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2 MSK Clinical Conditions > Foot and Ankle Problems (Session 5) > Flashcards

Foot and Ankle Problems (Session 5) Flashcards

1
Q

What is the usual mechanism for an ankle fracture?

A

Inversion/eversion injury

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2
Q

What co-morbidities may affect fracture healing?

A

Diabetes, neuropathy, peripheral vascular disease, smoking

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3
Q

If a patient has fracture blisters why does surgery need to be delayed?

A

Allow the blisters to heal

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4
Q

Why do open ankle fractures require urgent surgery?

A

Reduce risk of osteomyelitis (requires extensive irrigation and debridement)

Osteomyelitis= bone infection

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5
Q

Define an ‘ankle sprain’

A

Partial/complete tear of 1+ ligaments of ankle joint

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6
Q

What’s the porgnosis for an ankle sprain?

A
  • 90% heal with rest
  • Some cause late ankle instability, sometimes require surgery
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7
Q

Give some factors for increased risk of ankle sprains

A
  • Weak muscles/tendons that cross ankle joint
  • Weak/lax ankle ligaments
  • Inadequate joint poprioception
  • Slow neuromuscular response to an off-balance position
  • Running on uneven surfaces
  • Shoes with inadequate heal support
  • Wearing high-heeled shoes
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8
Q

What causes ankle sprains?

A

Excessive strain on ligaments of ankle: excessive external rotation, inversion, eversion

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9
Q

What is the most common mechanism of injury in ankle sprains?

A

Inversion injury

Affecting plantar-flexed and weightbearing foot

Anterior talofibular ligament most at risk of sprain

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10
Q

What is an avulsion fracture?

A

Tendon/ligament=placed under tension

Instead of tendon/ligament tearing, fragment of bone= pulled off at insertion site

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11
Q

In children, what could an unfused 5th metatarsal apophysis be confused with on an x-ray?

A

5th Metatarsal fracture

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12
Q

In what age group does an achilles tendon rupture most commonly occur?

A

30-50years

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13
Q

State 3 mechanisms of injury for an achilles tendon rupture?

A
  1. Forceful push-off with extended knee (jumping)
  2. Fall with foot outstretched in front and ankle dorsiflexed
  3. Falling from height/abruptly stepping into hole/off kerb
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14
Q

What is the ‘vascular watershed’ area on the achilles tendon?

A
  • 6cm proximal to insertion of achilles tendon onto calcaneal tuberosity
  • Area of decreased vascualrity and thickness

Area MOST SUSCEPTIBLE to tearing

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15
Q

What are the signs/symptoms of an achilles rupture?

A
  1. Sudden, severe pain at back of ankle/in calf
  2. Sound of loud pop/snap
  3. Palpable gap/depression
  4. Initial pain and swelling followed by bruising
  5. Inability to stand on tip toe or to push-off whilst walking
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16
Q

What test can be used to test for a ruptured tendon?

A

Thompson test

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17
Q

What other tests are used to demonstrate the gap in the Achilles tendon?

A

MRI

Ultrasound

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18
Q

Why is surgical reconstruction difficult with a ruptured Achilles tendon?

A

Two ends of the tendon= frayed

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19
Q

How are achilles tendon ruptures treated?

A
  1. Conservatively - foot held in aircast boot
  2. Surgery
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20
Q

What is the re-rupture rate following surgery or conservative management?

A

2-8%

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21
Q

Why does surgery have a relatively high complication rate?

(5-10% of patients have wound complications)

A

Overlying skin=poorly vascularised

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22
Q

What is hallux valgus? (3)

A
  1. Varus deviation of first metatarsal
  2. Valgus deviation/lateral rotation of hallux
  3. Prominence of first metatarsal head
    1. With/without overlying callus
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23
Q

In which population is hallux valgus most common?

A

Middle aged females

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24
Q

What is the most common cause of a ‘bunnion’?

:Bony deformity at first metacarpophalangeal joint

A

Hallux valgus

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25
Q

Give some factors which are thought to cause hallux valgus:

A

Secondary to:

  • Trauma
  • Arthritic/metabolic conditions eg gout
  • Rheumatoid arthritis
  • Psoriatic arthritis
  • Connective tissue discorders eg Ehlers-Danlos syndrome
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26
Q

Once hallux valgus is present, the pull of which tendon exarcerbates the problem?

A

Extensor hallucis longus tendon

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27
Q

Why should surgery on a hallux valgus foot not be carried out for cosmetic reasons alone?

A

May convert painless foot to painful foot

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28
Q

What surgery can be performed on a hallux valgus?

A

Metatarsal osteotomy

Realigning fragments

Osteotomy: surgical cutting of a bone, especially to allow realignment

29
Q

What is Hallux rigidis?

A

Osteoarthiritis of 1st metatarsophalangeal joint

30
Q

Why is the 1st metatarsophalangeal joint prone to osteoarthritis?

A

Joint under tremendous stress during walking

31
Q

What are the signs and symptoms of hallux rigidus?

A
  • Pain in MTPJ on :
    • walking
  • attempted dorsiflexion of toe
  • Patients tend to compensate- walk on outside of their foot
  • Range of dorsiflexion= restricted
  • Dorsal bunion (osteophyte) may develop
32
Q

Useful info: What do the following terms mean?

A
33
Q

How is Hallux rigidus managed?

A

Treatment ladder for OA:

  1. Activity modification
  2. Analgesia
  3. Orthotics/aids
  4. Intra-articular steroid injections
  5. Surgery
34
Q

What surgery may be performed on hallux rigidus?

A
  1. Arthrodesis (fusion at 1st MTPJ)
  2. Arthroplasty (replacement)
35
Q

What is the major difference between osteoarthritis of the ankle and osteoarthritis of the knee?

A

Nearly all cases of OA of the ankle are secondary arthritis

36
Q

What’s the main cause of osteoarthritis in the ankle joint?

A

Trauma (70-80% post traumatic)

Post traumatic osteoarthritis

37
Q

What other causes/risk factors are there for osteoarthritis in the ankle?

A
  1. Inflammation in the ankle joint (rheumatoid arthritis, reactive arthritis)
  2. Joint stress (ballet dancers, footballers)
  3. Obesity
38
Q

What % of cases of ankle osteoarthritis are primary?

A

7%

(Older patients, experience less pain, better range of motion compared to secondary osteoarthritis)

39
Q

How is ankle OA treated?

A
  • Arthrodesis (fusion)
    • Results= good
    • Often no discernible limp
  • Arthroplasty
40
Q

Name 4 types of toe deformities.

A
  1. Claw toe
  2. Mallet toe
  3. Hammer toe
  4. Curly toe
41
Q

Describe the ‘claw toe’

A

Usually affect all 4 toes

  1. MTPJ: hyperextended
  2. PIP: flexed
  3. DIP: flexed

Corns may develop over dorsum of toe/under head of metatarsal

42
Q

What causes claw toes?

A
  1. Muscle imbalance-

ligaments and tendons= unnaturally tight

usually due to Neurological damage

  • cerebral palsy
  • stroke
  • diabetes
  • alcohol dependence
  1. Trauma
  2. Inflammation
  3. Rheumatoid arthiritis
43
Q

How do a hammer toe and a mallet toe differ?

A

Hammer toe: PIPJ: flexed

Mallet toe: DIPJ: flexed

44
Q

In which toe are hammer and mallet deformities most common?

A

2nd toe

45
Q

What are the causes of hammer and mallet toes?

A
  1. Ill-fitting pointed shoes- toe in flexed position too long- muscles contract and shorten
  2. Pressure on second toe from adjacent halux valgus
46
Q

What causes curly toes?

A

Congenital

Flexor digitorum longus and flexor digitorum brevis (intrinsic muscles of foot) = too tight

47
Q

Which digits are usually involved with ‘curly toes’?

A

3rd-5th digits

Usually bilateral

48
Q

How are ‘curly toes managed’?

A

Usually asymptomatic

Conservative treatment- asymptomatic

Surgery rarely needed

49
Q

What is achilles tendinopathy?

A

Degenerative, not inflammatory condition

50
Q

What are the two points where achilles tendinopathy arises?

A
  1. Point of insertion of achilles tendon into calcaneum (insertional tendinopathy)
  2. Vascular watershed area
51
Q

What are the causes/ risk factors for achilles tendinopathy?

A
  1. Overuse (many years) eg long distance runners
  2. Can occur in inactive people
  3. Obesity
  4. Diabetes
52
Q

What are the signs and symptoms of Achilles tendinopathy?

A
  1. Pain/stiffness along achilles tendon in morning
  2. Pain in tendon worsens with activity
  3. Severe pain 24hrs after exercising
  4. Thickening of tendon
  5. Swelling present all the time- worsened with activity
  6. Palpable bone spur (w./ insertional tendinopathy)
53
Q

What is another name for ‘flat foot’?

A

Pes planovalgus

54
Q

What is a flat foot?

A

Collapsed medial arch of foot- medial border of foot almost touches ground

+Valgus angulation of hindfoot

55
Q

Why is it most young children ‘appear’ flat footed?

A

Arches not yet developed

Large amount of subcutaneous adipose tissue on sole of foot

  • Arch begins to form around 5yrs*
  • Abnormal if persists into adolescence*
56
Q

What is the difference between flexible and rigid flat feet?

A
  • Flexible:
    • ​No medial arch whilst standing normally
    • On tip toes-
      • normal medial arch appears
      • Valgus deviation into normal alignment
  • Rigid: symptomatic- often requires treatment
    • ​ALWAYS abnormal
    • Result of:
      • Tarsal coalition: failure of tarsal bones to separate during embryonic development
57
Q

How can an adult acquire flat feet?

A

Dysfunction of tibialis posterior tendon

(usually supports medial longitudinal arch of foot whilst walking)

Spring ligament stretches

Plantar aponeurosis stretches

Talar head displaced inferomedially

Medial longitudinal arch= flattened

58
Q

In which population does an adult acquired flatfoot usually occur?

A

Middle-aged females

59
Q

How will someone with adult acquired flatfoot present?

A
  • History of:
    • change of shape of foot
    • Pain behind medial malleolus
60
Q

What are the risk factors for an adult acquired flatfoot?

A
  • Obesity
  • Hypertension
  • Diabetes
  • Pregnancy (temporary)- increases laxity of ligaments
61
Q

How are adult acquire flatfeet managed?

A

Orthotics (improves symptoms in 80% patients)

Physiotherapy- improve muscle strength

Some- require:

surgical reconstruction

Arthrodesis if secondary OA develops

62
Q

What % of people with diabetes mellitus are affected by foot disease?

A

15%

63
Q

Why does having diabetes mellitus cause foot disease in so many patients? (3)

A
  1. Loss of sensation- peripheral neuropathy
  2. Ischaemia- peripheral arterial disease
  3. Immunosupression- poor glycaemic control
64
Q

What foot complications do patients with diabetes mellitus acquire?

A

Infection

Ulcers

Amputations

65
Q

How is the risk of acquiring foot disease in patients reduced?

A

Regular diabetic foot clinics, checked for:

  • Corns
  • Cracks
  • Dry skin
  • Sensation and perfusion of feet
  • Shoes checked

Patients=educated on how to look after feet

Tight glycaemic control

66
Q

What causes Charcot arthropathy?

A

Poorly-controlled diabetes

  • Neuropathy
  • Abnormal loading of foot
  • Repeated microtrauma
  • Metabolic abnormalities- osteolysis
  • Fractures
  • Dislocation
67
Q

What is Charcot arthropathy?

A

Progressive destruction of bones, joints, soft tissues

Most common in ankle, foot, knee

68
Q

What are the signs and symptoms of Charcot arthopathy?

A
  • Reduced ability to detect pain, touch etc
  • Continue to walk on foot- make it worse
  • Muscle spasticity
  • Rocker bottom foot may develop
69
Q

How is charcot arthopathy treated?

A
  1. Optimise glycaemic control
  2. Reduce load on affected joints (difficult as pain usually not felt and often patient= obese)

2 MSK Clinical Conditions (10 decks)

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