T&O ankle and foot Flashcards
What is the definition of an ankle fracture?
Fracture of any malleolus (lateral, medial or posterior) with or without disruption to the syndesmosis
Tibial articular surface (plafond) fracture is not an ankle fracture this is a Pilon fracture
What is the ankle syndesmosis?
Fibrous structure consisiting of anterior inferior tibofibular ligament (AITFL) and posterior inferior tibiofibular ligament (PIFL) and interosseous mebrane
How are ankle fractures managed?
A
- Immediate reduction under sedation in A+E then put on below knee back slab
Repeat post reduction neurovascular exam
Repeat plain film radiography
Conservative
If non-displaced medial malleolus fracture, Weber A, Weber B without talar shift, those for surgical intervention
Below knee back slab for a week then bring back for x-ray and full cast
Surgical
ORIF if displaced bi/trimalleolar, Weber C, Weber B with talar shift, open fractures
What are the complications with ankle fractures?
Post traumatic arthritis (rare if appropriate reduction and fixation)
- ORIF: surgical site infection, DVT/PE, neurovascular injury, non-union, metalwork prominence
How are ankle sprains produced and how are they managed?
- High ankle sprain: to the syndesmosis
- Low ankle sprain: damage to ATFL and CFL
Usually due to inversion injury. Fingertip tendeness distal to malleoli, swelling and pain
Get plain film radiograph to rule out bony injury then RICE and early mobilisation
How do calcaneal fractures present?
Recent trauma
Pain and tenderness around calcaneal region
Inability to weight bear
Swollen and bruised
Shortened and widened heel
Varus deformity
Assess posterior heel skin integrity (any tenting or blanching needs emergency surgical intervention)
How are calcaneal fractures managed?
Conservative (<2mm displacement or normal Bohler’s angle)
- Cast immobilisation and no weight bearing for 10-12 weeks
Surgical
- Closed reduction with percutaneous pinning if large fracture but minimal displacement
- ORIF otherwise
- Emergency surgical fixation if any skin compromise
What are some complications with a calcaneal fracture?
Subtalar arthritis that can be treated with analgesia and physio. If unsuccessful with need subtalar arthrodesis
What is the pathophysiology of achilles tendonitis and achilles tendon rupture and what are some risk factors for this?
Repetitive action of tendon results in microtears leading to local inflammtion. Tendon becomes thickened, fibrotic and loses elasticity
Rupture occurs when substantial sudden force (e.g change in direction runnin) applied to tendon when already has tendonitis
Risk factors: unfit individual with sudden increase in exercise, poor footwear choice, male gender, obesity, fluoroquinolone use
How is Achilles tendon rupture investigated and managed?
Ix
Usually clinical but can use US if not sure
Mx
Tendonitis: stop precipitating exercise, NSAIDs, if chronic physiotherapy
Rupture: Analgesia and immobilisation in a plasta full equinus with crutches and no weight bearing. Hold position for 2 weeks then semi-equinus for 4 weeks then neutral for 4 weeks
Delayed presentation (>2 weeks) or rerupture needs surgical fixation with end to end tendon repair
How are talar fractures investigated and classified?
- AP and Lateral plain film radiographs in both dorsi and plantarflexion. Plantar reduces any subluxation present
- CT imaging if complex
- Hawkins Classification used for talar neck fractures to determine risk of AVN
How are talus fractures managed?
Depends on Hawkins class
Type I (Non displaced)
Conservative with plaster and non-weight bearing crutches for three months. Check for evidence of union and AVN in fracture clinic
Type II to IV
Initial closed reduction in A+E, put in cast and repeat radiograph. Then surgical fixation on next available list then period of non-weight bearing
What are some complications of talus fractures?
- AVN (especially in Hawkins II to IV)
- OA secondary to AVN or non-union which may need arthrodesis. Hawkins sign lucency is good predictor of low risk AVN at 6-8 weeks
How is a tibial pilon fracture managed?
Realignment and then put in below knee back slab
Repeat neurovascular assessment and plain film radiographs
Keep limb elevated
Monitor for compartment syndrome
Keep NBM with IV fluids in preparation for surgery
- Temporary spanning external fixator then ORIF 1-2 weeks later so soft tissue had time to heal. ORIF best done under traction
What are some complications of tibial pilon fracture surgixal repair?
Compartment syndrome
Wound infection or dehiscence
Delayed or non union
Post traumatic arthritis
What is a Lisfranc injury?
Severe injuries to lisfranc joint (medial cuneiform and base of second metatarsal) which can be ligamentous or bony
Often missed as subtle radiological features but crucial to diagnose as can lead to ongoing midfoot pain, instability and deformity
How are Lisfranc injuries managed?
ATLS protocol to ensure haemodynamic stability
- Closed reduction in A+E with gentle traction to midfoot and then backslab
- Conservative: if non-displaced then cast/air cast boot immobilisation then non-weight bearing mobilisation for 6-12 weeks
- Surgical: temporary external fixation until soft tissue swelling has gone down. then screw fixation or if severely comminuted primary arthrodesis
What are the complications of a Lisfranc Injury?
Post traumatic arthritis (more common in delayed ORIF and will need midfoot arthrodesis)
Midfoot compartment syndrome
What is hallux valgus and the pathophysiology of this?
Deformity of the 1st MTPJ where there is medial deviation of the first metatarsal and lateral deviation of the hallux with joint subluxation
More common in woman aged >65, wearing high heels/narrow footwear as holds foot in valgus positon
Metatarsal head escapes intrinsic anatomical control and extrinsic tendons cause metatarsal head to drift mediallly so bone proliferates on medial aspect of head of metatarsal and cartilage remodels
How does hallux valgus present?
- Painful medial prominence aggravated by walking and wearing narrow toes shoes
Make sure to assess foot non-weight bearing and weight bearing. Check range of movement (active and passive, should be no transverse movement in normal) and crepitus
How is hallux valgus investigated?
Plain film radiograph to look for lateral deviation and subluxation
Diagnosed when angle between first metatarsal and first proximal phalanx is greater than 15 degrees
How is hallux valgus managed?
Sufficient analgesia, adjust footwear, orthosis if flat feet, physiotherapy
Surgical: metatarsal osteotomy, only done if pain symptoms not just for cosmetic as this procedure can make pain worse
What are some complications of hallux valgus and surgical treatment of this deformity?
Hallux Valgus: AVN, non-union, displacement, reduced ROM
Surgery: wound infection, delayed healing, nerve injury, osteomyelitis
What is pes planovalgus?
Loss of medial longitudinal arch leading to flat foot
Due to posterior tibialis tendon deformity
- Pain behind medial malleolus
Usually affects middle aged women
