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MSK Exam 3 > Foot/Ankle > Flashcards

Foot/Ankle Flashcards

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1
Q

Most commonly fractured long bone

A

Tibia

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2
Q

Tibial Shaft Fracture etiology

A

Trauma

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3
Q

Tibial Shaft Fracture
Clinical Presentation

A
  • Leg pain
  • Worse with movement
  • Swelling
  • Open fractures are common
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4
Q

Tibial Shaft Fracture
Diagnosis

A
  • Evaluate the entire tibia-fibula,
    ankle, & knee
  • Tenderness, deformity, & soft
    tissue swelling along the tibia
  • Distal neurovascular exam:
  • Peroneal n. sensory exam:
  • Check for evidence of skin wounds
    suggestive of an open fracture
  • Evaluate for compartment syndrome
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5
Q

Peroneal n. sensory exam includes:

A
  • sensation to dorsal first
    webspace of foot
  • lateral dorsal foot
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6
Q

Peroneal n. motor exam includes:

A
  • ankle dorsiflexion
  • eversion
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7
Q

Tibial Shaft Fracture diagnosis

A
  • Obtain x-rays of the ankle
  • AP, lateral, mortise views
  • Obtain x-rays of the tibia-fibula &
    knee
  • AP, lateral views
  • Consider noncontrast CT
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8
Q

Tibial Shaft Fracture
Management

A
  • Most require operative repair
  • Well-approximated, low-force fractures of the tibial shaft may be managed
    nonoperatively
  • Fractures of the tibia associated with a fibular shaft fracture will require
    operative repair because of fracture instability
  • Open fracture, neurovascular injury, & compartment syndrome: All are indications for hospital admission & operative repair
  • Pain medications
  • Acute management
  • Position the patient’s knee in 10-15° of flexion
  • Long-leg posterior leg splint
  • Supporting stirrup splint to prevent ankle & knee movement
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9
Q

indications for hospital admission & operative repair of a tibial shaft fracture

A

Open fracture, neurovascular injury, & compartment syndrome

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10
Q

Tibial Shaft Fracture
Complications

A
  • Chronic pain & deformity
  • Compartment syndrome
  • Mal-union & nonunion
  • Osteomyelitis
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11
Q

Fibular Shaft Fracture epidemiology & etiology

A
  • Isolated midshaft or proximal fibula fractures = Rare
  • Isolated distal fibula fracture = Common
  • Majority of ankle fractures in older women
  • Fibular fractures may occur from repetitive loading
  • stress fractures
  • Fibula fractures often associated with tibial fractures
  • Trauma
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12
Q

Fibular Shaft Fracture
Clinical Presentation

A
  • Patients often complain of lateral leg pain,
    exacerbated with walking
  • Fibula only bears ~17% weight
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13
Q

Fibular Shaft Fracture
PE & Diagnosis

A
  • Evaluate the entire tibia-fibula,
    ankle, & knee
  • Tenderness, deformity, & soft
    tissue swelling along the fibula
  • Distal neurovascular exam
  • Check for evidence of skin wounds
    suggestive of an open fracture
  • X-rays of the ankle: AP, lateral, mortise views
  • X-rays of the tibia-fibula & knee: AP, lateral views
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14
Q

Fibular Shaft Fracture
Management

A
  • Most isolated fibula fractures of the proximal fibula & shaft can be managed nonoperatively
  • Place the patient in a long-leg posterior leg splint or cast with the ankle & knee immobilized
  • Pain medication
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15
Q

Fibular Shaft Fracture
Complications

A
  • Compartment syndrome
  • Mal- & non-union
  • Peroneal nerve injury
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16
Q

Tibia & Fibula Stress Fractures etiology

A
  • Overtraining
  • Especially sudden ↑ in training intensity
  • Incorrect biomechanics 2° training, anatomy, equipment
  • Tissue fatigue
  • Hormone imbalance
  • Poor nutrition
  • Vitamin D deficiency
  • Osteoporosis
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17
Q

Tibia & Fibula Stress Fractures
Clinical Presentation

A
  • Patient complains of ↑ pain with exercise
  • Pain becomes progressive & provoked with even lighter exercise
  • Focal pain
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18
Q

Tibia & Fibula Stress Fractures
Diagnosis

A
  • X-ray
  • AP & Lateral
  • May not be visible for 3
    weeks
  • Bone Scintigraphy
  • Will show ↑ uptake at the fx
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19
Q

Tibia & Fibula Stress Fractures management

A
  • REST from the STRESS
  • Low impact exercise can be substituted
    to maintain cardiovascular conditioning
  • Recumbent bicycling, pool running
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20
Q

Tibia & Fibula Stress Fractures complications

A
  • Adverse effects of NSAIDS
  • Recurrence
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21
Q

Referral Considerations for Tibia & Fibula Stress Fractures

A
  • Ortho consult
  • 2-3 weeks with no improvement or worsening
  • Consider psychiatric referral for women with female athletic triad
  • Menstrual dysfunction (2nd Amenorrhea), Osteoporosis, Disordered eating
  • Poor outcomes with irreversible osteoporosis amongst other
    complications
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22
Q

Female Athlete Triad

A
  1. Menstrual dysfunction
    * Dx no longer requires complete absence of periods, low estrogen levels
  2. Disordered eating
    * low or decreased energy intake, with or without eating disorder
  3. Decreased bone mineral density
    * Decreased bone health ↔ osteoporosis
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23
Q

Comprehensive history and what to watch for if suspecting female athlete triad:

A
  • Iron deficiency anemia, menstrual history
  • Bone loss - Z-score as opposed to a T-Score,
  • Weight loss, Less than 90% ideal body weight, Low BMI under 18.5
  • Stress fractures
  • Education, counseling, increase Ca and Vit D, body weight normalization
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24
Q

Ankle Fractures etiology

A

Traumatic MOI

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25
Ankle Fractures Types
* Distal fibular fractures are common * Lateral malleolus, medial malleolus, posterior malleolus (tibia), talar dome * Bimalleolar ankle fracture – lateral & medial malleoli * Trimalleolar ankle fracture – lateral, medial, & posterior malleoli * Maisonneuve (may-zone-newv) fracture – a fracture of the medial malleolus that extends through the syndesmotic membrane into the proximal fibula
26
Distal Fibular Fracture breakdown
Weber A, B, C
27
Ankle Fractures Clinical Presentation
* Acute pain after trauma * Swelling * Deformity * Inability to bear weight
28
Ankle Fractures Diagnosis
* Examine the entire tibia-fibula, ankle, & knee * Tenderness along the distal fibula and/or distal tibia * Edema * Ecchymosis * Ligamentous laxity * Distal neurovascular exam * Check for open wounds * X-ray: Obtain x-rays of the ankle * AP, lateral, mortise views * Consider CT for complex fx: Esp. if a talar fracture is suspected
29
Ankle Fractures management
* Most ankle fractures require operative repair * Treat fractures and/or ligamentous injuries to both the lateral & medial ankle as an unstable, bimalleolar fracture * Generally, isolated, nondisplaced malleolar fractures with intact ligaments can be immobilized with a short-leg walking cast or orthopedic boot * All other fracture patterns require a short-leg posterior splint with stirrups * Pain medication
30
Ankle Fractures Complications
* Mal- & non-union * Compartment syndrome * Post-traumatic ankle arthritis * Syndesmotic instability * Wound sloughing & deep soft tissue infection
31
Tarsometatarsal Fracture- Dislocation (Lisfranc) etiology
* Traumatic disruption of the Lisfranc ligamentous complex (stabilizes the juncture of the metatarsals & midfoot) * Classically, the injury pattern involves a fracture at the second metatarsal base or second cuneiform, along with resultant metatarsal subluxation/dislocation
32
Midfoot Fracture-Dislocation (Lisfranc) Clinical Presentation
* Patients often complain of pain & swelling of the foot * Often out of proportion with x-ray * Plantar ecchymosis * Midfoot instability
33
Midfoot Fracture-Dislocation (Lisfranc) diagnosis
* Tenderness, deformity, swelling, & overlying lacerations * Check distal neurovascular * Compartment syndrome * Obtain foot x-rays (AP, lateral oblique) * Widening of the space between the first & second metatarsal base > 2mm suggests a Lisfranc injury * Medial border of the 2nd (middle) cuneiform & 2nd metatarsal should be in linear alignment * Misalignment suggests Lisfranc * Weight bearing X-ray may help * Get the noncontrast CT
34
Midfoot Fracture-Dislocation (Lisfranc) Management
* Non-displaced * 6-8 weeks Non-weight bearing & cast immobilization * Then rigid arch support x 3 months * Displaced * ORIF
35
Midfoot Fracture-Dislocation (Lisfranc) Complications
* Mal- & nonunion * Compartment syndrome * Post-traumatic arthritis
36
Referral Considerations for Midfoot Fracture-Dislocation (Lisfranc)
* Immediate referral for compartment syndrome or open fracture * Typically referred to Ortho, could consider a podiatrist
37
Calcaneal & Talar Fractures epidemiology & etiology
* Calcaneus → Most commonly fx tarsal bone * ~2% of all fractures in adults * Talus fractures = rare Etiology * Traumatic
38
Calcaneal & Talar Fractures Clinical Presentation
* Acute localized pain following trauma * Unable to weight bear on affected foot
39
Calcaneal & Talar Fractures Diagnosis
* Point tenderness * Localized swelling * Check distal neurovascular * X-ray * Hindfoot * AP, Lateral, Harris views * Ankle views * CT should be strongly considered
40
Calcaneal & Talar Fractures management
* All intraarticular fractures will require surgery * Extraarticular, non-displaced fractures may be managed conservatively with splinting, then casting x 6-8 weeks
41
Calcaneal & Talar Fractures Complications
* Talar fractures often disrupt blood supply leading to osteonecrosis * Chronic pain * Arthritis * Complex Regional Pain syndrome * Plantar compartment syndrome
42
5th Metatarsal Fractures AKA
“Jones Fracture”
43
Metatarsal Fracture etiology
* Trauma * Direct blow * Torsion * Stress/Overuse
44
Metatarsal Fracture Clinical Presentation
* Patients complain of pain & swelling at the site * Traumatic & acute * Insidious in onset with stress fractures
45
Metatarsal Fracture Diagnosis
* Tenderness & local deformity * Axial loading (flick/bump test) the affected toe should only produce pain in fractures & not with a soft tissue injury * Perform a distal neurovascular exam * Note overlying lacerations * X-rays (AP, lateral, oblique) * May consider obtaining ankle x-rays to assess for concurrent, more proximal injuries * Possibly CT
46
Metatarsal Fracture management
* Generally, closed metatarsal fractures without concurrent dislocations can be managed on an outpatient basis after immobilization * Short leg cast, rocker shoe * Metatarsal head & neck fractures * Generally nonoperative, unless multiple metatarsal fractures involved * 5 th Metatarsal Fractures (Jones Fracture) * Zone 2 (possibly) & 3 may require ORIF
47
Metatarsal Fracture Complications
* Non/mal-union * Recurrence
48
Metatarsal Fracture referral considerations
* Ortho or podiatry consult: * Zone 2-3 Jones fracture * Open fractures, multiple fractures * Significant displacement or angulation (>10°)
49
Phalange Fracture (Toe) epidemiology & etiology
Epidemiology * Phalangeal fractures are common * Fractures toes 2-5 are 4 times as common as fractures of the first toe * First toe fractures are often displaced * Fractures of the lesser phalanges are often comminuted & nondisplaced Etiology * Trauma * Crush, axial loading * Stress/overuse
50
Phalange Fracture (Toe) Clinical Presentation
* Acute pain & swelling after trauma * Occasionally subungual hematoma can occur with crush injuries
51
Phalange Fracture (Toe) Diagnosis
* Clinical exam * X-ray * AP, Lateral, Oblique
52
Phalange Fracture (Toe) Management
* Most phalanx fractures are nondisplaced * Manage nonoperatively by splinting the injured toe to an adjacent toe (“buddy taping”), consider a surgical shoe * 3-6 weeks * First toe, bears a lot of weight & balance * Nondisplaced fracture: buddy tape splint & rigid walking cast/surgical shoe for 3-6 weeks * Displaced fracture: may attempt closed reduction, but persistent displacement requires surgery
53
Phalange Fracture (Toe) complications
* Pain * Malunion or nonunion * Arthritis * Nail bed deformity * Interdigital corn from a persistently displaced toe fracture rubbing against an adjacent toe
54
Ankle Sprains Etiology
Etiology * Trauma * Torsion * Types: * Inversion (MOST COMMON): Involving lateral ligaments * Eversion: Involving the medial ligaments * Syndesmotic (aka ”High Ankle sprains”): Involving the interosseous ligaments & membrane between the tibia & fibula
55
How many ankle sprains occur daily in the US?
25,000
56
Ankle Sprains Clinical Presentation
* Acute pain & swelling following torsion trauma * Varying levels of difficulty in weight bearing
57
Ankle Sprains Diagnosis
* Identify tender structures involved via palpation * Note swelling & location * Special Stress Tests * Anterior Drawer * Inversion Test * Kleiger Test * Eversion Test
58
Ankle sprain grading
* grade I, no macroscopic ligament tear * grade II, partial ligament tear * grade III, complete ligament tear
59
Ankle Sprains Management
* RICES * Crushed Ice (1/2 hr q 2 hrs) * Compression wrap (use a horseshoe pad around malleolus) * Ankle bracing * Cam walking boot for high ankle sprains * Physical rehabilitation * NSAIDS
60
Ankle Sprains Complications
* pain * decreased range of motion * chronic ankle instability * recurrent sprain
61
“High Ankle Sprain”
● Syndesmosis injury ● External Rotation ● Loss of integrity between tibia and fibula ● Possible fracture ● Delayed Dx associated with destabilized ankle joint and arthritis ● Cotton test, Kleiger test, Hopkin test, Anterior drawer ● MRI ● Neg instability → Cam Boot ● Instability → Syndesmostic Screw
62
Achilles Tendonitis etiology
* Overuse injury * Tendinopathy occurs due to failed inflammatory/healing: * haphazard proliferation of tenocytes * disruption of collagen fibers * increase in non-collagen matrix * degeneration of Achilles tendon displaying increased vascularization
63
Achilles Tendonitis Clinical Presentation
* Intermittent pain related to activity * Stiffness after prolonged rest * Swelling at the tendon insertion * ↓ strength & endurance of the triceps surae (gastrocnemius/soleus)
64
Achilles Tendonitis diagnosis
* Localized tenderness to palpation * Painful & ↓ strength with resisted range of motion Imaging-not usually necessary * Ultrasound * MRI
65
Achilles Tendonitis management
* Activity modification * NSAIDS * Physical rehabilitation * Surgery for resistant cases
66
Achilles Tendonitis Complications
* Rupture
67
Achilles Tendon Tear etiology
* Unknown exact cause → likely related to underlying tendinopathy * Rapid, forceful contraction of triceps surae * Particularly eccentric loading
68
Achilles Tendon Tear Clinical Presentation
* “Someone shot me” “Who kicked me (in the back of the leg)” * Sudden, severe pain localized to the Achilles tendon
69
Achilles Tendon Tear diagnosis
(2 or more of the following) * (+) Thompson test (calf squeeze test) * Most reliable within 48 hours of injury * ↓ plantar flexion reduced ROM * Palpable tendon gap/divot Imaging * MRI * Ultrasound
70
Achilles Tendon Tear
* Nonsurgical * diabetes * neuropathy * immunocompromised * age ≥ 65 years * tobacco use * sedentary lifestyle * obesity (BMI > 30) * peripheral vascular disease * dermatologic disorders * Gradual casting/bracing in plantar flexion until foot reaches neutral position. * Physical rehabilitation * Surgery for complete/severe ruptures
71
Achilles Tendon Tear Complications
* DVT * Rerupture * Pain * Infection * ↓ ROM & Strength
72
Hallux Valgus (Bunion) Epidemiology & etiology
Epidemiology * Adult females & the elderly * Family predisposition Etiology * abduction from midline * metatarsal head adducted toward body midline * Multifactorial
73
Hallux Valgus (Bunion) Clinical Presentation
* Localized pain & swelling over the MTPJ * Aggravated by footwear * May occur with a concurrent hypertrophic bursae
74
Hallux Valgus (Bunion) Diagnosis
* Clinical findings * X-ray * Normal Hallux Valgus angle * <15°
75
Hallux Valgus (Bunion) Management
* Shoe wear modification can help alleviate pain * Initial treatment of choice for the elderly & patients with neurologic or vascular compromise * Orthoses * Do not prevent progression of hallux valgus * Custom-made foot orthoses may be effective for foot pain * Pain medication * Surgery * Most effective for correcting deformity * More helpful in pain relief than orthoses
76
Hallux Valgus (Bunion) complications
* Ulcerations * Conservative care does not reverse deformity
77
Ingrown Toenail etiology
* Foreign body reaction * Nail bed is compressed from the side, the edge/corner of the nail penetrates the cuticle. * Inflammatory reaction 2° to presence of the keratinaceous nail material in the flesh of the toe.
78
Ingrown Toenail Clinical Presentation
* Localized pain & swelling * Typically unilateral * Stage I→ localized induration, swelling, pain * Stage II→ abscess * Stage III→ granulation tissue forms, inhibiting drainage
79
Ingrown Toenail Diagnosis
* Clinical diagnosis * Stage II & III * X-ray * R/O osteomyelitis & subungual exostosis (cartilaginous outgrowth on a bone eg. bone spur)
80
Ingrown Toenail Management
* Stage I: Warm soaks, proper nail trimming, wide toe box shoes * Stage II: Warm soaks, cephalosporin abx, digital block & partial nail removal * Stage III: Digital block & complete nail removal
81
Ingrown Toenail Complications
* Recurrence * Deformity * Infection * Pain
82
Interdigital (Morton) Neuroma etiology
* Repeated trauma of metatarsal heads * overly tight shoe or high heels? → unproven * Other causes * Flattening of the medial arch * Ischemic changes within interdigital nerve * Bunion formation * Perineural fibromas form (esp. 3rd branch of plantar n.)
83
Interdigital (Morton) Neuroma Clinical Presentation
* Pain (burning) & numbness * 2nd – 3rd webspace * Radiates to toes
84
Interdigital (Morton) Neuroma diagnosis
* Palpation * Esp. 2nd – 3rd webspace * “Pencil Eraser” test * Squeeze test * Lateral compression to metatarsal heads → (+) pain * US & MRI * ↑ sensitivity for Morton neuroma
85
Interdigital (Morton) Neuroma Management
* Footwear modification * Low heel * Wide toe box * Well cushioned (metatarsal pad) * Poor evidence for steroid injection * Surgery
86
Plantar Fasciitis etiology
* Repetitive microtrauma from prolonged walking or running + incomplete healing * Degenerative tendonosis
87
Plantar Fasciitis Clinical Presentation
* Insidious onset of plantar pain * Focal pain following prolonged rest * “First step in the morning”
88
Plantar Fasciitis Diagnosis
* Tender to palpation * Classically 1-2 cm from the calcaneal tuberosity * X-ray (Not necessary for dx) * ~50% of cases develop a heal spur (though the spur is not the cause of the pain)
89
Plantar Fasciitis Management
* 95% of cases are successfully managed conservatively * May take 6-12 months to fully resolve * Orthosis * Night splint * NSAIDS * Physical rehabilitation * Corticosteroid injection * Surgery
90
Plantar Fasciitis Complications
* Chronic pain * Altered gait → other kinetic chain problems (ankle, knee, hip, back)

MSK Exam 3 (6 decks)

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