Ortho III Flashcards
What is plantar fasciitis
inflammation of the plantar fascia.
The plantar fascia is thick connective tissue. It attaches to the calcaneus at the heel, travels along the sole of the foot and branches out to connect to the flexor tendons of the toes.
Presentation of plantar fasciitis
gradual onset of pain on the plantar aspect of the heel. This is worse with pressure, particularly when walking or standing for prolonged periods. There is tenderness to palpation of this area.
Mx of plantar fasciitis
Rest Ice Analgesia (e.g., NSAIDs) Physiotherapy Steroid injections (can be very painful and rarely cause rupture of the plantar fascia or fat pad atrophy)
Surgery rarely
What is fat pad atrophy
affects the fat pad over the heel of the foot (under the calcaneus). The fat pad protects the heel from impact.
Why does atrophy atrophy occur
can occur with age or inflammation from repetitive impacts, such as jumping activities, running, walking, and obesity. Local steroid injections (used to treat plantar fasciitis) can cause fat pad atrophy.
Presentation of fat pad atrophy
similar to plantar fasciitis, with pain and tenderness over the plantar aspect of the heel. Symptoms are worse with activities, particularly when barefoot on hard surfaces.
Mx of fat pad atrophy
Management involves comfortable shoes, custom insoles, adapting activities (e.g., avoiding high heels) and weight loss if appropriate.
What is Morton’s neuroma
dysfunction of a nerve in the intermetatarsal space (between the toes) towards the top of the foot. The abnormal nerve is usually located between the third and fourth metatarsal. It is caused by irritation of the nerve relating to the biomechanics of the foot.
Presentation of Morton’s neuroma
Pain at the front of the foot at the location of the lesion
The sensation of a lump in the shoe
Burning, numbness or “pins and needles” felt in the distal toes
High-heels or narrow shoes may exacerbate it
Mx of Morton’s neuroma
Deep pressure applied to the affected intermetatarsal space on the dorsal foot causes pain
Metatarsal squeeze test
Mulder’s sign
Mx of Morton’s neuroma
Adapting activities (e.g., avoiding high heels) Analgesia (NSAIDs if suitable) Insoles Weight loss if appropriate Steroid injections Radiofrequency ablation Surgery (e.g., excision of the neuroma)
What is a hallux valves deformity
Bunions
bony lump created by a deformity at the metatarsophalangeal joint (MTP) at the base of the big toe. The first metatarsal becomes angled medially, the big toe (hallux) become angled laterally (towards the other toes), and the MTP joint becomes inflamed and enlarged
Mx of bunions
Conservative management is with wide, comfortable shoes and analgesia. Patients can use bunion pads to protect the bunion from friction inside their shoes.
Surgery is the definitive treatment.
Most common type of spinal stenosis
Lumbar spinal stenosis
Causes of spinal stenosis
Congenital spinal stenosis
Degenerative changes, including facet joint changes, disc disease and bone spurs
Herniated discs
Spinal fractures
Spondylolisthesis (anterior displacement of a vertebra out of line with the one below)
Tumours
Presentation of spinal stenosis
Intermittent neurogenic claudication
Lower back pain
Buttock and leg pain
Leg weakness
Cauda equina syndrome in severe compression
Diagnosis and ix - spinal stenosis
MRI
Investigations to exclude peripheral arterial disease (e.g., ankle-brachial pressure index and CT angiogram) may be appropriate where symptoms of intermittent claudication are present.
Mx of spinal stenosis
Exercise and weight loss (if appropriate)
Analgesia
Physiotherapy
Decompression surgery where conservative treatment fails (with variable results)
Laminectomy
Presentation of trochanteric bursitis
Trendelenburg test
Resisted abduction of the hip
Resisted internal rotation of the hip
Resisted external rotation of the hip
What does the trendelenburg test involve
The Trendelenburg test involves asking the patient to stand one-legged on the affected leg. Normally, the other side of the pelvis should remain level or tilt upwards slightly. A positive Trendelenburg test is when the other side of the pelvis drops down, suggesting weakness in the affected hip.
Mx of trochanteric bursitis
Rest Ice Analgesia (e.g., ibuprofen or naproxen) Physiotherapy Steroid injections
What are baker’s cysts associated with
Degnerative changes in knee
Meniscal tears (an important underlying cause)
Osteoarthritis
Knee injuries
Inflammatory arthritis (e.g., rheumatoid arthritis)
Presentation of baker’s cyst
Pain or discomfort Fullness Pressure A palpable lump or swelling Restricted range of motion in the knee (with larger cysts)
What can a ruptured baker’s cyst lead to
Compartment syndrome
Mx of symptomatic baker’s cyst
Modified activity to avoid exacerbating symptoms Analgesia (e.g., NSAIDs) Physiotherapy Ultrasound-guided aspiration Steroid injections
Surgical mx - arthroscopy
Presentation of meniscal tears
Pain Swelling Stiffness Restricted range of motion Locking of the knee Instability or the knee “giving way”
Special tests for meniscal tears
McMurray’s test and Apley grind test
Ottawa knee rules for x-ray
Age 55 or above
Patella tenderness (with no tenderness elsewhere)
Fibular head tenderness
Cannot flex the knee to 90 degrees
Cannot weight bear (cannot take 4 steps – limping steps still count)
IX for meniscal tears
MRI scan
Arthroscopy
Mx of meniscal tears
RICE
NSAIDs
physiotherapy
Surgery
