What is the most common mechanism of an ankle sprain and why?
Inversion is more common for ankle sprians because
1. The fibula bone is in the way (it is longer than tibia)
2. On the medial side of the ankle deltoid ligament complex are huge
vs. the smaller more easily sprained ligaments(anterior talor fibular ligament, calcanear fibular ligament, posterior talar fibular ligament)
9 year old inverts ankle playing soccer
-Now complains of lateral ankle and mid-foot pain
- On exam he has
* Diffuse tenderneess over the anterior talar-fibular ligament (ATF) and base of teh 5th metatarsal
* Non-tender over posterior ankle, negative squeeze and external rotation tests
* Pain with resisted eversion
In addition to a classic lateral (ATF) sprain, he has?
5th avulsion fracture
What are the different 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
Why do you use the squeeze test (squeezing the tibia and fibular)?
Why do you do an exteranal rotation test (of the ankle)?
Squeeze test will result in pain either distal or proximal tibia/fibula, suggesting a fracture.
*An example is a Maisonneuve (proximal fibula) fracture
External rotation test should not increase pain in typical lateral ankle sprain. However if there is pain then you worry about an atypical ankle sprain.
* Medial pain would suggest a strained medial deltoid ligament.
* Middle pain would suggest high ankle sprain
What tissue heals with least complete recovery?
What should make you suspicious of joint mice (loose bodies)?
What ligament is least likely to heal? and Why?
a. Ankle anterior talar fibular ligament
b. Ankle calcaneal fibular ligament
c. Knee anterior cruciate ligament
d. Knee medial collateral ligament
e. Thenar ulnar collateral ligament
ACL, knee anterior cruciate ligament,
Most inside the knee w/ the least vasculature
Other four have soft tissue envelopes keeping them in place. ACL is floating around free in the knee, so the ends can span large gaps.
What does ligament healing require?
1. Good blood supply
2. Needs damaged section to be approximated or guided to correct area
3. Needs relative rest
What are the stages of bony healing (and timeframe)?
Clot formation (minutes-hours)
Repair Stage (1-2+ weeks-3+months)
* osteoclasts and osteoblasts invade blood clot
What are the stages of the repair stage in bony healing (and timeframe)?
Repair Stage (1-2+weeks-3+months)
Osteoclasts and osteoblasts invade blood clot
Soft callus (2-6 weeks)
Hard callus (4 to 12+ weeks)
Callus matures (12-26 weeks)
Bony gaps bridged (6-12 months)
Remodeling stage (1-2 years)
What factor most influences strength of healed bone?
Calcium content of bony repair is the most important factor
Size of callus/time since initial injury/type of treatment/size of gaps on x-rays
13 yo soccer player complains of knee pain. Denies any known injury.
Pain to palpation of tibial tubercle
Pain with resisted knee extension
What is the underlying pathology?
Relative weakness of the immature skeleton compared to the mature skeleton.
Define the following:
Metaphysis- area between shaft and growth plate
Physis- growth plate
Epiphyses- end of long bone
What is Osgood-Schlatter's characterized by?
Inflammation of patellar ligament on tibial tuberosity
Soft tissue swelling
Tibial tuberosity fracture
What is apophysitis/pain pattern/treatments/complications?
Pain and inflammation of ossification centers from repetitive tension.
Pain pattern can be: 1. after activity 2. at the beginning of activity 3. throughout activity. 4. all the time
Treatments: Activity as tolerated, stretching, ice, NSAIDs
Complications: Bony hypertrophy; fracture (rare)
What are common sites for apophysitis?
Osgood-Schlatter- tibial tubercle
Sever's- Calcaneal apophysitis
Sinding-Larsen-Johansson- Distal patellar pole
Anterior superior iliac spine (ASIS)-Sartorius
Anterior inferior iliac spine (AIIS)-Rectus femoris
Little leaguer's elbow (medial epicondyle)