MSK wk 2 Flashcards
What ar ethe major problems of the forefoot?
Hallux valgus Hallux rigidus Lesser toe deformities Morton's neuroma Metatarsalgia Rheumatoid forefoot
What is the presentation of hallux valgus?
“bunion”
Pressure symptoms from shoe
Pain from crossing does
Metatarsalgia
What causes hallux valgus?
Genetic
Foot wear
Female>male
What is the pathogenesis of hallux vagus?
Lateral angulation of great toe
Tendons pull relaigned to lateral angle - worsens defmority
Continues in a cycle
Less weight goes through great toe
Eventually abnormalities of the lesser toes occur
How do you diagnose hallux vagus?
Clinical
X-rays )to check for severity of underlying bone deformity)
How do you manage hallux vagus?
Non-operative - shoe wear modification
Activity modification
Orthotics to correct deformity
Analgesia
Operative - osteotomy
release soft tissues
What is hallux rigidus?
Stiff big toe - osteoarthritis of MTP of toe
AKA hallux limitus
Hallux nonextensus
What are the symptoms of hallux rigidus?
Many asymptomatic
Pain (extreme dorsiflexion)
How do you diagnose hallux rigidus?
Clinical
X-ray
What is teh non-operative management of hallux rigidus?
Activity modification
Shoe wear rigid soles
Analgesia
What are teh types of surgery available for hallux rigidus?
Cheilectomy (remove dorsal impingement)
Arthrodesis (imbolisation of joint)
Arthroplasty
What is the best surgery for hallux rigidus?
Arthrodesis (MTP fusion)
Permanent
When is a hemiarthroplasty indicated in hallux rigidus?
When need to maintian range of movement
Although high failure rate so best in low demand patients
What are the lesser toe deromities?
Claw toes (both proximal + distal) Hammer toes (Distal) Mallet toes (proximal)
Where interphalangeal joints are permanently flexed
What is the aeitiology of lesser toe deformtiies?
Imbalance of flexor/extensors Shoes Neurological Rheumatoid arthrits Idiopathic
What are teh symptoms of lesser toe deformities?
Deformity
Pain from dorsum
Pain from plantar side
What are the treamtnet options for lesser toe deformities?
Non-oper
Activity/shoe modification
Orthotic insoles
Operative Flexor to extensor transfer Fusionof interphangeal joints Release metatarsophalngeal joint Shortening ostetomy of metatarsal
What is another name for interdigital neuralgia?
Morton’s neuroma
What casues morton’s neuroma?
Mechanically induced degenerative neuropathy
Females 40-60
Associated with high hell shoes
What are hte symtoms of morton’s neuroma?
2nd/3rd webspace
Neuralgic burning pain in toes
Intermittent
Altered sensation into toes
How do you diagnose morton’s neuroma?
Clinical
Mulder’s click
US best, MRI good
How do you manage morton’s neuroma?
Injection for small lesions
Surgery - excision of lesion including section of normal nerve
What are the complications with surgery for morton’s neuroma?
Numbness
Possible recurrance
Up to 30% still have pain 1yr post surgery
What is metatarsalgia?
A symptom - pain of metatarsals
Sometimes difficult to treat
What can cause metatarsalitis?
Syovitis Bursitis Arthritis Neuralgia Neuromata Freibergs disease
How do you treat rheumatoid forefoot?
Shoewear/orthotics
Operative - toe - MTP arthrodesis
Smal toes - arthroplasty
What are the pain midfoot problems?
Ganglia
Osteoarthrits
Plantar fibromatosis
What causes dorsal foot ganglia?
Underlying arthritis
Underlying tendon pathology
-arises from joint or tendon sheath
What are the symptoms of sorsal foot ganglia?
Pain from shoe wear pressure
Pain from underlying problem
How do you treat dorsal foot ganglia?
Non-operative - aspiration
Operative - excision
However high rate of return
What types of midfoot arthritis are there?
Post-traumatic
Osteoarthritis
Rheumatoid arthritis
What are the treatmnets for midfoort arthritis?
Non-op
Injections - x-ray guided
Operative - fusion
What is plantar fibromatosis?
“ledderhose disease”
Similar to druptyns but foot
Progressive and usually asymptomatic
How do you treat plantar fibromatosis
Non-op - avoid pressure, shoewear
Operative - excision
Radiotherapy
Combination (high risk complications but low risk of recurrance)
What are the main problems of the hindfoot?
Achilles tendonitis Plantar fasciitis Ankle osteoarthritis Tibialis posterior dysfunction Charcots foot Diabetic foot ulcerfoot
What is achilles tendonitis/tendinosis
Degenerative /overuse condition with little inflammation
Tendinosis is histopathy
Tendiopathy used to describe symptoms
What causes achilles tendiopathy>
Common in non-athletic people Obesity Steroids Diabetes Middle aged
What causes paratenonopathy?
Commonest in athletic populations 30-40
More common in men
What are the symptoms of achilles tendinopathy?
Recurrent episodes of pain during or following exercise
Difficulty fitting shoes
Sometimes rupture
How do you diagnose achilles tendinopathy?
Tenderness + test for rupture
- simmonds + test angle
US/MRI
What is the simmonds rupture test?
Squeeze calf (soleus) If foot moves, tendon is not fully ruptures If failure to move full rupture
What is the treatment for achilles tendinopathy?
Weight loss
Shoe wear/acitivty modification
Immbolisation
Operative - gastronemius recession
Release and debridement of tendon
What is plantar fasciitis?
Chronic degeneration of fibroblast hypertophy
Disorganised/dysfunctional blood vessesl/collagen
Leads to unable to make extra cellular matrix required for matrix/repair and remodelling
Note, fasciosis is a better term
What causes plantar fasciitis?
Unknown, but associated with:
Obesity
Lowerlimb rotational deformities
Running with poorly padded shoes on hard surfaces
Tight gastro-soleus complex
High intensity/rapid increase in training
What are teh symptoms of plantar fasciitis?
Pain first thing in morning
Pain on weight bearing after weight
Pain located at origin of plantar fascia
What are the differentials for plantar fasciitis?
Nerve entrapment
Arthritis
Calcaneal pathology
How do you diagnose plantar fasciitis?
Mainly clinical
Ocasionally radiography
How do you treat plantar fasciitis?
Rest/ICE NSAIDs Stretching Physio Injections Night splinting
What newer treatments are there for plantar fasciitis?
Extracorporeal Shockwave therapy Topaz Plasma Coblation Nitric Oxide Platelet Rich Plasma Endoscopic / Open Surgery
How do you diagnose ankle arthritis?
Clinical
Radiographs
CT to exclude adjacent joint arthritis
How do you manage arthritis?
Weight loss
Activity modification
Analgesia
Physio
Sugery:
Anterior symptoms only - arthroscopic anterior debridement
Arthrodesis (gold standard)
Joint replacement - difficult to revise
What is tibialis posterior tendon dysfnction?
Acquired flat foot planovalgus
Common but under recognised
What are the symptoms of tibialis posterior tendon dysfunction?
Medial or lateral pain
Double or single heel raise
How do you diagnose tibialis posterior tendon dysfunction?
Clinically
What is the heel raise test?
Raise heels
Normally heel should swing inwards as it rises
Swings outwards in positive
How do you manage tibialis posterior tendon dysfunction?
Orthotics Reconstruction of tendon Triple fusion (subtalar, talonavicular, calcaneocuboid)
What are the aims of surgical treatment of diabetic foot ulcer?
Improve vascular supply
Debride ulcers + deep samples for microbiology
Correct any deformity to offload area
Sometimes amputation to mitigate damage
What is the prognosis of a diabetic foot ulcer?
25% go on to get amputation
5 yr mortality
What causes charcot neurarthropathy?
Anything that causes neuropathy
Diabetes most common
Most common with syphillis historically
What is the pathophysiology of charcots foot?
Neurotraumatic - loss of proprioception and protective pain sensation
Or neurovascular - abnormal autonomic nervous system results in increased vascular supply + bone reabsorption
How do you diagnose charcot’s foot?
Consider in any diabetic with acutely swollen red foot
Esp with neuropathy
Frequntly not painful
MRI/radiograph
3degree difference between limbs
How do you manage charcot’s foot?
Immoblisation until acute fragmentation revolved
Correct deformity
(to prevent ulceration/infection/amputation)
What are common conditions of the hand - ellective?
Drupuytren's disease Trigger finger De quevain's tenovaginiits Nerve entrapments (carpal/cubital tunnel syndromes) ganglion OA
Who is likely to get dupuytren’s?
Men more than women Almost exclusively white Associated with diabetes Alochol Tobacco HIV Epilepsy
What is the pathology of drupruten’s?
Myofibroblast proliferation and collagen depositation leading to a progressive thickening of the palmar fascia
Causes digital protraction of fingers
What are the functional problems in druputren’s?
Loss of figner extension
Hard to do simple tasks - grip, wash face, hands in pocket
How do you treat drupuytren’s?
Radiotherpahy (splints don’t work)
Partial/dermo fasciectomy
Arthrodesis
Why is partial fasciectomy the gold standard for drupuytren’s?
Good correction achieved
Wound takes 2-3 weeks
Druputytren’s can’t be cured
What is dermofasciectomy?
A more radial procedure, removing skin may reduce recurrance
Requires more inetnsive physio
What are the benefits to percutaneous needle fascitomy?
Quick + no wounds
Return to activity in 2-3 days
Can be repeated
However risk of nerve injury and higher recurrance
What is the pathology behind trigger finger?
Swelling in tendon which catches on bone
Who gets trigger finger?
Women more than men - 40s-60s
Ring finger most common, then thumb and middle
Associated with RA, diabetes, gout
How do you diagnose trigger finger?
Patient history
Clickingsensation on digit movement
Lump in palm under pulley
Clicking may become lcoked
What can cause trigger finger?
Repitive use of hand
Local trauma
How do you treat trigger finger?
Splint/steroids
Or seurgically - percutaneous release or open surgery
What is the clinical history of de quervians syndrome?
Several weeks of pain localised to radial side of wrist
Pain aggravated by thumb mvement
Localised swelling - potentially
Localised tenderness over tunnel
Who gets De quervains syndrome?
Women 50-60 most common
Increased in post partum/lactating women
Associated with regular ulnar deviation
What is the pathology of de quervains syndrome?
A fibroossous tunnel in 1st dorsal extensor compartment
Leads to thickening of localised segment
30% have compartment divided by septum
How do you diagnose de quervains syndrome?
Examine thumb joints (consider OA at base of thumb)
Finklesteins test
Resisted thumb extension
How do you treat de quervains syndrom?
Splints/steroir
Decompression surgery
What is a ganglion?
Myxoid degeneration from a joint synovia “lump”
Who is most likely to get gnaglia?
Women 2x, most common 20-40yrs
Associated with recurrent injury around wrist
What is the presentation of ganglia?
More common on dorsal side (3:1) 3x
70% of all swellings on hand
How do you diagnose a ganglia
Firm, non-tender lump witha change in size
Smooth, only occasionally lobulated
Normally not fixed to underlying tissue - NEVER to skin
How do you treat ganglia?
Reassure + observe - aspiration
Operate - excise
What are the symptoms of OA at base od thumb?
Pain Stiffness Swelling Deformity Loss of function
Who gets OA at base of thumb?
1/3 of all women
What are the presenting features of base of thumb OA?
Pain on opening jars or pinching
Dorsal subuxation
Metacarpal adduction
MCP hyperextension
Where should you test if OA is found in base of thumb?
Scapho-trapezio-trapezoinal OA at wrist
How do you treat osteoarthritis base of thumb?
Life style modifications
NSAIDs
Splint/steroid
Opertive
Replacement
fusion
Trapeziectomy - gold standard
