Session 4 Clinical Flashcards
What’s the most commonly fractures tarsal bone
Calcaneus
Most calcaneal fractures occur from
Forceful landing on a heel, talus is driven down into calcaneus
What is compartment syndrome
Trauma (blunt or penetrating) to a fascial compartment may lead to haemorrhage and/or oedema and cause a rise in intra-compartmental pressure.
Clinical signs of compartment syndrome
Severe pain in the limb, which is excessive for the degree of injury, increasing and not relieved by analgesia. Pain is classically exacerbated by passive stretch of the muscles.
Short term consequences of compartment syndrome
- Decreased perfusion of muscle
- Ischaemic muscle releases mediators
- These further increase capillary permeability and exacerbate the rise in intracompartmental pressure
- Neurovascular signs develop late, loss of peripheral pulses and increased capillary refill time. Distal Parasthesia preceded loss of motor function
Long term consequences of compartment syndrome
Rhabdomyolysis (muscle necrosis) and acute kidney injury which may become chronic.
Necrotic muscle may also undergo fibrosis- causing Volkmann’s ischaemic contracture (permanent painful and disabling contracture)
Mechanism of injury for an ankle fracture
Inversion or eversion
Co-morbidities for delayed fracture healing
Diabetes, neuropathy, peripheral vascular disease, smoking
Open ankle-fractures key points
Urgent surgery with extensive irrigation and debridement to reduce the risk of osteomyelitis (infection of the bone)
What happens in Talar shift
Ankle mortise becomes unstable and widens so that the talus can shift medially or laterally within the ankle joint.
Happens when there is disruption of any two out of the syndesmosis, medial or lateral ligaments.
Treatment of stable ankle fracture
Non-operative such as air cast boot or fibreglass cast for comfort. Can weight-bear safely and low rate of complications
Treatment for unstable ankle fractures
Surgical stabilisation
Sprained ankle definition
Partial or complete tear of one or more ligaments of the ankle joint
Factors that contribute to increased risk of ankle sprains
Weak muscles/tendons, weak/lax ligaments (hereditary or due to repetitive ankle strains) , inadequate joint proprioception, slow neuromuscular response , running on uneven surfaces, shoes with inadequate heel support, high heeled shoes
Ankle sprains cause
Excessive external rotation, inversion or eversion of the foot due to an external force
most common mechanism of injury in ankle sprains
Inversion injury affecting a plantar-flexed and weight bearing foot (anterior talofibular ligament is most at risk of sprain)
What is an avulsion fracture
When a tendon or ligament is placed under tension and instead of it tearing, a fragment of bone is pulled off at insertion site
Why is avulsion fraction of 5th metatarsal tuberosity common in severe sprain of ankle
Fibularis brevis tendon is attached to a tubercle on the base of the 5th metatarsal
What can be confusingly mistaken for a 5th metatarsal tuberosity avulsion fracture
Unfused apophysis on 10-16 year old
Causes of Achilles’ tendon rupture
- forceful push off with extended knee (jumping)
- fall with foot outstretched and ankle dorsiflexed
- falling from high, into hole, or off kerb
Why is Achilles’ tendon vascular watershed more susceptible to tear
Decreased vascularity and thickness of tendon
Symptoms and signs of Achilles’ tendon rupture
- Sudden and severe pain at back of ankle or calf
- Sound of pop or snap
- palpable/visible gap in tendon
- Swelling followed by bruising
- Inability to stand on tip toe or push off whilst walking
How do you test for ruptured Achilles’ tendon
Thompson’s test/Simmond’s test (calf squeeze, foot should plantar flex)
Why is surgical reconstruction of a tendon difficult
Two ends are frayed like a mop head
Hallux valgus definition
Distal part of big toe deviated laterally
What can hallux valgus lead to
Painful movement of 1st MTPJ and difficulty with footwear
Hallux valgus can occur secondary to
Trauma, arthritis/metabolic conditions such as gout, rheumatoid arthritis and psoriatic arthritis and to connective tissue disorders causing ligament outs laxity such as Ehlers-Danilo’s syndrome
What exacerbates hallux valgus
Line of pull on extrinsic tendons
what is hallux rigidus
OA of 1st MTPJ- results in stiffness (joint usually under tremendous stress when walking)
Symptoms of Hallux rigidus
Pain in MTPJ on walking and dorsiflexion of toe. In severe cases, pain present at rest, walk on outside of foot. Range of dorsiflexion can become severely restricted. Dorsal bunion may develop
Arthroplasty meaning
Joint replacement
Arthrodesis meaning
Joint fusion
Excision arthoplasty meaning
Surgical removal of the joint with interposition of soft tissue
Osteotomy menaing
Surgical cutting do bone to allow realignment
Treatment of hallux rigidus
Activity modification, analgesia, orthotics, aids, intra-articular steroid injections.
Arthrodesis if severe or arthroplasty
Nearly all cases of OA of the ankle are
Secondary arthritis (post-traumatic).
Some are from joint stress e.g. ballet dancers, footballers, obesity
OA of ankle treatment
Arthrodesis or maybe arthroplasty
What is claw toe
- hyperextention at the MTPJ and flexion at the PIP joint
Claw toe develops due to
Muscle imbalance causing ligaments and tendons to become unnaturally tight e.g. neurological damage (such as cerebral palsy, stroke, diabetes or alcohol dependence). Can also be from trauma, inflammation and RA.
Hammer toe/Mallet toe meaning and cause
Hammer toe- flexed at PIPJ
Mallet toe- flexed at DIPJ
Ill-fitting pointed shoes, pressure on second toe from an adjacent hallux valgus
Curly toes key points
Congenital, 3rd to 5th digits usually. Tendons of FDL or FDB are too tight. Surgery rarely needed- usually passive extension.
What is Achilles tendinopathy
Degenerative not inflammatory process (degenerative change).
Where can tendinopathy develop
Point of insertion into calcaneum or vascular watershed area within tendon
What causes Achilles tendinopathy
Years of overuse e.g. long distance runners, sprinters.
Obesity, diabetes.
Symptoms and signs of Achilles tendinopathy
- Pain and stiffness along Achilles’ tendon in morning/worsens with activity
- Severe pain 24 hrs after exercising
- Thickening of tendon
- Swelling that is present all the time but worsens during activity
- Palpable bone spur
Treatment for Achilles tendinopathy
Physiotherapy to improve vascularity and promote healing
What is flat foot (pes planovalgus)
Medial arch of foot has collapsed- valgus angulation of hind foot caused
When is flat foot normal
in young as large amount of subcutaneous adipose tissue in sole of foot (medial fat pad) and arches have not yet developed
Flexible fat feet key points
No medial arch whilst standing normally, but one forms on tip toes
Rigid flat foot key points
Always abnormal- develop usually as a result of tarsal coalition (failure of tarsal bones to separate during embryonic development)
Symptomatic- requires treatment
Adult acquired flat foot key points
- Dysfunction of tibialis posterior tendon
- Obesity, hypertension and diabetes
- Pregnancy due to increased laxity
- Need orthotics or physio, rarely surgical reconstruction or Arthrodesis
Foot disease in diabetes includes
Infection, ulceration or destruction of the tissues of the foot
What can lead to foot ulcers, severe infections and other serious complications of diabetic foot
- Loss of sensation due to peripheral neuropathy
- Ischaemia due to peripheral arterial disease and micro vascular disease
- Immunosupression due to poor Glycaemic control
- Continual weight-bearing exacerbates problem
Poorly controlled diabetes can lead to
Charcot arthropathy
What’s Charcot arthropathy
Ankle and foot- combination of neuropathy, abnormal loading, repeated microtrauma and metabolic abnormalities
Lead to inflammation causing muscle spasticity, osteolysis, fractures, dislocation and deformity.
Treatment if Charcot arthropathy
Optimisation of glycaemic control and reduction of load
