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Orthopaedic Surgery > Conditions Of The Ankle And Surgery > Flashcards

Conditions Of The Ankle And Surgery Flashcards

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1
Q

What is the syndesmosis of the ankle comprised of?

A
  • anterior inferior + posterior inferior tibiofibular ligament
  • inter-osseous membrane
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2
Q

Define ankle fracture

A

A fracture of any malleolus (lateral, medial or posterior) with or without disruption to the syndesmosis

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3
Q

What classification is used to classify lateral malleolus fractures of the ankle?
What are the types?

A

Weber classification
- Type A: below the syndesmosis
- Type B: at the level of the syndesmosis
- Type C: above the level of the syndesmosis (highest likelihood of ankle instability)

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4
Q

What are the Ottawa Ankle rules?
What is it used for?

A

If there is presence of any of the following, an x-ray of the ankle is needed:
- bone tenderness at posterior edge or tip of either malleolus
- inability to bear weight immediately + in 4 steps in the ED

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5
Q

Contraindications of the Ottawa Ankle rules (when can they not be used)

A
  • pt is intoxicated or uncooperative
  • has other distracting painful injuries
  • diminished sensation in legs
  • gross swelling
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6
Q

Investigations of ankle fracture

A
  • X ray (in AP, lateral and mortise view) | ankle must be in full dorsiflexion
  • CT may be needed for surgical planning
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7
Q

Management of ankle fracture

A
  • immediate fracture reduction
  • below knee back slab
  • post reduction neurovascular examination + repeat X-ray
  • surgical management: ORIF using plates + screws
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8
Q

When is conservative management used for ankle fractures?

A
  • non displaced medial malleolus fractures
  • Weber type A or B without talar shift
  • if unfit for surgery
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9
Q

When is surgical management required for ankle fracture

A
  • displaced bimalleolar or trimalleolar fractures
  • Weber C
  • Weber B with talar shift
  • open fractures
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10
Q

What demographic are ankle fractures most common in?

A

Younger males
Older females

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11
Q

Classification of ankle sprain

A
  • high ankle sprain: injuries to the syndesmosis
  • low ankle sprains: injuries to the anterior talofibular ligament + calcaneofibular ligament
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12
Q

What is the most common ligament damaged in ankle sprains?

A

Calcaneofibular ligament
Check??

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13
Q

Common presentation of ankle sprain

A
  • following inversion injury
  • swelling + pain
  • potential not to weight bear
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14
Q

Investigations of suspected ankle sprain

A

X-ray to rule out bony injury

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15
Q

Management of ankle sprain

A

Conservative management
- analgesia
- RICE
- early mobilisation

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16
Q

Risk factors for ankle sprain

A
  • weak muscles/tendons across ankle joint
  • weak or lax ligaments
  • uneven surfaces
  • inadequate heel support
  • high heels
  • slow response to being off balance
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17
Q

List the three lateral ligaments of the ankle

A

Anterior talofibular
Posterior talofibular
Calcaneofibular

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18
Q

What is the name of the medial ankle ligament?

A

Deltoid ligament

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19
Q

Name the bones of the feet

A
  • talus
  • calcaneus
  • navicular
  • cuboid
  • 3 cuneiforms
  • metatarsals
  • phalanges
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20
Q

Name the tarsal bones of the foot

A
  • talus
  • calcaneus
  • navicular
  • cuboid
  • 3 cuneiforms
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21
Q

Common cause of 5th metatarsal fracture

A

Stepping on curb
Climbing steps
Inversion injuries

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22
Q

Why can forced inversion injuries cause a 5th metatarsal fracture?

A

The peroneus brevis + plantar aponeurosis both insert into the 5th metatarsal and cause significant tension during forced inversion

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23
Q

Presentation of 5th metatarsal fracture

A
  • pain, swelling + bruising to lateral foot
  • tenderness on palpation
  • difficulty weight bearing
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24
Q

Management of 5th metatarsal fracture

A

Walking boot or cast
Analgesia
RICE

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25
What are tibial pilon fractures?
Severe injuries affecting the articular surface of the distal tibia (caused by high energy axial loads *e.g. RTC*
26
What are tibial pilon fractures characterised by?
Articular impaction Severe comminution Soft tissue injury
27
Presentation of tibial pilon fractures
- severe ankle pain - inability to weight bear - possible ankle deformity - swelling + bruising
28
What classification is used for the severity of tibial pilon fractures? What are the types?
**Ruedi and Allgower** - **Type 1**: undisplaced intraarticular - **Type 2**: displaced intraarticular - **Type 3**: comminuted or impacted fracture
29
Management of tibial pilon fractures
- realignment of limb + apply below-knee backstab - repeat neurovascular assessment + X-ray - elevation of limb - _surgical_: if there is significant soft tissue swelling: **temporary spanning external fixator is applied then ORIF is done 7-14 days later** - in older patients or if ORIF fails; fusion of ankle with hindfoot nail
30
Management of ankle OA
- activity modifications - physical therapy - analgesia - steroid injections - weight management - supportive footwear
31
What are lisfranc injuries?
Severe injuries to the tarometatarsal (lisfranc) joint between the medial cuneiform + base of the 2nd metatarsal . Either solely ligaments us or involving the bones of the midfoot (fracture-dislocation)
32
Mechanism of lisfranc injuries
Occur following severe torsional or translational forces applied through a plantarflexed foot *e.g. RTC or athletic injury*
33
Presentation of lisfranc injuries
- sever pain in midfoot - difficulty weight bearing - swelling + tenderness over midfoot - plantar bruising - piano key sign
34
What sign is involved in lisfranc injuries? What does it involve
**piano key sign** Moving each toe, one at a time, to see if it causes pain
35
Radiological features of lisfranc injuries
- widening of the interval between the base of 1st + 2nd metatarsal - bony fragment in the space between the 1st + 2nd metatarsal - malaligment of the distal talus bones to their associated metatarsal
36
What classification is used to classify Lisfranc injuries?
Hardcastle and Myerson classifcation
37
Management of lisfranc fracture
- ensure pt is Haemodynamically stable - _if no significant displacement_: **cast immobilisation + non weight bearing mobilisation** - _if significantly displaced_: **closed reduction in A&E** then **screw fixation** in surgery
38
What are the first and second most commonly fractured tarsal bones?
Calcaneus (first) Talus (second)
39
Mechanism of calcaneus fracture
Fall from a height With significant axial loading onto the bone
40
What are the two types of classifications of calcaneus fractures?
- **intraarticular**: involves the articular surfaces of the subtalar joint - **extraarticular**: most often avulsion fractures
41
What classification is used for intra-articular calcaneus fractures? What are the types?
**Sanders classification** - **type 1**: no displaced posterior facet - **type 2**: one fracture line in posterior facet (2 fragments) - **type 3**: two fracture lines in posterior facet (3 fragments) - **type 4**: comminuted with more than three fracture lines in the posterior facet (4 or more fragments)
42
Presentation of calcaneus fractures
- pain and tenderness around calcaneal region - inability to weight bear - swollen and bruised - possibly varus deformity
43
What is the gold standard for assessing calcaneal fractures?
CT imaging
44
Management of calcaneus fractures
- **closed reduction with percutaneous pinning** if minimally displaced - **ORIF** for most cases - analgesia - non weight bearing
45
Main complication of calcaneal fracture
Subtalar arthritis
46
What are the two types of Achilles tendinopathy?
- **insertional tendinopathy**: within 2cm of the insertion point on the calcaneus - **mid-point tendinopathy**: 2-6cm
47
Risk factors of Achilles tendinopathy
- sports that stress the Achilles *e.g basketball, tennis, track* - inflammatory conditions *e.g. RA + ankylosing spondylitis* - diabetes - raised cholesterol - fluoroquinolone abx *e.g. ciprofloxacin*
48
Presentation of Achilles tendinopathy
- pain or aching in Achilles tendon with activity - stiffness - tenderness - swelling - nodularity on palpation
49
Management of Achilles tendinopathy
- exclude Achilles tendon rupture - *Simmonds’ calf squeeze test* + USS - rest + modified activities - analgesia - orthotics *e.g. insoles* - Physiotherapy - ESWT: extracorporeal shock wave therapy
50
Why are steroid injections into the Achilles tendon avoided?
Risk of tendon rupture
51
Risk factors of Achilles tendon rupture
- sports that stress the Achilles *basketball, track, tennis* - increasing age - existing Achilles tendinopathy - family history - fluoroquinolone abx *ciprofloxacin*
52
What medicine has a link with Achilles tendon pathology?
**Fluoroquinolone abx** *e.g. Ciprofloxacin + levofloxacin* Rupture can spontaneous occur within 48 hours of starting
53
Presentation of Achilles tendon rupture
- sudden onset of pain in Achilles - snapping sound or sensation - feeling as though something has hit them in the back of the leg
54
Examination signs of Achilles tendon rupture
- tenderness - palpable gap - weakness of plantar flexion - unable to stand on tip toes - positive simmonds calf squeeze test
55
What test can be used if suspecting Achilles tendon rupture? Describe it
**Simmonds’ calf squeeze test** - Pt is prone - squeeze the calf - if intact the ankle with plantar flex - a lack of plantarflexion > positive test > Achilles tendon rupture
56
Diagnostic imaging of Achilles tendon rupture
USS
57
Management of Achilles tendon rupture
- RICE - immobilise with boot (first in plantarflexed position then to neutral over time)| consider VTE prophylaxis - analgesia - surgically reattaching Achilles (difficult to do)
58
What is SImmonds triad?
Calf squeeze test, palpation of tendon + observation of angle of declination For Achilles tendon rupture
59
What is the mortise view of the ankle?
Modified AP X ray of ankle Rotated internally by 10-20 degrees to better visualise the ankle joint
60
What is the medial clear space of the ankle?
Space between the medial talus + the lateral edge of the medial malleolus
61
What is the upper limit of the medial clear space?
4mm (Or 5? Check)
62
What is the lateral clear space?
Distance between the medial border of the fibula + the lateral border of the posterior tibia 1cm above the tibial plafond (distal end of tibia)

Orthopaedic Surgery (10 decks)

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