Ankle fractures and foot

Question 1

Medial ligament

Answer 1

Deltoid ligament

Question 2

Lateral ligaments

Answer 2

Anterior and posterior inferior talofibular ligaments

Calcaneofibular ligament

Question 3

Immediate Mx

Answer 3

ATLS 
History and examination 
Check NV status 
Gain IV access and take bloods 
Give pain relief 
Reduction + below knee back slab
Recheck NV supply + xray 
Fixation 
Rehab 

If open: 
Abx 
Tetanus
Picture 
Cover wound with a sterile dressing

Question 4

Mechanism of injury

Answer 4

Inversion or eversion

Question 5

Blisters

Answer 5

Cleavage injury between dermis and epidermis due to friction

Severe soft tissue injury

Question 6

Fracture examination

Answer 6

Proximal fibula 
Syndesmosis 
Midfoot 
Subtalar joint 
Base of 5th metatarsal 
Sensation and pulse

Question 7

Ottawa rules for radiotherapy

Answer 7

Xray indicated if:

• tenderness over posterior half of lateral malleolus and base of 5th metatarsal
• tenderness over the posterior half of medial malleolus and navicular tuberosity
• Unable to weight bear

Question 8

Mortise view

Answer 8

Xray taken with leg internally rotated by 15 - 20 degrees

medial clear space should be within 4mm all the way around

Syndesmosis overlap of 1mm

Question 9

Unstable fracture

Answer 9

Talar shift
Fracture in 2 places
Weber C fracture

Question 10

Talar shift

Answer 10

Talus displaced laterally so medial clear space increases

Question 11

What causes talar shift

Answer 11

Deltoid ligament tear
medial malleolus fracture
Normally Weber B

Question 12

Weber classification

Answer 12

Weber A - below syndesmosis
Weber B - at syndesmosis
Weber C - above syndesmosis

Question 13

Weber mx

Answer 13

Weber A - normally stable with non surgical mx
Weber B - normally stable but can have talar shift
Weber C - always unstable requires surgery

Question 14

Stress test

Answer 14

If unsure whether stable or unstable pt can test stability by weight-bearing Xray

Question 15

SPAN/ SCAN/PLAN

Answer 15

SPAN - external fixation when extensive soft tissue injury
SCAN - CT
PLAN - plan surgery if internal fixation needed and rehab

Question 16

Commonest cause of injury

Answer 16

Supination ecternal rotation

Question 17

How to treat isolated Weber B

Answer 17

Treat symptomatically if stable

Unstable - with boot and review after 1 week with Xray on admission

Question 18

Trimalleolar fracture Ix

Answer 18

Requires CT for surgery planning

Question 19

Hindfoot nailing

Answer 19

Consider to allow pt to mobilise quicker

If there is very poor soft tissue quality

Question 20

Ankle fracture in diabetics

Answer 20

Investigate:

• charcot foot
• vascular compromise
• infection - osteomyelitis

Longer healing time
Double fixation required

Question 21

Hallux Valgus

Answer 21

• Great toe deviates laterally at MTP joint
• Pressure of MTP against shoe → bunion
• ↑ wt. bearing at 2nd metatarsal head
- pain: “Transfer metatarsalgia”
- → hammer toe

Question 22

Morton’s neuroma

Answer 22

• Pain from pressure on an interdigital neuroma
between the metatarsals.
• Pain radiates to medial side of one toe and lateral side
of another.
• Rx: neuroma excision

Question 23

Ix of ankle fractures

Answer 23

Xray - AP and lateral

CT scan if complex

Question 24

Complications of ankle fracture

Answer 24

OA

ORIF - DVT, NS injury, nin - union and metal work prominence

Question 25

Ankle sprain

Answer 25

Present following inversion:

High ankle sprains - injuries to the syndesmosis

Low ankle sprains - injuries to the anterior talofibular ligament (ATFL) and the calcaneofibular ligament (CFL)

Mx: RICE

Question 26

Calcaneal fracture mechanism of injury

Answer 26

Fall from height whereby there is significant axial loading directly onto the bone.

Often presents with concurrent fractures

Question 27

Achilles Tendonitis

Answer 27

Inflammation of the Achilles (calcaneal) tendon prevalent in those that do high-intensity activities such as running and jumping

Question 28

Clinical features of Achilles Tendonitis rupture

Answer 28

Sudden-onset severe pain in the posterior calf

Audible popping sound

On examination:
Loss of power of ankle plantarflexion

Question 29

Simmonds’ Test

Answer 29

Test for Achilles tendon rupture.

Patient kneeling on a chair, with the affected ankle hanging off the edge of the chair, squeeze the affected calf. If the Achilles tendon is in continuity, the foot will plantarflex; however, plantarflexion is absent when the tendon is ruptured.

Question 30

Management of Tendonitis

Answer 30

Stop precipitating exercise NSAIDs
Ice
Rehab and physio

Question 31

Achilles tendon rupture mx

Answer 31

Analgesia

Immobilisation with slpint in a plaster - 2 weeks then 4 weeks then neutral position for 4 weeks

Question 32

Plantar fasciitis

Answer 32

Inflammation of the plantar fascia

Caused by micro tears

Sharp pain across the plantar aspect of the foot, most severely in the heel

Clinical diagnosis

Question 33

RF for plantar fasciitis

Answer 33

Anatomical factors, such as excessive pronation or pes cavus (high arches)

Weak plantar flexors or tight gastrocnemius or soleus

Prolonged standing or excessive running

Leg length discrepancy

Obesity

Unsupportive footwear

Question 34

Mx of plantar fasciitis

Answer 34

Activity moderation 
Regular analgesics
Physio
Shoe with a well-cushioned heel
Corticosteroid injections

Question 35

Syndesmosis

Answer 35

Binds the distal tibia and fibula together

Consist of:

• anterior inferior tibulofibular ligament
• posterior inferior tinulofibular ligament
• interosseus ligament