Foot and Ankle Emergencies

Question 1

what is a foot and ankle emergency?

Answer 1

• Requires immediate attention.
  
  • Fracture -high impact/force injury
  • Infection
• Time is of the essence-
  
  • Delay in treatment or mistreatment can lead to permanent loss of function, loss of limb or even loss of life.
• Quick ID of injury can quicken and get the protocols started earlier
• Examples
  • Infection with gas in the soft tissues.
  • Septic joint
  • Open fractures.
  • Closed injury with elevated compartment pressures.
  • Fractures/dislocations involving the calcaneus, talus and Lisfranc’s joint.
  • Lots of gas in the ED at ACMC
  • Open fracture exposure depends on center (Level 1 has higher amt of open fxs of ankle)

Question 2

initial management

Answer 2

• ABC’s - Primary and secondary survey
• Hemodynamically stable
• Initial Imaging
  
  • Plain films usually
• Secondary imaging
  
  • CT, US, MRI if facility has available
• Labs if appropriate
• Consultant calls
• Treatment

Question 3

Emergencies

Answer 3

• Open fractures
• Compartment syndrome/crush injury
• Ischemic foot
• Infection
  
  • Gas gangrene
  • Necrotizing fasciitis
  • Septic joint

Question 4

examination red flags

Answer 4

• Edema
• Ecchymosis
  
  • Mondor sign - calcaneal fracture - this looks more like a lisfranc to me
• Erythema
• Point Tenderness
• Obvious deformity
• Gait abnormality

Question 5

focused food and ankle exam

Answer 5

• MSK- observe for deformity and red flags
• ROM of ankle, subtalar joint, forefoot joints
  
  • High tib-fib squeeze
    
    • Syndesmotic injury
  • Ankle external rotation test
    
    • Syndesmotic injury
  • Anterior drawers, talar tilt
    
    • ATFL or CFL injury
  • Stress foot abduction test
    
    • Lisfranc fracture dislocation
• NEURO-
  
  • gross distal sensation
• VASC-
  
  • DP and PT pulses; if you cant feel them- Doppler them!
• DERM-
  
  • open wounds or other red flags

Question 6

Foot and ankle injury: radiographs

Answer 6

• Follow the Ottawa Rules
• WB vs NWB- depends on injury
• But when in doubt, order the films
  
  • 2 views minimum, preferably 4 views
    
    • Ankle AP, lateral, Mortise
    • Foot AP, oblique and lateral
    • Calcaneal axial, high tibia/fibula
• Ankle radiographs: AP, mortise, lateral
• Foot radiographs: AP, lat, oblique
• Special radiographs: Calcaneal axial (Calcaneal fracture), High Tibia/fibula (Look for Maisonneuve fracture (high fibula))
• Special imaging: CT, MRI, US dependent on type of injury

Question 7

Ankle fractures

Answer 7

• Mechanism- force and torsion
• Etiology- high or low energy impact or rotation of the foot on the ankle
• How many malleoli?
  
  • Isolated
  • Bimalleolar
  • trimalleolar
• Classification- Weber

Question 8

ankle fracture management in the ED

Answer 8

• UNIMALLEOLAR AND BIMALLEOLAR
  
  • Assess, xrays
  • Reduce the fracture if possible
    
    • Distract, Increase the deformity, reduce
    • Get post-reduction xrays
  • Jones compression dressing, posterior splint
  • NWB with crutches
  • Imaging- applies to all fractures; if complex get a CT scan
• Trimaleolar
  
  • Reduce the fracture if possible
    
    • Increase the deformity, distract, reduce
  • Jones compression dressing, posterior splint
  • NWB with crutches
  • Call consultant if reduction is not adequate or skin is broken

Question 9

Jones compression dressing and posterior splint

Answer 9

The Robert Jones dressing is a thick, padded bandage classically applied to the thigh and leg. It is thought to reduce swelling by applying even pressure to the extremity, which in turn should promote healing.

Question 10

treatment of trimaleolar fx

Answer 10

• Non-displaced, stable
  
  • Posterior splint, Jones, NWB
  • F/u 5 – 7 days
• Displaced, unstable
  
  • Attempt closed reduction followed by open reduction internal fixation (ORIF)
• Likely will need ORIF depending on severity
• Aggressive physical therapy post-op or post-injury
• Anticipate 6 to 8 weeks for healing
• Watch for Chronic Post-Traumatic Ankle Pain
  
  • Osteochondral fracture of talus
  • CRPS
  • Occult fracture
• An osteochondral injury is an injury to the smooth surface on the end of bones, called articular cartilage (chondro), and the bone (osteo) underneath it. The degree of injury ranges from a small crack to a piece of the bone breaking off inside the joint.
• Complex regional pain syndrome (CRPS) is a chronic (lasting greater than six months) pain condition that most often affects one limb (arm, leg, hand, or foot) usually after an injury. CRPS is believed to be caused by damage to, or malfunction of, the peripheral and central nervous systems.

Question 11

closed reduction principles

Answer 11

• Steady traction
• Recreate direction of injuring force
• Reverse direction into correction
• Correct rotational, then angulational deformity

Question 12

calcaneal fxs

Answer 12

• High energy injuries
  
  • Axial load/fall
  • Lateral process of the talus acts as a wedge
• Treatment
  
  • Imaging- NWB plain films B/L feet;
    
    • then if fx- CT with 3D recon is preferable
  • NWB
  • Jones compression splint
  • If fracture blisters occur, use oil emulsion dressing to cover
  • Usually delay in ORIF of 1-2 weeks while edema and skin issues resolve

Question 13

talar fractures

Answer 13

• High energy
• MVA or fall
• Can be extruded
• High risk of AVN
• Open or closed
• Management
  
  • Imaging- NWB plain films, CT with 3D recon
  • NWB
  • DO not attempt to reduce
  • Call for consultant
  • Treated as emergency due to high rate of AVN
  • ORIF vs casting and immobilization
  • Can be prolonged course for healing >12 weeks

Question 14

Lisfranc fracture/dislocation

Answer 14

• Lisfranc was a French sugeon
• Usually high energy injury… MVA, fall from height, equestrian injury
• Injury is forced dorsiflexion of midfoot on forefoot, causing fracture and dislocation of metatarsal-cuneiform articulations
• Evaluation
  
  • NWB AP and Medial Oblique radiographs;
  • Monitor for signs of vascular injury and compartment syndrome
  • Check for malalignment at met-cuneiform articulation
    
    • Mostly dorsal dislocation
    • Can be complete or incomplete in relationship to met bases
  • Call consultant- do not attempt to reduce
  • Neuro checks in ED
  • If stable, Jones splint

Question 15

fractures with high potential for bad outcomes

Answer 15

• Open fractures
• Calcaneal fractures
• Talar neck fractures
• Non-reducible fractures

Question 16

fracture complications

Answer 16

• Non/Mal union
• Compartment syndrome
• Complex regional pain syndrome
• Osteoarthritis
• Osteonecrosis/avascular necrosis
• OCD in talus

Question 17

osteochondral defect of the talus

Answer 17

• Usually result of impact or mal-reduction during fracture or ORIF

Question 18

Complex regional pain syndrome (CRPS)

Answer 18

• Hyperalgesia
• Mechanical, thermal allodynia
• Sudomotor changes
• Often occurs secondary to ankle injury!
• Usually managed outpatient with aggressive PT
• Careful with pain meds

Question 19

achilles tendon rupture

Answer 19

• Common injury in men >45 yrs old
• “weekend warriors”
• Feel a ”pop” or like someone hit them with a bat in the back of the leg
• Focal pain and inability to bear weight on affected limb
• Thompson-Dougherty Test
  
  • Positive= rupture
  • Negative= intact
• Should be able to palpate defect or “dell”
• Imaging
  
  • Helpful if Thompson test is questionable
  • Also useful if neglected rupture
• Treatment
  
  • Controversial - Open repair vs casting

Question 20

Soft tissue wounds

Answer 20

• Treatment principles
  
  • All are contaminated to varying degrees
  • Almost all require prophylactic antibiotics
  • Don’t forget tetanus prophylaxis
  • When in doubt, leave it open!
• Tidy
  
  • < 6 hours old
• Untidy
  
  • Wounds with tissue loss
• Infected wounds
  
  • > 8 hours old

Question 21

Less complex fractures

Answer 21

• Distal to metatarsal neck
• Closed
• Non to slightly displaced
• Single
• Usually treatable with taping and post op shoe

Question 22

complex fractures

Answer 22

• Open
• Proximal to met neck
• Involves tendon or ligament avulsion
• Intra-articular
• Multiple
• Needs additional imaging
• Can lead to poor outcome, even if treatment is ideal
• May require ORIF and prolonged follow up

Question 23

External fixation

Answer 23

• Open fractures
• unstable fractures
• Skin compromise
• Delay to OR

Question 24

open fractures

Answer 24

• All open fractures are considered contaminated wounds
• All open fractures require immediate treatment, stabilization, irrigation and soft tissue management
• Treat all open fractures as an emergency
• Start appropriate antibiotic therapy
• Tetanus prophylaxis
• Do an adequate (in OR) debridement and irrigation
• Stabilize the fracture

Question 25

compartment syndrome

Answer 25

* The foot & leg are divided into compartments, separated by fascia. * Bleeding into a compartment may lead to elevated intracompartmental pressures * Findings * Hx of crush injury, high velocity penetrating injury * Anticoagulation therapy * Pain out of proportion * Intra-compartmental pressure * The 5 P’s * Pain (severe) * Pulselessness * Palor * Paresthesia * Pain with passive stretch * Not reliable * Treatment * IV hydration * Supplemental O2 * Do not elevate extremity * Immediate fasciotomy! * Complications * Permanent nerve and muscle loss * Rhabdomyolysis * Necrosis leading to amputation

Question 26

Charcot's neuropathy

Answer 26

* A relatively painless, progressive, destructive arthropathy * Charcot neuropathic osteoarthropathy (CN), commonly referred to as the Charcot foot, is a condition affecting the bones, joints, and soft tissues of the foot and ankle, characterized by inflammation in the earliest phase. The Charcot foot has been documented to occur as a consequence of various peripheral neuropathies; however, diabetic neuropathy has become the most common etiology. The interaction of several component factors (diabetes, sensory-motor neuropathy, autonomic neuropathy, trauma, and metabolic abnormalities of bone) results in an acute localized inflammatory condition that may lead to varying degrees and patterns of bone destruction, subluxation, dislocation, and deformity. The hallmark deformity associated with this condition is midfoot collapse, described as a “rocker-bottom” foot (Fig. 1), although the condition appears in other joints and with other presentations. Pain or discomfort may be a feature of this disorder at the active (acute) stage, but the level of pain may be significantly diminished when compared with individuals with normal sensation and equivalent degrees of injury. * Will mimic infection in presentation * Red hot swollen foot * Usually totally neuropathic “it doesn’t hurt” * Get plain films * Workup for infection * Basic labs- CBC, sed rate, CRP, culture wounds if appropriate * Associated plantar wounds- usually source of infection if present

Question 27

diabetic foot infections

Answer 27

* Very common * Polymicrobial * Poor compliance and glycemic control * neuropathy * Hemodynamically stable? * Sepsis? DKA? * Basic labs- CBC, CMP, sed rate, CRP * Plain films; CT helpful to eval for gas * Call for consultant and admission * To OR for I&D or more… * Treatment * Fluids, fluids, fluids * abx * NPO * Dressings * Usually gauze to cover until we get there * To OR for debridement * Cultures intra-op * Will require wound care for prolonged period

Question 28

gout vs septic joint

Answer 28

* Warm, red swollen joint * What can help differentiate? * History * Joint aspiration * Films * Labs

Question 29

Puncture wounds

Answer 29

* “Stepped on a nail” * Were they wearing shoes? * Tetanus * Clean wound - no pressure irrigation * Risk of pseudomonas - treat with Cipro

Question 30

dog bites

Answer 30

* Tetanus * Films * Rabies prophylaxis? * Clean wound - no pressure irrigation * Wound closure? * Antibiotic prophylaxis: * Deep puncture wounds * Crush injury * Venous or lymphatic injury * Wounds on hand, face, genitalia or joint * Wounds requiring closure * Imunocompromised hosts