Foot and ankle

Question 1

Pathophysiology of Morton’s neuroma

Answer 1

Metatarsal head deformity > irritation of interdigital nerves (most commonly third interspace) > traumatic Morton’s neuroma

Middle-aged females

Question 2

Management of Morton’s neuroma

Answer 2

US imaging

Steroid injection

Excision

Question 3

Definition of bunion

Answer 3

First metatarsal in varus, hallux in valgus –> prominent MTP

May cause pain (esp with shoe fittings)

Question 4

Management of bunion

Answer 4

Advice on footwear

Foot strengthening exercises

Surgery if inhibiting lifestyle

Question 5

Plantar fasciitis presentation

Answer 5

Immobility/inactivity, obesity, excessive walking are risk factors

Plantar heel pain due to degeneterative (not inflammatory) changes in plantar fascia

Question 6

Management of plantar fasciitis

Answer 6

Tendon stretching

Orthotics

Shockwave therapy

Question 7

Ottawa Ankle Rules for ankle X-ray series

Answer 7

Pain in malleolar zone AND posterior tips of medial or lateral malleoli or inability to weight-bear 4-steps

Pain in midfoot zone AND tenderness in 5th metatarsal or navicular or inability to weight-bear 4 steps

Question 8

Features of ankle X-rays

Answer 8

Symmetrical gap around talus in mortise view

Tibiofiular line in continuity with talus lateral border

Tibiofibular clear space <6mm

Question 9

Weber classificaiton of ankle fractures

Answer 9

A: Distal to syndesmosis

B: Through syndesmosis

C: Above syndesmosis, will need operative

Question 10

Emergency management of ankle fracture

Answer 10

Closed reduction

Fixation with POP

Elevate to reduce swelling

X-ray

Question 11

Management of ankle sprain

Answer 11

Ottawa ankle rules for X-ray ?fracture

Assess N/V status

RICE

Anlgesia + encourage return to activity

Complete inability to weight bear (ligament rupture) > 10d immobilisation

Encourage return if unable to weight-bear at 24h/full weight bear by 4d

Question 12

What is a Maisonneuve fracture

Answer 12

Fracture proximal fibula + syndesmotic rupture

Eversion + lateral rotation

ALWAYS EXAMINE PROXIMAL FIBULA IN ANKLE INURY, esp. medial malleolus

Question 13

What is a trimalleolar fracture?

Answer 13

Lateral + medial malleoli + posterior tip of tibia

Requires urgent ortho consultation

Question 14

Presentation of Lisfranc fracture

Answer 14

Tarso-metatarsal joint disruption (ligament, cartilage, bone)

Widening of gap between cuneiform and base of 2nd metatarsal

Needs prompt ORIF

Question 15

Complications of Lisfranc

Answer 15

Compartment syndrome, devastating arthritis, persistent pain

Question 16

What is a pilon fracture?

Answer 16

Distal tibial metaphysis

From axial load

Often comminuted and unstable

Question 17

Causes of Charcot (neuropathic) joint

Answer 17

Diabetes

Syringomyelia

Neurosyphilis

Question 18

X-ray features of Charcot joint

Answer 18

6 Ds:

Destruction of cartilage

Dislocation

Degeneration (joint space loss)

Distension of the joint (i.e. effusion)

Density of bone normal for the patient

Debris (loose bodies)

Question 19

Management of ankle fracture

Answer 19

Weber A: Walking cast/boot

Weber B: Below-knee cast for 6/52 (possibly non-weight bearing if only stress XR instability) or ORIF

Weber C: ORIF

VTE prophylaxis for all!

Early mobilisation

Question 20

What causes pes cavus

Answer 20

Commonly neurological (e.g. Charcot-Marie-Tooth)

Question 21

What is the most common cause of pes planus?

Answer 21

Insufficiency of posterior tibialis tendon