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

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 INJURED

WHAT WOULD YOU LOOK FOR ON PHYSICAL EXAMINATION?

PHYSICAL EXAM  Swollen first MTP joint  + drawer  Reduced ROM

DRAWER TEST (video)

IMAGING?

INITIAL RADIOGRAPHIC FINDINGS

RADIOGRAPHIC FINDINGS: 1 WEEK POST INJURY

OTHER STUDIES?

ULTRASOUND (video)

IMAGING  MRI  Definitive study of capsular disruption, plantar plate disruption, and articular damage  Sagittal images for capsular pathology

IMAGING  MRI  Definitive study of capsular disruption, plantar plate disruption, and articular damage  Sagittal images for capsular pathology

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)

NONOPERATIVE MANAGEMENT  WHAT CAN YOU DO FOR AN IN-SEASON ATHLETE TO KEEP HIM ON THE FIELD?

Shoe inserts

SURGERY

DRAWER AFTER SURGERY

CASE 2 Michael J. Coughlin M.D. Boise, Idaho

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

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

Exam-swollen posterior ankle, and Achilles

MORE TENDERNESS – POSTERIOR ANKLE

Normal AP ankle xray

Lateral x-ray – some arthritis, os trigonium present

WHAT NOW?  Treatment??  Further studies??

MRI

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

INJECTION?

TECHNIQUE: POSITIONING

TECHNIQUE  PORTALS ADJACENT TO ACHILLES AT LEVEL OF TIP FIBULA  4 MM SCOPE INSERTED LATERAL  SHAVER MEDIAL Drawing courtesy CN van Dijk

TECHNIQUE  PORTALS ADJACENT TO ACHILLES AT LEVEL OF TIP FIBULA  4 MM SCOPE INSERTED LATERAL  SHAVER MEDIAL

TECHNIQUE  SHAVER BLADE INITIALLY DIRECTED LATERAL  SCOPE INITIALLY DIRECTED MEDIAL  GOAL: IDENTIFY FHL Drawing courtesy CN van Dijk

TECHNIQUE  SHAVER BLADE INITIALLY DIRECTED LATERAL  SCOPE INITIALLY DIRECTED MEDIAL  GOAL: IDENTIFY FHL

OS TRIGONUM RESECTION

OS TRIGONUM RESECTION

OS TRIGONUM RESECTION