Foot and ankle Flashcards
(54 cards)
1
Q
nerves that supply foot and ankle
A
- Superficial peroneal nerve over dorsum of foot
- Deep peroneal nerve in first web space
- Saphenous nerve on medial border foot
- Sural nerve on lateral border of foot
- Tibial nerve in sole
2
Q
When to x ray ankle
A
Ottawa ankle rules: if pain in malleolar zone AND
- tender over distal 6cm of lateral mallolus OR
- tender and post edge of tip or medial malleolus (6cm) OR
- unable to bear weight both immediately and in ED for four steps
3
Q
Classification systems of ankle/ malleoli fractures
A
Lauge hansen classification (MOI)
- 1st word: position of foot
- 2nd word: direction of mvt of talus in relation to leg
> Supination-adduction (SAD) - A
> Supination-Ext rotation (SER) - most common - B
> Pronation-abduction (PAB) - B/C
> Pronation-ER (PER) -C
Danis Weber classification: based on level of fibular fracture relative to syndesmosis
- TypeA: infra-syndesmotic
- TypeB: trans
- TypeC: supra
4
Q
Mgx of ankle/malleoli #
A
Undisplaced - A/B: NWB BK cast - C: fix Displaced (reduce asap) - A/B: closed reduction + IF - C: ORIF > cast
5
Q
Distal tibial #
- aka
- types
- mgx
A
- pilon #/ tibial plafond #
- Types
I: undisplaced
II: minimally displaced
III: markedly displaced
mgx:
- pain relief + abx + elevation + splint
- ext fix
- sx after swelling subsides (ORIF, ext fix, perc pinning)
6
Q
What maintains the arches of the foot
A
- Ligaments: spring, short plantar, long plantar
- Muscle tendons
- medial: tibialis posterior and anterior
- lateral: peroneus longus
7
Q
What is
- equinus
- calcaneus
- plantaris
- pes valgus
- pes varus
A
- equinus: downward pointing foot
- calcaneus: upward pointing foot
- plantaris: only forefoot pointing downward
- pes valgus: pronation with abduction
- pes varus: supination with adduction
8
Q
Features of club foot (congenital talipes equinovarus)
A
CAVE
- midfoot cavus
- forefoot adducted and supinated
- hindfoot in varus
- heel in equinus
9
Q
Types of clubfoot and their differences
A
- Flexible/ positional
- able to dorsiflex foot
- foot an be passively externally rotated
- full ROM
- due to position in womb
- easily correctable physio and stretching - Structural
- idiopathic
- neuromuscular/ paralytic (e.g. CP, spina bifida) resulting in muscle imbalance
10
Q
Club foot
- signs of severity
- complications
A
- deep creases appear posteriorly and medially
- atrophic calf muscles
cx: secondary growth changes in bone
11
Q
Mgx of club foot
A
- Correct early, fully and maintain reduction
- Rule out assoc dz (DDH, spina bifida)
Conservative (just born):
- manipulation and serial casting (up to 4wk) then abduction orthosis. (until ext rotation of 60deg achieved)
- ponsetti casting: toe to groin casting with plaster of Paris
> correct in CAVE sequence (dorsiflex first ray, reduce talus with pressure on medial distal tibia, forefoot adducted in supination, sx release of archilles tendon by perc tenotomy) - abduction orthosis:
> Dennis Browne boots
> Moulded ankle foot orthoses
Operative
- release capsular and ligamentous contractors and fibrotic bands
- lengthen tendons to reposition foot
- hold with cast and K wires
- maintain with orthosis
12
Q
Examination findings of flat foot
A
hindfoot: valgus mid foot: planus forefoot: pronation foot: abduction too many toes sign
flexible flat foot:
- toe toe: heel invert and arch forms
- jacks test: arch restored
13
Q
types of flat foot and relevant mgx
A
- infantile flat foot (congenital vertical talus)
- rocker bottom foot and valgus
- mgx: sx correction <2yo - children and adolescence
- flexible
> generalised ligamentous laxity (normal till 7)/ collagen tissue disorders (marfan)
> tight tendoachilles
> mgx: stretch TA, good shoes, medial arch support
- rigid/ spasmodic/ fixed
>If underlying disorder (polio): splint or op+muscle rebalance
>cast/splint/sx: triple arthrodesis if pain bad
- adults
- painful rigid: footwear, arch support
- tx any underlying disorder
- tibialis rupture: op repair/ tendon replacement
14
Q
how to access ligamentous laxity
A
Beighton score 4 or more - hand flat on floor with knee flex (1) - hyperextend elbow (1/1) - hyperextend knee (1/1) - bend thumb back to forearm (1/1) - bend little finger back to hand (1/1)
total 9 points
15
Q
What is the Silfverskiold test
A
to differentiate gastrocnemius tightness from achilles tightness
- improved ankle dorsiflexion with knee flexed compared to extended = gastrocnemius tightness
- equivalent = achilles tightness
16
Q
Causes of flat foot in children
A
Flexible:
- idiopathic (physiological in young children)
- ligament - marfan/ ehler danlos
Rigid:
- bone: tarsal coalition - abnormal bone connecting calcaneum to talus/ navicular (calcaneo navicular/ talo-calcaneum)
- inflammatory jt condition
- neuromsk disorder - cerebral palsy
17
Q
Causes of adult flat foot
A
- constitutional flat feet (asymptomatic for many years)
- recent onset
> tibialis posterior tendon dysfunction (trauma/sports)
18
Q
Causes of claw toes
A
imbalance between intrinsic and extrinsic muscles of lesser toes
2’ neurological disorders
- UMN: CP/MS/stroke
- LMN: polio
- peripheral neuropathy - DM/ CMT
- Charcot marie tooth
19
Q
Causes of pes cavus
A
- muscle imbalance
- neuromuscular disorders (intrinsic muscle weak)
e. g. CP, polio, CMT, muscular dystrophy - others: burns, compartment syndrome
20
Q
What are some features of Charcot Marie tooth disease
A
- Peroneal muscle atrophy
- Pes cavus + claw toes
- Distal muscle atrophy (inverted champagne bottle legs)
- Bilateral foot drop / high stepping gait / weak ankle dorsiflexion
- Absent reflexes
- Slight / no sensory loss in the limbs
- Thickened nerves
- Optic atrophy
21
Q
Mgx of pes cavus
A
- rule of spinal disorders and neuromuscular abnormalities
- conservative: custom shoes and moulded supports
- sx: tendon rebalancing operation
- fixed deformities sx: ST release + transfers + arthrodesis
22
Q
RF for hallux valgus
A
- hereditary
- loss of muscle tone
- RA
- wearing enclosed footwear
23
Q
associated deformities of hallux valgus
A
- inflamed bunion
- hammer toe
- metatarsalgia
- OA of 1st MTPJ
- callosities
- pes planus
(valgus alignment of MTPJ worsened by pull of EHL and intrinsics)
24
Q
Mgx of hallux valgus
A
Teens
1. conservative: foot wear modifications + physio
2. Sx: corrective osteotomy
Adults
- SX: bunionectomy + 1st MT realignment osteotomy + ST rebalancing
- arthrodesis if MTPJ v osteoarthritis
25
Hallux rigidus
- what
- specific symptoms
- mgx
What: primary OA of MTPJ of great toe
S/S: cannot dorsiflex, push off pain, diffuse lateral forefoot pain
```
Mgx:
- lifestyle: rocker soled shoes, avoid toe dorsiflexion (e.g. squatting)
- meds: panadol, NSAIDs
- SX
> osteotomy (young)
> joint arthroplasty (old)
> severe OA: arthrodesis
```
26
Mgx of lesser toes deformities
foot wear modification
| sx: tenotomy, tendon transfer, resection, arthrodesis
27
Tendoachilles rupture
- location
- RF
- PE findings
- mgx
rupture at musculous tedinous junction, rarely near calcaneus
RF: age>40, steroid LT
PE:
- gap in tendon (5cm above insertion of tendon - MT junction)
- weak plantar flexion against resistance
- simmond test: lack of plantaflexion
- cannot tie toe
mgx
- conservative: cast heel in equinus, shoe with raised heel
- operative: repair with cast/ lockable brace
28
Archilles tendonitis
- s/s
- a/w
- mgx
c/o:
- pain, aggravated by passive stretching
- tender, swelling
- crepitus on plantar flexion
a/w Haglund deformity (prominence at posterior superior calcaneus where tendon laterally inserts into calcaneus)
mgx:
- rest, gentle stretching, nsaids
- proper footwear, orthotics
- no steroids
29
mgx of paratendonitis
conservative
- rest, ultrasound, heel raise
Op
- excision of inflammed and degenerate tissue
30
approach to painful ankle
1. bone
- #
- AVN of talus
- osteochondritis dissecans of talus (op removal if displaced fragment, else activity limitation)
2. joint:
- footballer ankle/ anterior ankle impingement syndrome (repeated forced dorsiflexion > tear ant capsule > bone spur/ exostosis > pain/ limited ROM)
3. tendon
- tenosynovitis (tibialis pos, peroneal tendons) - steroid
- rupture (snap): repair if active, else splint
4. ligaments
- lig instability, sprain, tear
31
Causes of posterior heel pain
1. traction apophysitis (sever disease)
| 2. retrocalcaneal bursitis
32
plantar fasciitis
- what
- insertion of plantar fascia
- s/s
- mgx
what: chronic inflammation from repetitive strain injury and micro tears of plantar fascia
runs from medial Calcaneal tuberosity to heads of MT bone
pain at medial Calcaneal tubercle
worse on toe dorsiflexion
mgx
conservative
- rest, NSAIDs, physio - stretching exercises, corticosteroid injection, ice cubes, heel cup, us therapy
surgical
- plantar fascia release
33
Common sites of stress #
- march # (2nd & 3rd MT)
- head of femur
- distal end of femur
- tibia
34
Causes of forefoot pain
```
Generalised: metatarsalgia
Localised:
- sasamoiditis
- freiberg disease (osteochondritis of 2nd MT head)
- stress march # (2nd/3rd MT)
- morton Metatarsalgia
```
35
Morton neuroma
- commonly where
- s/s
- mgx
-3rd inter metatarsal space
s/s:
- pain, tingling
- mulder click: painful click on squeezing MT heads together
```
mgx:
foot wear mod
sx:
- nerve compression release by dividing tight transverse inter metatarsal ligament
- excision of neuroma if v bad
```
36
What is a Maisonneuve fracture
| - x ray findings
spiral fracture of the proximal third of the fibula associated with a tear of the distal tibiofibular syndesmosis and the interosseous membrane
- unexplained increase in medial clear space
- tibiofibular clear space widened (should be<5mm)
37
components of deltoid ligament
- ant tibiotalar
- pos tibiotalar
- tibionavicular
- tibiocalcaneal
38
Ottawa foot rules
Foot x ray series required: pain in midfoot AND
- bone tender at base of 5th MT OR
- tender at navicular OR
- unable to bear weight immediately and in ED for 4 steps
39
Grading of ligamentous injuries
1: strain
- no gift
2: sprain - partial tear
- gift with end point
3. complete tear
- gift with no end point
- significant instability
- talar tilt
40
mgx of peroneal tendon subluxation
- surgical anatomical repair of superior peroneal retinaculum
- below knee plaster
- physio
41
complications of ankle # in chidlren
1. malunion if reduction imperfect
<10yo: accommodated by growth and modelling
>10yo: osteotomy
2. asymmetrical growth
early fusion of physis on one side, veer into varus
3. limb shortening
42
What is bohler angle
measured at intersection of a line drawn btwn post. sup. aspect of calcaneal tuberosity to highest point of post. articular facet and another line drawn to ant. process of calcaneum
N: 25-40deg
decreased in intra-articular #
43
What is a lisfranc injury
| - how to screen
2nd T-MT displacement injury (med cuneiform and base of 2nd MT)
- medial edge of 2nd MT in line with medial edge of 2nd cuneiform
- medial edge of 4th MT in line with medial side of cuboid
44
what is a Jones fracture
| - prognosis
```
# of mid shaft of 5th MT
- prone to non union: injury at watershed area of BS
```
45
What is the most common cause of intoning gait
based on age
1. Infants (< 1yo): metatarsus adductus
2. Toddlers (1 – 3 yo): tibial intorsion, usually resolves by 6 yo
3. Pre-school (3 – 6yo): femoral neck anteversion, usually resolves by 10yo
46
X ray findings in hallux valgus
Hallux valgus angle: n <15
Intermetatarsal angle: n<9
OA changes in 1st MTPJ
47
Tx for hallux valgus
Conservative: analgesia, proper footwear or orthotics, physio
Surgery:
- bunionectomy
- realignment osteotomy with soft tissue rebalancing
- excision arthroplasty (resect medial eminence + base of prox phalanx)
- arthrodesis
48
Mgx of pes plasnus
conserv: insole, orthotics, anal, physio
Sx: pos tibialis reconstruction
49
Causes of pain from hallux valgus
- transverse metatarsalgia: improper weight bearing on 1st MTPJ
- bursitis
- clawed toe (MT head, toe of toe, callosities on dorsum of PIPJ)
50
Classification for DM foot ulcers
King's College Classification
Wagner Classification
determines mgx:
- lower grades respond to abx+debridement
- higher grades (2-5) require amputation
51
Management of DM foot ulcers
depends on severity. Multidisciplinary team.
low grade:
- conservative: education, footwear, regular podiatry exam
- total contact cast for off loading, walking brace, foot wear modification
mod grade:
- surgical debridement, wound care
- empiric (augmentin, clindamycin, ciprofloxacin) then culture specific abx
high grade
- partial or major amputation
- vascular consultation
52
Charcot joint
- what is it
- theories
progressive degeneration of a weight bearing joint resulting in deformity
Theories
- German Neurovascular Theory: loss of autonomic tone > vasodilation > more blood supply & osteoclast > brittling and collapse
- French Neurotrauma theory: sensory loss > abnormal mvt > repetitive trauma > inflammatory resorption > collapse
53
Charcot joint
| - Classification
Brodsky classification (by location): tarsalMT, subtalar joint, ankle joint
Eichenholtz classification (by staging)
0: clinical: erythema, edema, no x ray features
1: fragmentation: #, dislocation, deformity, instability
2: coalescence stage: resorption of debris
3: reparative stage: remodelling and reorganisation
54
Mgx of charcot joint
by stage! (Eichenoltz)
- Early (0-1-2): limited weight bearing, total contact casting, CROW (charcot restraint orthotic walker)
- Late (3): surgery osteotomy - removal of bony prominences
