ankle and foot Flashcards
initial presentation
” Pain over injured ligaments
“ Swelling or bruising
“ Loss of function
“ Patient may describe hearing a pop during the initial injury or a feeling of instability while ambulating.
a ankle sprain might be assoc with these 4
- Peroneal tendon tear
- Subluxation, sprain of subtalar joint,
- Fracture @ the base of the 5th metatarsal
- Avulsion fracture of the calcaneus or talus
physical exam for an ankle sprain
” Tenderness to palpation (TTP) over affected ligaments or bony areas if fracture occurred
“
Always palpate proximally to r/o fracture of prox fibula or tibia and distally to r/o foot fracture
Neurovascular exam to ensure intact
ottawa ankle rules
help rule out the need for a XRAY
what views do you get for the ankle on XRAY
b. 3 views of the ankle (lateral, anterior posterior (AP), oblique)
bone tenderness in these areas are required
posterior edge or tip of the lateral malleolous
navicular and
the fifth metatarsal
which ligament is most frequently sprained in the ankle
Anterior talofibular ligament í MC ligament that is sprained
If pain is on lateral aspect of ankle how do we classify
Grade I -III
Anterior talofibular ligament and calcaneofibular ligament with mild laxity of one or both ligaments.
REFERS TO WHAT GRADE OF LATERAL ANKLE SPRAI
Grade II
Grade III sprain is associated with
injury and significant laxity of both anterior talofibular ligament and calcaneofibular ligament
Grade I injury refers to
ATF ligament with no instability
what are some cluses that the ankle is unstable
if pain on the medial side
a. May see small avulsion fracture of tibia where deltoid ligament attaches
Oblique fracture of fibula may cause disruption of the deltoid ligament
Look for lateral shifting of talus
When found, refer to specialist for repair
goal of ankle sprain tx
- The goal is to prevent re-injury and allow tightening of ligaments to prevent chronic instability
- Consider MRI if persistent pain >8 weeks despite treatment (r/o peroneal tendon injury or osteochondral defect)
Weber classification (A, B and C)
- A - weight bearing tolerated
- Extending from mortise and going up or down - B
- Just above the ankle mortise - C (weight bearing is not tolerated
goal of ankle sprain tx and consideration
- The goal is to prevent re-injury and allow tightening of ligaments to prevent chronic instability
- Consider MRI if persistent pain >8 weeks despite treatment (r/o peroneal tendon injury or osteochondral defect)
tx for mild sprain
WBAT in ankle brace 3-4 wks
RICE (rest, ice, compression, elevation)
NSAIDs
Recovery may take 8-12 wks
tx for severe ankel sprain
Immobilization for 3-4 weeks: weight bearing as tolerated (WBAT) with crutches in controlled ankle motion boot (CAM boot) or non-weight bearing splint for those too painful.
- Rest, Ice, NSAIDs
- At 3-4 weeks (usually 3) transition into ankle brace for 3 weeks and then wean out
- You can Rx physical therapy to start gentle ROM, then progress to strength and balance.
- Can take 8-12 weeks to heal.
space between talus & medial malleolus = should be
<4mm
always feel in the mid-foot with an ankle sprain
- Always feel base of 5th metatarsal, navicular,
also malleolar zone
where tibia & fibula articulate w/ talar dome
Mortise
syndesmotic ankle injuries
13% of the time these occurs with fractures and can lead to end stage arthritis if not identified properly
supination internal rotation injuries that involve the distal aspect of the ankle
the high ankle sprain causes pain more proximally, just above the ankle joint,
dorsiflexion with external rotation will cause gapping and stress
these people need surgery
need valgus stress XRAY and if you get gapping in the medial clear space =specialist!
areas involved with stable ankle fracture
Non-displaced → involves ONE malleolus but no ligament structures; non-displaced
Unstable ankle fx
Displaced → involve BOTH sides of ankle joint
both malleoli + distal fibula w/ disruption of deltoid ligament
Maisonneuve:
ankle fx + proximal fibula fx, deltoid ligament tear and mortise disruption
ankle fracture needs referral when
Bimalleolar + Triamalleolar Fxs
Maisonneuve:
→ Anything with WIDENED mortise
WEBER classification for ankle fractures
A → ant fib fx
B →starts at the mortise and can extent proximally, sometimes the only way to know is referral
C →starts just proximal to ankle mortise
nonoperative ankle fracture tx
STABLE fractures
NWB cast initially, change to wt bearing once evidence of healing bone on X-Ray (typically 4-6 wk range from initial DOI)
Gradually increase wt bearing status + start PT as needed
operative ankle fracture
- UNSTABLE fractures
- Typically ORIF (open reduction, internal fixation)
talus Fx MOA
extreme forceful dorsiflexion
Results from high energy trauma (MVA, fall from height)
big worry with talus fx
Risk of AVN; worse w/ displacement
MC fx site at talar neck
CM of talus fx
Moderate ankle swelling
TTP over anterior ankle + often talar neck dorsally
Possible varus/valgus deformity
Assess neurovascular status
pain out of proportion –> compartment syndrome
views for suspected talus fx
Lat, AP, Oblique
Consider CT of ankle if high suspicion and to characterize
Hawkins classification of talar neck I-IV
chance of AVN with hawkings talus classifications
→ I-10% AVN II- 40% III-90% IV - 100%
classification of talar fxs
Hawkins
fracture without displacement-I
fracture of the talar neck with sublux or dislocation
full dislocation-III
also dislocated from the Talonavicular joint-
IV
dislocation of talar dome
III
i. 90% risk of AVN
type 3 plus talonavicular joint is also dislocated
i. 100% risk of AVN
tx for talar fx
a. All referred to orthopedic specialist
i. Non-displaced treated non-operatively with serial x-rays. Still up to 10% chance of AVN
ii. Displaced treated with ORIF
i. Traumatic disruption of the tarsometatarsal joints: fracture, dislocation or both
lisfranc ligament hold and the lateral aspect of 1st cuneiform to 2nd metatarsal
Critical injury to the 2nd tarsometatarsal joint
is what we are worried about here
Midfoot (Lisfranc) Fracture/Injury CM and MOA
iv. Often present as a “sprain” over dorsum of foot
v. Mechanism is often axial loading verticle foot or torque to fixed foot
1. “I was going down the stairs and thought there was another step”
vi. Foot may be mild to moderately swollen, maximum tenderness/swelling over distal mid-foot
PE for Midfoot (Lisfranc) Fracture/Injury suspection
Physical Exam: stabilize hindfoot and try to rotate forefoot
Positive = pain
DX tests for midfoot
where should we see on AP
Oblique
Diagnostics
X-ray: standing AP, Lateral and Oblique of the foot. Stress/weight bearing views prn.
On AP: Medial aspect of 2nd MT should line up with medial aspect of middle cuneiform. Shift = Lisfranc injury
On oblique: Medial 4th MT should line up with medial cubiod surface. Shift = Lisfranc injury
If high degree of suspicion and x-ray unclear, MRI of foot should be obtained
tx for midfood non-displaced
- Nondisplaced:
a. 8 weeks in NWB cast followed by use of rigid arch support for 3 months
tx for midfoot displaced
Displaced >2mm:
a. ORIF
b. Remove fixation after 6 months with custom rigid orthotic for 6 additional months
- ***When missed and delayed 6 weeks, ORIF no longer an option and joint must be FUSED - Maintain a high index of suspicion
MOA Metatarsal fractures
Result from direct blow or twisting mechanism
PE for metatarsal fx
dx
Swelling, point tenderness (be aware of major swelling in 1st metatarsal can lead to compartment syndrome)
Axial loading (compressing metatarsal head toward calcaneus) useful exam technique to r/o soft tissue injury
” X-ray: AP, Lateral and Oblique of foot
non-displaced metatarsal fx
: Short Leg Cast or CAM walker and weight bear as tolerated (WBAT)
a. RTC 3-4 weeks for X-ray to check healing and again @ 6 weeks discontinuation cast as fracture shows signs of healing
unstable metatarsal fx
may need surgical intervention. Generally 4mm displacement or 10 degrees of apical angulation or multiple fractures.
….special consideration for 5th Metatarsal Fractures
a. Styloid Avulsion Fractures
b. Jones’ Fracture
- Most common fracture of base of 5th metatarsal
iv. Avulsion Fracture of 5th Metatarsal Styloid (Pseudo-Jones)
what tendon attaches to the 5th metatarsal
a. What tendon attaches there peroneous brevis
Action of that muscle?
tx for jone’s vs pseudo jones
pseudo=
CAM boot or post-op shoe WBAT x 4-6 weeks
jones=
NWB cast x 6 weeks, use X-ray to determine if any bone healing and clinical exam for point tenderness over fx site
6. Refer to Specialist as soon as possible!!!!
Phalangeal Fractures
reduce for displaced and buddy tape
Buddy tape + Post-op shoe 4-6 weeks for great toe
For displaced fractures, reduce fracture after applying digital block to reduce pain
what do you do for a fx of the great toe
Fractures of Great toe often require orthopedic referral for surgical option if displaced d/t role as important weightbearing surface
used a lot more for weight bearing
Very common, especially among active males and females age 30-50 years playing quick stop and go sports like racquetball and basketball.
Achilles tendon rupture
feels like you’re walking in sand
PE for achilles rupture
a. Thompson’s test: positive if ______
i. Squeeze the calf and see if it plantarflexes or not
ii. These pts can still plantarflex
if complete tear of achilles tendon you will see
all the way through the tendon, patient will have decreased or inability to plantar flex the foot with manual contraction of muscle
non-operative tx of achilles rupture
- Casting in NWB plantarflexed position approx 8-10 weeks
i. Operative tx for achilles tear
- Often choice for active individuals: surgical repair of tendon optimal in first two weeks after date of injury
- Slightly lower re-rupture rate
- Walking in CAM boot by about 5 weeks post-op
thompson’s test in partial
a. Negative Thompson’s test
b. Treatment
i. Nonoperative: immobilization in either NWB cast or walker boot (apprx 4-6 weeks) in plantarflexion
why don’t you put fxs in a cast initially
SPLINT b/c of compartment syndrome
want inflammation to go down
follow up for stable fxs
fractures typically follow up within 12-14 days for X-ray, diagnosis and treatment
f/u for unstable fxs
fractures should follow up within 1-3 days for X-ray, diagnosis, possible reduction, treatment which may include surgical intervention
DOI bone callus starts forming to the point where the bone gets sticky (knitting together) at around the __ week mark
h. In general at 2 weeks out from DOI bone callus starts forming to the point where the bone gets sticky (knitting together).
True evidence of bone healing not usually seen on Xray until
True evidence of bone healing not usually seen on Xray until approx 4-6 weeks out from DOI
stable fx RT
f. Stable fractures return to clinic at 4 week mark from date of injury (DOI) for X-ray to check healing
nonoperative ankle fracture tx
STABLE fractures
NWB cast initially, change to wt bearing once evidence of healing bone on X-Ray (typically 4-6 wk range from initial DOI)
Gradually increase wt bearing status + start PT as needed
operative ankle fracture
- UNSTABLE fractures
- Typically ORIF (open reduction, internal fixation)
talus Fx MOA
extreme forceful dorsiflexion
Results from high energy trauma (MVA, fall from height)
big worry with talus fx
Risk of AVN; worse w/ displacement
MC fx site at talar neck
CM of talus fx
Moderate ankle swelling
TTP over anterior ankle + often talar neck dorsally
Possible varus/valgus deformity
Assess neurovascular status
pain out of proportion –> compartment syndrome
views for suspected talus fx
Lat, AP, Oblique
Consider CT of ankle if high suspicion and to characterize
Hawkins classification of talar neck I-IV
chance of AVN with hawkings talus classifications
→ I-10% AVN II- 40% III-90% IV - 100%
classification of talar fxs
Hawkins
fracture without displacement-I
fracture of the talar neck with sublux or dislocation
full dislocation-III
also dislocated from the Talonavicular joint-
IV
dislocation of talar dome
III
i. 90% risk of AVN
type 3 plus talonavicular joint is also dislocated
i. 100% risk of AVN
tx for talar fx
a. All referred to orthopedic specialist
i. Non-displaced treated non-operatively with serial x-rays. Still up to 10% chance of AVN
ii. Displaced treated with ORIF
i. Traumatic disruption of the tarsometatarsal joints: fracture, dislocation or both
lisfranc ligament hold and the lateral aspect of 1st cuneiform to 2nd metatarsal
Critical injury to the 2nd tarsometatarsal joint
is what we are worried about here
Midfoot (Lisfranc) Fracture/Injury CM and MOA
iv. Often present as a “sprain” over dorsum of foot
v. Mechanism is often axial loading verticle foot or torque to fixed foot
1. “I was going down the stairs and thought there was another step”
vi. Foot may be mild to moderately swollen, maximum tenderness/swelling over distal mid-foot
PE for Midfoot (Lisfranc) Fracture/Injury suspection
Physical Exam: stabilize hindfoot and try to rotate forefoot
Positive = pain
DX tests for midfoot
where should we see on AP
Oblique
Diagnostics
X-ray: standing AP, Lateral and Oblique of the foot. Stress/weight bearing views prn.
On AP: Medial aspect of 2nd MT should line up with medial aspect of middle cuneiform. Shift = Lisfranc injury
On oblique: Medial 4th MT should line up with medial cubiod surface. Shift = Lisfranc injury
If high degree of suspicion and x-ray unclear, MRI of foot should be obtained
tx for midfood non-displaced
- Nondisplaced:
a. 8 weeks in NWB cast followed by use of rigid arch support for 3 months
tx for midfoot displaced
Displaced >2mm:
a. ORIF
b. Remove fixation after 6 months with custom rigid orthotic for 6 additional months
- ***When missed and delayed 6 weeks, ORIF no longer an option and joint must be FUSED - Maintain a high index of suspicion
MOA Metatarsal fractures
Result from direct blow or twisting mechanism
PE for metatarsal fx
dx
Swelling, point tenderness (be aware of major swelling in 1st metatarsal can lead to compartment syndrome)
Axial loading (compressing metatarsal head toward calcaneus) useful exam technique to r/o soft tissue injury
” X-ray: AP, Lateral and Oblique of foot
non-displaced metatarsal fx
: Short Leg Cast or CAM walker and weight bear as tolerated (WBAT)
a. RTC 3-4 weeks for X-ray to check healing and again @ 6 weeks discontinuation cast as fracture shows signs of healing
unstable metatarsal fx
may need surgical intervention. Generally 4mm displacement or 10 degrees of apical angulation or multiple fractures.
….special consideration for 5th Metatarsal Fractures
a. Styloid Avulsion Fractures
b. Jones’ Fracture
- Most common fracture of base of 5th metatarsal
iv. Avulsion Fracture of 5th Metatarsal Styloid (Pseudo-Jones)
what tendon attaches to the 5th metatarsal
a. What tendon attaches there peroneous brevis
Action of that muscle?
tx for jone’s vs pseudo jones
pseudo=
CAM boot or post-op shoe WBAT x 4-6 weeks
jones=
NWB cast x 6 weeks, use X-ray to determine if any bone healing and clinical exam for point tenderness over fx site
6. Refer to Specialist as soon as possible!!!!
Phalangeal Fractures
reduce for displaced and buddy tape
Buddy tape + Post-op shoe 4-6 weeks for great toe
For displaced fractures, reduce fracture after applying digital block to reduce pain
what do you do for a fx of the great toe
Fractures of Great toe often require orthopedic referral for surgical option if displaced d/t role as important weightbearing surface
used a lot more for weight bearing
Very common, especially among active males and females age 30-50 years playing quick stop and go sports like racquetball and basketball.
Achilles tendon rupture
feels like you’re walking in sand
PE for achilles rupture
a. Thompson’s test: positive if ______
i. Squeeze the calf and see if it plantarflexes or not
ii. These pts can still plantarflex
if complete tear of achilles tendon you will see
all the way through the tendon, patient will have decreased or inability to plantar flex the foot with manual contraction of muscle
non-operative tx of achilles rupture
- Casting in NWB plantarflexed position approx 8-10 weeks
i. Operative tx for achilles tear
- Often choice for active individuals: surgical repair of tendon optimal in first two weeks after date of injury
- Slightly lower re-rupture rate
- Walking in CAM boot by about 5 weeks post-op
thompson’s test in partial
a. Negative Thompson’s test
b. Treatment
i. Nonoperative: immobilization in either NWB cast or walker boot (apprx 4-6 weeks) in plantarflexion
why don’t you put fxs in a cast initially
SPLINT b/c of compartment syndrome
want inflammation to go down
follow up for stable fxs
fractures typically follow up within 12-14 days for X-ray, diagnosis and treatment
f/u for unstable fxs
fractures should follow up within 1-3 days for X-ray, diagnosis, possible reduction, treatment which may include surgical intervention
DOI bone callus starts forming to the point where the bone gets sticky (knitting together) at around the __ week mark
h. In general at 2 weeks out from DOI bone callus starts forming to the point where the bone gets sticky (knitting together).
True evidence of bone healing not usually seen on Xray until
True evidence of bone healing not usually seen on Xray until approx 4-6 weeks out from DOI
stable fx RT
f. Stable fractures return to clinic at 4 week mark from date of injury (DOI) for X-ray to check healing
ii. Ankle arthritis is degradation where
- Degradation of cartilage between tibia and talar joint
3 risk factors for ankle arthritis
a. Previous traumatic ankle injury
b. Obesity
c. Rheumatologic disease
hx you need to take for ankle arthritis
a. OPQRS
b. Differentiate between recent trauma vs worsening chronic condition
c. What treatments have they tried?
d. How long can they walk before needing rest due to the pain?
exam of ankle arthritis
" Often moderate to severe swelling " Mild increased warmth " May be tender to palpation over joint " Decreased plantar/dorsiflexion " Compare with opposite ankle
XRAYS needed for ankle arthritis
” 3 view X-ray of ankle usually sufficient
“ Anterior Posterior (AP)
“ Lateral
“ Oblique
tx for ankle arthritis
a. Controlled Ankle Motion (CAM) boot
b. Ankle Foot Orthotic (AFO)
c. Intra-articular steroid injections
Surgery for ankle arthritis
i. Ankle replacement
ii. Ankle arthrodesis (Fusion)
ankle replacement
- Replaces articulation surfaces of tibia/talus
- Preserves ankle ROM
- Continue normal daily activities with exception of running/jumping and heavy labor.
Ankle arthrodesis (Fusion)
what is it and when is it ideal
Completely replaces ankle joint with bone
Loss of ankle ROM (front to back motion)
More ideal for:
a. Large patients >250lbs
b. Failed ankle replacement
c. Heavy laborers
i. 31 yo female runner c/o R bottom of heel pain worse in morning that seems to improve as the day goes on and then returns again at the end of the day.
vi. Plantar Fasciitis
Plantar Fasciitis
May find tenderness to palpation directly over medial calcaneal tuberosity and may extend distally along plantar fascia. Often NTTP.
plantar fasciitis is the result of
Heel pain arises from the medial calcaneal tuberosity and 1-2 cm along plantar fascia
Inflammation of both bone and plantar fascia commonly occurs
Pain will often be worse with first few steps in the morning or initially walking after prolonged non-weight bearing
tx of plantar fasciitis
a. Stretching of fascia via heel cord stretches and plantar fascia massage 3-4 times a day
b. Orthotics (heel pad)
c. NSAIDs
d. Splinting: night splint hold foot in slight dorsiflexion effective for those with start up paine.
CAM boot for 4 weeks
Cortisone injection into heel area (sterile technique)
g. Commonly takes 6-12 months to fully resolve, even if treated perfectly
heeling time for plantar fasciitis
Commonly takes 6-12 months to fully resolve, even if treated perfectly
Heel Spurs
what are they and what do they resolve from
Often result from prolonged plantar fasciitis
Calcium deposit that forms where plantar fascia connects to bone (medial calcaneal tuberosity)
Tx of heel spurs
You don’t treat the spur, you treat the symptoms if plantar fasciitis is present. Often these are asymptomatic though they can be quite striking
X-ray medium used to confirm location of heel spur
65 yo female at your primary care office says…My foot hurts on the side and I can’t fit into any of my shoes anymore….plus it looks weird. What’s wrong with it? Can this be fixed?”
- Pain and swelling primary complaints: women want to wear cuter shoes
a. More common in women vs men, 10:1
dx of bunions
often obvious on exam by deformity
a. X-ray standing AP views of foot to measure angle of deformity/severity
tx of bunions
appropriate footwear: shoes with wide toebox shoes with padding if needed
42 yo female with complaint of burning pain on bottom of foot, especially after taking her aerobics class or when wearing her high heels.
Perineural fibrosis of the common digital nerve as it passes between metatarsal heads
PE with Morton’s Neuroma
” Placing firm pressure on the interspace between the toes while squeezing metatarsal heads together
“ Isolated pain on plantar aspect of web space is consistent with intermetatarsal neuroma
“ Inspect foot for calluses or other evidence of stress points in foot (ie: r/o stress or metatarsalgia)
“ Range Metatarsalphalangeal joints and Tarsometatarsal joints to r/o inflammation, synovitis or arthritis (midfoot)
tx of Morton’s Neuroma
” Appropriate shoes
“ Low heel
“ Wide toe box
“ Soft soled
“ Metatarsal Pad
“ Placed in shoe to keep metatarsal heads apart
“ Cortisone injection proximal to metatarsal head
“ Place needle in line with MTP joint (dorsal approach), inserting needle into the plantar aspect of foot- pull back 1cm and inject
“ 1-2ml anesthetic/1ml corticosteroid
“ If symptoms persist refer to orthopedic foot and ankle surgeon or podiatrist for surgical excision
hyperkeratotic lesion formed on a toe (can be soft or hard)
i. Corn
hyperkeratotic lesion formed anywhere but a toe
ii. Callus
tx of corns and callus
v. Treatment: pressure relief or paring down lesion
1. Paring down: shaving lesion layer by layer with a scalpel
2. Appropriate fitting footwear to relieve pressure
3. Silicone cushions or donut pads to shift pressure
Most common symptom of morton’s neuroma
Forefoot plantar pain and/or burning pain
