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Orthopaedics > Foot And Ankle > Flashcards

Foot And Ankle Flashcards

(85 cards)

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1
Q

How many bones are in the foot

A

26

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2
Q

What are the proximal tarsal bones

A

Calcaneus

Talus

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3
Q

Bones in the mid foot

A

Navicular
Cuboid
Cuneforms

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4
Q

Bones that make up the forefoot

A

Metarsals and phalanges

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5
Q

Joints that articulate with the talus

A

Talonavicular joint
Ankle joint - talus articulates with the tibia and fibula
Subtalar joint - talus articulates with the calcaneus

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6
Q

What holds to talus in place and what inserts into the talus and how is this different to other bones

A

The talus is held in place by ligaments
No muscles insert into the talus
This increases its risk of avascular necrosis

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7
Q

What structures lie behind the medical malleolus

A 
T - tibialis posterior 
D - flexor digitorum longus 
A - Posterior tibial artery 
V - post tib vein 
N - post tib nerve 
H - flexor hallucis longus
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8
Q

What is the knot of Henry

A

The intersection of the flexor hallucis longus and the flexor digitorum longus
Cross point and the medial plantar surface of the foot

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9
Q

What does ‘beef to the heel‘ mean

A

The muscle belly of the flexor hallucis longus inserts into the great distal phalanx

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10
Q

What is important to determine in a foot and ankle hx

A

SOCRATES
- PMH, DHx, FHx, SHx
Regard patient holistically regarding the benefit of surgery
Comorbidities
The disability the pathology causes
Anything that might impede the success of surgery
Remember to address the patients concerns and symptoms as you are going to treat the patient and their symptoms the pathology is secondary

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11
Q

Foot and ankle - examination

A

The examination is used to confirm the diagnosis
Look - inspection - walking aids, shoes for patterns of wear, hairy patch spinal dysraphism, scoliosis, leg for overall limb alignment
Look for varus valgus Iimb and then assess gait looking ofr the three phases of gait - the heel strike, mid stance and toe off - symmetrical and even throughout
Foot weight bearing so stood, pea planus, pes cavus, toe deformities - hammer claw, halux valgus
Ensure to look for scar, swelling, erythema
Face wall - calf musculature, too many toes sign - should see 2 if more post tib tendon issue
Bilateral heel raise - valgus to inversion
Single leg raise - valgus to varus and problem - musculature or post tib tendon
Close inspection - between toes callus or corn
Feel
1) tendoachilles
2) perineal tendons
3)lateral mallelous
4)joint line
5)Medial mallelous
6) post tib tendon -insertion
7) plantar fascia
8) sinus tarsi
9) base of 5th metatarsal head
10) extensor tendon
11) bunion
12) meta tarsal heads
13) bunionette
Move
Proximal to distal
Ankle range of movement - dorsi and plantar flexion on the ankle
Subtalar movement - stabilise talus with one hand move the hind foot inversion and eversion
Midtarsal - stabilise midfoot - adduction or abduction
1st metatarsal - stabilise midfoot - depress 1st metatarsal
Check movement of the toes
Tendon function
Post tib tendon - plantar flexed and inverted position hold foot in position like stone and tell them to resist pressure you apply and feel the tendon
Perineal tendon- dorsiflex and evert - hold like stone and resist your movement - palpate tendon and assess function
Tibialis anterior - dorsiflex and invert - hold like stone resist movement
Ankle instability - anterior drawer test- relax foot and plantar flex - stabilise ankle and drawer the other foot forward - anterior talofibular ligament laterally
Lateral ligamentus complex - invert foot and feel the ligaments below lateral malleolus excessive opening up = incompetence
OA at 1MT - axial grind - pain - look at face - stabilise foot and move up and down - hallucinations rigidus
Tendoachilles - Simmons manoeuvre- patient prone, relax foot - squeeze calf should see plantar flexion of the foot if the Achilles is intact
Pes cavus - hindfoot varus - Coleman block test - put patient on a a wooden block allow the 1st MT head to be depressed - hindfoot goes from varus to valgus position - flex hindfoot moment at subtalar joint
Complete - NV status and joint above and below

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12
Q

Investigations

A 
Plain film radiograph
Exclude serious or similar diagnoses
CT
MRI - soft tissue deformity
US
Diagnostic fluid
May be therapeutic fluid removal
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13
Q

Diff diag

Adults

A 
Arthritis 
Instability
Deformity 
Nerve entrapment
Tendon disease
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14
Q

Diff diag children

A 
Flat feet
Heel pain
Club foot
Curly toes
Poly/syndactyly
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15
Q

Tx

A 
Con - non-op 
Advice and reasses - don’t make patient afraid to come back 
Podiatry 
Orthotics
Physio
Med- analgesia, steroid injections
Surg 
Soft tissue procedures - curettage 
Bone and joint op - fusion osteotomy
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16
Q

Axial (x-section of ankle) groups

A 
Groups are in relation to the Achilles’ tendon
- medial to achilles tendon 
Medial malleolus 
Flexor hallucis longus 
Flexor digitorum longus 
Post tib NAV
Tibialis posterior 
- Lateral to the Achilles’ tendon
Lateral malleolus
Fib longus and breves
Sural nerve 
Short saph v
Terminal branches of fib artery 
- anterior 
Saph nerve
Long saph v
Tib ant 
Ext hall long
Superficial fib 
Ex dig L
Fib tertios 
Deep ( just infront of talus)
Deep fib nerve 
Dorsalis pedis artery
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17
Q

Common adult presentation

A

Ankle pain
Foot pain
Heel pain
toe pain

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18
Q

Ankle pain caused by what

A

Injury recurrent micro injury, bigger injury - can lead to arthritis
Twist - potential underlying osteochondral defect
Sprain- instability
Break - deformity
Can lead to these problems esp if no tx well from the start

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19
Q

Long term complication of severe sprain or ankle fracture

A

Arthritis

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20
Q

What are the features of moderate arthritis

A

Pain
Swelling
Stiffness

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21
Q

What are the radiological signs of severe OA

A

L - loss of joint space
O - osteophytes
S - subchondral cysts
S - sunchondral sclerosis

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22
Q

What is a common occurrence of a severe sprain

A

osteochondral injury

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23
Q

Symptoms of an osteochondral injury

A

Dull deep ache

Severe disabling

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24
Q

Cause of osteochondral injury following minor trauma

A

Intrinsic defect of the talar cartilage

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25
Tx of osteochondral injury
Manage con with rest analgesia | Definitive - surg arthroscopic tx curettage
26
What causes ankle instability
Ligament sprain
27
Mx of ankle instability
``` RICE Rest Ice Compress Elevate ```
28
Which examination finding positive in ankle instability
Anterior drawer | Stablise talus and pull the foot forwards
29
Arthritis mx
Conservative - keep active, weightloss help, muscle strengthening physio etc Med - analgesia Severe - surgery, arthroplasty - total ankle replacement artherosclerosis - ankle fusion
30
What will foot deformity affect
Gait, posture and proximal joints
31
What is the aim of tx in foot deformity
``` Flexible foot Foot not too cavus or planus Comfortably fits a shoe Pain free NV not compromised ```
32
Common causes of foot pain
Arthritis/ RA Metatarsalgia Tarsal Tunnel syndrome Tibialis posterior tendon dysfunction
33
What is metatarsalgia
``` Pain in the ball of the foot can b due to a mild deformity Morton’s neuroma can cause it Overweight Shoes Running Flat feet Bursitis or arthritis ```
34
What is tarsal tunnel syndrome
Tibialis nerve entrapment under the flexor retinaculum | A person with flat feet is at risk
35
What can cause tibialis posterior tendon deformity
Injury or trauma Rupture can be complete or incomplete can both cause adult flat foot due to the short exclusion of the tendon Tendinosis from repeated micro trauma 2 insertion point into the navicular tuberosity and the 2,3,4 metatarsal heads
36
What causes the signs of tibialis posterior tendon deformity
As the tendon loses its function the medial longitudinal arch of the foot collapses which causes a relative internal rotation of the tibia and talus There is eversion of the subtalar joint which forces the heel into a valgus allignment and abduction at the talonavicular joint. Varus alignment of the heel causes a lateral shift in the normal axis of the Achilles’ tendon which in time will lead to a contracture. As the deformity gets worse, the distal fibula comes into contact with the lateral calcaneus, causing lateral hindfoot pain.
37
What are the signs associated with a tibilalis posterior ligament deformity
Flat foot Valgus heel deformity Single limb heel rise - difficulty performing this test Too many toes
38
What are the symptoms tibilais post deformity
Can get pain and swelling along the path of the tendon particularly behind the medial malleolus
39
Tx tibialis post deformity
Con - orthotics Surg - depends on the stage of the deformity whether the deformity is still flexible or has become fixed calcaneus osteotomy, post tib tendon excision
40
Causes of heel pain
``` Achilles tendinopathy Plantar fasciitis Haglunds deformity Nerve entrapment Tumour Stress fracture - march fracture Inflammatory enthesopathy - inflammation of the attachment of muscle or ligament to a bone ```
41
What is plantar fasciitis
The plantar fascia supports tot he arch of the foot - most common cause of plantar heel pain Degenerate changes from micro trauma not inflammatory as the name might suggest
42
Symptoms of plantar fasciitis
Initial insidious onset of pain Intense pain during the first steps of walking or after a period of inactivity Lessening pain with moderate foot activity but worsening later during the day after long periods of standing or walking Exam features Tenderness on palpation of the plantar heel area Limited ankle dorsiflexion (with knee is extension) and a positive Windlass st - reproduction of pain by extension of the first metatarosphalangeal joint Antalgic gait (abnormal walking to avoid joint pain) or limping
43
Diff diag of plantar fasciitis
``` Achilles tendinitis Calcaneus stress fractures Fat pad atrophy Sub-calcaneal bursitis Nerve entrapment Peripheral neuropathy rupture, neoplasm and vascular insufficiency ```
44
Mx plantar fasciitis
``` Most make a recovery in 6 months Rest - long periods of standing and walking Wear shoes with a good arch support Insoles, heel pads Analgesia and required If overweight - lose weight Ice pack Self - physio - exercises stretches Med - steroid injection Surg - extra corporeal shockwave therapy Surgical division of the plantar fascia ```
45
Achilles tendinitis mx
Steroid injection- Evidence has shown they aren’t beneficial orthotics Physio Eccentric loading exercise ESWT inc blood supply inc healing process Surgery
46
Types of heel tendon pathologies
Non-insertional insertional Plantar fasciitis
47
Common children foot conditions
``` Flat foot Heel pain Club foot Curly toes Poly/syndactyly ```
48
Flat feet is it a problem ? What is it also called
Can be normal fo children to have flat feet their feet are still developing and their is a spectrum of foot shape and on one end is flat and that’s still normal Problem when it is fixed or painful Pes planus
49
How to check if a flat foot deformity is fixed
On tip toe the arch reforms so no tx is required
50
T of flat foot in children
A only conservative as many children age they grow out of the flat foot Heel stretching Orthotics Surgery rarely
51
Heel pain in children Cause What to exclude Mx
Tarsal tunnel Rare plantar fasciitis Exclude - tumour, infection, trauma In active child rest more
52
Types of gait disturbance in children
Toe walking In toeing Out toeing exclude a foot deformity rarely a ‘foot’ issue
53
Club foot Long name
Congenital talipits equinovarus
54
What signs does the deformity have
C: cavus A: adduction V: varus E: equinus - plantar flexion Foot cannot be passively exerted and dorsiflexed through the normal range
55
Tx of club foot
Ponsetti casting Foot is manipulated and placed in a plaster cast, correction is gradual If its not worked = surgery
56
Serious conditions to exclude
Tumour Acral lentiginous- subungual melanoma Infection - necrotising fasciitis Trauma or non-accidental injury Disabling -dysplasia
57
What is non -accidental injury
Children possible cause SmAll fracture v important As up to 50% whose NAI are missed will have a fatal injury
58
Pes cavus - what is it
High arch | Claw toe
59
Cause pes cavus
Neuromuscular - Charcot Marie tooth Hereditary motor and sensory neuropathy Also be idiopathic
60
Tx pes cavus
Underlying | Symptoms
61
What is osteomyelitis
Bone and joint infection
62
Causes of osteomyelitis
Acutely haematogenous Secondary to contagious local infection Direct inoculation from trauma or surgery
63
Clinical features of osteomyelitis
Adults is affects cancellous bone - feet/ vertebrae Children - vascular Bon e- femurs Lead to cortexerosion - holes - cloacae Exudation of pus lifts up the periosteum interrupting blood supply to underlying bone and necrotic fragments of bone may form- sequestrae New bone may form. Involucrum Tx ab
64
Common toe problems
``` Hallux valgus Bunion/bunionette Hallux rigidus Corn and callus Nail problem Morton’s neuroma ```
65
What is hallux rigidus
1st MTPJ OAmarked loss of dorsiflexion and pain
66
wHat do you need to exclude in hallux rigidus
Gout | Most commonly effects the 1st MTPJ - podagra
67
Tx of hallux rigidus
Con - rocker-bottom shoes Steroid injection Surg - cheilectomy arthroplasty
68
What is hallux valgus
Deformity on the 1st MTPJ lateral deviation of >15 deg | Bunion
69
What is a bunion
Medial prominence produced by the varus deformity of 1st metatarsal head Unsightly and some have pain, can’t wear normal shoes
70
Complications of hallux valgus
Toe crowding Mid foot arthritis Corns, calluses Flat feet
71
Tx hallux valgus
Con - pain relief, orthotics | Surg - make foot fit the shoe, soft tissue release can be more than one operation
72
Causes of bunion and lesser toe deformity
Biomechanical risk factors Weight high Tight /high heel shoe
73
What is the difference between a callus and a corn
Corn - dorsum of the foot | Callus - plantar surface
74
Describe a hammer toe
Extended MTP Hyperflexed DIP Extended DIP
75
What is hammer toes associated with
Contracture of the flexor digitorum longus
76
Which toes is most likely affected with hammer toe
2nd toe
77
Describe deformity of a Claw toe
Extended MTP Flexed PIP and DIP Toe digs into the foot
78
Tx claw toe
Tatar’s also shortening or PIP arthrodiesis
79
Describe the deformity of a mallet toe
Flexion deformity of the DIP alone
80
Tx mallet toe
Flexor tenotomy | DIP joint arthrodiesis
81
What is a Morton’s neuroma
Symptomatic perineural fibrosis around a plantar digital nerve of the foot. The conditions is though to be to chronic entrapment of the nerve by the intermetatarsal ligament Non-neoplasticism
82
Tx Morton’s neuroma
Orthotics Steroid injection Neuroectomy
83
Ingrown toe nail long name
Onychoncryptosis
84
Cause of ingrown toe nail
Incorrect nail cutting +- pressure of shoes predisposes lateral nail digging into flesh - an get infection and is known as proud flesh
85
Mx ingrown toe nail
Let the nail grow out and cut straight Treat proud flesh with cotton wool soaked surgical spirit Surg - recurrent = hole nail removal or wedge excision

Orthopaedics (7 decks)

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