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Ankle And Foot

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  • 1. 2/3/2010 Ahmed Alhubaishi Ankle and foot Define the following terms: ◦Tibial plafond ◦Mortise ◦Posterior malleolus ◦Sprain/strain ◦Ankle ring 1
  • 2. 2/3/2010  An emergency physician who applies the Ottawa Ankle Rules correctly would send which of the following ambulatory patients with a chief complaint of “ankle pain” for x-ray?  a. A 40-year-old male with tenderness upon palpation of the posterior edge of the medial malleolar tip  b. A 25-year-old female with edema, ecchymosis,and tenderness just anterior to the lateral malleolus  c. A 60-year-old male with lateral edema, ecchymosis, and a positive anterior drawer test  d. A 16-year-old male with posterior ankle tenderness and a positive Thompson test  An emergency physician who applies the Ottawa Ankle Rules correctly would send which of the following ambulatory patients with a chief complaint of “ankle pain” for x-ray?  a. A 40-year-old male with tenderness upon palpation of the posterior edge of the medial malleolar tip  b. A 25-year-old female with edema, ecchymosis,and tenderness just anterior to the lateral malleolus  c. A 60-year-old male with lateral edema, ecchymosis, and a positive anterior drawer test  d. A 16-year-old male with posterior ankle tenderness and a positive Thompson test 2
  • 3. 2/3/2010 Using OAR which of the following not for X-ray:  Bone tenderness at med. Malleolus  Bone tenderness at lat. Malleolus  Bone tenderness of the posterior edge distal 6 cm to the ankle  Inability to bear wt on ankle now and immediately after the injury  Soft tissue swelling over med. And lat. malleolus Using OAR which of the following not for X-ray:  Bone tenderness at med. Malleolus  Bone tenderness at lat. Malleolus  Bone tenderness of the posterior edge distal 6 cm to the ankle  Inability to bear wt on ankle now and immediately after the injury  Soft tissue swelling over med. And lat. malleolus 3
  • 4. 2/3/2010 Ottawa rules When OAR cannot be applied??? 4
  • 5. 2/3/2010 When OAR cannot be applied??? 1. Altered level of consciousness 2. Subacute or chronic injuries 3. Injuries to hindfoot or forefoot 4. Not designed to pick up # < 3 mm One of the following ankle # can be Rx as OPD with close ortho. FU:  Fibular # proximal to tibiotalar ( t-t) joint line  Lat. Malleolus # below the T-T joint line  Lat. Malleolus # with deltoid lig. Rupture  Unimalleolar # with syndesmotic diastasis 5
  • 6. 2/3/2010 One of the following ankle # can be Rx as OPD with close ortho. FU:  Fibular # proximal to tibiotalar ( t-t) joint line  Lat. Malleolus # below the T-T joint line  Lat. Malleolus # with deltoid lig. Rupture  Unimalleolar # with syndesmotic diastasis What is this? 6
  • 7. 2/3/2010 The ankle ring consists of the following: tibial plafond, medial malleolus, deltoid ligaments, calcaneus, lateral collateral ligaments, lateral malleolus syndesmotic ligaments. The integrity of this ring determines the stability of the ankle 7
  • 8. 2/3/2010  Which of the following is the most commonly injured soft-tissue structure(s) of the ankle?  a. Lateral collateral ligaments  b. Medial collateral ligaments  c. Inferior tibiofibular ligaments  d. Achilles tendon  Which of the following is the most commonly injured soft-tissue structure(s) of the ankle?  a. Lateral collateral ligaments  b. Medial collateral ligaments  c. Inferior tibiofibular ligaments  d. Achilles tendon 8
  • 9. 2/3/2010  Each of the following ligaments are part of the ankle syndesmosis except:  a. Anterior inferior tibiofibular ligament (AITFL)  b. Posterior inferior tibiofibular ligament (PITFL)  c. Interosseous ligament (IOL)  d. Calcaneofibular ligament (CFL)  Each of the following ligaments are part of the ankle syndesmosis except:  a. Anterior inferior tibiofibular ligament (AITFL)  b. Posterior inferior tibiofibular ligament (PITFL)  c. Interosseous ligament (IOL)  d. Calcaneofibular ligament (CFL) 9
  • 10. 2/3/2010 Ankle ligaments- lateral Ankle ligaments – medial (deltoid) 10
  • 11. 2/3/2010  All of the following terms describe a motion of the talus within the mortise except:  a. adduction.  b. external rotation.  c. supination.  d. plantar flexion.  All of the following terms describe a motion of the talus within the mortise except:  a. adduction.  b. external rotation.  c. supination.  d. plantar flexion. 11
  • 12. 2/3/2010  Widening of the medial clear space on ankle radiographs suggests injury to each of the following structures except:  a. lateral ligament complex.  b. deltoid ligament.  c. anterior inferior tibiofibular ligament (AITFL).  d. posterior inferior tibiofibular ligament (PITFL).  Widening of the medial clear space on ankle radiographs suggests injury to each of the following structures except:  a. lateral ligament complex.  b. deltoid ligament.  c. anterior inferior tibiofibular ligament (AITFL).  d. posterior inferior tibiofibular ligament (PITFL). 12
  • 13. 2/3/2010  Pain at the ankle during squeeze testing is suggestive of injury to which structure(s)?  a. Medial collateral ligaments  b. Inferior tibiofibular ligaments  c. Lateral collateral ligaments  d. Peroneal tendons  Pain at the ankle during squeeze testing is suggestive of injury to which structure(s)?  a. Medial collateral ligaments  b. Inferior tibiofibular ligaments  c. Lateral collateral ligaments  d. Peroneal tendons 13
  • 14. 2/3/2010  On a normal AP ankle x-ray, the amount of tibiofibular overlap should be at least:  a. 2 mm.  b. 4 mm.  c. 6 mm.  d. 8 mm.  On a normal AP ankle x-ray, the amount of tibiofibular overlap should be at least:  a. 2 mm.  b. 4 mm.  c. 6 mm.  d. 8 mm. 14
  • 15. 2/3/2010 15
  • 16. 2/3/2010 -Malleoli superimposed each other -- body of calcaneous visible -Base of 5 th m.t 16
  • 17. 2/3/2010 -entire joint space -talar dome No overlap between the previous two -symmetrical joint space -Width of medial space 2-3 mm --T-F ovelap not less than 1-2 mm 17
  • 18. 2/3/2010  Widening of the medial clear space or a lesser degree of tibulofibular overlap suggests injury to to the medial ligament,syndesmosis or both 18
  • 19. 2/3/2010  The Lauge-Hansen classification of ankle fractures is based on:  a. the anatomic location of the fibular fracture with respect to the mortise.  b. the mechanism of injury.  c. the degree of articular involvement.  d. the presence or absence of syndesmotic disruption.  The Lauge-Hansen classification of ankle fractures is based on:  a. the anatomic location of the fibular fracture with respect to the mortise.  b. the mechanism of injury.  c. the degree of articular involvement.  d. the presence or absence of syndesmotic disruption. 19
  • 20. 2/3/2010  Inversion injury. There is a transverse avulsion fracture of the lateral malleolus below the mortise caused by supination-adduction forces (arrow).The lateral ligaments remain intact. This injury is classified as Lauge-Hansen SA grade 1 or Danis- Weber type A. 20
  • 21. 2/3/2010  The medial clear space is widened, suggesting deltoid and/or syndesmotic ligament disruption (arrowhead). There is an isolated spiral fracture of the fibula occurring at the level of the mortise caused by supination-external rotation forces.This injury is classified as Lauge-Hansen SE grade 2 or Danis-Weber type B. 21
  • 22. 2/3/2010 What is this? What is this? MAISONNEUVE’S FRACTURE 22
  • 23. 2/3/2010  Characteristics of a Maisonneuve fracture include all of the following except:  a. It occurs in the setting of forceful external rotation.  b. It is frequently associated with medial ligament and/or syndesmosis disruption.  c. It is highly unstable.  d. The diagnosis is readily made on routine ankle x-ray series.  Characteristics of a Maisonneuve fracture include all of the following except:  a. It occurs in the setting of forceful external rotation.  b. It is frequently associated with medial ligament and/or syndesmosis disruption.  c. It is highly unstable.  d. The diagnosis is readily made on routine ankle x-ray series. 23
  • 24. 2/3/2010 What is this? Pilon fracture  # of distal tibial metaphysis  Due to high energy mechanism  Usually comminuted, 20% open  Significant soft tissue loss  Talus derive into tibial plafond  Associated with: # of calcaneus,tibial platue, femoral neck, acetabulum, vertebrae 24
  • 25. 2/3/2010 Tillaux Fracture:  • Lateral tibia, involving articular surface  • Salter-Harris III fracture, mostly in adolescents  • Usually requires surgical fixation  The best test for Achilles tendon rupture is:  a. ability to pronate the foot.  b. ability to dorsiflex the foot.  c. the Thompson squeeze test.  d. the ―wiggle test.‖ 25
  • 26. 2/3/2010  The best test for Achilles tendon rupture is:  a. ability to pronate the foot.  b. ability to dorsiflex the foot.  c. the Thompson squeeze test.  d. the ―wiggle test.‖  All of the following fractures warrant orthopedic consultation in the ED except:  a. unimalleolar fracture.  b. bimalleolar fracture.  c. trimalleolar fracture.  d. triplane fracture. 26
  • 27. 2/3/2010  All of the following fractures warrant orthopedic consultation in the ED except:  a. unimalleolar fracture.  b. bimalleolar fracture.  c. trimalleolar fracture.  d. triplane fracture. When to consult ortho people to come and see pt with ankle pain ? 27
  • 28. 2/3/2010  Unimalleolar Fractures  Displaced medial malleolar fracture  Medial malleolar fracture with lateral collateral ligament rupture  Displaced lateral malleolar fracture  Lateral malleolar fracture with deltoid ligament rupture  Lateral malleolar fracture with widened medial clear space  Unimalleolar fracture with syndesmotic diastasis  Fibula fracture at or proximal to the tibiotalar joint line  Displaced posterior malleolar fracture  Posterior malleolar fracture involving more than 25% of joint surface  All Bimalleolar Fractures  All Trimalleolar Fractures  All Intraarticular Fractures With Step Deformity  All Open Fractures  All Pilon Fractures Clinical Pathway: Evaluation Of Ankle Injuries 28
  • 29. 2/3/2010 29
  • 30. 2/3/2010 Clinical Pathway: Management Of Ankle Injuries 30
  • 31. 2/3/2010 31
  • 32. 2/3/2010 CASE • 24 yo M football player • Another player rolled over his ankle from behind • ANKLE DISLOCATION: • • Usually posterior • • Often associated with fracture and ligamentous injury • Reduction: • • Place one hand behind heel, with other over dorsum of foot. • • Downward and anterior traction, with foot plantar-flexed initially. • • Finally bring ankle back to 90 degrees flexion. • Clinical Pearl: • Put the knee in a slightly flexed position (20-30 degrees) during the reduction to reduce tension at the ankle. • Post-reduction: • • Immobilize in short leg, 3-sided splint, ankle at 90 degrees • • Follow up with Orthopedic surgeon 32
  • 33. 2/3/2010 case • 20 year old male twisted his ankle while ―snowboarding‖ • Exam: Ankle is swollen, diffusely tender, and plain films are negative. • Ankle Sprain: • • R.I.C.E. (rest, ice, compression, elevation) • • Functional immobilization • o ACE, AirCast, taping, etc • • Crutches • o Weight-bearing as tolerated • • Follow up exam • o Approximately two weeks after injury • o Repeat physical exam for ligamentous damage • o Most patients will be much improved • o A few may have persistent pain, swelling, and joint effusion, • suggesting the possibility of occult fracture. • When should I consider CT or MRI for occult ankle fracture? • Consider CT or MRI in the setting of negative plain films, and: • o High clinical suspicion • o Persistent pain, swelling, effusion at follow- up • Important occult fractures of the ankle/foot: • o Talar dome • o Tillaux (lateral tibia) • o Calcaneus, Navicular • o Lateral process of the talus 33
  • 34. 2/3/2010 • Haapamaki, American Journal of Roentgenology, 2004 • Retrospective study, over 3 years • 344 patients with a fracture on ankle / foot CT • CT’s ordered to delineate fracture, or to r/o occult fracture • Most common occult fx in ankle (not visualized on plain films): • Calcaneus (20) • Talus (15) • Tillaux (7) • Pearls: • 1) CT helpful for: • a. High suspicion (mechanism, exam) • b. Poor recovery • 2) High risk situations: • a. Fall from height—Calcaneus • b. Adolescent—Tillaux • c. Snowboarding—Lat. process of Talus 34
  • 35. 2/3/2010 foot Q  What is CHOPART’S AND LISFRANCE’S JOINTS?  CHOPART: between midfoot and hindfoot  LISFRANCE: between midfoot and metatarsals 35
  • 36. 2/3/2010 foot What are the foot # need ortho consult in ED ? 36
  • 37. 2/3/2010  All talus fractures  All calcaneus fractures  Significant navicular fractures, especially if intraarticular  All cuboid fractures  Lisfranc injuries  Metatarsal shaft fractures with > 3 mm displacement or 10 degrees angulation  Metatarsal head and neck fractures  Jones fractures When BOEHLER’S angle < 20 degree means:  Navicular fracture  Cuboid fracture  Lisfrance’s fracture  Calcaneal fracture  First metatarsal fracture 37
  • 38. 2/3/2010 When BOEHLER’S angle < 20 degree means:  Navicular fracture  Cuboid fracture  Lisfrance’s fracture  Calcaneal fracture  First metatarsal fracture Boehler’s angle 38
  • 39. 2/3/2010 What is this? Calcaneus fracture:  • Calcaneus fractures most often occur in males (male:female = 5:1)  • Peak age: between 30 and 50 years.  • Associated injuries (Lumbar spine vertebral compression fractures)  • Treatment: Operative vs Casting 39
  • 40. 2/3/2010 What is this?  Talar body fracture  Risk of AVN 40
  • 41. 2/3/2010 What is this?  Talar neck #  50% of all talar #  Extreme dorsiflexion  Hawkin’s classification 1-4 41
  • 42. 2/3/2010 Talar Dome Fracture:  • Osteochondral lesion, articular surface  • CT and MRI both excellent to visualize lesion  • May be managed by cast (non- weight bearing), or by arthroscopic  surgery if loose fragments in joint What is this? 42
  • 43. 2/3/2010 Lisfrance’s fracture  AP view : ◦ medial margin of the base of the second metatarsal lines up with the medial margin of the middle cuneiform  oblique view: ◦ medial margin of the base of the third metatarsal lines up with the medial margin of the lateral cuneiform, and ◦ medial margin of the base of the fourth metatarsal lines up with the medial margin of the cuboid Types of lisfrance’s # 43
  • 44. 2/3/2010 What fracture is virtually pathognomonic for a Lisfranc injury? Fracture the base of second metatarsal What are these? 44
  • 45. 2/3/2010 What are these? Jones # Pseudojones # 45
  • 46. 2/3/2010  Jones’ fracture: transverse fracture at least 15 mm distal to proximal end of 5th metatarsal; high rate of malunion so call ortho  Pseudo-Jones’ fracture: avulsion fracture of tuberosity at 5th metatarsal base; treat symptomatically  Nonunion and chronic disability may result from inadequate immobilization of:  a. lateral malleolar avulsion fractures.  b. avulsion fractures of the tuberosity of the fifth metatarsal (pseudo-Jones).  c. fifth metatarsal shaft fractures (Jones).  d. lateral ligament tears with lateral malleolar avulsion fractures. 46
  • 47. 2/3/2010  Nonunion and chronic disability may result from inadequate immobilization of:  a. lateral malleolar avulsion fractures.  b. avulsion fractures of the tuberosity of the fifth metatarsal (pseudo-Jones).  c. fifth metatarsal shaft fractures (Jones).  d. lateral ligament tears with lateral malleolar avulsion fractures. What are the indications for reduction of a metatarsal fracture? 47
  • 48. 2/3/2010 Greater than 10 degrees angulation or 3 mm displacement Thank you 48

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