Ankle and foot Flashcards
Outline Weber’s classification of ankle fractures
Classification of lateral malleolar fractures
Type A: fracture inferior to syndesmosis
Type B: fracture at level of syndesmosis
Type C: fracture above ankle joint
Describe the features of a Type A weber ankle fracture
Syndesmosis intact
May fracture medial malleolus
Usually stable
How is a Type A weber ankle fracture treated?
Reduction and cast if stable, may need ORIF
If stable: advise early weight bearing
Describe the features of a Type B weber ankle fracture
Syndesmosis intact or partially torn
Possible medial fracture or deltoid ligament damage
Stability variable
How is a Type B weber ankle fracture treated?
Reduction and cast if stable
May need ORIF if unstable
If stable: advise early weight bearing
Describe the features of a Type C weber ankle fracture
Syndosmosis damaged ➔ widened joint
Usually medial fracture or deltoid ligament injury
Unstable ➔ fracture-subluxation
How is a Type C weber ankle fracture treated?
ORIF required due to instability
What is a bunion?
Swelling over the medial side of the first metatarsal head
How do the heels normally appear when standing?
Heels are normally in slight valgus while standing
How do the heels normally appear when on tiptoes?
Heels are normally inverted when on tiptoes
Describe the phases of the walking cycle
- Heel strike
- Move into stance
- Push-off
- Swing-through
What is the cause of foot-drop?
Weak ankle dorsiflexors
What gait abnormality may be seen with foot-drop?
High-stepping gait
Name the 3 standard views of the ankle for imaging
Anteroposterior (AP)
Mortise: AP view with inversion 15-20 degrees
Lateral
N.B. always image both ankles for comparison
Define Pes planovalgus
Flat-foot: flattened longitudinal arch, with the medial border in contact (or nearly in contact) with the ground.
Anterior flat-foot, if dropped metatarsal arch also
Define Pes cavus
Foot with excessive high longitudinal arch
Define Hallux valgus
Excessive lateral deviation of the big toe
Define Hammer toe
Flexion deformity of the PIPJ of one of the lesser toes, usually second or third. Hyperextension of DIPJ and MTPJ.
Define Claw-toes
Curled flexion of all the toes. MTP hyperextension with IP joint flexion.
Typically bilateral, and may severely restrict walking.
Seen with intrinsic muscle weakness.
Define Mallet toe
Flexion deformity of DIPJ of one of the lesser toes
Describe the presentation of idiopathic club-foot (congenital talipes equinovarus)
Ankle in equinus
Heel in varus
Forefoot adducted, flexed, and supinated
-adducted at talonavicular joint
Soles face posterior-medially
Heel usually small, deep creases posterior and medial
Skin and soft tissue of calf and medial side of foot are short and under-developed
Describe the epidemiology of club-foot
1-3 per 1000 births
Boys (2:1)
Bilateral 50%
FHx increases risk be 20-30x
What conditions must be examined for alongside club-foot?
Developmental dysplasia of the hip
Spina bifida
Describe the treatment of club-foot
Ponseti method: successive manipulation and casting on a weekly basis, typically for 6 casts.
-Requires strict follow-up regime of splintage in de-rotation boots until 3 years of age
If resistant:
- Open release of joint tethers
- Tendon elongation: achilles tendon
- Tendon transfer: anterior tibialis (medial cuneiform -> lateral cuneiform) to improve dorsiflexion
Differentiate metatarsus adductus and club-foot
Metatarsus adductus: adduction occurs at tarsometatarsal joints
Club-foot: adduction occurs at talonavicular joint
What is the prognosis and treatment of metatarsus adductus?
90% improve spontaneously or can be managed non-operatively using serial corrective casts followed by straight-last shoes.
Resistant: abductor hallucis muscle release
Describe the pathogenesis of rocker-bottom foot
Plantar dislocation of the head of talus from the navicular.
-cannot be passively corrected
Appears as a ‘vertical’ talus on lateral x-ray.
How can congenital vertical talus be differentiated from flexible forms of flat-foot?
Lateral x-ray whilst plantarflexed: Talus will not line up with the first metatarsal
How is congenital vertical talus treated?
Manipulation
Serial casting
Resistant: open surgery
How can flexible and rigid forms of flat-foot be differentiated in children/adolescents?
Jack toe raise test: dorsiflexion of the great toe whilst foot planted on ground
Flexible flat-foot: medial arch reappears
Rigid flat-foot: no change in medial arch appearance
Name 2 causes of rigid flat-foot
Congenital vertical talus
Tarsal coalition
Inflammatory arthritis
Neuromuscular disorder
Name 2 causes of unilateral flat-foot
Tibialis posterior synovitis or rupture
Risk factors include: obesity, diabetes, corticosteroid, surgical history
Describe the clinical features of Hallux valgus
Appears most commonly in women aged 50-70
Usually bilateral
N.B. familial type appears in late adolescence
Often asymptomatic besides deformity Medial bunion Overlapping second toe if marked valgus Pain due to: -pressure on large/inflamed bunion -splaying of forefoot and muscle strain (metatarsalgia) -associated deformities of lesser toes -secondary OA of first MTPJ
Describe the radiographic appearance of hallux valgus
Metatarsal adduction: >9 degrees
Hallux angulation: >15 degrees
What are the 3 types of hallux valgus?
Congruent: articular surfaces parallel and joint centred, but tilted towards valgus.
Deviated: articular surfaces not parallel, joint centred, tilted towards valgus.
Subluxated: not parallel or centred, slight subluxation.
Later stages are more likely to be unstable and progress.
How is hallux valgus treated in adolescents/young adults?
Conservative treatment: footwear encouraged
-as operative correction has 20-40% recurrence rate
Mild: soft-tissue rebalance or osteotomy
Moderate/severe: osteotomy +/- soft-tissue adjustment
How is hallux valgus treated in adults?
Excision of bunion
Metatarsal osteotomy
Soft-tissue rebalancing
Arthrodesis if MTPJ is osteoarthritic
Define Hallux rigidus
Rigidity of the first MTP joint
Name 3 causes of Hallux rigidus
Local trauma
Osteochronditis dissecans of first metatarsal head
Elderly: gout, CPPD, OA
Describe the clinical features of hallux rigidus
Pain on walking, esp. on slopes or rough ground
Painful and clumsy push-off stage of gait
Large osteophyte on dorsum of MTPJ
Restricted and painful dorsiflexion of the toe
Limited plantarflexion
Outline the management of hallux rigidus
Conservative: rocker-soled shoes
Young: extension osteotomy of proximal phalanx
Older with mild disease: osteophyte and slight metatarsal removal (cheilectomy) +/- extension osteotomy
Older with advanced disease: arthrodesis
How is claw-toe treated?
Conservative: metatarsal support
Dynamic correction tendon transfer
If fixed deformity:
- acceptance + footwear, or
- IP arthrodesis + tendon transfer
Jones procedure if great toe is clawed: transfer of extensor hallicus longus through the neck of first metatarsal
Describe the clinical features of rheumatoid arthritis in the forefoot
Forefoot: pain and swelling of MTPJ
Tenderness initially localises to MTPJ
Later involves the entire foot on pressing or squeezing
Increasing weakness of intrinsic muscles
Joint destruction -> characteristic deformities
- flattened anterior arch
- hallux valgus
- claw-toes
- prominent metatarsal heads in the sole
Describe the x-ray changes seen with rheumatoid arthritis of the forefoot
MTPJ involvement Osteoporosis Periarticular osteopenia and erosions Initially affects 4th and 5th toes -in contrast to rheumatoid arthritis of the hand
Outline the specific treatment of rheumatoid arthritis of the forefoot
Synovitis: corticosteroid injections + footwear
Synovectomy of MTPJ may slow disease progression
Advanced: treatment for claw-toes and hallux valgus
Claw-toe: Jone’s procedure, IP arthrodesis + tendon transfer
Hallux valgus: arthrodesis (preferred if arthritic)
Describe the clinical features of rheumatoid arthritis of the ankle and hindfoot
Early: Pain and swelling around the ankle
Walking becomes increasing difficult
Later: Deformities, tibialis posterior rupture or degeneration, progressive tarsal erosions causes severe valgus of the foot
Swelling and tenderness usually localised either:
- back of medial malleolus (tenosynovitis of tibialis post.)
- lateral malleolus (tenosynovitis of the peronei muscles)
Outline the specific treatment of rheumatoid arthritis of the ankle and hindfoot
Synovitis: splintage + steroid injections, below-knee orthosis will restore stability
Synovectomy may help
?Arthroplasty of ankle
Name 3 causes of osteoarthritis of the ankle
OA of the ankle is almost always secondary
Malunited fracture Recurrent instability Osteochondritis dissecans of the talus AVN of talus Haemoarthrosis in haemophilliacs
Describe the clinical features of osteoarthritis of the ankle
Pain and stiffness localised to the ankle: esp. when first standing up from rest
-patient often indicate transient pain in front of the ankle
Swollen ankle with palpable osteophytes and tenderness along the anterior joint line.
Restricted dorsiflexion and plantarflexion -> antalgic gait
-may produce a compensatory abduction in stand phase
List the x-ray changes seen in osteoarthritis of the ankle
Typical features of OA: Loss of joint space Osteophytes Subchondral sclerosis Subchondral cysts
Outline the specific management of osteoarthritis of the ankle
Offloading: walking stick
Weight loss if applicable
Arthrodesis
Describe the clinical presentation of achilles tendinitis
Pain and swelling around the achilles tendon due to local irritation of the tendon sheath or paratenon.
Function inhibited esp. at push-off.
Suspect tendon rupture if onset is very sudden.
What findings are seen on examination of achilles tendinitis?
Thickened and tender tendon in watershed (narrowest) area 4cm above insertion into the middle of calcaneus.
Describe the treatment of achilles tendinitis
Rest, Ice, Compression, Elevation
NSAIDs: topical or oral
Muscle strengthening and stretching exercises
Consider steroid injection under USS guidance
Which patients suffer from achilles tendon rupture and why?
Most patients are over 40 years old
Rupture likely occurs only if tendon is degenerate
More likely if history of achilles tendinitis
Describe the clinical features of achilles tendon rupture
Occurs typically with forceful plantarflexion
Feels like being struck above heel
Unable to rise on tiptoes
Gap is seen and felt 5cm above insertion of tendon
Weak plantarflexion, no tautening of tendon
What test is used to assess achilles tendon rupture?
Simmonds’ test: patient prone, calf squeeze
An intact tendon will cause involuntary plantarflexion, a ruptured tendon will show no movement.
How is achilles tendon rupture treated?
Early: plaster cast or boot with foot in equinus for 8 weeks, further raised heel shoes for 6 weeks
-commence physiotherapy at 4-6 weeks
Tendon repair with subsequent immobilisation as above
Name 3 causes of persistent pain around the ankle
Chronic ligamentous instability
Tenosynovitis of tibialis posterior or peroneal tendons
Rupture of posterior tibialis tendon
Osteochondritis dissecans of dome of talus
AVN of talus
What can be considered for physically active individuals suffering from a rupture of tibialis posterior tendon?
Operative repair
Tendon transfer: tendon of FDL
Name 3 common causes of painful foot
Mechanical pressure: more likely with deformity Joint inflammation or stiffness Localised bone lesion Peripheral ischaemia Muscular strain: usually secondary
Describe the presentation of plantar fasciitis
Pain under the ball of foot, or slightly anterior
Worse on weightbearing
Marked tenderness along distal edges of heel contact
Associated bony ‘spur’ on underside of calcaneum: attachment of plantar fascia
Mainly men aged 30-60
What is the treatment for plantar fasciitis?
Anti-inflammatory drugs
Corticosteroid injection
Pad to offload painful area
Can take 18-36 months to recover, but is generally self-limiting
Name 2 causes midfoot pain in children
N.B. midfoot pain in children in unusual
Kohler’s disease: flat dense navicular bone
Bony coalition
Name 1 cause of midfoot pain in adults
Ridge of bone develops on adjacent dorsal surfaces of medial cuneiform and first metatarsal
Name 3 causes of localised pain in the forefoot
Sesamoiditis: pain/tenderness underneath first metatarsal
Freiberg’s disease
Stress fracture: commonly 2nd and 3rd metatarsal
Morton’s metatarsalgia
Name 3 causes of metatarsalgia
Long standing deformities such as: Pes planus (flat-foot) Hallux valgus Hammer-toe Claw-toe Overlapping-toes
What is Freiberg’s disease?
Traumatic osteonecrosis of second metatarsal head
Pain over MTPJ
Tender palpable bony lump: metatarsal head
Describe the x-ray changes seen with Freiberg’s disease
Metatarsal head flattened and wide
Metatarsal neck thickened
Joint space apparently increased
How is Freiberg’s disease treated?
Analgesia
Walking plaster to offload pressure on metatarsal head
Synovectomy
Debridement
Cheilectomy
Discuss the clinical features Morton’s metatarsalgia
Patient typically a 50 year old woman
Pain in forefoot with radiation to toes
Tenderness of one intermetatarsal space: usually third
Pressure just proximal to interdigital web may elicit pain and tingling distally
Mulder’s click: painful click by squeezing metatarsal heads together
Describe the pathology of Morton’s metatarsalgia
Entrapment or compression of a digital nerve, with secondary thickening to created a neuroma
How is Morton’s metatarsalgia treated?
Protective padding and wider shoes
Steroid injection
Division of the tight transverse intermetatarsal ligament
Intractable pain -> excision of neuroma
Describe the x-ray features of a metatarsal stress fracture
Fusiform callus around a fine transverse fracture
What is Keratoderma blenorrhagica?
Scaly pustules on palms and soles that are seen with reactive arthritis
Which drug is associated with new-onset achilles tendon disorders?
Ciprofloxacin
