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Year 2 Clinical > Adult Foot and Ankle > Flashcards

Adult Foot and Ankle Flashcards

1
Q

Anatomy of the lateral foor and hindfoot to be aware of?

A
  • Distal fibula (lateral malleolus) and fibular shaft
  • Ankle lateral gutter and syndesmosis (joint where the tibia and fibular meet above the ankle)
  • Lateral wall of the calcaneus
  • Peronei (peroneus longus, brevus and tertius are leg muscles that originate on the fibula and insert onto the metatarsals)
  • CFl (calcaneofibular ligament) is below the medial malleolus; AFTL (anterior talofibular ligament)
  • Sural nerve (a finger breadth below the medial malleolus and it supplies the lateral foot)
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2
Q

Anatomy of the medial and hindfoot to be aware of?

A

Medial malleolus (distal end of the tibia)

Anteromedial tibiotalar joing

Deltoid ligament

PTT

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3
Q

Mnemonic to remember anatomy of the ankle tendons, from anterior to posterior, as they pass posterior to the medial malleolus, under the flexor retinaculum, in the tarsal tunnel?

A

Tom, Dick and Harry

  • Tibialis posterior
  • flexor Digitorum longus
  • flexor Hallucis longus
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4
Q

Posterior ankle and hindfoot anatomy?

A

Achilles tendon and calcaneal insertion

Retrocalcaneal space

Peroneal tendons

Flexor hallucis longus

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5
Q

Anterior ankle anatomy?

A

Anterior ankle joint

Superficial peroneal nerve (supplies sensation to the dorsum of the foot) and deep peroneal nerve (supplies the 1st interdigital cleft)

EHL and EDL

Saphenous nerve

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6
Q

Plantar ankle anatomy?

A

2nd and 5th MT bases

Tibialis posterior insertion

Master knot Henry (FDL and FHL are joined at here, so the big toe cannot be extended without the other being extended)

Cuboid tunnel

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7
Q

Which muscles should have their powers assessed, as part of the foot examination?

A

Tibialis anterior and posterior

Penroneus longus and brevis

EHL and FHL

EDL and FDL

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8
Q

Special tests in the adult foot and ankle?

A

……

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9
Q

What is pes planus?

A

Flat feet can be a normal variant, i.e: they are FLEXIBLE flat feet and form an arch when the patient tip-toes. Rigid flat feet are where the foot does not form an arch on tip-toes (this is pathological)

There may be assoc. ligamentous laxity and usually there is a familial assoc.

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10
Q

Most common cause of acquired flat foot deformity in adults?

A

Tibialis posterior dysfunction (AKA posterior tibial tendon dysfunction) which tends to occur in elderly women; it is usually present for years before the diagnosis

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11
Q

Anatomy of the tibialis posterior?

A

Courses immediately posterior to the medial malleolus and attaches to the navicular tuberosity and plantar aspect of the medial and intermediate cuneiforms

They are the primary dynamic stabilisers of the MLA (elevate the arch) and they also invert and plantarflex the foot

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12
Q

Risk factors for tibialis posterior dysfunction?

A

Obsese, middle-aged female

Increases with age

Flat fett

Hypertension, diabetes, seronegative arthropathies

Steroid injections

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13
Q

Presentation of tibialis posterior dysfunction?

A

Pain and/or swelling posterior to the medial malleolus (specific)

Change in foot shape and potentially a change in walking ability/balane; there may be a dislike of uneven surfaces

More noticeable hallux valgus

Lateral wall “impingement” pain

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14
Q

3 signs that are pathognomonic of tibialis posterior dysfunction?

A
  • Extreme heel vaglus
  • Boggy swelling
  • “Too many toes” sign on the lateral side, views from behind the foot
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15
Q

Classifications of TPD based on examination?

A

Type I - swelling, tenderness and slightly weak muscle power

Type II - planovalgus, midfoot abduction that is passively correctable

Type III and IV - fixity and mortise sign

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16
Q

Treatment of TPD?

A
  • PHYSIOTHERAPY and insoles to support the MLA
  • No steroid injections (unless florid synovitis)
  • Orthoses to accomodate foot shape; bespoke footwear
  • Surgery
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17
Q

What is pes cavus?

A

High-arched foot, often accompanied by clawing of the toes; usually, the cause if idiopathic although there may be other causes:
• Polio
• Spina bifida
• Club foot

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18
Q

Treatment of pes cavus?

A

Orthotics

If required, surgery

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19
Q

What is plantar fasciitis?

A

Inflammation of the plantar fascia that causes pain under the heel, usually beginning in the morning on the first step

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20
Q

Examination signs of plantar fasciitis?

A
  • Fullness/swelling in the plantarmedial aspect of the heel
  • Tenderness over the plantar aspect of the heel and/or plantarmedial aspect of the heel
  • Tinel’s test +ve for Baxter’s nerve (detects irritated nerves by tapping over the area)
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21
Q

Assoc. features of plantar fasciitis?

A

Heel spurs are present in many patient with the condition, although they do not cause the pain

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22
Q

Causes of plantar fasciitis?

A
  • Physical overload (excessive exercise or weight)
  • Seronegative arthropathyies, diabetes, abnormal foot shape (planovalgus or carovarus)
  • Improper footwear may be assoc.
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23
Q

Treatment of plantar fasciitis?

A

It is usually a SELF-LIMITING condition that disappears over 18-24 months

PHYSIOTHERAPY

NSAIDs, night splints, taping, heel cups/medial arch supports

Steroid injections

Occasionally, surgery

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24
Q

What is hallux valgus?

A

AKA bunion; lateral deviation of the great toe causes a valgus deformity on the 1st MTP joint

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25
Q

Occurrence of hallux valgus?

A

Increases with age and is more common in females

26
Q

Causes of hallux valgus?

A

Familial (hypermobility, joint laxity, etc)

Tight shoes

Rheumatoid arthritis

If it is bilateral, another cause should be considered

27
Q

Signs of hallux valgus?

A

Splayed forefoot with loss of muscle tone

28
Q

Consequences of hallux valgus?

A

Transfer metatarsalgia

Lesser toe impingement

Pain, deformity and cosmesis

Shoe difficulties

29
Q

Management of hallux valgus?

A

Non-operative - treat conservatively to palliate symptoms (shoe modifications and padding)

Operative - indications inc. a failure of conservative management, lesser toe deformities, lifestyle/functional limitation

30
Q

What is hallux rigidus?

A

OA of the 1st MTP joint

31
Q

Treatment of hallux rigidus?

A

Non-operative

Operative:
• Usually, fusion is used
• Joint replacement has less success

32
Q

Describe RA in the foot

A

Occurs early in the rheumatoid disease process, however it is becoming less common now

Surgery is most commonly required when it affects the forefoot

33
Q

Signs of RA in the foot?

A

Subluxed MTP joints

Hallux valgus

Clawed toes

Painful plantar calluses

Can affect the hindfoot (unstable subtalar joint allows the calcaneus to drift into the valgus; medial arch collapses and flat feet result) - often requires multiple joint fusions

34
Q

What is Morton’s neuroma?

A

Degenerative fibrosis of the digital nerve, near its bifurcation, causes forefoot pain (AKA metatarsalgia - burning and tingling in toes)

35
Q

Occurrence of Morton’s neuroma?

A

45-50 years old, usually, and it is more common in females

36
Q

Management of Morton’s neuroma?

A

Non-operative (insoles, injections)

Operative (excision)

37
Q

What is Tendo-Achilles tendinosis?

A

Repetitive microtrauma, with a failure of collagen repair, leads to loss fibre alignment/structure

A hypovascular region, proximal to the insertion point, develops

38
Q

Causes of Tendo-Achilles tendinosis?

A

Over-training

Drugs, e.g: steroids

39
Q

Symptoms of Tendo-Achilles tendinosis?

A

Pain and morning stiffness (eases with heat/walking)

40
Q

Management of Tendo-Achilles tendinosis?

A

Activity modifications/analgesia

NSAIDs

Orthotics and physiotherapy

Surgery

41
Q

Occurrence of Tendo-Achilles rupture?

A

Tends to occur >40 years, often in patients with a pre-existing tendinosis

42
Q

Symptoms of Tendo-Achilles rupture?

A

Sudden deceleration, with resisted calf contraction

Patients often describe feeling as though somebody had hit them over that area

43
Q

Examination findings of Tendo-Achilles rupture?

A

Inability to bear weight

Weak plantarflexion

Palpable painful gap

+ve calf squeeze (Simmonds) test

44
Q

Management of Tendo-Achilles rupture?

A

Controversial:
Non-operative and operative options all require an extended recovery time

The functional outcome is normally good though

45
Q

Describe claw, hammer and mallet toes

A

Claw toe - hyperextension at the MTP and flexion at the PIP and DIP

Hammer toe - flexion of PIP joint

Mallet toe - flexion at DIP joint

46
Q

Treatment of toe deformities (claw, hammer, mallet)

A

Surgery

47
Q

Cause of ankle sprains?

A

Twisting forces, e.g: inversion/twisting forces on a planted foot

Typically, it is the lateral ligaments (ATFL or CFL) that are the cause

48
Q

Signs of ankle sprains?

A

Pain, bruising and tenderness

49
Q

Management of ankle sprains?

A

Non-operative:
• RICE (rest, ice, compressions, elevation)
• Physiotherapy

Operative

50
Q

Causes of ankle fractures?

A

These are common and are usually due to twisting forces, e.g: inversion/twisting forces on a planted foot

51
Q

Classification of ankle fractures?

A

Weber A - fracture of the lateral malleolus distal to the syndesmosis

Weber B - fracture of the fibula at the level of the syndesmosis

Weber C - fracture of the fibula proximal to the syndesmosis

52
Q

Treatment of ankle fractures?

A 
Stable fractures (outside the ankle joint):
Immobilisation is required

Unstable fractures:
Surgery for fusion

53
Q

What is a Pilon fracture?

A

Fracture of the distal part of the tibia, inv. its articular surface at the ankle joint

Usually caused by high energy accidents

54
Q

Risks with Pilon fractures?

A

Joint damage may cause OA

Risk of infection

Non-union

Amputation

55
Q

Types of metatarsal fractures?

A

Fractures of the 5th metatarsal are very common and tend to be caused by inversion injuries

  1. Avulsion by peroneus brevis tendon (heal in a moon boot and do well)
  2. Jones fracture at the articulation between the 4th and 5th metatarsals (poor blood supply and risk of non-union)
  3. Proximal shaft (common site for stress fractures)
56
Q

What is a Lisfranc fracture?

A

A tarsometatarsal fracture that causes one/more of the metatarsals to be dislocated from the tarsus bone

Tends to be due to a high energy injury and there is a risk of OA

57
Q

Treatment of Lisfranc fracture?

A

Require fixation

58
Q

Signs of calcaneal fractures?

A

Fall in height of the foot and broadening

Look for other injuries as these tend to be due to, e.g: jumping out of a window and landing on the heel

59
Q

Management of calcaneal fractures?

A

Surgery has a high risk of infection and wound breakdown (benefit is unclear)

60
Q

Describe talus fractures

A

Caused by forced dorsiflexion/rapid deceleration; the talus has a reversed blood supply

There is a risk of avascular necrosis and OA

Year 2 Clinical (119 decks)

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