Ankle and Foot Flashcards
what is the syndesmosis of the ankle
its a strong fibrous structure that joins the tibia and fibula together
its comprised of the anterior inferior tibiofibular ligaments (AITFL), the posterior inferior tibiofibular ligament (PITFL) and the intra-osseous membrane
what is the best definition of an ankle fracture
fracture of any malleolus (posterior, medial or lateral) with or without disruption to the syndesmosis
what are the different types of ankle fractures
isolated medial and isolated lateral malleolus fractures
bimalleolar fractures (medial + lateral)
trimalleolar fractures (medial + lateral + posterior)
what classification is used in ankle fractures and describe it - what type is the most unstable
Weber classification
Type A - below the level of syndesmosis
Type B - at the level of the syndesmosis
Type C - above the level of the syndesmosis
the more proximal the injury, the higher the chance of ankle instability, therefore type C weber fractures almost always need surgical fixation
what type of ankle fractures are the most unstable
weber type C ankle fractures (above the syndesmosis)
what is talar shift and why is it important
talar shift is when the space between the medial border of the talus bone and the lateral border of the medial malleolus has increased
its important because talar shift is an indicator of instability
what type of fractures would be suitable for conservative management
minimally displaced fractures
weber type A or Type B (with no talar shift) fractures
management of ankle fractures
conservative; immediate fracture reduction (to restore anatomical alignment), below-knee backslab
surgical; ORIF (displaced fractures, weber type C, open fractures, weber type B with talar shift)
what are the main complications following fractures and surgical fixation (for all fractures)
post-traumatic arthritis
mal-union
neurovascular injury
ankle sprains can be injuries to what ligaments and which is most common
anterior talofibular ligament
calcaneofibular ligament (more common)
what is the main mechanism of injury in a calcaneus fracture
fall from height - significant axial loading directly onto the bone
how are calcaneus fractures classified
intra-articular (more common) - involves articular surface of the subtalar joint (talus and calcaneus)
extra-articular - usually avulsion fractures by the achilles tendon
gold standard investigation into calcaneal fractures
x-ray initially to diagnose the fracture
but CT scan is gold standard in calcaneal fractures
management of calcaneal fractures
conservative; cast immobilisation (most calcaneal fractures are intra-articular and as such usually require surgical intervention)
surgical; closed reduction can be attempted in large but minimally displaced fractures, ORIF is most common
what is achilles tendonitis
inflammation of the achilles tendon
what is the role of the achilles tendon and what muscles does it unite
it unites the gastrocnemius, plantaris and the soleus
it inserts into the calcaneus and produces plantarflexion at the ankle
what is the mechanism of an achilles tendon tear
when a substantial sudden force is applied across the tendon
the precipitating event is often a sudden jump or a sudden change in direction when running
risk factors for achilles tendonitis or rupture
unfit individual who has a sudden increase in exercise frequency
poor footwear
male gender
obesity
clinical features of achilles tendonitis
gradual onset pain and stiffness in the posterior ankle, often worse on movement
tenderness over the tendon on palpation
clinical features of an achilles tendon rupture
sudden onset very severe pain in the posterior calf
audible popping sound
loss of power of ankle plantarflexion
investigations into achilles tendon rupture
clinical diagnosis
management of achilles tendonitis and rupture
tendonitis; ice, NSAIDs, rehab and physio
rupture; analgesia and immobilisation, ankle splinted in plaster in full equinus (plantarflexed) (nowadays usually a moonboot is used)
what is the common mechanism of injury of a talar fracture
typically high energy trauma in which the ankle is forced into dorsiflexion
this causes the talus to press against the tibia and fracture
what is the talus at high risk of when fractured
avascular necrosis
reliant on an extra-osseous blood supply which is highly susceptible to interruption in the context of fractures
management of talar fractures
broadly, all displaced fractures require immediate reduction and surgical repair, whereas all undisplaced fractures may be managed conservatively in a non weight bearing orthosis
depending on the type of talar fracture according to the hawkins classification, what management does each require
type 1 = conservative
type 2-4 = closed/open reduction with definitive surgical fixation
what is a tibial pilon fracture and what is the common mechanism of injury
severe fractures affecting the distal tibia - caused by high energy axial loads as it is injured when the talus is pushed up into it
associated with RTC and characterised by severe communition and soft tissue injury
what is it important to look/check for in tibial pilon fractures
check for open fracture, compartment syndrome, peripheral pulses and peripheral nerves
what peripheral nerves should be checked in tibial pilon fractures
superficial peroneal
deep peroneal
tibial nerves
management of tibial pilon fractures
realignment of the limb and application of a below knee backslab
elevate limb and keep NBM in prep for surgery
operative treatment to reconstruct the articular surface and protect the soft tissue surrounding the joint
what are Lisfranc injuries
severe injuries to the tarsometatarsal joint between the medial cuneiform and the base of the 2nd metatarsal
multiple interosseous ligaments support this area of which the Lisfranc ligament is the largest and strongest
what is a key risk in Lisfranc injuries
compartment syndrome
what is a sign that is highly suggestive of a Lisfranc injury
plantar bruising
what are the 2 key radiological features of Lisfranc injuries
widening of the interval between the base of the 1st and 2nd metatarsals
bony fragments visible (fleck sign) in the space between the 1st and 2nd metatarsal, indicates avulsion of the Lisfranc ligaments from the 2nd metatarsal
management of Lisfranc Injuries
conservative; for those with minimal displacement, cast immobilisation and non-weight bearing for 6-12 weeks
surgical; for those with clear displacement screw fixation is required
what is the lay term for hallux valgus
bunion
what is hallux valgus
deformity of the first metatarsophalangeal joint
characterised by medial deviation of the 1st metatarsal and lateral deviation of the halux, with associated joint subluxation
what are the characteristic signs of hallux valgus
medial deviation of the first metatarsal + lateral deviation of the hallux, with associated joint subluxation
risk factors for hallux valgus
anatomical variants, genetic predisposition, environmental factors
high heeled or narrow fitting shoes can aggravate it by keeping the hallux in a valgus position
management of hallux valgus
conservative; analgesia , adjusting footwear to prevent worsening the deformity, physio
surgical; for those who’s QOL is significantly impacted by the condition, several surgical procedures available depending on severity of the deformity
what is the plantar fascia and what are its origins and insertions
thick fibrous band of connective tissue originating from the medial process of the calcaneal tuberosity and inserting at each of the proximal phalanges
risk factors for plantar fasciitis
anatomical factors
weak plantarflexors or tight gastrocnemius
prolonged standing or excessive running
obesity
unsupportive footwear
management of plantar fasciitis
conservative; activity moderation and regular analgesics, adjust footwear and physio
surgical; corticosteroid injections, plantar fasciotomy
