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Ankle and Foot: Common Acute Injuries

Ankle and Foot: Common Acute Injuries. Kevin deWeber, MD, FAAFP Director, Sports Medicine Fellowship USUHS/DeWitt. Traumatic Injuries to the Ankle. Ankle Sprains (25% of all Sports Injuries) Ankle Fractures Achilles tendon rupture. Traumatic Injuries to the Foot.

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Ankle and Foot: Common Acute Injuries

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  1. Ankle and Foot:Common Acute Injuries Kevin deWeber, MD, FAAFP Director, Sports Medicine Fellowship USUHS/DeWitt

  2. Traumatic Injuries to the Ankle Ankle Sprains (25% of all Sports Injuries) Ankle Fractures Achilles tendon rupture Traumatic Injuries to the Foot • 5th Metatarsal Fractures • Lisfranc Injuries

  3. Bones & Ligaments

  4. Anatomy

  5. Anatomy

  6. Anatomy

  7. Anatomy

  8. Anatomy

  9. Anatomy

  10. SUBTALAR JOINT: Inversion and Eversion

  11. Evaluation History Mechanism of injury Location of pain Continued activity? Weight bearing? Previous injuries Prior treatment Field vs Office Evaluation

  12. Physical Examination Inspection Palpation Range of motion Strength testing Special tests

  13. Inspection: Swelling, Ecchymosis, Deformity

  14. Palpation AXIOM OF SPORTS MEDICINE: “Find out what is tender, then figure out what’s there.” Knowing your anatomy is critical

  15. ROM: dorsiflexion/plantarflexion (Active & Passive)

  16. ROM: Inversion/Eversion

  17. Special Tests

  18. Anterior Drawer Test (ATFL)

  19. Talar Tilt - ATFL/CFL

  20. Syndesmosis Injury Squeeze Test External Rotation Test

  21. Squeeze Test External Rotation Test

  22. Thompson’s Test Integrity of Achilles Tendon + is no movement

  23. Ankle Radiographs AP Lateral Mortise

  24. Lateral Ankle Sprains • Inversion injuries • Graded 1-3 • 1: no ligament laxity • 2: slight laxity • 3: complete ligament rupture • ATFL first  CFL second  PTFL last • ATFL 3rd-deg: + Anterior Drawer • ATFL & CFL 3rd-degr: + AntDrawer & Talar Tilt

  25. Do ankle sprains need x-rays? • Ottowa Ankle Rules: if any of the 5 positive, get x-rays • Inability to bear wt initially and in ER • TTP over posterior Medial Malleolus • TTP over posterior Lateral Malleolus • TTP over 5th MT base • TTP over Navicular bone

  26. Ottawa Ankle Rules **Or inability to bear weight

  27. Ankle Sprain Treatment • PRICEM • NSAID short course may speed recovery • Crutches prn, weight bearing as tolerated • Protect ankle ligaments (brace) • Consider cast/boot if severe pain • Early referral to Physical Therapy • Early ROM • Strength exercises • Proprioception exercises • Sports-specific drills • Sports/Duty • Follow-up in 2 weeks

  28. Ankle Sprain Tx BIG-THREE • PROTECTION (BRACE) • STRENGTH EXERCISE • PRIPRIOCEPTION TRAINING

  29. Chronic Pain after Ankle Sprain Inadequate Rehab ( Top 3) Slow Rehab Instability Talar Dome OCD Peroneal Tendon Injury Synovial Impingement Complex Regional Pain Syndrome Subtalar Injury Tarsal Coalition Osteoarthritis Tarsal Tunnel Stress Fracture Interosseous Membrane Injury Refer to Sports Medicine

  30. Tib-Fib Syndesmosis Injuries“High Ankle Sprains” • If ANY widening of mortise, refer to Ortho • If any fibular tenderness, r/o fx (Maisonneuve) • Refer to Ortho • If none of the above, (grades 1-2), IMMOBILIZE, CRUTCHES • 2-4 weeks in cast • CAM boot until no pain walking • Refer to PhTh for good rehab

  31. Maisonneuve Fracture

  32. Mortise View is important Tib/Fib Clear Space should be < 5mm Medial Clear Space should be < 5mm If not….SCREW IT!

  33. Ankle Fractures

  34. Axioms in Ankle Fractures • Nondisplaced avulsions of medial or lateral malleolus: treat as grade 3 ankle sprains • +/- cast/boot, early mobilization • Combinations of medial and lateral fracture/sprain: UNSTABLE; refer to Ortho • Displaced >2mm: refer • Mortise widening: refer

  35. Achilles Tendon Rupture • Thompson Test positive • May have gap in tendon • Ultrasound sensitive for tear • Find Sports Med doc

  36. Thompson Test for Achilles tendon rupture POSITIVE neg

  37. Ultrasound of Achilles rupture

  38. Achilles Rupture Treatment • Treatment controversial; Refer to Ortho • Surgical: better for young, active • Lower rate of re-rupture • Higher wound complications • Casting: better for old, less active • Up to 40% re-rupture • Lower cost and wound complications

  39. 5th Metatarsal Fracture Avulsion of base Jones Fracture Metaphyseal-Diaphyseal junction w/in 1.5cm of tuberosity Midshaft Fracture (stress fractures are different)

  40. 5th MT Base Avulsions • Treat similar to ankle sprains • Bulky dressing • X-rays in 2-4 weeks to assure healing • RTP 4-6 weeks • EXCEPTION: Refer if fx is intra-articular

  41. 5th MT Metaphysis/Diaphysis Jxn“Screw that Mr. Jones the Middle Man!” • Screw fixation OR NWB short-leg cast 6 weeks • Trend for faster healing with Screw • 8 wks vs 12 wks • Lower rate of Nonunion • 20% vs 7%

  42. Cast, hard-sole shoe, bulky dressings as needed RTP in about 6 weeks 5th MT Shaft Fracture

  43. L I S F R A N C I N J U R Y

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