T&O - ankle and foot Flashcards
What makes up the ankle joint?
- Talus bone articulates with the mortise (medial and lateral malleolus)
- Tibia and fibula join at the syndesmosis - a strong sutrcutre comprised of anterior inferior tibiofibular ligament and posterior inferior tibiofibular ligament
How are ankle fractures classed anatomically?
- Isolated lateral malleolar
- Isolated medial malleolar
- Bimalleolar (medial + lateral)
- Trimalleolar (medial + lateral + posterior malleolar)
How can lateral malleolar fractures be further classified?
Weber Classification
- Type A - below the syndesmosis
- Type B - at the level of the syndesmosis
- Type C - above the level of the syndesmosis
How does the location of lateral malleolar fractures affect the management?
- More proximal fractures have highter chance of ankle instability
- Therefore type C fractures almost always need surgical fixation
How do patients present if they have an ankle fracture?
- Traumatic injury followed by ankle pain
- May be an associated deformit
- May have neurovascular compromise if very deformed
What are the Ottawa ankle rules?
If there is any uncertainty e.g. no deformity but cannot monbilise ankle use these rules. Presence of any of the features means plan radiographs must be taken
In what situations can the Ottawa ankle rules not be applied?
- Intoxicated/ Uncooperative
- Other distracting painful injuries
- Diminished leg sensation
- Gross swelling
How are suspected ankle fractures investigated?
Plain radiograph AP and Lateral
Ankle must be in full dorsiflexion when the X-Ray is taken
Which patients are managed conservatively for ankle fractures?
- Non-displaced medial malleolus fractures
- Weber A or B fractures without talar shift
- Patients unfit for surgery
When is ORIF indicated for ankle fractures?
- Displaced bimalleolar or trimalleolar fractures
- Weber C classifications
- Weber B classifications with talar shift
- Open fractures
What complications can follow an ankle fracture?
- Post traumatic arthritis (Rare if appropriately reduced and fixated)
-
If undergone ORIF:
- Surgical site infection
- DVT
- PE
- Neurovascular injury
- Non union
- Metalwork prominence
Which tarsal bone is the most commonly fractured?
Calcaneum
By what mechanism do calcaneal fractures occur?
Usually a fall from high with significant axial loading onto the bone
How are calcaneal fractures divided on the basis of subtalar involvement?
-
Intra-articular (75% of calcaneal fractures)
- involves articular surgace of the subtalar joint
-
Extra-articular (25% of calcaneal fractures) \
- These are commonly avlusion fractures includin avulsion of the calcaneal tuberosity by the achilles tendon
How do calcaeneal fractures appear clinically?
- Recent trauma eg fall from height or RTA
- Pain and tenderness around calcaneal region
- Inability to weight bear
- O/E : swollen, bruised with potential shortened and widened heel
- May have varus deformity
What imaging should be done in suspected calcaneal fracutres?
- Plain radiograph: AP, lateral and oblique views
- CT imaging is the gold standard and should be done in any syspected case
How are calcaneal fractures managed?
Majority intra-articular fractures require surgical intervention unless <2mm displaced or a near normal Bohler’s angle
Extra-articular fractures are treated non-operatively unless there is significant displacement. Cast + NWB for 10-12 weeks
What is achilles tendonitis?
Inflammation of the achilles tendon
Prevalent in those who engage in high intensity activities causing the tendon to chronically overload
Describe the pathophysiology behind achilles tendonitis?
- Repetitive action of the tendon causes microtears leading to localised inflammation
- Overtime the tendon becomes thickened and loses elasticity
- Rupture can aoocur when a sudden force is aplplied across the tendon
What are some of the risk factors for achilles tendonitis or rupture?
- Unfit individuals who have a sudden increase in exercise frequency
- Poor footwear
- Male
- Obesity
- Recent floroquinolone use
What are the clinical features of achilles tendonitis?
- Gradual onset of pain and stiffness at the posterior ankle
- Worse with movement
- Can imprve with mild exercise or heat application
- O/E there is tenderness over the tendon, usually worst 2-6cm above insertion site
What clinical test can be done to indicate achilles tendon rupture?
Simmond’s Test
Where do the majority of talar fractures occur anatomically?
- 50% are through the talar neck
- Less commonly through the body, lateral or posterior process
How are talar fractures classified?
Hawkins Classification
What is a talar pilion fracture?
Severe injury to the distal tibia that are articularly impacted and severly comminuted
How are Pilon fractures classified?
What are Lisfranc injuries?
Severe injury to the tarsometatarsal joints can be solely ligamentous or involve the bony structures of the midfoot
How are Lisfranc injuries managed?
- Ensure haemodynamic stability
- Closed reduction in A&E to correct any cross deformity
- Conservative management can be done if there is no significant displacement (cast immobilisation + non weight bearing for 6-12 weeks)
- Surgical fixation usually a screw between medial cuneiform and 2nd metatasal if there is clear displacement
What is Hallux Valgus?
Deformity of the 1st metatarsophalangeal joint with medial deviation of the 1st metatarsal and associated joint subluxation
What is plantar fasciitis? Describe the pathophysiology
Inflammation of plantar fascia - connective tissue from medial process of calcaneal tuberosity to the proximal phalanges causing infracalcaneal pain
Theory: micro-tears to the plantar fascia occur causing chronic breakdown of the structure
How is plantar fasciitis diagnosed?
Clinically - investigations only done if there is a doubt in the diagnois
Plain X-rays can be done to exclude bony injury if there is a history of trauma - may see a heel spur in 50% of plantar fasciitis cases
