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Orthopaedics & Rheumatology > Foot and Ankle > Flashcards

Foot and Ankle Flashcards

1
Q

Ankle Joints

A
  • Ankle is a hinge joint
  • Motions = flexion/extension
  • Inversion/eversion occurs at calcaneo-talar joint (below the ankle)
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2
Q

Lateral Ligaments of the Ankle

A
  • Anterior talo-fibular - 1st to tear in ankle sprains
  • Calcaneo-fibular
  • Posterior talo-fibular
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3
Q

Medial Ligaments of the Ankle

A
  • Deltoid ligament
  • Tibiofibular ligament
    • aka inerosseous ligament
    • aka syndesmotic ligament
    • joins distal tibia-fibula
    • maintains integrity of mortise joint
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4
Q

Extensor Tendons of the Ankle

A
  • dorsiflexors
  • pass anterior to the ankle
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5
Q

Plantar Flexor Tendons of the Ankle

A
  • pass posterior to medial malleolus
  • “tom, dick and harry”
    • Tibialis posterior
    • Flexor digitorum
    • Flexor hallicus
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6
Q

Peroneal Tendons of the Ankle

A
  • evertors of the ankle
  • pass posterior to the lateral malleolus
  • Peroneal longus and brevis
    • Brevis is often involved in avulsion fractures of the 5th metatarsal
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7
Q

Achilles Tendon

A
  • arises from gastroc and soleus
  • inserts on calcaneous
  • plantar flexes the foot - strongest plantar flexor
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8
Q

Retinacula

A

Fibrous bands that hold tendons in place

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9
Q

Ankle Sprains

A
  • Ligamentous injury
    • usually inversion mechanism
    • >90% lateral ligaments
      • most are anterior talo-fibular ligament
      • very few are deltoid ligament and tib-fib syndesmosis
    • Lateral ligaments tear in sequence anterior to posterior
    • Deltoid ligament sprain
      • due to eversion mechanism
      • usually with associated fibula fx
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10
Q

Ankle Sprains: clinical

A
  • pain, swelling
  • +/- inability to bear weight
  • foot may be inverted (talar tilt)
  • passive inversion results in increased pain
  • stress maneuvers
    • drawer test
    • inversion stress
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11
Q

Ottawa Ankle Rules

A
  • bony tenderness along distal 6cm of tibia or fibula
  • bony tenderness at base of 5th metatarsal
  • inability to bear weight both immediately after injury and in emergency department
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12
Q

Ankle Sprain: Classification

A
  • First-degree
    • ligament stretching
    • local tenderness, minimal swelling
  • Second-degree
    • severe stretching/partial tearing
    • more tenderness and swelling
    • abnormal stress tests
  • Third-degree
    • complete rupture
    • can’t bear weight
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13
Q

Ankle Sprain: management

A
  • ice, elevation
  • immobilize with plastic or plaster splint
  • consider crutches
    • if moderate-severe
    • if difficulty bearing weight with splint
  • third degree sprains may need surgery (rare)
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14
Q

Ankle Fractures

A
  • may be malleolar, bimalleolar, trimalleolar
  • often disrupt tib-fib ligament and mortise joint
    • tib-fib (syndesmotic) ligament normally maintains integrity of mortise
    • exception: distal fibula fx
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15
Q

Weber Classification

A
  • Weber A
    • fibula fx below syndesmosis
    • mortise usually intact
  • Weber B
    • fibula fx at level of syndesmosis often tearing ligament
    • may disrupt mortise
  • Weber C
    • fibula fx above syndesmosis, always tearing ligament, disrupting mortise
    • always unstable
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16
Q

Ankle Fracture: clinical

A
  • pain, swelling, bruising, inability to bear weight
  • significant deformity if dislocation is present
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17
Q

Ankle Fracture: management

A
  • reduce fracture-dislocations
  • immobilize in splint
  • elevate
  • surgery needed if mortise disrupted
    • need to restore anatomic position of talus on mortise
    • ensure smooth articular surface
  • cast 6-8 weeks
  • arthritis likely if poorly aligned joint surface
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18
Q

Calcaneous Fracture

A
  • most commonly fractured tarsal bone
  • mechanism usually due to compression
    • e.g fall from height
    • 10% associated with lumbar fx
    • 26% associated with other extremity injury
  • Clinical: swelling, pain, ecchymosis
  • X-ray: standard foot films usually demonstrate, consider calcaneal views
  • Treatment: surgical, need to restore anatomy
19
Q

Talar Fracture Etiology

A
  • usually due to foot hyper-plantar flexion
  • fx may involve dome, neck or body
  • talus covered by cartilage, blood supply, tenuous
    • fx may lead to avascular necrosis
20
Q

Talar Fracture Clinical

A
  • intense pain
  • inability to bear weight
  • localized tenderness and swelling
  • may have loss of normal foot contour
  • caution “ankle sprain” misdiagnosis
  • diagnose with foot x-rays
21
Q

Talar Fracture Management

A
  • ice, elevation, immobilization
  • nonsurgical, if non-displaced minor chip fx of dome
  • surgery, if displaced fx of neck or body
22
Q

Midfoot: Cuboid Fracture

A
  • usually due to crush injury
  • usually associated navicular or cuneiform injuries
  • pain/swelling/tenderness
  • foot x-ray
  • conservative prescription if non-displaced
  • ORIF if displaced
23
Q

Midfoot: Proximal 5th Metatarsal Fx

A
  • the most common metatarsal fx
  • often occurs with lateral ankle sprain
  • always check for tenderness at base of 5th MT when evaluating ankle sprain
  • ankle x-rays must visualize this area
  • usually due to inversion/avulsion of proximal bone by peroneus brevis tendon
  • treatment:
    • usually conservative, immobilize, crutches
24
Q

Jones Fracture of 5th Metatarsal

A
  • Not an avulsion fracture
  • Involves diaphysis of 5th metatarsal
  • Has higher incidence of non-union or delayed union
25
Q

Forefoot Fractures: stress fx

A
  • stress fractures of midshaft metatarsals
    • usually 2nd and 3rd MT’s, which are relatively fixed
      • 1st, 4th, 5th relatively mobile
    • due to excessive stress over time
    • may not appear on x-ray for 2-3 weeks
    • if suspected:
      • bone scan
      • repeat xray in 2-3 weeks
    • Rx: rest, possibly immobilize
26
Q

Forefoot Fractures: complete

A
  • Complete midshaft metatarsal
    • usually crush mechanism
    • occasionally due to twisting mechanism
    • often more than one MT is fractured
    • Rx: ice, immobilize with plaster/fiberglass
27
Q

Forefoot Fractures: phalanges

A
  • common: often see fracture-dislocation
  • usually due to direct trauma or hyper-extension
  • exam: pain/swelling, deformity if dislocated
  • Rx:
    • reduce fx and/or dislocation
    • immobilize with dynamic splinting (buddy taping)
    • stiff-soled shoes
    • great toe bears 1/3 of weight of body on that side may require walking cast
    • if unable to reduce may require internal fixation (rare)
28
Q

Metatarsalgia

A
  • Nagging forefoot pain over middle metatarsal heads
  • Usually due to faulty weight distribution
    • e.g weight gain, hallux valgus, flat foot
    • metatarsal heads bear disproportionate weight
    • also, gout. rheum athritis
  • Treatment symptomatic, directed at cause
29
Q

Morton’s Neuroma

A
  • a neuropathy of interdigital nerve, usually proximal to bifurcation
  • usually nerve supplying 2nd and 3rd toes
  • nonspecific inflammation of nerve with proliferative connective tissue
  • most common in middle-aged women
  • Clinical:
    • sudden attacks of sharp or burning pain, radiating to toes
    • at first, pain only with walking
    • later, pain even at rest
    • localized webspace tenderness, reproduces pain
    • may palpate small mass in webspace
  • Management: initial steroid/lidocaine injection, definitive surgical excision
30
Q

Hallux Rigidus

A
  • stiffness of MTP joint of great toe
  • caused by arthritis, local trauma, gout
  • more common in men
  • clinical: pain with walking, tender MTP joint, pain with dorsiflexion
  • X-ray: arthritic changes, osteophytes, narrowed joint space
  • Management: rocker-soled shoes, NSAIDs, possibly surgery (joint replacement vs fusion)
31
Q

Hallux Valgus

A
  • most common foot deformity
  • great toe angles “inward” (valgus)
  • more common in females
  • often familial
  • obvious deformity
    • prominent bunion
    • red, swollen
  • management: conservative - wide, padded shoes. surgical - corrective osteotomy
32
Q

Hammertoe

A
  • PIP joint fixed in flexion, DIP extended
  • most commonly affects second toe
  • shoe pressure may produce corns/calluses on dorsum of toe
  • treatment: operative: joint excision
33
Q

Pes Planus (Flat Foot)

A
  • due to collapsed medial arch
  • may be congenital or acquired (polio, rheum. arthritis, tendon ruptures)
    • flexible most common
    • rigid due to congenital vertical talus or spasmodic peroneal muscles
  • Clinical:
    • arching feet with standing/walking
    • shoes wear badly esp over arch
    • on exam medial border of foot almost touches ground when standing
  • Management: small children usually none, older kids/adolescents arch support, if underlying condition may need surgical correction
34
Q

Plantar Fasciitis

A
  • usually an overuse injury
    • runners, standing occupations, also rheum arthritis and gout
  • strain of fascial fibers, friction causes periostitis of calcaneous
  • Clinical:
    • pain over plantar surfaces: increased pain with walking, running. relief with rest
    • tender to palpation over anterior calcaneus
    • pain with passive dorsiflexion
  • Management: rest, NSAIDs, heel and arch supports, steroid injection
35
Q

Posterior Tibial Tendonitis

A
  • post. tibial tendon is a plantar flexor of foot
    • passes posterior to medical malleolus
  • overuse injury
  • management:
    • rest, NSAIDs
    • possibly immobilize
    • possible steroid injection
36
Q

Peroneal Tendonitis

A
  • peroneal tendons pass posterior to lateral malleolus
  • overuse injury
  • management:
    • rest, NSAIDs
    • possible immobilie
    • possible steroid injection
37
Q

Tarsal Tunnel Syndrome

A
  • entrapment of posterior tibial nerve by flexor retinaculum
  • due to inflammation
    • repetitive activity
    • rheum arthritis
    • pregnancy
    • acute trauma: fx dislocation, soft tissue swelling
  • clinical: numbness, pain of sole of foot
  • Management: rest, NSAIDS, immobilize, possible surgery
38
Q

Subluxing Peroneal Tendons

A
  • occurs after injury that disrupts peroneal retinaculum
  • acute or chronic
  • tendons sublux or actually disclose over lateral malleolus
  • seen best with foot eversion
  • treatment: surgical
39
Q

Achilles Tendonitis

A
  • overuse of calf muscles
  • tenderness, increased pain with dorsiflexion
  • acute management: rest, ice, NSAIDs, immobilize
  • chronic management: surgery to divide fascia
40
Q

Achilles Tendon Rupture

A
  • usually due to forced dorsiflexion of ankle
    • initiating sprint
    • slipping on stair
  • also may see with direct trauma
    • blow to taut tendon, laceration
  • may be partial or complete
  • most common in middle-aged men
  • symptoms: sudden pain, pt may hear snap, difficulty stepping off
  • exam: swelling of distal calf, palpable tendon defect, weak plantar flexion, may still be able to flex, positive thompson test
41
Q

Thompson Test

A
  • sensitive to detect achilles rupture
  • pt lies prone with knee flexed at 90 degrees
  • squeeze calf, foot should plantar flex
  • achilles rupture: foot does not flex
42
Q

Achilles Tendon Rupture Management

A
  • splint in equinus
  • non-weight bearing
  • refer to ortho
  • conservative: casting x 8 weeks, physical therapy
  • surgical: recommended for younger, athletic pts
43
Q

Hindfoot Bursitis

A
  • Two bursae
    • between calcaneus and achilles tendon
    • between achilles tendon and skin
  • overuse injury
    • poorly fitting shoes
  • inflammation, pain on motion
  • management:
    • rest, NSAIDs, proper fitting shoes
    • consider steroid injection

Orthopaedics & Rheumatology (5 decks)

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