foot and ankle Flashcards
True foot and ankle emergencies (5)
Open fractures (OR right away) Check for pulses first!!! Compartment syndrome/crush injury Ischemic foot Infection (blisters = bad)
red flags of foot injury
edema-compare ecchymosis -mondor Point Tenderness Obvious deformity Gait abnormality
mondor
– sign of calcaneal fx (look at the sole of the foot)
approach to erythema as a rf
Whiteness with erythema around – no vascular supply present, huge crater underneath present
Looking for streaking/lymphangitis – infection going up lymph chain (signals a much worse infxn)
Draw a line around the cellulitis – if the redness crosses the blue line, then come back right away for IV abx
High tib-fib squeeze
checks for
Syndesmotic injury – looking for maisoneuve fx
Ankle external rotation test allows for evaluation of
Syndesmotic injury
Move their foot to the side
Anterior drawers, talar tilt
helps evaluate what
ATFL or CFL injury
Stabilize lower leg with hand on top; grab the calcaneus and move the foot forward and back
stress foot abduction tests looks for
Lisfranc fracture dislocation
Move the toes and the forefoot to see if there is movement of the mid foot
other than MSK what other systems would you want to evaluate
NEURO-gross and distal
VASC DERM -DP and PT pulses; if you cant feel them- Doppler them!
DERM- Open wounds or other red flags
ankle rules xray
need to be non tender over the malleolus
weight bearing for at least three steps
foot rules xray
any tenderness in the mid foot
base of metatarsal or navicular bone
three views of the foot
AP, Lateral, and oblique views
three views of the ankle
AP, Lateral, and Mortise views
if problem with proximal leg get this xray
Calcaneal axial, high tibia/fibula (if problem with proximal leg)
suspect Calcaneal fracture
weber classification
describes destruction of syndysmosis in ankle fractures
weber A
most distal
below syndesmosis
weber B
level of syndesmosis
weber V
above level of syndesmosis
special view of joint that helps evaluate syndesmosis
stress view
preferred treatment for non-displaced stable fracture of the ankle (isolated malleolar)
Non-displaced, stable
Posterior splint, Jones, NWB
F/u 5 – 7 days
three types of ankle fractures
isolated
bimalleolar
trimalleolar
jones compression dressing
splint for ankle fracture
the idea is that you want to reduce the swelling
jones fractures concerns
not a lot of blood flow so they need to be splinted and NWB VS Dancers with is an avulsion
trimal MOA
severe force from underneath or twisting
bony ligamentous ring is completely disrupted and a cradle needs to be formed to keep the NVS intact
post traumatic ankle pain causes
Watch for Chronic Post-Traumatic Ankle Pain
Osteochondral fracture of talus
CRPS (Complex regional pain syndrome)
Occult fracture
MOI for calcaneal fracture
what is the imaging study of choice
fall from a height
Imaging- NWB plain films B/L feet;
*Then if fx- CT with 3D recon is preferable
if pt has a calcaneal fx what else do you worry about?
what do you ask any traumatic pt
Also worry about lumbar spine and the other foot
NECK PAIN
BACK PAIN
CP
ABD PAIN?
management of calcaneal fx
NWB
Jones compression splint
If fracture blisters occur, use oil emulsion dressing to cover
Usually delay in ORIF of 1-2 weeks while edema and skin issues resolve
talar fx MOI
High energy
MVA or fall
talus tx
NWB
DO NOT attempt to reduce
Call for consultant
Treated as emergency due to high rate of AVN
ORIF vs casting and immobilization
Can be prolonged course for healing >12 weeks
MOI of lisfranc
FORCED Dorsifelxion
MVA
fall from height
equestrian injury
CAN OCCUR WITHOUT FX but the pt will be unable to bear weigh t
xray for suspected lisafranc
NWB AP and Medial Oblique radiographs;
WB and stress abduction films if old
pts with suspected lisfranc need to monitor for what?
Monitor for signs of vascular injury and compartment syndrome
Check for malalignment at met-cuneiform articulation
after establishing lisfranc what should you do?
Call consultant- do not attempt to reduce; it is reduced in the OR
Neuro checks in ED
If stable, Jones splint
Fractures with high potential for bad outcomes**
Open fractures
Calcaneal fractures
Talar neck fractures
Lisfranc fractures
Non-reducible fractures
N O lisa tala him to cal
fracture complications
Non/Mal union (jones fx)
Compartment syndrome
Complex regional pain syndrome
what do you see with CRPS
Hyperalgesia
mechanical thermal allodynia
Sudomotor changes
Often occurs secondary to ankle injury!
(manage with PT)
OCD in talus (Osteochondral defect of the talus)
can occur during surgery or during the injury
Usually result of impact or mal-reduction during fracture or ORIF
Needs a podiatrist
Won’t be able to walk
Easy to miss
thermal allodynia
can lead to the triggering of a pain response from stimuli which do not normally provoke pain.
who do we see ATR in
Common injury in men >45 yrs old
“Weekend warriors”
presentation
Feel a ”pop” or like someone hit them with a bat in the back of the leg
Focal pain and inability to bear weight on affected limb
Thompson-Dougherty Test-Positive (if foot doesn’t move when calf is squeezed)= rupture
Negative= intact
imaging if thompson’s test is weird
ULS
MRI
Helpful if Thompson test is questionable
Also useful if neglected rupture
treamtent of achilles tendon tx
We splint the patient in equinus (pointed toe – allows your achilles to find itself)
plantar fracture
untidy vs infected
Untidy
Wounds with tissue loss
Infected wounds
> 8 hours old
mnmgt of foot fractures
Obtain at least two radiographic views 90° apart
Check for associated fracture/dislocation
Attempt closed reduction
picture of less complex fractures
still hurt a fuck ton
Distal to metatarsal neck
Closed
Non to slightly displaced
Single
Usually treatable with taping and post op shoe
buddy tape! +post op shoe
complex fractures of the foot
proximal to met neck
Involves tendon or
ligament avulsion – they have to restabilize the
tendinous or ligamentous connection
tx of complex foot fractures
Multiple
Needs additional imaging
Can lead to poor outcome, even if treatment is ideal
May require ORIF and prolonged follow up
how determine if a fx is open or not
look for continued oozing to determine is this open or nah
“no oozing since they arrived –> probably not open”
fat molecules in the blood–> might be open
“there is a small 1cm wound just medial to the fx, not oozing, appears superficial with some concern for open fracture”
open fx treatment
Treat all open fractures as an emergency
Evaluate the patient for other injuries
Start appropriate antibiotic therapy (ANCEF)
Tetanus prophylaxis
Do an adequate (in OR) debridement and irrigation
Dry blood on a wound carries infxn
Stabilize the fracture (with towels, blankets, or splint until the consultant arrives)
Arrange appropriate wound coverage
Start early rehabilitation
easy explanation for compartment syndrome
Bleeding into a compartment may lead to elevated intracompartmental pressures
blood supply going into a muscle that is considered excess might disrupt the “ziplock bag”
at risk for muscle death
IV hydration is needed to avoid rhabdomyolosis
other than necrosis what are the complications of compartment syndrome
Permanent nerve and muscle loss
Rhabdomyolysis – CK is elevated
Get renal failure and can be fatal
Necrosis leading to amputation
Charcot foot -what is it
Neuro-arthropathy – a relatively painless, progressive, destructive arthropathy
seen with distinct erosion of the bone
Charcot foot -tx
Will mimic infection in presentation
Red hot swollen foot
Usually totally neuropathic “it doesn’t hurt”
Get plain films – will see joint destruction
Workup for infection
Basic labs- CBC, sed rate, CRP, culture wounds if appropriate
Associated plantar wounds- usually source of infection if present
diabetic foot ulcer
Polymicrobial Poor compliance and glycemic control Neuropathy Hemodynamically stable? If grey → no vascular supply
criteria for sepsis
Sepsis. Meeting SIRS Criteria?
workup for foot ulcer
Basic labs- CBC, CMP, sed rate, CRP
Plain films; CT helpful to eval for gas
(probe to bone is osteomyelitis )
Call for consultant and admission
To OR for I&D or more…
treatment of foot ulcer
Fluids, fluids, fluids
abx
NPO (please?)
Dressings
Usually gauze to
cover until we get there
To OR for debridement
Cultures intra-op
Will require wound care for prolonged period
what needs to be on the foot and ankle ROS
foot pain
swelling
coughing up blood?
CHEST PAIN
document this shit to rule out DVT
ruling out septic joint
full ROM
