[3] Hallux Valgus Flashcards
What is hallus valgus commonly termed?
Bunion
What is hallux valgus?
A deformity at the first metatarsophalangeal joint
What is hallux valgus characterised by?
Medial deviation of the first metatarsal and lateral deviation with or without rotation of the hallux, associated with joint subluxation
How common in hallux valgus?
One of the most common foot problems in adult population, with a prevalence of around 35% in those aged >65 years
Which gender is hallux valgus more common in?
Women
What should happen to the digits during the gait cycle?
They should remain parallel to the long axis of the foot
What makes it possible for the digits to remain parallel to the long axis of the foot during the gait cycle?
Balance between static stabilisers and dynamic stabilisers
What are the static stabilisers in the foot?
Bones and ligaments
What are the dynamic stabilisers in the foot?
Muscles and tendonsq
What is the result of the gross anatomy on the foot on the first metatarsal?
It means the first metatarsal is inherently unstable, heavily relying on the stabilising structures
What is the result on the heavy reliance of the first metatarsal on other structures for stability?
There is a greater risk of disturbing the fine balance
What happens once the metatarsal head escapes the intrinsic anatomical control?
The extrinsic tendons become a deforming force, causing the first metatarsal head to drift medially
What does the medial joint tension cause when the metatarsal head escapes intrinsic anatomical control cause?
The bone to proliferate on the dorsomedial aspect of the head of the first metatarsal, with the cartilage being affected by the subsequent remodelling
What factors can further contribute to hallux valgus?
Anatomical variants
Genetic predisposition
Environmental factors
What footwear can contribute to hallux valgus in predisposed individuals?
Wearing high-heeled or narrow-fitting footwear
Why can high-heeled or narrow fitting footwear contribute to hallux valgus?
It keeps the hallux in a valgus position
What are the main risk factors for developing hallux valgus?
Female
Connective tissue disorders
Hypermobility syndromes
What anatomical variants predispose to the development of hallux valgus?
Long first metatarsal bone
Malalignment of the first MTP
Flat feet
How does hallux valgus typically present?
Painful medial prominence
What is likely to aggravate the painful medial prominence in hallux valgus?
Walking
Weight-bearing activities
Wearing narrow toed shoes
Describe likely symptom progression in hallux valgus
Symptoms have often been present for some time before progression, however have worsened in frequency and intensity
What should be assessed on examination in hallux valgus?
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
What is the importance of checking for movement and crepitus in hallux valgus?
The presence of associated pain and crepitation is indicative of cartilage degeneration
What might be visible on examination in long-standing joint sublaxation?
Contracture of the extensor hallicus longus
What might excessive keratosis on the foot indicate in hallux valgus?
Signs of abnormal weight distribution from an altered gait
What is a normal range of movement of the foot?
5mm in both the dorsal and plantar direction from the neutral, with no motion detectable in the transverse plane
What are the differential diagnoses for hallux valgus?
Gout Septic arthritis Hallux rigidus Osteoarthritis Rheumatoid arthritis
What is the main investigation in hallux valgus?
Radiographic imaging
What useful information can be obtained from radiographic imaging in hallux valgus?
Determine degree of lateral deviation
See signs of joint sublaxation
How is lateral deviation measured on radiographic imaging?
As the angle between the first metatarsal and the first proximal phalanx
What degree of lateral deviation on radiographic imaging is diagnostic of hallux valgus?
Greater than 15 degrees
What degree of lateral deviation on radiographic imaging is considered to be mild hallux valgus?
15-20 degrees
What degree of lateral deviation on radiographic imaging is considered to be moderate hallux valgus?
21-39 degrees
What degree of lateral deviation on radiographic imaging is considered to be severe hallux valgus?
> 40 degrees
What is involved in the conservative management of hallux valgus?
Prescription of sufficient analgesia
Adjustment of footwear
Physiotherapy
What is the purpose of analgesia in hallux valgus?
To limit the effects of the condition on QoL
What is the purpose of the adjustment of footwear in hallux valgus?
Prevent worsening of deformity
Prevent irritation of the skin over the medial eminence
When might an orthosis be useful in hallux valgus?
If the patient is has flat feet, then an orthosis may help to prevent the progression of the condition
What is done in physiotherapy for hallux valgus?
Stretching exercises
Gait re-education
Which hallux valgus patients should be considered for surgical intervention?
Those whose quality of life is significantly impacted by the condition
What surgical procedures can be used in the management of hallux valgus?
Chevron procedure
Scarf procedure
Lapidus procedure
Keller procedure
What happens in a chevron procedure?
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
What is a chevron procedure commonly used for?
Mild deformities
What happens in a scarf procedure?
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
What is a scarf procedure commonly used for?
Moderate to severe deformity
What happens in a lapidus procedure?
The base of the 1st metatarsal and medial cuneiform are fused
When is a lapidus procedure commonly used?
When the underlying cause is tarsometatarsal joint hypermobility
What happens in a Keller procedure?
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
When is a keller procedure commonly used?
When first MTPJ arthritis is severe
What are the potential surgical complications of procedures used for hallux valgus?
Wound infection
Delayed healing
Nerve injury
Osteomyelitis
What are the complications of hallux valgus?
Avascular necrosis
Non-union
Displacement
Reduced ROM
What is the prognosis of hallux valgus?
Variable, as the deformity may remain stable, or progress rapidly
What is the role of conservative management in hallux valgus?
It may alleviate symptoms, but will never correct the deformity
