In all three injury pattern groups, an initial anatomic reduction was essential for good results. A 40-year-old male suffers the isolated injury shown in figure A with no associated fractures. An 18-year-old football player presents to the emergency department after sustaining an ankle injury. Which of the following is the most important for achieving a satisfactory outcome following open reduction internal fixation for this injury? Fig. Chopart dislocations are rare injuries and are challenging to treat. 4 —Chopart fracture-dislocation in 27-year-old woman after twisting ankle injury. (OBQ09.204) A 32-year-old female sustains the injury shown in Figure A. (OBQ09.70) (OBQ10.40) A 32-year-old taxi driver sustains a displaced supination external rotation ankle injury after slipping off of a curb. Progressive weightbearing in 3-4 weeks based on radiographs, Deltoid ligament repair vs reconstruction, Removal of syndesmotic screws in 3-6 months. (OBQ09.76) Marginal impaction of the anteromedial tibial plafond, Posterolateral osteochondral lesion of the talus. Quadricortical syndesmotic screw fixation, Restoration of fibular length and rotation, Lateral collateral ligament complex repair. (OBQ04.49) Lateral ulnar collateral ligament of the elbow. Copyright © 2021 Lineage Medical, Inc. All rights reserved. A 31-year-old male sustains an irreducible ankle fracture-dislocation with the foot maintained in an externally rotated position. What is the most common fracture associated with a lateral subtalar dislocation? Subtalar dislocation involves dislocation of the subtalarand talonavicularjoints, with intact tibiotalar and calcaneocuboid joints, in the absence of a talar neck fracture. (OBQ10.121) MB BULLETS Step 1 For 1st and 2nd Year Med Students. Frontal, oblique, and lateral radiographs of the foot were obtained. 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? Recommended management should consist of? Chopart Fractures and Dislocations. Surgical fixation with absolute stability would be most appropriate for which of the following fracture patterns? choprt … How long from today’s visit will his braking time be expected to return to normal? MB BULLETS Step 2 & 3 For 3rd and 4th Year Med Students. (OBQ13.87) What joint is dislocated in this radiograph? Which of the following is true when comparing Figure A to Figure B? MB BULLETS Step 1 For 1st and 2nd Year Med Students. Chopart fracture-dislocations occur at the midtarsal (Chopart) joint in the foot, i.e. A 32-year-old laborer reports left ankle pain and deformity. 1,2,5,8,10 In our case, a Chopart dislocation without navicular or cuboid fracture … 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. The attempted post reduction AP and lateral are shown in C and D. What structure is most likely preventing reduction? An intraoperative fluoroscopy image is provided in figure C. Which of the following is the best method to assess the integrity of the syndesmosis? He subsequently undergoes surgical fixation, and a post-operative radiograph is shown in Figure A. 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. (OBQ04.23) Chopart fracture-dislocations may therefore include fractures of the navicular, the cuboid, the talus, and calcaneus. (SBQ12FA.12) Fractures and dislocations of the midfoot and Chopart complex are among the most difficult foot injuries to manage. After undergoing the treatment seen in Figure A, when should a patient be expected to safely operate the brakes of an automobile? (SAE09FA.55) Which of the following is the most appropriate method to assess the competency of his deltoid ligament? Diagnosis is confirmed by radiographs which may show widening of the interval between the 1st and 2nd ray. Fractures can occur in isolation or as part of … What is the most appropriate plating technique utilized for the medial malleolus fracture typically seen in a displaced supination-adduction ankle 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. 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. anterior dislocation. Radiographs from the ER are provided in figures A and B. (OBQ12.127) At the eight-week postoperative visit, you are asked to fill out a return to work form. The commonly fractured bones are the calcaneus, cuboid and navicular. In an isolated ankle syndesmotic injury, the fibula is unstable in the incisura fibularis of the tibia. 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. Stress examination of the right ankle is shown in Figure A. Plain X-ray revealed tibiotalar dislocation … A 25-year-old man sustains a twisting injury to his ankle. The injury is closed, and the patient is neurovascularly intact. What is the most appropriate next step in treatment? open reduction and fixation of the fibula in the incisura fibularis indicated in most cases Of the following options, what would be the recommended treatment? Tarsometatarsal dislocation may also occur in the diabetic neuropathic joint Charcot. As a rule, coccygeal fracture/dislocations are treated with non-operative management (e.g. (SBQ12TR.104) 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). What is the cause of failure of closed reduction? (OBQ04.153) Chopart fracture-dislocations occur at the midtarsal (Chopart) joint in the foot, i.e. A 30-year-old male falls off the roof and sustains the injury seen in Figure A. A 25-year-old male sustains an ankle fracture dislocation and undergoes open reduction and internal fixation. (OBQ04.243) 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. The mean scores of the … Subtalar and Chopart dislocations are extremely rare in childhood but become slightly more common in older children and adolescents. Increased risk of intra-articular screw penetration. Chopart ligament: bifurcate ligament comprising the calcaneonavicular and calca… Plain radiographs often grossly underestimate the extent of injury. dislocation,1,7 whereas 15% to 30% of all anterior glenohumeral dislo-cations7 result in GT fracture. (OBQ09.123) Which of the following is most appropriate step based on Figures A and B? (OBQ07.223) The high functional restrictions in Chopart dislocations can Fractures and dislocations of the midfoot and Chopart complex are among the most difficult foot injuries to manage. 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? 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? 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. Topics Covered From Orthobullets in Study Plan. (OBQ08.93) The mean scores … A 40-year-old man fell off of a ladder at work sustaining the injury shown in Figures A and B. What is the most reliable method to evaluate the competence of the deltoid ligament? What is the mechanism for the fracture pattern shown in Figure A? A 37-year-old female sustains the injury seen in Figures A and B. (OBQ09.259) A 19-year-old male sustains the injury shown in Figure A while skiing. This is a patient who presents with foot pain following a motor vehicle accident. By FORE 2014 Current Solutions in Foot and Ankle Surgery FEATURING Michael Clare. (OBQ13.54) What is the most appropriate definitive treatment? 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. 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 Joint: articulation between the hindfoot (calcaneus and talus) and the midfoot (navicular, cuboid and cuneiforms) comprising the calcaneocuboid and talocnavicular joints. Which of the following is unique with this particular ankle fracture pattern and must be recognized by the operating surgeon to optimize outcomes? Plain radiograph. He returns to clinic five months following surgery complaining of continued ankle pain and instability with weight bearing. (OBQ09.17) Subchondral debridement of any osteochondral defect, Casting or splinting in a neutral position postoperatively. 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. His immediate post-operative AP radiograph is seen in Figure A. Measurement of medial clear space widening, Anterior drawer test with comparison to the contralateral ankle, Evaluation of the syndesmosis on preoperative CT scan. The injury is named after Jacques Lisfranc de St. Martin (2 April … The Chopart articular space was used by François Chopart (1743-1795) as a practical space for amputation in cases of distal foot tumor. A 68-year-old female sustains a closed ankle fracture and is treated with open reduction and internal fixation. Four months later, he returns for follow-up with mild ankle discomfort, and a radiograph is shown in Figure A. Sixty-five (65%) patients had follow-up after an average of 9 years (range, 2–25 years). A 32-year-old female sustained a bimalleolar ankle fracture and was treated with open reduction and internal fixation four months ago. MB BULLETS Step 1 For 1st and 2nd Year Med Students. A 34-year-old female requests a second opinion following open reduction internal fixation (ORIF) of her left ankle three weeks ago. Which of the following is most correlated with positive outcomes when treating this injury? The treating surgeon is faced with a wide array of treatment challenges. Bosworth Fracture-Dislocation: Overview . Radiographs are shown in Figures 25a through 25c. An otherwise healthy 45-year-old female slips and falls with immediate right ankle pain. 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. A 34-year-old man sustains a twisting injury to his left ankle playing soccer. The Lauge-Hansen classification of ankle fractures identifies characteristic fracture patterns based on mechanism of injury. The anatomy in this region of the foot is quite intricate with numerous articulations. 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? Most commonly affecting the anterior aspect of the vertebral body, wedge fractures are considered a single-column (i.e. rare; posterior dislocation. 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. A 33-year-old male is involved in a motor vehicle accident and suffers a right pilon fracture. (OBQ16.260) ORTHO BULLETS Orthopaedic Surgeons & Providers His radiograph is shown in Figure A. (OBQ12.150) Lisfranc Injury (Tarsometatarsal fracture-dislocation) – Foot & Ankle – Orthobullets. Chopart fracture-dislocations may therefore include fractures of the navicular, the cuboid, the talus, and … A 40-year-old male patient sustains a bimalleolar ankle fracture and undergoes open reduction and internal fixation. This is an AAOS Self Assessment Exam (SAE) question. They are … ORTHO BULLETS Orthopaedic Surgeons & Providers The primary treatment was operative in 91 (83%) feet and nonoperative in 19 (17%) feet. 6 weeks after initiation of weight bearing, Once full range of motion of the ankle and knee exist. (OBQ09.121) (OBQ06.140) 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. An unsuccessful attempt at reduction in the emergency department with sedation was made. (OBQ08.175) useful to help determine presence of superimposed osteomyelitis Revision plating of the fibula and syndesmosis reduction and fixation. Widening of the tibia-fibular clear space with external rotation stress would be a result of injury of which structure? In the Lauge-Hansen classification system, a pronation-abduction ankle fracture has what characteristic fibular fracture pattern? talonavicular and calcaneocuboid joints which separate the hindfoot from the midfoot . Significant angulation or displacement may require closed … 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. (SBQ18FA.18) His pedal pulses are palpable. MB BULLETS Step 2 & 3 For 3rd and 4th Year Med Students. talonavicular and calcaneocuboid joints which separate the hindfoot from the midfoot . 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. Multiple attempts at a closed reduction are made, but are unsuccessful. Diagnosis is typically made through clinical evaluation and confirmed with plain radiographs. Physical therapy for ambulation assistance and proprioception training, Revision open reduction and internal fixation with open syndesmosis reduction, Addition of syndesmosis screw from fibula to tibia, Open medial ankle ligament reconstruction, Ankle Simple Bimalleolar Fracture ORIF with 1/3 Tubular Plate and Cannulated Screw of Medial Malleol, Ankle Isolated Lateral Malleolus Fracture ORIF with Lag Screw, Type in at least one full word to see suggestions list, Bobby Menges Memorial HSS Limb Deformity Course 2021, Discussion: Bone Transport, High Energy Fractures, Ankle Distraction Arthroplasty, and Fusion after Trauma, High Energy Fractures of the Ankle and Hindfoot - Rachael Da Cunha, MD, FRCSC, 2021 Orthopaedic Trauma & Fracture Care: Pushing the Envelope, Ankle Fractures & Syndesmosis - Jackson Lee, MD, Question Session⎪Ankle Fractures & Replantation, Bimalleolar Equivalent Ankle Fracture in 55M. Which of the following could have prevented this patient from developing persistent pain? 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. Which of the following statements accurately describe this radiograph? Plain radiographs often grossly underestimate the extent of injury. Bridge plating of the fibula with oblique medial malleolar screws, Antiglide plating of the fibula with oblique medial malleolar screws, Intramedullary fibular screw with medial malleolar tension banding, Fibular plating with open correction of plafond impaction with medial malleolar antiglide plate, Fibular plating with open correction of syndesmosis and oblique medial malleolar screws. (OBQ05.89) ), may still require sinus tarsi/lateral approach to remove subtalar debris, place in short leg cast with non-weightbearing for 4-6 weeks, place temporary transarticular pins or spanning external fixator, long-term follow up of these injuries show degenerative changes, subtalar joint most commonly affected with up to 89% of patients demonstrating radiographic arthrosis (, Adult Knee Trauma Radiographic Evaluation, Proximal Humerus Fracture Malunion and Nonunion, Distal Radial Ulnar Joint (DRUJ) Injuries, more common in young or middle-aged males, typically result from a high-energy mechanism, may be only remaining blood supply with a talar neck fracture, due to lateral malleolus acting as strong buttress, preventing lateral dislocation, results from inversion force on plantarflexed foot, sustentaculum tali acts as fulcrum for the neck of the talus to pivot around, associated with posterior process of talus, dorsomedial talar head, and navicular fractures, reduction blocked by peroneal tendons, EDB, talonavicular joint capsule, results from eversion force on plantarflexed foot, anterior process of calcaneus acts as fulcrum for the anterolateral corner of the talus to pivot around, associated with lateral process of talus, anterior calcaneus, cuboid, and fibula fractures, 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. Type in at least one full word to see suggestions list, Dislocations of the Talus - Educational Animation, Talus fracture with subtalar dislocation 63M. 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? 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. a dislocation of the mid-tarsal joints of the foot, often with associated fractures of the calcaneus, cuboid and navicular bone. (OBQ06.28) History reveals that he sustained a left ankle fracture 2 years ago and was treated with closed reduction and casting. 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 … March 7, 2014. Wedge fractures (also known as compression fractures) are hyperflexion injuries to the vertebral body resulting from axial loading. Appropriate treatment of the bimalleolar ankle fracture shown in Figure A includes which of the following? Following closed reduction and splinting, what would be the next best step? (OBQ05.205) (OBQ14.216) Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC. (OBQ08.210) 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. MB BULLETS Step 2 & 3 For 3rd and 4th Year Med Students. What is the most appropriate management? 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. Which of the following ankle fractures seen in Figures A-E most likely occurred as a result of abduction of the foot relative to the tibia? Fracture-dislocation of the mid-tarsal joint, which carries the eponymous name Chopart fracture. The anatomy in this region of the foot is quite intricate with numerous articulations. (OBQ08.103) (OBQ11.17) 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 Her ankle was swollen and deformed. Most coccygeal fractures have a transverse orientation 2. 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.
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