foot and ankle Flashcards
typical signs of congenital talipes equino varus
CAVE
- C: Midfoot cavus (tight intrinsics, FHL, FDL)
- A: Metatarsus adductus (tight tibialis posterior)
- V: Hindfoot in varus (tight tendoachilles, tibialis posterior and anterior)
- E: Heel in equinus (tight tendoachilles)
management of talipes equino varus
- rule out associated disorders (DDH, spinal bifida, arthrogryphosis)
1) conservative (within 1/2 days of birth)
- ponsetti method of manipulation & serial casting (toe to groin plaster of paris)
- followed by foot abduction orthosis: dennis browne boots for infants; moulded ankle foot orthosis for older children
2) surgical (seldom)
- posteromedial soft tissue release & tendon lengthening
- corrective osteotomy
signs elicited in pes planus
- too many toes sign (N: only 4th and 5th toe seen)
- tip toe/dorsiflex: flexible flat foot if medial arch restored and heels invert
- jack’s test: great toe passive extension restores arch as plantar fascia tightens
- beighton’s score: >4
management of infantile flat foot (congenital vertical talus)
operation before 2 years
- no passive correction as tendons and ligaments on dorsolateral side of foot usually shortened)
signs of congenital vertical talus
- rocker bottom foot
- foot in valgus
causes of flexible flat foot in children/adolescents
1) general ligamentous laxity
2) tight tendoachilles (2ndary to growth spurt > muscle imbalance)
3) collagen tissue disorders
management for flexible flat foot in children/adolescents
conservative:
- stretching
- shoes with medial arch support
causes of rigid flat foot/spasmodic flat foot in children/adolescents
1) tarsal coalition +/- peroneal spasm
2) inflammatory joint condition
3) neuromuscular disorder (e.g. CP)
4) ligament (e.g. marfan’s, ehler danlos)
5) idiopathic
management of rigid flat foot in children/adolescents
operation + muscle rebalancing
- remove bony irregularity
- triple arthrodesis if pain intolerable
causes of flat foot in adults
1) constitutional flat feet
2) recent onset
- underlying disorder: RA/general muscular weakness
- tibialis posterior tendon dysfunction
management for flat foot in adults
1) painful rigid flatfoot: foot wear + arch support
2) underlying disorder: treat disorder
3) tibialis posterior tendon dysfunction: operative repair/tendon replacement
commonest foot deformity
halux valgus
risk factors for hallux valgus
- idiopathic
- hereditary
- ra
- loss of muscle tone
- wearing enclosed foot wear
deformities a/w hallux valgus
- inflamed bunion
- hammer toe
- metatarsalgia
- secondary OA of 1st MTPJ
- callosities
- pes planus
signs on XR of hallux valgus
weight bearing XR
- degree of metatarsal & hallux angulation (N: intermetatarsal angle 9deg; hallux valgus angle 10deg)
- presence of OA of 1st MTPJ
management of hallux valgus
1) conservative
- foot wear modifiaiton
- physiotherapy
2) operative
- corrective osteotomy + ST rebalancing around 1st MTPJ
2nd commonest deformity of 1st MTPJ
hallux rigidus
XR complications of achilles tendonitis
1) haglund’s deformity
2) bony spurs
3) intratendineal calcification
management of achilles tendonitis
conservative:
- rest, gentle stretching of tendon, nsaids
- proper foot wear (arch support) +/- orthotics
DO NOT inject steroids > achilles tendon prone to rupture
risk factors for rupture of achilles tendon
LT use of steroids
sign of ruptured achilles tendon
simmond’s test: lack of plantarflexion on squeezing calf
management of ruptured achilles tendon
1) conservative
- cast heel in equinus to approximate tendon ends
- shoes with raised heel
2) surgical (more reliable)
- tendon repair > cast
signs of posterior tibial tendon rupture
- hindfoot: valgus during weight bearing
- midfoot: pes planus
- tenderness around medial malleolus
- active inversion of ankle painful + weak
management of posterior tibial tendon rupture
1) conservative: poorly mobile patients
- splintage
2) surgical: physically active patients
- operative repair or tendon transfer with FDL
differential diganosis for posterior heel pain
1) haglund’s deformity
2) traction apophysitis
3) retrocalcaneal bursitis
commonest cause of heel pain
plantar fasciitis
attachment of plantar fascia
medial calcaneal tuberosity to heads of MT
risk factors for plantar fasciitis
1) men aged 30-65yo
2) runners, jumpers, ballet dancers, obese
3) a/w systemic disease (DM, enthesiopathies - seroneg + seropositive arthritis)
management of plantar fasciitis
1) conservative (90% resolve)
- rest
- stretching exercises (roll ball on heel)
- foot wear modification: supportive shoes with heel cup
- corticosteroid injections
- nsaids
2) surgical
- plantar fascia release
common site of stress fractures in foot
2nd and 3rd metatarsal bones
common sites of stress fractures
head of femur distal end of femur tibia vertebrae 2nd and 3rd metatarsal bones
management of stress fracture of foot
rest
ligaments which make up the lateral ligament complex of ankle
1) ATFL
2) PTFL
3) CFL
frequency of injury of each lateral ligament in relation to one another
ATFL > CFL > PTFL
mechanism of injury of lateral ligament complex
inversion while ankle in plantarflexion
signs of ATFL injury
1) tenderness max just distal and anterior to lateral malleolus
2) pain on passive inversion of ankle
3) anterior drawer for grade III ATFL injury
4) talar tilt
investigations for ATFL injury
XR: AP + lateral + mortise
are mortise stress XR always required?
NO
- only to demonstrate instability if operative repair considered
ligaments which make up the medial ligament complex (deltoid ligament)
1) anterior tibiotalar
2) posterior tibiotalar
3) tibionavicular
4) tibiocalcaneal
management for ATFL injury
1) conservative
- muscle strengthening to prevent recurrent sprains: peroneus longus and brevis)
- taping: prevents excessive movement
- change foot wear
- proprioception exercises
2) surgical
- brostrum procedure: ligament repair
grading of ankle ligamentous injuries
grade I: microscopic tear of collagen fibres
- mimimal tenderness and swelling
- pain but no give
grade II: macroscopic tear of collagen fibres
- moderate tenderness and swelling
- less painful than grade I (pain on motion)
- solid end point to give
grade III: complete tear of collagen fibres
- significant tenderness and swelling
- little to no pain
- no end point
- talar tilt
management of ankle ligamentous injuries
grade I and II:
1) conservative
- RICE
- bandage/brace > begin physiotherapy immediately> protective weight bearing with crutches > stop when patient can walk
grade III:
1) convservative
- brace with hinged knee orthosis + crutches > physiotherapy
note: past - BK cast immobilisation from knee to toes with foot plantar grade
2) surgery: athletes
most common joint for ankle dislocation
subtalar joint
commonest mechanism of injury of ankle malleoli
abduction +/- lateral rotation of ankle
- lateral malleoli shears off at oblique angle
- rupture of deltoid ligament/transverse avulsion fracture of medial malleolus
classification of ankle fractures
1) lauge hansen classification
2) danis weber classificaiton
management of ankle fractures
1) reduce swelling
- elevate leg +/- foot pump
2) reduce fracture
- undisplaced: non weight bearing below knee cast
- displaced: reduce ASAP (type A and B: CRIF, type C ORIF)
types of pilon fractures
I: undisplaced
II: minimally displaced
III: markedly displaced
injuries a/w pilon fracture
1) compartment syndrome
2) compression fracture of vertebral column (esp L1)
3) contralateral fracture of
- calcaneum
- tibial plateau
- pelvis
- acetabulum (vertical shear)
4) vascular injuries
management of pilon fracture
1) conservative
- pain relief
- antibiotics prophylaxis
- elevation
- splint
management of pilon fracture
1) conservative
- pain relief
- antibiotics prophylaxis
- elevation
- splint
2) surgical
- primary stabilisation: calcaneal traction/external fixator +/- fibular fracture fixation
- definitive surgery (after ST optimised): percutaneous pinning
indications for ORIF for ankle fractures
1) fracture dislocation
2) type C fractures
3) trimalleolar fractures
4) talar shift/tilt
5) failure to achieve or maintain closed reduction
complications of ankle fracture
1) early
- vascular injury in severe fracture subluxation
- wound breakdown and infection (esp DM)
2) late
- incomplete reduction (common) > secondary OA
- non union of medial malleolus due to flap of periosteum > prevent ORIF
- joint stiffness > prevent with mobility
- complex regional pain syndrome (swelling and diffuse tenderness, trophic changes and OP)
- high incidence of post traumatic OA from malunion/incomplete reduction
indications for surgery for pilon fracture
1) open fracture
2) displaced fracture
3) vascular compromise
4) compartment syndrome
management of ankle fractures in children
1) SH 1 or 2 (extraarticular): conservative
- closed reduction under GA
- full length cast > below knee walking cast
2) SH 3 or 4 (intraarticular)
- undisplaced: CR under GA
- displaced: ORIF with screws
complications of ankle fractures in children
1) malunion if reduction imperfect > valgus deformity
- children < 10: accommodated by growth and remodelling
- children > 10: osteotomy
2) asymmetrical growth
- fusion of physis (usually medial half) > distal tibia veers into varus (if bridge small> excise + replace with fat pad; if not supramalleolar osteotomy)
3) limb shortening
- proximal tibial epiphysiodesis in opp limb of young child
injuries a/w fracture of calceneus
- spine
- pelvis
- hip (femoral neck)
- tibial plateau
- knee ligamentous injuries
management of calcaneal fracture
1) extraarticular
- RICE
- conservative: bandage > exercise
2) intraarticular
- RICE
- undisplaced (conservative as above)
- displaced: ORIF (interfragmentary screws)
- severe: primary arthrodesis
