(OBQ08.216)
In the Lauge-Hansen classification system, a pronation-abduction ankle fracture has what characteristic fibular fracture pattern? J Orthop Surg Hong Kong ; With a negative stress image obtained in the office, how would you treat this patient? Past medical history includes insulin dependent diabetes mellitus for 35 years. A radiograph of her ankle is shown in Figure A. 4 —Chopart fracture-dislocation in 27-year-old woman after twisting ankle injury. rare; total dislocation (extruded talus) talus is completely dislocated from ankle and subtalar and talonavicular joints; results from continuation of forces required for medial or lateral dislocation with disruption of talocrural ligaments and extrusion of talus from ankle joint; usually open; Presentation Fig. Which of the bone fragments labeled on the distal tibia in the axial CT scan shown in Figure A is attached to the posterior inferior tibiofibular ligament? Most commonly affecting the anterior aspect of the vertebral body, wedge fractures are considered a single-column (i.e. A Lisfranc injury is a tarsometatarsal fracture dislocation characterized by traumatic disruption between the articulation of the medial cuneiform and base of the second metatarsal.
History reveals that he sustained a left ankle fracture 2 years ago and was treated with closed reduction and casting. in Lauge-Hansen supination-adduction fractures, estoration of marginal impaction of the anteromedial tibial plafond, leads to optimal functional results after surgery, time for proper braking response time (driving) returns to baseline at nine weeks for operatively treated ankle fractures, braking travel time is significantly increased until 6 weeks after initiation of weight bearing in both long bone and periarticular fractures of the lower extremity, deep deltoid inserts on posterior colliculus, lag screw fixation stronger if placed perpendicular to fracture line, lag by technique using 3.5 fully-threaded screw is biomechanically superior to lag by design using 4.0 partially-threaded screws, if the mortise is well reduced, results from operative and non-operative treatment are similar, can be treated operatively if also treating an ipsilateral syndesmosis injury, lag screw fixation with neutralization plating, most common disadvantage of using posterior antiglide plating is peroneal irritation if the plate is placed too distally, posterior antiglide plating is biomechanically superior to lateral plate placement, intramedullary retrograde screw placement, possible if fibula is a spiral pattern and screws can be placed at least 1 cm apart, the stiffest fixation construct for the fibula is a locking plate, period of immobilization usually 4-6 weeks after ORIF, duration of immobilization should be doubled in, need to fix with one of the options listed in section above, antiglide plate to treat a vertical medial malleolus fracture, orient screws parallel to joint for vertical medial malleolar fracture (Lauge-Hansen supination-adduction fracture pattern), stiffness of syndesmosis restored to 70% normal with isolated fixation of posterior malleolus (versus 40% with isolated, stress examination of syndesmosis still required after posterior malleolar fixation, posteroinferior tibiofibular ligament may remain attached to posterior malleolus and syndesmotic stability may be restored with isolated posterior malleolar fixation, rare fracture-dislocation of the ankle where the fibula becomes entrapped behind the tibia and becomes irreducible, posterolateral ridge of the distal tibia hinders reduction of the fibula, open reduction and fixation of the fibula in the incisura fibularis, fracture-dislocation of the ankle due to hyperplantarflexion, indicated if soft tissue conditions allow, primary closure at the index procedure can be performed in appropriately-selected Gustilo-Anderson grade I, II, and IIIA open fractures in otherwise healthy patients sustaining low-energy injuries without gross contamination, soft tissue conditions and overall patient characteristics, fixation usually not required when fibula fracture within 4.5 cm of plafond, up to 25% of tibial shaft fractures will have ankle injury (highest rate with distal 1/3 spiral fractures), lateral stress radiograph has more interobserver reliability than an AP/mortise stress film, best option is to assess stability intraoperatively with, instability of the syndesmosis is greatest in the anterior-posterior direction, largest risk factor for diabetic patients is presence of peripheral neuropathy, high suspicion for articular impaction of the tibial plafond in supination-adduction injuries, which should be addressed at the time of surgery, corrective osteotomy requires anatomic fibular and mortise correction for optimal outcomes, Loss of dorsiflexion with posterior fixation, rare with anatomic reduction and fixation. CT scans note anteromedial marginal impaction. The Cotton test evaluates which of the following structures? Diagnosis is typically made through clinical evaluation and confirmed with plain radiographs. A 45-year-old male with long-standing diabetes sustains the injury shown in Figure A.
Plain radiographs often grossly underestimate the extent of injury. The Lauge-Hansen classification of ankle fractures identifies characteristic fracture patterns based on mechanism of injury. A 32-year-old taxi driver sustains a displaced supination external rotation ankle injury after slipping off of a curb. Adult Knee Trauma Radiographic Evaluation, Proximal Humerus Fracture Malunion and Nonunion, Distal Radial Ulnar Joint (DRUJ) Injuries, bimalleolar and bimalleolar-equivalent fractures, primary restraint to anterolateral talar displacement, acts as buttress to prevent lateral displacement of talus, full-length tibia, or proximal tibia, to rule out Maisonneuve-type fracture, normal <6 mm on both AP and mortise views, based on foot position and force of applied stress/force, has been shown to predict the observed (via MRI) ligamentous injury in less than 50% of operatively treated fractures, Bosworth fracture-dislocation (posterior dislocation of the fibula behind incisura fibularis), A - infrasyndesmotic (generally not associated with ankle instability), if intact mortise, no talar shift, and < 3mm displacement, classically fractures with more than 4-5 mm of medial clear space widening on stress radiographs have been considered unstable and need to be treated surgically, recent studies have shown the deep deltoid may be intact with up to 8-10 mm of widening on stress radiographs, elderly or unable to undergo surgical intervention, examination has been shown to be largely unreliable in predicting medial injury, not necessary to repair medial deltoid ligament, only need to explore medially if you are unable to reduce the mortise, see isolated fibular fracture techniques above, evaluation of percentage should be done with CT, as plain radiology is unreliable, decision of approach will depend on fracture lines and need for fibular fixation, posterior to anterior lag screw and buttress plate, main feature is a vertical shear fracture of the posteromedial tibial rim, "spur sign" is a double cortical density at the inferomedial tibial metaphysis, fixation of posteromedial and posterior fragments with antiglide plating, tibiofibular clear space (AP) greater than 5 mm, any postoperative malalignment or widening should be treated with open debridement, reduction, and fixation, length and rotation of fibula must be accurately restored, outcomes are strongly correlated with anatomic reduction, placing reduction clamp on midmedial ridge and the fibular ridge at the level of the syndesmosis will achieve most reliable anatomic reduction, "Dime sign"/Shentons line to determine length of fibula, open reduction required if closed reduction unsuccessful or questionable, one or two cortical screw(s) or suture devices 2-4 cm above joint, angled posterior to anterior 20-30 degrees, maximum dorsiflexion of ankle not required during screw placement (can't overtighten a properly reduced syndesmosis), screws should be maintained in place for at least 8-12 weeks, must remain non-weight bearing, as screws are not biomechanically strong enough to withstand forces of ambulation, implant material (stainless steel screws, titanium screws, suture, bioabsorbable materials), suture devices are more forgiving on reduction, no difference in outcomes seen with hardware maintenance (breakage or loosening) or removal at 1 year, outcome may be worse with maintenance of intact screws, malreduction of isolated syndesmotic injuries improves with screw removal, multiple quadricortical syndesmotic screws (even in the absence of syndesmotic injury), tibiotalar Steinmann pins or hindfoot nailing, augment with intramedullary fibula K-wires, stiffer, more rigid fibular plates (instead of 1/3 tubular plates), maintain non-weightbearing postop for 8-12 weeks (instead of 4-8 weeks in normal patients, acts as buttress to prevent lateral displacement of talus.
Entrapment of which of the following structures is the most likely etiology?
Closed reduction and casting for 12 weeks, Open reduction and internal fixation with restricted weight bearing for 2 weeks, Open reduction and internal fixation with restricted weight bearing for 6 weeks, Open reduction and internal fixation with restricted weight bearing for 12 weeks. Lisfranc fracture, Lisfranc dislocation, Lisfranc fracture dislocation, tarsometatarsal injury, midfoot injury: An X-ray of a Lisfranc injury: Specialty: Orthopedics: A Lisfranc injury, also known as Lisfranc fracture, is an injury of the foot in which one or more of the metatarsal bones are displaced from the tarsus. (OBQ13.261)
Case presentation: We report the case of a 17-year-old woman who was injured while playing basketball. A 27-year-old man presents to the emergency department with an ankle fracture. These two joints lie in a plane perpendicular to the longitudinal arch of the foot, and act as a single unit with respect to the hindfoot. talonavicular and calcaneocuboid joints which separate the hindfoot from the midfoot .
Pure Chopart joint dislocations were observed in 28 (25%) feet, fracture-dislocations in 60 (55%) feet, and combined Chopart-Lisfranc joint fracture-dislocations in 22 (20%) feet. MB BULLETS Step 1 For 1st and 2nd Year Med Students. The mean scores of the … (OBQ04.23)
What is the most appropriate management? Pure Chopart joint dislocations were observed in 28 (25%) feet, fracture-dislocations in 60 (55%) feet, and combined Chopart-Lisfranc joint fracture-dislocations in 22 (20%) feet. By FORE 2014 Current Solutions in Foot and Ankle Surgery FEATURING Michael Clare.
Open reduction and internal fixation of the medial malleolus with syndesmosis reduction and suture-button repair, Repair of the anterior talo-fibular ligament, Open reduction internal fixation of the fibula with syndesmosis reduction and suture-button repair, Open reduction internal fixation of the medial malleolus and fibula, Open reduction internal fixation of the fibula and medial malleolus with syndesmosis reduction and suture-button repair. The anatomy in this region of the foot is quite intricate with numerous articulations. most appropriate stress radiograph to assess competency of deltoid ligament, more sensitive to injury than medial tenderness, ecchymosis, or edema, gravity stress radiograph is equivalent to manual stress radiograph, it has also been reported that there is no actual correlation between syndesmotic injury and tibiofibular clear space or overlap measurements, with external rotation stress applied to a dorsiflexed ankle is predictive of deep deltoid disruption, measured by bisection of line through tibial anatomical axis and another line through the tips of the malleoli, shortening of lateral malleoli fractures can lead to increased talocrural angle, talocrural angle is not 100% reliable for estimating restoration of fibular length, can also utilize the realignment of the medial fibular prominence with the tibiotalar joint, Talofibular sprain or distal fibular avulsion, Vertical medial malleolus and impaction of anteromedial distal tibia, Lateral short oblique fibula fracture (anteroinferior to posterosuperior), Posterior tibiofibular ligament rupture or avulsion of posterior malleolus, Medial malleolus transverse fracture or disruption of deltoid ligament, Transverse comminuted fracture of the fibula above the level of the syndesmosis, Anterior tibiofibular ligament disruption, Lateral short oblique or spiral fracture of fibula (anterosuperior to posteroinferior) above the level of the joint, lateral malleolus fracture with < 3mm displacement, bimalleolar fracture if elderly or unable to undergo surgical intervention, displaced isolated medial malleolar fracture, displaced isolated lateral malleolar fracture, bimalleolar fracture and bimalleolar-equivalent fracture, posterior malleolar fracture with > 25% or > 2mm step-off, goal of treatment is stable anatomic reduction of talus in the ankle mortise, see fracture patterns below for specific treatment, prolonged recovery expected (2 years to obtain final functional result), significant functional impairment often noted, anatomic reduction is considered the most important factor for a satisfactory outcome, worse outcomes with: smoking, decreased education, alcohol use, presence of medial malleolar fracture, ORIF superior to closed treatment of bimalleolar fractures. How long from today’s visit will his braking time be expected to return to normal? (OBQ16.260)
stable) fracture.. Less commonly wedge fractures refer to a subtype of tibial plateau fractures.
An otherwise healthy 45-year-old female slips and falls with immediate right ankle pain.
Four months later, he returns for follow-up with mild ankle discomfort, and a radiograph is shown in Figure A. ORTHO BULLETS Orthopaedic Surgeons & Providers In what direction is the fibula most unstable? A 19-year-old male sustains the injury shown in Figure A while skiing. The primary treatment was operative in 91 (83%) feet and nonoperative in 19 (17%) feet. Displacement of the fracture fragment is variable.
A 34-year-old man sustains a twisting injury to his left ankle playing soccer.
(OBQ13.87)
It corresponds to the center of the foot and allows for essential articulation by means of the talo-calcaneo-navicular joint (coxa pedis). Background: Ankle dislocation without fracture is an extremely rare injury because it is usually accompanied by concomitant malleolar fractures from the anatomical and mechanical viewpoints. What is the mechanism for the fracture pattern shown in Figure A?
(SBQ12FA.77)
(OBQ11.17)
March 7, 2014. MB BULLETS Step 2 & 3 For 3rd and 4th Year Med Students. 1,2,5,6,9,10 The surrounding bony articulations and ligamentous attachments of the navicular and cuboid create stable joints that are thought to require high energy to dislocate, typically accompanied by a concomitant fracture. Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC. What is the most appropriate plating technique utilized for the medial malleolus fracture typically seen in a displaced supination-adduction ankle fracture? A 35-year-old male with a pronation abduction ankle injury would have which of the following radiographs?
A 40-year-old male patient sustains a bimalleolar ankle fracture and undergoes open reduction and internal fixation. Figure A shows an isolated left ankle injury in an active 48-year-old recreational hockey player. The treating surgeon is faced with a wide array of treatment challenges. When comparing the fibular plating techniques shown in Figures A and B, the plate position shown in Figure B is associated with which of the following? Chopart fracture-dislocations may therefore include fractures of the navicular, the cuboid, the talus, and calcaneus. Progressive weightbearing in 3-4 weeks based on radiographs, Deltoid ligament repair vs reconstruction, Removal of syndesmotic screws in 3-6 months. An 18-year-old football player presents to the emergency department after sustaining an ankle injury.
(OBQ09.259)
Which of the following is the most important factor in deciding between a joint sacrificing and a joint preserving operation for this patient at this time? The primary treatment was operative in 91 (83%) feet and nonoperative in 19 (17%) feet. ORTHO BULLETS Orthopaedic Surgeons & Providers
lateral dislocations more likely to be open, talus has no muscular or tendinous attachments, foot will be locked in supination with medial dislocation, foot will be locked in pronation with lateral dislocation, talar head will be superior to navicular on lateral view, talar head will be collinear or inferior to navicular on lateral view, look for associated injuries or subtalar debris, closed reduction and short leg non-weight bearing cast for 4-6 weeks, medial dislocation reduction blocked by lateral structures including, lateral dislocation reduction blocked by medial structures including, typical maneuvers include knee flexion and ankle plantarflexion, followed by distraction and hindfoot inversion or eversion depending on direction of dislocation, perform a post-reduction CT to look for associated injuries, dictated by direction of dislocation and associated fractures, sinus tarsi approach to remove incarcerated lateral structures (EDB, etc. A 33-year-old female sustains the injury shown in Figure A as the result of a fall off a chair, and subsequently undergoes operative stabilization of her injury. Geriatric hip-proximal femur 2-5% 5% Femur, shaft and subtrochanteric 1-3% 3% Adolescent femur 0.5-1% 1% Distal femur 1-3% 3% Knee-patella and extensor mechanism 0.5-1% 1% Knee-dislocations 0.5-1% 1% Tibia, proximal 1-3% 3% Tibial shaft 1-2% 2% Tibia, distal (pilon) 1-2% 2% 7.5 Hip Dislocation 45 Femoral Neck FX 1.5 … Which of the following is true when comparing Figure A to Figure B?
A 34-year-old male falls 10 feet from a balcony and is brought to the emergency room with the deformity seen in Figure A. Radiographs shown are shown in Figure B and C. Which of the following structures can block closed reduction of this injury pattern? (OBQ07.223)
Anteroposterior radiograph of foot reveals talonavicular and, less pronounced, calcaneocuboid malalignment with small fracture fragment (arrow). Lisfranc Injury (Tarsometatarsal fracture-dislocation) – Foot & Ankle – Orthobullets. (OBQ09.52)
Most coccygeal fractures have a transverse orientation 2. Surgical fixation with absolute stability would be most appropriate for which of the following fracture patterns? (OBQ10.40)
(OBQ06.250)
Copyright © 2021 Lineage Medical, Inc. All rights reserved.
(OBQ09.121)
(OBQ08.93)
A 28-year-old male sustained an ankle injury 3 months ago, and was treated with closed management and splinting; a current x-ray is shown in Figure A. After undergoing the treatment seen in Figure A, when should a patient be expected to safely operate the brakes of an automobile? The commonly fractured bones are the calcaneus, cuboid and navicular. A 25-year-old male sustains an ankle fracture dislocation and undergoes open reduction and internal fixation. (OBQ07.39)
the scores for pure dislocations or fracture-dislocations of the Chopart joint, but significantly lower scores were noted with combined Chopart-Lisfranc joint fracture-dislocations. A 68-year-old female sustains a closed ankle fracture and is treated with open reduction and internal fixation. A 31-year-old male sustains an irreducible ankle fracture-dislocation with the foot maintained in an externally rotated position. Figure B is more likely to have an associated fracture, Figure A is more likely to be blocked from closed reduction by the extensor digitorum brevis, FIgure B is more likely to be blocked from closed reduction by the posterior tibial tendon, Figure A more likely to be stable following closed reduction. What is the most reliable method to evaluate the competence of the deltoid ligament? Chopart Joint: articulation between the hindfoot (calcaneus and talus) and the midfoot (navicular, cuboid and cuneiforms) comprising the calcaneocuboid and talocnavicular joints.
(SBQ12FA.12)
ORTHO BULLETS Orthopaedic Surgeons & Providers (OBQ09.173)
Wedge fractures (also known as compression fractures) are hyperflexion injuries to the vertebral body resulting from axial loading.
Her ankle was swollen and deformed. MB BULLETS Step 2 & 3 For 3rd and 4th Year Med Students. A tibial plafond fracture (also known as a pilon fracture) is a fracture of the distal end of the tibia, most commonly associated with comminution, intra-articular extension, and significant soft tissue injury. The commonly fractured bones are the calcaneus, cuboid and navicular. (OBQ06.140)
(OBQ09.76)
Significant angulation or displacement may require closed … (OBQ08.103)
The injury is closed, and the patient is neurovascularly intact. (OBQ09.123)
Chopart ligament: bifurcate ligament comprising the calcaneonavicular and calca… Chopart's fracture–dislocation is a dislocation of the mid-tarsal (talonavicular and calcaneocuboid) joints of the foot, often with associated fractures of the calcaneus, cuboid and navicular.
Fractures can occur in isolation or as part of … A 32-year-old female sustains the injury shown in Figure A. anterior dislocation. Fractures and dislocations of the midfoot and Chopart complex are among the most difficult foot injuries to manage. Chopart Fractures and Dislocations.
best demonstrated on the lateral projection 2; Treatment and prognosis. (OBQ06.85)
Which of the following is most correlated with positive outcomes when treating this injury? The high functional restrictions in Chopart dislocations can rare; posterior dislocation. Palpation of the medial ankle in the region of the deltoid. talonavicular and calcaneocuboid joints which separate the hindfoot from the midfoot . Which of the following is most appropriate step based on Figures A and B?
MB BULLETS Step 1 For 1st and 2nd Year Med Students. What is the most appropriate definitive treatment?
The treatment priorities should therefore include addressing all of the injured soft tissues by immediate joint reduction or restoring bony alignment, including the avoidance of threatening compartment syndromes. Widening of the tibia-fibular clear space with external rotation stress would be a result of injury of which structure?
Chopart dislocations are rare injuries and are challenging to treat. Multiple attempts at a closed reduction are made, but are unsuccessful.
He returns to clinic five months following surgery complaining of continued ankle pain and instability with weight bearing. Subchondral debridement of any osteochondral defect, Casting or splinting in a neutral position postoperatively. As with all proximal humerus fractures,mostGTfractures(85%to 95%) are minimally displaced and may be treated nonsurgically.8,9 Superior displacement of ,5mmis generally considered an indication for nonsurgical treatment,6,10 and several authors have reported … Which radiograph (Figures A-E) would best correlate with this finding? He has a BMI of 38, established peripheral neuropathy, and his most recent HbA1c is 8.8. (OBQ09.17)
Incarceration of the fibula behind the posterolateral ridge of tibia, Entrapment of the flexor hallucis longus (FHL) tendon, Entrapment of the extensor digitorum brevis (EDB). Following closed reduction and splinting, what would be the next best step? The injury is named after Jacques Lisfranc de St. Martin (2 April … (OBQ04.49)
His immediate post-operative AP radiograph is seen in Figure A. dislocation,1,7 whereas 15% to 30% of all anterior glenohumeral dislo-cations7 result in GT fracture.
Transverse fracture below the level of the syndesmosis, Short oblique fracture running from anteroinferior to posteriosuperior, Short oblique fracture running from posteroinferior to anteriosuperior, Comminuted fracture at or above the level of the syndesmosis.
(SBQ12TR.104)
At the eight-week postoperative visit, you are asked to fill out a return to work form. Marginal impaction of the anteromedial tibial plafond, Posterolateral osteochondral lesion of the talus. The treating surgeon is faced with a wide array of treatment challenges. Chopart fracture-dislocations may therefore include fractures of the navicular, the cuboid, the talus, and … Following operative repair of lower extremity long bone and periarticular fractures, what is the time frame for patients to return to normal automobile braking time? What is the most common fracture associated with a lateral subtalar dislocation? useful to help determine presence of superimposed osteomyelitis
(OBQ09.204)
A 32-year-old female sustained a bimalleolar ankle fracture and was treated with open reduction and internal fixation four months ago.
Calcaneocuboid fracture-dislocations are usually accompanied by comminuted calcaneus and cuboid impaction fractures. Plain radiograph.
(OBQ08.175)
Recommended management should consist of? Three fracture-dislocation patterns are recognized: dorsal, volar, and pilon. He subsequently undergoes surgical fixation, and a post-operative radiograph is shown in Figure A.
A 40-year-old male suffers the isolated injury shown in figure A with no associated fractures. Intra-articular injection of steroids into the ankle joint, bracing, and physical therapy, Intra-articular injection of hyaluronic acid product into the ankle joint, bracing, and physical therapy, Corrective osteotomy of the fibula and medial malleolus with reconstruction of the syndesmosis if unstable.
In all three injury pattern groups, an initial anatomic reduction was essential for good results. choprt … Syndesmosis sagittal plane reduction and fixation, Syndesmosis coronal plane reduction and fixation, Osteotomy and revision of the fibula and syndesmosis. Frontal, oblique, and lateral radiographs of the foot were obtained.
(OBQ06.28)
In which of the following radiographs of different types of ankle fractures should the medial malleolus be treated with screw fixation directed parallel to the ankle joint? As a rule, coccygeal fracture/dislocations are treated with non-operative management (e.g.
1,2,5,8,10 In our case, a Chopart dislocation without navicular or cuboid fracture … Fracture-dislocations of the proximal interphalangeal joint encompass a spectrum of injury severity, ranging from injuries that require little intervention to those that require advanced reconstructive surgery for optimal outcome. The mean scores …
Which of the following could have prevented this patient from developing persistent pain? Lateral ulnar collateral ligament of the elbow. Appropriate treatment of the bimalleolar ankle fracture shown in Figure A includes which of the following? In an isolated ankle syndesmotic injury, the fibula is unstable in the incisura fibularis of the tibia. (OBQ13.137)
(OBQ14.216)
An unsuccessful attempt at reduction in the emergency department with sedation was made. Stress examination of the right ankle is shown in Figure A. fragmentation of both articular surfaces of a joint leading to subluxation or dislocation; scattered "chunks" of bone in fibrous tissue; surrounding soft tissue edema; joint distension by fluid; heterotopic ossification; Bone scan indications.
a dislocation of the mid-tarsal joints of the foot, often with associated fractures of the calcaneus, cuboid and navicular bone. open reduction and fixation of the fibula in the incisura fibularis indicated in most cases On physical examination the patient is unable to feel a 5.07 gm monofilament on the plantar aspect of his foot. rare fracture-dislocation of the ankle where the fibula becomes entrapped behind the tibia and becomes irreducible; posterolateral ridge of the distal tibia hinders reduction of the fibula ; Operative. The anatomy in this region of the foot is quite intricate with numerous articulations.
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