ankle and foot.ppt

7/27/2019 ankle and foot.ppt

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Anatomy

There are 26 bone in the foot 7 tarsal , 5 metatarsal, 14 phalanges


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Movements at the ankle joint are mainlydorsiflexion and plantarflexion

The foot externaly rotates with dorsiflexionand internally rotates with plantarflexion

The lower leg muscle is divided into fourcompartments (superficial and deepposterior, lateral, anterior)

Only one muscle on the dorsum of the foot( digitorum brevis)


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The muscle on the planter aspect of the footare divided into four layers

The planter fascia is a very importantstructure that takes its origin from the heeland inserts into the bases of the proximalphalanges of the toes

Blood supply from ( anterior & posteriortibial, peroneal arteries)

Nerves (posterior tibial, saphenous, sural,

superficial & deep peroneal)


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1- Club foot2- Flat foot


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- Relatively common; the incidence is 1or 2 /1000 births

-Boys are affected twice as often as girls.-The condition is bilateral in one-third ofcases.

- Similar deformities are seen inneurological disorders, e.g.myelomeningocele, and in arthrogryposis.


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-Its mostly a problem passed fromparents to children (genetic), and it mayrun in families

If you have one baby with clubfoot, thechance of having a second child with thecondition are about one in 40.

-Clubfoot does not have anything to dowith the babys position duringpregnancy.


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The deformity is usually obvious at birth;the foot is both turned and twistedinwards so that the sole faces

posteromedially.The heel is usually small and high, anddeep creases appear posteriorly andmedially.The infant must always be examined forassociated disorders such ascongenital hip dislocation and spina

bifida.


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imagesultrasoundIn fact, doctors can see it ontaken after about four months of pregnancy
http://orthopedics.seattlechildrens.org/resources/glossary.asphttp://orthopedics.seattlechildrens.org/resources/glossary.asp


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X- rays : the tarsal bones are incompletelyossified at this age. However, the shape and

position of the tarsal ossific centers arehelpful in assessing progress after treatment


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If the condition is not corrected early, secondarygrowth changes occur in the bones and theseare permanent.

Relapse is common, specially in babies withassociated neuromuscular disorders.1-Conservative treatment:

Should begin early, preferably within a day or twoof birth.It consists of repeated manipulation and adhesive

strapping or application of plaster of Paris casts,

which will maintain the correction.


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2- Operative treatment :

The objectives are:A-The complete release of joint tethers

(capsular and ligamentous contractures and

fibrotic bands)B-Lengthening of tendons, so that the foot can

be positioned normally without unduetension.


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After operative correction, the foot isimmobilized in its corrected position in aplaster cast.

Kirschner wires are sometimes insertedacross the intertarsal and ankle joints toaugment the hold. The wires and cast are

removed at 6-8 weeks.After that, hobble boots (Dennis Browne) or acustomized othosis are used to maintain thecorrection.


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Infantile Flat Foot (Congenital Vertical

Talus)

Flat Foot in Children and Adolescents Flat Foot in adults


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Its a rare neonatal condition usually affects

both feet.

In appearance it is the very opposite of a club-foot; the foot is turned outwards (valgus) andthe medial arch is not only flat, it actuallycurves the opposite way from the normal,

producing the appearance of a rocker-bottomfoot.


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X-ray features are characteristic: The calcaneum is in equinus and the talus

points into the sole of the foot, with the

navicular dislocated dorsally onto the neck ofthe talus.

Passive correction is impossible

The only effective treatment is byoperation, ideally before the age of 2

years.


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When weight-bearing, the foot is turnedoutwards and the medial border of the footis in contact with the ground; the heel

becomes valgus.

Two forms of the condition are recognized:1- Flexible flat-foot

2-Stiff (rigid) flat-foot


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Which appears in toddlers as a normal stagein development.It usually disappears after a few years when

medial arch development is complete. Thearch can be restored by simply dorsiflexingthe great toe.Many of the children with flexible flat-foot

have ligamentous laxity and there may be afamily history of both flat-feet, and jointhypermobility.


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-Which cannot be corrected passively, andshould alter the examiner to an underlyingabnormality.

-In older children and adolescents, conditionsto be considered are1-Tarsal coalition (often a bar of boneconnecting the calcaneum to the talus or the

navicular)2-Inflammatory joint condition3-Neurological disorder.


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flexible flat-foot: no symptoms, but the parentsnotice that the feet are flat or the shoes wear badly,the deformity becomes noticeable when the

youngster stands.The first test :ask the patient to go up on tiptoes:if the heels invert, it is a flexible deformity.Then examine the foot with the child sitting or lying.Feel for localized tenderness and test the range ofmovement in the ankle, the subtalar and midtarsal

joints.A tight Achilles tendon may induce a compensatoryflat-foot deformity.


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Teenagers and young adults sometimespresent with a painful, rigid flat-foot.On examination, the peroneal and extensor

tendons appear to be in spasm,sometimes itscalled Spasmodic flat-footIn some cases a definite cause may be found,

but in many no specific cause is identified.The spine, hips, and knees should always beexamined as well as, joint hypermobility and

neuromuscular abnormalities.


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- X-ray are unnecessary for asymptomatic,flexible flat-feet.-For Pathological flat-feet (usually painful, and

stiff), standing AP, lateral and oblique viewsmay help to identify underlying disorders.

-CT scanning is the most reliable way of

demonstrating tarsal coalitions.


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Young children with flexible flat-feet requireno treatment. Parents need to be reassured.If the condition is obviously due to anunderlying disorder such as poliomyelitis,splintage or operative correction and musclerebalancing may be needed.Spasmodic flat-foot is relieved by rest in acast or a splint. If there is an abnormal tarsalbar or other bony irregularity, this may haveto be removed.In late cases, if pain is intolerable, a triplearthrodesis may be necessary.


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When adults present with symptomatic flat-feet thefirst thing to ask is whether they always had flat-feet or whether it is of recent onset.More recent deformities may be due to an

underlying disorder such as rheumatoid arthritis orgeneralized muscular weakness,Unilateral flat-foot should make one think of tibialisposterior synovitis or rupture.

Patients with painful rigid flat-feet may requiremore robust splintage.Those with tibialis posterior rupture can be helpedby operative repair or replacement of the defective

tendon

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