Ankle & Foot Flashcards
What is comprised of in the ankle joint?
Talus bone which articulates with the mortise
Mortise is compromised of the tibial plafond and medial malleolus (distal end of tibia) and the lateral malleolus distal end of fibula)
What is the syndesmosis?
Very strong fibrous structure comprised of the anterior inferior tibiofibular ligament (AITFL), posterior inferior tibiofibular ligament (PITFL) and the intra-osseous membrane. This is where the distal fibula and tibia join.
What is an ankle fracture?
Fracture of any malleolus (lateral, medial or posterior, with or without disruption to the syndesmosis
What is the Weber classification?
Classifies lateral malleolus fractures
Type A - below syndesmosis
Type B - at the level of the syndesmosis
Type C - above the level of the syndesmosis
What type of ankle fractures need surgical fixation?
Type C - because higher the fracture the greater the probability of ankle instability
What classification is used more commonly used in orthopaedic practice?
Lauge-Hansen classification - based on position of ankle at time of injury and deforming force involved
What clinical features will someone with ankle fracture have?
Ankle pain following traumatic injury
Associated deformity - in fracture dislocations (urgent reduction required)
May have neurovascular compromise and often open fractures.
When are Ottawa ankle rules used and what are they?
Where there is diagnostic uncertainty e.g. able to mobilise and has no deformity
These state a plain radiograph should be undertaken if:
- bone tenderness at the posterior edge or tip of the lateral malleolus
- bone tenderness at the posterior edge or tip of medial malleolus
- an inability to weight bear both immediately and in the emergency department for 4 steps
- pain in fibula, base of 5th metatarsal or/and dorsal mid foot
What investigations should be done for ankle fractures?
X-ray - AP and lateral of the ankle
Check for Talar shift
May require CT - if complex esp when displaced posterior malleolus fragment
How are ankle fractures classified anatomically?
Isolated medial malleolar fractures
Isolated lateral malleolar fractures
Bimalleolar fractures
Trimalleolar fractures
What is the initial management for ankle fractures?
Immediate fracture reduction under sedation to realign the fracture.
Once reduced ankle should be placed in a below knew back slab
Repeat neurovascular examination
May require repeat x-rays if reduction not adequate
When is conservative management opted for in ankle fractures?
- Non-displaced medial malleolus fractures
- Weber A fractures or Weber B without talar shift
- Unfit for surgery
What is the surgical intervention for ankle fractures?
Open reduction and internal fixation (ORIF)
Which ankle fractures require surgical management?
- Displaced bimalleolar or trimalleolar
- Weber C fractures
- Weber B fractures with talar shift
- Open fractures
What are the complications of ankle fractures?
Post traumatic arthritis
ORIF:
- infection
- DVT/PE
- neurovascular injury
- non-union
- metalwork prominence
What is the main differential diagnosis for ankle fractures?
Ankle sprain
What are ankle sprain and what are the two types?
Ligamentous injury
High ankle sprain - syndesmosis
Low ankle sprain - anterior talofibular ligament (ATFL), calcaeofibular ligament (CFL) latter more common
What is the usual mechanism of injury in an ankle sprain?
Inversion injury on a planterflexed ankle
What are the clinical findings of ankle sprain?
Swelling and pain - potentially not being able to weight bear
Fingertip tenderness distal to the malleoli
What is the investigation and management of ankle sprains?
X-ray - rule out bony injury
Managed conservatively - analgesia and RICE and early mobilisation
Which people is Achilles tendinitis more prevalent?
People who engage in high-intensity activities and chronically overload the tendon
What can occur as a result of Achilles tendinitis?
Achilles’ tendon rupture
What are the risk factors for Achilles tendinitis?
Unfit individual with sudden increase in exercise freq Poor footwear Male gender Obesity Fluoroquinolone use
What is the presentation of Achilles tendinitis?
Gradual onset of pain and stiffness in the posterior ankle often worse with movement. Improved my mild exercise or heat application.
Tenderness on palpation
What is the test for an Achilles rupture?
Simmonds test
What are the main differentials for Achilles tendinitis?
Ankle sprain
Stress fracture
OA
What investigation can be performed if there is uncertainty of diagnosis in Achilles tendinitis/rupture?
Ultrasound
What is the management for Achilles tendinitis?
RICE
Anti - inflammatory medication regularly
Chronic cases require- rehab and physio
What is the management for Achilles’ tendon rupture?
Analgesia and immobilisation with ankle splinting in a plaster in full equinus. Crutches and not allowed to weight bear. - 2 weeks
Then semi-equinus for further 4 weeks and the neutral for another 4 weeks
Delayed presentation of >2weeks and re rupture requires surgical fixation with end-to-end tendon repair.
What is hallux valgus?
Medial deviation of the first metatarsal and lateral deviation +/- rotation of the hallux with associated joint subluxation
What are the risk factors for developing hallux valgus?
Female
Connective tissue disorders
Hyper mobility syndromes
Anatomical variants e.g. flat feet
How does hallux valgus typically present?
Painful medial prominence - present for long period of time before increasing in freq/intensity
What signs may be present in the examination of hallus valgus?
Examination lateral deviation of hallux - evidence of inflammation and skin breakdown over prominence- assess both in non-weight bearing and weight bearing foot
Contracture of the extensor hallux tendon may be visible in long standing joint subluxation and any excessive keratosis
What are the differential diagnosis for hallux valgus?
Gout Septic arthritis Hallux rigidus OA RA
What investigation would you do for hallux valgus?
X-ray - measure angle of lateral deviation and signs of subluxation
Mild - 15-20 degrees
Moderate - 21-39
Severe - >40 degrees
What is the initial management of hallux valgus?
Sufficient analgesia
Adjusting footwear - if flat feet may need orthosis
Physio
What are the surgical options for hallux valgus?
Offered in quality of life significantly affected :
- Chevron procedure
- Scarf procedure
- Lepidus procedure
- Keller procedure
What are the surgical complications for hallux valgus?
Wound infection Delayed healing Nerve injury Osteomyelitis Recurrence
What are complications of hallux valgus?
Avascular necroisis
Non-union
Displacement
Reduced ROM
What are some associated injuries with ankle fractures?
Proximal fibula fracture - maisonneuve fracture
Base of 5th metatarsal - dancers fracture
When would you use an external fixation for ankle fractures?
When there is soft tissue compromise/swelling
You would elevate limb, non-weight bearing and delay surgery
What do you look for to assess the mortice joint?
Medial clear space (>4mm)
Concurgency of the joint
Overlap between then the fibula and tibia (>1mm)
Fibula shortening
What should be done if a posterior malleolus fracture of the ankle is suspected?
CT scan should be ordered and it should be assumed that the posterior inferior tibiofibular ligament is damaged
This requires fixation
What should be done in a pt with multiple co-morbities including diabetes that has a unstable ankle fracture and are unfit or surgery?
Semi-stable - cast and monitor
Unstable - hind foot nailing is an option - but can risk other fractures esp in osteoporotic bones
