Foot and AnkleFoot and Ankle

Fractures,Sprains, and Soft Fractures,Sprains, and Soft Tissue DisordersTissue Disorders

Ankle SprainAnkle Sprain

• 25,000 people sprain 25,000 people sprain an ankle every dayan ankle every day

• 85% of the time 85% of the time lateral collateral lateral collateral ligaments injured ligaments injured (anterior talofibular (anterior talofibular and calcaneofibular)and calcaneofibular)

• Inversion injuryInversion injury• 5% syndesmosis injury5% syndesmosis injury

• symptoms: pain, symptoms: pain, swelling, loss of swelling, loss of functionfunction

• Treatmentis aimed at Treatmentis aimed at preventing chronic preventing chronic pain and instabilitypain and instability

• NSAIDS, ice, NSAIDS, ice, compression, elevationcompression, elevation

• Air stirrup, WBAT, and Air stirrup, WBAT, and physical therapyphysical therapy

• Should improve in 6 Should improve in 6 weeksweeks

Ankle FracturesAnkle Fractures

• Fractures involve the medial or lateral Fractures involve the medial or lateral malleolus, the posterior lip of the tibia, the malleolus, the posterior lip of the tibia, the collateral liagamentous structures, or the talar collateral liagamentous structures, or the talar domedome

• Stable fractures= one malleolus , no ligamentsStable fractures= one malleolus , no ligaments• Unstable fractures= both malleoli or a distal Unstable fractures= both malleoli or a distal

fibula and disruption of the deltoid ligamentfibula and disruption of the deltoid ligament• Unstable fractures= vulnerable for Unstable fractures= vulnerable for

displacement, instability, and posttraumatic displacement, instability, and posttraumatic arthritis arthritis

• Symptoms: pain, Symptoms: pain, swelling, tenderness, swelling, tenderness, deformitydeformity

• Examination: include Examination: include evaluation of the evaluation of the posterior tibial pulse posterior tibial pulse and posterior tibial and posterior tibial nerve (plantar nerve (plantar sensation)sensation)

• X-rays: AP, lateral, X-rays: AP, lateral, oblique (mortise oblique (mortise view)view)

• Cat Scan for Cat Scan for complex fractures complex fractures with articualr with articualr surface involvement surface involvement or lateral portion of or lateral portion of the distal tibiathe distal tibia

• Treatment: Treatment:

• Stable unimalleolar fxs= WB SLCStable unimalleolar fxs= WB SLC

• Unstable fractures= ORIFUnstable fractures= ORIF

Maisonneuve FractureMaisonneuve Fracture

• Fracture of the proximal fibula with Fracture of the proximal fibula with torn medial deltoid ligament, and torn medial deltoid ligament, and disruption of the ankle mortisedisruption of the ankle mortise

• Palpate proximal fibular with all Palpate proximal fibular with all medial ankle pain presentationsmedial ankle pain presentations

• Treatment= ORIFTreatment= ORIF

Fractures of the HindfootFractures of the Hindfoot

• Talus fracture: usually result of severe traumaTalus fracture: usually result of severe trauma• Calcaneus fracture: MVA or fall from a heightCalcaneus fracture: MVA or fall from a height

• Sx: tenderness over talonavicular joint anterior Sx: tenderness over talonavicular joint anterior to the medial malleolus, tenderness with side to the medial malleolus, tenderness with side to side compression of the heel, swelling in the to side compression of the heel, swelling in the heel & ankle, and the inability to weight bear heel & ankle, and the inability to weight bear

• Tx: ORIF Tx: ORIF • * watch for plantar compartment syndrome* * watch for plantar compartment syndrome* • Talus fx: can lead to osteonecrosis Talus fx: can lead to osteonecrosis

Fracture of the MetatarsalFracture of the Metatarsal

Jones’ Fracture: proximal metaphysis of the Jones’ Fracture: proximal metaphysis of the fifth metatarsalfifth metatarsalpropensity for non or delayed unionpropensity for non or delayed unionNWBC 6 weeks, folllowed by WB cast until NWBC 6 weeks, folllowed by WB cast until healing occurshealing occurs

Base of the Fifth Metatarsal Fracture: Base of the Fifth Metatarsal Fracture: inversion injury inversion injury R/O with suspicion of ankle fractureR/O with suspicion of ankle fracture

Most respond to closed reductionMost respond to closed reduction

Fracture of the MidfootFracture of the Midfoot

• Lisfranc Fracture-DislocationLisfranc Fracture-Dislocation– Critical injury to the second Critical injury to the second

tarsometatarsal joint=stabilizing apex tarsometatarsal joint=stabilizing apex for the other tarsometatarsal joints since for the other tarsometatarsal joints since it “keys” into a slot in the cuneiformsit “keys” into a slot in the cuneiforms

– *Easily missed and misdiagnosed as an *Easily missed and misdiagnosed as an ankle sprain*ankle sprain*

• ExamExam– Careful examination will Careful examination will

reveal area of reveal area of maximum tenderness maximum tenderness over the over the tarsometatarsal jointtarsometatarsal joint

– Stabilize the calcaneus Stabilize the calcaneus and rotate and/or and rotate and/or adduct the adduct the forefoot=severe painforefoot=severe pain

• X-raysX-rays– AP, laterl, oblique views AP, laterl, oblique views

of the foot, standing if of the foot, standing if possiblepossible

– Common error is to Common error is to obtain only ankle filmsobtain only ankle films

– Normal Normal alignment=medial alignment=medial aspect of the middle aspect of the middle cuneiform with the cuneiform with the medial aspect of the medial aspect of the second metatarsal basesecond metatarsal base

– Stress views , CT, MRIStress views , CT, MRI

• TreatmentTreatment– Significant swelling occurs-elevate and iceSignificant swelling occurs-elevate and ice– Beware of Compartment SyndromeBeware of Compartment Syndrome– Nondisplaced injuries=NWBCNondisplaced injuries=NWBC– Displaced=ORIFDisplaced=ORIF

Morton’s NeuromaMorton’s Neuroma

• Fibrosis of the common digital nerve as it Fibrosis of the common digital nerve as it passes between the metatarsal headspasses between the metatarsal heads

• *commonly between the third and fourth *commonly between the third and fourth toes*toes*

• Sx: plantar pain, numbness, and “walking on Sx: plantar pain, numbness, and “walking on a marble”a marble”

• * firmly squeeze metatarsal heads with one * firmly squeeze metatarsal heads with one hand while applying direct pressure to the hand while applying direct pressure to the interspace with the otherinterspace with the other

• Tx: metatarsal bar, injection, surgical excisionTx: metatarsal bar, injection, surgical excision

Plantar FasciitisPlantar Fasciitis

• Plantar heel pain that occurs where the Plantar heel pain that occurs where the plantar fascia arises from the medial plantar fascia arises from the medial calcaneal tuberositycalcaneal tuberosity

• Sxs: focal pain often increased upon Sxs: focal pain often increased upon awakening or when rising from a resting awakening or when rising from a resting postionpostion

• Tx: 95% conservative treatmentTx: 95% conservative treatment– Achilles & plantar fascia stretching, night Achilles & plantar fascia stretching, night

splints, NSAIDs, injectionsplints, NSAIDs, injection

Achilles Tendinitis & Achilles Tendinitis & RuptureRupture• Rupture: sudden, severe calf pain Rupture: sudden, severe calf pain

described as a gunshot wound or direct described as a gunshot wound or direct hithit

• Middle-aged men = weekend athletesMiddle-aged men = weekend athletes• Swelling and ecchymosis from the calf to Swelling and ecchymosis from the calf to

heelheel• Weakness with push-offWeakness with push-off• + Thompson test=absence of plantar + Thompson test=absence of plantar

flexion with calf compressionflexion with calf compression

• Tendinitis: insertional or 4-5 cm proximalTendinitis: insertional or 4-5 cm proximal– Insidious pain that increases with exerciseInsidious pain that increases with exercise– Often after a change in training habitsOften after a change in training habits– Protuberant posterolateral bony proces of the calcaneusProtuberant posterolateral bony proces of the calcaneus

– Treat conservativelyTreat conservatively

Shin SplintsShin Splints

• Chronic leg Pain- palpation of the tibial Chronic leg Pain- palpation of the tibial crest will usually identify a pinpoint spotcrest will usually identify a pinpoint spot– Compression of the tibia and fibula will Compression of the tibia and fibula will

result in pain at the fracture siteresult in pain at the fracture site

– Tx: reduction in athletic activity 4-6 wksTx: reduction in athletic activity 4-6 wks– NSAIDsNSAIDs– Removable cast for ambulationRemovable cast for ambulation– Progressive training shedule: no more than 10% weekProgressive training shedule: no more than 10% week

Diabetic Foot: Charcot FootDiabetic Foot: Charcot Foot

• Insensate foot fails to provide sensory Insensate foot fails to provide sensory feedback, causing the skin to break feedback, causing the skin to break down due to unperceived repetitive down due to unperceived repetitive traumatrauma

• 3 major clinical problems=diabetic 3 major clinical problems=diabetic ulceration, deep infection, and Charcot ulceration, deep infection, and Charcot jointsjoints

• Sxs: hot, red, swollen with intact skinSxs: hot, red, swollen with intact skin– Elevate foot 5 mins=Charcot will lose Elevate foot 5 mins=Charcot will lose

rednessredness

• Evaluation must include checking for Evaluation must include checking for cellulitis, osteomyelitis, and goutcellulitis, osteomyelitis, and gout

• X-raysX-rays• Vascular studies if pulses are absent or a Vascular studies if pulses are absent or a

nonhealing ulcer is presentnonhealing ulcer is present• There is no noninvasive study that There is no noninvasive study that

differentiates Charcot xray changes from differentiates Charcot xray changes from osteomyelitis: GENERALLY- osteomyelitis osteomyelitis: GENERALLY- osteomyelitis will develop only if the skin has been will develop only if the skin has been violatedviolated