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P-2 Ortho 3 > Lecture 2 > Flashcards

Lecture 2 Flashcards

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1
Q

How do ankle fractures usually present?

A

Acute pain and swelling following trauma

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2
Q

MC injured wt bearing joint of the body, that has increasing incidence in the elderly and diabetic populations?

A

Ankle fractures

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3
Q

OA and fractures?

A

They are going to get OA

Primary ankle OA = 7-9%
Post-traumatic = 70-78%

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4
Q

What comprises the mortise of the ankle?

A

tibial plafond
Medial malleolus
Lateral malleolus

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5
Q

Stability in the ankle?

A

Bony articulation is more stable with dorsiflexion

A highly congruent joint

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6
Q

Lateral ligamentous complex?

A

Anterior talofibular ligament

Posterior talofibular ligament (strongest)

Calcanofibular ligament (limits inversion)

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7
Q

Anterior, posterior and inferior stability of the ankle joint?

A

Anterior-inferior tibiofibular ligament (AITFL)

Posterior-inferior talofibular ligament (PITFL) - volkmans tubercle

Inferior transverse ligament (ITL) (part of the PITFL?)

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8
Q

Ankle’s always swell, how does this affect treatment?

A

Medial, lateral and or posterior swelling can lead to infections and problems with the surgery so often must wait for the swelling to go down before cutting the pt

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9
Q

Common exam findings with ankle fx?

A

Swelling (medial, lateral, posterior)

Tenderness at fx site

Palpable gap on medial side (maybe)

External rotation or lateral displacement (maybe)

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10
Q

A distal fib (lateral malleolus) fx w tenderness over the medial deltoid ligament is presumed to be?

A

Unstable bimalleolar injury until proven otherwise

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11
Q

What must always be assessed with ankle fractures? Or any other fx for that matter

A

Assess circulation and innervation to posterior tibial, superficial peroneal and deep peroneal nerves distal to the fx

Lacerations assessed for open fractures

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12
Q

What radiology needs to be ordered for most ankle fx?

A

AP
Lateral
Mortise

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13
Q

What is a mortise view?

A

15* internally rotated AP

The relationship of the tib, fib and talus are the clearest with the mortise view

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14
Q

Danis weber classifications?

A

Weber A: below the joint
- fibular fx is distal to ankle mortise

Weber B: at the joint
- fibula fx oblique and begins at the level of the ankle mortise and extends proximally

Weber C: “train wreck”

  • tibiofibular syndesmosis disrupted with widening of the distal tibiofibular articulation
  • medial malleolus fracture or deltoid ligament injury present
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15
Q

Danis webber A treatment?

A

Closed reduction with casting

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16
Q

Danis-weber B treatment?

A

Closed reduction and casting

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17
Q

Warning sign of badness for danis weber B?

A

stress exam reveals medial clear space widening > 5mm

Makes treatment more complicated

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18
Q

What is a manual stress view?

A

Assess the integrity of the deltoid ligament medial clear space

With Ankle in maximum dorsiflexion external rotation force is applied to the foot-mortise view is obtained

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19
Q

Radiology techs always want to pull on the ankle to get a stress view but what is the best way to do it?

A

Gravity has been shown to be equally effective and much less traumatic to the pt

(Hang the leg ff the table and get your x ray)

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20
Q

Danis-webber C treatment?

A

Open reduction with internal fixation (ORIF)

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21
Q

What are bimalleolar injuries?

A

Fractures of the lateral and medial malleolus or fracture of the distal fibula with disruption of the deltoid ligament

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22
Q

What fracture is associated with syndesmotic disruption?

A

Maissoneuve fracture

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23
Q

What is a tillaux fracture?

A

Avulsion injury of the lateral tibial articular surface (anterior or posterior) (ATFL)

More common in kids because in adults the ligament is weaker than the bone so the ligament gives out first

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24
Q

Trimalleolar injury

A

lateral malleolus, the medial malleolus, and the distal posterior aspect of the tibia (aka posterior malleolus)

May also include posterior dislocation of the ankle

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25
Why are trimalleolar fractures a big deal?
They are highly unstable and hard to reduce
26
Initial treatment of all ankle fx?
Reduce dislocations (ASAP) Non-weight bearing L&U splint Call ortho
27
How is a closed reduction performed?
Anatomic reduction of the mortise using the Quigley maneuver (suspended great toe) Then Well padded L and U splint with good proximal, distal and apex molds, ankle in neutral flexion
28
Ankle reductions hurt, what is an alternate to conscious sedation to perform the procedure?
PRC - intraarticular hematoma block 20ga needle into medial ankle, medial to the TA tendon , hematoma is aspirated and 12cc of lidocaine is injected in its place
29
How are weber a’s treated?
Stable fx Like an ankle sprain can be immobilized or put in a non weight bearing or partial weight bearing cast
30
How are weber B and C or bimalleolar fractures treated?
Unstable Open reduction and internal fixation
31
What do unstable or displaced fractures require?
Closed or open reduction Usually open reduction has the best joint function prospects
32
What do all open fractures require?
Immediate surgical debridement
33
What type of fracture accounts for 10% of fractures?
Foot fractures
34
What is a pseudo-jones fracture?
MC foot fracture: | avulsion of the 5th metatarsal proximal tuberosity
35
Adults vs kids?
Fractures are more common than sprains in kids
36
When do stress fractures usually occur?
After a sudden increase in activity or change in factors (i.e. surface you run on)
37
What will metatarsal fractures look like on exam?
Swelling Ecchymosis TTP over the fx
38
What factors are not criterial for ottawa guidelines?
Tenders to the: - heel - 4th metatarsal ``` Tenderness to the: - lateral malleolus - medial malleolus - navicular bone Are all criteria for ottowa guidelines ```
39
What x-rays need to be ordered for suspected metatarsal fx?
AP Lateral Oblique
40
Stress fractures on x ray?
May not show up for 3-4 weeks so serials are needed Or you can do MIR/bone scan
41
You had a high impact injury and fractured the first metatarsal, what do you win?
Surgery Play stupid games, win stupid prizes
42
Zones of the 5th metatarsal?
Regions of the diaphysis of the 5th metatarsal metatarsal, 3 stripes Zone 1: proximal Zone 2: distal to zone 1 Zone 3: distal to zone 2 Look at slide 47 it will make more sense
43
What is a classic jones fracture and what does that mean for the pt?
Zone 2 fracture of the proximal diaphysis of the 5th metatarsal They need more extensive immobilization
44
What is common with zone 3 fractures?
Can result in nonunion or delayed union
45
Treatment of non-displaced metatarsal neck fractures?
Short leg cast, fracture brace or hard soled shoe Whatever provides the minimum amount of immobilization while providing adequate comfort They are allowed to have weight bearing
46
When do x rays need to be done for metatarsal fractures?
At injury After 1 week (displacement) After 6 weeks (confirm healing)
47
What metatarsal fxs get surgery?
Multiple metatarsal fxs >4mm of displacement or >10% of angulation Zone 2 or 3 of 5th Displaced or comminuted fx of 1st Open fx
48
The typical fx that causes injury to the 3 zones of the 5th metatarsal?
Zone 1: avulsion Zone 2: jones Zone 3: stress
49
Metatarsal zones and surgery?
Zone 1: non operative Zone 2: non operative (unless nonunion) Zone 3: operative
50
Adverse outcomes for metatarsal fxs?
If displacement or shortening occurs: - painful plantar callosities under metatarsal heads - Transfer lesions under neighboring heads
51
Summary of metatarsal fx?
Mostly nonopp with hard soled shoe except: - multiple fx - >4mm displacement - >10* angulation - proximal 5th in zone 2,3 - displaced or comminuted of 1st - open fx
52
What is fleck sign?
Avulsion fx off the base of the second metatarsal or medial cuneiform signifying disruption of the lisfrank ligament
53
What is a lisfrank injury?
Fracture-dislocations of the midfoot Easy to miss traumatic disruption of the tarsometarsal joint
54
What is the typical MOI for lisfrank injuries?
``` Significant trauma Or Indirect mechanism - athletics - tripping/falling off the curb ```
55
Presentation of lisfrank injuries
Pt reports a sprain Pain is localized to the dorsum of midfoot Swelling (may be mild)
56
What clinical sign is highly associated with lisfrank injuries?
Plantar arch ecchymosis Specifically over the tarsometatarsal joint rather than the ankle ligaments
57
How to examine a lisfrank injury?
Stabilize the hindfoot (calcaneus) Rotate and/or abduct the forefoot Lisfrank - severe pain Ankle sprain - minimal pain
58
Radiology studies?
AP laeral Oblique Subtle injuries may need wt bearing radiographs as spontaneous reduction can occur
59
What to look for on x ray?
AP: Medial aspect of the middle cueniform should line up with the medial aspect of the second metatarsal Oblique: Medial aspect of 4th metatarsal should align with the medial aspect of the cuboid
60
Your x ray shows lateral deviation of the 2nd metatarsal base
This is associated with a small avulsion fracture (seen with lisfrank)
61
My x rays dont show anything but my exam strongly suggest lisfrank?
Get x rays under anesthetic Or can do CT/MRI 36% are radiographically occult
62
What does radiographically occult mean?
Clinical signs of a fx but nothing on x ray. 2-4 weeks later x ray shows new bone formation
63
Tx for lisfrank?
Non-displaced: - 6-8 weeks of non-wt bearing cast - 3 months of rigid arch support Displaced: - surgery
64
adverse outcomes associated with lisfrank?
Compartment syndrome (acute) Post traumatic osteoarthritis Instability Sensory impairment Deformities (claw/contracture)
65
Summary for lisfrank injuries?
Frequently missed (have a low threshold for advanced images/consult) Poor outcomes if missed Displacement requires surgery Screen for compartment
66
Calcaneus fracture requires what MOI?
High energy (MVA/Fall)
67
What needs to be r/o with calcaneus and talus fractures?
Spine and affected limb injuries b/c it is often from a high impact injury
68
Presentation of calcaneus and talus fracture?
Acute pain Instability Inability to ambulate
69
Exam for calcaneus and talus fx?
Swelling TTP Pulses may be absent (swelling) Assess function of superficial peroneal, deep peroneal, sural, medial and lateral plantar nerves distal to fx Palpate spine and entire lower limb for TTP
70
What diagnostic studies are needed for calcaneus and talus fx?
AP and Lat of hind foot Harris heel views AP lat and mortise of ankle
71
Hawkins classification of talar neck fx?
He said only know that II and beyond may have blood supply issues II, III, IV are all displaced
72
What is a “snowboarder’s talus fx”?
Lateral process of talus is fractured
73
What is bohler’s angle?
Angle made from - highest point of posterior tuberosity and posterior facet of calcaneus - highest point on anterior process of talus Normal is 20-40* Decreased = fx
74
Intra-articular calcaneal fx types
Look on slide 80 there are a bunch
75
Tx for calcaneus and talus fx?
Immediate: - splint from toe - upper calf or a jones dressing - elevate above heart and ice x 2hrs Surgical reduction and fixation Rehab for ROM after fx is healed
76
Adverse outcomes from calcaneus and talus fx?
Talar neck: blood supply -> osteonecrosis ``` Chronic pain Posttraumatic arthritis Osteonecrosis of talus Tarsal tunnel syndrome Complex regional pain syndrome Plantar compartment syndrome (calcaneal or talar fx) ```
77
Summary for calcaneus and talus fx?
Screen for spinal injury Talar neck fx may lead to osteonecrosis All require urgent ortho surg consult Lots of after effects
78
What is a phalanx fx?
Phalangeal fx usually involving proximal phalanx usually from direct trauma Rarely results in major disability
79
MC phalanx fx?
5th or little toe
80
Presentation of phalanx fracture?
Pain Swelling Ecchymosis Bony tenderness Deformity of toe (maybe)
81
Treatment for distal fx
Minor: buddy tap | - maybe add some padding
82
Closed reduction under digital block or open reduction and pinning is rarely necissary but should be considered when:
Marked angulated fx | Involves articular surface of MTP joint or interphalangeal joint of the great toe
83
Deformity for phalanx fx?
Chronic swelling and deformity are possible but unlikely
84
Summary of phalanx fx
Who cares tape that shit together and do something useful with your life
85
The hallux valgus angle is formed by a line along the first metatarsal shaft and a line along the shaft of the proximal phalanx is used to guide treatment. What is normal hallux valgus angle?
<15*
86
Hallux valgus aka?
Bunion
87
What is hallux valgus?
Lateral deviation of the great toe at the MTP joint that leads to a painful prominence of the medial aspect of the first metatarsal head The big toe gets forced toward the other toes and hurts
88
Who gets hallux valgus?
Female (10:1)
89
Presentation of hallux valgus?
Hypertrophic bursa over medial eminence of 1st metatarsal Great toe pronated w callus on medial aspect Can lead to numbness or tingling over medial aspect of great toe
90
Exam for bunions? (normal angles and mobility)
Normal MTP motion - extension 60-90* - flexion 30* Valgus angulation at the MP joint - <15* is normal 1-2 intermetarsal angle - normal <10* - (a big v measurement of the 1st and 2nd metatarsal)
91
Treatment for hallux valgus?
Fix your shoes Arch support can decrease pressure if associated w flat foot Not helpful: - PT - Splints Surgery if disabling
92
What surgery should be avoided? | Why?
Joint arthroplasty High complication rate
93
Hallux rigidus
Degerative arthritis of MP joint of the great toe and MC site of arthritis in the foot
94
Describe hallux rigidus presentation
Pain + stiffness as toe moves into dorsiflexion (Toe-off phase of gait) Osteophytes usually develop on lateral side of joint Toe is in normal alignment
95
Hallmark of hallux rigidus?
Stiffness of great toe with LOSS OF EXTENSION AT MP JOINT
96
Tx for hallux rigidus
Non-operative tx: shoes to limit dorsal flexion - stiff-soled - modified steel shank - rocker bottom NSAIDS Surgery - excision of osteophytes - arthrodesis
97
Keller procedure?
Resection of the joint Reserved for older and lower demand patients
98
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P-2 Ortho 3 (6 decks)

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