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Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 16 Foot, Ankle, and Lower Leg Conditions.

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Presentation on theme: "Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 16 Foot, Ankle, and Lower Leg Conditions."— Presentation transcript:

1 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 16 Foot, Ankle, and Lower Leg Conditions

2 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy Skeletal features of the lower leg, ankle, and foot

3 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy (cont’d) Forefoot –Metatarsals and phalanges; numerous joints –Support and distribute body weight throughout the foot –Toes Smooth the weight shift to the opposite foot during walking Help maintain stability during weight-bearing –1 st digit – hallux or “great toe” – main body stabilizer during walking or running

4 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy (cont’d) Midfoot –Navicular, cuboid, 3 cuneiforms; numerous joints –Talocalcaneonavicular joint (TCN) Talus moves simultaneously on calcaneus and navicular Combined action of talonavicular and subtalar joint

5 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy (cont’d) Hindfoot –Calcaneus and talus –Talocrural joint (ankle joint) Hinge joint; plantarflexion and dorsiflexion Articulation of talus, tibia, and fibula Fibula extends farther distally than tibia – limits eversion Talar dome wider anteriorly – more stable in dorsiflexion

6 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy (cont’d) Hindfoot (cont’d) –Talocrural joint (ankle joint) (cont’d) Ligaments Medial: deltoid Lateral :anterior talofibular; posterior talofibular; calcaneofibular –Subtalar joint Behaves as a flexible structure

7 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy (cont’d) Ligaments supporting the midfoot and hindfoot region Ligaments supporting the midfoot and hindfoot region, lateral and medial views

8 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy (cont’d) Tibiofibular joints –Superior—proximal –Inferior—distal –Interosseous membrane

9 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy (cont’d) Plantar arches –Support and distribute body weight –Longitudinal arch—medial and lateral –Transverse arch –Ligaments Spring (calcaneonavicular) Long plantar Short plantar

10 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy (cont’d) Arches of the foot Medial longitudinal arch

11 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy (cont’d) Plantar arches –Plantar fascia Provides support for the longitudinal arch Plantar fascia

12 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy (cont’d) Nerves –Sciatic nerve Tibial nerve Common peroneal nerve—deep and superficial peroneal nerves –Femoral—saphenous

13 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy (cont’d) Blood supply –Femoral artery –Popliteal –Anterior and posterior tibial –Anterior tibial Dorsal pedal Blood supply to the leg, ankle, and foot region

14 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Kinematics and Major Muscle Actions Muscles of the lower leg and foot. A. Lateral and medial view

15 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Kinematics and Major Muscle Actions (cont’d) Muscles of the lower leg and foot. B. Posterior view

16 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Kinematics and Major Muscle Actions (cont’d) Intrinsic muscles of the foot. A. Dorsal view

17 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Kinematics and Major Muscle Actions (cont’d) Intrinsic muscles of the foot. B. Plantar view

18 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Kinematics and Major Muscle Actions (cont’d) MUSCLECOMPARTMENTPRIMARY ACTION Tibialis anteriorAnteriorDorsiflexion, inversion Extensor digitorum longus AnteriorToe extension, dorsiflexion Extensor hallucis longus AnteriorExtension of great toe Peroneus tertiusAnteriorEversion, dorsiflexion Peroneus longusLateralEversion, plantar flexion Peroneus brevisLateralEversion, plantar flexion

19 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Kinematics and Major Muscle Actions (cont’d) MUSCLECOMPARTMENTPRIMARY ACTION Flexor digitorum longus Posterior, deepToe flexion, plantar flexion Flexor hallucis longusPosterior, deepFlexion of he great toe, plantar flexion Tibialis posteriorPosterior, deepInversion, plantar flexion GastrocnemiusPosterior, superficialPlantar flexion, knee flexion SoleusPosterior, superficialPlantar flexion PlantarisPosterior, superficialPlantar flexion, knee flexion

20 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Kinematics and Major Muscle Actions (cont’d) Gait cycle –Consists of alternating periods of single-leg and double-leg support –Requires a set of coordinated, sequential joint actions of the lower extremity Gait

21 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Kinematics and Major Muscle Actions (cont’d) Motions –Toe—flexion and extension –Ankle (subtalar)—dorsiflexion and plantarflexion –Foot and ankle Inversion and eversion Pronation and supination

22 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Kinematics and Major Muscle Actions (cont’d) Motions of the foot and ankle. A. Dorsiflexion and plantar flexion. B. Eversion and inversion. C. Supination of the subtalar joint

23 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Injury Prevention Physical conditioning –Strengthening Extrinsic muscles Intrinsic muscles –Flexibility Achilles tendon

24 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Injury Prevention (cont’d) Protective equipment –Braces; orthotics Footwear –Demands of sport; wear shoe for its intended purpose –Proper fit

25 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Toe and Foot Conditions Toe deformities –Hallux rigidus Degenerative arthritis in first MTP S&S Tender, enlarged first MTP joint Loss of motion Difficulty wearing shoes with an elevated heel Hallmark sign—restricted toe extension

26 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Toe and Foot Conditions (cont’d) Toe deformities –Hallux valgus Thickening of the medial capsule and bursa, resulting in severe valgus deformity Asymptomatic or symptomatic Treatment—symptomatic

27 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Toe and Foot Conditions (cont’d) Hallux valgus

28 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Toe and Foot Conditions (cont’d) Hammer toe –Extension of MTP joint, flexion at PIP joint, and hyperextended at the DIP joint Claw toe –Hyperextension of MTP joint and flexion of DIP and PIP joints Mallet toe –Neutral position at MTP and PIP joints, flexion at DIP joint

29 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Toe and Foot Conditions (cont’d) S&S: painful callus formation on dorsum IP joints Toe deformities

30 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Toe and Foot Conditions (cont’d) Pes cavus –Excessively high arch that does not flatten during weight bearing –Causes can vary –Rigid foot

31 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Toe and Foot Conditions (cont’d) Pes planus –Flat foot; arch or instep of the foot collapsing & contacting the ground –Typically, acquired deformity resulting from injury or trauma –Mobile foot

32 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Toe and Foot Conditions (cont’d) Both conditions can be asymptomatic, but associated with common injuries Common foot deformities

33 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Contusions Heel contusion –Thick padding of adipose tissue—does not always suffice –Stress in running, jumping, changing directions –S&S Severe pain in heel Unable to bear weight

34 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Contusions (cont’d) Heel contusion (cont’d) –Management: cold; heel cup or doughnut pad; referral –Condition may persist for months

35 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Contusions (cont’d) Gastrocnemius contusion –S&S Immediate pain and weakness Rapid hemorrhage and muscle spasm → palpable mass –Management: Cold with gentle stretch If symptoms persist > 2-3 days, physician referral

36 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Contusions (cont’d) Tibial contusion (shin bruise) –Vulnerable lack of padding –Minor injury—caution: repeated blows → damage periosteum –Management: standard acute –Key: prevention

37 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Lower Leg Contusions Acute compartment syndrome –Lower leg includes 4 nonyielding compartments –MOI: direct blow anterolateral aspect of the tibia –Rapid ↑ in tissue pressure → neurovascular compromise

38 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Lower Leg Contusions (cont’d) Acute compartment syndrome (cont’d) –S&S History of trauma Increasingly severe pain—out of proportion to situation Firm and tight skin over anterior shin

39 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Lower Leg Contusions (cont’d) Acute compartment syndrome (cont’d) –S&S (cont’d) Loss of sensation between 1st and 2nd toes on dorsum of foot Diminished pulse—dorsalis pedis artery Functional abnormalities within 30 minutes

40 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Lower Leg Contusions (cont’d) Acute compartment syndrome (cont’d) –Management: Cold NO compression or elevation immediate referral to ER or summon EMS –Irreversible damage can occur within 12–24 hours

41 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Toe and Foot Sprains IP & MP joints –MOI: tripping or stubbing the toe –S&S Pain, dysfunction, immediate swelling Dislocation—gross deformity

42 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Toe and Foot Sprains (cont’d) Midfoot sprains –MOI: severe dorsiflexion, plantarflexion, or pronation –More frequent in activities in which foot is unsupported –S&S Pain and swelling is deep on medial aspect of foot Weight bearing may be too painful

43 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Toe and Foot Sprains (cont’d) Turf toe –Sprain of the plantar capsular ligament of 1st MTP joint –MOI: forced hyperflexion or hyperextension of great toe –Acute or repetitive overload –Valgus ↑ susceptibility

44 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Toe and Foot Sprains (cont’d) Turf toe (cont’d) –S&S (cont’d) Pain, point tenderness, and swelling on plantar aspect of MP joint Extreme pain with extension –Potential for tear in flexor tendons or fracture of sesamoid bones

45 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Toe and Foot Sprains (cont’d) Management toe and foot sprains –Standard acute –Physician referral

46 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Ankle Sprains Inversion ankle sprain –MOI: plantarflexion and inversion –Predisposing factors Lateral malleolus projects farther downward Least stable position of ankle is plantar flexion Weakness in peroneals ↓ ROM in Achilles tendon

47 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Ankle Sprains (cont’d) Inversion ankle sprain

48 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Ankle Sprains (cont’d) SIGNS AND SYMPTOMS 1stPain and swelling on anterolateral aspect of lateral malleolus Point tenderness over ATFL 2 nd Tearing or popping sensation felt on lateral aspect Pain and swelling on anterolateral and inferior aspect of lateral malleolus Painful palpation over ATFL and CFL May also be tender over PTFL, deltoid ligament, and anterior capsule area 3 rd Tearing or popping sensation felt on lateral aspect Diffuse swelling over entire lateral aspect with or without anterior swelling Can be very painful or absent of pain

49 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Ankle Sprains (cont’d) Eversion ankle sprain –Mechanism: excessive dorsiflexion and eversion –Deltoid ligament –Potential Lateral malleolus fx; bimalleolar fx Tear of anterior tibiofibular ligament & interosseous membrane

50 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Ankle Sprains (cont’d) Eversion ankle sprain (cont’d) –Predisposing factors Excessive pronation Hypomobile foot

51 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Ankle Sprains (cont’d) Eversion Sprain (cont’d) –S&S Mild to moderate injuries Often unable to recall the mechanism Some initial pain at time of injury, but often subsides and individual continues to play

52 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Ankle Sprains (cont’d) Eversion sprain (cont’d) –S&S (eversion sprain) Mild to moderate injuries Swelling May not be as evident as a lateral sprain Between posterior aspect of lateral malleolus and Achilles tendon Point tenderness in involved ligaments

53 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Ankle Sprains (cont’d) Eversion Sprain (cont’d) –S&S Severe injuries PROM pain-free in all motions except dorsiflexion

54 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Ankle Sprains (cont’d) Syndesmosis sprain (High Ankle Sprain) –Spreading of space at distal tibiofibular joint –MOI: dorsiflexion and external rotation –Common: anterior inferior tibiofibular ligament –S&S Point tenderness over the anterolateral tibiofibular joint Significant pain and swelling Difficulty bearing weight

55 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Ankle Sprains (cont’d) Management of ankle sprains –Standard acute –Use of crutches if unable to walk without limp –Physician referral

56 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Ankle Sprains (cont’d) Subtalar dislocation –MOI: fall from a height (as in basketball or volleyball); foot lands in inversion –Disrupts interosseous talocalcaneal & talonavicular ligament

57 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Ankle Sprains (cont’d) Subtalar dislocation (cont’d) –S&S Extreme pain and total loss of function is present Gross deformity may not be clearly visible Foot may appear pale and feel cold to the touch Individual may show signs of shock

58 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Ankle Sprains (cont’d) Subtalar dislocation –Concern: potential for peroneal tendon entrapment and neurovascular damage –Management: medical emergency; activate EMS; monitor neurovascular function

59 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Tendinopathies of the Foot & Lower Leg Strains & Tendinitis –Common sites Achilles tendon just proximal to insertion on calcaneus Tibialis posterior just behind medial malleolus Tibialis anterior on dorsum of foot just under extensor retinaculum Peroneal tendons just behind lateral malleolus and at distal attachment on base of 5th metatarsal

60 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Tendinopathies of the Foot & Lower Leg (cont’d) Strains & Tendinitis –Predisposing factors Training errors Direct trauma Infection from a penetrating wound into tendon Abnormal foot mechanics producing friction between shoe, tendon, and bony structure Poor footwear that is not properly fitted to foot

61 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Tendinopathies of the Foot & Lower Leg (cont’d) –S&S (tendinitis) History of morning stiffness Localized tenderness over tendon Swelling or thickness in tendon and peritendon tissues Pain with passive stretching and with active and resisted motion

62 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Tendinopathies of the Foot & Lower Leg (cont’d) –Management Do not permit to continue activity until seen by a physician Suggest the application of cold to the area to decrease pain and potential spasm

63 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Tendiopathies of the Foot & Lower Leg (cont’d) Gastrocnemius strain –Medial head or musculotendinous junction –Mechanism Forced dorsiflexion while knee is extended Forced knee extension while foot is dorsiflexed Muscular fatigue with fluid–electrolyte depletion & cramping

64 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Tendinopathies of the Foot & Lower Leg (cont’d) Gastrocnemius strain (cont’d) –S&S Immediate pain, swelling, loss of function –Management: standard acute; crutches if unable to walk w/out a limp If symptoms persist > 2-3 days or mod- severe injury, physician referral

65 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Tendinopathies of the Foot & Lower Leg (cont’d) Gastrocnemius muscle strain

66 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Tendinopathies of the Foot & Lower Leg (cont’d) Achilles tendon rupture –MOI: push-off of forefoot while knee is extending –More common in individuals over age 30 –S&S “Pop” Inability to stand on toes Visible defect Excessive passive dorsiflexion

67 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Tendinopathies of the Foot & Lower Leg (cont’d) Achilles tendon rupture (cont’d) –Management Compression wrap; immediate transport to emergency care facility or physician

68 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Tendinopathies of the Foot & Lower Leg (cont’d) Achilles tendon rupture

69 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Overuse Conditions Plantar fasciitis –Extrinsic and intrinsic risk factors –S&S Pain at plantar, medial heel Pain with first steps in the morning, but diminshes 5-10 min ↑ pain with passive extension of great toe and ankle dorsiflexion Pain relieved with activity, but recurs after rest

70 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Overuse Conditions (cont’d) Plantar fasciitis (cont’d) –Management: Do not permit to continue activity until seen by a physician Suggest application of cold to decrease pain and spasm

71 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Overuse Conditions (cont’d) Medial tibial stress syndrome –Periostitis along posteromedial tibial border (distal third) Soleus insertion Excessive pronation → eccentric contraction of soleus → periostitis –Other contributing factors Recent changes in running distance, speed, footwear, or running surface

72 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Overuse Conditions (cont’d) Medial tibial stress syndrome (cont’d) –S&S Dull pain begins at any point in the workout; occasionally sharp and penetrating Pain along posteromedial border of tibia in distal third Pain is relieved with rest, but may recur hours after activity stops

73 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Overuse Conditions (cont’d) –S&S (MTSS) (cont’d) Pain with resisted plantar flexion or standing on tiptoe Often an associated varus alignment of the lower extremity, including a greater Achilles tendon angle.

74 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Overuse Conditions (cont’d) –Management: Do not permit to continue activity until seen by a physician Suggest application of cold to decrease pain and spasm

75 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Overuse Conditions (cont’d) Exertional compartment syndrome –Characterized by exercise-induced pain and swelling that is relieved by rest –Compartments most frequently affected— anterior (50%–60%) & deep posterior (20-30%) –Usually seen in well-conditioned individuals <40 yrs old

76 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Overuse Conditions (cont’d) Exertional compartment syndrome –S&S Exercise-induced pain that is often described as a tight, cramplike, or squeezing ache and a sense of fullness Often affects both legs Relieved with rest, only to recur if exercise resumes Anterior compartment—mild foot drop; paresthesia dorsum of foot

77 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Overuse Conditions (cont’d) Exertional compartment syndrome –Management: Stop activity Assessment by qualified health care practitioner

78 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Foot and Lower Leg Fractures Repetitive microtraumas → apophyseal or stress fractures Tensile forces associated with severe ankle sprains → avulsion fractures of 5th metatarsal Severe twisting → displaced and undisplaced fractures in foot, ankle, or lower leg

79 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Foot and Lower Leg Fractures (cont’d) Freiberg's disease –Avascular necrosis of 2nd metatarsal head –Active adolescents ages 14–18 –S&S: diffuse pain in forefoot

80 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Foot and Lower Leg Fractures (cont’d) Sever's disease –Traction-type injury of calcaneal apophysis –Seen in ages 7–10 –S&S Heel pain with activity Decreased heel cord flexibility Pain with standing on tiptoes

81 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Foot and Lower Leg Fractures (cont’d) Stress fractures –Common: Running and jumping, especially after significant ↑ training mileage; change in surface, intensity, or shoe type Women w/ amenorrhea 6 months+ and oligomenorrhea

82 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Foot and Lower Leg Fractures (cont’d) Stress fractures (cont’d) –Common sites 2nd metatarsal Sesamoid bones Navicular Calcaneus Tibia and fibula

83 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Foot and Lower Leg Fractures (cont’d) Stress fracture (cont’d) –S&S Pain begins insidiously; ↑ with activity and ↓ with rest Pain usually limited to fracture site

84 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Foot and Lower Leg Fractures (cont’d) Avulsion fractures –Eversion sprain—deltoid lig. avulses distal medial malleolus –Inversion sprain—plantar aponeurosis or peroneus brevis tendon avulses base of 5th metatarsal (type II)

85 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Foot and Lower Leg Fractures (cont’d) Avulsion fractures –Jones fracture Type I transverse fracture into the proximal shaft of 5th metatarsal at junction of diaphysis and metaphysis Often overlooked in conjunction with a severe ankle sprain Complications: nonunions and delayed unions are common

86 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Foot and Lower Leg Fractures (cont’d) Avulsion fractures

87 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Foot and Lower Leg Fractures (cont’d) Displaced fractures and dislocations –MOI Direct compression (e.g., falling from a height) Compression & shearing (i.e., twisting mechanism) –Potential neurovascular complications

88 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Foot and Lower Leg Fractures (cont’d) Displaced fractures and dislocations (cont’d) Phalanges –MOI: axial load (e.g. jamming toe) or direct trauma (e.g., crushing) –Swelling; ecchymosis; pain; able to walk Metatarsals –Swelling; pain –Pain increases with weight bearing –Potential for displacement

89 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Foot and Lower Leg Fractures (cont’d) Displaced fractures and dislocations (cont’d) –Metatarsals (cont’d) 1st metatarsal dislocated from 1st cuneiform; other 4 metatarsals are displaced laterally, usually in combination with fracture at base of 2nd metatarsal History of severe midfoot pain, paresthesia, or swelling in midfoot region with variable flattening of arch or forefoot abduction

90 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Foot and Lower Leg Fractures (cont’d) Tibia-fibula fractures –Nearly 60% of tibial fractures involve the middle and lower third of the tibia. –MOI: torsional force, resulting in either a spiral or oblique fracture of the lower third of the tibia.

91 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Foot and Lower Leg Fractures (cont’d) Tibia-fibula fractures (cont’d) –S&S Gross deformity Gross bone motion at the suspected fracture site Immediate swelling, extreme pain, or pain with motion

92 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Foot and Lower Leg Fractures (cont’d) Ankle fracture–dislocation –MOI Landing from a height with foot in excessive eversion or inversion Being kicked from behind while the foot is firmly planted

93 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Foot and Lower Leg Fractures (cont’d) Ankle fracture–dislocation (cont’d) –S&S Foot displaced laterally at a gross angle to lower leg Extreme pain Can compromise the posterior tibial artery and nerve

94 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Foot and Lower Leg Fractures (cont’d) Fracture management –Mild Standard acute with physician referral –Serious conditions Activate emergency plan, including summoning EMS Assess and treat for shock

95 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Coach and Onsite Assessment S &S that require immediate physician referral (potential for EMS) –Obvious deformity suggesting a dislocation, fracture, or ruptured Achilles tendon –Significant loss of motion or muscle weakness –Excessive joint swelling –Possible epiphyseal or apophyseal injuries

96 Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins Coach and Onsite Assessment (cont’d) S &S that require immediate physician referral (potential for EMS) (cont’d) –Abnormal sensation, or absent or weak pulse –Gross joint instability –Any unexplained pain that affects normal function Refer to Application Strategy 16.2


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