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4489450498030500571507447915571501518285396684515182852457451179830Anatomy 00Anatomy 246380539750Ankle Injuries00Ankle Injuries 3136908303895Ankle Fractures00Ankle Fractures16129008997315Classification00Classification27832059535795Weber00Weber34499559535795A00A38322259535795Supination adduction injury; fibula fracture below syndesmosis 1 Fibula only (stable; manage closed) 2 Fibula and medial malleolus (bi) 3 Above + posteromedial tibial fracture (tri)00Supination adduction injury; fibula fracture below syndesmosis 1 Fibula only (stable; manage closed) 2 Fibula and medial malleolus (bi) 3 Above + posteromedial tibial fracture (tri)34499558997315Uni / bi / trimalleolar; bi and tri and unstable, uni depends of extent of damage00Uni / bi / trimalleolar; bi and tri and unstable, uni depends of extent of damage1607820830389560% open fractures are caused by MVA, 10% from GSWUnstable fracture: suggested by swelling of both sides of ankle, deformityStable fracture: suggested by no deformity, minor swelling, unilateral symptoms0060% open fractures are caused by MVA, 10% from GSWUnstable fracture: suggested by swelling of both sides of ankle, deformityStable fracture: suggested by no deformity, minor swelling, unilateral symptoms27832058997315Pott’s00Pott’s3187704160520Ankle Sprain00Ankle Sprain16122657575550Management00Management27901907581265Rest; Ice (10mins per 2hrs for 48hrs) Compression, Elevation (to prevent swelling post-cooling); encourage early mobilisation with ankle strapping, motion and strength exercises at 48-72hrs; maybe OT for III00Rest; Ice (10mins per 2hrs for 48hrs) Compression, Elevation (to prevent swelling post-cooling); encourage early mobilisation with ankle strapping, motion and strength exercises at 48-72hrs; maybe OT for III16122655687060Classification00Classification32156406899275Complete tear of 2+ parts of lateral ligament; severe pain; decreased weight bearing; joint movement with AP stressing; needs POP for 6-8/52 and maybe OT00Complete tear of 2+ parts of lateral ligament; severe pain; decreased weight bearing; joint movement with AP stressing; needs POP for 6-8/52 and maybe OT27838405691505I00I27857456223635II00II27832056899910III00III32156406223000Partial tear (anterior talo-fibular + calcaneofibular); pain at rest; limited weight bearing; moderate-severe pain+swelling; tender inferior to lateral malleolus; mild-moderate instability00Partial tear (anterior talo-fibular + calcaneofibular); pain at rest; limited weight bearing; moderate-severe pain+swelling; tender inferior to lateral malleolus; mild-moderate instability32156405686425Partial tear (usually anterior talo-fibular); little swelling, pain; no altered ROM; can weight bear00Partial tear (usually anterior talo-fibular); little swelling, pain; no altered ROM; can weight bear16122654486910Pathology00Pathology27857454486910Medial = deltoid ligament (10%): usually associated with fracture (Maissoneuve), rarely damaged aloneLateral (90%): Anterior talo-fibular ligament most common (90% of laterals), test with ant drawer test Posterior talo-fibular, test with post drawer test Calcaneo-fibular, test with talar tilt test00Medial = deltoid ligament (10%): usually associated with fracture (Maissoneuve), rarely damaged aloneLateral (90%): Anterior talo-fibular ligament most common (90% of laterals), test with ant drawer test Posterior talo-fibular, test with post drawer test Calcaneo-fibular, test with talar tilt test16122654160520Epidemiology00Epidemiology2783840416052075% ankle injuries are sprains0075% ankle injuries are sprains3187702436495X-Ray Interpretation00X-Ray Interpretation38322252436495On AP: distance between tibia and fibula 1cm proximal to tibial plafond should be <6mm; if not, rupture of distal tibiofibular ligament95% sensitivity overall00On AP: distance between tibia and fibula 1cm proximal to tibial plafond should be <6mm; if not, rupture of distal tibiofibular ligament95% sensitivity overall16129002436495003187701545590Ottawa Ankle Rules00Ottawa Ankle Rules16129001545590Pain near malleoli AND inability to weight bear (4 steps) immediately and in ED OR tender posterior / inferolateral / medial malleolus100% sensitivity; 41% specificity for clinically relevant fractures (98% sensitivity, 50% specificity if 1-15yrs); reduces XR’s by 30%00Pain near malleoli AND inability to weight bear (4 steps) immediately and in ED OR tender posterior / inferolateral / medial malleolus100% sensitivity; 41% specificity for clinically relevant fractures (98% sensitivity, 50% specificity if 1-15yrs); reduces XR’s by 30%1612900541020Hinge/saddle joint; wider anteriorly than posteriorly; thin capsule; curved surface of talus locks into place in dorsiflexion; lateral weaker than medial, especially anterior talofibularSubtalar joint: inferior talus + calcaneus; inversion and eversionMidtarsal joint: talonavicular, calcaneo-cuboid; abduction, adduction of forefootTarso-metatarsal: Lisfranc00Hinge/saddle joint; wider anteriorly than posteriorly; thin capsule; curved surface of talus locks into place in dorsiflexion; lateral weaker than medial, especially anterior talofibularSubtalar joint: inferior talus + calcaneus; inversion and eversionMidtarsal joint: talonavicular, calcaneo-cuboid; abduction, adduction of forefootTarso-metatarsal: Lisfranc318770541020Anatomy00Anatomy 28784557941310High fibular fractureANDDisruption of ankle syndesmosis00High fibular fractureANDDisruption of ankle syndesmosis3067057941310Dupuytren’s Fracture00Dupuytren’s Fracture16122657941945003067056372225Maisonneuve Fracture00Maisonneuve Fracture37534856372226Proximal fibula fracutre (within 6cm of top)ANDMedial malleolus (or deltoid ligament rupture)Unstable; needs OT; due to external rotational force00Proximal fibula fracutre (within 6cm of top)ANDMedial malleolus (or deltoid ligament rupture)Unstable; needs OT; due to external rotational force161290063722250016129005159375Management00Management313690448310Ankle Fractures00Ankle Fractures27832055165090Conservative: minimally displaced (<3mm) avulsion fractures of distal fibula without deltoid ligament injury (ie. Weber A1) = treat as sprainPOP: non-displaced fractures with intact mortice joint without deltoid ligament injury = below knee POPOT: displaced / unstable / mortice incongruity / bi/tri malleolar / contralateral ligament damage00Conservative: minimally displaced (<3mm) avulsion fractures of distal fibula without deltoid ligament injury (ie. Weber A1) = treat as sprainPOP: non-displaced fractures with intact mortice joint without deltoid ligament injury = below knee POPOT: displaced / unstable / mortice incongruity / bi/tri malleolar / contralateral ligament damage1612900446405Classification00Classification2783205441325Weber00Weber344804929171890034480501661160C00C38303201661160Fibula fracture above syndesmosis 1 Fibula only (stable; all involve a tibfib ligament injury; manage closed if stable but careful as posterior ligaments may also be involved) 2 Complex fracture of fibula 3 Proximal fracture of fibula00Fibula fracture above syndesmosis 1 Fibula only (stable; all involve a tibfib ligament injury; manage closed if stable but careful as posterior ligaments may also be involved) 2 Complex fracture of fibula 3 Proximal fracture of fibula3448050440690B00B3830320440690Supination extension rotation injury; fibula fracture at level of syndesmosis; most common 1 Fibula only (stable; manage closed) 2 Fibula and medial malleolus fracture / medial ligament injury (bi) 3 Above + posterolateral tibial fracture (tri)00Supination extension rotation injury; fibula fracture at level of syndesmosis; most common 1 Fibula only (stable; manage closed) 2 Fibula and medial malleolus fracture / medial ligament injury (bi) 3 Above + posterolateral tibial fracture (tri)3162302769870Achille’s Tendon Rupture00Achille’s Tendon Rupture15913104528820Management00Management27482804529455OT if: young and detected <6hrs (lower rates of muscle atrophy, re- rupture; earlier return of activity; risk of infection, skin necrosis, fistula formationEquinus cast otherwise with delayed surgical repair at 2-3/52 if no sign of repair00OT if: young and detected <6hrs (lower rates of muscle atrophy, re- rupture; earlier return of activity; risk of infection, skin necrosis, fistula formationEquinus cast otherwise with delayed surgical repair at 2-3/52 if no sign of repair15913103843020Assessment00Assessment27482803843020Unable to walk / stand on toes; defect 2-6cm proximal to calcaneum; can still plantar flex without resistance; Thompson-Doherty-Simmons squeeze test00Unable to walk / stand on toes; defect 2-6cm proximal to calcaneum; can still plantar flex without resistance; Thompson-Doherty-Simmons squeeze test15913103300095MOI00MOI2748280276860040-50yrs; associated with rheumatoid arthritis, SLE, chronic renal failure, long term steroids, gout, quinolones0040-50yrs; associated with rheumatoid arthritis, SLE, chronic renal failure, long term steroids, gout, quinolones15913102768600Epidemiology00Epidemiology27482803300095Forceful dorsiflexion of foot; blood supply weakest 2-6cm above calcaneus hence most common site of rupture00Forceful dorsiflexion of foot; blood supply weakest 2-6cm above calcaneus hence most common site of rupture316230552450Ankle Dislocation00Ankle Dislocation1591310808355003235960552450Anterior: force on dorsiflexed foot; associated anterior tibial fracturePosterior: most common; usually associated with ruptured tibiofibular ligament or lateral malleolus fracture; posterior force on plantarflexed foot Lateral: results in malleolus fractureSuperiorManagement: relocate ASAP (by ED doc if dusky foot, absent pulse, tenting of skin); hang leg over edge of stretcher with flexed knee grasp toes and calcaneum plantar flex and invert traction moving whole foot in direction oppostite to deformity (usually anterolaterally) OT00Anterior: force on dorsiflexed foot; associated anterior tibial fracturePosterior: most common; usually associated with ruptured tibiofibular ligament or lateral malleolus fracture; posterior force on plantarflexed foot Lateral: results in malleolus fractureSuperiorManagement: relocate ASAP (by ED doc if dusky foot, absent pulse, tenting of skin); hang leg over edge of stretcher with flexed knee grasp toes and calcaneum plantar flex and invert traction moving whole foot in direction oppostite to deformity (usually anterolaterally) OT ................
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