Flashcards in The Ankle & Foot Deck (31):
What type of joint is the ankle joint?
What are the articulations?
Hinge synovial joint
(Mortise and tenon joint)
The tibia and fibula distally form a bracket shaped socket 'mortise'
The body of the talus fits snugly in to the mortise 'tenon'
The talus is wedge-shaped
How many articulations are between the tibia and fibula?
What are these articulations?
Proximal - tibial-fibular articulation
Intermediate - interosseous membrane
Distal - tibio-fibular syndesmosis (the ligaments form a syndesmosis) - anterior inferior tibial-fibular ligament
What are the ligaments of the ankle joint?
Deltoid (medial) ligament - attached to the medial malleolus - resists over-eversion
The deep deltoid ligament prevents talar shift
Lateral ligament -originates from the lateral malleus - three separate ligaments (anterior, posterior talofibular, calcaneofibular) - resists over-inversion
The anterior talofibular ligament is the most commonly injured
What are the three arches of the foot?
Medial longitudinal arch - higher than the lateral arch
Lateral longitudinal arch
What makes up the medial longitudinal arch of the foot?
Calcaneus, talus, navicular, cuneiforms, 1st, 2nd and 3rd metatarsals
Supported by tibialis anterior and posterior, plantar ligaments and aponeurosis
What makes up the lateral longitudinal arch of the foot?
Calcaneous, cuboid, 4th and 5th metatarsals
Supported by FDL, flexor hallucis, plantar ligaments and aponeurosis
What makes up the transverse arch of the foot?
Occurs from articulations of tarsal with metatarsals
What type of fracture is a Pott's fracture?
When does this type of fracture occur?
What is the course of events?
1. Forced eversion pulls on the medial ligaments producing an avulsion fracture of the medial malleolus
2. The talus moved laterally, breaking off the lateral malleolus
3. The tibia moves anteriorly and its distal end is sheared off by the talus
In a severe sprain of the ankle, why is it not uncommon to find that the patient has an avulsion of the fifth metatarsal tuberosity?
The fibularis brevis tendon is attached to the tuberosity of the fifth metatarsals
What are the limits of inversion and eversion at the sub-talar joint?
30 degrees of inversion
15 degrees of eversion
Inversion and eversion takes place at the subtalar joint - allows us to walk on uneven surfaces
Why does the foot in a child appear to be flat?
The arches have not developed fully and also due to the presence of subcutaneous adipose in the tissue of the foot
What is meant by plantar fasciitis?
Inflammation of the plantar fascia
Common cause of pain in the heel - any injury is usually at the site where the fascia attaches to the heel (~4cm from the heel)
Worse first thing in the morning, described like walking on to a pin/needle
What is the management of plantar fasciitis?
Footwear - 1cm heel pads -they shift the weight off the heel to be more evenly distributed
Steroid injections - by can lead to fat pad atrophy
What is meant by hallux valgus?
Bony growth of the metatarsal head
Valgus deformity of the phalanx with varus deformity of the metatarsal
The sesamoids are displaced laterally
More common in women, exacerbated by heels
What are the management options of hallux valgus?
Surgical correction - indicated with severe pain and second toe symptoms due to the shift of weight when bearing
What is meant by hallux rigidus?
Osteoarthritis at the first MTPJ
Can present as a lump or bulge over the joint
Painful with reduced range of movement
What is meant by club foot?
What are the possible causes?
This means the ankle is pointing downwards and the feet are turned inwards (inversion and plantarflexion
Positioning in uterus, idiopathic, teratological associated with spina bifida and cerebral palsy
What is meant by pes cavus?
Unusually high medial longitudinal arch. There is decreased shock absorption when walking
It can be idiopathic, congenital eg club foot
Use of insoles to help with the distribution of weight
What is meant by pes plantus?
Flat feet - loss of medial longitudinal arch
Valgus deformity of the hindfoot
Abduction of the forefoot - too many toes sign
The most common acquired cause in adults in posterior tibial tendon insufficiency
What is meant by a Lisfranc injury?
Disruption between the articulation of the medial cuneiform and the base of the second metatarsal
What is meant by a Morton's neuroma?
How does it present clinically?
Benign neuroma of the intermetatarsal plantar nerve
Commonly between the third and four MT or second and third
More common in women
Forefoot pain/burning/shooting/ worse with walking
What is the Danis-Weber classification of ankle fractures?
Type A - fibular fracture below the syndesmosis
Type B - fibular fracture at the level of the syndesmosis
Type C - fibular fracture above the level of the syndesmosis - most unstable, usually accompanied with talar shift - ORIF
What is the cutaneous innervation to the foot?
Deep fibular nerve - skin between the first two toes
Superficial fibular nerve - dorsum of the foot
Medial and lateral plantar nerves - plantar surface of the foot
Medial calcaneal branch - skin over the heel
What is meant by a Maisonneuve fracture?
Fracture of the medial malleolus, complete tear of the interosseous membrane, and proximal fibular fracture
Widening of the joint
Requires surgical fixation
What is the UHL pathway for ankle fracture?
Stable (lateral malleolus #, Weber B, undisplaced, - nurse led stable ankle pathway, complete cast at 48hours, allow WB, repeat X-ray and full cast
Unstable (medial malleolus #, Weber C, talar shift, - options: gravity stress view: moulded cast, NWB, X-ray: surgical fixation
What is meant by a tri-malleolar fracture?
Fracture of the medial and lateral malleoli
In addition to the posterior malleolus - back of the tibia - avulsion by the posterior tibiofibular ligament
What is meant by hammer toe?
What are the management options?
flexion of PIPJs with extension of the DIPJs
Non-Op: shoes with high toe boxes, foam or silicon gel sleeves
Surgical: tendon release/tranfers
What is meant by claw toe?
What are the management options?
MTPJ hyperextension with PIPJ and DIPJ flexion
Causes include: Charcot's joint, Stroke, Cerebral palsy
Taping and shoe modification are first line. Various different surgical options targeting the affected tendons
What is meant by mallet toe?
What are the treatment options?
Flexion of the DIPJ
Normal PIPJ and MTPJ
Non-op: shoes with high toe boxes, gel sleeves
Surgical fixation options
What are the Ottawa rules?
For x-raying suspected ankle fractures
Pain in the malleolar region and one of the following:
Bony tenderness over the medial malleolus
Bony tenderness over the lateral malleolus
Unable to weight bear four steps at the time of injury and now