Orthopaedic foot and ankle pathologies Flashcards
What are the treatment options for foot and ankle disease
When should you operate?
Analgesia shoe wear modification Weight loss physio insoles and bracing
when non-operative management fails
What are some common diseases of the feet?
Bunions, plantar fascitis, achille tendonitis morton’s neuroma
What are some common diseases of the forefoot?
Hallux valgus Hallux rigidus Lesser toe deformities Morton's neuroma Metatarsalgia Rheumatoid Forefoot
What is hallux valgus?
Who gets it?
What are the symptoms?
Bunions, prominence of medial big toe tarsal
Genetic, foot wear, female preponderance
Pressure symptoms from show
Pain from crossing over of toes
Metatarsalgia
What is the pathogenesis of hallux valgus?
How do you diagnose hallux valgus?
Lateral angulation of big toe
Tendons pull realigned to lateral centre of toe,
Vicious cycle of increased pull creating an increased deformity
Sesamoid bones sublux- less weight goes through the big toe
As deformity progresses abnormalities of the lesser toes occur
Diagnosis- look at foot, X-rays
How do you treat hallux valgus
What are the two main surgical procedures for hallus valgu?
Non-operative- shoe wear modification, orthotics, activity modification, analgesia
Opearative- release lateral soft tissues, osteomy 1st metatarsal, generally goof outcome but recurrence inevitable
Scarf osteotomy- learn for exam
Basal osteotomy- esepcially this one
What is hallux rigitidis?
Stiff big toe Hallux limitus Hallux non exntensus Osteoarthrtits of 1st MTP joint Bimodal distrubution age
Who gets hallux rigitidis?
What are the symptoms?
How do you diagnose it?
not known, possibly genetic, possinly multiple microtrauma
many asymptomatic, pain at extreme dorsiflexion, limits range of movement
clinical, x-rays
How do you manage hallux rigitidis?
non operative- activity modification, shoe wear with rigid sole, analgesia
Surgery- Cheilectomy, arthrodesis, arthroplasty
What is a cheilectomy?
What is the gold standard for hallux rigitidus treatment?
What are the benefits/risks with are there with 1st MTPJ hemiarthoplasty
Surgery to remove a small piece of bone to increase dorsiflexion
1st MTPJ fusion
Good ROM, high failure rate, better for lwo demenad patients
What are common issues of the lesser toe?
What causes them?
Claw toes
Hammer toes
Mallet toes
hyper flexion at the PIP joints
Who gets lesser foot deformities
What are the symptoms of a lesser foot deformity?
imbalance between flexors/extensors
shoe wear
Neurological/rheumatoid arthrits
idiopathic
deformity
Pain from dorsum
Pain from plantar side(as toe is pushed down)
What is the treatment for lesser toe deformities?
non operative- activity modification
Shoe wear- falt shoes with high toe
Orthotic insoles
Opearative- flexor to extesnor transfer
Fusion of interphalangeal joint
Shortening osteomy of metatarsal
What is mortons neuroma?
Inflamation, swelling, severe pain and numbnes caused my a lesion to the nerve between digits
Who gets mortons neuroma?
What are the symptoms of mortons neuroma?
Mechanically induced degenrative neurtopathy
Affects females ages 40-60
Frequently associated with wearing high heeled shoes
Common digital nerves relatively tethered to one metarsal and movement in adjacent metatarsals causing a mechanical shear
Symptoms- typically affects 3rd following by 2nd webspace/toes
Neuralgic burning pain into toes
Intermittent
Altered sensation in webspace
How do you diagnose mortons neuroma?
How do you treat it?
clinical, mulder’s click, USS, MRI
injection for small lesions
Surgery- excise lesion
Leads to numbness, recurrence, 30% have pain post op
What is metatarsalgia?
Symptom not a diagnosis
Careful examination should localise course
Synovitis, bursitis, arthritis, neuralgia
Neuromata, freibergs disese
If no obvious cause consider tight gastrocnemius
How do you treat rheumatoid forefoot (inflammation that causes toes to be messed up)
non-operative- shoewear orthotics/activity etc
operative- many descrbed techniques, current gold standard, 1st MTPJ arthodesis, 2nd-5th toe excision arthroplasty
What are some common pathologies of the forefoot
Ganglia
Osteoarthritis
Plantar fibomatosis
What are dorsal foot ganglia
Who gets them
What are the symptoms?
Arise from joint or tendon sheath
Idiopathic, underlying arthritis, underlying tendon pathology
Symptoms- pain from pressure from show wear
pain from underlying problem
How are they treayed
Aspiration
Bible bashing
Excise
High rate of return (50%)
What are the categories of midfoot arthritis
How is it treated?
Post raumatic
Osteoarthits
Rheumatoid
Non operative- shoe wear, orhtotics
Injections-x-ray guided
Operative-fusion
What is plantar fibromatosis
Dupuytren’s of the foot
Progressive
usually asymptomatic unless very large of in weight bearing area
How is plantar fibromatosis treated?
Non operative- avoid pressure
Excision (80% recurrence)
Radiotheraoy
Combination radiotherapy and surgery
What are some common pathologies of the hindfoot?
Achilles tendonitis Plantar fascitis Ankle osteoarthritis Ankle osteoarthritis Tibialis posterior dysfunction tion Cavovarus foot
What is achilles tendonitis?
Degernative/overuse condition with very little inflammation
can be caused bu bursitis, non insertional/mid substance issues
Insertional tendinopathy
Paratendinopathy
Who gets achilles tendinopathy?
Athletic populations aged 30/ More likely in males Obesity steroids diabetes
What are the symptoms of achilles tendinopathy?
Pain durin exercis Pain following exercise Recurrent epiosdes Difficulty fitting shoes RUPTURE
How do you diagnose achilles tendinopathy?
Clinical- tenderness, test for rupture
Investigations- USS, MRI
What is the treatment of achilles tendinopathy?
Non-operative- activity modification, weight loss, modify shoes, Physio
Operative treatment- gastricnemius rescession, release and debride tendon
What is plantar fascitis?
Chronic degenerative changem fibroblast hypertrophy, disorgansied and dysfuncitonal lood vessles and colalgen
microtears
What causes plantar fasciatis?
Not known Atheltes high intesnity/ rapid increases Running with poorly padded shoes Obesity Prolonged standing Foor rotational deformities Tight gastro-soleus complex
What are the symptoms of plantar fascitis?
Pain first thing in the morning
Pain on weight bearinfg after rest
Pain at origin of plantar fascia
Frequently long lasting
What are differentials fro plantar fascitis
Nerve entrapment
Arthtrits
Calcaneal pathology
Mainly clincial
Occasionally X-rays USS and MRI
How do you treat plantar fascitis?
Restm change training Stretch achilles Ice NSAIDS orthoses- heel pads Physio Weight loss Injections Night splints
What are some new age treatments of plantar fascitis?
Extracorpeal shockwave therapy Topaz plasma coblation Nitric oxide Platlet rich plasma Endoscopic/ open surgery
Who gets ankle arthritis?
What are the symptoms?
Mean age of presentaiton is 46 years
Commonly post traumatic
idiopathic
Pain/stiffness
How do you diagnose ankle arthritis?
What is the non operative management?
Clinical, radiographs, CT scan (exclude adjacent joitn arthrits)
Non operatie management- weight loss, activity modification, analgesia, physio, steroid injection
What is the operative management of ankle arthritis?
Athroscopic anterior debridement- only for anterior symptoms
Athrodesis(ankle fusion) gold standard
Joint replacement- maintains ROM, long term outocmes?, not easy to fix
What is tibiali posterior tendon dysfunction
Acquired adult flat foor planovalgus Relatively common under recognsied 4 stages Largely clinical diagnosis- double and single heel raise Medial or lateral pain Orthoses or surgery
What is the double single limb heel raise?
How is it diagnosed
How is it managed
Heels go from varus to valgus and they rise
Clinical, MRI to assess tendon
Orthotics-medial arch support Reconstruction of tendon (tendon transfer) Triple fusion (subtalar, talonavicular and calcaneocuboid)
How does a diabetic foot ulcer develop?
DIabetic neuropathy lack of sweting dry cracked skin skin more sensitive to minro trauma Poor vascular supply Lack of patient education
How do you treat a diabetic foot ulcer?
Prevention Modify the main detriments to healing Diabetic control Smoking Vascular supply External pressure (splints, shoes, weight bearing) Internal pressure Infection, nutrition
What surgical options are available for a diabetic foot ulcer?
Improve vascular supply
Debride ulcers and get deep samples from microbiology
Correct any deformity to offload area
Amputation
What is charcot neuropathy?
Rapid bone destruction in 3 areas,
fragmentation, coalescene and remodelling
Who gets charcots neuropathy
What are the theories of pathophysiology?
Any causes of neuropathy
Diabetes commonest cause
Historically originally described and most common with syphillis
Lack of proprioception and protective pain sensation
Neurovascualr- abnormal autonomic nervous system results in increased vascular supply bone resorption
How is charcots neuropathy diagnosed?
High index of suspicion, consider an diabetic with swollen erythematous foot, espicially with neuropathy
Radiographs
MRI
How is charcots foot managed?
Prevention
Immobilisation-non weight bearing until fragmentation resolves
Deformity leads to ulceration lead to amputation
What is the minimum knowledge for exams?
BOA syllabus
