Foot and Ankle Fractures Sprains and Soft Tissue

Foot and Ankle Fractures, Sprains, and Soft Tissue Disorders

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

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

• 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

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

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

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

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

Fracture of the Midfoot • Lisfranc Fracture-Dislocation – Critical injury to the second tarsometatarsal joint=stabilizing apex for the other tarsometatarsal joints since it “keys” into a slot in the cuneiforms – *Easily missed and misdiagnosed as an ankle sprain*

• Exam – Careful examination will reveal area of maximum tenderness over the tarsometatarsal joint – Stabilize the calcaneus and rotate and/or adduct the forefoot=severe pain • X-rays – AP, laterl, oblique views of the foot, standing if possible – Common error is to obtain only ankle films – Normal alignment=medial aspect of the middle cuneiform with the medial aspect of the second metatarsal base – Stress views , CT, MRI

• Treatment – – Significant swelling occurs-elevate and ice Beware of Compartment Syndrome Nondisplaced injuries=NWBC Displaced=ORIF

Morton’s 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

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

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 test=absence of plantar flexion with calf compression

• 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

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

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 problems=diabetic ulceration, deep infection, and Charcot joints • Sxs: hot, red, swollen with intact skin – Elevate foot 5 mins=Charcot will lose redness

• 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