Lower Extremity Orthopedics lower leg and ankle disorders- Jaynstein- Exam 2

Question 1

Tibial Plateau fracture: describe this fracture

Answer 1

Fracture of the proximal tibia–> intra-articular fx

-Represents a high energy injury – often associated with other ST injuries

Question 2

Tibial Plateau fracture MOI:

Answer 2

• Valgus or varus twist with axial loading

- Direct trauma

Question 3

Tibial Plateau fracture Sxs:

Answer 3

Severe pain, swelling

Question 4

Tibial Plateau fracture dx:

Answer 4

• Xray – make sure you eval proximal and distal tibia

- Xrays often miss this fx, if high suspicion get a CT wo contrast

Question 5

Tibial Plateau fracture tx:

Answer 5

• Pain control
• Consult ortho on all
• -Non-op – no to min displacement–> Hinged brace, crutches

–Operative – displaced, comminuted, open–> ORIF (surgery)

Question 6

Tibial plateau fx complications

Answer 6

• Peroneal nerve injury – assess for and document foot drop!
• May need MRI to assess for ST injury – ACL and meniscal tears common
• Compartment syndrome

Question 7

Tibial Shaft fracture: -how common?

-MOI?

Answer 7

Common fracture

MOI: torsional injury, direct blow

Question 8

Tibial shaft fx dx:

Answer 8

xray

Question 9

Tibial shaft fx tx:

Answer 9

• No to minimal displacement–> splint with crutches, then walking cast
• Displaced or comminuted –>splint with crutches, ORIF

Question 10

Fibula Shaft Fracture Dx?

Tx?

Answer 10

**The fibula is non-weight bearing bone

Dx: xray – make sure you visualize entire bone

Tx: splint –> cast, weight bearing fine

Question 11

What is the MC reason for missed athletic participation?

Answer 11

ankle sprains

Question 12

______ injuries are 80% of ankle sprains

Answer 12

inversion

Question 13

CFL- MOI?

Answer 13

CFL= calcaneofibular ligament

-torn CFL MOI: inversion injury. Pain at the base of fibula

Question 14

ATFL- MOI:

Answer 14

ATFL= anterior tibiofibular ligament

*ATFL is the weakest ligament
MOI: inversion injury
-Pain across tib/fibula syndesmosis

Question 15

How common is an ATFL injury?

Answer 15

Most common! Isolated ATFL tear in 70%

• CFL 2nd MC
• Lateral Malleolus fx- 3rd

Question 16

High ankle sprain accounts for ___% of ankle sprains

Answer 16

10%.

• Syndesmosis injury
• *Tibiofibular and interosseous ligaments

Question 17

Low ankle sprain accounts for __% of ankle sprains

Answer 17

> 90%

-*Anterior talofibular ligament (ATFL) and Calcaneofibular ligament (CFL)

Question 18

Ankle sprain PE: Anterior drawer test assesses ______

Answer 18

ATFL

Question 19

Ankle sprain PE: Talar tilt test assesses _____ and ____

Answer 19

ATFL & CFL

Question 20

Ankle sprain Dx:

Answer 20

XRAYS OVER ORDERED! Evaluates for fx, not ligamentous injury

Ottawa Ankle Rules: (96-99% sensitive in ruling out ankle fracture):

• Inability to bear weight
• Medial or lateral malleolus point, bony tenderness
• 5MT(5th metatarsal) base tenderness
• Navicular tenderness

-MRI evaluates for ligamentous injury

Question 21

Ankle sprain: 1st degree (KNOW)

Answer 21

=stretching of the fibers

-Walkable, min swelling

Tx: RICE, ace bandage, keep moving and weight bearing

Question 22

Ankle sprain: 2nd degree (KNOW)

Answer 22

=partial tear
-+/- walking, moderate swelling

Tx: RICE, might need 2-3 days NWB, airsplint

Question 23

Ankle sprain: 3rd degree (KNOW)

Answer 23

Third degree: complete tear
-No walking, **“egg-shaped” swelling within 2 hours, can be less painful than 2nd deg

Tx: -RICE, NWB(non weight bearing) 3-7 days with re-exam in 5-7 days.
-+/- surg vs PT

Question 24

Ankle sprain: Prolonged ________ leads to more complications!

Answer 24

immobilization

Question 25

The ____ bears more weight per unit area than any other joint in the body

Answer 25

ankle

Question 26

ankle fracture -Malleoli Fractures: - Lateral malleolus- fx of ______ - Medial malleolus- fx of the _____

Answer 26

- lateral malleolus- fx of the fibula | - medial malleolus= fx of tibia

Question 27

The fibula is a ______ bone

Answer 27

NWB

Question 28

Tx of Isolated lateral malleolus fracture with < 3mm displacement:

Answer 28

Ortho referral, likely walking boot 6-8 weeks -if Displaced, comminuted, open -->surgical repair

Question 29

MedialMalleoli Fx: The tibia is the _____ _____ bone of the LE

Answer 29

weight bearing

Question 30

__-__% of tibia fractures occur in conjunction with fibular fracture

Answer 30

70-85%

Question 31

MedialMalleoli Fractures tx

Answer 31

- More likely to be surgical | - -Splint, crutches, ortho referral

Question 32

Bimalleolar fracture=

Answer 32

Fracture of both the medial and lateral malleoli

Question 33

Trimalleolar fracture=

Answer 33

fracture of the medial malleolus, lateral malleoli, and fracture of the posterior aspect of the tibia

Question 34

Achilles tendon rupture demographic

Answer 34

- More common in men, 30-40yo - Risks: “weekend warrior,” fluoroquinolone use - MOI: Traumatic, abrupt injury – “someone just shot me in the foot” or “pop”

Question 35

Achilles tendon rupture Sxs:

Answer 35

Severe pain, inability to bear weight | **“someone just shot me in the foot” or “pop”

Question 36

PE tests for achilles tendon rupture

Answer 36

- Thompson Test | - Achilles feels soft

Question 37

PE tests for achilles tendon rupture

Answer 37

- Thompson Test (= flip them over, squeeze their ankle and they should dorsiflex) - Achilles feels soft

Question 38

Achilles tendon rupture tx:

Answer 38

- Ortho referral --> surgical repair | - Splint, crutches, pain meds

Question 39

Phalangeal fx: how common

Answer 39

- Very common! | - Rarely surgical – buddy tape +/- hard soled (cast) shoe

Question 40

Metatarsal fractures: non-operative tx?

Answer 40

- stiff soled shoe or walking boot with weight bearing as tolerated - Non-displaced fractures of 1-4

Question 41

Metatarsal fractures: operative tx?

Answer 41

- percutaneous pinning - Open fractures - Any displacement in the first metatarsal fracture or multiple fxs

Question 42

5th Metatarsal fracture: how common?

Answer 42

Very common fracture – “dancers fracture”

Question 43

5th Metatarsal fracture MOI:

Answer 43

- Forced inversion during plantar flexion of the foot and ankle - The peroneus brevis and lateral band of plantar fascia insert on base

Question 44

Jones vs Pseudo-Jones

Answer 44

*Avulsion = Pseudo Jones Wt bearing ok *Jones and stress fractures require non-weight bearing

Question 45

Plantar Fasciitis: - describe this condition - Risks?

Answer 45

- Inflammation of the aponeurosis at its origin on the calcaneus - Chronic overuse leads to microtears in the origin of the plantar fascia Risks: obesity, decreased ankle dorsiflexion in a non-athletic population (tightness of the foot and calf musculature), and weight bearing endurance activity (dancing, running)

Question 46

Plantar Fasciitis Sxs and Dx

Answer 46

Sxs: Sharp heel pain – insidious upon stepping out of bed, worse at end of the day, may be bilateral Dx: Clinical – pinpoint tenderness, dorsiflexion of the toes and foot increases tenderness with palpation

Question 47

Plantar Fasciitis tx:

Answer 47

stretching, NSAIDs and arch support

Question 48

Other common foot disorders

Answer 48

Hammer toe Corns and Calluses Bunions Ingrown Toe Nails

Question 49

Hammer Toe

Answer 49

=Flexion deformity of the PIP joint with extension of DIP (toes 2-5) - Common in high heel wearers - Clinical dx Tx: Non-op to start – “wide” shoes, padding/splinting Podiatry referral for chronic pain

Question 50

Describe Corns vs calluses

Answer 50

=A toughened area of skin which has become relatively thick and hard in response to repeated friction, pressure, or other irritation Corn – painful, small with very hard center Callus – larger, non-painful

Question 51

Tx corns and calluses

Answer 51

file/remove, padding

Question 52

bunions aka ____ _____

Answer 52

hallux valgus

Question 53

Bunions: etiology

Answer 53

=Pressure on the lateral MCP joint causes the metatarsal head displaces medially – bony deformity - Slow onset, can become very painful * *Huge genetic component!

Question 54

bunions tx

Answer 54

- Wide shoes, padding - Pain control - Podiatry referral--> Surgery

Question 55

Ingrown toe nails

Answer 55

=Painful condition in which the nail grows so that it cuts into one or both sides of the paronychium or nail bed -May or maybe not be concurrently infected Tx: warm water soaks, antibacterial ointment, well fitting shoes (open toe shoes best), nail lifting or removal