Ankle And Foot Injuries

Question 1

What is a maisonneuve fracture?

Answer 1

External rotational force on the ankle that causes damage up the leg as it twists

Aka fibulotibialis ligament tear

Question 2

What are the 3 elements of a maisonneuve fracture?

Answer 2

1. Deltoid ligament rupture or medial malleolus injury
2. Tear in interosseus membrane
3. Proximal fibula fracture

Question 3

What is the clinical presentation of a masionneuve fracture?

Answer 3

Suspect if you find:
- TTP at fibular head or proximal fibular shaft (leg squeeze test)
- significant medial malleolus tenderness and swelling
- negative radiographs (suggest syndesmosis tear)

Question 4

Imaging if you suspect maisonneuve fracture

Answer 4

Fibular radiograph

Question 5

Management of maisonneuve fracture ?

Answer 5

Surgery
- reduce and stabilize the fractured medial malleolus
- secure the fibula to the distal tibia
- allows the interosseous membrane to heal

Question 6

Evaluation of an achilles injury

Answer 6

Exam:
- palpable defect in the tendon 2-6cm from the calcaneous
- maybe calf swelling
- unable to stand on toes
- thompsons test

Question 7

Why does the thompson test work (Achilles injury)

Answer 7

If the achilles tendon is ruptured, the foot witll not plantar-flex when the calf is squeezed

Question 8

Imaging for achilles tendon injury

Answer 8

POCUS is first line
Obtain MRI if dx is not clear

Question 9

Range of lisfranc injuries

Answer 9

Sprains to fracture-dislocations
- concurrent fractures of the hindfoot and forefoot are common
- especially fracture of the second metatarsal

Question 10

MOI for lisfranc injury

Answer 10

Sprain: low veloicty indirect force
Fracture: plantarflexion with axial load
- strenuous jumping over an obstacle
- usually sports or MVC

Question 11

If you have a metatarsal fracture you need to?

Answer 11

Assess for lisranc injury

Question 12

When to suspect lisfranc injury?

Answer 12

• significant pain with torsion of midfoot
• pain in passive dorsiflexion
• pain in plantarflexion of the foot
• ottawa ankle rules

Question 13

Imaging for suspected lisfranc injury

Answer 13

Bilateral weight bearing A/P, lateral and 30-degree oblique views for the foot
- CT if xr is equivocal

Question 14

What xr findings show an unstable lisfranc injury?

Answer 14

Bony displacement 1mm or greater between the bases of the 1st and 2nd metatarsal

Question 15

What is the nunley classification system?

Answer 15

A rule to group low-energy ligamentous injury by:
- diastasis and
- preservation or loss of arch height

Question 16

Nunley classification types (lisfranc)

Answer 16

Type I: non-displaced
Type II: involve diastasis between 1st and 2nd metatarsal heads
Type III: diastases with loss of arch height

Question 17

Definition of diastasis

Answer 17

Separation of bones that are normally attached

Question 18

Who do ottawa ankle rules apply to?

Answer 18

Age >18
Not intoxicated
No distracting injuries
No Decreased sensation

There are separate rules for children

Question 19

What are the ottawa foot and ankle rules?

Answer 19

Images required for pain in the malleolar zone or mid foot AND bony tenderness to the:
- posterior edge/tip of the lateral or medial malleolus
- navicular
- Base of the 5th metatarsal
Or unable to bear weight both at time of injury and in the ED

Question 20

Navicular fracture goal of treatment

Answer 20

Maintain the anatomy and restoration of articular congruity.
- the central part of the navicular is avalscular

Question 21

Complications of navicular fracture

Answer 21

Avascular necrosis
Nonunion
Instability

All can lead to flat foot deformities

Question 22

How to manage navicular fractures?

Answer 22

Non-displaced: non-weightbearing short leg cast for 6-8 wks
- orthopedic reeval in 2 wks

Displaced (unstable):
- orthopedic evaluation in ED