Differential Diagnosis II

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    JC Lau 2002

    Differential Diagnosis II Mid-term

    ANKLE SPRAIN PRESENTATION

    CASE I – 20 year old male sustained an ankle injury. He has had multiple ankle injuries to both ankles over the last few years. He is very active and in addition to playin basketball and soccer! he also is a snowboarder. He injured his ankle snowboardin "Dorsiflexion, inversion injury #

    $% &H' $(J)*+ $, ACUTE "2 -ays# (- &H'*' $, SIGNIICANT S!ELLING/

    "ISTOR# Lookin for Instability 

    $% Me&'anism

    • $f they fell forward on their board! they will do a -*,$%L'1$($(3'*,$( sprain

    • -ue to boot holdin foot in -orsifle4ion yet still allowin foot to rotate inside.

    (% Lots of s)elling

    • $ndicative of L&, of injury

    • 5ill throw off a lot of tests because fluid acts almost like a 6splint6

    *% Otto)a G+idelines  • $nability to bear weiht after injury * durin e4amination

    • 7in point pain  8ony tenderness "specific areas of bony tenderness#

    a. 9alleoli b. (avicular   c. Cuboid d. :th 9& head

    E,AMINATION

    ,-ra ; < views you must take "if no findin! wait 2 weeks and reshoot films# $% A  . P An/le

    (% Lateral An/le

    *% Mortise 0ie)  • 5ill reveal a Talar Dome Fracture * Osteochondritis Dessicans of the ankle

    • 9ortise view is taken ;7 with 20= internal rotation

    1% ( Additional 2ie)s a. 9ortise $nversion &ilt b. 9ortise 'version &ilt

    • &ake two lines "one at the top of &alus! one at bottom of &ibia#

    • &his anle is the Talar Tilt , should NOT be > 10°

    Positi0e Talar Tilt findings

    • $f anle is open! patient has &*( the Calcaneofibular ligament ! Anterior Talofibular

    ligament 

    • 9ust also look for tearin of the Interosseous Membrane and Tibiofibular

    ligament 

    If ,-ra is NEGATI2E3 >. -rawer &est 2. &alus *ock test

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    Tests for Interosseso+s tear  1. S4+ee5e test  E6ternal &om7ression test

    • 7ain elicited with test due to further separation of $nterosseous tear@@

    . E6ternal Rotation test  ; B!T test to use"" 

    • 7atient is seated with ankle in neutral position

    • &hen 7,,$3'L+ '4ternally rotate the ankle

    POSITI2E INDING3 Lookin for end;rane pain

    !. S4+ee5e  Dorsifle6ion test 

    • 7ain or limitation with 7,,$3' -orsifle4ion

    • &hen sAueeBe

    POSITI2E INDING3 &here will then be an Increase in #orsifle$ion andor #ecrease in %ain

    Res+lts of Interosseso+s tear 

    • Calcification ",yndosmosis#

    Diagnosis >. 8Sno)9oarder:s fra&t+re; 

    • &ateral %rocess of the Talus is fractured 

    • 9ay see on Lateral %ilm or  – 7 "with internal or e4ternal rotation#

    • 7ossibly even an bliAue %ilm

    2. Me&'anism of Sno)9oarder:s ra&t+re  -orsifle4ion and $nversion

    'ATINT ()!T IN)*# +I! AN& AT A !'O*TIN- .NT T+AT /O) A* T+ #OCTO* O* /O) A* '*!NT TO 2A3 T+ AN& 4IT+IN 50 3IN)T! '*IO* TO AN/ !I-NIICANT !4&&IN- 4+AT I! /O)* A''*OAC+6

    E,AMINATION – in order 

    >. ttawa Duidelines 2. Look for deformity

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    • Cal&ane+s ad. $nterosseous &aloCalcaneal Liament

    • $nside ,inus &arsi

    • -ianosed with 9*$

    • Can et entrapped

    2. 8ifurcate Liament

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    • $f this ets torn! often becomes unstable

    An/le S7rains

    $% General Notes• $nversion  7lantarfle4ion is 9,& C99(

    a% IN2ERSION SPRAIN/ ,eAuence of &earin "from front to back#

    •  nterior &alofibular 

    • Calcaneofibular 

    • 7osterior &alofibular "this will only tear if ,'3'*'@#

    9% E2ERSION SPRAIN/

    • -eltoid Liament – rarely torn@

    (% E0al+ation a% 7alpate for bony tenderness "for fracture#

    9%  nterior -rawer test&% &ilt &est d% ttawa *ules

    • $nability to bear weiht after injury or at time of evaluation

    • &enderness at specific bony areas "9alleoli! (avicular! Cuboid! Head of :th 9

    • 3ust ta7e 29ray if AN/ of these are found"" 

    Grading of Ligament In

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    d% M+s&le Strengt'ening

    • 7eroneals

    • &ibialis nterior 

    • Hip bductors

    • !trengthening of .*TO*! and #O*!I&2O*! :ill hel% %re;ent inF "to see how to test for flatfeet#

     A 8=9year9old runner has been told that he has flatfeet  +e is :ondering if you thin7 he does and  :hat can be done about it

    $% Non-)eig't 9earing 7osition! is t'ere an ar&'

    lat oot

    $% Tarsal Coalition 

    • Connection between Calcaneus and &alus and (avicular that

    should not be there "connective tissue bride#

    • 9ust take an 1;ray

    • C& ,can or 9*$

    (% Ti9ialis Posterior R+7t+re

    • *heumatoid rthritis predisposes to this

    NORMAL "&here is an arch#

    >. (ormally

    • 'ven if a person a flat footed! there should be an arch

    (% E6&e7tion

    • CH$L-*'(@

    • &his is because when baby is in;utero! there is a period of time

    that takes bones to 6-';*&&'6

    • %eet are turned "baby fetal position#  once baby bears

    weiht! bones will rotate into normal position

    • &his does not occur in some people  Tarsal -oalition

    If Ar&' is 7resent (& flat footed

    :

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    If Ar&' is NOT 7resent

    >. $s 9edial rch presentsufficientG

    • Can you et a finer underneath

    2. 'valuate patient 7*('! e4amine relationship between forefoot and hindfoot a. 'valuate %orefoot 3arus3alus

    b. 'vaulate Hindfoot 3arus3alus • 3alus  eversion

    MOST COMMON3 >. "indfoot 2ar+s 

    • Have a lot to move when heel strike occurs to et to pronation

    • $t is the 6rate6 that the patient has to pronate that causes the problem  patient will have

    a tendency to O)*/'O%&T*000 

    • Hindfoot 3arus will look supinated statistically! but will behave opposite durin motion

    "3'*;pronates@@#

    2. orefoot 2alg+s 

    • 5ith %orefoot 3alus! when patient bears weiht ? th and :th diits will not be touchin

    • ,ub&alar joint must supinate to et ?th and :th diits down to the round@@  &hus

    Hindfoot must be 3arus to allow for %orefoot 3alus to be able to bear weiht@@

    Ort'odi&s $% "indfoot 2ar+s

    • 9edial post would be placed on heel to prevent pronation@

    (% orefoot 2alg+s

    • Lateral %orefoot post to eliminate need for Hindfoot 3arus@

    In Utero &a+ses of lat oot >. IN9)T*O en;ironment  causes

    • It has caused bony mal%osition that CANNOT be e$ercised or ad

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    • ( need use orthodic )(L',, they are e4periencin symptoms@

    S'oe Re&ommendations >. ,hoes 7arts

    U77er  )pper part of shoe

    $% "eel Co+nter 

    • &he hiher the heel counter! the more cushion 8)& more

    predisposition to $nversion sprain@@  7erson who sprains ankle easy should have a small heel counter 

    (% 2am7 ; where laces o

    *% Toe ?o6

    Sole of S'oe

    $% Insole

    (% Midsole a. )sually made of/

    • E2A "for cushion#

    • Pol+ret'ene "for durability#

     #ual #ensity  is a combination of the two.

     9ost shoes have this combo@@

    b. ften add $* or D'L that is encapsulated

    • ,ometimes with a plastic bar 

    • &his e4tends the life of the shoe@@

    c. %L'1$8$L$&+ ,H)L- 8' & &H' 9'&&*,L, NOT T"E MIDOOT"middle of shoe#@@

    • $f it bends at 9id;foot! it will predispose person to 7lantar;

    fascitis@@@

    *% O+tsole

    2. Lasts  the 9L- of the shoe a% Straig't Last 9% Semi;&+r0ed Last &% C+r0ed Last

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    • %ront is slip;lasted

    • 8ack is 8oard;lasted

    S'oe Re&ommendations

    Pronator 

    Motion -ontrol $hoe  8oard lasted 

    ,traiht Last

    • 8ecause you want a very firm Heel Counter.

    • 9id;sole is 6built up6 thus is the H'3$',& shoe@@

    • 7ronator cannot be dianosed just from L&'*L shoe wear@

     Diagnosti& sign is bule on medial aspect of shoe from pronation@@

    Normal B Mild Pronator 

    $tability $hoe  ,emi;curved last  Combination last

    S+7inator 

    -ushion $hoe  Curved last  ,lip last

    1 &I-+T!T of all shoes""