Trauma and orthopaedics (1): Foot and ankle

Question 1

bones of the foot

Answer 1

DO purpose games

Question 2

three arches of the of

Answer 2

medial longitudinal arch

lateral longitudinal arch

transverse arch

Question 3

joints of the foot and ankle

Answer 3

ankle joint

subtalar joint

Question 4

ankle joint allows for

Answer 4

• mortis joint (talus sits within tibia- very stable)
  
  • hinge joint
• plantar flexion and dorsiflexion
• formed by the articulation of the talus, tibia, and fibula bones.
• ligaments v important for stability

Question 5

subtalar joint allows for

Answer 5

inversion/eversion

Question 6

syndesmosis

Answer 6

strong ligamentous joint between the tibia and fibula

Question 7

plantarflexion vs dorsiflexion

Answer 7

§

Question 8

inversion vs eversion

Answer 8

Question 9

Foot can be divided into 3 regions:

Answer 9

• Hindfoot talus and calcaneus
• Midfoot navicular, cuboid and cuneiforms
• Forefoot metatarsals and phalanges

Question 10

stability of the ankle joint created by

Answer 10

1. Bone
2. Joint capsule
3. Ligament
4. Muscle

Question 11

ankle stability: bone

Answer 11

• Transmits the weight of the body to the foot and has three articulations
  
  • Superiorly- ankle joint between the talus, tibia and fibula
    
    • syndesmosis between fibula and tibia
  • Inferiorly- subtalor joint, between the talus and calcaneus
  • Anteriorly- talonavicular joint between the talus and navicular
• Trochlear of the talus articulates with the tibia and fibula
  
  • Wider anteriorly
  • Provides stability in a dorsiflexed ankle

Question 12

stability of the ankle joint: msucle

Answer 12

Muscles wrap around the metatarsals and onto the medial aspect like a stirrup

Question 13

stability of the ankle joint: capsule

Answer 13

The joint capsule anteriorly is a broad, thin, fibrous layer, posteriorly the fibres are thin and run mainly transversely blending with the transverse ligament and laterally the capsule is thickened, and attaches to the hollow on the medial surface of the lateral malleolus. The synovial membrane extends superiorly between Tibia & Fibula as far as the Interosseous Tibiofibular Ligament

It forms the seal that contains the synovial fluid within the joint, imparts passive stability by limiting joint movement, and provides active stability via its proprioceptive nerve endings.

Question 14

what sort of joint is the ankle

Answer 14

hinge- movement only in one plane

Question 15

stability of the ankle: ligaments

Answer 15

• All hinge joints possess collateral ligaments for stability
• Ligaments act as thickenings of the joint capsule
• Keep movement in one plane and prevent hyperplantar and hyper dorsiflexion as well as hyperinvesion and hyper extension

Question 16

neurovascular supply to the foot

Answer 16

do a purpose games

Question 17

hallux valgus

Answer 17

‘bunion’

a deformity at the first metatarsophalangeal joint(MTPJ).

Question 18

cause of hallux valgus deformity

Answer 18

It is characterised by medial deviation of the first metatarsal and lateral deviation +/- rotation of the hallux, with associated joint subluxation.

Question 19

Risk factors for hallux valgus

Answer 19

• female
• connective tissue disorder
• hyper-mobility syndromes
• high-heels or narrow fitting footwear

Question 20

presentation of hallux valgus

Answer 20

• painful medial prominence
• aggravated by
  
  • walking
  • weight bearing
• lateral deviation of hallux
• evidence of inflammation

Question 21

DD for hallux valgus

Answer 21

• Gout
• Septic arthritis
• Hallux rigidus
• Osteoarthritis
• Rheumatoid arthritis

Question 22

investigation for hallux valgus

Answer 22

x-ray

to look for degree of lateral deviation and joint subluxation

diagnosis:

hallux valgus is diagnosed if the angle to be corrected is greater than 15 degrees (mild 15-20°, moderate 21–39°, and severe >40°)

Question 23

management of hallux valgus

Answer 23

conservative

• sufficient analgesia
• adjust footwear
• orthosis
• physiotherapy

surgery (for poor quality of life)

Question 24

complications of hallux valgus

Answer 24

Complications of hallux valgus include avascular necrosis, non-union, displacement and reduced ROM.

Prognosis is variable in this condition as the deformity may remain stable or progress rapidly. Conservative management can help to alleviate symptoms but will never correct the deformity.

Question 25

achilles tenonditis

Answer 25

**inflammation** of the Achilles (calcaneal) tendon

Question 26

pathophysiology of achilles tendonitis

Answer 26

Achilles tendon unites the **gastrocnemius**, **soleus**, and **plantaris muscles**. It inserts in to the **calcaneus**and produces **plantarflexion** **of the ankle**. **Repetitive action** of the tendon results in **microtears** leading to localised inflammation. Over time the tendon becomes thickened, fibrotic, and loses elasticity with **repeated episodes**.

Question 27

**Achilles tendon rupture** occurs when

Answer 27

a substantial **sudden force** is applied across the tendon, often in the context of existing Achilles tendonitis. The **precipitating event** could be a movement such as a sudden jump or rapid change in direction whilst running.

Question 28

RF for achilles tenonditis

Answer 28

* **unfit individual** who has a **sudden increase** in exercise frequency. * **poor footwear choice** * **male** **gender** * **obesity** * recent ciprofloxacin **use** (for tendon rupture).

Question 29

presentation of tenodnitits

Answer 29

**gradual onset of pain** and stiffness in the posterior ankle, often **worse with movement**. This can usually be improved with mild exercise or heat application. On examination, there is **tenderness** over the tendon on palpation (usually worse 2-6cm above its insertion site), with pressure over the tendon with your fingers reproducing this pain.

Question 30

tendon rupture

Answer 30

In cases of **tendon rupture**, patients will often describe **sudden-onset severe pain** in the posterior calf, accompanied with an **audible popping sound** and a feeling that something ‘went’. On examination, there will be a marked **loss of power** of ankle plantarflexion (the peroneal tendons contribute to plantarflexion so this movement remains, but significantly weakened). The most commonly used indicators of a clinical tendon rupture are **Simmonds test** (below) and a **palpable ‘step’** in the Achilles tendon.

Question 31

simmons test

Answer 31

With the patient kneeling on a chair, with the affected ankle hanging off the edge of the chair, squeeze the affected calf. If the Achilles tendon is in continuity, the foot will plantarflex; however, plantarflexion is absent when the tendon is ruptured

Question 32

investigation for achilles tenodnitis rupture

Answer 32

**ultrasound scan**

Question 33

management of of tendonitis

Answer 33

* stop activity * NSAIDS * ice *

Question 34

management of achilles rupture

Answer 34

**Initial management (for 2 weeks)** * analgesia and immobilisation with ankle splinted in plaster in full **equinus** (i.e. with ankle and toes maximally pointed) * crutches **after 2 weeks** * the ankle is brought in to ‘semi-equinus’, and **held for a further 4 weeks**. * After this, the ankle is brought in to the neutral position and **held again for 4 weeks**. delayed presentation (\>2 weeks)- surgery

Question 35

**Hallux rigidus**

Answer 35

**(arthritis of big toe)**

Question 36

hallux rigidus presentation

Answer 36

**Presentation:** pain in MTPJ, lump over joint

Question 37

**hallux rigidus X-ray signs:**

Answer 37

loss of joint space, osteophytes, subchondral cysts, subchondral sclerosis

Question 38

management of hallux rigidus

Answer 38

**Conservative**: orthotics, aids, painkillers, steroid injections, activity modification **Surgical treatment:** Re-align to take weight off = osteotomy Remove = excision arthroplasty Fuse= arthrodesis Replace= arthroplasty Gold standard = 1st MTP joint fusion * Create fracture * Stabilise * Allow normal bone repair

Question 39

ankle arthritis cause

Answer 39

post- ankle fracture Usually secondary: Post traumatic 70-80% Inflammatory 12% Primary OA = 7%

Question 40

management of ankle arthritis

Answer 40

**1st line:** analgesia and modify activity, limit movements **Surgery** * arthrodesis (fusion) Or * ankle replacement

Question 41

mortons neuroma

Answer 41

* Branch between digital nerves become irrigated- swelling (sensory nerve- very painful * In the intermetatarsal space (third and fourth)

Question 42

presentation of mortons neuroma

Answer 42

* Pain at front of foot * Sensation of lump in shoe * Burning, numbness or pins and needles

Question 43

investigations of mortons neuroma

Answer 43

**Investigation:** USS or MRI

Question 44

management of mortons neuroma

Answer 44

Adapting activities Analgesia Insoles Weight loss Steroid injections Radiofrequency ablation Surgery eg excision of neuroma

Question 45

**Toe deformities**

Answer 45

**Claw toe:** in balance due to neurological abnormality **Hammer toe:** idiopathic in balance/hallux valgus **Mallet toe:** idiopathic **Curly toe:** congenital

Question 46

planovalgus

Answer 46

flat foot

Question 47

flat foot common in

Answer 47

* Very common children * Female * Middle age * Issue with the posterior tibial tendon

Question 48

Presentation of flat feet

Answer 48

* Progressive deformity * History of trauma * Pain behind medial malleolus * If you look from behind you can see lots of toes

Question 49

management of flat feet

Answer 49

* Conservative * Insoles medial arch support * Physiotherapy * Operation * Reconstruction of tendon if flexible foot * Arthrodesis if stiff foot

Question 50

ankle fracture

Answer 50

An ankle fracture is a **fracture of any malleolus** (lateral, medial, or posterior), **with or without** **disruption** to the**syndesmosis**.

Question 51

descriptive terms for ankle fracture

Answer 51

* Words used to describe * **Syndesmosis**- between the tibia and fibular * **The mortis**- how the talus sits under the tibia * **Stable/unstable**- if position acceptable pt can be treated without surgery. Unstable likely to move out of place * **Posterior/medial/lateral mal- malleolus** * **Tri or bi malleolar- bi- medial and lateral , tri – posterior** (has a big chunk of the syndesmosis attached to it), medial and lateral * **Weber A/B/C**- classification of fracture * **Talar shift-** if the talus has moved

Question 52

descriptive terms for ankle fracture

Answer 52

* Words used to describe * **Syndesmosis**- between the tibia and fibular * **The mortis**- how the talus sits under the tibia * **Stable/unstable**- if position acceptable pt can be treated without surgery. Unstable likely to move out of place * **Posterior/medial/lateral mal- malleolus** * **Tri or bi malleolar- bi- medial and lateral , tri – posterior** (has a big chunk of the syndesmosis attached to it), medial and lateral * **Weber A/B/C**- classification of fracture * **Talar shift-** if the talus has moved

Question 53

description of ankle fracture

Answer 53

Crudely, they can be described as **isolated lateral malleolar fractures**, **isolated medial malleolar fractures**, **bimalleolar fractures** ( = medial + lateral malleolar fracture), and **trimalleolar fractures** ( = medial + lateral + posterior malleolar fracture).

Question 54

classification of ankle fracture

Answer 54

Weber A B C

Question 55

Weber A

Answer 55

* fracture **below the syndesmosis** (distal) * least serious * stable- no surgery required

Question 56

Weber B

Answer 56

* **at level of syndesmosis** * **more serious** * **can cause talor shift**

Question 57

Weber C

Answer 57

* above the syndesmosis * most serious * will require surgery

Question 58

the more proximal the fracture the

Answer 58

higher the likelihood of ankle instability therefore Type C fractures will almost always need **surgical fixation**

Question 59

talar shift

Answer 59

Question 60

presenation of ankle fracture

Answer 60

Patients will often present with **ankle pain** following a traumatic injury. There may be **associated deformity** in cases of fracture dislocation (which require urgent reduction). Very deformed ankles, which are common, may have **neurovascular compromise** and are often **open fractures** (typically over the medial side), so be sure to carefully check the skin integrity.

Question 61

investigation for ankle fracture

Answer 61

X-ray * AP * lateral looking at * joint space (talar shift)

Question 62

management of ankle fracture : initial

Answer 62

Initial management requires **immediate** **fracture reduction**, usually performed under sedation in the Emergency Department, to **realign the fracture** to anatomical alignment. Any patients that have with evidence of an [open fracture](https://teachmesurgery.com/orthopaedic/principles/open-fractures/) should be managed accordingly. Once reduced, the ankle should be placed in a **below knee back slab**. You must then repeat and document the **post-reduction neurovascular examination**. Request a repeat plain film radiography; if the reduction is not adequate, repeat reduction attempts are required.

Question 63

conservative management for ankle fracture opted for in

Answer 63

* **Non-displaced medial malleolus fractures** * **Weber A** **fractures** or **Weber B fractures without talar shift** * Those **unfit for surgical intervention**

Question 64

surgical manageemnt of ankle fracture

Answer 64

ORIF **Open reduction and internal fixation** (ORIF) is often required in ankle fractures to achieve stable anatomical reduction of the talus within the ankle mortise.

Question 65

**Ankle fractures** that require an ORIF include:

Answer 65

* **Displaced bimalleolar** or **trimalleolar fractures** * **Weber C fractures** * **Weber B fractures with talar shift** * **Open fractures**

Question 66

remember after performing a procedure e.g. reduction or surgery assess..

Answer 66

neurovascular function before and just after

Question 67

complications of ankle fracture

Answer 67

**post-traumatic arthritis**, DVT or PE neurovascular injury

Question 68

**Foot fractures**

Answer 68

**Lisfranc fracture** * Either torn ligaments or broken bones in mid foot area **Jones fracture** * inversion injury ie wearing high heels twists and falls * Break your 5th metatarsal (join pinky toe) **Stress fracture** * small break or crack * Typically caused by overuse * Can see a callus forming on X-ray **Calcaneal fracture** * get it from jumping from a height