Basic Orthopaedics for PA Students Foot and Ankle Charles Walker, Ph.D. PA-C
NCCPA Knowledge and Skills Area for Ankle / Foot Disorders of the Ankle/Foot Fractures/dislocations Sprains/strains
Reading: Essentials, Section Seven with particular attention to the following pages: 406419; 422-425; 448-462; 508-510 Netter’s Anatomy, Plates 488A-B; 489 A-B; 491 A-B Overview of Ankle and Foot
Anatomy of the Ankle and Foot Bones of the forefoot, midfoot and hindfoot (Netter’s Plates 488A 488B 489A 489B) Calcaneus Talus Articulations Navicular Cuboid Cuniforms Metatarsals Phalanges Bones of the ankle joint (Netter’s Plates 488A 488B 489A 489B) Talus Tibia Fibula Articulations Ligaments of the ankle (Netter’s Plates 491A 491B) Lateral Collateral Ligaments Syndesmotic Ligament Deltoid Ligaments
Common Clinical Presentations:
Chief Complaint: Pain most common cc: of foot. Chronic pain more common than acute pain. Chronic pain > 2 week duration. Acute pain < 2 week duration. Acute pain think fracture, sprain, strain or infection Acute pain over metatarsals (esp distal portion of 2 nd and 3rd) is suggestive of stress fracture Forefoot problems: 9 times more likely in women than men high heels, pointed toed shoes Most Common Problems: Bunions hammer toe claw toe ingrown nails metatarsalgia Morton’s neuroma’s Other Common Problems: Hallux rigidus Stress fractures
Midfoot Problems: Chronic dorsal pain Degenerative arthritis Pt will often be able to pinpoint the exact location of the pain Boney prominence (dorsal bossing) often can be palpated Plantar pain is uncommon Plantar fasciitis or plantar fibromas Hindfoot Problems: Plantar heel pain most common Plantar fasciitis o Pt will report painful first steps in AM ; o Pt pain free at rest; o focal pain directly over plantar medial heel Posterior heel pain o irritation from shoes o prominent calcaneus (Haglund’s Deformity) o dystrophic changes of the Achilles tendon at its insertion Posterior tibial dysfunction is a commonly overlooked problem o Characterized by pain and tenderness posterior and distal to the medial malleolus in the region of the posterior tibial tendon. o Progressive changes here can lead to acquired flat foot Ankle Problems: Acute Pain Sprains anterolateral pain, swelling and ecchymosis (frequently) Chronic Pain: Instability anterolateral pain with intermittent episodes of giving way Low grade pain and swelling o peroneal tendon injuries o osteochondral lesions o subtalar arthritis/synovitis
Fractures of the Ankle
Structures Affected Include: Lateral malleolus medial malleolus posterior malleolus collateral ligamentous structure deltoid ligamentous structures talar dome Working Definitions of Fractures Stable Ankle Fracture Only one side of joint involved Treat Symptomatically Fibula only weight bearing cast 4-6 weeks Unstable Ankle Fracture More than one side of joint affected; Common Unstable Fractures of Ankle Bimalleolar (lateral and medial malleolus or distal fibula and deltoid ligament);
Trimalleolar (involves posterior malleolus) Trimal with posterior dislocation trimal fracture-dislocation o Vulnerable for displacement and posttraumatic arthritis Treatment – Non-displaced o NWB long/short leg cast with prolonged immobilization Displaced o closed or open reduction o NWB long/short leg cast with prolonged immobilization Open fractures o surgical debridement Clinical Presentation Varied but usually involve some element of twisting or rotation PE: Swelling, tenderness, palpable gap, ecchymosis (often), ext. rotation and lateral displacement all common Palpate all malleoli for tenderness, palpate the deltoid ligament; palpate the proximal fibula for tenderness b/c when accompanied with medial swelling Maisonneuve fracture (unstable ext rotation injury) Access circulatory status and sensory status Examine all lacerations as possible indications of an open fracture Diagnostic tests: X-ray – AP Lateral and mortise views, include proximal fibula if necessary CT necessary in complex fractures
Fractures of the Calcaneus and Talus
Definition: Calcaneus and talus fractures usually resulting from severe trauma Seldom occur together When both fractured usually involves the articular surfaces and are serious injuries Symptoms: Acute pain and inability to bear weight PE: Swelling, tenderness. Access nerve functions of superficial peroneal (eversion), deep peroneal (foot drop, ↓dorsiflexion), sural, medial and lateral plantar nerves distal to the fracture Access circulatory status (DP, AT, PT) including cap refill of toes Compartment syndrome is possible esp with notable swelling in the arch Palpate the L-Spine tenderness possible fracture Diagnostic Tests: X-ray AP and Lateral of the hindfoot AP and mortise of the ankle AP and lateral L-Spine if tenderness CT for complex fractures or further evaluation Treatment: Splinting with well padded posterior splint from toe to upper calf Elevate extremity above the heart Ice for 20 minutes q 1-2 hours Surgical reduction and fixation often needed
Surgical debridement of open fracture
Fractures of the Metatarsal
Working Definitions Zones of Fracture (Essentials, p. 453) Zone 1 Zone 2 Classic Jones Fracture Fracture of proximal diaphysis of the 5th metatarsal Requires more intentional immobilization Zone 3 Can result in non-union or delayed union Fractures of metatarsals usually heal with non-operative treatment except as noted Clinical Symptoms Pain with weight bearing and swelling common PE: Swelling , ecchymosis and tenderness over fracture site Diagnostic Tests: AP, lateral and oblique of foot Treatment: Non-displaced metatarsal neck and shaft fx short leg cast, fracture brace or wooden soled shoe Weight bearing as tolerated Repeat x rays in one week to check displacement Then in 6 weeks to confirm healing Displaced Fractures with 4 mm displacement or 10° angulation Closed or open reduction 5th metatarsal fractures may be easy or difficult to manage. Easy to treat: Avulsion fractures of the fifth metatarsal base (zone 1) or proximal metaphyseal fractures (zone 2) do well with non-operative treatment. Immobilize with fracture brace, wooden soled shoe until sx subside Difficult to treat: Acute fractures (Zone 2) NWB in short leg cast 6-8 weeks. Some (athletes) need early internal fixation. Fractures in Zone 3 often resemble stress fractures have problems with non-union Fractures which require further evaluation: Multiple fractures Fractures with >4mm displacement or >10° of angulation Fractures occurring in Zone 2 and 3 Displaced or comminuted fractures of 1st metatarsal Open fractures surgical intervention
Fractures/Dislocations of the MidFoot
Aka Lisfranc fracture / dislocation Easy to miss Traumatic disruptions of tarsometatarsal joints
2nd Metatarsal injury is critical since 2MT “keys” into the cuboid and stabilizes the midfoot Clinical Symptoms Sprain type sx Pain localized to dorsum of midfoot Swelling relatively mild PE Max tenderness and swelling over tarsometatarsal joint vs ankle ligaments Stabilize hindfoot and rotate and/or abduct forefoot Severe Pain in Lizfranc fx Diagnostic Tests AP Lat Obliques of foot (consider WB films) Look for colinearity of medial aspect of mid cuniform with medical aspect of 2 nd MT on AP Look for colinearity of medial aspect of mid cuniform with medical aspect of 4th MT on Oblique Compare with uninjuried foot Treatment Non-displaced – 6-8 weeks of NWB cast immobilization followed by rigid arch support for 3 months Displacement – surgical intervention for stability
Fractures of the Phalanges
Aka Broken toe Most commonly 5th phalanges Usually involves proximal phalanx Usually caused by direct trauma Symptoms Pain; Swelling; Ecchymosis PE: Deformity; local boney tenderness; pain; swelling; ecchymosis Tests: AP X ray Treatment: Buddy taping (usually the toe medial to affected toe) with gauze placed b/w toes to absorb moisture and avoid maceration Closed or open reduction under anesthesia are rarely needed except in cases of severe angulation or articular surface involvement
Stress Fractures of the Foot and Ankle
Aka March Fracture Definition Caused by repetitive overloading to fatigue Increased level of activity or beginning a new type of activity – marching Weakened bone conditions predispose patients to stress fractures (amenorrhea, osteopenia and overuse a common triad) Metatarsals a common site of stress fractures esp 2nd metatarsal but also navicular, calaneus and fibula
Symptoms Insidious pain and swelling Increased pain with WB and relieved with rest Diffusely swollen dorsum in metatarsal fractures Lateral swelling in fibula fractures PE Localized tenderness and concomitant swelling directly over fracture site Ecchymosis appears occasionally Diagnostic tests Bone scan within 5 days is usually positive X rays may be negative for up to 2 weeks post fracture but will show healing callus after 3-4 weeks Treatment Reduced activity and protective footwear Metatarsal fx stiff soled shoe, wooden soled shoe or removable short leg fracture brace Calcaneal or fibular fractures benefit from 2-4 weeks of immobilization in short leg walking cast Navicular and 5th MT fractures should be casted and NWB 5th MT often requires IF
Sprains and Strains of the Ankle and Foot
Aka inversion injury; high ankle sprain’ lateral collateral ligament tear Definition Usually results in an injury to the lateral ligaments of the ankle (Posterior tibiofibular ligament; Anterior Talofibular ligament; Calcaneofibular ligament) or the Anterior tibiofibular ligament (high ankle sprain) High ankle sprains increase recovery time Deltoid ligaments (medially) are less common injuries Symptoms Pain over injured ligament, swelling; loss of function Report a popping sound followed by immediate swelling and inability to walk a more severe sprain History of ankle sprains may indicate chronic ankle instability PE Ecchymosis and swelling around entire ankle joint not just lateral side Tenderness on palpation over the anterior talofibular and calcaneofibular ligament Palpate the lateral and medial malleolus and base of the 5th MT for crepitus or tenderness caused by fracture Pain in anterior tibiofibular ligament suggests high ankle sprain squeeze test – compress the tibia and fibula together at mid calf external rotation test – Dorsiflex the ankle and ext rotate the foot pain in region of distal tibiofibular junction (aka syndesmosis) is positive for high ankle sprain Diagnostic Tests Tenderness over the distal fibula, ankle joint, syndesmosis or other boney structure x rays are needed to evaluate for fracture Marked swelling and inability to bear weight are indications for x rays Treatment:
Goal of treatment is to prevent chronic pain and instability Phase 1 – NSAID’s, ice, compression, elevation, brace or air stirrup to promote soft tissue healing. WB as tolerated, crutches as needed. 48° after injury contrast baths. Severe sprains may need cast or cast boot for 3 weeks to facilitate healing and walking Phase 2 – begins when patient can bear weight w/o increased pain or swelling (usually 2-4 weeks). Begin exercises to increase peroneal and dosiflexion strength, Achilles tendon stretching also. Continue until patient has full ROM and 80% strength. (NO plantar flexion exercises since this position is the least stable position of the ankle) Phase 3 – usually begins 4-6 weeks after the injury. Begin functional conditioning: proprioception, agility and endurance training. Proprioception – stand on injured ankle, elevate other foot, close eyes Agility and Endurance – running (walking) in progressively smaller Figure of 8 patterns strengthens peroneal muscles and adds to agility. Begin to wean patient off air stirrup or brace Long term bracing may be indicated for the athlete involved in high risk ankle sprain sports – volleyball, basketball and soccer. Failure to improve indicates need for further evaluation.
Musculoskeletal System
Disorders of the Shoulder Fractures/dislocations Rotator cuff disorders Separations Sprain/strain Disorders of the Forearm/Wrist/Hand Fractures/dislocations • Boxer's • Colles' • Gamekeeper's thumb • Humeral • Nursemaid's elbow • Scaphoid Sprains/strains Tenosynovitis • Carpal tunnel syndrome • de Quervain's tenosynovitis • Elbow tendinitis • Epicondylitis Disorders of Back/Spine Ankylosing spondylitis Back strain/sprain Cauda equina Herniated disk pulposis Kyphosis/scoliosis Low back pain Spinal stenosis Disorders of the Hip Aseptic necrosis Fractures/dislocations Slipped capital femoral epiphysis Disorders of the Knee Bursitis Fractures/dislocations Meniscal injuries Osgood-Schlatter disease Sprains/strains Disorders of the Ankle/Foot Fractures/dislocations Sprains/strains Infectious Diseases Acute/chronic osteomyelitis Septic arthritis Neoplastic Disease Bone cysts/tumors Ganglion cysts Osteosarcoma Osteoarthritis Osteoporosis Rheumatologic Conditions Fibromyalgia Gout/pseudogout Juvenile rheumatoid arthritis Polyarteritis nodosa Polymyositis Polymyalgia rheumatica Reiter's syndrome Rheumatoid arthritis Systemic lupus erythematosus Scleroderma Sjogren's syndrome
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% of Exam Content Knowledge & Skill Areas
16
History Taking & Performing Physical Examinations Using Laboratory & Diagnostic Studies Formulating Most Likely Diagnosis Clinical Intervention Clinical Therapeutics Health Maintenance Applying Scientific Concepts
14
18
14 18 10 10 Total: 100%
The tasks you’ll be tested on can be grouped into seven categories. Click on the category for a list of tasks and evaluative objectives that will help you gauge the depth of knowledge required.
1. History Taking & Performing Physical Examinations Knowledge of: • Etiologies associated with presenting symptoms or physical findings. • Signs and symptoms of selected medical conditions. • Risk factors for development of selected medical conditions. • Pertinent historical information associated with selected medical conditions. • Physical examination techniques. • Physical examination of findings associated with selected medical conditions. • Appropriate physical examination directed to selected medical conditions. Skills in: • Identification of pertinent historical information.
• Association of current complaint with presented history. • Identification of pertinent physical examination information.
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2. Using Laboratory & Diagnostic Studies Knowledge of: • Indications for initial and subsequent diagnostic or laboratory studies. • Cost effectiveness of diagnostic studies or procedures. • Relevance of common screening tests for selected medical conditions • Normal and abnormal diagnostic data. Skills in: • Selection of appropriate diagnostic or laboratory studies. • Collection of diagnostic or laboratory specimens. • Interpretation of diagnostic or laboratory studies results. • Prediction or diagnostic or laboratory studies results.
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3. Formulating Most Likely Diagnosis Knowledge of: • Interpreting history as probable cause to differentiate disorders. • Interpreting particular physical findings in order to differentiate disorders. • Clinical implications and correlation of subjective and objective data. Skills in: • Correlation of normal and abnormal diagnostic data. • Formulation of differential diagnosis. • Selection of most likely diagnosis in light of presented data.
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4. Clinical Intervention Tasks: • Indications, contraindications, complications, and techniques for selected procedures. • Management of selected medical conditions to exclude pharmacologic agents. • Follow-up and monitoring of therapeutic regimens. • Indication for admission to hospital or other facilities. • Conditions that constitute medical emergencies. • Discharge planning • Available medical or surgical options • Universal precautions • Sterile technique • Informed consent • Surgical principles • Wound healing • Appropriate patient education regarding current condition and related risk factors. Skills in: • Formulating and implementing plans
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5. Clinical Therapeutics Knowledge of: • Pharmocokinetic properties of pharmacologic agents used in the treatment of • selected conditions. • Indications, contraindications, side effects, and adverse reactions of • pharmacologic agents. • Follow-up and monitoring of pharmacologic regimens. • Risks for, clinical presentation of, and treatment of drug interactions.
• Risks for, clinical presentation of, and treatment of acute drug toxicity. Skills in: • Selection of appropriate pharmacologic therapy for selected medical conditions.
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6. Health Maintenance Knowledge of: • Epidemiology of selected medical conditions. • Risk factors for conditions amenable to prevention or detection in an • asymptomatic individual. • Relative value of common screening tests for conditions amenable to prevention • or detection in an asymptomatic individual. • Appropriate patient education regarding preventable conditions or needed • lifestyle modifications. • Immunization schedules for infants, children, adults and foreign travelers. • Behavioral change models. • Stress adaptation and coping. Skills in: • Counseling and patient education techniques.
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7. Applying Scientific Concepts Knowledge of: • Underlying pathologic processes or pathways associated with a given condition. • Normal and abnormal anatomy and physiology including human growth, • development and sexuality. • Normal and abnormal microbiology.