Forefoot pathology Flashcards
What is hallux valgus?
“Bunions”
What is the aetiology of hallux valgus?
- Genetic
- Foot wear
- Significant female preponderance
SSx of hallux valgus?
- Pressure symptoms from shoe wear
- Pain from crossing toes over
- Metatarsalgia (pain and injury in ball of foot)
Pathogenesis of hallux valgus?
- Lateral angulation of big toe
- Tendons will pull realigned to lateral of centre of rotation of toe, worsening deformity
- Vicious cycle of increased pull creating increased deformity
How do we diagnose hallux valgus?
- Clinical
- Xray: determine severity of underlying bone deformity/exclude degenerative change
How do we manage hallux valgus?
Non-operative
- shoe modification
- Orthotics to offload pressure/correct deformity
- Activity modification
- Analgesics
Operative
- Release lateral soft tissues
- Osteotomy 1st metatarsal
What is hallux rigidus?
‘A stiff big toe’
Osteoarthritis of 1st MTP joint
Aetiology of hallux rigidus?
- Not really known
- Possibly genetic/possibly multiple microtrauma
SSx of hallux rigidus?
- Many are assymptomatic
- Pain [often at extreme of dorsiflexion]
- Limited range of movement
How does one diagnose hallux rigidus?
Via clinical judgement and radiography
Management of hallux rigidus?
Non-operative
- Activity mods
- Shoe wear with rigid sole
- Analgesia
Surgery
- Cheilectomy [remove bony lump]
- Arthrodesis [immobilisation of joint]
- Arthroplasty [reconstruction of joint]
What are the two main operations for hallux rigidus?
- 1st MTPJ fusion
- gold standard treatment
- permanent
- 1st MTPJ hemiartroplasty
- good option to maintain ROM
- high failure rate
- better for low demand patients
What are three lesser toe deformities?
- Claw toes
- Hammer toes
- Mallet toes
What is the aetiology of the lesser toe deformities?
- Imbalance between flexors/extensors
- Shoe wear
- Rheumatoid arthritis
- Idiopathic
SSx for lesser toe deformities?
- Deformity
- Pain on dorsum
- Pain from plantar side
Management for lesser toe deformities?
Non-operative
- Activity mods
- Shoe wear - flat shoes with high toe box to accomodate deformity
- Orthotic insoles
Operative
- FLexor to extensor transfer
- Fusion to interphalangeal joint
- Release metatarsophalangeal joint
- Shortening osteotomy of metatarsal
What is interdigital neuralgia (Morton’s neuroma)?
A common interdigital nerve block
Aetiology of Morton’s neuroma?
- Mechanically induced degenerative neuropathy
- Affects females 40-60 generally
- Often associated with high heel use
- Common digital nerve relatively tethered to one metatarsal and movement in adjacent metatarsal causing mechanical shear
SSx of Morton’s neuroma?
- Typically effects 3rd followed by 2nd webspace/toes
- Neuralgia burning pain into toes
- Intermittant
- Altered sensation in webspace
Diagnostic signs for Morton’s neuroma?
- Clinical diagnosis (duhh)
- Mulder’s click
- USS is best investigation
Management for Morton’s neuroma?
- Injection for small lesions
- Surgery: excision of lesion including a section of normal nerve
- numbness
- recurrance
- up to 30% have pain 1yr after surgery
What is metatarsalgia?
‘Pain under the metatarsal bones’
A symptom not a diagnosis
Careful examination should localise site.
Differential for metatarsalgia?
- Synovitis
- Bursitis
- Arthritis
- Neuralgia
What is the treatment for rheumatoid forefoot?
Non-operative
- shoewear, orthotics, activity
Operative
- Many described techniques
- Current gold standard
- 1st MTPJ arthrodesis
- 2-5th toe excision arthroplasty
