foot and ankle

  1. diabetic foot: what causes it
    neuropathy- loose protective mechanism

    vascular
  2. probe test: percentage of osteo if positive
    67%
  3. factors that allow good healing in diabetic feet:
    • lymphocyte count over 1500/mm3
    • serum albumin over 3.0 g/dl

    ABI:

    index of > 0.45 and toe pressure >40mm Hg are needed to heal ulcer

    transcutaneous oxygen pressures: over 40mHg good for healing
  4. what is best shoe mod for ulcers
    rocker bottom soles
  5. four principles of ulcer care
    • provide moist environment
    • absorb exudate
    • act as a barrier
    • off-load pressure at ulcer

    grade 3 or more need decridementan abx before casting

    test silverskjold- may need tal
  6. PTTI risk factors
    • obesity
    • hypertension
    • diabetes
    • increased age
    • corticosteroid use
    • seronegative inflammatory disorders
  7. POSt tibialis anatomy
    origin: fibula, tibia, IOM

    • insertion:
    • ant limb- navicular tuberosity + 1st cuneifrom
    • middle limb_ 2 + 3rd cuneiform + MT 2-4
    • posterior limb-sustentaculum tali

    • hindfoot inverter, adducts supinate forefoot
    • plantar flex the ankle
  8. name stages of PTTI
    • stage 1- tenosynovitis
    • stage 2a- single heel -ve, arch collapse- flexible deformity/hindfoot

    stage 2b- flatfoot, flexible hind, forefoot abduction, ? 40% talonavicular uncoverage

    stage 3- rigid hindfoot valgus, forefoot abduction ( sinus tasi pain), subtalar arthritis

    stage 4-deltoid compromise, ankle pain, talar tilt
  9. Xray findings flat foot
    • AP foot
    • increased simmon angle- talo- first MT angle
    • talonavic uncoverage

    • lateral wb-
    • meary angle- over 4 is pes planus
    • calcaneal pitch- 17-32 degrees
    • decreased medial cuneiform floor height
    • subtalar arthritis

    ankle mortise- talar tilt
  10. FDL transfer- contraindications
    • synergistic with PT- 
    • rigidity of subtalar less than 15%, fixe forefoot varus over 12
  11. risk factors for hallux valgus
    • genetic predisposition
    • increased distal metaphyseal articular angle (DMAA)
    • ligamentous laxity (1st tarso-metatarsal joint instability)
    • convex metatarsal head
    • 2nd toe deformity/amputation
    • pes planus
    • rheumatoid arthritis
    • cerebral palsy
  12. juvenile vs adult hallux valgus
    • often bilateral and familial
    • pain usually not primary complaint
    • varus of first MT with widened IMA usually present
    • DMAA usually increased
    • often associated with flexible flatfoot
  13. hallux valgus xray findings
    HVA- long axis 1st mt and prx valgus - wnl if less than 15

    IMA- long axis 1st and 2nd MT- WNL less than 9

    DMAA- long axis of toe-- then perp to that and / line articular cap  wnl less than 10

    HVI- long axi of proximal phalynz and distal phalynx wnl less than 10
  14. IMA /HVA cut off for distal and proximal procedures

    surgery indications Hallux valgus:
    13 degrees and 40 degrees

    • IMA over 10
    • HVA over 20

    DMAA over 20 consider double osteotomy
  15. akin osteotomy
    mcbride
    lapidus
    medial closing wedge proximal phalynx

    mcbride- capsule plication medially

    lapidus- 1st mt cuneiform fusion ( do for large IMA or OA)
  16. Hallux valgus algorithm
    Image Upload 1
  17. lisfranc mechanism of injury
    mechanism is usually caused by indirect rotational forces and axial load through hyperplantar flexed forefoot
  18. lisfranc ligaments
    lisfranc ligament-medial cuneiform to base of 2n MT- plantar side- tightens with pronaton and abduction

    plantar tarometatarsal ligaments- medial cuneiform - 2n + 3rd MT

    dorsal tarsometatarsal- weaker

    intermetatarsal btwn 2nd-5th
  19. 5 diagnostic criteria for lisfranc injury
    disruption of the continuity of a line drawn from the medial base of the second metatarsal to the medial side of the middle cuneiform

    widening of the interval between the first and second ray

    medial side of the base of the fourth metatarsal does not line up with medial side of cuboid on oblique view

    metatarsal base dorsal subluxation on lateral view

    disruption of the medial column line (line tangential to the medial aspect of the navicular and the medial cuneiform)

    fleck sign
  20. low ankle sprain
    • most common
    • ATFL- caused by plantar flexion and inversion
    • P/E- drawer laxity in plantar flexion

    • 2nd most common
    • CFL-dorsiflexion and inversion
  21. DDX for ankle pain that may have been missed
    • injury to the anterior process of calcaneus
    • injury to the lateral or posterior process of the talus
    • injury to the base of the 5th metatarsal
    • osteochondral lesion
    • injuries to the peroneal tendons
    • injury to the syndesmosis
    • tarsal coalition
    • impingement syndromes
  22. coughlin and shurnass classification
    • grade1- mild pain extrmes, dorsal soteophyte
    • 2- mod pain, <50%  joint space narrowing
    • 3-severe dorsal osteophyte >50%, STIFFNESS
    • 4- pain at mid range
  23. 1st mtp fusion ideal position
    • 10-15 of valgus  in relation to metatarsal shaft
    • 15 degree dorsiflexion
  24. peroneal tendon subluxation mechanism
    dorsiflexion and inversion- quick firing PL PB
  25. pathophysiology peroneal subluxation
    longitudonal tears - peroneous brevis in fibular groove

    see atfl/ cfl injuries in up to 75% of people
  26. peroneal b and l anatomy
    BP- s1 nerve root superficial peroneal, evert the foot

    PL -plantar flor

    superior peroneal retinaculum is the roof of the peroneal tendons
  27. charcot neuropathy foot

    incidence
    and risk factors
    • .1-1.4% of patients with diabetes
    • 7.5 % with neuropathy

    • diabetic neuropathy
    • alcoholism
    • leprosy
    • myelomeningocele
    • tabes dorsalis/syphilis
    • syringomyelia
  28. molecular biology of charcot- whats upregulated?
    Il-1/ TNF-alpha

    increased TFkB and RANK/RANKL/OPG
  29. brodsky classification
    Image Upload 2
  30. eichenholtz classification
    • 0- joint edema/ radiographs negative
    • 1- fragmentation
    • 2-coalesence
    • 3- reconstruction
  31. physical exam charcot
    • 3.3  higher temp
    • erythema that decreases with elevation
    • rocker bottom
    • collapse medial arch
  32. indium WBC scan
    cold for neuropathic joints and positive for osteomyelitis
  33. treatment Charcot foot
    full contact casting 2-4 months change every 2-4 weeks.

    then at stage III double rocker bottom shoe

    meds:

    • bisphosphonates
    • neuropathic pain medications
    • antidepressants
    • topical anesthetic
  34. optimal position for ankle fusion

    indications for TTC name 5
    • neutral dorsiflexion
    • 5-10° of external rotation
    • 5° of hindfoot valgus

    indications:

    • End-stage ankle and subtalar arthritis
    • Charcot neuroarthropathy
    • Significant hindfoot bone loss (failed total ankle arthroplasty, failed arthrodesis)
    • Osteonecrosis of the talus
    • Severe acute trauma
  35. normal range of motion of tibtiotalar
    • 20 degrees dorsiflexion
    • ankle plantat flexion 50
  36. takakura
    Image Upload 3
  37. contraindications for TAA- name 7
    • uncorrectable deformity,
    • severe osteoporosis
    • , talus osteonecrosis,
    • charcot joint,
    • ankle instability,
    • obesity,
    • and young laborers increase the risk of failure and revision
  38. hypovascular zone of achilles
    • 4-6 cm above calcaneoul insertion
    • post tib artery is the blood supply
  39. plantar fascitis treatment algorhitmn
    • 1- stretching/ heel pads/ dorefle night splint
    • 2- shockwave treatment
    • 3) surgery after 9 months of non
    • -surgical release and distal tarsal tunnel decompression
  40. base of 5th #

    3 zones
    • zone 1: hindfoot inversion
    • zone 2: forefoot adduction- JONES watershed ( 15-30% non-union)
    • zone 3: repetitive microtrauma- assoc with sensory neuropathy
    • Image Upload 4
  41. non union 5th mt after orif cause
    • smaller diamter screw < 4.5
    • too long which straightes the toe
  42. 1st mt fracture
    central metatarsals operarative indications
    always fix- as carries 30-50% of weight


    • sagittal plane deformity more than 10 degrees
    • >4mm translation
    • multiple fractures
  43. talus ocd
    most common posterior medial talar dome

    lateral- traumatic history, smaller and central ) less likely to spontaneously heal
  44. berndt and hardy
    • 1- small subchondral compression
    • 2-partial fragment detachment
    • 3- complete fragment detachement
    • 4- displaced fragment
  45. high ankle sprain mechanism

    assoc injuries

    pain is anterolateral
    forced external rotation

    • OCD- 15-25%
    • peroneal tendon injury up to 25%
    • weber c/ weber b
  46. ankle syndesmosis made up of:
    • AITFL- chaput to fibula
    • PITFL- volkman to lat malleolus
    • IOM
    • IOL
    • ITL
  47. high ankle sprain provocative tests:
    • hopkins- squeeze midcalf
    • external rotation test- knee an hip flexed and ext rotate foot
    • cotton
    • fibular translation
  48. ankle arthroscopy- name portals and risks
    • Anterolateral portal
    • risks superficial peroneal nerve    
    • most common neurovascular injury
    • specifically, the dorsal intermediate cutaneous branch

    • Anteromedial portal
    • risks saphenous nerve and vein

    • Anterocentral portal
    • risks dorsalis pedis artery

    • Posterolateral portal
    • risks sural nerve and short saphenous vein

    • Posteromedial portal
    • risks posterior tibial artery
  49. bilateral sesamoiditis
    • worry about reiters( urethritis/ conjuctivitis/iritis/ IBD
    • seronegative ra
    • psoriatic disease
  50. role of sesamoid
    • absorb weight
    • reduce friction MT head
    • protect FHL tendon
    • fulcrum for FHB
  51. girdle stone procedure of the toe what is it
    for claw toe

    FDL transfer
  52. bunnionnete
    • boney prominence +/- bursitis over lateral aspect of 5th metatarsal head
    • increased 4-5 intermetatarsal angle  (normal 6.5-8 degrees)  
    • increased lateral deviation angle (normal 0-7 degrees)  
    • increased width of MT head (normal <13mm)
    • lateral bowing of the 5th metatarsal bone
  53. classify a bunnionete
    • 1- enlarged 5th mt head or lateral exostosis
    • 2- congenital bow of 5th mt
    • 3- increased IMA btw 4-5th ( most common)
  54. bunnionate treatment
    • oblique diahyseal rotational osteotomy
    • - symptomatic 2 and 3 and IMA over 12

    if less do distal chevron
  55. DDX for tib ant rupture
    • Lumbar radiculopathy (L4)
    • can be differentiated from TA rupture by
    • intact tendon palpable
    • no ankle mass
    • may have dermatomal sensory abnormality
    • positive lumbar spine MRI
  56. treatment surgical for tib ant
    • plantaris/ hamstring graft
    • harvest half of tib ant and attach distally
    • EHL tenodises to EHB and use proxima EHL to repair
  57. TAA survival
    10 yearr- 70-90%
  58. Os trigonum physical exam and DDX
    FHL - posteromedial

    os trigonum- posterolateral

    os lies lateral to FHL, tibial nerve, PTT, and posterior tibial artery
  59. foot puncture wound facts
    • 10% get infection
    • 1-2% osteomyelitis

    S. aureou most common/ osteo is pseuodomonas
  60. hammer toe:
    • mtp straight
    • pip flex
    • dip ext

    due to overpull of edl

    • fdl to edl trasnfer
    • edl lengthething
    • fusion etc
  61. acquired equinovarus causes
    CVA

    • 25% regain normal ambulation
    • 75% regain some level of ambulation

    • SPLATT
    • split anterior tibialis tendon transfer ( to cuboid)


    TBI
  62. posterior tibial tunnel
    what defines it

    whats in it
    • an anatomic structure defined by
    • flexor retinaculum (laciniate ligament)
    • calcaneus (medial)
    • talus (medial)
    • abductor hallucis (inferior)
    • contents include
    • tibial nerve
    • posterior tibial artery
    • FHL tendon
    • FDL tendon
    • tibialis posterior tendon
  63. anterior tarsal tunnel
    • flattened space defined by
    • inferior extensor retinaculum
    • fascia overlying the talus and navicular 
    • contents include
    • deep peroneal nerve and branches
    • EHL
    • EDL
    • dorsalis pedis artery
  64. tarsal tunnel Dx EMG
    • positive finding include
    • distal motor latencies of 7.0 msec or more
    • prolonged SENSORY latencies of more than 2.3 msec
    • sensory (SAP) more likely to be abnormal than motor
    • decreased amplitude of motor action potentials of
    • abductor hallucis
    • or abductor digiti minimi
Author
jaykruijt
ID
336794
Card Set
foot and ankle
Description
foot
Updated