Session 7 Flashcards
(94 cards)
1
Q
Foot & ankle
- ? bones in foot
- ? tendons
- ? major arteries & veins cross the ankle
- ? nerves
A
- 28
- 12
- 2
- 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.
2
Q
Name all the bones that make up the foot & ankle
A
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
4
Q
What type of joint is the ankle ?
A
Hinge joint
5
Q
A
6
Q
A
7
Q
A
8
Q
- What is this image showing?
- This is normally common in?
- Presentation:
- Major cause?
- Treatment
A
- “Bunions”- Hallux (toe) Valgus (deformity)
- middle aged females, after menapause ligaments relax & heels
- don’t like look of feet,
pain over the bump,
difficulty with shoes
(Do not perform cosmetic surgery)
- Inappropriate shoes/behaviour is a major cause of problems - heels (not meant to stand on METATARSAL HEAD)
- Change shoes
- operation
- Change shoes
metatarsal osteotomy
(Surgical re-alignment of the big toe bone)
Sesamoids no longer sitting under metatarsal head
9
Q
vaLgus:
A
deviation of the distal limb away from the midline
10
Q
vaRus:
A
deviation of the distal limb towards the midline
11
Q
Which patient would wear the insole on he right and left?
A
Left valus
12
Q
How do you perform a metatarsal osteotomy
A
Cut bone
Two metal screws
moved so no longer points laterally
13
Q
- What is this image showing?
- Presentation:
A
- Hallux rigidus (arthritis of the big toe), osteoarthritis 1st MTPJ
- pain in MTPJ
lump over joint (& stiffness)
14
Q
- What is this image showing?
- X-ray signs of arthritis:
A
- 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
- Loss of joint space
Excess joint)
- Cysts (dark area)
- Subchondral sclerosis (marble) (Bone goes white
Worn away
Becomes rock hard)
15
Q
What is this image showing?
A
Hallux rigidus
No movement of the joint
16
Q
What is this image showing?
A
Ankle arthritis
Loss of joint space
Loss of osteophytes
Can’t really see cysts
Subchondral sclerosis
17
Q
Arthritis treatment LO
What are the two types of treatment
A
Conservative & surgical
18
Q
Why might they have conservative treatment? (3)
A
- Few complications
- Unfit for surgery
- Unable to cope/take time off work
19
Q
Give 5 examples of conservative treatment
A
- Braces
- Shoe modifications (rockers curved bits on bottom of sole)
- Painkillers
- Activity modifications
- Walking stick
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
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
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
23
Q
- How is athroplasty used to treat ankle arthritis?
- What is the advantage over arthrodesis
A
- Cut out joint surfaces & replace the surfaces with metal components
- 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
24
Q
What are the complications
A
Infection/wound breakdown
Use an antiobiotics segment
25
What is the largest tendon in the body
Achilles' tendon
26
1. Where is the vascular watershed in the Achilles tendon
2. Rupture typically in ? old
“weekend warriors” who often complain of?
4. If you get an Achilles tendon rupture can you still plantarflex?
5. Why is the Achilles tendon frequently injured?
1. Vascular “watershed” 6cm from insertion into calcaneus
2. 30-50 year
3. Often complain of being “kicked
on the back of the heel
4. Maybe if plantaris tendon still remains intact
5. Blood supply comes in from above and below the Achilles' tendon & joint
Hypovascular area no good blood supply area prone to injury
27
How do you test for an Achilles' tendon rupture?
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
28
All you should need is a clinical examination but if in doubt what investigations should you do?
29
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?
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)
2. 5-10%
3. 12
4. 2-8%
5. 90-95% function
30
What are these images showing?
Flatfoot valgus (laterally away from midline)
Loss of longitudinal arch
31
1. What is this image showing
2. Signs/symptom? Who usually gets flat feet?
1. flat foot: planovalgus (adult onset)
2. change in shape
location of pain females middle aged pain behind medial malleolus (symptom)
tibialis posterior dysfunction
32
Flatfoot- radiological assessment
What changes would you expect to see in a person with flat feet in a radiological assessment
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
33
What happens in Stage 4 flatfoot?
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
34
Flatfoot
1. Treatment:
2. Operation:
insoles – medial arch support
physiotherapy
80% better
2. reconstruction if flexible foot
arthrodesis if stiff foot
35
flat foot- reconstruction
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
36
What type of arthrodesis surgery is used for stiff joints
Tripple fusion (T-N, C-C and ST joins)
Tala navicular joint remove cartilage stiffen joint staple and get it to fuse
37
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
1. diabetics
2. foot
3. amputations
4. contra-lateral amputation
5. mortality (mobilise an artificial leg, more energy, more strain on the heart)
38
Why has this happened to the diabetics foot?
What will this lead to?
Diabetes causes loss of protective sensation in the foot
They are immunocomprimised
Vascular compromise
Severe infections
Will happen within a few days
39
How do we treat the infection?
Thorough clean up required (debridement)
Need to remove dead tissue as it acts as culture median for bacteria
40
What must diabetics do?
Inspect foot every day
41
What is this image showing?
Charcot arthropathy
42
1. What is Charcot arthropathy
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
Charcot Arthropathy
1. Leads to ?
2. Pathology is challenging -
3. Patients are challenging-
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)
3. obese
“cognitive problems: “candy brain” immunocompromised self neglect
(Diabetes affects brain
Effects capacity to reason /rationalise)
44
Ulcers on lateral malleolus and 5th metatarsals
45
Why has this happened
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
What is this image showing
Post Op- bracable foot
Foot underneath leg & back on the ground & get them walking again
47
What is this image showing
Rocket bottom foot
Bones in foot doing weight bearing
Ulcerative and will get infected
48
1. What is this image showing?
2. What is the problem?
1. Super construct
2. High risk surgery
(Damage to blood supply & losing the toes)
Prevention is better than cure
49
The mortise is supported by?
Supported by lateral, medial & syndesmotic ligaments
50
What are Ottowa rules
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
Not every ankle fracture is simple- respect for the soft tissues is the key
What type of fracture is this image showing
Open fractures soft tissue on bone
52
Ankle fracture assessment - Clinical
What must you consider?
Inversion/eversion Dislocation?
Medical comorbidities Beware neuropathic & osteoporosis
Soft tissue assessment
Open/closed
Skin at risk
Swelling & blisters
53
What is a stable & unstable fracture?
54
Is an ankle fracture unstable? What is talar shift?
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
56
Talus shift
57
Result in increased in medial malleolus space
58
Ankles fracture in a predicatble pattern depending on the ?
force applied and the position of the foot
59
What happens when you get an ankle fracture due to an everted foot
Medial malleolus
Ligaments
Fibula
Back of fibular as well
If foot goes other way
60
When happens to you ankle when you fall on an inverted foot
61
How do you treat stable & unstable ankle fractures
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
What is gait?
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
1. What type of gait do humans have?
2. When do we start walking
1. Bipedal gait
2. 1 yr old
64
5 Attributes
- Stability in Stance
- Foot Clearance in Swing
- Pre-positioning for Initial Contact
- Adequate Step Length
- Energy Conservation
65
Gait Cycle meaning
Describes the period of time from initial contact to next initial contact on the same side
66
Using the diagram label the stance & stable phase
67
Describe the gait cycle for walking (use the words left, right, stance, swing etc)
68
Describe the gait cycle for running
(use the words left, right, stance, swing etc)
69
Describe the stance phase in the gait cycle
- Initial Contact (Heel strike)
- Loading response
- Mid-stance (Foot flat)
- Terminal stance (Heel off )
- Pre-swing (Toe off )
70
Describe the swing phase
- Initial swing
- Mid-swing
- Terminal swing
71
Stride:
Distance from IC Right → IC Right
72
Step
Distance from IC Right → IC Left
73
Cadence
Steps per minute
74
Kinematics describes?
E.g.
motion
75
Kinetics describes?
E.g.
the things that cause motion
- forces
- moments
76
What plane is this? What motions can we actually see?
Saggital
Pelvic tilt, flexion/extension hip, knee, ankle
77
_Coronal_
Adduction/abduction pelvis, hip, knee, ankle
78
_Transverse_
Rotational position body and limbs
Little rotation at the pelvis
79
We can look at each of the joints individually using ?
(Sagittal) kinematics
80
Draw the basic sagittal kinematic graphs for the hip, knee & ankle
81
Explain the ankle kinematics graph
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
Explain the Knee kinematics graph
83
Explain the hip kinematics graph
84
Kinetics
1. Muscles produce force to?
2. Muscles work by (3)
1. Provide stability
Propel body segments
2. Concentric (shortening) – accelerate / power generation
Eccentric (lengthening) – decelerate / power absorption
Isometric (same length) – stability
85
Describe the muscles that are undergoing eccentric work in the ankle kinetics diagram
86
How do we conserve energy during gait?
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
Name 6 pathological gaits
- Antalgic / ‘Limp’
- Spastic
- Hemiplegic
- Diplegic
- Atheototic
- High steppage / Foot drop
- Parkinsonian / Festinant
- Trendelenberg / Waddling (Abductors are important)
- Ataxic / Cerebellar / Broad-based (drunkness)
88
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?
1. Painful leg
2. - 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
Hemiplegic Gait
1. What are the causes of hemiplegic gait?
2. Presentation of hemiplegic gait (4)
1. Hemi-Brain injury:
Stroke
Cerebral Palsy
Trauma
2. Flexed upper limb
Extended lower limb
Short step unaffected leg
Circumduction affected leg
90
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
1. Neuromuscular disorders
Cerebral Palsy (children)
2.
91
High Steppage Gait
1. Cause:
2. Presentation:
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
Parkinsonian
1. Cause:
2. Presentation: (3)
1. Neurological disease, Parkinsons
2. -Shuffling / Short step
- Forward flexed
- No arm swing
- Festinant (Almost falling into short stepping shuffling type of gait)
93
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.
Fibularis longus = peroneus longus
Fibularis brevis = peroneus brevis
Fibularis tertius = peroneus tertius
94
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?
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)
