Foot & Ankle Flashcards
What is hallux valgus?
bunion- Medial deviation of 1st metatarsal
What are the risk factors for hallux valgus?
Genes
Ligamentous laxity
RA
Cerebral palsy
Flat feet
2nd toe amputation
High heeled narrow toed shoes
How does hallux valgus present?
Often bilaterally,
It’s kind of obvious just look at the toe lol
Management for hallux valgus
Analgesia
Splints and spacers
Better fitting shoes
Surgical correction if all else fails
What is hallux rigidus?
OA of 1st metatarsophalangeal joint
Primary vs secondary hallux rigidus
Primary- degenerative
Secondary- result of injury
What can cause hallux rigidus?
Unknown distinct cause but trauma may predispose
How does hallux rigidus present?
Joint pain and motion loss
Transfer Metatalgia- referred pain to other part of foot due to increased strain
Dorso-medial paraesthesia (weird sensation in feet)
How is hallux rigidus investigated?
X-ray
How is hallux rigidus managed?
NSAIDs
injections- corticosteroids
orthotics
activity modifications
Worst case scenario can either chop off affected bone or just replace the whole toe
What is Morton’s neuroma?
Benign fibrotic thickening of plantar digital nerve due to irritation
Most common in third joint space
What causes Morton’s neuroma?
Repeat trauma of plantar interdigital nerves overlying intermetatarsal ligaments -> neuroma
What are the risk factors for Mortons neuroma?
Age
obesity
Generally more common in females -> high heel shoe use
How does Morton’s neuroma present?
Squeezing toes together produces a click
Shoes exacerbate pain
Burning and tingling sensation in affected toes
How is Morton’s neuroma investigated?
Ultrasound to find the swollen nerve
How is Morton’s neuroma managed?
Conservative options such as orthotics and analgesia
Steroid injections as a second line
Surgical excision of affected nerve as a last resort
What is a lesser toe deformity?
Deformity of the 4 smaller toes, leaving them in a curved position/overlapping
What causes a lesser toe deformity?
Imbalance between flexor and extensor tendon
What is a claw toe?
Extended MTP, flexed DIP and PIP
What is a hammer toe?
Neutral MTP with flexed PIP and extended DIP
How do lesser toe deformities present?
Pain in footwear
Rubbing
Usually curved
How are lesser toe deformities managed?
Toe sleeves to prevent skin issues secondary to rubbing, wide toe shoes
Surgical correction/amputation is possible
What is pes cavus?
High arched feet
What causes pes cavus?
Related to neuromuscular conditions, like cerebral palsy, spina bifida, etc
How does pes cavus present?
Pain in arch of foot and a visible larger curvature
What does pes cavus often present in conjunction with?
Claw doe deformity
How is pes cavus investigated?
X-ray
MRI to further investigate a suspected neurological cause
How is pes cavus managed?
Orthotics, braces, special shoes
More severe cases can get surgery eg soft tissue release, tendon transfers, arthrodesis
What is pes planus?
Flat feet
What is the most common cause of pes planus?
Tibialis posterior dysfunction
Common in women
How does the arch of our feet normally develop?
Starts out flat and develops as we learn to walk- sometimes this doesn’t happen
How can development of the arch in our feet variate?
Familial tendency, ligamentous laxity
Tibialis posterior dysfunction/rupture
RA
Diabetes -> Charcot foot
What are the types of flat feet?
Mobile- only present when patient is on tip toes- (familial/ligamentous laxity)
Rigid- flatness persistent regardless- sign of underlying bone issue or inflammation
How does pes planus present?
Pain and swelling posterior to medial malleolus (specific)
Change in foot shape
Mid foot and ankle pain
Change in walking ability, especially on uneven surfaces
Poor balance
Lateral wall impingement sensation (Sometimes)
How is pes planus investigated?
Observation
Imaging
Testing for TPD
How is pes planus managed?
If it causes no pain it doesn’t need treating
If painful-
Physio
Bespoke footwear
Orthotics
Surgery
Name a complication of flat feet
Higher risk of Tibialis posterior tendonitis
What is plantar fasciitis?
Inflammation of plantar aponeurosis (at origin of calcaneus)
What causes plantar fasciitis?
Repeat stress/degeneration
What are the risk factors for plantar fasciitis?
Physical overload
obesity
diabetes
age (atrophy of cushion pad)
improper footwear
How does plantar fasciitis present?
Well localised pain, exacerbated by walking
Likely swollen and tender
Positive tinels test for Baxter’s nerve (the nerve that runs inside the heel)
How is plantar fasciitis diagnosed?
Via clinical diagnosis
How is plantar fasciitis managed?
Rest
NSAIDs
Night splints
Heel support
Physio
Steroid injections
What causes Achilles tendon rupture?
Age related degeneration
Or a specific event, e.g. injury
What are the risk factors for an Achilles tendon rupture?
Age
steroids
ciprofloxacin use
RA
diabetes
Clinical presentation of Achilles tendon rupture
can’t weight bear
Palpable gap
Weak plantar flexion
Patient may hear audible rip sound at time of injury
Investigations for Achilles tendon rupture
US + MRI to distinguish between partial/complete tears
Treatment for an Achilles tendon rupture
Surgical repair
OR
Casting with foot plantarflexed to close tendon gap
What is Achilles tendonosis?
Inflammation of the Achilles tendon
What causes Achilles tendonosis?
Sport induced overuse ->
Repeat strain peritendonitis
(Micro tears + degeneration)
What are the risk factors for Achilles tendonosis?
Overtraining
Ciprofloxacin use
RA (or other inflammatory arthritis)
What is the basic pathophysiology of an Achilles tendonosis?
Repeat micro tears combined with failed collagen repair
How does Achilles tendonosis present?
Localised pain
Morning stiffness that eases with walking
How is Achilles tendonosis diagnosed?
Clinical but can use scans to confirm
How is Achilles tendonosis managed?
Activity modification
Analgesia
NSAIDs
Shockwave therapy
Orthotics
Physio
What causes a calcaneus fracture?
Most commonly a fall from height causing axial compression
How does a calcaneus fracture present?
Pain and difficulty weight bearing,
Swelling,
Other associated injuries from a fall
How is a calcaneus fracture investigated?
X-ray, CT scan,
Bohlers angle assessment
How is a calcaneus fracture managed?
Casting
Surgery is a bit shit so its not routine
Name complications of a calcaneus fracture
Risk of compartment syndrome, post injury arthritis, and permanent stiffness
What causes an ankle fracture?
Forceful inversion injury
What are the types of ankle fracture?
Can affect one or more part- medial malleolar, lateral malleolar, posterior malleolar
Stable- a break without impacting alignment, so ankle stays stable
Unstable- often bimalleolar or trimalleolar leading to misalignment of the joint (less common)
In terms of the ankle, what is meant by the syndesmosis?
The joint between the distal tibia and fibula
Explain the assessment criteria used for ankle fractures
Weber classification
A- below syndesmosis, stable, non surgical management
B- at syndesmosis level, negligible stability, may require surgery
C- above syndesmosis, unstable, needs surgery
How is an ankle fracture investigated?
X-ray AP and Lat
Check for soft tissue swelling and bony alignment
CT to clarify anatomy in most complex cases
How is an ankle fracture managed?
Determined by Weber class
Can be casting, moon boot, or ORIF
What causes an ankle sprain?
Twisting
How are ankle sprains graded?
1- stretch/microtears
2- partial ligament tear
3- complete rupture of ligament
4- chronic- recurrent sprains within 6 months
How do ankle sprains present?
Tenderness, swelling, bruising,
Loss in function
How are ankle sprains managed?
PRICE:
Protection
Rest
Ice
Compression
Elevation
What causes a talus fracture?
Forced dorsiflexion/rapid deceleration
High energy impact
Name another type of talus related fracture
Talar dome margin fracture-
Piece of bone fragment breaks off the superior talar surface
What are the risks that come with a talar fracture?
post traumatic arthritis
Avascular necrosis or malunion
How is a talar fracture managed?
Either cast immobilisation or surgery depending on severity
What is a lisfranc fracture?
Broken bones or ligaments of the midfoot
What causes lisfranc fractures?
High energy impact
How does a lisfranc fracture present?
Severe midfoot pain when weight bearing
How are lisfranc fractures investigated?
X-ray AP and oblique
(Other angles helpful as fracture may be subtle)
CT due to multi-joint involvement, and possible ligamentous avulsion injury
How are lisfranc fractures managed?
ORIF
What are some complications of a lisfranc fracture?
Post traumatic OA
What causes a 5th metatarsal injury?
Inversion
What are the 3 types of digit and metatarsal injury
Avulsion
Jones
Proximal shaft
avulsion metatarsal fracture
Twisting injury -> avulsion via peroneus brevis tendon
Treated with moon boot
Jones metatarsal fracture
Repeat trauma -> metaphyseal-diaphyseal junction fracture
Often needs surgery because of malunion risk
Proximal shaft (stress) metatarsal fractures
Repeat stress or overuse (eg jumping athletes) -> mid shaft fracture
Heals well with rest and immobilisation
How are metatarsal fractures investigated?
Lateral X-ray
Can be confused with lateral malleolar fractures
How does a 5th metatarsal fracture present?
Pain over lateral foot border, issues weight bearing
What is a pilon injury
High impact causes talus to smash into distal tibia
MDT managed due to severity and common soft tissue involvement
