Foot and ankle
Anatomy
Muscles, nerves, arteries: Figures 8-3, 8-4AB, and 8-5A-C
Figure 8-3. Dorsal view of the foot sole. (From Netter illustration from www.netterimages.com. Copyright Elsevier Inc. All rights reserved.)
Physical examination
Inspect for edema, erythema, ecchymosis, deformity, callus formation, ulceration, and hairlessness. On standing examination, note hindfoot alignment. Assess gait pattern.
Normal range of motion: Table 8-2
Table 8-2.
Normal Ankle/Foot Range of Motion
| Ankle dorsiflexion | 10-23 degrees |
| Ankle plantarflexion | 23-48 degrees |
| Inversion | 5-35 degrees |
| Eversion | 5-25 degrees |
| First metatarsophalangeal dorsiflexion | 45-90 degrees |
| First metatarsophalangeal plantarflexion | 10-40 degrees |
Differential diagnosis: Table 8-4
Table 8-4.
| Anterior ankle pain | Ankle arthritis, osteochondral dessicans talus |
| Medial ankle pain | Posterior tibial tendinopathy, medial malleolar injury |
| Lateral ankle pain | Peroneal tendinopathy, ankle sprain |
| Posterior ankle pain | Achilles tendinopathy or rupture, os trigonum, posterior impingement |
| Midfoot | Lisfranc injury, midfoot arthritis |
| Forefoot | Metatarsal fracture, stress fracture, metatarsalgia |
| Heel pain | Plantar fasciitis, calcaneal stress fracture, insertional Achilles tendinopathy |
| Great toe | Hallux rigidus, hallux valgus |
| Lesser toes | Toe fracture, hammertoe deformity, Morton neuroma |
Ankle arthritis
Imaging
Radiographs: Weight-bearing anteroposterior (AP), mortise, lateral
Treatment options
Operative management
Operative indications
Ankle arthrotomy with debridement/loose body removal
• Generally has limited value and indicated only in mild arthritis without significant joint space narrowing
• Indications: painful tibiotalar arthritis not responsive to nonoperative treatment, failed arthroplasty
• Contraindications: acute infection, acute neuropathic arthropathy, severe vascular disease
• Indications: tibiotalar arthritis not responsive to nonoperative management, low demand patients older than age 50-55 years, weight < 200 lb, maintained range of motion, normal/near normal alignment, no preexisting subtalar arthritis.
• Contraindications: acute infection, significantly diminished bone stock, neuropathy, severe vascular disease. Relative contraindications include deformity greater than 5 degrees and talar avascular necrosis.
Informed consent and counseling
• Major risks include nonunion (<10%), wound complications, nerve injury, infection, deep vein thrombosis (DVT), hardware loosening/failure, and development of arthritis in hindfoot/subtalar joint. A risk of amputation exists in cases of severe complication (≤5%).
• The complication rate increases with nicotine use, neuropathy, and vascular disease.
• Informed consent and counseling: Risks are similar to arthrodesis (infection, wound complications, DVT, hardware loosening). Recent studies report 10% to 30% reoperation rate and survival rates of 77% to 90% at 5- and 10-year follow-up. If surgery fails, consider conversion to arthrodesis (contraindicated in infection). Limited revision options are available.
Surgical procedures
Ankle arthrodesis (Fig. 8-8AB)
Figure 8-8. Postoperative anteroposterior (A) and lateral (B) views following ankle arthrodesis using anterior plate.
• Many implants for fixation are available, the most common being an anterior plate with cross-screws. An intraoperative radiograph is used to confirm appropriate placement.
• Open anterior approach is most common. An incision is made over the ankle between anterior tibial tendon and extensor hallucis longus (EHL).
• Structures at risk include superficial peroneal nerve and neurovascular bundle (posterior to EHL).
• The neurovascular bundle is mobilized, and the tibial osteophytes are removed to visualize joint. The joint is prepared by removing any remaining articular cartilage, and microfracturing and/or drilling the subchondral bone. A lamina spreader can be helpful for visualization.
• Align neutral dorsiflexion/plantarflexion, 0 to 5 degrees hindfoot valgus, 5 degrees external rotation. An intraoperative radiograph is used to determine correct alignment for fixation.
• A sugar tong splint is applied in the operating room after closure. The patient remains non–weight bearing.
Estimated postoperative course
• Sutures are removed and radiographs are obtained. A non–weight-bearing cast is applied for 4 weeks.
• Radiographs reviewed. The patient is transitioned to a weight-bearing cast for an additional 6 weeks.
• Remove cast. Obtain radiographs to evaluate for healing.
• Physical therapy is generally not indicated, but some patients may need some therapy for gait training.
Total ankle arthroplasty (Fig. 8-9AB)
• Second- and third-generation implants are now available, but there are still limited data on longevity. First-generation implants have a high failure rate.
• Both 2 and 3 component implants are available, primarily depending on surgeon preference.
• An open anterior approach is used as described in ankle arthrodesis. Major structures at risk include the superficial peroneal nerve and neurovascular bundle.
Subtalar arthritis
Imaging
Treatment options
Initial treatment should be nonoperative. NSAIDs, lace-up ankle brace, weight loss if indicated, activity modification (limit uneven surfaces), and corticosteroid injections
Operative management
Operative indications
Informed consent and counseling
Risks include infection, wound complications, arthritis in surrounding joints, nonunion (reported rates 0.5%), DVT, symptomatic hardware (especially if screw heads are prominent posteriorly). Some patients feel instability on uneven ground. At-risk structures: superficial peroneal and sural nerves, peroneal tendons
Surgical procedure
• Lateral incision is made about 2 cm distal to lateral malleolus, extending to the base fourth metatarsal. Extensor digitorum brevis is reflected to expose subtalar joint. Peroneal tendons are elevated from lateral calcaneous and retracted.
• Any remaining cartilage is removed, and the joint is debrided to cancellous bone.
• Fusion is performed at 5 degrees valgus. Two cannulated screws are placed from the non–weight-bearing portion of calcaneus toward the anterior margin posterior facet into the talus. Divergent screws have improved compression forces compared with parallel screws or a single screw. Intraoperative radiographs and guidewires are used to ensure appropriate placement of screws (Fig. 8-11).
Figure 8-11. Lateral radiograph status post subtalar arthrodesis using two divergent cannulated screws.
• The patient may require bone grafting or bone block if bone loss is present from previous trauma/calcaneal fracture.
• A posterior splint is applied in the operating room after closure. The patient remains non–weight bearing for 2 weeks.
Estimated postoperative course
Postoperative 2 weeks: sutures removed. Non–weight bearing in a boot. Remove boot multiple times daily for ankle motion to prevent stiffness.
Postoperative 6 weeks: radiograph reviewed. Start weight bearing in boot from weeks 6 to 12.
Ankle fractures
Physical examination
Edema, ecchymosis, tenderness over fracture site. Medial tenderness without medial malleolus fracture suggests deltoid ligament injury; does not necessarily signify unstable ankle joint
Fracture blisters with severe edema and soft tissue trauma
Visual deformity present if ankle dislocated or severe displacement of fracture
Imaging
• Weight-bearing ankle AP, mortise, lateral. Assess fracture, alignment, displacement.
• Weight bearing foot AP, oblique, lateral. Assess for fracture or malalignment.
• Stress radiographs of the ankle should be performed for isolated fibular fractures at the level of the ankle joint. To perform, gravity stress or external rotation and/or abduction stress is applied in a non–weight-bearing mortise view. Medial clear space greater than 4 to 5 mm indicates deltoid ligament injury and ankle instability (Fig. 8-12).
• Compare with contralateral ankle (mortise view is best). A 2-mm side-to-side difference in medial clear space indicates instability.
• CT scans are helpful to evaluate comminution and subtle displacement. Scan should be performed of bilateral ankles to compare syndesmosis and medial clear space.
• MRIs are usually not necessary but can be useful to evaluate the deltoid ligament and help determine ankle stability.
Classification systems
Danis-Weber classification is based on the location of the fibular fracture and does not address the medial structures.
• Type A: Transverse fracture at the level of or distal to the tibial plafond
• Type B: Spiral, oblique fracture at the level of distal tibiofibular joint and extends proximally. Associated with possible disruption of syndesmosis (Fig. 8-13).
• Type C: Fracture proximal to distal tibiofibular joint. Syndesmosis completely disrupted; anterior and posterior tibiofibular ligaments and interosseous membrane ruptured (Fig. 8-14)
Initial treatment
Treatment options
Weber A fractures: Nearly all can be treated nonoperatively, even with mild displacement.
• Immobilization in cast or walking boot, weight bearing as tolerated. Most fractures heal in 6 weeks.
• Consider nonoperative management when medial clear space is less than 4 to 5 mm and less than 2 mm greater than contralateral side on stress and static radiographs.
• Immobilization in cast or walking boot for 6 weeks. Weight bearing is progressed as tolerated.
• Frequent follow-up with radiographs (weekly for first 2 to 3 weeks). Surgical fixation is recommended if there is a change in stability or alignment.
• After 6 weeks of immobilization, transition to brace. Physical therapy may be helpful to regain motion and strength.
Operative management
Codes
Informed consent and counseling
Risks include wound complications, infection, nonunion, and DVT. The rate of complication is significantly higher in diabetics, nicotine users, and patients with peripheral vascular disease. Post-traumatic arthritis may still occur despite proper stabilization. Major structures at risk are the superficial peroneal nerve (crosses fibula approximately 4 to 5 cm proximal to joint) and saphenous vein (for medial incisions).
Surgical procedure
Open Reduction, Internal Fixation
• Distal fibular fractures—Multiple hardware options are available including locking and nonlocking plates and screws. Locking plates should be used when bone quality is poor or a patient is at high risk for nonunion (diabetes, osteoporosis).
• Medial malleolus fractures—Fixation devices include lag, partially threaded, or cannulated screws; Kirshner wires; tension bands; and buttress plate (used only for vertical sheer fractures to prevent proximal migration of fracture fragment).
Use a lateral approach for fixation of distal fibula, syndesmosis, and possibly posterior malleolus. Longitudinal incision is made directly over the distal fibula. Fibular fracture is reduced and stabilized, restoring proper length and rotation. Intraoperative radiograph is used for reduction, to confirm proper screw length, and to determine stability. After ORIF fibula, a radiograph is taken to evaluate medial clear space. If widening is present after ORIF fibula, a syndesmotic screw is placed (Fig. 8-15).
Estimated postoperative course
Postoperative 2 to 3 weeks: Sutures removed. Radiographs are obtained at each postoperative visit until complete healing is noted.
Postoperative 8 to 10 weeks: Discontinue boot and progress to shoe with ankle brace.
Plantar fasciitis (PF)
Morton’s (intermetatarsal) neuroma
Physical examination
Tenderness to palpation of intermetatarsal space. Pain is not reproduced with palpation of metatarsal heads or metatarsal-phalangeal (MTP) joints.
Mulder’s sign: Squeeze forefoot medial to lateral and apply dorsal pressure over affected web space. Positive test is audible or palpable click that causes pain.
Imaging
Treatment options
Surgical procedure
• Dorsal approach: A longitudinal incision is made over the involved web space. The dorsal interosseous fascia is split and retracted. Interosseous muscle is partially detached, metatarsal heads are retracted, and the intermetatarsal ligament is cut. The neuroma is exposed by retracting the digital artery and lumbrical muscle.
• Plantar approach: This is generally reserved for revision procedures. A longitudinal incision is made between the metatarsal heads. The plantar fascia is split and retracted to expose the neuroma.
• Once neuroma is exposed, it is dissected proximally and cut. The proximal stump retracts into the intrinsic muscles.
• Evaluate vascular status after excision to ensure digital artery intact and functioning.
Estimated postoperative course
Dorsal approach: weight bearing as tolerated in hard-soled post-operative shoe. Progress to normal shoe wear and activities as tolerated once incision healed, usually between 2 and 3 weeks postoperative.
The plantar approach requires greater protection with a splint or cast boot and more limited weight bearing to prevent wound complications. Sutures are removed 2 to 3 weeks postoperative. Progress to normal shoe wear and activities as tolerated once the wound has completely healed. This may be 3 to 4 weeks postoperative.
Diabetic foot and charcot arthropathy
Physical examination
Visual deformities: Claw-toe deformities are common from loss of intrinsic muscle tone. Rocker-bottom midfoot deformity is often present in Charcot arthropathy of midfoot.
• Inspect for presence of corns or calluses, open wounds, swelling, trophic changes, dependent rubor (arterial insufficiency), and bony prominences.
• Ulcers often develop at sites of callus formation or as a result of microtrauma.
• Increased warmth compared with the contralateral side can indicate Charcot arthropathy, venous insufficiency, or infection.
Imaging
Radiograph: weight-bearing AP, lateral, oblique of foot and AP, lateral, mortise of ankle
Classification systems
Multiple classification systems for diabetic foot ulcers, and Charcot arthropathy
Pinzer “risk factor” system to guide treatment of diabetic patients
• Risk Category 0: Normal appearance and sensation, mild to no deformity
• Risk Category 1: Normal appearance, insensate, no deformity
• Risk Category 2: Insensate foot with deformity, no history of prior ulcer
• Risk Category 3: Insensate foot with deformity and history of prior ulcer
Classification system of Charcot arthropathy:
• Stage 0: Clinical examination findings of erythema and edema. Radiographs are normal.
• Stage I: Fragmentation or dissolution phase. Radiographs demonstrate periarticular fragmentation, subluxation, or dislocation of joint. On examination, foot is warm, edematous, and erythematous.
• Stage II: Coalescence period, early healing phase. Radiographs show early sclerosis, fusion of bony fragments, and absorption of debris. On examination, there is less erythema and warmth than stage I.
• Stage III: Reconstruction phase. Radiographs reveal subchondral sclerosis, osteophytes, and narrow or absent joint spaces. On examination, visual deformity is present and there is no acute inflammation.
Treatment options
At-risk patients without Charcot arthropathy: based on Pinzur classification
• Risk Category 0: education, normal footwear, yearly clinical examination
• Risk Category 1: education, daily foot self-examination, protective over-the-counter insoles, appropriate footwear, biannual clinical examination
• Risk Category 2: education, daily foot self-examination, custom pressure-dissipating accommodative orthoses, inlay depth soft-leather shoes, clinical examination every 4 months
• Risk Category 3: education, daily foot self-examination, custom pressure-dissipating orthoses, inlay depth soft-leather shoes, clinical examination every 2 months
Charcot arthropathy: based on stage
• Stage I: immobilization using total contact casting, which reduces total load on the foot by one third. Length of immobilization depends on progression of disease/collapse, often 2 to 4 months.
• Stage II: ankle-foot orthosis or Charcot restraint orthotic walker (CROW) boot.
• Stage III: accommodative shoe and custom insole to decrease pressure on bony prominences
Surgical procedures
Amputation: Level of amputation and surgical techniques vary, depending on disease involvement.
Arthrodesis: As described in earlier sections of the chapter
Metatarsal fractures (including jones fracture)
Imaging
Classification system
Fifth metatarsal fractures are classified on the basis of location. Treatment recommendations are based on this classification system.
• Zone 1 (avulsion): Fifth metatarsal tuberosity fracture. Most common type (>90%). Often extends from insertion of peroneal brevis to involve the tarsometarsal joint.
• Zone 2 (Jones fracture): Distal to the tuberosity at metaphyseal-diaphyseal junction. Fracture extends to fourth to fifth intermetatarsal joint. Mechanism is adduction or inversion of the forefoot (Fig. 8-18).
Figure 8-18. Jones fracture of the fifth metatarsal.
• Zone 3: Proximal diaphyseal shaft fracture. Rare, less than 3% of fifth MT fractures. Frequently a stress injury and patients may report prodromal pain.
Treatment options
• First MT fractures nondisplaced, stable: immobilization (short leg cast or cast boot) for 6 weeks, weight bearing as tolerated.
• Lesser MT fractures nondisplaced or mild displacement (<4 mm translation, ≤10-degree sagittal angulation): hard-sole shoe for 4 to 6 weeks, weight bearing as tolerated.
• Zone 1: hard-soled shoe or short cast boot for 4 to 6 weeks, weight bearing as tolerated. Consider ORIF for significantly displaced fractures.
• Zone 2: short leg cast immobilization for 6 to 8 weeks, non–weight bearing.
• Concern for nonunion with nonoperative treatment exists, especially in noncompliant patients. ORIF is recommended for high-level athletes.
• Zone 3: high risk of nonunion, most surgeons recommend ORIF. If nonoperative treatment used, short leg cast immobilization with protected weight bearing for up to 3 months.
Surgical procedure
Orif fifth metatarsal fracture
Procedure: Screw fixation of fifth metatarsal fracture Zone 2 (Jones fracture)
• Longitudinal incision is made proximal to base of the metatarsal just dorsal to the border of the dorsal and plantar skin. Dissection performed down to bone.
• A guidewire is used to access the intramedullary canal from dorsal and medial position, under guidance of an intraoperative radiograph. Screw length is determined, and a 5.5-mm screw is placed across the fracture. The screw should be long enough for half of the threads to cross the fracture site. The screw is countersunk to decrease the risk of soft tissue irritation postoperatively. Due to the bend of the fifth MT, a screw with excess length can increase varus stress and result in a nonunion (Fig. 8-19).
Figure 8-19. Intraoperative radiograph demonstrating guidewire and screw placement for fixation of fifth metatarsal fracture.
• A sugar tong splint is applied before leaving the operating room, and the patient is non–weight bearing for 2 weeks.
Lisfranc fracture/injury (tarsometatarsal joint complex injury)
The Lisfranc ligament is a strong, interosseous attachment between the medial cuneiform and second metatarsal. A Lisfranc fracture describes an injury to the base of the metatarsal(s) at the attachment to the distal tarsal bones and Lisfranc ligament.
Symptoms include pain, inability to weight bear on affected foot, swelling, and bruising.
Most injuries are subtle, and many are missed on first evaluation and radiograph.
Imaging
Radiograph: weight-bearing AP, lateral, oblique of the foot. Include weight-bearing AP with both feet on same film for comparison.
• Most common finding in Lisfranc injury is lateral step-off at second tarsometatarsal (TMT) joint.
• Normal/uninjured foot: Medial border of second MT and medial border of middle cuneiform align on AP view. Oblique view demonstrates alignment of medial border fourth MT and medial border of cuboid (Fig. 8-20).
• If radiographs appear normal, but high suspicion for Lisfranc injury, evaluate with CT scan or MRI.
CT scan: can be used to evaluate subtle or occult fractures. CT scans allow for more precise evaluation of fractures including comminution and intra-articular extension (Fig. 8-21).
Initial treatment
Treatment options
Consider nonoperative management for stable injuries (no subluxation on radiograph or CT, no ligament tear on MRI, and negative stress examination under anesthesia).
Immobilize in cast boot for 6 to 10 weeks, and bear weight as tolerated.
If pain is persistent in the future, midfoot arthrodesis can be performed.
Nonoperative treatment is recommended for low-demand patients (little ambulation or nonambulatory), preexisting inflammatory arthritis, or insensate foot.
Surgical procedure
Open reduction internal fixation
Dorsal incision is made over the involved joint of midfoot. Many fixation techniques can be used, and multiple devices are available. Common techniques include screw fixation, dorsal plating, and Kirschner wires (most common for fourth or fifth TMT injuries).
Fractures are reduced, alignment of TMT joints is corrected, and hardware is placed. Intraoperative radiograph is used to determine alignment and correct placement of hardware (Fig. 8-22).
Estimated postoperative course
Postoperative 2 weeks: Sutures are removed at about 2 weeks, and the patient is transitioned to a short leg cast
Phalangeal fractures
Treatment options
Tarsal tunnel syndrome
Physical examination
Treatment options
Operative management
Informed consent and counseling
Risks and complications include continued pain despite release, increased symptoms, numbness dysesthesias, persistent tenderness or paresthesias over the tarsal tunnel, edema, nerve damage, vascular damage, infection, wound complications, difficulty with footwear, and causalgia or complex regional pain syndrome type 2
Surgical procedures
Curved medial incision extending above, behind, and below the medial malleolus beginning 10 cm proximal to medial malleolus and 2 cm posterior to tibia
Terminal branches of tibial nerve should be identified and released
Wound closed in layers, leaving retinaculum open
Patient placed in well-molded posterior splint, non–weight bearing
Estimated postoperative course
Achilles tendinopathy and rupture
History
Sharp unexpected dorsiflexion force to the ankle in conjunction with a strong contraction of the calf (e.g., tripping on a curb, unexpectedly stepping into a hole), pushing off the weight-bearing foot with the knee in extension (e.g., lunging for a tennis shot), and a strong or violent dorsiflexion force on a plantar-flexed ankle (e.g., jumping from a height)
Initial treatment
Acute Achilles ruptures may be treated surgically or nonsurgically with similar outcomes with appropriate patient selection. Nonsurgical treatment has lower complication rates; however, surgical repair has a faster recovery time, quicker return to sport activities, and slightly lower re-rupture rates. Missed or improperly treated ruptures can lead to significant weakness and altered gait mechanics.
ORTHOPAEDIC WARNING
Treatment options
With dynamic ultrasound or MRI imaging, rupture gap must be less than 5 mm with maximum plantarflexion, less than 10-mm gap with foot in neutral dorsiflexion, or greater than 75% apposition of tendon in 20 degrees of plantarflexion
Good candidates for non-operative management include those with systemic disease, medical comorbidities, smokers, and diabetics, as well as healthy individuals who meet the previously mentioned criteria and do not want to have surgery
Treatment protocol (Table 8-5)
Table 8-5.
Nonoperative Treatment Protocol for Achilles Tendon Rupture
| Initial Evaluation | Ultrasound (U/S) or magnetic resonance imaging (MRI) examination showing < 5 mm gap of tendon ends with maximal plantarflexion, <10 mm gap with neutral, or >75% apposition of tendon ends in 20 degrees PF. |
| Initial Management | Cast in full PF, non–weight bearing |
| 2-wk evaluation | May transition to pneumatic walking boot or bivalved cast with foot in 20 degrees PF with two 1-cm heel wedges, may be weight bearing. Must wear boot 24 hours/day |
| 4-wk evaluation | On examination, palpable continuity of tendon. If concern tendon not apposed, order repeat U/S or MRI. Patient may remove boot 5 minutes per hour to perform active dorsiflexion to neutral with passive plantarflexion. |
| 6-wk evaluation | On examination, continue to document continuity of tendon. Patient may remove one 1-cm lift. Continue range-of-motion exercises, may initiate more formal physical therapy protocol. |
| 8-wk evaluation | Document continued continuity of tendon. May decrease to zero lifts in boot and discontinue use of boot at night. Continue therapy program. |
| 10-wk evaluation | Discontinue use of boot and transition into a shoe with one 1-cm heel lift to be used for 3 additional months. Continue therapy program, and avoid aggressive sport activity until heel lift is discontinued. |
Surgical procedure
Estimated postoperative course
Early protected weight bearing and use of protective device that allows mobilization is key in successful rehabilitation of Achilles tendon ruptures
• Postoperative splint removed and wound inspected, well-healed sutures removed. If not, patient placed back into short leg cast for 1 week
• Once sutures removed, patient placed in removable boot with 2 heel wedges and allowed to initiate weight bearing as tolerated
• Heel wedges are gradually decreased over the course of the next 2 to 3 weeks, until the patient is weight bearing in the boot with no lifts
• Boot is discontinued after 1 week of weight bearing in boot with no lifts
• Physical therapy program initiated
• Patient may increase activities as tolerated after discontinuing use of boot, starting with nonimpact activities. Most people do not return to sport activity until at least 6 months after surgery.
Achilles tendinopathy
Initial treatment
This condition is likely chronic and noninflammatory in nature. It responds well to a specific rehabilitation program in which the patient’s compliance is crucial in its success. The goal of treatment is symptomatic only. The patient may always have thickened tendon or calcaneal bony prominence unless he or she undergoes surgical intervention. Recovery may follow a prolonged time course, taking 4 to 6 months before noticing improvement and even longer until the patient is back to reasonable activities comfortably.
Treatment options
Surgical procedures
Achilles tendon reconstruction using flexor hallicus longus (FHL) transfer
Estimated postoperative course
Postoperative course similar to recovery for acute rupture repair; may be delayed only if tendon transfer used to augment the Achilles tendon
• Splint and sutures removed; patient placed into cast or boot in 10 to 20 degrees of plantarflexion
Ankle sprain
Physical examination
Lateral ankle edema and ecchymosis exist.
Tenderness to palpation occurs over ATFL and CFL.
Anterior drawer test to assess injury to ATFL (Fig. 8-23): The patient is seated with the leg hanging off the side of the bed or table with the knee bent, the tibia is stabilized with one hand, and the foot is translated anteriorly with the other hand at the level of the heel. With sprain or partial rupture of ligaments, pain may be elicited. With a complete tear, the patient may demonstrate a suction sign.
Imaging
Radiograph: Weight-bearing foot (AP/oblique/lateral) and ankle (AP/mortise/lateral) if indicated per Ottawa Rules for Ankle radiographs (can be any one of the following):
Initial treatment
Lateral ligament ankle sprains are the most common musculoskeletal injuries in the United States. Goals of treatment include reduction in pain and edema and prevention of further injury. Inadequate treatment can lead to chronic problems including joint instability, pain, and loss of range of motion.
Treatment options
Rehabilitation
Cavovarus foot deformity
Physical examination
Classification (table 8-6)
Table 8-6.
Classification of Cavovarus Foot Deformity
Neurologic
Traumatic
Residual Clubfoot
Idiopathic
Treatment options
Operative management
Surgical procedures
Combination of soft tissue and bony procedures, which are numerous; indications and surgeon preference dictate type of procedure(s) used
Soft tissue release and tendon lengthening
Osteotomies—calcaneal, midfoot, dorsiflexion of 1st ray, talar neck, lateral column shortening
Hallux rigidus
Osteoarthritis of the first metatarsal-phalangeal joint (MTP joint)
Insidious onset of pain and stiffness at the great toe MTP joint
Presence of dorsal bony prominence can cause pain with shoe wear and impingement with activities
Patient may complain of lateral foot pain due to compensatory overload
Physical examination
Treatment options
Operative management
Informed consent and counseling
Risks of surgery include infection, nerve trapped in scar, progression of arthritis, and need for further surgery, such as arthrodesis, if pain continues.
It is important to discuss the objectives of surgery with the patient. In case of cheilectomy, the arthritic joint still remains; therefore, pain may still be present when stressed.
Surgical procedures
Cheilectomy
Hallux valgus
Physical examination
Note severity of hallux valgus deformity and presence of pes planus while patient is weight bearing.
Note skin changes (erythema, skin breakdown, callus formation).
Assess pain over medial eminence, with first MTP joint motion and first TMT joint laxity.
Evaluate second MTP joint for synovitis, second toe deformity, and metatarsal head overload.
Imaging
Initial treatment
The cause of a bunion is thought to be multifactorial and largely due to shoe/foot size mismatch, some genetic predisposition, and from repetitive forces applied to the first MTP joint. Only surgery can correct the deformity, but patients’ symptoms can be significantly relieved with appropriate conservative management.
Treatment options
Surgical procedures
Distal chevron osteotomy (fig. 8-27)
Longitudinal incision made over medial eminence with dissection down to joint capsule. Full-thickness dorsal and plantar skin flaps are created being careful to avoid the dorsomedial and plantar medial cutaneous nerve.
An L-shaped, distally based capsular flap is made for distal soft tissue release.
Dry, compressive dressing is applied with a postoperative shoe.
Estimated postoperative course
• Postoperative dressing removed and bunion dressing applied if indicated; change every week for 10 days for 8 weeks
• Sutures removed 2 to 3 weeks postoperative
• Immobilization in a postoperative shoe or CAM boot, weight bearing through heel only
Posterior tibial tendon dysfunction or acquired adult flatfoot deformity (AAFD)
Physical examination
Imaging
Surgical procedures
Flatfoot reconstruction (fig. 8-30)
Hardware: Kirschner wires, cannulated screws
Incision made from tip of medial malleolus extending distally to navicular
PTT sheath incised and tendon exposed. Tendon examined and debrided as indicated
Krakow suture technique used at distal aspect of FDL
Gastrocnemius recession then performed as indicated
All incisions sutured; posterior mold/sugar tong splint applied
Estimated postoperative course
• Postoperative dressing removed, sutures removed
• Patient placed in non–weight-bearing short leg cast or removable CAM boot
Subtalar joint dislocation
Treatment options
Closed reduction under sedation: Traction is placed on the foot and heel in line with the deformity. Countertraction is applied with the knee in flexion to relax the gastrocnemius. For medial dislocations, the foot is abducted and ankle is dorsiflexed. For lateral dislocations, the foot is adducted and the ankle is dorsiflexed.
Surgical procedures
Estimated postoperative course
Immobilization in non–weight-bearing short leg cast for 4 to 6 weeks followed by protected immobilization and weight bearing
Physical therapy as needed after cast removal to improve range of motion of subtalar joint
Tarsal fractures
Treatment options
Operative management
Surgical procedure
Orif calcaneus—minimally invasive approach
Estimated postoperative course
• First office visit and wound check. Sutures removed 10 to 14 days postoperatively
• Placed into immoveable device such as CAM walker boot or bivalve cast
• Strictly non–weight bearing, may initiate gentle ROM of ankle.
Talus fracture
Imaging (fig. 8-33)
Figure 8-33. Lateral view, talar body fracture.
Radiographs: Foot (AP/lateral/oblique) and ankle (AP/lateral/mortise). May consider Canale’s view (foot in maximum equinus, pronated 15 degrees, beam directed at 75-degree angle from horizontal plane) and Broden’s view (foot in neutral flexion with leg internally rotated 30 to 40 degrees. The beam is centered over the lateral malleolus; radiographs are taken at 40, 30, 20, and 10 degrees toward patient’s head) for further evaluation.
Classification
Talar neck: Hawkins classification (Table 8-7)
Table 8-7.
Hawkins Classification of Talar Neck Fractures
Type I: Nondisplaced
Type II: Displaced with subtalar joint subluxation
Type III: Displaced with dislocation of ankle and subtalar joint
Type IV: Displaced with dislocation at talonavicular joint
Orthopaedic procedures
Procedure (fig. 8-34)
1) Place patient in supine position with the ankle relaxed
2) Palpate the anterior joint line between anterior tibial tendon and anterior border of medial malleolous.
3) Prepare the skin with a bactericidal agent at the injection site.
4) Using sterile technique, insert needle into identified joint space, aiming posterolateral. Once the needle is in the joint space, there will be reduced resistance, allowing aspiration and/or easy injection of medication.
Aftercare instructions
1) Monitor for local erythema, edema, increased pain, or systemic symptoms. Notify clinician.
2) Local anesthetic effect will wear off within a few hours, and corticosteroid will take effect within 3 to 5 days. Patients may experience steroid flare where symptoms may be worse for the first 24 to 48 hours. This can be treated with NSAIDs and ice.
3) The patient should remain in the office for 30 minutes after injection to monitor for adverse effects.
4) He or she should avoid strenuous activity for 48 hours after injection.
Plantar fasciitis injection
Procedure (fig. 8-35)
1) Place the patient in supine or lateral recumbent position on the examination table.
2) Palpate insertion of plantar fascia on the medial, plantar calcaneus.
3) Prepare the medial aspect of the plantar heel with bactericidal solution.
4) Using sterile technique, insert a 25-gauge needle perpendicular to the skin from the medial aspect directly down to midline of the foot. Aspirate to ensure needle is not in a vessel and then slowly inject medication evenly as the needle is slowly withdrawn. Use caution to avoid injecting the calcaneal fat pad.
Aftercare instructions
1) Monitor for local erythema, edema, increased pain, or systemic symptoms and notify clinician of any symptoms.
2) Local anesthesia will wear off within a few hours, and the corticosteroid will take effect within 3 to 5 days. Patients may experience steroid flare where symptoms may be worse for the first 24 to 48 hours. This can be treated with NSAIDs and ice.
3) The patient should remain in the office for 30 minutes after injection to monitor for adverse effects.
4) Avoid strenuous activity for at least 48 hours after injection.
Morton’s neuroma injection
Procedure (fig. 8-36)
Figure 8-36. See text for the Morton neuroma injection procedure.
1) Place patient in supine position with foot in relaxed neutral position.
2) Palpate area of tenderness and mark location.
4) Insert needle on dorsal surface, pointed distal to proximal, at 45-degree angle to skin at marked site until reaching area of fullness. Be careful not to puncture through plantar skin.
Aftercare instructions
1) Patients should remain in the office for 30 minutes after injection to monitor for adverse effects.
2) Patients should avoid any strenuous activity for at least 48 hours after injection.
3) Caution patients on possible steroid flare where symptoms may be worse for the first 24 to 48 hours. This can be treated with NSAIDs and ice.
4) Call the office with any complaints of local erythema or systemic reaction.
Tarsal tunnel injection
Procedure (fig. 8-37)
Figure 8-37. See text for the tarsal tunnel injection procedure.
1) Place patient in lateral recombinant position.
2) Percuss posterior to medial malleolus to locate area of pain, mark. Also identify PTT.
4) Insert needle, pointed distally, approximately 2 cm proximal to marked location with needle at 30-degree angle to the skin.
Aftercare instructions
1) Patients should remain in the office for 30 minutes after injection to monitor for adverse effects.
2) Patients should avoid any strenuous activity for at least 48 hours after injection.
3) Caution patients on possible steroid flare where symptoms may be worse for the first 24 to 48 hours. This can be treated with NSAIDs and ice.
4) Call the office with any complaints of local erythema or systemic reaction.
