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14. Year 2: Musculoskeletal > Orthopaedic Foot Conditions > Flashcards

Orthopaedic Foot Conditions Flashcards

1
Q

Describe the general management of foot problems?

A

General management:

  • Non operative management
    • Analgesia
    • Shoe wear modification
    • Activity modification
    • Weight loss
    • Physiotherapy
    • Orthotics including insoles and bracing
  • Operative management
    • Only indication for this is failure of non-operative management
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2
Q

What are the different pathological groupings of disease based on underlying aetiology?

A
  • Vascular
  • Infective
  • Traumatic
  • Autoimmune
  • Metabolic
    • Endocrine/drugs
  • Inflammatory
  • Inherited
    • Congenital
  • Neurological
  • Neoplastic
  • Degenerative
  • Idiopathic
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3
Q

What are the different anatomical groupings of foot problems?

A
  • Forefoot problems
    • Hallux valgus
    • Hallux rigidus
    • Lesser toe deformities
    • Morton’s neuroma
    • Metatarsalgia
    • Rheumatoid forefoot
  • Midfoot problems
    • Ganglia
    • Osteoarthritis
    • Plantar fibromatosis
  • Hindfoot problems
    • Achilles tendonitis
    • Plantar fasciitis
    • Ankle osteoarthritis
    • Tibialis posterior dysfunction
    • Cavovarus foot
  • Other foot problems
    • Diabetic foot
      • Ulceration
      • Charcot foot
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4
Q

What are examples of forefoot problems?

A
  • Hallux valgus
  • Hallux rigidus
  • Lesser toe deformities
  • Morton’s neuroma
  • Metatarsalgia
  • Rheumatoid forefoot
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5
Q

What are examples of midfoot problems?

A
  • Ganglia
  • Osteoarthritis
  • Plantar fibromatosis
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6
Q

What are examples of hindfoot problems?

A
  • Achilles tendonitis
  • Plantar fasciitis
  • Ankle osteoarthritis
  • Tibialis posterior dysfunction
  • Cavovarus foot
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7
Q

What is hallus valgus also called?

A

Bunions

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8
Q

What is this?

A

Hallus valgus

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9
Q

What is the aetiology of hallus valgus?

A
  • Genetic
  • Footwear
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10
Q

Describe the epidemiology of hallus valgus in terms of sex?

A
  • Predominantly woman
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11
Q

Describe the pathophysiology of hallus valgus?

A
  • Lateral angulation of great toe
  • Tendons pull realigned to lateral of centre of rotation of toe worsening deformity
  • Vicious cycle of increasing pull increasing deformity
  • Sesamoid bones sublux, less weight goes through great tow
  • Abnormalities of lesser toes
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12
Q

What is the presentation of hallus valgus?

A
  • Pressure symptoms from shoe wear
  • Pain from crossing over of toes
  • Metatarsalgia
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13
Q

What investigation is done for hallus valgus?

A
  • X-ray
    • Determine severity of underlying bony deformity
    • Exclude associated degenerative change
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14
Q

What is the mangement of hallus valgus?

A
  • Non-operative
    • Shoe wear modification
      • Wide +/- high toe box
      • Orthotics to offload pressure/correct deformity
      • Activity modification
      • Analgesia
  • Operative
    • Indication is failure of non-operative treatment
    • Release lateral soft tissues
    • Osteotomy of 1st metatarsal +/- proximal phalanx
    • Good outcome but recurrence inevitable
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15
Q

What is indication for operative treatment of hallus valgus?

A
  • Indication is failure of non-operative treatment
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16
Q

What is hallux rigidus?

A

Means stiff big toe, basically osteoarthritis of 1st MTP joint

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17
Q

What is the aetiology of hallux rigidus?

A

Aetiology:

  • Not known
  • Possibly genetic
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18
Q

What is the presentation of hallux rigidus?

A
  • Many asymptomatic
  • Pain
    • Often at extreme of dorsiflexion
  • Limitation of range of movement
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19
Q

What investigation is done for hallux rigidus?

A

X-ray

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20
Q

What is the mangement of hallux rigidus?

A
  • Non-operative
    • Activity modification
    • Shoe wear with rigid sole
    • Analgesia
  • Operative
    • Cheilectomy
      • Remove dorsal osteophytes to stop dorsal impingement
    • Arthrodesis
      • 1st MTPJ fusion
        • Gold standard treatment
      • 1st MTPJ hemiarthroplasty
        • Good option to maintain ROM
        • High failure rate
    • Arthroplasty
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21
Q

What is a cheilectomy?

A
  • Remove dorsal osteophytes to stop dorsal impingement
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22
Q

What are the 3 classic terms of lesser toe deformities?

A
  • Claw toes
    • Flexion at proximal and distal interphalangeal joint
  • Hammer toes
    • Flexion of proximal interphalangeal joint and dorsiflexion at MTP joint
  • Mallet toes
    • Flexion at distal interphalangeal joint
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23
Q

What is claw toe?

A
  • Flexion at proximal and distal interphalangeal joint
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24
Q

What is hammer toes?

A
  • Flexion of proximal interphalangeal joint and dorsiflexion at MTP joint
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25
Q

What is mallet toes?

A
  • Flexion at distal interphalangeal joint
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26
Q

What is the aetiology of lesser toe deformities?

A
  • Imbalance between flexors/extensors
  • Shoe wear
  • Neurological
  • Rheumatoid arthritis
  • Idiopathic
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27
Q

What is the presentation of lesser toe deformties?

A
  • Deformity
  • Pain from dorsum and plantar side
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28
Q

What is the treatment of lesser toe deformities?

A
  • Non-operative
    • Activity modification
    • Shoe wear
      • Flatter shoes with high toe box
    • Orthotic insoles
  • Operative
    • Flexor to extensor transger
    • Fusion of interphalangeal joint
    • Release MTP joint
    • Shortening osteotomy of metatarsal
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29
Q

What is the aetiology of Morton’s neuroma?

A
  • Mechanically induced degenerative neuropathy
  • High heeled shoes
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30
Q

Describe the epidemiology of Morton’s neuroma in terms of age and sex?

A
  • Females aged 40-60
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31
Q

What is the presentation of Morton’s neuroma?

A
  • Typically affects 3rd, followed by 2nd webspace/toes
  • Neuralgic burning pain into toes
  • Intermittent
  • Altered sensation in webspace
  • Metatarsalgia
    • Symptom, not a diagnosis
32
Q

Which toe is most commonly affected by Morton’s neuroma?

A
  • Typically affects 3rd, followed by 2nd webspace/toes
33
Q

How is Morton’s neuroma diagnosed?

A
  • Mulder’s click
    • Best clinical test
  • USS best, MRI good
34
Q

What is the management of Morton’s neuroma?

A
  • Injection for small lesions
  • Surgery for excision of lesion and section of normal nerve
35
Q

What is the treatment of rheumatoid forefoot?

A
  • Non operative
    • Shoe wear
    • Orthotics
    • Activity
  • Operative
    • 1st MTPJ arthrodesis is gold standard
    • 2-5 toe excision arthroplasty
36
Q

What does dorsal foot ganglia arise from?

A

Arise from joint or tendon sheath

37
Q

What is the aetiology of dorsal foot ganglia?

A
  • Idiopathic
  • Underlying arthritis
  • Underlying tendon pathology
38
Q

What is the presentation of dorsal foot ganglia?

A
  • Pain from pressure shoe wear or underling problem
39
Q

What is the treatment of dorsal foot ganglia?

A
  • Non-operative
    • Aspiration
  • Operative
    • Excision
40
Q

What is the prognosis of dorsal foot ganglia?

A
  • High rate of return, 50%
41
Q

What is the aetiology of midfoot arthritis?

A
  • Post-traumatic arthritis
  • Osteoarthritis
  • Rheumatoid arthritis
42
Q

What is the treatment of midfoot arthritis?

A
  • Non-operative
    • Activity
    • Shoe wear
    • Orthotics
    • Injections
      • X-ray guided
  • Operative
    • Fusion
43
Q

What is plantar fibromatosis also known as?

A

Also known as Ledderhose disease

44
Q

What is the presentation of plantar fibromatosis?

A
  • Similar to duputrens of hand
  • Progressive
  • Usually asymptomatic unless very large or on weight bearing area
45
Q

What is the treatment of plantar fibromatosis?

A
  • Non-operative
    • Avoid pressure
    • Shoe wear
    • Orthotics
  • Operative
    • Excision
      • 80% risk of recurrence
46
Q

What is achilles tendonitis/tendonosis?

A

Degenerative/overuse condition with little inflammation

47
Q

What conditions are associated with achilles tendonitis/tendonosis?

A
  • Insertional tendinopathy
    • Within 2cm of insertion
  • Non-insertional tendinopathy
    • 2-7cm of insertion
  • Bursitis
  • Paratendinopathy
48
Q

What is the difference between insertional and non-insertional tendinopathy?

A
  • Insertional tendinopathy
    • Within 2cm of insertion
  • Non-insertional tendinopathy
    • 2-7cm of insertion
49
Q

Describe the epidemiology of paratendonopathy in terms of age and sex?

A
  • Common in athletic population
  • Age group 30-40
  • M:F 2:1
50
Q

Describe the epidemiology of tendonopathy in terms of age?

A
  • Age >40
51
Q

What are risk factors for paratendonopathy and tendonopathy?

A
  • Paratendonopathy
    • Common in athletic population
    • Age group 30-40
    • M:F 2:1
  • Tendonopathy
    • Commonest in non-athletic population
    • Age >40
    • Obesity
    • Steroids
    • Diabetes
52
Q

What is the presentation of achilles tendonitis/tendinosis?

A

Presentation:

  • Pain during exercise and following
  • Recurrent episodes
  • Difficulty fitting shoes
  • Rupture
53
Q

What investigations are done for achilles tendonitis/tendonosis?

A
  • USS
  • MRI
  • Achilles rupture test
    • Simmonds calf squeeze test
54
Q

What is the treatment for achilles tendonitis/tenodonosis?

A
  • Non-operative
    • Activity modification
    • Weight loss
    • Shoe wear modification
      • Slight heel
    • Physiotherapy
    • Extra-corporeal shockwave treatment
    • Immobilisation (in below knee cast)
  • Operative treatment
    • Gastrocnemius recession
    • Release and debridement of tendon
55
Q

What is the correct term for plantar fasciitis?

A

Fasciitis is incorrect term, fasciosis is better term

56
Q

What is fasciosis?

A

Fasciosis = chronic degernerative change, fibroblast hypertrophy, absence inflammatory cells, disorganised and dysfunctional blood vessels and collagen, asvascularity

57
Q

What is the aetiology of plantar fasciitis?

A
  • Not known
    • Seen more in athletes, running, obesity, occupation involving prolonged standing, foot deformities
58
Q

What are risk factors for plantar fasciitis?

A
  • Seen more in athletes, running, obesity, occupation involving prolonged standing, foot deformities
59
Q

What is the presentation of plantar fasciitis?

A
  • Pain
    • Worse in the morning
    • Pain on weight bearing after rest
    • Located at origin of plantar fascia
60
Q

What is the differential diagnosis of plantar fasciitis?

A

Differential diagnosis:

  • Nerve entrapment syndrome
  • Arthritis
  • Calcaneal pathology
61
Q

Describe the diagnosis of plantar fasciitis?

A
  • Mainly clinical
  • Occasionally x-rays, USS and MRI
62
Q

What is the treatment of plantar fasciitis?

A
  • Rest
  • Stretching
  • Ice
  • NSAIDs
  • Orthoses
  • Physiotherapy
  • Weight loss
  • Injections
    • Corticosteroid
      • Good in short term but makes condition worse in long term
  • Night splinting
  • Newer/3rd line treatments
    • Extracorporeal shockwave therapy
    • Topaz plasma coblation
    • Nitric oxide
    • Platelet rich plasma
    • Endoscopic/open surgery
63
Q

What is the aetiology of ankle arthritis?

A
  • Idiopathic
  • Post-traumatic
64
Q

Describe the epidemiology of ankle arthritis in terms of age?

A
  • Presents in 40s
65
Q

What is the presentation of ankle arthritis?

A
  • Pain
  • Stiffness
66
Q

Describe the diagnosis of ankle arthritis?

A
  • Clinical
  • Radiographs
  • CT scan
    • Exclude adjacent joint arthritis
67
Q

What is the management of ankle arthritis?

A
  • Non operative
    • Weight loss, activity modification, analgesia, physiotherapy, steroid injections
  • Operative
    • Arthrodesis
      • Gold standard treatment
      • Good long term outcome
    • Joint replacement
      • Maintain ROM
68
Q

What is posterior tibial tendon dysfunction?

A

Acquired adult flat foot planovalgus

69
Q

What is the presentation of posterior tibial tendon dysfunction?

A
  • Pain medial or lateral
70
Q

Describe the diagnosis of posterior tibial tendon dysfunction?

A
  • Double and single heel raise
    • In normal, heels should swing from valgus to varus as heel rises
    • Cant do this with posterior tibial tendon dysfunction
  • MRI
    • Assess tendon
71
Q

What is the treatment of posterior tibial tendon dysfunction?

A
  • Orthosis in early stages
  • Surgery in later stages
    • Reconstruction of tendon (tendon transfer)
    • Triple fusion (subtalar, talonavicular and calcaneocuboid)
72
Q

Describe the aetiology of diabetic foot ulcer?

A
  • Diabetic neuropathy
    • Patient unaware of trauma to foot
  • Diabetic autonomic neuropathy
    • Lack of sweating/normal serum production
      • Dry cracked skin
      • Skin more sensitive to minor trauma
  • Poor vascular supply
  • Lack of patient education
73
Q

What is the treatment of diabetic foot ulcer?

A
  • Prevention
  • Modify main treatment detriments to healing
    • Diabetic control
    • Smoking
    • Vascular supply
    • External pressure
      • Splints, shoes, weight bearing
    • Internal pressure
      • Deformity
    • Infection
    • Nutrition
  • Surgical treatment
    • Improve vascular supply
    • Debride ulcers and get deep samples for microbiology
    • Correct any deformity to offload area
    • Amputation
74
Q

Describe the aetiology of charcot neuroarthropathy?

A
  • Any cause of neuropathy
  • Diabetes commonest cause
75
Q

Describe the pathophysiology of charcot neuroarthropathy?

A
  • Neurotraumatic
    • Lack of proprioception and protective pain sensation
  • Neurovascular
    • Abnormal autonomic nervous system results in increased vascular supply and bone resorption
  • Characterised by rapid bone destruction in 3 stages
    • Fragmentation
    • Coalescence
    • Remodelling
76
Q

Describe the diagnosis of charcot neuroarthropathy?

A
  • High index of suspicion
  • Consider in any diabetic with acutely swollen erythematous foot especially with neuropathy
  • Radiographs
  • MRI scan
77
Q

Describe the management of charcot neuroarthropathy?

A
  • Prevention
  • Immobilisation/non-weight bearing
  • Correct deformity
    • Deformity leads to ulceration leads to infection leads to amputation

14. Year 2: Musculoskeletal (40 decks)

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