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Year 3 - Musculoskeletal > Common foot and ankle conditions > Flashcards

Common foot and ankle conditions Flashcards

1
Q

Non-opertative management of foot and ankle conditions?

A 
> Analgesia
> Shoe wear modification
> Activity modification
> Weight loss
> Physiotherapy
> Orthotics including insoles and bracing
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2
Q

When to operate in foot and ankle conditions?

A

The only indication for operative management is failure of non-operative management

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3
Q

Common forefoot problems?

A 
Hallux valgus
Hallux rigidus
Lesser toe deformities
Morton’s neuroma
Metatarsalgia
Rheumatoid Forefoot
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4
Q

What is another name for hallux valgus?

A

Bunions

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5
Q

Aetiology of Hallux valgus?

A

> Genetic
Foot wear
Significant female preponderance

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6
Q

Symptoms of hallux valgus?

A

> Pressure symptoms from shoe wear
Pain from crossing over of toes
Metatarsalgia

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7
Q

Pathogenesis of hallux valgus?

A

> Lateral angulation of great toe.
Tendons pull realigned to lateral of centre of rotation of toe worsening deformity
Vicious cycle of increased pull creating increased deformity
Sesamoid bones sublux – less weight goes through great toe
As deformity progresses abnormalities of lesser toes occur

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8
Q

Diagnosis of hallux valgus?

A

> Clinical
Xrays
- Determine severity of underlying bony deformity
- Exclude associated degenerate change (E.g. Arthritis)

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9
Q

Management of hallux valgus - Non-operative?

A

> Shoe wear modification (wide +/- high toe box)
Orthotics to offload pressure/correct deformity
Activity modification
Analgesia

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10
Q

Management of hallux valgus - Operative?

A

Operative (if non-operative failed or unacceptable to patient):
> Release lateral soft tissues
> Osteotomy 1st metatarsal +/- proximal phalanx
> Generally good outcome but recurrence inevitable

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11
Q

What is hallux rigidus?

A

> Stiff big toe

> Osteoarthritis of 1st MTP joint

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12
Q

Aetiology of hallux rigidus?

A

> Not known
Possibly genetic – typical shape of metatarsal head is slightly pointed rather than rounded
Possibly multiple microtrauma
Bimodal distribution of age

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13
Q

Aetiology of hallux rigidus?

A

> Not known
Possibly genetic – typical shape of metatarsal head is slightly pointed rather than rounded
Possibly multiple microtrauma
Bimodal distribution of age

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14
Q

Diagnosis of hallux rigidus?

A

> Clinical

> Radiographs

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15
Q

Diagnosis of hallux rigidus?

A

> Clinical

> Radiographs (Often visible osteocytes)

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16
Q

Management of hallux rigidus - Operative?

A 
Surgery:
> Cheilectomy
> Arthrodesis
> Arthroplasty
> 1st MTPJ fusion (Gold standard)
> 1st MTPJ hemiarthroplasty
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17
Q

What is Cheilectomy?

A

Remove dorsal impingement within hallux rigidus

It allows increase ROM in dorsiflexion

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18
Q

Examples of lesser toe deformities?

A

> Claw toes
Hammer toes
Mallet toes

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19
Q

Examples of lesser toe deformities?

A

> Claw toes
Hammer toes
Mallet toes

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20
Q

Aetiology of lesser toe deformities?

A 
> Imbalance between flexors/extensors
> Shoe wear 
> Neurological
> Rheumatoid arthritis
> Idiopathic
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21
Q

Symptoms of lesser toe deformities?

A

> Deformity
Pain from dorsum
Pain from plantar side (metatarsalgia)

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22
Q

Management of lesser toe deformities - Non-operative?

A

Non-operative:
> Activity modification

> Shoe wear – flat shoes with high toe box to accommodate deformity

> Orthotic insoles – metatarsal bar/dome support

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23
Q

Management of lesser toe deformities - Operative?

A 
Operative: 
> Flexor to extensor transfer
> Fusion of interphalangeal joint 
> Release metatarsophalangeal joint
> Shortening osteotomy of metatarsal
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24
Q

What is Interdigital Neuralgia – Morton’s Neuroma?

A

Inflammation, sever pain and numbness are the bifurcation of the common digital nerve due to mechanical stress

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25
Q

Aetiology of interdigital neuralgia?

A

> Mechanically induced degenerative neuropathy

> Tends to affect females aged 40-60

> Frequently associated with wearing high healed shoes

> Common digital nerve relatively tethered to one metatarsal and movement in adjacent metatarsal causing mechanical shear

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26
Q

Management of interdigital neuralgia - Non-operative?

A

Injection for small lesions

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27
Q

Management of interdigital neuralgia - Operative?

A

Surgery – excision of lesion including a section of normal nerve
> Numbness
> Recurrence
> Up to 30% have pain 1 year post surgery

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28
Q

Management of interdigital neuralgia - Operative?

A

Surgery – excision of lesion including a section of normal nerve:
> Numbness occurs
> Recurrence
> Up to 30% have pain 1 year post surgery

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29
Q

Interdigital Neuralgia – Morton’s Neuroma what is it usually incorrectly diagnosed as?

A

Forefoot pain

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30
Q

Management of rheumatoid forefoot - Non-operative?

A

Non-operative – shoewear/orthotics/activity etc

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31
Q

What is Metatarsalgia?

A

> Pain in the ball of your foot

> It is a symptom, not a diagnosis

> Causes include Synovitis, bursitis, arthritis, neuralgia, neuromata, Freiberg’s disease… etc

> If not obvious consider tight gastrocnemius

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32
Q

What is Rheumatoid forefoot?

A

Deformities often with degenerative changes

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33
Q

Aetiology of dorsal foot ganglia?

A

> Idiopathic
Underlying arthritis
Underlying tendon pathology

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34
Q

Symptoms of dorsal foot ganglia?

A

> Pain from pressure from shoe wear

> Pain from underlying problem

35
Q

Management of dorsal foot ganglia - Non-operative?

A

Non-operative:
> Aspiration
> “Family bible”

36
Q

What is Dorsal foot ganglia?

A

Build up of pseudocaspsule overlying a joint

37
Q

Management of dorsal foot ganglia - Operative?

A

Excision

38
Q

Prognosis f dorsal foot ganglia after treatment?

A

High rate of return - 50%

39
Q

Management of mid foot arthritis- Non-operative?

A

> Activity/shoewear/orthotics etc

> Injections – Xray guided

40
Q

Management of mid foot arthritis- Operative?

A

Fusion

41
Q

Prognosis of dorsal foot ganglia after treatment?

A

High rate of return - 50%

42
Q

Natural course of planter fibromatosis?

A

Progressive

43
Q

Management of mid foot arthritis- Non-operative?

A

> Activity /shoewear/orthotics etc

> Injections (steroid) – Xray guided

44
Q

Management of mid foot arthritis- Operative?

A

Fusion - Not the best but if extremely painful can to increase function (Even though there is a loss of function) due to decrease pain

45
Q

Management of planter fibromatosis - Operative?

A

> Operative – excision (up to 80% risk of recurrence)

> Combination radiotherapy/surgery (low risk recurrence/high risk complications)

46
Q

Common hind foot problems?

A 
> Achilles tendonitis/tendinosis
> Plantar fasciitis
> Ankle osteoarthitis
> Tibialis posterior dysfunction
> Cavovarus foot – already discussed by Mr Forrest
47
Q

What is Achilles tendinosis/tendinopathy?

A

Degenerative / overuse condition with little inflammation of the achilles tendon

More than one clinical condition:
> Insertional tendinopathy - within 2cm of insertion

> Non-insertional / mid-substance tendinopathy- 2-7cm of insertion

> Bursitis

  • Retrocalcaneal
  • Superficial calcaneal

> Paratendinopathy is a true inflammatory problem showing paratendonitis histologically

48
Q

Aetiology of Achilles paratendinopathy?

A

Paratendonopathy:
> Commonest in athletic populations
> Age group 30-40
> Male:Female = 2:1

49
Q

Management of planter fibromatosis - Operative?

A

> Operative – excision (up to 80% risk of recurrence)
Combination radiotherapy/surgery (low risk recurrence/high risk complications - wound healing, increase risk of cancer etc)

50
Q

Symtoms of Achilles tendinosis/tendinopathy?

A 
Symptoms
> Pain during exercise 
> Pain following exercise
> Recurrent episodes
> Difficuly fitting shoes (insertional)
> RUPTURE – don’t miss!
51
Q

What is Achilles tendinosis/tendinopathy?

A

Degenerative / overuse condition with little inflammation of the achilles tendon

More than one clinical condition:
> Insertional tendinopathy - within 2cm of insertion

> Non-insertional / mid-substance tendinopathy- 2-7cm of insertion

> Bursitis

  • Retrocalcaneal
  • Superficial calcaneal

> Paratendinopathy is a true inflammatory problem showing paratendonitis histologically (Sheath and first layer of tendon effected)

52
Q

Management of Achilles tendinosis/tendinopathy - Non-operative?

A 
Non-operative Treatment
> Activity modification
> Weight loss
> Shoe wear modification – slight heel
> Physiotherapy - Eccentric stretching
> Extra-corporeal shockwave treatment
> Immobilisation (in below knee cast)
53
Q

Achilles Rupture Tests?

A

1) Simmonds

2) “Angle of the Dangle” & Matles

54
Q

Symtoms of Achilles tendinosis/tendinopathy?

A 
Symptoms
> Pain during exercise 
> Pain following exercise
> Recurrent episodes
> Difficuly fitting shoes (insertional)
> RUPTURE – don’t miss!
55
Q

What is Plantar Fasciitis?

A

> Fasciitis is incorrect fasciosis better term

> Fasciosis - Chronic degenerative change, fibroblast hypertrophy, absence inflammatory cells, disorganised and dysfunctional blood vessels and collagen, asvascularity

> Cant make Extra Cellular Matrix required for repair and re-modelling

56
Q

What is Plantar Fasciitis?

A

> Fasciitis is incorrect fasciosis better term

> Fasciosis - Chronic degenerative change, fibroblast hypertrophy, absence inflammatory cells, disorganised and dysfunctional blood vessels and collagen, asvascularity

> Cant make Extra Cellular Matrix required for repair and re-modelling

57
Q

Achilles Rupture Tests?

A

1) Simmonds

2) “Angle of the Dangle” & Matles

58
Q

Symptoms of Plantar fasciitis?

A

> Pain first thing in morning
Pain on weight bearing after rest
Post-static dyskinesia
Pain located at origin of plantar fascia
Frequently long lasting – 2 years or more

59
Q

Achilles Rupture Tests - Simmonds?

A

Squeeze calf should plantarflex, if it doesn’t can indicate rupture

60
Q

Achilles Rupture Tests - “Angle of the Dangle” & Matles?

A

Feet hanging of side of bed, foot is dropped versus other foot

61
Q

Differential diagnosis of Plantar fasciitis?

A

> Nerve entrapment syndrome
Arthritis
Calcaneal pathology

62
Q

Management of Plantar fasciitis - third line treatment?

A 
> Extracorporeal 
> Shockwave therapy
> Topaz Plasma Coblation
> Nitric Oxide
> Platelet Rich Plasma
> Endoscopic / Open Surgery
63
Q

Aetiology of Ankle Arthritis?

A

> Mean age of presentation is 46 years
Commonly post-traumatic
Idiopathic

64
Q

Symptoms of Ankle Arthritis?

A

> Pain

> Stiffness

65
Q

Diagnosis of Ankle Arthritis?

A

> Clinical
Radiographs
CT scan – exclude adjacent joint arthritis

66
Q

Management of Ankle Arthritis - Non-operative?

A 
Weight loss
> Activity modification
> Analgesia
> Physiotherapy
> Steroid injections
67
Q

Management of Ankle Arthritis - Operative?

A

> If symptoms are exclusively anterior then arthroscopic anterior debridement

> Arthrodesis – open or arthroscopic

  • Gold standard
  • Good long term outcome

> Joint replacement

  • Maintain range of movement
  • Questionable long-term outcome especially in high demand patients
  • Not easy to revise even to fusion
68
Q

Management of Ankle Arthritis - Operative?

A

> If symptoms are exclusively anterior then arthroscopic anterior debridement

> Arthrodesis – open or arthroscopic

  • Gold standard
  • Good long term outcome

> Joint replacement:

  • Maintain range of movement
  • Questionable long-term outcome especially in high demand patients
  • Not easy to revise even to fusion
69
Q

Management of Ankle Arthritis - Operative?

A

> If symptoms are exclusively anterior then arthroscopic anterior debridement

> Arthrodesis – open or arthroscopic

  • Gold standard
  • Good long term outcome

> Joint replacement:

  • Maintain range of movement
  • Questionable long-term outcome especially in high demand patients
  • Not easy to revise even to fusion
70
Q

Presentation of Posterior Tibial Tendon Dysfunction?

A

> Acquired adult flat foot planovalgus
Largely clinical diagnosis – double & single heel raise.
Medial or lateral pain

71
Q

Diagnosis of Posterior Tibial Tendon Dysfunction?

A

Clinical

MRI to assess tendon

72
Q

Management of Posterior Tibial Tendon Dysfunction?

A

> Orthotics – medial arch support

> Reconstruction of tendon (tendon transfer)

> Triple fusion (subtalar, talonavicular and calcaneocuboid)

73
Q

Presentation of Posterior Tibial Tendon Dysfunction?

A

> Acquired adult flat foot planovalgus
Largely clinical diagnosis – double & single heel raise Valgus to varus does not occur.
Medial or lateral pain

74
Q

Treatment of Diabetic foot ulcer - Non-operative?

A

> Prevention

> Modify the main detriments to healing:

  • Diabetic control
  • Smoking
  • Vascular supply
  • External pressure (splints/shoes/weight bearing)
  • Internal pressure (deformity)
  • Infection
  • Nutrition
75
Q

Treatment of Diabetic foot ulcer - Operative?

A

> Improve Vascular Supply

> Debride ulcers and get deep samples for microbiology

> Correct any deformity to offload area

> Amputation

76
Q

Prognosis of Diabetic foot ulcer?

A

> 15% of all diabetics will develop ulceration

> 85% of all amputations for diabetes are preceded by foot ulceration

> 25% of patients with diabetic ulcers go on to amputation

> 5 year patient mortality 50%

77
Q

Prognosis of Diabetic foot ulcer?

A

> 15% of all diabetics will develop ulceration

> 85% of all amputations for diabetes are preceded by foot ulceration

> 25% of patients with diabetic ulcers go on to amputation

> 5 year patient mortality 50%

78
Q

Aetiology of Charcot Neuroarthropathy?

A

> Any cause of neuropathy

> Diabetes commonest cause

> Historically originally described and most common with syphillis

79
Q

Pathophysiology of Charcot Neuroarthropathy?

A

Pathophysiology – two theories:
1) Neurotraumatic
> Lack of proprioception and protective pain sensation

2) Neurovascular
> Abnormal autonomic nervous system results in increased vascular supply and bone resorption

80
Q

Characteristics (Stages) of bone destruction of Charcot Neuroarthropathy?

A

Characterised by rapid bone destruction occurring in 3 stages:

1) Fragmentation
2) Coalescence
3) Remodelling

81
Q

Diagnosis of Charcot Neuroarthropathy?

A

High index of suspicion
Consider in any diabetic with acutely swollen erythematous foot especially with neuropathy
Greater than 3 degree difference between limbs
Frequently not painful
Radiographs
MRI scan

82
Q

Management of Charcot Neuroarthropathy?

A

> Prevention

> Immobilisation / non-weight bearing until acute fragmentation resolved

> Correct deformity
- Deformity leads to ulceration leads to infection leads to amputation.

83
Q

What often causes the initial cause of a diabetic foot ulcer?

A

Decreased sweating can lead to increased risk of cracking of skin.

Decreased healing can lead to ulceration

Year 3 - Musculoskeletal (30 decks)

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