Mycobacterium marinum is the most common atypical
mycobacterium that can cause infection in humans. It is found in salt and fresh
water. It is an acid-fast bacilli. The wrist and the hand are affected in about
50% of the cases. It may cause skin and soft tissue infections after skin
abrasion. The patients are exposed to aquatic environments such as aquariums
and swimming pools. The disease often occurs following the cleaning of fish
tanks. The bacilli enter the body through scratches and abrasions, causing
lesions in the tissue. The diagnosis is usually delayed because the condition
is rare, and the history of aquatic exposure is usually not obtained. The hand
and wrist are commonly involved. There will be painful swelling of the hand.
Subcutaneous granules, masses, nodules, ulcers, and noncaseating granulomas are
present. It may present as chronic tenosynovitis of the hand. It affects the
extensors more than the flexors. It can cause a TB like disease in fish. The
chronic skin lesion is sometimes called a “swimming pool granuloma” or “fish
tank granuloma” in humans. The bacteria grows in a low temperature culture at
30o centigrade. The bacteria grows on Lowenstein-Jensen medium. It
requires lower temperature and a longer period of the incubation (up to 6 weeks
or more). It can be treated with oral antibiotics antimicrobial therapy.
Ethambutol and Rifampin if diagnosed early. Minocycline and Clarithromycin has
been described. Surgery is done in late stages and in deep infection. Surgery
entails synovectomy and debridement in addition to oral antibiotics for
approximately 3 months. Mycobacterium avium-intracellulare occurs in terminal
AIDS patients, or it also can occur in a non HIV patient.
Monteggia fracture is a fracture of the proximal ulna and
radial head subluxation. It is imperative that you restore the length and the
proper alignment of the ulna so that the radial head can be reduced. If we
malalign the ulna, then the radial head will remain subluxed. There are some
cases where the fracture of the ulna is so comminuted that we will be unable to
restore the length of the ulna. We will not even know if we restored the length
of the ulna.
There is a technique that I use in the reconstruction of the ulna
in cases where the ulna is too comminuted. I will open the fracture ulna, and I
will approach the radial head. I will reduce the radial head to the capitellum
and reduce the ulna to the radius and make sure that the proximal radioulnar
joint is anatomic. Once that joint is anatomic, I will pin it with either one
or two K wires. I transfix the ulna to the radial head. We know that the radial
head is reduced, now the ulna will be reduced because the radioulnar joint is
reduced. We are temporarily transfixing the ulna to the radial head, and that
will help to restore the proper length of the ulna. Once the proper length of
the ulna is defined, then reconstruction of the ulna is simplified utilizing a
dorsal ulnar plate. Next, the K wires are removed and the radioulnar joint is
tested for stability. Occasionally, the K wires may be left in place for a few
weeks if needed to provide additional stability, then removed later on.
Monteggia fracture is not a simple fracture. It is a
fracture of the proximal ulna with dislocation of the radial head. Monteggia
fracture can happen in children and in adults. It is one of the most common
injuries that is missed in the emergency room in children. The radial head may
be dislocated or subluxed, and this problem may not be clear on x-rays. If this
injury is missed, then the child will probably need a big surgery to deal with
this big problem. Treatment of this fracture depends on the age of the patient.
In general, in pediatric patients, you will do closed reduction of the ulna and
closed reduction of the radial head. In adult patients, you will do open
reduction with internal fixation of the ulna with dorsal plate and closed
reduction of the radial head. A line drawn from the proximal radius should
bisect the capitellum in all x-ray views. If you are in doubt and not sure, get
x-rays of the other side and compare. Always examine the patient for posterior
interosseous nerve injury.
The most common type is anterior Monteggia. That
means that the apex of the fracture is anteriorly and the radial head goes
anteriorly. Just make it a practice, when you have a fracture of the proximal
ulna, look at the radius and the radial head, and see the position of the
radial head in relationship to the capitellum. Anterior Monteggia is more
common in children. Posterior Monteggia constitutes 70-80% of Monteggia
fractures in adults. There are four types of Monteggia: Type I, Type II, Type
III, and Type IV. Monteggia fracture is classified according to the direction
of displacement of the radial head. The radial head has two relations: relation
with the capitellum and relation with the proximal radioulnar joint. When the
radial head subluxes or dislocates, it subluxes or dislocates from these two
joints. The radial head becomes free. This means that the radius is not
connected to the capitellum or to the superior radioulnar joint. A Type I
fracture is of the middle or the proximal third of the ulna with anterior
dislocation of the radial head, and it has the characteristic that the apex of
the ulnar fracture is anteriorly. Type I fracture is the most common of all
types (especially in children). Type I occurs in about 60% of fractures. In
children, reduce the fractured ulna and reduce the dislocation of the radial
head and immobilize the elbow in flexion and supination. When you flex the
elbow, especially more than 90 degrees, you will relax the biceps (watch the
circulation). A Type II fracture is a posterior type fracture. Posterior
Monteggia is the most common type in adults. It is associated with a higher
complication rate and carries the worst prognosis. 15% of Monteggia fractures
are Type II. It is a fracture of the middle or proximal third of the ulna with
posterior dislocation of the radial head. You should immobilize the elbow in
extension. Type III is a lateral Monteggia. About 20% of Monteggia fractures
are Type III. It is a fracture of the proximal ulna with lateral dislocation of
the radial head. 5% of Monteggia fractures are Type IV; it is very rare. It is
a fracture of the proximal ulna with anterior dislocation of the radial head
and fracture of the proximal third of the radius below the bicipital
tuberosity. The patient will need surgery, even in children. In this case, the
radial head is dislocated, and you also have fractures of the radius and the
ulna. The posterior interosseous nerve is adjacent to the radial neck, placing it
at risk for a traction injury with dislocation of the proximal radius.
You
should do a neurovascular examination. A nerve injury which involves the
posterior interosseous nerve is not uncommon. Ask the patient to “hitchhike”
and extend their fingers. Make sure the wrist is in dorsiflexion when you ask
the patient to extend the fingers. In posterior interosseous nerve injury, the
finger extensors will not be working. If the posterior interosseous nerve is
injured, observe the patient. In case of posterior interosseous nerve injury in
Monteggia fracture, you will reduce and stabilize the fracture and reduce the
radial head dislocation. Observe the nerve; do not explore the nerve. Typically
the nerve injury is a neuropraxia. It can be expected to resolve itself with
observation in 6-12 weeks. If it does not resolve, you will do EMG and nerve
studies after that period of observation. Any time that you have an ulnar shaft
fracture or any fracture of the proximal ulna, check the radial head position.
Make sure that the radial head is reduced to the capitellum (be aware that the
subluxation may be subtle). Recognition of Monteggia fracture in children is
important. Early appropriate treatment is much easier than treating a missed
radial head dislocation. To treat a Monteggia fracture in adult patients, do
open reduction internal fixation (ORIF) of the ulna. When the ulna is properly
aligned and fixed, the radial head will reduce by itself. After fixation of the
ulnar fracture, if the radial head is still not reduced, then assess the ulnar
reduction. Check for malalignment or malreduction of the ulna. It is imperative
that you restore the length and the proper alignment of the ulna, so that the
radial head can be reduced. If we malalign the ulna, then the radial head will
remain subluxed. Radial head instability may be caused by nonanatomic reduction
of the ulna or by interposition of the annular ligament. Fracture of the ulna
may be too comminuted, and it may not be reduced properly. The fracture may
also need bone graft later on for healing. A Monteggia variant associated with
radial head fracture, in addition to dislocation of the radial head fracture,
in addition to dislocation of the radial head and fracture of the ulna can be a
problem. The radial head fracture is usually fixed or replaced, a prosthesis is
used to replace the radial head in the elderly, especially if the fracture is
comminuted. The subluxation of the radial head is reduced, and the fractured
ulna is fixed as usual. Treatment is different in pediatric patients. The
radial head ossifies around four years of age. In Type I, Type II, and in Type
III Monteggia fractures, you will do closed reduction of the ulna to restore
the length of the ulna, and you will do closed reduction of the radial head.
Closed reduction is much more successful in young children. In anterior
Monteggia, you will immobilize the elbow in flexion and supination. In
posterior Monteggia, you will immobilize the elbow in extension. Ulnar fixation
with a rod or a plate is needed in older patients with unstable fractures. Type
IV fractures require surgery. Surgery is also done in cases where we are unable
to restore the proper length of the ulna, we are unable to reduce the ulna, and
we are unable to reduce the radial head. In this situation, we can use IM rod
or a plate. Dislocation of the radial head with fracture of both the radius and
ulnar shaft. Do closed reduction of the radial head with intramedullary pin
fixation of the radius and the ulnar shaft fractures. The radius and ulnar
shaft fractures are stabilized surgically to give a lever arm for reduction of
the radial head. In this type of fracture, the radial head subluxation may be
missed or unappreciated, because the focus is usually on the forearm fractures.
To treat a missed or neglected Monteggia fracture in children, do osteotomy of the
ulna and lengthening with correction of the angulation, and reduction of the
radial head in addition to plating of the ulna. The patient may need open
reduction of the radial head.
Lisfranc injury is an important topic. If Lisfranc injury is
not diagnosed and treated properly, it can lead to an altered gait, midfoot
arthritis, and long term disability. Lisfranc injury indicated disruption
between the base of the 2nd metatarsal and the medial cuneiform. Lisfranc
injuries are a spectrum of injuries of the tarsometatarsal joints. Diagnosing Lisfranc
injury is important. Diagnosis is missed in about 20%-30% of cases especially
in multiple trauma patients. A high index suspicion is needed to prevent
progression of the foot deformity, chronic pain, and dysfunction. You may need
weight-bearing films for diagnosis of Lisfranc injury. Lisfranc injury may also
be associated with compartment syndrome. Lisfranc injury could be purely
ligamentous or can be associated with fractures. ORIF is better in cases of
fractures. Arthrodesis is better in cases of purely ligamentous injury. In general,
ligamentous injury does worse than fractures. The Lisfranc ligament is a large
oblique ligament that extends from the plantar aspect of the medial cuneiform
to the base of the second metatarsal. The Lisfranc ligament stabilizes the 2nd
metatarsal and maintains the midfoot arch. Osseous stability is provided by the
roman arch of the metatarsals and the recessed keystone of the 2nd
metatarsal base. Tarsometatarsal joint complex is divided into three units:
medial, middle, and lateral. The medial is the 1st metatarsal joint
at 6o mobility. The middle is the 2nd and 3rd
tarsometatarsal joints, and it is rigid. The lateral is the 4th and
5th tarsometatarsal joints; it is mobile which is why you do not
fuse the 4th and 5th tarsometatarsal joints. The dorsalis
pedis artery and the deep peroneal nerve both run between the first and second
metatarsal bases. A direct injury with a plantar displacement is more common. Indirect
injuries are more common than direct injuries. They result from axial loading
or twisting on a plantar flexed midfoot. Dorsal displacement of the 2nd
metatarsal is more common. Check the alignment of the dorsum of the 2nd
metatarsal with the middle cuneiform. Associated fractures are typically tarsal
fractures, especially a cuboid fracture. A “Nutcracker” fracture results from
twisting injury causing forceful abduction of the forefoot. It is a fracture of
the base of the 2nd metatarsal and compression fracture of the
cuboid. nd
metatarsal, at the navicular, and cuboid. Check for widening between the first
and second ray (more than 2 mm is an indication for surgery). In the lateral
view, check the dorsal displacement or subluxation of a metatarsal. It should
be at the level of the corresponding cuneiform. Check for the FLECK sign (bony
fragment). Avulsion fragment of the Lisfranc ligament from the base of the 2nd
metatarsal. The medial side of the fourth metatarsal should line up with the
medial side of the cuboid on the oblique view (30o). CT scan can be
useful and MRI can confirm purely ligamentous injury. These injuries should be
treated with a cast. For a dorsal sprain and no instability, the patient can be
treated with non-weight bearing cast for 6 weeks and return to activity
gradually. Surgery can be done for instability. Open reduction internal
fixation with cortical screws if there is bony fractures. When you do ORIF- you
need anatomic reduction. Hardware removal between 5-6 months (some surgeons
leave the hardware in place indefinitely). Arthrodesis if the injury is purely
ligamentous. Healing of the ligaments is less reliable than bony healing. Purely
ligamentous injury needs primary arthrodesis. Arthrodesis is also done in old injuries
if there is delay in treatment for if there is failure of open reduction and
internal fixation of Lisfranc injury. Midfoot arthrodesis is also used for
chronic Lisfranc injury that leads to severe midfoot arthritis with progressive
arch collapse and midfoot abduction. Fusion of the medial and middle column;
first, second, and third tarsometatarsal joints. Do not fuse the lateral column
(lateral column is mobile). For the lateral column, do reduction and
stabilization by k-wire fixation. Post-traumatic arthritis occurs in up to 50%
of patients. Patient may have altered gait and long term disability. Purely ligamentous
injury has a worse prognosis than injuries with fractures. Malalignment of the
fractures usually lead to arthritis.
Lisfranc classifications are not useful in deciding the treatment or the
prognosis of the injury. Severe injuries are obvious, easily diagnosed, and may
develop compartment syndrome of the foot. Injuries with minimal displacement
could be missed, and they will need surgery regardless of the classification. Arthritis
may develop even with minimal displacement. In general, there are three
patterns of injury: total incongruity, partial incongruity, and divergent. Total
incongruity occurs when all five metatarsals are displaced in the same
direction. Total incongruity occurs lateral or medial, with lateral being more
common. Partial incongruity occurs when one or two metatarsals are displaced
from the others. Divergent occurs when the lateral displacement of the lesser
metatarsals with medial displacement of the first metatarsal. The one thing all
these injuries have in common is disruption of the tarsometatarsal joint
complex. The patient has severe pain in the midfoot and is unable to bear
weight. There may be some swelling in the midfoot dorsally. Plantar bruising
may be present, especially medially. Tenderness over the tarsometatarsal joint.
Check the skin condition and rule out compartment syndrome. Check the neurovascular
status of the foot. Plantar ecchymosis is a classic clinical sign of potential
Lisfranc injury. Wight bearing standing x-rays with comparison views if x-rays
are normal and if the physician clinically suspects a Lisfranc injury. Another alternative
is to get physician assisted midfoot stress radiograph. Obtain three views: AP,
oblique, and lateral. Medial border of the second metatarsal should line up
with the medial border of the middle cuneiform on both the AP and the oblique
view. Check for fractures, especially at the base of the 2
Type I
fractures are a stable avulsion fracture of the alar ligament near the tip of
the odontoid. A soft collar can be used to treat Type I fractures. Be aware of
significant ligamentous injuries. Type II fractures are at the base of the
odontoid process. Type II are the most common and are troublesome. The nonunion
rate is about 20-80% due to interruption of the blood supply. The risk factors
of nonunion include if the patient is over the age of 60 years old, if the
patient has more than 6mm of displacement, smoking and diabetes, and you are
unable to achieve reduction. In posterior displacement, extension injury (rare
type) the anterior displacement is more common (flexion injury). Delay in
treatment also increases the rate of nonunion. For treatment of young patients
with no nonunion risks use a halo. The patient is younger than 60 years. The
fracture is minimally displaced. Initial dens displacement is less than 6 mm,
and the reduction is within one week of the injury. Healing will occur in the
majority of cases.
If the patient has a nonunion risk, or when reduction of the
fracture cannot be achieved or maintained, then we need to think about surgery
and the fracture pattern. When the fracture pattern allows, you can put an
anterior screw into the odontoid (to preserve the motion of C1/C2). Odontoid
screw is used in younger patients instead of fusion to avoid loss of 50% of the
neck rotation). Do not use the anterior screw fixation in patients with
osteoporosis, in older patients, or in patients with a short neck. Another
scenario is, if the patient has nonunion risks but the fracture pattern does
not allow you to place an anterior odontoid screw, then you are going to fuse
C1 to C2 (this will lose 50% of neck rotation). In general, C1/C2 fusion is
used in cases of nonunion or it is used in cases of displaced fracture in the
older patient and it can also be used if there is a failure of treatment with a
halo. C1/C2 fusion can also be used if the fracture is comminuted and unstable.
Posterior C1/C2 fusion can be done with different screw or wire constructs. A
vascular watershed area exists between the apex of the odontoid, which is
supplied by branches of the internal carotid artery and the base of the
odontoid, which is supplied by branches of the vertebral artery. Type II
fracture of the odontoid may get nonunion due to cortical bone and poor blood
supply.
Type III fractures extend through the body of C2. This area is rich in
blood supply and the fracture heals in the majority of cases. Treatment for
Type III odontoid fractures includes external cervical orthosis (especially in
the elderly patient) and a halo (if the fracture is displaced) (do not use in
elderly patients). Odontoid fractures in the elderly can occur due to a simple
fall and usually the diagnosis is missed. It is associated with increased
complications and mortality. Do not use a halo in elderly patients. Use an
external cervical orthosis of some sort. Fibrous union might be adequate if the
fracture is not badly displaced, otherwise you will do fusion of C1/C2. For
example, an 80 year old patient with osteoporosis, who is a smoker and has a
displaced odontoid fracture that cannot be reduced, then this fracture will
lead to nonunion and more complications. You need to do posterior C1/C2
arthrodesis. In general, if the elderly patient with an odontoid fracture is
not a good surgical candidate, then you will give the patient a cervical
orthosis. You can do the C1/C2 fusion by using transarticular screws, which you
are not going to do if you have an aberrant vertebral artery. Another technique
can be done for the fusion where fusion between C1/C2 is done with the screw
placed into the C1 lateral mass and the C2 pedicle, plus a bone graft. There is
increased survival for the elderly patient that undergoes surgery for Type II
odontoid fracture. This may be a selection bias, because they have healthier
patients who are physiologically active and young who are fit for surgery. The
synchondrosis between the odontoid and the C2 body fuses by the age of 6 years.
Odontoid fracture in young children usually occurs by the age of 4 years.
Physicians may confuse the synchondrosis with a fracture. The treatment of
odontoid fracture in children is done with a Minerva brace or halo vest, if the
fracture is displaced. You will use more pins and less torque. Finger tighten
the pins. The Os Odontoideum looks like a fracture. It is oval shaped, it has
sclerotic edges, and Os is smaller than the normal dens. The Os Odontoideum is
a congenital process. The mechanism that causes the Os Odontoideum is unknown,
but it is probably developmental or it can result from an old trauma.
The usual story is that the patient visits the emergency
room and comes back to see the doctor because the patient is having constant shoulder
pain and is unable to move the shoulder. When examining the patient, the
patient will have limitation of external rotation of the shoulder. You may be
shown an x-ray, an AP view of the shoulder, and the interpretation of the x-ray
is that the shoulder appears normal. You need to get two x-ray views (orthogonal
views): AP view and axillary view. An AP view x-ray alone will not diagnose
posterior shoulder dislocation. When you have posterior dislocation of the
shoulder, the AP x-ray view will show the classic “lightbulb” humeral head due
to internal rotation of the shoulder.
The humeral head takes on a rounded
appearance. The axillary view x-ray will show dislocation of the shoulder
posteriorly. It is the best view to show the posterior shoulder dislocation. After
reduction, always get an axillary view and check concentric reduction. Locate the
coracoid (anteriorly) and outline it. Locate the acromion (posteriorly). Then locate
the glenoid and determine whether the dislocation is posterior or anterior. In posterior
dislocation of the shoulder, the axillary view will show the humeral head going
posteriorly away from the coracoid and in the direction of the acromion. With posterior
shoulder dislocation, the shoulder is locked in the internal rotation position
with prominence of the posterior shoulder, prominence of the coracoid process,
and flattening of the anterior shoulder. Posterior shoulder dislocation may be
associated with fracture of the lesser tuberosity. 50% of posterior shoulder
dislocations will have a Reverse Hill-sachs lesion or impaction fracture next
to the lesser tuberosity. When you examine the patient and you see limitation
of the range of motion, especially external rotation of the shoulder, you may
think it is adhesive capsulitis (frozen shoulder). Frozen shoulder can start by
limiting the external rotation, however it is usually a global restriction of
the range of motion.
Posterior dislocation of the shoulder is rare (about 5%)
and it is usually stable after reduction if no fracture is present. Posterior dislocation
of the shoulder usually occurs after seizures or electric shock. Why is it that
dislocation of the shoulder most commonly occurs as a posterior shoulder
dislocation with seizures and electric shock? This is a controversial subject. Some
physicians believe that this is due to the fact that the shoulder internal rotator
muscles (pectoralis major, latissimus dorsi, and subscapularis) are stronger
than the external rotator muscles. Up to 50% of posterior dislocations of the
shoulder can go undiagnosed when the patient is examined in the emergency room,
especially if dislocation results from seizures. If posterior dislocation of
the shoulder occurs due to seizures, the patient should be examined carefully
and neurology consult should be done to control the patient’s seizures. Any future
treatment of posterior dislocation of the shoulder may fail due to lack of
controlling seizures. Closed reduction is not difficult in the acute setting and
can be done up to 3 months. Instability is rare with absence of fracture. Immobilize
the arm in neutral rotation with the elbow at the side and posterior to the
plane of the body. Impaction less than 20%, do closed reduction and immobilize
in external rotation. Open reduction is done when posterior dislocation is
chronic or locked. In locked posterior dislocation, the deltopectoral approach
to the shoulder is usually used. If the defect is between 20%-40%, transpose the
lesser tuberosity or the subscapularis tendon into the defect. More than 45%
defect or if the dislocation is more than 6 months, do arthroplasty and place
the prosthesis in less retroversion.
There are many structures present at the anterior aspect of the
ankle. These structures are often susceptible to injury. There are many common
injuries and conditions around the ankle. Anterolateral impingement is a
painful limitation of full range of motion of the ankle due to soft tissue or
osseous (bony) pathology. Soft tissue thickening is commonly seen in athletes
with prior trauma that extends into the ankle joint. Tibial bone spur impinging
on the talus can become a source of chronic ankle pain and limitation of ankle
motion in athletes. Osseous (bony) is a spur on the anterior lip of the tibia
contacting the talus during dorsiflexion. Arthritis of the ankle joint is
commonly the result of a prior injury or inflammation to the ankle joint. It can
usually be diagnosed with an examination and x-ray. Osteochondritis Dissecans
of the Talus is a chip-type fracture that usually occurs with severe ankle
sprains. It causes pain, swelling, and stiffness of the ankle joint. X-rays, CT
scan, or MRI are commonly used for the diagnosis. Tibialis Anterior Tendonitis
is an overuse condition common in runners. It is a common injury that usually
accompanies anterior shin splints. If this tendon is strained, pain and
tenderness will be felt upon active dorsi-flexion or when the tendon is
touched.
There are many structures present at the medial aspect of
the ankle. These structures are often susceptible to injury. There are many
common injuries and conditions around the medial ankle. Posterior tibial
tendonitis or rupture can occur from overuse activities, degeneration, or
trauma. The posterior tibial tendon is one of the major supporting structures
of the foot. The tendon helps to keep the arch of the foot in its normal
position.
When there is insufficiency or rupture of the tendon, the arch begins
to sag, and a flatfoot deformity can occur with associated tight Achilles tendon.
The posterior tibial tendon rupture occurs in a hypovascular zone. This occurs
distal to the medial malleolus. It will present as painful swelling on the
posteromedial aspect of the ankle. The patient will be unable to perform a
single leg toe raise, the too many toes sign will be present, the patient will
be flatfoot, and there will be a fixed deformity of the hind foot. There are
four stages of posterior tibial tendon rupture. Rupture of the posterior tibial
tendon could be missed. Tarsal tunnel syndrome is compression of the tibial
nerve in the tarsal tunnel. The flexor retinaculum covers the nerve. Tarsal tunnel
syndrome is similar to compression of the median nerve in the carpal tunnel. It
can be caused by ganglia, accessory muscles, or soft tissue mass. Tarsal tunnel
syndrome can be differentially diagnosed as a herniated disc, a stress fracture
of the calcaneus, or plantar fasciitis. Tarsal tunnel syndrome will present as
pain on the medial side of the foot. The patient will have pain worse with
dorsiflexion due to tension on the nerve. There will be paresthesia and numbness
of the foot and a positive tinel’s sign behind the medial malleolus. Flexor hallucis
tendonitis is pain, swelling, and weakness posterior to the medial malleolus. Dorsiflexion
of the big toe may be reduced when the ankle is placed in dorsiflexion. Triggering
and pain along the tendon sheath may also occur with toe flexion. Flexor hallucis
tendonitis often occurs in activities such as ballet dancing, in which plantar
flexion is necessary. The deltoid ligament is the primary stabilizer of the ankle
joint. The deltoid ligament provides support to prevent the ankle from
everything. An isolated eversion sprain with a tear of the deltoid ligament is
a rare injury.
There are many structures present at the posterior aspect of
the ankle. These structures are often susceptible to injury. There are many
common injuries and conditions around the posterior ankle. Posterior ankle
impingement (os trigonum) is a posterior talar impingement of the os trigonum
or large process of the talus (stieda syndrome). This is a non-united piece of
accessory bone seen posterior to the talus. It is common in athletes such as
ballet dancers. There will be tenderness in the posterolateral aspect of the ankle
posterior to the peroneal tendon especially with passive plantar flexion. It may
be seen in association with flexor hallucis longus tenosynovitis. Flexor hallucis
longus tenosynovitis is a condition associated with ballet dancing, in which
extreme plantar flexion is necessary. It is characterized by swelling and pain
posterior to the medial malleolus. It is triggered by toe flexion. Dorsiflexion
of the big toe is less when the ankle is dorsiflexed. Achilles tendonitis is
irritation and inflammation that occurs due to overuse. It is characterized by
pain, swelling, and tears within the tendon. It is usually treated with therapy
and injection. Do not inject inside the tendon. It is rarely treated with
surgery. Achilles tendon can become prone to rupture with age, lack of use, or
by aggressive exercises. Rupture is diagnosed by the Thompson test and MRI. It is
treated by conservative treatments without surgery by using a cast or a boot. However,
rupture rate may be high if the patient is treated conservatively. Surgery is
done by approximation of the torn tendons. The risk of surgery is infection or
skin and wound complications.
There are many structures present on the lateral side of the
ankle. These structures are often susceptible to injury. Diagnosis of these
injuries can be confusing and many of these injuries can be missed. Diagnosis of
a sprained ankle may be the wrong diagnosis. A high ankle sprain is a
syndesmotic injury that may require surgery. Other injuries to the lateral side
of the ankle include peroneal tendon subluxation, rupture of the peroneus
longus tendon, peroneal tendonitis, anterior process of the calcaneus fracture,
lateral process of the talus fracture, and Achilles tendonitis.
