Ankle and foot orthopaedics and trauma

Question 1

What is the most common cause of acquired flatfoot deformity in adults?

Answer 1

Tibialis posterior dysfunction

Question 2

Which patients tend to be affected by tibialis posterior dysfunction?

Answer 2

Obese

Female

Increasing age - usually middle aged

Hypertension

Diabetes

History of steroid injections

Seronegative arthropathies

Question 3

What is the cause of the laxity here?

Answer 3

Left foot pes planus caused by tibialis posterior dysfunction

Arch has flattened so the foot everts

Question 4

What are the signs and symtpoms of tibialis posterior dysfunction?

Answer 4

Pain and/or swelling posterior to medial malleolus – very specific
Change in foot shape

Diminished walking ability/balance
Dislike of uneven surfaces
More noticeable hallux valgus
Lateral wall “impingement” pain

Question 5

How can a flexible pes planus be distinguished from a non-flexible pes planus?

Answer 5

Arch is still formed in flexible pes planus when standing on toes

Question 6

What are the treatment options for tibialis posterior dysfunction?

Answer 6

Physiotherapy
Insole to support medial longitudinal arch

Orthoses to accommodate foot shape
Bespoke footwear
Surgery

Question 7

Which treatment should not be given for tibialis posterior dysfunction?

Answer 7

Steroid injections

Question 8

Which classification is used to describe ankle fractures?

Answer 8

Weber’s classification

Question 9

Which kind of ankle fractures are stable?

Answer 9

Distal fibula fracture with no medial malleolus fracture or deltoid ligament rupture

Question 10

Which ankle fractures are unstable?

Answer 10

Distal fibula fracture with medial malleolus fracture or deltoid ligament rupture

Question 11

What is the treatment of a stable ankle fracture?

Answer 11

Cast or splint for around 6 weeks

Question 12

When is rupture of the deltoid ligament suspected?

Answer 12

Bruising and tenderness medially

Question 13

What is the usual treatment of unstable ankle fractures?

Answer 13

Open reduction internal fixation

Question 14

What is the treatment of an unstable ankle fracture if there is any talar shift or talar tilt, and why?

Answer 14

Anatomical reduction and rigid internal fixation

Used to minimise the risk of development of OA

Question 15

What is a pilon fracture?

Answer 15

A fracture of the distal tibia involving its articular surface

Question 16

What is a Jones fracture?

Answer 16

A fracture of the proximal end of the 5th metatarsal bone

Question 17

Why can a Jones fracture be problematic?

Answer 17

Higher risk of non-union (around 25%) due to poor blood supply

Question 18

How do fractures to the base of the 5th metatarsal tend to occur?

Answer 18

Inversion injury with an avulsion fracture at the insertion of the peroneus brevis tendon

Question 19

How do calcaneal fractures occur, and what other injuries should be looked for?

Answer 19

Fall from height onto heel

Therefore, also look for spinal injuries

Question 20

What is at risk of developing following a calcaneal fracture?

Answer 20

Compartment syndrome of the foot

Question 21

What is the prognosis of a calcaneal fracture dependant on?

Answer 21

Degree of involvement of subtalar joint

Degree of communition

Question 22

When is subtalar arthodesis a treatment option following a calcaneal fracture?

Answer 22

Development of chronic pain from subtalar joint damage

Osteoarthrtitis

Question 23

How do fractures of the talus tend to occur?

Answer 23

Forced dorsiflexion from rapid deceleration

e.g. RTA, aircraft crash

Question 24

What is at risk of developing following a talar fracture-dislocation or subluxation?

Answer 24

AVN of the talus

Question 25

What is a Lisfranc fracture?

Answer 25

A fracture of the base of the 2nd metatarsal is associated with dislocation of the base of the 2nd metatarsal with or without dislocation of the other metatarsals at the tarso‐metatarsal joints

Question 26

What is the usual presentation of a Lisfranc fracture?

Answer 26

Grossly swollen and bruised foot Unable to weight bear May have normal Xray - CT scan if in doubt

Question 27

What is the treatment for a Lisfranc fracture?

Answer 27

Closed or open reduction with screw fixation

Question 28

What is the treatment for multiple displaced fractures of the metatarsals?

Answer 28

Stabilisation with K wires

Question 29

How does plantar fasciitis present?

Answer 29

Heel pain Fullness or swelling medially to heel Can be worse after exercise or starting up after rest

Question 30

What would indicate plantar fasciitis on examination?

Answer 30

Positive tinel's test for Baxters nerve Swelling medially to heel

Question 31

What are the causes of plantar fasciitis?

Answer 31

Repetitive stress Seronegative arthropathies Diabetes Obesity Frequent walking on hard floors Improper footwear

Question 32

What is the treatment for plantar fasciitis?

Answer 32

Rest Achilles and plantar fascia stretching exercises Gel filled heel pad NSAIDs Corticosteroid injections Usually self-limiting

Question 33

What is hallux valgus?

Answer 33

Medial deviation of the 1st metatarsal causing deformity of the big toe

Question 34

What are some of the problems caused by hallux valgus?

Answer 34

Transfer metatarsalgia Lesser toe impingement Pain, deformity, cosmesis Shoe difficulties Formation of bunions and ulcers

Question 35

What is the surgery for hallux valgus?

Answer 35

Multiple osteotomies to realign the bones Soft tissue procedures to tighten slack tissues and release tight tissues

Question 36

What is hallux rigidus?

Answer 36

OA of the 1st MTPj

Question 37

What are some of the conservative treatment options for hallux rigidus?

Answer 37

Wearing of stiff soled shoe to limit motion at the MTPJ Removal of osteophytes

Question 38

What is the gold standard surgical treatment for hallux rigidus?

Answer 38

Arthrodesis

Question 39

What is pes cavus?

Answer 39

Abnormally high arch of the foot often related to neuromuscular conditions

Question 40

What is Morton's neuroma?

Answer 40

Degenerative fibrosis of common digital nerve near it’s bifurcation

Question 41

How does Morton's neuroma present?

Answer 41

Pain in forefoot Burning and tingling of toes

Question 42

Which patients are most commonly affected by Morton's neuroma?

Answer 42

Women aged 45-50

Question 43

What examination findings would implicate a Morton's neuroma?

Answer 43

Loss of sensation in affected web space Medio‐lateral compression of the metatarsal heads (exerted by squeezing the forefoot with your hand) may reproduce symptoms or produce a characteristic "click"; this is Mulder's click test

Question 44

What is the conservative management for Morton's neuroma?

Answer 44

Metatarsal pad or offloading insole Steroid or anaesthetic injections

Question 45

What is the surgical treatment for Morton's neuroma?

Answer 45

Excision of neuroma

Question 46

What can be used to diagnose a Morton's neuroma?

Answer 46

Ultrasound - can see an inflamed nerve

Question 47

What are the causes of Achilles tendonitis?

Answer 47

Repetitive strain Rheumatoid arthritis Quinolone antibiotics Gout

Question 48

What is the treatment for Achilles tendonitis?

Answer 48

Rest Physiotherapy Heel raise Splint or boot Tendon decompression

Question 49

Which patients tend to suffer from Achilles rupture?

Answer 49

Middle aged or older patients due to degenerative changes

Question 50

What signs on examinaton would indicate an Achilles rupture?

Answer 50

Unable to bear weight Weak plantar flexion Palpable painful gap Positive calf squeeze (Simmonds) test

Question 51

What is the conservative management of Achilles rupture?

Answer 51

Cast for up to 8 weeks in the equinous position - plantarflexed foot with toes pointing downwards to close gap between ruptured tendon sides

Question 52

Why do claw or hammer toes occur?

Answer 52

Imbalance of flexor and extensor mechanisms