Ortho Exam 2 (Ankle & Foot)

1. ATFL 2. calcaneofibular 3. PTFL

Ligaments that may be injured in a lateral ankle sprain

-immobilization -walking boot 4-8 weeks -reduction of causative activity

Management of metatarsal stress fractures

-reduction -may need surgical fixation

Management of multiple metatarsal fractures (or if angulation >10°)

-posterior splint -NWB -close follow-up

Management of non-displaced Jones fracture of the 5th metatarsal

-ortho referral -below knee cast 6-8 weeks

Management of non-displaced talus fracture

-NSAIDs, RICE, Activity modification -Avoid flat shoes and barefoot walking -silicone heel inserts -stretching -glucocorticoid injections

Management of plantar fasciitis

posterior splint, NWB, follow-up

Management of single non-displaced metatarsal fracture

-significant activity modification -repeat films

Management of stress fracture of the 5th metatarsal if plain film is negative

foot pain & swelling

Physical exam findings of talus fracture

1. The widened space (diastasis) between the bases of the first and second metatarsals 2. The "fleck" avulsion fracture adjacent to the base of the first metatarsal 3. Loss of alignment of the medial edge of the proximal second metatarsal with the medial edge of the second cuneiform

Three classic findings of Lisfranc injury on plain film

compartment syndrome

Tibial fractures are commonly associated with which ortho emergency?

walking boot 4-6 weeks

Treatment of non-displaced/isolated medial malleolar fracture

Unknown

Etiology of plantar fasciitis

deltoid ligament complex

Ligament injured in medial ankle sprain

-athletes -the sedentary

Achilles tendinopathy affects these populations:

proximal fibula

Always palpate ____________ with every ankle injury

-AP -lateral -mortise

Ankle plain film views

-orthotics -padding

Conservative management of Morton neuroma

-shoe modification: wide, low-heeled shoes -orthoses to improve support and alignment -night splinting to improve toe alignment -medial bunion pads to prevent irritation

Conservative management of hallux valgus

3 weeks

Consider glucocorticoid injections for plantar fasciitis if no improvement with conservative management for _____ weeks

ORIF (repair of syndesmosis and medial malleolus, usually not proximal fibula)

Definitive management of Maisonneuve fracure

ORIF

Definitive management of bimalleolar fracture

ORIF

Definitive management of trimalleolar fracture

ORIF

Definitive treatment of displaced or comminuted tibial fractures

conservative treatment with a cast

Definitive treatment of non or minorly displaced tibial fractures

fibrotic lesion of common digital nerves most commonly seen in second to fourth web spaces leading to numbness, pebble, or shock sensation

Describe Morton neuroma

FROM PROXIMAL TO DISTAL: 1. Avulsion fracture 2. Jones fracture 3. Stress fracture

Describe a fracture in each of the locations

FROM PROXIMAL TO DISTAL: 1. Avulsion fracture (proximal to IMT joint) 2. Jones fracture (at IMT joint) 3. Stress fracture (distal to IMT joint/proximal diaphysis)

Describe a fracture in each of the locations (in relation to the IMT joint)

lateral deviation of the hallux on the first metatarsal

Describe hallux valgus

inflammation or degeneration of the plantar fascia at the site where the plantar fascia inserts into the calcaneus

Describe plantar fasciitis

Tarsometatarsal (TMT) joint complex (where the tarsals articulate with the metatarsals - 5 metatarsals, 3 cuneiforms, and the cuboid bones)

Describe the Lisfranc joint

spiral fracture involving the proximal fibula and fracture of medial malleolus or rupture of deltoid ligament

Describe the Maisonneuve fracture

Avulsion fracture of the 5th metatarsal

Describe the finding

Avulsion of calcaneus

Describe the finding

Heel spurs (Halgund's deformity)

Describe the finding

Jones fracture of the 5th metatarsal

Describe the finding

Medial malleolar fracture

Describe the finding

Metatarsal fracture

Describe the finding

Morton neuroma

Describe the finding

Posterior ankle dislocation

Describe the finding

Stress fracture of the 5th metatarsal

Describe the finding

WEBER A: fibular fracture below the syndesmosis

Describe the finding

WEBER B: characteristic posterior spike on distal fragment, usually below the syndesmosis

Describe the finding

WEBER C: fibular fracture above the syndesmosis laterally +/- associated deltoid ligament medially

Describe the finding

hallux valgus (bunion)

Describe the finding

loss of Achilles contour due to rupture

Describe the finding

medial malleolus laxity

Describe the finding

subtalar dislocation (medial angulation)

Describe the finding

talus fracture

Describe the finding

tibial fracture

Describe the finding

Bimalleolar fracture

Describe the findings

Lisfranc injury

Describe the findings

Tib/fib fx

Describe the findings

trimalleolar fracture (medial + lateral + posterior malleoli)

Describe the findings

-squeeze test -high ankle sprain

Describe the special test + injury being assessed

-Talar tilt test -calcaneofibular ligament

Describe the special test + ligament being assessed

-anterior drawer test -ATFL

Describe the special test + ligament being assessed

-Thompson test -Achilles rupture

Describe the special test + tendon being assessed

sprain of the first MTP caused by forced hyperextension of the great toe against another surface

Describe turf toe

clinical

Diagnosis of Morton neuroma

clinical

Diagnosis of plantar fasciitis

plain film

Diagnosis of talus fracture

high risk of re-repture

Disadvantages of Achilles rupture non-surgical management

-microscopic tears -no joint instability -ability to bear weight + ambulate

Grade I ankle sprain:

-incomplete tear -mild to moderate instability -weight bearing + ambulation painful

Grade II ankle sprain

-complete tear -significant mechanical instability -unable to bear weight or ambulate

Grade III ankle sprain

syndesmosis

High ankle sprain disrupts _________

MRI

Imaging used for definitive diagnosis of Lisfranc injury

-plain films (often negative) -evaluate mortise and syndesmosis -evaluate soft tissue edema -MRI (used if pain is persistent for 6-8 weeks)

Imaging used in ankle sprain

-plain films -U/S -MRI (rarely used)

Imaging used to diagnosis Achilles rupture/tendinopathy

-splint with ankle at 90 degrees -NWB

Immediate management of bimalleolar fracture

-splint with ankle at 90 degrees -NWB

Immediate management of trimalleolar fracture

-posterior leg splint -NWB

Initial management of tibial fracture

splint ankle at 90 degrees

Initial treatment of Maisonneuve fracture

Maisonneuve fracture

Injury associated with medial malleolar fracture

-immediate: splint in Aquinas splint in plantar flexion, NWB -orthopedic evaluation in 1-2 days -surgical repair

Management of Achilles rupture

-activity modification, NSAIDs, RICE -taping/bandage -physical therapy

Management of Achilles tendinopathy

-RICE, NSAIDs -surgical intervention -return to sport 9-12 months

Management of Lisfranc injury if bony involvement

-RICE, NSAIDs -splint + NWB 6-10 weeks -PT

Management of Lisfranc injury if soft tissue injury

-closed reduction -ORIF

Management of ankle dislocation

-PRICE (p=protection with air cast) -NSAIDs -Crutches -early ROM -ortho referral for syndesmosis injury

Management of ankle sprains

-symptomatic treatment -RICE -hard soled post-op shoe (the velcro ones) -weight bearing as tolerated (WBAT)

Management of avulsion fracture of the 5th metatarsal

-buddy tape + hard-soled shoe for 4-6 weeks

Management of closed + non-displaced phalangeal fractures

usually surgical fixation

Management of displaced Jones fracture of the 5th metatarsal

-ortho referral -surgical eval

Management of displaced talus fracture

refer to ortho

Management of displaced, open, intra-articular, or hallux phalangeal fractures

-short leg cast + NWB up to 20 weeks -surgical repair if patient does not want to deal with cast for 20 weeks

Management of stress fracture of the 5th metatarsal if plain film is positive

ORIF of tibia

Management of tib/fib fx

buddy tape

Management of turf toe

pushing off ground

Mechanism of Achilles rupture

plantarflexion or vertical forces

Mechanism of Jones fracture of the 5th metatarsal

plantarfexion of foot, direct trauma or crush injury

Mechanism of Lisfranc injury

rotational or eversion injury

Mechanism of Maisonneuve fracture

adduction force on inverted ankle

Mechanism of Weber A fracture

rotational force on inverted ankle

Mechanism of Weber B fracture

rotational force on everted ankle

Mechanism of Weber C fracture

high energy trauma

Mechanism of ankle dislocation

inversion injury

Mechanism of avulsion fracture of the 5th metatarsal

dorsiflexion and/or eversion with rotational force

Mechanism of high ankle sprain

plantar flexion with inversion

Mechanism of lateral ankle sprain

eversion injury

Mechanism of medial ankle sprain

direct impact from talus on medial malleolus

Mechanism of medial malleolar fracture

-direct blows (dropping item on foot) -twisting mechanisms -stress fractures

Mechanism of metatarsal injury

-axial loading or crush injury

Mechanism of phalangeal fractures

chronic/overuse injuries → malunion

Mechanism of stress fracture of the 5th metatarsal

trauma

Mechanism of talus fracture

posterior + subtalar

Most common ankle dislocations

ATFL (anterior talofibular ligament)

Most common ankle ligament injury

lateral ankle sprain

Most common ankle sprain

Neck

Most common location of talus fracture

lateral process (20x risk of gen pop)

Most common location of talus fracture in snowboarders

tibial fracture

Most common long bone fracture in the body

Mortise

Name the view

-must have pain in the malleolar zone AND -bone tenderness at the posterior edge or tip of the lateral or medial malleolus OR -unable to bear weight immediately after the injury and for 4 steps in the ED

Ottawa ankle rules

-must have pain in the mid-foot zone AND -bone tenderness at the base of the 5th metatarsal or the navicular bone OR -unable to bear weight immediately after the injury and for 4 steps in the ED

Ottawa foot rules

-burning pain + stiffness 2-6cm above the posterior calcaneus -worse with activity, relieved with rest

Pain associated with Achilles tendinopathy

sharp heel pain

Pain associated with plantar fasciitis is described as:

-worse: morning, after inactivity, at night -better: middle of day after gradually increased activity

Pain associated with plantar fasciitis is worse during these times of day: And better at these times of day:

young runners + 40-60 y/o

Peak incidence of plantar fasciitis

-loss of achilles contour -positive Thompson test

Physical exam findings of Achilles rupture upon palpation and special testing

-tenderness -negative Thompson test

Physical exam findings of Achilles tendinopathy upon palpation and special testing

unable to bear weight

Physical exam findings of Lisfranc joint injury upon gait assessment

-swelling of mid-foot -plantar ecchymosis

Physical exam findings of Lisfranc joint injury upon inspection

may have reduced pulses

Physical exam findings of Lisfranc joint injury upon neurovascular exam

-palpable nodule which may reproduce pain and paresthesias

Physical exam findings of Morton neuroma upon palpation

-pain -valgus deformity

Physical exam findings of hallux valgus upon palpation

+ squeeze test

Physical exam findings of high ankle sprain upon special testing

positive anterior drawer +/- talar tilt test

Physical exam findings of lateral ankle sprain upon special testing

medial laxity

Physical exam findings of medial ankle sprain upon ROM

-pain -subungual hematoma

Physical exam findings of phalangeal fractures

pain with palpation along fascia while dorsiflexing toes

Physical exam findings of plantar fasciitis upon palpation

•Competitive sports (sprinters) •Cold weather training •Gender (M>F) •Age (older is worse) •Obesity •Antibiotics (fluoroquinolones) •Steroids

RFs for Achilles tendinopathy

•Gender (F>M) •Genetics •Abnormal foot mechanics

RFs of hallux valgus

-excessive training/running -obesity -prolonged standing -flat feet -footwear

RFs of plantar fasciitis

-steroid injection -surgical excision after 9-12 mos

Refractory management of Morton neuroma

surgical revision

Refractory management of hallux valgus

2 weeks

Repeat films in _____ weeks for stress fracture of the 5th metatarsal if plain films are negative

-full, pain-free active + passive ROM -no tenderness

Return to activity with ankle sprain

-gender (F>M) -indoor sports

Risk factors for ankle sprains

Sn: high Sp: low

Sn/sp of the Ottawa ankle rules

Sn: high Sp: low

Sn/sp of the Ottawa foot rules

"Struck violently in the back of the ankle"

Sudden Achilles rupture often feels like a patient was:

<1%

Talus fractures make up _____% of all fractures

Soleus + Gastrocnemius

The Achilles tendon is formed from these muscles:

ligamentous injuries

The Mortise view is used to assess:

Achilles tendon

The largest tendon in the body:

tenuous; avascular necrosis

The talus has a _________ blood supply, meaning there is a high risk for ______________

-walking boot 4-6 weeks -weight bearing as tolerated

Treatment of Weber A fracture

-walking boot 4-6 weeks -weight bearing as tolerated -if displaced, mortise disruption, or syndesmosis injury: ORIF

Treatment of Weber B fracture

ORIF

Treatment of Weber C fracture

surgical repair

Treatment of displaced medial malleolar fracture

20%

Up to ______% of Lisfranc injuries are missed

distal to proximal

When splinting ankle, splint (distal to proximal/proximal to distal)