Orthopaedics unit 4 Minor adult disorders - deck 2

Question 1

Define the term hallux

Answer 1

This is the big toe

Question 2

When talking about a condition and it used the term hallux this means it is referring to the big toe, however what more specifically within the big toe are conditions which use this term referring to ?

Answer 2

Disorders of the first metatarsophalangeal joint.

Question 3

Define what hallux valgus is

Answer 3

Hallux valgus refers to the turning away of the phalanges of the big toe from the mid-line, usually because of a deformity at the joint line.

Pic on the L shows hallux valgus

Question 4

Define what hallux rigidus is

Answer 4

OA of the metatarsophalangeal joint

Pic on the R shows hallux rigidus

Question 5

Can hallux valgus and hallux rigidus present together ?

Answer 5

Yes - they can also occur separately

Question 6

What factors does the treatment of hallux valgus and hallux rigidus depend on ?

Answer 6

Depends upon whether one or both conditions are present, and the age of the patient

Question 7

What age range may hallux rigidus present alone in ?

Answer 7

Adolescents and adults (in the elderly it rarely occurs without hallux valgus)

Question 8

What is hallux rigidus thought to be due to if it presents in an adolescent ?

Answer 8

A result of osteochondral fracture

Question 9

What are the treatment options for hallux rigidus presenting in an adolescence

Answer 9

1st line = conservative treatment with a metatarsal bar

2nd line = surgery (same as in adults)

Question 10

How does a metatarsal bar work in treating hallux rigidus and why does it often fail in adolescents, resulting in them requiring surgery?

Answer 10

• It works by providing a rocker at the front of the foot so that the toe need not bend in normal walking.
• This usually fails because youngsters do not accept the cosmetic consequences on their shoes

Question 11

What is the treatment of hallux rigidus in adults ?

Answer 11

Conservative should be tried but it is rarely successful ==> surgery is the mainstay

Question 12

What are the surgical options for the treatment of hallux rigidus ?

Answer 12

• For minor cases - Surgical removal of the osteophytes with an osteotomy of the proximal phalanx
• Surgical fusion in a neutral position is most reliable - for other cases

Interposition arthroplasty with a silicone plastic (silastic) spacer is an alternative which gives mixed results.

Question 13

Does surgical fusion for the treatment of hallux rigidus often given women problems with shoe heel height ?

Answer 13

No this is a folklore it rarely gives problems

Question 14

What is the age range for which hallux valgus alone may occur ?

Answer 14

At any age

Question 15

Who gets more problems with hallux valgus alone - m or f ?

Answer 15

Females

Question 16

What anatomical variation do many sufferers of hallux valgus alone have ?

Answer 16

A short first metatarsal, often in varus

Note - not all have this

Question 17

Is the cause of hallux valgus known ?

Answer 17

No

Question 18

What is the treatment for hallux valgus?

Answer 18

1. Conservative = includes the wearing of wider and deeper “accommodating” shoes to prevent painful bunions and the use of a spacer in the first web space to stop rubbing between the great and second toes.
2. Sugery

Question 19

What are the surgical options for treatment of hallux valgus alone ?

Answer 19

1. Realignment of the first metatarsal to a more lateral position and excision of any bony prominence (an exostosis) over the first metatarsal. This gives satisfactory results in any age
2. Keller’s procedure (think this is more 2nd line)

Question 20

Define what an exotosis is

Answer 20

This is is the formation of new bone on the surface of a bone.

Question 21

Define what the kellers procedure and who it should be avoided in

Answer 21

• Kellers procedure = excision of the metatarsophalangeal (MTP) joint
• It is to be avoided in the young and is probably unnecessary if the joint is not painful.

Question 22

Who is the combination of hallux valgus and hallux rigidus commonly seen in and why?

Answer 22

• In older people
• Where joint degeneration (rigidus) has formed usually secondary to the valgus deformity.

Question 23

What is the treatment for hallux valgus with rigidus

Answer 23

1st line = conservative, these older patients are usually satisfied having their pain relieved by well fitting, extra-depth shoes

2nd line = kellers procedure (arthroplasty)

Question 24

Why is kellers procedure usually the surgical treatment of choice in hallux valgus with rigidus but not in hallux valgus alone?

Answer 24

Because it serverly disrupts the normal foot biomechanics and hallux valgus alone often can be younger patients (talking younger than an elderly person) whereas hallux valgus with rigidus usually occurs in elderly people who are less active

The procedure itself also provides a safe, rapid way of providing relief

Question 25

What does the combination of claw foot and claw toes describe?

Answer 25

A condition of the foot where wasted muscles make the bones and the toe nails appear more prominent - ‘like a dogs foot’

Question 26

On close analysis what defects of the feet do many patients with claw foot and claw toes have?

Answer 26

Many of these patients do indeed have weak or denervated small muscles of the feet

Question 27

What are ‘claw foot’ and ‘claw toes’ often associated with?

Answer 27

Minor spinal abnormalities such as spina bidifa occulta - surgery for claw toes should therefore be approached with caution

Question 28

Describe what hammer toes are

Answer 28

The toe looks like the end of a hammer

Question 29

What is the cause of hammer toes ?

Answer 29

They are are secondary to the disruption of the metatarsophalangeal joints

Question 30

What are the treatment options for hammer toes ?

Answer 30

1st line = a good pair of soft and comfortable shoes

2nd line = Surgery: fusion of the interphalangeal joints in a straight position, so that they do not rub on the shoes

Question 31

What can painful condition can abnormalities of the foot lead to and how do they lead to this ?

Answer 31

Abnormalities of the foot (e.g. claw foot and hammer toes) leading to prolapse of metatarsal heads and joint disruption are not understood. The patient may present with generally sore forefeet - termed metatarsalgia

Question 32

Define what mortons neuroma is

Answer 32

This is when one of the cutaneous nerves to the toes becomes trapped or irritated between the metatarsal heads giving rise to a neuroma

Question 33

What is mortons neuroma almost certainly secondary to ?

Answer 33

Repetitive trauma and may be therefore associated with metatarsal head prolapse ==> metatarsalgia

Question 34

What are the characteristic signs and symptoms of mortons neuroma ?

Answer 34

Pain - usually dull and throbbing with sharp exacerbations

Tingling of the toes

Classically, sideways compression of the foot produces a palpable click, reproducing the symptoms. (Mulders click test)

Question 35

What is the treatment of mortons neuroma ?

Answer 35

1st line = conservative; orthotics, steroid injects

2nd line = surgical excision

Question 36

What are some of the risks the patient should be aware of before undergoing surgical excision for mortons neuroma ?

Answer 36

• There may be sensory disturbance to the affected toes
• Also recurrence of neuromas is common

Question 37

What is an ingrown toe nail ?

Answer 37

This is a very uncomfortable condition where the curved nail grows into the nail fold and digs in

Question 38

What is the development of ingrown toe nails often associated with?

Answer 38

Poor nail care

Question 39

What can an ingrown toe nail lead to ?

Answer 39

Secondary infection developing

• Resulting in it becoming a long-term nagging infection with acute and very painful flare ups
• . It can also lead to secondary blood borne infections, which can have serious consequences if the sufferer has prosthetic joints or heart valves.

Question 40

What is the treatment of ingrown toe nails ?

Answer 40

Careful nail care and straight cutting usually will control the condition as it tends to recur

Definite treatment is difficult;

• Wedge resection of the nail bed may retain the toe nail and remove the problem.
• The surest way of relieving the problem is to remove the nail bed using phenol after removing the nail, but some cosmetic surgery may also be necessary

Question 41

Define what the plantar fascia is

Answer 41

A tough layer of fibrous tissue which runs from the os calcis (calcaneus) to each toe base

Question 42

Define what is meant by the term plantar fasciitis

Answer 42

This is a term which includes a number of vague, but nevertheless very incapacitating painful disorders of the foot, that result in inflammation of the plantar fascia

Question 43

What are the characteristic symptoms and signs of plantar fasciitis ?

Answer 43

• Soreness of the instep, often worse first thing on rising, or after sitting for a few hours
• symptoms are minimally relieved by walking but then persist as a debilitating ache
• Pain often exacerbated by a change of direction, or walking on rough ground
• On examination there may be tenderness at a point on the hindfoot, at the origin of the plantar fascia medially, but discomfort is often diffuse

Question 44

How long may cases of plantar fasciitis last ?

Answer 44

A few months or even years

Question 45

Most cases of plantar fasciitis resolve spontaneously - t or f ?

Answer 45

True

Question 46

what are the different conservative options for treating plantar fasciitis ?

Answer 46

• Insoles that are hollowed out under the tender area may help, but may cause discomfort around the edge of the hollow.
• Soft shoes and insoles, particularly modern sports trainers, can be of considerable value in relieving symptoms.

Question 47

If there is a marked tender point in someone with plantar fasciitis what technique can be done which is very effective in treating the patients symptoms (wouldn’t do this if tenderness was diffuse)

Answer 47

a local injection of steroids and long acting local anaesthetic

Question 48

For those who demand a surgical solution for plantar fasciitis what can be done and what are the results like for this procedure?

Answer 48

• surgical stripping of the fascia from the os calcis can be done
• Results are very unpredictable