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MSK > Foot and Ankle > Flashcards

Foot and Ankle Flashcards

1
Q

How is the foot divided up?

What constitutes each part?

A

Forefoot – metatarsals and phalanges; Midfoot – cuneiforms, cuboid and navicular; Hindfoot – talus and calcaneus

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2
Q

What arteries do you absolutely need in order to keep the foot alive?

A

Only either the dorsalis pedis or posterior tibial

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3
Q

What things do you examine in the foot and ankle examination?

A

Exposure – up above the knee; if in tight jeans or trousers then put the patient in a gown
Look – calf wasting, alignment and arches of foot; side view as well
Gait
Feel
Move – done before feeling – ask patient to flex and back again
Neurological – check for sensation at all nerve sites
Vascular - pulses
Special tests

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4
Q

Pes planus
Aka?
What is it?
What causes it?
How common is it?
Acquired flat feet in adults is associated with what?
What are flat footed people at risk of, related to this?
What other ligamentous problem is it associated with?
Treatment?

A

Flat foot
Medial longitudinal arch is collapsed; arch forms when patient stands on the tip toes
20% of general population; often familial
Acquired flat feet in adults is associated with dysfunction of the posterior tibialis tendon (a dynamic stabilizer of the medial arch) - may be due to stretch or rupture
Risk of tendonitis in the PTT
Associated with generalized ligamentous laxity
Mostly asymptomatic so no treatment; orthotics aren’t proven to do anything

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5
Q

Tibialis posterior dysfunction
Where does the tibialis posterior tendon insert?
What is its funtion?
What does repeated stress cause?

A

The tibialis posterior tendon inserts predominantly onto the medial navicular and serves to support the medial arch of the foot (as well as being a plantarflexor and invertor of the foot). The tendon is under repeated stress and particularly with degeneration can develop tendonitis, elongation and eventually rupture. Synovitis form RA can also result in tendon rupture.

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6
Q

Dysfunction of the tibialis posterior tendon
Common or uncommon?
Typical patient?
Course of presentation?

A

Most common cause of acquired flatfoot deformity in adult
Most commonly elderly women; starts off as obese middle aged woman and then progresses into later life
Usually present for years prior to diagnosis - patient has multiple medical consultations where it is often missed
Tends to present late

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7
Q

What motions of the foot does the posterioe tibialis tendon allow?

A

Inversion

Plantar flexion

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8
Q

Risk factors for posterior tibialis tendon dysfunction?

A 
Pes planus
Hypertension
Diabetes
Steroid injections 
Seronegative arthropathies
Tendinosis of unknown aetiology
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9
Q

What do most patients with PTT dysfunction report about their feet?
Symptoms?

A

“My foot shape has changed”
Pain and/or swelling posterior to medial malleolus – very specific
Change in foot shape
Diminished walking ability/balance
Dislike of uneven surfaces
More noticeable hallux valgus
Lateral wall “impingement” pain – fibula against calcaneus
The first thing the patient tends to remember is pain and swelling just behind the medial malleolus
Eventually ends up that they can’t push up off of their foot

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10
Q

What can you see on examination of a foot with PTT elongation or rupture??

A

Heel valgus
Boggy swelling
Front of foot peaking out at the side when viewed from behind

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11
Q

Treatment for posterior tibialis tendonitis?

What should you avoid giving?

A

Physiotherapy is the main treatment
Insole to support medial longitudinal arch is very important to avoid rupture
NO steroid injections, unless there is synovitis in the joint
NSAIDs can be given to relieve inflammation
If it fails to settle after this, surgical decompression and tenosynovectomy may prevent rupture.

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12
Q 
Pes cavus
What is this?
Causes?
What do you see on inspection?
Management?
A

Abnormally high arch in the foot
Can be idiopathic but is often related to neuromuscular conditions
Can see varus heel, clawing of toes
Most used management is orthotics; surgery if required may be complex

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13
Q 
Plantar fasciitis
Common or uncommon?
What time of day does it occur at and what do patients commonly complain of?
What causes it?
Risk factors?
Clinical symptms?
A

Very common
Mostly occurs first thing in the morning with stabbing pain on the plantar surface of the foot which eases off gradually through the day and can be worse after exercise
Caused by repetitive stress/overload or degeneration - self limiting
DM, obesity, frequent walking on hard floors
- Acute stabbing pain + agony
- Fullness or swelling plantarmedial aspect of heel
- Tenderness over plantar aspect of heel and/or plantarmedial aspect of heel

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14
Q

Plantar fasciitis
Which test is positive for which nerve?
Treatment?

A

Tinel’s test positive for Baxters nerve
Treatment is usually conservative
NSAIDs
Night splints - very useful but uncomfortable for patients
Heel cups or medial arch supports
Physiotherapy
Steroid injection
Surgery - 50% success, better if acute onset
NB – plantar fasciitis is usually self-limiting and will typically resolve within 18-24 months. Rest, Achilles and plantar fascia stretching exercises and a gel filled heel pad may help. Corticosteroid injection may also alleviate symptoms.

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15
Q 
Hallux valgus
Aka?
What is this?
Which people does it tend to occur in?
Male to female ratio?
Cause? 
Which MSK conditions is it associated with?
What is a splayed forefoot associated with?
A

Aka bunions
This is a deformity of the big toe due to medial deviation of the 1st metatarsal and lateral deviation of the toe itself
Tends to occur in hypermobile people, also adolescent supgroup
1:3
Something provokes the big to drift out medially, kind of towards the positon it is in in apes. This something is usually wearing shoes that are too tight for you
Rheumatoid arthritis + other inflammatory arthropathis as well as some neuromuscular diseases
Associated with loss of muscle tone and age

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16
Q

What problems does hallux valgus cause?

When should orthotics be used?

A 
Transfer metatarsalgia
Lesser toe impingement
Pain, deformity, cosmesis
Shoe difficulties
NB – orthotics should only be used to protect the tissues which are giving you pain.
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17
Q

What are the four main causes of pain in hallux valgus?

A
  1. 1st MTP joint
  2. Neuralgic pain on the inside of the joint - because a digital nerve is stretched by the bump
  3. Impingement on the overcrowded toes
  4. Transfer metatarsalgia – weight bearing is transferred from the big toe to the other toes of that foot
18
Q

Management of hallux valgus
Non-operative?
Operative?

A

Non-operative - shoe modifications, padding between first two toes
Operative
- Indications – failure of non-op, pain, lesser toe deformities, lifestyle limitation, overlapping, ulceration, functional limitation
- Many osteotomies (not core) – distal osteotomy is the most common procedure done
- Aim to realign the hallux and decrease the HV angle
- Correct any lesser toe deformities at same time (soft tissue releases, osteotomies, fusions)
Despite being commonest pathology, it is the major headache of orthopaedics – there are loads of operations which shows we aren’t good at it

19
Q 
Hallux ridigus
Aka?
Most common complaint?
Natural coarse of the problem?
Treatment?
When should surgery be considered?
Gold standard surgical treatment?
A

Osteoarthritis of the 1st MTP jointIt can be primary (degenerative) or secondary to osteochondral injury
Most common complaint is pain
after around two years the pain stops and goes down
Conservative treatment - stiff rigid insole to stop the toe bending and limit motion at the MTPJ
If the pain is either very severe, or doesn’t subside after trying non-operative measures, then consider surgery, which is either joint replacement or fusion (arthrodesis).
The gold standard surgical treatment is arthrodesis. Successful fusion should alleviate pain with the sacrifice of no motion (the toe is usually pretty stiff anyway)

20
Q

What is the main goal in surgery for rheumatoid foot?

A

The primary goal is to fuse the big toe in a position where the patient can put weight through it and balance – rigid heel or forefoot will do this

21
Q 
Morton's neuroma 
What is this?
Where does it typically occur?
Common or uncommon?
What is the underlying pathology?
What is the most common age group affected? 
More commonly male or female?
A

This is degenerative fibrosis of a digital nerve near its bifurcation, most commonly between 3rd and 4th metatarsals. It is very common.
The underlying pathology is irritated nerve -> inflammation -> neuroma formation. It’s is a degenerative process, causing fibrosis of the digital nerve.

22
Q

What do patients with Morton’s neuroma complain of?

What aggravates it?

A

Patients typically complain of burning forefoot pain (metatarsalgia) and tingling with numbness in the affected toes. It is aggravated by movement as the nerve sits right between the metatarsal heads so when the foot moves you knock the nerve.

23
Q 
What does clinical examination of Morton's neuroma show? 
What is Mulder's click test?
Which investigation might be useful?
Conservative management?
Surgical management?
A

Clinical examination may reveal loss of sensation in the affected web space. Medio‐lateral compression of the metatarsal heads (exerted by squeezing the forefoot with your hand) may reproduce symptoms or produce a characteristic “click”; this is Mulder’s click test.
Ultrasound may be used for diagnosis by demonstrating a swollen nerve.
Conservative management involves the use of a metatarsal pad or offloading insole. Steroid and localanaesthetic injections may relieve symptoms and aid diagnosis.
A neuroma can be excised. However, some patients continue to experience pain and there is a small risk of recurrence.

24
Q

What causes tendonitis of the achilles tendon?
What does this result in?
What are the risk factors for this?

A

Tendonitis of the Achilles tendon is caused by repetitive microtrauma and a failure of collagen repair with loss of fibre alignment/structure, resulting in a hypovascular region 2-6cm proximal to the insertion.
RF
- Over-training
- Some drugs e.g. Ciprifloxacin, steroids -> these generally reduce tendon strength and make them more likely to tear
- Cumulative trauma disorders (CTDs)

25
Q

Symptoms and signs of tendonitis of the achilles tendon?
Which investigations may be useful in diagnosis?
Management?
What can this condition predispose to?
What should you not do in order to prevent this?

A

The patient usually complains of morning stiffness which eases with heat and walking.
Investigations can be USS or MRI, but can also be clinical
Rest and footwear change really helps
NSAIDs, analgesia, orthotics, physio, surgery
Tendonitis predisposes to tendon rupture. Steroid injection should not be administered around the Achilles tendon due to risk of rupture.

26
Q 
Tendo-achilles rupture
Typical patient?
What condition do patients typicallly have prior to this? 
What then consequently causes rupture?
What feeling do patients describe?
A

There is often pre-existing tendinosis and a sudden deceleration with resisted calf contraction e.g. patient stepping off of a curb or lunging. Patients often describe a feeling of somebody hitting them just above the heel.

27
Q

Clinical features of achilles tendon rupture?

What is Simmonds test?

A

Unable to bear weight
Weak plantar flexion
Palpable painful gap
No plantarflexion of the foot is seen when squeezing the calf (Simmonds test)

28
Q

Management of Achilles tendon rupture?

A

Management is controversial – modern management is accelerated rehab – stick the patient in a cast for 9 weeks, then put them in a boot and get them to start working it early.
Both operative and non-operative management have an extended recovery time, but the functional outcome is normally good.

29
Q

Describe the following:
Claw toes
Hammer toes
Mallet toes

A

Claw toes – hyperextension at MTPJ, hyperflexion at PIP and DIP
Hammer – hyperextension at MTP, hyperflexion at PIP, DIP normal
Mallet – MTP normal, fixed DIP and PIP flexion
(remember that flexion is plantar flexion)

30
Q

Metatarsal stretch fracture
Which metatarsals are most commonly affected?
Who does it occur in?
What will xray show and when in the process is this?
Which other investigation can you do?
Treatment?

A

2nd metatarsal followed by 3rd
They may occur in runners, in soldiers, in dancers, or during distance walking in people not conditioned or used to prolonged walks.
Xrays may not demonstrate a fracture for around 3 weeks until resorption at the fracture ends occurs or callus begins to appear. Bone scan may be useful to confirm the diagnosis. Prolonged rest for 6‐12 weeks in a rigid soled boot is required to allow healing and resolution of symptoms.

31
Q

Which is the most commonly sprained ligament in the foot and ankle?

A

Anterior talofibular ligament (ATFL)

32
Q

Which motions cause sprains?
Which movement sprains the ATFL?
Which movement sprains the medial deltoid ligament?

A

Sprains are caused by twisting forces – commonly inversion or twisting forced on a planted foot. Inversion injury affects the ATFL (85% of sprains); 5% are eversion sprains which affect the medial deltoid ligament.

33
Q

How long must the patient have been doing physio before the consultant orthopod will see them?

A

6 months

34
Q

Do kids get ligament injuries?

A

No - they get injury of the bony insertions of ligaments

35
Q

Which classification is used for fractures of the ankle?

A

In general, stable fractures only involve one side They can be graded by Weber’s classification

  • Weber A – distal fibular fracture
  • Weber B - fracture goes through and around the ankle joint and syndesmoses
  • Weber C – occurs above the syndesmoses; usually unstable
36
Q

Which fractures tend to be stable and which tend to be unstable?

A

Stable fractures tend to be: distal fibular fracture with no medial malleolus fracture or deltoid ligament rupture.
Unstable fractures tend to be: distal fibular fracture WITH medial malleolus fracture of deltoid ligament rupture. It is unstable because of talar shift; if left then patient will soon get arthritis. The only solution is to fuse the ankle joint in serious arthritis - unstable ones have to be fixed.

37
Q

What should you always examine in ankle fracture?

A

Proximal end of the fibula

38
Q

What is a pilon fracture?

What are patients at high risk of developing?

A

Pilon fracture - high impact fracture where both feet land on a hard surface, causing both tibia to shatter distally with fracture up the shaft of the tibia, often with talus and fibula displacement. There are often soft tissue problems, and damage to the joint may lead to the development of early OA. There is also a risk of infection, non-union and amputation.

39
Q

What is the most commonly fractured metatarsal?
Which movement causes this?
What are the three types?

A
  1. Avulsion by peroneus brevis tendon (heal predictably in moonboot, do well) – associated with sudden inversion, e.g. stepping off of a curb.
  2. Jones fracture, poor blood supply, 25% risk non-union – this is intra-articular
  3. Proximal shaft (common site for stress fracture)
40
Q 
Lisfranc fracture
What is this?
High impact or low?
What do you see on x-ray?
What management do they commonly require?
A

This is dislocation at the 1st tarsometatarsal joint
These are commonly missed and devastating
Not much force is required to cause these
Metatarsals are dislocated off of the tarsals – the fracture may be subtle and the dislocation difficult to appreciate
All you see is a tiny fleck of bone and a slight widening of the gap
They often require fixation as the patient is at high risk of developing OA

41
Q 
Calcaneus fracture
What causes this?
Which other injuries should you look for?
What is seen on examination?
What is there risk of?
Management?
A

Fall from height
Look for other injuries especially spinal, often intra-articular
Significant swelling
Risk compartment syndrome
Management is controversial, high risk infection/wound breakdown with surgery, benefit not proven

42
Q

Talus fracture
What causes this?
What is there increased risk of consequently?

A

Forced dorsiflexion/rapid deceleration

Talus has reversed blood supply, risk of AVN, and OA

MSK (19 decks)

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