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Surgery block (Y3) > Trauma and orthopaedics (1): Foot and ankle > Flashcards

Trauma and orthopaedics (1): Foot and ankle Flashcards

1
Q

bones of the foot

A

DO purpose games

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2
Q

three arches of the of

A

medial longitudinal arch

lateral longitudinal arch

transverse arch

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3
Q

joints of the foot and ankle

A

ankle joint

subtalar joint

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4
Q

ankle joint allows for

A
  • mortis joint (talus sits within tibia- very stable)
    • hinge joint
  • plantar flexion and dorsiflexion
  • formed by the articulation of the talus, tibia, and fibula bones.
  • ligaments v important for stability
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5
Q

subtalar joint allows for

A

inversion/eversion

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6
Q

syndesmosis

A

strong ligamentous joint between the tibia and fibula

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7
Q

plantarflexion vs dorsiflexion

A

§

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8
Q

inversion vs eversion

A
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9
Q

Foot can be divided into 3 regions:

A
  • Hindfoot talus and calcaneus
  • Midfoot navicular, cuboid and cuneiforms
  • Forefoot metatarsals and phalanges
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10
Q

stability of the ankle joint created by

A
  1. Bone
  2. Joint capsule
  3. Ligament
  4. Muscle
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11
Q

ankle stability: bone

A
  • Transmits the weight of the body to the foot and has three articulations
    • Superiorly- ankle joint between the talus, tibia and fibula
      • syndesmosis between fibula and tibia
    • Inferiorly- subtalor joint, between the talus and calcaneus
    • Anteriorly- talonavicular joint between the talus and navicular
  • Trochlear of the talus articulates with the tibia and fibula
    • Wider anteriorly
    • Provides stability in a dorsiflexed ankle
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12
Q

stability of the ankle joint: msucle

A

Muscles wrap around the metatarsals and onto the medial aspect like a stirrup

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13
Q

stability of the ankle joint: capsule

A

The joint capsule anteriorly is a broad, thin, fibrous layer, posteriorly the fibres are thin and run mainly transversely blending with the transverse ligament and laterally the capsule is thickened, and attaches to the hollow on the medial surface of the lateral malleolus. The synovial membrane extends superiorly between Tibia & Fibula as far as the Interosseous Tibiofibular Ligament

It forms the seal that contains the synovial fluid within the joint, imparts passive stability by limiting joint movement, and provides active stability via its proprioceptive nerve endings.

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14
Q

what sort of joint is the ankle

A

hinge- movement only in one plane

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15
Q

stability of the ankle: ligaments

A
  • All hinge joints possess collateral ligaments for stability
  • Ligaments act as thickenings of the joint capsule
  • Keep movement in one plane and prevent hyperplantar and hyper dorsiflexion as well as hyperinvesion and hyper extension
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16
Q

neurovascular supply to the foot

A

do a purpose games

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17
Q

hallux valgus

A

‘bunion’

a deformity at the first metatarsophalangeal joint(MTPJ).

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18
Q

cause of hallux valgus deformity

A

It is characterised by medial deviation of the first metatarsal and lateral deviation +/- rotation of the hallux, with associated joint subluxation.

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19
Q

Risk factors for hallux valgus

A
  • female
  • connective tissue disorder
  • hyper-mobility syndromes
  • high-heels or narrow fitting footwear
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20
Q

presentation of hallux valgus

A
  • painful medial prominence
  • aggravated by
    • walking
    • weight bearing
  • lateral deviation of hallux
  • evidence of inflammation
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21
Q

DD for hallux valgus

A
  • Gout
  • Septic arthritis
  • Hallux rigidus
  • Osteoarthritis
  • Rheumatoid arthritis
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22
Q

investigation for hallux valgus

A

x-ray

to look for degree of lateral deviation and joint subluxation

diagnosis:

hallux valgus is diagnosed if the angle to be corrected is greater than 15 degrees (mild 15-20°, moderate 21–39°, and severe >40°)

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23
Q

management of hallux valgus

A

conservative

  • sufficient analgesia
  • adjust footwear
  • orthosis
  • physiotherapy

surgery (for poor quality of life)

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24
Q

complications of hallux valgus

A

Complications of hallux valgus include avascular necrosis, non-union, displacement and reduced ROM.

Prognosis is variable in this condition as the deformity may remain stable or progress rapidly. Conservative management can help to alleviate symptoms but will never correct the deformity.

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25
Q

achilles tenonditis

A

inflammation of the Achilles (calcaneal) tendon

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26
Q

pathophysiology of achilles tendonitis

A

Achilles tendon unites the gastrocnemius, soleus, and plantaris muscles. It inserts in to the calcaneusand produces plantarflexion of the ankle.

Repetitive action of the tendon results in microtears leading to localised inflammation. Over time the tendon becomes thickened, fibrotic, and loses elasticity with repeated episodes.

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27
Q

Achilles tendon rupture occurs when

A

a substantial sudden force is applied across the tendon, often in the context of existing Achilles tendonitis.

The precipitating event could be a movement such as a sudden jump or rapid change in direction whilst running.

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28
Q

RF for achilles tenonditis

A
  • unfit individual who has a sudden increase in exercise frequency.
  • poor footwear choice
  • male gender
  • obesity
  • recent ciprofloxacin use (for tendon rupture).
29
Q

presentation of tenodnitits

A

gradual onset of pain and stiffness in the posterior ankle, often worse with movement. This can usually be improved with mild exercise or heat application.

On examination, there is tenderness over the tendon on palpation (usually worse 2-6cm above its insertion site), with pressure over the tendon with your fingers reproducing this pain.

30
Q

tendon rupture

A

In cases of tendon rupture, patients will often describe sudden-onset severe pain in the posterior calf, accompanied with an audible popping sound and a feeling that something ‘went’.

On examination, there will be a marked loss of power of ankle plantarflexion (the peroneal tendons contribute to plantarflexion so this movement remains, but significantly weakened).

The most commonly used indicators of a clinical tendon rupture are Simmonds test (below) and a palpable ‘step’ in the Achilles tendon.

31
Q

simmons test

A

With the patient kneeling on a chair, with the affected ankle hanging off the edge of the chair, squeeze the affected calf. If the Achilles tendon is in continuity, the foot will plantarflex; however, plantarflexion is absent when the tendon is ruptured

32
Q

investigation for achilles tenodnitis rupture

A

ultrasound scan

33
Q

management of of tendonitis

A
  • stop activity
  • NSAIDS
  • ice
    *
34
Q

management of achilles rupture

A

Initial management (for 2 weeks)

  • analgesia and immobilisation with ankle splinted in plaster in full equinus (i.e. with ankle and toes maximally pointed)
  • crutches

after 2 weeks

  • the ankle is brought in to ‘semi-equinus’, and held for a further 4 weeks.
  • After this, the ankle is brought in to the neutral position and held again for 4 weeks.

delayed presentation (>2 weeks)- surgery

35
Q

Hallux rigidus

A

(arthritis of big toe)

36
Q

hallux rigidus presentation

A

Presentation: pain in MTPJ, lump over joint

37
Q

hallux rigidus X-ray signs:

A

loss of joint space, osteophytes, subchondral cysts, subchondral sclerosis

38
Q

management of hallux rigidus

A

Conservative: orthotics, aids, painkillers, steroid injections, activity modification

Surgical treatment:

Re-align to take weight off = osteotomy Remove = excision arthroplasty
Fuse= arthrodesis
Replace= arthroplasty

Gold standard = 1st MTP joint fusion

  • Create fracture
  • Stabilise
  • Allow normal bone repair
39
Q

ankle arthritis cause

A

post- ankle fracture

Usually secondary: Post traumatic 70-80% Inflammatory 12% Primary OA = 7%

40
Q

management of ankle arthritis

A

1st line: analgesia and modify activity, limit movements

Surgery

  • arthrodesis (fusion) Or
  • ankle replacement
41
Q

mortons neuroma

A
  • Branch between digital nerves become irrigated- swelling (sensory nerve- very painful
  • In the intermetatarsal space (third and fourth)
42
Q

presentation of mortons neuroma

A
  • Pain at front of foot
  • Sensation of lump in shoe
  • Burning, numbness or pins and needles
43
Q

investigations of mortons neuroma

A

Investigation: USS or MRI

44
Q

management of mortons neuroma

A

Adapting activities

Analgesia

Insoles

Weight loss

Steroid injections

Radiofrequency ablation

Surgery eg excision of neuroma

45
Q

Toe deformities

A

Claw toe: in balance due to neurological abnormality

Hammer toe: idiopathic in balance/hallux valgus

Mallet toe: idiopathic

Curly toe: congenital

46
Q

planovalgus

A

flat foot

47
Q

flat foot common in

A
  • Very common children
  • Female
  • Middle age
  • Issue with the posterior tibial tendon
48
Q

Presentation of flat feet

A
  • Progressive deformity
  • History of trauma
  • Pain behind medial malleolus
  • If you look from behind you can see lots of toes
49
Q

management of flat feet

A
  • Conservative
    • Insoles medial arch support
    • Physiotherapy
  • Operation
    • Reconstruction of tendon if flexible foot
    • Arthrodesis if stiff foot
50
Q

ankle fracture

A

An ankle fracture is a fracture of any malleolus (lateral, medial, or posterior), with or without disruption to thesyndesmosis.

51
Q

descriptive terms for ankle fracture

A
  • Words used to describe
    • Syndesmosis- between the tibia and fibular
    • The mortis- how the talus sits under the tibia
    • Stable/unstable- if position acceptable pt can be treated without surgery. Unstable likely to move out of place
    • Posterior/medial/lateral mal- malleolus
    • Tri or bi malleolar- bi- medial and lateral , tri – posterior (has a big chunk of the syndesmosis attached to it), medial and lateral
    • Weber A/B/C- classification of fracture
    • Talar shift- if the talus has moved
52
Q

descriptive terms for ankle fracture

A
  • Words used to describe
    • Syndesmosis- between the tibia and fibular
    • The mortis- how the talus sits under the tibia
    • Stable/unstable- if position acceptable pt can be treated without surgery. Unstable likely to move out of place
    • Posterior/medial/lateral mal- malleolus
    • Tri or bi malleolar- bi- medial and lateral , tri – posterior (has a big chunk of the syndesmosis attached to it), medial and lateral
    • Weber A/B/C- classification of fracture
    • Talar shift- if the talus has moved
53
Q

description of ankle fracture

A

Crudely, they can be described as isolated lateral malleolar fractures, isolated medial malleolar fractures, bimalleolar fractures ( = medial + lateral malleolar fracture), and trimalleolar fractures ( = medial + lateral + posterior malleolar fracture).

54
Q

classification of ankle fracture

A

Weber A B C

55
Q

Weber A

A
  • fracture below the syndesmosis (distal)
  • least serious
  • stable- no surgery required
56
Q

Weber B

A
  • at level of syndesmosis
  • more serious
  • can cause talor shift
57
Q

Weber C

A
  • above the syndesmosis
  • most serious
  • will require surgery
58
Q

the more proximal the fracture the

A

higher the likelihood of ankle instability

therefore Type C fractures will almost always need surgical fixation

59
Q

talar shift

A
60
Q

presenation of ankle fracture

A

Patients will often present with ankle pain following a traumatic injury. There may be associated deformity in cases of fracture dislocation (which require urgent reduction).

Very deformed ankles, which are common, may have neurovascular compromise and are often open fractures (typically over the medial side), so be sure to carefully check the skin integrity.

61
Q

investigation for ankle fracture

A

X-ray

  • AP
  • lateral

looking at

  • joint space (talar shift)
62
Q

management of ankle fracture : initial

A

Initial management requires immediate fracture reduction, usually performed under sedation in the Emergency Department, to realign the fracture to anatomical alignment. Any patients that have with evidence of an open fracture should be managed accordingly.

Once reduced, the ankle should be placed in a below knee back slab. You must then repeat and document the post-reduction neurovascular examination. Request a repeat plain film radiography; if the reduction is not adequate, repeat reduction attempts are required.

63
Q

conservative management for ankle fracture opted for in

A
  • Non-displaced medial malleolus fractures
  • Weber A fractures or Weber B fractures without talar shift
  • Those unfit for surgical intervention
64
Q

surgical manageemnt of ankle fracture

A

ORIF

Open reduction and internal fixation (ORIF) is often required in ankle fractures to achieve stable anatomical reduction of the talus within the ankle mortise.

65
Q

Ankle fractures that require an ORIF include:

A
  • Displaced bimalleolar or trimalleolar fractures
  • Weber C fractures
  • Weber B fractures with talar shift
  • Open fractures
66
Q

remember after performing a procedure e.g. reduction or surgery assess..

A

neurovascular function before and just after

67
Q

complications of ankle fracture

A

post-traumatic arthritis,

DVT or PE

neurovascular injury

68
Q

Foot fractures

A

Lisfranc fracture

  • Either torn ligaments or broken bones in mid foot area

Jones fracture

  • inversion injury ie wearing high heels twists and falls
  • Break your 5th metatarsal (join pinky toe)

Stress fracture

  • small break or crack
  • Typically caused by overuse
  • Can see a callus forming on X-ray

Calcaneal fracture

  • get it from jumping from a height

Surgery block (Y3) (38 decks)

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