Ankle 2 Flashcards

1
Q

Remind yourself which tendons make up the achilles tendon

A
  • Gastrocnemius
  • Soleus

*Plantaris inserts into achilles tendon

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2
Q

State the pathophysiology of achilles tendonitis

A
  • Repetitive action results in microtears
  • Microtears lead to localised inflammation

With repeated episodes, tendon can become thickened, fibrotic and loses elasticity with repeated episodes

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3
Q

Describe the typical presentation of achilles tendonitis

A
  • Gradual onset of pain & stiffness
  • ^^ worse with movement
  • Usually improved with mild exercise or heat application
  • Tenderness over tendon on palpation
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4
Q

Describe the typical presentation of achilles tendon rupture

A
  • Sudden onset of severe pain in posterior calf
  • Audible popping/feeling that something ‘went’
  • Weak plantar felxion
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5
Q

Explain why ankle plantar flexion is only weakened, not absent, in achilles tendon rupture

A

Peroneal muscles still intact and contribute to plantar flexion

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6
Q

What test can be used to assess for achilles tendon rupture?

A

Simmonds test

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7
Q

Discuss if any, and what investigations, are required for achilles tendonitis and rupture

A
  • Both are clincial diagnoses.
  • May do USS if unsure on diagnosis
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8
Q

Discuss the management of achilles tendonitis

A

Supportive

  • Stop precipitating exercise
  • Ice
  • Anti-inflammatories e.g. NSAIDs

Chronic cases may require physiotherapy.

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9
Q

Discuss the management of achilles tendon rupture, consider:

  • If present <2 weeks since injury
  • If present >2 weeks since injury
A

<2 weeks

  • Analgesia
  • Hold (two options see below)
    • Hold in full equinus for 2 weeks
    • Hold in semi-equinus for 4 weeks
    • Hold in netural position for another 4 weeks

**Options for holding: Either with plaster, give crutches and no weight bearing. Or with moonboot with large heel raise insert and can weight bear immediately

>2 weeks since injury or reoccurence

  • Surgical fixation with end to end repair
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10
Q

What is meant by equinus?

A
  • Equinus= condition in which dorsiflexion of foot is limited
  • When put ankle in equinus position to treat achilles tendon rupture we are referring to holding the ankle in a position with the ankle and toes maximally pointed
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11
Q

What is a Lisfranc injury?

A

Injury to tarsometatarsal joint between the medial cuneiform and the base of the 2nd metatarsal; can be solely ligamentous injuries or involve the bony structures of the midfoot (in which case called a fracture dislocation)

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12
Q

Why does a lisfranc injury occur between medial cuneiform & 2nd metatarsal

A
  • Stability of this joint comes from keystone configuration in which base of 2nd metatarsal fits into mortise created by medial & middle cuneiforms
  • Multiple interosseous ligaments support this area
  • The largest & strongest ligament is the Lisfranc ligament
  • Lisfranc ligament goes form medial cuneiform to base of 2nd metatarsal
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13
Q

State the typical mechanism of injury for Lisfranc injuries

A

Rotational forces or axial load through plantar flexed foot

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14
Q

Describe typical presentation of Lisfranc injury

A
  • Midfoot swelling
  • Midfoot tenderness
  • Plantar bruising
  • Midfoot pain
  • Piano key sign
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15
Q

What investigations are required for a suspected Lisfranc injury?

A
  • Plain film radiographs (AP, lateral & oblique)
  • ?CT fo pre-operative planning
  • ?MRI for purely ligamentous injuries
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16
Q

Signs of Lisfranc injury are subtle on radiographs; state at least one possible sign

A
  • Widening of interval between base of 1st & 2nd metatarsal
  • Dorsal displacement of proximal bases of 1st or 2nd metatarsals on lateral view
  • Bony fragment between 1st& 2nd metatarsal
  • Malalignment of medial border of lateral cuneiform and medial edge of 3rd metatarsal
17
Q

What classification is used to classify Lisfranc injuries?

A

Hardcastle & Myerson

18
Q

Discuss the management of Lisfrance injuries, consider management of:

  • Injuries without significant displacement
  • Injuries with significant displacement
A

Without significant displacement

  • Conservatively with cast immobilisation and non-weight bearing mobilisationfor 6-12 weeks

With significant displacement

  • ORIF (often with screw fixation between medial cuneiform & 2nd metatarsal)
  • Or athrodesis (if severly comminuted or displaced)
19
Q

State some potential complications of Lisfranc injuries

A
  • Post-traumatic arthritis
  • Midfoot compartment syndrome
20
Q

What is hallux valgus?

A

Deformity in which there is medial deviation of the 1st metatarsal and lateral deviation +/- rotation of the hallux with associated joint subluxation

21
Q

State somr risk factors for hallux valgus

A
  • Female
  • Connective tissue disorders
  • Hypermobility syndromes
  • Flat feet

*wearing high heeled for narrow fitting footwear can aggravate condition by keeping hallux in valgus position

22
Q

Describe typical presentation of hallux valgus

A
  • Painful medial prominece
  • Lateral deviation of hallux
  • Skin breakdown over prominence
  • Excessive keratosis in regions of foot due to abnromal weight distribution
23
Q

What investigations are done if you suspect hallux valgus?

A

Plain radiographs (AP, lat & oblique- weight bearing) to help assess severity

24
Q

We can measure the degree of lateral deviation of hallux; measure angle between first metatarsal & first proximal phalanx. What is a normal angle?

A

<15 degrees

25
Q

Discuss the management of hallux valgus, structure your answer as follows:

  • Conservative
  • Pharmacological
  • Surgical
A

Conservative

  • Adjust footwear
  • Orthosis if pt has falt feet
  • Physiotherapy

Pharmacological

  • Analgesia (WHO ladder)

Surgical

  • Variety of procedures to re-align joint… (Chevron, scarf, lapidus, keller)
26
Q

State some potential complications of hallux valgus

A

(many are related to surgery)

  • Recurrence
  • Reduced ROM
  • Avascular necrosis
  • Non-union
  • Displacement
27
Q

SEE GP MSK DECK for more on plantar fasciitis. For now just answer:

  • Management
  • Prognosis
A

First try:

  • Activity modification
  • Analgesia
  • Footwear with well cushioned heel and sturdy midfoot
  • Physiotherapy

Then can consider surgical management:

  • Corticosteroid injections
  • Plantar fasciotomy

Prognosis= good. Symptoms usually resolve following conservative management.