46

Plantar Fascia Rupture

Answer 46

-Avulsion of the Medial Plantar Process -Fleck / Fragment near the medial process of the calcaneal tuberosity — often associated with a plantar spur.

Question 47

Extensor Digitorum Brevis Avulsion

Answer 47

Classic look is a fragment o f bone arising at the dorsolateral aspect o f the anterior calcaneus

Question 48

Calcaneocuboid Ligament Avulsion

Answer 48

-Classic look is a small linear bone fragment located lateral to the calcaneocuboid joint