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MBBS Orthopedics > Foot and ankle > Flashcards

Foot and ankle Flashcards

1
Q

nerves that supply foot and ankle

A
  • Superficial peroneal nerve over dorsum of foot
  • Deep peroneal nerve in first web space
  • Saphenous nerve on medial border foot
  • Sural nerve on lateral border of foot
  • Tibial nerve in sole
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2
Q

When to x ray ankle

A

Ottawa ankle rules: if pain in malleolar zone AND

  • tender over distal 6cm of lateral mallolus OR
  • tender and post edge of tip or medial malleolus (6cm) OR
  • unable to bear weight both immediately and in ED for four steps
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3
Q

Classification systems of ankle/ malleoli fractures

A

Lauge hansen classification (MOI)
- 1st word: position of foot
- 2nd word: direction of mvt of talus in relation to leg
> Supination-adduction (SAD) - A
> Supination-Ext rotation (SER) - most common - B
> Pronation-abduction (PAB) - B/C
> Pronation-ER (PER) -C

Danis Weber classification: based on level of fibular fracture relative to syndesmosis

  • TypeA: infra-syndesmotic
  • TypeB: trans
  • TypeC: supra
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4
Q

Mgx of ankle/malleoli #

A 
Undisplaced
- A/B: NWB BK cast
- C: fix
Displaced (reduce asap)
- A/B: closed reduction + IF
- C: ORIF > cast
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5
Q

Distal tibial #

  • aka
  • types
  • mgx
A
  • pilon #/ tibial plafond #
  • Types
    I: undisplaced
    II: minimally displaced
    III: markedly displaced

mgx:

  • pain relief + abx + elevation + splint
  • ext fix
  • sx after swelling subsides (ORIF, ext fix, perc pinning)
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6
Q

What maintains the arches of the foot

A
  1. Ligaments: spring, short plantar, long plantar
  2. Muscle tendons
    - medial: tibialis posterior and anterior
    - lateral: peroneus longus
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7
Q

What is

  • equinus
  • calcaneus
  • plantaris
  • pes valgus
  • pes varus
A
  • equinus: downward pointing foot
  • calcaneus: upward pointing foot
  • plantaris: only forefoot pointing downward
  • pes valgus: pronation with abduction
  • pes varus: supination with adduction
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8
Q

Features of club foot (congenital talipes equinovarus)

A

CAVE

  • midfoot cavus
  • forefoot adducted and supinated
  • hindfoot in varus
  • heel in equinus
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9
Q

Types of clubfoot and their differences

A
  1. Flexible/ positional
    - able to dorsiflex foot
    - foot an be passively externally rotated
    - full ROM
    - due to position in womb
    - easily correctable physio and stretching
  2. Structural
    - idiopathic
    - neuromuscular/ paralytic (e.g. CP, spina bifida) resulting in muscle imbalance
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10
Q

Club foot

  • signs of severity
  • complications
A
  • deep creases appear posteriorly and medially
  • atrophic calf muscles

cx: secondary growth changes in bone

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11
Q

Mgx of club foot

A
  • Correct early, fully and maintain reduction
  • Rule out assoc dz (DDH, spina bifida)

Conservative (just born):
- manipulation and serial casting (up to 4wk) then abduction orthosis. (until ext rotation of 60deg achieved)

  • ponsetti casting: toe to groin casting with plaster of Paris
    > correct in CAVE sequence (dorsiflex first ray, reduce talus with pressure on medial distal tibia, forefoot adducted in supination, sx release of archilles tendon by perc tenotomy)
  • abduction orthosis:
    > Dennis Browne boots
    > Moulded ankle foot orthoses

Operative

  • release capsular and ligamentous contractors and fibrotic bands
  • lengthen tendons to reposition foot
  • hold with cast and K wires
  • maintain with orthosis
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12
Q

Examination findings of flat foot

A 
hindfoot: valgus
mid foot: planus
forefoot: pronation
foot: abduction
too many toes sign

flexible flat foot:

  • toe toe: heel invert and arch forms
  • jacks test: arch restored
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13
Q

types of flat foot and relevant mgx

A
  1. infantile flat foot (congenital vertical talus)
    - rocker bottom foot and valgus
    - mgx: sx correction <2yo
  2. children and adolescence
    - flexible
    > generalised ligamentous laxity (normal till 7)/ collagen tissue disorders (marfan)
    > tight tendoachilles
    > mgx: stretch TA, good shoes, medial arch support
  • rigid/ spasmodic/ fixed
    >If underlying disorder (polio): splint or op+muscle rebalance
    >cast/splint/sx: triple arthrodesis if pain bad
  1. adults
    - painful rigid: footwear, arch support
    - tx any underlying disorder
    - tibialis rupture: op repair/ tendon replacement
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14
Q

how to access ligamentous laxity

A 
Beighton score
4 or more
- hand flat on floor with knee flex (1)
- hyperextend elbow (1/1)
- hyperextend knee (1/1)
- bend thumb back to forearm (1/1)
- bend little finger back to hand (1/1)

total 9 points

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15
Q

What is the Silfverskiold test

A

to differentiate gastrocnemius tightness from achilles tightness

  • improved ankle dorsiflexion with knee flexed compared to extended = gastrocnemius tightness
  • equivalent = achilles tightness
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16
Q

Causes of flat foot in children

A

Flexible:

  • idiopathic (physiological in young children)
  • ligament - marfan/ ehler danlos

Rigid:

  1. bone: tarsal coalition - abnormal bone connecting calcaneum to talus/ navicular (calcaneo navicular/ talo-calcaneum)
  2. inflammatory jt condition
  3. neuromsk disorder - cerebral palsy
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17
Q

Causes of adult flat foot

A
  1. constitutional flat feet (asymptomatic for many years)
  2. recent onset
    > tibialis posterior tendon dysfunction (trauma/sports)
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18
Q

Causes of claw toes

A

imbalance between intrinsic and extrinsic muscles of lesser toes

2’ neurological disorders

  • UMN: CP/MS/stroke
  • LMN: polio
  • peripheral neuropathy - DM/ CMT
  • Charcot marie tooth
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19
Q

Causes of pes cavus

A
  • muscle imbalance
  • neuromuscular disorders (intrinsic muscle weak)
    e. g. CP, polio, CMT, muscular dystrophy
  • others: burns, compartment syndrome
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20
Q

What are some features of Charcot Marie tooth disease

A
  1. Peroneal muscle atrophy
  2. Pes cavus + claw toes
  3. Distal muscle atrophy (inverted champagne bottle legs)
  4. Bilateral foot drop / high stepping gait / weak ankle dorsiflexion
  5. Absent reflexes
  6. Slight / no sensory loss in the limbs
  7. Thickened nerves
  8. Optic atrophy
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21
Q

Mgx of pes cavus

A
  • rule of spinal disorders and neuromuscular abnormalities
  • conservative: custom shoes and moulded supports
  • sx: tendon rebalancing operation
  • fixed deformities sx: ST release + transfers + arthrodesis
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22
Q

RF for hallux valgus

A
  • hereditary
  • loss of muscle tone
  • RA
  • wearing enclosed footwear
23
Q

associated deformities of hallux valgus

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

(valgus alignment of MTPJ worsened by pull of EHL and intrinsics)

24
Q

Mgx of hallux valgus

A

Teens
1. conservative: foot wear modifications + physio
2. Sx: corrective osteotomy
Adults
- SX: bunionectomy + 1st MT realignment osteotomy + ST rebalancing
- arthrodesis if MTPJ v osteoarthritis

25
Q

Hallux rigidus

  • what
  • specific symptoms
  • mgx
A

What: primary OA of MTPJ of great toe

S/S: cannot dorsiflex, push off pain, diffuse lateral forefoot pain

Mgx:
- lifestyle: rocker soled shoes, avoid toe dorsiflexion (e.g. squatting)
- meds: panadol, NSAIDs
- SX
> osteotomy (young)
> joint arthroplasty (old)
> severe OA: arthrodesis
26
Q

Mgx of lesser toes deformities

A

foot wear modification

sx: tenotomy, tendon transfer, resection, arthrodesis

27
Q

Tendoachilles rupture

  • location
  • RF
  • PE findings
  • mgx
A

rupture at musculous tedinous junction, rarely near calcaneus

RF: age>40, steroid LT

PE:

  • gap in tendon (5cm above insertion of tendon - MT junction)
  • weak plantar flexion against resistance
  • simmond test: lack of plantaflexion
  • cannot tie toe

mgx

  • conservative: cast heel in equinus, shoe with raised heel
  • operative: repair with cast/ lockable brace
28
Q

Archilles tendonitis

  • s/s
  • a/w
  • mgx
A

c/o:

  • pain, aggravated by passive stretching
  • tender, swelling
  • crepitus on plantar flexion

a/w Haglund deformity (prominence at posterior superior calcaneus where tendon laterally inserts into calcaneus)

mgx:

  • rest, gentle stretching, nsaids
  • proper footwear, orthotics
  • no steroids
29
Q

mgx of paratendonitis

A

conservative
- rest, ultrasound, heel raise
Op
- excision of inflammed and degenerate tissue

30
Q

approach to painful ankle

A
  1. bone
    - #
    - AVN of talus
    - osteochondritis dissecans of talus (op removal if displaced fragment, else activity limitation)
  2. joint:
    - footballer ankle/ anterior ankle impingement syndrome (repeated forced dorsiflexion > tear ant capsule > bone spur/ exostosis > pain/ limited ROM)
  3. tendon
    - tenosynovitis (tibialis pos, peroneal tendons) - steroid
    - rupture (snap): repair if active, else splint
  4. ligaments
    - lig instability, sprain, tear
31
Q

Causes of posterior heel pain

A
  1. traction apophysitis (sever disease)

2. retrocalcaneal bursitis

32
Q

plantar fasciitis

  • what
  • insertion of plantar fascia
  • s/s
  • mgx
A

what: chronic inflammation from repetitive strain injury and micro tears of plantar fascia

runs from medial Calcaneal tuberosity to heads of MT bone

pain at medial Calcaneal tubercle
worse on toe dorsiflexion

mgx
conservative
- rest, NSAIDs, physio - stretching exercises, corticosteroid injection, ice cubes, heel cup, us therapy

surgical
- plantar fascia release

33
Q

Common sites of stress #

A
  • march # (2nd & 3rd MT)
  • head of femur
  • distal end of femur
  • tibia
34
Q

Causes of forefoot pain

A 
Generalised: metatarsalgia
Localised:
- sasamoiditis
- freiberg disease (osteochondritis of 2nd MT head)
- stress march # (2nd/3rd MT)
- morton Metatarsalgia
35
Q

Morton neuroma

  • commonly where
  • s/s
  • mgx
A

-3rd inter metatarsal space

s/s:

  • pain, tingling
  • mulder click: painful click on squeezing MT heads together
mgx:
foot wear mod
sx: 
- nerve compression release by dividing tight transverse inter metatarsal ligament
- excision of neuroma if v bad
36
Q

What is a Maisonneuve fracture

- x ray findings

A

spiral fracture of the proximal third of the fibula associated with a tear of the distal tibiofibular syndesmosis and the interosseous membrane

  • unexplained increase in medial clear space
  • tibiofibular clear space widened (should be<5mm)
37
Q

components of deltoid ligament

A
  • ant tibiotalar
  • pos tibiotalar
  • tibionavicular
  • tibiocalcaneal
38
Q

Ottawa foot rules

A

Foot x ray series required: pain in midfoot AND

  • bone tender at base of 5th MT OR
  • tender at navicular OR
  • unable to bear weight immediately and in ED for 4 steps
39
Q

Grading of ligamentous injuries

A

1: strain
- no gift
2: sprain - partial tear
- gift with end point
3. complete tear
- gift with no end point
- significant instability
- talar tilt

40
Q

mgx of peroneal tendon subluxation

A
  • surgical anatomical repair of superior peroneal retinaculum
  • below knee plaster
  • physio
41
Q

complications of ankle # in chidlren

A
  1. malunion if reduction imperfect
    <10yo: accommodated by growth and modelling
    >10yo: osteotomy
  2. asymmetrical growth
    early fusion of physis on one side, veer into varus
  3. limb shortening
42
Q

What is bohler angle

A

measured at intersection of a line drawn btwn post. sup. aspect of calcaneal tuberosity to highest point of post. articular facet and another line drawn to ant. process of calcaneum

N: 25-40deg
decreased in intra-articular #

43
Q

What is a lisfranc injury

- how to screen

A

2nd T-MT displacement injury (med cuneiform and base of 2nd MT)

  • medial edge of 2nd MT in line with medial edge of 2nd cuneiform
  • medial edge of 4th MT in line with medial side of cuboid
44
Q

what is a Jones fracture

- prognosis

A 
# of mid shaft of 5th MT
- prone to non union: injury at watershed area of BS
45
Q

What is the most common cause of intoning gait

A

based on age

  1. Infants (< 1yo): metatarsus adductus
  2. Toddlers (1 – 3 yo): tibial intorsion, usually resolves by 6 yo
  3. Pre-school (3 – 6yo): femoral neck anteversion, usually resolves by 10yo
46
Q

X ray findings in hallux valgus

A

Hallux valgus angle: n <15
Intermetatarsal angle: n<9
OA changes in 1st MTPJ

47
Q

Tx for hallux valgus

A

Conservative: analgesia, proper footwear or orthotics, physio

Surgery:

  • bunionectomy
  • realignment osteotomy with soft tissue rebalancing
  • excision arthroplasty (resect medial eminence + base of prox phalanx)
  • arthrodesis
48
Q

Mgx of pes plasnus

A

conserv: insole, orthotics, anal, physio
Sx: pos tibialis reconstruction

49
Q

Causes of pain from hallux valgus

A
  • transverse metatarsalgia: improper weight bearing on 1st MTPJ
  • bursitis
  • clawed toe (MT head, toe of toe, callosities on dorsum of PIPJ)
50
Q

Classification for DM foot ulcers

A

King’s College Classification
Wagner Classification

determines mgx:

  • lower grades respond to abx+debridement
  • higher grades (2-5) require amputation
51
Q

Management of DM foot ulcers

A

depends on severity. Multidisciplinary team.

low grade:

  • conservative: education, footwear, regular podiatry exam
  • total contact cast for off loading, walking brace, foot wear modification

mod grade:

  • surgical debridement, wound care
  • empiric (augmentin, clindamycin, ciprofloxacin) then culture specific abx

high grade

  • partial or major amputation
  • vascular consultation
52
Q

Charcot joint

  • what is it
  • theories
A

progressive degeneration of a weight bearing joint resulting in deformity

Theories

  • German Neurovascular Theory: loss of autonomic tone > vasodilation > more blood supply & osteoclast > brittling and collapse
  • French Neurotrauma theory: sensory loss > abnormal mvt > repetitive trauma > inflammatory resorption > collapse
53
Q

Charcot joint

- Classification

A

Brodsky classification (by location): tarsalMT, subtalar joint, ankle joint
Eichenholtz classification (by staging)
0: clinical: erythema, edema, no x ray features
1: fragmentation: #, dislocation, deformity, instability
2: coalescence stage: resorption of debris
3: reparative stage: remodelling and reorganisation

54
Q

Mgx of charcot joint

A

by stage! (Eichenoltz)

  • Early (0-1-2): limited weight bearing, total contact casting, CROW (charcot restraint orthotic walker)
  • Late (3): surgery osteotomy - removal of bony prominences

MBBS Orthopedics (13 decks)

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