Download Foot and Ankle

Foot and Ankle
Fractures,Sprains, and Soft Tissue
Disorders
Ankle Sprain
• 25,000 people sprain an
• symptoms: pain,
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ankle every day
85% of the time lateral
collateral ligaments
injured (anterior
talofibular and
calcaneofibular)
Inversion injury
5% syndesmosis injury
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swelling, loss of function
Treatmentis aimed at
preventing chronic pain
and instability
NSAIDS, ice,
compression, elevation
Air stirrup, WBAT, and
physical therapy
Should improve in 6
weeks
Ankle Fractures
• Fractures involve the medial or lateral malleolus,
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the posterior lip of the tibia, the collateral
liagamentous structures, or the talar dome
Stable fractures= one malleolus , no ligaments
Unstable fractures= both malleoli or a distal
fibula and disruption of the deltoid ligament
Unstable fractures= vulnerable for
displacement, instability, and posttraumatic
arthritis
• Symptoms: pain,
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swelling, tenderness,
deformity
Examination: include
evaluation of the
posterior tibial pulse
and posterior tibial
nerve (plantar
sensation)
• X-rays: AP, lateral,
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oblique (mortise view)
Cat Scan for complex
fractures with
articualr surface
involvement or lateral
portion of the distal
tibia
• Treatment:
• Stable unimalleolar fxs= WB SLC
• Unstable fractures= ORIF
Maisonneuve Fracture
• Fracture of the proximal fibula with torn
medial deltoid ligament, and disruption of
the ankle mortise
• Palpate proximal fibular with all medial
ankle pain presentations
• Treatment= ORIF
Fractures of the Hindfoot
• Talus fracture: usually result of severe trauma
• Calcaneus fracture: MVA or fall from a height
• Sx: tenderness over talonavicular joint anterior
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to the medial malleolus, tenderness with side to
side compression of the heel, swelling in the
heel & ankle, and the inability to weight bear
Tx: ORIF
* watch for plantar compartment syndrome*
Talus fx: can lead to osteonecrosis
Fracture of the Metatarsal
Jones’ Fracture: proximal metaphysis of the fifth
metatarsal
propensity for non or delayed union
NWBC 6 weeks, folllowed by WB cast until
healing occurs
Base of the Fifth Metatarsal Fracture: inversion
injury
R/O with suspicion of ankle fracture
Most respond to closed reduction
Fracture of the Midfoot
• Lisfranc Fracture-Dislocation
– Critical injury to the second tarsometatarsal
joint=stabilizing apex for the other
tarsometatarsal joints since it “keys” into a
slot in the cuneiforms
– *Easily missed and misdiagnosed as an ankle
sprain*
• Exam
– Careful examination will
reveal area of maximum
tenderness over the
tarsometatarsal joint
– Stabilize the calcaneus and
rotate and/or adduct the
forefoot=severe pain
• X-rays
– AP, laterl, oblique views of
the foot, standing if
possible
– Common error is to obtain
only ankle films
– Normal alignment=medial
aspect of the middle
cuneiform with the medial
aspect of the second
metatarsal base
– Stress views , CT, MRI
• Treatment
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Significant swelling occurs-elevate and ice
Beware of Compartment Syndrome
Nondisplaced injuries=NWBC
Displaced=ORIF
Morton’s Neuroma
• Fibrosis of the common digital nerve as it passes
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between the metatarsal heads
*commonly between the third and fourth toes*
Sx: plantar pain, numbness, and “walking on a
marble”
* firmly squeeze metatarsal heads with one
hand while applying direct pressure to the
interspace with the other
Tx: metatarsal bar, injection, surgical excision
Plantar Fasciitis
• Plantar heel pain that occurs where the plantar
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fascia arises from the medial calcaneal
tuberosity
Sxs: focal pain often increased upon awakening
or when rising from a resting postion
Tx: 95% conservative treatment
– Achilles & plantar fascia stretching, night splints,
NSAIDs, injection
Achilles Tendinitis & Rupture
• Rupture: sudden, severe calf pain
described as a gunshot wound or direct hit
• Middle-aged men = weekend athletes
• Swelling and ecchymosis from the calf to
heel
• Weakness with push-off
• + Thompson test=absence of plantar
flexion with calf compression
• Tendinitis: insertional or 4-5 cm proximal
– Insidious pain that increases with exercise
– Often after a change in training habits
– Protuberant posterolateral bony proces of the calcaneus
– Treat conservatively
Shin Splints
• Chronic leg Pain- palpation of the tibial
crest will usually identify a pinpoint spot
– Compression of the tibia and fibula will result
in pain at the fracture site
– Tx: reduction in athletic activity 4-6 wks
– NSAIDs
– Removable cast for ambulation
– Progressive training shedule: no more than 10% week
Diabetic Foot: Charcot Foot
• Insensate foot fails to provide sensory
feedback, causing the skin to break down
due to unperceived repetitive trauma
• 3 major clinical problems=diabetic
ulceration, deep infection, and Charcot
joints
• Sxs: hot, red, swollen with intact skin
– Elevate foot 5 mins=Charcot will lose redness
• Evaluation must include checking for cellulitis,
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osteomyelitis, and gout
X-rays
Vascular studies if pulses are absent or a
nonhealing ulcer is present
There is no noninvasive study that differentiates
Charcot xray changes from osteomyelitis:
GENERALLY- osteomyelitis will develop only if
the skin has been violated