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Y3 surgery > Orthopaedics - ankle & foot > Flashcards

Orthopaedics - ankle & foot Flashcards

1
Q

Achilles tendonitis

A

Inflammation of the Achilles tendon
More prevalent in those who engage in high-intensity activities which chronically overload the tendon

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2
Q

Achilles tendonitis & rupture pathophysiology

A

Achilles tendon = gastrocnemius, soleus & plantaris, inserts in to the calcaneus -> produces plantarflexion
Repetitive action of the tendon results in microtears leading to localised inflammation
Over time, the tendon becomes thickened, fibrotic & loses elasticity with repeated episodes
Achilles tendon rupture -> substantial sudden force is applied across the tendon
- Precipitating event could be a movement eg. sudden jump/rapid change in direction whilst running

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3
Q

Achilles tendonitis/rupture risk factors

A

Unfit individual who has a sudden increase in exercise frequency
Poor footwear choice
Male gender
Obesity
Recent fluoroquinolone use

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4
Q

Achilles tendonitis clinical features

A

Gradual onset of pain & stiffness in the posterior ankle, often worse with movement
Usually be improved with PT/heat application
Examination – tenderness, over the tendon on palpation, with pressure over the tendon with your fingers reproducing this pain

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5
Q

Achilles rupture clinical features

A

Patients will often describe sudden-onset severe pain in the posterior calf, accompanied with an audible popping sound & feeling that something went
Examination – marked loss of power of ankle plantarflexion

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6
Q

Simmonds test

A

With the patient kneeling on a chair, with the affected ankle hanging off the edge of the chair, squeeze the affected calf
If the Achilles tendon is in continuity, the foot will plantarflex, however plantarflexion is absent when the tendon is ruptured

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7
Q

Achilles tendonitis & rupture investigations

A

Clinical diagnoses
USS may be required – particularly useful to differentiate complete and partial tears

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8
Q

Achilles tendonitis management

A

Supportive measures – stop the precipitating exercise, ice, anti-inflammatory medication regularly
Chronic – require rehab & PT

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9
Q

Achilles rupture management

A

Acute partial-thickness or full-thickness Achilles tendon rupture requires analgesia and immobilisation with the ankle splinted in a plaster in full equinus (ankle and toes maximally pointed)
Provided with crutches and not allowed to weight bear
Position is held for 2 weeks, following this, the ankle is brought in to ‘semi-equinus’ & held for a further 4 weeks, after this the ankle is brought in to the neutral position & held again for 4 weeks
Delayed presentations (> 2 weeks)/cases of re-rupture require surgical fixation with an end-to-end tendon repair

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10
Q

Ankle fractures classification

A

Can be described as isolated lateral malleolar fractures, isolated medical malleolar fractures, bimalleolar fractures & trimalleolar fractures
Most common classification is Weber – classifies lateral malleolar fractures:
- Type A = below the syndesmosis
- Type B = at the level of syndesmosis
- Type C = above the level of the syndesmosis
The more proximal the injury, the higher the likelihood of ankle instability

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11
Q

Ankle fractures clinical features

A

Ankle pain following a traumatic injury
May be associated deformity
May have neurovascular compromise
Can be open fractures

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12
Q

Ottawa ankle rules

A

Used when there is diagnostic uncertainty
Plain radiographs may be undertaken:
1) Bone tenderness at the posterior edge/tip of the lateral malleolus OR
2) Bone tenderness at the posterior edge/tip of the medial malleolus OR
3) Inability to bear weight both immediately & in ED for 4 steps

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13
Q

Ankle fractures investigations

A

Plain radiographs – AP, lateral & mortise views -> check the joint space for uniformity, ensuring no evidence of talar shift
Complex fractures – require a CT scan for surgical planning

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14
Q

Ankle fractures initial & conservative management

A

Initial – immediate fracture reduction usually performed under sedation in ED to realign the fracture
Once reduced, ankle should be placed in a below knee back slab -> repeat & document post-reduction neurovascular examination
Request a repeat plain film radiograph
Conservative management for:
- Non-displaced medial malleolus fractures
- Weber A/Weber B fractures without talar shift
- Unfit for surgical intervention

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15
Q

Ankle fractures surgical management

A

ORIF is often required in ankle fractures:
- Displaced bimalleolar/trimalleolar fractures
- Weber C fractures
- Weber B fractures with talar shift
- Open fractures

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16
Q

Ankle fractures complications

A

Post-traumatic arthritis
Those who have undergone an ORIF -> surgical site infection, DVT/PE, neurovascular injury, non-union & metalwork prominence

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17
Q

Ankle sprain

A

Ligamentous injuries
High – injuries to the syndesmosis
Low – injuries to the anterior talofibular ligament & the calcaneofibular ligament
Present following an inversion injury on a plantarflexed ankle, swelling & pain, fingertip tenderness distal to the malleoli
Imaging of choice is with plain film radiographs, nearly all can be managed conservatively with analgesia, ice & elevation following by early mobilisation

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18
Q

Calcaneal fracture classification

A

Intra-articular – involves the articular surface of the subtalar joint
Extra-articular – commonly are avulsion fractures with sparing of the articular surface of subtalar joint

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19
Q

Calcaneal fracture clinical features

A

Recent trauma
Pain and tenderness around the calcaneal region with an inability to weigh bear
Examination – region will be significantly swollen & bruised, with potential for a shortened & widened heel
Important to assess for posterior heel skin integrity

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20
Q

Calcaneal fracture investigations

A

Plain film radiograph – AP, lateral & oblique views
CT imaging is gold standard for assessing calcaneal fractures & should be performed in any suspected case

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21
Q

Calcaneal fracture management

A

Majority of intra-articular calcaneal fractures – require surgical intervention
Certain extra-articular fractures will be treated non-operatively, with cast immobilisation & non-weight bearing for 10-12 weeks
Surgical intervention – closed reduced with percutaneous pinning can be attempted for large but minimally displaced fractures
ORIF is usually required for most calcaneal fractures
Any fracture with skin compromise warrants emergency surgical fixation

22
Q

Calcaneal fracture complications

A

Subtalar arthritis

23
Q

Hallux valgus

A

Deformity at the first metatarsophalangeal joint
Characterised by medial deviation of the first metatarsal & lateral deviation +/- rotation of the hallux with associated joint subluxation

24
Q

Hallux valgus risk factors

A

Female
Connective tissue disorders
Hypermobility syndromes
Anatomical variants – long first metatarsal bone, mal-alignment of the first MTP joint and flat feet

25
Q

Hallux valgus clinical features

A

Painful medial prominence, likely aggravated by walking, weight-bearing activities or wearing narrow toed shoes
Examination – assess position & lateral deviation of the hallux, ensure assessed in both a non-weightbearing position and weightbearing position, ROM and crepitus
Contracture of the extensor hallucis longus tendon may be visible in longstanding joint subluxation & any excessive keratosis

26
Q

Hallux valgus investigations

A

Main investigation – radiographic imaging

27
Q

Hallux valgus management

A

Sufficient analgesia
Adjusting footwear, PT
Surgical management – quality of life is significantly impacted
- Lots of different procedures possible: Chevron, Scarf, Lapidus, Keller procedure
- Complications: wound infection, delayed healing, nerve injury, osteomyelitis

28
Q

Hallux valgus complications

A

Avascular necrosis
Non-union
Displacement
Reduced ROM

29
Q

Lisfranc injuries

A

Severe injuries to the tarsometatarsal joint between the medial cuneiform and base of the 2nd metatarsal – can be solely ligamentous injuries/involving the bony structures of the midfoot

30
Q

Lisfranc injuries clinical features

A

Most commonly occur following severe torsional/translational forces applied through a plantar flexed foot
Severe pain in the midfoot & difficulty in weight-bearing
Examination – swelling and tenderness over the midfoot, plantar bruising is highly suggestive of a Lisfranc injury
Monitor for features of compartment syndrome

31
Q

Lisfranc injuries investigations

A

Plain film radiograph – AP, oblique & lateral foot views
CT scanning – useful in the pre-operative planning of more comminuted fractures
MRI imaging can confirm the presence of purely ligamentous injury

32
Q

Lisfranc injuries initial & conservative management

A

Significantly displaced injuries – closed reduction may be required in A&E, place in a backslab
Certain injuries without significant displacement can be primarily managed conservatively with cast immobilisation/air-cast boot & non-weight bearing mobilisation for 6-12 weeks with regular ortho follow-up and review

33
Q

Lisfranc injuries surgical management

A

If clear displacement must be managed operatively
Screw fixation = definitive fixation
Primary arthrodesis can be used for severely comminuted/displaced fracture-dislocations

34
Q

Lisfranc injuries complication

A

Post-traumatic arthritis – delayed management by ORIF/non-anatomical reduction
Midfoot compartment syndrome

35
Q

Plantar fasciitis

A

Inflammation of the plantar fascia of the foot
Common condition & can be unilateral/bilateral

36
Q

Plantar fasciitis pathophysiology

A

Micro-tears to the plantar fascia occur, suggesting a chronic breakdown of the structure
Individuals may be predisposed to the condition from any anatomical abnormality -> can result in an asymmetric loading on the plantar fascia

37
Q

Plantar fasciitis risk factors

A

Anatomical factors – excessive pronation/pes cavus (high arches)
Weak plantar flexors or tight gastrocnemius/soleus
Prolonged standing or excessive running
Leg length discrepancy
Obesity
Unsupportive footwear

38
Q

Plantar fasciitis clinical features

A

Sharp pain across the plantar aspect of the foot
Often felt more severely in the heel & can radiate down the arch distally
Classically it tends to be worst with the first few steps of the day/periods of inactivity
Examination – evidence of over-pronation, high arches, leg length discrepancy or femoral anteversion
Infracalcaneal region if commonly tender on palpation

39
Q

Plantar fasciitis investigations

A

Clinical diagnosis
Plain radiographs can be done to exclude bony injury & assess for a plantar heel spur
MRI is occasionally indicated if ongoing uncertainty

40
Q

Plantar fasciitis conservative management

A

Activity moderation & regular analgesics forms the mainstay of management
Footwear should be adjusted
PT

41
Q

Plantar fasciitis surgical management

A

Corticosteroid injection can be trialled if no improvement to conservative management
No improvement, plantar fasciotomy can be considered

42
Q

Talar fractures

A

Second most common tarsal bone to fracture
Typically occur following high-energy trauma, eg. fall from height or road traffic accident, during which the ankle is forced in to dorsiflexion -> talus presses against the tibial plafond, resulting in a fracture
High risk of avascular necrosis due to interruption of the extraosseous arterial supply

43
Q

Talar fractures clinical features

A

Patients will present with a history of high-impact trauma
Immediate pain and swelling around the ankle
Clear deformity if talus is dislocated
Examination – unable to dorsiflex/plantarflex, check if open fracture, assess distal neurovascular status

44
Q

Talar fractures investigations

A

Plain film radiographs – AP, lateral (taken in dorsiflexion & plantarflexion)
CT imaging for more complex injuries

45
Q

Talar fractures management

A

Depends on their Hawkins classification
All undisplaced may be managed conservatively in a non-weight bearing orthosis, whereas all displaced fractures require immediate reduction & subsequent surgical repair
Type I – treated conservatively in a plaster with non-weight bearing crutches for approx.. 3 months -> region should be assessed for evidence of union & AVN in fracture clinic
Type II to IV fractures – initially managed with attempted closed reduction in the ED, repeat radiographs
Definitive surgical fixation, post operatively will require an extended period of non-weight bearing

46
Q

Talar fractures complications

A

Avascular necrosis
OA

47
Q

Tibial pilon fractures

A

Severe injuries affecting the distal tibia
Caused by high energy axial loads as the tibial plafond is injured by the talus punching up into it
Characterised by articular impaction, severe comminution & often associated with considerable soft tissue injury
Complex injuries & often require specialist input

48
Q

Tibial pilon fractures clinical features

A

History of trauma, severe ankle pain and inability to weight bear
Examination – obvious ankle deformity, with associated significant swelling & bruising are common
Evidence of an open fracture, signs of compartment syndrome, peripheral pulses & peripheral nerve examination

49
Q

Tibial pilon fractures investigations

A

Urgent bloods – coagulation & group and save
Imaging – plain film radiographs with AP, lateral and mortise views, full length views of tibia and knee are required
CT is often required for pre-op planning

50
Q

Tibial pilon fractures initial management

A

Realignment of the limb & below-knee backslab
Repeat neurovascular assessment & check plain film radiographs should be performed, limb must be elevated and monitored for compartment syndrome
Simple undisplaced fractures may be treated non-operatively, but surgical management is preferred

51
Q

Tibial pilon fractures surgical management

A

Aims to reconstruct the articular surface, restore the alignment of the ankle mortise & protect the soft tissues around the ankle joint
Application of temporary spanning external fixator followed by definitive fixation (ORIF) 7-14 days later once the soft tissues have had opportunity to heal
Definitive fixation is best performed under traction

52
Q

Tibial pilon fractures complications

A

Compartment syndrome
Wound infection or dehiscence
Delayed or non-union
Post-traumatic arthritis

Y3 surgery (21 decks)

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