Conditions Of The Ankle And Surgery Flashcards
What is the syndesmosis of the ankle comprised of?
- anterior inferior + posterior inferior tibiofibular ligament
- inter-osseous membrane
Define ankle fracture
A fracture of any malleolus (lateral, medial or posterior) with or without disruption to the syndesmosis
What classification is used to classify lateral malleolus fractures of the ankle?
What are the types?
Weber classification
- Type A: below the syndesmosis
- Type B: at the level of the syndesmosis
- Type C: above the level of the syndesmosis (highest likelihood of ankle instability)
What are the Ottawa Ankle rules?
What is it used for?
If there is presence of any of the following, an x-ray of the ankle is needed:
- bone tenderness at posterior edge or tip of either malleolus
- inability to bear weight immediately + in 4 steps in the ED
Contraindications of the Ottawa Ankle rules (when can they not be used)
- pt is intoxicated or uncooperative
- has other distracting painful injuries
- diminished sensation in legs
- gross swelling
Investigations of ankle fracture
- X ray (in AP and lateral view) | ankle must be in full dorsiflexion
- CT may be needed for surgical planning
Management of ankle fracture
- immediate fracture reduction
- below knee back slab
- post reduction neurovascular examination + repeat X-ray
- surgical management: ORIF using plates + screws
When is conservative management used for ankle fractures?
- non displaced medial malleolus fractures
- Weber type A or B without talar shift
- if unfit for surgery
When is surgical management required for ankle fracture
- displaced bimalleolar or trimalleolar fractures
- Weber C
- Weber B with talar shift
- open fractures
What demographic are ankle fractures most common in?
Younger males
Older females
Classification of ankle sprain
- high ankle sprain: injuries to the syndesmosis
- low ankle sprains: injuries to the anterior talofibular ligament + calcaneofibular ligament
What is the most common ligament damaged in ankle sprains?
Calcaneofibular ligament
Check??
Common presentation of ankle sprain
- following inversion injury
- swelling + pain
- potential not to weight bear
Investigations of suspected ankle sprain
X-ray to rule out bony injury
Management of ankle sprain
Conservative management
- analgesia
- RICE
- early mobilisation
Risk factors for ankle sprain
- weak muscles/tendons across ankle joint
- weak or lax ligaments
- uneven surfaces
- inadequate heel support
- high heels
- slow response to being off balance
List the three lateral ligaments of the ankle
Anterior talofibular
Posterior talofibular
Calcaneofibular
What is the name of the medial ankle ligament?
Deltoid ligament
Name the bones of the feet
- talus
- calcaneus
- navicular
- cuboid
- 3 cuneiforms
- metatarsals
- phalanges
Name the tarsal bones of the foot
- talus
- calcaneus
- navicular
- cuboid
- 3 cuneiforms
Common cause of 5th metatarsal fracture
Stepping on curb
Climbing steps
Inversion injuries
Why can forced inversion injuries cause a 5th metatarsal fracture?
The peroneus brevis + plantar aponeurosis both insert into the 5th metatarsal and cause significant tension during forced inversion
Presentation of 5th metatarsal fracture
- pain, swelling + bruising to lateral foot
- tenderness on palpation
- difficulty weight bearing
Management of 5th metatarsal fracture
Walking boot or cast
Analgesia
RICE
What are tibial pilon fractures?
Severe injuries affecting the articular surface of the distal tibia (caused by high energy axial loads e.g. RTC
What are tibial pilon fractures characterised by?
Articular impaction
Severe comminution
Soft tissue injury
Presentation of tibial pilon fractures
- severe ankle pain
- inability to weight bear
- possible ankle deformity
- swelling + bruising
What classification is used for the severity of tibial pilon fractures?
What are the types?
Ruedi and Allgower
- Type 1: undisplaced intraarticular
- Type 2: displaced intraarticular
- Type 3: comminuted or impacted fracture
Management of tibial pilon fractures
- realignment of limb + apply below-knee backstab
- repeat neurovascular assessment + X-ray
- elevation of limb
- surgical: if there is significant soft tissue swelling: temporary spanning external fixator is applied then ORIF is done 7-14 days later
- in older patients or if ORIF fails; fusion of ankle with hindfoot nail
Management of ankle OA
- activity modifications
- physical therapy
- analgesia
- steroid injections
- weight management
- supportive footwear
What are lisfranc injuries?
Severe injuries to the tarometatarsal (lisfranc) joint between the medial cuneiform + base of the 2nd metatarsal
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Either solely ligaments us or involving the bones of the midfoot (fracture-dislocation)
Mechanism of lisfranc injuries
Occur following severe torsional or translational forces applied through a plantarflexed foot e.g. RTC or athletic injury
Presentation of lisfranc injuries
- sever pain in midfoot
- difficulty weight bearing
- swelling + tenderness over midfoot
- plantar bruising
- piano key sign
What sign is involved in lisfranc injuries?
What does it involve
piano key sign
Moving each toe, one at a time, to see if it causes pain
Radiological features of lisfranc injuries
- widening of the interval between the base of 1st + 2nd metatarsal
- bony fragment in the space between the 1st + 2nd metatarsal
- malaligment of the distal talus bones to their associated metatarsal
What classification is used to classify Lisfranc injuries?
Hardcastle and Myerson classifcation
Management of lisfranc fracture
- ensure pt is Haemodynamically stable
- if no significant displacement: cast immobilisation + non weight bearing mobilisation
- if significantly displaced: closed reduction in A&E then screw fixation in surgery
What are the first and second most commonly fractured tarsal bones?
Calcaneus (first)
Talus (second)
Mechanism of calcaneus fracture
Fall from a height
With significant axial loading onto the bone
What are the two types of classifications of calcaneus fractures?
- intraarticular: involves the articular surfaces of the subtalar joint
- extraarticular: most often avulsion fractures
What classification is used for intra-articular calcaneus fractures?
What are the types?
Sanders classification
- type 1: no displaced posterior facet
- type 2: one fracture line in posterior facet (2 fragments)
- type 3: two fracture lines in posterior facet (3 fragments)
- type 4: comminuted with more than three fracture lines in the posterior facet (4 or more fragments)
Presentation of calcaneus fractures
- pain and tenderness around calcaneal region
- inability to weight bear
- swollen and bruised
- possibly varus deformity
What is the gold standard for assessing calcaneal fractures?
CT imaging
Management of calcaneus fractures
- closed reduction with percutaneous pinning if minimally displaced
- ORIF for most cases
- analgesia
- non weight bearing
Main complication of calcaneal fracture
Subtalar arthritis
What are the two types of Achilles tendinopathy?
- insertional tendinopathy: within 2cm of the insertion point on the calcaneus
- mid-point tendinopathy: 2-6cm
Risk factors of Achilles tendinopathy
- sports that stress the Achilles e.g basketball, tennis, track
- inflammatory conditions e.g. RA + ankylosing spondylitis
- diabetes
- raised cholesterol
- fluoroquinolone abx e.g. ciprofloxacin
Presentation of Achilles tendinopathy
- pain or aching in Achilles tendon with activity
- stiffness
- tenderness
- swelling
- nodularity on palpation
Management of Achilles tendinopathy
- exclude Achilles tendon rupture - Simmonds’ calf squeeze test + USS
- rest + modified activities
- analgesia
- orthotics e.g. insoles
- Physiotherapy
- ESWT: extracorporeal shock wave therapy
Why are steroid injections into the Achilles tendon avoided?
Risk of tendon rupture
Risk factors of Achilles tendon rupture
- sports that stress the Achilles basketball, track, tennis
- increasing age
- existing Achilles tendinopathy
- family history
- fluoroquinolone abx ciprofloxacin
What medicine has a link with Achilles tendon pathology?
Fluoroquinolone abx
e.g. Ciprofloxacin + levofloxacin
Rupture can spontaneous occur within 48 hours of starting
Presentation of Achilles tendon rupture
- sudden onset of pain in Achilles
- snapping sound or sensation
- feeling as though something has hit them in the back of the leg
Examination signs of Achilles tendon rupture
- tenderness
- palpable gap
- weakness of plantar flexion
- unable to stand on tip toes
- positive simmonds calf squeeze test
What test can be used if suspecting Achilles tendon rupture?
Describe it
Simmonds’ calf squeeze test
- Pt is prone
- squeeze the calf
- if intact the ankle with plantar flex
- a lack of plantarflexion > positive test > Achilles tendon rupture
Diagnostic imaging of Achilles tendon rupture
USS
Management of Achilles tendon rupture
- RICE
- immobilise with boot (first in plantarflexed position then to neutral over time)| consider VTE prophylaxis
- analgesia
- surgically reattaching Achilles (difficult to do)
