ankle and foot Flashcards
(130 cards)
1
Q
initial presentation
A
” Pain over injured ligaments
“ Swelling or bruising
“ Loss of function
“ Patient may describe hearing a pop during the initial injury or a feeling of instability while ambulating.
2
Q
a ankle sprain might be assoc with these 4
A
- Peroneal tendon tear
- Subluxation, sprain of subtalar joint,
- Fracture @ the base of the 5th metatarsal
- Avulsion fracture of the calcaneus or talus
3
Q
physical exam for an ankle sprain
A
” Tenderness to palpation (TTP) over affected ligaments or bony areas if fracture occurred
“
Always palpate proximally to r/o fracture of prox fibula or tibia and distally to r/o foot fracture
Neurovascular exam to ensure intact
4
Q
ottawa ankle rules
A
help rule out the need for a XRAY
5
Q
what views do you get for the ankle on XRAY
A
b. 3 views of the ankle (lateral, anterior posterior (AP), oblique)
6
Q
bone tenderness in these areas are required
A
posterior edge or tip of the lateral malleolous
navicular and
the fifth metatarsal
7
Q
which ligament is most frequently sprained in the ankle
A
Anterior talofibular ligament í MC ligament that is sprained
8
Q
If pain is on lateral aspect of ankle how do we classify
A
Grade I -III
9
Q
Anterior talofibular ligament and calcaneofibular ligament with mild laxity of one or both ligaments.
REFERS TO WHAT GRADE OF LATERAL ANKLE SPRAI
A
Grade II
10
Q
Grade III sprain is associated with
A
injury and significant laxity of both anterior talofibular ligament and calcaneofibular ligament
11
Q
Grade I injury refers to
A
ATF ligament with no instability
12
Q
what are some cluses that the ankle is unstable
A
if pain on the medial side
a. May see small avulsion fracture of tibia where deltoid ligament attaches
Oblique fracture of fibula may cause disruption of the deltoid ligament
Look for lateral shifting of talus
When found, refer to specialist for repair
13
Q
goal of ankle sprain tx
A
- The goal is to prevent re-injury and allow tightening of ligaments to prevent chronic instability
- Consider MRI if persistent pain >8 weeks despite treatment (r/o peroneal tendon injury or osteochondral defect)
14
Q
Weber classification (A, B and C)
A
- A - weight bearing tolerated
- Extending from mortise and going up or down - B
- Just above the ankle mortise - C (weight bearing is not tolerated
15
Q
goal of ankle sprain tx and consideration
A
- The goal is to prevent re-injury and allow tightening of ligaments to prevent chronic instability
- Consider MRI if persistent pain >8 weeks despite treatment (r/o peroneal tendon injury or osteochondral defect)
16
Q
tx for mild sprain
A
WBAT in ankle brace 3-4 wks
RICE (rest, ice, compression, elevation)
NSAIDs
Recovery may take 8-12 wks
17
Q
tx for severe ankel sprain
A
Immobilization for 3-4 weeks: weight bearing as tolerated (WBAT) with crutches in controlled ankle motion boot (CAM boot) or non-weight bearing splint for those too painful.
- Rest, Ice, NSAIDs
- At 3-4 weeks (usually 3) transition into ankle brace for 3 weeks and then wean out
- You can Rx physical therapy to start gentle ROM, then progress to strength and balance.
- Can take 8-12 weeks to heal.
18
Q
space between talus & medial malleolus = should be
A
<4mm
19
Q
always feel in the mid-foot with an ankle sprain
A
- Always feel base of 5th metatarsal, navicular,
also malleolar zone
20
Q
where tibia & fibula articulate w/ talar dome
A
Mortise
21
Q
syndesmotic ankle injuries
A
13% of the time these occurs with fractures and can lead to end stage arthritis if not identified properly
supination internal rotation injuries that involve the distal aspect of the ankle
the high ankle sprain causes pain more proximally, just above the ankle joint,
dorsiflexion with external rotation will cause gapping and stress
these people need surgery
need valgus stress XRAY and if you get gapping in the medial clear space =specialist!
22
Q
areas involved with stable ankle fracture
A
Non-displaced → involves ONE malleolus but no ligament structures; non-displaced
23
Q
Unstable ankle fx
A
Displaced → involve BOTH sides of ankle joint
both malleoli + distal fibula w/ disruption of deltoid ligament
24
Q
Maisonneuve:
A
ankle fx + proximal fibula fx, deltoid ligament tear and mortise disruption
25
ankle fracture needs referral when
Bimalleolar + Triamalleolar Fxs
Maisonneuve:
→ Anything with WIDENED mortise
26
WEBER classification for ankle fractures
A → ant fib fx
B →starts at the mortise and can extent proximally, sometimes the only way to know is referral
C →starts just proximal to ankle mortise
27
nonoperative ankle fracture tx
STABLE fractures
NWB cast initially, change to wt bearing once evidence of healing bone on X-Ray (typically 4-6 wk range from initial DOI)
Gradually increase wt bearing status + start PT as needed
28
operative ankle fracture
- UNSTABLE fractures
| - Typically ORIF (open reduction, internal fixation)
29
talus Fx MOA
extreme forceful dorsiflexion
Results from high energy trauma (MVA, fall from height)
30
big worry with talus fx
Risk of AVN; worse w/ displacement
MC fx site at talar neck
31
CM of talus fx
Moderate ankle swelling
TTP over anterior ankle + often talar neck dorsally
Possible varus/valgus deformity
Assess neurovascular status
pain out of proportion --> compartment syndrome
32
views for suspected talus fx
Lat, AP, Oblique
Consider CT of ankle if high suspicion and to characterize
Hawkins classification of talar neck I-IV
33
chance of AVN with hawkings talus classifications
```
→
I-10% AVN
II- 40%
III-90%
IV - 100%
```
34
classification of talar fxs
Hawkins
fracture without displacement-I
fracture of the talar neck with sublux or dislocation
full dislocation-III
also dislocated from the Talonavicular joint-
IV
35
dislocation of talar dome
III
| i. 90% risk of AVN
36
type 3 plus talonavicular joint is also dislocated
i. 100% risk of AVN
37
tx for talar fx
a. All referred to orthopedic specialist
i. Non-displaced treated non-operatively with serial x-rays. Still up to 10% chance of AVN
ii. Displaced treated with ORIF
38
i. Traumatic disruption of the tarsometatarsal joints: fracture, dislocation or both
lisfranc ligament hold and the lateral aspect of 1st cuneiform to 2nd metatarsal
Critical injury to the 2nd tarsometatarsal joint
is what we are worried about here
39
Midfoot (Lisfranc) Fracture/Injury CM and MOA
iv. Often present as a "sprain" over dorsum of foot
v. Mechanism is often axial loading verticle foot or torque to fixed foot
1. "I was going down the stairs and thought there was another step"
vi. Foot may be mild to moderately swollen, maximum tenderness/swelling over distal mid-foot
40
PE for Midfoot (Lisfranc) Fracture/Injury suspection
Physical Exam: stabilize hindfoot and try to rotate forefoot
Positive = pain
41
DX tests for midfoot
where should we see on AP
Oblique
Diagnostics
X-ray: standing AP, Lateral and Oblique of the foot. Stress/weight bearing views prn.
On AP: Medial aspect of 2nd MT should line up with medial aspect of middle cuneiform. Shift = Lisfranc injury
On oblique: Medial 4th MT should line up with medial cubiod surface. Shift = Lisfranc injury
If high degree of suspicion and x-ray unclear, MRI of foot should be obtained
42
tx for midfood non-displaced
1. Nondisplaced:
| a. 8 weeks in NWB cast followed by use of rigid arch support for 3 months
43
tx for midfoot displaced
Displaced >2mm:
a. ORIF
b. Remove fixation after 6 months with custom rigid orthotic for 6 additional months
4. ***When missed and delayed 6 weeks, ORIF no longer an option and joint must be FUSED - Maintain a high index of suspicion
44
MOA Metatarsal fractures
Result from direct blow or twisting mechanism
45
PE for metatarsal fx
dx
Swelling, point tenderness (be aware of major swelling in 1st metatarsal can lead to compartment syndrome)
Axial loading (compressing metatarsal head toward calcaneus) useful exam technique to r/o soft tissue injury
" X-ray: AP, Lateral and Oblique of foot
46
non-displaced metatarsal fx
: Short Leg Cast or CAM walker and weight bear as tolerated (WBAT)
a. RTC 3-4 weeks for X-ray to check healing and again @ 6 weeks discontinuation cast as fracture shows signs of healing
47
unstable metatarsal fx
may need surgical intervention. Generally 4mm displacement or 10 degrees of apical angulation or multiple fractures.
48
….special consideration for 5th Metatarsal Fractures
a. Styloid Avulsion Fractures
| b. Jones' Fracture
49
1. Most common fracture of base of 5th metatarsal
iv. Avulsion Fracture of 5th Metatarsal Styloid (Pseudo-Jones)
50
what tendon attaches to the 5th metatarsal
a. What tendon attaches there peroneous brevis
Action of that muscle?
51
tx for jone's vs pseudo jones
pseudo=
CAM boot or post-op shoe WBAT x 4-6 weeks
jones=
NWB cast x 6 weeks, use X-ray to determine if any bone healing and clinical exam for point tenderness over fx site
6. Refer to Specialist as soon as possible!!!!
52
Phalangeal Fractures
reduce for displaced and buddy tape
Buddy tape + Post-op shoe 4-6 weeks for great toe
For displaced fractures, reduce fracture after applying digital block to reduce pain
53
what do you do for a fx of the great toe
Fractures of Great toe often require orthopedic referral for surgical option if displaced d/t role as important weightbearing surface
used a lot more for weight bearing
54
Very common, especially among active males and females age 30-50 years playing quick stop and go sports like racquetball and basketball.
Achilles tendon rupture
feels like you're walking in sand
55
PE for achilles rupture
a. Thompson's test: positive if ______
i. Squeeze the calf and see if it plantarflexes or not
ii. These pts can still plantarflex
56
if complete tear of achilles tendon you will see
all the way through the tendon, patient will have decreased or inability to plantar flex the foot with manual contraction of muscle
57
non-operative tx of achilles rupture
1. Casting in NWB plantarflexed position approx 8-10 weeks
58
i. Operative tx for achilles tear
1. Often choice for active individuals: surgical repair of tendon optimal in first two weeks after date of injury
2. Slightly lower re-rupture rate
3. Walking in CAM boot by about 5 weeks post-op
59
thompson's test in partial
a. Negative Thompson's test
b. Treatment
i. Nonoperative: immobilization in either NWB cast or walker boot (apprx 4-6 weeks) in plantarflexion
60
why don't you put fxs in a cast initially
SPLINT b/c of compartment syndrome
want inflammation to go down
61
follow up for stable fxs
fractures typically follow up within 12-14 days for X-ray, diagnosis and treatment
62
f/u for unstable fxs
fractures should follow up within 1-3 days for X-ray, diagnosis, possible reduction, treatment which may include surgical intervention
63
DOI bone callus starts forming to the point where the bone gets sticky (knitting together) at around the __ week mark
h. In general at 2 weeks out from DOI bone callus starts forming to the point where the bone gets sticky (knitting together).
64
True evidence of bone healing not usually seen on Xray until
True evidence of bone healing not usually seen on Xray until approx 4-6 weeks out from DOI
65
stable fx RT
f. Stable fractures return to clinic at 4 week mark from date of injury (DOI) for X-ray to check healing
66
nonoperative ankle fracture tx
STABLE fractures
NWB cast initially, change to wt bearing once evidence of healing bone on X-Ray (typically 4-6 wk range from initial DOI)
Gradually increase wt bearing status + start PT as needed
67
operative ankle fracture
- UNSTABLE fractures
| - Typically ORIF (open reduction, internal fixation)
68
talus Fx MOA
extreme forceful dorsiflexion
Results from high energy trauma (MVA, fall from height)
69
big worry with talus fx
Risk of AVN; worse w/ displacement
MC fx site at talar neck
70
CM of talus fx
Moderate ankle swelling
TTP over anterior ankle + often talar neck dorsally
Possible varus/valgus deformity
Assess neurovascular status
pain out of proportion --> compartment syndrome
71
views for suspected talus fx
Lat, AP, Oblique
Consider CT of ankle if high suspicion and to characterize
Hawkins classification of talar neck I-IV
72
chance of AVN with hawkings talus classifications
```
→
I-10% AVN
II- 40%
III-90%
IV - 100%
```
73
classification of talar fxs
Hawkins
fracture without displacement-I
fracture of the talar neck with sublux or dislocation
full dislocation-III
also dislocated from the Talonavicular joint-
IV
74
dislocation of talar dome
III
| i. 90% risk of AVN
75
type 3 plus talonavicular joint is also dislocated
i. 100% risk of AVN
76
tx for talar fx
a. All referred to orthopedic specialist
i. Non-displaced treated non-operatively with serial x-rays. Still up to 10% chance of AVN
ii. Displaced treated with ORIF
77
i. Traumatic disruption of the tarsometatarsal joints: fracture, dislocation or both
lisfranc ligament hold and the lateral aspect of 1st cuneiform to 2nd metatarsal
Critical injury to the 2nd tarsometatarsal joint
is what we are worried about here
78
Midfoot (Lisfranc) Fracture/Injury CM and MOA
iv. Often present as a "sprain" over dorsum of foot
v. Mechanism is often axial loading verticle foot or torque to fixed foot
1. "I was going down the stairs and thought there was another step"
vi. Foot may be mild to moderately swollen, maximum tenderness/swelling over distal mid-foot
79
PE for Midfoot (Lisfranc) Fracture/Injury suspection
Physical Exam: stabilize hindfoot and try to rotate forefoot
Positive = pain
80
DX tests for midfoot
where should we see on AP
Oblique
Diagnostics
X-ray: standing AP, Lateral and Oblique of the foot. Stress/weight bearing views prn.
On AP: Medial aspect of 2nd MT should line up with medial aspect of middle cuneiform. Shift = Lisfranc injury
On oblique: Medial 4th MT should line up with medial cubiod surface. Shift = Lisfranc injury
If high degree of suspicion and x-ray unclear, MRI of foot should be obtained
81
tx for midfood non-displaced
1. Nondisplaced:
| a. 8 weeks in NWB cast followed by use of rigid arch support for 3 months
82
tx for midfoot displaced
Displaced >2mm:
a. ORIF
b. Remove fixation after 6 months with custom rigid orthotic for 6 additional months
4. ***When missed and delayed 6 weeks, ORIF no longer an option and joint must be FUSED - Maintain a high index of suspicion
83
MOA Metatarsal fractures
Result from direct blow or twisting mechanism
84
PE for metatarsal fx
dx
Swelling, point tenderness (be aware of major swelling in 1st metatarsal can lead to compartment syndrome)
Axial loading (compressing metatarsal head toward calcaneus) useful exam technique to r/o soft tissue injury
" X-ray: AP, Lateral and Oblique of foot
85
non-displaced metatarsal fx
: Short Leg Cast or CAM walker and weight bear as tolerated (WBAT)
a. RTC 3-4 weeks for X-ray to check healing and again @ 6 weeks discontinuation cast as fracture shows signs of healing
86
unstable metatarsal fx
may need surgical intervention. Generally 4mm displacement or 10 degrees of apical angulation or multiple fractures.
87
….special consideration for 5th Metatarsal Fractures
a. Styloid Avulsion Fractures
| b. Jones' Fracture
88
1. Most common fracture of base of 5th metatarsal
iv. Avulsion Fracture of 5th Metatarsal Styloid (Pseudo-Jones)
89
what tendon attaches to the 5th metatarsal
a. What tendon attaches there peroneous brevis
Action of that muscle?
90
tx for jone's vs pseudo jones
pseudo=
CAM boot or post-op shoe WBAT x 4-6 weeks
jones=
NWB cast x 6 weeks, use X-ray to determine if any bone healing and clinical exam for point tenderness over fx site
6. Refer to Specialist as soon as possible!!!!
91
Phalangeal Fractures
reduce for displaced and buddy tape
Buddy tape + Post-op shoe 4-6 weeks for great toe
For displaced fractures, reduce fracture after applying digital block to reduce pain
92
what do you do for a fx of the great toe
Fractures of Great toe often require orthopedic referral for surgical option if displaced d/t role as important weightbearing surface
used a lot more for weight bearing
93
Very common, especially among active males and females age 30-50 years playing quick stop and go sports like racquetball and basketball.
Achilles tendon rupture
feels like you're walking in sand
94
PE for achilles rupture
a. Thompson's test: positive if ______
i. Squeeze the calf and see if it plantarflexes or not
ii. These pts can still plantarflex
95
if complete tear of achilles tendon you will see
all the way through the tendon, patient will have decreased or inability to plantar flex the foot with manual contraction of muscle
96
non-operative tx of achilles rupture
1. Casting in NWB plantarflexed position approx 8-10 weeks
97
i. Operative tx for achilles tear
1. Often choice for active individuals: surgical repair of tendon optimal in first two weeks after date of injury
2. Slightly lower re-rupture rate
3. Walking in CAM boot by about 5 weeks post-op
98
thompson's test in partial
a. Negative Thompson's test
b. Treatment
i. Nonoperative: immobilization in either NWB cast or walker boot (apprx 4-6 weeks) in plantarflexion
99
why don't you put fxs in a cast initially
SPLINT b/c of compartment syndrome
want inflammation to go down
100
follow up for stable fxs
fractures typically follow up within 12-14 days for X-ray, diagnosis and treatment
101
f/u for unstable fxs
fractures should follow up within 1-3 days for X-ray, diagnosis, possible reduction, treatment which may include surgical intervention
102
DOI bone callus starts forming to the point where the bone gets sticky (knitting together) at around the __ week mark
h. In general at 2 weeks out from DOI bone callus starts forming to the point where the bone gets sticky (knitting together).
103
True evidence of bone healing not usually seen on Xray until
True evidence of bone healing not usually seen on Xray until approx 4-6 weeks out from DOI
104
stable fx RT
f. Stable fractures return to clinic at 4 week mark from date of injury (DOI) for X-ray to check healing
105
ii. Ankle arthritis is degradation where
1. Degradation of cartilage between tibia and talar joint
106
3 risk factors for ankle arthritis
a. Previous traumatic ankle injury
b. Obesity
c. Rheumatologic disease
107
hx you need to take for ankle arthritis
a. OPQRS
b. Differentiate between recent trauma vs worsening chronic condition
c. What treatments have they tried?
d. How long can they walk before needing rest due to the pain?
108
exam of ankle arthritis
```
" Often moderate to severe swelling
" Mild increased warmth
" May be tender to palpation over joint
" Decreased plantar/dorsiflexion
" Compare with opposite ankle
```
109
XRAYS needed for ankle arthritis
" 3 view X-ray of ankle usually sufficient
" Anterior Posterior (AP)
" Lateral
" Oblique
110
tx for ankle arthritis
a. Controlled Ankle Motion (CAM) boot
b. Ankle Foot Orthotic (AFO)
c. Intra-articular steroid injections
111
Surgery for ankle arthritis
i. Ankle replacement
| ii. Ankle arthrodesis (Fusion)
112
ankle replacement
1. Replaces articulation surfaces of tibia/talus
2. Preserves ankle ROM
3. Continue normal daily activities with exception of running/jumping and heavy labor.
113
Ankle arthrodesis (Fusion)
what is it and when is it ideal
Completely replaces ankle joint with bone
Loss of ankle ROM (front to back motion)
More ideal for:
a. Large patients >250lbs
b. Failed ankle replacement
c. Heavy laborers
114
i. 31 yo female runner c/o R bottom of heel pain worse in morning that seems to improve as the day goes on and then returns again at the end of the day.
vi. Plantar Fasciitis
115
Plantar Fasciitis
May find tenderness to palpation directly over medial calcaneal tuberosity and may extend distally along plantar fascia. Often NTTP.
116
plantar fasciitis is the result of
Heel pain arises from the medial calcaneal tuberosity and 1-2 cm along plantar fascia
Inflammation of both bone and plantar fascia commonly occurs
Pain will often be worse with first few steps in the morning or initially walking after prolonged non-weight bearing
117
tx of plantar fasciitis
a. Stretching of fascia via heel cord stretches and plantar fascia massage 3-4 times a day
b. Orthotics (heel pad)
c. NSAIDs
d. Splinting: night splint hold foot in slight dorsiflexion effective for those with start up paine.
CAM boot for 4 weeks
Cortisone injection into heel area (sterile technique)
g. Commonly takes 6-12 months to fully resolve, even if treated perfectly
118
heeling time for plantar fasciitis
Commonly takes 6-12 months to fully resolve, even if treated perfectly
119
Heel Spurs
what are they and what do they resolve from
Often result from prolonged plantar fasciitis
Calcium deposit that forms where plantar fascia connects to bone (medial calcaneal tuberosity)
120
Tx of heel spurs
You don't treat the spur, you treat the symptoms if plantar fasciitis is present. Often these are asymptomatic though they can be quite striking
X-ray medium used to confirm location of heel spur
121
65 yo female at your primary care office says…My foot hurts on the side and I can't fit into any of my shoes anymore….plus it looks weird. What's wrong with it? Can this be fixed?"
3. Pain and swelling primary complaints: women want to wear cuter shoes
a. More common in women vs men, 10:1
122
dx of bunions
often obvious on exam by deformity
| a. X-ray standing AP views of foot to measure angle of deformity/severity
123
tx of bunions
appropriate footwear: shoes with wide toebox shoes with padding if needed
124
42 yo female with complaint of burning pain on bottom of foot, especially after taking her aerobics class or when wearing her high heels.
Perineural fibrosis of the common digital nerve as it passes between metatarsal heads
125
PE with Morton's Neuroma
" Placing firm pressure on the interspace between the toes while squeezing metatarsal heads together
" Isolated pain on plantar aspect of web space is consistent with intermetatarsal neuroma
" Inspect foot for calluses or other evidence of stress points in foot (ie: r/o stress or metatarsalgia)
" Range Metatarsalphalangeal joints and Tarsometatarsal joints to r/o inflammation, synovitis or arthritis (midfoot)
126
tx of Morton's Neuroma
" Appropriate shoes
" Low heel
" Wide toe box
" Soft soled
" Metatarsal Pad
" Placed in shoe to keep metatarsal heads apart
" Cortisone injection proximal to metatarsal head
" Place needle in line with MTP joint (dorsal approach), inserting needle into the plantar aspect of foot- pull back 1cm and inject
" 1-2ml anesthetic/1ml corticosteroid
" If symptoms persist refer to orthopedic foot and ankle surgeon or podiatrist for surgical excision
127
hyperkeratotic lesion formed on a toe (can be soft or hard)
i. Corn
128
hyperkeratotic lesion formed anywhere but a toe
ii. Callus
129
tx of corns and callus
v. Treatment: pressure relief or paring down lesion
1. Paring down: shaving lesion layer by layer with a scalpel
2. Appropriate fitting footwear to relieve pressure
3. Silicone cushions or donut pads to shift pressure
130
Most common symptom of morton's neuroma
Forefoot plantar pain and/or burning pain
