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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
Q
A

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).

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26
Q

What is the usual mechanism of injury in the Lisfranc fracture-dislocation?

A

Axial loading while in extreme ankle plantarflexion

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27
Q

What are the major types of Lisfranc fracture-dislocation?

A
  • Homolateral
  • Divergent
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28
Q
A

Lisfranc fracture-dislocation (homolateral)

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29
Q
A

Lisfranc fracture-dislocation (divergent)

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30
Q

What is the largest tendon in the body?

A

The Achilles tendon (fused tendons of the gastrocnemius and soles muscles)

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31
Q

Achilles tenosynovitis?

A

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.”

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32
Q
A

Tibialis anterior (extensor tibialis) tendon

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33
Q
A

Tibialis posterior tendon

Note: This is Tom in Tom, Dick, and Harry (medial to lateral).

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34
Q
A

Flexor digitorum longus tendon

Note: This is Dick in Tom, Dick, and Harry (medial to lateral).

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35
Q
A

Flexor hallucis longus tendon

Note: This is Harry in Tom, Dick, and Harry (medial to lateral).

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36
Q
A

Plantaris tendon

37
Q
A

Peroneus longus tendon

38
Q
A

Peroneus brevis tendon

39
Q
A

Osteochondral defect

Note: The term osteochondritis dessicans is used for this in younger pts without a known cause.

40
Q
A

Os trigonum

41
Q

What structures run in this neuromuscular bundle?

A
  • Tibial nerve
  • Posterior tibial artery
42
Q
A

Os trigonum syndrome (due to posterior impingment)

43
Q

What is this anatomical region referred to as?

A

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
Q

What is the most frequently injured ligament of the ankle?

A

The anterior talofibular ligament (ATFL)

Note: It is also the weakest ligament and is frequently injured during ankle inversion.

45
Q
A

ATFL (anterior talofibular ligament)

46
Q

Posterior tibial tendon injury leads to…

A

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
Q

What are the most likely locations for a tear of the posterior tibial tendon?

A

Chronic injury: posterior to the medial malleolus (most friction)

Acute injury: At its insertion on the navicular bone

48
Q
A

Posterior tibial tendinopathy (chronic injury due to friction against the medial malleolus)

49
Q

What structure is this?

A

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
Q

Acute flattening of the foot arch…

A

Think tear of the posterior tibial tendon

Note: When acute, the tear is most often at its insertion site on the navicular.

51
Q

Why do tears of the posterior tibial tendon lead to hindfoot valgus deformity?

A

Due to unopposed action from peroneus brevis

52
Q

1 and 2 are part of what ligament complex?

A

The spring ligament complex

53
Q
A

Sinus tarsi syndrome

Note: Do not call this in the setting of acute trauma.

54
Q

Where is the sinus tarsi located?

A

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
Q

Foot pain that is most severe in the morning…

A

Think plantars fasciitis

56
Q
A

Plantar fasciitis

57
Q

What are the 3 components of the plantar fascia?

A
  • Lateral band
  • Central band (thickest)
  • Medial band (thinnest)
58
Q

Bone scan

A

Plantar fasciitis

59
Q
A

Plantar calcaneal spur

Note: This can be a sign of plantar fasciitis.

60
Q
A

Thickening of the plantar fascia, suggestive of plantar fasciitis

Note: Greater than 4 mm is considered thickening.

61
Q
A

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
Q

What is the most common location for a tear of the peroneus brevis tendon?

A

At the lateral malleolus

63
Q

A split tear of the peroneus brevis tendon has a strong association (80%) with what other injury?

A

Lateral ankle ligament injury (e.g. ATFL tear)

64
Q
A

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
Q

Symptoms of tarsal tunnel syndrome

A

Pain/paresthesias in the distribution of the tibial nerve (involving the first 3 toes)

66
Q

Which tunnel is shown?

A

The tarsal tunnel (posterior to the medial malleolus)

67
Q

What structure encloses the tarsal tunnel?

A

The flexor retinaculum

68
Q

What structures pass through the tarsal tunnel?

A
  • Tibial nerve
  • Posterior tibial artery/vein
  • Medial flexor tendons (Tom, Dick, and Harry: TP, FDL, and FHL)
69
Q
A

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
Q

Dynamic ultrasound of the third intermetatarsal space -/+ foot squeeze

A

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
Q

What shape should a Morton’s neuroma have?

A

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
Q
A

Morton’s neuroma (arrow) with associated intermetatarsal bursitis (asterisk)

73
Q
A

Haglund’s deformity/syndrome

74
Q

What are the classic features of Haglund’s syndrome?

A
  • Haglund deformity (white arrow)
  • Achilles tendinopathy (thin yellow arrow)
  • Retrocalcaneal bursitis (open white arrow)
  • Retro-achilles bursitis (thick yellow/orange arrow)
75
Q
A

Haglund deformity

Note: This is also called “pump bump” because wearing high heels is a risk factor.

76
Q

What structure gets compressed in os trigonum syndrome?

A

Flexor hallucis longus tendon (during ankle plantarflexion)

Note: This tendon will often have tenosynovitis.

77
Q

Os trigonum syndrome is more common in what pt population?

A

Balet dancers (due to Pointe technique with lots of ankle plantarflexion)

78
Q

Present bilaterally without history of trauma

A

Achilles tendon xanthoma

Note: Pt will have very high cholesterol.

79
Q
A

Achilles tendinopathy

Note: The Achilles tendon should “smile,” a rounded appearance means tendinopathy.

80
Q

Risk factors for achilles tendon rupture

A
  • Sudden return to sports after deconditioning
  • Fluoroquinolone antibiotics
81
Q

Achilles tendon is completely ruptured, but the pt is still able to plantarflex…

A

Pt probably has an intact plantaris muscle

Note: 10% of pts don’t have a plantaris muscle.

82
Q
A

Tennis leg (plantaris muscle rupture, usually at the myotendinous junction)

Note: Focal fluid collection/edema between the soleus and medial head of gastrocnemius.

83
Q

Plantaris rupture (AKA tennis leg) is associated with what other injury?

84
Q
A

Calcaneal tuberosity avulsion fracture

Note: Usually seen in diabetes.

85
Q

Avulsion fractures of the calcaneal tuberosity are associated with…

86
Q
A

Avulsion fracture of a plantar calcaneal spur, suspicious for plantar fascia rupture

87
Q
A

Extensor digitorum brevis avulsion fracture from its calcaneal attachment

Note: Anterolateral calcaneal avulsion fracture.

88
Q
A

Cuboid avulsion fracture at the insertion site of the calcaneocuboid ligament insertion

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