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MSK > S5L2 - Foot And Ankle Disorders > Flashcards

S5L2 - Foot And Ankle Disorders Flashcards

1
Q

What are compartments of limbs bound by?

A

Deep fascia and bone

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2
Q

What is compartment syndrome?

A

Trauma to a fascial compartment that leads to haemorrhage and/or oedema and cause a rise in intracompartmental pressure.

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3
Q

What are the clinical signs of compartment syndrome?

A

Severe pain, not relieved by analgesia

Pain exacerbated by passive stretch of muscles.

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4
Q

How is compartment syndrome treated?

A

Surgical decompression (fasciotomy) should be performed of all affected compartment.

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5
Q

What are the short term consequences of compartment syndrome?

A

Decreased perfusion of muscle. Ischaemic muscles release mediators that further increase capillary permeability and exacerbate the rise in intracompartmental pressure. This can result in rhabdomyolosis (muscle necrosis) and acute kidney injury as a result.
Neuromuscular signs develop later on in the process and are often undeveloped at the time of diagnosis. Distal paraesthesia precedes loss of motor function

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6
Q

What occurs if the compartmental pressure exceeds the systolic pressure?

A

There will be a loss of peripheral pulses and increased capillary refill time. Ischaemia.

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7
Q

What nerve fibres are most susceptible to ischaemia?

A

Thin cutaneous nerve fibres are more at risk of ischaemia than larger motor fibres. Paraesthesia is experienced before loss of motor function in compartmental syndrome.

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8
Q

What are the long term consequences of compartmental syndrome?

A

Rhabdomyolysis ( muscle necrosis) can result in acute kidney injury which may become chronic
Necrotic muscle may also under go fibrosis leading to Volkmann’s Ischaemic contracture.

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9
Q

What is volkmanns Ischaemic contracture?

A

A painful and disabling contracture of the affected muscle groups

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10
Q

What is the usual mechanism of injury for an ankle fracture?

A

An inversion or eversion injury.

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11
Q

What must be considered during an ankle fracture?

A
  1. Need to consider their co-morbidities (diabetes, neuropathy, peripheral vascular disease, smoking) as these are likely to affect the healing of the fracture.
  2. Integrity of the overlying soft tissue structures.
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12
Q

What are open fractures?

A

When the skin barrier is breached and there is direct communication between the fracture and the external environment

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13
Q

What is the treatment for an open ankle fracture?

A

Urgent surgery, extensive irrigation and debridement to reduce the risk of osteomyelitis (infection of the bone)

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14
Q

What ligaments of the ankle form a ring when viewed in the coronal view?

A

Proximal part: articular surfaces of the tibia and fibula, united at the inferior tibiofibular joint by the syndesmotic ligaments
Medial part: medial ligaments of the ankle (fan shape from medial malleolus)
Inferior part: subtalar joint (talus and calcaneus)
Lateral side: lateral ligament complex of the ankle ( anterior talofibular, talocalcaneal, posterior talofibular)

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15
Q

What other structures are likely to have obtained damage in a fracture of the ankle?

A

Ligament damage within the ankle ligament ‘ring’

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16
Q

What is talar shift?

A

What the talus can shift medially or laterally within the ankle joint. Occurs as there is disruption of any two out of the syndesmosis, medial and lateral ligaments, making the ankle mortise unstable.

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17
Q

How are stable ankle fractures usually treated?

A

Non-operatively with an air cast boot or fibreglass cast for comfort. Low rate of secondary complications.

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18
Q

How are unstable ankle fractures treated?

A

Surgical stabilisation

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19
Q

What is an ankle sprain?

A

Partial or complete tear of one or more of the ligament of the ankle joint.

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20
Q

What factors lead to an increased risk of a sprained ankle?

A

Weak muscles/tendons that cross the ankle joint (esp the peroneal muscles)
Weak or lax ankle ligaments
Inadequate joint proprioception
Slow neuromuscular response to an off-balance position
Running on uneven surfaces
Shoes with inadequate heel support
Wearing high heeled shoes

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21
Q

What usually causes an ankle sprain?

A

Excessive external rotation, inversion or eversion of the foot due to an external force. Ligaments are pulled past their yield point and become damaged or ‘sprained’

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22
Q

What is the most common ankle sprain?

A

The anterior talofibular ligament. Usually occurs by an inversion injury affecting a plantar flexed and weight bearing foot.

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23
Q

In a severe sprain of the ankle, why is it not uncommon to find that the patient has an avulsion fracture of their fifth metatarsal tuberosity?

A

The peroneus brevis tendon is attached to a tubercle on the base of the 5th metatarsal. In an inversion injury (common ankle sprain) the peroneus brevis is placed under tension

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24
Q

What is an avulsion fracture?

A

When a tendon or ligament is put under tension and a fragment of bone is pulled off at the insertion site.

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25
Q

A fracture of the 5th metatarsal base can be easily confused with an unfused 5th metatarsal apophysis on an x-ray of a child’s foot. How can they be differentiated?

A

The orientation of the lucent line on the x-ray

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26
Q

Who most commonly suffers from Achilles’ tendon ruptures?

A

Men aged 30-50 years during recreational sports

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27
Q

Where is the common site of rupture of an Achilles’ tendon?

A

The vascular watershed area, 6cm proximal to the insertion of the Achilles’ tendon onto the calcaneal tuberosity. Area has decreased vascularity and thickness of tendon.

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28
Q

What are the signs and symptoms of an Achilles’ tendon rupture?

A

Sudden sever pain in the back of the ankle or in the calf
Loud pop or snap sound
Palpable gap or depression in the tendon
Pain, swelling, bruising
Inability to stand on tip toe

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29
Q

What test is used to check for a ruptured Achilles’ tendon?

A

Thompson’s test

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30
Q

How is an Achilles’ tendon rupture diagnosed?

A

Clinical observation - Thompson’s test
MRI
ultrasound

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31
Q

How is a ruptured Achilles’ tendon treated?

A

Usually conservatively with the foot being held in the right position using an air cast boot. 12 month recovery

32
Q

What is Hallux valgus?

A

Varus deviation of the first metatarsal
Valgus deviation of the great toe/hallux
Prominence of the first metatarsal head with or without an overlying callus

33
Q

Who is most likely to suffer from hallux valgus?

A

Middle aged females

34
Q

What are the consequences of hallux valgus?

A

Painful movement of the first metatarsal phalangeal joint

Difficulty with footwear

35
Q

How is hallux valgus treated?

A

If painful, surgery. Surgery involves metatarsal osteotomy and realigning fragments. A similar osteotomy may be needed in proximal phalanx of the great toe.

36
Q

What is hallux rigidus?

A

Osteoarthritis of the 1st metatarsal phalangeal joint resulting in stiffness of the joint.

37
Q

What are symptoms of hallux rigidus?

A

Pain in the 1st metatarsal phalangeal joint when walking and on attempted dorsiflexion of the toe. Patients inverting their foot when walking.restricted dorsiflexion of the great toe. Dorsal bunion on the MTPJ, which may rub on shoes.

38
Q

What are the different surgical managements of osteoarthritis?

A
  1. Arthroplasty = joint replacement
  2. Arthrodesis = joint fusion
  3. Excision arthroplasty = surgical removal of the joint with interposition of soft tissue
  4. Osteotomy = surgical cutting of the bone to allow realignment.
39
Q

What is the treatment ladder for osteoarthritis of the 1st MTPJ (hallux rigidus)?

A
  1. CONSERVATIVE MANAGEMENT - Activity modification, analgesia, orthotics or aids and sometimes intra-articular steroid injections. Aids include a rigid sole orthotic
  2. SURGERY - arthrodesis of the 1st MTPJ. Arthroplasty for this joint is available.
40
Q

What is the major difference between osteoarthritis of the ankle joint in comparison with the hip or knee?

A

Nearly all cases of osteoarthritis of the ankle are secondary arthritis. OA secondary to previously suffered trauma (post-traumatic arthritis), secondary to inflammation in the ankle joint (rheumatoid arthritis, reactive arthritis), joint stress or obesity

41
Q

How is ankle osteoarthritis usually treated?

A

Arthrodesis - ankle fusion. Patients can walk well after with no discernible limp.
Ankle arthroplasty - greater risks than arthrodesis such as prosthetic loosening and prosthetic infection.
Arthrodesis is the preferred method

42
Q

What are the 4 types of toe deformities to the lesser toes?

A
  1. Claw toe
  2. Hammer toe
  3. Mallet toe
  4. Curly toe
43
Q

What is claw toe?

A

Toes hyperextended at the MTPJ and flexed at the proximal interphalangeal joints and sometimes also flexed at the distal interphalangeal joint. Often affects all 4 small toes at the same time.

44
Q

What causes claw toe?

A

Ligaments and tendons becoming unnaturally tight.
Usually occurs due to neurological damage and may be secondary to conditions such as diabetes mellitus, alcohol dependency, stroke, cerebral palsy, trauma, inflammation or rheumatoid arthritis.

45
Q

What is hammer toe deformity?

A

Toe is permanently flexed at the proximal interphalangeal joint PIPJ. Usually affects the second toe

46
Q

What is a mallet toe deformity?

A

Toes are flexed at the distal interphalangeal joint DIPJ. Usually affects the second toe

47
Q

What can cause hammer and mallet deformities?

A

Ill fitting pointed toes, adjacent hallux valgus

48
Q

What are the long term consequences of hammer and mallet toe deformities?

A

Muscles contact and shorten making it harder to extend the toe. Over time, may lose all ability to extend the toe.

49
Q

What are curly toes?

A

3rd to 5th digits of the foot are curled. Usually bilateral.

50
Q

What causes curly toes?

A

Congenital. Thought to develop because the tendons of flexor digitorum longus or flexor digitorum brevis (an intrinsic muscle of the foot) are too tight.

51
Q

How are curly toes usually treated?

A

Conservatively - passives extension of the toes and stretching of the flexor tendons

52
Q

What is Achilles tendinopathy?

A

A degenerative process of the Achilles’ tendon.

53
Q

Where does Achilles tendinopathy usually occur?

A

At the insertion point of the Achilles’ tendon into the calcaneus
At the vascular watershed area within the Achilles’ tendon

54
Q

Who is prone to getting Achilles tendinopathy?

A

Athletes who have overused their Achilles’ tendons.

Diabetes and obesity are also risk factors

55
Q

What are the signs and symptoms of Achilles tendinopathy?

A

Pain and stiffness along the Achilles’ tendon in the morning
Pain worsens with activity
Severe pain a day after exercising
Thickening of the tendon
Swelling
A palpable bone spur in insertional tendinopathy.

56
Q

What is the treatment for Achilles tendinopathy?

A

Physiotherapy, eccentric stretching exercises to try and improve the vascularity of the tendon and promote healing.

57
Q

What is pes planovalgus?

A

Flat foot

58
Q

What is flat foot?

A

The medial arch of the foot has collapsed and there is a valgus angulation of the hind foot.

59
Q

When are flat feet normal?

A

In young children (babies). Arches have not yet developed and they have a large amount of subcutaneous adipose tissue in the sole of the foot.

60
Q

When is flat feet considered abnormal?

A

If flat feet persists into adolescence or reoccurs in later life.

61
Q

What is the difference between flexible and rigid flat feet?

A

Flexible flat feet = more common. Medial arch appears when standing on tip toes and the hind foot returns from valgus deviation to normal alignment.
Rigid flat feet = medial arch does not appear on tip toe. Always abnormal. Usually develop as a result of tarsal coalition. Usually symptomatic and requires treatment.

62
Q

What is tarsal coalition?

A

Failure of the tarsal bones to separate during embryonic development.

63
Q

How does an adult acquire flatfoot?

A

Dysfunction of the tibialis posterior tendon.

64
Q

What adults are prone to acquiring flatfoot?

A

Middle aged females

65
Q

What are the symptoms and signs of adult acquired flatfoot?

A

Change in the shape of the foot

Pain behind the medial malleolus

66
Q

What are risk factors for adult acquired flatfoot?

A

Obesity, hypertension and diabetes

Can occur during pregnancy due to increased laxity of the ligaments.

67
Q

Why does the hind foot develop valgus deformation during flatfoot?

A
  • lack of support of the medial arch stretches the spring ligament (plantar calcaneonavicular ligament) and the plantar aponeurosis.
  • stretching of the ligaments results in the talar head being displaced inferomedially, flattening the medial longitudinal arch
68
Q

How is adult acquired flatfoot treated?

A

Orthotics (insoles to support the medial arch)
Physiotherapy to improve muscle strength

Occasionally surgical reconstruction is required.
If secondary OA develops, arthrodesis of the joints of their hindfoot

69
Q

Why is foot disease a common complication of diabetes?

A
  • loss of sensation due to peripheral neuropathy
  • Ischaemia due to peripheral arterial disease
  • immunosuppression due to poor glycaemic control
  • loss of protective sensation leads patients to continue weight-baring on significant soft tissue abnormalities, exacerbating many problems
70
Q

What is done to reduce the risk of foot disease?

A

Patients attend diabetic foot clinics for screening. Feet checked for abnormalities and sensation and perfusion. Check shoes to see if they fit well and are supportive. Educate patients on how they should look after their feet.

71
Q

What reduces the risk of diabetics getting foot disease?

A

Tight glycaemic control to stop neuropathy and vascular disease and maintaining a healthy immune response.

72
Q

What is charcot arthroplasty?

A

Commonly involves the ankle and foot. Combination of neuropathy, abnormal loading of the foot, repeated micro trauma and metabolic abnormalities lead to inflammation causing osteolysis, fractures, dislocation and deformity.

73
Q

What causes Charcot arthropathy?

A

Poorly controlled diabetes

74
Q

What worsens Charcot arthropathy?

A

Neuropathy means patients continue to walk on the Charcot foot
Muscle spasticity worsens the deformity

75
Q

What is rocker bottom foot?

A

Occurs in severe cases of Charcot arthropathy. Bottom of foot becomes curve, like a rocker.

76
Q

What is the treatment for Charcot arthropathy?

A

Optimisation of glycaemic control

Reduction of load placed on afford joints

MSK (17 decks)

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