The Lower Extremity (2)

Bimalleolar Fractures

- Both medial and lateral disruption - Unstable fracture - Generally requires surgery to restore normal joint - Will get lots of swelling so splint adults in the ED, cast after swelling has had time to resolve (usually admit and operate 7-10 days after injury- there is not much skin or soft tissue over later maleolus- there are going to be plates and screws put it and you need good skin to put over the plate and screws- with a lot of swelling that makes it harder so wait for swelling to go down)

Achilles Tendon cont'd

- C/O acute pain in calf with difficulty ambulating - +/- palpable defect or mass in posterior calf - Positive thompson test (have them sit and squeeze the calf to see if foot moves) - Treatment: surgical repair vs conservative treatment (usually surgery will happen early but now you can do cast in plantar flexion and then do physical therapy- then its either successful or not- if its not successful then you do surgery)

Chondromalacia of the patella

- Causes anterior knee pain - Degeneration of the articular cartilage of the patella (if you have a platella that isnt tracking right over a period of time you are going to wear down the cartilage over time) - Graded as I thru IV depending on the severity - Diagnosed on arthroscopy (three articulations in knee- two between femur and tibia and then patella femoral joint- very common that people get runners knee or patella femoral pain with pain behind the knee cap- need to do quad strengthening exercises)

Achilles Tendonitis- treatment

- Decrease running - Small heel lift (put in shoe like a wedge) - NSAIDS - Ice - Stretching (Platelet rich plasma injection to try to help healing sometimes)

Bakers Cyst diagnosis and treatment

- Dx with U.S. and possibly MRI - Treated with rest, NSAIDS, can be aspirated (not usually)-but can recur. Can be surgically removed

*Maisonneuve Fracture* (KNOW)*****

- Fracture of the proximal fibula with syndesmosis rupture (ligament between the tibia and fibula bc forced comes up from medial malleolar fracture) and associated medial malleolar fracture or deltoid ligament rupture - Treatment: ORIF (why you always check out the entire leg)

Schatzker Type repair (all he said)

- Here the goal is that you still want to line up the joint- someone has a tibial plateau fracture they're still going to go for a CT scan (bc CT scan is best way to eval fracture)- CT scan always looks worse than fracture (looking down with axial view to see its shadered) - Only allow 2mm of depression of tibial plateau before we want to fix it (AGAIN - GOAL is that we want to line up your knee joint that is what we care most about)

Ankle Injuries: Treatment

- Ice - Elevation - NSAIDS,WBAT w/crutches - Early ROM (also physical therapy)

Calcaneal Fractures treatment

- Initial management: ICE, ICE, ICE - Treatment: depends on amount of displacement (can get jones dressing- cotton pading and ace rap- not a hard spint- high risk of compartment syndrome) (usually getting a trauma series- bc a lot of the time these pts fell from a height- do lumbar x-ray, pelvis x-ray, foot and ankle xray)

Ankle Mechanisms of injury

- Inversion (m/c- sprain ATFL- anterior talofibular ligament) - Eversion (not common) - External rotation/Internal rotation - Vertical Loading (jumped off building) (detoid ligament is medially) (lateral view will tell us if it is dislocated)

Patella Dislocation/Subluxation

- Lateral displacement of the patella - Acute vs. recurrent - Reduction occurs with extension of the knee - Positive patella apprehension test (lay them down and push it towards the outside) (once you have one patella dislocation you are at risk for another one- you need to do physical therapy- strengthening of the quads- can be related to patella tracking or trauma- people you see who were dancing very hard and all the sudden their knee cap comes out- many times they reduce themselves)

Lisfranc Injury

- Lisfranc joint: bases of 1st 3 metatarsals and the respecitve cuneiforms - Exam: + tenderness at Lisfranc's joint - Xray may reveal widening at the Lisfranc joint

Calcaneal Fractures

- May be intra or extra articular - *MC mechanism is axial load* - Get AP, lateral, oblique, heel view - **Associated with other injuries -vertebral column and lower ext*

Medial malleolar fracture

- Mechanism is eversion with tension on deltoid ligament - Need to eval whole length of fibula for proximal injury (someone has an ankle injury you evaluate the tibulua fibula and knee) - Commonly associated with lat and post mal fx

Pseudo-Jones Fracture

- More common and less serious than Jones - Avulsion fx at the base of the 5th metatarsal - Treated with initially NWB, then early weight bearing unless displaced(needs ORIF) (no sugery for pseudo-jones may be able to be weight baring right away- usually put them in a boot- CAM walker)

Metatarsal Fractures

- Most common mechanism of injury is a heavy object dropped onto the foot (or something sharp- the extersor hallucus longus (EHL) is on the top of the foot- they get a metatarsal fracture and can slice the EHL) - Twisting injuries can cause spiral fractures

Achilles Tendon Rupture

- Most commonly about 2 inches superior to calcaneal attachment - Mechanism of injury: Direct trauma or sudden dorsiflexion - Extra stretch applied to taut tendon (not going to miss this- just like the book- it feels like i got hit by a bat where my Achilles tendon is- will feel a pop)

Trimalleolar Fracture

- Occurs when there is a posterior injury to the ankle (posterior maleolus) - Treatment is ORIF --- most cases waiting 7-10 days to allow for swelling to subside (no swelling you dont have to wait but rare) (lateral view you see the posterior maleolus fracture- need the mortise ankle joint lined up as best as possible- non weight bearing after these surgeries)

Plantar Fasciitis

- Pain at posteromedial surface of the foot - Pain most severe initially upon arising - Pain decreases as the day goes on - Point tender at insertion on the calcaneus (comes along the bottle of the foot- usually medial aspect- will see heal spur on x-ray)

Achilles Tendonitis

- Pain at the Achilles Tendon - Pain often worse following activity, not during activity - Often there will be a palpable thickening over the tendon (painful to touch- thickening when you had it a long time)

2° Ankle Sprain

- Partially torn ligament - Positive tenderness to palpation - Positive swelling - +/- ecchymosis (if he sees you the day it happened you wont have the ecchymosis- depends when you see them) - Positive pain with ROM (pain with inversion) - Moderate functional loss - +/- instability

3° Ankle Sprain

- Positive swelling - Significant functional loss - Positive tenderness - Positive instability - Usually a *positive anterior drawer* (if you have no anteriotibular ligament)

Tibial Pilon Fractures

- Produced by rotational force - "explosion fracture" produced by axial load - Accurate classification requires a CT - Complications range as high as 54% (high)

Knee Dislocation- what to do

- Prompt reduction/admsission/splint ---*DO NOT CAST* - *Arteriography to R/O arterial injury* *(of the popliteal artery bc its at risk of rupture) - Beware of Compartment Syndrome - ****Document Neurovascular Status******

Jones Fracture: treatment

- SLC NWB x 6 weeks - Operative treatment: ORIF (most cases get treated surgically- usually will get a pin so you dont want to miss this) (when you have a fracture below joint line its considered a dancer fracture or pseudo-jones)

Knee Dislocation

- Severe limb threatening emergency - Mechanism is high velocity trauma - *Vascular injury to Popliteal Artery is most severe complication** (knee dislocation is commonly confused as a patella dislocation)

Medial malleolar fracture treatment

- TX-cast for 6 wks if nondisplaced and isolated - ORIF (open reduction internal fixation) if displaced or with associated fracture (most of the time you end up fixing it- if mortise isnt same all the way around you know that it needs to be reduced)

Jones Fracture

- Transverse fracture of the 5th metatarsal at the junction of the proximal metaphysis and diaphysis - Positive tenderness at lateral foot, positive swelling

Tibial Plateau Fractures

- Usually occur in older population > 50 - 60% affect the *lateral plateau* - 15% are isolated medial plateau injuries - *Fractures are a result of strong valgus or varus stress with axial loading** - Cause discongruity of the knee joint (problem- we want to fix everything to line up joints so you dont develop arthritis and chronic pain)

Osteoarthritis is diagnosed

on Xray (total knee replacement- you do put a plastic piece on the back of the patella- drill three small holes)

Chondromalacia stages

(look up pics on slide) (four is worst)

Lateral Malleolar Fractures

*Weber A:* Fx distal to mortise (below level of mortise) - Treatment: SLWC vs aircast vs running shoe *Weber B:* Fx at level of mortise (STARTS lat level of mortise) - Treatment: SLC vs ORIF *Weber C:* Fx above the mortise - Treatment: ORIF

Tibia/Fibula injury treatment

- *Closed:* initially splint, ice, elevation - *Definitive treatment is LLC (cast) vs. IM nailing* - *Open:* irrigation, IV antibiotics, open vs. closed reduction, external fixation, monitor for compartment syndrome

Ankle Injuries****** TQ

- *Inversion stress* is most common mechanism of injury (injures lateral ligaments) - *Most common ligament is anterior talofibular via inversion and plantar flexion**** TEST QUESTION

Plantar Fasciitis- treatment

- Achilles stretching - Ice (freeze water bottle and roll it under your foot) - Massage - Rest - NSAIDS - Heel cup (cushion for heal) - Arch support

Ankle Injuries: eversion injury

- Avulsion of medial malleolus or deltoid ligament rupture - Interosseus membrane - Treatment depends on extent of injury

Bakers Cyst

- Benign swelling of the bursa behind the knee joint (joint fluid- can get bigger and smaller over time) - Can arise from arthritis or meniscus tear - *Can possibly see best with knee extended* (swelling in back of knee), *and feel best with knee flexed*

Schatzker Types (SKIPPED)

1. - Split of lateral tibial plateau - Without articular depression - Generally occurs in young adults 2.- Split depressed fracture of lateral plateau - Results from a lateral bending force - Most common in 4th decade of life or later 3. - Isolated depression of the lateral plateau - Depression is usually central but may appear anywhere on plateau - May be stable or unstable 4. - Fracture of the medial plateau - Results from varus and axial loading - Intermediate to high energy trauma - Often see injuries to nerves and vessels 5. - Bicondylar plateau fracture - Varying degrees of depression - Results from high energy injuries - Keep an eye on the neurovascular status! 6. - Bicondylar tibial plateau fracture with diaphyseal metaphyseal dissociation - High energy trauma, often from falls - Explosive fracture

Most common ankle injury in the ED

Ankle Sprains (you think its a fracture but its negative)

Total Knee Replacement

Done for Severe Osteoarthritis in the Knee. - Conservative treatment usually fails joint replacement is the only option to return patient to daily activities and be painfree. PT, cortisone, Gel Shots (Synvisc, Supartz, ect.) to increase space (trying to create cushion- only will last around a year)

Ankle Sprains: 1st degree

Ligament stretching without evident tear - Mild swelling - Mild tenderness to palpation - Little or no functional loss - No instability

Ankle anatomy

Look at the slides for more pics - What we care about is the mortise of the ankle - Named after what they connect (talofibular is connecting talus and fibula, etc) (says- got to know normal ankle anatomy/hip /elbow- know all the xrays hes told us)

Tibia/Fibula: Mechanism of Injury

MC Direct trauma (MVA, Skiing) Exam: Pain, swelling & deformity (side note- when bones are still touching but slid along each other called translated)

Calcaneal fractures- Bohlers angle

Measured if a compression fracture is suspected (otherwise you will have a big fx u can see on xray)

Lisfranc Injury treatment

ORIF, or cast NWB at least 8 weeks (has to be fixed- can be a boney or ligamentum injury- you can do NWB for 8 weeks for elderly but they usually dont do well) (ballerina or football player)

Schatzker Type (ALL HE SAID)

Said don't need to know differnces between types only said -->>> - This is how we define tibial plateau fractures - Schatzker 1 is the best to have and they get worse and worse - Once you get to Schatzker 4 your on the medial side of the knee and once you are on medial side you are surgical

Ottowa ankle rules***

Tell you when you need an x-ray (in reality you usually just give anyone an x-ray when you suspect ankle fracture)

Patella Dislocation/Subluxation treatment

immediate immobilization& PT vs. surgery - If knee cap came out and you know it came out- send for an MRI to look at medial knee structures - Not hard to miss on physical exam- and you can pop back in (a lot of the times in PEDs they come in with it already reduced and come in with big swollen knee)