ankle ortho cases part 2

Hallux valgus
a common deformity in which there is medial deviation
of 1st metatarsal with big toe lateral deviation.
Etiology: 1-positive family history in 60%;
2-wearing high-heel pointed tight shoe; 3-metatarsus
primus varus; 4-old age with low muscle tone; 5-RA.
Pathology:
1-wide forefoot with 1st met med deviation &hallux lat deviation.
2-big toe tendons shift laterally? ?great toe lat. deviation &rotation (pronation) =nail faces medially. If valgus is severe? toe overriding.
3-bunion: is a prominance of 1st met head due to:
MPJ subluxation, bursa or soft tissue thickening.
4-late: OA of the 1st MPJ.
CF: a woman 50-70 yr or adolescent girl complaining of:
forefoot deformity; pain due to: 1-shoe pressure on a bunion;
2-pain under met heads; 3-lesser toes crowding &4-OA of 1stMPJ.
O/E: the hallux is in valgus &rotated; wide forefoot;
swollen &inflamed bunion; hammer toe.
X-ray: take a standing AP view &measure:
the valgus angle of the hallux which must not exceed 15° &
the intermetatarsal angle between the 1st &2nd met=<10°.
look at the 1stMPJ: congruent, deviated, subluxed? osteoarthritic.
?? conservative(flat-heel shoe with wide toe-box) for 1-adolescent with asymptomatic deformity &congruent joint &2-elderly.
Operative: either bony correction &/or ST reconstruction:
For high IMA? 1st met basal osteotomy;
For high HVA? 1st met distal osteotomy ± PP osteotomy;
Bunion? bony prominence excision(exostectomy).
Soft tissue reconstruction is indicated if the 1stMPJ is incongruent
which include: medial capsule reefing, lateral release, release or
transfer of adductor hallucis &tightening of the 1st web space.
For MPJ OA? joint fusion or excision of prox 1/3 of PP.
Claw toes: is a deformity characterized by
hyperextension at MPJ &flexion at IPJ.
Etiology: clawing is due to intrinsic muscles weakness
which may occur in: 1-neurological disorders like polio-
myelitis, peroneal muscle atrophy &peripheral neuropathy;
2-RA; 3-idiopathic as claw toes alone or with pes cavus.
CF: forefoot pain &under metatarsal heads; often it is bilateral.
O/E: early the deformity is mobile(passively correctable) but
later it becomes fixed &the MPJ may subluxate or dislocate.
There may be painful corns over IPJ &under met heads.
?: if the deformity is flexible? Conservative ?: wearing wide shoe(athletic is better) with insole like metatarsal pad or bar; or
Operative: extensor tendons elongation or flexor to extensor transfer.
If the deformity is fixed? Conservative ? by shoe modification or
Operative by: 1- IPJ arthrodesis; 2- MPJ excision arthroplasty.
Hammer toe:
is fixed flexion of PIPJ with hyperextension of MPJ &DIPJ.
CF: it commonly affects the 2nd toe of one or both feet. Shoe
pressure often causes painful corn over PIPJ &under mt head.
The cause is unknown though extensor dysfunction may play
a role or simply the toe is too
long or the shoe is too short.
?: correction &arthrodesis of PIPJ.
Mallet toe: is a toe with flexion of DIPJ; it s tip will
rub against the shoe resulting in a painful callosity.
?: fusion of DIPJ in a straight position.
Painful feet: can be due to:
1-mechanical pressure especially if the foot is deformed;
2-joint inflammation like RA; 3-localized bone lesion;
4-periphral ischemia; or 5-muscle strain.
Painful heel:
Sever s disease(traction apophysitis): boy (10yr)with pain &
tenderness over tendo Achillis insertion due to traction injury.
X-ray: ?density &fragmentation of calcaneal apophysis.
?: shoe with heel raise &few wks restriction of activities
(running &jumping).
Calcaneal bump(Haglund s deformity): a young woman with painful bump on the back of her heel &shoe friction causes pain &swelling.
?: wearing open-back shoe; if severe? excision of calcaneal knob.
Calcaneal bursitis: due to friction between Achillis tendon &
the skin or calcaneum causing pain &swelling. X-ray: bony spur.
?: open-back shoe or steroid injection.
Achillis tendonitis(para- or peri-tendonitis): overuse as in
athletes may cause inflammation of the paratenon resulting in
posterior swelling &pain. ?: ice-packs, rest &steroid injection.
In chronic cases ?surgical excision of paratenon or the spur.
Tendonosis: is degeneration of Achillis tendon which may
end with rupture.
Plantar fasciitis: is commonly affecting male 30-60 yr as inferior heel
pain typically with the 1st step out of bed or after a period of rest. O/E: localized tenderness under the heel. It is thought that overuse (traction)
will cause micro tears &inflammatory reaction at site of plantar fascia insertion to the calcaneum. It may be associated with Reiter s syndrome, gout or ankylosing spondylitis. Histology: shows areas of fascia
degeneration(fasciosis). X-ray: shows bony spur in 50% of patients.
?: NSAID, heel pad, local steroid injection; often it subsides within
6-12 months spontaneously. If resistant? surgical division of plantar
fascia ± excision of the spur.
Calcaneal bone lesions &subtalar joint arthritis:
can present as heel pain like stress fracture, osteomyelitis, osteoid
osteoma, bone cyst, giant-cell tumor, Paget s disease.
Subtalar arthritis like OA, RA, pyogenic or TB arthritis.
Painful mid-foot:
K?hler s disease(navicular osteochondritis): child <5yr.
CF: limp, pain &tender swelling over the navicular bone.
X-ray: dense &fragmented navicular nucleus.
?: it is self-limiting; if pain is severe? below-knee cast.
Over-bone: adults with high arch may develop a ridge of bone
on adjacent surface of medial cuneiform &1stmetatarsal which is
painful with shoe pressure. ?: shoe modification; if fails? excision.
Painful fore-foot(metatarsalgia): any foot deformity will result in
abnormal load distribution &pain:
1-foot abnormality: splay foot(wide forefoot occurs in mid-age women who put on weight) & cavus foot with pain under met heads.
2-toe abnormality: like hallux valgus, hammer toe &claw toes.
3-local disorders:
Freiberg s disease: is osteochondritis(avascular necrosis) of the 2nd
met head affecting young woman as a tender bony lump(MT head)
with stiff MPJ. X-ray: dense flat eroded head, thick neck, ? joint space.
?: rest, cast, modified shoe; if pain persists? surgical excision of
the affected met head.
Stress fracture: usually of the 2ndor 3rd metatarsal; affects young
adults after unaccustomed activity with tender swelling on dorsum of
the foot. X-ray: early is normal; 2weeks later: fusiform callus around a
fine transverse # line. ?: rest.
Morton s neuroma: is a compression of interdigital nerve under intermetatarsal lig. with secondary thickening(like a neuroma).
CF: 50yr woman with pain ¶sthesia localized to 3rd interspace radiating to 3rd &4th toe especially on wearing tight shoe. O/E:
tenderness in the 3rd interMT space; toe sensation may be ?; forefoot compression may reproduce the symptoms; local anesthetic injection will abolish the pain ¶sthesia. ?: low-heeled wide shoe with padding; local steroid; if fails? lig. release or even excision of the neuroma .
Tarsal tunnel syndrome: is the compression of tibial nerve or it s branches
as it passes under the flexor retinaculum causing pain ¶sthesia in medial forefoot more at night. Nerve conduction is slow. O/E: Tinel sign; dorsiflexion &eversion? pain &tingling. ?: surgical decompression