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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
What is the treatment of dorsal foot ganglia?
``` Non-operative - Aspiration - “Family bible” Operative - Excision (up to 50% recurrence rate) ```
26
What are the causes of midfoot arthritis?
Typically post-traumatic Idiopathic Rheumatoid
27
Describe the treatment of midfoot arthritis
``` Non-operative - Activity - Shoewear - Orthotics - X-ray guided injection Operative - Fusion ```
28
When is plantar fibromatosis symptomatic?
When very large or in a weightbearing area
29
How is plantar fibromatosis treated?
- 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
What are the common hindfoot problems?
- Achilles tendonitis/tendinosis - Plantar fasciitis - Ankle osteoarthitis - Tibialis posterior dysfunction - Cavovarus foot – already discussed by Mr Forrest
31
What is the aetiology for achilles paratendonopathy?
- Commonest in athletic populations - Age group 30-40 - Male:Female = 2:1
32
What is the aetiology for achilles tendonopathy?
- Commonest in non-athletic populations - Aged over 40 - Obesity - Steroids - Diabetes
33
What are the symptoms of achilles tendonopathy?
- Pain during exercise - Pain following exercise - Recurrent episodes - Difficuly fitting shoes (insertional) - Rupture – don’t miss!
34
How is achilles tendonopathy diagnosed?
Mainly clinical- assessing for tenderness and tests for ruptures Investigations can include ultrasound and MRI
35
What is the treatment for achilles tendonopathy?
``` 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
What is the aetiology of plantar fasciitis?
- 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
What are the symptoms of plantar fasciitis?
- 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
What is the differential diagnosis for plantar fasciitis?
Nerve entrapment syndrome Arthritis Calcaneal pathology
39
How is plantar fasciitis diagnosed?
Mainly clinical | X-rays, ultrasound and MRI also diagnostic
40
How is plantrar fasciitis treated?
``` 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
What is the peak age of incidence of ankle arthritis?
46
42
What are the symptoms of ankle arthritis?
Ankle pain and stiffness
43
How is ankle arthritis diagnosed?
Mostly clinical X-ray can be used to assess severity of disease CT scan used to assess adjacent joints
44
How is ankle arthritis treated?
``` 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
What is posterior tibial dysfunction?
An acquired adult flat foot planovalgus
46
What are the symptoms of posterior tibial dysfunction?
Initial medial pain when tendon inflamed that becomes lateral when valgus deformity severe enough to cause impingement Struggles with single heel raise
47
How is posterior tibial dysfunction investigated?
Diagnosis mainly clinical | MRI can be used to assess the tendon
48
Describe the management of posterior tibial dysfunction?
- Orthotics – medial arch support - Reconstruction of tendon (tendon transfer) - Triple fusion (subtalar, talonavicular and calcaneocuboid)
49
Describe the aetiology of diabetic foot disease
- 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
How is diabetic foot disease treated?
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
Describe the prognosis associated with diabetic foot ulcers?
- 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
What is the aetiology of charcot neuroarthropathy?
- Any cause of neuropathy - Diabetes commonest cause - Historically originally described and most common with syphillis
53
What are the three stages of charcot neuoarthropathy?
Fragmentation Coalescence Remodelling
54
What is diagnosis of charcot neuroarthropathy based on?
- 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
How is charcot neuroarthropathy managed?
- Prevention - Immobilisation / non-weight bearing until acute fragmentation resolved - Correct deformity

Musculoskeletal System (28 decks)

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