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Foot and Ankle Conditions Flashcards

1
Q

What is hallux valgus?

A

“BUNION”

Deformity of the great toe, whereby the hallux moves towards the second toe - can overly the second toe

Tendons pull the toe laterally, seamoid bones sublux

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2
Q

What sex does hallux valgus more commonly occur in?

A

Female

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3
Q

What risk factors contribute to the development of hallux valgus?

A
  • Age
  • Family history
  • Hypermobility
  • Footwear
  • Neuromuscular disease
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4
Q

What is the following deformity?

A

Hallux valgus - abducted hallux, adducted metatarsal, MTPJ angle >14.5o

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5
Q

What other features, beside the classic deformity, are associated with hallux valgus?

A
  • Pain - Pressure symptoms from wearing shoes
  • Evidence of hypermobility
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6
Q

How would you investigate hallux valgus?

A
  • Clinical diagnosis
  • Imaging - X-ray
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7
Q

What non-operative measures could you take to help manage someone with hallux valgus?

A
  • Shoe wear modification (wide +/- high toe box)
  • Orthotics to offload pressure/correct deformity
  • Activity modification
  • Analgesia
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8
Q

What surgical options are available for the treatment of hallux valgus?

A

Only indicated in painful bunions, not for aesthetic purposes

  • Lateral soft tissue release
  • Osteotomy - 1st metatarsal +/- proximal phalanx
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9
Q

What is hallux rigidus?

A

Osteoarthritis of the 1st MTPJ

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10
Q

How does hallux rigidus present?

A
  • Asymptomatic
  • Pain - dorsiflexion, on walking
  • Limited ROM - dorsiflexion
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11
Q

What general measures can be taken to manage someone with hallux rigidus?

A
  • Activity modification
  • Shoewear with rigid sole
  • Analgesia
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12
Q

What surgical options are available for someone with hallux rigidus?

A
  • Arthrodesis - MTPJ fusion - GOLD STANDARD
  • Chielectomy - remove dorsal impingement
  • Arthroplasty - good option to maintain range of motion, high failure rate
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13
Q

What is a cheilectomy?

A

Surgical procedure involving the removal of osteophytes from around a degenerate joint to regain further function and ROM. It is most commonly performed on those with hallux rigidus to remove dorsal impingement

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14
Q

What are the main lesser toe deformities?

A
  • Hammer toe
  • Mallet Toe
  • Claw toe
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15
Q

What toe deformity can be seen here?

A

Claw toe - extended MTPJ, Flexed PIP and DIP

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16
Q

What toe deformity can be seen here?

A

Mallet toe - Normal MTPJ, Neutral PIP, Flexed DIP

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17
Q

What toe deformity can be seen here?

A

Hammer toe - Extended MTPJ, Flexed PIP, Extended/neutral DIP

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18
Q

What can cause lesser toe deformities?

A

Imbalance between flexors/extensors

Trauma

  • Shoewear

Degenerative

  • Neurological
  • Rheumatoid arthritis
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19
Q

Besides actual deformity, what other features can be present in lesser toe deformities?

A
  • Pain - Dorsum/Plantar side
  • Calluses
  • Hallux valgus
  • Progression to fixed deformity
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20
Q

What should always be inestigated for in the presence of lesser toe deformities?

A
  • Presence of diabetic foot
  • Neurological status
  • Musculature
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21
Q

What non-operative measures could you employ to manage lesser toe deformities?

A
  • Activity modification
  • Shoewear – flat hoes with high toe box to accommodate deformity
  • Orthotic insoles – metatarsal bar/dome support
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22
Q

What surgical options are available to manage lesser toe deformities?

A
  • Flexor to extensor transfer
  • Fusion of IP joint
  • MTPJ release
  • Shortening osteotomy of metatarsal
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23
Q

What is interdigital neuralgia?

A

“Morton’s Neuroma”

Perineural Fibrosis of an intermetatarsal nerve

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24
Q

Where is the most common location for a Morton’s neuroma to develop?

A

3rd/4th webspace

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25
What percentage of morton's neuroma occur in the 2nd/3rd webspace of the foot?
35%
26
Which sex does Morton's neuroma more commonly occur in?
Females
27
How does Morton's Neuroma present?
* **Pain** - Metatarsalgia * Usually radiates to lateral side of one toe, and medial side of it's neighbour
28
What is metatarsalgia?
Aching pain in the metatarsal bones of the foot. Usually arises from beneath the metatarsal heads in the transverse plantar arch
29
What are risk factors for the development of metatarsalgia?
* **Increased BMI** * **High heels** * **Toe deformities** * **High-impact sports** * **Inflammatory arthritis** * **Morton's Neuroma**
30
What clinical test would increase your suspicion of a morton's neuroma?
Compressing the affected webspace elicits pain
31
How would you investigate a suspected morton's neuroma?
**Imaging** * **US** * **MRI**
32
What non-operative measures could you use to treat a Morton's Neuroma?
Injection therapy
33
What surgical options are available for Morton's neuroma?
**Surgical Excision** - Neuroma and Nerve
34
How would you treat a Rheumatoid forefoot, both operatively and non-operatively?
**Non-operative** * Shoewear, orthotics, activity **Operative** * Current gold standard - fuse 1st MTP joints - arthrodesis * 2-5th metatarsal head excision arthroplasty
35
What is a dorsal foot ganglia?
* Tumor or swelling on top of a joint or the covering of a tendon (tissue that connects muscle to bone) - dorsum of the foot * Thick, sticky, clear, colorless, jellylike material within the sac. * Depending on the size, cysts may feel firm or spongy
36
How would you treat a dorsal foot ganglia?
* Leave it be * Aspiration * Surgical excision
37
What can cause midfoot arthritis?
* Post-trauma * Osteoarthritis * Rheumatoid Arthritis
38
How would you treat midfoot arthritis?
**Non-operative** * Activity/shoewear/orthotics etc * Injections – xray guided **Operative** * Fusion
39
What is plantar fibromatosis?
Non-malignant thickening of the feet's deep connective tissue, or fascia
40
What is the following?
Plantar Fibromatosis
41
How would you manage someone with plantar fibromatosis?
**Non-operative** * Avoid pressure – shoewear/orthotocs **Operative** * Excision - high risk of recurrence - causes more
42
What is plantar fasciitis?
Inflammationof the point of attachment of the fascia in the sole of the foot to the calcaneus, causing pain and localised tenerness of the heel Self-limiting probelm
43
What can cause plantar fasciitis?
**Weight bearing** * **PROLONGED STANDING** * **Overweight/obesity** * **Running** * **Equinus** * **Pes Planus/Pes cavus**
44
How does plantar fasciitis occur?
Degenerative changes from microtrauma, leading to microtears in the fascia
45
What are the symptoms of plantar fasciitis?
* **Heel Pain** * Stabbing, knife-like * Radiates to lateral heel, plantar medial arch * When taking first few steps in morning/from sitting position (post static dyskinesia) * Worse with barefoot walking
46
On examination, what would suggest plantar fasciitis as the diagnosis?
* **Focal, pin point tenderness** - palpation of plantar medial/central calcaneal tuberosity (a lot of pain!), and potentially proximal third of the plantar fascia * **Lateral squeeze** - rule out stress fracture * **Dorsiflexion-eversion test** - positive
47
How would you diagnose plantar fasciitis?
***_Clinical diagnosis of exculsion_*** Occassionally imaging - US, MRI, X-Ray
48
How would you treat plantar fasciitis?
* **WEIGHT LOSS!!!!!** * **Rest, cross training** * **Stretching** – Achilles +/- direct stretching * **Ice** * **NSAIDs** * **Orthoses** * **Physiotherapy** * **Corticosteroid** * **Night Splinting**
49
What is tibialis posterior dysfunction?
Adult Acquired flat foot Process of tendinosis (degeneration) - posterior tibialis tendon becomes fibrotic through a process of repeated microtrauma
50
What can cause tibialis posterior dysfunction?
* **Charcots foot** * **Any degenerative process** * **Trauma**
51
What are the symptoms of tibialis posterior dysfunction?
* **Pain** - behind medial malleolus, along the instep * **Swelling** - behing medial malleolus * **Change in walking ability**
52
On examination, what would indijcate tibialis posterior dysfunction?
* **Swelling and tenderness** - behind medial malleolus * **Pain and Weakness**- with foot inversion * **Acquired flatfoot deformity** - too many toes sign (due to abduction of forefoot) * **Valgus heel deformity** Flattened medial longitudinal arch * **Unable to perform Single Heel Raise** - Normal is 8-10 times single heel rise, \>/= stage 2 - unable to perform 1 * **Double Heel Raise (tip toe test)** - flexible deformity resolves
53
If, on examination, you observed the following, what would you suspect?
Tibialis posterior dysfunction
54
If, on examination, you observed the following, what clinical tests could you do to help make the diagnosis?
* **Single/Double Heal Raise** * **Achilles Tendon Examination**
55
What classification system is used to classify the severity of tibialis posterior dysfunction?
Johnson and Strom classification
56
What are the different grades of tibialis posterior dysfunction in the Johnson and Strom classification system?
* **Stage 1 -** Medial pain, no deformity, can single heel raise * **Stage 2** - Flat foot, flexible deformity, cannot heel raise * **Stage 3** - Flat foot, fixed deformity * **Stage 4** - Ankle involvement
57
What non-operative interventions can be used in tibialis posterior dysfunction?
**Stage 1/2:** physiotherapy, orthotics (medial arch support), analgesia
58
What surgical options are available for those with stage 1 tibialis posterior dysfunction?
Surgical decompression of the tendon
59
What surgical options are available for those with stage 2 tibialis posterior dysfunction?
Surgical reconstruction (flexor digitorum longus transfer + calcaneal osteotomy)
60
What surgical options are available for those with stage 3 tibialis posterior dysfunction?
Joint fusion (subtalar, calcaneal cuboid, talonavicular)
61
What surgical options are available for those with stage 4 tibialis posterior dysfunction?
Joint and ankle fusion
62
What is a cavovarus foot deformity?
***Pes Cavus*** Excessively arched foot, giving an unnaturally high instep which does not flatten on weight-bearing Can be located in the forefoot, midfoot or hind foot
63
What are the causes of pes cavus?
* **Freidrich's Ataxia** * **Charcot-Marie-Tooth Disease** * **Trauma** * **Family history**
64
What symptoms can accompany pes cavus deformity?
* **Difficulty finding shoes that fit** * **Pain** - Metatarsalgia, Plantar fasciitis, Ankle arthritis, Achilles tendonitis
65
On examination, what would you see that would indicate cavovarus foot deformity?
* **Fixed Deformity** - Varus Hindfoot, high instep on weight bearing * **Neurological signs** - Progressive deformity, Muscle pain or weakness, Elevated creatine kinase * **Claw Toes**
66
What is the following foot deformity?
**Cavovarus foot/Pes cavus**
67
How would you treat someone with pes cavus?
* **Orthoses/footwear adaptation** * **Surgery** - soft tissue, bone, tendon transfer
68
How would you treat someone with ankle arthritis?
* **Non-operative management** - othoses * **Surgery** - osteotomy, arthrodesis (fusion), arthroplasty
69
How do diabetic foot ulcer's occur?
* **Diabetic neuropathy** - patient unaware of trauma + dry cracked skin due to lack of sweat * **Skin more sensitive to minor trauma** * **Poor vascular supply** - impairs healing process
70
What percentage of diabetics will develop ulceration?
15%
71
What are the modifiable determinants of healing of a diabetic foot ulcer?
* **Diabetic control** * **Smoking** * **Vascular supply** * **External pressure modification** * **Internal pressure (deformity)** * **Infection** * **Nutrition**
72
What is the 5 year mortality for those who develop diabetic foot ulcers?
50%
73
What percentage of those that develop diabetic foot ulcers go on to have the foot amputated?
25%
74
What is Charcot's arthropathy?
Progressive degeneration of a weight bearing joint, a process marked by bony destruction, bone resorption, and eventual deformity.
75
What are thought to be the processes behind the development of Charcot's Arthropathy?
* **Neurotrauma:** Loss of peripheral sensation and proprioception ⇒ repetitive microtrauma ⇒ resultant inflammatory resorption of traumatized bone leaves region weak and susceptible to further trauma. * **Neurovascular:** Dysregulated autonomic nervous system reflexes, and de-sensitized joints receive significantly greater blood flow ⇒ Resultant hyperemia leads to increased osteoclast resorption. This, in addition to mechanical stress, leads to bony destruction.
76
What is the following?
Diabetic Foot Ulcer - Complication of diabetes
77
The following deformity was found in someone with diabetes. What is the name of this deformity?
Charcot's Foot
78
What can Charcot's foot lead to?
**Osteomyelitis** - Chronic deformation may lead to repetitive trauma of the mid-foot (arch) during walking, leading to ulceration in this area
79
In those with Rheumatoid arhtritis of the foot, when is surgery indicated?
* **Pain in spite of conservative treatment** * **Deformity development** * **Need to stop medication for some reason**
80
What surgical procedures are available for those with rheumatoid arthritis in the forefoot?
* **Hallux -** Osteotomy, Fusion, Joint excision * **Forefoot arthroplasty** - hallux fused, with lesser MTPJ joint excsion
81
What surgical procedures are available for those with rheumatoid arthritis in the midfoot?
**Joint Fusion**
82
What surgical procedures are available for those with rheumatoid arthritis in the hindfoot?
Generally fusion or joint replacement * **Ankle joint:** Fusion or replacement * **Subtalar joint:** Fusion * **Talo-navicular joint:** Fusion * **Calcaneo-cuboid joint:** Fusion
83
What is the following?
Dorsal foot ganglion
84
What classifies someone as having ***_stage 1_*** tibialis posterior dysfunction?
* Medial pain * No deformity * Can single heel raise
85
What classifies someone as having ***_Stage 2_*** tibialis posterior dysfunction?
* Flat foot * Flexible deformity * Cannot heel raise
86
What classifies someone as having ***_Stage 3_*** tibialis posterior dysfunction?
* Flat foot * Fixed deformity
87
What classifies someone as having ***_Stage 4_*** tibialis posterior dysfunction?
Ankle Involvement
88
What is lisfrancs injury?
Fracture-dislocation at the 1st tarsometatarsal joint
89
What can be a complication of lisfrancs injury?
COmpartment syndrome of medial foot +/- later artritis
90
What can be seen in the following radiograph?
Lisfrancs injury
91
How would you manage lisfrancs injury?
Precise anatomic reduction with screw fixation acros 2nd tarsometatarsal joint (lisfranc joint)

MSK (27 decks)

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