5. Lower Limb Foot And Ankle Flashcards

Question

Subtalar joint

Answer 1

* where talus articulates with calcaneus – between talus and calcaneus * Orthopaedic surgeons include the talocalcaneal part of talocalcaneonavicular joint – between talus, calcaneal and neviculum

Answer 2

• compound joint: calcaneocuboid joint and talonavicular part of talocalcaneonavicular joint

Answer 3

Spring Ligament (Plantar Calcaneonavicular) Short plantar ligament (Plantar calcaneocuboid) Long plantar Ligament

Answer 4

– between sustentaculum tali and navicular | – Supports head of talus

Answer 5

– between the calcaneus and cuboid

Answer 6

– Also calcaneus to cuboid | – some fibres extend to bases of metatarsals (form a tunnel for peroneus longus)

Answer 7

Dorsiflexor or extensor compartment • Dorsiflex ankle, plus each muscle does one other thing If anterior compartment wasn't working you would have foot drop so toes would drag against the ground • Important for – swing phase of walking – posture

Answer 8

* I/Ointerosseous membrane * Lateral surface of tibia * Medial surface of fibula/ anterior intermuscular septum * Deep fascia of leg

Answer 9

* 4 muscles | * Deep peroneal nerve

Answer 10

* Thickenings of fascia - prevent tendons from bowstringing * Physically holds tendons close to the bone * Superior extensor retinaculum * Inferior extensor retinaculum

Answer 11

* Superior extensor retinaculum | * Inferior extensor retinaculum

Answer 12

tibialis anterior extensor digitorum longus Extensor hallucis longus Peroneus (fibularis) tertiarus

Answer 13

Against tibia * P: Lateral surface of tibia and I/O membrane * D: Medial cuneiform and base of 1st metatarsal * I: Deep Peroneal (fibular) (L4,L5) * A: Dorsiflexes ankle and inverts foot * With tibialis posterior invert foot

Answer 14

• P: Medial surface of fibula and I/O membrane • D: Forms extensor expansion over proximal phalanxes of lateral 4 digits – divides into central band - inserts into base of Middle phalanx – 2 lateral bands -converge and insert into base of Distal phalanx • I: Deep Peroneal (fibular) (L4,L5) • A: Dorsiflexes ankle and extends lateral 4 digits

Answer 15

Deep muscle • P: Middle part of anterior surface of fibula and I/O membrane • D: Base of distal phalanx of hallux • I: Deep Peroneal (fibular) (L4,L5) • A: Dorsiflexes ankle and extends great toe

Answer 16

Like and extension of extensor hallucis Not always present • P: Inferior 1/4 anterior fibula and I/O membrane • D: Dorsum of base of 5th metatarsal • I: Deep Peroneal (fibular) (L4,L5) • A: Dorsiflexes ankle and helps in foot eversion • May help to protect anterior tibiofibular ligament – most commonly injured nerve

Answer 17

Deep peroneal nerve

Answer 18

Arises from common peroneal nerve • Accompanies anterior tibial artery on the I/O membrane • In foot supplies muscles extensor digitorum and hallucis brevis And supplies 4 muscles above • and small area of skin in dorsum of 1st webspace Lesion can result in foot drop

Answer 19

Anterior tibial

Answer 20

• Comes off popliteal through popliteal fossa * Passes anteriorly through a gap in the superior part of the I/O membrane * Descends on membrane with DPN * Changes name midway between malleoli to dorsalis paedis artery * Palpated lateral to EHL tendon

Answer 21

``` Find the • Popliteal • Femoral • Posterior tibial • Dorsalis pedis ``` Learn to palpate those 4

Answer 22

Evertor compartment • Important for – walking – posture (resist when centre of gravity shifted medially)

Answer 23

* anterior intermuscular septum * lateral surface of fibula * posterior intermuscular septum * deep fascia 2 muscles and a retinaculum

Answer 24

* Tendons pass with common synovial sheath behind lateral malleolus * Peroneus brevis is in contact/ grooves lateral malleolus * Peroneus longus lies posterior to brevis (not in contact with malleolus)

Answer 25

* P: Head & superior 2/3 of lateral surface of fibula * D: Passes through groove in cuboid and to base of 1st metatarsal and medial cuneiform * I: Superficial peroneal (fibular) nerve, (L5, S1, S2) * A: Evert foot and weak plantar flexor of ankle

Answer 26

* P: Inferior 2/3 of lateral surface of fibula * D: Tuberosity on base of 5th metatarsal * I: Superficial peroneal (fibula) nerve, (L5, S1, S2) * A: Evert foot and weak plantar flexor of ankle

Answer 27

Superficial peroneal (fibular)

Answer 28

* Arises from common peroneal nerve * Descends in lateral compartment – supplies muscles * Become subcutaneous * Supplies skin distal 1/3 anterolateral surface leg * Splits into branches that supply most of skin dorsum of foot

Answer 29

• Perforating arteries and veins from anterior tibial artery and peroneal (fibular) artery There isn't one dedicated atery in the lateral compatment

Answer 30

• Sensate – feeling • wt bearing areas thicker – thicker skin – heel, lateral margin and “ball of foot” – Fibrous septa = Shock absorber =Anchors skin

Answer 31

(Deep fascia) • Helps protect deep structures from injury • Helps support longitudinal archesof the foot

Answer 32

* Heel * Lateral border of foot * Ball of the foot

Answer 33

Skin is anchored to fascia with fibrous septa

Answer 34

= Thick central part of deep fascia * Longitudinally arranged * lots of Bundles of collagen * Arises from calcaneus * Distally divides into 5 bands for each of the digits (become continuous with fibrous digital sheaths) * Reinforced distally by transverse fibres – help keep everything together

Answer 35

• Vertical intermuscular septa extend from margins of aponeurosis towards 1st and 5th metatarsals * Central (2) compartment – superficial and deep parts * Medial compartments * Lateral compartments * Interosseous compartments * Dorsal compartment (extensor hallucis brevis and extensor digitorum brevis)

Answer 36

* Abductor Hallucis * Flexor digitorum brevis * Abductor digiti minimi

Answer 37

• Two tendons = – Flexor Hallucis longus – Flexor digitorum longus • Two muscles = – Lumbricals – Quadratus plantae

Answer 38

* Flexor Hallucis brevis * Adductor Hallucis (oblique and transverse heads) * Flexor digiti minimi brevis

Answer 39

• Dorsal and plantar interossei

Answer 40

• Intrinisc muscle = in the foot * Extensor digitorum brevis and Extensor hallucis brevis * both Originate from calcaneus * Aid in extending toes • Extrinsic = muscles and tendons from leg that pass through foot

Answer 41

* Tibial nerve and posterior tibial artery divide into medial and lateral plantar nerves and arteries * Deep to abductor hallucis brevis * Medial plantar nerve & artery divide into common plantar digital nerves (sensory) and arteries that supply medial 3 and half digits * Provides sensation to first 3 and a half toes * Lateral plantar nerve & artery divide into superficial and deep branches * Superficial supply lateral supplies sensation of 1 and half digits * Deep branches pass medially * Artery forms deep plantar arch * Gives plantar MT arteries

Answer 42

* Anterior tibial artery becomes dorsalis paedis artery * Continues between EHL extensor hallucis and EDL extesor digitoris longus tendons * Tarsal arteries * Dorsal metatarsal arteries – branches * Communicate with deep plantar arch via perforating branches

Answer 43

• Saphenous nerve: Branch of femoral. Medial side of foot • Dorsum of foot – superficial & deep peroneal • Sole of foot- medial & lateral plantar • Laterally sural nerve: Branches from tibial and common peroneal nerves • Heel by – medial calcaneal branches of tibial nerve – lateral calcaneal branches of sural nerve

Answer 44

• Foot has flexibility due to arrangement of bones, ligaments and tendons – Shock absorbers – Springboards Longitudinal arch of foot – 2 longitudinal arches • Medial Longitudinal arch higher, formed by calcaneus, talus, navicular, 3 cuneiforms and 3 metatarsals • Lateral longitudinal arch – formed by calcaneus, cuboid, lateral 2 metatarsals Transverse arch of foot formed by cuboid, cuneiforms and bases of metatarsals

Answer 45

``` • Shape of united bones (above) • Fibrous tissue layers – Plantar aponeurosis Calcaneal to cuboid – Long plantar – Short plantar – Spring ```

Answer 46

* Intrinsic muscles * FHL and FDL * Tibialis anterior and Tibialis posterior and peroneus longus = other tendons that support arches of the foot

Answer 47

– paired veins accompany all arteries | 2 veins tend to accp=ompany every arter

Answer 48

– variable • Tend to become varicose veins – dilated under skin • Dorsal and plantar venous network • Medial marginal vein becomes great saphenous vein – pass behind medial malleous, medial patella, • Lateral marginal vein becomes short (small) saphenous vein

Answer 49

* Medial superficial lymphatic accompany GSV (great saphenous vein) drain in to superficial inguinal lymph nodes (then deep ILN) * Lateral superficial lymphatic accompany short saphenous to popliteal lymph nodes (then deep lymphatics) * Deep lymphatics vessels from foot follow main blood vessels carry lymph to deep ILN – inguinal lymph nodes * Deep ILN drain into external and common iliac, then lumbar lymphatic trunks

Answer 50

---> things seen in day to day practice • Ankle osteoarthritis • Hallux valgus (Bunions) • 1st MTP joint osteoarthritis (big toe arthritis) • Claw, hammer and mallet toes (bending of toes) • Flat foot deformity • Achilles tendinopathy (sprain in achilles tendon)

Answer 51

* Achilles tendon rupture * Sprained ankle * Ankle fracture

Answer 52

* Diabetes | * Charcot arthropathy

Answer 53

• Primary= as you get older you get degernation of joint due to wear and tear ○ (older, less pain than trauamtic arthritis and better ROM range of movement compared to secondary OA)

Answer 54

--->pathology precedes arthritis like infections ○ Most commonly post- traumatic ○ Septic arthritis ○ Medical condition (rheumatoid arthritis, inflammatory arthropathy) ○ Main problems CF – Pain, stiffness

Answer 55

* Narrow joint space * Condyles aren't as smooth as normal * Sclerotic margins and cysts

Answer 56

* More common in women * Medial deviation of the 1st Metatarsal – big toe faces outwards but metatarsal faces medially * Lateral deviation of the toe (+/- rotation) * 1st MT head becomes prominent (erythema, callous, pain) * Most common complaints - Pain, cosmesis (cosmetic issue), footwear problem

Answer 57

* Metatarsals goes medially | * Phalanges go laterally

Answer 58

Due to abnormal biomechanics in overpronated foot (flatfoot) • Trauma • Arthritis • Metabolic disorders (gout, inflammatory arthropathy) • Collagen disorders (familial) - especially if child has bunion • Wearing heels since a young age • Once present the extrinsic muscles continue to increase the deformity

Answer 59

* Splints = don't really work but pschologically help patient * Change in foot wear – seperation between great tor and second toe * Surgery (extensive and very painful)

Answer 60

* OA of the 1st Metatarsophalangeal joint – joint degerantes, narrows, red, bursitis * Multiple times the body weight passes through this joint when weight bearing

Answer 61

* idiopathic, * trauma, * sepsis, * metabolic/inflammatory condition

Answer 62

* Pain on dorsiflexion of 1st MTPJ * Compensatory alteration of gait, walking on the lateral border of the foot to off load the medial side – to deal with pain * Look at how the sole of their shoes are wearing * Progressive stiffness limiting movement * Dorsal osteophyte may rub in shoes * Reduced dorsiflexion of great toe

Answer 63

---> difficult to wear shoes as the rub inside shoes, cause ulcers on joint surface dorsal * Multiple toes * Hyperextension at MTPJ (metatarsal pharyngeal joint) with flexion at PIPJ (proxiaml interpharyngeal joint) * Corns/blisters - corns on tip, blisters on dorsum * Flexible/rigid

Answer 64

* tight tendons and ligaments * Neurological, Cerebral palsy, stroke * trauma, * inflammatory arthropathy (RA)

Answer 65

* Hammer - Flexion at PIPJ * Mallet – fixed at DIPJ dorsal interpharyngeal joint * Normally walk on the nail * Commonly second toe fi

Answer 66

* Pressure due to hallux valgu = as big toe moves, second toe moves upwards to compensate * poor footwear

Answer 67

* Collapse of the medial arch * In children the medial arch is not fully developed (subcutaneous fat) - but a lot of parents want to give an in sole to do something but it doesn’t make a difference * Normal for child to have flat foot don't develop arch after age 10 What happens? - excessive stretching of the spring ligament and plantar aponeurosis. The talar head drops, the arch flattens and the midfoot deviates laterally

Answer 68

* Idiopathic * Injury * degenerative (tibialis posterior dysfunction)

Answer 69

Flexible – no issue, don't do anything Fixed – bony problems in foot, are tarsals fused together Test for if it is felxible or fixed • Good up on tiptoes = arch will reform ○ Less likely to need surgert for flat foot • Other test = dorsiflex big toe and arch will reform (jack's test) used for children Tarsal coalition – calcaneum, navicular are completely separate • Coalitions can't be fixed with in soles, need commodative insole to fit foot shape

Answer 70

* Only help to remove the pain | * Don't visually change foot

Answer 71

One of the larger tendons in the lower limb | Withstands stresses from walking and running

Answer 72

* Insertional (into calcaneum) – any age group, not always related to activity * Non-insertional (body of tendon) – Younger age group, active

Answer 73

Degenerative

Answer 74

* Pain and stiffness particularly after inactivity (morning) * Pain at back of heel (worse with activity) * Tendon thickening * Swelling * Palpable spur (insertional)

Answer 75

Treatment ---> insoles but beware of achilles tendon rupture

Answer 76

Occurs at middle age Middle age - Pre-existing tendon pathology • Mainly middle age men who have been inactive and now want to be active Aetiology:- • Deceased perfusion blood supply • Increased stiffness (reduction in proteoglycans, with decreased water content and increased cross-linking of collagen) • Decreased collagen turnover and reduced ability to repair • Calcium deposition in the tendon

Answer 77

* Commonly occurs in middle-aged men * Forceful push-off (jumping, running) * Fall/slip into a hole suddenly * Forcefully DF ankle

Answer 78

Partial/Complete Tear – proximal to the calcaneum ``` CF clinical features – Sudden pain – Being “kicked in the heel” • Sound – pop/snap • Palpable gap • Unable to push-off ```

Answer 79

* Positive when squeezing of the calf muscles fails to elciti planatrflexion (movement) of the foot) * Test for achilles tendon rupture

Answer 80

---> Partial / complete rupture of ligaments around the ankle – more commonly lateral.

Answer 81

* weak muscles / ligaments around the joint * Neurological, ligamentous * Proprioception and balance * Uneven surfaces Increased stress on the ligaments when the foot is pushed beyond its range of motion

Answer 82

Rehab – wobble boards, yoga boards, trampolines

Answer 83

* Bruising on side of foot * Can be associated with an avulsion fracture of the 5th metatarsal base due to the pull of Peroneus brevis on its attachment Child – be wary as this might just be normal in them, examine child properly

Answer 84

* Inversion/eversion, internal and external rotation of the joint * Associated rupture of medial and lateral ligaments of the ankle joint * Can result in a fracture dislocation of the ankle joint * If below the distal tibiofibular joint the syndesmosis is intact and the fracture is considered stable

Answer 85

• Reducing it and pain | Try and return anatomy as close to normal

Answer 86

``` --> Very commonly affects the foot • Infection • Skin breakdown • Peripheral neuropathy resulting in loss of sensation • Peripheral ischaemia ``` Combination of the above can cause ulceration and other complications of diabetes Could lead to amputation below the knee

Answer 87

---> Progressive destruction of the tissues in the foot – bones, joints and soft tissue * Caused by a combination of peripheral neuropathy, abnormal weightbearing, inflammatory changes, fractures, osteolysis * The patient is commonly unaware of the damage being done due to loss of sensation and there fore contining normal activities exacerbating the damage being caused – thign sjust keep getting worse

Answer 88

--> pattern of walking | Can have normal and abnormal gait

Answer 89

* Heel/initial contact 9heel hits ground first) * Foot-flat – load - forefoot to the ground * Midstance – move forward * Heel-off * Toe-off (pre-swing) Stance and swing phases • 60% Stance • 40% Swing Heel stance Mid stance Toe off * Step is one foot = hell down to next heel down * Stride = both feet, so it is two steps

Answer 90

* Muscles – provide stability and propulsion | * Work both concentrically (shortening – acceleration) and eccentrically (lengthening – deceleration).

Answer 91

* Antalgic / painful limp = spend less time on the affected leg, quickly move off it * High stepping / foot drop (Tibialis anterior dysfunction) * Spastic – Hemi/diplegia * Trendelenburg gait Parkinsonian * Ataxic/broad based/cerebellar If right leg is hurting – give crutch to painful leg, so your pushing on the crutch instead of on the painful leg

Answer 92

* Limp * Pain * Short stance phase on affected leg * Lack body weight to shift to the affected leg * Short swing on unaffected leg * Uneven pattern

Answer 93

Foot drop • Sciatica • Neuromuscular Toes point down Increased hip flexion on affected side to clear the foot Foot slap = hear the foot go down as the dorsiflexors of foot aren't working can't hold it up

Answer 94

``` Neuromuscular – CP Scissoring – can't abducted Tight muscle groups Ankle – plantar flexed Forefoot – initial contact ```

Answer 95

``` Stroke, cerebral palsy, trauma • Flexed upper limb • Extended lower limb • Short step unaffected leg • Circumduction of the affected leg – swing leg round ```

Answer 96

``` Hip abductor weakness • Pain, neurology.. • Pelvis drops on the unaffected side in stance • Torso swings to the affected side • Waddling • Bilateral ``` Look at patient from behind to see pelvis tilt

Answer 97

* Neurological * Difficulty to initiate movement * Short shuffling steps – patients tend to trip as they can't lift leg * Bend forward * No arm swing

Answer 98

* Cerebellar disorders - Genetic, alcohol, sensory * Broad based * Unco-ordinated * Arms to balance * Appear ‘drunk’

Answer 99

Eversion Inversion Plantarfiexion Dorsifiexion

Answer 100

Fine motor actions

5. Lower Limb Foot And Ankle Flashcards

(124 cards)