Lecture trauma ankle_tendon
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This document discusses various ligamentous and tendinous injuries around the ankle. It begins by describing the anatomy of the medial and lateral ankle ligaments, as well as the syndesmosis ligaments. It then discusses the evaluation and treatment of common ankle injuries like ankle sprains, syndesmotic injuries, Achilles tendon ruptures, and peroneal tendon dislocations. For many of these injuries, the summary includes the typical mechanisms of injury, physical exam findings, imaging studies, and both non-operative and surgical treatment options and their supporting evidence.
Lecture trauma ankle_tendon
- 1. LLiiggaammeennttoouuss aanndd TTeennddoonn IInnjjuurriieess AAbboouutt tthhee AAnnkkllee UCMC Trauma Conference 5/2/12
- 2. Talus
- 3. Medial Superficial Superficial talotibial, naviculotibial, and calcaneotibial fibers Deep –Deep anterior talotibial and posterior talotibial fibers from posterior colliculus to talus –Strongest portion of the Deltoid ligament
- 4. Lateral Collateral Ligaments Anterior Talofibular Ligament – First injured in lateral sprain with plantarflexed ankle Calcaneofibular Ligament – Strongest lateral ligament – First injured in lateral sprain with dorsiflexed ankle Posterior Talofibular Ligament
- 5. Syndesmosis Anterior inferior tibiofibular ligament Posterior inferior tibiofibular ligament Transverse tibiofibular ligament Interosseous membrane
- 6. Ankle Sprains Most common ligamentous injury One sprain per day per 10,000 people 40% will have intermittent chronic problems (Garrick, Am J Sports Med, 1977) More common on the lateral aspect of the ankle
- 7. Physical Exam – Palpation over medial and lateral malleoli – Palpation over deltoid ligament – Palpation over ATFL, CFL, and PTFL – Neurovascular exam – Anterior drawer test for ATFL – Talar tilt to assess CFL – Squeeze test to look for syndesmotic injury EXAM
- 8. Most common mechanism of ankle injury is inversion stress with plantarflexion – May lead to ankle fracture, sprain, or syndesmotic injury Abduction or adduction are other mechanisms
- 9. AP of the Ankle – Tibio-Fibular Clear Space AB < 5mm is normal – Tibio-Fibular Overlap BC > 10 mm is normal
- 10. Mortise View – Ankle internally rotated – AB clear space – BC overlap – Talocrural angle (83 degrees) – Medial clear space <4 mm
- 11. Ankle Stress Radiographs Talar tilt view – Demonstrates complete ligamentous instability – Talar tilt <2 mm External rotation view – Useful in identifying syndesmotic injury
- 12. Ankle Stress Radiographs Anterior drawer stress view – No fracture seen – >3 mm anterior translation compared to contralateral side or >10 mm translation – Incongruency of ankle joint present – Ligamentous instability present
- 13. Lateral Ankle Sprains Commonly missed diagnoses – Peroneal tendon injuries – Achilles injuries – FX’s Lateral process of talus Anterior process of calcaneus Fifth metatarsal Lisfranc injuries – Osteochondral Lesion of the Talus
- 14. Lateral Ankle Sprains Lateral Process FX of the Talus “Snowboarders” injury
- 15. Ankle Sprain Treatment RICE ROM exercises Peroneal strengthening and proprioceptive training
- 16. Ligament Reconstructions These procedures use the peroneal tendons to reconstruct the lateral ligamentous complex Higher complication rates than Brostrom More restricted ankle and subtalar motion (Colville, JAAOS, 1998)
- 17. Medial Ankle Sprain 5% ankle sprains Forced eversion Injury to deltoid ligament May be associated with syndesmotic injury and/or Weber C fibula FX
- 18. Syndesmotic (High) Ankle Sprains
- 19. Syndesmosis Exam Squeeze Test – Squeeze the syndesmosis above the ankle®pain Abduction-External Rotation Stress Test – Further instability with external rotation (may be shown with x-ray) Gravity Stress Test – Foot hanging free in lateral position with mortise view taken
- 20. Stress Radiograph - Technique
- 21. Stress View SER-2 + Stress View Negative Stress view External Widened Medial rotation Clear of foot with ankle Space in neutral flexion (00) Stable Treatment FWBAT
- 22. Syndesmosis Injury Surgical Treatment – Maximally dorsiflex hindfoot – Reduce the syndesmosis with a large clamp under fluoro by internally rotating the fibula and compressing it to the tibia – Perform medial arthrotomy if unable to reduce in order to debride medial ankle joint
- 23. Fixation Screws are not lagged!
- 24. Syndesmosis Controversies Number of Screws – One vs. two, 3.5 mm screw vs. 4.5 mm screw Number of Cortices – Three vs. four cortices Ankle position during placement – Classically dorsiflexion was advocated – Tornetta showed no difference with plantarflexion
- 25. EEnnddoobbuuttttoonn aanndd HHeeaavvyy SSuuttuurree – PPootteennttiiaall BBeenneeffiittss fflleexxiibbllee ffiixxaattiioonn,, nnoo nneeeedd ffoorr iimmppllaanntt rreemmoovvaall,, eeaarrlliieerr wweeiigghhtt bbeeaarriinngg IImmpprroovveedd ssuubbjjeeccttiivvee oouuttccoommeess ssiimmiillaarr oobbjjeeccttiivvee oouuttccoommeess
- 26. Ankle Dislocations Isolated ankle dislocation is rare Mechanism is forced inversion that results in a posteromedial dislocation Anterolateral ligaments damaged Commonly open 30 - 90% Rule out neurovascular injury
- 27. Tibiotalar Dislocations Management closed injury – Check neurovascular status – Prompt closed reduction – Cast for 6 weeks in plantigrade position – Results generally good – Results not improved with acute ligament repair – Late instability rare
- 28. Achilles Tendon Ruptures AAnnaattoommyy – 1100-1122 ccmm lloonngg – 00..55-11..00 ccmm ddiiaammeetteerr – AAvvaassccuullaarr zzoonnee 22-66 ccmm pprrooxxiimmaall ttoo iinnsseerrttiioonn – FFiibbeerrss rroottaattee 9900 ddeeggrreeeess aatt iinnsseerrttiioonn
- 29. Achilles Tendon Rupture – Acute pain in the back of the ankle with contraction, no antecedent history of calf or heal pain – Average age 35 – Steroids, fluorquinolones, and chronic overuse may predispose to rupture Pathology – Rupture occurs 3-4 cm above the Achilles insertion in a watershed area
- 30. Achilles Tendon Rupture Physical Exam – Tenderness over achilles tendon – Palpable defect – Positive Thompson’s test – No evidence to support routine use of MRI, U/S, or Xray
- 31. Achilles Tendon Ruptures SSuurrggiiccaall rreeppaaiirr – YYoouunnggeerr aaccttiivvee ppaattiieennttss NNoonnooppeerraattiivvee ttrreeaattmmeenntt – OOllddeerr sseeddeennttaarryy ppaattiieennttss – PPaattiieennttss wwiitthh iinnccrreeaasseedd rriisskk ooff ssoofftt ttiissssuuee ccoommpplliiccaattiioonnss IIDDDDMM SSmmookkeerrss VVaassccuullaarr ddiisseeaassee BBMMII >> 3300
- 32. Management of Non-Operative Tx Short leg cast strategy (SLC) – SLC is applied w/ ankle in plantarflexion – Cast is brought out of equinus over 8-10 weeks – Walking is allowed (in the cast) at 4-6 weeks – Alternatively, consider using functional brace starting in 45 degrees of flexion – Following casting, a 2 cm heel lift is worn for an additional 2-4 months Long leg cast (LLC) – Initial LLC in gravity equinus for 6 weeks, followed by short leg cast for 4 weeks
- 33. Clinical Evidence to Support Nonoperative Treatment Benefits: no wound complications, no scar, decreased patient cost. Disadvantage: up to 39% re-rupture rate, increased patient dissatisfaction, decreased power, strength and endurance. Gillies and Chalmers- – 80% vs. 84.3% return of strength compared to unaffected side, non-op and operative, respectively Wills, 775 patients the overall complication rate of surgically treated Achilles tendon ruptures was 20%. – skin necrosis, wound infection, sural neuromas, adhesions of the scar to the skin, and the usual anesthesia risks
- 34. SSuurrggiiccaall ttrreeaattmmeenntt – PPrreeffeerrrreedd ffoorr aatthhlleetteess – MMeeddiiaall iinncciissiioonn aavvooiiddss tthhee ssuurraall nneerrvvee – PPeerrccuuttaanneeoouuss vvss.. OOppeenn ttrreeaattmmeennttss ddeessccrriibbeedd – IIssoollaattee tthhee ppaarraatteennoonn aass aa sseeppaarraattee layer
- 35. CClliinniiccaall RReessuullttss SSuurrggiiccaall RReeccoonnssttrruuccttiioonn BBeenneeffiittss:: 00--55%% rree--rruuppttuurree rraattee,, >> ppeerrcceennttaaggee ppaattiieennttss rreettuurrnn ttoo ssppoorrtt,, iimmpprroovveedd ppoowweerr,, ssttrreennggtthh,, aanndd eenndduurraannccee.. DDiissaaddvvaannttaaggeess:: >> ppaattiieenntt ccoosstt aanndd wwoouunndd ccoommpplliiccaattiioonnss CClliinniiccaall sseerriieess:: mmaannyy tteecchhnniiqquueess – MMoosstt BBuunnnneell oorr MMooddiiffiieedd KKeesssslleerr ssuuttuurree – SSoommee wwiitthh aauuggmmeennttaattiioonn EEHHLL vvss.. GGaassttrrooccnneemmiiuuss
- 36. Operative Support Cetti et al. compared operative versus non-operative treatment in a prospective study with 111 patients – In the operative group (56 patients), there were three re-ruptures (5%) and two deep infections, as compared with eight re-ruptures (15%) in the non-operative group (55 patients) – The operative group had a significantly higher rate of resuming sports activities at same level prior to rupture (57.1% vs 29.1% of pts), a lesser degree of calf atrophy (1.6 cm vs 1.1 cm calf circum.), significantly fewer complaints at 1 year (29% vs 49% of pts), and better ankle movement at 1 year (82% vs 53% of pts, op vs non-op, respectively)
- 38. Chronic Achilles Tendon Rupture History – Remote hx trauma, post pain, gradual improvement of symptoms, palpable tendon defect. – No hx trauma, gradual thickening of tendon, AM startup pain, pain ascending/descending stairs. Physical Exam – “Hatchet” posterior calf at site of defect at resolution of swelling – Positive Thompson test – Weakened plantar flexion
- 39. MRI <3 cm gap, <3 months old— primary repair >3cm gap—scar tissue debridement and V-Y lengthening of proximal gastroc tendon granted that remaining tissue no evidence inflammation Evidence chronic inflammation— augmentation with FHL tendon
- 40. Chronic Achilles Rupture Chronic rupture may be reconstructed with FHL, FDL, or slip from gastrocnemius
- 41. Achilles Tendon Ruptures Reconstruction of neglected rruuppttuurree wwiitthh ppeerroonneeuuss lloonngguuss aanndd ppllaannttaarriiss wweeaavvee
- 42. V-Y Lengthening: >3 cm Debride necrotic tissue Advance Tendon Suture Repair
- 43. FHL Transfer: >3cm with tendinopathy •Reflect abductor hallucis and flexor hallucis brevis •FHL medial to FDL
- 44. FHL Transfer Tag each end of tendon
- 45. FHL Transfer Distal FHL sutured to FDL with ankle and toes in neutral Confirm full hallux MTP dorsiflexion, otherwise retension and residual clawing
- 46. FHL Transfer
- 47. PPeerroonneeaall tteennddoonnss ccoouurrssee bbeehhiinndd tthhee ddiissttaall Peroneal TTeennddoonn DDiissllooccaattiioonn ffiibbuullaa TThhee ppeerroonneeuuss bbrreevviiss mmaayy hhaavvee ddeeggeenneerraattiivvee cchhaannggeess iiff tthhee iinnjjuurryy iiss nnoott iiddeennttiiffiieedd iinn aa ttiimmeellyy ffaasshhiioonn
- 48. Peroneal Tendon Dislocation X-ray – May show avulsion of retinaculum from fibula Conservative treatment – Casting in slight plantarflexion and inversion for 6 weeks non weight bearing – Allows the retinaculum to heal if the tendons can be reduced closed – Successful if the injury is identified early
- 49. PPeerroonneeaall TTeennddoonn DDiissllooccaattiioonn SSuurrggeerryy – OORRIIFF rreettiinnaaccuullaarr ppiieeccee iiff ppoossssiibbllee – RReeppaaiirr rreettiinnaaccuulluumm iiff ppoossssiibbllee – SSoofftt ttiissssuuee rreeccoonnssttrruuccttiioonn wwiitthh sslliinngg ffoorr rreettiinnaaccuulluumm
- 52. Posterior Tibial Tendon Rupture AAnnaattoommyy – AArriisseess ffrroomm ppoosstteerriioorr aassppeecctt iinntteerrmmuussccuullaarr sseeppttuumm – IInnsseerrttss oonn ttaarrssaall bboonneess – AAvvaassccuullaarr zzoonnee ppoosstteerriioorr ttoo mmeeddiiaall mmaalllleeoolluuss – HHiigghh ffrriiccttiioonnaall llooaadd ppoosstteerriioorr ttoo mmeeddiiaall mmaalllleeoolluuss
- 53. Posterior Tibial Tendon Rupture Function – Inverter of hindfoot – Locks transverse tarsal joint – Maintains height longitudinal arch – Maintains neutral position of hindfoot at degrees
- 54. Posterior Tibial Tendon History – More commonly an attritional rupture over time than an acute rupture – Patient may complain of flat foot and midfoot pain – Sports with quick changes of direction may put increased force on tendon X-ray – Foot x-ray may show medial talar displacement
- 55. AP Radiograph Talonavicular coverage- as arch collapses the talarhead coverage by the navicular is lost Talus-1st MT diverges or angle increases Anterior talocalcaneal angle increases
- 56. Lateral Radiograph A. Increased Talus-forefoot angle B. Increased Talus Calcaneous angle - plantarflexed talus C. Decreased Calcaneal Pitch Negative Med Cun-5th MT - normally the 5th MT is more plantar than the medial cuneiform A B C
- 57. Talus-1st MT and Calcaneal Pitch Colinear Talus-1st MT Normal calcaneal pitch Divergent Talus- 1st MT Loss of calcaneal pitch
- 58. Posterior Tibialis Reconstruction Surgery for the flexible deformity – Reconstruction of the posterior tibial tendon with FDL or FHL – Medial calcaneal wedge osteotomy or lateral column lengthening through the calcaneus – Fig 14, page 1705 from “Acquired adult flatfoot deformity” in Orthopaedics, 2002
- 59. Posterior Tibial Tendon Rupture Chronic rupture – Develop gradually – Women over 40 – Tenderness/swelling over tendon – Forefoot abduction – “too many toes” sign – Absent single heel raise –Loss of height of arch –Hindfoot valgus
- 60. Posterior Tibial Tendon Rupture Chronic rupture – Stage I Pain, weakness, no deformity – Stage II Flexible flatfoot deformity – Stage III Rigid flatfoot deformity Radiographic subluxation/arthritis
- 61. Posterior Tibial Tendon Rupture Management – Chronic rupture Stage I – Nonop (NSAID, arch support, AFO) – Tenosynovectomy if SXs persist Stage II tenosynovectomy – nonop (medial wedge, arch support, or AFO) – Surgical TX controversial – Reconstruction utilizing FDL or split anterior tibial tendon – Deformity frequently recurs – Calcaneal osteotomies hold promise
- 62. Thanks!