Ankle pt. 1

Orthos testing arteriosclerosis

Claudication and moses

Orthos testing achilles

Thompson

Orthos testing talofibular ligament

drawers

Orthos testing compartment syndrome

calf circumference

Orthos testing thrombophlebitis

Homans

Orthos testing peripheral artery disease

Buergers

Ankle Function

1.) Large hinge joint → dorsal flexion and plantar flexion

2.) injury: usually due to lateral stresses → inversion and eversion injuries

Ankle Sprains: inversion

1.) MC

2.) lateral ligaments: anterior talofibular ligaments, calcaneofibular ligaments, posterior talofibular ligament

Ankle Sprains: eversion

Medial ligament → deltoid ligament

Grade 1 ankle sprain

1.) mild, minimal tenderness and swelling

2.) weight bearing as tolerated, microscopic tearing of collagen fibers

3.) no splinting/cast

4.) isometric exercise, full ROM and stretching/strengthening exercises as tolerated

Grade 2 Ankle Sprain

1.) moderate tenderness and swelling, decreased ROM

2.) possible instability → complete tears of some but not all collagen fibers in the ligament

3.) immobilization with air splint

4.) physical therapy with ROM and stretching/strengthening exercises

Grade 3 Ankle Sprains

1.) severe, significant swelling and tenderness

2.) instability → complete tear/rupture of ligament

3.) immobilization, physical therapy similar to grade 2 but over longer period

4.) possible surgical reconstruction

Ottawa Ankle Rules

1.) a series of ankle x-ray films is required only if there is pain in malleolar zone and any of these findings:

-Bone tenderness at posterior edge or tip of lateral malleolus

-Bone tenderness at posterior edge or tip of medial malleolus

-Bone tenderness at base of 5th metatarsal

-Inability to bear weight both immediately and in ED

Ottawa Foot rules

1.) a series of food x-ray films is required only if there is any pain in mid-foot zone and any of these findings:

-Bone tenderness at base of 5th metatarsal

-bone tenderness at navicular

-inability to bear weight both immediately and in ED

Anterior Drawer Sign: + test

1.) excessive motion of the tibia over the talus compared to the opposite ankle = Injury to Anterior Talofibular Ligament

2.) Assesses Anterior Talofibular ligament

3.) Next steps: Calf circumference test → if + may suggest weakness in calf that affects ankle stability, diagnostic imaging

Posterior Drawer Sign: + test

1.) excessive motion compared to opposite ankle = injury to posterior talofibular ligament

2.) assesses posterior talofibular ligament

Inversion and rotation ankle injury

Anterior talofibular ligament sprain

Inversion and Adduction ankle injury

Lateral ligament sprain

Eversion and lateral rotation ankle injury

deltoid ligament sprain

Eversion and abduction ankle injury

Medial ligament sprain

Calf circumference test: +

1.) Reporting for increase: suggests either muscular hypertrophy or swelling

2.) reporting for decrease: suggests muscular atrophy which may be a result of disuse secondary to pain or ischemia

Calf Circumference: compartment syndrome

1.) increased measurement of calf plus symptoms could be suggestive of compartment syndrome

2.) S+S: onset could be exercise or direct injury, increase calf circumference, red glossy warm skin that is tender to touch, foot drop, some cases can involve peroneal nerve with sensory loss

Compartment Syndrome

1.) acute condition in which fascial compartment pressure exceeds perfusion pressure → caused by an initial traumatic or hemorrhagic event leading to edema or bleeding

2.) can result in irreversible tissue ischemia or necrosis

Clinical signs and symptoms of compartment syndrome

1.) palpable tenderness and swelling, pain out of proportion to injury or underlying process

2.) pain on passive stretch, paresthesia, paresis, pallor overlying compartment

3.) absence of distal pulses → a late finding and the diagnosis is ideally made when the pulses are still present

Peroneal Nerve Palsy

1.) may lead to severe disability with foot drop and paresthesia

2.) Peroneal Palsy: may demonstrate a greater motor deficit than sensory deficit because the deep motor branch is subject to tethering at two points → fibular neck and intermuscular septum

Traumatic Peroneal Palsy

may result from supracondylar fx, knee dislocation, and proximal tibia fx

Atraumatic peroneal nerve palsy

1.) may result from a large fabella which impinges on peroneal nerve behind knee

2.) may result from proximal tibiofibular synovial cyst (MRI)

3.) these patients often have a history of lumbar disc disease, ETOH use and diabetes

Volkmann’s Ischemia

1.) Loss of muscle function is usually not due to nerve involvement but to pathological change within muscle itself

2.) muscle develop ischemic necrosis, which is often called volklmann’s of the leg

3.) characterized by: swelling, edema, extravasation of muscle tissue by a fibrous scar → result is a firm, inelastic, and noncontractile muscle group

Fabella

1.) accessory ossicle, typically found in the lateral head of gastroc

2.) occurs in 20% of pop

Peripheral Artery disease: causation

1.) obstruction, traumatic occlusion, atherosclerosis

-Atherosclerosis: diabetes, buerger’s disease, raynaud’s phenomenon, assessment of lower extremity pulses

Buerger’s Disease (thromboangitis obliterans)

1.) inflammatory disease of the small and medium sized arteries and veins of the extremities → often seen in men and appears to be directly related to smoking

2.) may be an autoimmune element → raynaud’s phenomenon, ulcers and pain are typically seen

3.) immediate termination of smoking is critical

Buerger’s Test: +

1.) blood takes longer than 1 minute to return to foot = circulatory deficiency of lower leg

2.) measure arterial blood supply to lower limbs

3.) Side note: sciatic like pain is not uncommon in lower extremity vascular disorder

Buerger’s Test: next steps

Claudication test, homans sign, moses test

Scleroderma

1.) systemic sclerosis → group of rare disease that involve hardening and tightening of the skin and CT

2.) may cause problems with blood vessels, internal organs, and digestive tract (systemic Scleroderma)

Moses’ Test: +

1.) Calf pain = narrowing present → superficial femoral artery is involved 90%

2.) Indicates arteriole narrowing and possible arteriosclerosis obliterans

3.) rest and relief of pain = intermittent claudication

4.) Resting pain = greater degree of claudication

Arteriosclerosis Obliterans

1.) caused by arteriosclerotic narrowing or obstruction of large and small arteries that supply the extremities

2.) leading cause of obstructive arterial disease in LE after age of 30

3.) superficial femoral artery is affected by stenosis or obstruction in approximately 90% of the patients

4.) more common in males, Diabetes mellitus patients develop arteriosclerosis obliterans more frequently and at an earlier age