Clinical anatomy of the knee, foot and ankle

Question 1

Answer 1

Question 2

Answer 2

Question 3

Answer 3

Question 4

What kinds of forces do a) the lateral and b) medial collateral ligaments resist?

Answer 4

a) varus force
b) valgus force

Question 5

What forces are resisted by:

a) anterior cruciate ligament
b) posterior cruciate ligament

Answer 5

a) anterior translation and external rotationof the tibia
b) posterior translation of the tibia

Question 6

What is the common insertion of the knee extensor muscles?

Answer 6

Tibial tuberosity via the patellar tendon

Question 7

What can predispose to knee OA?

Answer 7

Previous injury e.g. meniscal tears, ligamentous injury

Misalignment (e.g. genu valgum, varus)

? Distance running

Question 8

How is knee OA managed?

Answer 8

Conservative management

If conservative is no longer sufficient- knee replacement which may be total (TKR) or partial

Question 9

Why should steroid injections for tendonitis of the extensor mechanism of the knee be avoided?

Answer 9

High risk of tendon rupture

Question 10

How is the extensor mechanism tested?

Answer 10

Straight leg raise

Question 11

How does the position of the patella on X-ray help locate an extensor mechanism tear?

Answer 11

High lying patella- PT rupture

Low-lying patella- quad rupture

Question 12

How is extensor mechanism rupture treated?

Answer 12

Surgical- tendon to tendon repair or reattachment

Question 13

What is patellofemoral dysfunction?

Answer 13

Anterior knee pain caused by the lateral pull of the quadriceps

Question 14

How does patellofemoral dysfunction present?

Answer 14

Anterior knee pain usually worse going downhill, knee locking, stiffening in a flexed position, “grinding” sensation

Question 15

How is patellofemoral dysfunction treated?

Answer 15

Vast majority improve PT aimed at strengthening vastus medialis

Question 16

What might cause patellar dislocation, and what direction is this almost always in?

Answer 16

Direct blow or twisting of the knee

Almost always lateral

Question 17

How do meniscal injuries classically present?

Answer 17

Twisting force on a loaded knee e.g. twising when playing football

Question 18

What do patients with meniscal tears complain on?

Answer 18

Localised pain, feeling as though the knee is about to give way, knee locking or catching, may be unable to fully extend knee

Question 19

Which meniscus is most commonly turn?

Answer 19

Medial

Question 20

What type of meniscal tear can cause a failure to fully extend the knee?

Answer 20

Bucket-handle meniscal tear

Question 21

What type of meniscal tear is suitable for surgery?

Answer 21

Longitudinal tears in the outer third of the meniscus in younger patients (very few are suitable)

Question 22

How are meniscal tears unsuitable for repair managed?

Answer 22

Conservatively- most tears heal themselves

Steroid injections may help

Persistent pain may be an indication for arthroscopic meniscectomy

Question 23

How do ACL ruptures typically present and what do patients complain of?

Answer 23

High rotational force on a planted foot

Deep pain in the knee, feeling of instability, tense swelling (haemarthrosis) within the knee

Question 24

What injuries can be caused by:

a) valgus force
b) varus force

Answer 24

a) MCL rupture and potentially ACL with higher forces (think Roy Keane on Alf-Inge Haaland)
b) LCL rupture

Question 25

What accompanies an ACL rupture in 25% of cases?

Answer 25

Meniscal tear

Question 26

What is the main ankle dorsiflexor?

Answer 26

Tibialis anterior

Question 27

Which ankle plantar flexor is missing from this diagram? What is the common insertion of these muscles?

Answer 27

Plantaris Calcaneus via the Achilles Tendon

Question 29

Answer 29

Question 30

Answer 30

Question 31

What is hallux valgus?

Answer 31

Deformity of the big toe- medial deviation of the first metatarsal and lateral deviation of the big toe itself

Question 32

In what groups of patient is hallux valgus more common?

Answer 32

Rheumatoid and other inflammatory arthropathies, neuromuscular disease (e.g. MS, cerebral palsy)

Question 33

How is hallux valgus treated a) conservatively and b) surgically? What is the satisfaction rate of the surgery?

Answer 33

a) wider "accomodating" shoes; spacer between first and second toes. b) osteotomy and release/tightening of tight/slack structures. 30% patients are unsatisfied with results.

Question 34

What is hallux rigidus?

Answer 34

OA of the first MTPJ.

Question 35

What is the gold standard for surgical treatment of hallux rigidus?

Answer 35

Arthrodesis

Question 36

Where do the medial and lateral plantar nerves arise from?

Answer 36

The tibial nerve

Question 37

What is Morton's neuroma and what causes it?

Answer 37

Swelling of nerve fibres in the foot due to repeated trauma. The third and second interspace nerves are most commonly affected.

Question 38

What do patient's with Morton's neuroma typically complain of?

Answer 38

Burning pain and tingling radiating into the affected toes; loss of sensation in the affected web space

Question 39

How does plantar fasciitis present?

Answer 39

Pain with walking at the plantar aponeurosis

Question 40

How is plantar fasciitis treated?

Answer 40

Rest, analgesia, Achilles/plantar fascia stretching, gel-filled heel pad, steroid injections

Question 41

What causes pes planus/flat feet?

Answer 41

Failure of the medial arch to develop properly

Question 42

In which groups of patients are flat feet seen?

Answer 42

People with generalised ligamentous laxity e.g. Ehler's Danlos Acquired- rheumatoid, charcot arthropathy, tibialis posterior tendon stretch/rupture

Question 43

What is pes cavus?

Answer 43

Abnormally high arch of the foot

Question 44

What kinds of condition is pes cavus related to?

Answer 44

Neuromuscular e.g. cerebral palsy, polio

Question 45

How do claw toes and hammer toes arise?

Answer 45

Acquired imbalance between flexor and extensor tendons

Question 46

What are the two most common mechanism of injury in the ankle?

Answer 46

Inversion injury and/or rotational force on a planted foot

Question 47

What are sprains of the lateral ankle ligaments commonly caused by?

Answer 47

Inversion injuries

Question 48

What are the criteria used to identify a suspected ankle fracture and give guidance as to whether they require an X-ray?

Answer 48

Ottowa criteria

Question 49

How are stable and unstable ankle fractures distinguished?

Answer 49

Stable- no medial fracture or rupture of the deltoid ligament Unstable- medial fracture or deltoid ligament rupture

Question 50

A patient with an injured ankle has medial tenderness and bruising, what might this suggest?

Answer 50

Deltoid ligament rupture

Question 51

How are stable and unstable ankle fractures treated?

Answer 51

Stable- walking cast or splint for around 6 weeks Ustable- ORIF with plates and screws

Question 52

Where is the commonest site of metatarsal fracture and what is the typical mechanism of injury?

Answer 52

5th metatarsal Inversion injury, avulsion fracture at site of insertion of peroneus brevis tendon

Question 53

How are 5th metatarsal fractures treated?

Answer 53

Cast, supportive bandaging, protective boot for 4-6 weeks

Question 54

What is a Jones fracture?

Answer 54

Fracture of the 5th metatarsal in the region of the proximal diaphysis- risk of non-union due to poor blood supply. May undergo screw fixatation in active patients

Question 55

Where is a common site for a metatarsal stress fracture? What is the typical history?

Answer 55

The second metatarsal. Typical history- sudden increased intensity of exercise

Question 56

How does Achilles tendonitis typically occur?

Answer 56

Repetive strain from sports Quinolone antibiotics e.g. ciprofloxacin can cause tendintiis RA, other inflammatory arthropathies, gout

Question 57

Why should a steroid injection never be given for Achilles tendonitis?

Answer 57

Risk of tendon rupture

Question 58

How do patients often describe the pain of Achilles tendon rupture?

Answer 58

"Like being shot" "Like being kicked"

Question 59

What clinical signs may be seen in Achilles tendon rupture?

Answer 59

Weakness of plantar flexion Palpable gap in the tendon Simmonds test positive (lack of plantar flexion when squeezing the calf)