Forefoot Pathology Flashcards
Long flexors and extensors are stabilized by what in the foot?
Stabilized by lumbricals
All digital contractures are a result of what?
Result of imbalance at MTPJ
What are the etiologies of hammertoes
- Flexor stabiliztion
- Extensor substitution
- Flexor substitution
What is flexor stabilization and during what phase of gait does it occur
- Failure of PTT to resupinate the foot results in overpronation.
- Extrinsics (FHL/FDL) fire earlier/longer/stronger to grasp ground during midstance
Midstance phase of gait
What is extensor substitution and during what phase of gait
- Weak anterior muscles: EDL/EHL overpowers intrinsics during swing phase of gait
- Cavus foot- EDL in position to overpower lumbricals just by passive stretch
- Equinus: extensors overworked to prevent tripping on forefoot
During the Swing phase of gait
What is flexor substitution and during what phase of gait?
Supinated foot with weak posterior muscle (achilles tendon) unable to PF foot during propulsion.
PT, FHL, FDL overpower to lumbricals
Propulsive phase of gait
Clinical presentation of forefoot pathology (3)
- Heloma molle
- Heloma durum
- Congruous, deviated, subluxed
Where is heloma molle found
- At the 4th interspace due to curly toe at 5th digit
- Head of 5th proximal phalanx rubs against the base of 4th proximal phalanx
Where are heloma durum found
At the dorsal IPJ
How to test the flexibility of a hammertoe
Reducibility determined by Kalikien push up test
Clinical tests used to diagnose hammertoe defermity
Lachman test: positive test is > 2 mm of dorsal displacement
Kilikian push up test
Conservative treatment options for hammertoes (4)
- Aperture pad
- Crest Pad
- Taping/Strapping
- Boudin Splint
What is the sequential release of MTPJ for hammertoe repair
1) Arthroplasty
2) Extensor tenotomy
3) Extensor hood release
4) Extensor Tendon lengthening
5) Flexor tendon transfer
What are some of the soft tissue procedures that can be done for overlapping 5th toe
- Incision from Distal Medial to Proximal Laterl
- Z-plasty or V-Y pasty
- tendon lengthening
What are hammertoe soft tissue procedures (4)
- Flexor or extensor percutaneous tenotomy
- Extensor tendon lengthening, Z-lengthening
- Capsulotomy
- Flexor tendon transfer
What is done with a flexor/extensor percutaneous tenotomy
- For hammertoe: cut @ PIPJ (for release FDL/FDB)
- For Clawtoe: cut @ DIPJ (release FDL)
What are the steps to Capsulotomy
- Includes extensor hood release
- J maneuver to release collaterals
What are the three Flexor tendon transfers
- Girdlestone Taylor
- Kuwada/Dockery
- Schuberth
What is the Girdlestone Taylor procedure
- bisect the tendon
- flexor reattached dorsally and sutured together to make a sling over proximal phalanx
What is the Kuwada/Dockery procedure
-reroute the tendon through distal drill hole
What is the Schuberth procedure
re-route tendon through proximal drill hill
What are specific procedures for 5th digit hammertoe procedures
- Derotational arthroplasty
- Ruiz Mora procedure
- Syndactyly
Describe derotational arthroplasty
Used for adductovarus of the 5th digit
-PIPJ arthroplasty and oblique removal of skin
What is the syndactyly procedure
When abnormal digit is fused a a normal adjacent digit to bring it down
Good treatment for flail toe
What are the osseous procedures for hammertoe correction (4)
Arthroplasty
- Arthrodesis
- Implant arhtroplasty
- Amputation
Techniques to be used for arthroplasty
Resectional (Keller)
Interpositional- interposition of tissue to keep inflammatory surfaces apart
-Implant
What is the anatomy of the plantar plate
crimp morphology
chinese finger trap
What is the most common etiology of predislocation syndrome
-elongated metatarsal or short neighboring metatarsal
What is the function of plantar plate and what is its healing potential
Plantar plate serves as a stabilizer during WB and has very poor healing potential
What is the clinical presentation for predislocation syndrome
- Grape like swelling
- Painful MT head/callus
- Crossover toe: rupture of the collateral ligaments
- Hammertoe:rupture of plantar plate
How to diagnose predislocation syndrome clinically
- Modified lachman test
- Arthrogram: extravasation
- MRI
- Ultrasound
What are the conservative treatment options
- Offloading
- Splinting
- orthosis
- MT pad
- Spica taping
Ligamentous correction for plantar plate tear
- Flexor tendon transfer: good for transverse plane deformity
- Capsulotomy or capsulorraphy
- Plantar plate repair: provides static stability
Ossesous correction for plantar plate tear
- IPJ arthrodesis
- Arthroplasty/arthrodesis
- Lesser MTPJ arhrodesis
What are some distal metatarsal procedures that can be done for metatarsalgia
Weil
Weil+plantar plate repair
- Jacoby
- Duvries
- Chevron
- DFWO
Describe the Weil and complications
-Cut is made parallel to weight bearing surface but appears to be made Distal- Dorsal to Proximal plantar
- Complications are:
- –Transfer lesions
- –recurrence
- –floating toe/flail toe
- –Dorsal contracture
Describe the jacoby procedure
V-osteotomy that can be PF or DF
Describe the Duvries procedure
plantar condylectomy on both sides of the MPJ
Describe the Chevron
Jacoby with removal of bone to shorten MT
Describe DFWO
same as Waterman procedure
