S3_L3 Trauma to the Ankle and Foot Flashcards by MindMed Official

Modified TF
A. Diagnostic ultrasound is used to determine tendon thickness, character, and presence of a tear.
B. It can also provide valuable information on the quality of torn ends to help make surgical repair decisions.

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Modified TF
A. The ankle and foot are the most frequently injured major joints of the body.
B. Ankle x-rays are the most frequently ordered studies in the ER.

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Modified TF
A. The Ottawa Ankle and Foot Rules are radiographs should be ordered after ankle or foot trauma if the patient is unable to bear weight AND has point tenderness either in the malleolar zone, midfoot zone, base of the 5th metatarsal, or the navicular.
B. These are 100% sensitive to detecting significant fractures.

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Modified TF
A. Ankle inversion injuries comprise 75% of all traumatic conditions at the ankle.
B. Injuries may vary from minor overstretching of ligaments to ligamentous rupture or avulsion creating instability and significant functional deficits.

A. Ankle inversion injuries comprise 85% of all traumatic conditions at the ankle.

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Modified TF
A. Fracture dislocations are the most severe type of injury.
B. Inversion sprains are more common than eversion sprains.

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Modified TF
A. Inversion sprain is caused by stress damage at the lateral collateral ligaments.
B. The ATFL and CFL are the most commonly injured.

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Modified TF
A. The ATFL is injured by landing on an inverted foot.
B. The CFL is injured by landing on a plantarflexed and inverted foot.

A. The ATFL is injured by landing on a plantarflexed and inverted foot.
B. The CFL is injured by landing on an inverted foot.

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Modified TF
A. Eversion sprain is caused by stress damage at the medial collateral ligaments.
B. It is associated with bony damage due to avulsion injuries.

NOTE: Bony avulsion occurs more commonly than ligament tear in eversion sprains

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Modified TF
A. Fracture of the medial malleolus and fracture of the lateral malleolus with rupture or avulsion of the medial collateral ligament are common injuries due to eversion stress.
B. Fracture of the medial malleolus is the most common injury.

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TRUE OR FALSE: The Maisonneurve fracture is due to a torn deltoid ligament, disrupted interosseous membrane on the lateral side of the joint, and a spiral fracture at the proximal fibula.

True

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Modified TF
A. Tendon pathology is the most common condition evaluated at the ankle and foot.
B. The MOI may be direct trauma or by overuse.

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Impingement Syndrome types

affects distal tibiofibular syndesmosis
affects posterior tibial region
affects anterolateral gutter

A. Anterolateral ankle impingement
B. Syndesmotic impingement
C. Posterior ankle impingement

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Microtearing within the tendon with subsequent healing by disorganized collagen, resulting in less tensile strength than healthy collagen
A. Tenosynovitis
B. Stenosing tenosynovitis
C. Tendinitis/Tendinopathy
D. Tendinosis
E. Tendon rupture

D. Tendinosis

NOTE: Increased signal within the tendon that does not get fluid bright on T2

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Complete tear requiring surgical repair. On axial view, shows missing tendons.
A. Tenosynovitis
B. Stenosing tenosynovitis
C. Tendinitis/Tendinopathy
D. Tendinosis
E. Tendon rupture

E. Tendon rupture

NOTE: Achilles tendon is the most common tendon in the LE that requires surgical repair

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Fluid in the tendon sheath surrounding a normal tendon
A. Tenosynovitis
B. Stenosing tenosynovitis
C. Tendinitis/Tendinopathy
D. Tendinosis
E. Tendon rupture

A. Tenosynovitis

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Development of adhesions in the tendon sheath that prevents normal gliding of the tendon
A. Tenosynovitis
B. Stenosing tenosynovitis
C. Tendinitis/Tendinopathy
D. Tendinosis
E. Tendon rupture

B. Stenosing tenosynovitis

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Partial tears of the tendon, focal or fusiform swelling with high signal within the tendon on T2 weighted images. It is the attenuation or thinning of the tendon that precedes complete rupture.
A. Tenosynovitis
B. Stenosing tenosynovitis
C. Tendinitis/Tendinopathy
D. Tendinosis
E. Tendon rupture

C. Tendinitis/Tendinopathy

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Plantaris and achilles tendon; partial tears of the Achilles tendon are very common

A. Posterior tendon pathology
B. Anterior tendon pathology
C. Lateral tendon pathology
D. Medial tendon pathology

A. Posterior tendon pathology

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Weekend warrior refers to the aging (>40) athlete who plays intermittently and suffers this injury because older tendons have decreased blood supply, low tensile strength, and less flexibility.

A. Posterior tendon pathology
B. Anterior tendon pathology
C. Lateral tendon pathology
D. Medial tendon pathology

A. Posterior tendon pathology

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Peroneus brevis and longus (principal evertors) are often injured during inversion sprains (longitudinal tears) because these evertors try to counteract the inversion forces.
A. Posterior tendon pathology
B. Anterior tendon pathology
C. Lateral tendon pathology
D. Medial tendon pathology

C. Lateral tendon pathology

NOTE: The retinaculum holding the tendons may be disrupted causing the tendons to chronically sublux over the fibula and cause abnormal friction

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Tibialis posterior, flexor digitorum longus, flexor hallucis longus; Tom Dick and a very nervous Harry
A. Posterior tendon pathology
B. Anterior tendon pathology
C. Lateral tendon pathology
D. Medial tendon pathology

D. Medial tendon pathology

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Tibialis posterior rupture common in rheumatoid arthritis, causes flat footedness; FHL is susceptible to tenosynovitis in ballerinas due to repetitive and extreme plantarflexion (en point)

A. Posterior tendon pathology
B. Anterior tendon pathology
C. Lateral tendon pathology
D. Medial tendon pathology

D. Medial tendon pathology

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Tibialis anterior, extensor hallucis longus, extensor digitorum longus and peroneus tertius; seldom affected by pathologies; tibialis anterior tendinitis can be seen in uphill runners
A. Posterior tendon pathology
B. Anterior tendon pathology
C. Lateral tendon pathology
D. Medial tendon pathology

B. Anterior tendon pathology

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Modified TF
A. Surgical treatment for pes cavus includes soft tissue and bony procedures, tendon transfers, osteotomy, plantar fascia releases, and joint arthrodesis.
B. Tightness is common in the plantar fascia in pes cavus.

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Modified TF A. Hallux rigidus is complete loss of motion of the big toe. B. Hallux limitis is partial loss of motion at the great toe, and flexion, extension, abduction, adduction are limited.

Modified TF A. Rehabilitation for phalangeal fractures is important to reestablish normal dorsiflexion of the 1st toe which allows for normal gait. B. Complications of this type of fractures are hallux limitus and hallux rigidus.

Modified TF A. Forefoot fractures' MOI: Metatarsal fractures result from direct trauma B. Complications include non-union, delayed union, and posttraumatic arthritis.

Modified TF A. In navicular fractures, radiographs identify most fracture lines. B. Stress fractures are best defined by MRI when radiographs are negative.

# The ff are the 4 types of navicular fractures, except A. Plantar avulsion fractures at the site of the attachment of the deltoid ligament B. Tuberosity fractures C. Body fractures D. Stress fractures E. None

A. Plantar avulsion fractures at the site of the attachment of the deltoid ligament ## Footnote A. **Dorsal** avulsion fractures at the site of the attachment of the deltoid ligament

Modified TF A. Treatment for navicular fracture is immobilization in a short leg cast for 4-6 weeks. B. Operative fixation is necessary for displaced fractures or avulsed fragments followed by partial weight bearing in a short cast.

Modified TF A. Navicular fractures can be stress fractures or avulsion fractures of its tuberosity due to its attachments. B. The posterior tibial tendon and insertion of the springy ligament attach to the navicular tuberosity.

Modified TF A. Sinus tarsi syndrome is caused by inversion injury or repetitive impingement of the soft tissue and ligaments due to an excessively supinated foot. B. Symptoms include a feeling of hindfoot instability and aggravation by weight-bearing activities.

A. Sinus tarsi syndrome is caused by inversion injury or repetitive impingement of the soft tissue and ligaments due to an excessively supinated foot. ## Footnote A. Sinus tarsi syndrome is caused by inversion injury or repetitive impingement of the soft tissue and ligaments due to an excessively **pronated** foot.

Modified TF A. In sinus tarsi syndrome, there is an area of pain and tenderness on the lateral side of the hindfoot originating from the sinus tarsus or the talocalcaneal sulcus, a tunnel between the calcaneus and talus. B. The sinus is usually filled with the interosseous talocalcaneal ligament, which, when injured, usually with lateral or inversion ankle sprains, can lead to the characteristic pain the patient feels.

# Associated injuries with ankle sprains, except A. Impingement syndrome B. Sinus tarsi syndrome C. Avulsion fractures D. Tearing of the distal tibiofibular syndesmotic complex E. Instability from sprains due to tearing of one or more of the principal stabilizing ligaments, allowing the mortise to widen F. None

F. None ## Footnote NOTE: Twisting of the foot is the usual cause of tearing of the distal tibiofibular syndesmotic complex

# Ankle fracture classification 1. Fracture of both malleoli 2. Fracture of both malleoli and the posterior rim/margin of the tibia, which is sometimes called the third malleolus 3. Fracture of either the lateral or medial malleolus A. Unimalleolar B. Bimalleolar C. Trimalleolar

1. B 2. C 3. A

Modified TF A. MOI of ankle fractures is usually an axial/rotational loading. B. Treatment complications include non–union and degenerative changes associated with post-traumatic arthritis.

Resultant injury patterns of ankle fractures are based on the ff, except A. Chronicity of preexisting ankle instability B. Patient’s age C. Bone density D. Comorbidities related to bony conditions E. Position of the foot during the time of loading F. Magnitude, direction, and rate of loading

D. Comorbidities related to bony conditions ## Footnote D. Comorbidities related to **soft tissue** conditions

Modified TF A. Fractures of the foot are generally located at the hindfoot, midfoot, and forefoot. B. Common fractures include fractures of the hindfoot and isolated fractures of the forefoot, metatarsals, and phalanges.

Modified TF A. The most frequently fractured tarsal is the calcaneus. B. It is fractured from falls from a height and the individual lands on their feet, and the injury is often bilateral and frequently associated with thoracolumbar spine due to the impact.

Modified TF A. The talus is the second most commonly fractured tarsal bone. B. It is fractured when a large force is applied to a plantarflexed foot, as when a driver slams into the brakes in an automobile collision.

TF ## Footnote B. It is fractured when a large force is applied to a **dorsiflexed** foot, as when a driver slams into the brakes in an automobile collision.

Modified TF A. In radiographic evaluation of talar fractures, routine radiologic evaluation of the foot demonstrates the talus adequately. B. CT Scan or MRI is used to further evaluate pain when radiographs are negative or to assist in pre-operative planning.

Modified TF A. Posttraumatic arthritis of the ankle and subtalar joints are common complications of talar fractures. B. The talus is not very vascularized and predisposed to developing avascular necrosis after a fracture.

Modified TF A. The relative immobility of the midfoot minimizes its susceptibility to isolated fractures B. Sprains and fracture subluxations or fracture dislocations can occur at the transverse tarsal joint and the tarsometatarsal joint.

Modified TF A. Phalangeal fractures are caused by objects being dropped on the toes or stubbing injuries, usually affecting the 1st and 5th toes. B. Phalangeal fractures are usually identifiable on routine radiographs of the foot and isolated radiographs can help with diagnosis.

Modified TF A. Hallux valgus is the deformity in which the 1st metatarsal is deviated medially and the great toe is deviated laterally (>10 degrees). B. Females are affected more than males.

Modified TF A. The clinical presentation of hallux valgus is the 1st MTP undergoes friction and stress in this deformity, bunion formation, and it is usually asymptomatic, may be painful if degeneration takes place. B. Etiologies include biomechanical dysfunction, improper footwear, and pes planus.

Modified TF A. Hallux valgus is also referred to as metatarsus primus varus. B. The AP view of the foot best demonstrates this deformity, and the 1st metatarsal angle describes the degree of medial deviation of the first metatarsal (>10 degrees).

TT ## Footnote NOTE: Treatment includes corrective orthosis, bunionectomy, arthrodesis, and resection arthroplasty

Modified TF A. Pes cavus is also known as claw foot. B. Its clinical presentation is lateral foot pain secondary to excessive weight bearing, metatarsalgia, plantar keratosis, and ankle instability.

# Hallmarks of talipes equinovarus, except A. An equinus or PF position of the heel B. Eversion of the subtalar joint with a varus position of the hindfoot C. Metatarsal adduction with varus position of the forefoot D. In more severe cases, subluxation or dislocation of the subtalar or talocalcaneonavicular joint (can’t be identified in radiograph before navicular ossifies by 2/3 years of age)

B. Eversion of the subtalar joint with a varus position of the hindfoot ## Footnote B. **Inversion** of the subtalar joint with a varus position of the hindfoot

Modified TF A. Impingement syndrome is the painful mechanical limitation of full ankle range of motion secondary to an osseous or soft tissue abnormality. B. Impingement leads to persistence of inflammation and synovitis, resulting in scar tissue/hypertrophied tissue and painful impingement of tissues under osseous structures.

# Most commonly occurring accessory bones, except A. Os trigonum B. Os intermetatarseum C. Os tibiale (accessory navicular) D. None

D. None

Modified TF A. Accessory bones of the foot usually form because of a failure of one or more ossification centers to unite with the main mass of bone. B. These may complicate the assessment if they are present in the area of a suspected fracture.

Modified TF A. MRI is routinely used to evaluate tendon abnormalities and usually tendons are low on all sequences. B. In the axial plane, tendons are round, oval, or flat.

# Rowe classification of calcaneal fractures 1. With central depression and comminution 2. Involve the subtalar joint 3. Beak fractures and avulsion fractures of the Achilles' tendon insertion A. Type 1 B. Type 2 C. Type 3 D. Type 4 E. Type 5

1. E 2. D 3. B

# Rowe classification of calcaneal fractures 1. Has the highest incidence (31%) 2. Fracture of the tuberosity, sustentaculum tali, or anterior process 3. Oblique fractures not extending into subtalar joint A. Type 1 B. Type 2 C. Type 3 D. Type 4 E. Type 5

1. E 2. A 3. C

Modified TF A. Calcaneal fractures are classified as intraarticular and extraarticular. B. Intraarticular fractures involve the subtalar joint and happen 3x more frequently than extraarticular.

TRUE OR FALSE: For calcaneal fractures, AP, lateral, and plantodorsal axial views of the calcaneus are obtained after the injury and bilateral imaging is done.

True

# Long-term complications of calcaneal fractures: A. Malunion B. Posttraumatic arthritis of the calcaneocuboid joint C. Posttraumatic arthritis of the subtalar joint D. Peroneal tendinitis E. All of the above

E. All of the above

# Etiology of flexible flat foot, except A. Torsional abnormalities B. Muscular imbalance C. Ligamentous laxity D. Neuropathy E. None

E. None

# Etiology of flexible flat foot, except A. Obesity B. Agenesis of sustentaculum tali C. Calcaneovalgus D. Equinus E. None

E. None

# Etiology of flexible flat foot, except A. Varus or valgus tibia B. Limb length discrepancy C. Compensated forefoot varus and an external tibial ossicle D. Tarsal coalition E. None

D. Tarsal coalition

Modified TF A. For talipes equinovarus, radiographs are of limited value. B. Radiographic assessment is significant later in monitoring osseus growth and development and assessing surgical outcome.

Modified TF A. Talipes equinovarus is the congenital club foot. B. Bilateral involvement is present in 50% of cases.

Modified TF A. For pes cavus, weight bearing radiographs are essential for inspection of degenerative joint changes calcaneal position and forefoot alignment. B. The calcaneal pitch > 30 degrees in pes cavus.

TT ## Footnote NOTE: The tarsometatarsal angle gives the value for the height of the arch in the sagittal plane

Modified TF A. Deformities of the foot may either be structural or anatomic and may be confined to the hindfoot, midfoot, or forefoot. B. These are caused by congenital conditions, developmental conditions, traumatic conditions, and neuromuscular impairment.

Modified TF A. Three-fifths of the talus is covered with articular cartilage due to its articulations to the ankle, calcaneus, and navicular. B. All talar fractures are considered intraarticular, and the usual fracture sites are head, body, and neck.

1. Requires excellent reduction and fixation because of its importance to weight bearing 2. Jones fracture A. 1st metatarsal fx B. 2nd, 3rd, 4th metatarsals fx C. 5th metatarsal fx

1. A 2. C ## Footnote NOTE: Jones fracture: fracture of the base of the 5th metatarsal

Due to direct trauma or avulsion of the tuberosity at the attachment of the lateral cord of the plantar aponeurosis, or to an inversion force A. 1st metatarsal fx B. 2nd, 3rd, 4th metatarsals fx C. 5th metatarsal fx

C. 5th metatarsal fx

injured from indirect twisting mechanisms and spiral fracture patterns, stress fractures occur at the distal shafts A. 1st metatarsal fx B. 2nd, 3rd, 4th metatarsals fx C. 5th metatarsal fx

B. 2nd, 3rd, 4th metatarsals fx

Modified TF A. The march fracture is a fracture of the 2nd metatarsal bone due to the accumulative stress syndrome. B. It is common in soldiers, hikers, and people whose duties entail much standing and walking.

Modified TF A. AP, lateral, and oblique radiographs adequately demonstrate most metatarsal fractures B. MRI is the best for evaluating occult stress fractures.

# Etiology of talipes equinovarus, except: A. Genetic and environmental factors B. Postural clubfoot C. All of the above D. None of the above

D. None of the above ## Footnote NOTE: Postural clubfoot is a less severe form associated with abnormal intrauterine positioning, and its risk factors include if (+) family history.

TRUE OR FALSE: Flat feet (pes planus) is normal in children and usually resolves with maturity.

True

# Etiology of rigid flat foot, except A. Torsional abnormalities B. Tarsal coalition C. Congenital vertical talus D. None

A. Torsional abnormalities

Modified TF A. Flexible flat feet may or may not be painful. B. Rigid flat feet with tarsal coalition are seen to be symptomatic in the second decade of life when the foot ossifies and great stresses are put on the tarsals owing to increased body weight and increased activity of sports or work.

Modified TF A. Treatment for phalangeal fractures is manual reduction and splinting or buddy taping to the adjacent digit with a hard sole for 3–4 weeks. B. Injuries to the 1st toe are treated more aggressively to ensure weight bearing function.

# Etiology of pes cavus, except A. Spinal cord tumors B. Calcaneal or talar fractures C. Friedrich’s ataxia D. Charcot Marie Tooth disease E. None

E. None

# Etiology of pes cavus, except A. Cerebral palsy B. Sequelae of burns or compartment syndromes C. Residual talipes equinovarus D. Poliomyelitis E. None

E. None

# Etiology of pes cavus, except A. Syringomyelia B. Muscular dystrophy C. All of the above D. None of the above

D. None of the above

Modified TF A. In the radiographic evaluation for pes planus, lateral radiographs may show deviations in calcaneal inclination. B. Talar declination producing a negative talometatarsal angle may also be seen.

Modified TF A. In the radiographic evaluation for pes planus, the medial column sag at the talonavicular or naviculocuneiform is seen. B. Pes planus is usually identified by radiographs, CT and MRI for determination of articular involvement.

TT ## Footnote NOTE: Navicular is the keystone of MLA

TRUE OR FALSE: For pes planus, orthotic heel stabilizers are used from the time the child starts walking until a normal supinatus is developed in the forefoot to hindfoot relationship near age 6.

True

Modified TF A. In the radiographic evaluation for pes planus, the talar beak is a secondary change (osteophyte) due to limitations of subtalar joint movement. B. It is commonly associated with talocalcaneal coalition and occurs because of subtalar joint limitation and subsequent dorsal subluxation of the navicular.

Modified TF A. Ankle sprains can be treated using cast immobilization, screw fixation via surgery, and immobilization for several weeks. B. For severe impingement syndrome, arthroscopic debridement is used.

Modified TF A. For pes planus, tarsal coalition of the talonavicular and calcaneonavicular is most common. B. The talometatarsal angle is formed by the intersection of a line drawn along the midshaft of the first metatarsal and a line bisecting the talus on the lateral view of the foot.

Modified TF A. Treatment for talipes equinovarus starts at birth, and the foot is manipulated into a more normal position and then casted (serial casting). B. Recasting and repositioning continue at intervals, usually complete after 3 months.

TT ## Footnote NOTE: After foot is realigned, normal position is maintained through stretching, exercises, night splints and orthopedic shoes for several years as needed

Modified TF A. Myxoid degeneration occurs due to aging or chronic overuse; connective tissue, such as tendons, are replaced by gelatinous or mucoid substances (homogenous, opaque, mucoid type of tissue). B. In cases of myxoid degeneration, the tensile strength of tendons is very low.

Modified TF A. Congenital vertical talus is the most serious pathological flat foot, where the foot is dorsiflexed and arch is convex at birth. B. It occurs in association with other congenital anomalies such as myelomeningocele, arthrogryposis, and developmental hip dysplasias.

TRUE OR FALSE: Xanthomas are fat deposits due to lipid disorders, and are common in the Achilles tendon.

True

TRUE OR FALSE: 80% of pes cavus is acquired, and 20% idiopathic.

True

Modified TF A. For midfoot fractures, fractures occur more than dislocations. B. Lisfranc (TMT) fracture dislocations are rare.

Modified TF A. For ankle fractures, non-operative treatment is for stable fracture patterns with intact distal tibiofibular syndesmosis. B. Treatment is long leg casts for 4–8 weeks with radiologic evaluation at 1–2 weeks intervals, and NWB until fracture is fully healed.

# High signal in tendons is usually abnormal and present when: A. If partial or complete tears are present B. If fluid is present in the sheath, which is diagnostic for tenosynovitis C. If myxoid degeneration has occurred due to aging or chronic overuse D. If xanthomas, tumors, or gouty deposits are present E. All of the above

E. All of the above

Modified TF A. Tendon pathology is treated conservatively with physical therapy (stretching, modalities for pain relief, exercises are more of the eccentric type). B. For ruptured tendons, surgical repair is done, and for subluxing tendons, surgical repair of the retinacula is done.

Operative treatment is indicated for calcaneal intraarticular fractures when it is necessary to restore the ff: A. Subtalar articulation B. Bohler angle C. Normal width of the calcaneus D. Normal calcaneocuboid articulation E. Calcaneal height F. All of the above

F. All of the above

Modified TF A. For calcaneal fractures, operative treatment involves large screws, plates, or bone grafting are used to restore or fixate the calcaneus. B. Recent surgical procedures use percutaneous screw fixation and external fixators for minimized complications.

Modified TF A. For calcaneal fractures, non–operative treatment is usually indicated for most extra–articular fractures or for severely comminuted fractures in osteopenic patients. B. Treatment involves protected casting for 4–6 weeks with a short leg cast with protected weight bearing.

Modified TF A. In treating forefoot fractures, short leg casts and immobilization for 2–4 weeks is done for non-displaced fractures. B. For displaced fractures, ORIF is important for the 1st and 5th metatarsals which help provide stability and protection and cast immobilization for 6 weeks.

Modified TF A. The surgical treatment for painful flat foot includes subtalar joint arthroereisis, an implantation of a disk the size of a pencil eraser in the sinus tarsi to block pronation of the subtalar joint. B. What is usually done is subtalar arthrodesis + heel cord lengthening + medial arch stabilization.

TT ## Footnote NOTE: Resection of the coalition site is also a surgical treatment procedure done

TRUE OR FALSE: For talar fractures, operative treatment is used to treat displaced fractures in order to restore subtalar joint congruity.

True

Modified TF A. For talar fractures, nonoperative treatment includes casting for 8-12 weeks in a short leg cast with no weight bearing until there is no evidence of healing. B. This is because the talus directly receives the weight of the entire body, so in order for it to heal, NWB should be done.

S3_L3 Trauma to the Ankle and Foot Flashcards

(101 cards)