CASE 1 Courtesy Michael J. Coughlin MD HISTORY 21 year old - - PowerPoint PPT Presentation

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CASE 1 Courtesy Michael J. Coughlin MD HISTORY 21 year old - - PowerPoint PPT Presentation

Jun 27, 2023 349 likes •753 views

CASE 1 Courtesy Michael J. Coughlin MD HISTORY 21 year old linebacker, with dorsiflexion injury pushing off (non contact) Swollen painful first MTP joint WHAT DOES THE MECHANISM OF INJURY SUGGEST? WHAT STRUCTURE(S) MIGHT BE

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CASE 1

Courtesy Michael J. Coughlin MD

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HISTORY

 21 year old

linebacker, with dorsiflexion injury pushing off (non contact)

 Swollen painful first

MTP joint

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WHAT DOES THE MECHANISM OF INJURY SUGGEST?

WHAT STRUCTURE(S) MIGHT BE INJURED

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WHAT WOULD YOU LOOK FOR ON PHYSICAL EXAMINATION?

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PHYSICAL EXAM

Swollen first MTP joint + drawer Reduced ROM

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DRAWER TEST (video)

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IMAGING?

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INITIAL RADIOGRAPHIC FINDINGS

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RADIOGRAPHIC FINDINGS: 1 WEEK POST INJURY

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OTHER STUDIES?

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ULTRASOUND (video)

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IMAGING

MRI

 Definitive study of

capsular disruption, plantar plate disruption, and articular damage

 Sagittal images for

capsular pathology

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IMAGING

MRI

 Definitive study of

capsular disruption, plantar plate disruption, and articular damage

 Sagittal images for

capsular pathology

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T2 sagittal STIR sequence of the great toe. Arrow demonstrates rupture of the capsular ligamentous complex just distal to the medial sesamoid bone.

McCormick and Anderson (2009-courtesy)

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NONOPERATIVE MANAGEMENT

WHAT CAN YOU DO

FOR AN IN-SEASON ATHLETE TO KEEP HIM ON THE FIELD?

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Shoe inserts

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SURGERY

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DRAWER AFTER SURGERY

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CASE 2

Michael J. Coughlin M.D. Boise, Idaho

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HISTORY

 37 year old male  Tripped while hiking 4 months ago  Pain posterior ankle  Reduced ROM ankle  No obvious ankle instability

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PHYSICAL EXAM

 ACHILLES INTACT  POSTERIOR TENDERNESS  POSITIVE POST IMPINGEMENT TEST  NO PAIN, CREPITUS W GREAT TOE ROM

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Exam-swollen posterior ankle, and Achilles

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MORE TENDERNESS – POSTERIOR ANKLE

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Normal AP ankle xray

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Lateral x-ray – some arthritis,

  • s trigonium present
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WHAT NOW?

Treatment?? Further studies??

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MRI

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Further treatment

 Would you excise os trigonum?  IF so-what approach?

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INJECTION?

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TECHNIQUE: POSITIONING

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TECHNIQUE

 PORTALS

ADJACENT TO ACHILLES AT LEVEL OF TIP FIBULA

 4 MM SCOPE

INSERTED LATERAL

 SHAVER MEDIAL

Drawing courtesy CN van Dijk

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TECHNIQUE

 PORTALS

ADJACENT TO ACHILLES AT LEVEL OF TIP FIBULA

 4 MM SCOPE

INSERTED LATERAL

 SHAVER MEDIAL

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TECHNIQUE

 SHAVER BLADE

INITIALLY DIRECTED LATERAL

 SCOPE INITIALLY

DIRECTED MEDIAL

 GOAL: IDENTIFY

FHL

Drawing courtesy CN van Dijk

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TECHNIQUE

 SHAVER BLADE

INITIALLY DIRECTED LATERAL

 SCOPE INITIALLY

DIRECTED MEDIAL

 GOAL: IDENTIFY

FHL

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OS TRIGONUM RESECTION

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OS TRIGONUM RESECTION

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OS TRIGONUM RESECTION