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Soft Tissue Trauma to the Ankle

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					ACUTE SOFT TISSUE TRAUMA OF THE ANKLE AND REARFOOT
Brian J. Novack, DPM Adjunct Clinical Faculty OCPM Surgery Department OCPM Ext. 7321

SOFT TISSUE TRAUMA
• ANATOMY • MECHANISM OF INJURY; PATHOMECHANICS • DIAGNOSIS • TREATMENT

SOFT TISSUE TRAUMASPECIFIC INJURIES
• LATERAL COLLATERAL LIGAMENT DISRUPTION/RUPTURE • DELTOID LIGAMENT DISRUPTION/RUPTURE • PERONEAL TENDON SUBLUXATION • INTRATENDINOUS PATHOLOGY OF PERONEAL TENDONS • SUBTALAR JOINT INSTABILITY/SINUS TARSI SYNDROME

LATERAL COLLATERAL LIGAMENT TRAUMA
• ANATOMY:
» » » » » Ligaments Capsule: Ankle Jt., STJ Retinaculum: IER Tendons Joint morphology

LIGAMENTOUS STRUCTURES
• • • • • • ATFL CFL PTFL CERVICAL LATERAL TALOCALCANEAL INTEROSSEOUS TALOCALCANEAL

ATFL
• BLENDS WITH ANTERIOR ANKLE JT CAPSULEINTRACAPSULAR • RESTRICTS INTERNAL ROTATION OF TALUS • STRESSED UPON PLANTARFLEXION AND INVERSION • LOW LOAD TO FAILURE • INSERTS ONTO BODY OF TALUS • 15-20 MM LONG

CFL
• EXTRACAPSULAR • BLENDS WITH PERONEAL TENDON SHEATH • STRESSED UPON DORSIFLEXION AND INVERSION • INSERTS ONTO SMALL TUBERCLE ON CALCANEUS POST-SUP TO PERONEAL TUBERCLE • 2-3 CM LONG • ATFL AND CFL FORM 105 DEGREE ANGLE • CROSSES BOTH AJ AND STJ

PTFL
• INTRACAPSULAR; WELLVASCULARIZED • MAXIMALLY STRESSED IN DORSIFLEXED POSITION • PREVENTS EXTERNAL ROTATION WITH ANKLE IN DF POSITION • HIGH LOAD BEFORE FAILURE • 3CM LONG

ADJUNCT LIGAMENTS
• CERVICAL: CONNECTS NECK OF TALUS WITH SUPERIOR SURFACE OF CALCANEUS; PROPRIOCEPTIVE ROLE • LATERAL TALOCALCANEAL: BLENDS WITH CFL, ATFL • INTEROSSEOUS T-C: AT MOST MEDIAL ASPECT OF SINUS TARSI; LARGE VASCULAR FORAMEN IS POST. TO ORIGIN

BIOMECHANICS
• ANKLE DORSIFLEXED ATFL LOOSE, CFL TAUT • ANKLE PLANTARFLEXED ATFL TAUT, CFL LOOSE • PTFL STRESSED WHEN ANKLE DORSIFLEXED • MOST COMMON MECHANISM OF INJURY: PF&INVERSION ATFL RUPTURE

PATHOMECHANICS
• MOST COMMON LIGAMENT INJURY INVOLVES ATFL; CAN BE MIDSUBSTANCE TEAR OR AVULSION • CFL TEAR TYPICALLY FOLLOWS ATFL DISRUPTION; ISOLATED CFL TEAR UNCOMMON; MIDSUBSTANCE/AVUL. • PTFL RUPTURE RARE; USUALLY FOLLOWS ATFL AND CFL DISRUPTION

INJURIES ASSOCIATED WITH LCL TRAUMA:
• ANKLE FX • TALAR FX: NECK, LATERAL PROCESS • 5TH MET. BASE AVULSION FX • C-C JT. FX • CUBOID FX • OCD TALAR DOME • ANTERIOR PROCESS CALC. FX • PERONEAL TENDON TRAUMA • MEDIAL ANKLE INJURY • NERVE DAMAGE • SYNDESMOTIC INJURY • BIFURCATE LIGAMENT INJURY • STJ. DISLOCATION/ SINUS TARSI SYNDROME • EDB STRAIN

DIAGNOSIS-LCL TRAUMA
• THOROUGH H&P!!!
– MECHANISM OF INJURY – POINT OF MAXIMAL TENDERNESS – ABILITY TO WALK, BEAR WEIGHT AFTER INJURY – POPPING SOUND, FEELING

PHYSICAL EXAM-LCL TRAUMA
• PALPATION OF LIGAMENTS • ROM OF AJ, STJ • PALPATION OF OSSEOUS STRUCTURES: FIBULA, 5TH MET. BASE • ANTERIOR DRAWER • TALAR TILT • RADIOLOGY

RADIOLOGY
• ANKLE VIEWS: AP, MORTISE, LATERAL • FOOT VIEWS: AP • STRESS VIEWS: ANTERIOR DRAWER, TALAR TILT • ANKLE/STJ ARTHROGRAM, PERONEAL TENOGRAM: only valid within 2-3 days!! • CT • MRI • ULTRASOUND

ANTERIOR DRAWER
• EVALUATES ATFL INTEGRITY • ANTERIOR DISPLACEMENT FORCE APPLIED TO POST. HEEL WHILE TIBIA IS STABILIZED ANTERIORLY • LATERAL VIEW TAKEN • MANUAL OR DEVICE • >5MM ANTERIOR DISPLACEMENT OF TALUS IN MORTISEATFL TEAR

TALAR TILT
• EVALUATES CFL (AND ATFL) • INVERSION FORCE APPLIED TO REARFOOT WHILE TIBIA STABILIZED MEDIALLY • AP ANKLE TAKEN • >15 DEGREES OF TALAR INVERSION OR 6-8 DEGREE GREATER THAN CONTRALATERAL LIMB CFL TEAR

STRESS VIEWS
• INVALID WHEN:
– – – – LIGAMENTOUS LAXITY CHRONIC LATERAL INSTABILITY INADEQUATE ANESTHESIA INADEQUATE MANEUVER/ STRESS

CLASSIFICATIONS
• ANATOMIC SYSTEM:
• GRADE I: ATFL TEAR • GRADE II: ATFL AND CFL TEAR • GRADE III: ATFL, CFL, AND PTFL TEAR

CLINICAL/ATHLETIC CLASSIFICATION
• GRADE I: PT. ABLE TO CONTINUE PLAYING SPORT • GRADE II: PT. ABLE TO BEAR WEIGHT • GRADE III: PT. UNABLE TO BEAR WEIGHT

PREVENTION
• • • • • • HIGH DEGREE OF RE-INJURY!!! PROPER SHOEGEAR TAPING BRACING MUSCLE STRENGTHENING PROPRIOCEPTIVE TRAINING

TREATMENT-ACUTE ANKLE SPRAIN
• P R I C E THERAPY • SEVERE SPRAIN CRUTCHES NWB, BK CAST, COMPRESSIVE SPLINT IF VERY SWOLLEN • LACE-UP, STIRRUP BRACING • PT • NSAIDS • ATHLETES EARLIER MOBILIZATION EARLIER RETURN TO FXN • YOUNG ATHLETES WITH GROSS INSTABILITY SURGICAL TX

SURGICAL TREATMENT
• REPAIR: ANATOMIC; DIRECT PRIMARY REPAIR OF TORN LIGAMENTS; IMBRICATION/AUGMENTATION/BONE ANCHORS • RECONSTRUCTION: NONANATOMIC; USE OF ST GRAFTS TO SERVE AS “NEW” LIGAMENTS; WILL AFFECT STJ MOTION AS WELL AS AJ MOTION; 1 OR 2 LIGAMENT

DELTOID LIGAMENT RUPTURES
• ANATOMY: MULTI-LAYERED; COLLICULI • DEEP DELTOID: PROVIDES GREATEST RESTRAINT AGAINST LATERAL TRANSLATION OF TALUS IN MORTISE (BESIDES FIBULA) • VALGUS TILTING OF TALUS REQUIRES COMPLETE RUPTURE OF SUPERFICIAL AND DEEP DELTOID

DIAGNOSIS
• MOST PTS ALSO HAVE LCL INJURIES, FIBULAR FX’S, SYNDESMOTIC INJURIES. • ISOLATED INJURY RARE • MUST EXCLUDE AFOREMENTIONED INJURIES & PT TENDON, FDL, FHL INJURY • PT NERVE, SAPHENOUS TRAUMA CAN ALSO SEEN WITH D.L. INJURY

DELTOID INJURIES MECHANISM OF INJURY
• STRONG LIGAMENT; REQUIRES CONSIDERABLE FORCE FOR DISRUPTION • CAN OCCUR AFTER PRONATIONEVERSION, INTERNAL ROTATION, FORCED PF OR DF. • SEEN IN SER, P-AB, PER ANKLE FX’S

RADIOLOGY
• • • • ROUTINE ANKLE VIEWS HIGH FIBULAR VIEW EVERSION STRESS RAGIOGRAPHS X-RAYS TYPICALLY NORMAL WITH INCOMPLETE RUPTURE • COMPLETE DL INJURY VALGUS TILT OF TALUS ON WB, STRESS VIEWS • LATERAL DISPLACEMENT OF TALUS IN RELATION TO TIBIA >2MM; 1CM OR MORE INDICATIVE OF COMPLETE DELTOID TEAR (INCREASED MEDIAL CLEAR SPACE)

LATERAL TALAR DISPLACEMENT OF 1MM OR MORE CAN CHANGE TIBIOTALAR CONTACT PROFOUNDLY!!

TREATMENT-DELTOID LIGAMENT INJURY
• DEPENDS ON ASSOCIATED INJURIES • INCOMPLETE TEARSBRACING, WALKING CAST 6-8 WEEKS • COMPLETE TEARS TREATMENT OF ASSOCIATED INJURIES. IF MEDIAL CLEAR SPACE STILL INCREASED AFTER FIXATION OF FIBULAR FX, ETC., THEN DIRECT REPAIR OF LIGAMENT IS INDICATED

PERONEAL TENDON SUBLUXATION
• ANATOMY
– COMMON SYNOVIAL SHEATH – LONGUS LATERAL AND POSTERIOR TO BREVIS – FIBRO-OSSEOUS TUNNEL BEHIND LATERAL MALLEOLUS – SUPERIOR PERONEAL RETINACULUM – POSTERIOR GROOVE: VARIABLE – FIBROCARTILAGINOUS RIDGE

ETIOLOGIC FACTORS
• RAPID DORSIFLEXION OF ANKLE FOLLOWED BY SUDDEN CONTRACTION OF PERONEALS • STJ POSITION EVERTED • 92% ORIGINATED DURING ATHLETIC ACTIVITY • SNOW SKIING!! • RUNNING, FOOTBALL, BASKETBALL, SOCCER

CLASSIFICATION: ECKART AND DAVIS
• GRADE I: RETINACULUM AND PERIOSTEUM SEPARATED FROM FIBROCARTLIGINOUS LIP • GRADE II: FIBROUS LIP ALSO ELEVATED ALONG WITH RET./PERIOSTEUM • GRADE III: THIN FRAGMENT OF BONE ALSO ELEVATED

DIAGNOSIS
• SNAP FOLLOWED BY PAIN • TENDONS OFTEN DISLOCATED AT TIME OF EXAM • ACTIVE CONTRACTION OF PERONEALS WILL PRODUCE SPONTANEOUS DISLOCATION; PF WILL REDUCE TENDONS • REPETITIVE ANKLE DF, THEN PFSUBLUXATION • ALSO CAN HAVE PT. FLEX KNEE WHILE EXTERNALLY ROTATING FOOT SUBLUXATION

RADIOLOGY
• ROUTINE X-RAYS:
– INCREASED ST VOLUME – FIBULAR FX PARALLEL TO LATERAL MALLEOLUS GRADE 3 INJURY

– MRI: SHOW RUPTURE OF SPR, INTRATENDINOUS PATHOLOGY

TREATMENT
• CONSERVATIVE: WALKING CAST, HEEL LIFT, STRAPPINGS, PADDING BEHING LATERAL MALLEOLUS: <60% SUCCESS RATE • MOST AUTHORITIES: SURGICAL CARE FOR ALL ACUTE AND CHRONIC CASES

SURGICAL CARE
• ANATOMIC ST RECONSTRUCTION: RETINACULOPLASTY • TISSUE TRANSFERS: LATERAL SLIP OF ACHILLES TENDON • GROOVE DEEPENING • BONE BLOCK PROCEDURES: KELLY, DuVRIES • RE-ROUTING PROCEDURES: PERONEAL TENDONS UNDERNEATH PART OR ALL OF CFL

INTRATENDINOUS PERONEAL PATHOLOGY
• MOST OFTEN INVOLVES LONGITUDINAL TEARING OF PERONEUS BREVIS TENDON • MECHANISM OF INJURY: PLANTARFLEXION AND INVERSION • MECHANICAL SHEARING AGAINST FIBULA +/OR CFL • ACUTE INJURY OR CHRONIC SHEARING

DIAGNOSIS
• HISTORY OF PAIN, MULTIPLE INVERSION ANKLE SPRAINS • TENDERNESS TO PALPATION ALONG TENDON • FUSIFORM EDEMA ALONG TENDONS, PAIN ALONG ENTIRE COURSE OF PERONEALS TENOSYNOVITIS • MUSCLE STRENGTH TESTING: CAN BE NORMAL • CAN HAVE PAIN UPON RESISTANCE TO ACTIVE EVERSION OF FOOT

RADIOLOGY
• PLAIN FILM: RULE OUT BONY PATHOLOGY; CALCANEAL AXIAL TO VIEW PERONEAL TUBERCLE • PERONEAL TENOGRAM: SENSITIVE FOR INTRATENDINOUS PATHOLOGY BUT NONSPECIFIC FOR TISSUE DAMAGE; INVASIVE • MRI: GOLD STANDARD FOR EVALUATION OF TENDON AND SHEATH PATHOLOGY

CONSERVATIVE TREATMENT
• • • • BRACING STRAPPING NSAID’S ORAL STEROIDS

SURGICAL CARE
• INDICATED FOR PATIENTS WHO FAIL CONSERVATIVE CARE • EVALUATION OF TENDONS AND SHEATH • DEBRIDEMENT OF PROLIFERATIVE SYNOVITIS • DEBRIDEMENT OF DAMAGED TENDON • TENDON REPAIR: 2-0 ABSORBABLE SUTURE

POST-OP CARE
• • • • COMPRESSIVE DRESSING 5-7 DAYS NWB BK CAST 2-3 WKS CAM-WALKER 3 WKS (WB) POST-OP PT

SUBTALAR INSTABILITY
• LIGAMENTOUS SUPPORT TO STJ:
– – – – – CFL LATERAL T-C LIGAMENT LATERAL ROOT OF IER CERVICAL INTEROSSEOUS T-C LIGAMENT

MECHANISM OF INJURY
• FRONTAL PLANE MOTION • SPECIFIC LIGAMENTOUS INJURIES ARE DETERMINED BY POSITION OF FOOT AT TIME OF INJURY
• CFL: STRESSED WHEN ANKLE IS DF • IOL: TENSION WHEN RF IS SUPINATED • CL: RESISTS PATHOLOGIC SUPINATION OF STJ

• ALL PTS. WHO SUSTAIN A TRUE LATERAL ANKLE SPRAIN CAN EXHIBIT S/S SUBTALAR INSTABILITY/ SINUS TARSI SYNDROME

DIAGNOSTIC AIDS
• STRESS VIEWS: LOOK FOR ANTERIOR MIGRATION/ FRONTAL PLANE TILT OF CALCANEUS IN RELATION TO TALUS • STJ ARTHROGRAPHY: FLATTENING OF SYNOVIAL MEMBRANE WITH LOSS OF NORMALLY OCCURRING SYNOVIAL RECESSES • STJ ARTHROSCOPY: SYNOVIAL MEMBRANE PROLIFERATION

STJ INSTABILITY CAN OCCUR ALONE OR IN COMBINATION WITH LATERAL ANKLE INSTABILITY!!!!

OPERATIVE CARE
• CFL REPAIR WITH IMBRICATION • LATERAL ANKLE RECONSTRUCTION PROCEDURES THAT RECONSTITUTE CFL:
• CHRISMAN-SNOOK • ELMSLIE • PLANTARIS GRAFT VS. P.BREVIS

SINUS TARSI SYNDROME
• CAN OCCUR S/P INVERSION ANKLE/RF INJURY • CHRONIC SYNOVITIS OF STJ • DAMAGE TO STJ LIGAMENTS • TENDERNESS TO PALPATION OF SINUS TARSI, ROM OF STJ • PAIN WHEN SUPINATING MIDFOOT ON REARFOOT

STS 2
• MUST RULE OUT TRAUMA TO IDCN • PLAIN FILM: NORMAL • DIAGNOSTIC BLOCK INTO SINUS TARSI-DEEP; MOST USEFUL TOOL IN DX! • MRI • STJ ARTHROGRAPHY

TREATMENT OF SINUS TARSI SYNDROME
• CONSERVATIVE: CORTICOSTEROID INJECTIONS, PT, TAPINGS, NSAIDS, ORTHOTICS • SURGICAL: EXCISION OF FAT PAD AND LIGAMENTOUS FLOOR; PRESERVE IOL AND CL; PRESERVE MEDIAL VASCULAR FORAMEN; DEBRIDEMENT OF PROLIFERATIVE SYNOVITIS; LATERAL OBLIQUE INCISION

THANK YOU
???QUESTIONS???


				
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posted:1/7/2010
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