Ankle + foot Flashcards
Bruising, edema (quickly)
“Pop” in foot followed by swelling, pain, inability to bear weight
ankle sprain
Most common sports injury
Most involve LCL (complex) as a result of inversion + plantar flexion
ankle sprain
ligament most commonly injured in an ankle sprain
anteroinferior tibiofibular ligament
grades of ankle sprains
I: no instability (microtears)
II: mild laxity (minor)
III: severe laxity, rupture of calcaneofibular + anterior talofibular ligaments (complete)
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
ankle sprain
How do you treat an ankle sprain?
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
All unstable syndesmosis are — —-, but not all are unstable syndesmoses!
ankle sprains
“High” ankle sprain – eversion, rotational injury
Specifically damage to the ligaments connecting the tibia and fibula
unstable syndesmosis
PE: external rotation stress
Squeeze test, proximal tenderness
XR: negative stress
MRI
unstable syndesmosis
How do you treat an unstable syndesmosis?
No instability = walking cast x 4 weeks + PT
Instability = fixation of syndesmosis
Ottawa ankle rules - order an X-ray if any of the following apply
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.
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
ankle fracture
Commonly a rotational injury
Deformity, bruising, open or closed, inability to bear weight
ankle fracture
XR: AP/lateral/mortise
Classify ankle fracture based on lateral malleolus
A = below syndesmosis
B = level of syndesmosis
C = above syndesmosis
ankle fracture
criteria for ankle fracture treatment
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
ankle fractures w/o separation tx
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
ankle fractures w/ separation tx
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
Pain with weight bearing activity, difficulty with uneven ground, swelling, history of prior injury
primary = rare
commonly post-traumatic
ankle arthritis
PE: swelling, areas of tenderness along tibiotalar joint, check standing alignment
XR: weight-bearing AP, lateral + mortise of ankle
ankle arthritis
ankle arthritis treatment
Non-surgical = NSAIDs, intra-articular injection, mechanical unloading (cane), bracing (arizona AFO)
Surgical = osteophyte excision, distraction arthroplasty, ankle arthrodesis, ankle arthroplasty
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
achilles tendonitis
inflammatory/degenerative – insertional vs non-insertional, seen in obesity, HTN, steroid use
achilles tendonitis
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
achilles tendonitis
achilles tendonitis tx
Non-surgical =
NSAIDs
immobilization (boot/cast)
heel lift
achilles sleeve
PT (stretching, eccentric strengthening)
avoid steroids
extracorporeal shockwave therapy
Sudden occurrence of heel pain after push-off movement, “pop”, calf pain
“Someone hit me”
achilles rupture
Zone of vascularity – less commonly chronic steroid use or antibiotics (quinolones)
seen often in weekend warriors
achilles rupture
Palpate for gap
+ Thompson test (no plantar flexion)
MRI best
achilles rupture
achilles rupture tx
Ice to area, analgesics, rest
Bracing, casting with gradual dorsiflexion towards neutral
Pain over fifth metatarsal area with edema and/or ecchymosis
Jones fracture
Fracture of metaphyseal-diaphyseal junction of 5th metatarsal
Non-union rate = high
Chronic stress injury
Jones fracture
XR: acute proximal diaphyseal fracture w/ medial fracture line extending into/towards intermetatarsal joint
Jones fracture
Usually non operative – REFER
Non-weight bearing 6-8 weeks
Walking boot 2-4 weeks
Surgery in those who fail conservative or in athletes
Jones fracture
Lateral foot/ankle pain, chronic
Instability of peroneals = tear
– pain at base of 5th metacarpal + extension into plantar medial foot
Peroneal tendonitis
peroneal tendonitis tx
Immobilization, NSAIDs, therapy
Continued pain → MRI
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
plantar fasciitis
Most common cause of heel pain – chronic overuse stress common in females 40-60y, older and obese, teachers, those who stand on their feet
plantar fasciitis
How do you treat plantar fasciitis
PT - formal therapy more effective
NSAIDs
Night splints
Inserts
Heel pad
Injection - only 1 cortisone injection
Pain, swelling, ecchymosis around lateral hindfoot
calcaneus fracture
Most common tarsal bone fracture – mostly displaced intra-articular from trauma and in young men
calcaneus fracture
Commonly have other extremity injuries or associated spine fractures
XR: displaced intra-articular fracture
calcaneus fracture
how do you treat calcaneus fracture
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
What’s good post op care for calcaneus fracture
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
Pain and swelling in midfoot with difficulty bearing weight – 1+ metatarsal bones are displaced from tarsus
Plantar ecchymosis
lisfranc injury
Low energy trauma or high energy from MVAs, industrial, height
3 oblique ligaments:
Dorsal
Interosseous (strongest)
Plantar
common in football/contact sport
lisfranc injury
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
Lisfranc injury
lisfranc treatment
Unstable - surgical management
Screw fixation, bridge plate fixation, tightrope fixation, primary fusion
Burning or cramping sensation in region of metatarsal heads (usually middle)
– worse with activity + relieved by rest
metatarsalgia
Anatomy abnormalities like hammertoes, clawed toes, hallux valgus deformities
High heel use
Pain in metatarsal region
metatarsalgia
How do you treat metatarsalgia
Transfer weight AWAY from affected heads
Low heeled shoes w/ sufficient room
Metatarsal bar placed on shoe
Localized aching pain, swelling and tenderness that increases w/ activity
Localized bone tenderness at fracture site
march fracture
Military, athletes
High volume stress from overuse or high impact activities
march fracture
how do you treat a march fracture
RICE
Pain management
Surgery not common
Flexion of PIP + hyperextension of MTP + DIP joints → PIP pain
toes
hammer toe
with —- —- you need to review
Underlying disease vs mechanical
Tight fitting shoes
hammer toe
How do you treat hammer toe
●Conservative
Analgesics
Proper footwear
Toe dividers
● Surgical - Rare
Arthroplasty
Pin
Tendon reconstruction
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
morton’s neuroma
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
Morton’s neuroma
PE: tenderness between 3rd and 4th metatarsal heads
– compression of foot may reproduce pain
Morton’s neuroma
how do you treat morton’s neuroma
Local injection of steroid or lidocaine may give temporary relief
Surgical resection often necessary
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)
hallux valgus
how do you treat hallux valgus?
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
Joint or foot deformity
Alteration of the shape of foot, ulcer, skin changes
charcot foot
DM → destruction of joint surfaces, accompanied by dislocations of 1+ joints w/ inappropriate pain response
Neuropathic, neurotrophic, neuroarthropathy joint
charcot foot
XR: marked destruction of joint surfaces + collapse of joint spaces w/ dislocations on foot
charcot foot
how do you treat charcot foot
Ortho consult
– limit destruction + preserve stable plantigrade foot to protect soft tissue + prevent ulceration → off loading
Surgery/”rocker-bottom shoe”
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
diabetic foot
— to distinguish charcot from osteomyelitis
MRI
How do you treat a diabetic foot
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
