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FRCS Orthopaedics > Foot & Ankle > Flashcards

Foot & Ankle Flashcards

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1
Q

At the distal tibiofibular joint, the fibula …………………..and
………translates with ankle dorsiflexion.

A

At the distal tibiofibular joint, the fibula externally rotates and proximally translates with ankle dorsiflexion.

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2
Q

In the toe-off phase of gait, the plantar fascia is …………as the metatarsophalangeal (MTP) joints …………. The longitudinal arch is ……………… This is termed the ……………….. The hindfoot
………………….and locks with firing of the ……………..

A

In the toe-off phase of gait, the plantar fascia is tightened as the metatarsophalangeal (MTP) joints extend. The longitudinal arch is accentuated. This is termed the windlass mechanism. The hindfoot
supinates and locks with firing of the posterior tibial tendon.

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3
Q

Plantar migration of the metatarsal head after a Weil osteotomy may lead to? why?

A

cock-up toe deformity as the axis of pull of the intrinsics moves dorsal to the center of rotation.

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4
Q

Cavovarus alignment demonstrates an ………………. longitudinal arch with hindfoot …………and a ………….ray. Pes planus is noted
with a ………………..arch with hindfoot ……………

A

Cavovarus alignment demonstrates an elevated longitudinal arch with hindfoot varus and a plantar-flexed first ray. Pes planus is noted
with a flat longitudinal arch with hindfoot valgus.

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5
Q

Vascular examination findings that are predictive for healing include?

A

toe pressure greater than 40 mm Hg and transcutaneous oxygen pressure greater than 30 mm Hg.

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6
Q

Inability to sense this is consistent with neuropathy and the most predictive sign for the development of a
foot ulceration?

A

Semmes-Weinstein 5.07 monofilament

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7
Q

Anterior drawer test at the ankle, what does it test and how do you do it?

A

—anterior pressure on the hindfoot with the ankle in plantar flexion evaluates the anterior talofibular ligament.

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8
Q

Varus stress test of ankle tests what and how do you do it?

A

—inversion of the ankle in dorsiflexion evaluates the calcaneofibular ligament.

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9
Q

Describe The Silfverskiöld test

A

Test ankle dorsiflexion with the knee extended and flexed with the hindfoot in neutral alignment.
• Tightness in both knee flexion and extension indicates Achilles contracture.
• Improvement in ankle dorsiflexion with knee flexion (relaxing the gastrocnemius origin proximal to the knee) indicates isolated
gastrocnemius contracture.

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10
Q

A key feature in the pathoanatomy of hallux valgus is ……..drift of the proximal phalanx, leading to …………….. migration of abductor
hallucis, which results in …………. and ………….

A

A key feature in the pathoanatomy of hallux valgus is lateral drift of the proximal phalanx, leading to plantar lateral migration of abductor
hallucis, which results in plantar flexion and pronation.

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11
Q

There are four key radiographic angular measurements in hallux valgus. what are trhey?

A

Hallux valgus angle (HVA) < 15

first-second intermetatarsal angle <9 (IMA),

hallux valgus interphalangeus (HVI) <10

distal
metatarsal articular angle (DMAA) <10

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12
Q

what procedures are needed in HV in the following scenarios?

• Spasticity (stroke or cerebral palsy)—?

Osteoarthritis or rheumatoid arthritis—?

• Ligamentous laxity—?•

First TMT degenerative joint disease (DJD)?

A
  • Spasticity (stroke or cerebral palsy)—first MTP fusion
  • Osteoarthritis or rheumatoid arthritis—first MTP fusion
  • Ligamentous laxity—Lapidus (first tarsometatarsal [TMT] realignment arthrodesis)
  • First TMT degenerative joint disease (DJD)—Lapidus
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13
Q

A distal …………………… (modified McBride) is never appropriate in isolation.

A

A distal soft tissue release (modified McBride) is never appropriate in isolation.

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14
Q

IMA 13 degrees or less AND HVA 40 degrees or less , which osteotomy?

A

distal chevron

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15
Q

IMA greater than 13 degrees OR HVA greater than 40 degrees? which osteotomy?

A

proximal metatarsal osteotomy

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16
Q

complications of HV surgery?

A

Recurrence—undercorrection of IMA or isolated soft tissue reconstruction. Recurrence of the deformity after surgical correction is the most common complication in juvenile and adolescent hallux valgus.
• Dorsal malunion—Lapidus or proximal crescentic osteotomy; results in transfer metatarsalgia
• Hallux varus—overresection of the medial eminence

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17
Q

define a hammer toe? and treatment?

A

Hammer toe—proximal interphalangeal (PIP) flexion (MTP dorsiflexed but should correct with elevation). Fixed deformity is treated with PIP arthroplasty (resection of distal neck and head of proximal phalanx)
or PIP arthrodesis.

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18
Q

define a claw toe and treatment?

A

Claw toe—PIP and distal interphalangeal (DIP) flexion with fixed MTP hyperextension • Flexible—flexor-to-extensor tendon transfer of flexor digitorum longus (FDL)
• Fixed—PIP arthroplasty/arthrodesis with MTP capsulotomy and extensor lengthening. A dislocated MTP joint requires use of a
distal metatarsal osteotomy (e.g., Weil) to reduce MTP joint.

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19
Q

define a mallet toe? and treatment?

A

Mallet toe—DIP flexion; flexible deformity treated with flexor tenotomy; fixed deformity with DIP arthroplasty or fusion

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20
Q

what is a crossover toe? and treatment

A

Crossover toe—sagittal and axial plane deformities. Key component is disruption of the plantar plate. May be iatrogenic from steroid
injection within MTP joint. Address with EDB transfer.

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21
Q

what is Frieberg disease? and treatment?

A

Freiberg disease—osteochondrosis of metatarsal head. Early-stage disease is treated with joint débridement. A dorsal closed-wedge
metaphyseal osteotomy may also be performed.

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22
Q

what is a congenital curly toe and treatment?

A

Congenital curly toe—perform tenotomy of FDL and flexor digitorum brevis in children with flexible deformities.

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23
Q

Bunionette deformity is treated based on the anatomic location of deformity.

  • Enlarged fifth metatarsal head—lateral co……………
  • Lateral bowing of fifth metatarsal diaphysis—………….
  • Widened fourth-fifth metatarsal angle—……………………..
A

Bunionette deformity is treated based on the anatomic location of deformity. • Enlarged fifth metatarsal head—lateral condylectomy • Lateral bowing of fifth metatarsal diaphysis—distal metatarsal osteotomy
• Widened fourth-fifth metatarsal angle—oblique diaphyseal
osteotomy

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24
Q

what is a turf toe ? and treatment?

A

Turf toe mechanism of injury is forced dorsiflexion resulting in avulsion of the plantar plate off the base of the phalanx and
subsequent proximal migration of the sesamoids. • Complete tears of the plantar plate treated with operative repair have demonstrated superior results compared to conservative
care.

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25
Complications of medial and lateral sesamoidectomy are?
hallux valgus and varus, respectively
26
what will happen if both sesamoids excised?
Cock-up deformity (or claw toe) will occur if both sesamoids are excised.
27
what is a Morton's neuroma ? treatment?
``` Interdigital neuritis (Morton neuroma) is a compressive neuropathy of the interdigital nerve, usually between the third and fourth metatarsals. Surgical treatment is via a dorsal approach, incision of the transverse intermetatarsal ligament and resection of the nerve 2 to 3 cm proximal to the intermetatarsal ligament. ```
28
The ........................….nerve may be injured during surgical approaches that require a plantar incision, such as a tibiotalocalcaneal arthrodesis with an intramedullary nail.
lateral plantar nerve
29
Upper motor neuron disorders most commonly result in an …………………... foot deformity. explain and how each is managed?
Equinus—overactivity of gastrocnemius-soleus complex • Equinus deformity is addressed with either an open Z-lengthening of the Achilles tendon or a percutaneous triplehemisection technique. • Varus—overactivity of tibialis anterior (lesser contributions from flexor hallucis longus [FHL], FDL, and tibialis posterior) • Varus deformity is addressed with a split anterior tibialis tendon transfer (SPLATT) to the lateral cuneiform or cuboid or total anterior tibial tendon transfer to the lateral cuneiform.
30
Genetics of CMT disease?
Type I hereditary motor-sensory neuropathy is the most common presentation of Charcot-Marie-Tooth disease (CMT). • Usually autosomal dominant with a duplication of chromosome 17 Release of the
31
Treatment of a flexible cavus deformity involves:
Release of the plantar fascia • Transfer of the peroneus longus into the peroneus brevis at the level of the distal fibula • A closed-wedge dorsiflexion osteotomy of the first metatarsal is always required. • If the deformity does not correct with Coleman block, perform a lateral calcaneal slide and/or closed-wedge osteotomy.
32
Nonoperative treatment of a fixed cavus deformity?
short-leg ankle-foot orthosis (AFO) with an outside (varus-correcting or lateral) T-strap is recommended. • Rocker sole can improve gait and decrease energy expenditure.
33
Peroneal nerve palsy results in ?
loss of the anterior and lateral compartments with loss of active dorsiflexion and eversion. This results in equinovarus
34
surgical treatment of peroneal nerve palsy ?
Transfer posterior tibial tendon (PTT) through the interosseous membrane anteriorly to the dorsal midfoot to restore dorsiflexion. Achilles tendon should be lengthened.
35
foot deformities in RA?
The toes sublux or dislocate dorsally, deviate laterally into valgus, and develop hammering.
36
“Rheumatoid forefoot reconstruction”
—first MTP arthrodesis, lesser metatarsal head resection with pinning of the lesser MTP joints, and closed osteoclasis of the interphalangeal joints versus PIP arthrodesis
37
The most common complication of forefoot arthroplasty is
intractable plantar keratoses.
38
Osteoarthritis etiology is typically ....................in the hindfoot and tibiotalar articulations, while ..................in the first MTP and midfoot joints.
Osteoarthritis etiology is typically posttraumatic in the hindfoot and tibiotalar articulations, while idiopathic in the first MTP and midfoot joints.
39
What is Hallux rigidus?
First MTP (hallux rigidus)—tenderness over dorsum of joint, limited dorsiflexion due to large dorsal osteophyte and pain with grind test
40
treatment of Hallux Rigidus?
Initial treatment is a stiff foot plate with extension under great toe (Morton extension). Surgical treatment in those with pain at extremes of range of motion (ROM)—dorsal cheilectomy. • Pain throughout ROM with positive grind—arthrodesis (neutral rotation, 10 to 15 degrees of dorsiflexion, and slight valgus)
41
surgical treatment of hindfoot arthritis?
Hindfoot arthritis—triple arthrodesis to correct arthritis secondary to deformity (0 to 5 degrees of hindfoot valgus, neutral abduction/ adduction, plantigrade)
42
Revision of malunited triple arthrodesis requires
calcaneal osteotomy and/or transverse tarsal osteotomy
43
Subtalar arthritis—Subtalar fusion nonunion risk is increased with
history of ankle arthrodesis and smoking.
44
Prior calcaneal fracture with loss of height results in?
anterior impingement, anterior ankle pain, and hindfoot pain and is treated with subtalar bone-block arthrodesis
45
Tibiotalar arthritis—Arthrodesis provides excellent pain relief with some restricted function. • The ideal position for fusion is
neutral dorsiflexion, 0 to 5 degrees of hindfoot valgus, and 5 to 10 degrees of external rotation
46
long term sequela of tibio-talar arthrodesis?
Leads to eventual arthritis in surrounding foot, most commonly the subtalar joint
47
Pes planus (flatfoot) deformity is most commonly caused by
posterior tibial tendon dysfunction in the adult. There is a zone of hypovascularity 2 to 6 cm from the PTT attachment on the navicular.
48
standing exam of pes planus valgus demonstrates?
asymmetric hindfoot valgus, depressed arch, and an abducted forefoot. • “Too many toes” when the foot is viewed posteriorly • Pain or an inability to perform a single-limb heel-rise indicates an insufficient PTT.
49
pes planus radiographs ?
Radiographs demonstrate a negative lateral talo–first metatarsal angle (Meary angle) and talonavicular uncoverage
50
PTT dysfunction stage 2 summary treatment?
FDL or FHL tendon transfer for ALL patients, gastrocnemius recession if contracture present, hindfoot valgus—medial slide calcaneal osteotomy • Forefoot abduction—lateral column lengthening • Forefoot supination • Stable medial column—Cotton osteotomy • Unstable medial column—first TMT arthrodesis
51
Stage III or fixed deformity is treated with
triple arthrodesis.
52
Pes cavus etiology is
neuromuscular, idiopathic, or traumatic (talus fracture malunion)
53
The Coleman block test is used to
``` assess the flexibility of the hindfoot (out of varus) when the first metatarsal plantar flexion (forefoot valgus) is eliminated. • If the hindfoot passively corrects into valgus, the deformity is forefoot driven (due to plantar-flexed first ray). ```
54
conservative treatment of cavus feet?
orthotics with a lateral heel wedge, decreased arch, and depressed first ray.
55
Surgical treatment for forefoot-driven deformity
first metatarsal dorsiflexion osteotomy
56
Surgical treatment for flexible hindfoot deformity
—lateral calcaneal closed-wedge osteotomy and first metatarsal dorsiflexion osteotomy
57
Peroneal tendon subluxation is caused by? treatment?
forced eversion and dorsiflexion, leading to disruption of superior peroneal retinaculum. This requires repair/reconstruction of the superior peroneal retinaculum and fibular groove deepening
58
FHL tenosynovitis is classically seen in dancers. symptoms? treatment?
Posteromedial ankle pain, triggering of first interphalangeal joint, and pain with resisted hallux plantar flexion • Operative treatment is FHL tenosynovectomy and release of the fascia.
59
Plantar fasciitis classically presents with
xquisite pain and tenderness over the plantar medial tuberosity of the calcaneus at the proximal insertion of the plantar fascia. There is pain with the first step in the morning and after prolonged standing. It is frequently associated with an Achilles or gastrocnemius contracture.
60
non op treatment of plantar fasciitis?
plantar fascia–specific stretching and Achilles stretching. Management also includes cushioned heel inserts, night splints, physical therapy, walking casts, cortisone injections, and antiinflammatory medication
61
operative treatment of plantar fasciitis? complications of over release?
Operative management includes limited (medial half) release of the plantar fascia. Complete release can place the longitudinal arch of the foot at risk, overload the lateral column, and lead to dorsolateral foot pain and metatarsal stress fractures.
62
what is Baxters neuritis?
Baxter neuritis is compression of the first branch of the lateral plantar nerve. It presents as plantar medial heel pain and can be difficult to differentiate from plantar fasciitis.
63
how do you treat insertional achilles tendinopathy and when are suture anchors needed and when is a FHL transfer needed?
Insertional Achilles tendinopathy treatment includes excision of the retrocalcaneal bursa, resection of a prominent superior calcaneal tuberosity, and débridement of the degenerative tendon. • If more than 50% tendon detachment is required, reattachment with suture anchors is indicated. FHL tendon transfer is indicated if more than 50% of tendon requires excision.
64
In noninsertional Achilles tendinopathy, MRI evidence of significant diffuse involvement without a focal area of disease indicates need for ?
FHL transfer.
65
The treatment of acute Achilles tendon ruptures remains controversial. Most studies noted that
nonoperative treatment results in an elevated rerupture rate while operative treatment increases wound complication and infection risks.
66
Chronic rupture of the Achilles tendon requires
FHL transfer.
67
pressures to diagnose chronic exertional compartment syndrome?
The standard pressures for diagnosis include intracompartmental pressures greater than 30 mm Hg after 1 minute of exercise, greater than 20 mm Hg after 5 minutes of exercise, or absolute pressures greater than 15 mm Hg.
68
differtial for Chronic exertional Compartmnet syndrome?
Popliteal artery entrapment may be confused with chronic exertional compartment syndrome. Dorsal pedal pulses may be obliterated with active ankle plantar flexion or passive dorsiflexion.
69
when are patients at risk ofdeveloping feet ulceration?
patients who cannot feel the 5.07 monofilament have lost protective sensation to their feet and are at risk for ulceration. • Motor neu
70
Motor neuropathy most commonly involves the common peroneal nerve with resultant
loss of tibialis anterior motor function with a footdrop. The small intrinsic musculature is also commonly affected, resulting in claw toes and subsequent toe-tip ulcerations.
71
minimum toe pressure for healing?
40 mmhg
72
Transcutaneous oxygen measurements (TcPO2) of the toes greater than ......mm Hg have been found to be predictive of healing. • Metabolic deficiency also impairs wound healing. Total protein less than …………. g/dL, WBC count less than ………. and albumin level less than ………. g/dL all predict poor healing potential.
Transcutaneous oxygen measurements (TcPO2) of the toes greater than 40 mm Hg have been found to be predictive of healing. • Metabolic deficiency also impairs wound healing. Total protein less than 6.0 g/dL, WBC count less than 1500, and albumin level less than 2.5 g/dL all predict poor healing potential.
73
when debrideing diabetic foot ulcers what additional procedure is usually necessary to offload areas?
Equinus contracture is very common, and Achilles lengthening will offload the midfoot/forefoot; required in recurrent forefoot/ midfoot ulceration or ulceration with equinus deformity
74
Eichenholtz classification
• I—Fragmentation: hyperemia, hot, swollen, erythematous • II—Coalescence: beginning of reparative process • III—Consolidation: smoothed bone edges with bony/fibrous ankylosis
75
Swelling and redness is classically
diminished with elevation. It is often confused with osteomyelitis clinically.
76
treatmeny of charcot foot?
Initial treatment is immobilization and non–weight bearing; best with a total-contact cast; transition to AFO or Charcot restraint orthosis walker boot once swelling/erythema subsides
77
Lisfranc amputation, what soft tissue procedures are needed?
arsometatarsal disarticulation; must transfer peroneal tendons to cuboid to prevent varus and perform Achilles lengthening to prevent equinus
78
Chopart amputation, what soft tissue procedures are needed?
—talonavicular and calcaneocuboid joint combined disarticulation; must transfer anterior tibialis to talus to prevent equinus and perform Achilles lengthening to prevent equinus
79
what is special about syme amputation?
Syme—ankle disarticulation; second lowest energy expenditure after a transmetatarsal amputation. Heel ulcers are absolute contraindication.
80
• Metatarsal fractures • Second metatarsal stress fracture is the most common and is classically described in amenorrheal dancers. treatment?
Treat in weight-bearing boot or hard-soled shoe. • Evaluate for metabolic bone disease in these patients, especially if insidious onset or if there is no distinct causal event (increase in training, initiation of new activity).
81
Fifth metatarsal fractures can be divided anatomically into avulsion fractures, fractures of the metaphyseal-diaphyseal junction, and fractures of the proximal diaphysis. treatment?
* Avulsion fractures—protected weight bearing • Metaphyseal-diaphyseal fractures—non–weight bearing; elite athletes or delayed healing treated with intramedullary screw fixation * Proximal diaphysis—intramedullary fixation
82
Lisfranc ligament is
between the medial cuneiform and base of second metatarsal
83
missed Lisfranc injury leads to ? treatment?
Missed diagnosis or improper treatment may lead to traumatic planovalgus deformity or posttraumatic arthritis. Midfoot realignment and arthrodesis is the appropriate salvage procedure.
84
Navicular stress fractures are secondary to r...………………….. especially running and jumping. They typically occur in the ………………... and patients complain of vague …………………... pain. • ..............................is the gold standard for diagnosis. • Nondisplaced fractures should be treated with ………………....
Navicular stress fractures are secondary to repetitive trauma, especially running and jumping. They typically occur in the central one third, and patients complain of vague dorsal midfoot or ankle pain. • Computed tomography (CT) is the gold standard for diagnosis. • Nondisplaced fractures should be treated with non–weight bearing.
85
The talus blood supply is provided by
posterior tibial artery, dorsalis pedis artery, and perforating peroneal artery. The artery of the tarsal canal carries the main supply to the talar body.
86
Hawkins sign is
a subchondral linear lucency of the talar dome that is indicative of talar revascularization. Sclerosis of the talar dome does not guarantee that AVN has occurred, but it is suggestive
87
Talar neck fractures are commonly associated with medial neck comminution, leading to a ............deformity. • .........malunion is highly associated with use of medial compression screws. This leads to a ...............deformity, limiting hindfoot ............that results in lateral border foot pain.
Talar neck fractures are commonly associated with medial neck comminution, leading to a varus deformity. • Varus malunion is highly associated with use of medial compression screws. This leads to a cavovarus deformity, limiting hindfoot eversion that results in lateral border foot pain.
88
Lateral process talus fractures are highly associated with
snowboarding or source of continued pain after an ankle sprain
89
Extraarticular calcaneal fractures may endanger posterior skin if there is significant displacement. treatment?
Urgent ORIF
90
Intraarticular calcaneal fractures result in ..........................blowout, resulting in ...........impingement and .........….tendon encroachment.
Intraarticular calcaneal fractures result in lateral wall blowout, resulting in subfibular impingement and peroneal tendon encroachment.
91
Indications for open reduction with internal fixation (ORIF) in intraarticular calcaneal fractures?
posterior facet fracture displacement greater than 2 to 3 mm, flattening of Böhler angle, varus malalignment of tuberosity
92
what at risk during placement of screws from lateral to medial— specifically at the level of the sustentaculum (constant fragment)
FHL
93
which patient tyoes have better outcome with ORIF?
flatter Böhler angle, age younger than 29 years, women, and those not involved in workers’ compensation, non smokers,have improved clinical outcomes with surgical compared to nonoperative management.
94
treatment of post traumatic subtalar arthritis?
subtalar arthrodesis
95
In cases with significant loss of calcaneal height, horizontal talus, and resultant anterior ankle pain,?
bone-block distraction arthrodesis of the subtalar joint is required.
96
Subtalar dislocations are most commonly
medial
97
The most common obstacles to reduction of a medial dislocation are
extensor digitorum brevis, the extensor retinaculum, and the peroneal tendons
98
Most common obstacles to reduction of a lateral dislocation are
interposed posterior tibial tendon and FHL tendon.
99
Lauge-Hansen classification system notes
the position of the ankle first, and the injury motion of the ankle relative to the leg second.
100
Bosworth fracture-dislocations
posterior dislocation of the fibula relative to the tibial incisura; require operative reduction
101
Posterolateral fibular antiglide plates are
biomechanically superior to lateral plates but cause increased peroneal irritation
102
Medial buttress plate required for fixation of
vertical medial malleolus fracture
103
mx of pilon frcatures?
SPAN SCAN PLAN delayed fixation, ORIF or TSF

FRCS Orthopaedics (7 decks)

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