Improving care in ED



2279657299960X-ray Interpretation00X-ray Interpretation2393951157605Anatomy 00Anatomy 46666157289164AP: Med border 2nd MT lines with medial border middle cuneiformOblique: Medial + lateral border 3rd MT lines with medial + lateral border lateral cuneiformMedial border 4th MT lines with medial border of cuboidLateral:MT should never be more dorsal than respective tarsal bone00AP: Med border 2nd MT lines with medial border middle cuneiformOblique: Medial + lateral border 3rd MT lines with medial + lateral border lateral cuneiformMedial border 4th MT lines with medial border of cuboidLateral:MT should never be more dorsal than respective tarsal bone15633707289165001496060408876539992301157605Talus: articulates with navicular and calcaneus; no muscular attachmentsMedial column: 1st MT + medial cunefiormMiddle column: 2-3rd MT + middle + lateral cuneiformsLateral column: 4-5th MT + cuboid Hindfoot: talus + calcaneusChopart joint: hindfoot/midfootMidfoot: med/mid/lat cuneiforms, navicular, cuboidLisfranc: joint between tarsal and metatarsal bones (between midfoot and forefoot)Forefoot: metatarsals and phalanxesTarsus: hindfoot + midfoot00Talus: articulates with navicular and calcaneus; no muscular attachmentsMedial column: 1st MT + medial cunefiormMiddle column: 2-3rd MT + middle + lateral cuneiformsLateral column: 4-5th MT + cuboid Hindfoot: talus + calcaneusChopart joint: hindfoot/midfootMidfoot: med/mid/lat cuneiforms, navicular, cuboidLisfranc: joint between tarsal and metatarsal bones (between midfoot and forefoot)Forefoot: metatarsals and phalanxesTarsus: hindfoot + midfoot1563370115760515633705906770Assessment00Assessment25787355906770May be able to weight bear if impacted; tender ant-lat, axial compression and abduction; leg shortened and externally rotated if extracapsular (internally rotated in dislocation)MRI: 100% sensitivity Bone scan: 95% sensitivity USS: demonstrates effusion00May be able to weight bear if impacted; tender ant-lat, axial compression and abduction; leg shortened and externally rotated if extracapsular (internally rotated in dislocation)MRI: 100% sensitivity Bone scan: 95% sensitivity USS: demonstrates effusion246380539750Foot Injury00Foot Injury 00 1649730856297503105158580120Calcaneal Fracture 00Calcaneal Fracture 37191958579485Most common fractured tarsal bone; associated with other leg injury in 25%, vertebral fracture in 10%, also with pelvic; 75% intra-articular; bilateral in 7%; risk of compartment syndrome; can also get avulsion fractures off anterior process and lateral calcaneum; 50% get chronic painMOI: fall from heightBohler’s salient angle: post tuberosity to highest midpoint / anterior tuberosity to midpoint; normal = 20-40°; fracture if <20°Management: conservative if non-displaced and extra- articular; all need admission00Most common fractured tarsal bone; associated with other leg injury in 25%, vertebral fracture in 10%, also with pelvic; 75% intra-articular; bilateral in 7%; risk of compartment syndrome; can also get avulsion fractures off anterior process and lateral calcaneum; 50% get chronic painMOI: fall from heightBohler’s salient angle: post tuberosity to highest midpoint / anterior tuberosity to midpoint; normal = 20-40°; fracture if <20°Management: conservative if non-displaced and extra- articular; all need admission3105156794500Subtalar Dislocation 00Subtalar Dislocation 30816556794499May be mistaken for ankle dislocation; foot inverted and internally rotated; talonavicular and talocalcneal ligament rupture; calcaneonavicular ligament intact; often associated with talar fracture; difficult to reduce00May be mistaken for ankle dislocation; foot inverted and internally rotated; talonavicular and talocalcneal ligament rupture; calcaneonavicular ligament intact; often associated with talar fracture; difficult to reduce164973067945010016497305270500003105151205230Talar Fracture 00Talar Fracture 30816555271135004464050527113500592709052705000039414451204595Neck and body fracture: neck most common (ie. 50%); due to forced dorsiflexion; associated with subtalar dislocations, avascular necrosis; neck and head fracture require OT ASAPHawkin’s classification: I non-displaced; no incongruity of subtalar joint; avascualr necrosis in 10%II displaced; ankle joint OK (may be subluxation of subtalar joint – distal talus and rest of foot while proximal talus stays OK); 30-50% risk of avascular necrosisIII displaced; dislocation of talus from ankle and subtalar Joint; (head goes anterioly, body goes post-medially, tibia goes between); avascular necrosis in 90%; reduce ASAPTalar dome (ie. Plateau) fracture: difficult to detect; consider in non-healing sprain; OT if displacedLateral process fracture: OTPosterior process fracture: Shepherd’s #, dancers and kickersPilon fracture: due to talus being forced into tibial metaphysis (eg. Fall from height); OT00Neck and body fracture: neck most common (ie. 50%); due to forced dorsiflexion; associated with subtalar dislocations, avascular necrosis; neck and head fracture require OT ASAPHawkin’s classification: I non-displaced; no incongruity of subtalar joint; avascualr necrosis in 10%II displaced; ankle joint OK (may be subluxation of subtalar joint – distal talus and rest of foot while proximal talus stays OK); 30-50% risk of avascular necrosisIII displaced; dislocation of talus from ankle and subtalar Joint; (head goes anterioly, body goes post-medially, tibia goes between); avascular necrosis in 90%; reduce ASAPTalar dome (ie. Plateau) fracture: difficult to detect; consider in non-healing sprain; OT if displacedLateral process fracture: OTPosterior process fracture: Shepherd’s #, dancers and kickersPilon fracture: due to talus being forced into tibial metaphysis (eg. Fall from height); OT1649730413893000164973012052301649730539750Pain in mid-foot AND Inability to weight bear (4 steps) immediately and in ED OR Tender base 5th metatarsal / navicular100% sensitivity, 79% specificity for clinically significant midfoot fractures00Pain in mid-foot AND Inability to weight bear (4 steps) immediately and in ED OR Tender base 5th metatarsal / navicular100% sensitivity, 79% specificity for clinically significant midfoot fractures310515539750Ottawa Foot Rules 00Ottawa Foot Rules 00 3105157990205MT Fracture00MT Fracture16084557990205If >3-4mm displacement or >10° angulation, require OT00If >3-4mm displacement or >10° angulation, require OT16084557622541Buddy strap; OT if great toe and unstable / intra-articular00Buddy strap; OT if great toe and unstable / intra-articular3105157622540Phalanx Fracture00Phalanx Fracture3105155775325Base of 5th MT Fracture00Base of 5th MT Fracture32321505774055Following inversion injury; usually extra-articularTuberosity / styloid fracture: are proximal to jointJones fracture: transverse fracture base 5th MT 1.5-3cm distal to proximal tubercle; intra-articular (intermetatarsal joint between 4th + 5th MT’s); 35-50% non-union rate; OT if >30% articular surface / >2mm displacement (otherwise POP)Pseudo-Jones fracture: avulsion of peroneus brevis tendon (tuberosity); usually non-dispaced; POPDiaphyseal stress #00Following inversion injury; usually extra-articularTuberosity / styloid fracture: are proximal to jointJones fracture: transverse fracture base 5th MT 1.5-3cm distal to proximal tubercle; intra-articular (intermetatarsal joint between 4th + 5th MT’s); 35-50% non-union rate; OT if >30% articular surface / >2mm displacement (otherwise POP)Pseudo-Jones fracture: avulsion of peroneus brevis tendon (tuberosity); usually non-dispaced; POPDiaphyseal stress #156083057740553105152818130Lisfranc Fracture / Dislocation00Lisfranc Fracture / Dislocation32321502817495Most common midfoot fractureMOI: high speed MVA; maybe rotational trauma; hyperextension of forefoot on midfoot dorsal dislocation at tarsoMT joint; may fracture 1st cuneiform and 2nd MT; fracture midfoot in 40%; Lisfranc ligament runs from lateral base medial cunieform to medial base of 2nd MTAssessment: may look normal; pain on passive movement / torsion of forefoot/midfoot with hindfoot heldXR: doesn’t line up as above; may need weight bearing views; bony displacement >1mm = unstable; need CT to see properly; should be <1mm between 1st and 2nd MTClassification: horizontal (all 5 MT’s move); partial / isolated (1 or 2 move); divergent (1st MT moves medially, others laterally)Management: ortho review; maybe conservative if undisplaced; OT if displacedComplication: dorsalis pedis artery compression / laceration; reflex sympathetic dystrophy; ongoing pain and disability; compartment syndrome if significant injury00Most common midfoot fractureMOI: high speed MVA; maybe rotational trauma; hyperextension of forefoot on midfoot dorsal dislocation at tarsoMT joint; may fracture 1st cuneiform and 2nd MT; fracture midfoot in 40%; Lisfranc ligament runs from lateral base medial cunieform to medial base of 2nd MTAssessment: may look normal; pain on passive movement / torsion of forefoot/midfoot with hindfoot heldXR: doesn’t line up as above; may need weight bearing views; bony displacement >1mm = unstable; need CT to see properly; should be <1mm between 1st and 2nd MTClassification: horizontal (all 5 MT’s move); partial / isolated (1 or 2 move); divergent (1st MT moves medially, others laterally)Management: ortho review; maybe conservative if undisplaced; OT if displacedComplication: dorsalis pedis artery compression / laceration; reflex sympathetic dystrophy; ongoing pain and disability; compartment syndrome if significant injury16319502818765310515436880Navicular Fracture00Navicular Fracture16319502272665Rare; usually dorsal avulsion fracture; due to eversion injury; assoc iatedwith deltoid ligament injury; risk of avascular necrosis; ortho review if displaced, intra-articular or comminuted00Rare; usually dorsal avulsion fracture; due to eversion injury; assoc iatedwith deltoid ligament injury; risk of avascular necrosis; ortho review if displaced, intra-articular or comminuted163195043624500512508543688000 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download