Foot And Ankle Flashcards
What are the risk factors for posterior tibial tendon infusfficiency
Obesity Hypertension Diabetes Increased age Corticosteroids Seronegative arthropathy
Discuss the presentation and management of PTTI
Most common cause of adult-acquired pes planus
Presentation:
- Medial ankle and foot pain with weakness
- Pes planus
- Hindfoot valgus - progresses from flexible (correctable with plantigrade foot) to rigid
- Forefoot abduction - too many toes sign
- Inability to perform single limb heel rise
X-rays:
- Lateral: Meary’s angle (line through talus and 1st MT should be 0) >4 degrees
- Subtalar arthritis
Treatment:
- Orthotics: initial treatment for stage II-IV, stage 1 walking cast for 3-4 months
- FDL transfer and calcaneal osteotomy
- First TMT joint arthrodesis and calcaneal osteotomy
Discuss the presentation and management of Achilles’ tendon rupture
Epidemiology
- Most common in middle aged men (weekend warrior)
- Risk with fluoroquinolone and steroid injections
Mechanism:
- Traumatic injury with forceful platanflexion or dorsiflexion
Presentation:
- “pop”
- weakness and limited weightbearing
- Palpable gap
- Decreased plantarflexion
- Thompson test
Investigations:
- X-ray to rule out avulsion
- Ultrasound to determine if complete or partial
Treatment:
- Functional bracing in equines (plantarflexed)
- Achilles’ tendon repair
List the risk factors for a diabetic foot ulcer
- Uncontrolled hyperglycemia
- Inability to offload area
- Poor circulation
- Infection
- Poor nutrition
What are the microbiological findings associated with increased rate of healing of diabetic foot ulcers
- Serum albumin: >3.0g/dL
- Total lymphocyte count: >1500/mm3
Discuss the presentation and management of diabetic foot ulcers
Mechanism:
- Have neuropathy (autonomic, sensory and motor) and angiopathy leading to increased risk due to change in mechanics and reduced ability to heal
Presentation:
- Painless
- Probe depth (increased depth increased risk of osteomyelitis)
- Presence of infection (cellulitis, pus, gangrene)
- Pulses
Investigations:
- transcutaneous oxygen pressure >30mmHg have greater possibility of wound healing
- X-ray
- Bone scan
Treatment:
Grade 0: skin intact but have increased risk
- shoe modification and serial exams
Grade 1: superficial ulcer
- office debridement and contact casting
Grade 2: deeper, full thickness extension
- operative debridement and contact casting
Grade 3: deep abscess or osteomyelitis
- operative debridement and contact casting
Grade 4: partial gangrene of forefoot
- local amputation
Grade 5: extensive gangrene
- amputation
Discuss the disruption that occurs with a Lisfranc injury
Tarsometarsal fracture dislocation:
Have disruption of the ligament between the medial cuneiform and base of 2nd metarsal
Discuss the presentation and management of lisfranc injuries
Mechanism:
- have axial load and indirect rotational force through hyperplantar flexed foot
Presentation:
- Severe pain and inability to weightbear
- Instability test: grasping metatarsal heads and applying a dorsal force while palpating bases with hands looking for subluxation or displacement
- Pronation and abduction reproduce pain
Investigations:
X-ray: Midfoot instability
- Discontinuity of line from the medial base of 2nd metatarsal to medial middle cuneiform
- Widening between 1st and 2nd ray (bony fleck sign in 1st intermetatarsal space)
- Dorsal displacement of the proximal base of the 1st or 2nd metatarsal on lateral
- Medial base of 4th metatarsal does not align with medial side of cuboid
- disruption of the medial column line (line tangential to medial navicular and medial cuneiform) on oblique
Management:
- Cast immobilization for 8 weeks: no displacement
- ORIF: >2mm shift
- Arthrodesis of 1-3 TMT joints for chronic injury
List the risk factors for hallux valgus
Intrinsic: - genetics - increased distal metaphysical articular angle - ligamentous laxity - convex metatarsal head - 2nd toe deformity or amputation - pes planus - rheumatoid arthritis - cerebral palsy Extrinsic - shoes with high heel and narrow toe box
Discuss the presentation and management of hallux valgus
Presentation:
- Hallux is valgus and pronated
- Examine for any other deformities, ROM, or midfoot changes
X-ray:
- Hallux valgus angle (Long axis of 1st MT and proximal phalanx): >15
- Intermetatarsal angle (Between long axis of 1st and 2nd MT): >10
- Distal metarsal articular (Long axis of 1st MT and line through base of distal articular cap): >10
- Hallux valgus interphalangeus (long axis of prox and dist phalanx): >10
Treatment:
- Shoe modification and orthotics
- Surgical management: type depends on degree of angulation
Discuss the presentation and management of hallux rigidus
Mechanism: - loss of motion of the MTP joint due to degenerative arthritis Presentation: - first ray and MTP pain worse with push off or force dorsiflexion of great toe - shoe irritation due to dorsal osteophyte - less severe pain with progression - Limited dorsiflexion - pain with grind test Investigations: X-ray: - dorsal osteophytes - joint space narrowing - subchondral sclerosis and cysts Treatment: - NSAIDS and activity modification - Cheilectomy to remove dorsal osteophyte - MTP arthroplasty or arthrodesis
Discuss the presentation and management of equinovarus foot
Mechanism
- most commonly occurs following stroke
- gastroc and ant+post tibialis are too strong
Treatment
- nonoperative: AFO, physical therapy, Botox injections
- operative: split anterior tibial tendon transfer
Discuss the presentation and management of foot drop
Mechanism: - inability to dorsiflex usually following peroneal nerve palsy Presentation: - Loss of motor ankle/toe dorsiflexion - Loss of first dorsal we space sensation Treatment: - AFO and therapy - Nerve repair or tendon transfer
Discuss the presentation and management of peroneal tendon subluxation and dislocation
Mechanism: - rapid dorsiflexion of an inverted foot Presentation: - “pop” following dorsiflexion - tenderness over the tendons - apprehension with eversion and dorsiflexion against resistance Treatment: - Short leg cast for 6 weeks - Repair of retinaculum in athletes
Discuss the presentation and management of base of 5th MT fracture
Mechanism:
- zone 1 (avulsion): hindfoot inversion
- zone 2 (metadiaphyseal junction/Jones #): forefoot adduction
- zone 3 (proximal diaphysis): repetitive micro trauma
Presentation:
- pain over lateral border of forefoot
- resisted foot eversion
- PwP
Treatment:
- protected weightbearing in stiff soled shoe or cast for Zone 1
- no weight bearing short leg cast for 6-8 weeks with Zone 2-3
- IM screw for zone 2-3
