What is the most common mechanism of an ankle sprain?
What are two commonly sprained ligaments in the ankle?
ATFL: Anterior talofibular ligament
CFL: Calcaneofibular ligament
What anatomical structure prevents eversion sprains?
The fibula is in the way
Also the Deltoid ligment complex
What are the phases of acute injury?
- Clot formation
- Repair: Fibroblast proliferation, neovascularization
What are the types of 5th metatarsal fractures?
Avulsion: 5th metatarsal base @ peroneus brevis insertion
Jones: traumatic fracture metaphyseal-diaphysis junction
Pseudo-Jones: stress fracture proximal diaphyseal
Dancer's: spiral fracture mid to distal diaphysis
Where is a common location in the foot for avulsion fractures? Which tendon causes this?
The Fibularis tertius tendon attaches to the base of the 5th metatarsal. Can roll foot on to lateral aspect and get avulsion fx of 5th metatarsal.
What is a Maisonneuve fracture? What is a good physical exam technique to test for this and how does it work?
Spiral fracture of the proximal fibula associated with a tear of the distal tibiofibular syndesmosis and the interosseous membrane.
Can test for this fracture by the Squeeze Test: squeeze the fib and tib together, this causes the ends to bow out and increases pressure. A positive test is pain at the ankle or knee. At the knee would raise suspicion of Maisonneuve fx.
If a patient has a lateral ankle sprain what type of reaction would you expect with external rotation of the ankle?
No change. This test does not stress the lateral side at all. If this was positive, there may be a medial or high ankle sprain - changing your differential.
Which type of tissue heals the least completely?
In a loose body (or joint mice) what do you need to be sure to check for on imaging?
You need to not only look for the loose body but also the donor site of where the loose body came from.
What sort of patient complaint would make you most suspicious of a loose body in a joint?
What are some requirements for good ligament healing?
- Good blood supply
- Damage section approximated or guided to correct area
What is a commonly torn ligament that is difficult to heal? Why?
ACL -- it is located inside the knee and gets little vasculature, it is also within the joint capsule and doesn't heal up as well.
What are the stages of bony healing?
1. Bleeding (seconds-minutes)
2. Clot formation (minutes-hours)
3. Inflammatory stage (hours-days)
4. Repair stage (1-2+ weeks - 3+ months): osteoclasts and osteoblasts invade the blood clot
5. Remodeling stage (1-2 years)
Break down the repair stage of bony healing from 1-2 weeks to 3+ months.
- Osteoclasts and osteoblasts invade blood clot
- Soft callus (2-6 wks)
- Hard callus (4-12+ wks)
- Callus matures (12-26 wks)
- Bony gaps bridged (6-12 mos)
Which factor most influences strength of healed bone?
Calcium content of bony repair
What is the reasoning behind apophysitis conditions such as Osgood-Schlatter disease?
There is a relative weakness in the immature skeleton of children compared to the mature skeleton -- places repetitive tension on certain tendons
Describe the Diaphysis, Metaphysis, Physis and Epiphyses in a long bone.
- Diaphysis = shaft
- Metaphysis = area between shaft & growth plate
- Physis = growth plate
- Epiphysis = end of long bone
What is apophysitis?
Pain and inflammation of ossification centers from repetitive tension.
What is the treatment for Apophysitis? Are there any complications from this condition?
Treatments: activity as tolerated, stretching, ice +/- NSAIDs
Complications: bony hypertrophy; fracture (rare)
Distal patellar pole
Anterior superior iliac spine (ASIS)
Anterior inferior iliac spine (AIIS)
Little leaguer's elbow
ACL graft healing timeline
Ligamentization: revascularization with vascular synovial layer
Allografts: starts at 4-6 weeks, complete revascularization ~20 wks, fixation weakest link until healed, remodeling 1 year ~ histological & biochemical properties of native ACL
Autografts: patellar tendon -- graft remodeling 4-8 wks, hamstring by 12 wks