Ankle

Question 1

What are the 3 types of ankle fractures?

Answer 1

Uni-malleolar
Bi-malleolar
Tri-malleolar

Question 2

What is the definition of an ankle fracture?

Answer 2

A fracture of any of the malleoli with or without disruption to the syndesmosis

Question 3

What are the 3 components that make up the syndesmosis?

Answer 3

Anterior inferior tibiofibular ligament

Posterior inferior tibiofibular ligament

Intra osseous membrane

Question 4

What rules are used to determine whether imaging is required if you are unsure if there has been an ankle fracture?

Answer 4

Ottawa ankle rules

Question 5

When do the Ottawa ankle rules indicate you need a plain radiograph for an ankle injury?

Answer 5

Bone tenderness/pain on posterior edge or tip of lateral malleolus

Bone tenderness/pain on posterior edge or tip of medial malleolus

Inability to immediately weight bear or walk 4 steps in ED

Question 6

What are the 3 malleoli of the ankle?

Answer 6

Medial (tibia)
Lateral (fibula)
Posterior (tibia)

Question 7

What is the approach to managing and assessing an ankle fracture?

Answer 7

A-E

NV status
Analgesia
Stop weight bearing
Elevate leg (reduce swelling)
X-ray
NBM
Fluids

Question 8

What is the imaging of choice for assessing ankle fractures?

Answer 8

Plain radiograph of ankle

Question 9

What are the 3 x-ray views required to assess an ankle fracture?

Answer 9

AP
Lateral
Mortise (10 degrees internally rotated)

Question 10

What feature is visible on x-ray if there has been disruption to any of the syndesmosis?

Answer 10

Talar shift

Question 11

What is Talar shift?

Answer 11

When the talus translates so it no longer fits perfectly within the mortise of the tibia

Question 12

What is the Danis Weber classification of ankle fractures?

Answer 12

Describes the level of ankle fracture SPECIFICALLY LATERAL MALLEOLAR FRACTURES in relation to the syndesmosis

Question 13

What are the 3 categories of the Danis Weber classification of ankle fractures?

Answer 13

A
B
C

Question 14

What is a class A Danis Weber fracture?

How stable is this?

Answer 14

Fracture o the fibula below the level of the syndesmosis

The most stable class

Question 15

What is a class B Danis Weber fracture?

How stable is this?

Answer 15

Fracture at the level of the syndesmosis

Less stable than class A

Question 16

What is a class C Danis Weber fracture?

How stable is this?

Answer 16

Fracture above the level of the syndesmosis

Least stable class

Question 17

How do you treat/manage ankle fractures?

Answer 17

Analgesia

Fracture reduction (+post fracture x-ray and Neurovasular assessment)

Immobilise (conservative)

Surgical (ORIF)

Question 18

How are ankle fractures immobilised following reduction?

Answer 18

Below the knee back slab

Question 19

What ankle fractures can be managed conservatively (just below knee back slab)?
Once the fracture has stopped swelling, what is used to keep the ankle immobile?

Answer 19

Weber A fractures
Weber B with no talar shift

Non displaced medial malleolar fractures

Switch from Backslab to CAM boot for next 6ths

Question 20

What ankle fractures will require surgical management? (ORIF)

Answer 20

Weber B with talar shift
Weber C

Displaced bi or trimalleolar fractures

OPEN FRACTURES

Question 21

What are some complications of ankle fractures?

Answer 21

Inc risk post traumatic osteoarthritis

ORIF Risks:
-infection
-NV injury
-non union
-DVT/PE

Question 22

What is a maisonneuvre fracture?

Answer 22

Injury of ankle occurs leading to force transmitting up the interosseous membrane leading to a break of the fibula head

Question 23

What nerve is at risk in a maisonnneuvre fracture?

Answer 23

Common fibula nerve since it wraps around the head of fibula

Question 24

What is a pilon fracture?

Answer 24

Fracture of the distal tibia due to impaction of the talus

Question 25

How does an Achilles tendon rupture present?

Answer 25

Ankle pain Struggle to plantar flex Cant weight bear Swelling around posterior ankle Cant see continuity of tendon

Question 26

What clinical test can be used to assess for Achilles tendon rupture?

Answer 26

Simmonds test

Question 27

What is a positive simmonds test? What is a negative Simmonds test?

Answer 27

+ve = reduced ankle movement on calf squeeze indicative of partial or complete Achilles rupture -ve = normal ankle movement on calf squeeze

Question 28

What Ix is done to assess severity of Achilles tendon rupture?

Answer 28

US of the tendon

Question 29

What is the conservative management of Achilles tendon rupture?

Answer 29

Equinous boot for 6-8weeks where you gradually reduce the angle of plantar Flexion Analgesia

Question 30

What is the surgical management of Achilles tendon rupture? When is it done? Why?

Answer 30

Operative repair When there is a huge gap between the rupture parts of the tendon When a quick fix is desired or needed Re rupture rates between conservative and surgical managemtn are the same

Question 31

What are the risk factors of Achilles tendon rupture?

Answer 31

Unfit people suddenly increasing amount of exercise Male Obese Fluroquinolones Poor footwear choice

Question 32

What part of the foot is involved in hallux ValGUS?

Answer 32

1st metatarsalphalangeal joint

Question 33

What is the positioning of the joint in hallux ValGUS?

Answer 33

1st metatarsal deviates MEDIALLY with LATERAL deviation of the phalanges with or without rotation with joint subluxation

Question 34

What are the risk factors of hallux ValGUS?

Answer 34

Female Connective tissue disorders Anatomical variance Age

Question 35

How does hallux ValGUS normally present?

Answer 35

Older woman Pain on side of big toe Rubs in shoe Progressively worse Visible deformity

Question 36

What imaging is done to assess hallux ValGUS?

Answer 36

Plain radiograph

Question 37

What is the conservative management for hallux ValGUS?

Answer 37

Analgesia Appropriate footwear Physio

Question 38

What bones does the Lis Francs ligament complex run between?

Answer 38

Medial cuneiform and base of the 2nd metatarsal

Question 39

What is the function of the Lis Francs ligament?

Answer 39

Aids stability of the mid foot

Question 40

How is the Lis Francs ligament complex normally injured?

Answer 40

Severe rotational or translation forces on a PLANTAR flexed foot

Question 41

What is normally visible on a plain radiograph of a Lis Francs injury?

Answer 41

Widening/shifting of the gap between the 1st and 2nd metatarsal

Question 42

What has a better prognosis? Lis francs injury involving just an avulsion fracture or Lis Francs injury involving only the Lis Franc ligaments

Answer 42

Just bony involvement Bones heal, the ligaments struggle to heal

Question 43

How does a Lis Francs injury present?

Answer 43

Severe pain (mid foot) Swelling + tenderness of mid foot Plantar bruising

Question 44

How is a Lis Francs injury managed?

Answer 44

Non significant displacement and NV intact can closed reduction and immobilisation Significant displacement or NV compromise warrants surgical intervention/temproary external fixation while swelling improves then (ORIF)

Question 45

What is the likely injury? Inverted foot Immediate pain and swelling on lateral side of foot

Answer 45

Avulsion fracture of 5th metatarsal

Question 46

What tendon is responsible for causing an avulsion fracture of the 5th metatarsal?

Answer 46

Fibularis brevis

Question 47

What is the Definiton of an avulsion fracture of the 5th metatarsal?

Answer 47

Fracture extends to the 5th metatarsal base to the cuboid bone

Question 48

What is the other type of avulsion fracture of the 5th metatarsal?

Answer 48

Jones fracture

Question 49

What is a jones fracture?

Answer 49

Inversion injury which extends between the 5th metatarsal base and 4th metatarsal

Question 50

What is the concern with an Avulsion fracture of the 5th metatarsal?

Answer 50

Has a retrograde blood supply from the nutrient artery so risk of AVN

Question 51

Where does the fibularis longus tendon insert? What is its function?

Answer 51

Runs under sole of the foot to the base of the 1st metatarsal; Everts foot

Question 52

What ligament is most commonly damaged with an inversion injury of the ankle?

Answer 52

Anterior talofibular ligament