Lower Leg Flashcards
unimalleolar fracture
medial OR lateral malleolus
Bimalleolar fracture
medial AND lateral malleolus
Trimalleolar fracture
both malleoli and posterior rim of tibia
Common MOI for distal tibia/fibula fractures
axial or rotational loading
Common MOI for calcaneus fractures
- What else can be injured during MOI
fall from height
- lumbar vertebra can also be injured/fractured after fall from height
Common MOI for talus fractures
forced ankle dorsiflexion
Forced _______ can cause avulsion fracture at navicular
eversion
Common MOI for metatarsal fractures
direct trauma - direct impact like dropping something heavy on the foot
Common MOI for phalangeal fractures
stubbing and direct trauma
pediatric physeal ankle fracture has worse prognosis if:
- > 1 week prior to reduction
- larger gap
- gap >/= 3 mm for Types 1 and 2
- younger patients
- higher risk of physics arrest in types 3-5
Why are fat grafts used during physeal fractures? Which type?
to stop physeal arrest
- used during type 5 if recognized early
cast time after physeal fracture type 1 and 2 reduction
4-6 weeks
cast time after physeal fracture type 3 and 4 reduction
- long leg NWB cast 1-4 weeks
- boot from week 5-8 (NWB for first 2 weeks)
How long is a patient NWB after type 3 or 4 physeal fracture reduction?
~6 weeks
- long leg NWB cast wk 1-4 the boot for weeks 5-8 w/ NWB for 2 weeks
With which physeal fracture is hardware typically removed after reduction?
If ORIF w/ Type 3 (> 2mm displacement)
What is Talipes Equinovarus?
clubfoot
characteristics of clubfoot. Who is more likely to get it?
- plantarflexed heel
- inversion STJ/varus rearfoot
- metatarsal adduction/varus forefoot
males > females and common bilaterally
What is rearfoot varus? What motion is limited? Where is subtalar in relation to midline?
- inversion of calcaneus
- limited pronation (DF, abduction, eversion)
- subtalar is farter from midline
What is rearfoot valgus? What motion is limited? Where is subtalar in relation to midline?
- eversion of calcaneus
- excessive pronation and limited supination (PF, adduction, inversion)
- subtalar joint is closer to midline
What is forefoot varus? What muscles are typically weak and what motion does this cause at the knee?
Inversion of the forefoot
- big toe is higher off ground in subtalar neutral
PF are weak and causes knee valgus
What is forefoot valgus? What is it commonly found w/?
Eversion of the forefoot
- pinky toe is higher than ground in subtalar neutral
- commonly found w/ rearfoot varus
pes planus
flat foot
What is rigid/congenital pes planus?
arch stays flat in weight bearing and non-weight bearing
what is acquired/flexible pes planus? What is the cause?
arch returns in non weight bearing
- laxity of medial arch stabilizers (tib posterior)
pes cavus
longitudinal arches accentuated
hallux valgus
- medial deviation of 1st metatarsal and lateral deviation of great toe
What gait deviations occur w/ hallux valgus?
- collapse of medial arch
- navicular drop
- pronation during push-off = less rigid foot
hallux rigidus and its characteristics
arthropathy of great toe
- pain
- swelling
- abnormal bone growth at dorsal aspect of 1st MTP
History and symptoms of hallux rigidus
History
- arthropathy (RA, gout, etc.)
- trauma to distal metatarsal
- repetitive great toe extension
Symptoms
- insidious onset, progressive
- 1st MTP pain
What specific activities would be difficult w/ hallux rigidus?
- walking up hill
- stair ambulation
- terminal stance - will have lift off instead of push off during gait
Physical exam of hallux rigidus
- limited great toe extension ROM at MTP (hard end feel)
- secondary gait alterations (limited terminal stance/push off)
- abrasion of skin superficial to dorsal 1st MTP
- swelling
- palpable osteophyte complex/tenderness
What is the most common ligament sprained during an inversion ankle sprain?
ATFL - anterior tibiofibular ligament
What other injuries must be included in differential diagnosis during lateral ankle sprains?
- avulsion fracture of 5th met styloid process (fibularis brevis)
- osteochondral lesion
- malleolar fracture
History and Symptoms of lateral ankle sprain
History
- 3rd decade of life (20s)
- common running/athletes injury
- MOI: forced ankle inversion
Symptoms
- lateral ankle pain/swelling
- painful w/ activities that place foot in supinated position
Physical exam findings of lateral ankle sprain
- antalgic gait (decreased stance time and decreased end ROM)
- increased figure 8 measurement
- local warmth/tenderness
- pain w/ inversion ROM
What special tests would be positive w/ lateral ankle sprains?
- anterior drawer test
- medial talar tilt stress test
- reverse anteriolateral drawer test
History and symptoms of medial ankle sprain
History
- MOI: forced ankle eversion
Symptoms
- medial ankle pain/swelling
- painful w/ activities that place foot in pronated position
Physical exam findings of medial ankle sprain
- antalgic gait
- increased figure 8
- warmth/tenderness distal to medial malleolus
- pain w/ pronation/eversion ROM
What special test would be positive for medial ankle sprain?
lateral talar tilt stress test
What injury would you suspect if patient reports pain w/ activities that place foot in supinated position? Pronated position?
supinated foot - lateral ankle sprain
pronated foot - medial ankle sprain
What ligament is typically involved in medial ankle sprains? Lateral ankle sprains?
medial - deltoid ligament
lateral - ATFL
What is the concern w/ syndesmotic sprains?
chronic instability/degenerative arthropathy
Common MOI for syndesmotic sprain
- forced DF
- forced eversion of talus
- forced ER of talus
wedge of talus pushes apart the mallelous
- someone trying to turn quickly on a planted foot
Symptoms of Syndesmotic sprain
- pain in distal leg
- aggravated w/ stair decent/walking up hill/ squatting
- aggravated w/ DF/any motion where tibial advancement occurs
Physical exam of syndesmotic sprain
- early heel-off in stance phase (trying to avoid tibial advancement)
- swelling/tenderness anterior tibiofibular joint
- pain at end-range DF ROM
What special tests would be positive for a syndesmotic sprain?
- fibular translation test - excessive laxity
- external rotation test
- syndesmosis squeeze test
History and symptoms of chronic ankle instability (CAI)
History
- recurrent inversion sprains
- fibular muscle weakness
- impaired proprioception
Symptoms
- often asymptomatic between ankle sprains
- feelings of ankle giving away
- ankle weakness
- difficulty/inability to run (worse on un-even surfaces)
Physical exam of chronic ankle instability (CAI)
diminished proprioceptive function of ankle
What is the cause of anterior ankle impingement?
soft tissue or bony spur formation at the anterior talocrural joint
History and symptoms of anterior ankle impingement
History
- recurrent/high trauma ankle sprains
Symptoms
- anterior ankle pain
- anterior ankle swelling
- painful w/ activities that place foot in DF position
Physical Exam findings of anterior ankle impingment
- antalgic gait/early heel off
- tenderness/palpable mass anterior tibiotalar joint
- pain/limited end range DF (A/PROM)
What special tests would be positive w/ anterior ankle impingement?
forced DF test
fibulari longus/brevis tendinopathy history and symptoms
History
- repeated inversion injuries
- anatomic abnormalities
Symptoms
- pain posterior to lateral malleolus
- subluxation of fibularis tendons
fibulari longus/brevis tendinopathy physical exam
- swelling/bruising lateral ankle
- pain w/ AROM < resistive testing ankle eversion and pronation
- pain w/ end-range inversion/supination (A/PROM)
- tenderness fibularis longus/brevis tendons
tibialis posterior tendinopathy history and symptoms
History
- insidious onset, progressive
- concomitant (at the same time) deltoid ligament injury
- sports that require quick directional change
Symptoms
- pain near area of insertion at navicular
- pain proximal to medial malleolus
tibialis posterior tendinopathy physical exam
- pronated foot/pes planus
- navicular drop
- tenderness/ swelling at navicular and proximal to medial malleolus
- painful resisted inversion and PF
- painful eversion and DF ROM
Feiss angle of a patient w/ pes planus? pes cavus?
pes planus - < 130 deg
pes cavus - > 150 deg
Achilles tendinopathy history and symptoms
History
- common MOI: intesne eccentric loading on triceps surae
- running injury
Symptoms
- pain near achilles insertion
- morning stiffness
Achilles tendinopathy physical exam
- tenderness/swelling/hypertrophy/palpable defect at achilles tendon
- pain w/ DF ROM
- Pain w/ AROM < resisted PF
Physical exam of achilles tendon rupture
- posterior calf tenderness/swelling/palpable defect
- pain w/ DF ROM
- weak/absent active/resisted PF
What special test would be positive for achilles tendon rupture?
thompson test
Risk factors for plantar faciitis
- limited DF ROM
- high BMI in non-athletic populations
Symptoms of plantar faciitis
- plantar medial heel pain that is worse in morning and after prolonged w/b activity
- pain w/ terminal stance
plantar fasciitis physical exam
- early heel off in stance
- guarding of tricpes surae
- swelling/tenderness origin of plantar fascia (heel spur)
- pain w/ PROM DF of ankle and toes (windlass test)
Metatarsalgia history and symptoms
History
- health condition that increase stress on the met head
Symptoms
- aggravated during prolonged weight bearing activities, mid terminal stance phases
Physical exam findings of metatarsalgia
- concomitant health conditions
- antalgic gait/diminished push-off
- observable calluses on plantar foot
- tender plantar met heads
- pain during mid and terminal stance
History and symptoms of interdigital neuroma
History
- insidious onset
- DF injury of toes
Symptoms
- pain in area of met heads and corresponding web space
Physical exam of interdigital neuroma
- tenderness
- + foot squeeze test
What nerve is entraped with tarsal tunnel syndrome?
posterior tibial nerve
- intrinsic muscles of plantar foot
symptoms of tarsal tunnel syndrome
- loss of plantar sensation
- pain and paresthesia at the plantar foot
- increasing intensity of symptoms w/ ankle DF activities
physical exam findings of tarsal tunnel syndrome
- antalgic gait
- limited/painful squat
- signs of invertor tendinopathy
- diminished plantar foot sensation
- weakness of intrinsic
- limited ROM, painful DF and eversion
Who is more likely to develop tarsal tunnel? What is the average age?
females have a greater incidence
average age of 47 yyears
Anterior ankle impingement CPR requirements
5/6 of the following:
- anteriolateral ankle joint tenderness
- anteriolateral ankle joint swelling
- pain w/ forced DF
- pain w/ single-leg activities
- pain w/ activites
- absence of ankle instability
What exercises can help with tib posterior tendinitis?
towel scrunches and marble pick ups w/ foot
Interventions for plantar faciitis
manual joint mobs - anterior and posterior talocruel to increase DF ROM
triceps surae stretching
