Orthopaedics - ankle & foot

Question 1

Achilles tendonitis

Answer 1

Inflammation of the Achilles tendon
More prevalent in those who engage in high-intensity activities which chronically overload the tendon

Question 2

Achilles tendonitis & rupture pathophysiology

Answer 2

Achilles tendon = gastrocnemius, soleus & plantaris, inserts in to the calcaneus -> produces plantarflexion
Repetitive action of the tendon results in microtears leading to localised inflammation
Over time, the tendon becomes thickened, fibrotic & loses elasticity with repeated episodes
Achilles tendon rupture -> substantial sudden force is applied across the tendon
- Precipitating event could be a movement eg. sudden jump/rapid change in direction whilst running

Question 3

Achilles tendonitis/rupture risk factors

Answer 3

Unfit individual who has a sudden increase in exercise frequency
Poor footwear choice
Male gender
Obesity
Recent fluoroquinolone use

Question 4

Achilles tendonitis clinical features

Answer 4

Gradual onset of pain & stiffness in the posterior ankle, often worse with movement
Usually be improved with PT/heat application
Examination – tenderness, over the tendon on palpation, with pressure over the tendon with your fingers reproducing this pain

Question 5

Achilles rupture clinical features

Answer 5

Patients will often describe sudden-onset severe pain in the posterior calf, accompanied with an audible popping sound & feeling that something went
Examination – marked loss of power of ankle plantarflexion

Question 6

Simmonds test

Answer 6

With the patient kneeling on a chair, with the affected ankle hanging off the edge of the chair, squeeze the affected calf
If the Achilles tendon is in continuity, the foot will plantarflex, however plantarflexion is absent when the tendon is ruptured

Question 7

Achilles tendonitis & rupture investigations

Answer 7

Clinical diagnoses
USS may be required – particularly useful to differentiate complete and partial tears

Question 8

Achilles tendonitis management

Answer 8

Supportive measures – stop the precipitating exercise, ice, anti-inflammatory medication regularly
Chronic – require rehab & PT

Question 9

Achilles rupture management

Answer 9

Acute partial-thickness or full-thickness Achilles tendon rupture requires analgesia and immobilisation with the ankle splinted in a plaster in full equinus (ankle and toes maximally pointed)
Provided with crutches and not allowed to weight bear
Position is held for 2 weeks, following this, the ankle is brought in to ‘semi-equinus’ & held for a further 4 weeks, after this the ankle is brought in to the neutral position & held again for 4 weeks
Delayed presentations (> 2 weeks)/cases of re-rupture require surgical fixation with an end-to-end tendon repair

Question 10

Ankle fractures classification

Answer 10

Can be described as isolated lateral malleolar fractures, isolated medical malleolar fractures, bimalleolar fractures & trimalleolar fractures
Most common classification is Weber – classifies lateral malleolar fractures:
- Type A = below the syndesmosis
- Type B = at the level of syndesmosis
- Type C = above the level of the syndesmosis
The more proximal the injury, the higher the likelihood of ankle instability

Question 11

Ankle fractures clinical features

Answer 11

Ankle pain following a traumatic injury
May be associated deformity
May have neurovascular compromise
Can be open fractures

Question 12

Ottawa ankle rules

Answer 12

Used when there is diagnostic uncertainty
Plain radiographs may be undertaken:
1) Bone tenderness at the posterior edge/tip of the lateral malleolus OR
2) Bone tenderness at the posterior edge/tip of the medial malleolus OR
3) Inability to bear weight both immediately & in ED for 4 steps

Question 13

Ankle fractures investigations

Answer 13

Plain radiographs – AP, lateral & mortise views -> check the joint space for uniformity, ensuring no evidence of talar shift
Complex fractures – require a CT scan for surgical planning

Question 14

Ankle fractures initial & conservative management

Answer 14

Initial – immediate fracture reduction usually performed under sedation in ED to realign the fracture
Once reduced, ankle should be placed in a below knee back slab -> repeat & document post-reduction neurovascular examination
Request a repeat plain film radiograph
Conservative management for:
- Non-displaced medial malleolus fractures
- Weber A/Weber B fractures without talar shift
- Unfit for surgical intervention

Question 15

Ankle fractures surgical management

Answer 15

ORIF is often required in ankle fractures:
- Displaced bimalleolar/trimalleolar fractures
- Weber C fractures
- Weber B fractures with talar shift
- Open fractures

Question 16

Ankle fractures complications

Answer 16

Post-traumatic arthritis
Those who have undergone an ORIF -> surgical site infection, DVT/PE, neurovascular injury, non-union & metalwork prominence

Question 17

Ankle sprain

Answer 17

Ligamentous injuries
High – injuries to the syndesmosis
Low – injuries to the anterior talofibular ligament & the calcaneofibular ligament
Present following an inversion injury on a plantarflexed ankle, swelling & pain, fingertip tenderness distal to the malleoli
Imaging of choice is with plain film radiographs, nearly all can be managed conservatively with analgesia, ice & elevation following by early mobilisation

Question 18

Calcaneal fracture classification

Answer 18

Intra-articular – involves the articular surface of the subtalar joint
Extra-articular – commonly are avulsion fractures with sparing of the articular surface of subtalar joint

Question 19

Calcaneal fracture clinical features

Answer 19

Recent trauma
Pain and tenderness around the calcaneal region with an inability to weigh bear
Examination – region will be significantly swollen & bruised, with potential for a shortened & widened heel
Important to assess for posterior heel skin integrity

Question 20

Calcaneal fracture investigations

Answer 20

Plain film radiograph – AP, lateral & oblique views
CT imaging is gold standard for assessing calcaneal fractures & should be performed in any suspected case

Question 21

Calcaneal fracture management

Answer 21

Majority of intra-articular calcaneal fractures – require surgical intervention
Certain extra-articular fractures will be treated non-operatively, with cast immobilisation & non-weight bearing for 10-12 weeks
Surgical intervention – closed reduced with percutaneous pinning can be attempted for large but minimally displaced fractures
ORIF is usually required for most calcaneal fractures
Any fracture with skin compromise warrants emergency surgical fixation

Question 22

Calcaneal fracture complications

Answer 22

Subtalar arthritis

Question 23

Hallux valgus

Answer 23

Deformity at the first metatarsophalangeal joint
Characterised by medial deviation of the first metatarsal & lateral deviation +/- rotation of the hallux with associated joint subluxation

Question 24

Hallux valgus risk factors

Answer 24

Female
Connective tissue disorders
Hypermobility syndromes
Anatomical variants – long first metatarsal bone, mal-alignment of the first MTP joint and flat feet

Question 25

Hallux valgus clinical features

Answer 25

Painful medial prominence, likely aggravated by walking, weight-bearing activities or wearing narrow toed shoes Examination – assess position & lateral deviation of the hallux, ensure assessed in both a non-weightbearing position and weightbearing position, ROM and crepitus Contracture of the extensor hallucis longus tendon may be visible in longstanding joint subluxation & any excessive keratosis

Question 26

Hallux valgus investigations

Answer 26

Main investigation – radiographic imaging

Question 27

Hallux valgus management

Answer 27

Sufficient analgesia Adjusting footwear, PT Surgical management – quality of life is significantly impacted - Lots of different procedures possible: Chevron, Scarf, Lapidus, Keller procedure - Complications: wound infection, delayed healing, nerve injury, osteomyelitis

Question 28

Hallux valgus complications

Answer 28

Avascular necrosis Non-union Displacement Reduced ROM

Question 29

Lisfranc injuries

Answer 29

Severe injuries to the tarsometatarsal joint between the medial cuneiform and base of the 2nd metatarsal – can be solely ligamentous injuries/involving the bony structures of the midfoot

Question 30

Lisfranc injuries clinical features

Answer 30

Most commonly occur following severe torsional/translational forces applied through a plantar flexed foot Severe pain in the midfoot & difficulty in weight-bearing Examination – swelling and tenderness over the midfoot, plantar bruising is highly suggestive of a Lisfranc injury Monitor for features of compartment syndrome

Question 31

Lisfranc injuries investigations

Answer 31

Plain film radiograph – AP, oblique & lateral foot views CT scanning – useful in the pre-operative planning of more comminuted fractures MRI imaging can confirm the presence of purely ligamentous injury

Question 32

Lisfranc injuries initial & conservative management

Answer 32

Significantly displaced injuries – closed reduction may be required in A&E, place in a backslab Certain injuries without significant displacement can be primarily managed conservatively with cast immobilisation/air-cast boot & non-weight bearing mobilisation for 6-12 weeks with regular ortho follow-up and review

Question 33

Lisfranc injuries surgical management

Answer 33

If clear displacement must be managed operatively Screw fixation = definitive fixation Primary arthrodesis can be used for severely comminuted/displaced fracture-dislocations

Question 34

Lisfranc injuries complication

Answer 34

Post-traumatic arthritis – delayed management by ORIF/non-anatomical reduction Midfoot compartment syndrome

Question 35

Plantar fasciitis

Answer 35

Inflammation of the plantar fascia of the foot Common condition & can be unilateral/bilateral

Question 36

Plantar fasciitis pathophysiology

Answer 36

Micro-tears to the plantar fascia occur, suggesting a chronic breakdown of the structure Individuals may be predisposed to the condition from any anatomical abnormality -> can result in an asymmetric loading on the plantar fascia

Question 37

Plantar fasciitis risk factors

Answer 37

Anatomical factors – excessive pronation/pes cavus (high arches) Weak plantar flexors or tight gastrocnemius/soleus Prolonged standing or excessive running Leg length discrepancy Obesity Unsupportive footwear

Question 38

Plantar fasciitis clinical features

Answer 38

Sharp pain across the plantar aspect of the foot Often felt more severely in the heel & can radiate down the arch distally Classically it tends to be worst with the first few steps of the day/periods of inactivity Examination – evidence of over-pronation, high arches, leg length discrepancy or femoral anteversion Infracalcaneal region if commonly tender on palpation

Question 39

Plantar fasciitis investigations

Answer 39

Clinical diagnosis Plain radiographs can be done to exclude bony injury & assess for a plantar heel spur MRI is occasionally indicated if ongoing uncertainty

Question 40

Plantar fasciitis conservative management

Answer 40

Activity moderation & regular analgesics forms the mainstay of management Footwear should be adjusted PT

Question 41

Plantar fasciitis surgical management

Answer 41

Corticosteroid injection can be trialled if no improvement to conservative management No improvement, plantar fasciotomy can be considered

Question 42

Talar fractures

Answer 42

Second most common tarsal bone to fracture Typically occur following high-energy trauma, eg. fall from height or road traffic accident, during which the ankle is forced in to dorsiflexion -> talus presses against the tibial plafond, resulting in a fracture High risk of avascular necrosis due to interruption of the extraosseous arterial supply

Question 43

Talar fractures clinical features

Answer 43

Patients will present with a history of high-impact trauma Immediate pain and swelling around the ankle Clear deformity if talus is dislocated Examination – unable to dorsiflex/plantarflex, check if open fracture, assess distal neurovascular status

Question 44

Talar fractures investigations

Answer 44

Plain film radiographs – AP, lateral (taken in dorsiflexion & plantarflexion) CT imaging for more complex injuries

Question 45

Talar fractures management

Answer 45

Depends on their Hawkins classification All undisplaced may be managed conservatively in a non-weight bearing orthosis, whereas all displaced fractures require immediate reduction & subsequent surgical repair Type I – treated conservatively in a plaster with non-weight bearing crutches for approx.. 3 months -> region should be assessed for evidence of union & AVN in fracture clinic Type II to IV fractures – initially managed with attempted closed reduction in the ED, repeat radiographs Definitive surgical fixation, post operatively will require an extended period of non-weight bearing

Question 46

Talar fractures complications

Answer 46

Avascular necrosis OA

Question 47

Tibial pilon fractures

Answer 47

Severe injuries affecting the distal tibia Caused by high energy axial loads as the tibial plafond is injured by the talus punching up into it Characterised by articular impaction, severe comminution & often associated with considerable soft tissue injury Complex injuries & often require specialist input

Question 48

Tibial pilon fractures clinical features

Answer 48

History of trauma, severe ankle pain and inability to weight bear Examination – obvious ankle deformity, with associated significant swelling & bruising are common Evidence of an open fracture, signs of compartment syndrome, peripheral pulses & peripheral nerve examination

Question 49

Tibial pilon fractures investigations

Answer 49

Urgent bloods – coagulation & group and save Imaging – plain film radiographs with AP, lateral and mortise views, full length views of tibia and knee are required CT is often required for pre-op planning

Question 50

Tibial pilon fractures initial management

Answer 50

Realignment of the limb & below-knee backslab Repeat neurovascular assessment & check plain film radiographs should be performed, limb must be elevated and monitored for compartment syndrome Simple undisplaced fractures may be treated non-operatively, but surgical management is preferred

Question 51

Tibial pilon fractures surgical management

Answer 51

Aims to reconstruct the articular surface, restore the alignment of the ankle mortise & protect the soft tissues around the ankle joint Application of temporary spanning external fixator followed by definitive fixation (ORIF) 7-14 days later once the soft tissues have had opportunity to heal Definitive fixation is best performed under traction

Question 52

Tibial pilon fractures complications

Answer 52

Compartment syndrome Wound infection or dehiscence Delayed or non-union Post-traumatic arthritis