Foot & Ankle - Orthobullets

  1. Most common casue of adult acquired flatfoot
    Tib post insufficiency
  2. 6 risk factors for Posterior tibial insufficiency
    • Obesity
    • Hypertension
    • Diabetes
    • Increased age
    • corticosteroids
    • Seronegative inflammatory disorders
  3. Acquired flatfoot deformities in the foot
    • Pes planus
    • Hindfoot valgus
    • Forefoot varus
    • Forefoot abduction
  4. Tib post: origin
    Innervation
    3 limbs insertion
    Blood supply
    HOw to test strenght
    • POsterior fibula/tibia/IOM
    • Tibial nerve L4-5

    • Anterior: inserts onto navicular tuberosity and first cuneiform
    • Middle limb: seond and third cuneiform, cuboid and 2-4 metatarsals
    • POsterior limb: sustentaculum tali

    Posterior tibial artery: watershed area 2-6 cm proximal to navicular insertion

    Isolate by placing foot in plantar flexion and eversion and test resistance
  5. Tib post: major antagonist
    Works during what phase of gait
    Peroneus brevis

    During toe off phase: PTT fires and locks the transverse tarsal joints creating a rigid lever arm

    During stance phase: adducts and supinated forefoot
  6. Posterior tibial tendon dysfunction stages: mention deformity, physical exam , radiographs
    • Stage 1
    • Tenosynovitis
    • Able to do single heel raise
    • Normal x rays

    • Stage 2A
    • Flatfoot deformity
    • flexible hindfoot
    • Normal forefoot
    • unable to do single heel raise
    • Arch collapse on x rays

    • Stage 2B
    • FLatfoot deformity
    • Flexible hindfoot
    • Forefoot abduction >40 degrees
    • Too many toes sign
    • unable to do single heel raise

    • Stage 3
    • Flatfoot deformity
    • Rigid hindfoot valgus
    • RIgid forefoot abduction
    • Arch collapse and subtalar arthritis

    • Stage 4
    • Same as 3 but with deltoid incompetence
    • X ray shows lateral talar tilt
  7. Normal value for: Meary angle
    Calcaneal pitch`
    • -4 to 4: if <-4, indicates pes planus
    • NOrmal btw 17 and 32 degrees
  8. Primary static stabilizer of TN joint
    Spring ligament
  9. Treatment of tib post insufficienc: non op (2)

    Operative
    • AFO with medial arch support: Stage 2-4
    • Cast 3-4 months: for stage 1

    Surgical

    Stage 2: FDL transfer to tib post 1st TMT fusion, calc osteotomy (medial), TAL, lateral column lenghtening, PTT debridement (all if no signs of arthritis, cotton osteotomy

    Stage 3: Hindfoot fusion >>typically triple

    Stage 4: tibiocalcaneal arthrodesis
  10. What tendon transfer can be done for tib post insufficiency and for what stage
    Stage 2 disease (flexible): transfer FDL to PT, identify it at knot of henry
  11. 2 corrective osteotomies than can be used for stage 2 tib post inssuficiency
    Medial calc slide

    Lateral calc neck lenghtening: better for correction of forefoot abduction
  12. INidication for cotton osteotomy
    COtton osteotomy: dorsal opening wedge medial cuneiform osteotomy

    In stage 2 PTTI if residual forefoot varus after correction of hindfoot, use this osteotomy to make a plantigrade foot by recreating the tripod effect
  13. Treatment for stage 3 tib psot dysfunction
    Triple arthodesis
  14. Polio: classic finding
    Onset
    • Motor weakness normal sensation
    • 20-40 yeasr after infection
  15. Morton's neuroma: location
    Structure that compresses
    Physical exam
    Provocative tests
    Confirm diagnosis using
    SUrgical treatment
    • 2nd and third interdigital nerves between the metatarsal heads
    • Transverse intermetatarsal ligament
    • Paresthesia in plantar aspect of webspace

    Mulder's click: bursal click elicited by squeezing metatarsals together

    Common digital nerve block: relief of pain

    Neurectomy: failed non op>>>dorsal neurectomy with burial stump within intrinsics + release of transverse ligament
  16. Foot deformity caused by CVA or TBI
    Equinovarus deformity

    • Equinus: from overactive gastrocs
    • Varus: From overactive tib ant
  17. Acquired equinovarus foot defomity: 2 causes
    If tendon transfer
    • Stroke
    • TBI

    Do split: SPLATT same as CP, put tib ant on cuboid
  18. Freibergs disease: definition
    Most common location
    Location of defect
    Non op mgmt
    Operative mgmt of advanced disease
    • Infarction and fracture of the metatarsal head
    • 2nd MT: 4th and 5th rarely affected
    • Upper half of articular surface
    • Activity modification, NSAI's, shoes with MT bars or pads
    • Partial MT resection arthroplasty and tissue interposition (EDL)
  19. Hammer toe: deformities 3
    • PIP flexion
    • DIP extension
    • MTP neutral or extended
  20. Hammer toe: caused by
    How to check if flexible

    Treatment if flexible
    Treatment if rigid
    • Overpull of EDL and intrinsic inbalance
    • Deformity should correct with ankle dorsiflexion

    • Transfer FDL to EDL
    • PIP resection arthroplasty +/- tenotomy and tendon transfers
  21. Mallet toe: DIP
    PIP
    MTP
    • Flexion
    • NOrmal
    • NOrmal
  22. Claw toe: DIP
    PIP
    MTP
    • Flex
    • flex
    • Hyperextend
  23. Mallet toe: main deformity
    Caused by
    Operative treatment if flexible
    Operative treatmentif rigid
    • Hyperflexion of DIP
    • Flexion contracture of FDL: from shoes, often toe is longer
    • Percutaneous FDL tenotomy or FDL transfer to dorsum
    • DIP fusion
  24. Most common deformity of lesser toes
    Hammer toe
  25. Turf toe: injury to what structure
    Hyperextension of D1 leading to injury of plantar plate and sesamoid complex at the MTP
  26. 1st toe MTP 4 stabilizing structures
    Osseous: MT and proximal phalanx articulation

    Tendons: FHB, Abductor hallucis and adductor hallucis

    Ligaments: MCL, LCL, intermetatarsal ligament

    Plantar plate: joint capsule that attaches to adductor hallucis, flexor tendon sheath, deep transverse intermetatarasal ligament
  27. Turf toe: physical exam manouver
    2 x ray findings
    Non op treatemnt
    Op treatment
    Long term complication
    Vertical lachman; compare to other side

    • Sesamoid fracture
    • Sesamoid migrated proximally

    Stiff soled shoe or walking boot: as well as rest and NSAID's

    Repair or excision of seamoid fracture: can use abductor hallucis transfer to reconstruct

    Hallux rigidus
  28. Claw toes: caused by
    MTP hyperextension: leads to unnoposed flexion of DIP and PIP by FDL
  29. Intrinsic weakness leads to what toe deformity
    Claw toes
  30. Claw toes operative management
    If rigid: EDB tenotomy, EDL lenghtening, FDL flexor to extensor transfer +/- PRoximal phalanx head and neck resection

    If flexible: FDL to extensor surface transfer
  31. TAA: Survivorship
    ROM post
    Pain?
    • at 10 years 70-90%
    • Pre op ROM is best predictor of post op ROM: no significant improvement after TAA
    • Significant improvement in pain and function
  32. Ideal patient for TAA 4 characteristics
    • Older and low demand
    • Normal BMI
    • Well aligned stable hindfoot
    • Good soft tissues
  33. 7 contraindications to TAA
    • Active infection
    • Peripheral vascular disease
    • Inadequate soft tissue coverage
    • Charcot arthropathy
    • Insufficient bone stock
    • Severe osteoporosis
    • Osteonecrosis of the talus
  34. 3 common technical errors in TAA
    • Prosthesis too lateral
    • Prosthesis too small: subsides
    • Not addressing pre op hindfoot valgus or varus
  35. TAA: most common location of intra op fracture
    Medial malleolus
  36. How to prevent bowstringing in TAA
    Avoid opening Tib ant tendon sheath
  37. 3 main vessels supplying blood to the foot
    • Peroneal artery
    • Dorsalis pedis: from anterior tibial
    • POsterior tibial
  38. Peroneal artery: Location
    Terminal branch
    • Anterior to syndesmosis: pierces IOM 5 cm above lateral malleolus
    • Lateral calcaneal branch: brach that supplies flaps in clac ORIF
  39. 3 branches of posterior tibial artery in ankle

    3 branches to foot of posterior tibial artery
    • POsterior medial malleolar
    • COmmunicating branch
    • Artery of tarsal canal: major blood supply to talar body

    • Medial calcaneal branch: supply heel pad
    • Branch to adductor digiti minimi
    • Branch to fifth toe
  40. Os trigonum: location
    Symptomatic in what population
    DDX
    Treatment
    • Posterolateral tubercle of talus
    • Ballet dancers: extreme plantar flexion
    • Sheperds fracture: fracture of posterior process of talus
    • Symptomatic: if non op failed then can excise
  41. Treatment for tibiotalar impingement
    Arthroscopic debridement
  42. 5 casues of hallux varus
    • COngenital
    • Iatrogenic: overcorrection hallux valgus
    • Trauma
    • Inflammatory
    • Neurological
  43. 3 possible components of hallux varus deformity
    • Medial deviation of hallux relative to first MTP
    • Supination phalanx
    • Claw toe deformity
  44. Hallux varus treatment: non op

    Operative
    shoe modifiactions

    • Adductor hallucis reattachment to lateral sesamoid
    • Transfer EHL or EDB under transverse ligament to the metatarsal neck
    • 1st MTP fusion
  45. PLantar fascia: origin
    insertion
    FUnction
    • Medial calcaneal tuberosity
    • Base 5th MT, base of 5 proximal phalanges
    • Increase arch height as toes dorsiflex: major medial arch support
  46. 2 components of chopart joint

    How to lock/unlock it
    • TN
    • CC

    • Lock it with inversion
    • Unlock it with eversion
  47. Ligamentous support of TN joint
    Spring ligament
  48. Ligamentous support of calcaneocuboid joint
    • Superficial and deep inferior CC ligaments
    • Lateral limb of bifurcate ligament
  49. Lisfranc joint 3 columns and components
    • Medial column: 1st MTP
    • Middle column: 2-3 MTP
    • Lateral column: 4-5 MTP, both articulate with cuboid
  50. TMT Joint: Weakest layer
    Strognest layer
    • Dorsal layer
    • Interosseous layer: contains lisfranc ligament from medial cuniform to base 2nd MT
  51. TMT joint: most mobile column
    Column least mobile
    Column that carries most load
    • Lateral
    • Middle
    • Medial
  52. OCD talus 2 main locations / causes and characteritics
    Medial: usually posterior, no trauma, larger and deeper than lateral

    Lateral: central or anterior, associated with trauma, tend to be smaller and more superficial
  53. OCD lesions: whish location has lower incidence of healing
    Lateral: thought to be casued by trauma
  54. OCD talus lesion classification
    Stage 1: small area of subchondral compression

    Stage 2: partial fragment detachment

    Stage 3: complete detachment but undisplaced

    Stage 4: displaced fragment
  55. OCD lesion: non op management

    Operative
    Short leg cast and non weight bearing for 6 weeks: only if acute symptomatic

    Arthroscopic microdrilling, ORIF, osteochondral grafting
  56. High ankle sparin: mechanism of injury
    ER foot: talus pushes fibula away from tibia
  57. Syndesmosis composition 5
    • AITFL: avulsion leads to chaput fragment
    • PITF: Avulsion leads to volkman fragment
    • IOM
    • Interosseous ligamnt
    • Inferior transverse ligament
  58. BEst predictor of return to play following high ankle sprainx
    Abscence of syndesmosis tenderness
  59. 3 physical exam tests for the syndesmosis
    • Squeeze test: compression midcalf leads to pain
    • ER stress test: pain with External rotation and dorsiflexion of foot
    • Fibular translation: anterior and posterior drawar to the fibula casues pain
  60. 4 x ray findings of syndesmosis injury
    • Tibiofibular overlap <  6mm on AP (
    • Tibiofibular overlap <1mm on mortice 
    • Medial clear space < 5mm
    • Increased tibiofibular clear space: >5mm (measured 1 cm abovee joint line
  61. Non op management of high ankle sprain
    No eidence of ankle instability

    NWB CAM for 2-3 weeks: delay weightbearing until pain free
  62. 5 risk factors for tib ant rupture
    • Older age
    • DM
    • fluoroquinilone
    • Local steroids
    • inflammatory arthritis
  63. Ankle dorsiflexors: primary
    secondary
    • Tib ant
    • EHL, EDL
  64. Type of gait with tib and rupture
    Steppage gait: like drop foot
  65. Tib ant rupture surgical treatment: If acute
    If chronic
    • < 6 weeks: direct repair
    • > 6 weeks reconstruction: EHL split or full transfer
  66. most common reason for lower extremity amputations
    Foot ulcers: 85%
  67. DIabetic foot ulcers: 2 factors associated with increased healing potential

    5 factors associated with decreased healing potential
    • Serum albumin > 3 (30 in canada)
    • Total lymphocyte count > 1500

    • Uncontrolled hyperglycemia
    • Inability to offload affected area
    • Poor circulation
    • Infection
    • Poor nutrition
  68. Diabetic foot ulcers: 2 contributing factors to formation of ulcers
    • Neuropathy
    • Angiopaphy: peripheral vascular disease
  69. Brodsky classification of diabetic ulcers and treatment
    0: at risk, no ulcer >>>education

    1: Superficial ulceration, not infected >>>off loading total contact cast

    2: Deep ulceration, exposing tendon or joint >>>surgical debridement and wound care

    3: Extensive ulceration or abcess >>>debridement or amputation


    A: non ischemic

    B: Ischemia with no gangrene >>>refere to vascular

    C: Partial foot gangrene >>>>>>vascular reconstruction or amputation

    D: Complete gangrene >>>>amputation
  70. DIabetic ulcer: gold standard to assess wound healing potential
    Gold standrd for mechanical relief of plantar ulceration
    • Transcutaneous oxygen pressures: >30-40 have good potential
    • Total contact casting
  71. Diabetic ulcers: 4 tests that show decreased healing potential
    • Transcutaneous oxygen pressure < 20
    • ABI <45
    • Albumin <3
    • Total lymphocyte < 1500
  72. Lisfranc injury: mechanism of injury
    lisfranc ligament location
    Which tarsometatarsal ligaments are weakest
    Provocative physical exam manouver
    • Axial load with foot in plantar flexion
    • Medial cuneiform to base 2nd MT 
    • Dorsal: hence dorsal displacement of 2nd MT on lateral
    • Pronation and abduction: this is position of stress test
  73. xplain the concept of 3 columns of the TMT complex and its components
    • Medial column: Medial cuneiform and 1st metatarsal
    • Middle columb: Middle and lateral cuneiform + 2nd and 3rd MT
    • Lateral column: 4th + 5th MT + cuboid
  74. X-ray findings of lisfranc injury (5)
    • On AP: Medial border of 2nd MT with medial border of middle cuneiform
    • On Oblique: Medial border of 4th MT with medial border of cuboid
    • On Lateral: No dorsal subluxation of MT
    • Fleck sign: avulsion # off base 2nd MT
    • Widening >2mm btw 1st MT/Cuneiform and 2nd MT
  75. Best x ray to order if suspecting lisfranc + alternative
    • AP weight bearing of both feet on one cassette
    • Pronation abduction stress xray
  76. Describe fixation principle for Medial and lateral columns in complex TMT injuries
    • Medial: rigid fixation
    • Lateral: Flexible temporary fixation
  77. Describe general principles of fixation for TMT complex injuries (what to fix first)
    • Start from proximal to distal
    • Continue from medial to lateral
  78. Describe surgical approach for 3 column TMT complex injury (include mention of structures in danger)
    2 INCISIONS

    • Dorsal-medial:
    • Btw 1st and 2nd rays
    • Dorsalis pedis and Deep peroneal nerve identified and mobilized lateral
    • Interval BTW EHL and EHB
    • Visualize 1st TMT and medial aspect of 2nd TMT
    • Protect branches of SPN in proximal part of incision


    Dorsal Lateral

    • Centered over 4th MT
    • Visualize lateral 2nd MT + 3rd/4th TMT
    • Common extensor tendons mobilized medially
    • Muscle belly of EDB split in line with its fibers
  79. Lisfranc injuries evidence behind ORIF vs Arthrodesis for ligamentous patterns (4 advantages
    Arthrodesis group had

    • Improved functional outcome
    • Higher return to pre injury levels
    • Lower revision
    • Less pain

    • THIS IS THE QUOTED PAPER THATS SAYS ARTHRODESIS IS BETTER
  80. Hallux rigidus classification and treatment
    Based on physical exam and x rays

    Grade 0: stiffness, normal x ray

    Grade 1: Mild pain at extremes , mild dorsal osteophyte >>> dorsal cheilectomy

    Grade 2: Moderate pain with ROM, moderate dorsal osteophyte < 50% joint space narrowing >>> dorsal cheilectomy

    Grade 3: Pain at extremes ROm but no mid range pain , severe dorsal osteophyte + >50% joint space narrowing >>> MTP fusion

    Grade 4: Pain at midrange, x ray same as grade 3  >>>MTP FUSION
  81. Hallux rigidus: Non op orthosis
    INdication for MTP fusion
    Position of fusion
    Hard soled shoe or orthotic with morton's extension

    >50% joint space narrowing and dorsal osteophytes

    Position

    • 10-15 degrees valgus
    • 15 degrees dorsiflexion relative to the floor
  82. 9 risk factors for hallux valgus
    • Narrow shoes with heel
    • Genetic predisposition
    • Increased DMAA
    • ligamentos laxity : 1st MTP 
    • Convex metatarsal head
    • 2nd toe amputation
    • pes planus
    • RA
    • CP
  83. Hallux valgus: deforming forces 2
    • Adductor hallucis
    • Abductor hallucis: after sesamoids subluxed >> forces plantarflexion and pronation of phalanx
  84. 4 factors that differentiate juvenile from adult hallux valgus
    • Often bilateral and familial
    • Usually not painful
    • DMAA increased
    • Usually flexible flatfoot present
  85. Hallux valgus: other than measurement of angles, 2 other thngs to look for in x ray
    • Presence or absence of arthritis
    • Lateral displacement of sesamoids
  86. Hallux valgus: 4 angles to measure and normal values
    Hallux valgus angle: long axis 1st MT and proximal phalanx  <15 degrees


    Intermetatarsal angle: < 9 degrees

    DMAA: btw longitudinal axis of 1st MT and line through the base of the distal articular cap .....<10 degrees
  87. Hallux valgus surgery: 5 broad categories and indications for each
    Soft tissue (modified mcbride): HVA <25, IMA <15, DMAA not congruent

    Distal osteotomy: IMA < 13, HVA <40

    Proximal or combined osteotomy: IMA >13, HVA >40

    1st TMT fusion (lapidus):  TMT arthritis or joint intability

    MTP fusion: severe deformity or arthritis or spasticity
  88. Modified mcbride 3 parts
    • Release adductor from lateral sesamoid
    • Lateral capsulotomy
    • Medial capsule plication
  89. Hallux valgus in young patient with open physis...surgical procedure to offer
    1st cuneiform osteotomy
  90. Hallux varus complications  5
    • Recurrence: most common
    • AVN: 2 incisions
    • Malunion
    • Hallux varus
    • COck up deformity from injury to FHL
  91. Achilles tendon rupture: location
    Blod supply
    • 4-6 cm above calcaneal insertion in watershed area
    • From posterior tibial artery
  92. Achilles tendon rupture physical exam findings 3
    • Palpable gap
    • Thompson test: no dorsiflexion with gastrocs contraction
    • Increased resting tension lenght
  93. Achille stendon tear operative manangemnt: acute
    Chronic 2
    Direct repair

    • Gastrocs VY advancement
    • FLH Transfer: find it at the knot of henry
  94. base 5th metatarsal #: 3 zones + treatment
    Zone 1: pseudo jones ...enters articular surface..caused by peroneal brevis....non op >>>>Protected weight bearing in boot or hard soled shoe

    Zone 2: Jones #: Meta/dia junction.inter intermetatarasal joint...vascular watershed area > increased risk of non union>>>> Non weight bearing in cast

    Zone 3: Proximal diaphyseal #>>>usually stress fracture >>>Non weight bearing or operative if signs of non union/sclerosis
  95. Jones # orif: size screw

    3 things that lead to increase in rate of failure
    4.5: shown to increase rate of non union if smaller

    • Elite athlete
    • Return to sports prior to radiographic union
    • Fracture distraction or malreduction
  96. MTP dislocation: direction
    Stages of failure
    • Dorsomedial
    • Plantar plate disrupted > LCL fails >medial structure contracted > plantar plate fails
  97. What is the weil procedure and what is done for
    Done for MTP dislocation

    It is a shortening oblique osteotomy along with with soft tissue procedures to stabilize MTP
  98. FHL: Origin
    Action
    path behind ankle
    relationship to FDS
    Insertion
    mechanism of injury
    • Posterior fibula
    • Plantarflexion of hallux and MP joint
    • Btw postermedial/posterolateral tubercle of posterior talus
    • Dorsal to FDS
    • Distal phalanx toe
    • Excessive plantar-flexion
  99. FHL tendinitis: non op
    Operative mgmt
    • Rest/NSAID/arch support
    • Release FHL from fibro-osseus tunnel +/- tendon repair
  100. Tarsal tunnel syndrome: caused by
    5 causes
    Compression of tibial nerve

    • Ganglion cyst
    • osteophyte
    • tumor
    • Systemic inflammatory
    • Tenosynovitis
  101. Posterior tarsal tunnel: borders
    Contents (5)
    • Roof: Flexor retinaculum
    • Medial: calcaneus/talus
    • Inferior: abductor hallucis

    • Tibial nerve
    • Posterior tibial artery
    • FHL
    • FDL
    • Tib Post
  102. Anterior tarsal tunnel: borders
    contents (4)
    • Inferior extensor retinaculum
    • Fascia over talus and navicular

    • Deep peroneal nerve
    • EHL
    • EDL
    • dorsalis pedis artery
  103. Tibial nerve distal branches
    • Medial plantar
    • Lateral plantar
    • Medial calcaneal
  104. Best physical exam manouver to test tarsal tunnel syndrome
    PLantar flexion and inversion of ankle
  105. 3 layers that must be released in tarsal tunnel syndrome
    • Flexor retinaculum
    • Deep investing fascia of lower leg
    • Superficial and deep fascia of abductor hallucis
  106. Most commonly used sesamoid on foot
    Tibial sesamoid (medial(: Its largerm has more weight bearing
  107. Tendon btw foot sesamoids
    FHL
  108. Main complication following excision of both foot seasmoids
    COck up deformity of toe
  109. Plantar fasciitis: caused by
    2 risk factors
    Physical exam finding
    Inflamation at origin of plantar fascia (calcaneous)

    • Obesity
    • Decreased ankle dorsiflexion

    Tenderness to palpation medial calc tuberosity
  110. PLantar fasciitis: non op

    Operative (2)
    NSAID's, cushioned heel pads, dorsiflexion night splint

    • Plantar fascia release: release medial 1/3 to 2/3
    • Distal tarsal tunnel decompression
  111. Haglund defomity: what is it
    Enlargement of posterosuperior tuberosity of calc
  112. Puncture wound in foot: most common cause soft tissue infection
    Most common cause osteomyelitits
    Treatment if acute (within hours)
    • Staph A
    • Pseudomonas
    • Tetanus + prophylactic abx
  113. Bunionnette: classification
    Type 1: enlarged 5th MT head or lateral exostosis

    Type 2: congenital bow 5th MT, normal IMA


    Type 3 (most common): increased IMA

    Normal IMA6.5-8 degrees
  114. Bunionnette treatemnt: type 1
    Type 2-3 IMA <12
    Type 2-3 IMA >12
    Resection lateral third of 5th MT head

    Distal metatarsal osteotomy

    Onlique diaphyseal rotational osteotomy
  115. Navicular #: mechanism if avulsion
    Tuberosity # mechanism
    Body # mechanism
    • Plantar flexion
    • Eversion and contraction of posterior tibial tendon
    • Axial loading
  116. Navicular articulates with what bones (4)
    • Cuneiforms
    • Cuboid
    • Calcaneous
    • Talus
  117. Navicular body # classification
    Type 1: transverse of dorsal fragment that involves <50% bone (no deformity)

    Type 2: Oblique dorsolateral-plantarmedial..may have adduction deformity

    Type 3: Central or lateral comminution...abduction deformity
  118. Navicular # indications for ORIF (3) + goals of treatment
    • Avulsion # >25% articular surface
    • Tuberosity # > 5mm diastasis
    • Body # that are displaced or intra-articular


    Goal of treatment is maintain lateral column lenght
  119. Peroneal tendon subluxation: mechanism
    Physical exam
    tendon that usually tears
    associated injury
    Innervation of tendons
    • Rapid dorsiflexion of inverted foot
    • Apprehension to dorsiflexion and eversion
    • Peroneus brevis
    • ATFL: 75%
    • Superficial peroneal nerve: S1
  120. Peroneal tendons: which one is posterior in sulcus
    Relationship to one another in the foot
    What holds them in the retromalleolar sulcus
    • Longus is posterior: takes the long way
    • Superior peroneal retinaculum

    At the level of the peroneal tubercle of the calc, longus is inferior and brevis is superior...here it is covered by inferior peroneal retinaculum
  121. Classification of superior peroneal retinaculum tears
    Grade 1: SPR partially off fibula>>both tendons sublux

    Grade 2: separated from cartilofibrous ridge of lateral mall>>tendons sublux btw SPR and cartilofibrous ridge

    Grade 3: Cortical avulsion off fibula>>>tendons move under bony fragment

    Grade 4: SPR torn from Calc
  122. Peroneal tendon subluxation: non op mgmt/outcome

    Surgical options if acute
    Surgical options if chronic
    All acute injuries in non-professional athletes>cast x 6 weeks with the tendon reduces>>>outcome 50% success

    • Acute: direct repair and fibular groove deepening
    • Chronic:Fibular groove deepening + reconstruction with plantaris grafting
  123. Peroneal tendon tears: surgery if simple tear
    surgery if complex tear
    • Simple: core repair and tubularization
    • Complex tear: Tendon debridement and tenodesis of proximal and distal ends of tendon to peroneous longus
  124. Ankle scope portals and landmarks 4
    Anteromedial:Medial to tib ant at the level of joint

    Anterolateral: lateral to peroneous tertius and SPN

    Posterolateral: 2cm proximal from tip of lateral mall, btw peroneals and achilles

    Posteromedial: same levelas posterolateral but just medial to achilles tendon
  125. Ankle scope: Primary anterior viewing portal
    Portal that places SPN at risk
    Portal places saphenous vein at risk
    Portal that places sural nerve at risk
    • Anteromedial
    • Anterolateral
    • Anteromedial
    • Posterolateral
  126. Low ankle sprain: refers to injury to what ligaments
    Physical exam finding
    Non op mamagent
    • ATFL and CFL
    • Drawer laxity in plantarflexion (ATFL), drawer laxity in dorsiflexion (CFL)
    • Short immobilization followed by PT (neuromuscular training) with a functional brace
  127. ATFL reconstruction technique
    Gould modification of bronstrom


    Anatomic shortening and reinsertion of CFL and ATFL reinfroced with extensor retinaculum
  128. 2 medial ligaments in the ankle
    • Deltoid
    • Spring ligament
  129. ATFL: origin
    insertion function
    • 10mm proximal to tip of fibula
    • Articular cartilage of talus: 18mm from joint line
    • Resist inversion whith th ankl ein plantar flexion
  130. CFL: origin
    insertion
    function
    • 9mm proximal to tip of fibula
    • calcaneous 13mm distal to ST joint
    • Restraint of inversion with ankle plantarflexed
  131. Deltoid: 2 layers, origin, insertions and function
    • Superficial
    • Origin: anterior colliculus
    • Insertion: neck of talus, sustentaculum tali, posteromedial talar tubercle
    • FUnction: resist calc eversion

    • Deep
    • Origin: inferior and posterior aspect of medial mal
    • Insertion: medial and posteromedial talus
    • Function: Resist ankle Eversion
  132. Location of  stress fracture in foot in ballet dancers
    2nd MT: becasue it is the longest
  133. Indications for ORIF metatarsal # (3)
    • Open #
    • Displaced first metatarsal#: no intermetatarsal ligament support and bears 30-50% of weight
    • Central metatarsals: sagital plane deformity >10 degrees (transfer metatarsalgia) or 4 mm translation
  134. Gait cycle: 2 phases
    Which one is longer
    • Stance (60%): period of time the foot is on the ground
    • Swing: Period of time foot is moving forward
  135. Primary antagonist of tib ant
    Peroneous longus
  136. Leg nerve entrapments mention cause and location: Obturator
    LFCN
    Sciatic
    Saphenous
    Deep peroneal nerve
    Lateral plantar
    Medial plantar
    Obturator: At the level of hypertrophied adductors (skaters) ..can have chronic medial thigh pain

    LFCN: worse with prolonged flexion or tight belts

    Sciatic nerve: Ischial tuberosity or at level of piriformis (piriformis syndrome)

    saphenous: Hunter(adductor cannal) from prolonged kneeling

    Deep peroneal: inferior extensor retinaculum (aka anterior tarsal syndrome)

    Baxter nerve: entrappedbtw abductor hallucis longus and quadratus plantae

    Medial plantar: knot of henry where FDL and FHL cross
  137. Charcot neuropathy: caused by
    Loss of protective sensation
  138. Charcot foot: types and stages
    Type 1: Involves TMT and TN >>leads ti fixed rocker bottom

    Type 2: Involves ST, TN, CC (very unstable needs prolonged immobilization)

    Type 3A: Involves TT joint >>leads to valgus/varus

    Type 3B: After calc#>>proximal migration of tuberosity

    Type 4: Combination of areas

    Type 5: Isolated forefoot

    Stage 0: Joint edema, noral x rays

    Stage 1 (fragmentation): Osseous fragmentation and joint dislocation

    Stage 2 (coalescence): decreased local edema >>x rays show colaescence of fragments and absorption of bone debris

    Stage 3 (reconstuction): No local edema..xray show consolidation and remodelling of fracture fragments
  139. Charcot foot: differentiate from osteo with
    CRP and ESR values
    Non op managemnt
    Surgical treatment
    • Bone scan
    • Elevates
    • Total contact casting followed by CROW boot

    • Resection bony prominence and TAL
    • Deformity correction if cannot brace
    • Amputation
  140. Ankle arthritis: non op orthotic
    indication for supramalleolar osteotomy
    Fusion
    Rocker bottom shoe 

    • Supramalleolar osteotomy: Normal ROM, minimal talar tilt ot varus
    • Medial arthritis

    Arthrodesis: Elderly and less active
  141. What happens to foot after tibiotalar fusion
    50% develop ST arthritis at 10 years
  142. Ankle fusion: optimal position
    Non union rate
    What increases rate non union
    • Neutral dorsi, 5-10 ER< 5 degrees hindfoot valgus
    • 10%
    • Smoking
Author
egusnowski
ID
345823
Card Set
Foot & Ankle - Orthobullets
Description
Foot and ankle orthobullets
Updated