Orthopedic Procedures- Foot And Ankle

Question 1

Co-morbidities to worry about

Answer 1

Diabetes, Vascular disease and smoking

Question 2

Diabetic neuropathy- cause, complications, testing

Answer 2

Due to vascular insufficiency and nerve fiber loss
Stocking and glove pattern of sensory loss

Tissues get glycosylated, small tissues and nerves and BV’s don’t work- can’t feel lacerations–> infection/osteomyelitis

Test with Somme’s-Weinstein 5.07 monofilament

Question 3

Compilation of neuropathy, continue to walk on fracture and it starts to fragment–> deformity in stage 4. Usually in mid-foot: rocket bottom deformity
Ulcer on prominence of deformity

Answer 3

Charcot Arthropathy

Question 4

Radiographic Evaluation of ankle

Answer 4

AP, mortise X ray (fibular is set internally rotated about 15 degrees) and lateral
Should be standing

Question 5

Distal tibiofibular joint relationship- slightly movable fibrous joint
When insulted= high ankle sprain

Answer 5

Syndesmosis

Question 6

Bimalleolar ankle fracture

Answer 6

Twisting mechanism, energy goes up through lateral ligaments, breaking off lateral malleolus, moves back and breaks off medial malleolus

Question 7

A trimalleolar ankle fracture also involves what?

Answer 7

Posterior malleolus displacement

Question 8

Syndesmotic disruption with proximal fibula fracture- name and mechanism

Answer 8

Maisonneuve injury

Twisting mechanism, energy comes up through interosseous membrane and ends up in fibula

Just Correct syndesmosis

Question 9

Really bad ankle fracture, higher energy, articular involvement, almost always treated in a staged fashion

Answer 9

Pilon fracture

Take out fracture, try to get fusion, shortened tibia, distraction osteogenesis, turn clickers over time to gain length: Ankle arthrodesis with proximal tibia lengthening

Question 10

Ankle Arthritis- cause, treatment

Answer 10

Primary arthritis is rare- usually post traumatic

Mediations, injection, bracing

Gold standard is arthrodesis= fusion, subchondral bone exposed, wait for it to heal
arthroplasty may be an option- takes out a lot of bone

Question 11

Extra bone that sometimes develops being the talus connected by a fibrous band- can by symptomatic (posterior ankle pain)

Answer 11

Os trigonum

Question 12

High energy ankle fracture- look for associated spine injury
Involvement of posterior facet (subtalar joint)
CT is essential to look at this joint

Name and symptoms
Serious complication of this fracture

Answer 12

Calcaneus fracture- subtalar joint controls inversion and eversion of hindfoot, hard to walk on uneven surface if this joint is disrupted

Avulsion of Achilles- bone is pushing on skin: will Necrose through skin easily: emergency surgery

Question 13

High energy forced dorsiflexion ankle injury
Has poor blood supply because it has no tendinous attachments

Name and complications

Answer 13

Talus fracture- most common in neck (can also fracture head, body, processes of talus)
Two Bv’s supply talus and usually one is disrupted when fractured= avascular necrosis

Question 14

Dislocation or fracture of the tarsometatarsal joint, usually involved 1st and 2nd MTs (can dislocate all 5 metarsals laterally)
Can be purely ligamentous

Name and treatment strategy

Answer 14

Lisfranc injury- don’t want to rigidly fix lateral border because there is a lot of motion here, medial column realigned will fix lateral column with it
Can use Kay wires percutaneously to fix lateral metatarsals

Question 15

Lateral deviation of great toe on first metatarsal
AKA bunion
Toe rotates, pronates, sesamoids move, etc

Name, complications, treatment

Answer 15

Hallux Valgus- medial eminence usually symptomatic, 2nd toe crowding/hammering
*have to address deformity at joint level and at metatarsal level

Question 16

Congenital flexible flatfoot
Adult acquired flatfoot caused by:
Presents as:
Stages:
Treatment:

Answer 16

Pes planovalgus
In adults caused by posterior tibial tendon insufficiency (usually supports the arch)
Pain over posterior tibial tendon, deformity of ‘too many toes’ sign when standing (see toes laterally from behind), inability to do single limb-heel rise
Different stages- pain without deformity (stage 1), pain with flexible deformity, pain with fixed deformity, all of the above and resultant ankle arthritis/deformity (stage 4)

Early- PT, meds, bracing/unloading of PTT
Flexible deformity- FDL transfer, medial side calcaneal osteotomy, lateral column lengthening
Fixed deformity- triple arthrodesis

Question 17

Very high arched feet

Name, cause, presentation, treatment

Answer 17

Cavovarus- very rigid (unlike flexible planovalgus)
Usually neurological in nature: Charcot-Marie Tooth disease, cerebral palsy, stroke
Posterior tibial and fibularis longus tendon overpull causing hindfoot varus and forefoot valgus

Lateral foot and ankle pain
Can develop stress fractures
Standing exam shows cavus alignment- peek a boo heel align (heel is to the midline instead of to valgus like in flatfoot)
Coleman block test

Flexible- orthotics to correct deformity
Spasticity- tendon transfers to move deforming forces (Bridle procedure)
Rigid- lateralizing calcaneal osteotomy or arthrodesis