orthopaedic foot conditions Flashcards
What are the treatment options for orthopaedic foot conditions
analgesia
show wear change
activity changes
weight loss
physiotherapy
orthotics e.g insoles and bracing
What is the indication of surgery in orthopaedic foot conditions
When the non surgical treatment fails
What is seen in hallux valgus (bunions)
medial deviation of the first ray and vagus agulation of the big toe
What are the causes of hallux valgus
genetic
foot wear
Which gender is hallux valgus more common in
female due to men wearing more accomodating foot wear
What are the symptoms of hallux valgus
pressure symptoms from shoe wear
Pain from crossing over of the toes
metatarsalgia - pain in the metatarsals
What is used to diagnose hallux valgus
Xray - determine severity of the bony deformity and exclude associated degenerative changes
What is the management of hallux valgus
shoe wear modification
orthotics to offload pressure and correct the deformity
activity modification
analgesia
Operative - if non-op fails :
Release the lateral soft tissues
osteotomy of the first metatarsal - breaking the bone
What is hallux rigidus
Stiff big toe
What causes hallux rigidus
osteoarthritis of the first metatarsal-phalangeal joint
What is the main symptom of hallux rigidus
Pain at extreme dorsiflexion but usually asymptomatic
How is hallux rigidus diagnosed
clinically and radiographs
What is the management of hallux rigidus
activity modification
Shoe wear with rigid sole - very helpful option
analgesia
Surgical treatment :
Cheilectomy - if the pain is only during dorsiflexion of the big toe and the rest of the toe is fine
Arthrodesis
Arthroplasty
What is a cheilectomy
Remove the dorsal osteophytes - provides better range of dorsiflexion with less pain
What is 1st MTPJ fusion (arthrodesis)
The surface of the joint is debrided - fixation is then used to allow bone to cross over the joint
This is the gold standard surgical treatment of hallux rigidus
What is hammer toe
Flexion of the proximal inter-phalangeal joint and dorsiflexion of the metacarpal-phalangeal joint
What is claw toe
flexion of the proximal and distal inter-phalangeal joint
What is mallet toe
flexion of the distal inter-phalangeal joint
What are the causes of lesser toe deformities
imbalance between flexors and extensors
shoe wear
rheumatoid arthritis
What are the symptoms of lesser toe deformities
deformities
Pain from the dorsum and plantar sides
What is the treatment of lesser toe deformities
Non surgical:
Activity modification
Shoe wear - flat shoes with high toe box
Orthotic insoles
Surgical:
Flexor to extensor transfer - dividing the flexor tendon of the toe and moving it to the extensor
fusion of interphalangeal joint
release metatarsophalangeal joint
shortening osteotomy of metatarsal
What is mortons neuroma
Inflammation and swelling with severe pain and numbness
common plantar nerve is traumatised and new nerve sprouts grow with fibrous tissue around them and there is a painful lump which presses on them called a mortons neuroma
Who is mortons neuroma more common in
40-60 year old females
What are the symptoms of mortons neuroma
affects the 3rd and 2nd webspace/ toes
neuralgic burning sensation in the toes
Intermittent
altered sensation in the webspace
What is the best way to diagnose mortons neuroma
Mulder’s click - pain should localise between the metatarsal heads - if there is a lump on the nerve, if you press onto it, moving it dorsally and then squeeze it over the metatarsal head, it will make a clicking which is very painful
Ultrasound
What is the management of mortons neuroma
Injection for small lesions
Surgery:
excision of the lesion including part of the normal nerve which can lead to numbness and pain
What is metatarsalgia
A symptom and not a diagnosis
Pain coming from the forefoot - the digits and the metatarsals
What is rheumatoid forefoot
Pain
Hallux valgus
hammer toe
pressure areas with bursitis
caused by rheumatoid arthritis
What is the treatment of rheumatoid forefoot
Shoe wear to accomodate the deformity
orthotics
reduction in activity or a change in activity
Operative
Gold standards:
1st metatarsalphalangeal joint arthrodesis (fusion)
2-5th toe excision arthroplasty
Where do dorsal foot ganglia come from
joints or the tendon sheath
What causes dorsal foot ganglia
underlying arthritis
underlying tendon pathology
What are the symptoms of dorsal foot ganglia
Pain from pressure due to the shoes that are worn
Pain from underlying problem
What is the treatment of dorsal foot ganglia
aspiration of the ganglia - can confirm diagnosis as well
Surgical - excision - has a high rate of occurance
What kind of arthritis can affect the midfoot
Post traumatic arthritis
osteoarthritis
rheumatoid arthritis
What is the treatment of midfoot arthritis
activity modification
shoe wear modification
orthotics
Xray guided injections
Surgical:
Fusion of a joint
What is plantar fibromatosis
(Ledderhose disease)
Considered as the dupuytren’s of the foot
Causes lumps in the sole of the foot and is progressive
What is the treatment of plantar fibromatosis
Show wear management
orthotics
Surgical:
Excision - high recurrence rate
combination radiotherapy and surgery - low recurrence but high complication risk
What is achilles tendonitis/tendinosis
Degenerative condition with little inflammation of the achilles tendon
Who does paratendinopathy commonly affect
athletic individuals
30-40 years old
male 2:1 female
Who is commonly affected in tendonopathy
non-athletic
>40 Years
obese
steroid use
diabetics
What are the symptoms of achilles tendinopathy
Pain during exercise
pain after exercise
recurrent episodes
difficulty fitting shoes due to the rubbing feeling - suggests it is insertional
How is achilles tendonopathy diagnosed
Ultrasound
MRI - shows the severity
What is the achilles rupture test and describe it
Simmonds test - calf squeeze test - squeeze the calf and if the achilles tendon is normal the foot will move plantar flexion wise but if the achilles is ruptured, there will be no movement
What is the treatment of achilles tendonopathy
Activity modification
weight loss
shoe wear modification
physiotherapy
extra-corporeal shockwave treatment- vibrates tissue and stimulates fibrous tissue to form and heal
Immobilisation
Surgical treatment -
Gastrocnemius recession - lengthening the gastrocnemius
release and debridement of tendon
What is plantar fasciitis
Can’t make extra cellular matrix which is required for repair and remodelling
Chronic degenerative change, fibroblast hypertrophy, absent inflammatory cells, disorganised and dysfunctional blood vessels and collagen, avascularity
What are the symptoms of plantar fasciitis
Pain first thing in the morning
Pain on weight bearing after rest
Pain at the origin of plantar fascia
Commonly lasts for over 2 years
How is plantar fasciitis diagnosed
Mainly clinical
ultrasound and MRI can be used
Xrays can be used but are not that helpful
What is the treatment of plantar fasciitis
rest
activity modification
stretching of the achilles
ice
NSAIDs
orthoses - heal pads
physiotherapy
weight loss
corticosteroid injections - short tem
night splinting
Extracorporeal shockwave therapy can be done as a third line treatment
Who most commonly gets ankle arthritis
46 year old is the average age
commonly post traumatic
What are the symptoms of ankle arthritis
pain and stiffness of the ankle joint
How is ankle arthritis diagnosed
clinical
radiographs
CT scan
What is the treatment of ankle arthritis
weight loss
activity modification
analgesics
physiotherapy
steroid injections
Surgical treatment:
Arthrodesis (fusion) is the gold standard - screws are passed through the ankle joint to fuse it
Ankle replacement - can fail after few years
What happens when the tibialis posterior tendon malfunction
planovalgus foot - flat foot occurs in people who normally have a good arch
How is tibialis posterior tendon dysfunction diagnosed
Clinical - double and single heel raise - checking if the patient can stand on the tip toes
MRI to assess the tendon
What is the management of tibialis posterior tendon dysfunction
Orthotics - resting the tibialis posterior with medial arch support
Surgical:
reconstruction of tendon
triple fusion - subtalar, talonavicular and calcaneocuboid joints are fused
What are the foot conditions that can occur in diabetic foot
Ulceration and charcot foot
What is the cause of diabetic foot ulcer
Diabetic neuropathy - patient is unaware of trauma to the foot
What are features of diabetic neuropathy
Decreased sweating and sebum production so there is dry cracked skin
What is the treatment of diabetic foot ulcer
Prevention of the ulcers is the best method but treatment is hard once an ulcer is formed
Diabetic contro
stop smoking
reduce pressure where the ulcer is by using splints, shoes and weight bearing changes
Surgical treatment:
Improve vascular supply
debridement of ulcer and get samples for microbiology
correct any deformity which is causing increased pressure on the ulcer
amputation
What is the cause of charcot neuroarthropathy
any cause of neuropathy - diabetes is the most common
Syphillis
What happens in charcot neuropathy
Neurotraumatic - Lack of proprioception and protective pain sensation tso the joints are being put through excessive movements which cause damage
Neurovascular - abnormal autonomic nervous system results in increased vascular supply and bone resorptio
What are the 3 stages of bone destruction in charcot neuropathy
fragmentation
coalescence
remodelling
How is charcot neuropathy diagnosed
Clinically - Consider any diabetic with acute swollen erythematous foot with neuropathy
Radiographs
MRI scans
How is charcot neuroarthropathy treated
Prevention is best
Immobilisation
Surgical:
Correct the deformity as it could lead to increased pressure in an area which could cause ulceration and infection which would then lead to amputation
