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Foot & Ankle > Miller's Review Foot and Ankle > Flashcards

Miller's Review Foot and Ankle Flashcards

Ortho Foot and Ankle Review

1
Q

Deforming forces in hallux valgus

A

Abductor hallucis migrates plantar to MT head, 1st MT head migrates medial, EHL is now lateral to 1st MT and pronates it and pulls it into more valgus, lateral migration of the sesamoids erode the crista and allow further deformity

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2
Q

HVA

A

<15

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3
Q

IMA

A

<9

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4
Q

HVI

A

<10

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5
Q

DMAA

A

<10

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6
Q

Three types of hallux valgus deformities

A

Congruent = DMAA <10, Incongruent = DMAA >10 and degenerative

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7
Q

Treatment of incongruent bunion with stable 1st MT, IMA <13 and HVA <40

A

Distal metatarsal osteotomy

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8
Q

Treatment of incongruent bunion with stable 1st MT, IMA >13 and HVA >40

A

Proxial 1st MT osteotomy

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9
Q

Treatment of incongruent bunion with unstable 1st MT, IMA >13 and HVA >40

A

Lapidus

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10
Q

Indication for biplanar distal chevron osteotomy

A

Congruent DMAA with IMA <13, HVA<40 and stable 1st MTP joint. Can also consider an Akin.

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11
Q

Indication for double 1st MT osteotomy

A

Congruent DMAA with IMA >13, HVA >40 and stable 1st MTP joint. Can also consider Akin.

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12
Q

Is risk of AVN increased with distal osteotomy and lateral capsule release?

A

No, this was debunked.

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13
Q

Risks for post-bunionectomy hallux valgus

A

Excision of the fibular sesamoid, overcorrection of the IMA or excessive lateral release.

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14
Q

Techniques for correcting hallux varus

A

If it’s flexible can try taping. If that doesn’t work, then can transfer extensor tendon through IM membrane and medial capsule release. It may require distal osteotomy if increased DMAA.

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15
Q

Management of hallux rigidus

A

Non-op = extra depth shoes, Morton extension brace

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16
Q

Position of fusion of 1st MTP joint

A

Neutral rotation, 10-15 dorsiflexed and 5 of valgus

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17
Q

What is a hammertoe

A

MTP extended, PIP flexed, DIP extended

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18
Q

What is a claw toe

A

MTP extended, PIP and DIP flexed. This can start with volar plate laxity, MTP extended by EDL pull and FDL flexes PIP and DIP joints.

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19
Q

What is a mallet toe?

A

Isolated DIP flexion

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20
Q

What causes crossover toe?

A

Plantar plate attenuates, then collateral ligament attenuates

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21
Q

Hammertoe treatment algorithm

A

Fixed = PIP arthroplasty/arthrodesis, EDL lengthening if flexion >15 degrees

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22
Q

Mallet toe treatment algorithm

A

Doesn’t matter fixed or flexible.

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23
Q

Claw toe treatment algorithm

A

Fixed: PIP arthroplasty/arthrodesis, EDL lengthening, MTP capsulotomy +/- Weil shortening osteotomy to address MTP dislocation

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24
Q

Crossover toe treatment

A

EDB transfer to lateral lax MTP capsule and medial capsule release, FDL -> EDL transfer +/- Weil osteotomy

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25
Etiology of Freiberg infraction
AVN of 2nd MT head can occur from trauma, long 2nd MT head and overload
26
Natural history of Freiberg infraction
Central subchondral bone resorption, flattening, collapse and arthritis.
27
Freiberg infraction treatment
Rigid Morton extension orthotic. If that fails, can do a dorsal closing wedge osteotomy to remove diseased bone and rotate preserved plantar cartilage into the joint. Cutting out the 2nd MT head isn’t the correct answer because you’ll get transfer metatarsalgia (unless RA).
28
Types of bunionette deformity and treatment
I) bump, distal chevron osteotomy and lateral capsule release II) congenital lateral bow, oblique diaphyseal MT osteotomy III) IMA > 8 degrees, oblique diaphyseal MT osteotomy. Can’t do proximal osteotomy due to vascular watershed.
29
Classification and management of turf toe
I) Strain, stiff insole, taping and immediate return to play
30
Complications of hallux sesamoid excision
Tibial excision = hallux valgus.
31
Management of chronic cock up toe deformity from neglected turf toe
Fuse the contracted IP joint and transfer FHL to the base of the proximal phalanx to restore push off power
32
Most common location of Morton’s neuroma
3rd webbed space between the rigid and flexible 3rd and 4th MT heads
33
Management of Morton’s neuroma
Injections (only 14% get relief), no high heels, wide toe box, MT pads.
34
How far do you need to resect a Morton’s neuroma to minimize recurrence?
3cm proximal to MT heads, must incise transverse metatarsal ligament to visualize and resect. Recurrent or inadequately excised neuromas need to be exposed through a plantar incision.
35
Risk factor for Jones fracture and failure of fixation
Hindfoot varus, if supple should do orthotic with lateral post
36
Management of zone III base of 5th MT fractures
Typically from stress fracture, higher risk of non-union (33%), treat with IM screw
37
Most and least rigid midfoot columns
Most rigid = intermediate (<1mm movement), lease rigid = lateral (13mm), medial column ~ 3mm dorsal plantar translation
38
Best diagnostic test for midfoot arthritis
Piano key
39
Management of midfoot arthritis
Stiff shank shoe with rocker bottom for push off
40
Non-operative management in Lisfranc injury
Only indicated if there is no displacement on weight bearing radiographs, stress radiographs and no bony injury (i.e. likely ligament strain). NWB x 6 weeks, repeat x-rays before return to sport
41
Operative management in bony vs ligamentous Lisfranc
Ligamentous Lisfrancs do better with primary arthrodesis. If bony with associated fracture, can do primary ORIF.
42
X-ray needed for accessory navicular
External oblique foot x-ray
43
Typical navicular stress fracture orientation
Dorsolateral to plantarmedial, screws are placed lateral to medial to capture the best medial bone
44
Non-op management of navicular stress fracture
NWB 6-8 weeks, get follow-up CT prior to return to play to ensure it healed
45
Aside from C-sign and anteater sign, what other radiographic clues are there that a patient has a coalition?
Talar beaking
46
X-ray needed to assess the facet most commonly involved in subtalar coalition?
Harrix axial view will show you the middle facet
47
Etiologies for tarsal tunnel
Engorged veins, PVNS, ganglion cysts, nerve sheath tumors, progressive pes planus
48
EMG/NCS in tarsal tunnel
Only 50% will be diagnostic, make sure to check MRI for space occupying lesion
49
Tarsal tunnel treatment
Nonop: SSRI, antiseizure meds, TCAs and orthotic for hindfoot valgus 3-6 months
50
Best results after tarsal tunnel decompression
If there is a space occupying mass
51
Anatomic structure that fails leading to progressive flat foot deformity
Calcaneonavicular (spring) ligament no longer supports the talonavicular joint. This can occur after failure of the posterior tibial tendon.
52
Radiographic features of flat foot
Negative Meary angle, uncovering of talar head, valgus hindfoot alignment and valgus talar tilt in mortise
53
Conservative management of flat foot
Medial post, UCBL brace if flexible. Can use Arizona if rigid. AFO if stage IV and insufficient deltoid.
54
Operative management in flatfoot
1) no deformity, flexible = tenosynovectomy
55
Deformities that make up a cavovarus foot
Forefoot equinus relative to hindfoot and forefoot pronation from plantarflexed 1st ray
56
Diseases to think about with unilateral cavovarus foot
Tethered cord (spina bifida), compartment syndrome and polio
57
Diseases to think about with progressive bilateral cavovarus foot
Hereditary sensory motor neuropathies in 2/3…1/2 of these will be CMT
58
Orthotic for cavovarus foot
Lateral post without arch support, arch will worsen deformity
59
Surgical treatment of cavovarus foot that completely corrects after Coleman block testing
1st MT dorsiflexion osteotomy +/- plantarfascia release (sometimes PF is so tight it won’t allow dorsiflexion of the 1st MT)
60
Surgical treatment of cavovarus foot that has incomplete correction of varus with Coleman block testing.
Must add a lateral closing wedge calc osteotomy to take the hindfoot out of varus (or subtalar arthrodesis if arthritic)
61
Tendon transfer to consider in cavovarus foot
Peroneus longus to brevis transfer, removed force on 1st ray plantarflexion and strengthens weakened everters
62
Best test to diagnose peroneal tendon tears
u/s. MRI has lots of false positives
63
Surgical management of peroneal tendon tears
If <50% tear, tenosynovectomy, repair +/- tubularization.
64
Management of plantar fasciitis
Night splints and stretching, almost never need surgery
65
How to differentiate plantar fasciitis from calcaneal stress fracture.
Calc stress fx will have pain with medial/lateral calcaneal squeeze test
66
Management of retrocalcaneal bursitis with no tendinopathy and +Haglund deformity.
Don’t inject steroids because risk of Achilles rupture. Can perform isolated Haglund excision.
67
Management of Achilles tendinopathy with <50% repairable tendon.
Add FHL transfer
68
Indications for non-anatomic lateral ligament reconstruction for chronic ankle instability
Large athletes, ligamentously lax and hypermobility syndrome
69
Posteromedial vs anterolateral talar dome lesion
Posteromedial = congenital avascular lesion
70
Indications for microfracture in talus OCD
Good results if lesion <1cm
71
Rheumatoid forefoot findings and management.
MTP joints incompetent -> crossing toes
72
Rheumatoid hindfoot findings and management
Hindfoot valgus, treat with bracing, then triple arthrodesis if refractory. If ankle is involved, they do better with total ankle than a pantalar fusion (some evidence suggests they do better with BKA than pantalar fusion)
73
Define loss of foot protective sensation
Inability to detect 5.07 Semmes-Weinstein monofilimaent
74
Most common diabetic foot motor neuropathy
Common peroneal nerve -> foot drop and intrinsic weakness leading to claw toes
75
TBIs and toe pressures that are thresholds for being able to heal a diabetic foot ulcer
TBI > 0.45, toe pressure >40mmHg and TcO2 >40mmHg
76
Labs in diabetics that indicate ability to heal a foot ulcer
Total protein >6, WBC > 1500, albumin >2.5
77
Best test to diagnose a diabetic foot ulcer involving bone vs not involving bone
Tagged WBC scan. High false positive rate with MRI with Charcot foot. 67% have osteo if ulceration probes to bone.
78
Eichenholtz stages of Charcot arthropathy
Warmth/swelling/erythema -> bone resorption and fragmentation over 6-18 month time period. Don’t operate until in the consolidation phase.
79
Differentiating Charcot from osteo on exam
Redness improves with elevation in Charcot
80
Surgical principles for Charcot foot
Remove bony prominences, fuse unstable joints and lengthen the Achilles

Foot & Ankle (1 decks)

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