Lecture 45 shah hallux rigidus
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Transcript of Lecture 45 shah hallux rigidus
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Hallux Rigidus: Conservative care
Dr.Rajiv ShahFoot & ankle surgeon
‘Foot & ankle orthopaedics’Vadodara, Surat
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• Reported in 1887 by Davies-Colley - Hallux Flexus
• Cotterill coined the term Hallux Rigidus
• DuVries in 1959 and Moberg - hallux rigidus is the most common condition to affect the first MTP joint
• Also called as- hallux limitus- dorsal bunion- hallux dolorosus - hallux malleus- metatarsus primus elevatus (MPE)
History
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• Painful condition of great toe MTP joint
• Characterized by - Restricted motion (mainly
dorsiflexion)
- Proliferative periarticular
bone formation
Hallux Rigidus
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Etiology
Trauma
Intra articular fracture
Single episode Repetitive micro traumas
Crush Injury Acute chondral/
osteochondral injury
Forced hyperextension/plantar flexion injury
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Other Etiology
Congenital flattened/squared metatrsal head
Short first metatarsal
Long first metatrsal
Pes planus
Tight intrinsic muscles
Congruent MTP joint
Hindfoot pronation
Metatarsus primus elevatus
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Dorsal and dorsolateral
exostosis
Bony ledgeIncreased bulk
around the joint
Constricting footwear Dorsal
exostosis enlargement
Limitation of dorsiflexion
Pain Swelling MTP synovitis
Late Stage
Initial Stage
Symptoms
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• Swollen metatarsophalangeal (MTP) joint
• Everted gait
• Numbness develops over medial sensory nerve to the hallux
• Callus develops on lateral heel because of everted gait
• Hyperextension of hallux interphalangeal joint
Signs
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• Initial stages - Nonuniform joint space narrowing- Widening and flattening of first
metatarsal head
• Advanced stages - Subchondral cysts and sclerosis of
metatarsal head- Widening of base of proximal
phalanx- Hypertrophy of sesamoids
Radiographic evaluation
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Grade 0 Grade I
• Clinical- Only stiffness- Loss of passive motion
• ROM- Dorsiflexion 40-60
• Radiograph- Normal
• Clinical- Occasional pain- Pain at extremes of dorsiflexion
• ROM- Dorsiflexion 30-40 degrees
• Radiograph- Dorsal spur- Min joint narrowing- Min periarticular sclerosis- Minimal flattening of metatarsal head
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Grade II Grade III
• Clinical- Nearly constant subjective painsubstantial stiffness pain through out ROM (but not at mid ROM)
• ROM - 10 degrees or less Dorsiflexion
• Radiograph- Grade 2+ substantial narrowing, periarticular changes,>25% joint space involved no dorsal side,sesamoids enlarged
• Clinical- Moderate to severe pain and stiffness- Pain just before maximal dorsiflexion
• ROM- Dorsiflexion 10-30 degrees
• Radiograph- Osteophytes- <25%dorsal joint space involved- Mild to moderate joint narrowing and sclerosis
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Grade IV
• Clinical- nearly constant subjective pain andsubstantial stiffness - pain through out ROM+definite oain at mid ROM
• Radiograph- Grade 2+ substantial- narrowing,periarticular changes,>25% joint
space involved no dorsal side,sesamoids enlarged
• ROM 10 - degrees or less Dorsiflexion
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Management
Conservative
Surgical
•Cheilectomy•Phalangeal osteotomy•Plantar flexion osteotomy•Arthroplasty•Arthrodesis
Management
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Conservative Management
NSAIDs: reduces inflammation & pain due to synovitis
Modification of activities
Neurotropics: if neuritic pain Steroid injections
Conservative methods may be successful even in cases with severe hallux rigidus!
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•Morton’s extension•Carbon fibre plate insert•Commercially available inserts•Custom mould inserts
Conservative Management
Tapping
Footwear modifications
Orthotics:To stiffen the fore foot
To offload forefootTo reduce the forefoot/MTP
joint motion
•Stiff insoles•Rocker bottom shoe•Still medial shank•Wide/deep toe box•Low heels
Joint manipulation
Success rate is up to 60%-70%!
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That’s all…Thank you all…