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MSK: Trauma and Overuse, Foot Flashcards

1
Q

Next step:

A

Lumbar spine radiographs (to look for a T12-L2 burst fracture)

Note: Bilateral calcaneal fractures tend to occur in the setting of severe axial loading (e.g. jump out the window, which is why these are called Casanova fractures).

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2
Q
A

Casanova fracture (calcaneal fracture due to axial loading)

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3
Q

What tendons often become entrapped within this type of fracture?

A

Peroneal tendons

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4
Q

What is the most common tarsal bone fracture?

A

Calcaneus (60%)

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5
Q

What are the two major types of calcaneal fracture?

A
  • Extra-articular
  • Intra-articular

Note: This depends on whether the subtler joint is involved.

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6
Q

How can you check for an occult calcaneal fracture on radiographs?

A

Measure Bohler’s angle

Note: If less than 20 degrees, this is suspicious for an occult calcaneal fracture.

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7
Q

What is the normal Bohler’s angle?

A

20-40

Note: Less than 20 is suspicious for an occult calcaneal fracture.

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8
Q

What is the normal range for this angle?

A

The critical angle of Gissane is normally 100-130 degrees

Note: This can be used to evaluate the severity of a calcaneal fracture. Intra-articular fractures will have a fracture line extending through this Gissane angle.

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9
Q
A

5th metatarsal stress fracture

Note: These are high risk (hard to heal).

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10
Q
A

Jones fracture (base of the 5th metatarsal fracture)

Note: These are at high risk for non-union (treated with non-weight bearing cast or internal fixation).

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11
Q
A

Jones fracture (base of the 5th metatarsal fracture)

Note: These are at high risk for non-union (treated with non-weight bearing cast or internal fixation).

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12
Q
A

Normal 5th metatarsal apophysis

Note: Do not confuse this with an avulsion fracture (which should be more transverse and less longitudinal).

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13
Q
A

Avulsion fracture of the 5th metatarsal (AKA dancers fracture)

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14
Q

Avulsion fractures of the 5th metatarsal are commonly seen in what pt population?

A

Dancers (AKA dancers fracture)

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15
Q
A

Os peroneus (an accessory ossicle)

Note: This is seen in approximately 10% of the general population.

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16
Q

What structure is this accessory ossicle located in?

A

The os peroneus is located within the peroneus longus tendon

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17
Q
A

Painful Os Peroneus Syndrome (POPS)

Note: Progressive retraction of an os peroneus over time indicates repetitive injury to the peroneus longus tendon (POPS).

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18
Q
A

Painful Os Peroneus Syndrome (POPS)

Note: Edema surrounding an os peroneus just proximal to the peroneus longus tendon enters the cuboid tunnel.

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19
Q

What is the most common dislocation in the foot?

A

A lisfranc injury

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20
Q

What is the Lisfranc joint?

A

The combined tarso-metatarsal joints of the foot

Note: This joint is recessed at the 2nd digit, creating a “keystone” (arrow) locking mechanism.

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21
Q

What does the lisfranc ligament connect?

A

The medial cuneiform and the 2nd metatarsal base

Note: You can easily perform a forefoot amputation by cutting this ligament.

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22
Q

What radiographic view is needed to exclude a Lisfranc injury?

A

Weight-bearing foot radiographs

Note: You cannot exclude Lisfranc injury on non-weightbearing radiographs.

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23
Q
A

Lisfranc fracture-dislocation

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24
Q
A

Lisfranc fracture-dislocation

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25
Lisfranc injury Note: This is the "fleck sign" (a small bony fragment in the Lisfranc space representing avulsion fracture of the Lisfranc ligament from the 2nd metatarsal base).
26
What is the usual mechanism of injury in the Lisfranc fracture-dislocation?
Axial loading while in extreme ankle plantarflexion
27
What are the major types of Lisfranc fracture-dislocation?
- Homolateral - Divergent
28
Lisfranc fracture-dislocation (homolateral)
29
Lisfranc fracture-dislocation (divergent)
30
What is the largest tendon in the body?
The Achilles tendon (fused tendons of the gastrocnemius and soles muscles)
31
Achilles tenosynovitis?
No, the achilles tendon does not have a tendon sheath so it cannot have tenosynovitis Note: If there is inflammation around the tendon, call it "paratendinitis."
32
Tibialis anterior (extensor tibialis) tendon
33
Tibialis posterior tendon Note: This is Tom in Tom, Dick, and Harry (medial to lateral).
34
Flexor digitorum longus tendon Note: This is Dick in Tom, Dick, and Harry (medial to lateral).
35
Flexor hallucis longus tendon Note: This is Harry in Tom, Dick, and Harry (medial to lateral).
36
Plantaris tendon
37
Peroneus longus tendon
38
Peroneus brevis tendon
39
Osteochondral defect Note: The term osteochondritis dessicans is used for this in younger pts without a known cause.
40
Os trigonum
41
What structures run in this neuromuscular bundle?
- Tibial nerve - Posterior tibial artery
42
Os trigonum syndrome (due to posterior impingment)
43
What is this anatomical region referred to as?
Master knot of Henry (the location where the flexor hallucis longus tendon crosses over the flexor digitorum longus tendon at the level of the navicular bone) Note: Harry (FHL) crosses over Dick (FDL) at the master knot of Henry on its way to insert on the big toe (Harry is a hallucis tendon).
44
What is the most frequently injured ligament of the ankle?
The anterior talofibular ligament (ATFL) Note: It is also the weakest ligament and is frequently injured during ankle inversion.
45
ATFL (anterior talofibular ligament)
46
Posterior tibial tendon injury leads to...
Progressive flat foot deformity (and hindfoot valgus deformity) Note: The posterior tibial tendon is a primary stabilizer of the longitudinal arch of the foot.
47
What are the most likely locations for a tear of the posterior tibial tendon?
Chronic injury: posterior to the medial malleolus (most friction) Acute injury: At its insertion on the navicular bone
48
Posterior tibial tendinopathy (chronic injury due to friction against the medial malleolus)
49
What structure is this?
Posterior tibial tendon Note: This point, as it passes posterior to the medial malleolus, is a common site of injury due to chronic friction wear.
50
Acute flattening of the foot arch...
Think tear of the posterior tibial tendon Note: When acute, the tear is most often at its insertion site on the navicular.
51
Why do tears of the posterior tibial tendon lead to hindfoot valgus deformity?
Due to unopposed action from peroneus brevis
52
1 and 2 are part of what ligament complex?
The spring ligament complex
53
Sinus tarsi syndrome Note: Do not call this in the setting of acute trauma.
54
Where is the sinus tarsi located?
Between the lateral talus and calcaneus (separating the anterior subtler joint from the posterior subtler joint) Note: It is an important space for proprioception and balance.
55
Foot pain that is most severe in the morning...
Think plantars fasciitis
56
Plantar fasciitis
57
What are the 3 components of the plantar fascia?
- Lateral band - Central band (thickest) - Medial band (thinnest)
58
Bone scan
Plantar fasciitis
59
Plantar calcaneal spur Note: This can be a sign of plantar fasciitis.
60
Thickening of the plantar fascia, suggestive of plantar fasciitis Note: Greater than 4 mm is considered thickening.
61
Split tear of the peroneus brevis tendon Note: C-shaped or boomerang configuration of the peroneus brevis tendon enveloping the adjacent peroneus longus tendon.
62
What is the most common location for a tear of the peroneus brevis tendon?
At the lateral malleolus
63
A split tear of the peroneus brevis tendon has a strong association (80%) with what other injury?
Lateral ankle ligament injury (e.g. ATFL tear)
64
Think anterolateral ankle impingement syndrome (leading to the development of a hypertrophic synovial tissue mass) Note: Development of a "meniscoid mass" in the lateral gutter of the ankle can occur if there is lateral ankle instability (usually from a prior inversion injury where the ATFL and tibiofibular ligaments were injured).
65
Symptoms of tarsal tunnel syndrome
Pain/paresthesias in the distribution of the tibial nerve (involving the first 3 toes)
66
Which tunnel is shown?
The tarsal tunnel (posterior to the medial malleolus)
67
What structure encloses the tarsal tunnel?
The flexor retinaculum
68
What structures pass through the tarsal tunnel?
- Tibial nerve - Posterior tibial artery/vein - Medial flexor tendons (Tom, Dick, and Harry: TP, FDL, and FHL)
69
Morton's neuroma (perineural fibrosis, not actually a neuroma) Note: A soft tissue mass between the 3rd and 4th metatarsal heads is likely a Morton's neuroma.
70
Dynamic ultrasound of the third intermetatarsal space -/+ foot squeeze
Morton's neuroma (perineural fibrosis, not actually a neuroma) Note: This is Mulder's sign, where scar tissue pops out from the 3rd intermetaratsal space when you sneeze the pts foot.
71
What shape should a Morton's neuroma have?
Teardrop (inferior to the third intermetarsal space) Note: It should stay inferior to the toes. If it is more dumbbell shaped (also going above the toes) and fluid signal, think bursitis. You often have a Morton's neuroma below and bursitis above.
72
Morton's neuroma (arrow) with associated intermetatarsal bursitis (asterisk)
73
Haglund's deformity/syndrome
74
What are the classic features of Haglund's syndrome?
- Haglund deformity (white arrow) - Achilles tendinopathy (thin yellow arrow) - Retrocalcaneal bursitis (open white arrow) - Retro-achilles bursitis (thick yellow/orange arrow)
75
Haglund deformity Note: This is also called "pump bump" because wearing high heels is a risk factor.
76
What structure gets compressed in os trigonum syndrome?
Flexor hallucis longus tendon (during ankle plantarflexion) Note: This tendon will often have tenosynovitis.
77
Os trigonum syndrome is more common in what pt population?
Balet dancers (due to Pointe technique with lots of ankle plantarflexion)
78
Present bilaterally without history of trauma
Achilles tendon xanthoma Note: Pt will have very high cholesterol.
79
Achilles tendinopathy Note: The Achilles tendon should "smile," a rounded appearance means tendinopathy.
80
Risk factors for achilles tendon rupture
- Sudden return to sports after deconditioning - Fluoroquinolone antibiotics
81
Achilles tendon is completely ruptured, but the pt is still able to plantarflex...
Pt probably has an intact plantaris muscle Note: 10% of pts don't have a plantaris muscle.
82
Tennis leg (plantaris muscle rupture, usually at the myotendinous junction) Note: Focal fluid collection/edema between the soleus and medial head of gastrocnemius.
83
Plantaris rupture (AKA tennis leg) is associated with what other injury?
ACL tears
84
Calcaneal tuberosity avulsion fracture Note: Usually seen in diabetes.
85
Avulsion fractures of the calcaneal tuberosity are associated with...
Diabetes
86
Avulsion fracture of a plantar calcaneal spur, suspicious for plantar fascia rupture
87
Extensor digitorum brevis avulsion fracture from its calcaneal attachment Note: Anterolateral calcaneal avulsion fracture.
88
Cuboid avulsion fracture at the insertion site of the calcaneocuboid ligament insertion

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