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Gwen - MSK > Foot and Ankle Conditions > Flashcards

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
Q

What percentage of morton’s neuroma occur in the 2nd/3rd webspace of the foot?

A

35%

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26
Q

Which sex does Morton’s neuroma more commonly occur in?

A

Females

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27
Q

How does Morton’s Neuroma present?

A
  • Pain - Metatarsalgia
    • Usually radiates to lateral side of one toe, and medial side of it’s neighbour
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28
Q

What is metatarsalgia?

A

Aching pain in the metatarsal bones of the foot. Usually arises from beneath the metatarsal heads in the transverse plantar arch

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29
Q

What are risk factors for the development of metatarsalgia?

A
  • Increased BMI
  • High heels
  • Toe deformities
  • High-impact sports
  • Inflammatory arthritis
  • Morton’s Neuroma
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30
Q

What clinical test would increase your suspicion of a morton’s neuroma?

A

Compressing the affected webspace elicits pain

(mulder’s click)

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31
Q

How would you investigate a suspected morton’s neuroma?

A

Imaging

  • US
  • MRI
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32
Q

What non-operative measures could you use to treat a Morton’s Neuroma?

A

Injection therapy

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33
Q

What surgical options are available for Morton’s neuroma?

A

Surgical Excision - Neuroma and Nerve

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34
Q

How would you treat a Rheumatoid forefoot, both operatively and non-operatively?

A

Non-operative

  • Shoewear, orthotics, activity

Operative

  • Current gold standard - fuse 1st MTP joints - arthrodesis
  • 2-5th metatarsal head excision arthroplasty
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35
Q

What is a dorsal foot ganglia?

A
  • 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
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36
Q

How would you treat a dorsal foot ganglia?

A
  • Leave it be
  • Aspiration
  • Surgical excision
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37
Q

What can cause midfoot arthritis?

A
  • Post-trauma
  • Osteoarthritis
  • Rheumatoid Arthritis
38
Q

How would you treat midfoot arthritis?

A

Non-operative

  • Activity/shoewear/orthotics etc
  • Injections – xray guided

Operative

  • Fusion
39
Q

What is plantar fibromatosis?

A

Non-malignant thickening of the feet’s deep connective tissue, or fascia

40
Q

What is the following?

A

Plantar Fibromatosis

41
Q

How would you manage someone with plantar fibromatosis?

A

Non-operative

  • Avoid pressure – shoewear/orthotocs

Operative

  • Excision - high risk of recurrence - causes more
42
Q

What is plantar fasciitis?

A

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
Q

What can cause plantar fasciitis?

A

Weight bearing

  • PROLONGED STANDING
  • Overweight/obesity
  • Running
  • Equinus
  • Pes Planus/Pes cavus
44
Q

How does plantar fasciitis occur?

A

Degenerative changes from microtrauma, leading to microtears in the fascia

45
Q

What are the symptoms of plantar fasciitis?

A
  • 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
Q

On examination, what would suggest plantar fasciitis as the diagnosis?

A
  • 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
Q

How would you diagnose plantar fasciitis?

A

Clinical diagnosis of exculsion

Occassionally imaging - US, MRI, X-Ray

48
Q

How would you treat plantar fasciitis?

A
  • WEIGHT LOSS!!!!!
  • Rest, cross training
  • Stretching – Achilles +/- direct stretching
  • Ice
  • NSAIDs
  • Orthoses
  • Physiotherapy
  • Corticosteroid
  • Night Splinting
49
Q

What is tibialis posterior dysfunction?

A

Adult Acquired flat foot

Process of tendinosis (degeneration) - posterior tibialis tendon becomes fibrotic through a process of repeated microtrauma

50
Q

What can cause tibialis posterior dysfunction?

A
  • Charcots foot
  • Any degenerative process
  • Trauma
51
Q

What are the symptoms of tibialis posterior dysfunction?

A
  • Pain - behind medial malleolus, along the instep
  • Swelling - behing medial malleolus
  • Change in walking ability
52
Q

On examination, what would indijcate tibialis posterior dysfunction?

A
  • 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
Q

If, on examination, you observed the following, what would you suspect?

A

Tibialis posterior dysfunction

54
Q

If, on examination, you observed the following, what clinical tests could you do to help make the diagnosis?

A
  • Single/Double Heal Raise
  • Achilles Tendon Examination
55
Q

What classification system is used to classify the severity of tibialis posterior dysfunction?

A

Johnson and Strom classification

56
Q

What are the different grades of tibialis posterior dysfunction in the Johnson and Strom classification system?

A
  • 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
Q

What non-operative interventions can be used in tibialis posterior dysfunction?

A

Stage 1/2: physiotherapy, orthotics (medial arch support), analgesia

58
Q

What surgical options are available for those with stage 1 tibialis posterior dysfunction?

A

Surgical decompression of the tendon

59
Q

What surgical options are available for those with stage 2 tibialis posterior dysfunction?

A

Surgical reconstruction (flexor digitorum longus transfer + calcaneal osteotomy)

60
Q

What surgical options are available for those with stage 3 tibialis posterior dysfunction?

A

Joint fusion (subtalar, calcaneal cuboid, talonavicular)

61
Q

What surgical options are available for those with stage 4 tibialis posterior dysfunction?

A

Joint and ankle fusion

62
Q

What is a cavovarus foot deformity?

A

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
Q

What are the causes of pes cavus?

A
  • Freidrich’s Ataxia
  • Charcot-Marie-Tooth Disease
  • Trauma
  • Family history
64
Q

What symptoms can accompany pes cavus deformity?

A
  • Difficulty finding shoes that fit
  • Pain - Metatarsalgia, Plantar fasciitis, Ankle arthritis, Achilles tendonitis
65
Q

On examination, what would you see that would indicate cavovarus foot deformity?

A
  • Fixed Deformity - Varus Hindfoot, high instep on weight bearing
  • Neurological signs - Progressive deformity, Muscle pain or weakness, Elevated creatine kinase
  • Claw Toes
66
Q

What is the following foot deformity?

A

Cavovarus foot/Pes cavus

67
Q

How would you treat someone with pes cavus?

A
  • Orthoses/footwear adaptation
  • Surgery - soft tissue, bone, tendon transfer
68
Q

How would you treat someone with ankle arthritis?

A
  • Non-operative management - othoses
  • Surgery - osteotomy, arthrodesis (fusion), arthroplasty
69
Q

How do diabetic foot ulcer’s occur?

A
  • 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
Q

What percentage of diabetics will develop ulceration?

A

15%

71
Q

What are the modifiable determinants of healing of a diabetic foot ulcer?

A
  • Diabetic control
  • Smoking
  • Vascular supply
  • External pressure modification
  • Internal pressure (deformity)
  • Infection
  • Nutrition
72
Q

What is the 5 year mortality for those who develop diabetic foot ulcers?

A

50%

73
Q

What percentage of those that develop diabetic foot ulcers go on to have the foot amputated?

A

25%

74
Q

What is Charcot’s arthropathy?

A

Progressive degeneration of a weight bearing joint, a process marked by bony destruction, bone resorption, and eventual deformity.

75
Q

What are thought to be the processes behind the development of Charcot’s Arthropathy?

A
  • 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
Q

What is the following?

A

Diabetic Foot Ulcer - Complication of diabetes

77
Q

The following deformity was found in someone with diabetes. What is the name of this deformity?

A

Charcot’s Foot

78
Q

What can Charcot’s foot lead to?

A

Osteomyelitis - Chronic deformation may lead to repetitive trauma of the mid-foot (arch) during walking, leading to ulceration in this area

79
Q

In those with Rheumatoid arhtritis of the foot, when is surgery indicated?

A
  • Pain in spite of conservative treatment
  • Deformity development
  • Need to stop medication for some reason
80
Q

What surgical procedures are available for those with rheumatoid arthritis in the forefoot?

A
  • Hallux - Osteotomy, Fusion, Joint excision
  • Forefoot arthroplasty - hallux fused, with lesser MTPJ joint excsion
81
Q

What surgical procedures are available for those with rheumatoid arthritis in the midfoot?

A

Joint Fusion

82
Q

What surgical procedures are available for those with rheumatoid arthritis in the hindfoot?

A

Generally fusion or joint replacement

  • Ankle joint: Fusion or replacement
  • Subtalar joint: Fusion
  • Talo-navicular joint: Fusion
  • Calcaneo-cuboid joint: Fusion
83
Q

What is the following?

A

Dorsal foot ganglion

84
Q

What classifies someone as having stage 1 tibialis posterior dysfunction?

A
  • Medial pain
  • No deformity
  • Can single heel raise
85
Q

What classifies someone as having Stage 2 tibialis posterior dysfunction?

A
  • Flat foot
  • Flexible deformity
  • Cannot heel raise
86
Q

What classifies someone as having Stage 3 tibialis posterior dysfunction?

A
  • Flat foot
  • Fixed deformity
87
Q

What classifies someone as having Stage 4 tibialis posterior dysfunction?

A

Ankle Involvement

88
Q

What is lisfrancs injury?

A

Fracture-dislocation at the 1st tarsometatarsal joint

89
Q

What can be a complication of lisfrancs injury?

A

COmpartment syndrome of medial foot +/- later artritis

90
Q

What can be seen in the following radiograph?

A

Lisfrancs injury

91
Q

How would you manage lisfrancs injury?

A

Precise anatomic reduction with screw fixation acros 2nd tarsometatarsal joint (lisfranc joint)

Gwen - MSK (28 decks)

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