9/22/2017. I am a local. Born at Desert Samaritan

Transcription

1 I am a local Born at Desert Samaritan 1

2 MOUNTAIN VIEW HIGH SCHOOL ASU U OF IOWA MED SCHOOL PHOENIX FOR RESIDENCY 2

3 Discuss the 5 most controversial topics in foot and ankle Injuries that are routinely missed and how to recognize them 1. Achilles tendon ruptures Now what? 2. Lisfranc injury Just a foot sprain walk it off! 3. Jones fracture Keeping up with the Jones? 4. Charcot versus infection That looks bad bro 5. Ankle sprains/fractures Is it broke or just fractured?? Largest tendon in the body Blood flow from calcaneus and gastroc/soleus muscles Most tears are at watershed area 5-7 cm above insertion 3

4 May have underlying tendon disorder tendinosis Other risk factors include use of Abx and steroids Felt like I was kicked in the back of the leg 2 age groups Weekend warrior (males) Elderly Less explosive trauma Many can walk Exam Always check malleoli Lat Xray MRI rarely needed When prone with knee flexed Thompsons Resting Equinus Gap 4

5 Nonop Smokers Obese DM, PVD Regular people too??? Operative Young/Active Maybe better tension/strength Maybe lower rate of rerupture 5

6 Roughly 40% non-op One re-ruptured in each group Very happy with results of both treatments Key is appropriate early treatment and referral! Very important injury Frequently missed Mechanism typically higher energy Every midfoot sprain should be treated as Lisfranc until proven its not 6

7 Lisfranc Injury Historically fall from horse with foot caught in stirrup Often would end up in amputation PF or DF injury/fall Exam Unable to bear wt Plantar ecchymosis TTP midfoot Pain with midfoot motion 7

8 Xray Any altered midfoot anatomy Fleck sign WB xrays very important Consider MRI if not fractures only if WB XRAYS neg and suspicius or cannot bear weight after 1 week MRI more for sports type injuries CT if fractures present Tx Nonop Grade I and II sprains Nonweightbearing Some grade III based on risk factors I, II Boot 4-6 weeks III cast 6 Weeks Tx Operative Any Displacement ORIF vs Fusion Shared decision making When to refer Any Grade III for the most part 8

9 Fracture of the 5 th metatarsal Not to be confused with avulsion or stress fracture Acutely, any met fracture can be treated the same Prox to 4,5 articulation (Avulsion) Twisting injury Xrays Usually minimally displaced Watch for apophysis in youths 9

10 Treatment Short walking boot 4-6 weeks Rarely ORIF for displaced fractures Fibrous union possible Usually asymptomatic At the level of 4,5 Met articulation Jones Fracture Exam Check ankle lig Look for cavus foot Xrays Usually minimally displaced Level of 4,5 articulation Look for signs of chronic stress reaction 10

11 Tx Nonop vs Op Age Health Hobbies/work Previous injury Foot structure Tx Nonop Usually let them walk in a cast or boot early unless too painful Small chance it doesn t heal, but could be delayed. Nothing worse than 6 weeks in a cast and then still getting a screw 6-8 weeks in boot at least 11

12 Tx Operative Industrial Athletes Cavus foot Shared decision making Vitamin D eval and supplementation I treat these similar to Zone II However, these are more commonly chronic or at least subacute May result in more patients getting a screw 56 yom Swelling and redness for 5 days No major injury, maybe twisted foot week ago No fevers or chills Now what? 12

13 Yes, orthopedic surgeons get a history HTN, DM II, previous smoker No surgical history Works as a truck driver What next? +++ swelling and redness +/- tenderness over entire foot Able to wt bear Foot warm to the touch No palpable pulses (swelling?) Decreased sensation to touch with monofilament Xrays? Abx? Labs? Boot or cast? Do we have a diagnosis? 13

14 CHARCOT DM with neuropathy Redness decreases with elevation 50% pain, 50% painless Elevated CRP/ESR/WBC Can happen after minor trauma INFECTION Higher risk in DM Redness does not decrease with elevation Usually all painful Elevated WBC/CRP/ESR Often no event/cause chronic and progressive joint disease following loss of protective sensation Neuropathic joint, usually DM w/ neuropathy Mechanism: theories neurotraumatic insensate joints subjected to repetitive microtrauma body unable to adopt protective mechanisms to compensate for microtrauma due to abnormal sensation neurovascular autonomic dysfunction increases blood flow through AV shunting leads to bone resorption and weakening Ok to treat infection if suspected (fevers, chills, etc) MUST make NWB, splint and referral to specialist Helps prevent continued damage and chronic charcot changes 14

15 Requires multispecialty attention Internal medicine/primary care Orthopedic surgeon Orthotist Endocrinologist Neurologist Don t be afraid to ask for help! Total contact cast and NWB Avoid amputation Losing body part High risk surgical patients Surgeons do not like to fail! Mechanism typically same Exam can be very similar Both can have lots of pain and swelling 15

16 Grades I mild Stretch/minimal tearing II moderate Partial tear May require XRAY III complete tear Often unable to bear weight Need an XRAY TTP along posterior aspect of medial malleolus TTP along posterior aspect of lateral malleolus Unable to WB immediately or during exam Include foot XRAY TTP at 5 th metatarsal base TTP at anterior process of calcaneus I like WB XRAYS if possible Immobilize Splint, brace, boot, ace wrap Rest Ice Elevation Compression Crutches prn 16

17 Functional rehab Reduce swelling/pain ROM Strength Proprioception Sport specific Grade I few days Grade weeks Grade weeks Grade 2/3 During competition recommend brace for rest of season or 3 months (whichever greater) Occasionally for grade I+ Ability of the body to sense location, movement, position, orientation of its parts Xray Look for medial clear space widening Deltoid avulsion Post mal avulsion Occasional MRI 17

18 Tx Direct Blow Nonop WBAT in boot 4-6 weeks Assoc with deltoid or syndesmosis ORIF 18

19 Mechanism Usually inversion injuries Similar to ankle sprain Exam TTP lateral mainly Sometimes medially Tx Usually Nonop Watch closely Operative Large displacement Considerable instablility Increasing displacement on XRAYS Tx Operative Displaced Fx associated with lig injury Verticle shear Those with Varus alignment of distal tibia Cavovarus foot Severe Pes PlanoValgus When to refer Any displacement Any foot deformity Any hint of syndesmosis injury May require fluoro exam 19

20 Same as Bimalleolar ankle fractures 20

21 Mechanism Usually fixed foot and external rotation of body High Ankle Sprain Grade I, II, III Exam Tender higher up leg Sometimes TTP medial and along ATFL Check entire fibula with XRAY if tender Usually cannot bear weight early Tx Nonop Grade I, Grade II Most of these get MRI Sometimes confirm stability with fluoro if deltoid sprain as well Boot 2-6 weeks Operative Grade III Sedation, Sedation, Sedation, Sedation!! Traction only reduces >90% of dislocations early Be gentle If your struggling too much, need more sedation Stabilize in well padded splint 21

22 Any open wound on an extremity is an open fracture Tetanus and early antibiotics Stabilization of limb Represents large soft tissue injury Referral to ER for urgent debridement and surgical stabilization of bone Achilles tendon ruptures Splint in plantarflexion, NWB, early referral Lisfranc injury Treat every foot sprain as Lisfranc until proven not Jones fracture Boot better than shoe, NWB, Vit D Charcot NWB, NWB, NWB and early referral Ankle sprain/fracture Get xrays, NWB especially if DM. Early referral 22

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