Orthopedics 5th year, 9th lecture (Dr. Ali A.Nabi)


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The lecture has been given on May 14th, 2011 by Dr. Ali A.Nabi.

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Orthopedics 5th year, 9th lecture (Dr. Ali A.Nabi)

  2. 2. <ul><li>Injuries of the ankle and foot con be divided into: </li></ul><ul><li>Ligamentous injuries of the ankle. </li></ul><ul><li>Ankle fracture (malleolar F. or Pott’s F). </li></ul><ul><li>Tibial Plafond fractures </li></ul><ul><li>Fracture of the talus. </li></ul><ul><li>Fracture of the calcaneus. </li></ul><ul><li>Fracture of metatarsals and phalanges </li></ul>
  3. 3. ANATOMY <ul><li>1) Distal end of tibia </li></ul><ul><li>: ankle mortise </li></ul><ul><li>Distal end of fibula </li></ul><ul><li>2) Talus – trochlea of talus dome </li></ul><ul><li>3) Ligaments – a) lateral ligament </li></ul><ul><li>complex b) medial ( deltoid </li></ul><ul><li>ligament ) </li></ul><ul><li>c) syndesmosis </li></ul>
  4. 5. ANKLE SPRAINS <ul><li>- The most common acute sport injuries, 25% in every running or jumping sport </li></ul><ul><li>- Mechanism of injury: inversion and plantar flexion of the foot when landing off balance or clipping another player’s foot </li></ul>
  5. 6. ANKLE SPRAINS <ul><li>Sequence of injury: anterior talofibular ligament, calcaneofibular ligament, posterior talofibular ligament, musculotendinous units supporting the ankle joint </li></ul>
  6. 7. ANKLE SPRAINS <ul><li>Incidence increased in : </li></ul><ul><li>- individuals with varus malalignment of lower limbs </li></ul><ul><li>- calf muscle tightness </li></ul><ul><li>- previous incompletely rehabilitated ankle sprains </li></ul>
  7. 8. <ul><li>Medial Ankle Sprain </li></ul><ul><ul><li>MOI: Eversion </li></ul></ul><ul><ul><li>S/S: Pain and swelling around medial malleolus, pop, pain with eversion or external rotation, inability to bear weight </li></ul></ul><ul><ul><li>Structures Injured: Deltoid Ligament </li></ul></ul><ul><ul><li>Tx: Rule out fracture, RICE, ROM exercises, gradual return to activity (longer than LAS), taping </li></ul></ul><ul><ul><li>Special Tests: Talar Tilt (Eversion), Kleiger Test </li></ul></ul>
  8. 10. <ul><li>Inversion ( Lateral ) Ankle Sprain </li></ul><ul><li>Mechanism of Injury - Inversion </li></ul><ul><li>Typical presentation </li></ul><ul><ul><li>Pain on or near lateral malleolus </li></ul></ul><ul><ul><li>Swelling around lateral malleolus </li></ul></ul><ul><ul><li>Pain increases with lateral movements </li></ul></ul>
  9. 11. <ul><li>Lateral Ankle Sprain </li></ul><ul><ul><li>MOI: Inversion, Plantarflexion </li></ul></ul><ul><ul><li>S/S: Pain and swelling around lateral malleolus, Pop (repeatable c movement), Pain with MOI motions, Inability to bear weight </li></ul></ul><ul><ul><li>Structures Injured: Lateral Ankle Ligaments (anterior talofibular & calcaneofibular most commonly) </li></ul></ul><ul><ul><li>Tx: Rule out fracture, RICE, ROM exercises, gradual return to activity, taping </li></ul></ul>
  10. 16. ANKLE SPRAINS <ul><li>- Diagnosis: x-rays, stress x-rays </li></ul><ul><li>( inversion stress, anterior drawer test), ? MRI scan </li></ul><ul><li>- acute phase ( first 72 hours ): </li></ul><ul><li>RICE, then varies according to the severity of injury </li></ul>
  11. 18. GRADE 1 ( Mild ) SPRAINS <ul><li>- The anterior talofibular ligament affected </li></ul><ul><li>- stress: minimal change on inversion, normal anterior drawer </li></ul><ul><li>- treatment by encouraging early active movement: </li></ul><ul><li>a) stationary cycling </li></ul><ul><li>b) walking with protective taping or semi-rigid brace ( Aircast splint ) </li></ul>
  12. 19. GRADE 1 ( Mild ) SPRAINS <ul><li>c) NSAIDS (anti-inflammatory medication) </li></ul><ul><li>d) physiotherapy: electrotherapy, strengthening exercises, propreoception (1 legged stand ) </li></ul><ul><li>e) functional progression to running, jumping, hopping, swerving and cutting, recovery into 6 weeks </li></ul>
  13. 20. GRADE 2 (Moderate) SPRAINS <ul><li>- Complete tear of anterior talofibular ligament with some damage of the calcaneofibular ligament </li></ul><ul><li>- laxity when inversion, anterior drawer present </li></ul><ul><li>- treatment: a) 1 week crutches, joint taped or in aircast splint </li></ul><ul><li>b) follow grade 1 rehabilitation </li></ul>
  14. 21. GRADE 3 ( Severe ) SPRAINS <ul><li>- Uncommon severe injuries, associated with fractures </li></ul><ul><li>- treatment: 10 days NWB in aircast brace or POP, then PWB with the brace up to 6 weeks. Aggressive rehabilitation follows </li></ul><ul><li>- surgical reconstruction must be considered </li></ul>
  15. 22. PERONEAL TENDON INJURIES <ul><li>- Strong everters and weak plantar flexors of the foot </li></ul><ul><li>- mechanism of injury: </li></ul><ul><li>a) associated with lateral ligament injuries </li></ul><ul><li>b) forced dorsiflexion with slight inversion and reflex contraction of the tendons ( sprinting, uneven ground, ballet) </li></ul>
  16. 23. PERONEAL TENDON INJURIES <ul><li>- O/E: Behind lat.malleolus discomfort or swelling. Subluxation on resisting dorsiflexion with eversion </li></ul><ul><li>- treatment: a) acute phase – well-moulded short NWB cast with pad over lat.malleolus b) chronic phase – surgical correction, POP 4 weeks c) rupture of peroneal tendons – surgical correction </li></ul>
  17. 24. PERONEAL TENDON INJURIES <ul><li>TENDINITIS: </li></ul><ul><li>- occurs in dancers, basketball, volleyball </li></ul><ul><li>- combined cause of the lat.malleolus pulley action and foot malalignment </li></ul>
  18. 25. PERONEAL TENDON INJURIES <ul><li>TENDINITIS: </li></ul><ul><li>- TREATMENT – a) rest from sport, temporary use of heel wedge </li></ul><ul><li>b) physiotherapy, extreme cases: local injection into the sheath </li></ul><ul><li>c) gradual coaching programme, avoid rapid direction changes or sprinting – 6 weeks </li></ul><ul><li>d) failure of conservative treatment: tenolysis of peroneal tendons </li></ul>
  19. 26. ACHILLES TENDON INJURIES <ul><li>- Common tendon of gastrocnemius and soleus muscles </li></ul><ul><li>- tendon twists laterally from 15cm above insertion becoming more pronounced at 2-5cm above insertion. Blood supply reduced at this level </li></ul>
  20. 27. ACHILLES TENDON INJURIES <ul><li>- Aetiology factors: lack of rear foot support in shoes, terrain, excessive training loads, biomechanical factors of foot: over pronation, rear foot varus or valgus, pes cavus, tight calf muscles </li></ul>
  21. 29. <ul><ul><li>MOI: Forced ankle dorsiflexion while weight bearing </li></ul></ul><ul><ul><li>S/S: Pop, Feeling of being kicked in tendon, Inability to plantarflex foot, Gross deformity (observe and palpate), swelling, Lots of pain </li></ul></ul><ul><ul><li>Special Tests: Thompson Test </li></ul></ul><ul><ul><li>Treatment: Surgical Intervention to repair tear in tendon, Long rehab to restore ankle function </li></ul></ul>
  22. 32. Ankle fractures <ul><li>Fractures and fractures dislocation of the ankle are common. </li></ul><ul><li>It is also referred as Pott’s fractures. </li></ul><ul><li>The most obvious injury is fracture of one or both malleoli. </li></ul><ul><li>The invisible injury is rupture of one or more ligaments. </li></ul>
  23. 33. Ankle fractures <ul><li>Mechanism </li></ul><ul><li>The patient stumbles and falls. </li></ul><ul><li>The foot anchored to the ground and the body lunges forwards. </li></ul><ul><li>The ankle is twisted and talus is tilted and/or rotates focibly in the mortise, causing low energy fracture in one or both malleoli. </li></ul>
  24. 34. Ankle fractures <ul><li>Associated ligamental injuries may associated with such fractures. </li></ul><ul><li>If the malleolus is pushed off, it is usually fractures obliquely. </li></ul><ul><li>If the malleolus pulled off, it is usually fractures transversely. </li></ul>
  25. 35. Classification <ul><li>Danis and Weber (1991) which depends on the fibullar fracture </li></ul>
  26. 36. Classification <ul><li>Type A </li></ul><ul><ul><li>Transverse Fracture lateral malleolus Below syndesmosis, it associated with oblique or vertical fracture of medial malleolus. </li></ul></ul><ul><ul><li>Mechanism </li></ul></ul><ul><ul><li>Internal rotation and adduction </li></ul></ul>
  27. 37. Classification <ul><li>Type B </li></ul><ul><ul><li>Oblique fracture of lateral malleolus At level of syndesmosis, may associated with avalsion fracture of medial malleolus or torn deltoid ligament. </li></ul></ul><ul><ul><li>Mechanism </li></ul></ul><ul><ul><li>External rotation leads to oblique fracture </li></ul></ul>
  28. 38. Classification <ul><li>Type C </li></ul><ul><ul><li>Fibula fracture Above syndesmosis leading to torn tibiofibular ligament (Syndesmotic injury) </li></ul></ul><ul><ul><li>Mechanism </li></ul></ul><ul><ul><li>Abduction and external rotation. </li></ul></ul>
  29. 41. <ul><li>Medial and posterior malleolar fractures, deltoid ruptures may occur with any of these </li></ul>
  30. 42. Clinical features <ul><li>Common in skier, footballer and climbers. </li></ul><ul><li>H/O severe twisting, abduction or adduction injuries. </li></ul><ul><li>Severe pain. </li></ul><ul><li>Inability to stand on the affected limb. </li></ul><ul><li>Swelling and deformity. </li></ul><ul><li>Tenderness on one or both malleoli. </li></ul>
  31. 43. X-Ray <ul><li>At least three views </li></ul><ul><li>Ap. </li></ul><ul><li>Lateral. </li></ul><ul><li>Mortise view ( 30 ° oblique view). </li></ul>
  32. 45. Initial Managment <ul><li>Closed reduction </li></ul><ul><ul><li>Hematoma block </li></ul></ul><ul><ul><li>Conscious sedation </li></ul></ul><ul><li>Compression dressing, splint, and elevation </li></ul><ul><li>Early OR treatment </li></ul><ul><ul><li>Unstable fracture </li></ul></ul><ul><ul><li>No soft tissue compromise (blisters, severe swelling) </li></ul></ul><ul><ul><li>Open fractures </li></ul></ul><ul><li>Delayed treatment </li></ul><ul><ul><li>Stable in splint </li></ul></ul><ul><ul><li>Soft tissues need to recover </li></ul></ul><ul><li>Pain control </li></ul>
  33. 46. Medial Malleolar Fractures <ul><li>Nondisplaced fractures may be treated nonoperatively </li></ul><ul><li>Displaced fractures require anatomic reduction and fixation. </li></ul><ul><li>High nonuion rate </li></ul>
  34. 47. Lateral Malleolus Fractures <ul><li>Nonoperative managmement </li></ul><ul><ul><li>2-3 mm displacement </li></ul></ul><ul><ul><li>NO medial widening or syndesmotic injury </li></ul></ul><ul><ul><li>Cast or boot immobilization 6 wks </li></ul></ul><ul><ul><li>Follow closely! </li></ul></ul><ul><ul><li>Superior results </li></ul></ul>
  35. 48. Surgical Indications <ul><li>Bimalleolar / trimalleolar fractures </li></ul><ul><li>Syndesmotic disruption </li></ul><ul><li>Talar subluxation </li></ul><ul><li>Joint incongruity / articular stepoff </li></ul>
  36. 49. Posterior Malleolus <ul><li>May associated with bimalleolar fracture and called trimalleolar fracture and it is always need open reduction and internal fixation. </li></ul>
  37. 50. Complications <ul><li>Early </li></ul><ul><li>Vascular injury. </li></ul><ul><li>Wound breakdown and infection. </li></ul>
  38. 51. Complications <ul><li>Late </li></ul><ul><li>Malunion with varus or valgus deformity– corrective osteotomy. </li></ul><ul><li>Non union more common of medial malleolus. </li></ul><ul><li>Degenerative arthritis. </li></ul><ul><li>Joint stiffness, </li></ul><ul><li>Algodystrophy. </li></ul>
  39. 52. Fracture of the tibial Plafond <ul><li>Fall from highet, fracture depends on position of talus on impact: Comminuted fracture of tibial plafond. </li></ul><ul><li>Management: IF usually difficult: Skeletal traction, External fixator, Minimal internal fixation And plaster. </li></ul>
  40. 53. Injuries of talus <ul><li>Anatomy of talus: 60% covered by cartilage.B.supply critical( dorsal neck, artery of tarsal canal deltoid branch). So fracture talar neck will lead to avascular necrosis of the body. </li></ul><ul><li>Injuries include: Fracture neck, Fracture body, Dislocations </li></ul>
  41. 54. A-Fracture neck of talus <ul><li>Due to forcible dorsiflexion. Classified according to Hawkins into: </li></ul><ul><li>a-Undisplaced fracture. </li></ul><ul><li>Blood supply intact, avascular necrosis rare. Treated by below knee plaster for 2 months </li></ul>
  42. 55. A-Fracture neck of talus <ul><li>b- Displaced fracture neck with subtalar subluxation or dislocation: B.supply affected (30% AVN). </li></ul><ul><li>Treatment: Early, trial of Closed reduction, If failed OR and IF </li></ul>
  43. 56. A-Fracture neck of talus <ul><li>C:Fracture neck of talus with total dislocation of the body of talus. AVN more common, skin sloughing. </li></ul><ul><li>Treatment:Urgent, usually closed reduction fail and OR and IF ,followed by cast </li></ul>
  44. 57. <ul><li>Type D fracture </li></ul><ul><li>-type II injury with associated talar head dislocation </li></ul>
  45. 58. Complications of Injuries around talus include <ul><li>avascular necrosis of the body. </li></ul><ul><li>Osteoarthritis. </li></ul><ul><li>sloughing of the skin. </li></ul>
  46. 59. Fracture Calcaneus <ul><li>-5x more common in men </li></ul><ul><li>-largest and most frequently fractured tarsal bone </li></ul><ul><li>-falls (axial load) or twisting mechanisms ( fall from a height). </li></ul><ul><li>-extra-articular (25-35%) – good prognosis </li></ul><ul><li>-intra-articular (70-75%) – not so good prognosis! </li></ul><ul><li>-look for associated fractures </li></ul><ul><li>->50 % cases have associated other extremity or spinal fractures </li></ul><ul><li>-7% bilateral </li></ul><ul><li>-50% will have long-term disability </li></ul>
  47. 61. Types of Fracture calcaneus <ul><li>Types: </li></ul><ul><li>1- Isolated fractures: Fracture of sustentaculum tali, posterior or anterior process. Treatment: Elevation, Ice bags , bandage and active exercises </li></ul><ul><li>2-Avulsion fracture: Tendoachilis--IF </li></ul>
  48. 62. Types of Fracture calcaneus <ul><li>3-Extra-articular fr. Compressed fr. Outside the joint—Below knee plaster. </li></ul><ul><li>4- Intra-articular: Should he reduced accurately– Closed reduction and percutenous fixation, Or and plate fixation. </li></ul>
  49. 63. Complication of Fracture Oscalcis <ul><li>OA of subtalar joint—Arthrodesis </li></ul><ul><li>Widening of heel: impingement of peroneal tendon or sural nerve. </li></ul><ul><li>Spur formation of plantar aspect –Shaving. </li></ul><ul><li>Chronic pain and swelling </li></ul>
  50. 64. Metatarsal fractures <ul><li>Fracture base 5 th metatarsal: common, inversion, below knee cast. </li></ul><ul><li>Fracture shaft of metatarsal: Direct trauma- below knee cast </li></ul>
  51. 65. Metatarsal and Phalangeal fractures <ul><li>March fracture : Stress fr. Neck 2 nd less commonly 3 rd metatarsal, common in new soldiers, sclerotic ends, heel by rest in below knee cast </li></ul><ul><li>Phalangeal fractures. Direct trauma, adhesive tapping </li></ul>