Talar fracture mechanism
axial loading or hyperdorsiflexion (MVC, fall from height)
Most common fracture of the talus
Talar neck (50%)
Complication with talar fracture
tenuous blood supply runs distal to proximal along talar neck ■ high risk of AVN with displaced fractures
How to determine extent of AVN
MRI
Talar fracture treatment
• non-operative
■ indication: non-displaced
■ NWB, below-knee cast x 6 wk
• operative
■ indication: displaced
■ ORIF (high rate of nonunion, AVN)
■ neck fracture: ORIF
What are the components of the medial ankle ligament complex (deltoid)
Posterior tibiotala
Anterior tibiotalar
Tibiocalcaneal
Tibionavicular
What is the most common tarsal fracture
calcaneal
What needs to be r/o with calcaneal fracture
spine injury (fractures of thoracic or lumbar spine)
bilateral calcaneal fractures
Clinical features of calcaneal fracture
- marked swelling, bruising on heel/sole
- wider, shortened, flatter heel when viewed from behind
- varus heel
calcaneal fracture investigations
- X-rays: AP, lateral, oblique foot (mandatory views); can also assess with Broden view, Harris view, or AP ankle.
- loss of Bohler’s angle
- CT: gold standard, assess intra-articular extension
calcaneal fracture treatment
- closed vs. open reduction is controversial
- NWB cast x 3 mo with early ROM and strengthening
- Avoid wound complications (10-25%)
- Restore articular congruity
- Restore normal calcaneal width and height
- Maximum functional recovery may take longer than 12 mo
Achilles tendonitis mechanism
• chronic inflammation from activity or poor-fitting footwear • may also develop heel bumps (retrocalcaneobursitis or Haglund deformity
Achilles tendonitis clinical features
- pain, stiffness, and crepitus with ROM
* thickened tendon, palpable bump
Achilles tendonitis investigations
• X-ray: lateral, evaluate bone spur and calcification;
U/S, MRI (to assess degenerative change)
Achilles tendonitis treatment
• non-operative
■ rest, NSAIDs, shoe wear modification (orthotics, open back shoes)
■ heel sleeves and pads are mainstay of non-operative treatment
■ gentle gastrocnemius-soleus stretching, eccentric training with physical therapy, deep tissue calf massage
■ shockwave therapy in chronic tendonitis
■ DO NOT inject steroids (risk of tendon rupture)
What is a Haglund Deformity
an enlargement of the posterior superior tuberosity of the calcaneus
What is the best test for MCL in the elbow
Moving valgus stress test
Achilles tendon rupture mechanism
- loading activity, stop-and-go sports (e.g. squash, tennis, basketball)
- secondary to chronic tendonitis, steroid injection
Achilles tendon rupture clinical features
audible pop, sudden pain with push-off movement
- pain or inability to plantarflex
- palpable gap
- apprehensive toe off when walking
- weak plantarflexion strength
• Thompson test: with patient prone, squeeze calf, normal response is plantar flexion
■ no passive plantarflexion s positive test = ruptured tendon
Achilles tendon rupture investigations
• X-ray (to rule out other pathology),
U/S or MRI (for partial vs. complete ruptures)
Achilles tendon rupture treatment
• non-operative
■ indication: low athletic demand or elderly
■ cast foot in plantar flexion (to relax tendon) x 8-12 wk
• operative
■ indication: high athletic demand
■ surgical repair, then cast as above x 6-8 wk
Most common site of Achilles tendon rupture
2-6 cm from insertion where blood supply is the poorest
Complications of Achilles Tendon rupture
- Infection
- Sural nerve injury
- Re-rupture: surgical repair decreases likelihood of re-rupture compared to nonoperative management
Plantar fasciitis (heel spur syndrome) definition
- inflammation of plantar aponeurosis at calcaneal origin
- common in athletes (especially runners, dancers)
- also associated with obesity, DM, seronegative and seropositive arthritis
