Ankle & Foot Flashcards
S3Q3
ANKLE & FOOT: Anatomy
most what, most ligament, subtle/hairline fx what
ankle mortise - structure (2), tibial plafond what
chopart vs. lisfranc - other name, what part of foot
x bone for flatfoot, most injured phalanx (2), STJ structures (2
- most injured
- most ligament: ACTFL
- most injured phalanx: 1st & 5th
- subtle/hairline fx: mimic ankle sprain
- chopart/transverse tarsal joint: hindfoot & midfoot
- lisfranc/tarsometatarsal joint: mid & forefoot
- subtalar joint: talus & calcaneus
- ankle mortise: distal tibia & fibula
- tibial plafond: flat part of tibia
- navicular: for degree of flatfoot
ANKLE & FOOT: Anatomy - Joint Mobility
PF/DF, ABD/ADD - plane, joint
SUP vs. PRO (3.3)
SUP: SAID
PF/DF
- sagittal plane
- talocrural/ankle joint
ABD/ADD
- midline
- transverse tarsal/lisfranc joint
SUP
- INV, ADD, DF
PRO
- EV, ABD, PF
ANKLE & FOOT: Radiograph - Ankle
AP - see (6), how (position), ray
AP oblique - other name, see (1), how (1=2) + position, mortise width what + normal & abnormal value, ray
lateral - see (3.2), ray, superimposed (1)
AP VIEW
- see: fibula, tibia, tibiofibular articulation, med & lat malleoli, dome of talus
- how: supine
- ray: between malleoli
AP OBLIQUE / MORTISE VIEW
- see: mortise
- ray: between malleoli
- how: supine, IR 15-20 = put both malleoli in same plane & no superimpose
mortise width
- space between talar dome & ankle mortise
- N: 3-4mm, abnormal: extra 2mm
LATERAL VIEW
- see: talus, tibia, calcaneus, tibiotalar joint, subtalar joint
- ray: medial malleolus
- fibula superimposed by tibia & talus
ANKLE & FOOT: Radiograph - Ankle
stress view - for, alternative + purpose (2)
AP INV & EV:
how (1=2)
mortise - should be what if normal vs. if ligamental disruption (2G)
talar tilt - what, structures (2), values (INV EV abnormal)
STRESS VIEW
- for ankle instability
- MRI: chronic instability, associated injuries
AP INVERSION & EVERSION VIEW
- how: true AP = foot turn medially for INV, lat for EV
mortise
- stable during INV & EV
- if wider space between med malleolus & med border of talus = disrupted MCL
talar tilt
- displacement of talus
- lines across talar dome & tibial plafond
- N: 5-15 for INV, <10 for EV
- abnormal: difference of 5
ANKLE & FOOT: Radiograph - Ankle
anterior talar stress - how (position), apply stress where + lead to, value (normal & abnormal), ruptured ligament
ANT TALAR STRESS VIEW
- how: lateral position
- apply stress on heel = talus ant transposition on tibia
- N: 5mm separation, abnormal: >10mm
- ruptured: ATFL
ANKLE & FOOT: Radiograph - Foot
AP - see (8), angle value + purpose
oblique - ray, how (3), see (7.1)
AP
- see: phalanges, metatarsal, cuneiform, cuboid, navicular, sesamoid, all bones of forefoot & midfoot
- first metatarsal angle: <9, for forefoot deformity ax
OBLIQUE
- ray: 3rd MTP base
- how: lateral border of foot is elevated, ankle IR 45, leg IR 4
- see: phalanges, metatarsal, intermetatarsal 3rd cuneiform, cuboid, navicular, talus, calcaneus, midtarsal joint
ANKLE & FOOT: Radiograph - Foot
lateral - ray, see (3.5), bohler angle other name (2) + structures (2) + normal & if abnormal, calcaneal inclination other name + normal & 2 abnormal indications
LATERAL VIEW
- ray: 3rd MTP
- see: talus, calcaneus, subtalar joint, chopart joint, lisfranc joint, TNJ, CCJ
bohler angle / salient / tuberosity angle
- talus & calcaneus
- N: 25-40, less if fx
calcaneal inclination / calcaneal pitch
- N: 20-30
- less = pes planus, more = pes cavus
ANKLE & FOOT: Advanced Imaging
radio (1), CT (3), MRI (3)
- radio: late changes in bone density
- CT: complex fx, osteochondral, tarsal coalition
- MRI: stress fx, osteomyelitis, tendon disorder
ANKLE & FOOT: Advanced Imaging - CT Scan
from to (2.1)
bone signal - what + d/t
cartilage & joint space - trauma vs. OA joint space, oblique axial view see (3)
soft tissue - cons, bursa visible if + (2)
- from distal tibia to inf calcaneus
- from pos calcaneus to MTP head
- from distal tibia to forefoot
BONE SIGNAL
- spurs d/t ant impingement syndrome
CARTILAGE/JOINT SPACE
- trauma: inc joint space, OA: dec
- oblique axial view: best for STJ + loose bodies, articular cartilage
SOFT TISSUE
- ugly CT scan
- 4 bursa visible if there’s effusion; subcutaneous & subtendinous bursa at calcaneus
ANKLE & FOOT: Advanced Imaging - CT Scan
axial - see (9)
sagittal - see (9)
coronal - see (6)
axial: 2 joint, sag: 3 joint, coronal: 1 joint + talocalcaneal
AXIAL PLANE
- tibiofibular joint space, chopart joint space
- lat & med malleoli, calcaneus, talus, navicular, cuboid, 1st 3 cuneiform, sustentaculum tali of calcaneus
SAGITTAL PLANE
- talocrural joint space, chopart joint space, lisfranc space
- ant & pos rim of tibia, bodies of navicular & cuboid, 3 cuneiform, MTP shafts, sesamoid bones
CORONAL PLANE
- subtalar joint, talus, calcaneus, talocalcaneal coalition, ankle mortise, sustentaculum tali of calcaneus
ANKLE & FOOT: Advanced Imaging - MRI
most visible & pathological (1)
how - position, PF why (3)
magic angle effect - term, what, (4)
alignment - condition what + common joint (2) + type (2)
edema - signal, normal where
- most visible & patho: hindfoot
- supine, neutral or PF
- PF = dec magic angle, see fat plane between peroneal tendons, see CFL
magic angle effect
- straightened out
- fake inc signal on collagen (tendon, lit, fibrocartilage, hyaline cartilage)
ALIGNMENT
tarsal coalition
- tarsal bridging
- commonly with: TCJ, CNJ
- osseous or cartilaginous
EDEMA
- high signal on T2
- normal in joint fluid
ANKLE & FOOT: Advanced Imaging - MRI
BONE SIGNAL
contusion - (1.2), present as (2), signal (2)
stress fx - signal (2)
osteonecrosis - where + d/t, signal (1)
osteomyelitis - what, d/t (2), signal (2)
BONE SIGNAL
contusion
- microfracture at trabecular bone, edema & hemorrhage at marrow present as reticular/netlike
- signal: low, high
stress fx
- signal: low, high
osteonecrosis
- talar neck fx
- signal: inhomohenous c surrounding low
osteomyelitis
- infection of bone d/t DM, pressure ulcer
- signal: low, high
ANKLE & FOOT: Advanced Imaging - MRI
CARTILAGE & JOINT SPACE
RA - joints (2), sx (3)
gout - joint (1), sx (3), signal
SOFT TISSUE
tendon signal (2)
plantar fascitis - pathology (2), structure (2), normal (2) + where, if inflamed (1) + signal
CARTILAGE & JOINT SPACE
RA
- common in: STJ, MTPJ
- sx: fibrous pannus, synovitis, bone marrow edema
gout
- common in: 1st MTPJ
- sx: fibrous nodule as low signal, gouty tophi, inflammation
SOFT TISSUE
- tendon: low on both
plantar fascitis
- inflammation & microtear at fascial & perifascial tissue
- normal: thin dark, ant calcaneus
- inflamed: thicker, intermediate & high
ANKLE & FOOT: Advanced Imaging - MRI
SOFT TISSUE
sinus tarsi syndrome - ligament + purpose, normal (1) -> (2), signal (1.2)
antlat impingement syndrome - sx (2) of (1) where (2), signal + d/t, ligament
sinus tarsi syndrome
- torn interroseous ligament (for subtalar stability)
- normal: filled with fat
- become filled with scar (both low signal), granulations (low & high signal)
antlat impingement syndrome
- hypertrophy & scarring of synovium at gutter (space between tibia & fibula)
- low signal d/t scar
- ruptured ATFL
A&F: Conditions - Ankle Sprain
which more common, tx (2) + for severe (1)
inv vs. ev - ligament (3.1), associated (0.1)
sinus tarsi syndrome - d/t (2), sx (1)
impingement syndrome - sx, d/t (2), types (3) + structure, 1-2-2=1
inversion sprain
- LCL, ATFL, CFL
- more common
eversion sprain
- MCL
- bony avulsion
sinus tarsi syndrome
- d/t pronation or INV sprain
- sx: hindfoot instability
impingement syndrome
- d/t osseous or soft tissue abnormality
- sx: LOM
- types: antlat ankle (antlat gutter), syndesmosis (DTF syndesmosis), posterior (pos tibia)
tx
- cast, screw
- severe: arthroscopic debridement
A&F: Conditions - Tendon
trend, MOI (2)
tenosynovitis (1), stenosing (1=1), tendinitis/tendinopathy (1=1 + signal) (1-1), tendinosis (1+1=1), tendon rupture (tx + view)
- epi: most commonly evaluated ankle & foot
- MOI: overuse, trauma
tenosynovitis
- fluid in tendon sheath
stenosing tenosynovitis
- adhesions = ugly gliding
tendinitis/tendinopathy
- partial tear = focal or fusiform swelling c high signal
- attenuation or thinning = precursor to total rupture
tendinosis
- microtear + ugly collagen = dec tensile strength
tendon rupture
- complete, need surgery
- axial view
A&F: Conditions - Tendon
posterior - (2), who, old tendon = (3)
lateral - (1) + action, MOI, sublux where
medial - (3), 1st common in what condition + sx, 3rd susceptible to what condition in who d/t what
anterior - (4), d/t, 1st common in who
POSTERIOR
- plantaris, achilles
- old athletes (>40) = dec flexibility, tensile strength, blood supply
LATERAL
- peroneal brevis & longus (EV)
- MOI: inversion sprain
- sublux over fibula = ugly friction
MEDIAL
- tibialis pos, FDL, FHL
- tibialis posterior common in RA = flatfoot
- FHL = susceptible to tenosynovitis in ballerinas d/t PF
ANTERIOR
- TA, extensors, peroneus tertius
- TA = common in hill runners
A&F: Conditions - Tendon
imaging - signal, myxoid d/t (2), xanthomas what d/t what condition + where
Dx - US purpose (3)
tx- ruptured vs. subluxing tendons
imaging
- high signal
- myxoid degeneration: d/t aging, overuse
- xanthomas: fat deposits d/t lipid disorder, achilles tendon
dx
- US: character, thickness, tear
tx
- rupture = surgical repair
- sublux = surgical repair of retinacula
A&F: Conditions - Fx of Ankle
MOI (2), classification (3)
tx - conservative for (2) + NWB til when + eval when + (1) when, surgical for (1) + use (2)
complications (2)
- MOI: axial/rotational loading
- classification: unimalleolar, bimalleolar, trimalleolar (pos rim of tibia)
tx
conservative
- for: stable, DTF syndesmosis
- NWB til fx heal, eval every 1-2w
- long leg cast (4-8w)
surgical
- for unstable
- use plates & screws
complications
- non-union, PTA
A&F: Conditions - Calcaneal Fx
bone trend, MOI, side, associated
classification (2) + more common
view (3)
conservative - for (2) & (1) + WB + duration
surgical - for (1=3), use (3)
complications (3)
- most injured tarsal
- MOI: fall on feet, (B), with thoracolumbar d/t impact
- view: AP, lat, plantodorsal axial
- complications: PTA, non-union, peroneal tendinitis
classification
- intra-articular: subtalar joint, more common
- extra-articular
tx
conservative
- for: non-displaced, extra-articular
- short leg cast c protected WB (4-6w)
surgical
- for: intra-articular = bohler angle, calcaneal width, calcaneocuboid articulation
- use: plates, screws, bone graft
A&F: Conditions - Talar Fx
bone trend, MOI, usual site (3), articular, intra/extra
conservative - (1) + WB + duration
surgical - for (1)
complications (2)
- 2nd most injured tarsal
- MOI: trauma on dorsiflexed (brake)
- usual: head, neck, body
- 3/5 has articular cartilage, intra-articular
- complications: PTA, malunion, AVN
tx
- conservative: short leg cast NWB (8-12w)
- operative: for displaced
A&F: Conditions - Midfoot & Navicular Fx
midfoot fx
- trend, type (1>1), rare joint
navicular fx
- MOI (2), classification (3.1) + where
- tx: conservative (duration), operative (for 2)
MIDFOOT FX
- rare since immobile
- fx > dislocation
- lisfranc rare
NAVICULAR FX
- MOI: stress, avulsion fx
- classification: body fx, tuberosity fx, stress fx, dorsal avulsion at deltoid lig attachment
- conservative: immob (4-6w)
- surgical: for displaced, avulsed
A&F: Conditions - Forefoot Fx
MOI - main (1), 2nd-4th (3), 5th (2) + where
view (3)
conservative - for (1), (1) + immob duration
surgical - what for which toes (2), cast duration
MOI
- direct trauma
- 2nd-4th toe: stress fx, twist, spiral fx
- 5th: avulsion fx at lat cord of plantar aponeurosis, inversion
view
- AP, lat, oblique
tx
conservative
- for: non-displaced
- short leg cast + immob (2-4w)
surgical
- ORIF for 1st & 5th toe + cast (6w)
A&F: Conditions - Phalangeal Fx
phalangeal fx
- MOI (1) + bones (2)
- tx: which more focused, conservative (4) + duration
- complications (2)
hallux valgus
- sex, etiology (3)
- sx: undergo (2), form (1), symp/asymp
- view (1) + see (1)
- tx (4)
PHALANGEAL FX
- MOI: drop object; 1st & 5th toe
- tx: more on 1st toe
- conservative (3-4w): manual reduction, splint, buddy taping, hard sole
- complications: hallux limitus (partial), hallus rigidus (complete LOM)
HALLUX VALGUS
- epi: F>M
- eti: biomechanical, footwear, pes planus
- sx: 1st MTP undergo stress & friction, form bunion, asymp unless degeneration
- view: AP foot = primus
- tx: bunion, orthosis, arthro
