Ankle Sprains and Fractures

Question 1

Lateral Ankle ligaments

Answer 1

• anterior tibiofilular ligament
• anterior talofibular ligament
• cervical ligament
• dorsal talonavicular ligament
• calcaneonavicular ligament
• dorsal calcaneocuboid ligament
• calcaneofibular ligament
• posterior talofibular ligament

Question 2

Medial ankle ligaments

Answer 2

• Anterior tibiotalar ligament
• tibionavicular ligament
• tibiocalcaneal ligament
• posterior tibiotalar ligament
  deltoid ligament
• these are more formable ligaments meaning that they tend to have avulsion fracture more than sprain

Question 3

Sprain grades

Answer 3

• 1º= point tender, no loss of integrity (4% on stress strain curve - some micro tears)
• 2º50% disruption, mild loss of integrity (6% - can WB with assistive device)
• 3º= significant to complete rupture, significant loss of integrity (non WB)

Question 4

Ankle inversion sprains: mechanism

Answer 4

• most common
• plantar flexion and inversion
• anterior talofibular ligament most commonly involved

Question 5

Intervention for ankle inversion sprains in the acute protected motion phase

Answer 5

• early weight bearing with support (crutches and bracing)
• manual therapy: drainage, STM, joint mobilization
• cryotherapy
• therapeutic exercise: passive/active ROM

Question 6

What motion is the most important to recover with ankle inversion sprains

Answer 6

• DF for weight bearing
• open pack position is slightly PF

Question 7

Intervention for the progressive loading/sensory motor/therapeutic exercise phase of an inversion ankle sprain

Answer 7

• manual therapy, mobilization, manipulation both WB/NWB
• balance/proprioception such as SLS
• weight bearing functional activities and single limb balance
• balance and sports related activities

Question 8

Eversion ankle sprains: mechanism

Answer 8

• less common
• eversion with external rotation
• can cause avulsion fracture

Question 9

When is an eversion ankle sprain going to be stressed/what motions should be protected

Answer 9

• stressed during pronation
• can’t early WB to due to wanting to control stress on healing tissue
• Arch support soles and inserts can be used to control pronation

Question 10

High ankle sprain

Answer 10

• mechanism DF with tibial IR
• ER strain test
• slower progression with rehab
• NWB 3-4 weeks (difficult to protect against spreading in WB)

Question 11

ER strain test

Answer 11

• DF+ER of the foot on the tibia
• (+) = pain

Question 12

Tight rope procedure

Answer 12

• high ankle sprain
• small hole through fibula and tibia
• feed a cable through to keep the bones from spreading

Question 13

Achilles tendon injury

Answer 13

• 30-50 years told (tendonosis)
• recreational athletes
• most occur 2-6 cm proximal to insertion

Question 14

Why do most achilles tendon injuries occur 2-6 CM proximal to insertion

Answer 14

• microvascular along is length decreases around this point
• makes it susceptible to degenerative changes

Question 15

Achilles rupture surgical procedures types

Answer 15

• 1º repair
• Repair with augmentation
• reconstruction

Question 16

1º repair

Answer 16

• whip stitch to pull ends together
• prevents suture from stripping down the fibers

Question 17

Repair with augmentation

Answer 17

• the sutures (whip stitch) are strengthened with another tissue
• fascia from gastroc, FHL, peroneus brevis, plantaris

Question 18

Reconstruction

Answer 18

• uses fascia lata to reconstruct the tendon

Question 19

Achilles tendon repair rehab:
0-4 weeks: type of rehab and ankle immobilization

Answer 19

• compression dressing removed few days to a week post-op
• when compression dressing removed, below-knee cast applied; foot in 15-30ºof PF
• at 2-3 weeks new cast applied in less PF

Question 20

Achilles tendon repair rehab:
0-4 weeks: WB restrictions

Answer 20

• non weight bearing
• ambulation with crutches

Question 21

Achilles tendon repair rehab: 4 weeks: type of rehab and ankle immobilization

Answer 21

• cast set in equines removed and walking cast applied
• ankle positioned in neutral or with controlled ankle motion brace that limits DF to 0
• worn for 2-4 weeks

Question 22

Achilles tendon repair rehab:
4 weeks: WB restrictions

Answer 22

• weight bearing initiated while wearing immobilizer
• progress as tolerated

Question 23

Achilles tendon repair rehab:
6-8 weeks: type of rehab and ankle immobilization

Answer 23

• if walking cast used: replace with CAM brace allowing DF beyond neutral
• Active ROM exercises initiated

Question 24

Achilles tendon repair rehab:
6-8 weeks: WB restrictions

Answer 24

• Full Weight bearing wearing functional brace
• transition to shoe with 1-1.5 heel lift for 2-4 weeks

Question 25

Achilles tendon repair rehab: beyond 12 weeks: type of rehab and ankle immobilization

Answer 25

- functional brace gradually discontinued

Question 26

Achilles tendon repair rehab: beyond weeks: WB restrictions

Answer 26

- full weight bearing in regular shoes without lift

Question 27

What happens with a PF contracture

Answer 27

- difficult to recover motion - want to protect against this from developing

Question 28

Ankle fractures: Malleolar isolated non displaced

Answer 28

- 4-6 weeks - WB as healing permits - cast - 2º bony healing

Question 29

Malleolar fracture isolated displaced

Answer 29

- ORIF early ROM - 1º bony healing - 1 mm displaced = 40% reduction in contact area of the talocrural join = more susceptible to degeneration - contact of the TCJ helps to spread the force of walking over the joint

Question 30

Bimalleolar fracture

Answer 30

- usually unstable surgical fixation - equivalent lateral malleoli with deltoid ligament rupture/fracture - no medial or lateral stability

Question 31

trimalleolar fx

Answer 31

- sever ER of foot and IR of tibia - posterior lip of tibia is fracture as well as both malleoli

Question 32

Tibial Plafond (pylon) fracture

Answer 32

- high energy/axial compression - talar dome gets driven into tibia - intra-articular fracture = bruising to articular cartilage that can accelerate degeneration - significant soft tissue cartilage damage

Question 33

Talar Fracture

Answer 33

- causes talar neck and axial load - talar neck fracture can cause AVN - similar mechanism: axial compression with dorisflexion - managed ORIF with below knee cast NWB - bone healing 6-12 weeks

Question 34

Calcaneal fracture

Answer 34

- High velocity impact - fall off a ladder and land on heels - bony healing 8-12 weeks

Question 35

Calcaneal fracture ORIF goals

Answer 35

- joint stability - articular congruity - articulate integrity - near anatomic alignment

Question 36

What do you expect to see with someone who is NWB

Answer 36

- muscle atrophy of LE - hypomobility - decreased proprioception - plantarfasicitis - loading a foot that hasn't been loaded