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CMT-dos > Foot disorders/reactive arthritis > Flashcards

Foot disorders/reactive arthritis Flashcards

1
Q

Anatomy of the Foot

A

26 bones of the foot are divided into 3 groups:
Tarsals
Metatarsals
Phalanges

Plantar arches function to:
Distribute and absorb the body weight
Provide the foot with elasticity and resilience during locomotion
Adapt to uneven surfaces
Protect the neurovasculature on the plantar surface

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2
Q

Bunion

general

A

Hallux valgus deformity of the 1st metatarsal phalangeal (MTP) joint

Most common cause of forefootpain
Pain is exacerbated by wearing shoes

Diagnosed clinically based on a history of great toepain and increasing valgusdeformity

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3
Q

Bunion

Tx

A

Conservative management: wear roomy shoes, bunion pads/cushions, NSAIDs for pain, application of ice

Surgical management: bunionectomy

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4
Q

Morton neuroma

General and sx

A

Commonly occurs in runners
Mechanism involves a mechanically induced neuropathic degeneration of the interdigital nerves

Patient presents with burningpain and numbness at the third intermetatarsal space

Clicking sensation, tenderness, and crepitus during palpation

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5
Q

Morton neuroma

Tx

A

Strength exercises
Padded shoes inserts
Glucocorticoid and local anesthetic injection

Surgery for patients that have failed conservative management; rare recurrence after surgery

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6
Q

Corns and calluses

general

A

Arise from abnormal pressure over theskinand bony prominences from shoes orfootbreakdown

Calluses
Diffuse thickening of thestratum corneum layer on the plantar aspect of the foot

Corns
Central “core” that is hyperkeratotic and often painful

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7
Q

Corns and calluses

Tx

A

Application of salicylic acid or cryotherapy with liquid nitrogen
Education the patient on proper fitting shoes

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8
Q

Pes cavus & Pes planus

general
Causes in childhood and adulthood

A

Increased risk of midfootpainin individuals with these conditions

Pes cavus = high-arched feet
Usually caused by neurologic disorders
Foot is supinated

Pes planus = flat feet
Collapse of the longitudinal arches, especially the medial longitudinal arch
Foot is pronated
Normal for infants and young children due to ligamentous laxity
Pes planusin adulthood may be due to a breakdown in supporting structures (posterior tibialis tendon andspring ligament)

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9
Q

Pes cavus & Pes planus

Tx

A

Orthotic devices or bracing
Shoe modification

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10
Q

Plantar fasciitis

General
MOI

A

Condition that produces pain at the site of the attachment of the plantar fascia and the calcaneus (calcaneal enthesopathy), with or without accompanying pain along the medial band of the plantar fascia

Commonly due to overuse stress

Problematic for patient with heel spurs, pes cavus, and pes planus

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11
Q

Plantar fasciitis

pain

A

Medially located on the plantar surface
Most significant with first steps in the morning or after prolonged sitting

Tenderness is elicited by palpating thefasciafrom the heel to the forefoot while dorsiflexing the patient’s toes

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12
Q

Plantar fasciitis

Tx

A

Stretching exercises for the plantarfascia and calf muscles

Avoid the use of flat shoes and barefoot walking

Use arch supports and/or heel cups

Decrease physical activities (excessive running, dancing, or jumping)

Short-term trial (2–3 weeks) ofNSAIDs
If all previous measures fail, an injection of glucocorticoidsand a local anesthetic by a podiatrist or orthopedist

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13
Q

Lisfranc Injury

general
MOI

A

Tarsometatarsal fracture-dislocation characterized by disruption between the articulation of the medial cuneiform and base of the second metatarsal
Lisfranc ligament

An interosseous ligament between the medial cuneiform and the base of the 2nd metatarsalbone

Critical to stabilizing the 1st and 2nd tarsometatarsal joints and maintenance of the midfoot arch

Commonly occurs when there is indirect loading on a plantar-flexed foot or with acrush injury

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14
Q

Lisfranc injury

clin man

A

Severe midfoot pain
Swelling or deformity in the midfoot
Ecchymosis

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15
Q

Lisfranc injury

Diagnosis

A

Plain-film radiograph of the foot (weight-bearing)
Space between the base of the first and second metatarsal bones
Space is > 2 mm, then a Lisfranc ligament injury should be considered

Avulsion fracture (fleck sign) is seen at the base of the second metatarsal or medial cuneiform

MRI
Allow for assessment of the integrity of the ligament
Obtain for patients that cannot bear weight

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16
Q

Lisfranc injury

Tx

A

Non-operative for non-displaced injuries
6-8 weeks non-weight bearing in a cast

Operative for displaced injuries or significant instability of the midfoot

17
Q

Reactive Art

general
Aka

A

Previously known as Reiter’s syndrome

Seronegative autoimmune spondyloarthropathy that occurs in response to a previous gastrointestinal (GI) or genitourinary (GU) infection

♂>♀
Occurs more frequently in young adults (< 40 years of age)
70%–90% have the HLA-B27 allele

18
Q

Seronegative arthropathies include:

A

“PAIR”

Psoriatic arthritis
Ankylosing spondylitis
Inflammatory bowel disease–associated arthritis
Reactive Arthritis

19
Q

reactive art

etiology

A

Generally occurs 1–4 weeks after infections:

Genitourinary (GU):
Chlamydia trachomatis(most common)
Neisseria gonorrhoeae
Ureaplasma urealyticum

Gastrointestinal (GI):
Campylobacter jejuni(most common)
Shigella flexneri, S. dysenteriae,andS. sonnei
Salmonella enterica
Yersinia enterocoliticaandYersinia pseudotuberculosis
Escherichia coli

all gram negative.

20
Q

reactive arthritis

Articular manifestations

A

Onset is acute, within 1–4 weeks of an inciting infection
Peripheral arthritis
Joint involvement is generally asymmetric

Can be oligoarticular or polyarticular

Predominantly of the large weight-bearing joints of the lower extremities:
Knees
Ankles
Other common joints:
Shoulders, wrists, elbows, small joints of hands and feet
Back pain – severe disease

21
Q

reactive arthritis

On exam, joints will be:

A

Tender, warm, and swollen

22
Q

reactive arthritis

Enthesopathy:

A

Inflammation at the site of ligament, tendon, fascia, or joint capsule insertion to bone
Tenderness and swelling
Common insertion sites:
Achilles tendon
Plantar fascia (insertion site on the calcaneus)
Ischial tuberosities
Iliac crests
Tibial tuberosities
Ribs

23
Q

reactive arthritis

Hand and back S/Sx

A

Dactylitis:
Swollen fingers and toes (“sausage digits”)

Sacroiliitis:
Inflammation of the sacroiliac joints
Low back pain
Decreased lumbar flexion

24
Q

reactive arthritis

ocular and GU Sx

A

Ocular: visual acuity is fine
Conjunctivitis (most common)
Anterior uveitis
Episcleritis
Keratitis

Genitourinary:
Urethritis 7-14 days after sexual contact
Cervicitis
Prostatitis
Cystitis
Salpingo-oophoritis

25
Q

reactive arthritis

cutaneous & GI Sx

A

Mucocutaneous:
Keratoderma blennorrhagicum
Vesicles of the palms, soles, and around nails
Become hyperkeratotic and form crusts
Appears similar to pustular psoriasis

Balanitis circinata
Shallow, painless ulcers of the glans penis

Painless oral ulcers
Nail dystrophy

Gastrointestinal:
Intermittent diarrhea

26
Q

reactive arthritis

Classic Triad

A

This classic triad of symptoms is found in only about 30% of patients:

Conjunctivitis
Urethritis
Post-infectious arthritis

27
Q

reactive arthritis

Left: Conjunctivitis Middle: Balanitis circinate Right: Swollen right knee in a patient with reactive arthritis
A
Keratoderma blennorrhagicum
28
Q

reactive arthritis

Dx

A

Reactive arthritis is a clinical diagnosis based on:
Acute oligoarthritis and typical articular manifestations
Preceding GI or genitourinary (GU) infection
Presence of ≥ 1 extra-articular manifestation
Exclusion of other diagnoses

Supporting work-up:

Synovial fluid analysis

Laboratory findings:
Inflammatory markers (ESR and/or CRP) normal or ↑
Stool cultures → evaluate for causative organisms if the patient is having diarrhea
Urine or genital swab → evaluate forC. trachomatis and N. gonorrhoeae
HLA-B27 testing

Antigens of the organisms causing infection are frequently isolated, but no bacterial growth occurs on culture

29
Q

reactive arthritis

Acute Tx

A

Symptoms of ReA typically resolve in 3‒4 months, but prolonged or recurrent symptoms can occur in up to 50% of patients

Acute presentation (duration < 6 months):
Nonsteroidal anti-inflammatory drugs (NSAIDs)are the mainstay of therapy
Naproxen, Diclofenac, Indomethacin

Intra-articular or systemic glucocorticoids
Reserved for those with an inadequate response to NSAIDs

Disease-modifying antirheumatic drugs (DMARDs)
Indicated if a patient fails the above treatments

30
Q

reactive arthritis

Chronic ReA
Tx

A

(duration > 6 months):
DMARDs – methotrexate or sulfasalazine
Tumor necrosis factor (TNF) inhibitors
Considered in patients who do not respond to DMARDs

31
Q

ReA

Management of underlying infections

A

GI infection
Antibiotics are generally not indicated
Exceptions:
Severe disease, elderly or immunocompromised patients

GU infection
C. trachomatistreatment
First-line therapy with either:
Doxycycline 100 mg twice daily for 7 days
Azithromycin 1 g PO once

N.gonorrhoeae treatment
Single-agent therapy with ceftriaxone (Rocephin) is the preferred regimen:
500 mg IM once (individuals who weigh < 150 kg)
1,000 mg IM once (individuals who weigh ≥150 kg

CMT-dos (95 decks)

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