Foot-Ankle-Tibia Flashcards
Tibial Shaft Fracture
- Most common Long bone fracture
- Low energy mech: torsional, fibula fractures at a different level
- High energy: trauma, direct force, wedge shape, fibula fractures at same level
- associated with soft-tissue injury, compartment syndrome bone loss
- deformity, pain, inability to bear weight
Radiographs: tibial fracture
AP and lateral of entire bone and knee/ankle
CT of the joint if intra-articular extension is noted
Non-Operative Treatment of tibial fracture
For low energy; needs appropriate alignment
<5* angulation,
<1 cm shortening,
<10* rotational malalignment,
more than 50% cortical apposition
Long leg cast for 6-8 weeks
External Fixation of Tibial Fracture
Damage control ortho
open fractures
Intramedullary nailing (T)
unacceptable alignment
soft tissue injury
segmental or comminuted fractures
multi-trauma
Open Reduction Internal Ficxation (ORIF) (Tibia)
higher risk of non-union and infection
Acute compartment syndrome (CS)
Osseofascial pressures rise to reduce perfusion leading to muscle necrosis (surgical emergency
2-15% of tibial fractures
Muscle perfusion pressure (^P) is the diff b/n diastolic press and compartment press (<30 mmHg is considered critical)
Maintain high index of suspicion and look for signs
Emergent fasciotomy
Tibial Plafond (pilon) Fractures
intrarticular disc distal tibial fracture
high energy axial loading mechanism (MVC, fall)
Articular impaction, metaphyseal communication, extensive soft tissue damage
presents with pain, inability to bear weight, deformity
inspect soft tissue for injury, signs of CS
Non-Op management of Pilon Fracture
Stable fractures can receive a long leg cast, significant risk of malreduction, skin problems
Temporizing Spanning external fixation of Pilon Fractures
allows skin access
obtain CT of joint post op
leave in place 10-14 days
ORIF of Pilon Fracture
Definitive fixation with peri-articular plates and screws
infection (5-15%), wound slough (10%)
Ankle Fracture
15% of all ankle injury
Usually inversion
radiographs not always indicated
(ottawa ankle rules, CT/MRI not indicated)
Sonographic Ottowa Foot and Ankle Rules (SOFAR)
increases specificity to 100% versus Xray
Radiographs of ankle fracture
AP, Lat, Obl
full length of Tib/Fib inlcuded
External rotation stress if syndesmotic injury expected
Syndesmotic Injury and Evaluation
Ankle Joint (sprain) medial clear space
Tib/Fib clear space is normally <5mm
Non-op ankle fracture treatment
for isolated, non-displaced fracture
lateral malleolar fracture <3mm displaced
non-surgical candidate
ORIF of ankle
displaced fracture
bimalleolar fracture
open fracture
prolonged recovery- up to 2 yrs
Time to driving needs to be 6 weeks FOLLOWING weight bearing
Talar neck fracture
High energy mech with forced dorsiflexion and axial load
Vascular supply- post tib artery, ant tib artery, peroneal artery
fractures result in risk of avascular necrosis
Talar neck radiography
Ap/Lat/ Canale view
CT for displacement
Hawkins classification
Hawkins Classification
insert picuter
Treatment of Talar neck Fracture
Emergent reduction in ER
Non-op for non-displaced (short cast for 8-12 weeks (non weight bearing for 6 wks)
ORIF for any displaced fractures
Hawkins Sign
signals avascular necrosis
subchondral lucency at 6 weeks is indication of intact vasculature
Calcaneal Fracture
High energy axial load- MVC or high fall
high rate of complications
Intraarticular fractures
Radiography of Calcaneal fracture
Bohler angle, 20-40*
Treatment of calcaneal Fracture
ORIF for displaced
wait 10-14 for swelling resolution
Metatarsal Fracture
Direct crush injury or indirect twisting injury
stress fractures (look for a metabolic disorder, 2nd metatarsal base stress fracture in ballet dancers with amenorrhea)
presents with pain, inability to bear weight
Treatment of Metatarsal Fracture
Stiff soled shoe and weight bearing as tolerated
Surgery- displaced 1st fracture and central metas with severe displacement
Jones Fracture
5th metatarsal
common in athletes, laborers, military recruits
Mech: inversion injury w predromal stress injury
classified by vascular supply
Jones Fracture Classification
add
Treatment of Jones Fracture
add
Complications of Jones Fracture
non-union in zone 2- 30%
refracture in Zone 2- 33%
Chronic exertional compartment syndrome (CECS)
reversible ischemia to muscles in a fascial compartment
Occurs in runner (mainly anterior compartment)
Presents with burning pain in legs following activity that resolves with rest
Evaluation of CECS
imaging is usually normal, but used to rule out others
compartment pressure testing with exercise
What pressures are measured in CECS
- pre-exercise (resting)
- Immediate (post exercise)
- 5 min post exercise
Diagnostic criteria for CECS
Resting >15 mmHg
Immediate >30mmHg
5 min post >20 mmHg
Treatment of CECS
rest, NSAIDS
compartment release if not responsive to initial management after 3 months
Tibial stress syndrome
Overuse injury characterized by pain at distal medial aspect of tibia with activity
Diagnosis in 60% of leg pain syndromes
(other causes: stress fractre, CECS, nerve entrapment, lumbar rediculopathy)
Risk factors: runners with old/less absorbing shoes, training errors, hill training, over pronation)
Treatment of tibial stress syndrome
reduce activity 50%
change shoes
PT
Tibial stress fractures
overuse, common in athletes/military recruits
propagation of microfractures form repetitive loading
Tibial stress syndrome>stress response/reaction>fracture
Evaluation of Tibial Stress Fractures
radiography, dreaded black line, MRI- possible bone marrow edema
Treatment of Tibial Stress Fracture
Activity modification, avoid NSAIDS, consider BM stim
intramedullary tibial nail if fracture violates anterior cortex
Syndesmosis
AITFL
PITFL
TTFL
IOM
What is the weakest ligament of the ankle laterally?
Anterior talofibular ligament
F: restraint to inversion in plantarflexion
injured 85% of the time in lateral ankle sprains
What is the strongest lateral ligament?
PTFL, rarely injured
Calcaneal fibular ligament
primary restraint to inversion in neutral position
injured in 20-40% of lateral sprains
Accessory Ossicles
secondary ossification centers that remain separated from the normal bone
Sesamoids
bones incorporated into tendons and move with normal tendon motion
Most common Sesamoids
Hallux 100% Os Peroneum (talonvaicular) 9-20% Os Trigonum (behind heel) 10-25%
Lateral Ankle Sprains
Injury to lat ankle ligament with plantarflexion and inversion
(AL capsule>ATFL>CFL)
Risk Factors:
patient related- limited DF, decreased proprioception, balance deficiency
environment- indoor court sports, previous injury
Presentation:
pain, swelling, echymosis, +ant drawer, radiograph?
Classification of Lat ankle Sprain
1: none to ATFL stretch, minimal soft tissue
2: ATFL stretch to tear, moderate soft tissue
3: ATFL+/- CFL tear, severe soft tissue
Treatment of Lat ankle Sprain
1/2: short immobilization, early mobilization (PT)
3: 10 days casting followed by boot, then mobilization; early surgery not indicated
Complications:
- missed fractures
- osteochondral lesions
- injury to tendon
- injury to syndesmosis
- tarsal coalition
- impingement syndrome
Medial Ankle Sprain
Injury to medial ligaments with EVERSION, rare, radiography shows avulsion injury to medial malleolous, MRI, Mostly non-op treatment
If late surgery, perform stress radiography after fibular fixation
Syndesmotic Injury
Internal rotation on tibia with a fixed foot
Cotton test, squeeze test, ER stress test
Radiography may show widening of synd: >6mm TF clear space on xray, MRI if not seen
Treatment of Syndesmotic Injury
RICE preferred
RTP is 2x low ankle sprain (10-52 days)
Surgical fixation for obvious diastasis or high level athletes (screw or suture and buttons)
Lisfranc Injury
Tarsometatarsal joint injury from sprain to dislocation
Mechanism: axial loading or twisting on a plantarflexed foot or direct axial loading
often missed, high level of suspicion
What imaging should be performed in suspicion of Lisfranc?
WEIGHT BEARING AP, obl, and lat view of ankle
CT or MRI to confirm dx
Findings: widening, fleck sign
Treatment of Lisfranc
Reduction is key to long-term outcome
Nondisplaced: short leg non-weightbearing cast 6 weeks
Displaced: reduction and rigid internal fixation of 1-3 TMTs and temp fixation for TMT 4-5
Turf Toe
Hyperextension of plantar plate of 1 MTP
normal xray, MRI for soft tissue damage
Initial immobilization with early mobilization to prevent stiffness
May RTP with stiff sole shoe
Avoid injection
no surgery usually
Sesamoid disorders
Fracture, sesamoiditis, AVN, OA Bipartite sesamoid (97% tibial, 25% bilateral)
Radiography and MRI to confirm
Conservative treatment:
modified shoes with padding, NSAIDs, PT, injections, boot if necessary
Surgery=sesamoidectomy
Achilles Tendon Rupture
Sharp dorsiflexion force onto a tensioned tendon creating a rupture through a region of previous degeneration in the watershed area (4-6 cm from insertion)
Missed Dx in 24% of patients
Thompson test
Treatment controversy: operation: lower rerupture rate, higher complication rate
Plantar Fasciitis
Inflammation of plantar aponeurosis at its insertion at calcaneus
risks: obesity, decreased ankle dorsiflexion, endurance activities
Prestation: posteromedial hell pain that is worst with 1st step in morning
Exam: TTP at planter fascia insertion
Treatment: pain control, splint, stretching
Surgical release of plantar fascia if non responsive after nine months
Hallux Valgus
aka bunion
complex deformity of big toe, progressive
ADDUCTOR HALLICUS is deforming force
Treatment: shoe wear modification, surgical correction depending on severity
Normal angles of hallux
HVA <15*
IMA <9*
DMAA <10*
HVI <10*
