Conditions Of The Leg, Ankle + Foot Flashcards
What is compartment syndrome?
A condition resulting from increased pressure within a closed fascial compartment that compromises the neurovascular bundle
Causes of compartment syndrome
- Trauma
- Long bone fracture
- Can lead to oedema + haemorrhage > increases pressures
Treatment of compartment syndrome
Fasciotomy
Signs and symptoms of compartment syndrome
6 Ps
Pain
Paraesthesia
Pulselessness
Perishingly cold
Pallor
Paralysis
Operative complications of compartment syndrome
Poor surgical technique
Necrotic tissue
Nerve + vascular injury
Post-operative complication of compartment syndrome
Infection
Inability to close
Treatment failure
Short term consequences of inadequate treatment of compartment syndrome
- decreased blood supply > ischaemia
- ischaemic muscles release mediators >
^ capillary permeability > further ^ in pressure - nerves die within minutes of O2 loss
- acute kidney injury due to Rhabdomyolysis (ischaemia > muscle death > myoglobin)
Long term consequences of inadequate treatment of compartment syndrome
- necrotic muscle undergoes fibrosis causing Volkman’s ischaemic contraction
- acute kidney failure > chronic
Fracture defintion
Discontinuation in cortex of bone
Open/compound fracture
Fracture with break in skin
Bimalleolus fracture meaning
Both medial + later malleoli are fractured
Trimalleolar fracture meaning
Medial, lateral + posterior malleolus fractured
Cause of bi/trimalleolar fractures
High energy trauma
What is a stable fracture?
Undisplaced fracture
Treatment of stable fracture
Fibreglass cast
Aircast boot
What is an unstable fracture?
Displaced + loss of bone
Treatment of unstable fracture
Surgical stabilisation
Realignment
Avulsion fracture meaning
Bone breaks due to excessive tension through the inserting tendon
Common cause of 5th metatarsal fracture
Stepping on curb
Climbing steps
What muscle inserts into the 5th metatarsal?
Peroneus brevis
What do you need to look out for in children’s x rays from 5t metatarsal fracture?
The 5th metatarsal is unfused
Looks like a fracture
What causes significant tension during forced inversion of the foot?
Peroneus brevis
Plantar aponeurosis
Both insert into 5th metatarsal
Ankle sprain meaning
Partial or complete tear of one or more ligament in ankle
What type of sprain is cause by forced eversion?
Medial ligament sprain
What type of sprain is cause by forced inversion?
Lateral ligament sprain
What ligament is most at risk of tearing in forced inversion?
Anterior talofibular ligament
Risks factors of sprains
- Weak muscles/tendons across ankle joint
- Weak or lax ligaments
- Uneven surfaces
- Inadequates heel support
- High heels
- Slow response to off balance
Treatment of sprains
90% heal with rest
Some requires surgery
Cause of sprains
Excessive strain on ligaments
- over inversion
- over eversion
- excessive external rotation
What is the most common mechanism of injury in ankle sprains?
Inversion injury
Effects plantarflexed + weight bearing foot
Hallux meaning
Great toe
Joint subluxation meaning
Partial dislocation
Describe hallux valgus
Medial deviation of 1st Metatarsal
Lateral deviation of proximal phalanx
Risk factors of hallux vagus
Female
>65 years old
Connective tissue disorders
Hyper mobility syndrome
Management of hallux valgus
Supportive footwear
Analgesia
Surgical correction - not for aesthetic reasons
What is analgesia?
Medication that acts to relieve pain
Tendiopathy meaning
Repetitive action causing micro tears in the tendon
Rupture meaning
Complete loss of attachment
Rupture site of achille’s tendon
Vascular watershed
Proximal to insertion of calcaneal tubercle
Why is the vascular watershed the rupture site in the Achilles tendon?
Area of decreased thickness and vascularity
Risk factors in Achilles rupture
Trauma
Poor footwear
Obesity
Drug induced
Sudden increase in exercise
Diagnosis of Achille’s tendon rupture or tendiopathy
Simmons test
Ultrasound
MRI scan
Describe the Simmond’s test
Squeeze calf
Foor plantarflexes - intact
No movement - ruptured
Treatment of Achilles tendon rupture
Analgesia
Physiotheraphy
Surgical fixation - difficult
Aircast boot
Why is surgical fixation of Achilles tendon rupture difficult?
Two ends fray so reconstruction is difficult
Mechanism of injury of Achilles tendon rupture
- Forceful push off with extended knee
- Fall with foot outstretched in front + ankle dorsiflexed > tendon forcibly overstretched
- Falling from height
- Abruptly stepping into hole/off curb
paraesthesia meaning
pins and needles
what causes Volkman’s ischaemic contraction?
inadequate treatment of compartment syndrome
Signs and symptoms of Achilles’ tendon rupture
Sudden serve pain at back of ankle
Loud pop or snap sound
Palpable gap/depression in tendon
Initial pain + swelling > bruising
Inability to stand on tip toes
Inability to push off when walking
Types of toe deformities
Claw toe
Mallet toe
Hammer toe
Curly toe
What toes are effected in claw toe?
Often all 4 small toes at once
How are joints effected in claw toe?
Hyperextension at MTPJ
Flexed at PIP
MTPJ meaning
Metatarsophalangeal joint
PIP meaning
Proximal interphalangeal joint
DIP meaning
Distal interphalangeal joint
What does claw toe result from?
Muscle imbalance
Causes ligament + tendon tightness
Due to neurological damage
What conditions can claw toe be secondary to?
Cerebral palsy
Stroke
Diabetes
Alcohol dependence
Rheumatoid arthritis
Trauma
Inflammation
What toe does hammer toe often effect?
2nd toe
What toe does mallet toe often effect?
2nd toe
What toe does curly toe often effect?
3rd + 5th digits
How are joints effected in hammer toe?
Flexed at PIP
How are joints effected in mallet toe?
Flexed at DIP
Causes of hammer and mallet toe
- Pressure from hallux valgus
- Ill fitting shoes > tight = constant flexed position > muscle contract + shorten > inability to extend
Cause of curly toe
Congenital
Flexor digitorum longus tendon is too tight
Treatment of curly toe
Stretching of flexor tendons
Passive toe extension
Is surgery needed in curly toe?
Only if pain on activity
For 6+ years
What age group are avulsion fractures more common in?
Teenagers
Explain how a long term consequence of compartment syndrome is Volkmann’s ischaemic contracture
- compartment pressure increase»_space; compartment syndrome
- due to lack of O2, muscles undergo infarction
- in repair, muscle tissues are replaced by scar tissue through fibrosis
- myofibroblasts in fibrosis contract
- flexion contracture
What joints are most commonly effected in osteoarthritis of the foot?
1st MTPJ
Mid foot -TMTJ - tarsometatarsal joints
Complications of osteoarthritis in MTPJ
Hallux rigidis
Hallux valgus
Ligament weakness
Corns + calluses
Complications of osteoarthritis in midfoot
Arch collapse
What joints are affected in osteoarthritis of the ankle?
Talocrural joint
Subtalar joint
Management of osteoarthritis in the foot + ankle
NSAIDs
Support brace
Surgery
Types of tendiopathy and their sites
Insertional tendiopathy - at point of insertion into calcaneum
Non-insertional tendiopathy - at vascular watershed area
Risk factors Achilles tendiopathy
Many years of overuse
Inactivity
Diabetes
Obesity
Signs + symptoms of Achilles tendiopathy
Pain + stiffness in morning
Pain that worsen with activity > severe 24hrs after
Thick tendon
Swelling
Palpable bone spur
What happens in flat foot?
Collapsed medial arch
Valgus angulation of hind foot { }
Who is flat foot normal in and why?
Young children
Arches haven’t developed yet
Medial arch forms ~ 5 years
When is flat foot abnormal?
Persists into adolescence
Occurs during or after adolescence
Describe flexible flat foot
- no medial arch when standing normally
- medial arch appears when standing on tiptoes + valgus hind foot disappears
Describe rigid flat foot
No medial arch
Valgus hind foot
Regardless of how patient is standing
Due to tarsal coalition
What is tarsal coalition?
Failure of tarsal bones to separate
Describe adults acquired flat foot
Dysfunction of Tibialis posterior tendon
Causes stretching of spring ligament and plantar aponeurosis»_space; flat medial arch
Risk factors for adult acquired flat foot
Obesity
Hypertension
Diabetes
Pregnancy - temporarily due to lax ligaments
How can diabetes effect feet?
Foot ulcers
Severe infection
Charot arthropathy
How does diabetes cause feet issues?
- loss of sensation due to peripheral neuropathy
- ischaemia due to peripheral arterial + micro vascular disease
- immunosuppression due to poor glycaemic control
Loss of protective sensation»_space; patients continue to weight bear on soft tissue abnormalities
What is used to decrease the risk of feet issues causes by diabetes?
Diabetic foot clinics for screening
- sensation + perfusion assessed
- correct shoes
- education - glycaemic control
- callouses + corns
- cracks + dry skin
What is charot foot?
Progressive destruction of bones + soft tissue of foot
How does charot foot happen?
Severe diabetic foot
Characterisations of charot foot
Multiple:
- joint dislocations
- fractures
- deformities
Presentation of charot foot
Pain?
Swelling
Loss of sensation
Loss of joint function
Instability
Treatment of charot foot
Treat underlying condition - diabetes > correct glycaemic control
Support deformity
What is hallux rigidus?
Osteoarthritis in 1st MTPJ»_space; stiffness of joint
Signs and symptoms of hallux rigidus
Pain in 1st MTPJ on walking and dorsiflexion of toe
Walking on outside of foot
Restricted dorsiflexion
Dorsal bunion
Surgical management of osteoarthritis
Arthrodesis - joint fusion
Athroplasty - joint replacement
Excision athroplasty - surgical removal of joint with interposition of soft tissue e.g. rolled up tendon
Osteotomy - surgical cutting of bone to allow realignment
What is arthroplasty?
Joint replacement
What is arthrodesis?
Joint fusion
What is excision arthroplasty?
Removal of a joint with interposition of soft tissue
*e.g. rolled up tendon**
What is osteotomy?
Surgical cutting of a bone to allow realignment
Classification of ankle (fibula) fracture
_weber’s classification_
- type A: below the syndesmosis
- type B: at the level of the syndesmosis
- type C: above the syndesmosis
