5 COMMON INJURIES IN THE FOOT & ANKLE
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1 5 COMMON INJURIES IN THE FOOT & ANKLE MICHAEL P. CLARE, MD FLORIDA ORTHOPAEDIC INSTITUTE TAMPA, FL USA MECHANISM OF INJURY HOW DID IT HAPPEN? HIGH ENERGY VS LOW ENERGY DIRECTION OF FORCES INVOLVED LIVING ANATOMY WHERE DOES IT HURT? WHAT LIVES THERE? 1
2 ANATOMY & BIOMECHANICS SYNDESMOSIS NORMAL OVERLAP ARTICULATION BETWEEN TIBIA & FIBULA DISTAL CRITICAL FOR STABILITY / DISTRIBUTION OF FORCES ACROSS ANKLE JOINT SYNDESMOSIS COMPLEX OF LIGAMENTS ANTERIOR INFERIOR TIBIOFIBULAR LIGAMENT POSTERIOR INFERIOR TIBIOFIBULAR LIGAMENT INTEROSSEOUS MEMBRANE INTEROSSEOUS LIGAMENT 2
3 DISTAL TIBIA/FIBULA/TALUS FORM ANKLE MORTISE ( ROOF ) SOME INHERENT STATIC STABILITY MULTIPLE LIGAMENTS ADDITIONAL STATIC STABILITY LATERAL ANTERIOR TALOFIBULAR (ATFL) CALCANEOFIBULAR (CFL) POSTERIOR TALOFIBULAR (PTFL) ANKLE CAPSULE MEDIAL DELTOID / SPRING COMPLEX DYNAMIC STABILIZERS SECONDARY STABILITY ATT / EHL / EDL EXIST IN BALANCE PTT PL / PB ACHILLES ACHILLES >>> PTT > ATT/EHL/EDL > PL / PB 3
4 HINDFOOT: TRIPLE JOINT COMPLEX ST CC TN ACCOMODATION TO UNEVEN GROUND COMPLEX 3-D ARTICULATIONS MAJORITY (~ 75%) OF MOTION THROUGH TALONAVICULAR JOINT SAME TENDONS INFLUENCE POSITION OF JOINTS WITH NORMAL GAIT MIDFOOT MT BASES/CUNEIFORMS & CUBOID LEVER ARM FOR AMBULATION 3-COLUMN THEORY LATERAL COLUMN: ACCOMODATE UNEVEN GROUND 4
5 SOME INHERENT STABILITY ROMAN ARCH CONFIGURATION 2ND MT KEYSTONE LIGAMENTS/JOINT CAPSULES DORSAL / PLANTAR / INTER-MT LIGS PLANTAR > DORSAL LIS FRANC LIGAMENT ALLOWS EXTRA MOTION FOR PUSHOFF (P LONGUS) METATARSAL CASCADE 1ST MT BEARS 50% OF BODY WEIGHT REMAINDER DISTRIBUTED TO 2ND-5TH MT TRIPOD OF FOOT 5
6 ESSENTIAL VS NON-ESSENTIAL ANKLE NAVICULOCUNEIFORM SUBTALAR INTERCUNEIFORM TALONAVICULAR 1 3 TMT CALCANEOCUBOID 4 & 5 TMT ACUTE ANKLE SPRAINS POLL OPEN THE MOST IMPORTANT DIAGNOSTIC TEST FOR AN ACUTE ANKLE SPRAIN IS: 1 PLAIN RADIOGRAPHS 2CT SCAN 3MRI 4 STRESS FLUOROSCOPY 0% 0% 0% 0% 6
7 ACUTE ANKLE SPRAINS MOST COMMON ORTHOPAEDIC INJURY PRESENTING TO ER USU INVERSION INJURY +/- ABLE TO BEAR WEIGHT CLINICAL EVALUATION SWELLING ANKLE JOINT EFFUSION TENDERNESS TO PALPATION NO NEED FOR TORTURE ~ EXCESSIVE PAIN / GUARDING WITH: ANTERIOR DRAWER TEST (ATFL) CALCANEAL INVERSION TEST (CFL) 7
8 MUST EXAMINE LATERAL FOOT 5TH METATARSAL LATERAL PROCESS OF TALUS ANTERIOR PROCESS OF CALCANEUS RADIOLOGIC EVALUATION INCLUDE ANKLE & FOOT MRI NO ROLE IN ACUTE ANKLE SPRAINS 8
9 OSTEOCHONDRAL FX TALUS LATERAL PROCESS TALUS FX ANTERIOR PROCESS CALCANEUS FX 9
10 TREATMENT: R.I.C.E. SPLINT / FX BOOT / LACEUP BRACE COMPRESSION WBAT WITH CRUTCHES NSAID S TREATMENT: REHAB EARLY MOTION / PROGRESS TO E/PROP ADVANCE ACTIVITIES AS TOLERATED 4-6 WEEKS TO FULL ACTIVITY FORMAL PTX IF SLOW PROGRESS POOR MAN S PTX EVERSION STRENGTHENING 10-COUNT CONCENTRIC-ECCENTRIC KNEE IN EXT / ANKLE IN PF (LOW & AWAY) PROPRIOCEPTION TIMED SINGLE LEG BALANCE COMPARE TO UNINJURED SIDE 10
11 SYNDESMOSIS INJURIES REQUIRES EXTERNAL ROTATION TENDER MEDIALLY & OVER SYNDESMOSIS SYNDESMOSIS INJURIES EXTERNAL ROTATION STRESS TEST ABDUCTION STRESS TEST SQUEEZE TEST 11
12 SPECTRUM OF INJURY SPRAIN (DELTOID / HIGH ANKLE SPRAIN) UNSTABLE PATTERN REQUIRING SURGERY HIGH ANKLE SPRAIN BY DEFINITION STABLE FX BOOT / STOCKING FOR COMFORT WBAT / EARLY MOTION 6-12 WEEKS TO FULL ACTIVITY ORIF SYNDESMOSIS 12
13 TREATMENT PROTOCOL 2 WEEKS ANKLE / FOOT 2 WEEKS NON-WEIGHTBEARING X 8 WEEKS 6 MONTH RECOVERY ACHILLES TENDON RUPTURES POLL OPEN IF YOU RUPTURED YOUR ACHILLES, HOW WOULD YOU HAVE IT TREATED? 1. NON-OPERATIVE TREATMENT 2 2. SURGERY 0% 0% 13
14 ACHILLES TENDON RUPTURES LARGEST / STRONGEST TENDON HIGHEST LOADS OF ANY TENDON ~ 10X BODY WT WITH RUN / JUMP AREA OF LOW VASCULARITY 2-6 CM FROM INSERTION (WATERSHED AREA) ACHILLES TENDON RUPTURES HEAVY LOAD / HIGH SPEED ECCENTRIC MUSCLE ACTION: RISK OF RUPTURE (+) ACUTE POP +/- ABLE TO BEAR WEIGHT A CLINICAL DIAGNOSIS PALPABLE DEFECT PF WEAKNESS / HYPERDORSIFLEXION (+) THOMPSON TEST MRI GENERALLY UNNECESSARY 14
15 SURGERY (VS NON-OP TX) 3X LOWER RE-RUPTURE RATE RISK OF WOUND COMPLICATIONS QUICKER RETURN TO ACTIVITY ~ NO DIFFERENCE AT 1 YEAR OPERATIVE TREATMENT IMMOBILIZATION IN EQUINUS ~ 10 DAYS POST-INJURY ALLOWS EARLY CONSOLIDATION OF INJURY HEMATOMA BETTER PURCHASE WITH SUTURE LESSENS WOUND COMPLICATIONS OPERATIVE TREATMENT THE MOST FINESSE OPERATION I DO 15
16 THE DISASTER COLONIZED SUTURE IMPLANT NON-OPERATIVE TX MUST IMMOBILIZE IN EQUINUS WITHIN 2 3 DAYS OF INJURY ASSUME TENDON ENDS IN CONTACT 16
17 TREATMENT PROTOCOL BOOT / HEEL 2-3 WEEKS PTX 2-3 WEEKS NON-WEIGHTBEARING X 6 WEEKS 8-9 MONTH RECOVERY LIS FRANC INJURIES MECHANISMS OF INJURY HYPERDORSIFLEXION +/- ROTATIONAL FORCES MVA / FALL FROM HEIGHT HYPERPLANTARFLEXION +/- ROTATIONAL FORCES SPORTS / GROUND LEVEL FALL CAN BE PARTIAL / MIDFOOT SPRAINS 17
18 VARIABLE INJURY PATTERNS BONY LIGAMENTOUS COMBINATION CLINICAL EVALUATION DEFORMITY TENDER AT 1ST TMT / LIS FRANC JOINTS RADIOLOGIC EVALUATION INVOLVED ANKLE & FOOT SPECTRUM OF INJURY PATTERNS DISRUPTION OF STABILIZING LIGAMENTS / CAPSULES +/- FX 18
19 HIGH ENERGY VS LOW ENERGY 20% MISDIAGNOSED (SUBTLE) CT SCAN CONTRALATERAL WB XR STRESS XR MRI DELAYED STRESS TEST IMMOBILIZE / WBAT & REPEAT EVAL / (WB) XR IN 1 WEEK NWB A/P WB A/P 19
20 MIDFOOT SPRAIN STABLE BY DEFINITION WBAT IN FX BOOT +/- MILD ARCH SUPPORT PROLONGED RECOVERY: ~ 3 MONTHS ORIF FOR TRUE DISRUPTION +/- PRIMARY ARTHRODESIS CONTROVERSIAL ORIF FOR HIGH ENERGY 20
21 TREATMENT PROTOCOL 2 WEEKS ANKLE / FOOT / MTP 2 WEEKS NON-WEIGHTBEARING X 8 WEEKS 6 MONTH RECOVERY 5TH METATARSAL FRACTURES 5TH METATARSAL FRACTURES PLANTARFLEXION / INVERSION SIMILAR TO ANKLE SPRAIN STRESS FX (ATHLETES) OFTEN WITH CAVUS ALIGNMENT 21
22 CLINICAL EVALUATION LOCALIZED SWELLING TENDERNESS AT FX SITE / PASSIVE MOTION OF 5TH MT PAIN WITH WEIGHTBEARING RADIOLOGIC EVALUATION ANKLE & FOOT TREATMENT PROGNOSIS DEPENDS ON FX LOCATION ZONE I: PROXIMAL METAPHYSEAL / AVULSION FX ZONE II: METAPHYSEAL FX: (TRUE JONES FX) ZONE III: METAPHYSEAL-DIAPHYSEAL JUNCTION 22
23 TREATMENT ZONE I USUALLY NON-OP TREATMENT LOW TOP FX BOOT / WBAT X 6 WKS ZONES II & III IMMOBILIZATION X 6-12 WEEKS ATHLETES: IMMEDIATE ORIF DELAYED UNION / NONUNION: ORIF ORIF 5TH MT (TRUE JONES) FX 4.5MM SOLID SCREW TREATMENT PROTOCOL 2 WEEKS ANKLE / FOOT 2 WEEKS NON-WEIGHTBEARING X 6-8 WEEKS 6 MONTH RECOVERY 23
24 CAVUS ALIGNMENT THE OVER-SUPINATOR / THE UNDER-PRONATOR POLL OPEN THE PROPER ORTHOTIC FOR A CAVUS FOOT IS: 1 1. MILD ARCH SUPPORT/MEDIAL POST 0% 2 2. ACCOMODATIVE INLAY 0% 3 3. LATERAL HEEL/SOLE WEDGE; 1ST MT RECESS 0% 4 4. SOLID ANKLE-FOOT ORTHOSIS 0% PATHOMECHANICS VARUS ANKLE 24
25 PATHOMECHANICS LOCKED HINDFOOT (SHOCK ABSORBER) PATHOMECHANICS OVERLOAD OF LATERAL MIDFOOT PATHOMECHANICS 25
26 CAVUS ALIGNMENT ASSOCIATED DIAGNOSES: LATERAL ANKLE INSTABILITY PERONEAL TENDON TEARS ZONE II-III 5TH MT STRESS FX NAVICULAR STRESS FX CAVUS ORTHOTIC LATERAL HEEL & SOLE WEDGE 1ST MT RECESS SUMMARY MECHANISM OF INJURY LIVING ANATOMY GOOD PHYSICAL EXAM & PLAIN XR: DIAGNOSIS IN >90% OF CASES TREATMENT BASED ON INJURY 26
27 27
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