Foot and Ankle

Question 1

Ankle Joints

Answer 1

• Ankle is a hinge joint
• Motions = flexion/extension
• Inversion/eversion occurs at calcaneo-talar joint (below the ankle)

Question 2

Lateral Ligaments of the Ankle

Answer 2

• Anterior talo-fibular - 1st to tear in ankle sprains
• Calcaneo-fibular
• Posterior talo-fibular

Question 3

Medial Ligaments of the Ankle

Answer 3

• Deltoid ligament
• Tibiofibular ligament
  
  • aka inerosseous ligament
  • aka syndesmotic ligament
  • joins distal tibia-fibula
  • maintains integrity of mortise joint

Question 4

Extensor Tendons of the Ankle

Answer 4

• dorsiflexors
• pass anterior to the ankle

Question 5

Plantar Flexor Tendons of the Ankle

Answer 5

• pass posterior to medial malleolus
• “tom, dick and harry”
  
  • Tibialis posterior
  • Flexor digitorum
  • Flexor hallicus

Question 6

Peroneal Tendons of the Ankle

Answer 6

• evertors of the ankle
• pass posterior to the lateral malleolus
• Peroneal longus and brevis
  
  • Brevis is often involved in avulsion fractures of the 5th metatarsal

Question 7

Achilles Tendon

Answer 7

• arises from gastroc and soleus
• inserts on calcaneous
• plantar flexes the foot - strongest plantar flexor

Question 8

Retinacula

Answer 8

Fibrous bands that hold tendons in place

Question 9

Ankle Sprains

Answer 9

• Ligamentous injury
  
  • usually inversion mechanism
  • >90% lateral ligaments
    
    • most are anterior talo-fibular ligament
    • very few are deltoid ligament and tib-fib syndesmosis
  • Lateral ligaments tear in sequence anterior to posterior
  • Deltoid ligament sprain
    
    • due to eversion mechanism
    • usually with associated fibula fx

Question 10

Ankle Sprains: clinical

Answer 10

• pain, swelling
• +/- inability to bear weight
• foot may be inverted (talar tilt)
• passive inversion results in increased pain
• stress maneuvers
  
  • drawer test
  • inversion stress

Question 11

Ottawa Ankle Rules

Answer 11

• bony tenderness along distal 6cm of tibia or fibula
• bony tenderness at base of 5th metatarsal
• inability to bear weight both immediately after injury and in emergency department

Question 12

Ankle Sprain: Classification

Answer 12

• First-degree
  
  • ligament stretching
  • local tenderness, minimal swelling
• Second-degree
  
  • severe stretching/partial tearing
  • more tenderness and swelling
  • abnormal stress tests
• Third-degree
  
  • complete rupture
  • can’t bear weight

Question 13

Ankle Sprain: management

Answer 13

• ice, elevation
• immobilize with plastic or plaster splint
• consider crutches
  
  • if moderate-severe
  • if difficulty bearing weight with splint
• third degree sprains may need surgery (rare)

Question 14

Ankle Fractures

Answer 14

• may be malleolar, bimalleolar, trimalleolar
• often disrupt tib-fib ligament and mortise joint
  
  • tib-fib (syndesmotic) ligament normally maintains integrity of mortise
  • exception: distal fibula fx

Question 15

Weber Classification

Answer 15

• Weber A
  
  • fibula fx below syndesmosis
  • mortise usually intact
• Weber B
  
  • fibula fx at level of syndesmosis often tearing ligament
  • may disrupt mortise
• Weber C
  
  • fibula fx above syndesmosis, always tearing ligament, disrupting mortise
  • always unstable

Question 16

Ankle Fracture: clinical

Answer 16

• pain, swelling, bruising, inability to bear weight
• significant deformity if dislocation is present

Question 17

Ankle Fracture: management

Answer 17

• reduce fracture-dislocations
• immobilize in splint
• elevate
• surgery needed if mortise disrupted
  
  • need to restore anatomic position of talus on mortise
  • ensure smooth articular surface
• cast 6-8 weeks
• arthritis likely if poorly aligned joint surface

Question 18

Calcaneous Fracture

Answer 18

• most commonly fractured tarsal bone
• mechanism usually due to compression
  
  • e.g fall from height
  • 10% associated with lumbar fx
  • 26% associated with other extremity injury
• Clinical: swelling, pain, ecchymosis
• X-ray: standard foot films usually demonstrate, consider calcaneal views
• Treatment: surgical, need to restore anatomy

Question 19

Talar Fracture Etiology

Answer 19

• usually due to foot hyper-plantar flexion
• fx may involve dome, neck or body
• talus covered by cartilage, blood supply, tenuous
  
  • fx may lead to avascular necrosis

Question 20

Talar Fracture Clinical

Answer 20

• intense pain
• inability to bear weight
• localized tenderness and swelling
• may have loss of normal foot contour
• caution “ankle sprain” misdiagnosis
• diagnose with foot x-rays

Question 21

Talar Fracture Management

Answer 21

• ice, elevation, immobilization
• nonsurgical, if non-displaced minor chip fx of dome
• surgery, if displaced fx of neck or body

Question 22

Midfoot: Cuboid Fracture

Answer 22

• usually due to crush injury
• usually associated navicular or cuneiform injuries
• pain/swelling/tenderness
• foot x-ray
• conservative prescription if non-displaced
• ORIF if displaced

Question 23

Midfoot: Proximal 5th Metatarsal Fx

Answer 23

• the most common metatarsal fx
• often occurs with lateral ankle sprain
• always check for tenderness at base of 5th MT when evaluating ankle sprain
• ankle x-rays must visualize this area
• usually due to inversion/avulsion of proximal bone by peroneus brevis tendon
• treatment:
  
  • usually conservative, immobilize, crutches

Question 24

Jones Fracture of 5th Metatarsal

Answer 24

• Not an avulsion fracture
• Involves diaphysis of 5th metatarsal
• Has higher incidence of non-union or delayed union

Question 25

Forefoot Fractures: stress fx

Answer 25

• stress fractures of midshaft metatarsals
  
  • usually 2nd and 3rd MT’s, which are relatively fixed
    
    • 1st, 4th, 5th relatively mobile
  • due to excessive stress over time
  • may not appear on x-ray for 2-3 weeks
  • if suspected:
    
    • bone scan
    • repeat xray in 2-3 weeks
  • Rx: rest, possibly immobilize

Question 26

Forefoot Fractures: complete

Answer 26

• Complete midshaft metatarsal
  
  • usually crush mechanism
  • occasionally due to twisting mechanism
  • often more than one MT is fractured
  • Rx: ice, immobilize with plaster/fiberglass

Question 27

Forefoot Fractures: phalanges

Answer 27

• common: often see fracture-dislocation
• usually due to direct trauma or hyper-extension
• exam: pain/swelling, deformity if dislocated
• Rx:
  
  • reduce fx and/or dislocation
  • immobilize with dynamic splinting (buddy taping)
  • stiff-soled shoes
  • great toe bears 1/3 of weight of body on that side may require walking cast
  • if unable to reduce may require internal fixation (rare)

Question 28

Metatarsalgia

Answer 28

• Nagging forefoot pain over middle metatarsal heads
• Usually due to faulty weight distribution
  
  • e.g weight gain, hallux valgus, flat foot
  • metatarsal heads bear disproportionate weight
  • also, gout. rheum athritis
• Treatment symptomatic, directed at cause

Question 29

Morton’s Neuroma

Answer 29

• a neuropathy of interdigital nerve, usually proximal to bifurcation
• usually nerve supplying 2nd and 3rd toes
• nonspecific inflammation of nerve with proliferative connective tissue
• most common in middle-aged women
• Clinical:
  
  • sudden attacks of sharp or burning pain, radiating to toes
  • at first, pain only with walking
  • later, pain even at rest
  • localized webspace tenderness, reproduces pain
  • may palpate small mass in webspace
• Management: initial steroid/lidocaine injection, definitive surgical excision

Question 30

Hallux Rigidus

Answer 30

• stiffness of MTP joint of great toe
• caused by arthritis, local trauma, gout
• more common in men
• clinical: pain with walking, tender MTP joint, pain with dorsiflexion
• X-ray: arthritic changes, osteophytes, narrowed joint space
• Management: rocker-soled shoes, NSAIDs, possibly surgery (joint replacement vs fusion)

Question 31

Hallux Valgus

Answer 31

• most common foot deformity
• great toe angles “inward” (valgus)
• more common in females
• often familial
• obvious deformity
  
  • prominent bunion
  • red, swollen
• management: conservative - wide, padded shoes. surgical - corrective osteotomy

Question 32

Hammertoe

Answer 32

• PIP joint fixed in flexion, DIP extended
• most commonly affects second toe
• shoe pressure may produce corns/calluses on dorsum of toe
• treatment: operative: joint excision

Question 33

Pes Planus (Flat Foot)

Answer 33

• due to collapsed medial arch
• may be congenital or acquired (polio, rheum. arthritis, tendon ruptures)
  
  • flexible most common
  • rigid due to congenital vertical talus or spasmodic peroneal muscles
• Clinical:
  
  • arching feet with standing/walking
  • shoes wear badly esp over arch
  • on exam medial border of foot almost touches ground when standing
• Management: small children usually none, older kids/adolescents arch support, if underlying condition may need surgical correction

Question 34

Plantar Fasciitis

Answer 34

• usually an overuse injury
  
  • runners, standing occupations, also rheum arthritis and gout
• strain of fascial fibers, friction causes periostitis of calcaneous
• Clinical:
  
  • pain over plantar surfaces: increased pain with walking, running. relief with rest
  • tender to palpation over anterior calcaneus
  • pain with passive dorsiflexion
• Management: rest, NSAIDs, heel and arch supports, steroid injection

Question 35

Posterior Tibial Tendonitis

Answer 35

• post. tibial tendon is a plantar flexor of foot
  
  • passes posterior to medical malleolus
• overuse injury
• management:
  
  • rest, NSAIDs
  • possibly immobilize
  • possible steroid injection

Question 36

Peroneal Tendonitis

Answer 36

• peroneal tendons pass posterior to lateral malleolus
• overuse injury
• management:
  
  • rest, NSAIDs
  • possible immobilie
  • possible steroid injection

Question 37

Tarsal Tunnel Syndrome

Answer 37

• entrapment of posterior tibial nerve by flexor retinaculum
• due to inflammation
  
  • repetitive activity
  • rheum arthritis
  • pregnancy
  • acute trauma: fx dislocation, soft tissue swelling
• clinical: numbness, pain of sole of foot
• Management: rest, NSAIDS, immobilize, possible surgery

Question 38

Subluxing Peroneal Tendons

Answer 38

• occurs after injury that disrupts peroneal retinaculum
• acute or chronic
• tendons sublux or actually disclose over lateral malleolus
• seen best with foot eversion
• treatment: surgical

Question 39

Achilles Tendonitis

Answer 39

• overuse of calf muscles
• tenderness, increased pain with dorsiflexion
• acute management: rest, ice, NSAIDs, immobilize
• chronic management: surgery to divide fascia

Question 40

Achilles Tendon Rupture

Answer 40

• usually due to forced dorsiflexion of ankle
  
  • initiating sprint
  • slipping on stair
• also may see with direct trauma
  
  • blow to taut tendon, laceration
• may be partial or complete
• most common in middle-aged men
• symptoms: sudden pain, pt may hear snap, difficulty stepping off
• exam: swelling of distal calf, palpable tendon defect, weak plantar flexion, may still be able to flex, positive thompson test

Question 41

Thompson Test

Answer 41

• sensitive to detect achilles rupture
• pt lies prone with knee flexed at 90 degrees
• squeeze calf, foot should plantar flex
• achilles rupture: foot does not flex

Question 42

Achilles Tendon Rupture Management

Answer 42

• splint in equinus
• non-weight bearing
• refer to ortho
• conservative: casting x 8 weeks, physical therapy
• surgical: recommended for younger, athletic pts

Question 43

Hindfoot Bursitis

Answer 43

• Two bursae
  
  • between calcaneus and achilles tendon
  • between achilles tendon and skin
• overuse injury
  
  • poorly fitting shoes
• inflammation, pain on motion
• management:
  
  • rest, NSAIDs, proper fitting shoes
  • consider steroid injection