Orthopedics Foot/Ankle

Question 1

Normal Anatomy Foot

Answer 1

Question 2

Foot/Ankle PE Inspection

• Inspection
  
  • Both ankles appear symmetric?
  • Swelling / Effusions?
  • Equinus =
  • B______
  • Pes planus =
• Tenderness to palpation?
  
  • B___ or l______ tenderness?
• ROM: dorsiflexion = /plantar flexion = /inversion/eversion
• Distal ______vascular exam
• Stability: Anterior/Posterior/Varus = /Valgus =
• _______ test for ankle sprain (syndesmosis)

Answer 2

• Inspection
  
  • Both ankles appear symmetric?
  • Swelling / Effusions?
  • Equinus = limited upward bending motion of foot towards front of leg
  • Bunion = bony bump that forms at the base of the toe
  • Pes planus = flat foot
• Tenderness to palpation?
  
  • Bone or ligament tenderness?
• ROM: dorsiflexion (up) /plantar flexion (down) /inversion/eversion
• Distal neurovascular exam
• Stability: Anterior/Posterior/Varus = towards midline/Valgus = away from midline
• Squeeze test for ankle sprain (syndesmosis)

Question 3

Common Conditions (1 slide each)

(9)

Answer 3

Ankle sprain

Ankle fracture

5th metatarsal fracture

Flat feet (pes planus) / posterior tibial tendon dysfunction

Bunion (hallux valgus)

Plantar fasciitis / heel spurs

Intoeing

Shin splints (not really foot/ankle…)

Tibial stress fracture

Question 4

Ankle Sprain

Very common tw_____ injuries to the ankle that are the most common reason for missed ______ participation.

• Diagnosis can be made clinically with (1) and (1) of the ankle and ____ with range of motion. Radiographs are only indicated when clinical examination meets criteria (Ottawa ankle rules).
  
  • inability to _____ weight
  • medial or lateral malleolus point _______
  • __th M______ base tenderness
  • n______ tenderness
  • 96-99% sensitive in ruling out ankle _____

Answer 4

Very common twisting injuries to the ankle that are the most common reason for missed athletic participation.

• Diagnosis can be made clinically with swelling and ecchymosis of the ankle and pain with range of motion. Radiographs are only indicated when clinical examination meets criteria (Ottawa ankle rules).
  
  • inability to bear weight
  • medial or lateral malleolus point tenderness
  • 5th MT base tenderness
  • navicular tenderness (middle foot)
  • 96-99% sensitive in ruling out ankle fracture

Question 5

Ankle Sprain

• Treatment usually includes a brief period of ______ followed by early functional (1) . Rarely, _____ management is indicated in the setting of syndesmosis injury with tibiofibular diastasis or chronic ankle instability with recurrent sprains.
• Ligament (1) (most common), _____ injuries much more common than medial
  
  • Inversion injury
• “_____ Test” can help to rule-out a syndesmotic injury, sometimes called a “high ankle sprain”
  
  • “Squeeze” fibula and tibia ~____-calf → + test ?

Answer 5

• Treatment usually includes a brief period of immobilization followed by early functional physical therapy. Rarely, operative management is indicated in the setting of syndesmosis injury with tibiofibular diastasis or chronic ankle instability with recurrent sprains.
• ATFL (most common), lateral injuries much more common than medial
  
  • Inversion injury
• “Squeeze Test” can help to rule-out a syndesmotic injury, sometimes called a “high ankle sprain”
  
  • “Squeeze” fibula and tibia ~mid-calf → + test is pain at the ankle

Question 6

Ankle Fracture

• Another huge topic!
• All fractures should be ______
• Ankle fractures are very common injuries to the ankle which generally occur due to a t______ mechanism.
• Diagnosis is made with ortho_____ radiographs of the ankle.
• Treatment can be nonoperative or operative depending on fracture displacement, ankle st_____, syn_____ injury, and patient a_____ demands.
• Focus your exam to determine if the tenderness is over the ____ (i.e. medial or lateral malleolus) or distal (_______)

Answer 6

• Another huge topic!
• All fractures should be referred
• Ankle fractures are very common injuries to the ankle which generally occur due to a twisting mechanism.
• Diagnosis is made with orthogonal radiographs of the ankle. (views obtained 90 degrees from initial view)
• Treatment can be nonoperative or operative depending on fracture displacement, ankle stability, syndesmosis injury, and patient activity demands.
• Focus your exam to determine if the tenderness is over the bone (i.e. medial or lateral malleolus) or distal (ligament)

Question 7

5th Metatarsal Fracture

Among the most common fractures of the foot and are predisposed to poor h______ due to the limited _____ supply to the specific areas of the 5th metatarsal _____.

• Diagnosis is made with p_____ radiographs of the foot.
• Treatment can include protected weight ______, im_______ or s______ depending on location of fracture, degree of dis_____, and ath_____ level of patient.
• Appropriate to refer ____ fractures
• Take home: Location (____ supply) affects treatment
• “Pseudo Jones” v. “True Jones” =

Answer 7

• Among the most common fractures of the foot and are predisposed to poor healing due to the limited blood supply to the specific areas of the 5th metatarsal base.
• Diagnosis is made with plain radiographs of the foot.
• Treatment can include protected weight bearing, immobilization or surgery depending on location of fracture, degree of displacement, and athletic level of patient.
• Appropriate to refer all fractures
• Take home: Location (blood supply) affects treatment
• “Pseudo Jones” = intra articular fracture v. “True Jones” = true jones is an extra-articular fracture

Question 8

Pes Planus/Posterior Tibial Tendon Insufficiency

• Most common cause of adult-acquired ____ foot deformity
• Caused by attenuation and tenosynovitis of the (1) tendon leading to medial ____ collapse.
• Diagnosis can be made clinically with loss of medial arch of the foot which may progress to hindfoot v____, forefoot ___duction and subsequent development of midfoot osteo______.
• Treatment is nonoperative with orthotics and ankle b____ in early stages. A variety of surgical options are available and indicated for progressive and ri_____ deformities, subtalar or midfoot ar_____, and failure of nonoperative management.
• Okay to refer a patient with ______ or questions about flat feet (______ is usually a ost appropriate first referral)

Answer 8

• Most common cause of adult-acquired flatfoot deformity
• Caused by attenuation and tenosynovitis of the posterior tibial tendon leading to medial arch collapse.
• Diagnosis can be made clinically with loss of medial arch of the foot which may progress to hindfoot valgus, forefoot abduction and subsequent development of midfoot osteoarthritis.
• Treatment is nonoperative with orthotics and ankle braces in early stages. A variety of surgical options are available and indicated for progressive and rigid deformities, subtalar or midfoot arthritis, and failure of nonoperative management.
• Okay to refer a patient with complaints or questions about flat feet (podiatry is usually a most appropriate first referral)

Question 9

Bunion/Hallux Valgus

• Complex v_____ deformity of the first ray that can cause medial ___ toe pain and difficulty with s___wear.
• Diagnosis is made _____ with presence of a hallux that rests in a valgus and ____nated position.
• Radiographs of the foot are obtained to identify the s____ of the disease and for surgical planning.
• Treatment can be nonoperative with _____ modifications for mild and minimally symptomatic cases._____ management is indicated for progressive deformity and difficulty with shoe wear.

Answer 9

• Complex valgus deformity of the first ray that can cause medial big toe pain and difficulty with shoe wear.
• Diagnosis is made clinically with presence of a hallux that rests in a valgus and pronated position.
• Radiographs of the foot are obtained to identify the severity of the disease and for surgical planning.
• Treatment can be nonoperative with shoe modifications for mild and minimally symptomatic cases. Surgical management is indicated for progressive deformity and difficulty with shoe wear.

Question 10

Plantar Fasciitis/Heel Spurs

Painful heel condition caused by inflammation of the plantar fascia apo_____ at its origin on the ______.

• Diagnosis is made clinically with tenderness to _______ at the ______ tuberosity of the calcaneus that worsens with _____lexion of the toes and foot.
• Treatment is a prolonged course of ____ control, achilles/plantar fascia st______, and orthotics.
• ______, surgical management is indicated in the case of progressive symptoms that fail nonoperative management.
• Often a patient will describe pain with ____ steps out of ____
• Sometimes associated with a heel s_____ (chicken/egg…)
• Gel heel _____!

Answer 10

Painful heel condition caused by inflammation of the plantar fascia aponeurosis at its origin on the calcaneus.

• Diagnosis is made clinically with tenderness to palpation at the medial tuberosity of the calcaneus that worsens with dorsiflexion of the toes and foot.
• Treatment is a prolonged course of pain control, achilles/plantar fascia stretching, and orthotics.
• Rarely, surgical management is indicated in the case of progressive symptoms that fail nonoperative management.
• Often a patient will describe pain with first steps out of bed
• Sometimes associated with a heel spur (chicken/egg…)
• Gel heel cups!
• Notes: Plantar aponeurosis is the modification of Deep fascia, which covers the sole. It is a thick connective tissue, that functions to support and protect the underlying vital structures of the foot. The fascia is thick centrally, known as aponeurosis and is thin along the sides.*

Question 11

Intoeing

1 of 3 causes, which one is this describing?

• 3-6 years (“W” sitters)
• Internal rotation >70 degrees and < 20 degrees of external rotation
• Treatment is observation with parental reassurance as most cases resolve by age 10.
• Rarely, surgical management is indicated in the presence of less than 10° of hip external rotation in children greater than 10 years of age.

Answer 11

Femoral Anteversion

Question 12

Intoeing

1 of 3 causes, which one is this describing?

• Most common cause in <4 yo
• Diagnosis: Thigh-foot angle > 10 degrees internal
• Usually resolves by age 4 (no treatment)
• Surgical management is indicated in children > 6-8 years of age with functional problems and thigh-foot angle >15 degrees.

Answer 12

Internal Tibial Torsion

Question 13

Intoeing

1 of 3 causes, which one is this describing?

• Infants (usually noticed in first year of life)
• Medial deviation of the forefoot (abnormal heel bisector), normal hindfoot
• 90% resolve spontaneously by age 4

Answer 13

Metatarsus Adductus

Question 14

Intoeing

Overall is complicated, so if in doubt, very reasonable to refer to a?

Answer 14

Pediatric orthopedic surgeon for a consultation

Question 15

Shin Splints (Tibial Stress Syndrome)

An _____ injury or r_______-load injury of the shin area that leads to persistent dull _____ leg pain.

• Diagnosis is made clinically with tenderness along the anterolateral or posteromedial distal _____.
  
  • Common in r______
  • Radiographs or bone scans may be obtained to rule out stress ______.
• Treatment is generally nonoperative with (3)
• Etiology: Tr______ periostitis
  
  • (1): tibialis anterior on tibia and interosseous membrane
  • (1): traction periostitis of tibialis posterior and soleus

Answer 15

An overuse injury or repetitive-load injury of the shin area that leads to persistent dull anterior leg pain.

• Diagnosis is made clinically with tenderness along the anterolateral or posteromedial distal tibia.
  
  • Common in runners
  • Radiographs or bone scans may be obtained to rule out stress fractures.
• Treatment is generally nonoperative with NSAIDs, rest and activity modifications.
• Etiology: Traction periostitis
  
  • Anterolateral: tibialis anterior on tibia and interosseous membrane
  • Posteromedial: traction periostitis of tibialis posterior and soleus

Question 16

Tibial Stress Fractures

• In the differential for shin splints…

An overuse injury where bone is subjected to repetitive stress, resulting in microfractures.

• Diagnosis can often be made on radiographs alone but ____ studies should be obtained in patients with normal radiographs with a high degree of suspicion for stress fracture.
• Treatment is a______ restriction with _______ weight-bearing in most cases.
• Surgical intramedullary nailing is recommended in the presence of an anterior tibia tension-sided stress ______(“dreaded _____ line”)

Answer 16

• In the differential for shin splints…

An overuse injury where bone is subjected to repetitive stress, resulting in microfractures.

Diagnosis can often be made on radiographs alone but MRI studies should be obtained in patients with normal radiographs with a high degree of suspicion for stress fracture.

• Treatment is activity restriction with protected weight-bearing in most cases.
• Surgical intramedullary nailing is recommended in the presence of an anterior tibia tension-sided stress fracture (“dreaded black line”)