Clinical Assessment and Investigation of Foot and Ankle Injuries II

Clinical Assessment and
Investigation of Foot and Ankle
Injuries
Reza Salleh FRACS
Foot and Ankle Injuries
Common
25-40% athletic injuries
7% workplace injuries
Up to 10% of all presentation to ER
HISTORY
Mechanism of injury indicates structures
potentially damaged
Lateral Ligament Complex
Lateral Collateral
Ligament
Complex
:Anterio
r talo-fibular
:Calcaneo-fibular
:Posterior talo-fibular
Mechanism of Injury
Majority of injuries occur in plantar-flexion
and inversion
Tear ATFL
CFL
PTFL
Structures Damaged
Lateral malleolar fractures
Lateral talar process
Anterior process calcaneum
Fracture base of 5th metatarsal
Forced Dorsi-Flexion of the
Ankle
Talar neck fractures
Achilles tendon ruptures
Forced Flexion or Twisting
Through the Mid-Foot
Lisfranc injuries
Fall from a Height, Direct
Impact
Calcaneal fractures
Tibial plafond fractures
Presentation
Pain
Swelling
Bruising
Instability
The “Painful Pop”
Fracture
Ligament/tendon rupture
Ligament dislocation
NO diagnostic significance
Examination
OBSERVATION
gait/ability to weight bear
swelling
bruising
PALPATION
Medial/lateral malleoli
Sinus tarsi (anterior process calcaneum
and lateral talar process)
Mid-Foot
Base of 5th metatarsal
Always palpate full length fibula !
MOVE
Ankle dorsi- and plantar-flexion
Sub-talar joint abduction and adduction
Mid-foot rotation
SPECIAL TESTS
Assess ligament stability
tendon integrity
Assessment of Lateral Ligament
Instability
Inversion stress test
unreliable
Movement through
subtalar complex
Anterior Draw Stress Test
Ankle in plantar flexion
and slight internal
rotation
Assessment of Distal TibioFibular Syndesmotic Instability
Easily missed
High index of suspicion
Always palpate medially
External Rotation Stress Test
Calf Squeeze Test
Assessment of Achilles Tendon
Integrity
Thompson test
Simmond’s test
When do you Xray?
Ottawa Guidelines (Stiell Ann Emerg Med 1992)
:if tender over malleoli, midfoot, 5th
metatarsal
:if unable to walk immediately after injury or
take 4 steps in ED
:reduces unnecessary Xrays 30-40%
If any clinical doubt then Xray
Majority of ankle injuries require Xrays
If suspicious of Maissoneuve injury include
entire fibular shaft
ALL mid-foot injuries require Xrays
Radiological Assessment
Syndesmosis
Ultrasound
Define extent of Achilles tendon ruptures
Always include ultrasound in maximal plantarflexion to determine if rupture opposes
Peroneal tendon ruptures
Lateral ligament injuries
CT Scan
Detect subtle fractures
CT Scan
Define fracture patterns
CT Arthrogram
Detect chondral damage and synovitis
High radiation levels
Only if MRI contra-indicated
MRI Scan
Assess chondral damage, oedema, “bone bruising”
MRI Scan
Assess chondral damage, oedema, “bone bruising”
MRI Scan
Assess ligament/tendon injuries
CONCLUSION
Be aware of the different mechanisms of injury
Careful assessment of bruising and tenderness
Consider special tests
Appropriate investigations