foot and ankle Flashcards
A 20 y.o. Female presents to the urgent care complaining of lateral ankle pain and swelling. The night before she was playing beach volleyball jumped up to make a block and states she landed on her partner’s foot rolling her ankle. She has point tenderness localized over the distal fibula and just below. She has pain with inversion and lateral ecchymosis. X-rays are negative for fracture.
lateral ankle sprain
Ankle Sprains
sx, pe
Signs & Symptoms
● Pain, swelling, ecchymosis
● May have felt a “pop” @ time of injury
Physical Exam
● Tenderness
● Pain & weakness with inversion/eversion
● Anterior drawer test- assesses ATFL integrity
● Talar tilt test- assesses CFL stability
Ankle Sprains (test)
med vs lateral MC; what ligaments for each
Lateral is most common - INVERSION injury
- ANTERIOR TALOFIBULAR LIGAMENT*** (ATF ligament) the main stabilizer during inversion.
- Calcaneofibular Ligament (CFL)
- Posterior Talofibular Ligament.
Medial - Deltoid ligament
- less common and due to EVERSION of ankle.
Ankle Sprains ottawa ankle rules
○ Sensitive to r/o fracture
○ Determine if you need xray
If you can walk after injury, not tender in the midfoot/ankle -> sprain, no xray
ankle sprain tx
conservative x
Grade I - Mild
- RICE, NSAIDs, No immobilization
Grade II - Moderate
- RICE, NSAIDs, Ankle support (AirCast/ankle brace), Physical Therapy
Grade III- Severe
- RICE, NSAIDs, Short period of Immobilization (short leg cast), Physical Therapy once immobilization is removed.
Achilles Tendon Rupture presentation and risk factors (test)
An eccentric contraction of the gastrocsoleus complex leads to an overload on the tendon -> Sudden heel pain after push-off -> pop sound, cannot bear weight, calf pain
Risk factors:
● FLUOROQUINOLONE use*
● STEROID INJECTIONS**
● Weekend warrior
● 75% from sports
● 30-50 y.o
Achilles Tendon Rupture: PE, dx, tx
Physical Exam
● Positive Thompson test - With patient supine flex knee (or hang foot off table) and squeeze gastrocnemius. Positive if NO PLANTAR FLEXION
Diagnosis: clinical dx
● X-rays to r/o fx
● MRI = best test
Treatment
●immediate management:
- Ice, Analgesics, NSAIDs
- Short leg splint or cast with ankle plantar flexed
- Urgent referral to ortho
● Non -Op: Serial casting/splinting from plantar flexion to dorsiflexion (6-12 weeks)
● Operative: Allows for early ROM; most ppl opt for surgery
ankle fracture classification
what classification
weber
Maisonneuve Fracture: fef and presentaiton
def:
- Spiral Fracture of the PROXIMAL third of the fibula (results from tearing of the distal syndesmosis)
- associated with a distal medial malleolar fracture or rupture of the deep deltoid ligament
clinical presentation:
- MEDIAL ankle pain/swelling
- Tenderness over proximal fibula
- Possible medial malleolus fracture or deltoid ligament injury
Pilon
(Tibial Plafond) Fracture MOA/Def, dx, tx
Def/MOA:
- Fracture of the DISTAL TIBIA from impact with the talus. Fracture extends intra-articular.
- High impact, fall from a height (suicide), fall off horse
Dx:
- X-Rays: AP, Lat, Mortise, Joint
above
- CT: For operative planning*
Tx: ORIF!!!!!!! wont heal on its own
PILE ON -> Imagine someone jumping off a roof (suicide attempt) and their tibia smashes like a plate (plafond) into their talus → Pilon fracture.
mortise joint
The malleoli of the tibia and fibula, together with the inferior transverse tibiofibular ligament, form a rectangular socket (mortise) into which the trochlea of the talus fits into
-Ankle joint also called mortise joint
Maisonneuve Fracture dx and tx
Diagnosis
● X-rays of joint above & below. AP, Lat, Mortise, Stress view
● Mortise typically 5-6mm. if >10mm =syndesmotic injury
Treatment: OPERATIVE
● Operative: Repair syndesmosis
● Non-op is RARE unless patient is poor surgical candidate.
jones fracture vs pseudojones fracture MOA, location, risks, tx
jones:
- occur when forefoot is planted, but heel is off the ground
- WATERSHED AREA: nonunion risk
- 5th metatarsal - at the junction of the proximal diaphysis
- tx: MC = operative
- Immediate: Posterior splint,
NWB, Ice, Elevation
● Operative (M.C.): IM fixation. Decreases risk of non-union
● Non-Op: NWB in short leg cast for 6-8 wks. Progress to WB or hard sole shoe.
Pseudojones: more proximal
- Fracture through the base of the 5th MT
- Plantar flexion with inversion
- not in watershed
- tx: Walking cast x 2-3 weeks; ORIF if displaced
jones fracture def and location and what to look out for (test)
Acute transverse fracture through the proximal diaphysis of the 5th metatarsal at the metaphyseal-diaphyseal junction.
- Often occur when forefoot is planted, but heel is off the ground
- Poor blood supply (watershed area). 15-50% risk of nonunion or malunion*******
Lisfranc injury
where is the joint; where is the injury, MOA, pathogneumonic sign
Lisfanc Joint: Base of the first 3 metatarsal heads & their respective cuneiforms.
Lisfanc Injury: A tarsometatarsal fracture dislocation characterized by traumatic disruption between the articulation of the MEDIAL CUNEIFORM & BASE of the 2ND METATARSAL
MOA: midfoot rotation + axial load
pathognomonic: FLECK Sign - Fx @ the base of the
2nd metatarsal pathognomonic for disruption of the tarsometatarsal ligaments
Plantar Fasciitis
def, rf, tx (what to avoid)
Chronic overuse leads to inflammation and micro tears at the plantar fascia.
risk factor:
- obese
- Flat feet, high arches, heel spurs
- Females > Males 40-60y.o.
Treatment
● Conservative: RICE, Topical NSAIDs, Self-massage, Heel lift, Physical therapy, Night splints
● Avoid corticosteroid injections (may lead to fat pad atrophy, plantar fascia rupture).
Lisfranc injury sx, imaging (what sign - test), tx
Signs & Symptoms
● Severe pain
● Inability to bear weight
Physical Exam
● Swelling, ecchymosis, tenderness, instability
Radiographs
● X-Rays: AP, Lat, Oblique
● Fleck Sign - Fx @ the base of the 2nd metatarsal pathognomonic for disruption of the tarsometatarsal ligaments****
Treatment
● Initial: RICE. Short leg splint or boot.
● Non Op: Stable & Non-displaced.
NWB. 2-6 weeks. Repeat x-rays in 2 weeks to assess stability.
● Operative: ORIF, NWB 6-8 weeks.
Walking cast or boot for an additional 6 weeks.
55 y.o. Female presents to the clinic complaining of foot pain. She states the pain runs along the bottom of her foot from her heel to the ball of her foot. She says at times it is sharp and is most severe upon awakening when she steps out of bed. Her medical history is positive for hypertension, DM & obesity.
Physical Exam reveals local tenderness localized over the fascia medial calcaneus. Pain is worsened with passive dorsiflexion.
X-Rays: Positive for heel spur.
Plantar Fasciitis
Hallux Valgus (Bunion)
Valgus deformity of the first MTP joint with lateral deviation of the proximal phalanx
- etiology: tight-fitting or pointy shoes, women, RA.
Signs & Symptoms
● Localized great toe pain & MTP joint pain
● Positive LATERAL deformity of phalanx
Treatment = conservative
● Comfortable WIDE toe shoes, NSAIDs
● Operative with correction of deformity if no response to conservative tx
Tarsal Tunnel Syndrome
what nerve, causes, sx, pe, tx
POSTERIOR TIBIAL NERVE COMPRESSION as it travels through the tarsal tunnel. Often from overuse, compressive footwear, edema.
Signs & Symptoms
● Pain & numbness @ MEDIAL MALLEOLUS, heel
& sole.
● Worse throughout day,night.
● NOT relieved with rest
Physical Exam
● Positive TINEL sign - reproduces symptoms
Treatment
● Rest, NSAIDs, properly fitting shoes
● Corticosteroid injections
● Operative: Tunnel release in severe cases
Neuropathic (Charcot) Arthropathy
Peripheral neuropathy from DM & peripheral vascular disease causes joint destruction
- Decreased sensation & repetitive microtrauma leads to bone resorption & weakening
Signs & Symptoms:
- Midfoot & ankle m.c.
● Often presents chronically with joint & foot deformity, ulcers and skin changes.
Labs: elevated ESR, normal WBC
Radiographs
● X-rays: joint space DESTRUCTION, increased bone density.
● MRI or bone scan to r/o osteomyelitis
Treatment:
● Non removable total contact cast.
● NWB recommended
morton neuroma: sx and PE
Signs & Symptoms
● BURINING forefoot pain.
● Numbness & tingling
● Relieved with rest and SHOE REMOVAL
● feels like theyre walking on a marble
Physical Exam
● Palpation reproduces symptoms
● Palpable painful mass
● MULDER’s sign - Squeeze the metatarsal joints while palpating affected space results in crunching & clicking
Interdigital (Morton’s) Neuroma
what is it and rf, which nerve
Compressive neuropathy of the forefoot interdigital nerve against the transverse metatarsal ligament during dorsiflexion of toes.
- 3rd webspace m.c.
- Microtrauma that leads to degeneration & thickening of interdigital nerve
Risk Factors
● F > M 25-50 y.o.
● Tight fitting shoes, high heels.
● Flat feet
Interdigital (Morton’s) Neuroma dx and tx
Diagnosis: Clinical
● X-rays: r/o other causes
● Ultrasound: non-compressible
hypoechogenic lesion within intermetatarsal space
● MRI: soft tissue lesion >5mm within intermetatarsal space
Treatment: wear proper shoes + antiinflammatory»_space;»> surgery
Non-op: Wide toe shoe with metatarsal support pad
○ Single corticosteroid injection under U/S(short-lived)
■ May atrophy sub-q fat pad
○ NSAID’s, Gabapentin, Lyrica to decrease nerve related symptoms
Operative: Surgical resection after 9-12 mo. of conservative tx.
○ Complications: permanent numbness,
residual stump
