1. Fractures,Sprains, and Soft Tissue Disorders
Foot and Ankle
Fractures,Sprains, and Soft Tissue Disorders

2. Ankle Sprain 25,000 people sprain an ankle every day
85% of the time lateral collateral ligaments injured (anterior talofibular and calcaneofibular)
Inversion injury
5% syndesmosis injury
symptoms: pain, swelling, loss of function
Treatmentis aimed at preventing chronic pain and instability
NSAIDS, ice, compression, elevation
Air stirrup, WBAT, and physical therapy
Should improve in 6 weeks

3. Ankle Fractures
Fractures involve the medial or lateral malleolus, the posterior lip of the tibia, the collateral liagamentous structures, or the talar dome
Stable fractures= one malleolus , no ligaments
Unstable fractures= both malleoli or a distal fibula and disruption of the deltoid ligament
Unstable fractures= vulnerable for displacement, instability, and posttraumatic arthritis

4. Symptoms: pain, swelling, tenderness, deformity
Examination: include evaluation of the posterior tibial pulse and posterior tibial nerve (plantar sensation)
X-rays: AP, lateral, oblique (mortise view)
Cat Scan for complex fractures with articualr surface involvement or lateral portion of the distal tibia

5. Treatment:
Stable unimalleolar fxs= WB SLC
Unstable fractures= ORIF

6. Maisonneuve Fracture
Fracture of the proximal fibula with torn medial deltoid ligament, and disruption of the ankle mortise
Palpate proximal fibular with all medial ankle pain presentations
Treatment= ORIF

7. Fractures of the Hindfoot
Talus fracture: usually result of severe trauma
Calcaneus fracture: MVA or fall from a height
Sx: tenderness over talonavicular joint anterior to the medial malleolus, tenderness with side to side compression of the heel, swelling in the heel & ankle, and the inability to weight bear
Tx: ORIF
* watch for plantar compartment syndrome*
Talus fx: can lead to osteonecrosis

8. Fracture of the Metatarsal
Jones’ Fracture: proximal metaphysis of the fifth metatarsal
propensity for non or delayed union
NWBC 6 weeks, folllowed by WB cast until healing occurs
Base of the Fifth Metatarsal Fracture: inversion injury
R/O with suspicion of ankle fracture
Most respond to closed reduction

9. Fracture of the Midfoot
Lisfranc Fracture-Dislocation
Critical injury to the second tarsometatarsal joint=stabilizing apex for the other tarsometatarsal joints since it “keys” into a slot in the cuneiforms
*Easily missed and misdiagnosed as an ankle sprain*

10. Exam
Careful examination will reveal area of maximum tenderness over the tarsometatarsal joint
Stabilize the calcaneus and rotate and/or adduct the forefoot=severe pain
X-rays
AP, laterl, oblique views of the foot, standing if possible
Common error is to obtain only ankle films
Normal alignment=medial aspect of the middle cuneiform with the medial aspect of the second metatarsal base
Stress views , CT, MRI

11. Treatment Significant swelling occurs-elevate and ice
Beware of Compartment Syndrome
Nondisplaced injuries=NWBC
Displaced=ORIF

12. Morton’s Neuroma
Fibrosis of the common digital nerve as it passes between the metatarsal heads
*commonly between the third and fourth toes*
Sx: plantar pain, numbness, and “walking on a marble”
* firmly squeeze metatarsal heads with one hand while applying direct pressure to the interspace with the other
Tx: metatarsal bar, injection, surgical excision

13. Plantar Fasciitis
Plantar heel pain that occurs where the plantar fascia arises from the medial calcaneal tuberosity
Sxs: focal pain often increased upon awakening or when rising from a resting postion
Tx: 95% conservative treatment
Achilles & plantar fascia stretching, night splints, NSAIDs, injection

14. Achilles Tendinitis & Rupture
Rupture: sudden, severe calf pain described as a gunshot wound or direct hit
Middle-aged men = weekend athletes
Swelling and ecchymosis from the calf to heel
Weakness with push-off
+ Thompson test=absence of plantar flexion with calf compression

15. Tendinitis: insertional or 4-5 cm proximal
Insidious pain that increases with exercise
Often after a change in training habits
Protuberant posterolateral bony proces of the calcaneus
Treat conservatively

16. Shin Splints
Chronic leg Pain- palpation of the tibial crest will usually identify a pinpoint spot
Compression of the tibia and fibula will result in pain at the fracture site
Tx: reduction in athletic activity 4-6 wks
NSAIDs
Removable cast for ambulation
Progressive training shedule: no more than 10% week

17. Diabetic Foot: Charcot Foot
Insensate foot fails to provide sensory feedback, causing the skin to break down due to unperceived repetitive trauma
3 major clinical problems=diabetic ulceration, deep infection, and Charcot joints
Sxs: hot, red, swollen with intact skin
Elevate foot 5 mins=Charcot will lose redness

18. Evaluation must include checking for cellulitis, osteomyelitis, and gout
X-rays
Vascular studies if pulses are absent or a nonhealing ulcer is present
There is no noninvasive study that differentiates Charcot xray changes from osteomyelitis: GENERALLY- osteomyelitis will develop only if the skin has been violated