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Foot and Ankle FRCS > Neurological > Flashcards

Flashcards in Neurological Deck (37):
1

What is Poliomyelitis?

  • VIRAL DESTRUCTION OF THE ANTERIOR HORN CELLS IN THE SPINAL CORD AND BRAIN STEM MOTOR NUCLEI

  • Hallmark
    • MOTOR WEAKNESS with NORMAL SENSATION

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2

What is polio's clinical features ?

  • MOTOR WEAKNESS NORMAL SENSATION
  • Flaccid, Asymmetrical Muscle weakness
  • Flexion, abduction contracture hip
  • Flexure contracture knee, valgus deformity and genorecurvatum
  • ankle -equinus, foot- valgus/varus

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3

What is the epidemiology of polio?

  • Present in developing countries- WHO tried to erradicate it in 2006 endemic in 6 countried
  • Eliminated in US and UK due to vaccination

4

What is its treatment of polio foot deformities?

non operative

  • lightweight orthosis
    • first line
    • Help pt maintain functional independence

Surgery

  • Contracture release,  Tendon transfer,  Arthrodesis
    • if orthosis not achieving satifiactory ADL's

5

Name associated conditions of Polio? What is it?

  • Post Polio Syndrome
  • AN aging phenomenon when more nerve cells become inactive with time.
  • Characterised by Muscle weakness, myalgia & fatigue
  • Doesn't represent reactivation of virus
  • Occurs in middle age (20-40 yrs after inital infection)
  • Occurs in up to 50% cases of polio
  • Leads to difficulties of ADL
  • Patients should exercise at sub-exhaustion levels to tone affected muscles groups without causing muscle breakdown

6

What is post polio syndrome tx?

Non operative

  • Limited exercise with periods of rest and lightweight orthosis
    • first line of tx
    • Maintain but not overuse muscles

Operative

  • Tendon transfers, contracture releases & arthrodesis
  • To optimise funcitonal capacity

7

Define Tarsal Tunnel syndrome?

  • Compression neuropathy caused by compression of TIBIAL nerve

8

What is the aetiology of tarsal tunnel syndrome?

  • Intrinsic
    • Ganglionic cyst
    • Tendonopathy
    • Tenosynovitis
    • Lipoma/tumour
    • Peri-neural fibrosis
    • Osteophytes
  • Extrinsic
    • Shoes
    • Trauma
    • Anatomical deformity- tarsal coalition/valgus hindfoot
    • Systemic inflammatory disease
    • Oedema of the lower extremity
  • IN 80% cases no cause for compression is found

9

Describe the prognosis of tarsal tunnel syndrome?

  • Result vary between 50-90%
  • Worse results with 'Double crush injury' and post operative scarring
  • Revision surgery less successful than index operation

10

Define the anatomy of the tarsal tunnel?

Anatomy defined by

  • Flexor retinaculum- Lacinate ligament
  • Calcaneus - medial
  • Talus- medial
  • Adbuctor hallucis- inferior

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11

What is in the tarsal tunnel?

  • Tibial Nerve- posterior
  • Posterior tibial artery
  • FHL tendon
  • FDL tendon
  • tibialis posterior tendon

12

What does the tibial nerve divide into?

  • Medial plantar
  • Lateral Plantar
  • Medical Calcaneal
  • The medial and lateral plantar nerves can be compressed  in their own sheaths, distal to tarsal tunnel
  • Bifurcation of tibial nerve in 5% cases occurs proximal to tarsal tunnel

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13

Describe the signs and symptoms of tarsal tunnel syndrome?

Hx of previous trauma/ surgery

Symptoms

  • Pain with prolonged standing/walking
  • Often vague medial foot pain
  • Sharp burning pains in foot
  • Intermittent numbness in plantar of foot

Signs

  • Tenderness of tibial n- Tinel's sign
  • Pes planus
  • Muscle wasting of foot instrinsics- abductor digit quntini, or abductor hallucis
  • Pain with dorsiflexion & eversion of ankle
  • Compression test
    • compression over tarsal tunnel= pain - sensitive and specific
    • Compression with plantarflexion & inversion

14

What investigations are helpful to aid diagnosis of tarsal tunnel syndrome?

  • Weight bearing radiographs- osseoud
  • MRI
    • exclude accessoty muscle/ soft tissue tumour
  • EMG
    • positive finding
    • distal motor latencies of >7.0ms
    • prolonged sensory latencies of >2.3msec
    • Sensory more likely abnormal cf motor
    • Decreased amplitude of motor action potentials of abductor hallucis or abductor digiti minimi

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15

What is the treatment of tarsal tunnel syndrome?

  • Non operative
    • Lifestyle modifications. medications
      • usually ineffective
      • NSAIDS/ SSRIs
      • Bracing
        • orthosis/ foot wear changes to adress aligment of hindfoot
        • try a period of short leg cast
  • Operative
    • Surgical Release of Tarsal Tunnel
      • 3-6 months after failed consx
      • compressive mass identified
      • reproducible findings
      • best outcomes- where a compressing anatomic stricture ganglionic cyst is identified and removed

16

Describe how would you release the tarsal tunnel?

  • 2 inicsion - medial ankle and medical foot
  • Identify the nerve proximally
  • Release these layers- 

17

What is the aetiology of deep peroneal nerve entrapment?

  • Impingement of DPN by distal margin of INFERIOR EXTENSOR mechanism
  • Also
  • Dorsal osteophytes over apex of medial longitudinal arch
  • Ganglionic cyst
  • Tight laces or ski boots
  • aka anterior TARSAL TUNNEL syndrome

18

What does the anterior tarsal tunnel contain?

  • Extensor digitorium Longus
  • Extensor hallucis longus
  • Tibialis anterior
  • deep peroneal nerve
  • Dorsalis pedis artery

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19

What are the signs and symtpoms of anterior tarsal tunnel?

Symptoms

  • Dysesthesia & parathesias of dorsum of foot & 1st web space
  • Vague foot pain

Signs

  • Tinel sign with symptoms in first web space

20

What are the tx for Anterior tarsal tunnel?

  • Non operative
    • Shoe Modification
    • First line
    • Well padded tongue of shoe
    • Full length rocker -sole steel shank
  • Operative
    • Surgical release of DPN by releasing retinaculum & ostephyte/ ganglion resection
      • failure of non op tx
    • symptoms of RSD are CI to release
    • Start distal, idenify nerve and release Proximally- nerve lateral to EHB
    • warn pt recovery is prolonged

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21

What is the cause of Ilioinguinal nerve entrapment?

What signs and symptoms of ilioinguinal entrapment?

  • Hypertophied abdominal muscles- result of intensive training

 

  • Symptoms
    • Hyperesthesia is common
    • Pain worse with hip hyperextension

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22

What is the tx of Ilioinguinal nerve entrapment?

  • Non operative
    • lifestyle modification
  • Operative
    • failed consx
    • Surgical release

23

What is the epidemiology and symptoms of Obturator nerve entrapment?

  • Common in skaters with well developed adductors
  • Chronic medial thigh pain

24

What investigations are useful in Ilioinguinal nerve entrapment?

What is the tx of Ilioinguinal nerve entrapment?

  • Nerve conduction studies

 

  • Tx
  • Conservative= Supportive

25

What are the symptoms of lateral femoral cutaneous nerve of the thigh entrapment?

  • Pain on lateral aspect of thigh
  • MERALGIA PAESTHETICA

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26

What is exacerbates the pain in lateral femoral cutaneous nerve of the thigh entrapment?

  • Tight belts and prolonged hip flexion

27

Describe the tx in lateral femoral cutaneous nerve of the thigh entrapment?

  • Non operative
    • PT, NSAIDS
      • postural excercises
      • release of compressive devices

28

Where is the sciatic nerve often entraped?

  • Any where along its length
  • Common= Level of ischial tuberosity
  • At piriformis muscle= pirifomis syndrome

29

What is Saphenous neuritis?

  • Compression of saphenous nerve
  • Usually at Hunter's canal
  • aka Surfer's neuropathy

Hunter's canal- aponeurotic canal extending from femoral triangle to addcuctor hiatus ( adductor magnus)

Anteriorly - Sartorius

Psoterior Medial - Adductor longus & adductor magnus

Laterally- vastus medialis

Superior- Inguinal ligament

 

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30

What is and define the anatomy of Hunter's canal?

  • Hunter's canal- aponeurotic canal extending from femoral triangle to addcuctor hiatus ( adductor magnus)

Boundaries

  • Anteriorly - Sartorius
  • Posterior Medial - Adductor longus & adductor magnus
  • Laterally- vastus medialis
  • Superior- Inguinal ligament

 

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31

What are the symptoms of saphenous neuritis?

How is it treated?

  • Pain inferior & medial to knee

 

Tx

  • Non operative
    • Knee pads- forst line of tx

32

Wher can the common peroneal nerve be compressed?

  • Behind fibula by ganglionic cyst or directed by trauma
  • fusion of proximal tibiofibulr joint may be required to prevent recurrence
  • PC- foot drop- inability to dorsiflex & evert foot
  • loss of sensation dorsum foot

33

What is the cause of superifical peroneal nerve compression?

  • Fascia defect- usually 12cm proximal to lateral malleolus where it exits the fascia of the anterolateral leg
  • Mechanisms include
    • Inversion injuty
    • Fascial defect

34

What are the symptoms of patient with superfical peroneal nerve compression?

What is the tx?

  • Sensation= Numbness & tingling over dorsum of foot, SPARING of 1st web space 
  • This worsens with Plantar flexion and Inversion of foot 

TX

  • Non operative
    • Observe
  • Operative
    • Fascial release
    • May be indicated in refractory cases

35

What is the cause of Lateral planar nerve compression?

How is it treated?

  • Compression of First branch of lateral plantar nerve - BAXTER's nerve - branch to abductor digiti quinti
  • Common nerve compression in runners
  • Medial heel pain- nerve travels across heel anterior to medial tuberosity of calcaneus
  • Chronic heel pain -similar to plantar fascitis
  • compression between fascia of ABDUCTOR HALLUCIS LONGUS and medial side of QUADRATUS PLANTAE

Tx

  • Operative
    • ​Surgical release of Abductor hallucis fascia

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36

Where does the medial plantar nerve get compressed?

What is the TX?

  • At the knot of Henry
    • where FDL and FHL cross
  • Most common cause of compression is foot orthotics

Tx

Non operative

  • Discontinue orthotics

 

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37

Where does the sural nerve get entraped?

What does tx involve?

  • Anywhere along course
  • Most vunerable 12-15mm distal to tip of fibula as foot rests in equius position
  • Tx
    • Surgical release