Orthopaedics unit 4 Minor adult disorders - deck 2 Flashcards
Define the term hallux
This is the big toe
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 ?
Disorders of the first metatarsophalangeal joint.
Define what hallux valgus is
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
Define what hallux rigidus is
OA of the metatarsophalangeal joint
Pic on the R shows hallux rigidus
Can hallux valgus and hallux rigidus present together ?
Yes - they can also occur separately
What factors does the treatment of hallux valgus and hallux rigidus depend on ?
Depends upon whether one or both conditions are present, and the age of the patient
What age range may hallux rigidus present alone in ?
Adolescents and adults (in the elderly it rarely occurs without hallux valgus)
What is hallux rigidus thought to be due to if it presents in an adolescent ?
A result of osteochondral fracture
What are the treatment options for hallux rigidus presenting in an adolescence
1st line = conservative treatment with a metatarsal bar
2nd line = surgery (same as in adults)
How does a metatarsal bar work in treating hallux rigidus and why does it often fail in adolescents, resulting in them requiring surgery?
- 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
What is the treatment of hallux rigidus in adults ?
Conservative should be tried but it is rarely successful ==> surgery is the mainstay
What are the surgical options for the treatment of hallux rigidus ?
- 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.
Does surgical fusion for the treatment of hallux rigidus often given women problems with shoe heel height ?
No this is a folklore it rarely gives problems
What is the age range for which hallux valgus alone may occur ?
At any age
Who gets more problems with hallux valgus alone - m or f ?
Females
What anatomical variation do many sufferers of hallux valgus alone have ?
A short first metatarsal, often in varus
Note - not all have this
Is the cause of hallux valgus known ?
No
What is the treatment for hallux valgus?
- 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.
- Sugery
What are the surgical options for treatment of hallux valgus alone ?
- 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
- Keller’s procedure (think this is more 2nd line)
Define what an exotosis is
This is is the formation of new bone on the surface of a bone.
Define what the kellers procedure and who it should be avoided in
- 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.
Who is the combination of hallux valgus and hallux rigidus commonly seen in and why?
- In older people
- Where joint degeneration (rigidus) has formed usually secondary to the valgus deformity.
What is the treatment for hallux valgus with rigidus
1st line = conservative, these older patients are usually satisfied having their pain relieved by well fitting, extra-depth shoes
2nd line = kellers procedure (arthroplasty)
Why is kellers procedure usually the surgical treatment of choice in hallux valgus with rigidus but not in hallux valgus alone?
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
What does the combination of claw foot and claw toes describe?
A condition of the foot where wasted muscles make the bones and the toe nails appear more prominent - ‘like a dogs foot’
On close analysis what defects of the feet do many patients with claw foot and claw toes have?
Many of these patients do indeed have weak or denervated small muscles of the feet
What are ‘claw foot’ and ‘claw toes’ often associated with?
Minor spinal abnormalities such as spina bidifa occulta - surgery for claw toes should therefore be approached with caution
Describe what hammer toes are
The toe looks like the end of a hammer
What is the cause of hammer toes ?
They are are secondary to the disruption of the metatarsophalangeal joints
What are the treatment options for hammer toes ?
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
What can painful condition can abnormalities of the foot lead to and how do they lead to this ?
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
Define what mortons neuroma is
This is when one of the cutaneous nerves to the toes becomes trapped or irritated between the metatarsal heads giving rise to a neuroma
What is mortons neuroma almost certainly secondary to ?
Repetitive trauma and may be therefore associated with metatarsal head prolapse ==> metatarsalgia
What are the characteristic signs and symptoms of mortons neuroma ?
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)
What is the treatment of mortons neuroma ?
1st line = conservative; orthotics, steroid injects
2nd line = surgical excision
What are some of the risks the patient should be aware of before undergoing surgical excision for mortons neuroma ?
- There may be sensory disturbance to the affected toes
- Also recurrence of neuromas is common
What is an ingrown toe nail ?
This is a very uncomfortable condition where the curved nail grows into the nail fold and digs in
What is the development of ingrown toe nails often associated with?
Poor nail care
What can an ingrown toe nail lead to ?
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.
What is the treatment of ingrown toe nails ?
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
Define what the plantar fascia is
A tough layer of fibrous tissue which runs from the os calcis (calcaneus) to each toe base
Define what is meant by the term plantar fasciitis
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
What are the characteristic symptoms and signs of plantar fasciitis ?
- 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
How long may cases of plantar fasciitis last ?
A few months or even years
Most cases of plantar fasciitis resolve spontaneously - t or f ?
True
what are the different conservative options for treating plantar fasciitis ?
- 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.
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)
a local injection of steroids and long acting local anaesthetic
For those who demand a surgical solution for plantar fasciitis what can be done and what are the results like for this procedure?
- surgical stripping of the fascia from the os calcis can be done
- Results are very unpredictable
