Foot and Ankle Flashcards
ankle sprain vs fracture stats
- > 25K ankle sprains/day in US
- Inversion injuries are most common
- Sprain may also be associated with: peroneal tendon tear , subluxation, sprain of subtalar joint, fracture @ the base of the 5th metatarsal, avulsion fracture of the calcaneus or talus
ankle sprain vs fracture initial presentation
o Pain over injured ligaments
o Swelling or bruising
o Loss of function
o Patient may describe hearing a pop during the initial injury or a feeling of instability while ambulating.
ankle sprain vs fracture exam
Tenderness to palpation (TTP) over affected ligaments or bony areas if fracture occurred
- Always palpate proximally to r/o fracture of prox fibula or tibia and distally to r/o foot fracture
- Neurovascular exam to ensure intact
ankle sprain vs fracture diagnostics
X-ray- r/o fracture
- Can use Ottawa Ankle Rules to determine if x-rays are required
- 3 views of the ankle (lateral, anterior posterior (AP), oblique)
- Assess joint spaces for appropriate alignment (Mortise: where tibia and fibula articulate with talar dome)
ankle sprain vs fracture
o If no fracture visualized on X-ray, likely diagnosis is an ankle sprain
o Based on clinical findings you will have determined whether injury involves the lateral, medial or both sets of ankle ligaments
if pain is on lateral aspect of ankle
Classification of Lateral Ankle Sprains
- Grade I: Anterior talofibular ligament with no instability
- Grade II: Anterior talofibular ligament and calcaneofibular ligament with mild laxity of one or both ligaments.
- Grade III: injury and significant laxity of both anterior talofibular ligament and calcaneofibular ligament
Superficial Deltoid ligament: superficial deltoid lig primarily resists eversion of hindfoot;
which widens mortise and produces chronic ankle instability
if pain is on medial aspect of ankle
Danger! Review Xrays carefully
Clues that the joint may be unstable:
- May see small avulsion fracture of tibia where deltoid ligament attaches
- Oblique fracture of fibula may cause disruption of the deltoid ligament
- Look for lateral shifting of talus
- When found, refer to specialist for repair
o less than 4 mm o less than 4 mm o less than 4 mm o less than 4 mm o Less than 4mmm
in absence of a medial malleolar fracture deltoid ligament may be stretched or torn in all oblique frx of fibula;
medial ecchymosis appears after 24 hrs when the deltoid ligament has been disrupted)
ankle sprain treatment
o The goal is to prevent re-injury and allow tightening of ligaments to prevent chronic instability
Mild
- WBAT in ankle brace 3-4 weeks
- RICE
- NSAID’s
Severe
- Immobilization for 3-4 weeks: weight bearing as tolerated (WBAT) with crutches in controlled ankle motion boot (CAM boot) or non-weight bearing splint for those too painful.
- Rest, ice, NSAIDs
- At 3-4 weeks (usually 3) transition into ankle brace for 3 weeks and then wean out
- You can Rx physical therapy to start gentle ROM, then progress to strength and balance.
- Can take 8-12 weeks to heal.
ankle fracture
o Many different classifications of fracture patterns
o If joint is unstable, refer
o These will need referral: Maisonneuve Fracture: ankle fracture associated with fracture at proximal fibula, deltoid ligament tear and disruption of syndesmosis. Bimalleolar or trimalleolar fractures, Anything with widened mortise
o A ring usually breaks in two separate regions and this is often the case in the ankle joint. If there is a break in the tibia on the inner side, one has to look for a disruption somewhere between the fibula and the talus on the outer side. This may be a torn ligament which will not show on x-ray but is important none the less. The interosseous membrane between the tibia and the fibula must be considered an ankle ligament in this context. It is often torn in ankle injuries.
o The third malleolus is the back of the tibial joint surface which can be broken in some patterns of ankle fracture
ankle fracture treatment
Non operative
- Stable fracture
- NWB cast initially, change to weight bearing once evidence of healing bone on X-ray (typically 4-6 week range from initial DOI)
- Gradually increase weight bearing status and start Physical Therapy as needed
Operative
- Unstable fractures
- Typically ORIF (open reduction, internal fixation)
talus fractures
o Result from high energy trauma such as fall from height or MVA; consider compression fracture of lumbar spine in ddx
o Mechanism typically extreme forceful dorsiflexion
o Most common fracture site is the talar neck
o Tenuous blood supply so increased risk of avascular necrosis, worse with displacement
talus fractures exam
o Moderate ankle swelling and TTP over anterior ankle and often talar neck dorsally
o Possible varus/valgus deformity
o Assess neurovascular status
talus fractures diagnostics
o Begin with 3 view x-ray of ankle. Lateral, AP and oblique
o Consider CT of ankle if high suspicion and to characterize
Hawkins classification of talar neck fractures 1-4
o I-10% AVN, II- 40%, III-90%, IV – 100%
talus fractures treatment
All referred to orthopedic specialist
- Non-displaced treated non-operatively with serial x-rays. Still up to 10% chance of AVN
- Displaced treated with ORIF
midfoot (lisfranc) fracture/injury
- Traumatic disruption of the tarsometatarsal joints: fracture, dislocation or both
- Result from significant trauma or indirect mechanism (Originally described in soldiers whose horse fell on their foot)
- Critical injury to the 2nd tarsometatarsal joint (Stabilizing apex for other TMT joints as it “keys” into cuneiforms, Additionally no connective tissue holding 1st metatarsal to the 2nd metatarsal)
- However, there is no connective tissue holding the first metatarsal to the second metatarsal. A twisting fall can break or shift (dislocate) these bones out of place.
- Unrecognized Lisfranc injuries can have serious complications such as joint degeneration and compartment syndrome
- Falling forward over a plantar flexed foot like when missing a step on a staircase
- Often present as a “sprain” over dorsum of foot
- Mechanism is often axial loading verticle foot or torque to fixed foot
- Foot may be mild to moderately swollen, maximum tenderness/swelling over distal mid-foot
- Physical Exam: stabilize hindfoot and try to rotate forefoot (Positive = pain)
midfoot (lisfranc) fracture/injury diagnostics
o X-ray: standing AP, Lateral and Oblique of the foot. Stress/weight bearing views prn. (On AP: Medial aspect of 2nd MT should line up with medial aspect of middle cuneiform. Shift = Lisfranc injury, On oblique: Medial 4th MT should line up with medial cubiod surface. Shift = Lisfranc injury)
o If high degree of suspicion and x-ray unclear, MRI of foot should be obtained.
o Comparison views often helpful
o MRI or CT scan if no dx from xray
Midfoot (lisfranc) injuries treatment
Nondisplaced:
-8 weeks in NWB cast followed by use of rigid arch support for 3 months
Displaced >2mm:
- ORIF
- Remove fixation after 6 months with custom rigid orthotic for 6 additional months
- Can take up to 12 weeks to heal properly
o Adverse outcome when misdiagnosed or improperly treated: compartment syndrome, arthritis, instability
o ***When missed and delayed 6 weeks, ORIF no longer an option and joint must be FUSED - Maintain a high index of suspicion
metatarsal fractures
o Result from direct blow or twisting mechanism
o Acute fractures are painful making weightbearing difficult
o PHYSICAL EXAM:
o Swelling, point tenderness (be aware of major swelling in 1st metatarsal can lead to compartment syndrome)
o Axial loading (compressing metatarsal head toward calcaneus) useful exam technique to r/o soft tissue injury
o DIAGNOSTICS (X-ray: AP, Lateral and Oblique of foot)
o Heavy object drop onto foot
o Great toe=1st metatarsal
metatarsal fractures: treatment and special considerations
o Typically heal with non operative treatment
o Non-displaced fractures: Short Leg Cast or CAM walker and weight bear as tolerated (WBAT) (RTC 3-4 weeks for X-ray to check healing and again @ 6 weeks discontinuation cast as fracture shows signs of healing)
o Unstable or displaced fractures may need surgical intervention. Generally 4mm displacement or 10 degrees of apical angulation or multiple fractures.
o However….special consideration for 5th Metatarsal Fractures (Styloid Avulsion Fractures, Jones’ Fracture)
o “true Jones” fracture occurs one inch distal to the base of the fifth metatarsal
o It is not due to peroneus brevis tendon avulsion but rather a twisting inversion injury to the foot. Greenspan states that more proximal injuries are frequently misinterpreted as Jones fractures but really are avulsion fractures by the peroneus brevis tendon. These latter fractures heal quickly, while more distal fractures may undergo fibrous union only.
avulsion fracture of 5th metatarsal styloid (pseudo jones)
o Most common fracture of base of 5th metatarsal (What tendon attaches there? Action of that muscle?)
o Swollen and point tender over fracture site
o Diagnosis: X-ray: AP, Lateral and Oblique of foot
o Treatment: CAM boot or post-op shoe WBAT x 4-6 weeks (Recheck X-ray for healing, if evidence of healing start firm soled shoe, Recheck @ 6 weeks for healing, If evidence of well healed bone, start regular shoe and activity as tolerated)
o Often fail to heal, but are rarely symptomatic
o Try to initiate ankle ROM as soon as possible
Jones fracture
o Often result from sudden force under lateral aspect of the distal 5th metatarsal (landing on side of foot/direct blow)
o DIAGNOSTICS: X-ray AP, Lateral and Oblique of foot
o Fracture in the proximal metaphysis of 5th metatarsal (metaphyseal-diaphyseal junction)
o Often lead to nonunion or delayed union due to low blood supply in that area
o Initial treatment NWB cast x 6 weeks, use X-ray to determine if any bone healing and clinical exam for point tenderness over fx site (If no evidence of healing both radiograph or clinical con’t NWB cast, If some evidence of healing than up to discretion of surgeon whether to allow WB, Sometimes even after some evidence of healing, this fracture ends up needing surgical intervention 3 months out from DOI.)
o Refer to Specialist as soon as possible!!!!
o Transverse fx extend joint between base of 4th and 5th MT
o Can take 8-12 weeks
o Sometimes need to be pinned if displaced or screw in if properly aligned but needs help along with bone healing
phalangeal fractures
o Fracture involving phalanx of the toe
o Typically caused by direct trauma (think jamming toe into couch or table leg)
o Patient may c/o of dull throbbing pain after incident
o Toe will likely be swollen and point tender
o Always note nerve status in documentation
o Confirm Diagnosis with X-ray: AP, Lateral and Oblique
o Treatment: buddy tape (Buddy tape + Post-op shoe 4-6 weeks for great toe)
o For displaced fractures, reduce fracture after applying digital block to reduce pain
o Fractures of Great toe often require orthopedic referral for surgical option if displaced d/t role as important weightbearing surface
o Oblique often useful w/o shadow
achilles tendon rupture
o Very common, especially among active males and females age 30-50 years playing quick stop and go sports like racquetball and basketball.
o Occurs from sudden and forceful plantarflexion as gastroc is contracted.
o Tear often occurs @ 3-6 cm proximal to insertion of Achilles tendon at the site of poorest blood supply.
