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Foot & Ankle > Foot & Ankle > Flashcards

Foot & Ankle Flashcards

1
Q
  1. ) What is conservative tx for Morton’s neuroma?

2. ) For surgical resection of Morton’s neuroma - what is the difference b/t a plantar vs dorsal approach?

A

1.) Wide toe box, pads, last try injection
2.) Both have similar rates of complications.
Dorsal -> typically used for primary
Plantar -> typically used for revision due to increased likelihood of neuroma excision

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2
Q

Besides plantar fasciitis, what is another cause of medial heel pain? What causes it and what muscle does it innervate?

A

Compression of the 1st branch of the lateral plantar nerve = Baxter’s nerve.
Compression is due to Abductor Hallicus
Innervates abductor digiti quinti
(*remember compressed by the abductor on the one side of the foot and innervates the abductor on the other side of the foot!)

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3
Q

What should you be thinking about in a Charcot foot w/ RECURRENT ulcerations?

A

Surgical fix the deformity or perform exostecomty

+/- Achilles lengthening PRN and protective footwear!

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4
Q

When the great toe deviates in Hallux valgus - what happens to the pull of the abductor hallucis?

A

Flexion and pronation

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5
Q

What 2 muscles make up the conjoined tendon to the big toe and where do they insert? During what procedure do you need to be careful that you don’t release the conjoined tendon - and what happens if you do?

A

Conjoined tendon inserts on the lateral base of the proximal phalanx of the big toe - made up of lateral head of FHB and Adductor hallucis.
Be careful not to release during lateral soft tissue release during Hallux Valgus correction -> if release it inadvertently can lead to Hallux Varus!

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6
Q

What is the most common complication of a Weil Osteotomy and why does this occur?

A

Floating toe
The translation of the MT head changes the center of rotation and converts the interossei from MTP plantar flexors to dorsiflexors

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7
Q

What is the best shoe for Charcot foot w/ TMT collapse?

A

Double rocker shoe (sequence should always be Total contact cast -> CROW walker -> Double rocker shoe)

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8
Q

What % of gait cycle is spent in Stance vs Swing phase?

Which has more muscle activity?

A

Stance 60%
Swing 40%
Stance phase has more muscle activity!
Swing phase is largely momentum - this is created by GS causing plantarflexion and hip flexors firing at terminal stance which propels the lower extremity forward -> knee flexion in early swing and extension at terminal swing are all passive. The main contraction during swing phase is concentric contraction of TA to get foot to clear floor and position for initial contact of heel strike.

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9
Q

What is the only muscle that is active during swing phase?

A

TA w/ concentric contraction (the rest of the motion is from momentum created by ankle plantar flexors and hip flexors).
Most muscle activity occurs during Stance phase!!

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10
Q

Which part of the gait cycle does quad weakness effect the most?

A

Midstance (quad contracts during midstance to prevent buckling of the knee)

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11
Q

What are the typical angles:

  1. ) HVA
  2. ) IMA
  3. ) HVI
  4. ) DMAA
A
  1. ) HVA < 15
  2. ) IMA < 9
  3. ) HVI < 10
  4. ) DMAA < 10 (tells you joint congruency - incongruent have low DMAA, congruent have high DMAA!!)
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12
Q

What angles in Hallux Valgus signify mild, moderate, severe dz?

A

Mild: HVA < 40, IMA < 13 (distal procedure/osteotomy)
Moderate: HVA > 40, IMA 13-16 (proximal osteotomy)
Severe: HVA > 40, IMA > 16

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13
Q

When should you consider a Lapidus = 1st TMT fusion in Hallux Valgus case?

A
  1. ) Ligamentous hypermobility

2. ) 1st TMT arthritis

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14
Q

What are the 3 main iatrogenic causes of Hallux Varus following treatment for Hallux Valgus?
~~~~~~
How do you treat Hallux Varus in this situation?

A

1.) Removal of lateral/fibular sesamoid
2.) Overcorrection of IMA
3.) Excess lateral release - release some of conjoint tendon (made up of FHB and adductor hallucis)
~~~~~~~
Flexible = tendon transfer
Rigid = fusion 1st MTP

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15
Q

If person with Hallux Valgus has ANY 1st MTP arthritis - what do you do?

A

ONLY need arthrodesis!! (will be able to correct the deformity w/ this as well!)

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16
Q

What are 2 main complications follow Hallux Valgus correction?

A
  1. ) AVN of MT head (not due to lateral release!)

2. ) Iatrogenic Hallux varus

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17
Q
  1. ) What is the operative treatment for Grade 1 and 2 Hallux Rigidus?
  2. ) What is operative treatment for Grade 3 Hallux Rigidus?
A
  1. ) Cheilectomy = removal of bump and 30% of MT head (may add a prox phalanx dorsiflexion osteotomy)
  2. ) 1st MTP arthrodesis (rarely done! Only if sick/elderly -> Keller arthroplasty)
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18
Q

What is the definition of the following lesser toe deformities?

  1. ) Hammer
  2. ) Claw
  3. ) Mallet
A

MTP/PIP/DIP

  1. ) Hammer = hyperext/flex/hyperext
  2. ) Claw = hyperext/flex/flex
  3. ) Mallet = isolated DIP flex
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19
Q

What is the treatment for:

  1. ) Fixed Hammertoe
  2. ) Flexible Hammertoe
A
  1. ) Fixed Hammertoe -> PIP arthroplasty/arthrodesis +/- EDL lengthening
  2. ) Flexible Hammertoe -> Girdlestone Taylor FDL to extensor tendon transfer
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20
Q

What is the treatment for:

  1. ) Fixed mallet toe
  2. ) Flexible mallet toe
A

IT’S THE SAME!

FDL tenotomy w/ DIP arthroplasty vs arthrodesis

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21
Q

What causes crossover toe deformity?

A

Multiplanar instability:

Plantar plate disruption + attenuation of lateral collateral ligaments -> migration of 2nd toe over greater toe!

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22
Q

What is the treatment for a crossover toe deformity?

A

If MTP joint is NOT dislocated -> tendon transfer (EDB tendon transfer w/ medial capsule release OR Girdlestone-Taylor FDL to extensor tendon transfer)
If MTP joint IS dislocated -> Weil distal MT osteotomy to help relocated the joint!

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23
Q

What is the primary cause of Freiberg Infraction? Secondary?

A
  1. ) Trauma (often due to long 2nd MT)

2. ) Vascular

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24
Q
  1. ) What is the primary treatment of Freiberg Infraction?

2. ) What are the surgical options?

A

1.) Stiff orthotics - carbon fiber stiff extension
2.) Depends on cartilage:
If still have cartilage -> joint debridement
If any joint destruction -> dorsiflexion MT osteotomy (b/c plantar cartilage is unaffected so want this to articulate instead!)

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25
Q

What are the 3 types of Bunionette Deformities and what are their treatments?

A

Type 1 -> enlarge 5th MT head: distal osteotomy and shift head medial + lateral capsule release
Type 2 -> bowing of the 5th MT diaphysis (congenital deformity): MT shaft osteotomy
Type 3 -> widening of 4/5 IMA (> 8 degrees): MT shaft osteotomy
[NEVER a proximal osteotomy - watershed zone!!!]

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26
Q
  1. ) What is the treatment for a sesamoid capsule strain?

2. ) What is the treatment for plantar plate tear?

A
  1. ) NONOP -> stiff insole, may toe tape and immediate return to play
  2. ) Operative repair back to proximal phalanx!
27
Q
  1. ) What injury mechanism and what structure causes a 5th MT Zone 1 avulsion fracture?
  2. ) What is treatment?
  3. ) What are surgical indications?
A
  1. ) Inversion injury; Pull of LATERAL BAND OF PLANTAR FASCIA (less extent pull of peroneus brevis)
  2. ) WBAT in HSS (even in elite athletes!)
  3. ) Rotated fragment, skin compromise
28
Q
  1. ) What is the treatment for 5th MT Zone 2 and 3 fx?

2. ) What can cause recurrent fx?

A

1.) Elite athlete -> IM screw
Regular person -> Cast and NWB
2.) Hindfoot varus!! Look for it! -> if present then need either a lateral closing wedge or lateral calc shift!

29
Q
  1. ) What are the 3 columns of the foot?
  2. ) Which one is least mobile and most effected by arthritis?
  3. ) Which column is MOST mobile?
A
  1. ) Medial (1st TMT), middle (2nd, 3rd TMT), lateral (4th and 5th TMT)
  2. ) Middle - fuse!
  3. ) Lateral - LEAVE it that way! NEVER fuse!! (if need to fix it, just Kwire it and remove later)
30
Q

What is the treatment for chronic or purely ligamentous Lisfranc injuries?
What is the exception?

A

Arthrodesis!!

Age < 14 yo do ORIF, DO NOT FUSE!!

31
Q
  1. ) What XR view is used to see an accessory navicular?
  2. ) If fails immobilization what is surgical tx?
  3. ) What if patient also has flatfoot w/ lateral pain?
A
  1. ) External oblique
  2. ) Excision w/ advancement of PTT
  3. ) Correct the flatfoot with surgery too!
32
Q

What area of the navicular has poor blood supply?

A

Central portion

33
Q
  1. ) What is the typical orientation of a navicular stress fracture?
  2. ) If non-displaced on CT what is treatment?
  3. ) What is the operative indication and what is direction of screw placement?
A
  1. ) Dorsal lateral to plantar medial
  2. ) NWB in cast x 6-8 wks. Repeat CT scan prior to restarting activity!
  3. ) ANY displacement = surgery! Lateral to medial screw. Again, need CT scan prior to return to play!
34
Q

What causes tarsal coalition?

A

Failure of differentiation

35
Q

What XR views are needed to see:

  1. ) Talocalcaneal coalition
  2. ) Calcaneonavicular coalition
A
  1. ) Harris axial view (may also see talar beaking on lateral XR!)
  2. ) Internal oblique
36
Q
  1. ) What is the primary treatment for symptomatic coalition?
  2. ) What surgery should be performed if needed?
A
  1. ) Immobilization
  2. ) Resection of coalition…except FUSION if for a talocalcaneal coalition that takes up > 50% of ENTIRE subtalar joint (typically this middle facet is the only one affected…and if this is 100% affected, this does not take up > 50% of entire subtalar joint - so would NOT fuse!)
37
Q
  1. ) What is the physiologic problem that leads to adult acquired flatfoot?
  2. ) Incompetence of what structure leads to arch collapse?
A
  1. ) Watershed area of PT (2-6 cm proximal to insertion) -> tenosynovitis and rupture
  2. ) Spring Ligament failure (which doesn’t happen until after PT rupture)
38
Q

In PTTD what orthotic do you use if:

  1. ) Early, flexible deformity w/ NO lateral pain?
  2. ) Flexible deformity w/ lateral pain?
A
  1. ) Medial post

2. ) UCBL brace/Arizona or custom modeled lace up brace

39
Q

What are 3 main causes of unilateral cavovarus foot?

A
  1. ) Spina Bifida/tethering of spinal cord
  2. ) Compartment syndrome
  3. ) Poliomyelitis
40
Q
  1. ) In cavovarus foot what test do you do to determine if forefoot driven?
  2. ) What is first line treatment?
  3. ) What is surgical treatment for forefoot driven cavovarus?
  4. ) What is added if varus not completely corrected w/ Coleman block test?
  5. ) What 2 additional soft tissue procedures can be performed to aid in correction?
A

1.) Coleman block test
2.) Lateral post orthotics (NO medial arch support!!)
3.) 1st MT dorsiflexion osteotomy; or 1st MTC dorsiflexion arthrodesis if arthritic
4.) Lateral closing wedge calc osteotomy (no more lateral slide due to pressure on tarsal tunnel!)
5.) Partial plantar fascia release to help dorsiflexion of MT’s.
PL to PB transfer to elimiated the plantarflexion deforming force on 1st ray!

41
Q

What is the surgical treatment for peroneal tendon tear with:

  1. ) < 50% torn
  2. ) > 50% torn
  3. ) 100% tear/absent peroneals
A
  1. ) Debridement, repair
  2. ) Tenodesis
  3. ) FHL transfer to 5th MT base (want to keep eversion of foot so don’t develop varus!)
42
Q

With peroneal pathology, what other foot deformity should you look out for? And what do you do if they also have it?

A

Cavovarus!

Lateral closing wedge osteotomy!

43
Q
  1. ) What mechanism/PE manuever can you use to dislocate peroneal tendons?
  2. ) What should you look for on XR for peroneal dislocation?
A
  1. ) Forced dorsiflexion, eversion

2. ) Fleck sign off of fibula = SPR pulled of bone

44
Q
  1. ) What is useful diagnostic tool for calc stress fx?

2. ) What is treatment?

A
  1. ) MRI

2. ) NWB in cast 6-8 wks

45
Q
  1. ) If have complete failure of conservative treatment for plantar fasciiitis what is the operative treatment?
  2. ) What structure is at risk of injury?!
A
  1. ) OPEN resection of the 1/4 of plantar fascia and decompress 1st branch of lateral plantar nerve at abductor fascia!
  2. ) lateral plantar nerve! (NOT medial!)
46
Q
  1. ) What is the modified Brostrom and who gets it?
  2. ) Who is it contraindicated in and what should be done instead?
  3. ) What other pathology should be looked for and corrected if present?
A
  1. ) Repair of ATFL, CFL and incoorporation of inferior peroneal retinaculum. Recommended for those who continue to have instability despite 3 months of functional rehab!
  2. ) Ligamentously lax, revision, and LARGE athletes -> peroneal tendon sacrificing procedure (peroneal used to reconstruct)
  3. ) Hindfoot varus -> do lateral closing wedge if present!!
47
Q

For consider OCD pathology:

  1. ) What test do you order if you suspect an OCD but can’t see it on XR?
  2. ) What test do you order if you can see OCD on XR?
A
  1. ) MRI

2. ) CT to allow accurate measurement of size and planning for surgery

48
Q

In OCD pathology, what is the typical etiology of:

  1. ) Posteromedial located lesion
  2. ) Anterolateral located lesion
A
  1. ) Congenital

2. ) Post-traumatic

49
Q

What type of orthotics should be used in RA patients?

A

SOFT!!! (never rigid!) - do not want any pressure!

50
Q
  1. ) In RA pts, in regards to forefoot deformity what surgery should be done at 1st MTP?
  2. ) What about for lesser toes?
A
  1. ) Always arthrodesis (regardless of underlying visible arthritis)
  2. ) Lesser toes -> Either MT head resection of ALL lesser MT heads and pinning in place x 6 wks (only time to pick this!); or Weil osteotomy
51
Q

In RA pts with hindfoot deformity what is the treatment?

A

Fusion to correct the deformity!

52
Q
  1. ) In RA pts w/ ankle pathology/deformity what is the typical treatment? Other possibility?
  2. ) What is the cavet/what must you avoid in these patients?
A
  1. ) Ankle fusion; however if patient has adjacent hindfoot arthritis OR a prior triple -> ankle replacement!!
  2. ) AVOID PANTALAR ARTHRODESIS!!! (they do better with a BKA if can’t do an arthroplasty)
53
Q

In DM, what types of neuropathy are seen?

A

Sensory (Semmes-Weinstein 5.07 monofiliament)
Motor neuropathy -> Common peroneal nerve effected -> see foot drop and clawtoes (due to lack of intrinsics)
Autonomic neuropathy -> lack of sweating leads to cracked skin -> portal for infection!

54
Q 
What are the values of the following that are a/w POOR healing of DM ulcer:
WBC count 
Albumin 
Total protein 
ABI 
Transcutaneous oxygenation pressures 
Absolute toe pressures
A
  • WBC count < 1500
  • Albumin < 2.5
  • Total protein < 6
  • ABI < 0.45 (note: ABI > 1 are usually due to calcification of vessels)
  • Transcutaneous oxygenation pressures < 40 mmHg
  • Absolute toe pressures < 40 mmHg
55
Q

In DM patients what pathology should you always look for to make sure they are not putting excess pressure on forefoot?

A

Tight Achilles! Perform Silfverskiold test! ->
* if Gastroc only tight (reduced dorsiflexion only w/ knee in extension) = Strayer aka Gastroc recession.
* if dorsiflexion decreased in knee flexion and extension = tight achilles -> Hoke triple step cut.
Make sure to perform this prior to total contact casting.

56
Q
  1. ) What test can be used to better evaluate osteomyelitis in DM patient who might also be going through Charcot?
  2. ) What test is NOT good for eval for osteomyelitis in patient who might also being going through Charcot?
A
  1. ) Bone scan w/ Indium

2. ) Bone scan w/ Technecium alone (will be HOT in BOTH!)

57
Q
  1. ) In a foot w/ Charcot, what stage should NOT be operated on?
  2. ) What stage can you operate? And what typically is operation?
A
  1. ) Stage 1 (development) & 2 (coalescence) = fragmentation, bone destruction stage (total contact casting and protected WB)
  2. ) Stage 3 (reconstruction) = typically perform ostectomy and correct deformity via fusion, then always look for Achilles tightness and place in total contact cast!
58
Q

How is the diagnosis of Morton’s Neuroma typically made?

A

Clinical diagnosis!!! History and physical exam!

59
Q

What is the 1st line of tx for accessory navicular and tarsal coalitions?

A

Cast immobilization x 4-6 wks!

60
Q

In patient’s with tarsal tunnel syndrome, a favorable outcome after surgical decompression is MC seen in what scenario?

A

Caused by a space occupying lesion (ie Ganglion cyst)

61
Q

An adequate release of the tarsal tunnel also requires the release of what structure distally?

A

Release of the deep fascia of the abductor hallucis muscle

62
Q

In questions that talk about a patient who underwent ENDOSCOPIC plantar fascia release for plantar fasciitis and now return reporting flattening of the foot - what is the cause of this?

A

Excessive plantar fascia release!! (NEVER do endoscopic and only release medial 1/4 of plantar fascia!)

63
Q
  1. ) What is the surgical treatment for insertional achilles tendinosis w/o insertional calcifications?
  2. ) What is surgical treatment w/ insertional calcifications?
  3. ) What is the surgical treatment of intrasubstance Achilles tendinosis?
A
  1. ) medial or lateral approach w/ bursectomy & resect Haglund deformity
  2. ) Central approach w/ removal of Haglund deformity, calcifications and if > 50% tendon removed then do FHL transfer
  3. ) Debride tendon, if > 50% removed then FHL transfer
64
Q

Peroneus brevis is the primary antagonist to which muscle?

A

Posterior Tibialis

Foot & Ankle (1 decks)

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