The Ankle & Foot

Question 1

What makes up the ankle?what is an ankle fracture?

Answer 1

Talus bone within the Mortise (tibial plafound, medial/ lateral malleoli) & fibula & tibia

Attached by strong fibrous syndesmosis

Fracture - fracture any maelleolus +/- disruption syndesmosis

Question 2

How can ankle fractures be classified?

Answer 2

Isolated medial malleus
Isolated L M
Bimalleolar
Trimalleolar (+posterior m)

Weber classification Lateral malleus fracture:
Type A below syndesmosis
B level of
C above

Question 3

Explain the Ottawa ankle rules

Answer 3

Clinical decision tool

Ankle plain film radiographs only required ankle fractures if pain in malleolar regions &:
- bone tenderness posterior edge/ tip LM
OR
- bone tenderness posterior edge/ tip MM
OR
- inability weight bear immediately & in emergency department 4 steps

Question 4

Management of ankle fractures

Answer 4

Fracture reduction usually under sedation - realign

-> below knee back slab -> repeat NV examination -> plain film radiograph

Conservative:
Non displaced MM
Weber A or B without talar shift
Unfit

Surgery:
ORIF

Question 5

How can ankle sprains be classified

Answer 5

Ligamentous injuries
High - anterior tibial fibular ligament
Low - calcaenofibular ligament, more common

Inversion injury in plantarflexed ankle
✅rice - early mobilisation

Question 6

What does the Achilles/ calcaeneal tendon unite?

Answer 6

Gastrocnemius
Soles
Plantaris
Inserts into calcaneus -> plantarflexion

Question 7

Which drug can increase the risk of Achilles’ tendon rupture?

Answer 7

Fluroquinolone

Question 8

What is the simmon’d’s test?

Answer 8

Assess potential Achilles’ tendon rupture
Kneeling affected ankle hanging off -
Squeeze affected calf - if tendon in continuity foot plantarflexion

Question 9

Management of Achilles’ tendon rupture

Answer 9

Initial
Analgesia
Immobilisation 
Splinted plaster
Crutches 
Equinus
2 weeks

Ankle brought semi equinus
4 weeks

Neutral position 4 weeks

Delayed presentation (>2wks) / re rupture - surgical fixation end to end tendon repair

Question 10

The talus I second most common tarsal bone to fracture, how would this occur? Where on the talus does it occur? What’s it at risk of?

Answer 10

High energy trauma e.g. fall height ankle forced in to dorsiflexion

59% through talar neck
Body/ lateral process/ posterior process

High risk avascular necrosis

Unable dorsiflexed or planatarflex

Question 11

Management of talar fractures depending on Hawkins classification

Answer 11

Type 1 - undisplaced - conservative plaster 3months crutches

Type 2 to 4 - subtalar dislocation (+tibiotalar dislocation + talonavicular d) closed reduction, cast, repeat radiographs
-> Definitive surgical fixation

Question 12

What is hallux valgus also called & what is it?

Answer 12

Bunion
Angle 1st MT & 1st proximal phalanx >15d
Deformity 1st MTPJ
Medial deviation 1st mt & lateral deviation +/- rotation hallux
Associated joint subluxation

35% >65yrs, women

Question 13

How does hallux valgus present?

Answer 13

Painful medial prominence
Aggravated walking, weight bearing, narrow shoes

Pain, creptiation - cartilage degeneration

Long-standing - EHL tendon visible, XS keratosis abnormal weight distribution

Question 14

Management of hallux valgus

Answer 14

Analgesia
Adjusting footwear
Orthosis - flat feet
PhysioT

Surgical (QOL impacted): 
Chevron procedure (v shaped oestomy)
Scarf procedure (longitudinal osteotomy) 
Lapdogs p (base 1st mt & medial cuneiform fused)
Keller P (remove diseased joint surfaces)

Question 15

Complications of hallux valgus

Answer 15

Avascular necrosis
Non union
Displacement
Reduced ROM

Question 16

What is plantar fasciitis? Who is more likely to get it?

Answer 16

Inflammation plantar fascia foot
Most common cause infracalcaneal pain (80% heel pain complaints)
Sharp pain heel

40-60yrs, obese, unsupportive footwear, prolonged running/ standing, weak plantar flexors, tight gastrocnemius/ soles, Xs pronation, leg length discrepancy

Thick fibrous CT band -> proximal phalanges

Micro tears