2A - Musculoskeletal > Orthopaedic Foot Conditions > Flashcards

Orthopaedic Foot Conditions Flashcards

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1
Q

Describe the general management of foot problems?

A

General management:

  • Non operative management
    • Analgesia
    • Shoe wear modification
    • Activity modification
    • Weight loss
    • Physiotherapy
    • Orthotics including insoles and bracing
  • Operative management
    • Only indication for this is failure of non-operative management
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2
Q

What are the different pathological groupings of disease based on underlying aetiology?

A
  • Vascular
  • Infective
  • Traumatic
  • Autoimmune
  • Metabolic
    • Endocrine/drugs
  • Inflammatory
  • Inherited
    • Congenital
  • Neurological
  • Neoplastic
  • Degenerative
  • Idiopathic
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3
Q

What are the different anatomical groupings of foot problems?

A
  • Forefoot problems
    • Hallux valgus
    • Hallux rigidus
    • Lesser toe deformities
    • Morton’s neuroma
    • Metatarsalgia
    • Rheumatoid forefoot
  • Midfoot problems
    • Ganglia
    • Osteoarthritis
    • Plantar fibromatosis
  • Hindfoot problems
    • Achilles tendonitis
    • Plantar fasciitis
    • Ankle osteoarthritis
    • Tibialis posterior dysfunction
    • Cavovarus foot
  • Other foot problems
    • Diabetic foot
      • Ulceration
      • Charcot foot
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4
Q

What are examples of forefoot problems?

A
  • Hallux valgus
  • Hallux rigidus
  • Lesser toe deformities
  • Morton’s neuroma
  • Metatarsalgia
  • Rheumatoid forefoot
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5
Q

What are examples of midfoot problems?

A
  • Ganglia
  • Osteoarthritis
  • Plantar fibromatosis
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6
Q

What are examples of hindfoot problems?

A
  • Achilles tendonitis
  • Plantar fasciitis
  • Ankle osteoarthritis
  • Tibialis posterior dysfunction
  • Cavovarus foot
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7
Q

What is hallus valgus also called?

A

Bunions

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8
Q

What is this?

A

Hallus valgus

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9
Q

What is the aetiology of hallus valgus?

A
  • Genetic
  • Footwear
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10
Q

Describe the epidemiology of hallus valgus in terms of sex?

A
  • Predominantly woman
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11
Q

Describe the pathophysiology of hallus valgus?

A
  • Lateral angulation of great toe
  • Tendons pull realigned to lateral of centre of rotation of toe worsening deformity
  • Vicious cycle of increasing pull increasing deformity
  • Sesamoid bones sublux, less weight goes through great tow
  • Abnormalities of lesser toes
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12
Q

What is the presentation of hallus valgus?

A
  • Pressure symptoms from shoe wear
  • Pain from crossing over of toes
  • Metatarsalgia
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13
Q

What investigation is done for hallus valgus?

A
  • X-ray
    • Determine severity of underlying bony deformity
    • Exclude associated degenerative change
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14
Q

What is the mangement of hallus valgus?

A
  • Non-operative
    • Shoe wear modification
      • Wide +/- high toe box
      • Orthotics to offload pressure/correct deformity
      • Activity modification
      • Analgesia
  • Operative
    • Indication is failure of non-operative treatment
    • Release lateral soft tissues
    • Osteotomy of 1st metatarsal +/- proximal phalanx
    • Good outcome but recurrence inevitable
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15
Q

What is indication for operative treatment of hallus valgus?

A
  • Indication is failure of non-operative treatment
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16
Q

What is hallux rigidus?

A

Means stiff big toe, basically osteoarthritis of 1st MTP joint

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17
Q

What is the aetiology of hallux rigidus?

A

Aetiology:

  • Not known
  • Possibly genetic
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18
Q

What is the presentation of hallux rigidus?

A
  • Many asymptomatic
  • Pain
    • Often at extreme of dorsiflexion
  • Limitation of range of movement
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19
Q

What investigation is done for hallux rigidus?

A

X-ray

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20
Q

What is the mangement of hallux rigidus?

A
  • Non-operative
    • Activity modification
    • Shoe wear with rigid sole
    • Analgesia
  • Operative
    • Cheilectomy
      • Remove dorsal osteophytes to stop dorsal impingement
    • Arthrodesis
      • 1st MTPJ fusion
        • Gold standard treatment
      • 1st MTPJ hemiarthroplasty
        • Good option to maintain ROM
        • High failure rate
    • Arthroplasty
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21
Q

What is a cheilectomy?

A
  • Remove dorsal osteophytes to stop dorsal impingement
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22
Q

What are the 3 classic terms of lesser toe deformities?

A
  • Claw toes
    • Flexion at proximal and distal interphalangeal joint
  • Hammer toes
    • Flexion of proximal interphalangeal joint and dorsiflexion at MTP joint
  • Mallet toes
    • Flexion at distal interphalangeal joint
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23
Q

What is claw toe?

A
  • Flexion at proximal and distal interphalangeal joint
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24
Q

What is hammer toes?

A
  • Flexion of proximal interphalangeal joint and dorsiflexion at MTP joint
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25
What is mallet toes?
* Flexion at distal interphalangeal joint
26
What is the aetiology of lesser toe deformities?
* Imbalance between flexors/extensors * Shoe wear * Neurological * Rheumatoid arthritis * Idiopathic
27
What is the presentation of lesser toe deformties?
* Deformity * Pain from dorsum and plantar side
28
What is the treatment of lesser toe deformities?
* Non-operative * Activity modification * Shoe wear * Flatter shoes with high toe box * Orthotic insoles * Operative * Flexor to extensor transger * Fusion of interphalangeal joint * Release MTP joint * Shortening osteotomy of metatarsal
29
What is the aetiology of Morton's neuroma?
* Mechanically induced degenerative neuropathy * High heeled shoes
30
Describe the epidemiology of Morton's neuroma in terms of age and sex?
* Females aged 40-60
31
What is the presentation of Morton's neuroma?
* Typically affects 3rd, followed by 2nd webspace/toes * Neuralgic burning pain into toes * Intermittent * Altered sensation in webspace * Metatarsalgia * Symptom, not a diagnosis
32
Which toe is most commonly affected by Morton's neuroma?
* Typically affects 3rd, followed by 2nd webspace/toes
33
How is Morton's neuroma diagnosed?
* Mulder’s click * Best clinical test * USS best, MRI good
34
What is the management of Morton's neuroma?
* Injection for small lesions * Surgery for excision of lesion and section of normal nerve
35
What is the treatment of rheumatoid forefoot?
* Non operative * Shoe wear * Orthotics * Activity * Operative * 1st MTPJ arthrodesis is gold standard * 2-5 toe excision arthroplasty
36
What does dorsal foot ganglia arise from?
Arise from joint or tendon sheath
37
What is the aetiology of dorsal foot ganglia?
* Idiopathic * Underlying arthritis * Underlying tendon pathology
38
What is the presentation of dorsal foot ganglia?
* Pain from pressure shoe wear or underling problem
39
What is the treatment of dorsal foot ganglia?
* Non-operative * Aspiration * Operative * Excision
40
What is the prognosis of dorsal foot ganglia?
* High rate of return, 50%
41
What is the aetiology of midfoot arthritis?
* Post-traumatic arthritis * Osteoarthritis * Rheumatoid arthritis
42
What is the treatment of midfoot arthritis?
* Non-operative * Activity * Shoe wear * Orthotics * Injections * X-ray guided * Operative * Fusion
43
What is plantar fibromatosis also known as?
Also known as Ledderhose disease
44
What is the presentation of plantar fibromatosis?
* Similar to duputrens of hand * Progressive * Usually asymptomatic unless very large or on weight bearing area
45
What is the treatment of plantar fibromatosis?
* Non-operative * Avoid pressure * Shoe wear * Orthotics * Operative * Excision * 80% risk of recurrence
46
What is achilles tendonitis/tendonosis?
Degenerative/overuse condition with little inflammation
47
What conditions are associated with achilles tendonitis/tendonosis?
* Insertional tendinopathy * Within 2cm of insertion * Non-insertional tendinopathy * 2-7cm of insertion * Bursitis * Paratendinopathy
48
What is the difference between insertional and non-insertional tendinopathy?
* Insertional tendinopathy * Within 2cm of insertion * Non-insertional tendinopathy * 2-7cm of insertion
49
Describe the epidemiology of paratendonopathy in terms of age and sex?
* Common in athletic population * Age group 30-40 * M:F 2:1
50
Describe the epidemiology of tendonopathy in terms of age?
* Age \>40
51
What are risk factors for paratendonopathy and tendonopathy?
* Paratendonopathy * Common in athletic population * Age group 30-40 * M:F 2:1 * Tendonopathy * Commonest in non-athletic population * Age \>40 * Obesity * Steroids * Diabetes
52
What is the presentation of achilles tendonitis/tendinosis?
Presentation: * Pain during exercise and following * Recurrent episodes * Difficulty fitting shoes * Rupture
53
What investigations are done for achilles tendonitis/tendonosis?
* USS * MRI * Achilles rupture test * Simmonds calf squeeze test
54
What is the treatment for achilles tendonitis/tenodonosis?
* Non-operative * Activity modification * Weight loss * Shoe wear modification * Slight heel * Physiotherapy * Extra-corporeal shockwave treatment * Immobilisation (in below knee cast) * Operative treatment * Gastrocnemius recession * Release and debridement of tendon
55
What is the correct term for plantar fasciitis?
Fasciitis is incorrect term, fasciosis is better term
56
What is fasciosis?
Fasciosis = chronic degernerative change, fibroblast hypertrophy, absence inflammatory cells, disorganised and dysfunctional blood vessels and collagen, asvascularity
57
What is the aetiology of plantar fasciitis?
* Not known * Seen more in athletes, running, obesity, occupation involving prolonged standing, foot deformities
58
What are risk factors for plantar fasciitis?
* Seen more in athletes, running, obesity, occupation involving prolonged standing, foot deformities
59
What is the presentation of plantar fasciitis?
* Pain * Worse in the morning * Pain on weight bearing after rest * Located at origin of plantar fascia
60
What is the differential diagnosis of plantar fasciitis?
Differential diagnosis: * Nerve entrapment syndrome * Arthritis * Calcaneal pathology
61
Describe the diagnosis of plantar fasciitis?
* Mainly clinical * Occasionally x-rays, USS and MRI
62
What is the treatment of plantar fasciitis?
* Rest * Stretching * Ice * NSAIDs * Orthoses * Physiotherapy * Weight loss * Injections * Corticosteroid * Good in short term but makes condition worse in long term * Night splinting * Newer/3rd line treatments * Extracorporeal shockwave therapy * Topaz plasma coblation * Nitric oxide * Platelet rich plasma * Endoscopic/open surgery
63
What is the aetiology of ankle arthritis?
* Idiopathic * Post-traumatic
64
Describe the epidemiology of ankle arthritis in terms of age?
* Presents in 40s
65
What is the presentation of ankle arthritis?
* Pain * Stiffness
66
Describe the diagnosis of ankle arthritis?
* Clinical * Radiographs * CT scan * Exclude adjacent joint arthritis
67
What is the management of ankle arthritis?
* Non operative * Weight loss, activity modification, analgesia, physiotherapy, steroid injections * Operative * Arthrodesis * Gold standard treatment * Good long term outcome * Joint replacement * Maintain ROM
68
What is posterior tibial tendon dysfunction?
Acquired adult flat foot planovalgus
69
What is the presentation of posterior tibial tendon dysfunction?
* Pain medial or lateral
70
Describe the diagnosis of posterior tibial tendon dysfunction?
* Double and single heel raise * In normal, heels should swing from valgus to varus as heel rises * Cant do this with posterior tibial tendon dysfunction * MRI * Assess tendon
71
What is the treatment of posterior tibial tendon dysfunction?
* Orthosis in early stages * Surgery in later stages * Reconstruction of tendon (tendon transfer) * Triple fusion (subtalar, talonavicular and calcaneocuboid)
72
Describe the aetiology of diabetic foot ulcer?
* Diabetic neuropathy * Patient unaware of trauma to foot * Diabetic autonomic neuropathy * Lack of sweating/normal serum production * Dry cracked skin * Skin more sensitive to minor trauma * Poor vascular supply * Lack of patient education
73
What is the treatment of diabetic foot ulcer?
* Prevention * Modify main treatment detriments to healing * Diabetic control * Smoking * Vascular supply * External pressure * Splints, shoes, weight bearing * Internal pressure * Deformity * Infection * Nutrition * Surgical treatment * Improve vascular supply * Debride ulcers and get deep samples for microbiology * Correct any deformity to offload area * Amputation
74
Describe the aetiology of charcot neuroarthropathy?
* Any cause of neuropathy * Diabetes commonest cause
75
Describe the pathophysiology of charcot neuroarthropathy?
* Neurotraumatic * Lack of proprioception and protective pain sensation * Neurovascular * Abnormal autonomic nervous system results in increased vascular supply and bone resorption * Characterised by rapid bone destruction in 3 stages * Fragmentation * Coalescence * Remodelling
76
Describe the diagnosis of charcot neuroarthropathy?
* High index of suspicion * Consider in any diabetic with acutely swollen erythematous foot especially with neuropathy * Radiographs * MRI scan
77
Describe the management of charcot neuroarthropathy?
* Prevention * Immobilisation/non-weight bearing * Correct deformity * Deformity leads to ulceration leads to infection leads to amputation
2A - Musculoskeletal
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