Foot and Ankle

1
Foot and Ankle

• Fractures,Sprains, and Soft Tissue Disorders

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Ankle Sprain

• 25,000 people sprain an ankle every day
• 85 of the time lateral collateral ligaments
  injured (anterior talofibular and
  calcaneofibular)
• Inversion injury
• 5 syndesmosis injury

• symptoms pain, 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

3
Ankle Fractures

• Fractures involve the medial or lateral
  malleolus, 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

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• Symptoms pain, swelling, tenderness, deformity
• Examination include evaluation of the posterior
  tibial pulse and posterior tibial nerve (plantar
  sensation)

• X-rays AP, lateral, oblique (mortise view)
• Cat Scan for complex fractures with articualr
  surface involvement or lateral portion of the
  distal tibia

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• Treatment
• Stable unimalleolar fxs WB SLC
• Unstable fractures ORIF

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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

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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
  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
  

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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

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Fracture of the Midfoot

• Lisfranc Fracture-Dislocation
• Critical injury to the second tarsometatarsal
  jointstabilizing apex for the other
  tarsometatarsal joints since it keys into a
  slot in the cuneiforms
• Easily missed and misdiagnosed as an ankle
  sprain

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• Exam
• Careful examination will reveal area of maximum
  tenderness over the tarsometatarsal joint
• Stabilize the calcaneus and rotate and/or adduct
  the forefootsevere pain

• X-rays
• AP, laterl, oblique views of the foot, standing
  if possible
• Common error is to obtain only ankle films
• Normal alignmentmedial aspect of the middle
  cuneiform with the medial aspect of the second
  metatarsal base
• Stress views , CT, MRI

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• Treatment
• Significant swelling occurs-elevate and ice
• Beware of Compartment Syndrome
• Nondisplaced injuriesNWBC
• DisplacedORIF

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Mortons Neuroma

• Fibrosis of the common digital nerve as it passes
  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

13
Plantar Fasciitis

• Plantar heel pain that occurs where the plantar
  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

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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 testabsence of plantar flexion with
  calf compression

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• 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

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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

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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 problemsdiabetic ulceration,
  deep infection, and Charcot joints
• Sxs hot, red, swollen with intact skin
• Elevate foot 5 minsCharcot will lose redness

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• Evaluation must include checking for cellulitis,
  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