ankle and foot
TRANSCRIPT
2/3/2010
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Ankle and foot
Ahmed Alhubaishi
Define the following terms:
◦Tibial plafond
◦Mortise
◦Posterior malleolus
◦Sprain/strain
◦Ankle ring
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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
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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
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Ottawa rules
When OAR cannot
be applied???
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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
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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?
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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
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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
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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)
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Ankle ligaments- lateral
Ankle ligaments – medial
(deltoid)
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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.
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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).
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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
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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.
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-Malleoli
superimposed
each other
-- body of
calcaneous
visible
-Base of 5 th
m.t
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-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
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Widening of the medial clear space or
a lesser degree of tibulofibular overlap
suggests
injury to to the medial
ligament,syndesmosis or
both
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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.
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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.
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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.
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What is this?
What is this?
MAISONNEUVE’S
FRACTURE
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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.
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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
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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.‖
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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.
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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
?
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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
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Clinical Pathway: Management
Of Ankle Injuries
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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
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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
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• 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
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foot
Q
What is CHOPART’S AND
LISFRANCE’S JOINTS?
CHOPART: between midfoot and
hindfoot
LISFRANCE: between midfoot and
metatarsals
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foot
What are the foot # need
ortho consult in ED
?
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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
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When BOEHLER’S angle < 20
degree means: Navicular fracture
Cuboid fracture
Lisfrance’s fracture
Calcaneal fracture
First metatarsal fracture
Boehler’s angle
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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
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What is this?
Talar body fracture
Risk of AVN
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What is this?
Talar neck #
50% of all talar #
Extreme dorsiflexion
Hawkin’s classification 1-4
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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?
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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 #
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What fracture is virtually
pathognomonic for a
Lisfranc injury?
Fracture the base of
second metatarsal
What are these?
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What are these?Jones #
Pseudojones #
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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.
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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?
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Greater than 10
degrees angulation
or
3 mm displacement
Thank you