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MSK > Session 7 > Flashcards

Session 7 Flashcards

1
Q

Foot & ankle

  1. ? bones in foot
  2. ? tendons
  3. ? major arteries & veins cross the ankle
  4. ? nerves
A
  1. 28
  2. 12
  3. 2
  4. 5

the ankle is comprised of the tibia (shin bone), fibula and talus. These bones make up the tibiofibular joints, the talocrural joint and the subtalar joint. The foot consists of 26 bones: 14 phalangeal (toes) 5 metatarsal and 7 tarsal. Additionally, there are 2 sesamoid bones beneath the first metatarsal. The bones of the foot form the interphalangeal joints, the metatarsophalangeal joints and intermetatarsal joints, the tarsometatarsal joint, the subtalar joint and the midtarsal joint.

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2
Q

Name all the bones that make up the foot & ankle

A
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3
Q

What is the image showing?

What is most of the foot supported by?

arch is made up of?

A

Should have an arch

Most of foot supported my medial column

Arch made up of talus, navicular, cuneiform, first metatarsals

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4
Q

What type of joint is the ankle ?

A

Hinge joint

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5
Q
A
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6
Q
A
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7
Q
A
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8
Q
  1. What is this image showing?
  2. This is normally common in?
  3. Presentation:
  4. Major cause?
  5. Treatment
A
  1. “Bunions”- Hallux (toe) Valgus (deformity)
  2. middle aged females, after menapause ligaments relax & heels
  3. don’t like look of feet,

pain over the bump,

difficulty with shoes

(Do not perform cosmetic surgery)

  1. Inappropriate shoes/behaviour is a major cause of problems - heels (not meant to stand on METATARSAL HEAD)
    • Change shoes
      - operation

metatarsal osteotomy

(Surgical re-alignment of the big toe bone)

Sesamoids no longer sitting under metatarsal head

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9
Q

vaLgus:

A

deviation of the distal limb away from the midline

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10
Q

vaRus:

A

deviation of the distal limb towards the midline

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11
Q

Which patient would wear the insole on he right and left?

A

Left valus

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12
Q

How do you perform a metatarsal osteotomy

A

Cut bone

Two metal screws

moved so no longer points laterally

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13
Q
  1. What is this image showing?
  2. Presentation:
A
  1. Hallux rigidus (arthritis of the big toe), osteoarthritis 1st MTPJ
  2. pain in MTPJ

lump over joint (& stiffness)

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14
Q
  1. What is this image showing?
  2. X-ray signs of arthritis:
A
  1. Hallux rigidus (osteoarthritis of the first MTPJ)
    • Loss of joint space
      - Osteophytes (extra bone) (Body tries to increase SA of joint that doesn’t work

Excess joint)

  • Cysts (dark area)
  • Subchondral sclerosis (marble) (Bone goes white

Worn away

Becomes rock hard)

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15
Q

What is this image showing?

A

Hallux rigidus

No movement of the joint

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16
Q

What is this image showing?

A

Ankle arthritis

Loss of joint space

Loss of osteophytes

Can’t really see cysts

Subchondral sclerosis

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17
Q

Arthritis treatment LO

What are the two types of treatment

A

Conservative & surgical

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18
Q

Why might they have conservative treatment? (3)

A
  • Few complications
  • Unfit for surgery
  • Unable to cope/take time off work
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19
Q

Give 5 examples of conservative treatment

A
  • Braces
  • Shoe modifications (rockers curved bits on bottom of sole)
  • Painkillers
  • Activity modifications
  • Walking stick
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20
Q

Arthritis surgical treatments (5)

A

“Re-align”- osteotomy (cutting the bone)

“Restrict”- arthrodesis/fusion (surgical stiffening of the joint)

“Replace”- arthroplasty (joint replacement)

“Remove”- excision arthroplasty (can’t remove an ankle joint)

“Resurface”- cartilage/bone transplant

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21
Q

How do we perform fusion to fix hallux rigidus

A

gold standard:

fusion

  • create a “fracture” instead of the joint
  • stabilize the “fracture” (with (2) screws)
  • allow normal bone repair to fuse the joint
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22
Q

How is arthrodesis used to treat ankle arthritis?

If you fuse the ankle joint how do you move the foot?

A

Key hole surgery, two holes remove surface of joint

Movements in foot not ankle

But can’t put on a welly due to angle you have to put your foot in

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23
Q
  1. How is athroplasty used to treat ankle arthritis?
  2. What is the advantage over arthrodesis
A
  1. Cut out joint surfaces & replace the surfaces with metal components
  2. Ankle replace can move ankle afterwards

Protects joint above and below

Whereas fusion won’t do will put stress above and below joint can get arthritis in long term

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24
Q

What are the complications

A

Infection/wound breakdown

Use an antiobiotics segment

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25
Q

What is the largest tendon in the body

A

Achilles’ tendon

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26
Q
  1. Where is the vascular watershed in the Achilles tendon
  2. Rupture typically in ? old

“weekend warriors” who often complain of?

  1. If you get an Achilles tendon rupture can you still plantarflex?
  2. Why is the Achilles tendon frequently injured?
A
  1. Vascular “watershed” 6cm from insertion into calcaneus
  2. 30-50 year
  3. Often complain of being “kicked

on the back of the heel

  1. Maybe if plantaris tendon still remains intact
  2. Blood supply comes in from above and below the Achilles’ tendon & joint

Hypovascular area no good blood supply area prone to injury

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27
Q

How do you test for an Achilles’ tendon rupture?

A

Feel a gap when palpate two tendons & gap in between

However if present late might not get classical signs

Can do Thompson test

Squeeze calf foot should plantarflex

Means continuity

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28
Q

All you should need is a clinical examination but if in doubt what investigations should you do?

A
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29
Q
  1. How do we treat Achilles’ tendon rupture?
  2. ? wound complications with surgery
  3. ? month recovery
  4. Re-rupture rate 5. How much function will be restored?
A
  1. Most now treated conservatively (Immobilise with foot platarflex tendons come together again

Initial immobilise then after several weeks start gradually moving as tendons like to move)

  1. 5-10%
  2. 12
  3. 2-8%
  4. 90-95% function
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30
Q

What are these images showing?

A

Flatfoot valgus (laterally away from midline)

Loss of longitudinal arch

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31
Q
  1. What is this image showing
  2. Signs/symptom? Who usually gets flat feet?
A
  1. flat foot: planovalgus (adult onset)
  2. change in shape

location of pain females middle aged pain behind medial malleolus (symptom)

tibialis posterior dysfunction

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32
Q

Flatfoot- radiological assessment

What changes would you expect to see in a person with flat feet in a radiological assessment

A

Talus starts to collapse & points into ground

Medial arch start to drop

Medial & lateral arch start to be at the same level

Uncovering of the head of the talus

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33
Q

What happens in Stage 4 flatfoot?

A

Deltoid ligament insufficiency/ankle involvement

Whole of the ankle joint starts to tip

Talus starts to collapse & points into ground

Medial arch start to drop

Medial & lateral arch start to be at the same level

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34
Q

Flatfoot

  1. Treatment:
  2. Operation:
A

insoles – medial arch support

physiotherapy

80% better

  1. reconstruction if flexible foot

arthrodesis if stiff foot

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35
Q

flat foot- reconstruction

A

Cut the heel bone & realigned it then shifted the heel back underneath the leg

Screwed the calcaneus but have moved it medially

Also reconstructed the ligament under the foot

Medial part of foot of the ground

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36
Q

What type of arthrodesis surgery is used for stiff joints

A

Tripple fusion (T-N, C-C and ST joins)

Tala navicular joint remove cartilage stiffen joint staple and get it to fuse

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37
Q

Diabetes and the foot LO

  1. 15% of ? experience foot problems
  2. 25% of diabetic hospitalisations for the ?
  3. 50% of major ? are in diabetics
  4. 66% probability of ? within 5 years
  5. 50-70% ? within 5 years after major amputation- worse than a lot of cancers
A
  1. diabetics
  2. foot
  3. amputations
  4. contra-lateral amputation
  5. mortality (mobilise an artificial leg, more energy, more strain on the heart)
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38
Q

Why has this happened to the diabetics foot?

What will this lead to?

A

Diabetes causes loss of protective sensation in the foot

They are immunocomprimised

Vascular compromise

Severe infections

Will happen within a few days

39
Q

How do we treat the infection?

A

Thorough clean up required (debridement)

Need to remove dead tissue as it acts as culture median for bacteria

40
Q

What must diabetics do?

A

Inspect foot every day

41
Q

What is this image showing?

A

Charcot arthropathy

42
Q
  1. What is Charcot arthropathy
A
  1. Loss of pain sensation leads to destruction of joints

Lose propriosection lose ability to know joint is there

Thus overstress joint and bash feet to pieces

Neuropathic joints

43
Q

Charcot Arthropathy

  1. Leads to ?
  2. Pathology is challenging -
  3. Patients are challenging-
A
  1. massive deformity & bone loss
  2. loss of bone stock

soft bone due to inflammation

lack of pain as a reminder

(Difficult to fix together)

  1. obese

“cognitive problems: “candy brain” immunocompromised self neglect

(Diabetes affects brain

Effects capacity to reason /rationalise)

44
Q
A

Ulcers on lateral malleolus and 5th metatarsals

45
Q

Why has this happened

A

Fibula on the right tibia on the left

Walking on the fibula

Patient does not have a proper ankle joint

Un-bracable Charcot foot

46
Q

What is this image showing

A

Post Op- bracable foot

Foot underneath leg & back on the ground & get them walking again

47
Q

What is this image showing

A

Rocket bottom foot

Bones in foot doing weight bearing

Ulcerative and will get infected

48
Q
  1. What is this image showing?
  2. What is the problem?
A
  1. Super construct
  2. High risk surgery

(Damage to blood supply & losing the toes)

Prevention is better than cure

49
Q

The mortise is supported by?

A

Supported by lateral, medial & syndesmotic ligaments

50
Q

What are Ottowa rules

A

Any bony tendonous

Bad of medial malleolus

Navicular bone

If they cannot bear weight on ankle something seriously wrong

Tendon over medial & lateral malleolus

Tendon over navicular

51
Q

Not every ankle fracture is simple- respect for the soft tissues is the key

What type of fracture is this image showing

A

Open fractures soft tissue on bone

52
Q

Ankle fracture assessment - Clinical

What must you consider?

A

Inversion/eversion Dislocation?

Medical comorbidities Beware neuropathic & osteoporosis

Soft tissue assessment

Open/closed

Skin at risk

Swelling & blisters

53
Q

What is a stable & unstable fracture?

A
54
Q

Is an ankle fracture unstable? What is talar shift?

A

Talus moves out form the mortis

Clear space which is the ankle joint which should be equal all the au around ankle joint

Talus shifted laterally

55
Q
A
56
Q
A

Talus shift

57
Q
A

Result in increased in medial malleolus space

58
Q

Ankles fracture in a predicatble pattern depending on the ?

A

force applied and the position of the foot

59
Q

What happens when you get an ankle fracture due to an everted foot

A

Medial malleolus

Ligaments

Fibula

Back of fibular as well

If foot goes other way

60
Q

When happens to you ankle when you fall on an inverted foot

A
61
Q

How do you treat stable & unstable ankle fractures

A

Stable ankle fractures

  • Can weight-bear safely
  • Need cast/boot only for comfort
  • Low rate of complications or

arthritis

Unstable ankle fractures

  • Need surgical stabilisation
  • Can be high risk surgery in complicated diabetic/poor blood supply (6% amputation rate)
62
Q

What is gait?

A

mechanism by which the body is

transported using coordinated movements

of the major lower limb joints

energy-efficient interaction of MSK and Neurological systems

63
Q
  1. What type of gait do humans have?
  2. When do we start walking
A
  1. Bipedal gait
  2. 1 yr old
64
Q

5 Attributes

A
  • Stability in Stance
  • Foot Clearance in Swing
  • Pre-positioning for Initial Contact
  • Adequate Step Length
  • Energy Conservation
65
Q

Gait Cycle meaning

A

Describes the period of time from initial contact to next initial contact on the same side

66
Q

Using the diagram label the stance & stable phase

A
67
Q

Describe the gait cycle for walking (use the words left, right, stance, swing etc)

A
68
Q

Describe the gait cycle for running

(use the words left, right, stance, swing etc)

A
69
Q

Describe the stance phase in the gait cycle

A
  • Initial Contact (Heel strike)
  • Loading response
  • Mid-stance (Foot flat)
  • Terminal stance (Heel off )
  • Pre-swing (Toe off )
70
Q

Describe the swing phase

A
  • Initial swing
  • Mid-swing
  • Terminal swing
71
Q

Stride:

A

Distance from IC Right → IC Right

72
Q

Step

A

Distance from IC Right → IC Left

73
Q

Cadence

A

Steps per minute

74
Q

Kinematics describes?

E.g.

A

motion

75
Q

Kinetics describes?

E.g.

A

the things that cause motion

  • forces
  • moments
76
Q

What plane is this? What motions can we actually see?

A

Saggital

Pelvic tilt, flexion/extension hip, knee, ankle

77
Q
A

Coronal

Adduction/abduction pelvis, hip, knee, ankle

78
Q
A

Transverse

Rotational position body and limbs

Little rotation at the pelvis

79
Q

We can look at each of the joints individually using ?

A

(Sagittal) kinematics

80
Q

Draw the basic sagittal kinematic graphs for the hip, knee & ankle

A
81
Q

Explain the ankle kinematics graph

A

Beginning of stance phase ankle has a hint of dorsiflexion (initial contact of the heel)

Loading phase ankle slightly plantarflexes to ease the foot down

Then moving the body weight over the foot (second movement of plantarflexion to dorsiflexion)

Three Rockers in Stance phase

82
Q

Explain the Knee kinematics graph

A
83
Q

Explain the hip kinematics graph

A
84
Q

Kinetics

  1. Muscles produce force to?
  2. Muscles work by (3)
A
  1. Provide stability

Propel body segments

  1. Concentric (shortening) – accelerate / power generation

Eccentric (lengthening) – decelerate / power absorption

Isometric (same length) – stability

85
Q

Describe the muscles that are undergoing eccentric work in the ankle kinetics diagram

A
86
Q

How do we conserve energy during gait?

A
  1. Minimise excursion of centre of gravity (S2 of pelvis)
  2. Control momentum
  3. Transfer energy between body

segments (produce either through muscle contraction or passively by ligaments & tendons) 4. Phasic muscle action (allows muscle to work for a long period of time without fatigue)

87
Q

Name 6 pathological gaits

A
  • Antalgic / ‘Limp’
  • Spastic
  • Hemiplegic
  • Diplegic
  • Atheototic
  • High steppage / Foot drop
  • Parkinsonian / Festinant
  • Trendelenberg / Waddling (Abductors are important)
  • Ataxic / Cerebellar / Broad-based (drunkness)
88
Q

Antalgic Gait

  1. What is the problem?
  2. How does the patients gait change?
  3. How does the patient walk
  4. Where should the walking stick be?
A
  1. Painful leg
    • Short stance phase affected leg (on affected leg)
      - Lack body weight shift to affected leg (leaning over in the opposite direction)
      - Short swing phase unaffected leg( other leg comes quite quickly to take over)
  3. Uneven
  4. Opposite hand

Shift body weight onto the stick rather than the affected leg

89
Q

Hemiplegic Gait

  1. What are the causes of hemiplegic gait?
  2. Presentation of hemiplegic gait (4)
A
  1. Hemi-Brain injury:

Stroke

Cerebral Palsy

Trauma

  1. Flexed upper limb

Extended lower limb

Short step unaffected leg

Circumduction affected leg

90
Q

Diplegic Gait

  1. Seen in people who have ?

 Scissoring

 Tight Muscle groups

 Psoas / Adductors / HS / Calf

 Ankle plantar f lexed

 Forefoot Initial Contact

Struggle to clear foot from the ground

Can’t heel strike

Can’t take weight on the effected side

A
  1. Neuromuscular disorders

Cerebral Palsy (children)

2.

91
Q

High Steppage Gait

  1. Cause:
  2. Presentation:
A
  1. Foot Drop (inability to dorsiflex):
    - Sciatica
    - Common Peroneal n. Palsy
    - Neuromuscular disorders
  2. -Toes hanging down ( generally fall over)
    - Excessive hip flexion affected side
    - Foot slap

Can be a central or peripheral nervous problem

92
Q

Parkinsonian

  1. Cause:
  2. Presentation: (3)
A
  1. Neurological disease, Parkinsons
  2. -Shuffling / Short step
    - Forward flexed
    - No arm swing
    - Festinant (Almost falling into short stepping shuffling type of gait)
93
Q

The following muscles of the lateral compartment of the leg have two names:

Fibularis longus = ?

Fibularis brevis = ?

Fibularis tertius = ?

The common fibular nerve is also referred to as the common peroneal nerve.

A

Fibularis longus = peroneus longus

Fibularis brevis = peroneus brevis

Fibularis tertius = peroneus tertius

94
Q

Structure of the Vertebral column

  1. How many vertebrae are there? What are each of the sections of the vertebrae called & how many vertebrae are in each section
  2. How many Discrete Single Vertebrae are there? What does this allow?
  3. Mobile section of the spine ?
  4. Immobile section of the spine?
  5. How many vertebrae are fused? What do the fused vertebrae form?
A
  1. 33 vertebrae: 7 cervical, 12 thoracic, 5 lumbar, 5 sacral, 4 coccygeal
  2. 24 separable vertebrae • All capable of individual movement
  3. Cervical & Lumbar
  4. Relatively Immobile – Thoracic (due to ribs & angles)
  5. 9 vertebrae fused to give 2 innominate structures

– Sacrum (fusion of 5 vertebrae)

– Coccyx (fusion of 4 vertebrae)

MSK (7 decks)

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