Lower leg Foot Fracture

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Life structures 101. Lower leg 3 Primary JointsMedial malleolus w/average talusTibial plafond w/talar domeLat malleolus w/lat talus3 Bones:Tibia, Fibula and Talus. 3 sets of Ligaments:Lateral guarantees (ATFL, CFL, PTFL)Syndesmotic LigamentsMedial securities (Deltoid). Tibia. Fibula. Bone. . BONES.

Presentation Transcript

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Lower leg & Foot Fracture/Dislocations Shawn Dowling

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ANKLE 3 Primary Joints Medial malleolus w/average bone Tibial plafond w/talar arch Lat malleolus w/lat bone 3 Bones: Tibia, Fibula and Talus 3 sets of Ligaments: Lateral pledges (ATFL, CFL, PTFL) Syndesmotic Ligaments Medial guarantees (Deltoid) ANATOMY 101

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BONES Fibula Tibia Talus

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LIGAMENTS Syndesmotic Ligaments Medial Collateral Ligaments Lateral Collateral Ligaments

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JOINTS Fibulotalar Tibiotalar (mid) Tibia Fibula Tibiotalar (horizontal) Talus

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Complicated (28 bones, 57 enunciations) Subdivided in 3 fragments & mvts Hindfoot - inv/ever Midfoot - abd/include Forefoot – flex/ext Joints Talo-crural jnt Inversion/eversion Hindfoot – mid foot (Choparts) Inversion/eversion Midfoot – forefoot (Lisfranc's)* Abd/adduction MTP-IP Flex/expansion FOOT

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HINDFOOT bone calcaneus navicular cuboid MIDFOOT Medial cuneiforms metatarsals sesamoids FOREFOOT phalanges

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Choparts Lisfrancs MTP IP

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What are steady cracks? Lower leg shapes a ring Disruption of just 1 structure is steady Disruption of > 1 is unsteady

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Approach to Ankle/Foot X-beams Go through total approach (ABC's) 3 sees AP, lat, Mortise (15-20 ° int spoil) lower leg, Direct proof of damage: survey bones Indirect confirmation of wounds: are all lower leg estimations ordinary? Joint emission? Depict x-beam, as opposed to just naming it

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Management all in all Chip/separation #'s <3mm = Tx as sprain Non-dislodged, non-intra-articular, stable #'s 3 wks NWB thrown, 3-5 wks WB thrown, f/u with cast center Unstable #'s, intra-articular # - talk with Ortho Open – saline splashed dsg, IV ABx, Td, Ortho desperately NV trade off – lessen and call Ortho Urgently

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Diagnosis?Classification?Treatment? Does it transform you mgmt in the event that they have a delicate deltoid tendon?

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Lateral Malleoli #'s MC lower leg #, MOI: usu reversal harm Weber order – used to decide danger of syndesmosis damage and in this way requirement for agent repair Management NWB x 3wks, WB x 3-5wks* Refer B's or C's, Functional bimalleolar's to ortho

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Stable ? Is the area critical? Administration? What estimations/lines do you take a gander at in the lower leg? What do they connote?

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Syndesmosis harm 1 >10 mm B A Medial clear Space <5mm 2 3 4 A-B = talar tilt <3 is typical

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Point out 3 variations from the norm. Analysis? Stable? Treatment?

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Diagnosis? Treatment?

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Bimalleolar/Trimalleolar #'s Involve the average, parallel or potentially back malleoli Splint, torment control, NPO Need to address ortho as they will probably require OR

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Mechanism of harm? Related wounds? Administration?

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PILON # Mechanism of damage pivotal load? Related wounds calcaneus, C,T & L spine, pelvis, intra-stomach. Administration OR, approx half are open cracks

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Description? What would you like to know/evaluate? What would you like to do? How?

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Ankle Dislocations Relatively normal, as a rule assoc w/# Describe the position of foot/bone to tibia If open, Tx accordingly X-beams ought not defer diminishment if NV bargain or skin rising present Analgesia/PS, Reduce, support, post-red movies

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Pediatric Ankle Injuries Not simply minimal grown-up # The tendon connections are more grounded than the physis in this way more #'s, less sprains Overall administration is like grown-ups Although with breaks you can acknowledge more angulation (next to zero dislodging) LLC throws are the underlying decision for most #'s

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Can we apply OAR/OFR in youngsters? Six reviews took a gander at approving OAR in peds Different age bunches (2-18, 6-16) Sens 85*-100*% Considered all # Some viewed as all #, others just "huge #")

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BMJ 2003. Precision of OAR to prohibit breaks of the lower leg and mid-foot: A deliberate audit This review references the majority of the OAR done in kids and additionally grown-ups

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Problems with the reviews Haven't thought of a typical meaning of critical # Unsure of what to do with SH-1, conflicting Dx Local practice (and Edmonton) – variable some apply it, some utilization lead + attentiveness, others utilize clinical judgment

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Conclusion This should be further considered Need to figure out which #'s are huge But I think they will probably be approved Although I think they'll need to Tx SH1 as particular wounds

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Describe crack? Arrangement? Administration? SH-2 LLC x 3 wks, then SLC X 1-3 wks

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Describe break? Order? Administration? SH2 Reduction/immbolize (air cast)

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SALTR L ower (epiphysis) R am (Crush) S traight T hru the Physis A bove (metaphysis)

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Non-agent administration for SH 1-2 Attempt shut lessening, can acknowledge more angulation Long leg cast x 3wks, trailed by SLC x 3wks SH 3-4 - > OR SH 5 - >poor fx visualization Complications for SH 3-5 incorporate development capture, appendage length inconsistency

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Acute Skin corruption NV harm Compartment disorder # Blisters Wound contamination/osteo Chronic Mal-union Non-union Post-traumatic joint inflammation AVN Chronic agony Chronic unsteadiness Ankle # Complications

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Describe # Do you have to address Ortho? ?ottawa lower leg rules Talar Dome # Yes – Ortho to find in cast center

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Describe # Anything unique about this bone? Blood stream distal to proximal like scaphoid and proximal femur, thusly inc AVN hazard Is there an order framework for these #'s?

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Talus Neck Body Head Chopart's joint

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Talar breaks Minor talar cracks Chip and separation breaks of neck ,head, and body. Generally same system as lower leg sprains Talar neck breaks half of major talar wounds. outrageous dorsiflexion compel Hawkins arrangement Talar body breaks 23% of all talar cracks (counting minor cracks) Major talar body cracks are unprecedented normally pivotal stacking (e.g. falls) Talar head cracks Uncommon (5-10%) compressive constrain transmitted up through the talonavicular joint connected on a plantarflexed foot

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Hawkins Classification of Talar Neck Fractures Type 1: = nondisplaced; Type 2: subtalar subluxation Type 3: disengagement of the talar body (half open #'s) Type 4: separation of the talar body & diversion of the talonavicular joint. Break sort impacts administration & visualization Thanks Moby

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Describe harm. Name this injury.v Management?

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Describe harm. Name this damage Lisfranc Management? On the other hand

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What to search for on x-beam: Normally, average part of metatarsals 1-3 ought to adjust to average fringes of cuneiforms Metatarsals ought to be adjusted dorsally to tarsals on horizontal view Medial 4 th metatarsal ought to adjust to average cuboid Any crack or separation of the navicular or cuneiforms or augmenting between metatarsals 1-3 Proximal 2 nd metatarsal # is patho gnomonic Thanks Dave

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Normal Lisfranc joint arrangement Tx: Need to address ortho May attempt shut decrease

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Describe. Administration NWB cast # usu from direct injury

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Describe. Administration Walking cast x 2-3 weeks Avulsion sort #

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Metatarsal # Treatment: Nondisplaced or min uprooted breaks of metatarsal 2-4 stiff shoe, throwing, or crack support. Non uprooted 1 st metatarsal  NWB BK strolling cast (cuz it's a noteworthy WB surface) Displaced 1 st or 5 th metatarsal  ER ortho Attempt shut lessening if >3mm relocation or 10 degrees angulation Thanks Dave

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Phalangeal #'s Non-dislodged: amigo tape, (air give if hallux included a role as they are difficult) Significant removal/angulation: shut diminishment - > talk with ortho if decrease is insufficient (esp w/hallux) If subungal hematoma is available with tuft # - clear hematoma and repair nail bed

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10 °

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Posterior tuberosity pinnacle of front process summit of back feature

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Calcaneus # Management Order Harris (hub view), may require CT Probably ought to address Ortho for all since x-beams under-gauge degree of harm But… non-dislodged, additional articular – NWB cast x 6-8 wks Otherwise, Tx changes extensively and is best dictated by Ortho

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Summary Ankle #'s If #/damage disturbs>1 structure in ring = temperamental or if intra-articular – ortho Otherwise: NWB cast x 3wks Foot Stable, additional articular, wgt bearing surface NWB cast Unstable, or intra-articular – ORTHO Stable, additional articular, non-wgt bearing surface: moderate mgmt (inflexible shoe, strolling cast, pal tape) If in uncertainty, Look up administration of # - excessively numerous particularities to remember

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References Emergency Medicine Reports Management of Acute Foot and Ankle Disorders in the Emergency Department: Part I—The Ankle . Administration of Acute Foot and Ankle Disorders in the Emergency Department: Part I — The Foot. Rosens www.wheelessonline.com Moritz and Dave Dyck's Rounds Google Images