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*Surgery > Foot-Ankle-Tibia > Flashcards

Foot-Ankle-Tibia Flashcards

1
Q

Tibial Shaft Fracture

A
  • 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
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2
Q

Radiographs: tibial fracture

A

AP and lateral of entire bone and knee/ankle

CT of the joint if intra-articular extension is noted

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3
Q

Non-Operative Treatment of tibial fracture

A

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

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4
Q

External Fixation of Tibial Fracture

A

Damage control ortho

open fractures

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5
Q

Intramedullary nailing (T)

A

unacceptable alignment

soft tissue injury

segmental or comminuted fractures

multi-trauma

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6
Q

Open Reduction Internal Ficxation (ORIF) (Tibia)

A

higher risk of non-union and infection

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7
Q

Acute compartment syndrome (CS)

A

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

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8
Q

Tibial Plafond (pilon) Fractures

A

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

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9
Q

Non-Op management of Pilon Fracture

A

Stable fractures can receive a long leg cast, significant risk of malreduction, skin problems

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10
Q

Temporizing Spanning external fixation of Pilon Fractures

A

allows skin access

obtain CT of joint post op

leave in place 10-14 days

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11
Q

ORIF of Pilon Fracture

A

Definitive fixation with peri-articular plates and screws

infection (5-15%), wound slough (10%)

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12
Q

Ankle Fracture

A

15% of all ankle injury

Usually inversion

radiographs not always indicated
(ottawa ankle rules, CT/MRI not indicated)

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13
Q

Sonographic Ottowa Foot and Ankle Rules (SOFAR)

A

increases specificity to 100% versus Xray

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14
Q

Radiographs of ankle fracture

A

AP, Lat, Obl

full length of Tib/Fib inlcuded

External rotation stress if syndesmotic injury expected

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15
Q

Syndesmotic Injury and Evaluation

A

Ankle Joint (sprain) medial clear space

Tib/Fib clear space is normally <5mm

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16
Q

Non-op ankle fracture treatment

A

for isolated, non-displaced fracture

lateral malleolar fracture <3mm displaced

non-surgical candidate

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17
Q

ORIF of ankle

A

displaced fracture

bimalleolar fracture

open fracture

prolonged recovery- up to 2 yrs

Time to driving needs to be 6 weeks FOLLOWING weight bearing

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18
Q

Talar neck fracture

A

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

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19
Q

Talar neck radiography

A

Ap/Lat/ Canale view

CT for displacement

Hawkins classification

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20
Q

Hawkins Classification

A

insert picuter

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21
Q

Treatment of Talar neck Fracture

A

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

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22
Q

Hawkins Sign

A

signals avascular necrosis

subchondral lucency at 6 weeks is indication of intact vasculature

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23
Q

Calcaneal Fracture

A

High energy axial load- MVC or high fall

high rate of complications

Intraarticular fractures

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24
Q

Radiography of Calcaneal fracture

A

Bohler angle, 20-40*

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25
Q

Treatment of calcaneal Fracture

A

ORIF for displaced

wait 10-14 for swelling resolution

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26
Q

Metatarsal Fracture

A

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

27
Q

Treatment of Metatarsal Fracture

A

Stiff soled shoe and weight bearing as tolerated

Surgery- displaced 1st fracture and central metas with severe displacement

28
Q

Jones Fracture

A

5th metatarsal

common in athletes, laborers, military recruits

Mech: inversion injury w predromal stress injury

classified by vascular supply

29
Q

Jones Fracture Classification

A

add

30
Q

Treatment of Jones Fracture

A

add

31
Q

Complications of Jones Fracture

A

non-union in zone 2- 30%

refracture in Zone 2- 33%

32
Q

Chronic exertional compartment syndrome (CECS)

A

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

33
Q

Evaluation of CECS

A

imaging is usually normal, but used to rule out others

compartment pressure testing with exercise

34
Q

What pressures are measured in CECS

A
  • pre-exercise (resting)
  • Immediate (post exercise)
  • 5 min post exercise
35
Q

Diagnostic criteria for CECS

A

Resting >15 mmHg

Immediate >30mmHg

5 min post >20 mmHg

36
Q

Treatment of CECS

A

rest, NSAIDS

compartment release if not responsive to initial management after 3 months

37
Q

Tibial stress syndrome

A

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)

38
Q

Treatment of tibial stress syndrome

A

reduce activity 50%

change shoes

PT

39
Q

Tibial stress fractures

A

overuse, common in athletes/military recruits

propagation of microfractures form repetitive loading

Tibial stress syndrome>stress response/reaction>fracture

40
Q

Evaluation of Tibial Stress Fractures

A

radiography, dreaded black line, MRI- possible bone marrow edema

41
Q

Treatment of Tibial Stress Fracture

A

Activity modification, avoid NSAIDS, consider BM stim

intramedullary tibial nail if fracture violates anterior cortex

42
Q

Syndesmosis

A

AITFL
PITFL
TTFL
IOM

43
Q

What is the weakest ligament of the ankle laterally?

A

Anterior talofibular ligament

F: restraint to inversion in plantarflexion

injured 85% of the time in lateral ankle sprains

44
Q

What is the strongest lateral ligament?

A

PTFL, rarely injured

45
Q

Calcaneal fibular ligament

A

primary restraint to inversion in neutral position

injured in 20-40% of lateral sprains

46
Q

Accessory Ossicles

A

secondary ossification centers that remain separated from the normal bone

47
Q

Sesamoids

A

bones incorporated into tendons and move with normal tendon motion

48
Q

Most common Sesamoids

A 
Hallux 100%
Os Peroneum (talonvaicular) 9-20%
Os Trigonum (behind heel) 10-25%
49
Q

Lateral Ankle Sprains

A

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?

50
Q

Classification of Lat ankle Sprain

A

1: none to ATFL stretch, minimal soft tissue
2: ATFL stretch to tear, moderate soft tissue
3: ATFL+/- CFL tear, severe soft tissue

51
Q

Treatment of Lat ankle Sprain

A

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
52
Q

Medial Ankle Sprain

A

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

53
Q

Syndesmotic Injury

A

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

54
Q

Treatment of Syndesmotic Injury

A

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)

55
Q

Lisfranc Injury

A

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

56
Q

What imaging should be performed in suspicion of Lisfranc?

A

WEIGHT BEARING AP, obl, and lat view of ankle

CT or MRI to confirm dx

Findings: widening, fleck sign

57
Q

Treatment of Lisfranc

A

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

58
Q

Turf Toe

A

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

59
Q

Sesamoid disorders

A 
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

60
Q

Achilles Tendon Rupture

A

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

61
Q

Plantar Fasciitis

A

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

62
Q

Hallux Valgus

A

aka bunion
complex deformity of big toe, progressive
ADDUCTOR HALLICUS is deforming force

Treatment: shoe wear modification, surgical correction depending on severity

63
Q

Normal angles of hallux

A

HVA <15*
IMA <9*
DMAA <10*
HVI <10*

*Surgery (9 decks)

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