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MSK Exam 3 > Foot/Ankle > Flashcards

Foot/Ankle Flashcards

1
Q

Most commonly fractured long bone

A

Tibia

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2
Q

Tibial Shaft Fracture etiology

A

Trauma

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3
Q

Tibial Shaft Fracture
Clinical Presentation

A
  • Leg pain
  • Worse with movement
  • Swelling
  • Open fractures are common
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4
Q

Tibial Shaft Fracture
Diagnosis

A
  • Evaluate the entire tibia-fibula,
    ankle, & knee
  • Tenderness, deformity, & soft
    tissue swelling along the tibia
  • Distal neurovascular exam:
  • Peroneal n. sensory exam:
  • Check for evidence of skin wounds
    suggestive of an open fracture
  • Evaluate for compartment syndrome
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5
Q

Peroneal n. sensory exam includes:

A
  • sensation to dorsal first
    webspace of foot
  • lateral dorsal foot
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6
Q

Peroneal n. motor exam includes:

A
  • ankle dorsiflexion
  • eversion
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7
Q

Tibial Shaft Fracture diagnosis

A
  • Obtain x-rays of the ankle
  • AP, lateral, mortise views
  • Obtain x-rays of the tibia-fibula &
    knee
  • AP, lateral views
  • Consider noncontrast CT
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8
Q

Tibial Shaft Fracture
Management

A
  • Most require operative repair
  • Well-approximated, low-force fractures of the tibial shaft may be managed
    nonoperatively
  • Fractures of the tibia associated with a fibular shaft fracture will require
    operative repair because of fracture instability
  • Open fracture, neurovascular injury, & compartment syndrome: All are indications for hospital admission & operative repair
  • Pain medications
  • Acute management
  • Position the patient’s knee in 10-15° of flexion
  • Long-leg posterior leg splint
  • Supporting stirrup splint to prevent ankle & knee movement
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9
Q

indications for hospital admission & operative repair of a tibial shaft fracture

A

Open fracture, neurovascular injury, & compartment syndrome

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10
Q

Tibial Shaft Fracture
Complications

A
  • Chronic pain & deformity
  • Compartment syndrome
  • Mal-union & nonunion
  • Osteomyelitis
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11
Q

Fibular Shaft Fracture epidemiology & etiology

A
  • Isolated midshaft or proximal fibula fractures = Rare
  • Isolated distal fibula fracture = Common
  • Majority of ankle fractures in older women
  • Fibular fractures may occur from repetitive loading
  • stress fractures
  • Fibula fractures often associated with tibial fractures
  • Trauma
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12
Q

Fibular Shaft Fracture
Clinical Presentation

A
  • Patients often complain of lateral leg pain,
    exacerbated with walking
  • Fibula only bears ~17% weight
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13
Q

Fibular Shaft Fracture
PE & Diagnosis

A
  • Evaluate the entire tibia-fibula,
    ankle, & knee
  • Tenderness, deformity, & soft
    tissue swelling along the fibula
  • Distal neurovascular exam
  • Check for evidence of skin wounds
    suggestive of an open fracture
  • X-rays of the ankle: AP, lateral, mortise views
  • X-rays of the tibia-fibula & knee: AP, lateral views
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14
Q

Fibular Shaft Fracture
Management

A
  • Most isolated fibula fractures of the proximal fibula & shaft can be managed nonoperatively
  • Place the patient in a long-leg posterior leg splint or cast with the ankle & knee immobilized
  • Pain medication
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15
Q

Fibular Shaft Fracture
Complications

A
  • Compartment syndrome
  • Mal- & non-union
  • Peroneal nerve injury
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16
Q

Tibia & Fibula Stress Fractures etiology

A
  • Overtraining
  • Especially sudden ↑ in training intensity
  • Incorrect biomechanics 2° training, anatomy, equipment
  • Tissue fatigue
  • Hormone imbalance
  • Poor nutrition
  • Vitamin D deficiency
  • Osteoporosis
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17
Q

Tibia & Fibula Stress Fractures
Clinical Presentation

A
  • Patient complains of ↑ pain with exercise
  • Pain becomes progressive & provoked with even lighter exercise
  • Focal pain
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18
Q

Tibia & Fibula Stress Fractures
Diagnosis

A
  • X-ray
  • AP & Lateral
  • May not be visible for 3
    weeks
  • Bone Scintigraphy
  • Will show ↑ uptake at the fx
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19
Q

Tibia & Fibula Stress Fractures management

A
  • REST from the STRESS
  • Low impact exercise can be substituted
    to maintain cardiovascular conditioning
  • Recumbent bicycling, pool running
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20
Q

Tibia & Fibula Stress Fractures complications

A
  • Adverse effects of NSAIDS
  • Recurrence
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21
Q

Referral Considerations for Tibia & Fibula Stress Fractures

A
  • Ortho consult
  • 2-3 weeks with no improvement or worsening
  • Consider psychiatric referral for women with female athletic triad
  • Menstrual dysfunction (2nd Amenorrhea), Osteoporosis, Disordered eating
  • Poor outcomes with irreversible osteoporosis amongst other
    complications
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22
Q

Female Athlete Triad

A
  1. Menstrual dysfunction
    * Dx no longer requires complete absence of periods, low estrogen levels
  2. Disordered eating
    * low or decreased energy intake, with or without eating disorder
  3. Decreased bone mineral density
    * Decreased bone health ↔ osteoporosis
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23
Q

Comprehensive history and what to watch for if suspecting female athlete triad:

A
  • Iron deficiency anemia, menstrual history
  • Bone loss - Z-score as opposed to a T-Score,
  • Weight loss, Less than 90% ideal body weight, Low BMI under 18.5
  • Stress fractures
  • Education, counseling, increase Ca and Vit D, body weight normalization
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24
Q

Ankle Fractures etiology

A

Traumatic MOI

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25
Q

Ankle Fractures
Types

A
  • Distal fibular fractures are common
  • Lateral malleolus, medial malleolus, posterior malleolus (tibia), talar
    dome
  • Bimalleolar ankle fracture – lateral & medial malleoli
  • Trimalleolar ankle fracture – lateral, medial, & posterior malleoli
  • Maisonneuve (may-zone-newv) fracture – a fracture of the medial
    malleolus that extends through the syndesmotic membrane into the
    proximal fibula
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26
Q

Distal Fibular Fracture breakdown

A

Weber A, B, C

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27
Q

Ankle Fractures
Clinical Presentation

A
  • Acute pain after trauma
  • Swelling
  • Deformity
  • Inability to bear weight
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28
Q

Ankle Fractures
Diagnosis

A
  • Examine the entire tibia-fibula,
    ankle, & knee
  • Tenderness along the distal fibula
    and/or distal tibia
  • Edema
  • Ecchymosis
  • Ligamentous laxity
  • Distal neurovascular exam
  • Check for open wounds
  • X-ray: Obtain x-rays of the ankle
  • AP, lateral, mortise views
  • Consider CT for complex fx: Esp. if a talar fracture is suspected
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29
Q

Ankle Fractures management

A
  • Most ankle fractures require operative
    repair
  • Treat fractures and/or ligamentous injuries to
    both the lateral & medial ankle as an
    unstable, bimalleolar fracture
  • Generally, isolated, nondisplaced malleolar
    fractures with intact ligaments can be
    immobilized with a short-leg walking cast or
    orthopedic boot
  • All other fracture patterns require a short-leg
    posterior splint with stirrups
  • Pain medication
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30
Q

Ankle Fractures
Complications

A
  • Mal- & non-union
  • Compartment syndrome
  • Post-traumatic ankle arthritis
  • Syndesmotic instability
  • Wound sloughing & deep soft tissue infection
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31
Q

Tarsometatarsal Fracture- Dislocation (Lisfranc) etiology

A
  • Traumatic disruption of the Lisfranc ligamentous complex (stabilizes the
    juncture of the metatarsals & midfoot)
  • Classically, the injury pattern involves a fracture at the second
    metatarsal base or second cuneiform, along with resultant metatarsal subluxation/dislocation
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32
Q

Midfoot Fracture-Dislocation (Lisfranc)
Clinical Presentation

A
  • Patients often complain of pain & swelling of
    the foot
  • Often out of proportion with x-ray
  • Plantar ecchymosis
  • Midfoot instability
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33
Q

Midfoot Fracture-Dislocation (Lisfranc) diagnosis

A
  • Tenderness, deformity, swelling, &
    overlying lacerations
  • Check distal neurovascular
  • Compartment syndrome
  • Obtain foot x-rays (AP, lateral oblique)
  • Widening of the space between the
    first & second metatarsal base > 2mm suggests a Lisfranc injury
  • Medial border of the 2nd (middle) cuneiform & 2nd metatarsal should be in linear alignment
  • Misalignment suggests Lisfranc
  • Weight bearing X-ray may help
  • Get the noncontrast CT
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34
Q

Midfoot Fracture-Dislocation (Lisfranc)
Management

A
  • Non-displaced
  • 6-8 weeks Non-weight bearing & cast
    immobilization
  • Then rigid arch support x 3 months
  • Displaced
  • ORIF
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35
Q

Midfoot Fracture-Dislocation (Lisfranc)
Complications

A
  • Mal- & nonunion
  • Compartment syndrome
  • Post-traumatic arthritis
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36
Q

Referral Considerations for Midfoot Fracture-Dislocation (Lisfranc)

A
  • Immediate referral for compartment syndrome or open fracture
  • Typically referred to Ortho, could consider a podiatrist
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37
Q

Calcaneal & Talar Fractures epidemiology & etiology

A
  • Calcaneus → Most commonly fx tarsal bone
  • ~2% of all fractures in adults
  • Talus fractures = rare
    Etiology
  • Traumatic
38
Q

Calcaneal & Talar Fractures
Clinical Presentation

A
  • Acute localized pain following trauma
  • Unable to weight bear on affected foot
39
Q

Calcaneal & Talar Fractures
Diagnosis

A
  • Point tenderness
  • Localized swelling
  • Check distal neurovascular
  • X-ray
  • Hindfoot
  • AP, Lateral, Harris views
  • Ankle views
  • CT should be strongly considered
40
Q

Calcaneal & Talar Fractures management

A
  • All intraarticular fractures will require surgery
  • Extraarticular, non-displaced fractures may be managed conservatively with
    splinting, then casting x 6-8 weeks
41
Q

Calcaneal & Talar Fractures
Complications

A
  • Talar fractures often disrupt blood supply leading to osteonecrosis
  • Chronic pain
  • Arthritis
  • Complex Regional Pain syndrome
  • Plantar compartment syndrome
42
Q

5th Metatarsal Fractures AKA

A

“Jones Fracture”

43
Q

Metatarsal Fracture etiology

A
  • Trauma
  • Direct blow
  • Torsion
  • Stress/Overuse
44
Q

Metatarsal Fracture
Clinical Presentation

A
  • Patients complain of pain & swelling at the site
  • Traumatic & acute
  • Insidious in onset with stress fractures
45
Q

Metatarsal Fracture
Diagnosis

A
  • Tenderness & local deformity
  • Axial loading (flick/bump test) the
    affected toe should only produce
    pain in fractures & not with a soft
    tissue injury
  • Perform a distal neurovascular
    exam
  • Note overlying lacerations
  • X-rays (AP, lateral, oblique)
  • May consider obtaining ankle x-rays
    to assess for concurrent, more
    proximal injuries
  • Possibly CT
46
Q

Metatarsal Fracture management

A
  • Generally, closed metatarsal fractures without concurrent dislocations can be
    managed on an outpatient basis after immobilization
  • Short leg cast, rocker shoe
  • Metatarsal head & neck fractures
  • Generally nonoperative, unless multiple metatarsal fractures involved
  • 5
    th Metatarsal Fractures (Jones Fracture)
  • Zone 2 (possibly) & 3 may require ORIF
47
Q

Metatarsal Fracture
Complications

A
  • Non/mal-union
  • Recurrence
48
Q

Metatarsal Fracture referral considerations

A
  • Ortho or podiatry consult:
  • Zone 2-3 Jones fracture
  • Open fractures, multiple fractures
  • Significant displacement or angulation (>10°)
49
Q

Phalange Fracture (Toe) epidemiology & etiology

A

Epidemiology
* Phalangeal fractures are common
* Fractures toes 2-5 are 4 times as common as fractures of the first toe
* First toe fractures are often displaced
* Fractures of the lesser phalanges are often comminuted & nondisplaced
Etiology
* Trauma
* Crush, axial loading
* Stress/overuse

50
Q

Phalange Fracture (Toe)
Clinical Presentation

A
  • Acute pain & swelling after trauma
  • Occasionally subungual hematoma can
    occur with crush injuries
51
Q

Phalange Fracture (Toe)
Diagnosis

A
  • Clinical exam
  • X-ray
  • AP, Lateral, Oblique
52
Q

Phalange Fracture (Toe)
Management

A
  • Most phalanx fractures are nondisplaced
  • Manage nonoperatively by splinting the injured
    toe to an adjacent toe (“buddy taping”),
    consider a surgical shoe
  • 3-6 weeks
  • First toe, bears a lot of weight & balance
  • Nondisplaced fracture: buddy tape splint &
    rigid walking cast/surgical shoe for 3-6 weeks
  • Displaced fracture: may attempt closed
    reduction, but persistent displacement requires
    surgery
53
Q

Phalange Fracture (Toe) complications

A
  • Pain
  • Malunion or nonunion
  • Arthritis
  • Nail bed deformity
  • Interdigital corn from a persistently displaced toe fracture rubbing against an
    adjacent toe
54
Q

Ankle Sprains
Etiology

A

Etiology
* Trauma
* Torsion
* Types:
* Inversion (MOST COMMON): Involving lateral ligaments
* Eversion: Involving the medial ligaments
* Syndesmotic (aka ”High Ankle sprains”): Involving the interosseous
ligaments & membrane between the tibia & fibula

55
Q

How many ankle sprains occur daily in the US?

A

25,000

56
Q

Ankle Sprains
Clinical Presentation

A
  • Acute pain & swelling following
    torsion trauma
  • Varying levels of difficulty in
    weight bearing
57
Q

Ankle Sprains
Diagnosis

A
  • Identify tender structures involved via palpation
  • Note swelling & location
  • Special Stress Tests
  • Anterior Drawer
  • Inversion Test
  • Kleiger Test
  • Eversion Test
58
Q

Ankle sprain grading

A
  • grade I, no macroscopic ligament tear
  • grade II, partial ligament tear
  • grade III, complete ligament tear
59
Q

Ankle Sprains
Management

A
  • RICES
  • Crushed Ice (1/2 hr q 2 hrs)
  • Compression wrap (use a horseshoe pad around malleolus)
  • Ankle bracing
  • Cam walking boot for high ankle sprains
  • Physical rehabilitation
  • NSAIDS
60
Q

Ankle Sprains
Complications

A
  • pain
  • decreased range of motion
  • chronic ankle instability
  • recurrent sprain
61
Q

“High Ankle Sprain”

A

● Syndesmosis injury
● External Rotation
● Loss of integrity between tibia and
fibula
● Possible fracture
● Delayed Dx associated with
destabilized ankle joint and arthritis
● Cotton test, Kleiger test, Hopkin
test, Anterior drawer
● MRI
● Neg instability → Cam Boot
● Instability → Syndesmostic Screw

62
Q

Achilles Tendonitis etiology

A
  • Overuse injury
  • Tendinopathy occurs due to failed inflammatory/healing:
  • haphazard proliferation of tenocytes
  • disruption of collagen fibers
  • increase in non-collagen matrix
  • degeneration of Achilles tendon displaying increased vascularization
63
Q

Achilles Tendonitis Clinical Presentation

A
  • Intermittent pain related to activity
  • Stiffness after prolonged rest
  • Swelling at the tendon insertion
  • ↓ strength & endurance of the triceps surae (gastrocnemius/soleus)
64
Q

Achilles Tendonitis diagnosis

A
  • Localized tenderness to palpation
  • Painful & ↓ strength with resisted range of motion
    Imaging-not usually necessary
  • Ultrasound
  • MRI
65
Q

Achilles Tendonitis management

A
  • Activity modification
  • NSAIDS
  • Physical rehabilitation
  • Surgery for resistant cases
66
Q

Achilles Tendonitis
Complications

A
  • Rupture
67
Q

Achilles Tendon Tear etiology

A
  • Unknown exact cause → likely related to underlying tendinopathy
  • Rapid, forceful contraction of triceps surae
  • Particularly eccentric loading
68
Q

Achilles Tendon Tear
Clinical Presentation

A
  • “Someone shot me” “Who kicked me (in the back of the leg)”
  • Sudden, severe pain localized to the Achilles tendon
69
Q

Achilles Tendon Tear diagnosis

A

(2 or more of the following)
* (+) Thompson test (calf squeeze test)
* Most reliable within 48 hours of injury
* ↓ plantar flexion reduced ROM
* Palpable tendon gap/divot
Imaging
* MRI
* Ultrasound

70
Q

Achilles Tendon Tear

A
  • Nonsurgical
  • diabetes
  • neuropathy
  • immunocompromised
  • age ≥ 65 years
  • tobacco use
  • sedentary lifestyle
  • obesity (BMI > 30)
  • peripheral vascular disease
  • dermatologic disorders
  • Gradual casting/bracing in plantar
    flexion until foot reaches neutral
    position.
  • Physical rehabilitation
  • Surgery for complete/severe
    ruptures
71
Q

Achilles Tendon Tear
Complications

A
  • DVT
  • Rerupture
  • Pain
  • Infection
  • ↓ ROM & Strength
72
Q

Hallux Valgus (Bunion) Epidemiology & etiology

A

Epidemiology
* Adult females & the elderly
* Family predisposition
Etiology
* abduction from midline
* metatarsal head adducted toward body midline
* Multifactorial

73
Q

Hallux Valgus (Bunion)
Clinical Presentation

A
  • Localized pain & swelling over the MTPJ
  • Aggravated by footwear
  • May occur with a concurrent hypertrophic
    bursae
74
Q

Hallux Valgus (Bunion)
Diagnosis

A
  • Clinical findings
  • X-ray
  • Normal Hallux
    Valgus angle
  • <15°
75
Q

Hallux Valgus (Bunion)
Management

A
  • Shoe wear modification can help alleviate pain
  • Initial treatment of choice for the elderly & patients with neurologic or
    vascular compromise
  • Orthoses
  • Do not prevent progression of hallux valgus
  • Custom-made foot orthoses may be effective for foot pain
  • Pain medication
  • Surgery
  • Most effective for correcting deformity
  • More helpful in pain relief than orthoses
76
Q

Hallux Valgus (Bunion) complications

A
  • Ulcerations
  • Conservative care does not reverse deformity
77
Q

Ingrown Toenail etiology

A
  • Foreign body reaction
  • Nail bed is compressed from the side, the edge/corner of the nail penetrates
    the cuticle.
  • Inflammatory reaction 2° to presence of the keratinaceous nail material in
    the flesh of the toe.
78
Q

Ingrown Toenail
Clinical Presentation

A
  • Localized pain & swelling
  • Typically unilateral
  • Stage I→ localized induration, swelling,
    pain
  • Stage II→ abscess
  • Stage III→ granulation tissue forms,
    inhibiting drainage
79
Q

Ingrown Toenail
Diagnosis

A
  • Clinical diagnosis
  • Stage II & III
  • X-ray
  • R/O osteomyelitis & subungual
    exostosis (cartilaginous outgrowth
    on a bone eg. bone spur)
80
Q

Ingrown Toenail
Management

A
  • Stage I: Warm soaks, proper nail trimming, wide toe box shoes
  • Stage II: Warm soaks, cephalosporin abx, digital block & partial nail removal
  • Stage III: Digital block & complete nail removal
81
Q

Ingrown Toenail
Complications

A
  • Recurrence
  • Deformity
  • Infection
  • Pain
82
Q

Interdigital (Morton) Neuroma etiology

A
  • Repeated trauma of metatarsal heads
  • overly tight shoe or high heels? → unproven
  • Other causes
  • Flattening of the medial arch
  • Ischemic changes within interdigital nerve
  • Bunion formation
  • Perineural fibromas form (esp. 3rd branch of plantar n.)
83
Q

Interdigital (Morton) Neuroma
Clinical Presentation

A
  • Pain (burning) & numbness
  • 2nd – 3rd webspace
  • Radiates to toes
84
Q

Interdigital (Morton) Neuroma diagnosis

A
  • Palpation
  • Esp. 2nd – 3rd webspace
  • “Pencil Eraser” test
  • Squeeze test
  • Lateral compression to metatarsal heads → (+) pain
  • US & MRI
  • ↑ sensitivity for Morton neuroma
85
Q

Interdigital (Morton) Neuroma
Management

A
  • Footwear modification
  • Low heel
  • Wide toe box
  • Well cushioned (metatarsal pad)
  • Poor evidence for steroid injection
  • Surgery
86
Q

Plantar Fasciitis etiology

A
  • Repetitive microtrauma from prolonged
    walking or running + incomplete healing
  • Degenerative tendonosis
87
Q

Plantar Fasciitis
Clinical Presentation

A
  • Insidious onset of plantar pain
  • Focal pain following prolonged rest
  • “First step in the morning”
88
Q

Plantar Fasciitis
Diagnosis

A
  • Tender to palpation
  • Classically 1-2 cm from the
    calcaneal tuberosity
  • X-ray (Not necessary for dx)
  • ~50% of cases develop a heal
    spur (though the spur is not the
    cause of the pain)
89
Q

Plantar Fasciitis
Management

A
  • 95% of cases are successfully managed conservatively
  • May take 6-12 months to fully resolve
  • Orthosis
  • Night splint
  • NSAIDS
  • Physical rehabilitation
  • Corticosteroid injection
  • Surgery
90
Q

Plantar Fasciitis
Complications

A
  • Chronic pain
  • Altered gait → other kinetic chain problems (ankle, knee, hip, back)

MSK Exam 3 (6 decks)

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