Foot And Ankle Flashcards

1
Q

How many bones are in the foot

A

26

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2
Q

What are the proximal tarsal bones

A

Calcaneus

Talus

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3
Q

Bones in the mid foot

A

Navicular
Cuboid
Cuneforms

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4
Q

Bones that make up the forefoot

A

Metarsals and phalanges

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5
Q

Joints that articulate with the talus

A

Talonavicular joint
Ankle joint - talus articulates with the tibia and fibula
Subtalar joint - talus articulates with the calcaneus

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6
Q

What holds to talus in place and what inserts into the talus and how is this different to other bones

A

The talus is held in place by ligaments
No muscles insert into the talus
This increases its risk of avascular necrosis

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7
Q

What structures lie behind the medical malleolus

A
T - tibialis posterior 
D - flexor digitorum longus 
A - Posterior tibial artery 
V - post tib vein 
N - post tib nerve 
H - flexor hallucis longus
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8
Q

What is the knot of Henry

A

The intersection of the flexor hallucis longus and the flexor digitorum longus
Cross point and the medial plantar surface of the foot

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9
Q

What does ‘beef to the heel‘ mean

A

The muscle belly of the flexor hallucis longus inserts into the great distal phalanx

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10
Q

What is important to determine in a foot and ankle hx

A

SOCRATES
- PMH, DHx, FHx, SHx
Regard patient holistically regarding the benefit of surgery
Comorbidities
The disability the pathology causes
Anything that might impede the success of surgery
Remember to address the patients concerns and symptoms as you are going to treat the patient and their symptoms the pathology is secondary

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11
Q

Foot and ankle - examination

A

The examination is used to confirm the diagnosis
Look - inspection - walking aids, shoes for patterns of wear, hairy patch spinal dysraphism, scoliosis, leg for overall limb alignment
Look for varus valgus Iimb and then assess gait looking ofr the three phases of gait - the heel strike, mid stance and toe off - symmetrical and even throughout
Foot weight bearing so stood, pea planus, pes cavus, toe deformities - hammer claw, halux valgus
Ensure to look for scar, swelling, erythema
Face wall - calf musculature, too many toes sign - should see 2 if more post tib tendon issue
Bilateral heel raise - valgus to inversion
Single leg raise - valgus to varus and problem - musculature or post tib tendon
Close inspection - between toes callus or corn
Feel
1) tendoachilles
2) perineal tendons
3)lateral mallelous
4)joint line
5)Medial mallelous
6) post tib tendon -insertion
7) plantar fascia
8) sinus tarsi
9) base of 5th metatarsal head
10) extensor tendon
11) bunion
12) meta tarsal heads
13) bunionette
Move
Proximal to distal
Ankle range of movement - dorsi and plantar flexion on the ankle
Subtalar movement - stabilise talus with one hand move the hind foot inversion and eversion
Midtarsal - stabilise midfoot - adduction or abduction
1st metatarsal - stabilise midfoot - depress 1st metatarsal
Check movement of the toes
Tendon function
Post tib tendon - plantar flexed and inverted position hold foot in position like stone and tell them to resist pressure you apply and feel the tendon
Perineal tendon- dorsiflex and evert - hold like stone and resist your movement - palpate tendon and assess function
Tibialis anterior - dorsiflex and invert - hold like stone resist movement
Ankle instability - anterior drawer test- relax foot and plantar flex - stabilise ankle and drawer the other foot forward - anterior talofibular ligament laterally
Lateral ligamentus complex - invert foot and feel the ligaments below lateral malleolus excessive opening up = incompetence
OA at 1MT - axial grind - pain - look at face - stabilise foot and move up and down - hallucinations rigidus
Tendoachilles - Simmons manoeuvre- patient prone, relax foot - squeeze calf should see plantar flexion of the foot if the Achilles is intact
Pes cavus - hindfoot varus - Coleman block test - put patient on a a wooden block allow the 1st MT head to be depressed - hindfoot goes from varus to valgus position - flex hindfoot moment at subtalar joint
Complete - NV status and joint above and below

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12
Q

Investigations

A
Plain film radiograph
Exclude serious or similar diagnoses
CT
MRI - soft tissue deformity
US
Diagnostic fluid
May be therapeutic fluid removal
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13
Q

Diff diag

Adults

A
Arthritis 
Instability
Deformity 
Nerve entrapment
Tendon disease
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14
Q

Diff diag children

A
Flat feet
Heel pain
Club foot
Curly toes
Poly/syndactyly
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15
Q

Tx

A
Con - non-op 
Advice and reasses - don’t make patient afraid to come back 
Podiatry 
Orthotics
Physio
Med- analgesia, steroid injections
Surg 
Soft tissue procedures - curettage 
Bone and joint op - fusion osteotomy
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16
Q

Axial (x-section of ankle) groups

A
Groups are in relation to the Achilles’ tendon
- medial to achilles tendon 
Medial malleolus 
Flexor hallucis longus 
Flexor digitorum longus 
Post tib NAV
Tibialis posterior 
- Lateral to the Achilles’ tendon
Lateral malleolus
Fib longus and breves
Sural nerve 
Short saph v
Terminal branches of fib artery 
- anterior 
Saph nerve
Long saph v
Tib ant 
Ext hall long
Superficial fib 
Ex dig L
Fib tertios 
Deep ( just infront of talus)
Deep fib nerve 
Dorsalis pedis artery
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17
Q

Common adult presentation

A

Ankle pain
Foot pain
Heel pain
toe pain

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18
Q

Ankle pain caused by what

A

Injury recurrent micro injury, bigger injury - can lead to arthritis
Twist - potential underlying osteochondral defect
Sprain- instability
Break - deformity
Can lead to these problems esp if no tx well from the start

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19
Q

Long term complication of severe sprain or ankle fracture

A

Arthritis

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20
Q

What are the features of moderate arthritis

A

Pain
Swelling
Stiffness

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21
Q

What are the radiological signs of severe OA

A

L - loss of joint space
O - osteophytes
S - subchondral cysts
S - sunchondral sclerosis

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22
Q

What is a common occurrence of a severe sprain

A

osteochondral injury

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23
Q

Symptoms of an osteochondral injury

A

Dull deep ache

Severe disabling

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24
Q

Cause of osteochondral injury following minor trauma

A

Intrinsic defect of the talar cartilage

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25
Q

Tx of osteochondral injury

A

Manage con with rest analgesia

Definitive - surg arthroscopic tx curettage

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26
Q

What causes ankle instability

A

Ligament sprain

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27
Q

Mx of ankle instability

A
RICE
Rest 
Ice
Compress
Elevate
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28
Q

Which examination finding positive in ankle instability

A

Anterior drawer

Stablise talus and pull the foot forwards

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29
Q

Arthritis mx

A

Conservative - keep active, weightloss help, muscle strengthening physio etc
Med - analgesia
Severe - surgery, arthroplasty - total ankle replacement artherosclerosis - ankle fusion

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30
Q

What will foot deformity affect

A

Gait, posture and proximal joints

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31
Q

What is the aim of tx in foot deformity

A
Flexible foot
Foot not too cavus or planus 
Comfortably fits a shoe 
Pain free
NV not compromised
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32
Q

Common causes of foot pain

A

Arthritis/ RA
Metatarsalgia
Tarsal Tunnel syndrome
Tibialis posterior tendon dysfunction

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33
Q

What is metatarsalgia

A
Pain in the ball of the foot can b due to a mild deformity 
Morton’s neuroma can cause it 
Overweight 
Shoes 
Running
Flat feet 
Bursitis or arthritis
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34
Q

What is tarsal tunnel syndrome

A

Tibialis nerve entrapment under the flexor retinaculum

A person with flat feet is at risk

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35
Q

What can cause tibialis posterior tendon deformity

A

Injury or trauma
Rupture can be complete or incomplete can both cause adult flat foot due to the short exclusion of the tendon
Tendinosis from repeated micro trauma
2 insertion point into the navicular tuberosity and the 2,3,4 metatarsal heads

36
Q

What causes the signs of tibialis posterior tendon deformity

A

As the tendon loses its function the medial longitudinal arch of the foot collapses which causes a relative internal rotation of the tibia and talus
There is eversion of the subtalar joint which forces the heel into a valgus allignment and abduction at the talonavicular joint. Varus alignment of the heel causes a lateral shift in the normal axis of the Achilles’ tendon which in time will lead to a contracture. As the deformity gets worse, the distal fibula comes into contact with the lateral calcaneus, causing lateral hindfoot pain.

37
Q

What are the signs associated with a tibilalis posterior ligament deformity

A

Flat foot
Valgus heel deformity
Single limb heel rise - difficulty performing this test
Too many toes

38
Q

What are the symptoms tibilais post deformity

A

Can get pain and swelling along the path of the tendon particularly behind the medial malleolus

39
Q

Tx tibialis post deformity

A

Con - orthotics
Surg - depends on the stage of the deformity whether the deformity is still flexible or has become fixed
calcaneus osteotomy, post tib tendon excision

40
Q

Causes of heel pain

A
Achilles tendinopathy 
Plantar fasciitis 
Haglunds deformity 
Nerve entrapment 
Tumour
Stress fracture - march fracture 
Inflammatory enthesopathy - inflammation of the attachment of muscle or ligament to a bone
41
Q

What is plantar fasciitis

A

The plantar fascia supports tot he arch of the foot - most common cause of plantar heel pain
Degenerate changes from micro trauma not inflammatory as the name might suggest

42
Q

Symptoms of plantar fasciitis

A

Initial insidious onset of pain
Intense pain during the first steps of walking or after a period of inactivity
Lessening pain with moderate foot activity but worsening later during the day after long periods of standing or walking
Exam features
Tenderness on palpation of the plantar heel area
Limited ankle dorsiflexion (with knee is extension) and a positive Windlass st - reproduction of pain by extension of the first metatarosphalangeal joint
Antalgic gait (abnormal walking to avoid joint pain) or limping

43
Q

Diff diag of plantar fasciitis

A
Achilles tendinitis 
Calcaneus stress fractures 
Fat pad atrophy 
Sub-calcaneal bursitis 
Nerve entrapment Peripheral neuropathy rupture, neoplasm and vascular insufficiency
44
Q

Mx plantar fasciitis

A
Most make a recovery in 6 months 
Rest - long periods of standing and walking 
Wear shoes with a good arch support
Insoles, heel pads
Analgesia and required
If overweight - lose weight 
Ice pack
Self - physio - exercises stretches 
Med - steroid injection 
Surg - extra corporeal shockwave therapy 
Surgical division of the plantar fascia
45
Q

Achilles tendinitis mx

A

Steroid injection- Evidence has shown they aren’t beneficial
orthotics
Physio
Eccentric loading exercise
ESWT inc blood supply inc healing process
Surgery

46
Q

Types of heel tendon pathologies

A

Non-insertional
insertional
Plantar fasciitis

47
Q

Common children foot conditions

A
Flat foot 
Heel pain 
Club foot
Curly toes
Poly/syndactyly
48
Q

Flat feet is it a problem ? What is it also called

A

Can be normal fo children to have flat feet their feet are still developing and their is a spectrum of foot shape and on one end is flat and that’s still normal
Problem when it is fixed or painful
Pes planus

49
Q

How to check if a flat foot deformity is fixed

A

On tip toe the arch reforms so no tx is required

50
Q

T of flat foot in children

A

A only conservative as many children age they grow out of the flat foot
Heel stretching
Orthotics
Surgery rarely

51
Q

Heel pain in children
Cause
What to exclude
Mx

A

Tarsal tunnel
Rare plantar fasciitis
Exclude - tumour, infection, trauma
In active child rest more

52
Q

Types of gait disturbance in children

A

Toe walking
In toeing
Out toeing
exclude a foot deformity rarely a ‘foot’ issue

53
Q

Club foot Long name

A

Congenital talipits equinovarus

54
Q

What signs does the deformity have

A

C: cavus
A: adduction
V: varus
E: equinus - plantar flexion

Foot cannot be passively exerted and dorsiflexed through the normal range

55
Q

Tx of club foot

A

Ponsetti casting
Foot is manipulated and placed in a plaster cast, correction is gradual
If its not worked = surgery

56
Q

Serious conditions to exclude

A

Tumour Acral lentiginous- subungual melanoma
Infection - necrotising fasciitis
Trauma or non-accidental injury
Disabling -dysplasia

57
Q

What is non -accidental injury

A

Children possible cause
SmAll fracture v important
As up to 50% whose NAI are missed will have a fatal injury

58
Q

Pes cavus - what is it

A

High arch

Claw toe

59
Q

Cause pes cavus

A

Neuromuscular - Charcot Marie tooth
Hereditary motor and sensory neuropathy
Also be idiopathic

60
Q

Tx pes cavus

A

Underlying

Symptoms

61
Q

What is osteomyelitis

A

Bone and joint infection

62
Q

Causes of osteomyelitis

A

Acutely haematogenous
Secondary to contagious local infection
Direct inoculation from trauma or surgery

63
Q

Clinical features of osteomyelitis

A

Adults is affects cancellous bone - feet/ vertebrae
Children - vascular Bon e- femurs
Lead to cortexerosion - holes - cloacae
Exudation of pus lifts up the periosteum interrupting blood supply to underlying bone and necrotic fragments of bone may form- sequestrae
New bone may form. Involucrum
Tx ab

64
Q

Common toe problems

A
Hallux valgus 
Bunion/bunionette 
Hallux rigidus
Corn and callus
Nail problem 
Morton’s neuroma
65
Q

What is hallux rigidus

A

1st MTPJ OAmarked loss of dorsiflexion and pain

66
Q

wHat do you need to exclude in hallux rigidus

A

Gout

Most commonly effects the 1st MTPJ - podagra

67
Q

Tx of hallux rigidus

A

Con - rocker-bottom shoes
Steroid injection
Surg - cheilectomy arthroplasty

68
Q

What is hallux valgus

A

Deformity on the 1st MTPJ lateral deviation of >15 deg

Bunion

69
Q

What is a bunion

A

Medial prominence produced by the varus deformity of 1st metatarsal head
Unsightly and some have pain, can’t wear normal shoes

70
Q

Complications of hallux valgus

A

Toe crowding
Mid foot arthritis
Corns, calluses
Flat feet

71
Q

Tx hallux valgus

A

Con - pain relief, orthotics

Surg - make foot fit the shoe, soft tissue release can be more than one operation

72
Q

Causes of bunion and lesser toe deformity

A

Biomechanical risk factors
Weight high
Tight /high heel shoe

73
Q

What is the difference between a callus and a corn

A

Corn - dorsum of the foot

Callus - plantar surface

74
Q

Describe a hammer toe

A

Extended MTP
Hyperflexed DIP
Extended DIP

75
Q

What is hammer toes associated with

A

Contracture of the flexor digitorum longus

76
Q

Which toes is most likely affected with hammer toe

A

2nd toe

77
Q

Describe deformity of a Claw toe

A

Extended MTP
Flexed PIP and DIP
Toe digs into the foot

78
Q

Tx claw toe

A

Tatar’s also shortening or PIP arthrodiesis

79
Q

Describe the deformity of a mallet toe

A

Flexion deformity of the DIP alone

80
Q

Tx mallet toe

A

Flexor tenotomy

DIP joint arthrodiesis

81
Q

What is a Morton’s neuroma

A

Symptomatic perineural fibrosis around a plantar digital nerve of the foot. The conditions is though to be to chronic entrapment of the nerve by the intermetatarsal ligament
Non-neoplasticism

82
Q

Tx Morton’s neuroma

A

Orthotics
Steroid injection
Neuroectomy

83
Q

Ingrown toe nail long name

A

Onychoncryptosis

84
Q

Cause of ingrown toe nail

A

Incorrect nail cutting +- pressure of shoes predisposes lateral nail digging into flesh - an get infection and is known as proud flesh

85
Q

Mx ingrown toe nail

A

Let the nail grow out and cut straight
Treat proud flesh with cotton wool soaked surgical spirit
Surg - recurrent = hole nail removal or wedge excision