ankle ortho cases part 1

The ankle &foot
Clinical assessment
Symptoms: pain? localized or diffuse like metatarsalgia.
deformity? in the ankle, foot or toes.
swelling? localized or diffuse(unilat.?surgical or bilat.?medical).
Corns: keratosis on the dorsum &callosities on the sole.
Instability of ankle? causes episodes of giving way.
numbness? either diffuse(DM) or
localized(nerve root or peripheral nerve).
Signs: standing? front &back, tiptoes &heels.
Gait? examine the components of walking cycle: heel-strike, stance, push-off &swing-through, that can be disturbed by pain, stiffness, deformity or muscle weakness like foot-drop or high –stepping gait.
for deformity &ulcers(ischemic or neuropathic). look? Sitting or lying
Feel the skin temperature &pulses, tenderness, swelling &lumps.
Move: examine the movements of ankle, subtalar, midtarsal joints &toes.
Ankle instability: medial &lateral stress tests and anterior
&posterior drawer tests.
Muscle power, shoes &general examination.
Imaging: ankle? AP, lat. &mortise views. subtalar? lat. view.
calcaneum? lat. &axial views. Foot &toes? AP &lat. views.
Stress view for ankle stability.
CT? for fracture &bony coalition.
MRI? for tendons &ligament injury and soft tissue problems.
Congenital deformities: Talipes equinovarus :
(idiopathic club-foot): tali = talus (ankle) & pes = foot.
Incidence: 1/1000. ?: ? ratio 2:1. Bilat. in 1/3 of cases.
Etiology: one or more of the following may have a role:
1-genetic defect; 2-NM disorder; 3-malposition in uterus.
The same(or even more severe) deformity may be seen in
myelomeningocele &arthrogryposis.
Pathology: Calcaneum is small, inverted &in equinus.
Talus neck is deviated medially while the body is
rotated laterally. Navicular &forefoot are shifted medially
&supinated.
The skin &soft tissues of the calf &medial side of the
foot are short &underdeveloped. If the deformity is not
corrected early, secondary permanent bony deformity
may occur. Even with ?, foot may remain short &calf thin.
CF: the deformity is seen at birth(foot is turned &twisted inward)
with equinus ankle, adducted &supinated forefoot, thin calf, small,
high inverted heel with deep crease posteromedially.
O/E: the deformity is fixed &cant be corrected passively, while
in a normal baby(&those with postural club foot), the foot can
be dorsiflexed &everted so the toes can touch the shin.
The infant should be examined for DDH, spina bifida
&arthrogryposis(absence of skin creases).
X-ray: to assess progress after ?.
AP view: draw 2 lines, one through calcaneum &other
through talus, they will form an angle(kite s T-C angle) between
20-40° normally but in club foot they are almost parallel.
Lateral view: kite s angle is normally 20-40°; if <20°?equinus.
Differential diagnosis: look for the
following possibilities:
1-Spina bifida: there is sensory &motor
loss, so avoid pressure on the skin to
prevent pressure sore.
2-Arthrogryposis: congenital disorder in which there is failure of
soft tissue &muscle differentiation leading to soft tissue contracture &limitation of joint movement with absence of skin creases.
3-Poliomyelitis: there is flaccid muscle paralysis with cold,
blue limb due to poor circulation but sensation is normal.
The limb is smaller than normal.
Treatment: the aim is: 1-early full correction of the deformity
&2-hold the correction until the foot stop growing.
Club-feet are divided into: easy clubfoot which respond to conservative ? & resistant(need surgical correction) clubfoot characterized by:
1-small high heel; 2-thin calf & 3-severe forefoot adduction.
Conservative ?(Ponseti serial casting):
Start on the 2nd or 3rd day after birth by stretching the foot to normal or near normal position &holding it by adhesive strapping or light cast. First, correct adduction, inversion &lastly equinus deformity. Repeat this process every week for 6-8wks until the foot is overcorrected then apply plastic splint until the child start walking.
Operative ?: best done at 2-6 mths. The idea is: 1-release joint
tethers (capsule, lig. &fibrotic bands); 2-tendon lengthening.
Posteromedial release operation: for hindfoot equinus? elongate
tendo Achillis by Z-plasty; if still there is equinus? divide posterior capsule of ankle &subtalar joints. The superficial deltoid &calcaneofibular lig. may need release. Sometimes, FDL &FHL need elongation.
For forefoot varus? elongate tibialis
posterior tendon, divide talonavicular capsule.
K-wires may help holding corrected position.
Postoperative: cast for 2months, then
splint(Dennis Browne or ankle-foot orthosis).
Relapsed clubfoot:
If the postoperative casting or splinting is poor, the deformity
may recur; *For <5yr child, ?? the same soft tissue release.
*For children > 5yr? soft tissue release + bony correction:
1-resect a small wedge of bone between calcaneum &cuboid
(Evans operation). 2-calcaneal osteotomy to correct varus heel.
*For those aged >10yr? corrective osteotomy &fusion.
*Gradual distraction by Ilizarov circular external fixator is used
for difficult relapsed cases.
Metatarsus adductus: 90% will resolve spontaneously;
the others may need serial casting,
splint or surgery.
Talipes calcaneovalgus: presents as flexible
foot dorsiflexion; may be associated with
DDH; it often corrects spontaneously.
Arches of the foot: are 3:
1-medial arch: calcaneum, talus, navicular &medial cuneiform.
2-lateral arch: calcaneum, cuboid &lateral cuneiform.
3-anetrior arch: heads of metatarsals.
Flat foot(pes planus or pes valgus): in a normal foot the medial
arch may be high or low but in flat foot, the apex of the medial
arch is collapsed &medial border of the foot is (or nearly)
in contact with the ground &the heel is in valgus &the foot
is pronated at subtalar &midtarsal joints. Flat foot is usually
asymptomatic but may cause chronic ache or foot sprain.
Etiology: one or more may be the cause:
1-development disorder; 2-ligament laxity;
3-loss of muscle power; &4-abnormal load distribution.
Pathological varieties: 1-congenital flat foot;
2-physiological FF; 3-joint hypermobility; 4-weak FF;
5-compensatory FF; &6-spasmodic FF.
Congenital flat foot(congenital vertical talus): is rare &
usually bilateral. The talus is vertical &pointing toward the
sole with talo-navicular ?. The foot is stiff &flat with boat-
shape appearance(rocker-bottom). The hind-foot is in equinus with
ligament &tendon shortening on dorsolateral surface.
X-ray? equinus calcaneum, vertical talus with dorsal navicular ?.
Repeat x-ray with plantar flexion? the talus will be unchanged
while in flexible flat foot, the navicular return to normal position.
?? conservative ? by manipulation &casting
usually will fail, so operation is more effective:
OR + soft tissue release? 1-ETA + ankle &
subtalar capsulotomy to correct equinus;
2-open reduction of talonavicular ? + transfer
of tibialis anterior tendon to the neck of talus;
3-anteroateral release ± lengthening.
Flexible flat-foot: is quite normal below 6yr, after that the medial arch
start to develop. Some have lig. laxity, overweight or family history
of flat feet. O/E: the medial arch can be restored by great toe extension
(jack test) or standing on tiptoe(tiptoe test). Occasionally, it may persist into adult life which is often asymptomatic needs no ?. Some may
have pain after long standing or walking? arch support,
adapting shoes &muscle strengthening exercise:
(toe (walking on: toe, heel, side foot &curved foot).
Joint hypermobility: like Marfan s syndrome may
have flat foot; ?? conservative.
Weak flat foot: due to weak muscles as paralytic disorders;
rupture of tibialis posterior tendon or synovitis(e.g. RA);
or old age with obesity; ?? conservative(rarely operative).
Spasmodic flat foot: the foot is often stiff &flat.
Causes: some cases are idiopathic, others are caused by
abnormality of subtalar joint like: tarsal coalition
(bony bar between talus &calcaneum), subtalar
injury(# &post-traumatic OA), inflammatory
arthritis, gout or low grade infection.
CF: young adult have painful &stiff flat-foot;
sometimes with spasm of extensor &peroneal muscles.
O/E: subtalar joint mvt(inversion/eversion) are painful &limited.
X-ray: look for a visible pathology e.g. OA, arthritis or tarsal coalition which appears as a bony bar(oblique view is better), though it may be cartilaginous or fibrous need CT or isotope scan for diagnosis.
?? some respond to NSAID, 6wks walking cast? brace.
for tarsal coalition? operative removal of bar;
for OA? arthrodesis may be required;
if suspect infection? AB.
Compensatory flat foot: due to other deformity:
1-fixed ankle equinus or forefoot varus;
2-knock-knee: shifts body wt. medially? arch collapse;
3-external limb rotation? = = ? arch collapse.
?? correction of the anatomical defect.
Pes cavus(high-arched feet): medial arch is higher than normal &
often there is clawing of the toes(hyperextension of MPJ &flexion of IPJ).
Etiology: most cases are due to intrinsic muscle weakness
or paralysis from neuromuscular disorders like hereditary
neuropathy, spina bifida, poliomyelitis; or post-traumatic
compartment syndrome leading to Volkmann s contracture
of the sole.
Pathology: 1-high medial arch; 2-claw toes; 3-metatarsal heads
are pushed down into the sole; 4-callosities under
metatarsal heads; 5-inverted heel; & 6-tight plantar fascia.
CF: a 10 yr old boy presents with bilateral deformity
with pain &callosities under metatarsal heads &over
IPJ of the toes. O/E: the deformity is clear; early, it
can be corrected passively, but later it become fixed.
X-ray: weight-bearing lateral view to measure:
calcaneal pitch(n=0-30°), if >30°= calcaneus deformity,
& Meary s angle(n=0°), if >0°= plantaris deformity.
MRI: to exclude spine disorders(tethered cord).
?: conservative? custom-made shoes.
Operative(soft tissue release, osteotomy, tendon transfer):
For varus heel, if mobile? plantar fascia release;
if fixed? calcaneal osteotomy.
For mid-foot cavus, if mobile? Jones tendon transfer +
transfer of peroneus longus to brevis;
if fixed? corrective metatarsal osteotomy.
Severe cases? triple arthrodesis.
Big toe clawing? Jones tendon transfer +arthrodesis of IPJ.
Lesser toes? flexor tendon transfer to the extensor hood;
if fixed clawing? IPJ arthrodesis.
Jones operation: transfer the tendon of extensor hallucis
longus to the neck of the 1st metatarsal to lift it up