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Medicine II > ankle and foot > Flashcards

ankle and foot Flashcards

1
Q

initial presentation

A

” 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.

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2
Q

a ankle sprain might be assoc with these 4

A
  1. Peroneal tendon tear
  2. Subluxation, sprain of subtalar joint,
  3. Fracture @ the base of the 5th metatarsal
  4. Avulsion fracture of the calcaneus or talus
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3
Q

physical exam for an ankle sprain

A

” 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

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4
Q

ottawa ankle rules

A

help rule out the need for a XRAY

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5
Q

what views do you get for the ankle on XRAY

A

b. 3 views of the ankle (lateral, anterior posterior (AP), oblique)

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6
Q

bone tenderness in these areas are required

A

posterior edge or tip of the lateral malleolous
navicular and
the fifth metatarsal

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7
Q

which ligament is most frequently sprained in the ankle

A

Anterior talofibular ligament í MC ligament that is sprained

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8
Q

If pain is on lateral aspect of ankle how do we classify

A

Grade I -III

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9
Q

Anterior talofibular ligament and calcaneofibular ligament with mild laxity of one or both ligaments.

REFERS TO WHAT GRADE OF LATERAL ANKLE SPRAI

A

Grade II

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10
Q

Grade III sprain is associated with

A

injury and significant laxity of both anterior talofibular ligament and calcaneofibular ligament

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11
Q

Grade I injury refers to

A

ATF ligament with no instability

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12
Q

what are some cluses that the ankle is unstable

A

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

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13
Q

goal of ankle sprain tx

A
  1. The goal is to prevent re-injury and allow tightening of ligaments to prevent chronic instability
  2. Consider MRI if persistent pain >8 weeks despite treatment (r/o peroneal tendon injury or osteochondral defect)
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14
Q

Weber classification (A, B and C)

A
  1. A - weight bearing tolerated
  2. Extending from mortise and going up or down - B
  3. Just above the ankle mortise - C (weight bearing is not tolerated
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15
Q

goal of ankle sprain tx and consideration

A
  1. The goal is to prevent re-injury and allow tightening of ligaments to prevent chronic instability
  2. Consider MRI if persistent pain >8 weeks despite treatment (r/o peroneal tendon injury or osteochondral defect)
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16
Q

tx for mild sprain

A

WBAT in ankle brace 3-4 wks

RICE (rest, ice, compression, elevation)

NSAIDs
Recovery may take 8-12 wks

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17
Q

tx for severe ankel sprain

A

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.
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18
Q

space between talus & medial malleolus = should be

A

<4mm

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19
Q

always feel in the mid-foot with an ankle sprain

A
  • Always feel base of 5th metatarsal, navicular,

also malleolar zone

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20
Q

where tibia & fibula articulate w/ talar dome

A

Mortise

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21
Q

syndesmotic ankle injuries

A

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!

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22
Q

areas involved with stable ankle fracture

A

Non-displaced → involves ONE malleolus but no ligament structures; non-displaced

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23
Q

Unstable ankle fx

A

Displaced → involve BOTH sides of ankle joint

both malleoli + distal fibula w/ disruption of deltoid ligament

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24
Q

Maisonneuve:

A

ankle fx + proximal fibula fx, deltoid ligament tear and mortise disruption

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25
Q

ankle fracture needs referral when

A

Bimalleolar + Triamalleolar Fxs
Maisonneuve:
→ Anything with WIDENED mortise

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26
Q

WEBER classification for ankle fractures

A

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

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27
Q

nonoperative ankle fracture tx

A

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

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28
Q

operative ankle fracture

A
  • UNSTABLE fractures

- Typically ORIF (open reduction, internal fixation)

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29
Q

talus Fx MOA

A

extreme forceful dorsiflexion

Results from high energy trauma (MVA, fall from height)

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30
Q

big worry with talus fx

A

Risk of AVN; worse w/ displacement

MC fx site at talar neck

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31
Q

CM of talus fx

A

Moderate ankle swelling

TTP over anterior ankle + often talar neck dorsally

Possible varus/valgus deformity

Assess neurovascular status
pain out of proportion –> compartment syndrome

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32
Q

views for suspected talus fx

A

Lat, AP, Oblique
Consider CT of ankle if high suspicion and to characterize

Hawkins classification of talar neck I-IV

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33
Q

chance of AVN with hawkings talus classifications

A 
→
 I-10% AVN
 II- 40%
 III-90%
IV - 100%
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34
Q

classification of talar fxs

A

Hawkins

fracture without displacement-I
fracture of the talar neck with sublux or dislocation
full dislocation-III
also dislocated from the Talonavicular joint-
IV

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35
Q

dislocation of talar dome

A

III

i. 90% risk of AVN

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36
Q

type 3 plus talonavicular joint is also dislocated

A

i. 100% risk of AVN

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37
Q

tx for talar fx

A

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

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38
Q

i. Traumatic disruption of the tarsometatarsal joints: fracture, dislocation or both

A

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

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39
Q

Midfoot (Lisfranc) Fracture/Injury CM and MOA

A

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

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40
Q

PE for Midfoot (Lisfranc) Fracture/Injury suspection

A

Physical Exam: stabilize hindfoot and try to rotate forefoot

Positive = pain

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41
Q

DX tests for midfoot

where should we see on AP

Oblique

A

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

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42
Q

tx for midfood non-displaced

A
  1. Nondisplaced:

a. 8 weeks in NWB cast followed by use of rigid arch support for 3 months

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43
Q

tx for midfoot displaced

A

Displaced >2mm:

a. ORIF
b. Remove fixation after 6 months with custom rigid orthotic for 6 additional months

  1. ***When missed and delayed 6 weeks, ORIF no longer an option and joint must be FUSED - Maintain a high index of suspicion
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44
Q

MOA Metatarsal fractures

A

Result from direct blow or twisting mechanism

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45
Q

PE for metatarsal fx

dx

A

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

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46
Q

non-displaced metatarsal fx

A

: 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

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47
Q

unstable metatarsal fx

A

may need surgical intervention. Generally 4mm displacement or 10 degrees of apical angulation or multiple fractures.

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48
Q

….special consideration for 5th Metatarsal Fractures

A

a. Styloid Avulsion Fractures

b. Jones’ Fracture

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49
Q
  1. Most common fracture of base of 5th metatarsal
A

iv. Avulsion Fracture of 5th Metatarsal Styloid (Pseudo-Jones)

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50
Q

what tendon attaches to the 5th metatarsal

A

a. What tendon attaches there peroneous brevis

Action of that muscle?

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51
Q

tx for jone’s vs pseudo jones

A

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!!!!

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52
Q

Phalangeal Fractures

A

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

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53
Q

what do you do for a fx of the great toe

A

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

54
Q

Very common, especially among active males and females age 30-50 years playing quick stop and go sports like racquetball and basketball.

A

Achilles tendon rupture

feels like you’re walking in sand

55
Q

PE for achilles rupture

A

a. Thompson’s test: positive if ______
i. Squeeze the calf and see if it plantarflexes or not
ii. These pts can still plantarflex

56
Q

if complete tear of achilles tendon you will see

A

all the way through the tendon, patient will have decreased or inability to plantar flex the foot with manual contraction of muscle

57
Q

non-operative tx of achilles rupture

A
  1. Casting in NWB plantarflexed position approx 8-10 weeks
58
Q

i. Operative tx for achilles tear

A
  1. Often choice for active individuals: surgical repair of tendon optimal in first two weeks after date of injury
  2. Slightly lower re-rupture rate
  3. Walking in CAM boot by about 5 weeks post-op
59
Q

thompson’s test in partial

A

a. Negative Thompson’s test
b. Treatment
i. Nonoperative: immobilization in either NWB cast or walker boot (apprx 4-6 weeks) in plantarflexion

60
Q

why don’t you put fxs in a cast initially

A

SPLINT b/c of compartment syndrome

want inflammation to go down

61
Q

follow up for stable fxs

A

fractures typically follow up within 12-14 days for X-ray, diagnosis and treatment

62
Q

f/u for unstable fxs

A

fractures should follow up within 1-3 days for X-ray, diagnosis, possible reduction, treatment which may include surgical intervention

63
Q

DOI bone callus starts forming to the point where the bone gets sticky (knitting together) at around the __ week mark

A

h. In general at 2 weeks out from DOI bone callus starts forming to the point where the bone gets sticky (knitting together).

64
Q

True evidence of bone healing not usually seen on Xray until

A

True evidence of bone healing not usually seen on Xray until approx 4-6 weeks out from DOI

65
Q

stable fx RT

A

f. Stable fractures return to clinic at 4 week mark from date of injury (DOI) for X-ray to check healing

66
Q

nonoperative ankle fracture tx

A

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

67
Q

operative ankle fracture

A
  • UNSTABLE fractures

- Typically ORIF (open reduction, internal fixation)

68
Q

talus Fx MOA

A

extreme forceful dorsiflexion

Results from high energy trauma (MVA, fall from height)

69
Q

big worry with talus fx

A

Risk of AVN; worse w/ displacement

MC fx site at talar neck

70
Q

CM of talus fx

A

Moderate ankle swelling

TTP over anterior ankle + often talar neck dorsally

Possible varus/valgus deformity

Assess neurovascular status
pain out of proportion –> compartment syndrome

71
Q

views for suspected talus fx

A

Lat, AP, Oblique
Consider CT of ankle if high suspicion and to characterize

Hawkins classification of talar neck I-IV

72
Q

chance of AVN with hawkings talus classifications

A 
→
 I-10% AVN
 II- 40%
 III-90%
IV - 100%
73
Q

classification of talar fxs

A

Hawkins

fracture without displacement-I
fracture of the talar neck with sublux or dislocation
full dislocation-III
also dislocated from the Talonavicular joint-
IV

74
Q

dislocation of talar dome

A

III

i. 90% risk of AVN

75
Q

type 3 plus talonavicular joint is also dislocated

A

i. 100% risk of AVN

76
Q

tx for talar fx

A

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

77
Q

i. Traumatic disruption of the tarsometatarsal joints: fracture, dislocation or both

A

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

78
Q

Midfoot (Lisfranc) Fracture/Injury CM and MOA

A

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

79
Q

PE for Midfoot (Lisfranc) Fracture/Injury suspection

A

Physical Exam: stabilize hindfoot and try to rotate forefoot

Positive = pain

80
Q

DX tests for midfoot

where should we see on AP

Oblique

A

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

81
Q

tx for midfood non-displaced

A
  1. Nondisplaced:

a. 8 weeks in NWB cast followed by use of rigid arch support for 3 months

82
Q

tx for midfoot displaced

A

Displaced >2mm:

a. ORIF
b. Remove fixation after 6 months with custom rigid orthotic for 6 additional months

  1. ***When missed and delayed 6 weeks, ORIF no longer an option and joint must be FUSED - Maintain a high index of suspicion
83
Q

MOA Metatarsal fractures

A

Result from direct blow or twisting mechanism

84
Q

PE for metatarsal fx

dx

A

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

85
Q

non-displaced metatarsal fx

A

: 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

86
Q

unstable metatarsal fx

A

may need surgical intervention. Generally 4mm displacement or 10 degrees of apical angulation or multiple fractures.

87
Q

….special consideration for 5th Metatarsal Fractures

A

a. Styloid Avulsion Fractures

b. Jones’ Fracture

88
Q
  1. Most common fracture of base of 5th metatarsal
A

iv. Avulsion Fracture of 5th Metatarsal Styloid (Pseudo-Jones)

89
Q

what tendon attaches to the 5th metatarsal

A

a. What tendon attaches there peroneous brevis

Action of that muscle?

90
Q

tx for jone’s vs pseudo jones

A

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!!!!

91
Q

Phalangeal Fractures

A

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

92
Q

what do you do for a fx of the great toe

A

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

93
Q

Very common, especially among active males and females age 30-50 years playing quick stop and go sports like racquetball and basketball.

A

Achilles tendon rupture

feels like you’re walking in sand

94
Q

PE for achilles rupture

A

a. Thompson’s test: positive if ______
i. Squeeze the calf and see if it plantarflexes or not
ii. These pts can still plantarflex

95
Q

if complete tear of achilles tendon you will see

A

all the way through the tendon, patient will have decreased or inability to plantar flex the foot with manual contraction of muscle

96
Q

non-operative tx of achilles rupture

A
  1. Casting in NWB plantarflexed position approx 8-10 weeks
97
Q

i. Operative tx for achilles tear

A
  1. Often choice for active individuals: surgical repair of tendon optimal in first two weeks after date of injury
  2. Slightly lower re-rupture rate
  3. Walking in CAM boot by about 5 weeks post-op
98
Q

thompson’s test in partial

A

a. Negative Thompson’s test
b. Treatment
i. Nonoperative: immobilization in either NWB cast or walker boot (apprx 4-6 weeks) in plantarflexion

99
Q

why don’t you put fxs in a cast initially

A

SPLINT b/c of compartment syndrome

want inflammation to go down

100
Q

follow up for stable fxs

A

fractures typically follow up within 12-14 days for X-ray, diagnosis and treatment

101
Q

f/u for unstable fxs

A

fractures should follow up within 1-3 days for X-ray, diagnosis, possible reduction, treatment which may include surgical intervention

102
Q

DOI bone callus starts forming to the point where the bone gets sticky (knitting together) at around the __ week mark

A

h. In general at 2 weeks out from DOI bone callus starts forming to the point where the bone gets sticky (knitting together).

103
Q

True evidence of bone healing not usually seen on Xray until

A

True evidence of bone healing not usually seen on Xray until approx 4-6 weeks out from DOI

104
Q

stable fx RT

A

f. Stable fractures return to clinic at 4 week mark from date of injury (DOI) for X-ray to check healing

105
Q

ii. Ankle arthritis is degradation where

A
  1. Degradation of cartilage between tibia and talar joint
106
Q

3 risk factors for ankle arthritis

A

a. Previous traumatic ankle injury
b. Obesity
c. Rheumatologic disease

107
Q

hx you need to take for ankle arthritis

A

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?

108
Q

exam of ankle arthritis

A 
"	Often moderate to severe swelling
"	Mild increased warmth
"	May be tender to palpation over joint
"	Decreased plantar/dorsiflexion
"	Compare with opposite ankle
109
Q

XRAYS needed for ankle arthritis

A

” 3 view X-ray of ankle usually sufficient
“ Anterior Posterior (AP)
“ Lateral
“ Oblique

110
Q

tx for ankle arthritis

A

a. Controlled Ankle Motion (CAM) boot
b. Ankle Foot Orthotic (AFO)
c. Intra-articular steroid injections

111
Q

Surgery for ankle arthritis

A

i. Ankle replacement

ii. Ankle arthrodesis (Fusion)

112
Q

ankle replacement

A
  1. Replaces articulation surfaces of tibia/talus
  2. Preserves ankle ROM
  3. Continue normal daily activities with exception of running/jumping and heavy labor.
113
Q

Ankle arthrodesis (Fusion)

what is it and when is it ideal

A

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

114
Q

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.

A

vi. Plantar Fasciitis

115
Q

Plantar Fasciitis

A

May find tenderness to palpation directly over medial calcaneal tuberosity and may extend distally along plantar fascia. Often NTTP.

116
Q

plantar fasciitis is the result of

A

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

117
Q

tx of plantar fasciitis

A

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

118
Q

heeling time for plantar fasciitis

A

Commonly takes 6-12 months to fully resolve, even if treated perfectly

119
Q

Heel Spurs

what are they and what do they resolve from

A

Often result from prolonged plantar fasciitis

Calcium deposit that forms where plantar fascia connects to bone (medial calcaneal tuberosity)

120
Q

Tx of heel spurs

A

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

121
Q

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?”

A
  1. Pain and swelling primary complaints: women want to wear cuter shoes
    a. More common in women vs men, 10:1
122
Q

dx of bunions

A

often obvious on exam by deformity

a. X-ray standing AP views of foot to measure angle of deformity/severity

123
Q

tx of bunions

A

appropriate footwear: shoes with wide toebox shoes with padding if needed

124
Q

42 yo female with complaint of burning pain on bottom of foot, especially after taking her aerobics class or when wearing her high heels.

A

Perineural fibrosis of the common digital nerve as it passes between metatarsal heads

125
Q

PE with Morton’s Neuroma

A

” 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)

126
Q

tx of Morton’s Neuroma

A

” 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

127
Q

hyperkeratotic lesion formed on a toe (can be soft or hard)

A

i. Corn

128
Q

hyperkeratotic lesion formed anywhere but a toe

A

ii. Callus

129
Q

tx of corns and callus

A

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

130
Q

Most common symptom of morton’s neuroma

A

Forefoot plantar pain and/or burning pain

Medicine II (21 decks)

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