Term
| There are how many bones in the foot? How many joints? |
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Definition
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Term
___ is the most common sports injury
it accounts for 10% of all ER visits
50% result in long term sequelae |
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Definition
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Term
| 85% of ankle sprains involve the ___ ligament as a result of inversion and plantar flexion of the ankle |
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Definition
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Term
| Most ankle sprains can be treated by primary care or athletic training. Which need to be referred to ortho? |
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Definition
chronic, recurrent sprains
fx on one side and sprain on the other |
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Term
| A ___ ankle sprain is one that goes through the syndesmosis. it likely tears the ___ ligament |
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Definition
high
talofibular (either anterior or posterior) |
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Term
| What is the normal amount of dorsi- and plantar flexion of the ankle? |
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Definition
10 degrees dorsiflexion
25 degrees plantar flexion |
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Term
| How do you test the anterior talofibular ligament for instability suggestive of sprain? |
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Definition
anterior drawer - draw calcaneous and talus anteriorly while pushing tibia posteirorly
translation of 5mm more than the contralateral side is indicative of sprain |
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Term
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Definition
I: no instability
II: mild laxity of ligament
III: severe laxity, rupture of calcaneofibular and anterior talofibular ligaments |
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Term
| The ___ test is to check stability of the calcaneofibular and anterior talofibular ligaments. |
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Definition
talar tilt test
Inversion and translation: tear of anterior talofibular
Eversion and translation: tear of the calcaneofibular |
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Term
| how do you test stability of talofibular syndesmosis? |
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Definition
squeeze the pts tibia and fibula together with the pts legs dangling and with the foot in dorsiflexion
pos if it produces pain |
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Term
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Definition
determine the need for radiographs in pts with an ankle injury:
Pain in the malleolar zone and any one of the following:
1. bone tenderness along the distal 6cm of the posterior edge of the fibula or tip of the lateral malleolus
2. Bone tenderness along the distal 6cm of the posterior edge of the tibia or tip of the medial malleolus
3. inability to bear weight for 4 steps both immediately and in the ER |
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Term
| 3 xray views of the ankle |
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Definition
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Term
| Ankle sprain treatment in general |
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Definition
Phase I: done regardless of severity of injure
- RICE
- crutches (until severity is determined(
- anti-inflammatory meds
Phase II (weeks 2-4) and III (weeks 4-6):
Rehab - early ROM, weight bearing as tolerated, alphabet exercises, proprioception, balance board |
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Term
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Definition
1. lateral stabilization/ankle brace for 1 mon
2. ice & elevation for 1st 2-3 days
3. avoid painful activity
4. immediate weight bearing is allowed
5. NSAID |
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Term
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Definition
1. crutches first 5-7 days. physical activity prohibited
2. ace wrap/tubagrip - compression
3. lateral stabilization/ankle brace when wb is started
4. non-weight bearing exercise after 7 days. wb after 2-3 weeks
5. ROM immediately
6. peroneal strengthening after 7 days (theraband) |
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Term
| grade III ankle sprain tx |
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Definition
ankle immobilization with walking cast for 3-4 weeks
PT |
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Term
| when should surgical tx of ankle sprains be considered |
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Definition
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Term
| what is considered an unstable ankle fx? |
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Definition
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Term
| what is a trimalleolar fx? |
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Definition
| fractures of the medial, lateral, and posterior malleoli (distal posterior end of tibia) |
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Term
| what ankle fxs should be referred? |
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Definition
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Term
| Optimal tx for ankle fractures are 4 criteria: |
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Definition
1. dislocations and fx should be reduced as soon as possible and splinted in the most normal position possible
- if fx is open, give abx and take to ER for irrigation and debridement of wound
- never try to "pop" an open wound back into place
2. all joint surfaces must be precisely restored
3. fx must be held in a reduced psotion during bony healing
4. joint motion should begin as early as possible |
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Term
| What is the plan for an isolated, undisplaced fx of either malleoli (an unseparated fx)? |
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Definition
immobilization in short leg cast with ankle in neutral position for 6-8 weeks (cast wtih crutches, and then boot)
followed by PT
can be treated by primary care |
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Term
| How do you treat a fx with displacement? |
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Definition
it must be reduced and the stability of the syndesmosis must always be checked
isolated lateral malleolar fxs are usually treated nonoperatively
bimalleolar or displaced medial malleolar fxs usually require surgery |
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Term
| general principles of ORIF |
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Definition
1. gently handle soft tissue to minimize risk of infection and wound-healing
2. lateral malleolus should be fixed first to establish length
3. remove any soft tissue or periosteum from fx site |
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Term
What injury?
Mechanism of injury is usually mechanical overload from eccentric contraction of gastrocsoleus complex. occurs as a sudden, foreceful dorsiflexion of foot as the gastrocsoleus is contracted, such as when sliding into third base.
typical pt is a 30-50 y/o male recreational athlete
pt describes sudden pain in the heel after attempting to push off
can easily happen in a pt with hagland's deformity
other causes: steroids, quinolone, gout, renal insufficiency, arterioscerlosis, hyperthyroidism |
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Definition
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Term
| Thompson test is used to diagnose ____. this, with hx is usually all that is needed for diagnosis. MRI can be helpful but is not usually needed. Xray is not usually helpful. |
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Definition
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Term
| Tx for achille's tendon rupture |
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Definition
refer to ortho
surgery usually
gradual casting and immobilization with gradual progressive weight bearing and PT over 6-12 weeks |
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Term
What type of fx?
fx of the metaphyseal-diaphyseal junction of the 5th metatarsal. has high non-union rate. most are superimposed on chronic stress injury
tx? |
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Definition
jones fx
strict, non-weight bearing for 6-8 weeks
walking boot additional 2-4 weeks
surgery in those who fail conservative tx or in athletes |
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Term
what dx? runner with pain in plantar aspect of heel that is worst with the first few steps after waking up in the morning. heel is sensitive to touch and with dorsiflexion of the foot.
what tx? |
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Definition
platar fasciitis
tx is symptomatic
cold, heel lift/pad, NSAIDs, stretching/PT, night splints, steroid/lidocain injection, short leg walking cast |
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Term
general term for pain arising from the metatarsal head region:
often due to high arch, improper shoe selection, tight achille's tendon, abnormal foot posture, atrophy of platar fat pad,
frequently associated wtih hammertoe, clawed toe, hallux valgus
sx: burning or cramping in region of metatarsal heads. worse with activity, better with rest.
tx? |
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Definition
metatarsalgia
tx: metatarsal pads, low-heeled shoes -- take pressure off metatarsal heads |
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Term
what dx?
caused by perineural fibrosis of the plantar nerve where the lateral and plantar branches communicate. probably secondary to repetitive trauma.
sx: severe burning, pain, numbness, shooting pains, tingling in foot between the 3rd and 4th toe. compression of forefoot may reproduce pain.
tx? |
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Definition
morton's neuroma
tx: local injection of steroids/lidocaine for temporary relief
surgical resection is often necessary |
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Term
What dx?
neuropathic, neurotrophic, or neuroarthropathic joint, usually caused by DM
characterized by the destruction of the joint surfaces, fxs often accompanied by dislocations of one or more joints in a pt with an inappropriate pain response (peripheral neuropathy due to DM)
Requirements: active pt with neuropathy and adequate blood supply |
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Definition
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Term
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Definition
Stage 1: acute inflammation where there is swelling, redness, increased warmth; radiographs reveal fx and dislocations and instability... need to R/O infection
Stage 2: signs of healing, less swelling, warmth and xray with new bone formation
stage 3: chronic phase with consolidation and resolution of inflammation and creation of the rocker bottom (arch collapses, hindfoot and ankle with risk of collapse into varus or valgus and risk of ulceration) |
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Term
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Definition
limit joint destruction and preserve a stable plantigrade foot that protects soft tissues and prevents ulceration
acute phase - immobilize foot; total contact cast, AFO
subacute phase - surgery for bony prominence; if affects ankle (IM nailing)
rocker bottom shoe |
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Term
___ are the most common reason for hospitalization in diabetics.
more than half of all non-traumatic amputations are performed on diabetics |
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Definition
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Term
| When would you want to refer a diabetic to surgery for foot problems? |
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Definition
| low ischemic index (blood presure in brachial artery divided by that in dorsalis pedis and post tibial arteries) and neuropathy |
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Term
DM foot problems - get ___ radiographs of both feet and ankles to r/o osteomyelitis or charcot
MRI can help distinguish this
technitium bone scan is sensitive to diagnose osteomyelitis but not specific |
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Definition
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Term
What tx if...
1. abcess or osteomyelitis?
2. gangrene? |
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Definition
1. emergency surgery wtih drainage and wound left open for closure at a later date
2. amputation |
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Term
what dx?
woman:men = 10:1
causes: tight, pointed shoes, congenital deformity, sever flat foot, chronic achille's tendon tightnes, spacicity, hypermobility of first metatarsocuneiform joint, RA
pt reports medial eminence pain, plantar 1st metatarsal or lesser metatarsal head pain, often results in hammertoe deformities, impingement on 2nd toe, inability to wear certain shoes, abnoraml callus formation beneath metatarsal head along medial aspect of great toe
first metatarsalcuneiform jt needs to be examined for hypermobility
dx: weight-bearing, AP, lateral, oblique views. angle >15 degrees
tx? |
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Definition
hallux valgus
tx: operative only if it's causing symptomatic problems or if pt is dancer or athlete |
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Term
what dz are these procedures used to correct?
mcbride, chevron, akin, metatarsal osteotomy, and keller |
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Definition
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Term
dx: plantar flexion deformity of the PIP joint
pain to dorsum of toe
may have callus or ulceration or nail deformity
tx? |
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Definition
hammertoe
tx: proper footwear, toe sleeves/slings. surgery if necessary |
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Term
| when would AP/lateral radiographs of the foot be helpful? |
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Definition
proximal IP flexion deformity
MTP hyperextension
hallux valgus |
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Term
what dx?
fixed extension of the mtp joint and flexion of the pip joint; flexion of the dip may be present. usually affects all lesser toes. often related to neuro disorder or inflammatory arthritis
sx: pain, corns, calluses
tx? |
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Definition
claw toe
tx: evaluation of footwear, OTC splints, stretching, surgical corrrection |
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Term
what dx?
flexion deformity of DIP - may be fixed or flexible. generally the 2nd toe.
sx: pain to dorsum of DIp or at tip of toe. callus, ulceration, nail deformity
tx? |
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Definition
mallet toe
shoes with wide toe
extra-depth shoe
pad around toe
surgical tx |
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Term
What dx?
young, active adult who has just begun training for a marathon presents with pain, swelling, and point tenderness over the metatarsal head. what would you do? what dx? what tx? |
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Definition
get radiographs - ap, lateral, oblique. if nothing shows up, do it again in a week or two.
march/stress fx
tx: weight bearing restriction, walking boot or short leg cast |
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Term
what dx?
injury to the complex between the first & second metatarsal and first adnd second cuneiform. may see widening of this joint space with dorsal dislocation of the second metatarsalwhich needs to be surgically repaired.
sx: pain, edema, malalignment; pain with axial loading |
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Definition
| lisfranc dislocation -- refer! needs closed reduction asap |
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Term
1. clinical condition that suggests a fx. x rays may not be positive until 2-3 weeks after fx occurs.
2. fx that occurs bc bone is weakened due to some abnormal condition
3. fx that occurs when weak bone is stressed normally (insufficiency) or normal bone stressed stressed excessively (fatigue). Usually seen in weight bearing bones |
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Definition
1. occult
2. pathologic
3. stress |
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Term
1. amount of end to end contact of the fx
2. fx healing in unsatisfactory alignment
3. failure of a fx to heal
4. disruption in the continuity of the joint
5. complete dislocation of joint occurring with a fx
6. partial disruption in the continuity of the joint
7. failure of bone healing causing a "false joint" ocnsisting of soft tissue |
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Definition
1. apposition
2. malunion
3. nonunion
4. dislocation
5. fracture-dislocaiton
6. subluxation
7. pseudoarthrosis |
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Term
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Definition
hematoma/inflammation
soft callus
hard callus
remodeling |
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Term
| risk factors for nonunion |
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Definition
smoking
infection
inadequate immobilization
nsaid
malnutrition
poor blood supply |
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Term
a fx is considered delayed union/healing if it hasn't healed in __-__ weeks
a fx is considered non-union if it hasn't healed after ___ mos or if there is no radiographic evidence of callus formation after ___ mos |
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Definition
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Term
keys to fx healing
1. keep bone ends in ____
2. maintain ____
3. keep fragments adequately ____ |
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Definition
apposition
blood supply
immobilized |
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Term
| past xrays, when would you get ct or mri when suspecting a fx? |
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Definition
ct for bone
mri for soft tissue |
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Term
| rule of 2's for fx assessment |
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Definition
2 views taken at 90 deg
2 joints (one above, one below)
2 weeks
2 limbs (in kids, look at the other limb) |
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Term
Match the nerve injuries:
Contusions neurotmesis
Crush neuropraxia
Transection axontmesis |
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Definition
Contusions - neuropraxia - will recover within 2-3 mos
crush - axontmesis - will recover at 2 cm/mon
transection - neurotmesis - will not recover |
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Term
| Where are two common sites for axonotmesis via crush injury to occur? |
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Definition
radial nerve - spiral fx to humerus resulting in wrist drop
peroneal nerve - fx to fibular neck resulting in foot drop
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Term
| What are some advantages of closed fx treatment? |
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Definition
prevents devascularization
decreases risk of infection |
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Term
| What are some advantages of open fx treatment |
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Definition
displaced jt fx
fxs that cannot be held by closed methods
fx of the LE in elderly to promote early mobilization
certain epiphyseal fxs that could result in growth distrubrance
jt fx in which early mobility is key |
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Term
| What qualifies as adequate reduction? |
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Definition
rotational deformity is completely corrected regardless of age
in adults, angular deformity is completely corrected
in kids, some angular deformity is acceptable if it's in the same plane of motion as the joint
perfect apposition not always necessary
fxs involving weight bearing joints require exact reduction
slight shortening in upper extremity is ok but proper length in lower extremity is necessary |
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Term
| fiberglass v. plaster casts |
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Definition
fiberglass: light weight, strong, short shelf-life, more expensive, can get wet
plaster - easier to manipulate, long shelf-life, low cost, cannot get wet, heavier |
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Term
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Definition
sugar tong
posterior
ulnar-gutter |
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Term
| 3 potential complications of casting |
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Definition
compartment syndrome
volkmann's ischemic contracture
pressure ulcers |
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Term
condition that develops when perfusion of the nerve and muscle decreases to the point where it is unable to sustain viability.
pressure in fascial compartments rise second to fx bleeding until compartment pressure exceeds bp and capillaries collpase, which obstructs venous outflow and increases tissue pressure and leads to necrosis |
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Definition
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Term
What dx? pt with cast begins experiencing:
pain on passive stretching of muscles
paresthesias or sensory loss
tenseness or weakness of involved muscles
paralysis
pallor in extremities
poikilothermia
diastolic pressure of compartment <30mmHg |
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Definition
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Term
| tx for compartment syndrome |
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Definition
assess for circulatory compromise
split the case
may need fasciotomy
palpate compartment
assess pROM, sensory fxn |
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Term
| ___ is a rare complication that results from untreated arterial injury or compartment syndrome secondary to swelling in a tight case or after trauma (crush injury). is a surgical emergency. |
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Definition
| volkmann's ischemic contracture |
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Term
What dx?
trauma --> swelling --> compression of blood vessels and thus decreaesd blood flow --> ischemia --> injuries to nerves and muscles --> nerves and muscles shorten and stiffen --> pull on joint at end of muscle --> joint is stiff, remains bent, and cannot straighten |
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Definition
| volkmann's ischemic contracture |
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Term
What dx?
common disorder of unknown cause that often follows a relatively minor injury
pathology is unclear but there is some disturbance of the sympathetic ns which leads to intense pain and vasomotor sx
usually affects extremities
early recognition is difficult
more common in women
smokers at increased risk,
30-50 y/o most likely
main sx: pain out of proportion to injury, esp burning pain
dystrophic and atrophic phases - first skin becomes sweaty and warm, then shiny and dry and cool. skin and muscle atrophy.
what tx? |
|
Definition
reflex sympathetic dystrophy AKA complex regional pain syndrome
tx: prevention mainly by controlling swelling and early use of extremity
restore motion with exercise, repeated sympathetic blocks, surgery, antidepressants, corticosteroids, CA channel blockers |
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Term
| pt presents with pain under an area that is casted. what should you suspect? |
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Definition
| pressure ulcer - remove cast and inspect |
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Term
| Fxs requiring special attention |
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Definition
open
displaced interarticular
all femur fxs
including both bones of lower leg in adults |
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Term
| fx that develops due to some abnormal local condition that causes bone to become weakened |
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Definition
pathologic
usually due to tumor |
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