Week 4 - I - Foot and Ankle (1) - Ankle O.A, Hallux valgus & rigidis, Morton's neuroma, Metatarsal stress fracture Flashcards
Ankle OA may be idiopathic / primary OA or as a consequence of previous injury Which sport has players that are particularly prone to ankle OA?
Football players are particularly prone to ankle OA
Which movement of the foot may result in anterior damage to the foot with osteophyte formation? When can this osteophyte formation cause pain?
Repeated dorsiflexion may result in anterior damage with osteophyte formation at the 1st metatarsal head
Anterior osteophytes can cause pain during dorsiflexion resulting in impingement
What may be carried out as treatment for the anterior osteophytes that arise at the 1st metatarsal head?
Pain on dorsiflexion may be improved with removal of the anterior osteophytes (known as cheilectomy).
For patients with significant pain from advanced ankle osteoarthritis, what two surgical options exist as treatment? Which provides more pain relief?
The two surgical options for ankle OA are Arthrodesis - fusion of the ankle joint and Ankle replacement
Ankle arthrodesis and ankle replacements provide equivalent pain relief.
Which surgical options for ankle OA * provides better functional outcome? * has higher rates of early loosening? * should be reserved for the elderly?
Ankle replacements may afford better functional outcome due to some preservation of motion however due to the compressive and shearing forces of the relatively small bones, they have higher rates of early loosening
Ankle replacements should also be reserved for elderly patients as once failure occurs, fusion is usually required
Which ankle surgery option for OA is thought to perhaps be more reliable as the need for further surgery is much less and re‐operation rates are lower?
Ankle arthrodesis is perhaps a more reliable option than ankle replacement as the need for further surgery is much less and re‐operation rates are lower.
What is hallux valgus? Which sex is it more common in?
Hallux valgus is a deformity of the big toe due to medial deviation of the 1st metatarsal head and lateral deviation of the toe itself
The condition is more common in females
Hallux valgus is commoner in rheumatoid arthritis and other inflammatory arthropathies as well as some neuromuscular diseases (multiple sclerosis, cerebral palsy). What has been implicated in the development of hallux valgus? What may happen due to the 1st and 2nd toes rubbing together?
The wearing of tight footwear has been implicated in hallus valgus however no evidence exists that shoes tight shoes or high heels are to blame
The first and second toes may rub causing ulceration and skin breakdown
What is the common term for hallux valgus? What is the conservative treatment of the condition?
Common term is bunions - usually bilateral
Consevative treatment involves
* wearing wider and deeper ‘accomodating’ shoes to prevent painful bunions
* also use of a spacer (wedge in the first web space) to prevent the toes rubbing together
Many patients want surgery to improve the appearance of their foot Why should you be catuois in giving surgery to patients who want it for cosmetic reasons alone?
Should be cautious to giving surgery for cosmetic reasons alone in hallux valgus as these patients often tend to be unhappy with results
If conservative treatment for hallux valgus does not work, what is a surgical treatment option?
Excision/resection arthroplasty - also known as Keller’s procedure
Involves osteotomies to realign the bones and soft tissue procedures to tigten slack tissues
What is hallux rigidus? Why can it occur?
Hallux rigidus is osteoarthritis of the 1st metatarsophalngeal joint
It can occur as a primary (degenrative) condition or secondary to osteochondral injury
Which range of motion can be affected by hallux rigidus? What is the conservative management of the condition?
Hallux rigidus can result in anterior osteophytes at the first MTPJ which can impinge during dorsiflexion of the big toe limiting this motion
Conservative management may involve -
* wearing a stiff soled shoe to limit motion at the MTPJ (insert a metal bar into the sole of a shoe)
* Chieletomy (removal of osteophytes) can also help
What is the gold standard surgical treatment for hallux rigidus? What does this prevent woman wearing?
The “gold standard” surgical treatment is arthrodesis.
Successful fusion should alleviate pain with the small sacrifice of no motion (the toe is usually pretty stiff anyway).
Arthrodesis prevents women wearing high heels.
What is Morton’s neuroma?
Morton’s neuroma is a painful condition that affects one of the plantar nerves between the toes (plantar interdigital nerves)
What do the plantar interdigital nerves arise from? How can they form a neuroma (benign growth of nerve tissue)?
The plantar interdigital nerve arise from the medial and lateral plantar nerves (terminal branches of the tibial nerve)
Repeated trauma to the nerves (ie tight fitting shoes) can cause the nerves to become irritated and swollen resulting in a neuroma
Which sex is more commonly affected and what is an implicated cause?
Women are four times more commonly affected than men and the wearing of high heels has been implicated as a cause
How does morton’s neuroma present? Which interspace is the most commonly affected?
Morton’s neuroma presents as a burning pain and tingling (paraesthesia) radiating into the affected toes
The third intersapce nerve is the most commonly affected (between third and fourth toe) followed by the second intersapce nerve
What may clinical examination of a patient with a ptoential Morton’s neuroma reveal? What test can be carried out on examination - explain it
Clinical examination may reveal loss of sensation in the affected web space
Medio-lateral compression of the metatarsal heads (exerted by squeezing the forefoot with your hand) may reproduce symptoms - pain and paraesthesia or
produce a characterisitc click - this is Mulder’s click test
How is Mortons neuroma diagnosed? What is conservative management? What is carried out if it fails?
Ultrasound may be used for diagnosis demonstrating a swollen nerve
Conservative management involves the use of a metarsal pad or offloading insole - steroid and local anaesthetic injections may relive symptoms and aid diagnosis
Neuroma can be excised if necessary
The metatarsal bones are the long bones in your foot that connect your ankle to your toes. A stress fracture is a break in the bone that happens with repeated injury or stress. Stress fractures are caused by overly stressing the foot when using it in the same way repeatedly * Which metatarsals head do stress fractures most commonly occur in? * Who do metatarsal stress fractures commonly occur in? (hence their common name?)
Metatarsal stress fractures most commonly occur in the 2nd metatarsal followed by the 3rd metatarsal head
Metatarsal stress fractures are commonly known as march fractures - due to the fact they may occur in
- * runners,
- * in soldiers on prolonged marches,
- * in dancers or
- * during distance walking in people not conditioned or used to prolonged walks
Why may xrays not demonstrate a fracture initially in metatarsal fractures? What may be useful for confirming the diagnosis?
Xrays may not demonstrate a fracture for around 3 weeks until resorption at the fracture end occurs or callus begins to appear (soft callus takes around 2-3 weeks to form)
Radionucleotide bone scan may be useful to confirm diagnosis
What is the treatment of a metatarsal stress fracture?
Prolonged rest for 6-12 weeks in a rigid soled boot is required to allow healing and resolution of symptoms
