Foot/Ankle Flashcards
Most commonly fractured long bone
Tibia
Tibial Shaft Fracture etiology
Trauma
Tibial Shaft Fracture
Clinical Presentation
- Leg pain
- Worse with movement
- Swelling
- Open fractures are common
Tibial Shaft Fracture
Diagnosis
- 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
Peroneal n. sensory exam includes:
- sensation to dorsal first
webspace of foot - lateral dorsal foot
Peroneal n. motor exam includes:
- ankle dorsiflexion
- eversion
Tibial Shaft Fracture diagnosis
- Obtain x-rays of the ankle
- AP, lateral, mortise views
- Obtain x-rays of the tibia-fibula &
knee - AP, lateral views
- Consider noncontrast CT
Tibial Shaft Fracture
Management
- 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
indications for hospital admission & operative repair of a tibial shaft fracture
Open fracture, neurovascular injury, & compartment syndrome
Tibial Shaft Fracture
Complications
- Chronic pain & deformity
- Compartment syndrome
- Mal-union & nonunion
- Osteomyelitis
Fibular Shaft Fracture epidemiology & etiology
- 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
Fibular Shaft Fracture
Clinical Presentation
- Patients often complain of lateral leg pain,
exacerbated with walking - Fibula only bears ~17% weight
Fibular Shaft Fracture
PE & Diagnosis
- 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
Fibular Shaft Fracture
Management
- 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
Fibular Shaft Fracture
Complications
- Compartment syndrome
- Mal- & non-union
- Peroneal nerve injury
Tibia & Fibula Stress Fractures etiology
- Overtraining
- Especially sudden ↑ in training intensity
- Incorrect biomechanics 2° training, anatomy, equipment
- Tissue fatigue
- Hormone imbalance
- Poor nutrition
- Vitamin D deficiency
- Osteoporosis
Tibia & Fibula Stress Fractures
Clinical Presentation
- Patient complains of ↑ pain with exercise
- Pain becomes progressive & provoked with even lighter exercise
- Focal pain
Tibia & Fibula Stress Fractures
Diagnosis
- X-ray
- AP & Lateral
- May not be visible for 3
weeks - Bone Scintigraphy
- Will show ↑ uptake at the fx
Tibia & Fibula Stress Fractures management
- REST from the STRESS
- Low impact exercise can be substituted
to maintain cardiovascular conditioning - Recumbent bicycling, pool running
Tibia & Fibula Stress Fractures complications
- Adverse effects of NSAIDS
- Recurrence
Referral Considerations for Tibia & Fibula Stress Fractures
- 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
Female Athlete Triad
- Menstrual dysfunction
* Dx no longer requires complete absence of periods, low estrogen levels - Disordered eating
* low or decreased energy intake, with or without eating disorder - Decreased bone mineral density
* Decreased bone health ↔ osteoporosis
Comprehensive history and what to watch for if suspecting female athlete triad:
- 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
Ankle Fractures etiology
Traumatic MOI
Ankle Fractures
Types
- 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
Distal Fibular Fracture breakdown
Weber A, B, C
Ankle Fractures
Clinical Presentation
- Acute pain after trauma
- Swelling
- Deformity
- Inability to bear weight
Ankle Fractures
Diagnosis
- 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
Ankle Fractures management
- 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
Ankle Fractures
Complications
- Mal- & non-union
- Compartment syndrome
- Post-traumatic ankle arthritis
- Syndesmotic instability
- Wound sloughing & deep soft tissue infection
Tarsometatarsal Fracture- Dislocation (Lisfranc) etiology
- 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
Midfoot Fracture-Dislocation (Lisfranc)
Clinical Presentation
- Patients often complain of pain & swelling of
the foot - Often out of proportion with x-ray
- Plantar ecchymosis
- Midfoot instability
Midfoot Fracture-Dislocation (Lisfranc) diagnosis
- 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
Midfoot Fracture-Dislocation (Lisfranc)
Management
- Non-displaced
- 6-8 weeks Non-weight bearing & cast
immobilization - Then rigid arch support x 3 months
- Displaced
- ORIF
Midfoot Fracture-Dislocation (Lisfranc)
Complications
- Mal- & nonunion
- Compartment syndrome
- Post-traumatic arthritis
Referral Considerations for Midfoot Fracture-Dislocation (Lisfranc)
- Immediate referral for compartment syndrome or open fracture
- Typically referred to Ortho, could consider a podiatrist
Calcaneal & Talar Fractures epidemiology & etiology
- Calcaneus → Most commonly fx tarsal bone
- ~2% of all fractures in adults
- Talus fractures = rare
Etiology - Traumatic
Calcaneal & Talar Fractures
Clinical Presentation
- Acute localized pain following trauma
- Unable to weight bear on affected foot
Calcaneal & Talar Fractures
Diagnosis
- Point tenderness
- Localized swelling
- Check distal neurovascular
- X-ray
- Hindfoot
- AP, Lateral, Harris views
- Ankle views
- CT should be strongly considered
Calcaneal & Talar Fractures management
- All intraarticular fractures will require surgery
- Extraarticular, non-displaced fractures may be managed conservatively with
splinting, then casting x 6-8 weeks
Calcaneal & Talar Fractures
Complications
- Talar fractures often disrupt blood supply leading to osteonecrosis
- Chronic pain
- Arthritis
- Complex Regional Pain syndrome
- Plantar compartment syndrome
5th Metatarsal Fractures AKA
“Jones Fracture”
Metatarsal Fracture etiology
- Trauma
- Direct blow
- Torsion
- Stress/Overuse
Metatarsal Fracture
Clinical Presentation
- Patients complain of pain & swelling at the site
- Traumatic & acute
- Insidious in onset with stress fractures
Metatarsal Fracture
Diagnosis
- 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
Metatarsal Fracture management
- 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
Metatarsal Fracture
Complications
- Non/mal-union
- Recurrence
Metatarsal Fracture referral considerations
- Ortho or podiatry consult:
- Zone 2-3 Jones fracture
- Open fractures, multiple fractures
- Significant displacement or angulation (>10°)
Phalange Fracture (Toe) epidemiology & etiology
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
Phalange Fracture (Toe)
Clinical Presentation
- Acute pain & swelling after trauma
- Occasionally subungual hematoma can
occur with crush injuries
Phalange Fracture (Toe)
Diagnosis
- Clinical exam
- X-ray
- AP, Lateral, Oblique
Phalange Fracture (Toe)
Management
- 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
Phalange Fracture (Toe) complications
- Pain
- Malunion or nonunion
- Arthritis
- Nail bed deformity
- Interdigital corn from a persistently displaced toe fracture rubbing against an
adjacent toe
Ankle Sprains
Etiology
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
How many ankle sprains occur daily in the US?
25,000
Ankle Sprains
Clinical Presentation
- Acute pain & swelling following
torsion trauma - Varying levels of difficulty in
weight bearing
Ankle Sprains
Diagnosis
- Identify tender structures involved via palpation
- Note swelling & location
- Special Stress Tests
- Anterior Drawer
- Inversion Test
- Kleiger Test
- Eversion Test
Ankle sprain grading
- grade I, no macroscopic ligament tear
- grade II, partial ligament tear
- grade III, complete ligament tear
Ankle Sprains
Management
- 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
Ankle Sprains
Complications
- pain
- decreased range of motion
- chronic ankle instability
- recurrent sprain
“High Ankle Sprain”
● 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
Achilles Tendonitis etiology
- 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
Achilles Tendonitis Clinical Presentation
- Intermittent pain related to activity
- Stiffness after prolonged rest
- Swelling at the tendon insertion
- ↓ strength & endurance of the triceps surae (gastrocnemius/soleus)
Achilles Tendonitis diagnosis
- Localized tenderness to palpation
- Painful & ↓ strength with resisted range of motion
Imaging-not usually necessary - Ultrasound
- MRI
Achilles Tendonitis management
- Activity modification
- NSAIDS
- Physical rehabilitation
- Surgery for resistant cases
Achilles Tendonitis
Complications
- Rupture
Achilles Tendon Tear etiology
- Unknown exact cause → likely related to underlying tendinopathy
- Rapid, forceful contraction of triceps surae
- Particularly eccentric loading
Achilles Tendon Tear
Clinical Presentation
- “Someone shot me” “Who kicked me (in the back of the leg)”
- Sudden, severe pain localized to the Achilles tendon
Achilles Tendon Tear diagnosis
(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
Achilles Tendon Tear
- 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
Achilles Tendon Tear
Complications
- DVT
- Rerupture
- Pain
- Infection
- ↓ ROM & Strength
Hallux Valgus (Bunion) Epidemiology & etiology
Epidemiology
* Adult females & the elderly
* Family predisposition
Etiology
* abduction from midline
* metatarsal head adducted toward body midline
* Multifactorial
Hallux Valgus (Bunion)
Clinical Presentation
- Localized pain & swelling over the MTPJ
- Aggravated by footwear
- May occur with a concurrent hypertrophic
bursae
Hallux Valgus (Bunion)
Diagnosis
- Clinical findings
- X-ray
- Normal Hallux
Valgus angle - <15°
Hallux Valgus (Bunion)
Management
- 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
Hallux Valgus (Bunion) complications
- Ulcerations
- Conservative care does not reverse deformity
Ingrown Toenail etiology
- 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.
Ingrown Toenail
Clinical Presentation
- Localized pain & swelling
- Typically unilateral
- Stage I→ localized induration, swelling,
pain - Stage II→ abscess
- Stage III→ granulation tissue forms,
inhibiting drainage
Ingrown Toenail
Diagnosis
- Clinical diagnosis
- Stage II & III
- X-ray
- R/O osteomyelitis & subungual
exostosis (cartilaginous outgrowth
on a bone eg. bone spur)
Ingrown Toenail
Management
- 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
Ingrown Toenail
Complications
- Recurrence
- Deformity
- Infection
- Pain
Interdigital (Morton) Neuroma etiology
- 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.)
Interdigital (Morton) Neuroma
Clinical Presentation
- Pain (burning) & numbness
- 2nd – 3rd webspace
- Radiates to toes
Interdigital (Morton) Neuroma diagnosis
- Palpation
- Esp. 2nd – 3rd webspace
- “Pencil Eraser” test
- Squeeze test
- Lateral compression to metatarsal heads → (+) pain
- US & MRI
- ↑ sensitivity for Morton neuroma
Interdigital (Morton) Neuroma
Management
- Footwear modification
- Low heel
- Wide toe box
- Well cushioned (metatarsal pad)
- Poor evidence for steroid injection
- Surgery
Plantar Fasciitis etiology
- Repetitive microtrauma from prolonged
walking or running + incomplete healing - Degenerative tendonosis
Plantar Fasciitis
Clinical Presentation
- Insidious onset of plantar pain
- Focal pain following prolonged rest
- “First step in the morning”
Plantar Fasciitis
Diagnosis
- 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)
Plantar Fasciitis
Management
- 95% of cases are successfully managed conservatively
- May take 6-12 months to fully resolve
- Orthosis
- Night splint
- NSAIDS
- Physical rehabilitation
- Corticosteroid injection
- Surgery
Plantar Fasciitis
Complications
- Chronic pain
- Altered gait → other kinetic chain problems (ankle, knee, hip, back)
