Paul Alley MD,DPM,MS,FACS,FAAOS,BFD Eby Orthopaedics,Jasper,Indiana

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1 Paul Alley MD,DPM,MS,FACS,FAAOS,BFD Eby Orthopaedics,Jasper,Indiana

2 Very common Bone=fractures Description (cracked,broke,busted,or smashed) A=anatomic area of bone eg: head,neck,shaft B=bone involved C=condition (comminuted,transverse,oblique) Soft tissue: open,closed,degloved Eponyms

3 Soft tissues =Tendons and Ligaments Strains, Sprains and Overuse Majority of these respond to non surgical treatment.

4 Survey of common foot and ankle injuries that are likely to show up in your office or urgent care Most of these injuries you can care for as well as I can.

5 Grandpa said it best 2 types I found while training Most difficult year in Ortho residency 1950 s requirements for Ortho training vs today

6 Achilles Posterior tibial Peroneals

7 Non insertional May be the result of remote trauma that resulted in a partial tear May feel a lump that moves along with the tendon during plantarflexion and dorsiflexion

8 Pump bump (retrocalcaneal exostosis) Evolving process Peritendonitis Tendonitis Tendonosis Treatment: Timing in evolution. Overall 50%effective for all comers. Physical therapy (Stretch,strengthening,modaliti es,achillotrain) Don t inject*

9 Can feel a defect in the tendon Usually repaired patient is a good candidate Can heal without surgery,but rerupture rate can be 20x greater* Don t forget the fluroquinolones

10 PTTD most common cause of adult onset flat foot Staged classification ( I-IV) Pain and swelling along the PTT (I) Arch lowers (II) Subtalar arthritis (III) Ankle arthritis (IV) Progressive difficulty in doing a single limb heel rise Too many toes sign Progressive loss of motion in STJ,AJ

much excursion. IF tears, doesn t repair well.

11 Immobilize Orthoses, Arizona brace, Ritchie brace PT / Modalities PTT is a supporting tendon and doesn t have much excursion. IF tears, doesn t repair well. Treatment may require tendon transfers,osteotomies,or fusions

12 Associated injury with ankle sprains May be associated with high arched foot. Pain over the sinus tarsi Increased with resisted eversion Popping Peroneals

most important for stability Check for lateral pain or

13 Medial (deltoid) sprains are rare as an isolated injury due to boney continuity Deep deltoid component most important for stability Check for lateral pain or fx (Maisonneuve) Widened medial clear space on mortise view

14 Most common ATFL and CFL most common PTF not usually involved Mechanism: Inversion and plantarflexion Acute,chronic,multiple episodes Ability to weight bear

15 For obtaining Xrays after foot or ankle injuries Criteria: if FOOT injury Any MIDFOOT pain and: Inability to bear weight ( 4 steps) after injury on in the ER or Pain at the base of the 5 th MT or Pain at the NAVICULAR

16 Any pain in the malleolar zone AND: Bone pain at the tip of the Medial malleolus or along the posterior edge of the distal 6 cm of the tibia Bone pain at the tip of the LM or the distal 6cm of the fibula Inability to bear weight immediately after injury or in ER for 4 steps

High Ankle Sprains Pain ABOVE the ankle Don t usually occur with lower ankle sprains Twisting injury AITFL,IOL,PITFL,Inferior transverse lig Pain with squeeze

17 High Ankle Sprains Pain ABOVE the ankle Don t usually occur with lower ankle sprains Twisting injury AITFL,IOL,PITFL,Inferior transverse lig Pain with squeeze proximal calf under a flexed knee referred to the syndesmosis Pain over the syndesmosis with external rotation of ankle. Associated with fractures and/or dislocations

Mortise view to assess the medial and lateral clear

18 Xrays essential to rule out associated fx High fibula= Maisonneuve Posterior malleolus= PITFL insertion Mortise view to assess the medial and lateral clear spaces Tear drop on distal fibula=fibula is externally rotated

19 Goal is to establish and maintain the normal tibia and fibular relationship Swelling reduction ( R.I.C.E.) Compression dressing ( Jones) SLC when weightbearing or Walking boot PT important to assist ROM and Peroneal strenghtening. Long recovery (Return to play 12 weeks) May need ORIF if Fx (Plates & screws,dogbone tight rope) Later reconstruction or creation of synostosis

$soft tissue that surrounds the fracture XRAYS: one$ view is no view Joint above and joint below Comparison

20 Description Classification systems Don t forget the soft tissue that surrounds the fracture XRAYS: one view is no view Joint above and joint below Comparison views Weight bearing views Advanced imaging: Bone scans,mri,ct

21 Description (MM,LM,Bimalleolar,Trimalleolar,Eqivalents) Classification AO,Lauge-Hanson,Weber Weber classifies the fracture with repect to location of fibular fracture in relation to the level of the ankle joint: A=below B=at the level of the joint C=above

arch Metatarsals 1,2,3 should line up with their respective 1,2,3 cuneiform bones.

22 Lisfranc (TMT) joints Key to the transverse arch of the foot Provide structural stability to the foot 2 TMT recessed and thought to be the keystone of the transverse arch Metatarsals 1,2,3 should line up with their respective 1,2,3 cuneiform bones. Lisfranc ligament runs between C1 and M2 No ligament between M1 andm2 Don t forget WB views.

23 MVA Industrial accidents Sports injuries (equestrian,football) Axial load applied to the heel of a plantarflexed foot

24 Midfoot pain with significant swelling Course of DP artery between 1 & 2 MT bases

25 ORIF if > 2mm stepoff at the TMTs Potentially unstable injury so mary suggest ORIF regardless of displacement. Recent advocates for FUSION of joints. (Don t move much anyway) 10 weeks NWB then 2 weeks protected WB followed by removal of screws at 12 weeks. Fusion = 6 weeks NWB then 2weeks PWBAT

26 First Metatarsal 2,3,4 Metatarsals Fifth metatarsal

27 Short thick and strong Injuries usually occur secondary ro direct trauma Important in weight bearing Needs anatomic reduction

$Act as a unit Overuse Stress fracture Twisting injury Spiral$

28 Act as a unit Overuse Stress fracture Twisting injury Spiral fracture Direct trauma;bending moment more transverse or comminuted

$fracture then treat like one.$

29 Often 2 nd MT (long and thin) Initial Xrays may be normal for 2-3 weeks Serial Xrays,Bone scans,mri C-128 tuning fork If suspect fracture then treat like one. Fx boot or shoe x 3weeks or until see bone callus Then Stiff soled shoe; Carbon fiber plate; Orthotics

30 Head,Neck, Shaft, Base Displacement >2-4mm consider ORIF Intrinsic muscles and DTML Check serial xrays for healing ORIF / osteotomy can be done electively

$Shaft = Dancer fractures Often heal well$

31 Shaft = Dancer fractures Often heal well without surgery Occaisionally need plate fixation

$Avulsion fracture vs Jones fracture Often nondisplaced Jones fx at jct of metaphysis and diaphysis Associated with$

32 Avulsion fracture vs Jones fracture Often nondisplaced Jones fx at jct of metaphysis and diaphysis Associated with inversion ankle injuries Overpull of Peroneus brevis tendon Vascular watershed zone Pull of peroneus brevis and peroneus tertius

$weeks with PWBAT then to fracture shoe$ +/- ankle rehab.

33 Treatment: Avulsion Short boot x 3-4 weeks with PWBAT then to fracture shoe +/- ankle rehab. Jones-NWB in boot x 6 weeks vs ORIF with intramedullary screw.

$Many fractures and soft tissue injuries can be cared for by non- ortho experts.$

34 Many fractures and soft tissue injuries can be cared for by non- ortho experts. Non displaced,nonarticular,simple pattern Don t forget about soft tissue injuries that accompany bone injuries Consider joints above and below (Maisonneuve,Lisfranc) Proper initial xrays

35 I follow up at intervals when I expect to move the patient to the next level: NWB to WB Cast to boot or splint Adding PT: Swelling reduction,rom,stretching and strengthening,balance,ect. PRN worries questions or concerns

Outline. Ankle/Foot Anatomy Ankle Sprains Ottawa Ankle Rules DDx: The Sprain That Wasn t

Outline. Ankle/Foot Anatomy Ankle Sprains Ottawa Ankle Rules DDx: The Sprain That Wasn t Ankle Injuries Outline Ankle/Foot Anatomy Ankle Sprains Ottawa Ankle Rules DDx: The Sprain That Wasn t Anatomy: Ankle Mortise Bony Anatomy Lateral Ligament Complex Medial Ligament Complex Ankle Sprains