Lecture 41 parekh er f&a
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Lecture 41 parekh er f&a
- 1. Emergency Room: Foot and Ankle Injuries Selene G. Parekh, MD, MBA Associate Professor of Surgery Partner, North Carolina Orthopaedic Clinic Department of Orthopaedic Surgery Adjunct Faculty Fuqua Business School Duke University Durham, NC 919.471.9622 http://seleneparekhmd.com Twitter: @seleneparekhmd
- 3. Lateral Ankle Sprains • Most common specific injury in sports • Finland 16-21% of all sports injuries • Basketball 45% of injuries • Soccer 31% of injuries • Anatomy
- 4. Lateral Ankle Sprains • Most common specific injury in sports • Finland 16-21% of all sports injuries • Basketball 45% of injuries • Soccer 31% of injuries • Anatomy
- 5. Lateral Ankle Sprains • Most common specific injury in sports • Finland 16-21% of all sports injuries • Basketball 45% of injuries • Soccer 31% of injuries • Anatomy
- 6. Lateral Ankle Sprains • Most common specific injury in sports • Finland 16-21% of all sports injuries • Basketball 45% of injuries • Soccer 31% of injuries • Anatomy
- 7. Lateral Ankle Sprains • Biomechanics • Dorsiflexion: ATFL loose, CFL taut • Plantarflexion: ATFL taut, CFL loose • ATFL • Adduction in PF, restricts IR of talus in mortise • CFL • Adduction in neutral/DF • PTFL • Prevents ER in DF • IOL • Controls rotation
- 8. Lateral Ankle Sprains • Pathology • Associated injuries • Tear of P. long/br. • Talar chondral injury • Medial ligament & syndesmotic injuries • Fx lateral talus & fibula, 5th metatarsal fx, anterior process calcaneus fx • Post-sprain neuritis
- 9. Lateral Ankle Sprains • Diagnosis • Immediate swelling & pain, difficulty WB • Tenderness over affected structures • ROM • Pain with anterior drawer, “suction sign” with anterior subluxation of talus • Inversion stress- pain/instability
- 10. Lateral Ankle Sprains • Radiologic Evaluation • 3 views • Talar Tilt • Anterior drawer • MRI
- 11. Lateral Ankle Sprains • Clanton Classification • I - Stable symptomatic tx • II - Unstable • Group 1: non-athlete, older functional tx • Group 2: young athlete • A: (-) stress test functional tx • B: (+) stress test surgical • C: Subtalar instability functional tx
- 12. Lateral Ankle Sprains • Acute • RICE • Mobilization with support • Lace-up, stirrup brace, walking boot, cast • Atrophy, stiffness • Physical therapy • ROM, peroneal, dorsiflexor strengthening, Achilles stretching • Proprioceptive: wobble, mini-trampoline
- 13. Lateral Ankle Sprains • Surgical treatment • Acute • Controversial • Young athlete • Gross instability • Associated fracture • Talocrural dislocation • Direct repair/fixation of bony fragments
- 14. Surgical Options • Modified Brostrum • Imbricate using native tissue • Supplement using IER • Anatomic allograft reconstructions
- 15. Old Technique vs New Technique “Chrisman Snook / Watson Jones” Style Anatomic Secondary Procedure using Bio Tenodesis Screws
- 16. Lateral Ankle Ligament Reconstruction w/ Free Graft Overview Courtesy of Tom Clanton, MD
- 17. Anatomic Weave
- 21. Knee Surg SportTram Arth 2012 • Use of semitendinosus allograft tendon for chronic lateral ankle instability • Retrospective study of n=28 ankles • Reconstruction ATFL/CFL with interference screws • Mean follow-up 19 months • VAS scores 62 (p<0.05) • AOFAS scores 6391 (p<0.05) Taken from Caprio et al, Foot Ankle Clin 2006
- 22. Knee Surg SportTram Arth 2012 • Talar tilt 17.8 ° 6.7 °(p<0.05) • Anterior drawer 10.0 4.5mm (p<0.05) • 21/24 (88%) satisfied with surgery • Conclusion • Viable option for chronic lateral ankle instability with poor ligamentous tissues
- 24. •Fall/MVA •Usually non-operative ─ Swelling control ─ Early ROM ─ PWB Calcaneal Tuberosity Fracture Collinge C and Heier K., OTA
- 25. Tuberosity Avulsion •Surgical urgency • Pull of Achilles brings fragment near skin • Plantar flexion splint in ER • Percutaneous reduction with lag screws/plate Collinge C and Heier K., OTA
- 27. Parekh Technique •Posterior split technique •Release Achilles insertion •Remove fragment
- 28. Parekh Technique •Harvest FHL •Transfer FHL •Close Achilles split •Reattach Achilles insertion site
- 29. Ankle Dislocations • Usually associated w/ fractures • Mechanism • Foot usually in DF position • Defined by direction of talus • Medial, lateral, posteromed, posterior, rotatory • Physical • NV exam • Gross deformity • Diagnosis • Ankle films • Triage • Refer to ortho immediately • Treatment • Reduce & repeat NV exam • Jones dressing w/ splint or AO splint
- 30. Subtalar Dislocations • Physical • Gross deformity • NV exam • Medial dislocation • Calcaneus displaces medially • Talar head prominent laterally • Mechanism • Inversion • Lateral dislocation • Calcaneus displaces laterally • Talar head prominent medially • Mechanism • Eversion
- 31. Subtalar Dislocations • Diagnosis • Ankle xrays • CT scan • Triage • Refer to ortho immediately • Treatment • Medial dislocation • Prompt CR w/ knee flexion • Failed CR secondary to talar head entrapment in EDBr • Lateral dislocation • Prompt CR w/ knee flexion • Failed CR secondary to interposed PTT • Place in AO splint
- 32. Infections of the F&A
- 33. Bacterial Infections • Most common organisms • Staphylococcus aureus • β-hemolytic streptococcus
- 34. Bacterial Infections: Cellulitis • Physical • Erythema, edema • Charcot vs. infection • Diagnosis • Ankle films • Gas, soft tissue edema • Treatment • Immobilize • Antibiotics • Oral • Keflex, Bactrim, augmentin • IV • Ancef, unasyn • Triage • Mild: refer to ortho within days • Severe: refer to ortho immediately
- 35. Bacterial Infections: Felon • Pus collects in pulp/distal phalanx • Organisms • Strep or Gram neg (diabetes) • Physical • Erythema, edema, tender • Diagnosis • Foot films • Gas, soft tissue edema • Treatment • Immobilize • Antibiotics • Triage • Refer to ortho immediately
- 36. Bacterial Infections: Puncture Wounds • Most common in children • Pseudomonas aeruginosa • Polymicrobial (diabetes) • Physical • Erythema, edema, tender • Diagnosis • X-ray • MRI • Ultrasound • Triage • Mild: refer to ortho within days • Severe: refer to ortho immediately • Treatment • Immobilize • Antibiotics • Coverage for Staph, Strep, & Pseudomonas • Tetanus prophylaxis
- 37. Bacterial Infections: Necrotizing Fasciitis • Organisms • Group A β-hemolytic Streptococcus pyogenes • Often polymicrobial • Rapidly progressive • Limb/life threatening • Mortality 23-76% • Physical • Erythema, edema, tender • Bullae • Septic shock • End organ failure • Affects skin/underlying tissue • Muscle initially spared
- 38. Bacterial Infections: Necrotizing Fasciitis • Diagnosis • Early • Benign • Difficult to differentiate from cellulitis • Erythema • Tense swollen extremity • Bullae • Skin discoloration • Subcutaneous crepitation • Failure to respond to antibiotics • Sepsis
- 39. Bacterial Infections: Necrotizing Fasciitis • Triage • Refer to ortho immediately • Treatment • Supportive • IV antibiotics • Clindamycin • Vancomycin • Extensive surgical debridement • Repeat debridements • Hyperbaric oxygen (controversial)
- 40. Bacterial Infections • Fascial space infections • Triage • Refer to ortho immediately • Septic arthritis • Triage • Refer to ortho immediately • Osteomyelitis • Triage • Acute: refer to ortho immediately • Chronic: refer to ortho within 1-2 weeks • Lyme disease
- 41. Fungal Infections • Athlete’s foot • Organisms • Trichophyton rubrum & T. mentagrophytes • Common infection • Skin & nails • Sole & interdigital spaces • Symptoms • Pruritis • Cracking • Scaling • Blisters • Treatment • Topical Clotrimazole • Terbinofine