Foot and Ankle

1. Foot and Ankle Fractures,Sprains, and Soft Tissue Disorders

2. 25,000 people sprain an ankle every day 85% of the time lateral collateral ligaments injured (anterior talofibular and calcaneofibular) Inversion injury 5% syndesmosis injury symptoms: pain, swelling, loss of function Treatmentis aimed at preventing chronic pain and instability NSAIDS, ice, compression, elevation Air stirrup, WBAT, and physical therapy Should improve in 6 weeks Ankle Sprain

3. Ankle Fractures • Fractures involve the medial or lateral malleolus, the posterior lip of the tibia, the collateral liagamentous structures, or the talar dome • Stable fractures= one malleolus , no ligaments • Unstable fractures= both malleoli or a distal fibula and disruption of the deltoid ligament • Unstable fractures= vulnerable for displacement, instability, and posttraumatic arthritis

4. Symptoms: pain, swelling, tenderness, deformity Examination: include evaluation of the posterior tibial pulse and posterior tibial nerve (plantar sensation) X-rays: AP, lateral, oblique (mortise view) Cat Scan for complex fractures with articualr surface involvement or lateral portion of the distal tibia

5. Treatment: • Stable unimalleolar fxs= WB SLC • Unstable fractures= ORIF

6. Maisonneuve Fracture • Fracture of the proximal fibula with torn medial deltoid ligament, and disruption of the ankle mortise • Palpate proximal fibular with all medial ankle pain presentations • Treatment= ORIF

7. Fractures of the Hindfoot • Talus fracture: usually result of severe trauma • Calcaneus fracture: MVA or fall from a height • Sx: tenderness over talonavicular joint anterior to the medial malleolus, tenderness with side to side compression of the heel, swelling in the heel & ankle, and the inability to weight bear • Tx: ORIF • * watch for plantar compartment syndrome* • Talus fx: can lead to osteonecrosis

8. Fracture of the Metatarsal Jones’ Fracture: proximal metaphysis of the fifth metatarsal propensity for non or delayed union NWBC 6 weeks, folllowed by WB cast until healing occurs Base of the Fifth Metatarsal Fracture: inversion injury R/O with suspicion of ankle fracture Most respond to closed reduction

9. Fracture of the Midfoot • Lisfranc Fracture-Dislocation • Critical injury to the second tarsometatarsal joint=stabilizing apex for the other tarsometatarsal joints since it “keys” into a slot in the cuneiforms • *Easily missed and misdiagnosed as an ankle sprain*

10. Exam Careful examination will reveal area of maximum tenderness over the tarsometatarsal joint Stabilize the calcaneus and rotate and/or adduct the forefoot=severe pain X-rays AP, laterl, oblique views of the foot, standing if possible Common error is to obtain only ankle films Normal alignment=medial aspect of the middle cuneiform with the medial aspect of the second metatarsal base Stress views , CT, MRI

11. Treatment • Significant swelling occurs-elevate and ice • Beware of Compartment Syndrome • Nondisplaced injuries=NWBC • Displaced=ORIF

12. Morton’s Neuroma • Fibrosis of the common digital nerve as it passes between the metatarsal heads • *commonly between the third and fourth toes* • Sx: plantar pain, numbness, and “walking on a marble” • * firmly squeeze metatarsal heads with one hand while applying direct pressure to the interspace with the other • Tx: metatarsal bar, injection, surgical excision

13. Plantar Fasciitis • Plantar heel pain that occurs where the plantar fascia arises from the medial calcaneal tuberosity • Sxs: focal pain often increased upon awakening or when rising from a resting postion • Tx: 95% conservative treatment • Achilles & plantar fascia stretching, night splints, NSAIDs, injection

14. Achilles Tendinitis & Rupture • Rupture: sudden, severe calf pain described as a gunshot wound or direct hit • Middle-aged men = weekend athletes • Swelling and ecchymosis from the calf to heel • Weakness with push-off • + Thompson test=absence of plantar flexion with calf compression

15. Tendinitis: insertional or 4-5 cm proximal • Insidious pain that increases with exercise • Often after a change in training habits • Protuberant posterolateral bony proces of the calcaneus • Treat conservatively

16. Shin Splints • Chronic leg Pain- palpation of the tibial crest will usually identify a pinpoint spot • Compression of the tibia and fibula will result in pain at the fracture site • Tx: reduction in athletic activity 4-6 wks • NSAIDs • Removable cast for ambulation • Progressive training shedule: no more than 10% week

17. Diabetic Foot: Charcot Foot • Insensate foot fails to provide sensory feedback, causing the skin to break down due to unperceived repetitive trauma • 3 major clinical problems=diabetic ulceration, deep infection, and Charcot joints • Sxs: hot, red, swollen with intact skin • Elevate foot 5 mins=Charcot will lose redness

18. Evaluation must include checking for cellulitis, osteomyelitis, and gout • X-rays • Vascular studies if pulses are absent or a nonhealing ulcer is present • There is no noninvasive study that differentiates Charcot xray changes from osteomyelitis: GENERALLY- osteomyelitis will develop only if the skin has been violated