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Common Foot and Ankle Problems

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6. hammer, mallet, claw toe. 7. fifth metatarsal fractures. 8. is there a ... hammer, mallet, claw toe 3:3. try non-operative first: toe cap, sleeve, pad ... – PowerPoint PPT presentation

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Title: Common Foot and Ankle Problems


1
Common Foot and Ankle Problems
  • Christopher Mann
  • Consultant Orthopaedic and Trauma Surgeon
  • Specialising in Foot Ankle surgery
  • Bradford Teaching Hospitals
  • Capio Yorkshire Clinic, Bingley
  • Nuffield Hospital, Leeds

2
overview
  • 1. basic anatomy, principles
  • 2. hallux rigidus
  • 3. hallux valgus (bunion)
  • 4. plantar fasciitis
  • 5. Mortons neuroma
  • 6. hammer, mallet, claw toe
  • 7. fifth metatarsal fractures
  • 8. is there a fracture? Ottawa rules
  • 9. others

3
basic anatomy, principles17
  • bones tibia? medial malleolus
  • fibula ?lateral malleolus
  • ankle mortise like tenon mortise
  • talus, calcaneus
  • navicular 3 cuneiforms
  • metatarsals and phalanges
  • arches longitudinal, transverse

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basic anatomy, principles 27
  • arches bones, ligaments, tendons
  • tibialis anterior, extensor hallucis longus both
    easy to feel
  • try lifting own big toe and ankle up- feel both
  • pulses dorsalis pedis lateral to EHL
  • absent in 13
  • posterior tibial behind med malleolus

8
basic anatomy, principles 37
  • tibialis posterior posterior tibia ?
  • behind medial malleolus ?
    navicular, all others (apart from1)
  • -failure causes arch
    collapse,flatfoot nerves tibial main nerve
  • superficial peroneal, deep peroneal,
    sural, saphenous
  • Tom Dick A N d Harry, Tom Has A Nasty Dirty Pencil

9
basic anatomy, principles 47
  • ankle joint ? foot up, down
  • subtalar joint complex? hindfoot inversion
    eversion (heel in/out) eg walking on rough,
    uneven, sloping ground
  • subtalar jt complex subtalar jt TN CC jts
  • foot is floppy when feeling, locked when
    levering
  • midfoot some up/down (ankle fusion!), side to
    side

10
basic anatomy, principles 57
  • history
  • look from behind- too many toes sign
  • sole for calluses
  • shoes for uneven wear
  • skin, shape, position
  • antalgic gait less time in stance
  • feel pulses, sensation, swellings
  • move foot ??, heel ?, forefoot, toes ??

11
basic anatomy, principles 67
  • surgery indicated mainly for PAIN failure of
    nonoperative measures
  • safer to operate on the shoe than on the foot
  • occasionally stitch in time saves 9
  • cosmesis alone very dodgy
  • suggest 70 good/satis, 20 equivocal, 10 poor
    results generally (compare with THR!)

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basic anatomy, principles 77
  • calluses, corns, keratoses caused by skin
    squashed between bony prominence on inside
    shoe (or ground) on outside
  • verrucas can mimic, punctate bleeding when
    shaved
  • Rx remove or lessen one or both
  • flexible deformity ? soft tissue procedure
    (except inflammatory arthritides do bony)
  • fixed deformity ? bony procedure

14
hallux rigidus 13
  • osteoarthritis of big toe MTP joint
  • drugs
  • activity modification
  • footwear modification
  • casting
  • orthoses (inserts,splints)
  • local corticosteroid injection
  • (ambulatory aids, weight loss, physiotherapy)

15
hallux rigidus 23
  • stiff, knobbly big toe MTPJ
  • often subtle, lateral osteophyte
  • painful, stiff dorsiflexion eg walking
  • often tender dorsally
  • Rx stiff soled shoe or rocker bottom or stiff
    insole with soft, roomy upper
  • occasionally helped with MUA, injection
  • cheilectomy stalactite-ectomy!
  • classic generous dorsal resection

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hallux rigidus 33
  • cheilectomy doesnt burn bridges but not very
    reliable
  • pts can fully weightbear straight away
  • most reliable fusion
  • non-weightbearing on forefoot for 10-12 weeks
  • clinical and radiological union
  • angle of set vital
  • rarely Kellers, ??replacement

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hallux valgus 14
  • bunio turnip
  • strict nomenclature unnecessary
  • full house
  • bunion (enlarged median eminence, bursa)
  • hallux rigidus
  • 2nd claw toe
  • intractible plantar keratoses

24
hallux valgus 24
  • female male 4 1
  • nature AND nurture genes AND shoes!
  • familial tendency
  • C/O pain, difficulty in shoe fitting
  • can be rapidly progressive ( a stitch in
    time…)

25
hallux valgus 34
  • over 150 procedures described!
  • first MT deviates medially, hallux laterally
  • soft tissues stretched over medial eminence
    contracted on lateral side
  • most operations include break re-set 1st MT
    and distal soft tissue procedure
  • currently trendy scarf and Aiken osteotomies

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hallux valgus 44
  • refer if pain or rapidly progressive or anxious
  • preferably try wide and deep shoes first
  • refer to specialist capable of individualising
  • eg shortening / elevating 1st MT ? lesser MT head
    overload? transfer lesion
  • expect no forefoot weightbearing 2 months
  • off work 3-4 months
  • prolonged stiffness swelling
    numbness top of toe

29
plantar fasciitis, heel pain 13
  • common, easy to diagnose
  • heel spurs not relevant, Xray in specialist
    clinic
  • classic start-up pain
  • tender over sole heel area
  • philosophy of rest gel heel cups
  • chemical rest steroid injection
  • philosophy of stretch excercises, night
    splints

30
plantar fasciitis, heel pain 23
  • philosophy of fanning the inflammatory fire
  • ultrasound, friction, massage, lithotripsy!
  • all to increase blood flow
  • correct biomechanical predisposing factors
  • I.e.podiatrist, orthotist
  • ultrasound-guided injection
  • surgery is last resort
  • full release can cause flatfoot
  • limited release?

31
plantar fasciitis, heel pain 33
  • achilles tendonitis / tendinosis /paratendinosis
  • insertional achilles tendinosis……
  • similar philosophy
  • refer, usually get ultrasound

32
Mortons neuroma 12
  • not really true neuromacallosity of nerve
  • passes under deep transverse IM ligament
  • typically burning pain in 2 adjacent toe sides
  • takes shoe off to rub foot
  • O/E positive Mulders click
  • ultrasound

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Mortons neuroma 22
  • metatarsal dome or pad to spread heads apart
    (proximal to heads!)
  • ultrasound-guided injection
  • excision- dorsal or plantar. Dorsal better.
  • recurrence true stump neuroma!

35
hammer, mallet, claw toe 13
  • aide-memoir hammer is proximal to mallet in
    alphabet and in toe!
  • claw toe where MTPJ extended
  • severe claw toe MT head uncovered
  • plunger effect of Stainsby makes worse

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hammer, mallet, claw toe 23
  • commonest cause of all 3 unknown
  • diabetes?periph. neuropathy?intrinsic
  • imbalance
  • inflammatory arthritis eg rheumatoid ?
    tendon attrition, rupture
  • C/O pain at tip, or over affected
    interphalangeal joint

39
hammer, mallet, claw toe 33
  • try non-operative first toe cap, sleeve, pad
  • occasional tendon procedure only (flexible)
  • usually fusion but often just one side of joint
  • stiff, but corrected shape
  • wire emerging from pulp
  • full weightbearing unless wire crosses MTPJ
  • wire out at 4-6 weeks

40
fifth metataral fractures
  • common and harmless, heal in 5 weeks
  • immobilisation unnecessary but may be required
    for comfort
  • pull-off by ?peroneus brevis ?lateral band
    plantar fascia
  • intra-articular, yet innocent usually
  • Jones fracture of proximal shaft often non-union,
    often needs fixing

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fracture ? Ottawa rules 13
  • fracture in less than 15 sprains presenting
  • Ottawa ankle rules clinical decision aid to ?
    unnecessary Xrays
  • highly accurate at excluding ankle fractures
    after sprain injury
  • sensitivity almost 100
  • specificity lower, 26
  • ? rays by 30-40

43
fracture ? Ottawa rules 23
  • Accuracy of Ottawa ankle rules to exclude
    fractures of the ankle and mid-foot systematic
    review
  • Bachmann et al BMJ 2003326417-419
  • medicolegally safe!

44
fracture ? Ottawa rules 33
  • ankle Xrays only if
  • pain in malleolar region AND
  • bony tenderness OR inability to bear weight
  • specifically posterior distal 6cm or tip of
    medial malleolus or lateral malleolus, base 5th
    metatarsal or navicular
  • inability to bear weight both immediately and at
    presentation (4 steps)

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47
other topics
  • 1. rheumatopid forefoot
  • 2. ankle hindfoot arthritis
  • 3. midfoot arthritis
  • 4. diabetic foot
  • 5. acquired flatfoot
  • 6. ingrown toenail

48
rheumatoid forefoot
  • customised shoes with insoles
  • cant trust soft tissue integrity longterm so
    bony procedures
  • stop disease-modifying agents pre-op
  • usually hallux MTPJ fusion and lesser MT head
    resection
  • reliable but not brilliant after 5-10 years
  • other options include shortening lesser MTs and
    preserving lesser MTP joints

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ankle hindfoot arthritis 13
  • subtalar joint arthritis often associated with TN
    and CC arthritis
  • expected after calcaneal fracture
  • end stage tibialis posterior incompetence
  • ankle arthritis common after ankle fractures
  • usual nonoperative measures but also including
    calliper
  • fusion is mainstay of surgical management

51
ankle hindfoot arthritis 23
  • perhaps 1 in 100 chance of ultimately needing
    amputation?
  • ankle replacements still much poorer results than
    THR, TKR.
  • 70 survival 7 years
  • failed ankle replacement salvage nightmare
  • can do round of golf on ankle fusion
  • combined (tibio-talo-calc) fusions often nail

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ankle hindfoot arthritis 33
  • fusions usually 3 months in plaster, of which
    first 2 non-weightbearing
  • double this in diabetics risk of Charcot
  • can try arthroscopic debridement and /or
    cheilectomy of ankle prior to fusion

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midfoot arthritis
  • quite uncommon as primary
  • common after Lisfranc midfoot fracture-dislocation
    s
  • usually arch collapses
  • Rx customised orthotics, shoes
  • often injections diagnostically first
  • then fusions

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diabetic foot 12
  • vital role of patient education
  • regular checks
  • risks of Charcot arthropathy and amputation
  • double the protection time for all foot and ankle
    fractures, even in young
  • even if no obvious neuropathy
  • otherwise real risk of destruction

65
diabetic foot 22
  • diabetes commonest cause of Charcot
  • role of walking boot and total contact cast
  • surgery if threatened ulceration

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acquired flatfoot 13
  • in adults usually due to tibialis posterior
    incompetence / insufficiency
  • term covers whole range of pathology from
    synovitis to full rupture
  • pain but no deformity
  • flexible deformity
  • fixed deformity
  • fixed deformity, painful arthritis

69
acquired flatfoot 23
  • too many toes sign
  • more subtle difficulty in single heel rise
  • mainstay is orthotics
  • UCBL insole
  • possibly calliper
  • ?early debridement
  • USS and MRI may mislead (false reassurance)

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acquired flatfoot 33
  • surgery when flexible, nonoperative failure
  • medialising calcaneal osteotomy and tendon
    transfer
  • when rigid, triple arthrodesis
  • refer when arch collapse or change in foot shape
    noticed

73
ingrown toenail 12
  • cut nail square
  • avoid constricting shoes
  • some pts anatomically predisposed
  • 90 growth from germinal matrix
  • 10 from nail bed itself
  • reasonable to avulse nail as first line
  • eg to let infection settle

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ingrown toenail 22
  • definitive chemical (phenol) ablation or sugical
    (Zadeks) ablation
  • phenol slightly lower recurrence, takes longer to
    heal deep chemical burn
  • Zadeks quicker to heal but slightly higher
    (?15) recurrence
  • both require weekly dressings for 4-6 weeks

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