20. Ankle & Foot Disorders

MC long bone fracture

Tibia shaft

MOI of tibula & fibula shaft fractures (older, younger)

- Younger → MVA, fall from height (wedge / short oblique fracture)

- Older → Fall, twisting / indirect force (spiral fracture with fibula fracture)

S/S & PE of tibula & fibula shaft fractures

- Severe pain w/ swell & bruise

- Inability to weight bear

- Assess firmness of lower leg for ACS

- Assess posterior tibialis & dorsalis pedis pulses

Diagnostic workup of tibula & fibula shaft fractures

X-ray — AP & lateral tibia / fibula

Management of tibula & fibula shaft fractures

- Displaced, unstable → Intermedullary nailing

- Proximal/distal shaft fractures → ORIF

Complications of tibula & fibula shaft fractures

- Compartment syndrome

- Nerve injury

Shin splints AKA

Medial tibial stress syndrome — Traction periostitis

Stress reaction (define)

Increased metabolic activity in bone W/O cortical disruption — Seen on MRI

Stress fracture (define)

Radiologically visible bone stress injury

Risk factors for MTSS, stress fracture / reaction

- Prolonged run / jump (hurdlers, military recruits)

- Sudden increase in training volume / intensity

- Female athletes — Female athlete triad

S/S & PE of medial tibial stress syndrome

- Vague, diffuse pain along medial-distal tibia

- Worse at beginning of activity, decreases during training

S/S & PE of stress fracture

- Localized tenderness of mid/distal medial tibia lasting weeks to months

- Pain remains & increases during activity

Diagnostic workup of medial tibial stress syndrome vs. stress fracture

- X-ray — Stress fracture → Periosteal reaction, cortical thickening, fracture line; MTSS normal

- MRI — High sensitive / specificity (next step); Stress fracture → Periosteal/bone edema

Management of medial tibial stress syndrome

- Activity modification, shoe modifications

- Pain at rest / ADLs → CAM walker boot

MC type of malleolar ankle fractures

Unimalleolar (also bi & trimalleolar)

MOI of malleolar ankle fractures

Rotational / twisting force

Classification of malleolar ankle fractures

Lauge - Hansen — Uses foot position & direction of force applied

S/S & PE of malleolar ankle fractures

- Severe localizing ankle pain, swell, ecchymoses post-trauma

- Difficulty to weight bear

Diagnostic workup of malleolar ankle fractures

- X-ray — AP, lateral, & oblique (mortise)

- CT — Trimalleolar fractures

- MRI — Associated ligament / cartilage injury

Management of malleolar ankle fractures

- Stable → RICE, CAM boot

- Unstable → ORIF

Complications of malleolar ankle fractures

- Wound issues / delayed healing

- DVT

- Post-trauma arthritis

Maisonneueve fracture

Disruption of syndesmosis with associated proximal fibula fracture

MOI of maisonneueve fracture

External rotation of ankle

What should be done on PE with any ankle injury?

Palpation of proximal tibula/fibula for injury

S/S & PE of maisonneueve fracture

Localized pain over ankle +/- proximal tibia

Diagnostic workup & findings of maisonneueve fracture

- X-ray — AP, lateral, oblique ankle (widening of mortise) AND AP & lateral of tibula/fibula

- MRI — Assess syndesmosis / ankle ligaments

Management of maisonneueve fracture

Surgical — Maisonneuve w/ syndesmosis disruption is unable injury!

MC injury in organized sports

Lateral ankle sprain — Anterior talofibular ligament (ATFL)

Ligaments of high ankle / syndesmotic sprains

Anterior & posterior tibiofibular ligament

Classifications of low ankle sprains (3)

- Ligament disruption

- Ecchymosis / swelling

- Pain with weight bearing

**Each grade I-III

MOI of high ankle sprain

External rotation

S/S & PE of ankle sprain (& special tests)

- Localized pain post injury

- Increased pain with passive inversion / eversion

- Difficulty weight bearing

- Anterior drawer — Limited usefulness

Ottawa Ankle Rules

Ankle film if 1/3:

- Bone tenderness at lateral malleolus

- Bone tenderness at medial malleolus

- Inability to walk 4 steps after injury AND immediately in ED

Foot films if 1/3:

- Bone tenderness at base of 5th metatarsal

- Bone tenderness at navicular bone

- Inability to walk 4 steps after injury AND immediately in ED

Diagnostic workup of ankle sprain

- X-ray +/- weight bearing if tolerated — R/o fracture

- MRI — Persistent pain, chronic instability

Management of ankle sprain

- Conservative; Immobilization with brace, PT — 1st line

- Chronic pain/instability, disruption of syndesmosis → Operative

Insertional achilles tendonitis (define)

Thickening & inflammation at insertion of Achilles

Retrocalcaneal bursitis (define)

Inflammation of bursa between anterior aspect of achilles & posterior aspect of calcaneus

Risk factors for Achilles tendonitis

- Stop & go sports

- Repetitive trauma

- Poor running mechanisms / aggravating footwear

- FQs

S/S & PE of Achilles tendonitis

- Localized pain / tender of achilles

- Worse with activity

- Haglund deformity — Enlargement of posterior tuberosity of calcaneus

Diagnostic workup & management of Achilles tendonitis

Clinical & conservative (1st line)

What is the largest tendon in the body?

Achilles tendon

MOI of Achilles tendon rupture

Sudden force — Push of foot with initiation of rapid acceleration

S/S & PE of Achilles tendon rupture (& special tests)

- Pop → Weakness & difficulty walking

- Palpable defect

- Weakness with ankle plantar flexion

- Thompson test — Lack of plantar flexion with calf squeeze

Diagnostic workup of Achilles tendon rupture

- MRI — Confirms partial vs. complete tear

- X-ray lateral ankle

Management of Achilles tendon rupture

Surgical — Open / percutaneous primary repair

MC tarsal fracture

Calcaneus fractures

MOI of calcaneus fracture

Traumatic axial loading of foot from fall / jump from height — Falling from ladder, jumping into shallow pool

S/S & PE of calcaneus fracture

- Severe heel pain post-trauma

- Swell / bruise of heel

Diagnostic workup of calcaneus fracture

- X-rays — Lateral & Harris

- CT — Concerns for intraarticular / comminuted fracture

Management of calcaneus fracture

Nondisplaced, extraarticular → Cast / boot immobilization

MC location of 5th metatarsal base fractures

Zone 1 — PseudoJones

MOI of zone 1 5th metatarsal base fracture

Inversion of foot — Landing awkwardly, uneven surface

MOI of zone 2 & 3 5th metatarsal base fractures

Vertical / mediolateral force on base of 5th MT w/ raised heel & plantar flexed forefoot

S/S & PE of 5th metatarsal base fractures

Localized tender / swell of lateral border of foot

Diagnostic workup of 5th metatarsal base fractures

- X-ray AP, lateral, oblique foot

- MRI — Concern for occult

- CT — Assess for nonunion/delayed healing

Management of 5th metatarsal base fractures

- Minimally displaced zone 1&2 → Conservative with weight bearing as tolerated in hard soled shoe

- Displaced 2&3 → ORIF

Complications of 5th metatarsal base fractures

- Nonunion — Especially zone 2

- Refracture

Lisfranc injury

Disruption of articulation of medial cuneiform ad base of 2nd metatarsal — Sprain, tear, or fracture dislocation

Function of lisfranc ligament

Stabilizes 1st & 2nd tarsometatarsal joint & maintenance of mid foot arch

MOI of lisfranc injury

Axial load through hyper plantar flexed forefoot — MVA, fall from height

S/S & PE of lisfranc injury

- Pain / swell of mid foot after injury

- Tenderness over 2nd tarsometatarsal joint

- Plantar ecchymoses — More complexed injuries

Diagnostic workup of lisfranc injury

- X-ray AP, lateral, oblique with weight bearing for comparison

- MRI — Detecting lisfranc tear

Management of lisfranc injury

- Stable → Casting & non-weight bear

- Instability / displacement → ORIF

MCC of foot pain in adults

Plantar fasciitis

Plantar fasciitis

Inflammation of plantar fascia aponeurosis at calcaneus

Risk factors / causes of plantar fasciitis

- Obesity

- prolonged standing on hard surface

- Flat feet

S/S & PE of plantar fasciitis

- Plantar heel pain w/ local point tenderness

- Worse with initiation of walking, improves throughout day & worsens at end of day

Diagnostic workup of plantar fasciitis

Clinical; XR can show calcaneal heel spur

Management of plantar fasciitis

NSAID, ice, activity, splint, foot orthosis / cushioned footwear

Morton's neuroma

Compressive neuropathy of interdigital nerve

MC location of Morton's neuroma

3rd & 4th interdigital nerves between metatarsal head

Cause of Morton's neuroma

- Compression of interdigital nerve around transverse intermetatarsal ligament

- Repetitive microtrauma — Tight fitting shoes

S/S & PE of Morton's neuroma

- Localized burning pain in foot in 3rd inter metatarsal space

- Worse with weight bearing / narrow toe shoes

- Improvement with removing shoes

- Reproducible S/S with compression of mid foot

Diagnostic workup of Morton's neuroma

Clinical; US → Oval, hypo echoic mass parallel to metatarsal bones & digital nerve block → numbness of toe w/ NO pain

Management of Morton's neuroma

Wide shoes, metatarsal pad, corticosteroid injection — 1st line (conservative)

Hallux valgus

Valgus deformity of big toe — Bunion

Risk factors of hallux valgus

- Females

- Shoes (vs. barefoot)

- Genetic / inflammatory joint disease

- High heels & narrow toe box

S/S & PE of hallux valgus

- Pain over prominent medial prominence +/- slowly progressive valgus deformity if 1st metatarsal joint

- Worse when wearing shoes

Diagnostic workup of hallux valgus

Clinical; XR can r/o MTP joint arthritis

Management of hallux valgus

Shoe modification — 1st line

Hallux rigidus

Pain & loss of motion of 1st MTP secondary to osteoarthritis

S/S & PE of hallux rigidus

Pain, stiff, dorsal prominence of 1st MTP

Diagnostic workup of hallux rigidus

X-rays AP, lateral, oblique foot

Management of hallux rigidus

NSAID, activity mod, orthotics, corticosteroid injection — 1st line (conservative)