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High Risk Quiz Flashcards

1
Q

What is a neuropathic ulcer?

A
  • occurs in pressure areas in an insensate foot
  • common where there are structural/biomechanical abnormalities
  • common in those with diabetes
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2
Q

What are the characteristics of a neuropathic ulcer?

A
  • even wound margins
  • periwound HK
  • superficial or deep (can have sinus formation)
  • painless (mainly due to lack of sensation)
  • pt usually has palpable pulses
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3
Q

How do you treat a neuropathic ulcer?

A
  • offloading is most important
  • need to look at biomechanics and correction of structural deformities
  • education on neuropathy/diabetes control
  • dressings
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4
Q

What is an ischaemic/arterial ulcer?

A
  • a wound that forms due to lack of blood supply to the area
  • in combination with arterial insufficiency
  • common on the toes, met head, malleoli, and med/lat borders of the foot
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5
Q

What are the characteristics of an ischaemic ulcer?

A
  • demarcated edges
  • presence of necrotic tissue
  • pale base
  • little to no HK
  • painful
  • absent pedal pulses
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6
Q

How do you treat an ischaemic ulcer?

A
  • refer to vascular surgeon
  • if wound is dry then paint with betadine
  • if wound is wet then consider wet gangrene
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7
Q

What is a venous ulcer?

A
  • venous ulcers occur when there is chronic venous insufficiency/valve dysfunction that leads to oedema
  • the skin becomes thin and weak, and prone to ulceration
  • common in the medial/lateral malleolar regions and posterior calf
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8
Q

What are the characteristics of a venous ulcer?

A
  • irregular margins
  • nil periwound HK
  • nil/mild pain
  • dry/thin skin
  • hyper pigmentation (red/brown staining)
  • pulses are present but can be hard to palpate due to oedema
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9
Q

How do you treat a venous ulcer?

A
  • reduce the oedema e.g. with compression therapy
  • address the underlying medical concern (e.g. venous insufficiency)
  • encourage activity and ambulation to work muscle pump and optimise venous/lymph return
  • dressings
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10
Q

What is a pressure ulcer?

A
  • external pressure causes local ischaemia, cellular death and tissue damage
  • elderly and bed ridden are most affected
  • can be hospital acquired
  • common on posterior heel or bony prominences e.g. trochanter, sacrum, calcaneus, 1st/5th MPJs, malleoli
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11
Q

What are the characteristics of a pressure ulcer?

A
  • skin may be intact on initial presentation, followed by breakdown
  • can be superficial or deep extending to subcutaneous tissue, tendon or bone
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12
Q

How do you treat a pressure ulcer?

A
  • prevention! early ID, mobilising patients, foam overlays and air mattresses, resting AFOs, heel lifts/herbst cradle, sheepskin heel protectors, bed cradles
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13
Q

What types of dressings are available and on what type of wound would you use them? (groups)

A
  • semi-permeable films ( superficial/low exudating wounds)
  • hydrogels (dry/low exudating wounds)
  • hydrocolloids (uninfected low/moderate exudating wounds)
  • manuka honey (low/moderately exudating wounds)
  • alginates (moderate/high exudating wounds)
  • foams (low/high exudating wounds)
  • antimicrobials (low/high exudating wounds)
  • hydrofiber (high exudating wounds)
  • negative pressure wound therapy (non-bleeding non-infected wounds)
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14
Q

Which part of the anatomy is affected by digital deformities?

A

IPJ, MPJ, tendons, joint capsules and ligamentous structures.

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15
Q

What are the possible aetiologies of digital deformities?

A
  • ill-fitting footwear
  • biomechanics of foot
  • congenital e.g. long ray
  • trauma
  • attrition due to synovitis of plantar plate, capsule &/or collateral ligament
  • neuromuscular e.g. CMT, CP, MS
  • diabetes
  • inflammatory disease e.g. RA or Psoriatic arthopathy

All of these factors can lead to an imbalance between the extensor and flexor muscles of the toes, leading to lesser toe deformities.

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16
Q

How does a long metatarsal cause a lesser toe deformity?

A

It is more prone to injury such as stubbing as it is longer than other toes. In footwear it may buckle.

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17
Q

In which plane is a digital deformity easiest to correct?

A

Sagittal plane, followed by frontal plane and transverse plane.

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18
Q

What are the possible digital deformities?

A
  • hammer toe
  • claw toe
  • mallet toe
  • digitus adductus
  • digitus abductus
  • varus toe
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19
Q

What test do you do to classify whether a hammer toe is rigid or flexible?

A

‘Push up Test’
Rigid - minimal relocation of the base of the phalanx to the met head
Flexible - complete realignment of the deformity

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20
Q

How do the extrinsic and intrinsic muscles work together to keep a toe in rectus alignment?

A

Extrinsics - extend MPJ and flex IPJ

Intrinsics - flex MPJ and extend IPJ

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21
Q

What are the categories of digital dysfunction?

A

flexor substitution
flexor stabilisation
extensor substitution

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22
Q

Describe flexor stabilisation in pes planus.

A

In late stance phase the flexors attempt to stabilise a pronated foot - they fire longer.

Pull of FDL shifts medially - adductovarus of toes 4/5 common.

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23
Q

Describe flexor substitution in pes cavus.

A

Occurs in a supinated foot in late stance phase.
The flexors try to substitute for a weak triceps surae and overpower the interrossei.
Usually see straight contracture of lesser toes.

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24
Q

Describe extensor substitution.

A

Evident during swing phase.
EDL gains mechanical advantage over the intrinsics - EDL is becoming main DF of foot for whatever reason.
All lesser toes become contracted and retracted at the MPJs.

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25
Q

What are the surgical goals of correcting digital deformities?

A
  • re-establish a rectus alignment
  • stability to resist reoccurrence
  • shorten the toe if required
  • alleviate pain!
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26
Q

What procedures could be used to correct a hammertoe?

A

Soft tissue:
May be used in elderly low activity patients or in flexible digital deformity
- V to Y plasty (lengthening of contracted tissue)
- Stab tenotomy (percutaneous flexor tenotomy)
- Extensor tenotomy (isolated)
- Flexor tenotomy (in combination with an osseous correction)
- capsulotomy (release of a tight capsule)
- Flexor tendon transfer (stabilise a digit and decrease dorsiflexed proximal phalanx)

Osseous:

  • arthroplasty (remodelling of joint via excision of bone)
  • Arthrodesis (fusion of a joint to provide stability)
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27
Q

What procedure could be done to alleviate problems caused by a cross over toe?

A

Digital amputation of cross over toe.

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28
Q

What procedure could be done to alleviate problems caused by a bone prominence?

A

Ostectomy - removal of a prominent bone (exostosis)

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29
Q

What is a percutaneous internal fixation and when is it used?

A

Refers to an exposed pin utilised to maintain stability.

- 3 weeks for arthroplasty, 6 weeks for arthrodesis

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30
Q

What is the aetiology of IGTNs?

A
  • oral retinoids (causes nail to become brittle, slow growing and the skin becomes fragile)
  • trauma
  • fungal nail infections
  • hereditary - HAV, foot type
  • genetic factors
  • geriatric
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31
Q

What is the aetiology of onychogryphosis?

A
  • trauma
  • pressure (e.g. footwear)
  • fungal infection
  • diabetes
  • PVD
  • nutritional
  • psoriasis
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32
Q

What is the aetiology of onychauxis?

A
  • diabetes
  • psoriasis
  • PVD
  • hereditary
  • acromegaly
  • infection
  • genetic/chronic disorder
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33
Q

What types of nail surgery can be performed for and IGTN?

A
  • nail excision and avulsion
  • chemical matrixectomy
  • partial excisional matrixectomy
  • total excisional matrixectomy
  • subungal ostectomy
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34
Q

What are ‘red flags’ for nail surgery?

A
  • diabetes
  • paediatrics
  • PVD/arterial insufficiency
  • blood thinner use
  • current infection
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35
Q

In which patients is a subungal exostosis common?

A

May cause an IGTN.

  • 40+
  • often involuted nails
  • pain on distal dorsal aspect of nail
  • may be associated with trauma
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36
Q

In which patients is a subungal osteochondroma common, and what does it cause?

A

May cause an IGTN.

  • teenagers/young adults
  • nail plate may appear normal
  • suspect when rapid onset
  • may be hx of trauma
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37
Q

How may a periungual verrucae be surgically treated?

A
  • partial or total excisional matrixectomy of the nail and wart
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38
Q

What may cause plantar plate deterioration?

A
  • cross over toe
  • overlapping hammertoe
  • capsulitis
  • bursitis
  • pre-dislocation syndrome
  • metatarsalgia
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39
Q

How does the plantar plate receive nutrition?

A

Has poor blood supply - relies on synovial fluid.

40
Q

Where is the plantar plate located?

A
  • in the capsule of the MPJ
  • the met head rests directly on it
  • 2-3mm thick
41
Q

Can the plantar plate degenerate?

A

Yes - pp degenerates with age. Usually degenerates around distal attachment to the proximal phalanx.
Not all worn out or torn pp’s are symptomatic.

42
Q

What are the signs that the plantar plate is torn?

A
  • pain on palpation of the plantar toe sulcus
  • malalignment of digits
  • loss of toe purchase
  • lateral or medial deviation (if tear is lateral the toe will deviate medially)
43
Q

What is the clinical classification of plantar plate tears?

A

Stage 1:

  • mild plantar pain and oedema at MPJ
  • tenderness with manipulation of joint
  • no anatomical malalignment

Stage 2:

  • noticeable deviation of toe
  • in stance toe isn’t purchasing but it has purchasing power
  • positive vertical stress test

Stage 3:

  • moderate oedema around whole MPJ
  • subluxation and dislocation (cross over toes)
  • phalangeal base is in fixed dislocated position
44
Q

What may lead to a plantar plate tear?

A

Structural and biomechanical deformities that increase loading in the forefoot:

  • long 2nd met
  • HAV deformity
  • biomechanical hypermobility
45
Q

What investigations could you order if you suspect a plantar plate tear?

A

X-rays or ultrasound.

46
Q

How could you conservatively treat a plantar plate tear?

A
  • taping
  • corticosteroid injections (but if do this then toe must be strapped into downward position too) - this would treat associated synovitis

NB: with conservative treatment, while you may treat the pain the deformity may still progress

47
Q

When would you surgically treat a plantar plate tear?

A
  • when it is not responsive to conservative treatment after 3 months
  • if there is a severe deformity
  • ultimate surgical aim: a rectus toe with ground gripping strength
48
Q

What type of surgery would you use to correct a deformity resulting from a plantar plate tear?

A

Depends on what the deformity is - if a hammertoe, transverse plane deviation, or dislocation/subluxation.

Direct primary repair: stitch the plantar plate back together.

Amputation in really severe cases.

49
Q

What are the key risk factors for patients with diabetes?

A
  • peripheral neuropathy (sensory, motor, autonomic)
  • peripheral arterial disease
  • structural deformity
  • previous ulceration
50
Q

What is the common causal pathway for diabetic ulceration?

A

Neuropathy + Deformity + Minor Trauma (environmental event), over time leading to ulceration

Trauma can be acute or chronic e.g. a cut or continued pressure for footwear.

51
Q

Ulceration can be life threatening due to…

A

Sepsis! May lead to multiple organ shut down, and has a significant risk of death.

52
Q

What are the additional costs associated with ulceration?

A
  • limited mobility
  • social isolation
  • family issues
  • loss of work time
  • psychological impact
  • septicaemia/bacteremia
  • loss of function
  • amputation
  • health care costs
53
Q

Early intervention for ulceration involves…

A

Assessment, Education and Intervention.

54
Q

Describe what observations need to be made when assessing a wound.

A
  • aetiology
  • location
  • size/depth
  • clinical appearance (wound bed, edges, surrounding tissue)
  • exudate (amount/type/colour)
  • pain
  • presence of infection
  • wound classification system e.g. texas
55
Q

Name the intrinsic factors that affect wound healing.

A
  • age
  • mental state
  • skin condition
  • nutrition
  • medical conditions
  • infection
56
Q

Name the extrinsic factors that affect wound healing.

A
  • medications e.g. DMARDs (Methotrexate), corticosteroids
  • smoking
  • mobility/activity
  • pressure
  • hygiene
57
Q

Name some of the common causes of lower extremity wounds.

A
  • arterial insufficiency
  • venous insufficiency
  • neuropathy
  • pressure
  • surgical
  • burns
  • neoplastic disorders (e.g. melanoma)
58
Q

What disorders can cause peripheral neuropathy?

A
  • Hereditary disorders (e.g. CMT)
  • Systemic/Metabolic disorders (e.g. DM, habitual alcohol use)
  • Systemic effects of malignancies (e.g. cancers)
  • Infections or inflammatory conditions (e.g. HIV, Guillan-Barre)
  • Exposure to toxic compounds (e.g. glue sniffing)
  • Neuropathy secondary to drug use
  • Miscellaneous e.g. trauma (severing of nerve)
59
Q

What disorders can cause peripheral vascular disease?

A
  • superficial femoral occlusive disease
  • tibial artery disease
  • atherosclerosis
  • smoking
  • renal disease
  • small vessel disease (e.g. Reynaud’s disease)
60
Q

What disorders can result in immunosuppression?

A
  • organ transplants
  • chemo
  • stem cell transplant
61
Q

Why is offloading an ulcer important?

A
  • increased plantar pressure during ambulation is one of the major causative factors in the development of foot ulcers
  • reduced healing time
  • reduced risk of infection
  • reduced risk of further complications/cost
  • better patient outcome/quality of life
62
Q

Name some different methods of offloading.

A
  • bed rest
  • crutches
  • wheelchairs
  • sheepskin boots (hospital grade ugg boot)
  • post-op shoe
  • medical grade/custom footwear
  • orthoses
  • pneumatic/air cast walker
  • non-pneumatic walker
  • total contact cast
  • Charcot Restraint Orthotic Walker (CROW)
  • Pressure Relieving Ankle Foot Orthotic
  • Herbst Cradle (falls risk as patient cant walk in this - only for use in bed)
63
Q

Why is patient compliance important to remember when deciding on a method of offloading?

A

Patient may be able to remove offloading.

They may not understand why they need it, or be motivated to wear it if it impacts daily living/work commitments.

64
Q

What is the pathogenesis of a Morton’s Neuroma?

A
  1. Smaller IM distance: worsened with small toe box, toe off can compress the nerve against IM ligament.
  2. Met 4/5 more mobile than 2/3
  3. Intermetatarsal Bursitis: dorsal to transverse metatarsal ligament - bursa compresses nerve to ligament.
65
Q

What diagnostic tests could you order for a Morton’s Neuroma?

A

X-ray (rule out #), ultrasound.

66
Q

What are the conservative treatment methods for a Morton’s Neuroma?

A
  • no treatment
  • modified activity
  • change of footwear
  • functional orthoses (met dome)
  • NSAIDs/pain meds
  • cortisone/local anaesthetic injections
67
Q

What are the surgical treatment options for a Morton’s Neuroma?

A
  • Neurectomy - surgical excision (dorsal approach preferred)
68
Q

Is HAV inheritable?

A

Yes - highly inheritable

  • large IM angle 1-2
  • long 1st met
  • round 1st met head
  • abnormal muscle tendon insertion (tip post, EHL)
  • abnormal foot posture (pes cavus/planus)
69
Q

What are the significant findings associated with HAV?

A
  • pain associated with medial subcutaneous bony prominence
  • aggravated by footwear
  • great toe laterally deviated often with axial values rotation
  • widening of forefoot or splay foot
  • need to rule out rheumatoid arthritis
70
Q

What are some associated findings with HAV?

A
  • hammertoe
  • plantar HK
  • central metatarsalgia
  • onychocryptosis
  • neuritis
  • knee pain
  • self reported arthritis
71
Q

After which age is HAV likely to progress more quickly?

A

At age 55… indicates that if going to operate might have better outcomes before 50

72
Q

What is Juvenile Hallux Valgus?

A
  • onset is before 10 y.o.

- can be surgically corrected - usually delay until skeletal maturity

73
Q

What classification system is used for HAV?

A

Manchester Scale - has been validated.

74
Q

What do you look for when assessing ROM at the 1st MPJ?

A
  • normal ROM is 90 degrees DF
  • crepitus or smooth
  • flexible/rigid deformity (can you correct it into rectus)
  • WBing and NWBing ROM
75
Q

What conservative treatments are available for HAV?

A
  • waiting
  • toe alignment splints at night
  • foot exercises
  • orthotic therapy
  • physical therapy
  • width and depth of footwear
76
Q

What are the surgical options for HAV?

A
  • most evidence for chevron osteotomy
  • may need a combination of soft tissue and bone procedures
  • Silver procedure (just removes medial bump)
  • McBride procedure (soft tissue)
  • Reverdin procedure
  • Mitchell osteotomy
  • first MPJ arthrodesis (long term poor predictability)
77
Q

What are possible complications of surgical management of HAV

A
  • joint stiffness

- transfer metatarsalgia

78
Q

What is hallux rigidus?

A

A term used to describe symptoms commonly associated with degenerative joint disease of the first MPJ.

  • stiffness and pain
  • no motion

Hallux limitus is when there is <65 degrees dorsiflexion at the 1st MPJ.

79
Q

Who is OA of the 1st MPJ most common in?

A
  • middle age men
  • active (usually runners)
  • often bilateral and familial
80
Q

What are the proposed aetiologies of 1st MPJ OA?

A

Many theories - most likely multi-factorial

  • include long/short 1st met
  • long/wide prox phalanx
  • trauma
  • arthropathies
  • plantar fascia contracture
  • RF varus
  • FF varus
  • age
  • females
  • accessory navicular
  • tarsal coalition
81
Q

How may trauma be a etiological factor for 1st MPJ OA?

A
  1. direct macro trauma causes osteochondral fracture
  2. direct/indirect micro trauma to joint in combination with other predisposing factors
  3. iatrogenic
82
Q

How may a muscle spasm contribute to pain in the 1st MPJ?

A

Muscle spasms immobilise the joints as a protective mechanism to pain. The cyclic process of immobilisation propagates articular degeneration and fusion.

83
Q

How could a long 1st met cause OA of the 1st MPJ?

A
  • long 1st met disrupts the met parabola and 1st met cannot adequately plantar flex
84
Q

What are the clinical signs of 1st MPJ OA?

A
  • pain within and around 1st MPJ
  • rubor and swelling
  • occasionally paraesthesia due to compression of digital nerve
  • palpable and visible dorsal, medial & lateral joint osteophyte
  • sometimes IPJ hyperextension
85
Q

What imaging could you order if you suspected 1st MPJ OA?

A

X-rays… looking for:

  • gradual joint destruction
  • osteophyte
  • joint space narrowing
  • articular surface flattening
  • subchondral lesions
  • sesamoid hypertrophy/osteopenia
  • hallux valgus interphalangeus
86
Q

What are the Ddx for 1st MPJ OA?

A
  • plantar plate injury
  • turf toe
  • nerve entrapment
  • OM/septic arthritis
  • Gout
87
Q

What would you see in a Grade 0 1st MPJ OA?

A
  • no xray changes
  • normal joint space
  • normal 1st met head and proximal phalanx contouring
88
Q

What would you see in a Grade 1 1st MPJ OA?

A
  • may be hallux equinus
  • peri-articular subchondral sclerosis
  • minimal dorsal osteophytes
  • minimal 1st met head flattening
  • good joint space preservation
89
Q

What would you see in a Grade 2 1st MPJ OA?

A
  • moderate dorsal osteophytes
  • moderate 1st met head flattening
  • minimal joint space narrowing
  • lateral 1st MPJ exostosis
  • may see sesamoid hypertrophy
  • may see subchondral cyst formation
90
Q

What would you see in a Grade 3 1st MPJ OA?

A
  • severe dorsal osteophytes
  • moderate 1st met head flattening
  • loss of visible joint space
  • sesamoid hypertrophy
  • sub chondral cyst formation
  • intra-articular bone fragments
91
Q

What would you see in a Grade 4 1st MPJ OA?

A
  • excessive dorsal osteophytes
  • minimal/absent joint space
  • sesamoid fusion
  • subchondral cyst formation
  • other OA changes
92
Q

What are the conservative treatment options for 1st MPJ OA?

A
  • oral or topical NSAIDs
  • orthoses to facilitate 1st MPJ motion
  • sesamoid mobilisation/flexor strengthening
  • intra-articular cortison
93
Q

When would you be looking to limit joint motion in someone with 1st MPJ OA?

A

around grade 3 - looking at surgery, orthosis with a Morton’s extension, rocker sole shoes, carbon fibre plates

94
Q

What types of surgical management are available for those with 1st MPJ OA, and what may dictate your choice of procedure?

A

Procedure choice dictated by the amount of viable articular cartilage present (over or under 50%) - will be a joint salvage procedure or a joint destruction procedure.

  • valente cheilectomy (useful for grade 1-2 HR)
  • youngswick-austin osteotomy (useful for grade 1-2 HR)
  • silastic interposition arthroplasty (less active patients)
  • capsular interposition arthroplasty (advanced HR)
  • implant arthroplasty
  • semi implant arthroplasty
  • arthrodesis (grade 4 HR)
95
Q

When is an arthrodesis indicated for 1st MPJ OA?

A
  • indicated for grade 4 (end stage HR)

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