Knee&Foot Part2 (2).pdf

Knee & Foot Part 2 Dr.Sarkawt S.Kakai Orthopedic surgeon Foot Learning objectives Club foot, Arch problems: pes cavus & congenital vertical talus, Big toe: hallux valgus &hallux rigidus, Deformities of lesser toes. Glossary of foot postures Plantigrade is the normal neutral position of the foot – i....

Knee & Foot Part 2 Dr.Sarkawt S.Kakai Orthopedic surgeon Foot Learning objectives Club foot, Arch problems: pes cavus & congenital vertical talus, Big toe: hallux valgus &hallux rigidus, Deformities of lesser toes. Glossary of foot postures Plantigrade is the normal neutral position of the foot – i.e. when the patient stands the sole is at right angles to the leg. Talipes equinus refers to the shape of a horse’s foot – i.e. the hindfoot is fixed in plantarflexion (pointing downwards). Plantaris looks similar, but the ankle is neutral and only the forefoot is plantarflexed. Equinovarus describes a foot that points both downwards and inwards. Calcaneus is fixed dorsiflexion at the ankle. A dorsiflexion deformity in the midfoot produces a rocker-bottom foot. Pes planovalgus (flat-foot) describes a flattened longitudinal arch. A dropped metatarsal arch is called anterior flat-foot. Pes cavus is a foot with an excessively high arch. Hallux valgus means lateral deviation of the big toe. Congenital talipes equinovarus (idiopathic club-foot) In this deformity the foot is curved downwards and inwards – the ankle in equinus, the heel in varus, and the forefoot adducted, flexed and supinated. The skin and soft tissues of the calf and the medial side of the foot are short and under-developed. If the condition is not corrected early, secondary growth changes The cause is unknown. A chromosomal defect, arrested development in utero, An embryonic event such as a vascular injury. Male: Female ratio is 2:1, bilateral in 50% of cases Muscle contractures contribute to the characteristic deformity that includes (CAVE) Cavus (tight intrinsics, FHL, FDL) Adductus of forefoot (tight tibialis posterior) Varus (tight tendoachilles, tibialis posterior, tibialis anterior) Equinus (tight tendoachilles) Physical exam Imaging Treatment Small foot and calf medial and posterior foot skin creases foot deformities Radiographs: often not taken Ultrasound: clubfoot sometimes diagnosed in utero Non operative: Ponseti method of serial manipulation and casting Operative: posteromedial soft tissue release and tendon lengthening Ring fixator (Illizarovl Frame) application and gradual correction Arthrodesis Pes Cavus In pes cavus the foot is highly arched and the toes are drawn up into a ‘clawed’ position, forcing the metatarsal heads down into the sole. A foot deformity characterized by cavus, hindfoot varus, plantarflexion of the 1st ray, and forefoot adduction Pathophysiology Neurologic 67% due to a neurologic condition unilateral - rule out tethered spinal cord or spinal cord tumor bilateral - most commonly due to Charcot-Marie-Tooth (CMT) disease Cerebral pulsy Idiopathic usually subtle and bilateral Traumatic talus fracture malunion compartment syndrome Physical exam Coleman block test evaluates flexibility of hindfoot deformity Technique: place 1" block under the lateral foot Findings: flexible hindfoot will correct to neutral or valgus when block placed under lateral aspect of foot Imaging Radiograph AP foot: talocalcaneal angle < 20° (nl 20-45°) Lateral footl: ateral talo-first metatarsal angle (Meary's angle) > 4° apex dorsal Electrodiagnostic Studies (EMG/NCS) MRI Treatment Non-operative Accomodative shoe wear Ankle foot orthosis (AFO) Operative Soft tissue reconstruction and tendon transfer ± osteotomy Arthrodesis Congenital vertical talus (congenital convex pes valgus) Is a rare congenital condition caused by neuromuscular or chromosomal abnormalities in neonates that typically presents with a rigid flatfoot deformity The arch is sometimes reversed leading to a ‘rocker-bottom’ appearance. Physical exam Rigid rocker bottom deformity: fixed hindfoot equinovalgus rigid midfoot dorsiflexion forefoot abducted and dorsiflexed Diagnosis is made with forced plantar flexion lateral radiographs that show persistent dorsal dislocation of the talonavicular joint. MRI to rule out neurologic disorder Treatment is usually serial manipulation and casting followed by surgical release and talonavicular reduction and pinning at age 6-12 months. Commonly referred to as a bunion, Is a complex valgus deformity of the first ray that can cause medial big toe pain and difficulty with shoe wear More common in women Hallux Valgus Risk factors Intrinsic Genetic predisposition Rheumatoid arthritis Extrinsic shoes with high heel and narrow toe box Two forms exist adult hallux valgus adolescent & juvenile hallux valgus Symptoms: presents with difficulty with shoe wear due to medial eminence, pain over prominence at MTP joint and Hallux rests in valgus and pronated Radiographic Measurements in Hallux Valgus Hallux valgus (HVA) Long axis of 1st MT and prox. phalanx Normal < 15° Intermetatarsal angle (IMA) Between long axis of 1st and 2nd MT Normal < 9 ° Treatment Adult hallux valgus Nonoperative: shoe modification/ pads/ spacers/orthoses Operative: surgical correction soft tissue procedure in very mild disease in young female distal osteotomy in mild disease (IMA < 13) proximal or combined osteotomy in more moderate disease (IMA > 13) Juvenile and adolescent hallux valgus Nonoperative: shoe modification, pursue nonoperative management until physis closes Operative: surgical correction, best to wait until skeletal maturity to operate Hallux rigidus is a common foot condition characterized by pain and loss of motion of the 1st MTP joint in adults due to degenerative arthritis. females > males (2:1), most commonly noted in the 5th and 6th decade of life Physical examination swelling Symptoms of First ray and 1st of the 1st MTP joint and dorsal prominence over the MTP joint pain 1st MTP joint Treatment Nonoperative Operative NSAIDS, activity modification, intra-articular injections & Morton's extension orthotic Dorsal cheilectomy Keller Procedure (resection arthroplasty) Lesser toes deformities Hammer Toe Is an isolated flexion deformity of the proximal IP joint of one of the lesser toes Usually the second or third. The distal IP joint and the MTP joint are pulled into hyperextension. Shoe pressure may produce a painful corn on the dorsally projecting proximal IP (PIP) ‘knuckle’. Operative correction is indicated for pain or for difficulty with shoes. The toe is shortened and straightened by excising the PIP joint and performing a fusion. Claw Toe Is a lesser toe deformity characterized by MTP hyperextension and resulting PIP and DIP flexion. Cause synovitis is the most common cause trauma Symptoms pain at the level of the unstable MTP joint metatarsalgia Treatment A trial of nonoperative management with shoe modification and taping. Surgical management is indicated for progressive deformity, fixed contractures, and dorsal toe ulcerations. Mallet Toe Is a lesser toe deformity characterized by hyperflexion of the DIP joint. Physical exam Callositieson toe: toe; pain results from impacting the ground with gait Treatment A trial of nonoperative management with shoe modification and toe sleeves. Surgical management is indicated for progressive deformity, fixed contractures, and dorsal toe ulcerations. Claw toe vs. Hammer toe vs. Mallet toe Claw toe Hammer toe Mallet toe DIP Flexion Normal Flexion PIP Flexion Flexion Normal MTP Hyperextension Slight extension Normal Overlapping Toe Is a rare congenital condition caused by contraction of the extensor digitorum longus in children that presents with a digit that overlaps another. Diagnosis is made clinically with adduction and slight external rotation of the affected digit while overlapping another digit. Treatment is usually passive stretching and buddy taping. Surgery management is indicated for patients who fail nonoperative treatment and remains symptomatic. https://docs.google.com/forms/d/e/1FAIpQLScxgUZNgPLBoSbX6J_3kZpR3MFNhaQ3BKqB5Bzb4rTSMMm YiQ/viewform?usp=pp_url References Solmon, L., & Warwick, D. (2014). The Knee. In Apley and Solomon's Concise System of Orthopaedics and trauma (Fourth, pp. 286–306). essay, CRC PRESS. Gokkus, K., Sanjay, G. and McKean, J. (2020) Hammer Toe, Orthobullets. Available at: https://www.orthobullets.com/foot-and-ankle/7014/hammer-toe (Accessed: December 27, 2022). Goldstein Deirdre Ryan, R. et al. (2021) Clubfoot (congenital talipes equinovarus), Orthobullets. Available at: https://www.orthobullets.com/pediatrics/4062/clubfoot-congenital-talipesequinovarus (Accessed: December 27, 2022). Team, O. et al. (2021) Cavovarus foot in pediatrics & adults, Orthobullets. Available at: https://www.orthobullets.com/pediatrics/4063/cavovarus-foot-in-pediatrics-and-adults (Accessed: December 27, 2022). Team, O., Souder, C. and Morales, J. (2022) Congenital vertical talus, Orthobullets. Available at: https://www.orthobullets.com/pediatrics/4066/congenital-vertical-talus (Accessed: December 27, 2022).