Ankle + foot Flashcards

1
Q

Bruising, edema (quickly)

“Pop” in foot followed by swelling, pain, inability to bear weight

A

ankle sprain

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2
Q

Most common sports injury
Most involve LCL (complex) as a result of inversion + plantar flexion

A

ankle sprain

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3
Q

ligament most commonly injured in an ankle sprain

A

anteroinferior tibiofibular ligament

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4
Q

grades of ankle sprains

A

I: no instability (microtears)
II: mild laxity (minor)
III: severe laxity, rupture of calcaneofibular + anterior talofibular ligaments (complete)

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5
Q

Palpate to localize pain, ROM, muscle strength, proprioception
Anterior drawer for ATF
= feeling of laxity or subluxation (>5mm than contralateral side)
Talar tilt test for calcaneofibular and anterior talofibular
Evert foot (deltoid)
Gross gapping at mortise

XR: AP, lat, mortise views to evaluate for fractures, occult and osteochondral injuries

A

ankle sprain

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6
Q

How do you treat an ankle sprain?

A

RICE, crutches, anti-inflammatory medications

Phase II (weeks 2-4): ICE, strength

Phase III (4-6 weeks): more agility, proprioception, balance board

Surgical treatment not usually indicated in acute injury – chronic instability
Free ligament reconstruction
/+ ankle arthroscopy

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7
Q

All unstable syndesmosis are — —-, but not all are unstable syndesmoses!

A

ankle sprains

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8
Q

“High” ankle sprain – eversion, rotational injury

Specifically damage to the ligaments connecting the tibia and fibula

A

unstable syndesmosis

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9
Q

PE: external rotation stress
Squeeze test, proximal tenderness

XR: negative stress
MRI

A

unstable syndesmosis

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10
Q

How do you treat an unstable syndesmosis?

A

No instability = walking cast x 4 weeks + PT

Instability = fixation of syndesmosis

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11
Q

Ottawa ankle rules - order an X-ray if any of the following apply

A

Pain along lateral malleolus, medial malleolus.
Midfoot pain, 5th metatarsal or navicular pain.
Unable to walk more than four steps in the ER or exam room.

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12
Q

Fracture below syndesmosis - distal malleolus or avulsion

Bimalleolar = medial + lateral
Trimalleolar = medial, lateral, posterior

Most common intra-articular fracture
Determined by stability of fracture pattern

A

ankle fracture

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13
Q

Commonly a rotational injury

Deformity, bruising, open or closed, inability to bear weight

A

ankle fracture

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14
Q

XR: AP/lateral/mortise

Classify ankle fracture based on lateral malleolus
A = below syndesmosis
B = level of syndesmosis
C = above syndesmosis

A

ankle fracture

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15
Q

criteria for ankle fracture treatment

A

Criteria:
1) Dislocations + fractures reduced ASAP
- Splint with joint in most normal position possible
- Open = antibiotics and take to OR for irrigation + debridement
2) All joint surfaces must be restored
3) Fracture must be helped in reduced position during bony healing
4) Joint motion should begin asap

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16
Q

ankle fractures w/o separation tx

A

Fractures w/o separation = short leg cast w/ ankle in neutral position and immobilization is continued for 6-8 weeks
Cast 4-6 weeks
Cam walker
PT

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17
Q

ankle fractures w/ separation tx

A

Fractures w/ separation = reduced (check syndesmosis stability)
Isolated lateral fractures non-op
Bimalleolar + medial need surgery → ORIF
Immobilize for 6 weeks then slow advancement with weight bearing
PT for ROM, strength

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18
Q

Pain with weight bearing activity, difficulty with uneven ground, swelling, history of prior injury

primary = rare
commonly post-traumatic

A

ankle arthritis

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19
Q

PE: swelling, areas of tenderness along tibiotalar joint, check standing alignment

XR: weight-bearing AP, lateral + mortise of ankle

A

ankle arthritis

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20
Q

ankle arthritis treatment

A

Non-surgical = NSAIDs, intra-articular injection, mechanical unloading (cane), bracing (arizona AFO)

Surgical = osteophyte excision, distraction arthroplasty, ankle arthrodesis, ankle arthroplasty

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21
Q

Posterior hindfoot pain – develops with initial morning activity and increases with exercise
Eventually developed into pain at rest
Insertional = localized to junction of tendon + bone

A

achilles tendonitis

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22
Q

inflammatory/degenerative – insertional vs non-insertional, seen in obesity, HTN, steroid use

A

achilles tendonitis

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23
Q

PE: find area of maximal tenderness

Check tendon integrity – gapping, nodularity
Thompson test

XR: Haglund deformity, calcification of calcaneal insertion

MRI = partial Achilles tendon tear, peritendinous thickening, tendinosis, nodularity, calcification

A

achilles tendonitis

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24
Q

achilles tendonitis tx

A

Non-surgical =

NSAIDs
immobilization (boot/cast)
heel lift
achilles sleeve
PT (stretching, eccentric strengthening)
avoid steroids
extracorporeal shockwave therapy

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25
Q

Sudden occurrence of heel pain after push-off movement, “pop”, calf pain

“Someone hit me”

A

achilles rupture

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26
Q

Zone of vascularity – less commonly chronic steroid use or antibiotics (quinolones)

seen often in weekend warriors

A

achilles rupture

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27
Q

Palpate for gap

+ Thompson test (no plantar flexion)

MRI best

A

achilles rupture

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28
Q

achilles rupture tx

A

Ice to area, analgesics, rest

Bracing, casting with gradual dorsiflexion towards neutral

29
Q

Pain over fifth metatarsal area with edema and/or ecchymosis

A

Jones fracture

30
Q

Fracture of metaphyseal-diaphyseal junction of 5th metatarsal
Non-union rate = high

Chronic stress injury

A

Jones fracture

31
Q

XR: acute proximal diaphyseal fracture w/ medial fracture line extending into/towards intermetatarsal joint

A

Jones fracture

32
Q

Usually non operative – REFER
Non-weight bearing 6-8 weeks
Walking boot 2-4 weeks

Surgery in those who fail conservative or in athletes

A

Jones fracture

33
Q

Lateral foot/ankle pain, chronic

Instability of peroneals = tear

– pain at base of 5th metacarpal + extension into plantar medial foot

A

Peroneal tendonitis

34
Q

peroneal tendonitis tx

A

Immobilization, NSAIDs, therapy

Continued pain → MRI

35
Q

Plantar heel pain on first step out of bed and resolves quickly when non weight-bearing

→ contracture of gastrocnemius or achilles is common

Often sharp, usually worse after period of rest when initiating walking, decreasing after ambulation, massage, stretching

A

plantar fasciitis

36
Q

Most common cause of heel pain – chronic overuse stress common in females 40-60y, older and obese, teachers, those who stand on their feet

A

plantar fasciitis

37
Q

How do you treat plantar fasciitis

A

PT - formal therapy more effective
NSAIDs
Night splints
Inserts
Heel pad
Injection - only 1 cortisone injection

38
Q

Pain, swelling, ecchymosis around lateral hindfoot

A

calcaneus fracture

39
Q

Most common tarsal bone fracture – mostly displaced intra-articular from trauma and in young men

A

calcaneus fracture

40
Q

Commonly have other extremity injuries or associated spine fractures

XR: displaced intra-articular fracture

A

calcaneus fracture

41
Q

how do you treat calcaneus fracture

A

ORIF
Closed reduction percutaneous fixation
ORIF w/ primary fusion
Consider:
Timing
Soft tissue swelling
Must wait
+ wrinkle sign
Fracture blisters
Be aware of peroneals
Dislocation

42
Q

What’s good post op care for calcaneus fracture

A

Post-op care:
– casting + non-weight bearing 6-10 weeks
– ROM exercises after 6 weeks
– wean from boot to shoe at 10-12 weeks
→ PT to gait training, ROM, strengthening

43
Q

Pain and swelling in midfoot with difficulty bearing weight – 1+ metatarsal bones are displaced from tarsus

Plantar ecchymosis

A

lisfranc injury

44
Q

Low energy trauma or high energy from MVAs, industrial, height
3 oblique ligaments:
Dorsal
Interosseous (strongest)
Plantar
common in football/contact sport

A

lisfranc injury

45
Q

Mechanism of injury is key

XR: standing bilateral AP to detect displacement
CT, MRI (can detect more subtle injury)

Fleck sign = fracture at base of 2nd metatarsal

A

Lisfranc injury

46
Q

lisfranc treatment

A

Unstable - surgical management
Screw fixation, bridge plate fixation, tightrope fixation, primary fusion

47
Q

Burning or cramping sensation in region of metatarsal heads (usually middle)

– worse with activity + relieved by rest

A

metatarsalgia

48
Q

Anatomy abnormalities like hammertoes, clawed toes, hallux valgus deformities

High heel use

Pain in metatarsal region

A

metatarsalgia

49
Q

How do you treat metatarsalgia

A

Transfer weight AWAY from affected heads
Low heeled shoes w/ sufficient room
Metatarsal bar placed on shoe

50
Q

Localized aching pain, swelling and tenderness that increases w/ activity

Localized bone tenderness at fracture site

A

march fracture

51
Q

Military, athletes
High volume stress from overuse or high impact activities

A

march fracture

52
Q

how do you treat a march fracture

A

RICE
Pain management
Surgery not common

53
Q

Flexion of PIP + hyperextension of MTP + DIP joints → PIP pain

toes

A

hammer toe

54
Q

with —- —- you need to review

Underlying disease vs mechanical

Tight fitting shoes

A

hammer toe

55
Q

How do you treat hammer toe

A

●Conservative
Analgesics
Proper footwear
Toe dividers

● Surgical - Rare
Arthroplasty
Pin
Tendon reconstruction

56
Q

Severe burning pain aggravated by activity located in 3rd web space w/ radiation to 3rd and 4th toes

– tight shoes aggravate with removing shoes + massaging foot relieving the pain
Numbness may occur

A

morton’s neuroma

57
Q

Women 25-50 with tight-fitting shoes, high heels, flat feet

Perineural fibrosis of plantar nerve where lateral + plantar branches communicate
Secondary to repetitive trauma

A

Morton’s neuroma

58
Q

PE: tenderness between 3rd and 4th metatarsal heads
– compression of foot may reproduce pain

A

Morton’s neuroma

59
Q

how do you treat morton’s neuroma

A

Local injection of steroid or lidocaine may give temporary relief

Surgical resection often necessary

60
Q

Bunion!
30s-50s
Rheumatoid arthritis, women
Shoewear = primary extrinsic of poorly-fitted, tight or pointed shoes

PE: observe degree of deformity, observe gait + look for abnormal ground contact (early heel rise = tightness)

A

hallux valgus

61
Q

how do you treat hallux valgus?

A

Shoewear modifications
Bunion pads
Toe spacers

Shoes, pads
In juveniles wait until done growing to consider surgery

Surgery is contraindicated in high-performance athletes + dancers until no longer able to perform

62
Q

Joint or foot deformity

Alteration of the shape of foot, ulcer, skin changes

A

charcot foot

63
Q

DM → destruction of joint surfaces, accompanied by dislocations of 1+ joints w/ inappropriate pain response

Neuropathic, neurotrophic, neuroarthropathy joint

A

charcot foot

64
Q

XR: marked destruction of joint surfaces + collapse of joint spaces w/ dislocations on foot

A

charcot foot

65
Q

how do you treat charcot foot

A

Ortho consult

– limit destruction + preserve stable plantigrade foot to protect soft tissue + prevent ulceration → off loading

Surgery/”rocker-bottom shoe”

66
Q

Monofilament
2 point discrimination

Assess skin, hair growth, perfusion, pulses, color

XR: weight bearing of both, look for changes, rule out osteomyelitis or charcot
Technetium bone scan = diagnose osteomyelitis
MRI to distinguish Charcot from osteo

A

diabetic foot

67
Q

— to distinguish charcot from osteomyelitis

68
Q

How do you treat a diabetic foot

A

Abscess or osteo → emergency surgery for drainage of infection, wound left open, dressing changes, closure at later date or amputation

Gangrene toes/forefoot → amputation

Entire foot → amputation

Surgery to remove any bony prominences and cause pressure to skin and increase risk of developing an ulcer