Foot & Ankle Flashcards
At the distal tibiofibular joint, the fibula …………………..and
………translates with ankle dorsiflexion.
At the distal tibiofibular joint, the fibula externally rotates and proximally translates with ankle dorsiflexion.
In the toe-off phase of gait, the plantar fascia is …………as the metatarsophalangeal (MTP) joints …………. The longitudinal arch is ……………… This is termed the ……………….. The hindfoot
………………….and locks with firing of the ……………..
In the toe-off phase of gait, the plantar fascia is tightened as the metatarsophalangeal (MTP) joints extend. The longitudinal arch is accentuated. This is termed the windlass mechanism. The hindfoot
supinates and locks with firing of the posterior tibial tendon.
Plantar migration of the metatarsal head after a Weil osteotomy may lead to? why?
cock-up toe deformity as the axis of pull of the intrinsics moves dorsal to the center of rotation.
Cavovarus alignment demonstrates an ………………. longitudinal arch with hindfoot …………and a ………….ray. Pes planus is noted
with a ………………..arch with hindfoot ……………
Cavovarus alignment demonstrates an elevated longitudinal arch with hindfoot varus and a plantar-flexed first ray. Pes planus is noted
with a flat longitudinal arch with hindfoot valgus.
Vascular examination findings that are predictive for healing include?
toe pressure greater than 40 mm Hg and transcutaneous oxygen pressure greater than 30 mm Hg.
Inability to sense this is consistent with neuropathy and the most predictive sign for the development of a
foot ulceration?
Semmes-Weinstein 5.07 monofilament
Anterior drawer test at the ankle, what does it test and how do you do it?
—anterior pressure on the hindfoot with the ankle in plantar flexion evaluates the anterior talofibular ligament.
Varus stress test of ankle tests what and how do you do it?
—inversion of the ankle in dorsiflexion evaluates the calcaneofibular ligament.
Describe The Silfverskiöld test
Test ankle dorsiflexion with the knee extended and flexed with the hindfoot in neutral alignment.
• Tightness in both knee flexion and extension indicates Achilles contracture.
• Improvement in ankle dorsiflexion with knee flexion (relaxing the gastrocnemius origin proximal to the knee) indicates isolated
gastrocnemius contracture.
A key feature in the pathoanatomy of hallux valgus is ……..drift of the proximal phalanx, leading to …………….. migration of abductor
hallucis, which results in …………. and ………….
A key feature in the pathoanatomy of hallux valgus is lateral drift of the proximal phalanx, leading to plantar lateral migration of abductor
hallucis, which results in plantar flexion and pronation.
There are four key radiographic angular measurements in hallux valgus. what are trhey?
Hallux valgus angle (HVA) < 15
first-second intermetatarsal angle <9 (IMA),
hallux valgus interphalangeus (HVI) <10
distal
metatarsal articular angle (DMAA) <10
what procedures are needed in HV in the following scenarios?
• Spasticity (stroke or cerebral palsy)—?
Osteoarthritis or rheumatoid arthritis—?
• Ligamentous laxity—?•
First TMT degenerative joint disease (DJD)?
- Spasticity (stroke or cerebral palsy)—first MTP fusion
- Osteoarthritis or rheumatoid arthritis—first MTP fusion
- Ligamentous laxity—Lapidus (first tarsometatarsal [TMT] realignment arthrodesis)
- First TMT degenerative joint disease (DJD)—Lapidus
A distal …………………… (modified McBride) is never appropriate in isolation.
A distal soft tissue release (modified McBride) is never appropriate in isolation.
IMA 13 degrees or less AND HVA 40 degrees or less , which osteotomy?
distal chevron
IMA greater than 13 degrees OR HVA greater than 40 degrees? which osteotomy?
proximal metatarsal osteotomy
complications of HV surgery?
Recurrence—undercorrection of IMA or isolated soft tissue reconstruction. Recurrence of the deformity after surgical correction is the most common complication in juvenile and adolescent hallux valgus.
• Dorsal malunion—Lapidus or proximal crescentic osteotomy; results in transfer metatarsalgia
• Hallux varus—overresection of the medial eminence
define a hammer toe? and treatment?
Hammer toe—proximal interphalangeal (PIP) flexion (MTP dorsiflexed but should correct with elevation). Fixed deformity is treated with PIP arthroplasty (resection of distal neck and head of proximal phalanx)
or PIP arthrodesis.
define a claw toe and treatment?
Claw toe—PIP and distal interphalangeal (DIP) flexion with fixed MTP hyperextension • Flexible—flexor-to-extensor tendon transfer of flexor digitorum longus (FDL)
• Fixed—PIP arthroplasty/arthrodesis with MTP capsulotomy and extensor lengthening. A dislocated MTP joint requires use of a
distal metatarsal osteotomy (e.g., Weil) to reduce MTP joint.
define a mallet toe? and treatment?
Mallet toe—DIP flexion; flexible deformity treated with flexor tenotomy; fixed deformity with DIP arthroplasty or fusion
what is a crossover toe? and treatment
Crossover toe—sagittal and axial plane deformities. Key component is disruption of the plantar plate. May be iatrogenic from steroid
injection within MTP joint. Address with EDB transfer.
what is Frieberg disease? and treatment?
Freiberg disease—osteochondrosis of metatarsal head. Early-stage disease is treated with joint débridement. A dorsal closed-wedge
metaphyseal osteotomy may also be performed.
what is a congenital curly toe and treatment?
Congenital curly toe—perform tenotomy of FDL and flexor digitorum brevis in children with flexible deformities.
Bunionette deformity is treated based on the anatomic location of deformity.
- Enlarged fifth metatarsal head—lateral co……………
- Lateral bowing of fifth metatarsal diaphysis—………….
- Widened fourth-fifth metatarsal angle—……………………..
Bunionette deformity is treated based on the anatomic location of deformity. • Enlarged fifth metatarsal head—lateral condylectomy • Lateral bowing of fifth metatarsal diaphysis—distal metatarsal osteotomy
• Widened fourth-fifth metatarsal angle—oblique diaphyseal
osteotomy
what is a turf toe ? and treatment?
Turf toe mechanism of injury is forced dorsiflexion resulting in avulsion of the plantar plate off the base of the phalanx and
subsequent proximal migration of the sesamoids. • Complete tears of the plantar plate treated with operative repair have demonstrated superior results compared to conservative
care.
Complications of medial and lateral sesamoidectomy are?
hallux valgus and varus, respectively
what will happen if both sesamoids excised?
Cock-up deformity (or claw toe) will occur if both sesamoids are excised.
what is a Morton’s neuroma ? treatment?
Interdigital neuritis (Morton neuroma) is a compressive neuropathy of the interdigital nerve, usually between the third and fourth metatarsals. Surgical treatment is via a dorsal approach, incision of the transverse intermetatarsal ligament and resection of the nerve 2 to 3 cm proximal to the intermetatarsal ligament.
The ……………………….nerve may be injured during surgical approaches that require a plantar incision, such as a tibiotalocalcaneal
arthrodesis with an intramedullary nail.
lateral plantar nerve
Upper motor neuron disorders most commonly result in an …………………… foot deformity. explain and how each is managed?
Equinus—overactivity of gastrocnemius-soleus complex • Equinus deformity is addressed with either an open Z-lengthening of the Achilles tendon or a percutaneous triplehemisection technique.
• Varus—overactivity of tibialis anterior (lesser contributions from flexor hallucis longus [FHL], FDL, and tibialis posterior)
• Varus deformity is addressed with a split anterior tibialis tendon transfer (SPLATT) to the lateral cuneiform or cuboid or total
anterior tibial tendon transfer to the lateral cuneiform.
Genetics of CMT disease?
Type I hereditary motor-sensory neuropathy is the most common presentation of Charcot-Marie-Tooth disease (CMT). • Usually autosomal dominant with a duplication of chromosome
17 Release of the
Treatment of a flexible cavus deformity involves:
Release of the plantar fascia • Transfer of the peroneus longus into the peroneus brevis at the level of the distal fibula
• A closed-wedge dorsiflexion osteotomy of the first metatarsal is always required.
• If the deformity does not correct with Coleman block, perform a
lateral calcaneal slide and/or closed-wedge osteotomy.
Nonoperative treatment of a fixed cavus deformity?
short-leg ankle-foot orthosis (AFO) with an outside (varus-correcting or lateral) T-strap is recommended. • Rocker sole can improve gait and decrease energy
expenditure.
Peroneal nerve palsy results in ?
loss of the anterior and lateral compartments with loss of active dorsiflexion and eversion. This
results in equinovarus
surgical treatment of peroneal nerve palsy ?
Transfer posterior tibial tendon (PTT) through the interosseous membrane anteriorly to the dorsal midfoot to restore dorsiflexion.
Achilles tendon should be lengthened.
foot deformities in RA?
The toes sublux or dislocate dorsally, deviate laterally into valgus, and develop hammering.
“Rheumatoid forefoot reconstruction”
—first MTP arthrodesis, lesser metatarsal head resection with pinning of the lesser MTP joints, and closed osteoclasis of the interphalangeal joints versus
PIP arthrodesis
The most common complication of forefoot arthroplasty is
intractable plantar keratoses.
Osteoarthritis etiology is typically ………………..in the hindfoot and tibiotalar articulations, while ………………in the first MTP and midfoot
joints.
Osteoarthritis etiology is typically posttraumatic in the hindfoot and tibiotalar articulations, while idiopathic in the first MTP and midfoot
joints.
What is Hallux rigidus?
First MTP (hallux rigidus)—tenderness over dorsum of joint, limited dorsiflexion due to large dorsal osteophyte and pain with grind test
treatment of Hallux Rigidus?
Initial treatment is a stiff foot plate with extension under great toe (Morton extension).
Surgical treatment in those with pain at extremes of range of motion (ROM)—dorsal cheilectomy.
• Pain throughout ROM with positive grind—arthrodesis (neutral
rotation, 10 to 15 degrees of dorsiflexion, and slight valgus)
surgical treatment of hindfoot arthritis?
Hindfoot arthritis—triple arthrodesis to correct arthritis secondary to deformity (0 to 5 degrees of hindfoot valgus, neutral abduction/
adduction, plantigrade)