Foot Flashcards
Talar fracture mechanism
axial loading or hyperdorsiflexion (MVC, fall from height)
Most common fracture of the talus
Talar neck (50%)
Complication with talar fracture
tenuous blood supply runs distal to proximal along talar neck ■ high risk of AVN with displaced fractures
How to determine extent of AVN
MRI
Talar fracture treatment
• non-operative
■ indication: non-displaced
■ NWB, below-knee cast x 6 wk
• operative
■ indication: displaced
■ ORIF (high rate of nonunion, AVN)
■ neck fracture: ORIF
What are the components of the medial ankle ligament complex (deltoid)
Posterior tibiotala
Anterior tibiotalar
Tibiocalcaneal
Tibionavicular
What is the most common tarsal fracture
calcaneal
What needs to be r/o with calcaneal fracture
spine injury (fractures of thoracic or lumbar spine)
bilateral calcaneal fractures
Clinical features of calcaneal fracture
- marked swelling, bruising on heel/sole
- wider, shortened, flatter heel when viewed from behind
- varus heel
calcaneal fracture investigations
- X-rays: AP, lateral, oblique foot (mandatory views); can also assess with Broden view, Harris view, or AP ankle.
- loss of Bohler’s angle
- CT: gold standard, assess intra-articular extension
calcaneal fracture treatment
- closed vs. open reduction is controversial
- NWB cast x 3 mo with early ROM and strengthening
- Avoid wound complications (10-25%)
- Restore articular congruity
- Restore normal calcaneal width and height
- Maximum functional recovery may take longer than 12 mo
Achilles tendonitis mechanism
• chronic inflammation from activity or poor-fitting footwear • may also develop heel bumps (retrocalcaneobursitis or Haglund deformity
Achilles tendonitis clinical features
- pain, stiffness, and crepitus with ROM
* thickened tendon, palpable bump
Achilles tendonitis investigations
• X-ray: lateral, evaluate bone spur and calcification;
U/S, MRI (to assess degenerative change)
Achilles tendonitis treatment
• non-operative
■ rest, NSAIDs, shoe wear modification (orthotics, open back shoes)
■ heel sleeves and pads are mainstay of non-operative treatment
■ gentle gastrocnemius-soleus stretching, eccentric training with physical therapy, deep tissue calf massage
■ shockwave therapy in chronic tendonitis
■ DO NOT inject steroids (risk of tendon rupture)
What is a Haglund Deformity
an enlargement of the posterior superior tuberosity of the calcaneus
What is the best test for MCL in the elbow
Moving valgus stress test
Achilles tendon rupture mechanism
- loading activity, stop-and-go sports (e.g. squash, tennis, basketball)
- secondary to chronic tendonitis, steroid injection
Achilles tendon rupture clinical features
audible pop, sudden pain with push-off movement
- pain or inability to plantarflex
- palpable gap
- apprehensive toe off when walking
- weak plantarflexion strength
• Thompson test: with patient prone, squeeze calf, normal response is plantar flexion
■ no passive plantarflexion s positive test = ruptured tendon
Achilles tendon rupture investigations
• X-ray (to rule out other pathology),
U/S or MRI (for partial vs. complete ruptures)
Achilles tendon rupture treatment
• non-operative
■ indication: low athletic demand or elderly
■ cast foot in plantar flexion (to relax tendon) x 8-12 wk
• operative
■ indication: high athletic demand
■ surgical repair, then cast as above x 6-8 wk
Most common site of Achilles tendon rupture
2-6 cm from insertion where blood supply is the poorest
Complications of Achilles Tendon rupture
- Infection
- Sural nerve injury
- Re-rupture: surgical repair decreases likelihood of re-rupture compared to nonoperative management
Plantar fasciitis (heel spur syndrome) definition
- inflammation of plantar aponeurosis at calcaneal origin
- common in athletes (especially runners, dancers)
- also associated with obesity, DM, seronegative and seropositive arthritis
Plantar fasciitis (heel spur syndrome) mechanism
• repetitive strain injury causing microtears and inflammation of plantar fascia
Plantar fasciitis (heel spur syndrome) clinical features
- insidious onset of heel pain, pain when getting out of bed, and stiffness
- intense pain when walking from rest that subsides as patient continues to walk, worse at end of day with prolonged standing
- swelling, tenderness over sole
- greatest at medial calcaneal tubercle and 1-2 cm distal along plantar fascia pain with toe dorsiflexion (stretches fascia)
Plantar fasciitis (heel spur syndrome) investigations
- plain radiographs to rule out fractures
- often see bony exostoses (heel spurs) at insertion of fascia into medial calcaneal tubercle
- spur is secondary to inflammation, not the cause of pain
Plantar fasciitis (heel spur syndrome) treatment
• non-operative
■ pain control and stretching programs are first-line
■ rest, ice, NSAIDs, steroid injection
■ physiotherapy: Achilles tendon and plantar fascia stretching, extracorporeal shockwave therapy
■ orthotics with heel cup – to counteract pronation and disperse heel strike forces
• operative
■ indication: failed non-operative treatment
■ endoscopic surgical release of fascia
■ spur removal is not required
Bunions (hallux valgus) definition
• bony deformity characterized by medial displacement of first metatarsal and lateral deviation of hallux
Bunions (hallux valgus) mechanism
- valgus alignment on 1st MTP (hallux valgus) causes eccentric pull of extensor and intrinsic muscles
- many associated deformities in foot from altered mechanics
- reactive exostosis forms with thickening of the skin, creating a bunion
- most often associated with poor-fitting footwear (high heel and narrow toe box)
- can be hereditary (70% have family history)
- 10x more frequent in women
Bunions (hallux valgus) clinical features
- painful bursa over medial eminence of 1st MT head
- pronation (rotation inward) of great toe
- numbness over medial aspect of great toe
Bunions (hallux valgus) investigations
• X-ray: standing AP/lateral/sesamoid view, NWB oblique
Bunions (hallux valgus) treatment
• indications: painful corn or bunion, overriding 2nd toe
• non-operative (first-line)
■ properly fitted shoes (low heel) and toe spacer
• operative: goal is to restore normal anatomy, not cosmetic reasons alone
■ osteotomy with realignment of 1st MTP joint (Chevron Procedure)
■ arthrodesis
Mobility of the metatarsals
• as with the hand, 1st, 4th, 5th MT are relatively mobile while the 2nd and 3rd are fixed
Avulsion of base of 5th metatarsal mechanism
Sudden inversion followed by contraction of peroneus brevis
Avulsion of base of 5th metatarsal clinical presentation
Tender base of 5th MT
Avulsion of base of 5th metatarsal treatment
req ORIF if displaced
Midshaft 5th metatarsal (Jones fracture) mechanism
stress injury
Midshaft 5th metatarsal (Jones fracture) clinical
painful shaft of 5th MT
Midshaft 5th metatarsal (Jones fracture) treatment
NWB BK cast x 6 weeks
ORIF if athlete
Shaft 2nd, 3rd MT (March Fracture) mechanism
stress injury
Shaft 2nd, 3rd MT (March Fracture) clinical
painful shaft of 2nd or 3rd MT
Shaft 2nd, 3rd MT (March Fracture) treatment
symptomatic
1st MT # mechanism
trauma
1st MT # clinical
painful 1st metatarsal
1st MT # treatment
ORIF if displaced otherwise NWB BK cast x 3 weeks then walking cast x 2 weeks
Tarso-MT fracture-dislocation (Lisfranc fracture) mechanism
Fall onto plantar flexed foot or direct crush injury
Tarso-MT fracture-dislocation (Lisfranc fracture) clinical
Shortened forefoot prominent base
Tarso-MT fracture-dislocation (Lisfranc fracture) treatment
ORIF
