Foot and ankle Flashcards
What defines exertional compartment syndrome?
1 - Resting compartment pressure <15 mm Hg*
2 - 1 minute post exercise >/= 30 mm Hg*
3 - 5 minute pressure >/= 20 mm Hg***
How do patients present with popliteal artery entrapment syndrome?
Intermittent claudication and decreased pulses***
May present with pain, coolness and tingling in LE which is exacerbated with walking but better w/ running with normal compartment pressures***
Due to compressive effect of the medial gastroc on the popliteal artery***
Silfverskiold test?
Improved ankle dorsiflexion with knee flexed = gastrocnemius tightness***
Equivalent ankle dorsiflexion w/ knee flexion and extension = achilles tightness
Antagonist of posterior tibias?
Peroneus brevis** (PT/PB)
Why does plantar flexion of the first ray occur in cavovarus foot?
Due to weakness of anterior tibialis and overruling of peroneus longus***
How to test ATFL?
Anterior drawer in 20 deg of plantar flexion***
Shift >8 mm = incompetent ATFL
What is spring ligament?
Calcaneonavicular ligament
Static stabilizer of medial longitudinal arch
From sustentaculum tali to inferior aspect of navicular**
Spring ligament likely attenuated in type II flatfoot deformity 2/2 posterior tibial tendon dysfunction***
How do transverse tarsal joints lock to allow toe off during gait?
Subtalar joint INVERTS –> locks transverse tarsal joints to allow hindfoot/midfoot to be stable for toe off
Eversion = unlocks transverse tarsal joints to allow supple foot to accommodate ground just after heel strike
What is ass’d with os trigonum?
Where is os in relation to FHL, tibial nerve, artery etc?
FHL tenosynovitis or entrapment***
Can give posterolateral ankle pain with passive ankle plantarflexion*** (vs FHL pain which is posteromedial)
Os lies LATERAL to structures**
What does tibialis anterior do during heel strike?
Eccentrically contracts***
quad also eccentrically contracts during this phase***
Which gait phase will be affected most by patient with quad atrophy?
Hamstring or hip flexor weakness?
MIDSTANCE***
During stance phase of gait quad contracts to prevent buckling of knee**
In contrast –> weakness of hamstring or hip flexors are most affected during the SWING phase
What % of gait is in stance phase?
60%**
Tx of base of 5th metatarsal fx?
Type I: nonop with WBAT in boot
Type II: athlete = ORIF
non athlete/rec athlete = NWB in cast***
Type III = NWB in cast***
Where does Lisfranc ligament go?
Interosseous ligament that goes from base of 2nd metatarsal to medial cuneiform on PLANTAR side***
ORIF vs arthrodesis for ligamentous Lisfranc injury?
Arthrodesis = improved functional outcomes*
Increased return to activity*
Decreased rates of secondary surgery (only one that is consistently found in studies though)
Most common metatarsal fx in kids <4 y/o?
1st metatarsal***
Once greater than 5 y/o,, 5th metatarsal is most common**
Who gets navicular fx?
Common complication?
Tx?
Running athletes running on hard surface* –> usually chronic overuse injury*
At high risk of AVN**
Most common complication = DELAYED UNION and NONUNION***
Tx stress fx:
Cast immobilization, NWB (6-8 weeks)
Operative: high level atheletes
Nonop failure/nonunion
Tx traumatic fx:
NWB cast –> acute avulsion fx, tuberosity fx, non/minimally displaced fx
Operative for fx:
Fragment excision –> avulsion that doesn’t heal with nonop
ORIF: avulsion w/ >25% articular
Displaced fx
ORIF followed by ex fix vs fusion
AVN –> fusion of TN and naviculocuneiform joints
What to consider in adult with chronic mid foot pain?
Spontaneous navicular AVN**
Operative vs nonop for Achilles tendon rupture?
How to reconstruct chronic rupture (>6 wks) with < 3 cm gap and >3cm gap?
Nonop = eviqualent strength*
may have higher re-rerupture rates (though now in question) –> not true if doing early functional rehab
FEWER COMPLICATIONS***
Chronic rupture
<3 cm gap: VY advancement
> 3cm: FHL transfer*
Requires functioning tibial nerve
Residual plantar flexion weakness at hallux (expected)*
Complications with Achilles tendon repair?
Wound healing = 5-10% Risk factors = smoking*** female steroids Open*** (vs perc)
Sural nerve injury* (more with perc*)
Haglund deformity/Achilles tendonitis - when to augment repair if requires surgery?
Augment with FHL* when >50% of Achilles is involved*
How do peroneal tendons subluxate/dislocate?
Longitudinal tear more common in which tendon?
Position of tendons?
Rapid DORSIFLEXION on an INVERTED foot* = rapid reflexive contraction of PL and PB*
Rapid contraction leads to injury to superior peroneal retinaculum***
Tear more common in peroneus brevis***
Brevis lies anterior and medial to longus at level of lateral malleolus*
Brevis behind bone, longus takes long way around*
At level of peroneal tubercle of calcaneus –> longus is INFERIOR and brevis is SUPERIOR***
Treatment of peroneal tears/dislocation?
Nonop: SLC with protected weight bearing –> poor success (50%)
Operative
Acute repair of superior peroneal retinaculum and deepening of fibular groove* –> elite athlete or if there is a LONGITUDINAL TEAR*
Groove deepening with soft tissue transfer and/or osteotomy
Chronic/recurrent dislocation*** (less able to reconstruct the SPR)
Must correct hind foot varus prior to any SPR recon procedure***
how to treat Peroneal brevis tear?
Dx?
Tx?
Same exam/findings as peroneal dislocation w/o instability
Dx: MRI is REQUIRED for dx***
Tx
Nonop: activity restriction and cam boot –> high failure rate
Operative
Core repair and tubularization of tendon –> simple tears**
Debridement of tendon w/ tenodeiss of distal and proximal ends to peroneus longus or recon with allograft*** –> complex tears w/ multiple longitudinal tears and significant tendinitis (>50% tendon involved)
Debridement of both longus and brevis w/ allograft or FHL** or FDL** transfer (to 5th metatarsal)**
Hindfoot osteotomy w/ peroneal tendon pathology –> varus hind foot contributes to peroneal pathology –> calc osteotomy or subtalar arthrodesis ***
Accessory muscle that can be seen in peroneal compartment?
Peroneus quartus***
Arises from peroneus brevis, present in 20% patients, ass’d w/ lateral ankle pain and peroneal tendon sx –> mass effect w/in peroneal tendon sheath**
Tx of tib anterior rupture?
Direct repair if < 6 weeks***
Recon if >6 weeks
augment with autograft (hamstring, plantaris etc) may be necessary vs EHL split transfer**
After either repair or recon will have some residual weakness***
Most common pathogen causing osteomyelitis after puncture through shoe?
Soft tissue infection after puncture?
Osteomyelitis: pseudomonas***
Soft tissue infection: Staph aureus***
What is 1st line tx for plantar fascia rupture?
Cast immobilization for 3-6 wks***
How to treat plantar fasciitis?
Night splints* (esp for chronic)*
Plantar fascia specific stretching program results in highest patient satisfaction at 8 wk f/u***
What causes adult acquired flatfoot?
What foot deformities occur?
Posterior tibial dysfunction***
Deformities: Pes Plans*** Hindfoot valgus*** forefoot varus*** Forefoot abduction***
Stages of Posterior tibial tendon insufficiency?
Stage I: No deformity, able to perform single heel rise, no changes on XR
Tx: AFO* vs Arizona brace, immobilization for 3-4 months, Medial heel lift w/ longitudinal arch –> UCBL w/ medial posting***
Stage IIA: flatfoot dermotiy with flexible hind foot, normal forefoot
Cannot perform single heel raise
XR: arch collapse
Tx: FDL transfer, calc osteotomy, TAL, +/- forefoot correction osteotomy, +/- lateral column lengthening
Stage IIB: Flatfoot dermotiy with flexible hind foot, FOREFOOT ABDUCTION/too many toes/>40% talonavicular uncoverage
Cannot perform single heel raise
XR: arch collapse
Tx: same as above, can consider isolated subtalar arthrodesis***
First TMT joint arthrodesis if 1st TMT hyper mobility**
Stage III: Flatfoot with RIGID HINDFOOT* valgus
XR: arch collapse with SUBTALAR ARTHRITIS*
Tx: Hindfoot arthrodesis (usually triple, but can do subtalar and talonavicular only)
Stage IV: Rigid hind foot with deltoid ligament compromise
XR: Arch collapse + subtalar arthritis + TALAR TILT on mortise view*
Tx: TTC arthrodesis*
What is cotton osteotomy? When to use?
Platarflexion (dorsal opening wedge) osteotomy of Medial cuneiform***
Used with a stable medial column in acquired flatfoot in adult to correct residual forefoot varus after hind foot correction**
What is relation of FHL and FDL at knot of Henry?
FHL passes DORSAL to FDL
FHL is “higher”/closer to dorsal surface
FDL is “down” towards bottom of foot/plantar surface
What Position is hallux in with hallux valgus?
Valgus and pronated***
Normal hallux valgus angle?
Normal inter metatarsal angle?
Normal distal metatarsal articular angle?
Normal hallux valgus interphalangeus angle?
Hallux valgus angle: Long axis of 1st degrees metatarsal and proximal phalanx, less than 15°
Intermetatarsal angle: Between long axis of 1st degrees and second metatarsal, less than 9°
Distal metatarsal articular angle: Between first metatarsal long axis and line through base of distal articular cap to identify MTP joint incongruity, less than 10°
Hallux valgus interphalangeus: Between long axis of distal phalanx and proximal phalanx, less than 10°
surgical correction of a dealt hallux valgus , when to do distal osteotomy? Proximal or combined osteotomy? First TMT arthrodesis? Fusion procedures? MTP resection arthroplasty?
Distal osteotomy: Mild disease, IMA less than 13
Proximal combined osteotomy: Indicated more moderate disease, IMA greater than 13
First TMT arthrodesis: Arthritis at TMT joint or instability
Fusion procedures: Indicated severe deformity, spasticity, arthritis
MTP arthroplasty resection: Only indicated elderly patients with low functional demand
treatment of juvenile or adolescent hallux valgus
best to wait until skeletal maturity operate, cannot perform proximal osteotomies the physis is open***
Surgery indicated symptomatic patient with IMA greater than 10° or HVA a greater than 20°**
consider double metatarsal osteotomy an adolescent patients with increased DMAA***
Adult hallux valgus treatment
went performed modified McBride?
when to do distal metatarsal osteotomy?
Went perform proximal metatarsal osteotomy?
When to perform double osteotomy?
When to perform first cuneiform osteotomy?
Went performed Akin osteotomy?
One perform Lapidus procedure?
When to perform MTP arthrodesis?
Modified McBride: To correct incongruent MTP joint inpatient with HVA less than 25°, IMA less than 15***
distal metatarsal osteotomy: Mild disease, HVA less than 40, IMA less than 13, chevron osteotomy***
proximal metatarsal osteotomy: Moderate disease, HVA greater than 40°, IMA greater than 13°, Ludloff or scarf osteotomy***
Double osteotomy: Severe dz, HVA 41-50, IMA 16-20 deg***
Akin: hallux valgus interphalgeus***
Lapidus: 1st metatrsocunieform arthrodesis, sever defromity or hypermobile 1st TMT joint
MTP arthrodesis: Severe DJD, Ehler-Danlos***
Most common cause of failure after hallux valgus tx?
Insufficient preop assessment and failure to follow indications***
Failure to perform lateral release of adductor hallucis tendon***
What causes neuropraxia after hallux valgus treatment?
Painful incisional neuromas frequently involve the MEDIAL DORSAL CUTANEOUS NERVE*** –> a terminal branch of SPN
Commonly injured during medial approach
What occurs if make cut for medial eminence resection in hallux valgus case too lateral/take too much bone?
Can cause iatrogenic hallux varus***
When to perform proximal 1st MT osteotomy and distal medial closing wedge osteotomy?
patient with an IMA greater than 13° and congruent MTP joint with a DMAA >10 deg***
Which direction is metatarsal Head displaced with Chevron osteotomy for hallux valgus?
Metatarsal head is translated LATERALLY***
When to do Akin osteotomy?
hallux valgus interphalangeus angle greater than 10 deg***
corrected with a proximal PHALANX osteotomy (Akin)***
What do juvenile bunions differ from adult
Juvenile: METATARSUS PRIMUS VARUS*
increased flexibility of 1st MP joint –> greater deformity*
HVA less than adult**
Less bursal thickening or prominence**
what 2 muscles conjoin at the lateral base of the proximal phalanx of the great toe?
Flexor hallucis brevis and ADductor hallucis***
Grading and Tx of Hallux rigidus?
Gr 0: stiffness but no XR changes
Tx: Stiff foot plate with MORTON’S EXTENSION***
Gr 1: Mild pain at extremes of motion, mild dorsal osteophytes but normal joint space
Tx: Stiff foot plate with MORTON’S EXTENSION*
Dorsal cheilectomy*
Moberg procedure = dorsal classing wedge osteotomy of proximal phalanx –> runners w/ reduced flexion (need 60 deg) or failure of cheilectomy to provide 30-40 deg of motion***
Gr 2: Moderate pain w/ ROM, moderate dorsal osteophyte with <50% joint space narrowing
Tx: Dorsal cheilectomy*
Moberg procedure = dorsal classing wedge osteotomy of proximal phalanx –> runners w/ reduced flexion (need 60 deg) or failure of cheilectomy to provide 30-40 deg of motion*
Gr 3: Signficiant stiffness, pain at extremest ROM, NO PAIN AT MID RANGE, >50% joint space narrowing
Tx: MTP arthrodesis
Gr 4: Pain at mid range of motion, same XR as grade 3
Tx: Arthrodesis
Where to fuse MTP joint in foot?
10-15 deg valgus, 15 deg dorsiflexion***
Best to assess intraop w/ foot plate to simulate weight bearing with 4-8 mm clearance of toe from plate***
Excessive dorsiflexion = pain at tip of toe, over IP and under 1st MT***
Excessive plantar flexion = increased pressure at tip of toe
What is issue with silastic implant for MTP joint dz in foot?
Osteolysis* and bone loss*
What to do if cheilectomy performed and can only achieve 20 deg of dorsiflexion?
Perform Moberg procedure*** –> need at least 30 deg of dorsiflexion in runners
Moberg - closing wedge osteotomy of proximal phalanx***
What to do when nonop tx fails for sesamoid fracture
Most common deformity if remove both sesamoids?
Remove tibial sesamoid?
Remove fibular sesamoid?
Partial or complete sesamoidectomy***
When nonop fails after 3-12 months***
Most common if remove both: cock up deformity***, don’t remove both
Remove tibial: Hallux valgus***
Remove fibular: Hallux varus***
What holds sesamoids together in foot?
Intersesamoid ligament* and plantar plate*
What is turf toe injury?
How happens?
Grades?
Tx?
Hyperextension injury to PLANTAR PLATE and sesamoid complex of hallux MTP***
Forefoot is fixed to ground and hallux MTP joint is hyperextended with axial load***
Grade 1: sprain
Grade 2: partial tear of plantar plate
Grade 3: complete tear of plantar plate
tx: rest, NSAID, taping, stiff soled shoe or walking boot for all grades
Repair Grade III that fail nonop, return to sport in 3-4 months***
How to treat crossover toe?
Complication?
Nonop w/ taping/shoe mod/Budin splint and NSAID
Operative: distal oblique shortening osteotomy/Weil –> for FIXED deformity***
Plantar plate repair
Complication: floating toe deformity* –> inability to flex MTP causing 2nd digit dorsiflexion deformity
Types of bunionette deformity?
Type I: Enlarged 5th MT head or lateralexostosis
Type II: congenital bow of 5th MT, normal 4-5 IMA
Type III: increased 4-5 IMA (most common)
Normal 4-5 IMA = 6..5-8 degrees
Tx: nonop is 1st line infall cases*** (75-90% success)
Operative
Lateral condylectomy: symptomatic type I deformities –> take lateral 1/3 5th MT head***
Distal MT osteotomy: long standing or severely symptomatic type I deformity or type II or III with IMA <12 deg***
Do Cehveron
Oblique rotation osteotomy: perform if IMA >12 deg*
Performed in DIAPHYSIS
Don’t do proximal due to poor blood supply in this region**
Which talar dome is more commonly involved with OCD lesion?
Medial vs lateral talar dome lesions
Medial talar dome lesions are more common***
Medial talar dome
Usually no history of trauma
More posterior
LARGER and DEEPER than lateral
Lateral talar dome Usually TRAUMATIC superficial and smaller Central or anterior Lower incidence of spontaneous healing More often DISPLACED and SYMPTOMATIC***
Treatment of talar OCD lesions
Nonop: immobilization and NWB
For acute injury, nondisplaced fragment w/ incomplete fx
Operative
ORIF
Acute lesion that is displaced***
Arthroscopy w/ removal of loose fragment, debridement, marrow stimulation
Chronic lesions*
<1 cm**
Retrograde drilling
Size >1 cm with intact cartilage cap***
Osteochondral grafting (OAT, ACI, etc)
Size > 1cm and displaced lesions*
Shoulder lesions*
TAA vs ankle fusion ambulation?
TAA: longer stride length, cadence and stride velocity
What % of ulcers that probe to bone have osteomyelitis?
67%***
What can cause falsely elevated ABIs? What number needed to heal an amputation and an ulcer?
Calcification in arteries can cause inaccurate doppler flow readings*** –> falsely elevated ABIs due to decreased compliance of vessels
ABIC >0.45* to heal toe ulcer and toe pressure >45 mm Hg*
Need toe pressure > 60 mm Hg to heal ulcer
What is a Keller resection arthroplasty?
Resection of the proximal phalanx BASE ***
Can be used in DM ulcer over IP joint
What nerve is commonly entrapped in the medial foot?
Baxter’s nerve***
1st branch of the lateral plantar nerve (first Brach after tibial nerve divides into medial and lateral plantar nerves*), lateral is the smaller of the two branches
What is last muscle to recover after injury to common peroneal nerve?
EHL***
Similar to EIP in UE**
What to think about when pt presents with pain over lateral distal leg w/ dysethsia over the dorsal of foot made worse with plantar flexion and inversion of ankle?
Superficial peroneal nerve entrapment***
Tx: release of fascial opening in distal leg to reduce the traction phenomenon***
What is optimal position of ankle arthrodesis?
Neutral dorsiflexion*
5-10 deg of ER*
5 deg hindfoot valgus*
5 mm posterior talar translation*
Risk factors for nonunion of ankle arthrodesis?
10% nonunion rate
Tobacco = 2.7x risk*** NEUROPATHY = greatest risk facet for persistent nonunion w/ revision of nonunion***
Arthrodesis of which joint has the greatest cumulative effect on the midfort and hind foot motion?
Talonavicular*** –> fusion eliminates almost all hind foot motion
Subtalar eliminates 75% of TN motion and 45% of calcaneocuboid motion
Most common nerve injury with ankle arthroscopy?
What tendon is closest to the anterolateral portal
Superficial peroneal nerve with anterolateral portal***
Tendon closest to anterolateral: peroneus terminus***
What muscle must be preserved or reconstructed after removing medial sesamoid to prevent hallux valgus?
Flexor hallucis brevis tendon***
Risk factors for nonunion after ankle arthrodesis?
Previous SUBTALAR fusion*** (27% vs 9% in general population)
Also presurgical varus malalignment (NOT valgus)
Obesity and approach not ass’d with higher nonunion rates***
