Ortho Block 4: Detailed Flashcards
What causes stress Fxs
Stress Fxs can also be AKA ?
Repetitive overloading causing bone failure when fatigue out lass repair processes
Insufficiency Fxs
Why are younger females at higher risk of stress Fxs
Why are older women at higher risk?
Female athlete triad: amenorrhea, osteopenia, eating d/os
Osteoporosis
What is the MC site of stress Fxs
Where can they also develop through out the foot and ankle
Metatarsals, especially #2
Navicular
Calcaneous
Medial malleolus
Fibula
How do PTs w/ stress Fxs present
What is the most reliable physical sign for these on PE?
Inc pain w/ weight bearing
Dec pain w/ rest
Metatarsal Fx= dorsal swelling
Fibula Fx= swollen lateral ankle
Pain/tenderness and swelling localized over area
How long does it take stress Fxs to show on imaging?
What two types of stress Fxs are at risk for malunion/non-union healing if proper rest is not observed?
3-4wks on x-ray
5 days on bone scan
MRI can confirm Dx, not routinely used
Jones Fx of 5th metatarsal
Navicular stress Fxs
How are stress Fxs in different locations Tx
How are 5th metatarsal stress Fxs better Tx in an athletic PT?
Metatarsal: stiff sole shoe/short leg brace
Calcaneal/fibular: 2-4wks imobilization in short leg cast
Navicular/5th metatarsal: casted, NWB
Internal fixation
Heel varus= ? Fx
Heel valgus= ? Fx
Which stress Fxs are referred w/ red flags?
Varus: 5th MT Fx
Valgus: fibula Fx
Navicular, 5th MT, all fibular
Failure to heal in 6wks/Recurrent Fxs= metabolic work up
1st MTP has ? sesamoids and which is more prone to Fx
The plantar aspect of each is surrounded by ? tendon
What does the dorsal aspect of the sesamoids articulate w/?
2: lateral, medial*
Flexor hallucis brevis
Plantar plate
Metatarsal head
What are 3 MOIs that can cause a sesamoid Fx
Dancing or running will cause ? types of Fxs
MC: direct trauma
Avulsion from MTP hyperdorsiflexion
Stress
Stress or Avulsion
What is the MC site for accessory sesamoids to be found
What type of sesamoid is a normal variant?
What do PTs complain of during PE when sesamoid is Fx?
Second MT head on tibial side
Bipartite
Point of pain will move w/ toe flexion/extension
Inc pain w/ dorsiflexion of 1st MTP
How are sesamoids best evaluated w/ imaging?
What imaging is used to differentiate between acute or stress Fxs of bipartite and sesamoids?
What imaging is used to differentiate between a Fx of the bipartite sesamoid or osteonecrosis?
Lateral: w/ internal oblique view
AP/Lat/Axial views
Tc-99m bone scan
MRI- marrow edema if Fx is present
How are sesamoid Fxs Tx w/out surgery
When do these types of Fxs have to be Tx w/ surgery
What is the adverse outcome of this injury
Short leg brace or stiff sole shoe w/ rocker bottom
When Sxs improve- felt pad x 6mon
Fx w/ plantar plate rupture
6-12mon healing time= limited dorsiflexion of 1st MTP
Phalangeal Fx usually involves ? part and is due to ?
Which toe is MC affected
What is the MC unlikely adverse outcome of this injury
Proximal phalynx
Direct trauma
5th toe
Permanent deformity
How are phalangeal Fxs Tx w/out surgery
When do these Fxs need to be reduced
When do they need to be referred?
Buddy taped to medial toe w/ gauze pad in between to prevent maceration
Angulated
Articular surface involvement
Interphalangeal joint involvement of great toe
Open/displaced intra-articular Fx
What type of metatarsal Fxs are unique and need extensive immobilization
How long can it take for a stress Fx on a metatarsal to show up?
Zone 2 proximal diaphysis of 5th metatarsal (Jones Fx)
Zone 3 of 5th MT, usually stress Fx
2-3wks
Define Zone 1-3 on the 5th MT
How are these Tx w/out surgery
How often are images needed
1: articular surface
2: articulation of proximal 4th and 5th MTs
3: extends 1.5cm distal to zone 2
Short leg cast/brace
Repeated @ 1wk and 6wks
A Fx of the 1st MT if often the result of ? injury and requires ? for Tx
What types of Fxs require surgical correction to protect weight bearing function of the foot?
Fx to Zone 3 can resemble ? Fxs
High impact injury
Surgery
Multiple Fxs w/ more than 4mm displacement
Apical angulation >10* on lateral view
Stress Fx exacerbated w/ inversion injury
What type of Fx to the 5th MT is more difficult to Tx
What are the 2 bones of the hind foot usually Fx during MVAs or falls
Acute Fx to Zone 2- NWB x 6-8wks
Athletes= internal fixation
Calcaneous
Talus
Since compartment syndrome is difficult to identify due to calcaneous/talus Fxs, what finding is indicative
Calcaneous Fxs need to have ? other injury r/o
Swelling in area of arch
Spinal Fx on ipsilateral side of injury
What x-ray views are needed to assess calcaneous Fxs
Coronal CT images are needed if suspected nerve entrapment is present
AP Lateral Mortise Harris
Evaluate subtalar/calcaneocuboid joints
Fx to ? bone in the ankle frequently leads to osteonecrosis
What are the first two things done during Tx of these injuries
Talus
Elevation above heart
Ice q20min
Ankle Fxs include injuries to ? bones
Unstable ankle Fxs involve ?
Lateral/Medial/Posterior malleolus
Collateral ligaments
Talar dome
Both sides of joint
Bimalleolar: lat/medial malleolus or distal fibula w/ disrupted deltoid ligament
Trimalleola
Posterior dislocation of the ankle may be present w/ ? Fx
What type of PE finding is assumed to be an unstable bimalleolar injury
Trimalleolar
Fx of distal fibular w/ TTP over medial deltoid ligament
Define a Maisonneuve Fx
What type of x-ray view allows for clear evaluation of the tibia, fibula and talus
Fx of proximal fibula from unstable external rotation injury including Fx of fibula, tear of medial deltoid and disrupted tibiofibular ligaments
Mortise view
If ankle injury doesn’t show Fx on initial x-rays, how long until repeat x-rays are taken?
What type of Fx may be present in the ankle after a rotational injury?
10-14 days
Osteochondral Fx
How are stable, unstable, unstable/not displaced Fx of the ankle Tx
If an osteochondral fragment is present in the joint space, successful pinning and fixation is only successful in ? PTs?
Stable: WBAT w/ cast x 4wks
Unstable, not displaced: NWB w/ cast and immobilization
Unstable, displaced: reduction needed
Young
When is rehab indicated after an ankle Fx
Define Lisfranc Fx-dislocation
Elder PT
Full ROM/balance not returned by 3mon
Fx-dislocaiton to the midfoot at the tarsometatarsal joints
How can Lisfranc Fx/Dislocations occur in athletes
What does this ‘critical’ injury involve
Where will PTs point their pain to be during PE
Tripping
2nd MT, joint wedges into slot in cuneiforms and is key to stabilizing other midfoot joints
Dorsum of midfoot
How can you tell a Lisfranc injury from an ankle sprain
What x-ray findings are indicative of a ‘normal’ foot and no injury
Stabilize calcaneous, rotate/abduct forefoot w/ other
+pain= Lisfranc
Medial aspect of cuneiform lines up w/ medial 2nd MT
Medial aspect of 4th MT lines up w/ medial cuboid
What does the Lisfranc ligament join and what does it provide?
What is the next step if injury suggests what x-rays don’t show?
Base of 2nd MT and medial cuneiform
Stability to tarsometatarsal joints
Sedation w/ stress radiographs of midfoot
What types of deviation is seen during a Lisfranc injury
How are these Tx w/out surgery
Fragment at base of 2nd MT
Lateral deviation of 2nd and 3rd MT
Medial deviation of 1st MT
8wks NWB, 3mon of rigid arch support
Any displacement= reduction and fixation
What can be added to a bandage surrounding a Lisfranc injury to reduce edema
What two Dzs are r/o when evaluating idiopathic toe walking
What PT population is toe walking common in?
Zinc oxide cream
Cerebral palsy
Muscular dystrophy
Speech/language delays
Autism
When quantifying the degree of dorsiflexion of a toe walker, what PE finding is indicative of an Achillies contracture
How are these cases Tx when Pt is a toddler
<10* passive dorsiflexion
Self resolve in 3-6mon
Autistic- PT, OT
When is serial casting for toe walking needed
What are the MC causes of unilateral toe walking?
Co-existing Achilles contractures
Limb length discrepancy
Cerebral palsy
Tethering of spinal cord
Define Tarsal Coalition
How is this condition linked w/ FamHx
Which types begins to present w/ Sxs earlier
Abnormal connection between two tarsal bones, MC calcaneous and navicular or talus and calcaneous
ASx but no hindfoot motion
Calcaneonavicular @ 9-13y/o w/ lateral pain
Talocalcaneal @ 13-16y/o deep in hind foot
What is seen in PTs w/ tarsal coalition on PE
What x-ray view is best for talocalcaneal bars
Rigid flat foot- hind foot valgus, fore foot abduction
No longitudinal arch
Restricted hindfoot motion from spastic peronial muscles
Harris heel view
What is the preferred Tx of tarsal coalitions after non-surgical efforts fail
What procedure is reserved for those who do not respond to resections or who are not candidates due to large coalitions or arthritic changes being present?
Resection of coalition w/ interposition of fat/muscle
Hind foot arthrodesis
Osteochondral lesions of the hyaline cartilage and subchondral bone can occur in what two ways?
How does this present?
Trauma: osteochondral Fx
Idipathic: subchondral avascularity
Pain, swelling/effusions, giving away
Hx of repeat/chronic sprains
Limited/painful A/PROM
What type of x-ray view is needed for viewing osteochondral lesions of the talus?
What will be seen?
What imaging is used for Dz staging?
Mortise views
Articular surface defect w/ halo of lucent bone on weight bearing surface
CT for medial lesion staging
MRI for cartilage/vascular assessment
How are osteochondral lesions Tx
Define Metatarsus Adductus and what causes it
If skeletal immature: time/immobilization
Skeletal mature: surgery
Medial deviation/adduction of forefoot
MC form intrauterine positioning issue
Metatarsus adductus usually presents w/ ? other positional deformities
What toe malformity may be observed but usually self resolves?
Congenital muscular torticollis
Medial tibial torsion
Hip dysplasia- rare
Atavistic/wandering adduction of great toe
What images are used to track metatarsus adductus
Since most cases self resolve, what parent education piece needs to be followed?
When do these cases need to be referred?
Foot photocopies
Hip US
Don’t place baby prone w/ feet turned in
Residual after 3-6mon old
Rigid adductus
An abnormally low or absent arch of the foot that in most cases is a normal variant commonly seen in infants and kids
What is the MC Dx of this variant
Flat foot
Flexible flatfoot
What are the etiologies of flat foot?
When is idiopathic rigid flatfoot commonly seen?
Congenital: tarsal coaltion, vertical talus
Neuromuscular: cerebral palsy, hypotonia
Inflammatory: juvenile idiopathic arthritis
Obesity
What PE test is used to assess flatfoot?
How is hindfoot flexibility assessed in these PTs?
Jack test: great toe extension test, re-creates arch during weight bearing in a flexible flatfoot
Tiptoe standing
What parental education needs to happen for kids w/ flat feet?
What is the exception to Peds needing surgical Tx for their flexible flatfoot?
Orthotics have no bearing on self resolving cases
People w/ high arcs are usually in pain while flat feet are ASx
Sxs persist despite stretching, orthosis, and shoe modificaitons= Osteotomy to lengthen lateral foot columns
Define Talipes Equinovarus
What is the acronym for this conditions?
Club foot
Cavus, midfoot (high arch)
Adduction, forefoot (
Varus, heel (adduction)
Equinus, ankle (plantar flexion)
How are positional club foots differentiated from inherent flexibility of a deformity
What congenital d/os are associated with club foot?
Spontaneous/rapid resolution
Absence of calf atrophy/foot size difference
Myelomeningocele
Arthrogryposis
What PE finding is common in congenital club foot and may even remain after Tx?
What social concern needs to be present when Tx this condition abroad?
What is the TxOC in the US?
Calf atrophy
Many of these PTs are ostracized due to belief condition is cursed
Ponseti method: all components of CAVE are Tx except hind foot equinus
What causes a Cavus Foot deformity
Define Cavovarus
Define Equinocavovarus
Abnormally high arch from equinus (plantar flexion)
Forefoot equinus
Hind foot equinus
Unilateral cavus foot is usually due to ? while bilateral cavus feet are due to ?
Define the Meary angle
Tethered spinal cord
CMTooth Dz
Cavus foot deformity causing 1st MTP is plantar flexed compared to talus causing increased angle
What causes Calcaneal Apophysitis
What ages does this normally self resolve?
Activity related pain in posterior heel from stress/microtrauma
9y/o in girls
11y/o in boys
What is a common variant seen on x-rays of calcaneal apophysitis
This issue can AKA ?
Calcaneous sclerosis
Sever’s Dz
Define Accessory Navicular
What may be seen on PE of this issue
Secondary ossification center develops on medial portion of tarsal naviular bone at attachment site of tibialis posterior tendon
TTP medial aspect of navicular
Pain w/ inversion resistance
Flexible pes planus
What is the TxOC for PTs w/ persistent accessory navicular Sxs
Define Os Trigonum
What causes pain w/ this d/o
Excision of navicular portion
Secondary ossification center on posterior talus that is Sx on soccer/ballet
Impingement between talus and tibia w/ plantar flexion
Osteochondritis dissecans of the talus may result in ? 3 issues
What is a common cause of rigid flat feet in kids?
Pain w/ activity
Locking of joint
Swelling
Tarsal coalition
Osteonecrosis of navicular bone is AKA ?
How do these PTs present
How is it best Tx
Kohler Dz
Male 4-8y/o w/ limp and out-toeing of foot during walk
Short leg walking cast x 4-8wks
Define a Freiberg infarction
How does it present?
Osteonecrosis of head of 2nd MT
Adolescents after trauma
TTP on MT head w/ movement
How are ASx Hallux Valgus cases Tx
What is the adverse outcome when this presents in Peds?
Define Turf Toe and what causes it
Night brace
Post-operative recurrence rate is higher
Sprain of 1st MTP from hyperextension/forced ROM
What are two unique facts about Turf Toe
How are these injuries graded
Significant morbidity association
Account for more missed game time than ankle sprains
1: stretch injury of the capusle
2: partial tear of plantar ligament
3: complete tear of MTEP ligament; no playing, can’t walk normally
What are two adverse outcome from a Turf Toe injury
How are these injuries Tx
Hallux Rigidus
Instability
1, 2: stiff/rocker sole shoe
3: protected weight bearing/immobilization x 2wks, 6wk rest period from sports
What is the MC cause of lesser toe deformities
Improperly fitting shoes
Intrinsic (foot) muscle imbalance
Extrinsic (leg) muscle imbalance
Define Claw Toe
This d/o affects ? toes
This can be due to ? issues
Fixed extension of MTP, flexion of PIP, +/- DIP contraction
All lesser toes
Charcto Tooth Dz, RA
What PT population frequently develops claw toes?
Define Hammer Toe
What is the difference in appearance w/ weight/non-weight bearing
DM w/ peripheral neuropathy
Correctable extension deformity of MTP, flexion deformity of PIP, no DIP deformity
Passive extension w/ standing
Neutral w/ non-weight bearing
Define Mallet Toe
Which toe is MC affected by hammer/mallet toe?
What has been shown to be the primary cause of a MTP deformity w/ hammer toe
Flexion deformity of DIP, normal PIP, MTP
2nd toe due to tight shoes
Plantar plate rupture
PTs w/ toe deformities can develop corns ?
PTs w/ hyper extension of the MTP joint, ? bone is displaced plantarly causing inc of pressure on plantar side
Dorsum of PIP or tip of toe
Metatarsal head
When assessing toe deformities, ? issue needs to be searched for?
When would a neuro work up be indicated for PTs w/ toe deformities
Cavus foot
Claw toe w/ high arch
How is the presence of a plantar plate rupture assessed for duing a toe deformity PE?
What is the mainstay of Tx for these deformities
Anterior drawer/Shock test
Roomy box shoe
Sesamoiditis is AKA ?
D/os of these bones include ? 4
Dancer’s Toe
Fx
Osteonecrosis
Arthritis
Inflammation
What would be seen on PE in sesamoiditis cases
How would normal variants be differentiated from Fxs on x-ray?
Pain under 1st MT head and w/ dorsiflexion
ROM restricted
Normal variants- smooth edges
Fx- rough/irregular edges
Fungal infections of the nail are called ?
What are the two MC microbes that cause this
What PO meds can be used
Onychomycosis
Trichophyton rubrum/mentagrophytes
I/F/K-azole, Terbinafine
When are nail fungal infections referred to Ortho?
What are clusters of plantar warts called?
How are warts differentiated from calluses on exam?
Old/liver can’t tolerate PO anti-fungals
Mosaic warts
Warts are painful when pinched from sides
How are plantar warts managed
What are some causes of metatarsalgia
If these lead to calluses on the sole, the callus is called ?
Paring, keratolytic agents (salicyclic acid)
Abnormal metatarsal length
Claw/hammer toes
Intactable plantar keratosis
When assessing metatarsalgia, the discovery of a callus in a line formation indicates ?
What test will be positive during PE if there is MTP joint instability
Overload of metatarsal head
Anterior drawer (shock test)
How are calluses located under a metatarsal head T when associated w/ metatarsalgia
Define an Interdigital Neuroma
Plantar condylectomy
Morton’s neuroma/Plantar interdigital neuroma
Perineural fibrosis of common digitalis nerve passing between metatarsal heads
Fibrosis occurs from repetitive irritation of nerves
Where do Norton’s Fibromas MC show?
What is the MC presenting issue
3rd web space, between 3 and 4th MT heads
2nd then 1st are lower
Plantar pain in forefoot
Dysesthesia/paresthesia
Rarely night pain
What PE test is conducted for interdigital neuromas
What may be felt and is indicative of a positive test
Piano key test
Compression test
Mulder sign- clicking/grinding MT heads
What procedure can be Dx and therapeutic of interdigital neuromas?
If these are persistent and need surgery, what ligament is released to provide comfort?
Lidocaine/CCS injection proximal to neuroma
Division of transverse metatarsal ligament to release plantar nerve
What are the 3 stages of an ingrown toe nail
Why would x-rays be obtained for Grades 2 or 3
Infalmmation
Abscess
Granulation- less painful than stage 2
R/o subungual exotosis and osteomyelitis
How are each grades of ingrown nails Tx
Hallux valgus can cause the great to to shift which direction?
What is a common secondary complication seen on PE?
1: warm soak, trimming, socks
2: warm soaks w/ Cephalosporin PO
3: partial/complete nail plate excision
Pronate- inward rotation causing medial callus formation
2nd toe over rides that lateral pointing big toe
What angles are measured on weight bearing x-rays to assess bunions
What is the initial Tx in adults
Hallux valgus angle
Intermetatarsal angle
Education, shoe modification
? is AKA for degernerative arthritis of the MTP in great toe
This Dz is the MC ? of the foot and MC ? of the toe
Hallux rigidus
Arthritis manifestation
2nd malady, 1st= hallux valgus
What do PTs w/ hallux rigidus complain of?
What is the hallmark finding of this issue
What PE finding indicates a severe problem
Pain from lateral/dorsal osteophytes
Pain w/ toe off phase of gait
Stiff great toe w/ loss of extension
Pain @ mid range of motion
How is Hallux Rigidus Tx w/ surgery
What procedure is reserved for older and lower demand PTs
? procedure is not recommended
Cheilectomy
Arthrodesis
Keller procedure
Artificial joint
Bunionette is sometimes AKA ?
This is analogous to a ?
What are the common Sxs of Tarsal Tunnel Syndrome
Tailor’s bunion
Hallux valgus
Paresthesia/Dysethesia along medial ankle and is worse after walking
How can Tarsal Tunnel be managed
If surgery is an option, where is the nerve release done at?
Flat foot + pronation= orthotics can relieve Sxs
Distal tunnel released at bifurcation deep to abductor hallucis fascia
PTs w/ tarsal tunnel syndrome and pain radiating above the knee or severe pain to light touch need further work up for possible ?
What is the MC cause of medial ankle pain of middle aged PTs?
Herniated disk
CRPS
Posterior tibial tendon dysfunction
What are preceding risk factors of posterior tendon dysfunction
What are the MC Sxs at presentation
Flexible flatfoot CCS injection DM HTN Hx of trauma
Pain/swelling at medial ankle
What PE finding is seen in posterior tendon dysfunction
What would cause Sxs to get better and change the location of the pain?
Too many toe sign- due to forefoot abduction, hindfoot valgus
Inability to stand on toes/ball of foot
Tendon rupture
Lateral ankle pain
Posterior tendon dysfunction w/out flat foot is Tx ?
What Tx is recommended if flexible flatfoot it present?
What Tx is recommended if rigid flatfoot is present?
Cast/brace x 4wks Activity modification NSAID
Tendon transfer w/ osteotomy realignment
Arthrodesis of hindfoot
When are PTs w/ posterior tendon dysfunction referred to Ortho?
Pain around the Achilles tendon can arise from what structures?
PTs w/ medial ankle pain
Insertional Achilles tendinosis
Retrocalcaneal bursitis
Haglund syndrome
Pre-Achilles bursitis
How is a pump bump in posterior heel pain differentiated from Haglund deformity
What is the MC cause of posterior heel pain in older PTs?
Prominent calcaneous processes develop bursa irritated by shoes= bump pump on posterolateral aspect of heel
Insertion tendonosis w/ enthesopathy, calcification and degeneration tears of tendon
How is Achilles tendinosis confirmed w/ PE
If it is a retrocalcaneal bursitis, what will be seen on PE?
Squeezing tendon inc pain
Swelling, redness and pain anterior to tendon increased w/ squeeze/lateral movement of bursa
When should PTs w/ posterior heel pain begin Achilles stretch routines
What non-surgical option may alleviate all Sxs in 6wks
After inflammation phase
Casting
Where does the plantar fascia originate and insert
Define the Windlass mechanism
O: medial tuberosity of calcaneous
I: proximal phalanges
Tightens fascia, Inversion of hindfoot, External leg rotation, Elevates arch
What is the MC cause of heel pain in adults
What passive movement can inc pain of plantar fasciitis
When are x-rays needed?
Plantar Fasciitis
Dorsiflexion of toes activates windlass mechanism
Systemic Sxs
Pain at rest
Half of PTs w/ plantar fasciitis develop ? ortho anomoly sen on x-ray
If a bone scan were to be done, where would increased uptake be seen?
How long can it take for this condition to resolve
Enthesophyte at origin of flexor brevis superior to plantar fascia
Medial calcaneal tuberosity
6-12mon
What non-surgical Tx is considered for plantar fasciitis after 12mon of non-surgical relief
What are the lateral ligaments of the ankle
What ligamentous structure holds the distal tibial and fibula together
Focal shock wave Tx
ATFL, CFL
Anterior tibiofibular syndesmosis
What is the MC injury to the subtalar joint
What ligament is on the medial side of the ankle
What PE finding suggests an injury to the tibiofibular syndesomosis
Inversion injury tearing ligaments
Deltoid ligament
Squeeze test
External rotation test
What is the MC adverse outcome of ankle sprains
What are the 3 phases of rehab
Joint instability from incomplete rehab
1: NSAIDs, RICE
2: when PT can bear weight w/out pain/swelling, until full ROM and normal strength
3: agility, proprioception, endurance
When does the Thompson test hold the most validity for Dx Achilles tears
How are these Tx w/out surgery
What Tx is recommended for minor and major tears
Within 48hrs of injury
Casting/bracing until ankle returns to neutral
RICE, immobilization x 5 days
Achilles tears need to be evaluated w/in ? time frame
What predisposing factor increases DM PTs to ulcerations
24hrs
Autonomic dysfunction: dry, scaly, cracking skin on feet/legs
If PT w/ ulcer on foot can be probed to the bone, what is the Dx
What imaging is used for difficult cases to differentiate between osteomyelitis or Charcot foot?
Osteomylelitis
Tech-99 scan
If callus develops on the sole of the forefoot, its AKA ?
Usually calluses in this location present w/ ?
Intractable plantar keratosis
Metarsalgia
Where do heloma molle form
Where do periungual corn develop
Toe webs
Painful lesions at edge of nail, usually w/ mallet toe or improper fitting shoes
What procedure is reserved for callues that fail non-surgical Tx?
What is a benign thickening of the plantar fascia
Plantar condylectomy
Plantar fibroma
