ankle/ foot patho- Dr Davies Flashcards
Ottawa Ankle Rules
about it
Ankle radiographs account for 2% for all radiographs taken (2nd to c-spine)
When used, any fractured missed should be minor and unlikely to lead to increased morbidly
Ottawa Ankle Rules
the rules
Where to palate:
- palpate distal, posterior tip and the posterior 6 cm of the lateral malleoli (Pots fracture) and the medial malleoli
- fifth metatarsal (Jone’s Fracture)
- navicular bone- the whole bone
______ ankle sprains/ day
25,000
*one of the most common musclosketelar injuries that occur
how often is the AFTL the ligament involved in the injury?
85% of the time
AFTL is involved in what type of injuries?
plantar flexion, inversion injuries
What is the order of the ligaments that are injured?
ATFL
CF
PTFL
grade 1 sprain in ankle
interstitial injury, but not a lot of laxity
grade 2 sprain ankle
partial tearing; pain, swelling; increased laxity in the ligament (no 2+ or 1+ in the grade 2 for the ankle)
grade 3 sprain ankle
completely torn
High ankle sprain
one of the few ankle injuries that will need surgery
if someone has a high ankle sprain, it will involve the tib-fib jt, which is connected by syndesmosis.
High ankle sprain will be a syndesmotic injury= diastasis; this is an unstable joint, this can lead to OA
Need to do an ORIF
From http://www.wheelessonline.com/ortho/syndesmotic_sprain
- Discussion:
- if only syndesmotic ligaments are divided (w/ fibula & collateral ligaments intact) there will be no widening of mortise or lateral displacement of talus;
- compressing the fibula and tibia above the ankle elicits tenderness at the syndesmosis, implies injury to the syndesmosis;
From http://www.wheelessonline.com/ortho/syndesmotic_injuries_of_the_ankle
- Anatomy:
- syndesmosis is made up of anterior-inferior tibiofibular ligament, interosseous ligament, and posterior-inferior fibular ligaments,
inferior transverse tibiofibular ligament, and interosseous ligament;
- these stabilize the mortise by opposing the fibula in the fibular notch (incisura fibularis tibiae);
imaging
radiograph
stress radiograph- plantar flex and invert the ankle to her the talar tilt measurement
*bone contusion, OCD lesions, etc
Talar Tilt measurement
line though the top of the malleolus and then a line on top of the talus; compare bilaterally
Salter’s Harris
when there is a stress to the growth plate but can not be seen because of the growth plate
Casting
for the fibula- do not need to cast the knee, but ankle (short leg cast)
for the tibia- need to have the cast cross the ankle and knee (long leg cast)
long leg cylinder cast does not imm the ankle
Shin Pain
progression of
"shin splints" Myositis Tendonitis/ osus Periostis Medial Tibial Stress Syndrome Stress Fracture
Myositis, tendonitis, periostitis for shin pain
Criacs muscle tendon sequence to see if it is the muscles involved
Palpating to see if it is more muscle belly or more bone
If it is the Criac- more tendon
If it is more on bone- periostits
If it is more on muscle- myostis
Lateral shin pain
most likely myositis of the anterior tibial muscle
Medial Tibial Stress Syndrome
The in between the inflammation of the bone and the stress fracture
Pain, inflammation (of muscle, tendon, and bone) involving the shin area
medial shin pain
posterior tibialis (muscle or tendon)
When imaging to use for stress fracture?
MRs, rarely radiographs at first (takes 3-4 weeks for calcification to occur), bone scan (know something is going on, but don’t know what)
Most common areas for stress fractures in the LE
metatarsal
tibia
proximal femur
another name for a tibial stress fracture
the dreaded black line; tibia is a weight bearing bone. very bad to get a stress fracture here
chronic compartment syndrome
how this works
the muscles in these compartment response when exercising; more blood will flow to the muscles, increasing the fluid in the area. this increases the intra compartmental pressure in the area
which compartment is most likely involved in Chronic compartment syndrome (order)
lateral
anterior
deep
superficial
Wick Catheter
tells the amount of pressure in the compartment;
record the resting pressure then have the patient exercise to see the increase pressure change
How do define the Chronic Compartment with the Wick Catheter’s Chart? (3)
- resting is higher
- exercise increases faster
- takes longer to get back to the pre exercise pressure
treatment for Chronic compartment syndorme
don’t exercise to the point of pain or fasciotomy
Fasciotomy
Problem is that it will scar down again
small insicion to tear the fascia apart so that the pressure will not build up
End result if acute compartmental syndrome is not found in time
amputation!
description of acute compartmental syndrome
foot drop swollen, red, glossy looking "woody feel" distal pulses- diminished neurological symptoms
What are the 6 P’s for acute compartment syndrome?
Pain (out of proportion to clinical exam) Pressure (tense swelling) Pain (with passive stretch) Paralysis (muscle weakness) Pulses (diminished/ absent) Paresthesia (sensory deficits) *palpation- woody feeling
what do you do for acute compartment syndrome?
get them to the ER as fast as possible
High Ankle Sprian- what does it effect
distal tib fib ligament; the swelling/ bruising will be laterally (more proximal to the normal ankle sprain)
Surgery for the High ankle sprain
screw fixation for about 12 weeks to fixate the joint
Will take out the screw to help regain dorsiflexion (cant do DF with the screw)
ankle arthroscopy
Number one reason to preform is anterior impingement syndrome (arthroscopy debrement)
Number two- OCD; where the talus hits the tibia (can do a microfracture as well)
Can do an arthroscopy diagnostically
For an accessory bone
Os Trigonum
an accessory bone on the back of the talus; hurts in plantar flexion causing impingement (artho or open surgery
Tarsal Tunnel Release
release the retinaculum to release the pressure on the nerve (hopefully the doctor will address the cause- pronation)
CAI- chronic ankle instability (what may be involved)
- capsules/ ligaments are loose
- muscles cant provide dynamic stability
- no or low proprioception
Lateral Ankle Reconstruction
classification
- Anatomic repair
- Non anatomic repair
- Dynamic reconstruction
Anatomic repair of the ligaments
ligament is torn, you repair it; direct primary repair of the torn ligaments; usually ATFL and CFL
*Brostrom
Non anatomic repair
changing the anatomy
*Brostrom with Gould modification
Dynamic reconstruction
using the muscle tendon to reconstruct the ankle
*Watson Jones ligament reconstruction
Brostrom with Gould modification
Start with the anatomic repair and then take the extensor reticulum and tighten the ankle
Watson Jones ligament reconstruction
take the peroneus brevis tendon; leave it attached distally; bring it back up through the lateral malleolus (drill holes); will tighten up the lateral side of the ankle
Achilles tendonitis/osus
-itis, -osus (will have degenerative changes when you have osus); eccentric exercises is the most effective for regenerating/ decreasing pain in the long run
Description of Achille’s tendonitis (how it looks)
thicken type of tendon compared to the other side
order for Achilles…
Achilles tendon-it is, -osus, rupture (can be a traumatic rapture too)
Subjective for Achilles
“ive been shot”
hear a pop
30-50 age category
Objective for Achilles
Swelling; bruising
finger tip test and Thompson/simmons test
*can have a radiograph if you think there may be an avulsion; MRI will show the rupture)
Treatment for Achilles
Closed reduction or surgically repaired
Surgery: end to end approximation; may take the plantaris tendon to support it. Will debree the ends and sow the two ends together.
rehab for Achiiles
will do non weighing for 4-6 weeks; then you will go into the CAM walker
CAM (stands for)
control ankle motion
PTTD- posterior tibial tendon dysfunction
will see this commonly in older adults
not helping your medial longitudinal arch; should have a nice arch, but instead there will be a excessive pronation
TAA- total ankle replacement
if the ankle is too messed up- total ankle
rare
IRMT
inflammatory reaction to microtrauma
IRMT (what is it)
overuse syndrome
*running
abnormal stresses (shear, compression, tension)
Rule of 3 with running
range of motion
angular of velocity
forces on the joints
*as in- increases stresses on the body
microtraumatc injuries in runners
excessive compensatory prolonged pronation
excessive pronation
increase supination
Causes of injuries for runners
Training programs
Training surfaces
Footwear
Training programs (causes of injury)
60% of running injury due to improper training:
Frequency
Duration
Intensity
Training surfaces (causes of injury)
too hard too soft wet/icy crowned surface (IT band syndrome) down hill (increase knee strain
Foot wear (causes of injury)
number of miles on shoes (300)
shoe construction
wear pattern
Sesamoiditis
inflammation of sesamoid bones; may need to surgically remove, orthotics
*he said this was not important
Turf Toe
Sprain of the 1st MTP jt; common in football players
have to use the 1st MTP so this is a big deal (will lead to OA problems)
Taping, maybe an orthotic
Bunionectomy
One of the most common surgeries in the foot
Have a thick Hallux Valus; no longer pushing off the foot correcting
*will do an osteotomy of the 1st ray
Metatarslagia
pain in the forefoot area
- shoes that have a small toe box, etc
- sorbathane, etc can help, orthotics
Morton’s Neuroma
plantar nerves will bifurcate into digital nerves; where this occurs is where a Morton’s neuroma can occur; can occur between any of the metatarsal, but is most common between 3 and 4
*Molder’s Sign to confirm
orthotics to help with a protective pad, an injection, surgery to remove
Stress fractures**** (how to determine)
MOI- excessive increased activity
Pain on palpation of a long bone
Pain increases with weight bearing activity
Cuboid Syndrome
Occurs in the midfoot
Could be overuse syndrome or from traumatic ankle sprain
Do palpations, Do Ap mobility, do distraction, cuboid whip (follow up with tape to prevent subluxation)
Chopart injury
in the tarsal (between the tarsal)
need ORIF
Lisfarc injury
between the metatarsal and tarsals
can be a subluxation/ dislocation or fracture
need ORIF
Planter Fascitis
about
inflammation of plantar fascia
Can occur in supinated foot due to decreased shock absorbion
Plantar Fascitis
s/s
pain along medial tubercle of calcaneus (may have osteophytes
worsens with first steps in morning
Plantar Fascitis
treatment
rest, modalities, anti-inflammatories limit excessive pronation increase flexibility night time splints/ heel cups *taping, plantar fasciotomy
