Painful foot or ankle? Don't overlook these 5 injuries
A missed diagnosis of one of these conditions risks delay in referral for orthopedic evaluation and surgical management—possibly leading to complications.
PRACTICE RECOMMENDATIONS
› Suspect higher-grade syndesmotic disruption (which typically requires surgical intervention) in patients whose ankle pain persists after 3 weeks of immobilization or who have a tibial or fibular diastasis on a plain film. C
› Order weight-bearing x-rays to make an accurate diagnosis of Lisfranc injury. Refer for potential surgical intervention if diastasis is evident at the base between the first and second metatarsals. C
› Distinguish between proximal diaphysial (Jones) fracture of the fifth metatarsal, diaphysial stress fracture, and avulsion fracture—essential because avulsion fracture can be treated nonoperatively but the other 2 require surgical intervention. C
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
Management. Some degree of controversy surrounds preferred treatment of Achilles tendon rupture, although available evidence demonstrates that these injuries can be effectively managed by surgical repair or nonoperative treatment, as outcomes are comparable.3,5 Operative management tends to reduce the risk of repeat rupture, compared to nonoperative treatment; however, the potential for surgical complications, including wound infection, sensory disturbance, and adhesions favors nonoperative treatment.3,4,6
Nonoperative treatment consists of referral to a functional rehabilitation program, without which outcomes are, on the whole, less favorable than with surgery.3,6 Surgery is preferred if functional rehabilitation is unavailable, 6 months of conservative management fails, or there is avulsion injury.3,4,6
Injury to the syndesmosis
A complex of ligaments that provide dynamic stability to the ankle joint, the tibiofibular syndesmosis comprises:
- the anterior inferior tibiofibular ligament
- the posterior inferior tibiofibular ligament
- the inferior transverse tibiofibular ligament
- the interosseous membrane.
These structures are further supported by the deltoid ligament.7,8
Commonly referred to as a “high ankle sprain,” a syndesmotic injury is present in as many as 20% of ankle fractures and 5% to 10% of ankle sprains. Injury typically results from external rotation with hyperdorsiflexion of the ankle. Recovery is typically prolonged (ie, twice as long as recovery from a lateral ankle sprain). The diagnosis is missed in as many as 20% of patients; failure to recognize and treat syndesmotic instability appropriately can lead to posttraumatic arthritis.7,9
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