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)
