Foot and Ankle Flashcards
(43 cards)
1
Q
Ankle Joints
A
- Ankle is a hinge joint
- Motions = flexion/extension
- Inversion/eversion occurs at calcaneo-talar joint (below the ankle)
2
Q
Lateral Ligaments of the Ankle
A
- Anterior talo-fibular - 1st to tear in ankle sprains
- Calcaneo-fibular
- Posterior talo-fibular
3
Q
Medial Ligaments of the Ankle
A
- Deltoid ligament
- Tibiofibular ligament
- aka inerosseous ligament
- aka syndesmotic ligament
- joins distal tibia-fibula
- maintains integrity of mortise joint
4
Q
Extensor Tendons of the Ankle
A
- dorsiflexors
- pass anterior to the ankle
5
Q
Plantar Flexor Tendons of the Ankle
A
- pass posterior to medial malleolus
- “tom, dick and harry”
- Tibialis posterior
- Flexor digitorum
- Flexor hallicus
6
Q
Peroneal Tendons of the Ankle
A
- evertors of the ankle
- pass posterior to the lateral malleolus
- Peroneal longus and brevis
- Brevis is often involved in avulsion fractures of the 5th metatarsal
7
Q
Achilles Tendon
A
- arises from gastroc and soleus
- inserts on calcaneous
- plantar flexes the foot - strongest plantar flexor
8
Q
Retinacula
A
Fibrous bands that hold tendons in place
9
Q
Ankle Sprains
A
- Ligamentous injury
- usually inversion mechanism
- >90% lateral ligaments
- most are anterior talo-fibular ligament
- very few are deltoid ligament and tib-fib syndesmosis
- Lateral ligaments tear in sequence anterior to posterior
- Deltoid ligament sprain
- due to eversion mechanism
- usually with associated fibula fx
10
Q
Ankle Sprains: clinical
A
- pain, swelling
- +/- inability to bear weight
- foot may be inverted (talar tilt)
- passive inversion results in increased pain
- stress maneuvers
- drawer test
- inversion stress
11
Q
Ottawa Ankle Rules
A
- bony tenderness along distal 6cm of tibia or fibula
- bony tenderness at base of 5th metatarsal
- inability to bear weight both immediately after injury and in emergency department
12
Q
Ankle Sprain: Classification
A
- First-degree
- ligament stretching
- local tenderness, minimal swelling
- Second-degree
- severe stretching/partial tearing
- more tenderness and swelling
- abnormal stress tests
- Third-degree
- complete rupture
- can’t bear weight
13
Q
Ankle Sprain: management
A
- ice, elevation
- immobilize with plastic or plaster splint
- consider crutches
- if moderate-severe
- if difficulty bearing weight with splint
- third degree sprains may need surgery (rare)
14
Q
Ankle Fractures
A
- may be malleolar, bimalleolar, trimalleolar
- often disrupt tib-fib ligament and mortise joint
- tib-fib (syndesmotic) ligament normally maintains integrity of mortise
- exception: distal fibula fx
15
Q
Weber Classification
A
- Weber A
- fibula fx below syndesmosis
- mortise usually intact
- Weber B
- fibula fx at level of syndesmosis often tearing ligament
- may disrupt mortise
- Weber C
- fibula fx above syndesmosis, always tearing ligament, disrupting mortise
- always unstable
16
Q
Ankle Fracture: clinical
A
- pain, swelling, bruising, inability to bear weight
- significant deformity if dislocation is present
17
Q
Ankle Fracture: management
A
- reduce fracture-dislocations
- immobilize in splint
- elevate
- surgery needed if mortise disrupted
- need to restore anatomic position of talus on mortise
- ensure smooth articular surface
- cast 6-8 weeks
- arthritis likely if poorly aligned joint surface
18
Q
Calcaneous Fracture
A
- most commonly fractured tarsal bone
- mechanism usually due to compression
- e.g fall from height
- 10% associated with lumbar fx
- 26% associated with other extremity injury
- Clinical: swelling, pain, ecchymosis
- X-ray: standard foot films usually demonstrate, consider calcaneal views
- Treatment: surgical, need to restore anatomy
19
Q
Talar Fracture Etiology
A
- usually due to foot hyper-plantar flexion
- fx may involve dome, neck or body
- talus covered by cartilage, blood supply, tenuous
- fx may lead to avascular necrosis
20
Q
Talar Fracture Clinical
A
- intense pain
- inability to bear weight
- localized tenderness and swelling
- may have loss of normal foot contour
- caution “ankle sprain” misdiagnosis
- diagnose with foot x-rays
21
Q
Talar Fracture Management
A
- ice, elevation, immobilization
- nonsurgical, if non-displaced minor chip fx of dome
- surgery, if displaced fx of neck or body
22
Q
Midfoot: Cuboid Fracture
A
- usually due to crush injury
- usually associated navicular or cuneiform injuries
- pain/swelling/tenderness
- foot x-ray
- conservative prescription if non-displaced
- ORIF if displaced
23
Q
Midfoot: Proximal 5th Metatarsal Fx
A
- the most common metatarsal fx
- often occurs with lateral ankle sprain
- always check for tenderness at base of 5th MT when evaluating ankle sprain
- ankle x-rays must visualize this area
- usually due to inversion/avulsion of proximal bone by peroneus brevis tendon
- treatment:
- usually conservative, immobilize, crutches
24
Q
Jones Fracture of 5th Metatarsal
A
- Not an avulsion fracture
- Involves diaphysis of 5th metatarsal
- Has higher incidence of non-union or delayed union
25
Forefoot Fractures: stress fx
* stress fractures of midshaft metatarsals
* usually 2nd and 3rd MT's, which are relatively fixed
* 1st, 4th, 5th relatively mobile
* due to excessive stress over time
* may not appear on x-ray for 2-3 weeks
* if suspected:
* bone scan
* repeat xray in 2-3 weeks
* Rx: rest, possibly immobilize
26
Forefoot Fractures: complete
* Complete midshaft metatarsal
* usually crush mechanism
* occasionally due to twisting mechanism
* often more than one MT is fractured
* Rx: ice, immobilize with plaster/fiberglass
27
Forefoot Fractures: phalanges
* common: often see fracture-dislocation
* usually due to direct trauma or hyper-extension
* exam: pain/swelling, deformity if dislocated
* Rx:
* reduce fx and/or dislocation
* immobilize with dynamic splinting (buddy taping)
* stiff-soled shoes
* great toe bears 1/3 of weight of body on that side may require walking cast
* if unable to reduce may require internal fixation (rare)
28
Metatarsalgia
* Nagging forefoot pain over middle metatarsal heads
* Usually due to faulty weight distribution
* e.g weight gain, hallux valgus, flat foot
* metatarsal heads bear disproportionate weight
* also, gout. rheum athritis
* Treatment symptomatic, directed at cause
29
Morton's Neuroma
* a neuropathy of interdigital nerve, usually proximal to bifurcation
* usually nerve supplying 2nd and 3rd toes
* nonspecific inflammation of nerve with proliferative connective tissue
* most common in middle-aged women
* Clinical:
* sudden attacks of sharp or burning pain, radiating to toes
* at first, pain only with walking
* later, pain even at rest
* localized webspace tenderness, reproduces pain
* may palpate small mass in webspace
* Management: initial steroid/lidocaine injection, definitive surgical excision
30
Hallux Rigidus
* stiffness of MTP joint of great toe
* caused by arthritis, local trauma, gout
* more common in men
* clinical: pain with walking, tender MTP joint, pain with dorsiflexion
* X-ray: arthritic changes, osteophytes, narrowed joint space
* Management: rocker-soled shoes, NSAIDs, possibly surgery (joint replacement vs fusion)
31
Hallux Valgus
* most common foot deformity
* great toe angles "inward" (valgus)
* more common in females
* often familial
* obvious deformity
* prominent bunion
* red, swollen
* management: conservative - wide, padded shoes. surgical - corrective osteotomy
32
Hammertoe
* PIP joint fixed in flexion, DIP extended
* most commonly affects second toe
* shoe pressure may produce corns/calluses on dorsum of toe
* treatment: operative: joint excision
33
Pes Planus (Flat Foot)
* due to collapsed medial arch
* may be congenital or acquired (polio, rheum. arthritis, tendon ruptures)
* flexible most common
* rigid due to congenital vertical talus or spasmodic peroneal muscles
* Clinical:
* arching feet with standing/walking
* shoes wear badly esp over arch
* on exam medial border of foot almost touches ground when standing
* Management: small children usually none, older kids/adolescents arch support, if underlying condition may need surgical correction
34
Plantar Fasciitis
* usually an overuse injury
* runners, standing occupations, also rheum arthritis and gout
* strain of fascial fibers, friction causes periostitis of calcaneous
* Clinical:
* pain over plantar surfaces: increased pain with walking, running. relief with rest
* tender to palpation over anterior calcaneus
* pain with passive dorsiflexion
* Management: rest, NSAIDs, heel and arch supports, steroid injection
35
Posterior Tibial Tendonitis
* post. tibial tendon is a plantar flexor of foot
* passes posterior to medical malleolus
* overuse injury
* management:
* rest, NSAIDs
* possibly immobilize
* possible steroid injection
36
Peroneal Tendonitis
* peroneal tendons pass posterior to lateral malleolus
* overuse injury
* management:
* rest, NSAIDs
* possible immobilie
* possible steroid injection
37
Tarsal Tunnel Syndrome
* entrapment of posterior tibial nerve by flexor retinaculum
* due to inflammation
* repetitive activity
* rheum arthritis
* pregnancy
* acute trauma: fx dislocation, soft tissue swelling
* clinical: numbness, pain of sole of foot
* Management: rest, NSAIDS, immobilize, possible surgery
38
Subluxing Peroneal Tendons
* occurs after injury that disrupts peroneal retinaculum
* acute or chronic
* tendons sublux or actually disclose over lateral malleolus
* seen best with foot eversion
* treatment: surgical
39
Achilles Tendonitis
* overuse of calf muscles
* tenderness, increased pain with dorsiflexion
* acute management: rest, ice, NSAIDs, immobilize
* chronic management: surgery to divide fascia
40
Achilles Tendon Rupture
* usually due to forced dorsiflexion of ankle
* initiating sprint
* slipping on stair
* also may see with direct trauma
* blow to taut tendon, laceration
* may be partial or complete
* most common in middle-aged men
* symptoms: sudden pain, pt may hear snap, difficulty stepping off
* exam: swelling of distal calf, palpable tendon defect, weak plantar flexion, may still be able to flex, positive thompson test
41
Thompson Test
* sensitive to detect achilles rupture
* pt lies prone with knee flexed at 90 degrees
* squeeze calf, foot should plantar flex
* achilles rupture: foot does not flex
42
Achilles Tendon Rupture Management
* splint in equinus
* non-weight bearing
* refer to ortho
* conservative: casting x 8 weeks, physical therapy
* surgical: recommended for younger, athletic pts
43
Hindfoot Bursitis
* Two bursae
* between calcaneus and achilles tendon
* between achilles tendon and skin
* overuse injury
* poorly fitting shoes
* inflammation, pain on motion
* management:
* rest, NSAIDs, proper fitting shoes
* consider steroid injection
