Ankle + foot Flashcards by Maya Birchler

Bruising, edema (quickly)

“Pop” in foot followed by swelling, pain, inability to bear weight

ankle sprain

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Most common sports injury
Most involve LCL (complex) as a result of inversion + plantar flexion

ankle sprain

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ligament most commonly injured in an ankle sprain

anteroinferior tibiofibular ligament

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grades of ankle sprains

I: no instability (microtears)
II: mild laxity (minor)
III: severe laxity, rupture of calcaneofibular + anterior talofibular ligaments (complete)

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Palpate to localize pain, ROM, muscle strength, proprioception
Anterior drawer for ATF
= feeling of laxity or subluxation (>5mm than contralateral side)
Talar tilt test for calcaneofibular and anterior talofibular
Evert foot (deltoid)
Gross gapping at mortise

XR: AP, lat, mortise views to evaluate for fractures, occult and osteochondral injuries

ankle sprain

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How do you treat an ankle sprain?

RICE, crutches, anti-inflammatory medications

Phase II (weeks 2-4): ICE, strength

Phase III (4-6 weeks): more agility, proprioception, balance board

Surgical treatment not usually indicated in acute injury – chronic instability
Free ligament reconstruction
/+ ankle arthroscopy

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All unstable syndesmosis are — —-, but not all are unstable syndesmoses!

ankle sprains

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“High” ankle sprain – eversion, rotational injury

Specifically damage to the ligaments connecting the tibia and fibula

unstable syndesmosis

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PE: external rotation stress
Squeeze test, proximal tenderness

XR: negative stress
MRI

unstable syndesmosis

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How do you treat an unstable syndesmosis?

No instability = walking cast x 4 weeks + PT

Instability = fixation of syndesmosis

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Ottawa ankle rules - order an X-ray if any of the following apply

Pain along lateral malleolus, medial malleolus.
Midfoot pain, 5th metatarsal or navicular pain.
Unable to walk more than four steps in the ER or exam room.

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Fracture below syndesmosis - distal malleolus or avulsion

Bimalleolar = medial + lateral
Trimalleolar = medial, lateral, posterior

Most common intra-articular fracture
Determined by stability of fracture pattern

ankle fracture

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Commonly a rotational injury

Deformity, bruising, open or closed, inability to bear weight

ankle fracture

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XR: AP/lateral/mortise

Classify ankle fracture based on lateral malleolus
A = below syndesmosis
B = level of syndesmosis
C = above syndesmosis

ankle fracture

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criteria for ankle fracture treatment

Criteria:
1) Dislocations + fractures reduced ASAP
- Splint with joint in most normal position possible
- Open = antibiotics and take to OR for irrigation + debridement
2) All joint surfaces must be restored
3) Fracture must be helped in reduced position during bony healing
4) Joint motion should begin asap

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ankle fractures w/o separation tx

Fractures w/o separation = short leg cast w/ ankle in neutral position and immobilization is continued for 6-8 weeks
Cast 4-6 weeks
Cam walker
PT

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ankle fractures w/ separation tx

Fractures w/ separation = reduced (check syndesmosis stability)
Isolated lateral fractures non-op
Bimalleolar + medial need surgery → ORIF
Immobilize for 6 weeks then slow advancement with weight bearing
PT for ROM, strength

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Pain with weight bearing activity, difficulty with uneven ground, swelling, history of prior injury

primary = rare
commonly post-traumatic

ankle arthritis

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PE: swelling, areas of tenderness along tibiotalar joint, check standing alignment

XR: weight-bearing AP, lateral + mortise of ankle

ankle arthritis

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ankle arthritis treatment

Non-surgical = NSAIDs, intra-articular injection, mechanical unloading (cane), bracing (arizona AFO)

Surgical = osteophyte excision, distraction arthroplasty, ankle arthrodesis, ankle arthroplasty

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Posterior hindfoot pain – develops with initial morning activity and increases with exercise
Eventually developed into pain at rest
Insertional = localized to junction of tendon + bone

achilles tendonitis

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inflammatory/degenerative – insertional vs non-insertional, seen in obesity, HTN, steroid use

achilles tendonitis

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PE: find area of maximal tenderness

Check tendon integrity – gapping, nodularity
Thompson test

XR: Haglund deformity, calcification of calcaneal insertion

MRI = partial Achilles tendon tear, peritendinous thickening, tendinosis, nodularity, calcification

achilles tendonitis

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achilles tendonitis tx

Non-surgical =

NSAIDs
immobilization (boot/cast)
heel lift
achilles sleeve
PT (stretching, eccentric strengthening)
avoid steroids
extracorporeal shockwave therapy

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Sudden occurrence of heel pain after push-off movement, “pop”, calf pain “Someone hit me”

achilles rupture

Zone of vascularity – less commonly chronic steroid use or antibiotics (quinolones) seen often in weekend warriors

achilles rupture

Palpate for gap + Thompson test (no plantar flexion) MRI best

achilles rupture

achilles rupture tx

Ice to area, analgesics, rest Bracing, casting with gradual dorsiflexion towards neutral

Pain over fifth metatarsal area with edema and/or ecchymosis

Jones fracture

Fracture of metaphyseal-diaphyseal junction of 5th metatarsal Non-union rate = high Chronic stress injury

Jones fracture

XR: acute proximal diaphyseal fracture w/ medial fracture line extending into/towards intermetatarsal joint

Jones fracture

Usually non operative – REFER Non-weight bearing 6-8 weeks Walking boot 2-4 weeks Surgery in those who fail conservative or in athletes

Jones fracture

Lateral foot/ankle pain, chronic Instability of peroneals = tear – pain at base of 5th metacarpal + extension into plantar medial foot

Peroneal tendonitis

peroneal tendonitis tx

Immobilization, NSAIDs, therapy Continued pain → MRI

Plantar heel pain on first step out of bed and resolves quickly when non weight-bearing → contracture of gastrocnemius or achilles is common Often sharp, usually worse after period of rest when initiating walking, decreasing after ambulation, massage, stretching

plantar fasciitis

Most common cause of heel pain – chronic overuse stress common in females 40-60y, older and obese, teachers, those who stand on their feet

plantar fasciitis

How do you treat plantar fasciitis

PT - formal therapy more effective NSAIDs Night splints Inserts Heel pad Injection - only 1 cortisone injection

Pain, swelling, ecchymosis around lateral hindfoot

calcaneus fracture

Most common tarsal bone fracture – mostly displaced intra-articular from trauma and in young men

calcaneus fracture

Commonly have other extremity injuries or associated spine fractures XR: displaced intra-articular fracture

calcaneus fracture

how do you treat calcaneus fracture

ORIF Closed reduction percutaneous fixation ORIF w/ primary fusion Consider: Timing Soft tissue swelling Must wait + wrinkle sign Fracture blisters Be aware of peroneals Dislocation

What's good post op care for calcaneus fracture

Post-op care: – casting + non-weight bearing 6-10 weeks – ROM exercises after 6 weeks – wean from boot to shoe at 10-12 weeks → PT to gait training, ROM, strengthening

Pain and swelling in midfoot with difficulty bearing weight – 1+ metatarsal bones are displaced from tarsus Plantar ecchymosis

lisfranc injury

Low energy trauma or high energy from MVAs, industrial, height 3 oblique ligaments: Dorsal Interosseous (strongest) Plantar common in football/contact sport

lisfranc injury

Mechanism of injury is key XR: standing bilateral AP to detect displacement CT, MRI (can detect more subtle injury) Fleck sign = fracture at base of 2nd metatarsal

Lisfranc injury

lisfranc treatment

Unstable - surgical management Screw fixation, bridge plate fixation, tightrope fixation, primary fusion

Burning or cramping sensation in region of metatarsal heads (usually middle) – worse with activity + relieved by rest

metatarsalgia

Anatomy abnormalities like hammertoes, clawed toes, hallux valgus deformities High heel use Pain in metatarsal region

metatarsalgia

How do you treat metatarsalgia

Transfer weight AWAY from affected heads Low heeled shoes w/ sufficient room Metatarsal bar placed on shoe

Localized aching pain, swelling and tenderness that increases w/ activity Localized bone tenderness at fracture site

march fracture

Military, athletes High volume stress from overuse or high impact activities

march fracture

how do you treat a march fracture

RICE Pain management Surgery not common

Flexion of PIP + hyperextension of MTP + DIP joints → PIP pain toes

hammer toe

with ---- ---- you need to review Underlying disease vs mechanical Tight fitting shoes

hammer toe

How do you treat hammer toe

●Conservative Analgesics Proper footwear Toe dividers ● Surgical - Rare Arthroplasty Pin Tendon reconstruction

Severe burning pain aggravated by activity located in 3rd web space w/ radiation to 3rd and 4th toes – tight shoes aggravate with removing shoes + massaging foot relieving the pain Numbness may occur

morton's neuroma

Women 25-50 with tight-fitting shoes, high heels, flat feet Perineural fibrosis of plantar nerve where lateral + plantar branches communicate Secondary to repetitive trauma

Morton's neuroma

PE: tenderness between 3rd and 4th metatarsal heads – compression of foot may reproduce pain

Morton's neuroma

how do you treat morton's neuroma

Local injection of steroid or lidocaine may give temporary relief Surgical resection often necessary

Bunion! 30s-50s Rheumatoid arthritis, women Shoewear = primary extrinsic of poorly-fitted, tight or pointed shoes PE: observe degree of deformity, observe gait + look for abnormal ground contact (early heel rise = tightness)

hallux valgus

how do you treat hallux valgus?

Shoewear modifications Bunion pads Toe spacers Shoes, pads In juveniles wait until done growing to consider surgery Surgery is contraindicated in high-performance athletes + dancers until no longer able to perform

Joint or foot deformity Alteration of the shape of foot, ulcer, skin changes

charcot foot

DM → destruction of joint surfaces, accompanied by dislocations of 1+ joints w/ inappropriate pain response Neuropathic, neurotrophic, neuroarthropathy joint

charcot foot

XR: marked destruction of joint surfaces + collapse of joint spaces w/ dislocations on foot

charcot foot

how do you treat charcot foot

Ortho consult – limit destruction + preserve stable plantigrade foot to protect soft tissue + prevent ulceration → off loading Surgery/”rocker-bottom shoe”

Monofilament 2 point discrimination Assess skin, hair growth, perfusion, pulses, color XR: weight bearing of both, look for changes, rule out osteomyelitis or charcot Technetium bone scan = diagnose osteomyelitis MRI to distinguish Charcot from osteo

diabetic foot

--- to distinguish charcot from osteomyelitis

MRI

How do you treat a diabetic foot

Abscess or osteo → emergency surgery for drainage of infection, wound left open, dressing changes, closure at later date or amputation Gangrene toes/forefoot → amputation Entire foot → amputation Surgery to remove any bony prominences and cause pressure to skin and increase risk of developing an ulcer

Ankle + foot Flashcards

(68 cards)