Ankle and Foot Flashcards
Joint responsible for:
- flexion/extension?
- inversion/eversion?
tibiotalar joint
calcaneotalar joint
Ligaments
Lateral
- Anterior talo-fibular
- Calcaneo-fibular
- Posterior talo-fibular
Medial
- Deltoid ligament
Interosseus
- interosseus, syndesmosis or tibofibular ligament
- maintains integrity of mortise joint
Ankle Sprains
MOI Sxs PE Rad Classification Tx
MOI
- MC’ly inversion mechanism, involving lateral ligaments tearing in sequence from anterior to posterior
- Deltoid ligament sprain from eversion mechanism and usually associated with fibula fx
Sxs
- pain, swelling
- +/- inability to bear weight
- +/- talar tilt (inverted foot)
PE
- Drawer test
- inversion stress increases pain
Rad
- x-ray (will be normal)
- Ottawa Ankle Rules – order only if:
- -bony tenderness along distal 6cm of tibia or fibula
- -bony tenderness at base of 5th metatarsal
- -inability to bear weight in ED and immediately after injury
Classification:
- First degree: ligament stretching, local tenderness, minimal swelling
- Second degree: severe stretching/partial tearing; more tenderness and swelling; abnormal stress tests
- Third degree: complete rupture, can’t bear weight; may require surgical repair
Tx
- RICE
- immobilize, consider crutches
- third degree sprains may need surgery (rare)
Ankle Fxs
Path
Classification (name for classification)
Signs/sxs
Tx
Path
- can be malleolar, bimalleolar, trimalleolar
- often disrupt tib-fib ligament, thus disrupting mortise joint
Weber Classification
- Weber A: fib fx below syndresmosis; mortise usually intact
- Weber B: fib fx at level of syndesmosis; often tears ligament, disrupts joint
- Weber C: fib fx above syndesmosis; always tears ligament and disupts joint
Signs/Sxs
- pain, swelling, bruising, inability to bear weight
- significant deformity if dislocation present
Tx
- if dislocated, reduce
- immobilize in splint; cast 6-8 weeks
- elevate
- surgery if mortise disrupted
- arthritis likely if poorly aligned joint surface
Calcaneus Fx
MOI
Signs
X-ray
Tx
MOI
- usually from compression i.e. fall from height or MVA
- sometimes associated with lumbar fx and other extreme injuries b/c requires significant force
Signs
- swelling, pain, ecchymosis
X-ray
- standard foot films
- consider calcaneal views
Tx
- surgery
Talar fx
MOI
Signs/Sxs
Rad
Tx
MOI
- usually due to foot hyper-planter flexion
- may involve dome, neck or body
- talus covered with cartilage so has tenuous blood supply may –> avascular necrosis
Signs/Sxs
- intense pain
- inability to bear weight
- localized tenderness and swelling
- loss of normal foot contour (bulge on ant. ankle)
Rad
- foot x-rays
- easily missed – caution of ankle sprain misdx
Tx
- ice, elevation, immobilization
- non surgical if non displaced minor chip fx. of dome
- surgical if displaced or fx. of neck or body
Cuboid Fracture
MOI
Signs
Rad
Tx
MOI
- usually due to crush injury
- associated with navicular or cuneiform injuries
Signs
- pain/swelling/tenderness
Rad
- foot x-ray
Tx
- if non-displaced: conservative tx
- if displaced ORIF
Proximal 5th metatarsal fx
MOI
Tx
MC metatarsal fx
MOI
- occurs with lateral ankle sprain; usually due to inversion/avulsion of proximal bone by peroneus brevis tendon
- always check for tenderness at base of 5th MT when evaluating ankle sprain
Tx
- usually conservative
- immobilize, crutches
Jones Fracture
- involved diaphysis of 5th metatarsal
- has higher incidence of non-union or delayed union
Stress Fxs of Forefoot
which MT’s involved?
MOI
Rad
Tx
Involve midshaft metatarsals
- usually 2nd and 3rd which are relatively fixed
MOI
- due to excessive stress over time
Rad
- may not appear on x-ray for 2-3 weeks. Repeat after this time frame.
Tx
- rest, possibly immobilize
Comple midshaft metatarsal fx
MOI
Tx
MOI
- usually crush injury
- occasionally twisting
- often more than one involved
Tx
- ice, immobilize with cast
Phalangeal fxs
MOI
PE
Tx
MOI
- usually direct trauma or hyperextension
- often seen fx-dislocation
PE
- pain/swelling
- deformity if dislocated
Tx
- reduce if necessary
- dynamic splinting (buddy taping)
- stiff soled shoes
- if great toe involved may need walking cast b/c bears 1/3 weight
Metatarsalgia
Sxs
Etiology
Tx
Sxs
- nagging forefront pain over middle metatarsal heads
Etiology
- faulty weight distribution –>metatarsal heads bear disproportionate amount of weight
- e.g. weight gain, hallux valgus, flat foot
- also: gout, RA
Tx
- sx’tic
- directed at cause
Morton’s Neuroma
Etiology
Sxs
PE
Tx
Etiology
- neuropathy of interdigital nerve proximal to bifurcation b/c nonspecific inflammation of nerve with proliferative connective tissue
- ususally supplying 2nd and 3rd toes
- MC in middle aged women
Sxs
- sudden attacks of sharp or burning pain radiating to the toes
- at first pain only with walking–>pain at rest
PE
- localized webspace tenderness, reproduces pain
- may palpate small mass
Tx
- initial: steroid injection
- definitive: surgical excision
Hallux Rigidus
etiology
sxs
rad
tx
Etiology
- stiffness of MTP joint of great toe
- caused by arthritis, local trauam, gout
- MC in men
Sxs
- pain with walking
- tender MTP joint, pain with dorsiflexion
Rad
- x-ray: arthritic changes
Tx
- rocker soled shoes
- NSAIDs
- possibly surgery: joint replacement/fusion
Hallux Valgus
MC foot deformity - prominent bunion - red, swollen Great toe angles inward (valgus) Often familial
Management
- conservative: wide, padded shoes
- corrective surgery
Hammertoe
PIP joint fixed in flexion, DIP extended
MC’ly in 2nd toe from bad footwear
Shoe pressures may produce corns/calluses on dorsum of toe
Tx:
- surgical joitn excision
Pes Planus
AKA
Patho
Tx
Flat foot
Patho
- collapsed medial arch
- can be congenital or acquired (polio, RA, tendon rupture)
- flexible MC
- rigid (congenital or spasmodic peroneal muscles)
Tx
- small kids: none
- older kids/adults: arch supports
- tx underlying condition if applicable
Plantar fasciitis
etiology
sxs
tx
Etiology
- overuse injury (running, standing occupations, RA, gout)
- strain of fascial fibers causes periostitis of calcaneus
Sxs
- pain over plantar surface
- worse with activity, relieved by rest
- tender to palpation over anterior calcaneus
- pain with passive dorsiflexion
Tx
- rest, NSAIDs
- heel and arch supports
- steroid injection if refractory
Posterior tibial tendonitis
etiology
tx
Etiology
- acts as a flexor of the foot, passes posterior to medial malleolus
- overuse injury
Tx
- rest, NSAIDs
- +/- steroid injection, immobilization
Peroneal tendonitis
etiology
tx
Etiology
- pass posterior to lateral malleolus; act to resist varus force
- overuse injury
Tx
- rest, NSAIDs
- +/- steroid injection, immobilization
Tarsal tunnel syndrome
etiology
sxs
tx
Etiology
- entrapment of posterior tibial nerve by flexor retinaculum (medial malleolus)
- Due to inflammation (repetitive activity, RA, pregnancy, acute trauma/soft tissue swelling)
Sxs
- numbness, pain of sole of foot
Tx
- rest, NSAIDs
- immbolization
- possibly surgery
Subluxing peroneal tendons
- occurs after injury that disrupts peroneal retinaculum
- acute or chronic
- tendons sublux or actually dislocate over lateral malleolus
- seen best with foot eversion
- tx surgically
Achilles tendonitis
etiology
sxs/signs
acute vs. chronic management
Etiology
- overuse of calf muscles
Sxs/Signs
- tenderness, inc’d pain with dorsiflexion
Acute management
- rest, ice, NSAIDs, immobilization
Chronic management
- surgery to divide fascia
Achilles tendon rupture
MOI
Sxs
PE
Tx
MOI
- forced dorsiflexion
- initiating sprint/slipping on stair
- direct trauma
- -blow to taut tendon or laceration
- MC middle aged men
Sxs
- sudden pain
- may hear snap
- difficult stepping off
PE
- swelling of distal calf
- palpable tendon defect
- positive Thompson test
Tx
- initially splint equinus (toe pointed)
- refer to ortho
- can tx conservatively (casting X8weeks + PT) or surgically (esp. for younger, athletic pts)
Hindfoot bursitis
bursae (2)
etiology
sxs
tx
Two bursae:
- b/w calcaneus and achilles
- b/w achilles and skin
Etiology
- Overuse injury; often poorly-fitting shoes
Sxs
- Inflammation, pain on motion
Tx
- rest, NSAIDs, properly fitting shoes
- consider steroid injection
