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Musculoskeletal System > Orthopaedic Foot Problems > Flashcards

Orthopaedic Foot Problems Flashcards

1
Q

How are foot problems grouped anatomically?

A

Forefoot problems
Midfoot problems
Hindfoot problems

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2
Q

What are the common forefoot problems?

A
  • Hallux valgus
  • Hallux rigidus
  • Lesser toe deformities
  • Morton’s neuroma
  • Metatarsalgia
  • Rheumatoid Forefoot
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3
Q

What is the aetiology of hallux valgus?

A
  • Genetic
  • Foot wear
  • Significant female preponderance
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4
Q

What are the symptoms of hallux valgus?

A
  • Pressure symptoms from shoe wear
  • Pain from crossing over of toes
  • Metatarsalgia (pain and inflammation in metatarsals)
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5
Q

Describe the pathogenesis of hallux valgus?

A

– Lateral angulation of great toe.
– Tendons pull realigned to lateral of centre of rotation of toe worsening deformity
– Vicious cycle of increased pull creating increased deformity
– Sesamoid bones sublux – less weight goes through great toe
– As deformity progresses abnormalities of lesser toes occur

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6
Q

What investigations are used in hallux valgus?

A

Diagnosis predominantly clinical

X-rays helpful to exclude arthritis and plan surgery

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7
Q

Describe the management of hallux valgus?

A

Non-operative
- Shoe wear modification (wide +/- high toe box)
- Orthotics to offload pressure/correct deformity
- Activity modification
- Analgesia
Operative (if non-operative failed or unacceptable to patient)
- Release lateral soft tissues
- Osteotomy 1st metatarsal +/- proximal phalanx
- Generally good outcome but recurrence inevitable

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8
Q

What is hallux rigidus?

A

Osteoarthritis of the first MTP joint

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9
Q

What ages are most commonly affected by hallux rigidus?

A

Bimodal peak- 20s/30s and in elderly

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10
Q

What are the symptoms of hallux rigidus?

A

Often asymptomatic
Pain
Limited range of movement

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11
Q

What investigations can be used in hallux rigidus?

A

Diagnosis is clinical but x-rays can be used to plan surgeries

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12
Q

Describe the management of hallux rigidus

A 
Non-operative
-	Activity modification
-	Shoe wear with rigid sole
-	Analgesia
Operative
-	Cheilectomy
-	Arthrodesis
-	Arthroplasty
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13
Q

What are the common lesser toe deformities and what causes each?

A

Claw toe- hyperextension at MTP with flexion at DIPs and PIPs
Hammer toe- fixed flexion at PIP
Mallet toe- fixed flexion at DIP

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14
Q

What is the aetiology of lesser toe deformities?

A
  • Imbalance between flexors/extensors
  • Shoe wear
  • Neurological
  • Rheumatoid arthritis
  • Idiopathic
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15
Q

What are the symptoms of lesser toe deformities?

A
  • Deformity
  • Pain from dorsum
  • Pain from plantar side (metatarsalgia)
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16
Q

Describe the treatment of lesser toe deformities

A 
Non-operative
-	Activity modification
-	Shoe wear – flat shoes with high toe box to accommodate deformity 
-	Orthotic insoles – metatarsal bar/dome support
Operative
-	Flexor to extensor transfer
-	Fusion of interphalangeal joint
-	Release metatarsophalangeal joint
-	Shortening osteotomy of metatarsal
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17
Q

What is the aetiology of interdigital neuralgia?

A
  • Mechanically induced degenerative neuropathy
  • Tends to affect females aged 40-60
  • Frequently associated with wearing high healed shoes
  • Common digital nerve relatively tethered to one metatarsal and movement in adjacent metatarsal causing mechanical shear
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18
Q

What are the symptoms of interdigital neuralgia?

A
  • Typically affects 3rd followed by 2nd webspace/toes
  • Neuralgic burning pain into toes
  • Intermittent
  • Altered sensation in webspace
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19
Q

How is interdigital neuralgia diagnosed?

A

Diagnosis mainly clinical
Mulder’s click present
Ultrasound is diagnostic
MRI not as good but can give better overview of foot

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20
Q

Describe the management of interdigital neuralgia

A
  • Corticosteroid injection for small lesions
  • Surgery – excision of lesion including a section of normal nerve (causes numbness, recurrence common, up to 30% have pain 1 year post operatively)
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21
Q

How is rheumatoid forefoot treated?

A 
Non-operative 
– shoewear/orthotics/activity etc
Operative
-	1st MTPJ arthrodesis
-	2-5th toe excision arthroplasty
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22
Q

What are the common midfoot problems?

A
  • Ganglia
  • Osteoarthritis
  • Plantar fibromatosis
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23
Q

What is the aetiology of dorsal foot ganglia?

A
  • Idiopathic
  • Underlying arthritis
  • Underlying tendon pathology
24
Q

What are the symptoms of dorsal foot ganglia?

A
  • Pain from pressure from shoe wear

- Pain from underlying problem

25
Q

What is the treatment of dorsal foot ganglia?

A 
Non-operative
-	Aspiration
-	“Family bible”
Operative
-	Excision (up to 50% recurrence rate)
26
Q

What are the causes of midfoot arthritis?

A

Typically post-traumatic
Idiopathic
Rheumatoid

27
Q

Describe the treatment of midfoot arthritis

A 
Non-operative
-	Activity
-	Shoewear
-	Orthotics
-	X-ray guided injection
Operative
-	Fusion
28
Q

When is plantar fibromatosis symptomatic?

A

When very large or in a weightbearing area

29
Q

How is plantar fibromatosis treated?

A
  • Non-operative – avoid pressure – shoewear/orthotics
  • Operative – excision (up to 80% risk of recurrence)
  • Radiotherapy (similar recurrence as operative)
  • Combination radiotherapy/surgery (low risk recurrence/high risk complications)
30
Q

What are the common hindfoot problems?

A
  • Achilles tendonitis/tendinosis
  • Plantar fasciitis
  • Ankle osteoarthitis
  • Tibialis posterior dysfunction
  • Cavovarus foot – already discussed by Mr Forrest
31
Q

What is the aetiology for achilles paratendonopathy?

A
  • Commonest in athletic populations
  • Age group 30-40
  • Male:Female = 2:1
32
Q

What is the aetiology for achilles tendonopathy?

A
  • Commonest in non-athletic populations
  • Aged over 40
  • Obesity
  • Steroids
  • Diabetes
33
Q

What are the symptoms of achilles tendonopathy?

A
  • Pain during exercise
  • Pain following exercise
  • Recurrent episodes
  • Difficuly fitting shoes (insertional)
  • Rupture – don’t miss!
34
Q

How is achilles tendonopathy diagnosed?

A

Mainly clinical- assessing for tenderness and tests for ruptures
Investigations can include ultrasound and MRI

35
Q

What is the treatment for achilles tendonopathy?

A 
Non-operative Treatment
-	Activity modification
-	Weight loss
-	Shoe wear modification – slight heel
-	Physiotherapy – Eccentric stretching
-	Extra-corporeal shockwave treatment
-	Immobilisation (in below knee cast)
Operative Treatment
-	Gastrocnemius recession
-	Release and debridement of tendon
36
Q

What is the aetiology of plantar fasciitis?

A
  • Not known
  • In athletes associated with high intensity or rapid increase in training
  • Running with poorly padded shoes or hard surfaces
  • Obesity
  • Occupations involving prolonged standing
  • Foot/lower limb rotational deformities
  • Tight gastro-soleus complex
37
Q

What are the symptoms of plantar fasciitis?

A
  • Pain first thing in morning
  • Pain on weight bearing after rest
  • Post-static dyskinesia
  • Pain located at origin of plantar fascia
  • Frequently long lasting – 2 years or more
38
Q

What is the differential diagnosis for plantar fasciitis?

A

Nerve entrapment syndrome
Arthritis
Calcaneal pathology

39
Q

How is plantar fasciitis diagnosed?

A

Mainly clinical

X-rays, ultrasound and MRI also diagnostic

40
Q

How is plantrar fasciitis treated?

A 
Most resolve spontaneously
Treated with:
-	Rest, change training
-	Stretching – Achilles +/- direct stretching
-	Ice
-	NSAIDs
-	Orthoses – Heel pads
-	Physiotherapy
-	Weight loss
-	Injections – corticosteroid (good in short term but may make condition worse long term)
-	Night Splinting
41
Q

What is the peak age of incidence of ankle arthritis?

A

46

42
Q

What are the symptoms of ankle arthritis?

A

Ankle pain and stiffness

43
Q

How is ankle arthritis diagnosed?

A

Mostly clinical
X-ray can be used to assess severity of disease
CT scan used to assess adjacent joints

44
Q

How is ankle arthritis treated?

A 
Non-operative
-	Weight loss
-	Activity modification
-	Analgesia
-	Physiotherapy
-	Steroid injections
Operative
-	Arthroscopic anterior debridement if symptoms are exclusively anterior
-	Arthrodesis (open or arthroscopic, gold standard)
-	Joint replacement
45
Q

What is posterior tibial dysfunction?

A

An acquired adult flat foot planovalgus

46
Q

What are the symptoms of posterior tibial dysfunction?

A

Initial medial pain when tendon inflamed that becomes lateral when valgus deformity severe enough to cause impingement
Struggles with single heel raise

47
Q

How is posterior tibial dysfunction investigated?

A

Diagnosis mainly clinical

MRI can be used to assess the tendon

48
Q

Describe the management of posterior tibial dysfunction?

A
  • Orthotics – medial arch support
  • Reconstruction of tendon (tendon transfer)
  • Triple fusion (subtalar, talonavicular and calcaneocuboid)
49
Q

Describe the aetiology of diabetic foot disease

A
  • Diabetic neuropathy – patient unaware of trauma to foot
  • Diabetic autonomic neuropathy
  • Lack of sweating / normal sebum production
  • Dry cracked skin
  • Skin more sensitive to minor trauma
  • Poor vascular supply
  • Lack of patient education
50
Q

How is diabetic foot disease treated?

A

Treatment involves modification of the main detriments to healing (smoking, diabetic control, vascular supply, external pressure etc)
Surgical treatment involves:
- Improve Vascular Supply
- Debride ulcers and get deep samples for microbiology
- Correct any deformity to offload area
- Amputation

51
Q

Describe the prognosis associated with diabetic foot ulcers?

A
  • 15% of all diabetics will develop ulceration
  • 85% of all amputations for diabetes are preceded by foot ulceration
  • 25% of patients with diabetic ulcers go on to amputation
  • 5 year patient mortality 50%
52
Q

What is the aetiology of charcot neuroarthropathy?

A
  • Any cause of neuropathy
  • Diabetes commonest cause
  • Historically originally described and most common with syphillis
53
Q

What are the three stages of charcot neuoarthropathy?

A

Fragmentation
Coalescence
Remodelling

54
Q

What is diagnosis of charcot neuroarthropathy based on?

A
  • High index of suspicion
  • Consider in any diabetic with acutely swollen erythematous foot especially with neuropathy
  • Greater than 3 degree heat difference between limbs
  • Frequently not painful
  • Radiographs
  • MRI scan
55
Q

How is charcot neuroarthropathy managed?

A
  • Prevention
  • Immobilisation / non-weight bearing until acute fragmentation resolved
  • Correct deformity

Musculoskeletal System (28 decks)

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