10_ankle and foot.pdf

Mr Georgios Arealis, MD, PhD, FRCS -Consultant Trauma & Orthopaedic Surgeon Shoulder & Upper Limb Specialist East Kent Hospitals University NHS Foundation Trust - Visiting Professor, Faculty of Medicine, Health and Social Care Canterbury Christchurch University -Honorary Researcher, School Of Engine...

Mr Georgios Arealis, MD, PhD, FRCS -Consultant Trauma & Orthopaedic Surgeon Shoulder & Upper Limb Specialist East Kent Hospitals University NHS Foundation Trust - Visiting Professor, Faculty of Medicine, Health and Social Care Canterbury Christchurch University -Honorary Researcher, School Of Engineering and Digital Arts University Of Kent - Clinical tutor Clinical and Educational Supervisor, Stage 3, Year 5 medical students, King's College London - Clinical tutor, Sutgical group, Kent and Medway Medical School Ankle and foot STRUCTURE INTRODUCTION Look Feel Move Function Special Tests Neurology THANK THE PATIENT COMPLETE EXAMINATION PRESENT EXAMINATION FINDINGS Introduction (WIPE) Wash hands, Intro, ?Patient (DOB, Name), Explain/ consent Expose lower limb above knee and remove shoes Respect privacy, ask for chaperone General inspection, including walking aids around bedside and shoes LOOK Inspection when standing– Front, back, side Scars Previous surgery or trauma Color Red: infection/ inflammation Bruising: recent trauma/ heamarthrosis if on anticoagulation Psoriasis plaques Calluses and ulcers Swelling Effusion ankle/ hallux Achilles Haglund's deformity/ swelling Muscle wasting, measure calf 10cm below tibial tuborocity and compare sides Deformity Toe/ hallux misalignment/ deformity Heel varus or valgus (up to 5 degrees normal) Foot arch: flat (pes planus) or high (pes cavus) scars Bruising from trauma Psoriasis vulgaris scars cellulitis Bruising, ligament injury Calluses and ulcers, diabetic Swelling and redness, infection Achilles tendonitis Swelling and redness, gout Ankle OA, swelling Pitting and non-pitting oedema The biggest difference between pitting and non-pitting edema is the way the two conditions respond to pressure. - Pitting oedema responds to pressure, be it from a finger or a hand, while non- pitting edema does not. If you press on skin with your finger and it leaves an indentation = pitting edema. - Non-pitting oedema, on the other hand, does not respond to pressure or cause any sort of indentation. Pitting oedema Non-pitting oedema Myxoedema Lipoedema Unilateral muscle wasting High arch, non pathologic Unilateral muscle wasting and pes cavus, CMT pes cavus, Charcot-Marie-Tooth disease Hallux valgus and hammertoe Claw toe Rearfoot Angle (RFA) Four locations are palpated and marked using a skin marker pen. These are: (1) the base of the calcaneus (2) the Achilles tendon attachment (3) the centre of the Achilles tendon at the height of the medial malleoli (4) the centre of the posterior aspect of the calf 15 cm above marker three. The RFA is measured using a goniometer. The arms of the goniometer were aligned with the line connecting marker one and two (line 1) and the other arm with the lines connecting marker three and four (line 2). The RFA is measured as the acute angle between the projection of line one and line two. RFA ≥ 5° valgus represents a pronated foot type 4° valgus to 4° varus a neutral foot ≥ 5° varus a supinated foot. FEEL Temperature: assess and compare Increased+(swelling and loss ROM) = arthritis: septic or inflammatory inc. gout Pulses Posterior tibial pulse: posterior to the medial malleolus Dorsalis pedis pulse: over the dorsum of the foot, lateral to the extensor hallucis longus tendon, over the second and third cuneiform bones. Palpate all joints, feel for crepitus, swelling, irregularity and pain Medial and lateral ligament complex: common site of sprains Plantar fascia: tenderness common site of tendinitis Achilles tendon palpation Note any focal tenderness or swelling suggestive of tendonitis. Note any discontinuity in the tendon suggestive of rupture. Gait MOVE Ask the patient to walk away and turn back Active & Passive, Compare sides Ankle plantar flexion (extension): 45° Ankle dorsiflexion (flexion): 20º EvaRsion/ pRonation: 20º INversion/ supINation: 30º (toes IN) Toe and hallux flexion and extension Passive movement only: Subtalar joint: Patient prone, flex knee to 90/ ankle max dosriflexion and hold the ankle firmly with one hand and the heel with the other, place the thumb in the arch and move at the subtalar joint, expect about 20 degrees Midtarsal joint: Patient supine, hold the heel firm with one hand and the end of the 5th MTT with the other: Invert the rear foot, move at the MT is minimal Evert the rear foot x3 ROM GAIT Antalgic Trendelenburg Gait High stepping gait is associated with foot drop, which can be caused by peroneal nerve palsy: trauma, surgery, spinal disease Gait cycle Simmonds Triad of tests for a suspected Achilles tendon rupture Palatable gap Ankle of declination (foot more plantarflexed when supine) Thomson calf squeeze: Patient lies supine with both feet relaxed and out of the examining table Squeezing the calf doesn’t result in ankle movement when the Achilles is torn, compare sides Single Leg Heel Raise Test For tibialis posterior disfunction SPECIAL TESTS Patient is asked to single leg heel raise The test is positive when unable to raise or invert Complete the examination Complete with joint above and below and neurological examination (= similar to spine) and vascular examination Thank the patient Dispose of PPE appropriately and wash your hands Present your findings Imaging and tests Common Pathologies