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Year 3 - Surgery > 2.09 Trauma and Orthopaedics - The Ankle and Foot > Flashcards

2.09 Trauma and Orthopaedics - The Ankle and Foot Flashcards

1
Q

What is achilles tendonitis?

A

Inflammation of the achilles tendon, often due to chronic overload of the tendon via high-intensity activities.

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2
Q

What is the function of the achilles tendon?

A

Unites the gastrocnemius, soleus and plantaris muscles.

Inserts into the calcaneous and produces plantarflexion of the ankle.

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3
Q

What is the pathophysiology of achilles tendonitis?

A

Repetitive action of the tendon results in microtears and localised inflammation. Over time the tendon becomes thickened, fibrotic and loses elasticity.

If substantial sudden force is applied across the tendon once fibrosed, the achilles tendon will rupture.

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4
Q

What are the risk factors for achilles tendonitis?

A
  • unfit individual
  • sudden increase in exercise frequency
  • male gender
  • poor footwear support
  • obesity
  • fluoroquinolone use
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5
Q

What are the clinical features of achilles tendonitis?

A
  • gradual onset of pain
  • stiffness
  • worse with movement
  • relieved by heat or exercise

OE tenderness over tendon on palpation

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6
Q

What are the clinical features of achilles tendon rupture?

A
  • sudden onset severe pain
  • audible popping sound
  • loss of plantarflexion
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7
Q

Which special test can be used to assess for achilles tendon rupture?

A

Simmonds test - positive test if absent plantarflexion of foot when calf is squeezed.

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8
Q

How is achilles tendonitis investigated?

A

Usually clinical diagnosis.

May use x-ray to exclude bony injury.

May use x-ray to differentiate complete and partial tears.

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9
Q

How is achilles tendonitis managed?

A
  • stop precipitating exercise
  • ice the area
  • use NSAIDs
  • rehabilitation and physiotherapy
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10
Q

How is achilles tendon rupture managed?

A
  • analgesia
  • immobilisation
  • splinted in a plaster

Surgical intervention if delayed presentation (>2/52)

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11
Q

What is plantar fasciitis?

A

Inflammation of the plantar fascia in the foot.

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12
Q

Give the pathophysiology of plantar fasciitis.

A

Micro-tears to the plantar fascia in the foot causes inflammation, and subsequent infracalcaneal pain.

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13
Q

Give some risk factors for plantar fasciitis.

A
  • unsupportive footwear
  • obesity
  • weak plantar flexors
  • anatomical factors (e.g. pes cavus)
  • prolonged standing
  • excessive running
  • leg length discrepancy
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14
Q

What are the clinical features of plantar fasciitis?

A
  • sharp pain in heel
  • worst with few steps of the day
  • eases with activity

OE over-pronation, high arches, leg length discrepancy and tenderness upon calcaneal palpation may be present.

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15
Q

What are the investigations for plantar fasciitis?

A

Usually a clinical diagnosis.

Plain radiographs used to exclude bony injury and assess for plantar heel spur.

MRI scan occasionally indicated if there is ongoing uncertainty of the diagnosis.

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16
Q

What is the significance of a plantar heel spur being visible on x-ray?

A

Indicates an abnormal loading of the plantar fascia, which may explain the aetiology.

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17
Q

How is plantar fasciitis managed?

A
  • activity modification
  • footwear adjusted to give good arch support
  • regular analgesia (NSAIDs)
  • physiotherapy
  • corticosteroid injections
  • plantar fasciotomy
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18
Q

What is hallux valgus?

A

The medial deviation of the first MTPJ + lateral deviation of the hallux, with associated joint subluxation.

AKA bunion.

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19
Q

What are the risk factors for hallux valgus?

A
  • female gender
  • wearing high-heeled or narrow-fitting footwear
  • connective tissue disorders
  • hypermobility syndromes
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20
Q

What are the clinical features of hallux valgus?

A
  • painful medial prominence
  • aggravated by walking, weight-bearing activities, narrow shoes

OE lateral deviation of hallux; contracture of extensor hallucis longus tendon; excessive keratosis of foot

21
Q

Give some differentials for hallux valgus.

A
  • gout
  • septic arthritis
  • hallux rigidus
  • osteoarthritis
  • rheumatoid arthritis
22
Q

What investigations are used to assess halux valgus?

A

Plain film radiographs to assess the degree of lateral deviation and signs of joint subluxation.

If angle between first metatarsal and proximal first phalanx > 15° = hallux valgus.

23
Q

What is the management of hallux valgus?

A
  • analgesia
  • adjusting footwear
  • physiotherapy

Surgical management via osteotomy to restore the normal shape of the hallux can be used.

24
Q

What are some surgical complications for fixation of hallux valgus?

A
  • wound infection
  • delayed healing
  • nerve injury
  • osteomyelitis
25
Q

Give some complications of hallux valgus.

A
  • avascular necrosis
  • non-union
  • displacement
  • reduced ROM
26
Q

Which bones comprise the ankle joint?

A

Articulation between the mortise and the talus bone.

Mortise composed of distal tibia and distal fibula.

27
Q

What is the syndesmosis?

A

A strong fibrous structure that joins the tibia and fibula.

Comprised of:

  1. Anterior inferior tibiofibular ligament (AITFL)
  2. Posterior inferior tibiofibular ligament (PITFL)
  3. Intra-osseous membrane (IOM)
28
Q

What is the definition of an ankle fracture?

A

The fracture of any malleolus (lateral, medial or posterior), with or without disruption to the syndesmosis.

29
Q

How are ankle fractures classified?

A

Weber classification

Type A = below the syndesmosis (most stable)

Type B = at the level of the syndesmosis

Type C = above the level of the syndesmosis (least stable)

30
Q

What are the clinical features of an ankle fracture?

A
  • ankle pain
  • traumatic injury
  • associated deformity
  • neurovascular compromise
31
Q

How are suspected ankle fractures investigated?

A

Plain radiograph with AP and lateral views.

Check for talar shift.

32
Q

A patient with a suspected ankle fracture goes for x-ray. See the image attached showing their x-ray, and describe the next steps of their management.

A

X-ray reveals posterior malleolar fracture, therefore CT scan required for surgical planning.

33
Q

How are ankle fractures initially managed?

A
  • immediate fracture reduction
  • below knee back slab
  • post-reduction neurovascular examination
34
Q

When is conservative management of ankle fractures opted for?

A
  • non-displaced medial malleolus fracture
  • Weber A fractures
  • Weber B fracture without talar shift
35
Q

When is the surgical management for ankle fractures indicated?

A
  • displaced bimalleolar and trimalleolar fracture
  • Weber C fracture
  • Weber B fracture with talar shift
  • open fracture
36
Q

What is the surgical management of ankle fracture?

A

ORIF

37
Q

What are the complications of ankle fractures?

A

Post-traumatic osteoarthritis

38
Q

What are the complications of ORIF?

A
  • surgical site infection
  • DVT / PE
  • neurovascular injury
  • non-union
  • metalwork prominence
39
Q

What is an ankle sprain?

A

A ligamentous injury of the ankle, which can be classified as either high or low ankle sprains.

High ankle sprains are injuries to the syndesmosis.

Low ankle sprains are injuries to the anterior talofibular ligament, and the calcaneofibular ligament (most common).

40
Q

What are the clinical features of an ankle sprain?

A
  • inversion injury on plantarflexed ankle
  • swelling
  • pain
  • ?unable to weight bear
  • fingertip tenderness distal to malleoli
41
Q

How is ankle sprain and ankle fracture differentiated?

A

As both present very similarly, plain-film radiograph will either confirm or exclude bony injury.

42
Q

How are ankle sprains treated?

A
  • RICE (rest, ice, compression, elevation)
  • early mobilisation
43
Q

What is the main complication of a talar fracture and why does this occur?

A

Avascular necrosis, as the talus is reliant on extraosseous arterial supply.

This supply is easily interrupted in talar fractures, making it susceptible to AVN.

44
Q

What is a tibial pilon fracture?

A

A severe injury affecting the distal tibia, caused by high-energy axial loads.

The fractures are characterised by articular impaction, severe comminution, and are often associated with soft tissue injury. They are complex injuries which require specialist input.

45
Q

What are the clinical features of tibial pilon fractures?

A
  • history of high energy trauma (e.g. RTA)
  • severe ankle pain
  • inability to weight-bear
  • obvious ankle deformity
  • significant swelling
  • skin blistering
46
Q

How are tibial pilon fractures investigated?

A

As a result of high-energy trauma, begin with ATLS.

Urgent bloods, including coagulation and group and save, should be sent.

Plain film radiograph and CT imaging to assess and allow pre-operative planning.

47
Q

How are tibial pilon fractures managed?

A

Follow ATLS guidelines.

Realign the limb
Neurovascular assessment
Elevate limb
Operative treatment to reconstruct and restore the ankle joint.

48
Q

What are the common complications of tibial pilon fractures?

A
  • compartment syndrome
  • neurovascular injury
  • open fracture / infection

Year 3 - Surgery (30 decks)

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