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Flashcards in ankle and foot Deck (130):
1

initial presentation

" 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

a ankle sprain might be assoc with these 4

1. Peroneal tendon tear
2. Subluxation, sprain of subtalar joint,
3. Fracture @ the base of the 5th metatarsal
4. Avulsion fracture of the calcaneus or talus

3

physical exam for an ankle sprain

" 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

ottawa ankle rules

help rule out the need for a XRAY

5

what views do you get for the ankle on XRAY

b. 3 views of the ankle (lateral, anterior posterior (AP), oblique)

6

bone tenderness in these areas are required

posterior edge or tip of the lateral malleolous
navicular and
the fifth metatarsal

7

which ligament is most frequently sprained in the ankle

Anterior talofibular ligament í MC ligament that is sprained

8

If pain is on lateral aspect of ankle how do we classify

Grade I -III

9

Anterior talofibular ligament and calcaneofibular ligament with mild laxity of one or both ligaments.

REFERS TO WHAT GRADE OF LATERAL ANKLE SPRAI

Grade II

10

Grade III sprain is associated with

injury and significant laxity of both anterior talofibular ligament and calcaneofibular ligament

11

Grade I injury refers to

ATF ligament with no instability

12

what are some cluses that the ankle is unstable

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

goal of ankle sprain tx

1. The goal is to prevent re-injury and allow tightening of ligaments to prevent chronic instability
2. Consider MRI if persistent pain >8 weeks despite treatment (r/o peroneal tendon injury or osteochondral defect)

14

Weber classification (A, B and C)

1. A - weight bearing tolerated
2. Extending from mortise and going up or down - B
3. Just above the ankle mortise - C (weight bearing is not tolerated

15

goal of ankle sprain tx and consideration

1. The goal is to prevent re-injury and allow tightening of ligaments to prevent chronic instability
2. Consider MRI if persistent pain >8 weeks despite treatment (r/o peroneal tendon injury or osteochondral defect)

16

tx for mild sprain

WBAT in ankle brace 3-4 wks

RICE (rest, ice, compression, elevation)

NSAIDs
Recovery may take 8-12 wks

17

tx for severe ankel sprain

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

space between talus & medial malleolus = should be

<4mm

19

always feel in the mid-foot with an ankle sprain

- Always feel base of 5th metatarsal, navicular,

also malleolar zone

20

where tibia & fibula articulate w/ talar dome

Mortise

21

syndesmotic ankle injuries

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

areas involved with stable ankle fracture

Non-displaced → involves ONE malleolus but no ligament structures; non-displaced

23

Unstable ankle fx

Displaced → involve BOTH sides of ankle joint

(both malleoli + distal fibula w/ disruption of deltoid ligament)

24

Maisonneuve:

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