Term
| Ankle Anatomy: boney, joints |
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Definition
• Bonyanatomy
– Calcaneus/talus(dome)
– Tibia(medialmalleolus) – Fibula(lateralmalleolus)
• Composedof2joints: – True Ankle joint
– Subtalar joint
• Trueanklejoint contains the tibia, fibula, and talus
• Allows for dorsiflexion and plantar flexion |
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Term
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Definition
• Subtalar joint consists of the talus and the calcaneus
• Allows for inversion and eversion |
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Term
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Definition
• Anterior talofibular
• Posterior talofibular
• Calcaneofibular
• Anterior tibiofibular
• Posterior tibiofibular
[image] |
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Term
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Definition
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Term
| Ankle Ring purpose, components |
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Definition
• Integrity of the ring necessary for stability of the ankle
• Consists of the following:
– Tibial plafond,
– Medial malleolus,
– Deltoid ligaments,
– Calcaneus,
– Lateral collateral ligaments
– Lateral malleolus
– Syndesmotic ligaments |
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Term
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Definition
• Types of injuries
• Ankle sprain/Ligamentous injury
• Ankle fracture/Bony injury
• Joint Dislocation |
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Term
| Ankle Injury Pathophysiology, types of injuries |
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Definition
• Excessive inversion stress (85%) is the most common cause of ankle injuries for two reasons:
– Medial malleolus is shorter than the lateral malleolus, allowing the talus to invert more than evert.
– Deltoid ligament stabilizing the medial aspect is stronger
• However, given the above when eversion injuries occur there is often substantial damage |
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Term
| Ankle examination what to do/examine |
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Definition
• Look at the ankle for signs of deformity, redness, or swelling
• Feel for tender areas, systematically checking: – the anterior joint line
– the lateral gutter and lateral ligaments
– the syndesmosis
– the posterior joint line
– the medial ligament complex – the medial gutter
• Feel for an effusion, synovitis, deformity, bony prominence and loose bodies.
• Examine for neurovascular compromise |
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Term
| Ankle Joint Testing for each ligament |
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Definition
• Drawer and Talar tilt examination techniques are used to assess ankle instability
• Anterior talofibular ligament
– Anterior drawer test
• Calcaneofibular ligament – (Talar Tilt) Inversion stress test
• Deltoid ligament
– (Talar Tilt) Eversion stress test
• Use of these techniques in acute injuries an be limited by pain, edema, and muscle spasm
[image] |
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Term
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Definition
• X-rays are only required if:
• There is any pain in the malleolar zone and:
• Bone tenderness along the distal 6 cm of the posterior edge of the tibia or tip of the medial malleolus
• Bone tenderness along the distal 6 cm of the posterior edge of the fibula or tip of the lateral malleolus
• An inability to bear weight both immediately and in the ED |
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Term
| Ottawa Ankle Rules: The Numbers |
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Definition
• In a meta-analysis the pooled negative likelihood ratios for the ankle and midfoot were 0.08 (95% confidence interval 0.03 to 0.18) and 0.08 (0.03 to 0.20)
• Applying these ratios to a 15% prevalence of fracture gave a less than 1.4% probability of actual fracture
• Sensitivity of almost 100%
• Reduce the number of unnecessary radiographs by 30-40% |
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Term
| Ankle Sprain Classification, grades |
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Definition
• Grade 1: Ligament stretching with microscopic tearing but not macroscopic tearing.
– Little swelling is present
– Little or no functional loss and no joint instability
– Able to fully or partially bear weight.
• Grade 2: Partial tear
– Moderate-to-severe swelling, ecchymosis
– Moderate functional loss, and mild-to-moderate joint instability
– Difficulty bearing weight
• Grade 3: Complete rupture of the ligament
– Immediate and severe swelling and ecchymosis
– Moderate-to-severe instability of the joint
– Cannot bear weight without experiencing severe pain. |
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Term
| Ankle Ligamentous Injury Types |
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Definition
• ATFL(anterior talofibular ligament) is the most likely component of the lateral ankle complex to be injured in a lateral ankle sprain
• In forced dorsiflexion, the PTFL (posterior talofibular ligament) can rupture
• External rotation can disrupt the deep deltoid ligament on the medial side
• Forced adduction in neutral and dorsiflexed positions can disrupt the Calcaneofibular (CFL) |
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Term
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Definition
• Account 10% of all ankle sprains and as high as 18% of football players
• Excessive external rotation of the talus or forced dorsiflexion causes the talus to place pressure on the fibula
• Results in spreading of the distal syndesmosis as well as damage to anterior or posterior tibiofibular ligament
[image] |
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Term
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Definition
• PRICES
• Protection
• Relative rest
• Ice
• Compression
• Elevation
• Support
• Good return instructions also a must as always |
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Term
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Definition
• Most report full recovery at 2 weeks to 36 months (36-85%)
– Independent of the initial grade of sprain
– Most recovery occurs within the first 6 months
• After 12 months, the risk of recurrent ankle sprain returns to pre-injury levels
• Re-sprains occur in up to 36% of patients, athletes are at increased risk |
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Term
| Isolated Malleolar Fracture (Unimalleolar) |
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Definition
• EDDocsdescribe based off number fractures
– unimalleolar, bimalleolar, trimalleolar
• Distalfibulaorless common tibial fracture
• Fracturesbelowthe Tibiotalar line (T-t, distal to the tibial plafond) are usually stable |
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Term
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Definition
• Involves the lateral and medial malleolus
• ED Treatment involves fracture reduction and realignment
• Initial ED management is usually followed by surgical fixation
• Ortho consult in ED |
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Term
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Definition
• Involves the lateral malleolus, medial malleolus, and the distal posterior aspect of the tibia
• Unstable, loss of lateral control
• Surgical repair is required
• Ortho consult in ED |
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Term
| Ankle Fracture Classifications |
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Definition
• Danis-Weber classification often used by Ortho
– Some correlation with need for operative stabilization
– Lauge-Hansen alternative classification system
• Type A: Transverse fibular avulsion fracture, occasionally with an oblique fracture of the medial malleolus
– From internal rotation and adduction
– Usually stable fractures
often used by Ortho
– Somecorrelationwithneed for operative stabilization
– Lauge-Hansenalternative classification system
• Type A: Transverse fibular avulsion fracture, occasionally with an oblique fracture of the medial malleolus
– Frominternalrotationand adduction
– Usuallystablefractures
• Type B: Oblique fracture of the lateral malleolus with or without rupture of the tibiofibular syndesmosis and medial injury
– From external rotation – May be unstable
• Type C High fibular fracture with rupture of the tibiofibular ligament and transverse avulsion fracture of the medial malleolus
– From adduction or abduction with external rotation
– Usually unstable and require operative repair |
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Term
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Definition
• Fracture of the distal tibial metaphysis combined with disruption of the talar dome.
• Result of an axial loading mechanism drives the talus into the tibial plafond
– Foot braced against a floorboard in an auto collision.
– Skiers coming to an unexpected sudden stop
– Free fall from heights
• Fractures often open and can be associated with lumbar spine injuries
[image] |
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Term
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Definition
• Proximal fibular fracture coexisting with a medial malleolar fracture or disruption of the deltoid ligament
• Associated with partial or complete disruption of the syndesmosis
• Important to perform a physical exam or xrays to assess for this in ankle injuries
[image] |
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Term
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Definition
• Salter-Harris (SH) type III injury of the anterolateral tibial epiphysis
• Caused by extreme eversion and lateral rotation
• Incidence is highest in adolescents because the fracture occurs after the medial aspect of the epiphyseal plate closes but before the lateral
[image] |
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Term
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Definition
• Associated fractures are the rule rather than the exception with ankle dislocations
• Neurovascular injury is the principal concern
• Tented skin may be subject to ischemic necrosis
• Immediate reduction in the ED is often required |
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Term
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Definition
• Phalanges
– proximal, middle, distal
• Metatarsals
• Tarsals
– Calcaneus – Talus
– Navicular – Cuboid
– Cuneiforms
• Medial/lateral longitudinal and transverse metatarsal arches
[image] |
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Term
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Definition
• X-ray series is indicated if there is any pain in the midfoot zone and any one of the following:
• Bone tenderness at the base of the fifth metatarsal (for foot injuries)
• Bone tenderness at the navicular bone (for foot injuries)
• An inability to bear weight both immediately and in the emergency department for four steps. |
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Term
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Definition
• Toe Injuries
• Metatarsal fracture • Jones’ fracture
• Lisfranc fracture
• Navicular fracture • Calcaneal fracture |
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Term
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Definition
• Buddy tape the broken toe to an adjacent, uninjured toe
• Apply a rigid flat-bottom orthopedic shoe
• Union of fracture segments occurs in 3-8 weeks
• Symptoms usually improve much earlier
• Irreducible fractures sometimes require open reduction and internal fixation |
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Term
| First metatarsal fracture |
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Definition
• Least commonly fractured metatarsal
• Bears twice the weight of other metatarsal heads.
• Treat minimally displaced or nondisplaced fractures with immobilization without weight bearing
• Displaced fractures usually require open reduction and internal fixation
-big toe |
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Term
| Internal metatarsal fracture |
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Definition
• Nondisplaced and displaced fractures usually heal well, with weight bearing as tolerated, in a cast or rigid flat-bottom orthopedic shoe.
• Elastic support bandages may be equivalent or superior to casts
• Must look for Lisfranc Injury as this is a game changer
• March fracture is a stress fracture of the second or third metatarsal that occurs in joggers. |
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Term
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Definition
• Transverse fracture of the 5th metatarsal
• Must be atleast 15mm distal to proximal end
• High rate of malunion
• As above contact Ortho
• Pseudo-Jones:avulsion fracture of tuberosity at 5th metatarsal |
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Term
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Definition
• Site of articulation between the midfoot and forefoot
• Dislocation at the TMT joint
• Result of direct blow to the joint or by axial loading along the metatarsal, either with medially or laterally directed rotational forces
• Fracture at the base of second metatarsal should raise concern for this type on injury
• Often need weight bearing films to see displacement
[image] |
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Term
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Definition
• Avuslsion fracture most common
• Type 1: coronal fracture with no dislocation
• Type 2: dorsolateral to plantomedial fracture with medial forefoot displacement
• Type 3: comminuted fracture with lateral forefoot displacement
• Most patients are placed in a non–weight-bearing cast for 6 weeks
• All navicular body fractures with 1 mm or more of displacement require open reduction and internal fixation. |
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Term
| Calcaneal fracture- Bohler’s angle |
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Definition
• Calcaneus fractures most often occur in males 5:1
• Peakage: between30 and 50 years.
• Associated injuries (Lumbar spine vertebral compression fractures)
• Treatment:Operative vs Casting
• Ortho Consult |
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Term
| Basic Anatomy of the Knee |
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Definition
• LargeHingeJoint • Femur
• Tibia
• Fibula
• Patella
[image] |
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Term
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Definition
– Medial Collateral Ligament (MCL)
– Lateral Collateral Ligament (LCL)
– Anterior Cruciate Ligament (ACL)
– Posterior Cruciate Ligament (PCL) |
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Term
| cartilage and menisci of knee |
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Definition
• Articular Cartilage • Medial Meniscus • Lateral Meniscus
[image] |
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Term
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Definition
• Injuries to one or more of the ligaments of the knee (ACL, PCL, MCL, and LCL)
• Injuries to the bony structures (Patellar fractures, femur fractures, tibial fractures)
• Injuries to the meniscus and articulating surface |
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Term
| Key Pieces of History for knee assessment and determining injury type |
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Definition
• Fracture
– High-velocity collision Inability to immediately bear weight
"Pop" occurred with injury
• ACL tear
– Cutorpivotmechanismofinjury Knee "gave way"
Inability to continue participation "Pop" felt or heard with injury
• PCL tear
– Blow to proximal tibia
--Less instability than ACL tear
• Meniscal tear
– Squat/kneel associated with a twist Clicking
Locking
Pain with rotational movement
• Overuse syndrome
– Occupational or recreational repetitive movement |
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Term
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Definition
| ligament injuries (most ACK or MCL) |
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Term
| Evaluation of the Injured Knee |
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Definition
• Palpate the knee and determine the areas of maximal tenderness
• Examine and note the presence and location of any effusion
• Evaluate the Range of Motion at the Knee
• Evaluate the movement and stability of the patella
• Perform specific ligamentous stability testing
• Perform Meniscal examination
• Examine for neurovascular compromise |
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Term
| Differential Diagnosis- Effusions, knee injuries |
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Definition
• Trauma
– Ligamentous injury
-Intra-articular fracture
-Patellar dislocation
-Meniscus injury
• Polyarthritis
– Reiter's syndrome
-Juvenile rheumatoid arthritis
-Rheumatoid arthritis
• Infection
– Gonorrhea
-Lyme disease
-Tuberculosis
-Brucellosis
• Gout
• Pseudogout (calcium pyrophosphate
deposition disease)
• Osteoarthritis and overuse syndrome • Tumor
– Malignant: Chondroblastoma
Giant cell tumor Ewing's sarcoma Osteosarcoma Synovial sarcoma
-Benign:
Aneurysmal bone cyst Fibrous cortical defect Fibrous dysplasia Osteochondroma Osteoid osteoma |
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Term
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Definition
• The knee should be able to range from hyperextension to 135 degrees of flexion
• Loss of active extension and inability to maintain passive extension are indicative of quadriceps and patellar tendon |
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Term
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Definition
• Examine the patella, with ROM testing, feeling for catches and grinding, push down on patella
• Next test the movement of the patella testing for lateral laxity (Patellar Dislocation |
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Term
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Definition
• Anterior Drawer sign
– Performed at 90 degrees flexion
– Make sure the quadriceps muscles are relaxed
– Compare the amount of laxity of movement compared to unaffected side
• Lachman’s Test
– Performed at 20 to 30 degrees flexion
[image] |
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Term
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Definition
• Posterior Drawer sign
– Gold Standard
– Performed similarly to Anterior drawer sign
• Posterior Sag Sign
– Observe the lag at
maximum muscle
relaxation
– Compare to unaffected
leg
[image] |
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Term
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Definition
• Valgus stressing of the MCL at both 0 and 30 degrees
• Testing at 30 degrees removes the stabilization provided by the cruciate ligaments
[image] |
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Term
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Definition
• LCL testing similar to MCL testing
• Varus stress testing
• Performed at 0 and 30 degrees
[image] |
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Term
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Definition
• McMurray’s Test to evaluate for Meniscal injury
• Positive test is “clicking” along joint line along with pain during internal and external rotation
[image] |
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Term
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Definition
• Age 55 years or older
• Isolated tenderness of patella (1)
• Tenderness at head of fibula (2)
• Inability to flex to 90°
• Inability to bear weight both immediately and in ED |
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Term
| Ottawa Knee Rules: The Numbers |
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Definition
• In one meta-analysis the decision rule had a sensitivity of 1.0 (95% confidence interval 0.96 to 1.0) in identifying clinically important fractures.
• In the same study the potential reduction in use of radiography was estimated to be 49%
• The probability of fracture, if the decision rules were negative, was estimated to be 0% (95% CI 0% to 0.5%)
• Not worth a patient complaint |
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Term
| Plain Films for knee injuries |
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Definition
• Traditional Standard of Care when concern for fracture
• Generally A/P and Lateral performed in ER
• AdditionalUseful images include a “Sunrise” view |
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Term
| Computer Tomography for knee injuries |
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Definition
• Useful in detecting tibial plateau fracture
• Usually performed when diagnosis is unclear |
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Term
| Ultrasound for knee injuries |
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Definition
• Often used to examine the musculature of a joint while in use
• Provides dynamic imaging for examining muscle tears, tendon ruptures, and other soft tissue injuries. |
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Term
| Magnetic Resonance Imaging for knee injuries |
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Definition
• Most useful for examination of meniscal injuries
• Can be used for evaluating for ligamentous injury
– ACL has high sensitivity but poor sensitivity in determining complete versus partial tear
– Very sensitive in PCL |
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Term
| Patellar Fractures treatment |
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Definition
• If extension is possible without displacement
– non operative management
– Initially treated in knee immobilizer
– Treated long leg cast 4-6 weeks
– Operative management consists of ORIF |
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Term
| Patellar Dislocation treatment |
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Definition
• Closed reduction may be attempted
– Gentle extension of the leg with anterio medial pressure on the lateral aspect of the patella
– Following reduction patient should be placed in a knee immobilizer for 3-6 weeks
– 30-50% recurrence rate in properly treated primary dislocations |
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Term
| Distal Femur Fracture treatment |
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Definition
• Usually secondary to MVC or significant fall
• After examination, the leg should be splinted
• If joint incongruity, Othro consult and ORIF
• Patients are at risk for fat embolus |
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Term
| Tibial Plateau Fracture facts and treatment |
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Definition
• More common in the elderly
• Usually strong varus force as cause
• By definition are intrarticular
• Often with associated ACL or MCL injury (20-25%)
• Patient should be made non- weight bearing and placed in immobilization either with a long leg cast or immobilizer
• Patient may require ORIF in more serious or displaced fractures |
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Term
| Epiphyseal Fracture facts and treatment |
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Definition
• Constitute a fracture through an open growth plate
• Anatomic reduction
• Ice, elevation, immobilization with a long leg splint
• Early orthopedic consultation |
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Term
| types of salter-harris fractures |
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Definition
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Term
| Osteochondritis Dissecans (OCD) facts and treatment |
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Definition
• Unknown etiology, thought to be related to chronic or acute trauma
• Occurs mostly in adolescent males
• Usually seen on plain films
• In patients with open growth
plates, treat with protected
weight bearing
• Poor prognosis if closed
• If loose piece, may require surgery
[image] |
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Term
| Meniscal Injuries facts and treatment |
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Definition
• Crescent shaped semilunar fibrocartilaginous structures
• Diagnosis via MRI after clinical suspicion
• Unless locking, initial management is NSAIDs, ice, knee immobilization, non weight bearing, and orthopedic referral
• Ultimate management is determined often secondary to associate ligamentous injury
[image] |
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Term
| ACL injuries facts and treatment |
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Definition
• 50%ofACLinjuriesareassociatedwithmeniscal injuries
• Oftenassociatedwithbleedingandthus immediate swelling
• GradeIandIIshouldbemanagedconservatively with pain meds and range of motion exercises
• Patientshouldbemadenonweightbearing
• Ifp ossible, patient should not be placed in a knee immobilizer if an isolated injury |
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Term
| PCL injuries facts and treatment |
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Definition
• Hyperflexion and dashboard injuries when isolated injury
• Generally managed non-operatively
• Treated long term with quadriceps strengthening |
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Term
| MCL injuries facts and treatment |
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Definition
• Often due to a direct blow to the lateral aspect of the knee
• Should be placed in knee immobilizer and allowed to “scar” down
• Long term management is generally non operative in isolated injury |
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Term
| LCL injury facts and treatment |
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Definition
• Less common than others, due to protection provided by other leg
• Management the same as with MCL
– Non-operative management
– Knee immobilization |
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Term
| Osgood-Schlatter disease facts and treatment |
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Definition
• Apophyseal injury
• Due to inflammation of the growth plate at the upper end of the tibia
• Typically presents with anterior knee pain
• 20-30% bilateral
• Age: female 8-12 years & male between 12-15 years
• Male sex (3:1)
• Rapid skeletal growth
• Repetitive sprinting and jumping sports
Diagnosis
• Painful symptoms are often brought on by running, jumping, and other sports-related activities.
• In some cases, both knees have symptoms, although one knee may be worse than the other.
• Knee pain and tenderness at the tibial tubercle
• Swelling at the tibial tubercle
• Tight muscles in the front or back of the thigh
Treatment
• •
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Focuses on reducing pain and swelling
Limit activity until participation is pain-free
• Most patients able to return in 2-3 weeks
Formal physical therapy
• Adequate stretching
• Focus on the quadriceps and hamstrings |
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