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Orthopaedics > Ankle Injury > Flashcards

Ankle Injury Flashcards

1
Q

Learning outcome

A

Ligament

  1. Acute lateral ligament complex injury
  2. Recurrent lateral ligament instability
  3. Acute medial ligament complex injury
  4. Inferior tibiofibular ligament injury

Fracture

  1. Malleolar fracture
  2. Tibial plafond fracture

Tendon

  1. Posterior tibial tenosynovitis
  2. Peroneal tenosynovitis
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2
Q

Mechanism of ankle injury

A

Axial loading

  • malleolar fracture
  • tibial plafond fracture

External rotation, eversion

  • medial ligament injury
  • syndesmosis ligament injury
  • posterior tibialis tendon rupture
  • malleolar fracture

Inversion

  • lateral ligament injury
  • malleolar fracture
  • peroneal tendon rupture
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3
Q

Acute lateral ligament complex injury pathology

A
  1. Also known as low ankle sprain (ATFL, CFL)
  2. 90% of ankle sprain
  3. Associated injury:
    - peroneal tendon injury
    - deltoid ligament injury/medial malleolus fracture
    - base of 5th metatarsals (tendon pull)
    - anterior process of calcaneus
    - lateral process of talus
  4. Classification of low ankle sprain based on ligament disruption, degree of swelling and pain on weight bearing
    I- none, minimal, normal
    II- mild laxity, moderate, mild
    III- complete, severe, severe
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4
Q

Acute lateral ligament injury diagnosis

A

Hx

  1. trauma: extensive inversion
    - plantar flexion: atfl
    - dorsiflexion: cfl, ptfl
  2. pain
    - can bear weight: partial
    - cannot bear weight: total
  3. swelling
  4. bruises: anterior to lateral malleolus
  5. giving away: varusly
  6. pop sound

PE

  1. tenderness: anterior/inferior/posterior lateral malleolus
  2. pain on passive inversion
  3. anterior drawer test: grade III ATFL tear
  4. talar tilt test: CFL tear

X-ray

  1. Anterior drawer test: >10mm or >5mm compare to normal (Lateral view)
  2. Talar tilt: 15 degree or >5 degree compare to normal (Mortise view)
  3. Look for avulsion fracture of base of 5th metatarsal
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5
Q

X-Ray indication of ankle injury?

A

Ottawa Ankle Rules

  1. Pain around medial/lateral malleolus
  2. Unable to near weight immediately after injury
  3. Unable to walk 4 steps in ED
  4. Bone tenderness (tip of malleolior base of 5th metatarsal)
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6
Q

Causes of recurrent lateral ankle instability

A
  1. Non-healing previous acute ankle ligament injury
  2. Peroneal tenosynovitis
  3. Peroneal tendon tear/rupture
  4. Avulsion fracture of lateral malleolus
  5. Superior extensor retinaculum tear
    * look for tendon subluxation during foot eversion or dorsiflexion with resistance
  6. Osteochondral lesion
  7. Ankle arthritis
  8. Fracture
    - lateral process of talus
    - anterior process of calcaneus
    - jones fracture (base of 5th metatarsal)
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7
Q

Acute Lateral Ligament Complex Injury Treatment

A
  1. Conservative

“PRICER”

  • Protection (crutch, splint, brace)*protected mobilization leads to earlier recovery than rigid immobilization
  • Rest
  • Ice (20 mins every 2 hours or any activity cause pain)
  • Compression
  • Elevation
  • Rehabilitation
    ~ 1-3 weeks
  1. Operative
    - if pain persist over 12 weeks
    - re-investigation may requires MRI/CT
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8
Q

Treatment for recurrent lateral ligament instability

A

Conservative

  1. Rest
  2. Physiotherapy: stenghthen peroneus muscle
  3. Modify shoe-wear (raise outer side of heel)

Operative

  • *according to etiology
    1. Ligament reconstruction (using peroneus brevis tendon)
    2. Arthroscopic debridement
    3. Ligament anatomical tighthening/repair “Gould Operation/Brostrom-Karlsom”
    4. Postoperative:
  • ankle immobilized in eversion (2 weeks)
  • below knee cast (4 weeks) + bear weight
  • removable brace (3 months)
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9
Q

Acute medial ligament complex injury diagnosis

A

Hx

  1. trauma: extensive eversion or external rotation
  2. pain
    - can bear weight: partial
    - cannot bear weight: total
  3. swelling
  4. bruises: medial malleolus
  5. giving away: valgusly

PE

  1. tenderness: medial malleolus
  2. pain on passive eversion
  3. eversion: superficial deltoid
  4. external rotation: deep deltoid
  5. valgus tilting: too many toes or single heel raised test

X-ray
1. medial space widening

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10
Q

Acute inferior tibiofibular ligament injury diagnosis

A

Hx

  1. trauma: extensive external rotation
  2. pain: in front of ankle
  3. swelling: in front of ankle
  4. bruises

PE

  1. Hopkin’s squeeze test (pain at syndesmosis)
  2. External rotation test

X-ray

  1. widening of tibiofibular space >5mm (mortise)
  2. tibiofibular overlapping
    - on mortise <2mm
    - on ap <5mm
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11
Q

Ankle malleolus fracture diagnosis

A

Hx

  1. trauma
    - low-energy (twisting)
    - high-energy (axial loading)
Danis and Weber
Type A:  ADDUCTION/INTROT
- transverse fibular below syndesmosis
- oblique/vertical medial malleolus 
Type B: EXTROT
- oblique fibular at syndesmosis
- avulsion medial malleolus 
Type C: ABDUCTION/EXTROT
- fibular above syndesmosis
- avulsion medial malleolus
  1. pain: malleolus
  2. swelling: malleolus
  3. bruises

PE

  1. Tenderness: malleolus
  2. Deformity
  3. Bruises

X-ray: fracture as Danis-Weber

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12
Q

Accurary of ankle reduction?

A

(1) the fibula must be restored to its full length
(2) the talus must sit squarely in the mortise, with the talar and tibial articular surfaces parallel
(3) the medial joint space must be restored to its normal width, i.e. the same width as the tibio-talar space (about 4 mm)
(4) oblique x-rays must show that there is no tibiofibular diastasis

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13
Q

Tibial Plafond Fracture diagnosis?

A
  1. Mechanism: high energy axial-loading
  2. Fracture with intact ligaments produce 3 fragments:
    - medial malleolar (deltoid lig)
    - posterolateral/Volkmann fragment (PITFL)
    - anterolateral/Chaput fragment (AITFL)
  3. Classified according to amount of displacement and comminution
    I - non-displaced
    II - minimally displaced
    III - comminuted

++ Hx, Pe, X-ray as normal fracture

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14
Q

Peroneal tendon subluxation diagnosis (+/-superior peroneal retinaculum tear)

A

Hx

  1. trauma: rapid dorsiflexion with foot inversion
  2. pain: in front of ankle
  3. swelling: posterior to lateral malleolus
  4. bruises

PE

  1. tenderness over tendons
  2. lump “pseudotumour” over peroneal tendon
  3. compression test: pain with passive dorsiflexion and eversion
  4. apprehension test: dorsiflexion or eversion against resistance
  5. varus ankle

X-ray

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15
Q

Posterior tibial tenosynovitis rupture

A

Hx

  1. trauma: extensive external rotation
  2. pain: medial ankle
  3. swelling: medial ankle
  4. bruises

PE

  1. pes planus
  2. ankle valgus
  3. forefoot abduction “too many toes sign”
  4. tenderness: posterior to medial malleolus
  5. single heel raised test (loss of inversion)
  6. weak inversion (examiner apply eversion force to counter)

X-ray

  1. Increase simmons angle (AP)
  2. Increase meary angle (Lateral)
  3. Decrease medial cuneiform height
  4. Decrease calcaneal pitch
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Orthopaedics (47 decks)

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