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Ankle and foot Flashcards

1
Q

Outline Weber’s classification of ankle fractures

A

Classification of lateral malleolar fractures
Type A: fracture inferior to syndesmosis
Type B: fracture at level of syndesmosis
Type C: fracture above ankle joint

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2
Q

Describe the features of a Type A weber ankle fracture

A

Syndesmosis intact
May fracture medial malleolus
Usually stable

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3
Q

How is a Type A weber ankle fracture treated?

A

Reduction and cast if stable, may need ORIF

If stable: advise early weight bearing

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4
Q

Describe the features of a Type B weber ankle fracture

A

Syndesmosis intact or partially torn
Possible medial fracture or deltoid ligament damage
Stability variable

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5
Q

How is a Type B weber ankle fracture treated?

A

Reduction and cast if stable
May need ORIF if unstable
If stable: advise early weight bearing

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6
Q

Describe the features of a Type C weber ankle fracture

A

Syndosmosis damaged ➔ widened joint
Usually medial fracture or deltoid ligament injury
Unstable ➔ fracture-subluxation

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7
Q

How is a Type C weber ankle fracture treated?

A

ORIF required due to instability

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8
Q

What is a bunion?

A

Swelling over the medial side of the first metatarsal head

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9
Q

How do the heels normally appear when standing?

A

Heels are normally in slight valgus while standing

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10
Q

How do the heels normally appear when on tiptoes?

A

Heels are normally inverted when on tiptoes

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11
Q

Describe the phases of the walking cycle

A
  1. Heel strike
  2. Move into stance
  3. Push-off
  4. Swing-through
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12
Q

What is the cause of foot-drop?

A

Weak ankle dorsiflexors

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13
Q

What gait abnormality may be seen with foot-drop?

A

High-stepping gait

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14
Q

Name the 3 standard views of the ankle for imaging

A

Anteroposterior (AP)
Mortise: AP view with inversion 15-20 degrees
Lateral

N.B. always image both ankles for comparison

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15
Q

Define Pes planovalgus

A

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

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16
Q

Define Pes cavus

A

Foot with excessive high longitudinal arch

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17
Q

Define Hallux valgus

A

Excessive lateral deviation of the big toe

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18
Q

Define Hammer toe

A

Flexion deformity of the PIPJ of one of the lesser toes, usually second or third. Hyperextension of DIPJ and MTPJ.

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19
Q

Define Claw-toes

A

Curled flexion of all the toes. MTP hyperextension with IP joint flexion.

Typically bilateral, and may severely restrict walking.
Seen with intrinsic muscle weakness.

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20
Q

Define Mallet toe

A

Flexion deformity of DIPJ of one of the lesser toes

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21
Q

Describe the presentation of idiopathic club-foot (congenital talipes equinovarus)

A

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

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22
Q

Describe the epidemiology of club-foot

A

1-3 per 1000 births
Boys (2:1)
Bilateral 50%
FHx increases risk be 20-30x

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23
Q

What conditions must be examined for alongside club-foot?

A

Developmental dysplasia of the hip

Spina bifida

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24
Q

Describe the treatment of club-foot

A

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
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25
Differentiate metatarsus adductus and club-foot
Metatarsus adductus: adduction occurs at tarsometatarsal joints Club-foot: adduction occurs at talonavicular joint
26
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
27
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.
28
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
29
How is congenital vertical talus treated?
Manipulation Serial casting Resistant: open surgery
30
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
31
Name 2 causes of rigid flat-foot
Congenital vertical talus Tarsal coalition Inflammatory arthritis Neuromuscular disorder
32
Name 2 causes of unilateral flat-foot
Tibialis posterior synovitis or rupture Risk factors include: obesity, diabetes, corticosteroid, surgical history
33
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 ```
34
Describe the radiographic appearance of hallux valgus
Metatarsal adduction: >9 degrees | Hallux angulation: >15 degrees
35
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.
36
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
37
How is hallux valgus treated in adults?
Excision of bunion Metatarsal osteotomy Soft-tissue rebalancing Arthrodesis if MTPJ is osteoarthritic
38
Define Hallux rigidus
Rigidity of the first MTP joint
39
Name 3 causes of Hallux rigidus
Local trauma Osteochronditis dissecans of first metatarsal head Elderly: gout, CPPD, OA
40
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
41
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
42
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
43
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
44
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 ```
45
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)
46
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)
47
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
48
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 ```
49
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
50
List the x-ray changes seen in osteoarthritis of the ankle
``` Typical features of OA: Loss of joint space Osteophytes Subchondral sclerosis Subchondral cysts ```
51
Outline the specific management of osteoarthritis of the ankle
Offloading: walking stick Weight loss if applicable Arthrodesis
52
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.
53
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.
54
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
55
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
56
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
57
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.
58
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
59
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
60
What can be considered for physically active individuals suffering from a rupture of tibialis posterior tendon?
Operative repair | Tendon transfer: tendon of FDL
61
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 ```
62
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
63
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
64
Name 2 causes midfoot pain in children
N.B. midfoot pain in children in unusual Kohler's disease: flat dense navicular bone Bony coalition
65
Name 1 cause of midfoot pain in adults
Ridge of bone develops on adjacent dorsal surfaces of medial cuneiform and first metatarsal
66
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
67
Name 3 causes of metatarsalgia
``` Long standing deformities such as: Pes planus (flat-foot) Hallux valgus Hammer-toe Claw-toe Overlapping-toes ```
68
What is Freiberg's disease?
Traumatic osteonecrosis of second metatarsal head Pain over MTPJ Tender palpable bony lump: metatarsal head
69
Describe the x-ray changes seen with Freiberg's disease
Metatarsal head flattened and wide Metatarsal neck thickened Joint space apparently increased
70
How is Freiberg's disease treated?
Analgesia Walking plaster to offload pressure on metatarsal head Synovectomy Debridement Cheilectomy
71
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
72
Describe the pathology of Morton's metatarsalgia
Entrapment or compression of a digital nerve, with secondary thickening to created a neuroma
73
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
74
Describe the x-ray features of a metatarsal stress fracture
Fusiform callus around a fine transverse fracture
75
What is Keratoderma blenorrhagica?
Scaly pustules on palms and soles that are seen with reactive arthritis
76
Which drug is associated with new-onset achilles tendon disorders?
Ciprofloxacin

Musculoskeletal (17 decks)

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