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Foot and Ankle FRCS > Neurological > Flashcards

Neurological Flashcards

Interdigital neuroma Tarsal tunnel syndrome anterior tarsal tunnel syndrome SPN entrapment Diabetic foot Poliomyelitis Diabetic foot

1
Q

What is Poliomyelitis?

A
  • VIRAL DESTRUCTION OF THE ANTERIOR HORN CELLS IN THE SPINAL CORD AND BRAIN STEM MOTOR NUCLEI

​

  • Hallmark
    • MOTOR WEAKNESS with NORMAL SENSATION
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2
Q

What is polio’s clinical features ?

A
  • MOTOR WEAKNESS NORMAL SENSATION
  • Flaccid, Asymmetrical Muscle weakness
  • Flexion, abduction contracture hip
  • Flexure contracture knee, valgus deformity and genorecurvatum
  • ankle -equinus, foot- valgus/varus
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3
Q

What is the epidemiology of polio?

A
  • Present in developing countries- WHO tried to erradicate it in 2006 endemic in 6 countried
  • Eliminated in US and UK due to vaccination
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4
Q

What is its treatment of polio foot deformities?

A

non operative

  • lightweight orthosis
    • first line
    • Help pt maintain functional independence

Surgery

  • Contracture release, Tendon transfer, Arthrodesis
    • if orthosis not achieving satifiactory ADL’s
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5
Q

Name associated conditions of Polio? What is it?

A
  • Post Polio Syndrome
  • AN aging phenomenon when more nerve cells become inactive with time.
  • Characterised by Muscle weakness, myalgia & fatigue
  • Doesn’t represent reactivation of virus
  • Occurs in middle age (20-40 yrs after inital infection)
  • Occurs in up to 50% cases of polio
  • Leads to difficulties of ADL
  • Patients should exercise at sub-exhaustion levels to tone affected muscles groups without causing muscle breakdown
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6
Q

What is post polio syndrome tx?

A

Non operative

  • Limited exercise with periods of rest and lightweight orthosis
    • first line of tx
    • Maintain but not overuse muscles

Operative

  • Tendon transfers, contracture releases & arthrodesis
  • To optimise funcitonal capacity
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7
Q

Define Tarsal Tunnel syndrome?

A
  • Compression neuropathy caused by compression of TIBIAL nerve
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8
Q

What is the aetiology of tarsal tunnel syndrome?

A
  • Intrinsic
    • Ganglionic cyst
    • Tendonopathy
    • Tenosynovitis
    • Lipoma/tumour
    • Peri-neural fibrosis
    • Osteophytes
  • Extrinsic
    • Shoes
    • Trauma
    • Anatomical deformity- tarsal coalition/valgus hindfoot
    • Systemic inflammatory disease
    • Oedema of the lower extremity
  • IN 80% cases no cause for compression is found
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9
Q

Describe the prognosis of tarsal tunnel syndrome?

A
  • Result vary between 50-90%
  • Worse results with ‘Double crush injury’ and post operative scarring
  • Revision surgery less successful than index operation
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10
Q

Define the anatomy of the tarsal tunnel?

A

Anatomy defined by

  • Flexor retinaculum- Lacinate ligament
  • Calcaneus - medial
  • Talus- medial
  • Adbuctor hallucis- inferior
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11
Q

What is in the tarsal tunnel?

A
  • Tibial Nerve- posterior
  • Posterior tibial artery
  • FHL tendon
  • FDL tendon
  • tibialis posterior tendon
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12
Q

What does the tibial nerve divide into?

A
  • Medial plantar
  • Lateral Plantar
  • Medical Calcaneal
  • The medial and lateral plantar nerves can be compressed in their own sheaths, distal to tarsal tunnel
  • Bifurcation of tibial nerve in 5% cases occurs proximal to tarsal tunnel
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13
Q

Describe the signs and symptoms of tarsal tunnel syndrome?

A

Hx of previous trauma/ surgery

Symptoms

  • Pain with prolonged standing/walking
  • Often vague medial foot pain
  • Sharp burning pains in foot
  • Intermittent numbness in plantar of foot

Signs

  • Tenderness of tibial n- Tinel’s sign
  • Pes planus
  • Muscle wasting of foot instrinsics- abductor digit quntini, or abductor hallucis
  • Pain with dorsiflexion & eversion of ankle
  • Compression test
    • compression over tarsal tunnel= pain - sensitive and specific
    • Compression with plantarflexion & inversion
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14
Q

What investigations are helpful to aid diagnosis of tarsal tunnel syndrome?

A
  • Weight bearing radiographs- osseoud
  • MRI
    • exclude accessoty muscle/ soft tissue tumour
  • EMG
    • positive finding
    • distal motor latencies of >7.0ms
    • prolonged sensory latencies of >2.3msec
    • Sensory more likely abnormal cf motor
    • Decreased amplitude of motor action potentials of abductor hallucis or abductor digiti minimi
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15
Q

What is the treatment of tarsal tunnel syndrome?

A
  • Non operative
    • Lifestyle modifications. medications
      • usually ineffective
      • NSAIDS/ SSRIs
      • Bracing
        • orthosis/ foot wear changes to adress aligment of hindfoot
        • try a period of short leg cast
  • Operative
    • Surgical Release of Tarsal Tunnel
      • 3-6 months after failed consx
      • compressive mass identified
      • reproducible findings
      • best outcomes- where a compressing anatomic stricture ganglionic cyst is identified and removed
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16
Q

Describe how would you release the tarsal tunnel?

A
  • 2 inicsion - medial ankle and medical foot
  • Identify the nerve proximally
  • Release these layers-
17
Q

What is the aetiology of deep peroneal nerve entrapment?

A
  • Impingement of DPN by distal margin of INFERIOR EXTENSOR mechanism
  • Also
  • Dorsal osteophytes over apex of medial longitudinal arch
  • Ganglionic cyst
  • Tight laces or ski boots
  • aka anterior TARSAL TUNNEL syndrome
18
Q

What does the anterior tarsal tunnel contain?

A
  • Extensor digitorium Longus
  • Extensor hallucis longus
  • Tibialis anterior
  • deep peroneal nerve
  • Dorsalis pedis artery
19
Q

What are the signs and symtpoms of anterior tarsal tunnel?

A

Symptoms

  • Dysesthesia & parathesias of dorsum of foot & 1st web space
  • Vague foot pain

Signs

  • Tinel sign with symptoms in first web space
20
Q

What are the tx for Anterior tarsal tunnel?

A
  • Non operative
    • Shoe Modification
    • First line
    • Well padded tongue of shoe
    • Full length rocker -sole steel shank
  • Operative
    • Surgical release of DPN by releasing retinaculum & ostephyte/ ganglion resection
      • failure of non op tx
    • symptoms of RSD are CI to release
    • Start distal, idenify nerve and release Proximally- nerve lateral to EHB
    • warn pt recovery is prolonged
21
Q

What is the cause of Ilioinguinal nerve entrapment?

What signs and symptoms of ilioinguinal entrapment?

A
  • Hypertophied abdominal muscles- result of intensive training
  • Symptoms
    • Hyperesthesia is common
    • Pain worse with hip hyperextension
22
Q

What is the tx of Ilioinguinal nerve entrapment?

A
  • Non operative
    • lifestyle modification
  • Operative
    • failed consx
    • Surgical release
23
Q

What is the epidemiology and symptoms of Obturator nerve entrapment?

A
  • Common in skaters with well developed adductors
  • Chronic medial thigh pain
24
Q

What investigations are useful in Ilioinguinal nerve entrapment?

What is the tx of Ilioinguinal nerve entrapment?

A
  • Nerve conduction studies
  • Tx
  • Conservative= Supportive
25
What are the symptoms of lateral femoral cutaneous nerve of the thigh entrapment?
* **Pain on lateral aspect of thigh** * **MERALGIA PAESTHETICA**
26
What is exacerbates the pain in lateral femoral cutaneous nerve of the thigh entrapment?
* **Tight belts and prolonged hip flexion**
27
Describe the tx in lateral femoral cutaneous nerve of the thigh entrapment?
* Non operative * **PT, NSAIDS** * postural excercises * release of compressive devices
28
Where is the sciatic nerve often entraped?
* Any where along its length * Common= Level of **ischial tuberosity** * **At piriformis muscle**= pirifomis syndrome
29
What is Saphenous neuritis?
* **Compression of saphenous nerve** * Usually at **Hunter's canal** * aka Surfer's neuropathy Hunter's canal- aponeurotic canal extending from femoral triangle to addcuctor hiatus ( adductor magnus) Anteriorly - Sartorius Psoterior Medial - Adductor longus & adductor magnus Laterally- vastus medialis Superior- Inguinal ligament
30
What is and define the anatomy of Hunter's canal?
* Hunter's canal- aponeurotic canal extending from femoral triangle to addcuctor hiatus ( adductor magnus) Boundaries * Anteriorly - Sartorius * Posterior Medial - Adductor longus & adductor magnus * Laterally- vastus medialis * Superior- Inguinal ligament
31
What are the symptoms of saphenous neuritis? How is it treated?
* **Pain inferior & medial to knee** Tx * Non operative * **Knee pads- f**orst line of tx
32
Wher can the common peroneal nerve be compressed?
* Behind fibula by ganglionic cyst or directed by trauma * fusion of proximal tibiofibulr joint may be required to prevent recurrence * PC- foot drop- inability to dorsiflex & evert foot * loss of sensation dorsum foot
33
What is the cause of superifical peroneal nerve compression?
* **Fascia defect**- usually 12cm proximal to lateral malleolus where it exits the fascia of the anterolateral leg * Mechanisms include * Inversion injuty * Fascial defect
34
What are the symptoms of patient with superfical peroneal nerve compression? What is the tx?
* Sensation= **Numbness & tingling over dorsum of foot,** SPARING of 1st web space * This worsens with **Plantar flexion** and **Inversion of foot ** **TX** * Non operative * **Observe** * Operative * **Fascial release** * May be indicated in refractory cases
35
What is the cause of Lateral planar nerve compression? How is it treated?
* Compression of **First branch of lateral plantar nerve** - BAXTER's nerve - branch to _abductor digiti quinti_ * Common nerve compression in runners * **Medial heel pain-** nerve travels across heel anterior to medial tuberosity of calcaneus * **Chronic heel pain** -similar to _plantar fascitis_ * compression between fascia of **ABDUCTOR HALLUCIS LONGUS and medial side of QUADRATUS PLANTAE** **Tx** * Operative * **​Surgical release of _Abductor hallucis fascia_**
36
Where does the medial plantar nerve get compressed? What is the TX?
* At the **knot of Henry** * where **FDL and FHL cross** * Most common cause of compression is **foot orthotics** **Tx** Non operative * **Discontinue orthotics**
37
Where does the sural nerve get entraped? What does tx involve?
* Anywhere along course * Most vunerable 12-15mm distal to tip of fibula as foot rests in equius position * Tx * **Surgical release**

Foot and Ankle FRCS (31 decks)

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