Orthopaedics Foot conditions Flashcards
In general, what are the non-operative management options for foot and ankle conditions?
Analgesia
Shoe wear modification
Activity modification
Weight loss
Physiotherapy
Orthotics e.g. insoles and bracing
What is hallux valgus also known as?
Bunions
What happens in hallux valgus?
Lateral deviation of big toe so it sits and rubs on second toe
->google picture
Cause of hallux vulgus?
Genetics
Footwear
Who is more likely to develop hallux valgus?
Women > men
Symptoms of hallux valgus?
Pressure symptoms from shoe wear
Pain from crossing over of toes
Metatarsalgia
->often bilateral
Pathogenesis of Hallux Valgus?
Lateral angulation of great toe as tendons pull which worsens alignment
Diagnosis of hallux valgus?
Examination
X-rays to determine severity of bony deformity
Non-operative management of hallux valgus?
Shoe wear modification- wider toes boxes
Orthotics to offload pressure and correct deformity
Activity modification
Analgesia
->conservative measure much preferred to operative treatment
Operative management for hallux valgus may be carried out if non-operative management fails.
What can be done?
Release of lateral soft tissues
Osteotomy of 1st metatarsal +/- proximal phalanx
Hallux rigidis?
Stiff big toe caused by osteoarthritis of 1st MTP joint
Symptoms of hallux rigidus?
Many asymptomatic
Pain- often at extreme dorsiflexion
Limitation of range of movement
Diagnosis of hallux rigidus?
History and examination
Radiographs
Non-operative management of hallux rigidus?
Activity modification
Shoe wear with a rigid sole
Analgesia
Surgical management of hallux rigidus?
Cheilectomy- particularly when pain on dorsiflexion
Arthrodesis
Arthroplasty
Gold standard of operative treatment for hallux rigidus?
1st MTPJ fusion
->permanent, very good option for young athletic patient
What are the three classical lesser toes deformities?
Claw toes
Hammer toes
Mallet toes
Claw toes?
Flexion at proximal and distal interphalangeal joint
Hammer toe?
Flexion at proximal interphalangeal joint and dorsiflexion at MTP joint
Mallet toe?
Flexion at distal interphalangeal joint - often pain of nail impinging of sole of their shoes
Causes of lesser toe deformitiers?
Imbalance between flexors/extensors w/ flexors being more active
Footwear
Neurological
Rheumatoid arthritis
Which specific lesser toe deformity has more of a neurological link?
Claw toes
Symptoms of lesser toe deformities?
Deformity
Pain from dorsal and plantar side
Non-operative treatment of lesser toe deformities?
Activity modification
Footwear- flat shoes with high toe box to accommodate deformity
Orthotic insoles
Operative treatment for lesser toe deformaities?
Flexor to extensor transfer
Fusion of interphalangeal joint
Release of metatarsophalangeal joint
Shortening osteotomy of metatarsal
Morton’s neuroma?
Thickening of tissue which surrounds the digital nerve leading to the toes
Cause of Morton’s neuroma?
Mechanically induced degenerative neuropathy
High heel shoes
Who tends to be affected by Morton’s neuroma?
Women 40-60
Where does Morton’s neuroma tend to affect>?
3rd webspace most common, followed by 2nd webspace
Symptoms of Morton’s neuroma?
Neuralgic burning pain in toes- intermittent
Altered sensation in webspace
Diagnosis of Morton’s neuroma?
Clinical
Ultrasound best, MRI good- but not very helpful
Which clinical test is used in Morton’s neuroma?
Mulder’s click
->probably best diagnostic test
Management of Morton’s neuroma?
Steroid injection for small lesions
Surgery- excision of lesion including section of normal nerve
->surgery can cause numbness and reoccurrence
Metatarsalgia?
Any pain coming from forefoot
->symptom, not a condition!
Non-0opertaive treatment for rheumatoid forefoot?
Shoewear
Orthotics
Activity modification
Gold standard operative treatment for rhematoid forefoot?
1st MTPJ fusion
2-5th toe arthroplasty
Dorsal foot ganglia?
Lump of foot arising from joint or tendon sheath
Aetiology of dorsal foot ganglia?
Idiopathic
Underlying arthritis
Underlying tendon pathology
Symptoms of dorsal foot gangllion?
Pain- either from pressure from shoes or underlying problem
Non-operative management of dorsal foot ganglia?
Footwear modification
Aspiration of fluid- like in ganglion of hand, viscous fluid comes out and this can be used to confirm diagnosis too
Operative treatment of dorsal foot ganglia?
Excision
->v poor prognosis and leaves scar which can rub on shoe
Causes of mid-foot arthritis?
Post-traumatic arthritis
Osteoarthritis
Rheumatoid arthritis
Treatment of midfoot arthritis?
Non-operative- surprise, surprise, footwear modification, activity, modification, orthotics
Injections- x-ray guided
Opertaive-fusion
Plantar fibromatosis?
Progressive connective tissue proliferation of the superficial plantar aponeurosis of the foot
->known as Dupuytrens of the foot, looks like a lump in the middle of palmar aspect of foot basically
Symptoms of Plantar fibromatosis?
Usually asymptomatic unless very large or on weightbearing area
Treatment of Plantar fibromatosis?
Non-operative = same
Operative= excision (but 80% reoccurrence)
Radiotherapy (same recurrence)
Combination of radiotherapy and surgery for best results if non-operative management does not work
Achilles tendoitis?
Degenerative/overuse condition with little inflammation
->term tendonitis can be confusing due to little inflammation, will now call achilles tendinopathy
Aetiology of Achilles tendinopathy?
Paratendonopathy- common in athletic populations
Tendonopathy- common in non-athletic populations
->think of para as in Paralympian = athletics or something
Causes of tendonopathy which can cause Achilles tendinopathy?
Age
Obesity
Steroids
Diabetes
Symptoms of Achilles tendinopathy?
Pain during or following exercise
Recurrent episodes for a few weeks which then settle but comes back
Difficulty fitting shoes
->do not miss a ruptured Achilles tendon!!! early treatment much better
Diagnosis of Achilles tendinopathy?
Clinical for tenderness and testing for rupture
Ultrasound or MRI to see extent of condition
Test for achilles tendon rupture?
Simmonds test
->gently squeezing calf, no movement in Achilles tendon rupture
Non-opertaive treatment of Achilles tendinopathy?
Activity modification
Weight loss
Shoe modification
Physio
Extra-corporeal shockwave treatment- vibrates tissues and promotes healing
Immobilisation in below the knee cast
Operative treatment of Achilles tendinopathy?
Gastrocnemius recession
Release and debridement of tendon
Plantar fasciosis/fasciitis?
Chronic degenerative change, fibroblast hypertrophy, absent inflammatory cells and dysfunctional blood vessels
What can cause Plantar fasciosis/fasciitis?
Athletes with high intensity or rapid increase in training
Running with poorly padded shoes on hard surfaces
Obesity
Prolonged standing
Symptoms of Plantar fasciosis/fasciitis?
Pain first thing in the morning
Pain on weight bearing after rest
->typical presentation, diagnosis often made based on this history, ultrasound and MRI sometimes used
Treatment of Plantar fasciosis/fasciitis?
Rest, change training
Stretching
Ice
NSAIDs
Orthoses- heel pads
Physio
Weight loss
Injections- good for short term
Night splinting
What are some of the newer treatments which can used for Plantar fasciosis/fasciitis instead of operation?
Extracorporeal shockwave therapy
Topaz plasma coblation
Nitric oxide
Ankle arthritis is most common when?
In older age but mean age is 46
Commonly post-traumatic
Symptoms of ankle arthritis?
Pain and stiffness
Diagnosis of ankle arthritis?
Clinically by restricted movement, pain
Radiographs and CT can be useful to look at the ankle and adjacent joints
Non-operative management of ankle arthritis?
Weight loss
Activity modification
Analgesia
Physiotherapy
Steroid injections
Gold standard of ankle arthritis surgery?
Arthrodesis (fusion)- either open or arthroscopic
Tiabialis posterior tendon dysfunction?
Progressive condition, acquired adult flat foot planovalgus
Diagnosis of Tiabialis posterior tendon dysfunction?
Largely clinical- double and single heel raises used to see if patient can stand on their tiptoes
MRI to assess tendon
Treatment of Tiabialis posterior tendon dysfunction?
Orthotics- medial arch support
Surgery in latter stages- reconstruction of tendon or triple fusion
Valgus?
Force pushing in towards centre of body
Varus?
Force that pushing out away from centre of body
Diabetic foot ulcers often occur because of what?
Well diabetes…but because patient looses sensation and feet and cannot feel pain caused by ulceration so can go missed for ages
Treatment of diabetic foot ulcers?
Prevention better than cure e.g. well fitting shoes, regular cleaning and inspection of feet
Modify the main detriments to healing e.g. improve diabetic control, smoking cessation, infection control, nutrition
What is involved in surgical treatment of diabetic foot ulcers?
Improve vascular supply
Debride ulcers and get samples for microbiology
Amputation if severe
Cause of Charcot’s foot?
Any cause of neuropathy
Diabetes- commonest cause
Charcot neuroarthropathy is characterised by rapid bone destruction occurring in three stages.
What are these three stages?
Fragmentation
Coalescence
Remodelling
Diagnosis of Charcot neuroarthropathy?
Radiographs
MRI scan
Any diabetic with acutely swollen erythematous foot, Charcot neuroarthropathy especially with neuropathy, diagnosis until proven otherwise
Management of Charcot neuroarthropathy?
Prevention better
Acute inflammatory phase= immobilisation
Correct deformity
