management

Anatomy

5 Annular pulleys

3 Cruciate pulleys

Pathology

A1 and A5 expendable

Loss of other annular pulleys can lead to bowstringing

- A2 & A4 +/- A3

Aetiology

Rock climbers

- usually when slipping

May hear or feel a pop

Develop swelling / tenderness / pain

Bowstringing

Definition

Chronic, non metabolic bone disorder

Characterised by increased bone resorption, bone formation and remodelling

Epidemiology

Rare < 40

1 – 3 % population over 60

M > F

Aetiology

Unknown

Paramyxovirus implicated

- measles

- RSV

- canine distemper virus

Electron Microscope

Epidemiology

1/3 caucasian women > 64

Risk Factors

Insufficient bone mass at time of skeletal maturity

- peak bone mass is achieved at age 25

Rapid loss of bone after menopause

Low body weight / weight loss / history of smoking / steroids

Primary

Type 1

- postmenopausal

- high turnover / osteoclast mediated

- F x 6

Non Operative

Options

Metatarsalgia

- preMT dome

Claw toes

- wide deep toe box

Foot drop

- AFO

Insensate foot

- custom orthosis

Varus

- lateral heel wedge

- AFO (flexible)

- medial iron with lateral T strap

Surgical Algorithm

Stage 1 Tendonitis

Non-operative

Walking cast / NSAIDS

- 6/52

UCBL

- 3/12

- worn inside the shoe

- ends under malleoli

- controls the heel (which must be flexible)

- supports the arch

Operative / Synovectomy and debridement

(+/- FDL transfer and calcaneal osteotomy +/- T Achilles lengthening)

Aim

Stable, shoe-able plantigrade foot

Multidisciplinary approach

Multidisciplinary foot clinics (MDFC) 1^st established UK 1980s

- shown to significantly reduce rate of diabetic amputations

- involve:

Endocrinologist +/- diabetic nurse

- glycaemic control crucial

Podiatrist

- non-surgical debridement

- orthoses

Operative v Nonoperative Literature

1.  Buckley etal JBJS Am 2002

Prospective multi-centred RCT

- 309 displaced intra-articular fractures

- operative v non operative management

- 2 year follow up

Findings

- used patient orientated functional outcomes

- overall VAS and SF36 not significantly different between 2 groups

Improved Operative Outcome if

- not workers compensation

- women

- < 29

Definition

High ankle sprain

Epidemiology

Uncommon

- often unrecognised or misdiagnosed as lateral ligament injuries

- seen in ice hockey

1-15% of ankle sprains involve the syndesmosis

Mechanism Injury

Hyperdorsiflexion and forced external rotation

Anatomy

Structures

- anterior inferior tibiofibular ligament (AITFL)

Definition

Tibial facture with break in skin

- open wound communicating with fracture or haematoma

Patient is immediately at higher risk of deep infection

Diagnosis

Wound continuously oozes dark red fracture haematoma

Epidemiology

Up to 1/4 of tibia fractures open

Gustilo and Anderson Classification

Grade 1

- wound < 1cm

- usually inside out

AORI / Andersen Orthopedic Research Institute

T Tibial  F Femoral

1.  Contained Metaphyseal Defect

2.  Damaged Metaphyseal

A.  One Condyle

B.  Both Condyles

3.  Deficient Metaphysis +/- collaterals +/- extensor mechanism

1.  Contained Metaphyseal defect