Page 975 - TNFlipTest

Toronto Notes 2019
Foot
Orthopedics OR41
Achilles Tendon Rupture
Mechanism
• loadingactivity,stop-and-gosports(e.g.squash,tennis,basketball) • secondarytochronictendonitis,steroidinjection
Clinical Features
• audiblepop,suddenpainwithpush-offmovement • painorinabilitytoplantarflex
• palpablegap
• apprehensivetoeoffwhenwalking
• weakplantarflexionstrength
• Thompsontest:withpatientprone,squeezecalf,normalresponseisplantarflexion
■ no passive plantarflexion is positive test = ruptured tendon
Investigations
• X-ray(toruleoutotherpathology),U/SorMRI(forpartialvs.completeruptures)
Treatment
• indication:lowathleticdemand
■ cast foot in plantar flexion (to relax tendon) x 8-12 wk
■ new level 1 evidence suggests no difference in re-rupture rates between operative and non-operative
management with functional rehabilitation. • operative
■ indication: high athletic demand
■ surgical repair, then cast as above x 6-8 wk
Plantar Fasciitis (Heel Spur Syndrome)
Definition
• inflammationofplantaraponeurosisatcalcanealorigin
• commoninathletes(especiallyrunners,dancers)
• alsoassociatedwithobesity,DM,seronegativeandseropositivearthritis
Mechanism
• repetitivestraininjurycausingmicrotearsandinflammationofplantarfascia
Clinical Features
• insidiousonsetofheelpain,painwhengettingoutofbed,andstiffness
• intensepainwhenwalkingfromrestthatsubsidesaspatientcontinuestowalk,worseatendofdaywith
prolonged standing
• swelling,tendernessoversole
• greatestatmedialcalcanealtubercleand1-2cmdistalalongplantarfascia
• painwithtoedorsiflexion(stretchesfascia)
Investigations
• plainradiographstoruleoutfractures
• oftenseebonyexostoses(heelspurs)atinsertionoffasciaintomedialcalcanealtubercle • spurissecondarytoinflammation,notthecauseofpain
Treatment
• non-operative
■ pain control and stretching programs are first-line
■ rest, ice, NSAIDs, steroid injection
■ physiotherapy: Achilles tendon and plantar fascia stretching, extracorporeal shockwave therapy ■ orthotics with heel cup – to counteract pronation and disperse heel strike forces
• operative
■ indication: failed non-operative treatment ■ endoscopic surgical release of fascia
■ spur removal is not required
Bunions (Hallux Valgus)
Definition
• bonydeformitycharacterizedbymedialdisplacementoffirstmetatarsalandlateraldeviationofhallux
Mechanism
The most common site of Achilles tendon rupture is 2-6 cm from its insertion where the blood supply is the poorest
Complications of Achilles Tendon Rupture
• Infection
• Sural nerve injury
• Re-rupture: surgical repair decreases
likelihood of re-rupture compared to non- operative management
Cuneiform
Navicular
Bone spur
Talus
Calcaneus
• manyassociateddeformitiesinfootfromalteredmechanics
• valgusalignmentof1stMTP(halluxvalgus),loosemedialandtightlateraljointcapsule,adductor
Figure 48. X-ray of bony heel spur
Surgical Versus Nonsurgical Treatment of Acute Achilles Tendon Rupture: A Meta-Analysis of Randomized Trials
J Bone Joint Surg Am. 2012; 94(23): 2136–2143. Purpose: To compare surgical treatment and conservative treatment of acute Achilles tendon rupture.
Methods: A meta-analysis was performed looking at randomized trials comparing surgical with nonsurgical treatment or comparing different surgical treatments of Achilles tendon rupture. Only adult patients were included. Delayed presentations wereexcluded. Theprimaryoutcomeswerethe re-rupture rate, complication rate, and long-term function.
Results: If functional rehabilitation was employed, re-rupture rates were equal for surgical and nonsurgical patients (risk difference = 1.7%, p = 0.45). If not, the absolute risk reduction achieved by surgery was 8.8% (p = 0.001 in favor of surgery). Surgery was associated with an absolute risk increase of 15.8% (p = 0.016 in favor of non-operative management) for complications other than re-rupture. There was no significant difference between the two treatments with regard to other functional outcomes.
Conclusions: Conservative treatment should be considered at centers using functional rehabilitation. This resulted in re-rupture rates similar to those for surgical treatment while offering the advantage of
a decrease in other complications. Surgical repair should be preferred at centers that do not employ early-range-of-motion protocols as it decreased the re-rupture risk in such patients.
hallucis becomes a deforming force
• formation of a reactive exostosis and thickening of the skin creates a bunion
• associatedwithpoor-fittingfootwear(highheelandnarrowtoebox)
• canbehereditary(70%havefamilyhistory)
• 10xmorefrequentinwomen