Foot and Ankle Emergencies Flashcards
1
Q
what is a foot and ankle emergency?
A
- Requires immediate attention.
- Fracture -high impact/force injury
- Infection
- Time is of the essence-
- Delay in treatment or mistreatment can lead to permanent loss of function, loss of limb or even loss of life.
- Quick ID of injury can quicken and get the protocols started earlier
- Examples
- Infection with gas in the soft tissues.
- Septic joint
- Open fractures.
- Closed injury with elevated compartment pressures.
- Fractures/dislocations involving the calcaneus, talus and Lisfranc’s joint.
- Lots of gas in the ED at ACMC
- Open fracture exposure depends on center (Level 1 has higher amt of open fxs of ankle)
2
Q
initial management
A
- ABC’s - Primary and secondary survey
- Hemodynamically stable
- Initial Imaging
- Plain films usually
- Secondary imaging
- CT, US, MRI if facility has available
- Labs if appropriate
- Consultant calls
- Treatment
3
Q
Emergencies
A
- Open fractures
- Compartment syndrome/crush injury
- Ischemic foot
- Infection
- Gas gangrene
- Necrotizing fasciitis
- Septic joint
4
Q
examination red flags
A
- Edema
- Ecchymosis
- Mondor sign - calcaneal fracture - this looks more like a lisfranc to me
- Erythema
- Point Tenderness
- Obvious deformity
- Gait abnormality
5
Q
focused food and ankle exam
A
- MSK- observe for deformity and red flags
- ROM of ankle, subtalar joint, forefoot joints
- High tib-fib squeeze
- Syndesmotic injury
- Ankle external rotation test
- Syndesmotic injury
- Anterior drawers, talar tilt
- ATFL or CFL injury
- Stress foot abduction test
- Lisfranc fracture dislocation
- High tib-fib squeeze
- NEURO-
- gross distal sensation
- VASC-
- DP and PT pulses; if you cant feel them- Doppler them!
- DERM-
- open wounds or other red flags
6
Q
Foot and ankle injury: radiographs
A
- Follow the Ottawa Rules
- WB vs NWB- depends on injury
- But when in doubt, order the films
- 2 views minimum, preferably 4 views
- Ankle AP, lateral, Mortise
- Foot AP, oblique and lateral
- Calcaneal axial, high tibia/fibula
- 2 views minimum, preferably 4 views
- Ankle radiographs: AP, mortise, lateral
- Foot radiographs: AP, lat, oblique
- Special radiographs: Calcaneal axial (Calcaneal fracture), High Tibia/fibula (Look for Maisonneuve fracture (high fibula))
- Special imaging: CT, MRI, US dependent on type of injury
7
Q
Ankle fractures
A
- Mechanism- force and torsion
- Etiology- high or low energy impact or rotation of the foot on the ankle
- How many malleoli?
- Isolated
- Bimalleolar
- trimalleolar
- Classification- Weber
8
Q
ankle fracture management in the ED
A
- UNIMALLEOLAR AND BIMALLEOLAR
- Assess, xrays
-
Reduce the fracture if possible
- Distract, Increase the deformity, reduce
- Get post-reduction xrays
- Jones compression dressing, posterior splint
- NWB with crutches
- Imaging- applies to all fractures; if complex get a CT scan
- Trimaleolar
- Reduce the fracture if possible
- Increase the deformity, distract, reduce
- Jones compression dressing, posterior splint
- NWB with crutches
- Call consultant if reduction is not adequate or skin is broken
- Reduce the fracture if possible
9
Q
Jones compression dressing and posterior splint
A
The Robert Jones dressing is a thick, padded bandage classically applied to the thigh and leg. It is thought to reduce swelling by applying even pressure to the extremity, which in turn should promote healing.
10
Q
treatment of trimaleolar fx
A
- Non-displaced, stable
- Posterior splint, Jones, NWB
- F/u 5 – 7 days
- Displaced, unstable
- Attempt closed reduction followed by open reduction internal fixation (ORIF)
- Likely will need ORIF depending on severity
- Aggressive physical therapy post-op or post-injury
- Anticipate 6 to 8 weeks for healing
- Watch for Chronic Post-Traumatic Ankle Pain
- Osteochondral fracture of talus
- CRPS
- Occult fracture
- An osteochondral injury is an injury to the smooth surface on the end of bones, called articular cartilage (chondro), and the bone (osteo) underneath it. The degree of injury ranges from a small crack to a piece of the bone breaking off inside the joint.
- Complex regional pain syndrome (CRPS) is a chronic (lasting greater than six months) pain condition that most often affects one limb (arm, leg, hand, or foot) usually after an injury. CRPS is believed to be caused by damage to, or malfunction of, the peripheral and central nervous systems.
11
Q
closed reduction principles
A
- Steady traction
- Recreate direction of injuring force
- Reverse direction into correction
- Correct rotational, then angulational deformity
12
Q
calcaneal fxs
A
- High energy injuries
- Axial load/fall
- Lateral process of the talus acts as a wedge
- Treatment
- Imaging- NWB plain films B/L feet;
- then if fx- CT with 3D recon is preferable
- 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
- Imaging- NWB plain films B/L feet;
13
Q
talar fractures
A
- High energy
- MVA or fall
- Can be extruded
- High risk of AVN
- Open or closed
- Management
- Imaging- NWB plain films, CT with 3D recon
- 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
14
Q
Lisfranc fracture/dislocation
A
- Lisfranc was a French sugeon
- Usually high energy injury… MVA, fall from height, equestrian injury
- Injury is forced dorsiflexion of midfoot on forefoot, causing fracture and dislocation of metatarsal-cuneiform articulations
- Evaluation
- NWB AP and Medial Oblique radiographs;
- Monitor for signs of vascular injury and compartment syndrome
- Check for malalignment at met-cuneiform articulation
- Mostly dorsal dislocation
- Can be complete or incomplete in relationship to met bases
- Call consultant- do not attempt to reduce
- Neuro checks in ED
- If stable, Jones splint
15
Q
fractures with high potential for bad outcomes
A
- Open fractures
- Calcaneal fractures
- Talar neck fractures
- Non-reducible fractures
