6. Clinical Podiatry Flashcards
What are the clinical patterns of tinea pedis?
What are common infecting organisms?
Chronic (moccasin or papulosquamous)
- Trichophyton rubrum
Acute (interdigital or vesicular)
- Trichophyton mentagrophytes
Ulcerative
- Trichophyton mentagrophytes with Pseudomonas or Proteus
What are the clinical patterns of onychomycosis?
What are common infecting organisms?
-
Distal subungual onychomycosis (DSO) ~ 90%
- Most common
- Trichophyton rubrum
-
Proximal subungual onychomycosis (PSO) ~ 1%
- Seen in immunocompromised patients
- Trichophyton rubrum
-
Superficial white onychomycosis (SWO) ~ 10%
- Trichophyton mentagrophytes
-
Candidal onychomycosis
- Candida albicans
What test confirms tinea pedis or onychomycosis?
- Potassium hydroxide (KOH) preparation of skin or nail specimen
- *Septate hyphae confirms diagnosis
lamisil:
mechanism of action
Inhibits ergosterol synthesis
phenol:
define
Carbolic acid
during a partial nail avulsion (PNA) procedure,
why is alcohol used after phenol?
Phenol is soluble in alcohol, and
the alcohol will irrigate excess phenol from the nail groove
For a nail avulsion, what can be done for anesthesia
if the patient is allergic to all local anesthetics?
- Saline block (pressure induced block)
- Pressure cuff
- Benadryl block (blocks histamine release)
For bunion, what does the position of the tibial sesamoid indicate?
Why isn’t the fibular sesamoid evaluated?
- The tibial sesamoid indicates the abnormal effects of the adductor and flexor brevis tendons.
- Once the fibular sesamoid reaches the intermetatarsal space, it travels in the frontal plane (as opposed to transverse), therefore the tibial sesamoid is a more reliable indicator of deformity.
hallux varus causes:
- congenital
- traumatic
- iatrogenic
- Congenital
- Clubfoot
- Metatarsus adductus
- Traumatic
- MPJ dislocation
- Fracture
- Iatrogenic
- Overcorrection of intermetatarsal angle
- Excessive resection of medial eminence or staking the head
- Fibular sesamoidectomy
- Overaggressive capsulorrhaphy
- Bandaging too far into varus
what is staking the head?
(with regards to bunions)
Excessive resection of the 1st metatarsal head with cutting into the sagittal groove may lead to hallux varus
types of hammertoes
-
Flexor stabilization
- Most common
- Stance phase
- Flexors overpower interossei
- Pronated foot
-
Extensor substitution
- Swing phase
- Extensors overpower lumbricals
- Anterior cavus, ankle equinus, anterior compartment muscle weakness
-
Flexor substitution
- Least common
- Stance phase
- Deep compartment muscles overpower interossei
- Supinated, high arch foot or weakened Achilles
accidentally severing the quadratus plantae results in…
Adductovarus deformity of digits 4 and 5 as the pull of FDL is unopposed
differences between flexible, semi-rigid, and rigid deformities
- Flexible – reducible when NWB and WB
- Semi-rigid – reducible when NWB only
- Rigid – non-reducible
Haglund deformity:
pump bump;
bony enlargement on the back of the heel. The soft tissue near the Achilles tendon becomes irritated when the bony enlargement rubs against shoes. This often leads to painful bursitis, which is an inflammation of the bursa
xray measurements to evaluate a Haglund deformity
- Parallel pitch lines
- Fowler & Philip
- Total angle
Silfverskiöld test:
purpose, positive, negative
- Determines gastroc vs. gastroc-soleus
-
Positive test
- Dorsiflexion of the foot to neutral or beyond with the knee in flexion
- Gastroc equinus
- Negative test
- Lack of dorsiflexion of the foot to neutral with knee in flexion and in extension
- Gastroc-soleus equinus
Lachman test
- Determines if there is a plantar plate tear or rupture.
- While stabilizing the metatarsal, a dorsal translocation of the proximal phalanx greater than 2 mm is suggestive of rupture.
Mulder sign
Identifies a Morton neuroma by a palpable click when compressing metatarsal heads and palpating the interspace
Sullivan sign
Separation of digits caused by a mass within the interspace
(e.g. by a neuroma)
Q angle:
define
Angle between the:
- axis of the femur and the
- line between the patella and tibial tuberosity
what to do if patient has edema with a cast
- If edema goes down in AM → gravity edema → normal
- If edema does not go down in AM → abnormal
Raynaud phenomenon
Recurrent vasospasm of digits usually in response to stress or cold
Raynauds phenomenon:
stages
“White → blue → red”
- Pallor – spasm of digital arteries
- Cyanosis – deoxygenation of blood pools
- Rubor – hyperemia
what is an ABI?
Ankle Brachial Index – compares ankle to arm pressures
- Normal: 1
- Intermittent claudication: 0.6-0.8
- Rest pain: 0.4-0.6
- Ischemic ulcerations: <0.4
what might falsely elevate the
ankle brachial index (ABI)
Vessel calcifications/non-compressible vessels
What other tests are typically performed with an ABI?
-
Segment pressures
- Measured at high thigh, above the knee, below the knee, ankle, midfoot, and toe
- Normal 70-120 mm Hg
- Drop between segments >30 mm Hg indicate disease in vessel above
-
Pulse volume recordings (PVRs)
- Normal waveforms are triphasic
- Waveforms are widened and blunted with severe disease
most common type of skin cancer
Basal cell carcinoma –
found on sun-exposed parts of the body
skin cancer with “cauliflower-like” appearance
Squamous cell carcinoma
found on sun-exposed parts of the body
most common type of melanoma
Superficial spreading melanoma
found on any part of the body
most malignant skin cancer
Nodular melanoma
may be misdiagnosed as pyogenic granuloma
most benign skin cancer
Lentigo melanoma
typically found on back, arms, neck, and scalp
skin cancer typically found on the palms, soles, and nail beds?
Acral lentiginous melanoma
Hutchinson sign
Pigment changes in the eponychium seen with subungual melanoma
most common vascular proliferation
hemangioma
vascular malignancy appears as
red-blue plaques or nodules and has a high incidence in AIDS
Kaposi sarcoma
plantar fibromatosis:
associated conditions
- Ledderhose disease
- Dupuytren contracture
- Peyronie disease
another name for congenital convex pes valgus
vertical talus
congenital convex pes valgus (CCPV):
radiographic findings
- Calcaneus in equinus,
- plantarflexed talus,
- dorsally dislocated navicular,
- increased talo-calc angle
additional radiographic study recommended for
neonates with congenital convex pes valgus (CCPV) aka vertical talus
Lumbosacral films
three coalitions of the rearfoot
- talocalcaneal (TC)
- calcaneonavicular (CN)
- talonavicular (TN)
percentage of bilateral tarsal coalitions
50%
most symptomatic rearfoot coalition
calcaneonavicular (CN)
asymptomatic rearfoot coalition
talonavicular (TN)
most common rearfoot coalition to least
T-C > C-N > T-N
Which T-C facet is most commonly fused?
*Medial > anterior > posterior
What are the ages of fusion
for rearfoot coalitions?
- T-N (3-5 years)
- C-N (8-12 years)
- T-C (12-16 years)
tarsal coalitions:
clinical symptoms
- Pain
- Limited ROM of STJ and possibly MTJ
- Peroneal spastic flatfoot
tarsal coalitions:
radiographic findings
- Rounding of lateral talar process
- Talar beaking due to increased stress on talonavicular ligament
- Asymmetry of anterior subtalar facet
- Narrowing or absence of middle and posterior subtalar facets
- Halo sign – circular ring of increased trabecular pattern due to altered compressive forces
- Anteater sign – C-N coalition in which calcaneus has elongated process on lateral view
- Putter sign – T-N coalition in which neck of talus unites with broad expansion of navicular
anterior facet of calcaneus
is best seen by which radiographic views
- Medial oblique
- Ischerwood
middle and posterior facets of calcaneus
are best seen by which radiographic view?
Harris Beath
symptomatic tarsal coalitions:
treatments
- Orthotics or supportive therapy
- Immobilization
- NSAIDs
- Badgley – surgical resection of coalition or bar with interposition of muscle belly
- Isolated fusion or triple arthrodesis
clubfoot:
3 components
- FF adductus
- RF varus
- ankle equinus
clubfoot:
contracted ligaments/capsules
- Posterior
- Posterior tib-fib
- Posterior talo-fib
- Lateral calcaneofibular
- Syndesmosis
- Medial
- Superficial deltoid
- Tibionavicular
- Calcaneonavicular
- Talo-Navic, Navic-Cunei, and Cunei-1st MT joints
- Spring ligament
clubfoot:
which muscles/tendons are contracted
- Posterior
- Achilles tendon
- Plantaris tendon
- Medially
- PT, FDL, and FHL
- Abductor hallucis
- Anteriorly
- Tibialis anterior
clubfoot:
technique for treatment
Ponseti technique
- Serial casting
- First correct the FF and RF deformities, and then correct ankle equinus
- During manipulation, pressure is applied to the head of the talus (not the calcaneus)
- 4-8 casts, percutaneous Achilles tenotomy (last cast for 3 weeks), occasional TA transfer, and D-B bar brace until age 3 y/o to prevent relapse
clubfoot:
most accepted theory of etiology
Germ plasma defect-malposition of head and neck of talus
Simon Rule of 15
- For clubfoot, children <3 years → talo-navicular subluxation
- T-C angle is <15° and talo-1st metatarsal angle is >15°
