Clinical correlate #1: Foot
Use the clinical materials below as well as the anatomic drawings in the first link to answer the questions
Study questions:
Reference texts
A. http://www.aafp.org/afp/20020901/785.html
Foot Fractures Frequently Misdiagnosed as Ankle Sprains. Judd DB, Kim DH. Am Fam Physician 2002;66:785-94.
Most ankle injuries are straightforward ligamentous injuries. However, the clinical presentation of subtle fractures can be similar to that of ankle sprains, and these fractures are frequently missed on initial examination. Fractures of the talar dome may be medial or lateral, and they are usually the result of inversion injuries, although medial injuries may be atraumatic. Lateral talar process fractures are characterized by point tenderness over the lateral process. Posterior talar process fractures are often associated with tenderness to deep palpation anterior to the Achilles tendon over the posterolateral talus, and plantar flexion may exacerbate the pain. These fractures can often be managed nonsurgically with nonweight-bearing status and a short leg cast worn for approximately four weeks. Delays in treatment can result in long-term disability and surgery. Computed tomographic scans or magnetic resonance imaging may be required because these fractures are difficult to detect on plain films
B. http://www.aafp.org/afp/20031215/2413.html
Evaluation and Management of Toe Fractures Hatch RL, Hacking, S. Am Fam Physician 2003;68:2413-8.
Fractures of the toe are one of the most common lower extremity fractures diagnosed by family physicians. Toe fractures most frequently are caused by a crushing injury or axial force such as stubbing a toe. Joint hyperextension and stress fractures are less common. Most patients have point tenderness at the fracture site or pain with gentle axial loading of the digit. Anteroposterior and oblique radiographs generally are most useful for identifying fractures, determining displacement, and evaluating adjacent phalanges and digits. Referral is indicated in patients with circulatory compromise, open fractures, significant soft tissue injury, fracture-dislocations, displaced intra-articular fractures, or fractures of the first toe that are unstable or involve more than 25 percent of the joint surface. Most children with fractures of the physis should be referred, but children with selected nondisplaced Salter-Harris types I and II fractures may be treated by family physicians. Stable, nondisplaced toe fractures should be treated with buddy taping and a rigid-sole shoe to limit joint movement. Displaced fractures of the lesser toes should be treated with reduction and buddy taping. Patients with displaced fractures of the first toe often require referral for stabilization of the reduction.
C. http://www.aafp.org/afp/20030101/85.html IOLOGIC DECISION-MAKING
Tarsal Navicular Stress Fractures Coris EE. Lombardo JA. Am Fam Physician 2003;67:85-90.
Stress fractures of the tarsal navicular bone are being recognized with increasing frequency in physically active persons. Diagnosis is commonly delayed, and outcome often suffers because physicians lack familiarity with the condition. Navicular stress fractures typically present in a running athlete who has gradually increasing pain in the dorsal midfoot with occasional radiation of pain down the medial arch. Because initial plain films are often normal, the next diagnostic test of choice is triple-phase bone scan, which is positive early in the process and localizes the lesion well. After a positive bone scan, a computed tomographic scan should be obtained to provide anatomic detail and guide therapy. Nondisplaced, noncomminuted fractures respond well to six weeks of nonˇweight-bearing cast immobilization. Displacement, comminution, and delayed or nonunion fractures are indications for surgical open reduction internal fixation.
D. http://www.aafp.org/afp/990501ap/2516.html
Fractures of the Proximal Fifth Metatarsal Strayer SM. Reece, SG. Petrizzi J
Fractures of the proximal portion of the fifth metatarsal may be classified as avulsions of the tuberosity or fractures of the shaft within 1.5 cm of the tuberosity. Tuberosity avulsion fractures cause pain and tenderness at the base of the fifth metatarsal and follow forced inversion during plantar flexion of the foot and ankle. Local bruising, swelling and other injuries may be present. Nondisplaced tuberosity fractures are usually treated conservatively, but orthopedic referral is indicated for fractures that are comminuted or displaced, fractures that involve more than 30 percent of the cubometatarsal articulation surface and fractures with delayed union. Management and prognosis of both acute (Jones fracture) and stress fracture of the fifth metatarsal within 1.5 cm of the tuberosity depend on the type of fracture, based on Torg's classification. Type I fractures are generally treated conservatively with a nonweight-bearing short leg cast for six to eight weeks. Type II fractures may also be treated conservatively or may be managed surgically, depending on patient preference and other factors. All displaced fractures and type III fractures should be managed surgically. Although most fractures of the proximal portion of the fifth metatarsal respond well to appropriate management, delayed union, muscle atrophy and chronic pain may be long-term complications.
E. Ottawa Ankle Rules
http://www.ohri.ca/programs/clinical_epidemiology/OHDEC/ankle_rule/flash_ankle_rule.htm
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