Orthopaedics: Foot

Mechanism

·                 axial loading or hyperdorsiflexion (MVA, fall from a height)

·                 60% of talus covered by articular cartilage

·                 tenuous blood supply runs distal to proDma1 along talar neck.

o       high risk of AVN with displaced fractures

 

Investigations

·                 x-rays: AP, lateral

·                 CT to better characterize fracture

·                 MRI can clearly define extent of AVN

 

Treatment

·                 undisplaced: non-weight bearing below knee cast x 20-24 weeks

·                 displaced: ORIF (high rate of nonunion, AVN)

 

Calcaneal Fracture

 

Mechanism

·                 axial loading: fall from a height onto heels

·                 10% of fractures associated with compression fractures of thoracic or lumbar spine

·                 5% are bilateral

 

Physical Examination

·                 swelling, bruising on heel/sole

·                 wider, shortened, flatter heel when viewed from behind

 

Investigations

·                 x-rays: AP, lateral, oblique (Broden's view)

·                 loss of Bohler's angle

·                 CT - assess intraarticular extension

 

Treatment

·                 closed vs. open reduction is controversial

·                 non-weight bearing cast approximately 3 months with early ROM and strengthening

 

Achilles Tendonitis

 

Mechanism

·                 chronic inflammation from activity or poor-fitting footwear

·                 may also develop heel bumps (retrocalcaneobursitis)

 

Physical Examination

·                 pain, stiffness and crepitus with ROM

·                 thickened tendon, palpable bump

 

Treatment

·                 rest, NSAIDs

·                 gentle stretching, deep tissue calf massage

·                 orthotics, open back shoes

·                 Do NOT inject steroids (risk of tendon rupture)

 

Achilles Tendon Rupture

 

Mechanism

·                 loading activity, stop-and-go sports (e.g. squash, tennis, basketball)

·                 secondary to chronic tendonitis, steroid injection

 

Clinical Features

·                 audible pop, sudden pain with push off movement

·                 sensation of being kicked in heel when trying to plantar flex

·                 palpable gap

·                 apprehensive toe off when walking

·                 weak plantar flexion, +ve Thompson test: with patient prone, squeezing the calf muscles should passively plantar flex the foot to demonstrate intact Achilles tendon

o       +ve test = no passive plantar flexion = ruptured tendon

 

Treatment

·                 low demand or elderly: cast foot in plantar flexion (to relax tendon) x 8-12 weeks

·                 high demand: surgical repair, then cast as above x 6-8 weeks

 

Plantar Fasciitis (Heal Spur Syndrome)

 

Mechanism

·                 repetitive strain injury causing microtears and inflammation of plantar fascia

·                 female:male = 2:1

·                 common in athletes (especially runners)

·                 also associated with obesity, DM, seronegative and seropositive arthritis

 

Clinical Features

·                 morning pain and stiffness

·                 intense pain when walking from rest that subsides aa patient continues to walk

·                 swelling, tenderness over sole

·                 greatest at medial calcaneal tubercle and 1-2 cm distal along plantar fascia

·                 pain with toe dorsiflexion (stretches fascia)

 

Investigations

·                 plain radiographs m rule out fractures

·                 often see exostoses (heel spurs) at insertion offilsda into medial calcaneal tubercle (see Figure 47)

·                 spur is reactive to inflammation, not the cause of pain

 

 

Treatment

·                 rest, ice, NSAIDs, steroid injection

·                 PT: stretching, ultrasound

·                 orthotics with heel cup

o       to counteract pronation and disperse heel strike forces

·                 endoscopic surgical release of:lUcia in refractory cases

o       spur removal is not required

 

Bunions (Hallux Valgus)

 

Mechanism

 

·                 valgus alignment on 1st MTP (hallux valgus) causes eccentric pull of extensor and intrinsic muscles

·                 reactive exostosis forms with thickening of the skin creating a bunion

·                 most often associated with poor-fitting footwear but can be hereditary

·                 l0x more frequent in women

 

Clinical Features

·                 painful bursa over medial eminence of 1st metatarsal head

·                 pronation (rotation inward) of great toe

·                 numbness over medial aspect of great toe

 

Treatment

·                 cosmetic and to relieve pain

·                 non-operative first

o       properly fitted shoes low heel) and toe spacer

·                 surgical

·                 osteotomy with realignment of 1st MTP joint

 

Metatarsal Fracture

·                 as with the hand, 1st, 4th, 5th metatarsals (MT) are relatively moblle, while the 2nd and 3rd are fixed (Table 18)

·                 use Ottawa Foot Rules to determine need fur x-ray