[3] Hallux Valgus

Question 1

What is hallus valgus commonly termed?

Answer 1

Bunion

Question 2

What is hallux valgus?

Answer 2

A deformity at the first metatarsophalangeal joint

Question 3

What is hallux valgus characterised by?

Answer 3

Medial deviation of the first metatarsal and lateral deviation with or without rotation of the hallux, associated with joint subluxation

Question 4

How common in hallux valgus?

Answer 4

One of the most common foot problems in adult population, with a prevalence of around 35% in those aged >65 years

Question 5

Which gender is hallux valgus more common in?

Answer 5

Women

Question 6

What should happen to the digits during the gait cycle?

Answer 6

They should remain parallel to the long axis of the foot

Question 7

What makes it possible for the digits to remain parallel to the long axis of the foot during the gait cycle?

Answer 7

Balance between static stabilisers and dynamic stabilisers

Question 8

What are the static stabilisers in the foot?

Answer 8

Bones and ligaments

Question 9

What are the dynamic stabilisers in the foot?

Answer 9

Muscles and tendonsq

Question 10

What is the result of the gross anatomy on the foot on the first metatarsal?

Answer 10

It means the first metatarsal is inherently unstable, heavily relying on the stabilising structures

Question 11

What is the result on the heavy reliance of the first metatarsal on other structures for stability?

Answer 11

There is a greater risk of disturbing the fine balance

Question 12

What happens once the metatarsal head escapes the intrinsic anatomical control?

Answer 12

The extrinsic tendons become a deforming force, causing the first metatarsal head to drift medially

Question 13

What does the medial joint tension cause when the metatarsal head escapes intrinsic anatomical control cause?

Answer 13

The bone to proliferate on the dorsomedial aspect of the head of the first metatarsal, with the cartilage being affected by the subsequent remodelling

Question 14

What factors can further contribute to hallux valgus?

Answer 14

Anatomical variants
Genetic predisposition
Environmental factors

Question 15

What footwear can contribute to hallux valgus in predisposed individuals?

Answer 15

Wearing high-heeled or narrow-fitting footwear

Question 16

Why can high-heeled or narrow fitting footwear contribute to hallux valgus?

Answer 16

It keeps the hallux in a valgus position

Question 17

What are the main risk factors for developing hallux valgus?

Answer 17

Female
Connective tissue disorders
Hypermobility syndromes

Question 18

What anatomical variants predispose to the development of hallux valgus?

Answer 18

Long first metatarsal bone
Malalignment of the first MTP
Flat feet

Question 19

How does hallux valgus typically present?

Answer 19

Painful medial prominence

Question 20

What is likely to aggravate the painful medial prominence in hallux valgus?

Answer 20

Walking
Weight-bearing activities
Wearing narrow toed shoes

Question 21

Describe likely symptom progression in hallux valgus

Answer 21

Symptoms have often been present for some time before progression, however have worsened in frequency and intensity

Question 22

What should be assessed on examination in hallux valgus?

Answer 22

Assess position and lateral deviation of the hallux
Check for evidence of inflammation or skin breakdown over the prominence at the base of the hallux
Check for worsening of the prominence in the weight-bearing position
Assess range of movement (active and passive) and crepitus

Question 23

What is the importance of checking for movement and crepitus in hallux valgus?

Answer 23

The presence of associated pain and crepitation is indicative of cartilage degeneration

Question 24

What might be visible on examination in long-standing joint sublaxation?

Answer 24

Contracture of the extensor hallicus longus

Question 25

What might excessive keratosis on the foot indicate in hallux valgus?

Answer 25

Signs of abnormal weight distribution from an altered gait

Question 26

What is a normal range of movement of the foot?

Answer 26

5mm in both the dorsal and plantar direction from the neutral, with no motion detectable in the transverse plane

Question 27

What are the differential diagnoses for hallux valgus?

Answer 27

``` Gout Septic arthritis Hallux rigidus Osteoarthritis Rheumatoid arthritis ```

Question 28

What is the main investigation in hallux valgus?

Answer 28

Radiographic imaging

Question 29

What useful information can be obtained from radiographic imaging in hallux valgus?

Answer 29

Determine degree of lateral deviation | See signs of joint sublaxation

Question 30

How is lateral deviation measured on radiographic imaging?

Answer 30

As the angle between the first metatarsal and the first proximal phalanx

Question 31

What degree of lateral deviation on radiographic imaging is diagnostic of hallux valgus?

Answer 31

Greater than 15 degrees

Question 32

What degree of lateral deviation on radiographic imaging is considered to be mild hallux valgus?

Answer 32

15-20 degrees

Question 33

What degree of lateral deviation on radiographic imaging is considered to be moderate hallux valgus?

Answer 33

21-39 degrees

Question 34

What degree of lateral deviation on radiographic imaging is considered to be severe hallux valgus?

Answer 34

>40 degrees

Question 35

What is involved in the conservative management of hallux valgus?

Answer 35

Prescription of sufficient analgesia Adjustment of footwear Physiotherapy

Question 36

What is the purpose of analgesia in hallux valgus?

Answer 36

To limit the effects of the condition on QoL

Question 37

What is the purpose of the adjustment of footwear in hallux valgus?

Answer 37

Prevent worsening of deformity | Prevent irritation of the skin over the medial eminence

Question 38

When might an orthosis be useful in hallux valgus?

Answer 38

If the patient is has flat feet, then an orthosis may help to prevent the progression of the condition

Question 39

What is done in physiotherapy for hallux valgus?

Answer 39

Stretching exercises | Gait re-education

Question 40

Which hallux valgus patients should be considered for surgical intervention?

Answer 40

Those whose quality of life is significantly impacted by the condition

Question 41

What surgical procedures can be used in the management of hallux valgus?

Answer 41

Chevron procedure Scarf procedure Lapidus procedure Keller procedure

Question 42

What happens in a chevron procedure?

Answer 42

A 'V shaped' osteotomy of the distal first metatarsal is created, allowing the first metatarsal to be shifted laterally back into a normal alignment, then fixed by pins and screws

Question 43

What is a chevron procedure commonly used for?

Answer 43

Mild deformities

Question 44

What happens in a scarf procedure?

Answer 44

A longitudinal osteotomy is made within the shaft of the first metatarsal, for the distal portion to be moved laterally and fixed with two screws

Question 45

What is a scarf procedure commonly used for?

Answer 45

Moderate to severe deformity

Question 46

What happens in a lapidus procedure?

Answer 46

The base of the 1st metatarsal and medial cuneiform are fused

Question 47

When is a lapidus procedure commonly used?

Answer 47

When the underlying cause is tarsometatarsal joint hypermobility

Question 48

What happens in a Keller procedure?

Answer 48

An incision is made over the first MTPJ and the joint capsule is opened to expose the joint, with the disease joint surfaces being removed for a space to be left that is stabilised by suturing of surrounding tissues and subsequent scar tissue

Question 49

When is a keller procedure commonly used?

Answer 49

When first MTPJ arthritis is severe

Question 50

What are the potential surgical complications of procedures used for hallux valgus?

Answer 50

Wound infection Delayed healing Nerve injury Osteomyelitis

Question 51

What are the complications of hallux valgus?

Answer 51

Avascular necrosis Non-union Displacement Reduced ROM

Question 52

What is the prognosis of hallux valgus?

Answer 52

Variable, as the deformity may remain stable, or progress rapidly

Question 53

What is the role of conservative management in hallux valgus?

Answer 53

It may alleviate symptoms, but will never correct the deformity