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Phase II: Musculoskeletal > Ankle and foot > Flashcards

Flashcards in Ankle and foot Deck (76):

Outline Weber's classification of ankle fractures

Classification of lateral malleolar fractures
Type A: fracture inferior to syndesmosis
Type B: fracture at level of syndesmosis
Type C: fracture above ankle joint


Describe the features of a Type A weber ankle fracture

Syndesmosis intact
May fracture medial malleolus
Usually stable


How is a Type A weber ankle fracture treated?

Reduction and cast if stable, may need ORIF
If stable: advise early weight bearing


Describe the features of a Type B weber ankle fracture

Syndesmosis intact or partially torn
Possible medial fracture or deltoid ligament damage
Stability variable


How is a Type B weber ankle fracture treated?

Reduction and cast if stable
May need ORIF if unstable
If stable: advise early weight bearing


Describe the features of a Type C weber ankle fracture

Syndosmosis damaged ➔ widened joint
Usually medial fracture or deltoid ligament injury
Unstable ➔ fracture-subluxation


How is a Type C weber ankle fracture treated?

ORIF required due to instability


What is a bunion?

Swelling over the medial side of the first metatarsal head


How do the heels normally appear when standing?

Heels are normally in slight valgus while standing


How do the heels normally appear when on tiptoes?

Heels are normally inverted when on tiptoes


Describe the phases of the walking cycle

1. Heel strike
2. Move into stance
3. Push-off
4. Swing-through


What is the cause of foot-drop?

Weak ankle dorsiflexors


What gait abnormality may be seen with foot-drop?

High-stepping gait


Name the 3 standard views of the ankle for imaging

Anteroposterior (AP)
Mortise: AP view with inversion 15-20 degrees

N.B. always image both ankles for comparison


Define Pes planovalgus

Flat-foot: flattened longitudinal arch, with the medial border in contact (or nearly in contact) with the ground.

Anterior flat-foot, if dropped metatarsal arch also


Define Pes cavus

Foot with excessive high longitudinal arch


Define Hallux valgus

Excessive lateral deviation of the big toe


Define Hammer toe

Flexion deformity of the PIPJ of one of the lesser toes, usually second or third. Hyperextension of DIPJ and MTPJ.


Define Claw-toes

Curled flexion of all the toes. MTP hyperextension with IP joint flexion.

Typically bilateral, and may severely restrict walking.
Seen with intrinsic muscle weakness.


Define Mallet toe

Flexion deformity of DIPJ of one of the lesser toes


Describe the presentation of idiopathic club-foot (congenital talipes equinovarus)

Ankle in equinus
Heel in varus
Forefoot adducted, flexed, and supinated
-adducted at talonavicular joint

Soles face posterior-medially
Heel usually small, deep creases posterior and medial
Skin and soft tissue of calf and medial side of foot are short and under-developed


Describe the epidemiology of club-foot

1-3 per 1000 births
Boys (2:1)
Bilateral 50%
FHx increases risk be 20-30x


What conditions must be examined for alongside club-foot?

Developmental dysplasia of the hip
Spina bifida


Describe the treatment of club-foot

Ponseti method: successive manipulation and casting on a weekly basis, typically for 6 casts.
-Requires strict follow-up regime of splintage in de-rotation boots until 3 years of age

If resistant:
-Open release of joint tethers
-Tendon elongation: achilles tendon
-Tendon transfer: anterior tibialis (medial cuneiform -> lateral cuneiform) to improve dorsiflexion


Differentiate metatarsus adductus and club-foot

Metatarsus adductus: adduction occurs at tarsometatarsal joints

Club-foot: adduction occurs at talonavicular joint


What is the prognosis and treatment of metatarsus adductus?

90% improve spontaneously or can be managed non-operatively using serial corrective casts followed by straight-last shoes.

Resistant: abductor hallucis muscle release


Describe the pathogenesis of rocker-bottom foot

Plantar dislocation of the head of talus from the navicular.
-cannot be passively corrected

Appears as a 'vertical' talus on lateral x-ray.


How can congenital vertical talus be differentiated from flexible forms of flat-foot?

Lateral x-ray whilst plantarflexed: Talus will not line up with the first metatarsal


How is congenital vertical talus treated?

Serial casting
Resistant: open surgery


How can flexible and rigid forms of flat-foot be differentiated in children/adolescents?

Jack toe raise test: dorsiflexion of the great toe whilst foot planted on ground

Flexible flat-foot: medial arch reappears
Rigid flat-foot: no change in medial arch appearance


Name 2 causes of rigid flat-foot

Congenital vertical talus
Tarsal coalition
Inflammatory arthritis
Neuromuscular disorder


Name 2 causes of unilateral flat-foot

Tibialis posterior synovitis or rupture

Risk factors include: obesity, diabetes, corticosteroid, surgical history


Describe the clinical features of Hallux valgus

Appears most commonly in women aged 50-70
Usually bilateral
N.B. familial type appears in late adolescence

Often asymptomatic besides deformity
Medial bunion
Overlapping second toe if marked valgus
Pain due to:
-pressure on large/inflamed bunion
-splaying of forefoot and muscle strain (metatarsalgia)
-associated deformities of lesser toes
-secondary OA of first MTPJ


Describe the radiographic appearance of hallux valgus

Metatarsal adduction: >9 degrees
Hallux angulation: >15 degrees


What are the 3 types of hallux valgus?

Congruent: articular surfaces parallel and joint centred, but tilted towards valgus.

Deviated: articular surfaces not parallel, joint centred, tilted towards valgus.

Subluxated: not parallel or centred, slight subluxation.

Later stages are more likely to be unstable and progress.


How is hallux valgus treated in adolescents/young adults?

Conservative treatment: footwear encouraged
-as operative correction has 20-40% recurrence rate

Mild: soft-tissue rebalance or osteotomy
Moderate/severe: osteotomy +/- soft-tissue adjustment


How is hallux valgus treated in adults?

Excision of bunion
Metatarsal osteotomy
Soft-tissue rebalancing

Arthrodesis if MTPJ is osteoarthritic


Define Hallux rigidus

Rigidity of the first MTP joint


Name 3 causes of Hallux rigidus

Local trauma
Osteochronditis dissecans of first metatarsal head
Elderly: gout, CPPD, OA


Describe the clinical features of hallux rigidus

Pain on walking, esp. on slopes or rough ground
Painful and clumsy push-off stage of gait
Large osteophyte on dorsum of MTPJ

Restricted and painful dorsiflexion of the toe
Limited plantarflexion


Outline the management of hallux rigidus

Conservative: rocker-soled shoes

Young: extension osteotomy of proximal phalanx
Older with mild disease: osteophyte and slight metatarsal removal (cheilectomy) +/- extension osteotomy
Older with advanced disease: arthrodesis


How is claw-toe treated?

Conservative: metatarsal support
Dynamic correction tendon transfer

If fixed deformity:
-acceptance + footwear, or
-IP arthrodesis + tendon transfer

Jones procedure if great toe is clawed: transfer of extensor hallicus longus through the neck of first metatarsal


Describe the clinical features of rheumatoid arthritis in the forefoot

Forefoot: pain and swelling of MTPJ
Tenderness initially localises to MTPJ
Later involves the entire foot on pressing or squeezing
Increasing weakness of intrinsic muscles

Joint destruction -> characteristic deformities
-flattened anterior arch
-hallux valgus
-prominent metatarsal heads in the sole


Describe the x-ray changes seen with rheumatoid arthritis of the forefoot

MTPJ involvement
Periarticular osteopenia and erosions
Initially affects 4th and 5th toes
-in contrast to rheumatoid arthritis of the hand


Outline the specific treatment of rheumatoid arthritis of the forefoot

Synovitis: corticosteroid injections + footwear
Synovectomy of MTPJ may slow disease progression

Advanced: treatment for claw-toes and hallux valgus
Claw-toe: Jone's procedure, IP arthrodesis + tendon transfer
Hallux valgus: arthrodesis (preferred if arthritic)


Describe the clinical features of rheumatoid arthritis of the ankle and hindfoot

Early: Pain and swelling around the ankle
Walking becomes increasing difficult
Later: Deformities, tibialis posterior rupture or degeneration, progressive tarsal erosions causes severe valgus of the foot

Swelling and tenderness usually localised either:
-back of medial malleolus (tenosynovitis of tibialis post.)
-lateral malleolus (tenosynovitis of the peronei muscles)


Outline the specific treatment of rheumatoid arthritis of the ankle and hindfoot

Synovitis: splintage + steroid injections, below-knee orthosis will restore stability

Synovectomy may help
?Arthroplasty of ankle


Name 3 causes of osteoarthritis of the ankle

OA of the ankle is almost always secondary

Malunited fracture
Recurrent instability
Osteochondritis dissecans of the talus
AVN of talus
Haemoarthrosis in haemophilliacs


Describe the clinical features of osteoarthritis of the ankle

Pain and stiffness localised to the ankle: esp. when first standing up from rest
-patient often indicate transient pain in front of the ankle

Swollen ankle with palpable osteophytes and tenderness along the anterior joint line.

Restricted dorsiflexion and plantarflexion -> antalgic gait
-may produce a compensatory abduction in stand phase


List the x-ray changes seen in osteoarthritis of the ankle

Typical features of OA:
Loss of joint space
Subchondral sclerosis
Subchondral cysts


Outline the specific management of osteoarthritis of the ankle

Offloading: walking stick
Weight loss if applicable


Describe the clinical presentation of achilles tendinitis

Pain and swelling around the achilles tendon due to local irritation of the tendon sheath or paratenon.
Function inhibited esp. at push-off.

Suspect tendon rupture if onset is very sudden.


What findings are seen on examination of achilles tendinitis?

Thickened and tender tendon in watershed (narrowest) area 4cm above insertion into the middle of calcaneus.


Describe the treatment of achilles tendinitis

Rest, Ice, Compression, Elevation
NSAIDs: topical or oral

Muscle strengthening and stretching exercises

Consider steroid injection under USS guidance


Which patients suffer from achilles tendon rupture and why?

Most patients are over 40 years old
Rupture likely occurs only if tendon is degenerate
More likely if history of achilles tendinitis


Describe the clinical features of achilles tendon rupture

Occurs typically with forceful plantarflexion
Feels like being struck above heel
Unable to rise on tiptoes

Gap is seen and felt 5cm above insertion of tendon
Weak plantarflexion, no tautening of tendon


What test is used to assess achilles tendon rupture?

Simmonds' test: patient prone, calf squeeze

An intact tendon will cause involuntary plantarflexion, a ruptured tendon will show no movement.


How is achilles tendon rupture treated?

Early: plaster cast or boot with foot in equinus for 8 weeks, further raised heel shoes for 6 weeks
-commence physiotherapy at 4-6 weeks

Tendon repair with subsequent immobilisation as above


Name 3 causes of persistent pain around the ankle

Chronic ligamentous instability
Tenosynovitis of tibialis posterior or peroneal tendons
Rupture of posterior tibialis tendon
Osteochondritis dissecans of dome of talus
AVN of talus


What can be considered for physically active individuals suffering from a rupture of tibialis posterior tendon?

Operative repair
Tendon transfer: tendon of FDL


Name 3 common causes of painful foot

Mechanical pressure: more likely with deformity
Joint inflammation or stiffness
Localised bone lesion
Peripheral ischaemia
Muscular strain: usually secondary


Describe the presentation of plantar fasciitis

Pain under the ball of foot, or slightly anterior
Worse on weightbearing
Marked tenderness along distal edges of heel contact
Associated bony 'spur' on underside of calcaneum: attachment of plantar fascia
Mainly men aged 30-60


What is the treatment for plantar fasciitis?

Anti-inflammatory drugs
Corticosteroid injection
Pad to offload painful area

Can take 18-36 months to recover, but is generally self-limiting


Name 2 causes midfoot pain in children

N.B. midfoot pain in children in unusual

Kohler's disease: flat dense navicular bone
Bony coalition


Name 1 cause of midfoot pain in adults

Ridge of bone develops on adjacent dorsal surfaces of medial cuneiform and first metatarsal


Name 3 causes of localised pain in the forefoot

Sesamoiditis: pain/tenderness underneath first metatarsal
Freiberg's disease
Stress fracture: commonly 2nd and 3rd metatarsal
Morton's metatarsalgia


Name 3 causes of metatarsalgia

Long standing deformities such as:
Pes planus (flat-foot)
Hallux valgus


What is Freiberg's disease?

Traumatic osteonecrosis of second metatarsal head
Pain over MTPJ
Tender palpable bony lump: metatarsal head


Describe the x-ray changes seen with Freiberg's disease

Metatarsal head flattened and wide
Metatarsal neck thickened
Joint space apparently increased


How is Freiberg's disease treated?

Walking plaster to offload pressure on metatarsal head



Discuss the clinical features Morton's metatarsalgia

Patient typically a 50 year old woman
Pain in forefoot with radiation to toes
Tenderness of one intermetatarsal space: usually third
Pressure just proximal to interdigital web may elicit pain and tingling distally
Mulder's click: painful click by squeezing metatarsal heads together


Describe the pathology of Morton's metatarsalgia

Entrapment or compression of a digital nerve, with secondary thickening to created a neuroma


How is Morton's metatarsalgia treated?

Protective padding and wider shoes
Steroid injection
Division of the tight transverse intermetatarsal ligament

Intractable pain -> excision of neuroma


Describe the x-ray features of a metatarsal stress fracture

Fusiform callus around a fine transverse fracture


What is Keratoderma blenorrhagica?

Scaly pustules on palms and soles that are seen with reactive arthritis


Which drug is associated with new-onset achilles tendon disorders?