Foot & Ankle Emergencies Flashcards by Beth Miller

what constitutes a foot & ankle emergency?

soft tissue infxn w/ gas
open fx
closed injury w/ elevated compartment pressures & vascular compromise
fxs/dislocations involving th eankle calcaneus, talus and Lisfranc’s joint

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triage

ABCs
primary & secondary survey
isolated foot & ankle injury
time from injury

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do this before calling surgery

NPO
tetanus prophylaxis
Abx
IVF hydration

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Labs

CBC
CMP
sed rate & crp (very helpful)
lactate

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imaging

plain films 
CT
ULS
MRI
*choose the best one, don't have to do all

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infxn?

febrile, WBC elevated?
to wht level is infxn (toes, foot, ankle or above)
soft tissue involvement (gas?)
necrosis (necrotizing fasciitis?)
sepsis

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fractures

open vs closed
dislocation, extrusion of bone outside of body
polytrauma

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soft tissue compromise (needs to be taken care of first)

open fx w/ contamination
compartment syndrome
crush injuries (worst)
tendon rupture

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open fx

all open fx are considered contaminated wounds

require IMMEDIATE tx

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Type I open fx

clean wound
less than 1 cm long
no crushing component
internal to external injiury

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Type II open fx

moderate contamination
more than 1 cm long, less than 5 cm
minimal comminution
outside to inside injury

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Type III open fx (A-C)

contaminated wound
extensive soft tissue damage
severe comminution
neurovascualr injury

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what’s broken

ankle
rearfoot
midfoot
forefoot

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ankle fx

very common

Ottowa rules- tells us if we should order x-rays

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Ottowa Rules

reasons to order plain film x-rays

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tib-fib fxs

significant displacement
uni, bi, or trimalleolar
skin compromise (fx blister)
vascular compromise (pulseless?)
edema (can turn into fx blisters)
inability to ambulate

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radiographs for tib-fib fx

order 3 views:
ankle
2 views of foot

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if there is a wide mortise, order what?

high tib-fib plain film looking for Maisonneuve fx

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if high energy ankle fx, get what if you suspect an intra-articular injury?

CT scan w/ 3D recon

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do i try to reduce?

yes
distract, increase, reduce the fx
get conscious sedation, muscle relaxants on board

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how to treat minimally displaced fx

posterior splint and jones compression dressing: 1 layer of web roll+coban+web roll+coban….3 layers- then put on posterior cast

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ORIF

open reduction internal fixation

definitive tx for many fx’s

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calcaneal fx

Mondors sign
edema
open component
vascular compromise
outcome is always bad/ usually from high energy from height

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Mondors sign

pt w/ calcaneal fx

immense amount of ecchymosis in arch

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radiographs for calcaneal fx

``` 3 views of both feet calcaneal axial consider spine films if mechanism consistent Bohler's Angle Angle of Gissane's ```

Bohler's Angle

decreased in calcaneal fx

Angle of Gissane's

increased in calcaneal fx

always get this in calcaneal fx

CT with 3D recon

10% of calcaneal fx's lead to what?

compartment syndrome

soft tissue injury | elevated intracompartmental pressures from bleeding into that compartment

the 5 P's of compartment syndrome

``` pain (severe) pulselessness pallor paresthesias pain w/ passive stretch ```

how to dx compartment syndrome

check pressure if > 30 mmHg= compartment syndrome immediate fasciotomy in OR needs to be opened & pressure needs to be released

if compartment syndrome untreated

rhabdomyolysis & permanent nerve damage

ORIF vs CAST in calcaneal fx

nondisplaced, minimal fx---> cast will work ORIF for severe posterior splint + jones compression

talus fx

``` open or extruded acute fx (emergency) polytrauma soft tissue envelope *always a bad fx ```

tenous blood supply & very high chance of AVN?

talus fx

talus fx mech

high energy impact of tibia into talus; crush component

radiographs for talus fx

3 vies of ankle & 3 of foot

classification of talus fx (Hawkings classification)

I- through neck II-thru neck & subtalar III-displaced frx of talar neck w/ dislocation of body of talus from both subtalar joint and the ankle joint IV-subtalar, tibiotalar, and talonavicular joint subluxation or dislocation usually immediately to OR in acute setting!!

Lisfranc fx/ dislocations

deformity vascular compromise open compartment

mech of Lisfranc fx/ dislocation

high energy forced dors/plantarflexion injuries across Lisfranc's joint

radiographs for Lisfranc fx/ dislocation

3 vies of foot & include medial oblique | *CT scan if in doubt

subtle Lisfranc fx

problematic easily missed in EM setting can cause problems in future

toe fx's

most distal toe fx if nondisplaced & extra-articular, do well w/ modified wt bearing & buddy splinting

infection

chronic vs acute fulminant? gangrene wet vs dry *these are red flags

infxn & co-morbidities

DM PVD immune compromise

acute setting infxn mngt

NPO labs- CBC, CMP, HgA1c, lactate, others PRN admission ermergent OR visit

exam findings of nasty infected foot

odor crepitus obvious tissue necrosis

radiographs in infxn

3 views of foot & ankle | look for gas in tissue

soft tissue injury

``` tendon rupture (achilles, posterior tibial, extensor hallacis longus) crush injury (failure rate is high) ankle sprains ```

Achilles tendon rupture

weekend warrior | felt "pop" in achilles while playing basketball, felt like someone hit them w/ baseball bat

physical sign of Achilles tendon rupture

palpable dell in tendon approx 2-3 cm proximal to insertion

imaging for Achilles TR

MRI or ULS

Thompson-Dougherty test

pathognomic for Achilles rupture

tx for Achilles TR

cast | end-to-end repair

ankle sprain grading system

I,II,III based on level of ligamentous injury often lateral ligaments

ankle sprain grades I, II, III

I-mild stretch II-partial tear III-full tear

S/sx of ankle sprain

``` ecchymosis edema guarding fx? ambulatory ```

radiographs for ankle sprain

3 views of ankle- always bilateral views | consider stress views to locate specific injuries to specific ligamnets

+ anterior drawer & talar tilt

ATFL ligament & C... usually injured

MRI is best imaging modality for?

ligaments

tx for ankle sprain

RICE PT gradual return to activity

if peristent after 2-5 wks, consider OCD of talus or other occult fx of the foot

DIAL a PIMP

dorsiflexion-inversion pain- anterolateral lesion | plantarflexion-inversion pain-posterior medial lesion

Crush injuries

``` open fx's soft tissue deficit amputation vascular compromise compartment syndrome *these are red flags! call ```

how to tx crush injury in acute setting

``` soft tissue deficit coerage immediate stabilization of fxs debridement of devitalized tissue appropriate Abx tetanus prophylaxis ```

crush are usually?

Gustillo IIIc injuries | require different types of surgeons

while waiting on consult

cover wounds hemostatsis medically stabilize assess for polytrauma

Foot & Ankle Emergencies Flashcards

(68 cards)