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phase iii orthopaedics > foot and ankle > Flashcards

foot and ankle Flashcards

1
Q

typical signs of congenital talipes equino varus

A

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)
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2
Q

management of talipes equino varus

A
  • 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

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3
Q

signs elicited in pes planus

A
  • 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
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4
Q

management of infantile flat foot (congenital vertical talus)

A

operation before 2 years

- no passive correction as tendons and ligaments on dorsolateral side of foot usually shortened)

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5
Q

signs of congenital vertical talus

A
  • rocker bottom foot

- foot in valgus

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6
Q

causes of flexible flat foot in children/adolescents

A

1) general ligamentous laxity
2) tight tendoachilles (2ndary to growth spurt > muscle imbalance)
3) collagen tissue disorders

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7
Q

management for flexible flat foot in children/adolescents

A

conservative:
- stretching
- shoes with medial arch support

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8
Q

causes of rigid flat foot/spasmodic flat foot in children/adolescents

A

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

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9
Q

management of rigid flat foot in children/adolescents

A

operation + muscle rebalancing

  • remove bony irregularity
  • triple arthrodesis if pain intolerable
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10
Q

causes of flat foot in adults

A

1) constitutional flat feet
2) recent onset
- underlying disorder: RA/general muscular weakness
- tibialis posterior tendon dysfunction

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11
Q

management for flat foot in adults

A

1) painful rigid flatfoot: foot wear + arch support
2) underlying disorder: treat disorder
3) tibialis posterior tendon dysfunction: operative repair/tendon replacement

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12
Q

commonest foot deformity

A

halux valgus

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13
Q

risk factors for hallux valgus

A
  • idiopathic
  • hereditary
  • ra
  • loss of muscle tone
  • wearing enclosed foot wear
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14
Q

deformities a/w hallux valgus

A
  • inflamed bunion
  • hammer toe
  • metatarsalgia
  • secondary OA of 1st MTPJ
  • callosities
  • pes planus
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15
Q

signs on XR of hallux valgus

A

weight bearing XR

  • degree of metatarsal & hallux angulation (N: intermetatarsal angle 9deg; hallux valgus angle 10deg)
  • presence of OA of 1st MTPJ
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16
Q

management of hallux valgus

A

1) conservative
- foot wear modifiaiton
- physiotherapy

2) operative
- corrective osteotomy + ST rebalancing around 1st MTPJ

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17
Q

2nd commonest deformity of 1st MTPJ

A

hallux rigidus

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18
Q

XR complications of achilles tendonitis

A

1) haglund’s deformity
2) bony spurs
3) intratendineal calcification

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19
Q

management of achilles tendonitis

A

conservative:

  • rest, gentle stretching of tendon, nsaids
  • proper foot wear (arch support) +/- orthotics

DO NOT inject steroids > achilles tendon prone to rupture

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20
Q

risk factors for rupture of achilles tendon

A

LT use of steroids

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21
Q

sign of ruptured achilles tendon

A

simmond’s test: lack of plantarflexion on squeezing calf

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22
Q

management of ruptured achilles tendon

A

1) conservative
- cast heel in equinus to approximate tendon ends
- shoes with raised heel

2) surgical (more reliable)
- tendon repair > cast

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23
Q

signs of posterior tibial tendon rupture

A
  • hindfoot: valgus during weight bearing
  • midfoot: pes planus
  • tenderness around medial malleolus
  • active inversion of ankle painful + weak
24
Q

management of posterior tibial tendon rupture

A

1) conservative: poorly mobile patients
- splintage

2) surgical: physically active patients
- operative repair or tendon transfer with FDL

25
Q

differential diganosis for posterior heel pain

A

1) haglund’s deformity
2) traction apophysitis
3) retrocalcaneal bursitis

26
Q

commonest cause of heel pain

A

plantar fasciitis

27
Q

attachment of plantar fascia

A

medial calcaneal tuberosity to heads of MT

28
Q

risk factors for plantar fasciitis

A

1) men aged 30-65yo
2) runners, jumpers, ballet dancers, obese
3) a/w systemic disease (DM, enthesiopathies - seroneg + seropositive arthritis)

29
Q

management of plantar fasciitis

A

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

30
Q

common site of stress fractures in foot

A

2nd and 3rd metatarsal bones

31
Q

common sites of stress fractures

A 
head of femur
distal end of femur
tibia
vertebrae
2nd and 3rd metatarsal bones
32
Q

management of stress fracture of foot

A

rest

33
Q

ligaments which make up the lateral ligament complex of ankle

A

1) ATFL
2) PTFL
3) CFL

34
Q

frequency of injury of each lateral ligament in relation to one another

A

ATFL > CFL > PTFL

35
Q

mechanism of injury of lateral ligament complex

A

inversion while ankle in plantarflexion

36
Q

signs of ATFL injury

A

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

37
Q

investigations for ATFL injury

A

XR: AP + lateral + mortise

38
Q

are mortise stress XR always required?

A

NO

- only to demonstrate instability if operative repair considered

39
Q

ligaments which make up the medial ligament complex (deltoid ligament)

A

1) anterior tibiotalar
2) posterior tibiotalar
3) tibionavicular
4) tibiocalcaneal

40
Q

management for ATFL injury

A

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

41
Q

grading of ankle ligamentous injuries

A

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
42
Q

management of ankle ligamentous injuries

A

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

43
Q

most common joint for ankle dislocation

A

subtalar joint

44
Q

commonest mechanism of injury of ankle malleoli

A

abduction +/- lateral rotation of ankle

  • lateral malleoli shears off at oblique angle
  • rupture of deltoid ligament/transverse avulsion fracture of medial malleolus
45
Q

classification of ankle fractures

A

1) lauge hansen classification

2) danis weber classificaiton

46
Q

management of ankle fractures

A

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)

47
Q

types of pilon fractures

A

I: undisplaced
II: minimally displaced
III: markedly displaced

48
Q

injuries a/w pilon fracture

A

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

49
Q

management of pilon fracture

A

1) conservative
- pain relief
- antibiotics prophylaxis
- elevation
- splint

50
Q

management of pilon fracture

A

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

51
Q

indications for ORIF for ankle fractures

A

1) fracture dislocation
2) type C fractures
3) trimalleolar fractures
4) talar shift/tilt
5) failure to achieve or maintain closed reduction

52
Q

complications of ankle fracture

A

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

53
Q

indications for surgery for pilon fracture

A

1) open fracture
2) displaced fracture
3) vascular compromise
4) compartment syndrome

54
Q

management of ankle fractures in children

A

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

55
Q

complications of ankle fractures in children

A

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

56
Q

injuries a/w fracture of calceneus

A
  • spine
  • pelvis
  • hip (femoral neck)
  • tibial plateau
  • knee ligamentous injuries
57
Q

management of calcaneal fracture

A

1) extraarticular
- RICE
- conservative: bandage > exercise

2) intraarticular
- RICE
- undisplaced (conservative as above)
- displaced: ORIF (interfragmentary screws)
- severe: primary arthrodesis

phase iii orthopaedics (6 decks)

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