Lower Leg/Ankle/Foot Injuries Flashcards
List the structures of the anterior compartment of the lower leg.
EHL, ED, AT, Peroneus tertius, Deep peroneal N.
Name the lateral structures in the lower lower leg compartment.
- Peroneus Longus
- Peroneus Brevis
- Superficial Peroneal nerve
Name the Deep Posterior structures in the lower lower leg compartment.
- FHL
- FDL
- PT
- Posterior Tibial N
Name the superficial posterior structures in the lower lower leg compartment.
- Gastrocneumius
- Soleus
- Sural nerve
What are some associated injuries from a tibial plateau fracture?
Compartment syndrome
meniscal injury
Name the different radiographs views for a supsected tibial plateau injury
- AP
- Lateral
- Internal
- External Oblique
Reasons to get ortho involved for a tibial plateau fracture.
- Compartment Syndrome
- Ligamentous injury
- Displaced/depressed
___ > mmHG for diagnosis of Acute Compartment Pressure Syndrome.
30
What is the formula for pressure testing for Acute Compartment Pressure?
< 30 = DBP- CP
Pedowitz Formula for Chronic Exertional Compartment Syndrome
Pre > 15 mm Hg
1 min post >30 mmHg
5 min post> 20 mm Hg
RTP following fasiotomy for Chronic Exertional Compartment Syndrome
6-12 weeks
Runner comes in with bilateral diffuse medial tibial shaft tenderness. Worst with exertion but can tough it out to comeplete runs. Diffusely tender on along medial tibial shaft.
What is the diagnosis and what is in the differential?
Medial Stress Syndrome
Compartment Syndrome should be in differential however once the pain starts while running these patients cannot push through it and must stop.
Tibial Stress Fracture- more localized tenderness
How can an MRI be useful for medial tibial shaft pain in runner who just started training for marathon?
MRI can differentiate b/t stress fracture and stress sydnrome.
What is a vascular condition that can often present like compartment syndrome in usually a male athlete < 40 yr. Provacative pain on exam with passive ankle dorsiflexion and active ankle planterflexion.
Popliteal Artery Entrapment
Definite study to confirm popliteal artery Entrapment
Arteriography
Doppler US exam with high false positive
Treatment for popliteal artery entrapment
surgical release
Where is the most common place for tibial stress fractures?
Middle 1/3 posteromedial tibia
Discuss the pros and cons of the following imaging modalities for Tibial stress fractures:
XRAY
Bone Scan
MRI
- Xray- often normal for 2-3 weeks
- Bone Scans are highly sensative with low specificity
- MRI good for grading.
For Popliteal Artery Entrapment give the 3 values of POST ABIs that would
a: be suggestive
b: indicative
A drop of ____ mmHg from baseline is also indicitive and usually correlates between 0.1-0.2 ABI)
A- ABI < .75 suggestibve
B- ABI <.50 indicative
Drop of 15 mmHg from baseline = (0.1-.0.2)
Describe the Fredericson Grading System for Medial Tibial Stress Syndrome and how it correlates with RTP
Grading system based on MRI
- Grade 1 - persosteal edema —–> RTP 2-3 weeks
- Grade 2- 4a ( progressive marrow edema changes with intracortical signal changes(4a) RTP 6-7 weeks
- Grade 4b- linear region of intracorticla signal change—-> RTP 9-10+ weeks
Is this tibial stress fracture high risk or low risk?
What is the treatment?
High risk ( tension side) - the dreaded black line. Anterior tibia
Treatment: NWB, cast vs. pneumatic bracing for 6-12 months. Depending on the level of the athlete this could require bone graft vs. intra-medullary nailing (faster RTP)
Catagorize this tibial stress fracture as high or low risk?
Low- posteriormedial tibia ( compression side)
Low Risk
Most common stress fx site in athletes
AVOID NSAIDS
Correct training/technique errors
RTP for low risk tibial stress fractures vs. high risk stress fractures
Low Risk (posteriormedial) - 2-6 weeks when sx resolve
High Risk( anteriormedial) 6-12 months
Describe the MOI from a fibular fracture?
Varus stress at knee
or
ankle in ER ( Maisonneuve fx)
What are some Physical Exam findings for a fibular fracture?
Usually associated with other injures and sometimes missed
Can Bear Weight
TTP at fracture site and distal
Treatment for a fibular fracture
Short walking boot 3-4 weeks
Crutches PRN
RTP for a fibular shaft fracture (that is not an ortho referal)
6-8 weeks/normal WB and ROM
Name 2 groups of athletes that are proned to fibular stress fractures?
Runners and ballet
Middle age women who just started to train for marathon presents with latera leg pain that is worse when running. If you suspected a fibular stress fracture where would you expet her to more tender?
If it was a young male runner where would the fracture/tenderness be?
3-4 cm proximal to lat mal
6-8 cm prox to lat mal- runners fracture
All though rare, name the 4 classifications of tibio-fibular joint dislocations
Most common?
Occurs in sliding?
Peroneal nerve or LCL inj
Trauma, popping sound, fibular head TTP, unstable and may lack knee extension
- Subluxation - generalized hypermobility
- Anterior Dislocation- sliding (most common)
- Posterior Dislocation- direct trauma or twisting, LCL or peroneal nerve inj
4 Superior Dislocation- rare, trauma
If you are suspcious of a tibio-fibula dislocation what is the best xray to get?
Lower leg with IR
This maximize distance between fibula and tibia.
compare contralateral side.
What is the treatment for Tibio-fibular dislocation?
Closed reduction and 3x weeks of immobilization
What is another name for tennis leg?
Where does it usually occur?
Who is it more common in?
What do they complain of?
What do you see on PE?
Gastrocnemius Tear
M>>L
Middle aged recreational athletes
Sharp posterior calf pain
TTP at MT junction with swelling and tracking echymosis
What is the treatment for tennis leg?
RICE
rehab
aspirate hematoma if present
RTP- 2-3 weeks
What is the weber classifcation of this fracture?
Treatment?
Weber TYPE A
ORTHO REFERAL ( FOR B AND C)
WHAT IS WEBER TYPE C
FIBULAR FRACTURE ABOVE MORTISE
WHAT IS A WEBER TYPE A?
FIBULAR FRACTURE BELOW THE MORTISE
Indication for ortho referral for ankle fracture
Weber B and C
Bi or tri malleolar fx
Posterior malleolar fx
>25% articular involvment and/or >2mm
How would you manage this?
Isolated malleloar avulsion fracture
Treat like ankle sprain
early mobilization
How would you treat an oblique nondisplaced malleolar fracture?
4-6 weeks walking boot/cast
RTP-normal range of motion and strenth
6-10 weeks
Which type of ankle dislocation ( ant, post, lateral) is the most common?
anterior
Which type of ankle dislocation ( ant, post, lateral) is always assoicated with fracture?
Lateral
Which type of ankle dislocation ( ant, post, lateral) is the least common?
posterior
The most common sports injury?
Lateral ankle sprain
Name the most common to least common ligament injuried in ankle sprain?
ATFL> CF>PTFL
How long should an ankle brace be worn following sprain?
6-12 months
What is an assoicated injury to suspect for a medial ankle sprain?
associated medial malleolus fx
What is the MOA for a high ankle sprain?
What is the name of the ligament?
AITiboFib Lig
Dorsaflexion/ER
What kind of fracture does a high ankle sprain predispose someone to?
Maisonneuve fx
What are some physical exam test that would make you concerned about a high ankle sprain?
Positive squeeze test
Positive ER test
Tenderness length
fibula translation test
stabilization test
https: //youtu.be/ANgWSz0UoDg
https: //youtu.be/W3SHqKqkK14
XRAY views to evaluate for high ankle sprain
entire tibia fibia
STANDING
AP, lateral, mortise, gravity stress views
What are you looking for on xray when suspecting high ankle sprain?
You diagnose patient with Grade 1 high ankle sprain.
XRAY
Physical Exam
Treatment
RTP
XRAY- negative
Physical Exam- stable
Treatment- PRICE with immobalization 2-4 weeks followed by functional brace
When examing an ankle for chronic instability what is a high yield physical exam finding?
Poor proprioception
MOI for calcaneus fracture
Fall (axial load) with or without plantar or dorsiflexion, twisting
Inability to bear weight
Indications for ortho referral with calcaneal fracture
displaced
intra-articular ( most common 70%)
Persistant pain (non union)
Discuss the non surgical treatment options of calcaneal fractures
a. Ant, med, or lateral processes
b. Tuberosity
C. Sustentaclum tali
d. Body (extra articular)
a. short-leg walking cast x 4 weeks
b. short leg NWB cast x 6 weeks
c. Short leg NWB cast 6-8 weeks
d. No immobilization, active rehab
Rehab following immobilzation 6-12 weeks RTP
Is a calcaneus stress fracture considered high or low risk?
Where do they commonly occur?
What is a positve test?
Best imaging?
Treatment?
RTP
Low risk
Body, post. to talus
Squeeze
XRAY delayed 3-4 weeks–> MRI
relative rest
RTP 4-6 weeks
Talus fracture MOI
Dorsiflexion, axial load, and twisting
What are the classifications of Talus fractures
1 and 2- stable
3 and 4- unstable
Indciations for ortho for talus fracture
displaced or comminuted
Intra-articular
Large avulsions
Unstable talar dome fx( III, IV) or persistent pain for 4-6 mo for stable I and II
List the following non op treatments for talus fx
a. Avulsion
b. Neck
c. Body
d. Head
e. Talar Dome
a. Short leg walking cast x 4wks
b. Short leg NWB cast x 4-6 weeks,then walkign cast x4 wks
c. Short leg NWB cast x6-8weeks
d. Short-leg walking cast x 6-8wks then longitudinal arch support x 3-6mon
e. Activity restriction or short leg walking cast (Type 1-2)
Snow border comes in with symtpoms of an ankle sprain. What fracture is commonly mistaken for an ankle sprain?
Talus (lateral process ) fracture
Usually TTP 1 cm from tip of lat mal.
Best seen on mortise view
Get CT if xray negative
How would you manage a “Snow borders fx”?
Criteria for ortho referral
Ortho referral: comminuted or >2mm displacement
Non displaced: NWB short leg cast x4 weeks
then walking cast for 2weeks
Indications for ortho for navicular fractures
Large displaced dorsal avulsion (>20% aritcular surface )
tuberosity fx > 1 cm prox displacement
Displaced body fx
Non-union/delayed union stress fracture
Discuss nonortho managment for Navicular fracture:
a. Dorsal Avulsion
b. Tuberosity
c. Body
a. short leg walking cast x 4-6wks
b. same as above
c. below- knee walking cast x 6-8wks
Navicular stress fractures are considered (high/low) risk
high
What type of athlete are prone to navicular stress fractures?
Why are navicular stress fx high risk?
track and field
central 1/3 has poor vascular supply and that is where compressive forces the highest.
Treatment for navicular stress fx
NWB cast x 6weeks
Can consider surgery
Sprain of the 1st/2nd T-MT joint, base of MT
Lisfranc
Lisfranc MOI
Direct- Crush injury
Indirect- axial load to heel with ankle planterflexed and toes dorisflexed
( Football lineman, stepping off curve)
Football lineman presents with midfoot pain dorsally . TTP at dorsal mid foot. Pain with eversion and abduction of forefoot. Pain with passive pronation/supination of TMT joint and positive shuck test
Lisfranc injury
What kind of XRAY and findings for Lisfranc injury?
Weight bearing AP
- > 2mm displacement b/t 1st and 2nd MT bases
- Avulsion fracutre “Fleck sign” - near base of the 2nd MT or medial cuniform
- Medial cortex of 2nd MT base line up with medial border of intermediate cuniform
Lateral
- Dorsal cortex of 1st MT and medial cuneiform line up
30 degree Oblique
- Medial cortex of 4th MT base line up with medial border of cuboid
What are the 3 classifications of Lis frranc injury
What is the treatment of Lisfranc injury (Stage 1, Stage 2, and Stage 3)
Stage 1- NWB cast 2 weeks and repeat xrays. If radiographic stable clinical assesment determines contnued immobilization ( up to 10 weeks)
STAGE 2 and 3 considered unstable = ORIF
What is the general treatment for nondisplaced MT fractures?
Short walking boot or post op shoe for 4-6 weeks
WBAT
What is the general managment for displaced MT fracture
Short leg NWB cast 2-3 wks
f/u Xray 1 wk
Transition to walking boot 3-4x weeks
Which MT fracture is considered high risk?
TX
2nd MT “ Ballet Dancers”
Involves volar and medial aspect of Lis Franc
Short- leg NWB cast x 4wks
Name the 3 types of 5th MT fratures
Styloid avulsion
Metaphyseal -Diaphyseal Junction ( Jones)
Diaphyseal Stress
