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Clin Med II - Ortho > Foot and Ankle > Flashcards

Foot and Ankle Flashcards

1
Q

Forefoot

A

metatarsals through phalanges

5 rays

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2
Q

Midfoot

A

Navicular
Cuboid
Cuneiform (medial, intermediate & lateral)

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3
Q

Hindfoot

A

Talus

Calcaneus

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4
Q

Ankle problems - in general

A 
Sprains
Fx
Achilles tendonitis
Peroneal tendonitis
Osteochondral lesion
Subtalar synovitis
Ankle arthritis - OA, RA
Tarsal tunnel
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5
Q

Hindfoot problems - in general

A

Plantar fasciitis
Haglund deformity
Poster tibial dysfuction

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6
Q

Midfoot problems

A

Plantar fasciitis
Plantar fibromas
OA

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7
Q

Forefoot problems

A 
Jones fx
Stress fx
Metatarsal fxs
Metatasalgia
Interdigital neuroma
Hallux rigitdus
Hallux valgus
Hammertoe
Clawtoes
Ingrown toenails
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8
Q

Hx - in general

A 
DETAILS!!!
Onset of injury/pain
MOI
Duration of symptoms
Affected on ADLs
Past trauma / sxs
Chronic illness
Employment
Exercise
Weight
Age/gender
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9
Q

PE - in general

A 
Inspection / observation
Neurovascular status
ROM
Palpation
Ligament stability
Muscle strength
Proprioception
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10
Q

Ankle Sprains - Epidemiology

A

Most common sports injury (40%)
10% of ALL ER visits
40-50% of pts have long term sequelae

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11
Q

Ankle Sprains - Grading

A

I - no instability
II - Mild laxity of ligaments
III - Severe laxity, rupture of calcaneofibular and anterior talofibular ligaments

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12
Q

Ankle Sprains - General

A

Most involve the lateral ligament complexes as results of plantar flexion and inversion

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13
Q

Ankle sprain - hx

A

MOI
Audible pop
Swelling
Decreased function

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14
Q

Ankle sprain - PE (in general)

A 
Observation
Bruising
Edema
Palpate to localize pain
ROM
Muscle strength
Proprioception
Ligamentous stability testing
Deltoid Ligament stability
Test integrity of tibiofibular syndesmosis
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15
Q

Ankle sprain - Palpate to Localize Pain

A 
Bony vs. ligamentous
Ligaments
- Lateral complex
- Medial complex
Bony Landmarks
- Medial and lateral malleoli
-Base and shaft of 5th metatarsal
Proximal fibula
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16
Q

Ankle Sprain - ROM

A

Functional

  • 10° dorsiflexion
  • 25° plantar flexion
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17
Q

Ankle Sprain - Ligamentous stability testing

A

Anterior talofibular ligament - Anterior Drawer

Talar tilt test

Deltoid Ligament stability

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18
Q

Anterior Drawer Test

A

Pt sitting with knee flexed to 90°
Stabilize tibia with one hand
Grip calcaneus and talus anteriorly while pushing tibia posteriorly
With significant ligament injury, there will be a feeling of laxity or subluxation
- Translation of 5mm more than contralateral side is a positive test

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19
Q

Talar Tilt Test

A

Tests stability of calcaneofibular and anterior talofibular ligaments
Place inversion strss on the heel with foot in plantar flexion
- Tests stability of the ATF ligament
Place inversion stress on the heel with foot in neutral of dosriflexion
- Tests stability of calcaneofibular ligament

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20
Q

Deltoid ligament stability

A

Stabilize pt’s leg around the tibia and calcaneus and evert the foot

Gross gapping at the mortise indicates torn deltoid ligament

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21
Q

Test integrity of tibiofibular syndesmosis

A

Squeeze Test

External rotation test

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22
Q

Squeeze test

A

With pt sitting on exam table legs dangling over the edge, foot is placed in dorsiflextion
Place one hand on the pt’s tibia and the other on their fibula (close to the ankle)
Squeeze the tow leg bones together, straining the ligaments of the ankle.
The test is positive if he or she feels pain over the space between the bones

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23
Q

External rotation test

A

Place ankle in dorsiflexion and externally rotate foot

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24
Q

Ankle Sprain imaging

A

Ottawa Ankle Rules

Determine the need for x-rays in pts with an ankle injury
Pain in malleolar zone and any one of the following
- Bone tenderness along the distal 6 cm of the posterior edge of the fibula or tip of the lateral malleolus
- Bone tenderness along the distal 6 cm of the posterio edge of the tibia or tip of the medial malleolus
- Inability to bear weight for 4 steps both immediately and in the ED

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25
Q

Ankle Sprain - Tx Phase I

A

RICE
Function ankle brace or stirrup
Weight bearing as tolerated and crutches as needed
NSAIDs

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26
Q

Ankle sprain - Tx Phase II and III

A

Rehab (2-8 weeks post injury)

Increase ROM and improve strength

Followed by proprioception, agility and endurance training

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27
Q

Ankle Sprain - Tx sx

A

Sx tx of the acute ligamentous injury is indicated only for the occasional elite athlete

Most ligamentous injuries will heal sufficiently with no significant disability

Less severe ankle sprains may cause chronic pain or functional instability if not tx conservatively

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28
Q

Chronic Ankle Instability - Tx

A

Non-operative

  • PT
  • Orthotic devices
  • External stabilization

Operative Tx
- Reserved only for those who have failed conservative tx and have persistent symptoms

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29
Q

MOI of Ankle fx

A

Inversion
Eversion
Outward Rotation

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30
Q

Stable Ankle fx

A

Involve one side of the joint

Fx of distal fibula w/o injury to deltoid ligaments

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31
Q

Unstable ankle fx

A

Include both side of the ankle joint

Bimalleolar or trimalleolar

Trimalleolar includes posterior malleolus of the tibia

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32
Q

Ankle fx - PE (in general)

A

Inspection

Palpation

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33
Q

Ankle fx - Inspection

A 
Deformity
- External rotation or lateral displacement of foot
Eccymosis
Edema
Laceration
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34
Q

Ankle fx - Palpation

A

Pain / tenderness
- Palpable gap
Deformity
Neurovascular status

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35
Q

Ankle fx - Imaging

A

X-rays

  • AP
  • Lateral
  • Mortise views
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36
Q

Types of Ankle fx

A

Avulsion fx
Bimalleolar fx
Trimalleolar fx
Open Fx

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37
Q

Ankle fx - Optimal tx criteria

A
  1. Dislocations and fxs should be reduced ASAP
    - Splint with joint in most normal position
    - If fx is open, give abx and take to OR for emergent irrigation and debridement
  2. All joint surfaces must be precisely restored
  3. Fx must be held in a reduced position during bony healing
  4. Joint motion should begin as early as possible
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38
Q

Ankle fx - Tx of stable fx of distal fibula

A

Weight bearing cast or pneumatic walker for 4-6 weeks

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39
Q

Ankle fx - Tx of unstable fx

A

REFER TO ORTHO

Unstable, non-displaced fx - non-weight bearing cast for 6-8 weeks

Unstable, displaced fx

  • Closed reduction or ORIF
  • ORIF provides better restoration of the joint function
  • Always check for widening of the ankle joint due to syndesmotic rupture
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40
Q

Ankle fx - Tx of open fx

A

Sx for irrigation and debridement and ORIF

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41
Q

Ankle fx - sx tx standard of care

A

ORIF
Immobilization for 6 weeks
Then weight bearing slowly advanced
PT for ROM, strength and ankle proprioception

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42
Q

Post Ankle Fx Tx Sequelae

A

Post-traumatic arthritis

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43
Q

Post-traumatic arthritis - Joints affected

A 
Tibiotalar (ankle)
Talonavicular
Subtalar
Calcaneocuboid
Tarsometatarsal
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44
Q

Clinical Presentation of Post-traumatic arthritis

A

Pain - worsened by standing or walking
Decreased ROM
Stiffness

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45
Q

PE of Post-traumatic arthritis

A

Pain to palpation over affected joint
Joint deformity
Loss of motion
Swelling

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46
Q

Dx imaging of Post-traumatic arthritis and findings

A

X-rays - weight bearing

  • AP
  • Lateral
  • Oblique

Findings

  • Joint space narrowing
  • Osteophytes
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47
Q

Tx for Post-traumatic arthritis

A 
Shoe Modifications
Orthotics
 - Foot
- AFO
NSAIDs
Steroid injections
Sx - Arthrodesis
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48
Q

Achilles Tendon Rupture - Epidemiology

A 
30-50 yo male, recreational athlete (weekend warrior)
Steroid use
Fluoroquinolones
Gout
Arteriosclerosis
Renal insufficiency
Hyperthyroid
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49
Q

Achilles Tendon Rupture - MOI

A

Mechanical overload from eccentric contraction of gastrocsoleus complex
Sudden, forceful dorsiflexion of foot as the gastrosoleus in contraction

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50
Q

Achilles Tendon Rupture - Hx and PE

A 
Pt report of hearing or feeling a "pop"
Difficulty with ambulation
Weakness with pushoff
Swelling with palpable defect in Achilles Tendon 
Ecchymosis
Thompson test - dx
51
Q

Achilles Tendon Rupture - dx imaging

A

MRI is extremely sensitive, but rarely needed

Hx & PE are usually dx

52
Q

Achilles Tendon Rupture - tx

A

REFER TO ORTHO

Non-operative tx
- serial casting of the lower leg with the ankle in plantar flexion

Sx tx

  • Repair the Achilles Tendon
  • Potential for wound healing problems
  • Also requires serial casting with gradual progression to weight bearing
  • PT for 6-12 weeks
53
Q

Posterior Tibial Tendon Dysfunction - Epidemiology

A

Overweight
Female
>50 yo
Primary cause of medial ankle pain in middle aged pts

54
Q

Posterior Tibial Tendon Dysfunction - MOI

A

Tendon becomes thickened and degenerates over time

Posterior tibial tendon is one of the main supporting structures of the medial ankle and arch

Function is lost and an acquired pes planus ensues

55
Q

Posterior Tibial Tendon Dysfunction - PE

A

Pain and swelling on the inside of the ankle
Loss of arch and ankle “rolls in” - medial arch decreased or flattened
Initially pain medially but eventually moves laterally as fibula impinges
Muscle weakness
Cannot do heel raise on affected side

56
Q

Posterior Tibial Tendon Dysfunction - Dx Imaging & Findings

A

Weight-bearing AP and lateral x-rays

Findings - sagging of talonavicular and naviculocuneiform joints

57
Q

Posterior Tibial Tendon Dysfunction - Tx Acute

A

NSAIDs
Immobilization (short leg cast or pneumatic walker)
Activity Modification

58
Q

Posterior Tibial Tendon Dysfunction - Chronic tx

A 
Orthotics
Sx
- Debridement of tendon
- Tendon transfer and realignment osteotomy
- Arthrodesis
59
Q

Plantar Fasciitis - General

A 
Inflammation of the plantar fascia, usually near the insertion of the fascia on the calcaneus
Probably secondary to repetitive strain 
Common condition
Bil heels may be affected
W>M,  2:1
60
Q

Plantar Fasciitis - Hx

A

Pain directly beneath the calcaneus
May be along the arch
Usually worse with the first steps in the morning or period of inactivity

61
Q

Plantar Fasciitis - PE

A

Point tenderness just anterior to calcaneus

Pain with dorsiflexion of toes and ankle

62
Q

Plantar Fasciitis - Dx imaging

A

Not generally necessary

Weight-bearing lateral needed if proceeding with steroid injection

63
Q

Plantar Fasciitis - Tx

A 
Tx s/s
Ice
Heel lift
NSAIDs
Activity/exercise modification
Stretching / PT
Night splints
Steroid injections
Short leg walking cast for 6 weeks is beneficial in some case
Refer to ortho if pt fails conservative tx (for sx)
64
Q

Lisfranc Dislocation - In General

A

Traumatic disruption of tarsometatarsal joints
Results from significant trauma or indirectly from athletic injury - typically an axial load on a plantar flex foot
Second metatarsal and intermediate cuneiform joint is crucial in maintaining the stability of the tarsalmetatarsal joints

65
Q

Lisfranc Dislocation - PE

A

Pain - over the tarsalmetatarsal joint
Edema - substantial
Malalignment - medial border of the second and fourth metatarsals should align with the medial borders of the middle cuneiform and the cuboid
Soft tissue damage - open wounds; vascular impairment; blistering

66
Q

Lisfranc Dislocation - dx imaging

A

x-ray

  • Lateral
  • AP - medial aspect of the middle cuneiform should align with the medial border of the second metatarsal
  • Oblique - medial aspect of fourth metatarsal should align with the medial border of the cuboid

May need weight bearing images for subtle injuries
May need comparison views
May see an avulsion fx
Any widening >2 mm is significant

67
Q

Lisfranc Dislocation - Tx

A 
REFER TO ORTHO
Non-displaced 
- Immobilize
- Non-weight bearing for 6-8 weeks
- Rigid arch support for 3 months
Displaced
- Closed reduction ASAP
- ORIF often required
- Post-op immobilized and non-weight bearing for  weeks, then slow progression
Remove hardware - 4 months post-op
68
Q

Charcot Foot - in general

A

Neuropathic, neurotrophic, or neutroarthropathic joint

DM - leading cause

69
Q

Charcot Foot - characterized by

A

Destruction of joint surfaces

Fx with accompanied dislocations of one or more joints with an inappropriate pain response

70
Q

Charcot Foot - requirements

A

Active pt with neuropathy and adequate blood supply

71
Q

Charcot Foot - Stages

A

I
- Acute inflammatory phase characterized by swelling, erythema, and increased warmth
- Radiographs reveal fx and dislocations
- MUST R/O INFECTIONS
2 - Signs of healing, less swelling, warmth and ex-ray shows new bone formation
3
- Chronic phase with consolidation and resolution of inflammation and creation of rocker bottom
- Arch collapses, hindfoot and ankle with risk of collapse into varus or valgus
- increased risk of ulcer formation

72
Q

Charcot Foot - tx

A

Refer to Ortho
Non-sx tx
- Stages 1 & 2 - immbolization splint, brace, orthosis or cast (weigh-bearing is debatable)
- Stage 3 - AFO or other accommodative footwear (rocker-bottom shoe)
Sx tx
- Early stages - ORIF & fusion
- Later stages - realignment osteotomy, fusion or removal of bone prominence

73
Q

Charcot Foot - goals of tx

A

Limit destruction of joint

Preserve stable plantigrade foot that protects soft tissues and prevents ulceration

74
Q

Jone Fx - in general

A

Fx of the metaphyseal-diaphyseal junction of the 5th metatarsal

Occur acutely or superimposed on chronic stress injurey

Swelling and pain on weight bearing

75
Q

Jone Fx - tx

A

Non-operative tx is usually appropriate

  • Strict non weight bearing for 6-8 weeks, b/c non-union can occur
  • Walking boot for additional 2-4 week
  • Sx is indicated for those who fail conservative tx or in athletes
76
Q

March fx - AKA

A

Fatigue fx
Stress fx
Insufficiency fx

77
Q

March fx - in general

A

Fx of the distal 1/3 of the metatarsal
Occurs due to repetive stressing
Occur when damage from a cylindrical loading of a bone overwhelms its physiologic repair capacity
Common in young active adults - women more prone to this injury regardless of age
Generally no hx of injury

78
Q

March fx - Hx

A

Initially complains of pain of varying degree

Pain is usually present at rest but aggravated with walking

79
Q

March fx - PE

A

Swelling and point tenderness over metatarsal

80
Q

March fx - dx imaging

A

X-rays
- AP, lateral, oblique
- Findings vary depending on stage in the process
- May be normal or periosteal reaction or show and incomplete fx or complete fx
Bone scan, CT, MRI - occult fx

81
Q

March fx - tx

A

Protection with short leg cast, post-op shoe or walking boot

Weight-bearing restricted until restoration of bone continuity and decreased pain - usually 3-4 week

82
Q

Metatarsal fx - in general

A

Fx of the shaft, neck or head

Often caused by direct crushing or indirect twisting injury to the foot

83
Q

Metatarsal fx - clinical features

A

Metatarsal shaft fx

  • Temporary disability (unless failure of healing)
  • Displacement is rare (non-fx metatarsals serve as an internal splint)

Metatarsal head and neck fx - Dorsal angulation is common and should be reduced

84
Q

Metatarsal fx - tx of metatarsal shaft fx

A

Non-displaced
- hard-soled shoe with partial weight bearing or short leg walking boot

Displaced
- Reduce and cast
Persistent displacement may require ORIF

85
Q

Metatarsal fx - Tx of Metatarsal head/neck fx

A

Usually heal w/o intervention
ORIF is controversial
Clost reduction with K wire placement under fluoro
Multiple metatarsal fx or those with >4mm of displacement need tx

86
Q

Metatarsalgia - in general

A

General term for pain arising from the metatarsal head region

Variety of abnorms may be responsible

  • High arch
  • improper shoe selection
  • tight Achilles tendon
  • abnorm foot posture
  • atrophy of plantar fat pad
  • Frequently associated with hammertoes, clawed toes and hallux valgus deformities
87
Q

Metatarsalgia - contributing factors

A

Tight toe muscles
Weak toe muscles
Hypermobile first foot bone (when joints move easily beyond the normal range expected fro that particular joint)
Tight Achilles tendon
Loose or tight footwear
High or unusual levels of physical activity
Hammertoe deformity
Excessive side-to-side movements when walking

88
Q

Metatarsalgia - hx

A

S/S
-burning or cramping sensation in the region of the metatarsal heads, usually 2, 3 and 4

Worse with activity and relieved by rest

89
Q

Metatarsalgia - PE

A 
Alignment of toes
Swelling
ROM
Stability of MTP joints
Palpate for swelling or masses
Note callous formation
90
Q

Metatarsalgia - dx imaging

A

X-rays - weight bearing

  • AP
  • Lateral

Assess metatarsal and toe alignment

91
Q

Metatarsalgia - tx

A

Transfer weight-bearing away fro affected metatarsal heads
Low-heeled shoes with sufficient room in the forefoot
Metatarsal bar or pads placed in shoe behind the metatarsal heads to transfer weight behind the metatarsal heads

92
Q

Morton’s neuroma - in general

A

Perineural fibrosis of the plantar nerve where the lateral and plantar branches communicate
- located by between in the 3rd web space
- probably secondary to repeated trauma
Fibrosis results in a painful swelling of the nerve
- pain typically described as severe and burning
- aggravated by activity
F:M, 5:1

93
Q

Morton’s neuroma - hx

A

Complains of “walking on a marble” or “winkle in sock”
Pain may radiate down to the 3rd and 4th toes
Tight shoes aggravate pain
Removing shoes and massaging foot relieves pain
Numbness in the affected toes may be present

94
Q

Morton’s neuroma - PE

A

Exquisite tenderness with palpation between the 3rd and 4th metatarsal heads
Palpable nodule often present
Compression of foot may reproduce pain

95
Q

Morton’s neuroma - tx

A 
Appropriate shoe wear
- Low-heeled, cushioned, wide toe box
- Metatarsal pad
Local injection of steroid with lidocaine may give temporary relief
Sx resection is often necessary
96
Q

Diabetic Foot - in general

A

Foot problems are the most common reason for hospitalization of a DM pt
More than half of all non-traumatic amputations are performed on DM

97
Q

Diabetic Foot - Patho

A 
Multi-factorial
Integument - poorly fitting shoes
Neurologic - DM peripheral neuropathy
Vascular - microvascular damage
Immunologic - inflammatory reactions
98
Q

Diabetic Foot - hx

A

Glycemic control
Past hx of foot sx
Previous or current abx
Recent trauma to foot

99
Q

Diabetic Foot - PE Inspection

A 
Internal and external wear patterns
- look at feet and shoes
- callous formation
Skin
Hair growth
Perfusion
Pulses
Color
100
Q

Diabetic Foot - PE Examination

A

Bony prominences - increases potential for skin breakdown
Monofilament testing
Wounds measured for width, length and depth - describe extent of tissue involvement

101
Q

Diabetic Foot - dx imaging

A

Needed to eval for Charcot foot

If concerned about osteomyelitis

  • not seen on x-rays until advanced
  • Technetium bone scan and MRI more sensitive to pick up early dz
102
Q

Diabetic Foot - Tx

A

Find balance between foot function and preservation of tissue

Superficial lesion - Dressing changes, total contact casting

Deep lesion

  • sx debridement
  • hospitalization
  • abx
  • aggressive wound care
103
Q

Diabetic Foot - Prevention

A

Proper footwear

Education if at risk for ulceration

104
Q

Diabetic Foot - tx abscess

A

Emergent sx for drainage of infection, wound left open, dressing changes, definitive closure at later date or amputation

105
Q

Diabetic Foot - tx gangrene toes / forefoot

A

appropriate amputation

106
Q

Diabetic Foot - tx entire foot gangrene

A

appropriate amputation

107
Q

Hallux rigidus - in general

A

arthritis of the MTP joint

Most common site of arthritis in the foot

108
Q

Hallux rigidus - clinical presentation

A

Pain with activity esp. in toe-off position
Stiffness
Loss of extension at MTP is hallmark

109
Q

Hallux rigidus - dx imaging

A

X-rays

Narrowing of MTP joint with osteophytes

110
Q

Hallux rigidus - tx

A 
Modified foot wear
- large soft toe box
- rocker bottom shoe
NSAIDs
Ice
Sx - excision of osteophytes or arthrodesis
111
Q

Hallux rigidus - Etiologies

A 
F:M, 10:1
Tight pointed shoes
Congenital deformity
Severe flat foot
Chronic Achilles tendon tightness
Spascity
Hypermobility of metatarsocuneiform joint
RA
112
Q

Hallux rigidus - hx

A

Pain
- medial eminence pain
- plantar 1st metatarsal or metatarsal head pain
Deformity
- impingement upon 2nd toe
- Resultant deformities of the lesser toes
Inability to wear certain shoes
Ask about - aggravating factors, occupation, level of athletic endeavors and type of shoe most often worn

113
Q

Hallux rigidus - PE

A

Inspection

  • Degree of deformity
  • Callous formation
  • Skin integrity

Palpation

  • ROM of ankle, subtalar, transverse tarsal and MTP joints
  • Neurovascular status
114
Q

Hallux rigidus - dx imaging

A

X-rays - weight bearing

  • AP
  • Lateral
  • Oblique

Note

  • normal hallux valgus is <15°
  • intermetatarsal angle
  • Congruency of joint
  • Arthrosis
  • Size of medial eminence
115
Q

Hallux rigidus - tx (non sx)

A

Shoes - adequate size and shape
Pads
Indication in cases of juvenile hallux valgus until pt is done growing
Indicated in high-performance athletes and dancers until unable to continue career

116
Q

Hallux rigidus - tx (sx)

A 
Not done for cosmetic reasons, but rather to correct symptomatic structural deformity 
Soft tissue - McBride only performed in mild Hallux valgus
Osteotomy
- Chevron
- Akin
- Metatarsal osteotomy
- Keller
Arthrodesis
117
Q

Hammer toe deformity - in general

A

Plantar flexion deformity of the PIP joint

Flexible vs. fixed

118
Q

Hammer toe deformity - clinical findings

A

Pain to dorsum of the toe
May have callous or ulceration
Deformity of nail

119
Q

Hammer toe deformity - dx imagining

A

x-rays - helpful in the eval of

  • proximal IP flexion deformity
  • MTP hyperextension
  • Hallux valgus
120
Q

Hammer toe deformity - tx (non-sx)

A

Proper footwear - open toebox

Toe sleeves to correct deformity - only useful in flexible deformity

121
Q

Hammer toe deformity - tx (sx)

A

Fixed deformity requires sx correction for proper shoe wear
Proximal phalangeal condylectomyand placement of K-wire
Correct any hallux valgus deformity to create room

122
Q

Claw toes

A

Fixed extension of the MTP joint and flexion of the PIP & DIP
Usually affects all the lesser toes
Often related to neurological d/o or inflammatory arthritis

123
Q

Mallet toe - in general

A

Flexion deformity of the DIP joint
May be fixed or flexible
Generally the second toe

124
Q

Mallet toe - tx

A

Tx for both claw toes and mallet toes is similar to tx of hammer toe

Non-sx

  • shoes with side toe box
  • pads around toes
  • OTC splints

Sx

  • Correction of deformity
  • may require release of flexor digitorum tendons

Clin Med II - Ortho (13 decks)

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