Lower Extremity Flashcards
Which metatarsal fracture is most common?
5th metatarsal
80% of metatarsal fractures are nondisplaced or minimally displaced, and conservative management is often preferred
Minimally displaced metatarsal shaft fractures have displacement of <_____ mm
<3 mm
Indications for ortho referral for metatarsal shaft fractures:
>____ mm displacement
>____ degrees dorsoplantar angulation
Intra-articular fracture
> 3 mm displacement
10 degrees dorsoplantar angulation
Intra-articular fracture
Management of NON-DISPLACED or minimally displaced metatarsal shaft fractures
Posterior splint and NWB x3-5 days –> X-ray for stability –> boot or short-leg walking cast x4-6 weeks with WBAT
Follow-up visits every 2-4 weeks with repeat X-ray at 4-6 weeks
Name the 3 types of PROXIMAL 5th metatarsal fracture (as opposed to metatarsal shaft fracture)
From most proximal to distal:
Zone 1: Tuberosity avulsion fracture
Zone 2: Jones fracture
Zone 3: Diaphyseal stress fracture
(1 & 2 are most common; 1 merits conservative management, 2 merits more aggressive management)
https://www.aafp.org/content/dam/brand/aafp/pubs/afp/issues/2016/0201/p183-f7.jpg
Ottawa Ankle & Foot Rules (validated in patients >= 6 y/o)
ANKLE X-ray indicated IF:
Pain in malleolar zone AND one of the following:
1) tenderness of POSTERIOR edge of medial malleolus (tibia)
2) tenderness of POSTERIOR edge of lateral malleolus (fibula)
3) Inability to bear weight x4 steps immediately AND in the ED
FOOT X-ray indicated IF:
Pain in midfoot zone AND one of the following:
1) tenderness of 5th metatarsal base
2) tenderness of navicular
3) Inability to bear weight x4 steps immediately AND in the ED
Why do we worry about Jones fractures?
They are located in a watershed area for blood supply and thus have a high rate of delayed union and nonunion
Management of NON-DISPLACED or minimally displaced tuberosity avulsion fracture (proximal 5th metatarsal)
Compressive dressing (e.g. Aircast, Ace wrap) with WBAT and ROM as tolerated –> short-leg walking boot x2 weeks (superior to cast)
After 2 weeks, generally can proceed with progressive ambulation and ROM as tolerated
Orthopedic referral indications for tuberosity avulsion fractures (proximal 5th metatarsal):
>____mm displacement on X-ray
>____mm step-off of cuboid
>____% involvement of metatarsal-cuboid joint surface
> 3mm displacement on X-ray
1-2mm step-off of cuboid
60% involvement of metatarsal-cuboid joint surface
Management of Jones fracture (proximal 5th metatarsal in Zone 2)
Non-operative:
Posterior splint & NWB x3-5 days –> short-leg cast & NWB x6-8 weeks. If X-ray shows callus and no point tenderness, can proceed to WBAT, PT/rehab. If not, continue with NWB for another 4 weeks and reassess. Surgery may be needed if not healing.
Operative management is superior for athletes and other highly active people
Orthopedic referral indications for Jones fracture:
1) >____mm displacement
2) _______
3) _______
1) >2mm displacement
2) Conservative management ineffective after 12 weeks
3) Athlete or highly active person
When examining the foot with concern for toe fracture, it is important to assess for nail bed injury and neurovascular status
When examining the foot with concern for toe fracture, it is important to assess for nail bed injury and neurovascular status
Management of great toe fractures
EITHER short-leg walking cast with toe plate that extends past great toe OR short-leg walking boot, WBAT. For 2-3 weeks. If no significant symptoms at that time, can proceed to buddy taping and use of rigid-sole shoe x3-4 weeks. More frequent follow-up required if intra-articular involvement or if reduction was required
Healing time is typically 4-6 weeks, with return to work/sport taking 6-8 weeks or longer
Great toe fractures require more intensive management than the lesser toes given its increased role in weight bearing and balance
Management of lesser toe fractures
Buddy taping and use of rigid-sole shoe, WBAT
Total healing time is about 4-6 weeks
Indications for ortho referral for toe fractures
Dislocation
Displaced intra-articular fractures
>10-20 degrees angulation (20 degrees in dorsoplantar plane or rotational deformity, 10 degree in mediolateral plane)
Average age of patients with hip fractures
80 years old
Mortality rate of hip fractures at 1 year
30%
Operative management of hip fractures should occur within _____ hours
24 hours (ideally)
48 hours (maximum)
Unless delay is required to stabilize comorbidities
Most common locations of hip fractures (2)
Femoral neck fracture (45-53%), also called intracapsular
Intertrochanteric (38-50%), which are between the greater and lesser trochanters
Image:
https://www.aafp.org/content/dam/brand/aafp/pubs/afp/issues/2022/1200/p675-f1.jpg
Common medications that decrease BMD (and thus increase risk for hip fractures)
Corticosteroids
PPIs
Loop diuretics
SSRIs
In which type of fracture does operative management improve mortality?
Hip fractures (nonoperative treatment is associated with 4x mortality rate compared to operative treatment)
Cefazolin is indicated ____ hours before hip fracture surgery and _____ hours afterwards
1-2 hours before
24 hours after
Presentation of femoral neck stress fractures
Insidious onset of anterior groin/buttock pain that is worse at night and with weight-bearing activities
Examination reveals pain with FADIR and log-roll test
How to diagnose femoral stress fractures
X-ray
If negative and continued suspicion, need MRI (X-ray is not sensitive enough to rule out)
