Clinical Podiatry Viva Continues

Front 1

What is the condition known as when transverse lines affect the majority of nails simultaneously?

Back 1

Beau's lines

Front 2

What are Beau's lines?

Back 2

When transverse lines affect the majority of nails simultaneously?

Front 3

What 4 skin conditions can cause pitting of the nails?

Back 3

1. Psoriasis
2. Lichen planus
3. Eczema
4. Alopecia

Front 4

What 2 things could cause a nail bed to go brown?

Back 4

1. Idiopathic
2. Subungual wart

Front 5

What 3 things can cause a nail bed to go white?

Back 5

1. Anaemia
2. Cirrhosis
3. Renal disease

Front 6

What 2 things can cause a nail bed to go green?

Back 6

1. Pseudomonas infection
2. Blistering diseases

Front 7

What 3 things can cause a nail bed to go yellow?

Back 7

1. Subungual corn
2. Wart or exostosis
3. Jaundice

Front 8

What can cause a nail bed to go black?

Back 8

Haematoma

Front 9

What 2 things can cause a lunula to go red?

Back 9

1. Congestive heart failure
2. Alopecia

Front 10

What 3 things can cause a lunula to go brown or black?

Back 10

1. Haematoma
2. Melanoma
3. Melanonychia

Front 11

What is melanonychia?

Back 11

It is a solitary dark longitudinal band in the nail

Front 12

What is the name for a solitary dark longitudinal band in the nail?

Back 12

Melanonychia

Front 13

What 3 things can cause a nail plate to go white?

Back 13

1. Onychomycosis
2. Trauma
3. Onycholysis

Front 14

What 4 things can cause a nail plate to go yellow?

Back 14

1. Nicotine or urine staining
2. Yellow nail syndrome
3. Jaundice
4. Wearing nail polish for a prolonged period of time

Front 15

What 5 things can cause a nail plate to go brown?

Back 15

1. Mycotic infection
2. Onychauxis
3. Onychogryphosis
4. Shoe dyes
5. Melanoma

Front 16

What is onychomadesis?

Back 16

It is the detachment of the nail from the bed in a proximal to distal fashion

Front 17

What is the detachment of the nail from the bed proximally to distally?

Back 17

Onychomadesis

Front 18

What are the six causes of onycholysis?

Back 18

1. Trauma (nail surgery, nail picking)
2. Peripheral vascular disease
3. Psoriasis
4. RA
5. Subungual tumours
6. Eczema

Front 19

What are the three causes of onychomadesis?

Back 19

1. Nail matrix infection or inflammation
2. Subungual blistering
3. Drugs

Front 20

What 3 skin conditions can lead to onychauxis?

Back 20

1. Fungal infections
2. Psoriasis
3. Lichen planus

Front 21

What is pachyonychia?

Back 21

A rare inherited disorder hallmarked by congenital thickening of the nail plate

Front 22

What is the function of periungual tissue?

Back 22

They seal the nail unit from damage

Front 23

What are six conditions that can cause periungual changes?

Back 23

1. Periungual warts - usually symptomatic, easily diagnosed by their appearance
2. Corns/callus - found within the nail sulci, may lead to pain on compression of the nail plate. Nail edges may be thickened or involuted.
3. Subungual exostosis - diagnosed by X-ray, may lead to lifting of the nail plate
4. Fibromas - associated with tuberous sclerosis
5. Malignant tumours - basal cell carcinoma, squamous cell carcinoma, subungual melanoma
6. Glomus tumours - causes of extreme pain when exposed to slight trauma or changes in temperature, often visible by digital illumination. Rarely found in toe.

Front 24

What type of sweat glands are particularly numerous across the palms and soles?

Back 24

Eccrine sweat glands

Front 25

What is anhidrosis?

Back 25

Lack of sweating

Front 26

What is the name for lack of sweating?

Back 26

Anhidrosis

Front 27

What is hyperhidrosis?

Back 27

Excessive sweat production

Front 28

What is the name for excessive sweat production?

Back 28

Hyperhidrosis

Front 29

What is bromhidrosis?

Back 29

Abnormal or offensive body odour

Front 30

What is the name for abnormal or offensive body odour?

Back 30

Bromhidrosis

Front 31

What are twelve conditions that cause anhidrosis?

Back 31

1. Ageing - sweat production decreases with age
Damage to neurological pathways
2. Autonomic neuropathy
3. Diabetes mellitus
4. Leprosy
5. CNS
6. Displacement of sweat glands
Dermatological lesions
7. Eczematous or psoriatic plaques
8. Lichen planus
9. Miliaria
10. Lack or loss of sweat glands
11. Damage/scarring to areas of skin
12. Congenital lack of sweat glands (ectodermal dysplasia)

Front 32

What is ectodermal dysplasia?

Back 32

Congenital lack of sweat glands

Front 33

What is congenital lack of sweat glands?

Back 33

Ectodermal dysplasia

Front 34

What is miliaria?

Back 34

Prickly heat rash

Front 35

What is the name for prickly heat rash?

Back 35

Miliaria

Front 36

What thirteen conditions can cause hyperhidrosis?

Back 36

Physiological
1. Normal in young adults
2. Exercise
3. Over-clothing or occlusive footwear
4. Emotions or stress
Endocrine disorders
5. Hypoglycaemia
6. Hyperthyroidism
7. Acromegaly
Dermatological
8. Associated with palmoplantar keratoderms
Other
9. Drugs
10. CNS disorders
11. Cardiovascular disorders
12. Respiratory failure
13. Tumours

Front 37

What are the two main methods of assessment in fungal disease?

Back 37

1. Wood's light
2. Mycology

Front 38

What chemical is used to assist diagnosis of fungal infections?

Back 38

Potassium hydroxide

Front 39

What are the three main biopsy techniques?

Back 39

1. Punch
2. Shave
3. Ellipse - removal of small lesions

Front 40

What is hyperkeratosis?

Back 40

A thickening of the stratum corneum

Front 41

What is the name for the thickening of the stratum corneum?

Back 41

Hyperkeratosis

Front 42

What 3 mechanical forces cause hyperkeratosis?

Back 42

1. Shear
2. Friction
3. Pressure

Front 43

What is callus?

Back 43

Hard dense yellowish plaques usually found on the plantar surface of the foot

Front 44

What are corns?

Back 44

Dark, hard, invaginated areas of hyperkeratosis present either alone or within a callus plaque

Front 45

What do patients complain of when they have corns?

Back 45

Stabbing pain when walking which may persist when resting or subside into a dull, soft tissue ache

Front 46

What do patients complain of when they have callus?

Back 46

A stinging burning sensation which is worse just after the start of rest and on resuming weightbearing

Front 47

What are thirteen causes of hyperkeratosis?

Back 47

Familial/inherited
1. Palmoplantar keratoderma - various types exist. Typically inherited forms begin in childhood
2. Icthyosis - many types. Characterised by dry, flaky skin affecting various parts of the body
3. Darier's disease - palmoplantar hyperkeratosis may occur; usually lesions are punctate in form
4. Pachyonychia congenita - a disease characterised by thickened nails. Associated palmoplantar hyperkeratosis may occur
Acquired
5. Palmoplantar keratoderma - normally arises in patients from their twenties
6. Keratoderma climactericum - yellow/brown papules which then coalesce to form thickened plaques across the soles of menopausal women. Fissuring is common
7. Reiter's disease - red, hyperkeratotic rash may occur on the soles called keratoderma blennorrhagica". Difficult to distinguish from pustular psoriasis
8. Chronic dermatitis - hyperkeratotic lesions may be observed accompanied by fissuring and crusting
9. Pustular psoriasis - yellow/brown sterile pustules occur with a hyperkeratosis of the palms and soles, typically in older patients
10. Syphilis - distinctive copper pink papules may occur on the sole with hyperkeratosis
11. Lymphoedema - dirty, brown lesions may occur over oedematous areas of the foot and lower leg
12. Hypothyroidism - a mild hyperkeratosis may occur on the soles but resolves with treatment
13. Tinea pedis - hyperkeratosis may occur as part of the eruption

Front 48

Where are the four most common sites for callus and corns?

Back 48

1. Diffuse callus beneath the third and fourth metatarsal heads
2. Callus solely beneath the second, first and fifth metatarsal heads
3. Dorsal corns on the fifth toes followed by the fourth, third and second
4. Interdigital lesions between the fourth/fifth toes followed by first/second and third/fourth toes

Front 49

What are the five different types of corns?

Back 49

1. Seed corns - tend to occur at the margins of weightbearing areas of the plantar aspect of the foot either singly or as disperse clusters
2. Hard corns
3. Vascular corns - intrusion of vascularised dermal tissue into the epidermis which causes it to bleed profusely when cut
4. Soft corns
5. Fibrous corns

Front 50

What are the xx factors of palmoplantar keratodermas?

Back 50

1. Characterised by hyperkeratosis of the palms and soles
2. Unlike normal callus the amount is much increased with a rapid return rate following debridement
3. Lesions bear no correlation to any weightbearing patterns

Front 51

What are the four categories of palmoplantar keratoderma?

Back 51

1. Diffuse PPK - across palms and soles (usually sparing the arch)
2. Focal PPK - discrete patches of hyperkeratosis with normal skin in between
3. Punctate PPK - numerous punctate corn-like lesions spread across the palms and soles
4. PPK with ectodermal dysplasia - PPK of any variety with accompanying features of ectodermal abnormalities eg hyperhidrosis, neurological or dental malformations

Front 52

What are the four main skin disorders with blistering as the principal feature?

Back 52

1. Epidermolysis bullosa
2. Bullous pemphigoid
3. Pemphigus
4. Dermatitis herpetiformis (rare below the knee)

Front 53

What are seven disorders that cause blistering?

Back 53

1. Friction - most common variety seen on the feet due to pressure and shearing forces
2. Fungal and bacterial infections eg tinea and erysipelas
3. Diabetes - an uncommon complication associated with hyperglycaemia
4. Thermal injury eg burns, cryosurgery
5. Eczema
6. Erythema multiforme
7. Severe sunburn/photosensitivity

Front 54

What are the three layers of the skin that blisters can develop at?

Back 54

1. Superficial - blisters occur in the stratum corneum and are associated with infections eg tinea pedia. Superficial blisters are more prone to rupture leaving open erosions which may be complicated by secondary infection
2. Intraepidermal - these usually occur in the stratum spinosum and are associated with acute eczema and viral vesicles
3. Subepidermal - these occur at the dermal-epidermal junction and are associated with epidermolysis bullosa

Front 55

What is epidermolysis bullosa?

Back 55

It is an inherited group of disorders where the skin reacts to minor trauma by blistering hence the feet are commonly involved.

Front 56

What is pemphigus?

Back 56

1. Relatively rare blistering disorder seen in middle age
2. Lesions tend to be intraepidermal and rupture easily
3. Pemphigus rarely affects the feet but oral lesions may be present
4. +ve Nikolosky's sign - ability to raise a blister when firm finger pressure is applied across the affected skin

Front 57

What is Nikolosky's sign?

Back 57

Ability to raise a blister when firm finger pressure is applied across the affected skin

Front 58

What is the sign called when there is an ability to raise a blister when firm finger pressure is applied across the affected skin?

Back 58

Nikolosky's sign

Front 59

What is bullous pemphigoid?

Back 59

1. Usually affects the over-sixties
2. Presents with large, tense, subepidermal blisters emerging on urticated skin including the foot

Front 60

What is dermatitis herpetiformis?

Back 60

1. Seen on extensor surfaces but rarely below the knees
2. Blisters are typically small and grouped with the appearance of herpetic lesions.
3. Pruritis is a common early symptom
4. Most sufferers also have coeliac disease

Front 61

What are the six subtypes of eczema?

Back 61

1. Atopic dermatitis
2. Asteatotic eczema
3. Discoid eczema
4. Lichen simplex
5. Stasis dermatitis (venous eczema, gravitational eczema)
6. Pompholyx

Front 62

What are the six factors for atopic dermatitis?

Back 62

1. Most common in childhood
2. Itch is the main symptom with rash localised to the flexures
3. Patients often have other allergic diseases
4. Due to constant scratching and rubbing, the skin roughens and reddens then become broken and later infected
5. The usual pathogen is Staph aureus which produces golden weeping and crusted skin
6. Later the skin thickens with accentuation of normal skin folds (lichenification)

Front 63

What are the four factors for asteatotic eczema?

Back 63

1. Usually seen in the elderly, especially those in institutional care
2. It results from low humidity, poor rinsing of soaps or detergents or over-vigorous washing.
3. Usual symptom is soreness and itching, most frequently on the shins
4. The skin is scaly, pink and the surface broken in a crazy paving pattern

Front 64

What are the four factors for discoid eczema?

Back 64

1. It is a very localised form of eczema
2. It presents as multiple, isolated and coin-shaped lesions.
3. Patients will complain of itching and because of the shape of the lesion assume they have a fungal infection
4. Lesions are red, scaly and superficially infected with golden crusting

Front 65

What are the five factors for lichen simplex?

Back 65

1. Patients usually complain of one or two itching patches
2. It frequently occurs on the medial aspect of the ankles and lateral calves
3. Itching may be very severe and the skin reacts by becoming thickened and lichenified
4. Sometimes the lesions may resemble plaques and other times nodules
5. The lesions are usually pink or brown and may be mistaken for lichen planus or psoriasis

Front 66

What are the five factors for stasis dermatitis (venous eczema, gravitational eczema)?

Back 66

1. Affects the lower legs
2. It usually occurs in patients with venous disease
3. Patients complain of itching or soreness and may have a history of previous venous ulceration
4. The skin is red, scaly and weeping. The underlying skin may feel firm and be discoloured blue brown with previous leakage of blood into the skin
5. Allergic contact dermatitis should always be considered as this is a common secondary feature

Front 67

What are the two factors of pompholyx?

Back 67

1. This is acute eczema of the palms and soles
2. As the plantar skin is so thick instead of the skin weeping it forms small blisters under the skin

Front 68

What are flexures?

Back 68

Skin folds, armpits, under the breast, between the buttocks and the groin and genital area. The parts of the skin that touch when a joint bends are called the flexor surfaces eg the flexor surface of the arm is the inner arm and the flexor surface of the leg is the back of the leg

Front 69

What are extensor surfaces?

Back 69

The parts of the skin on the opposite side of the joint are called the extensor surfaces.
eg the extensor surface of the arm is the outer arm, and the extensor surface of the leg is the front of the leg.

Front 70

What are the three factors of psoriasis?

Back 70

1. It consists of well defined, red plaques with loosely adherent silvery scales localised to the extensor surfaces
2. The nails develop pitting and ridging. The nail may come away and the undersurface of the nail can develop thick scaling
3. Arthritis is commonly associated with psoriasis

Front 71

What are four subtypes of psoriasis?

Back 71

1. Classic plaque psoriasis
2. Guttate psoriasis
3. Palmar plantar pustular psoriasis
4. Generalised pustular psoriasis and erythroderma

Front 72

What are the three factors of classic plaque psoriasis?

Back 72

1. The symmetrical rash affects the extensor surfaces of the skin, the knees and shins are frequently involved
2. The plaques are variable in size, pink, red or purple and well demarcated. The scales are large and silver in colour and can be easily scraped away revealing pinpoint bleeding
3. Usually nail changes will be evident on the toes

Front 73

What are the four factors of guttate psoriasis?

Back 73

1. This variant follows a streptococcal sore throat
2. Within a couple of weeks small innumerable plaques of psoriasis cover the body
3. The rash tends to resolve with no treatment in 2-3 months
4. Occasionally it can be recurrent or go on to develop into classical plaque type

Front 74

What are the five factors of palmar plantar pustular psoriasis?

Back 74

1. Occurs mainly in middle-aged female smokers
2. It is characterised by pustules on the palms and soles. The pustules initially are creamy coloured; as they mature they turn brown, the roof falls away leaving a scaly depression
3. Commonly mistaken for fungal or bacterial disease
4. A single digit may be all that is involved and the nail may be destroyed permanently
5. Smoking cessation does not help the rash

Front 75

What are the xx factors of generalised pustular psoriasis and erythroderma?

Back 75

1. In this variant it is widespread, of acute onset, often with systemic upset
2. Lakes of pus can develop on the skin which later scale
3. Occasionally it can be so widespread it affects the whole body causing loss of normal skin function.
4. Patients can become very ill and may die

Front 76

What is erythroderma?

Back 76

Intense and usually widespread reddening of the skin

Front 77

What are the two factors for vasculitis?

Back 77

1. There is inflammation within the blood vessels that results in leakage of blood into the surrounding skin
2. Lesions do not blanch. Early lesions are raised, red and itchy. Later the skin may blister or ulcerate.

Front 78

What are the five factors for lichen planus?

Back 78

1. LP is a common inflammatory condition that frequently affects the lower leg
2. The main presenting symptom is itch and rash. The rash consists of multiple, flat-topped, polygonal papules that have a shiny surface. The colour is pale pink through to violet and sometimes brown
3. The nails are also involved becoming pitted. Later the nail thins and becomes abnormal sometimes resulting in destruction of the nails
4. On the lower leg, LP can become very hypertrophic
5. LP is relatively short-lived (1-2 years) but hypertrophic disease may become chronic

Front 79

What are the four factors for granuloma annulare?

Back 79

1. Frequently misdiagnosed as tinea
2. Affects people under 30 particularly children
3. It starts as a single red papule spreading concentrically, becoming concave in the centre with a pink papular edge
4. The lesion is rarely scaly and does not itch

Front 80

What are the two factors for necrobiosis lipoidica?

Back 80

1. This condition occurs on the shin and is commonly seen in diabetics
2. The lesions start as red patches which enlarge. The centre becomes depressed and the skin yellows. Blood vessels may be visible traversing the patch.

Front 81

What are the three factors for chilblains (perniosis)?

Back 81

1. A familial vasospastic response to prolonged exposure to cold
2. Lesions begin on the apices of the toes, fingers and occasionally the ears
3. The chilblain begins as an erythema turning into a purple swollen lesion that may itch and burn. Ulceration is not uncommon

Front 82

What is the medical term for chilblains?

Back 82

Perniosis

Front 83

What is perniosis?

Back 83

Chilblains

Front 84

What are the two factors for erythrocyanosis?

Back 84

1. It commonly affects young, overweight women particularly those working in a cold environment
2. Cold evokes a vasospastic response resulting in purple discolouration of the buttock, thigh and shin area accompanied by a burning sensation

Front 85

What are the two factors for erythema multiforme?

Back 85

1. The lesions are symmetrical, concentric 'target' lesions occurring on the hands, feet and limbs.
2. Lesions may have a blistered bluish red centre with a more vivid surrounding erythema

Front 86

What are seven common causes of allergens in the lower limb?

Back 86

1. In the thigh (pocket area), phosphorous sesquisulphate (matches)
2. In the popliteal fossa, dyes in nylon tights
Foot and ankle
3. Venous leg ulcer treatments
4. Chromates (leather tanning)
5. Adhesives (epoxy resins)
6. Metals (nickel in buckles)
7. Medicaments especially those containing lanolin and parabens

Front 87

What are four reactions to drugs?

Back 87

1. A true allergic reaction to a drug (hypersensitivity)
2. The effects of overdosage (toxic reaction)
3. Side effects of a drug
4. Alteration by the drug of the normal immune response

Front 88

What are five patterns of drug eruptions?

Back 88

1. Toxic erythema - generalised erythema accompanied by fever
2. Urticaria
3. Erythema multiforme
4. Vasculitis - typically seens as painful purpura on the shins
5. Erythema nodusum

Front 89

What are the two sorts of infection of the skin?

Back 89

1. Viral
2. Bacterial

Front 90

What are three viral infections that affect the lower limb?

Back 90

1. Verrucae
2. Molluscum contagiosum
3. Herpes zoster (shingles)

Front 91

What are the eight factors for verrucae?

Back 91

1. Predominant viral infection of the foot
2. Caused by infection of the skin by the HPV virus
3. The virus affects the stratum spinosum and causes hyperplasia and formation of a benign tumour
4. In its early stages it appears as a small dark translucent puncture mark on the skin. More mature lesions show thrombosed capillaries
5. Mosaic warts are made up of multiple small tightly packed individual warts and may not be painful whereas plantar warts may be single or multiple and are usually painful
6. Verrucae can occur on non-weightbearing and weightbearing unlike corns which only appear on weight-bearing surfaces
7. Pinching causes great pain whereas pressing a corn causes pain if it is a corn
8. Verrucae appear encapsulated and the skin striae are broken whereas corns do not appear capsulated and the skin striae are not broken but pushed to one side

Front 92

What are the three factors for molluscum contagiosum?

Back 92

1. This is usually a contagious infection (usually of children) which involves the trunk but can affect the leg and foot
2. The lesion is papular and may range in size from a pinhead to a pea
3. The hard, shiny, pedunculated lesion has a central crater from which cheesy material may be expressed by pinching it

Front 93

What are the xx factors for herpes zoster (shingles)?

Back 93

1. Shingles is a recrudescence of previous chicken pox
2. It can occur at any age but most frequently in the elderly or immunosuppressed.
3. It presents as a 1-3 day history of pain or burning in one limb followed by haemorrhagic blisters and later superficial ulcers. Pain may persist for many weeks and months

Front 94

What are four bacterial infections that affect the lower limb?

Back 94

1. Ecthyma
2. Cellulitis
3. Pitted keratolysis
4. Erythrasma

Front 95

What are the four factors of ecthyma?

Back 95

1. This infection affects the full thickness of the epidermis
2. The main pathogens are Staph aureus and Streptococcus pyogenes
3. The patient may have recently been to a humid climate or had an insect bite
4. It presents as a shallow ulcer with a thick crusted top

Front 96

What is the medical term for cellulitis?

Back 96

Erysipelas

Front 97

What is erysipelas?

Back 97

Cellulitis

Front 98

What are five factors for cellulitis (erysipelas)?

Back 98

1. It is a serious infection
2. It caused mainly by Streptococcus pyogenes
3. It presents as a flu-like illness that is rapidly followed by a painful red advancing area usually on the lower leg
4. The affected area becomes swollen and the skin discoloured. The skin may even blister, necrose and ulcerate
5. Commonly a portal of entry is found such as tinea pedis or a fissured patch of eczema

Front 99

What are the five factors for pitted keratolysis?

Back 99

1. Bacterial overgrowths on the sole of the foot secrete proteolytic enzymes that produce multiple pits within the epidermis
2. The pathogens are microaerophilic diphtheroids
3. It is particularly common in patients with sweaty feet or who wear trainers.
4. Usually it is asymptomatic but sometimes the skin thins sufficiently to be tender
5. Odour is commonly offensive in such patients

Front 100

What are the four factors for erythrasma?

Back 100

1. It is a bacterial infection of creases and flexures between the toes of the foot
2. The pathogen is Proprionobacterium minutissimum
3. The skin is usually macerated and red/brown in colour
4. It has a strong odour and fluoresces coral pink in Wood's light

Front 101

What colour does microsporum fluoresce under Wood's light?

Back 101

Green

Front 102

What are the five patterns of fungal infection of the foot (tinea pedis)?

Back 102

1. Extension onto the dorsa of the foot
2. Blistering in the instep
3. Moccasin foot
4. Onychomycosis
5. Tinea incognito

Front 103

What are the four factors for fungal infections that extend onto the dorsum of the foot?

Back 103

1. In chronic disease the fungal infection spreads onto the dorsum
2. It produces itchy scaly rings with an active edge
3. The DDX is discoid eczema
4. Typical fungal causes include Tricophyton rubrum and less commonly Epidermophyton floccosum

Front 104

What are the three factors for fungal infections that cause blistering in the instep?

Back 104

1. It is an inflammatory reaction to fungus on the sole
2. The pathogen responsible is Tricophyton mentagrophytes
3. It is usually unilateral

Front 105

What are the three factors for moccasin foot?

Back 105

1. The sole of the foot can be generally involved with fungus (Tricophyton rubrum)
2. It produces thickened, scaly feet
3. Usually bilateral and the nails may also be involved

Front 106

What are the four factors for onychomycosis?

Back 106

1. Tinea pedis may progress to the toe nails
2. Infection may occur superficially on the nail plate or subungually invading under the hyponychium.
3. Proximal subungual involvement occurs rarely in immunocompromised patients or following chronic paronychia.
4. Total nail involvement and dystrophy may result

Front 107

What are the four factors for tinea incognito?

Back 107

1. Misdiagnosis of fungal infection is a problem as often the incorrect diagnosis made is eczema
2. The use of topical steroid to reduce inflammation consequently allows the unsuspected fungus to grow unchecked by the immune system
3. Patients present with a history of a persistent rash usually on the foot which fails to respond to steroid creams
4. The rash is red, ill-defined with nodules within that when squeezed express pus

Front 108

What is the four factors for scabies?

Back 108

1. Caused by the mite Sarcoptes scabei
2. Severe itching despite minimal evidence of infestation
3. Patients may describe itchy nodules or blisters, more pronounced than eczema
4. The primary lesion is the burrow of the mite, a linear or serpiginous white line with scaly opening at one end and a minute grey or red dot at the other end (mite)

Front 109

What are the four factors for larvae migrans (hookwork larvae)?

Back 109

1. The immature form of the parasite penetrates the skin and as the larvae migrate produces loops and tracks
2. Patients usually complain of itch and blistering
3. They are usually contracted on beaches or moist soil where faeces infected with hookworm have been
4. The disease is self-limiting

Front 110

What are three disorders of the subcutaneous tissue?

Back 110

1. Atrophy
2. Painful piezogenic papules
3. Erythema nodosum

Front 111

What is the subcutaneous layer of the skin?

Back 111

It is a layer of primarily adipose tissue and covers most of the lower limb, particularly the thighs, anterior shins and plantar surface

Front 112

What are the four factors for atrophy of the subcutaneous tissue?

Back 112

1. It is the most common disorder affecting the subcutaneous layer.
2. It occurs most frequently as a result of ageing and trauma eg heel pad atrophy in long distance runners and the elderly
3. Granulomatous change (panniculitis) around injection sites
4. Affected skin becomes depressed and scarring may occur

Front 113

What is panniculitis?

Back 113

Inflammation of subcutaneous tissue

Front 114

What is the medical term for inflammation of subcutaneous tissue?

Back 114

Panniculitis

Front 115

What are the three factors for painful piezogenic papules?

Back 115

1. On the plantar surface around the heels herniation of fat from the heel pad into the dermis may be evident on standing
2. As solitary or multiple nodules they may occasionally give rise to heel pain usually in middle-aged females
3. Diagnosis is established as pain will result from direct pressure while standing but when NWB the lesion completely disappears

Front 116

What are the four factors for erythema nodosum?

Back 116

1. This is an uncommon eruption affecting the shins presenting as painful nodules on the shins and less commonly the thighs and forearms
2. The rash starts as painful areas that enlarge into hot, red nodules which are acutely tender
3. These then resolve over a matter of weeks. The redness fades and takes on a bruised appearance
4. The condition is often associated with other diseases such as sarcoidosis and a variety of infections

Front 117

What is sarcoidosis?

Back 117

A multisystem disorder characterized by non-caseating granulomas (small inflammatory nodules) which can affect any organ in the body

Front 118

What six associated skin changes in the lower limb and foot are associated with diabetes mellitus?

Back 118

1. Increased incidence of skin infections (fungal and bacterial)
2. Skin stiffening
3. Ulceration (neurovascular)
4. Diabetic bullae
5. Necrobiosis lipoidica
6. Granuloma annulare

Front 119

What are diabetic bullae?

Back 119

Diabetic bullae are blister-like lesions that occur spontaneously on the feet and hands of diabetic patients. Although rare, it is a distinct marker for diabetes. Diabetic bullae appear to occur more commonly in men than women and between the ages of 17-84 years. It is also more common in patients whom have long-standing diabetes or with multiple diabetic complications

Front 120

What are associated skin changes in the lower limb and foot associated with lupus erythematosus?

Back 120

Erythematous scaly plaques with follicular plugging

Front 121

What are six associated skin changes in the lower limb and foot associated with systemic lupus erythematosus?

Back 121

1. Periungual erythema
2. Splinter haemorrhages
3. Onycholysis
4. Leuconychia
On the legs
5. Erythromelalgia - where blood vessels are episodially blocked and inflamed
6. Erythema nodosum

Front 122

What is erythromelagia?

Back 122

Erythermalgia, is a rare disorder in which blood vessels, usually in the lower extremities, are episodically blocked and inflamed

Front 123

What are two associated skin changes in the lower limb and foot associated with dermatomyositis?

Back 123

1. Periungual erythema with characteristic "ragged cuticles"
2. Occasional calcification within the skin

Front 124

What is dermatomyositis?

Back 124

Dermatomyositis is a connective-tissue disease related to Polymyositis that is characterized by inflammation of the muscles and the skin.

Front 125

What are associated skin changes in the lower limb and foot associated with systemic sclerosis/scleroderma?

Back 125

Tight waxy skin with later distal digital atrophy with calcinosis, ulceration and occasionally gangrene

Front 126

What is systemic sclerosis/scleroderma?

Back 126

Scleroderma is a chronic autoimmune disease characterized by a hardening or sclerosis in the skin or other organs. The systemic type or systemic sclerosis, the generalized type of the disease, can be fatal, as a result of heart, kidney, lung or intestinal damage

Front 127

What are four associated skin changes in the lower limb and foot associated with Ehlers-Danloss syndrome?

Back 127

1. Fragile skin with frequent bruising
2. Hypermobility
3. Poor wound healing
4. Showing large scars on the knees

Front 128

What are five associated skin changes in the lower limb and foot associated with RA?

Back 128

1. Skin atrophy
2. Nodules
3. Vasculitis with periungual infarcts
4. Splinter haemorrhages
5. Onycholysis with longitudinal ridging of the nails

Front 129

What are five associated skin changes in the lower limb and foot associated with hyperthyroidism?

Back 129

1. Hyperhidrosis
2. Clubbing
3. Onycholysis
4. Hyperpigmentation
5. Pretibial myxoedema

Front 130

What is pretibial myxoedema?

Back 130

Pretibial myxoedema presents with a swollen and lumpy appearance over the shins and sometimes also affects the feet. The skin may be discoloured pink or purple, with prominent hair follicles. This is known as ‘peau d'orange’ (orange-peel) appearance. It may instead look warty or ‘verrucous’

Front 131

What are the four associated skin changes in the lower limb and foot associated with hypothyroidism?

Back 131

1. Anhidrosis
2. Leuconychia
3. Pruritis
4. Palmar and plantar hyperkeratosis

Front 132

What are three associated skin changes in the lower limb and foot associated with acromegaly?

Back 132

1. Hyperhidrosis
2. Skin thickening
3. Coarse hair

Front 133

What are three associated skin changes in the lower limb and foot associated with hepatic disease?

Back 133

1. Clubbing
2. Spider naevi
3. Pruritis

Front 134

What are three associated skin changes in the lower limb and foot associated with renal disease?

Back 134

1. Hyperpigmentation or skin yellowing
2. Nail changes - half and half nails
3. Onycholysis

Front 135

What is a skin change in the lower limb and foot associated with Reiter's disease?

Back 135

Keratoderma blennorhagica

Front 136

What are six associated skin changes in the lower limb and foot associated with internal malignancy?

Back 136

1. Hyperpigmentation
2. Palmoplantar keratoderma
3. Secondary skin tumours
4. Pruritis
5. Nail clubbing
6. Bullous eruptions

Front 137

How many types of pigmented lesions are there and what are they?

Back 137

1. Freckles or ephelis
2. Lentigo
3. Seborrhoeic warts
4. Pigmented naevi
5. Junctional naevi
6. Blue naevi
7. Malignant melanoma

Front 138

What 2 process can pigmented lesions arise as a result of?

Back 138

1. Neoplastic processes
2. Inflammatory processes

Front 139

What are the three factors for freckles (ephelis)?

Back 139

1. Most common pigmented lesions, particularly in fair-skinned people exposed to the sun
2. They are usually innumerable, visible but not palpable and the pigmentation is usually evenly distributed and is generally slight
3. Darker freckles can also occur particularly after prolonged or excessive sun exposure

Front 140

What are the three factors for lentigo?

Back 140

1. It is a lesion where there is an increase in the number of melanocytes within the skin resulting in a pigmented patch
2. Lesions usually occur in older patients and arise on sun-exposed sites
3. The lesion is visible and not palpable, tends to be solitary and the pigmentation within it is usually light and always even

Front 141

What are the four factors for seborrhoeic warts?

Back 141

1. Very common, developing with advancing age
2. They appear as well-defined rough warty slightly raised lesions that have a stuck-on appearance
3. They usually occur on the trunk and proximal limbs but can arise on the lower leg. They do not develop on the sole
4. They are always benign but can become inflamed after minor trauma and may be mistaken for malignancy

Front 142

What is the medical term for moles?

Back 142

Pigmented naevi

Front 143

What do moles consist of?

Back 143

Melanocytes

Front 144

What is the common name for pigmented naevi?

Back 144

Moles

Front 145

What colour are moles when they are close to the epidermal surface?

Back 145

Red/brown

Front 146

What colour are moles when they are deeper in the skin?

Back 146

They become bluer

Front 147

What are junctional naevi?

Back 147

Collections of melanocytes (moles) along the dermal-epidermal junction

Front 148

What are collections of melanocytes (moles) along the dermal-epidermal junction?

Back 148

Junctional naevi

Front 149

Where are junctional naevi commonly found?

Back 149

The sole of the foot

Front 150

What are blue naevi?

Back 150

Melanocytes that have never reached the epidermis and instead have proliferated in the deeper dermis. They do not blanch and are almost always benign

Front 151

What are the six signs of malignant melanoma?

Back 151

1. Itching is an early and significant symptom particularly where the melanoma is not in general view
2. There may be a change in the surface of the mole, skin creases may be lost and hair follicles and pores may disappear
3. There will always be an increase in the size, shape or thickness of the mole which occurs over weeks and months and is usually asymmetrical
4. Colour will change within a mole. Pigment can both increase and decrease within the same lesion. Also as the melanocytes invade deeper into the skin they may appear blue or black. Rarely melanoma may lose all pigmentation
5. The surface of the melanoma may ulcerate and bleed particularly in advanced disease
6. The tumour may have spread by the time it is picked up. Tumours may develop along the lines of lymphatic drainage (in transit metastasis) in the draining lymph nodes or at distant sites

Front 152

What are eight benign tumours affecting the lower limb?

Back 152

1. Dermatofibroma
2. Seborrhoeic wart
3. Haemangioma
4. Lipoma
5. Clear cell acanthoma
6. Pyogenic granuloma
7. Eccrine poroma
8. Glomus tumour

Front 153

What are seven malignant tumours affecting the lower limb?

Back 153

1. Bowen's disease
2. Basal cell carcinoma
3. Squamous cell carcinoma
4. Melanoma
5. Kaposi's sarcoma
6. Porocarcinoma
7. Metastasis

Front 154

State four key facts about dermatofibromas.

Back 154

1. Always benign
2. Usually Asymptomatic
3. Firm tethered nodules in the skin sometimes with a slightly elevated surface.
4. Pigmented halo is often mistaken for sinister lesion

Front 155

What are five factors of pyogenic granulomas?

Back 155

1. They are common vascular proliferations
2. They grow rapidly over a few days or weeks.
3. They usually follow a minor injury
4. The surface is very easily broken and bleeding may be prolonged and frequent
5. In time, the lesion develops a surface epithelium that is more resilient, ultimately resemblinga haemangioma

Front 156

What are four factors for eccrine poroma

Back 156

1. They are benign tumours of the sweat duct that arise on the palms and soles
2. They are found in the over 40 age group
3. They are pink or red, painless and usually 1-2cm in diameter with a moist surface, surrounded by a moat-like depression
4. Occasionally they can undergo malignant change

Front 157

What is a haemangioma?

Back 157

Strawberry mark

Front 158

What is the medical term for a strawberry mark?

Back 158

Haemangioma

Front 159

What is a clear cell acanthoma?

Back 159

Clear cell acanthoma is a rare benign epithelial skin tumour

Front 160

What are four factors for Bowen's disease?

Back 160

1. It is a squamous cell carcinoma confined to the epidermis only
2. It is a condition of the elderly
3. It presents as a well-defined, erythematous, scaly patch on the lower leg. When the scale is picked off the surface may bleed and weep. The lesions are sometimes multiple
4. Left untreated they may persist for year but sometimes the disease can progress on to true invasive squamous cell carcinoma

Front 161

What are the five factors for basal cell carcinoma?

Back 161

1. Basal cell carcinoma usually presents on the face but occasionally occurs on the lower legs
2. Usually it presents as a fleshy nodule with a pearlescent appearance, having small blood vessels grossing the surface.
3. Advanced lesions ulcerate and if neglected may become very large
4. Despite being locally destructive they do not metastasise
5. Occasionally they remain superficial and indistinguishable from Bowen's disease

Front 162

What are the six factors for squamous cell carcinoma?

Back 162

1. It is a common malignant tumour of the lower leg presenting as a lump or as a bleeding ulcer
2. The tumour grows over a period of weeks and months
3. In time the tumour becomes painful particularly if it is invading bone or nerves
4. Occasionally it may develop with an old scar or leg ulcer. This should be considered especially in ulcers that fail to heal with conventional measures or ulcers with fleshy or rolled edges
5. Metastasis generally tends to be a late event usually to the regional lymph nodes
6. An SCC that arises on the foot may invade deeply with only minimal surface involvement mimicking pressure or neuropathic ulcers. Often in this site the tumour will have multiple sinuses that discharge offensive-smelling material

Front 163

What are four factors for Karposi's sarcoma?

Back 163

1. It presents as blue-black or purple patches that later become plaques or nodules.
2. Tumours range from 1-3cm and are usually multiple
3. Later lesions may involute or ulcerate and oedema may become a problem
4. Karposi's is associated with HIV

Front 164

What are two factors for porocarcinoma?

Back 164

1. It is a rare sweat duct tumour which often occurs on the lower leg
2. The history and clinical appearances are similar to SCC but the tumours are more likely to recur and metastasise.

Front 165

What are xx factors for metastasis?

Back 165

1. Tumours on the lower legs can metastasise to the draining lymph vessels and nodes particularly melanoma and squamous cell carcinoma
2. The tumours will usually appear as subcutaneous nodules and may be large
3. They may be firm and may feel as if they are attached to related structures

Front 166

What is the vamp?

Back 166

The front section which covers the forefoot and toes is called the vamp. The vamp is usually reinforced anteriorly by the toe puff which maintains the shape of this section and protects the toes

Front 167

What is the quarter of the shoe?

Back 167

The sides and back of the shoe upper are the quarters. The top edge forms the top line of the shoe. The medial and lateral sections often join in a seam at the centre of the heel. The eyelets for the laces form the anterior part of the quarter

Front 168

What are three factors about the linings of shoes?

Back 168

1. Linings are included in the quarters and vamps of shoes to increase comfort and durability
2. The lining for the bottom of the shoe is called the insock
3. It may cover the entire length of the shoe, three quarter or just the heel section

Front 169

What are two factors for the throat of a shoe?

Back 169

1. The throat is formed by the seam joining the vamp to the quarter.
2. The seam will not stretch and therefore dictates the maximum width of foot for which the shoe can be used

Front 170

What is a mudguard in a sports shoe?

Back 170

It is the reinforcing round the outside of the rim of the toe

Front 171

What is a saddle in a sports shoe?

Back 171

The saddle is reinforcing stitched to the outside of the shoe in the area of the arch

Front 172

What are three factors about collars and heel tabs in sports shoes?

Back 172

1. The topline of a sports shoe is often padded to form the collar
2. This may be shaped up around the back of the Achilles tendon to form a heel tab
3. Heel tabs were designed to protect the Achilles tendon but sometimes rub sensitive feet

Front 173

What are eleven points to look for in an ideal shoe?

Back 173

1. Laces with at least three eyelets
2. Low wide heel for good stability
3. Good width at the front of the shoe to prevent cramping the toes
4. Deep reinforced toe box
5. Firm stiffening around the heel
6. Curved back for close fit around the heel
7. Shaped topline, high enough up the instep for adequate fixation
8. Strong leather upper
9. Hard-wearing synthetic sole
10. Good fit
11. Good condition

Front 174

What are the four things to be looked at in an X-ray?

Back 174

1 A = alignment and variations
2. B = bone density
3. C = cartilage
4. S = soft tissue

Front 175

What is the cyma line on an X-ray?

Back 175

The talonavicular and calcaneocuboid joints together produce a superimposition on a lateral X-ray known as the cyma line. These curved joints together form a reverse 'lazy S' as an intact curve in a normal foot. In a pronated foot the S becomes broken as the talonavicular joint moves anterior and plantar to the calcaneocuboid joint and the reverse happens in a supinated foot.

Front 176

What are the ten accessory ossicles of the foot?

Back 176

1. Os tibiale externum
2. Processus uncinatus
3. Os intercuneiforme
4. Parsponea metatarsalia
5. Cuboideum secundarium
6. Os peroneum
7. Os vesalianum
8. Os intermetartarsum
9. Os naviculare
10. Os trigonum

Front 177

What is os tibiale externum?

Back 177

This ossicle lies under the insertion of tibialis posterior as it crosses the navicular and is subject to problems following forced abduction or eversion injuries

Front 178

What is os peroneum?

Back 178

This ossicle lies under peroneus longus in the peroneal groove of the cuboid and is sometimes not noticed except on a lateral or oblique X-ray. Occasionally it can be symptomatic particularly in a supinated foot

Front 179

What is os vesalianum?

Back 179

This ossicle is a secondary epiphysis at the 5th metatarsal base and must be differentiated from an avulsion fracture

Front 180

What is polydactyly?

Back 180

The presence of additional phalanges or complete digits

Front 181

What is the name for the presence of additional phalanges or complete digits?

Back 181

Polydactyly

Front 182

What is brachydactyly?

Back 182

The partial failure of development of a metatarsal segment or phalanges

Front 183

What is the partial failure of development of a metatarsal segment or phalanges?

Back 183

Brachydactyly

Front 184

What are the three forms that coalitions can take and what are they?

Back 184

1. Fibrous (syndesmosis)
2. Cartilaginous (synchondrosis)
3. Osseous (synostosis)

Front 185

What are the three types of coalitions?

Back 185

1. Talonavicular bar
2. Calcaneonavicular bar
3. Talocalcaneal bar

Front 186

What joint do coalitions limit?

Back 186

Subtalar joint motion

Front 187

What is increased indensity of bone on an X-ray called?

Back 187

Osteosclerosis or eburnation

Front 188

What is osteosclerosis or eburnation?

Back 188

It is increased indensity of bone on an X-ray

Front 189

What is decreased density of bone on an X-ray called?

Back 189

Osteopenia

Front 190

What is osteopenia on an X-ray?

Back 190

It is decreased density of bone

Front 191

What are the 10 causes of osteoporosis?

Back 191

1. Decrease in hormone production
2. Hypopituitarism - reduces bone growth and produces short, slender bones with thin cortices and there are delays in epiphyseal fusion
3. Cushing's syndrome - hyperactivity of the adrenal glands or pituitary adenoma
4. Turner's syndrome - undeveloped ovaries
5. Hyperthyroidism - excessive thyroid hormone replacement therapy increases the rate of bone remodelling
6. Disorders of Vitamin D metabolism - causes rickets in children and osteomalacia in adults
7. Hyperparathyroidism - due to hyperplasia of the parathyroid glands (primary type), persistent stimulation due to low serum calcium levels (secondary type) or an adenoma (tertiary type) or carcinoma will reduce bone density by resorption of calcium salts
8. Disuse of limbs - after injury or surgery
9. Autoimmune disease such as RA produce bone density changes
10. Smoking and alcohol intake

Front 192

What are seven causes of osteosclerosis?

Back 192

1. Hypoparathyroidism - deficiency of parathormone results in blood calcium levels falling and phosphate levels rising which can result in short lesser metatarsals, calcification in some ligaments of the spine
2. Hypervitaminosis D can lead to increased distal metaphyseal calcification and calcium deposits in the skin and periosteum
3. Paget's disease - causes excessive bone resorption followed by haphazard new bone formation and remodelling with severe characteristic thickening and deformity. Although the bones are very enlarged and appear dense they are of poor quality
4. Metastatic bone disease produces sclerotic changes
5. Osteopetrosis - causes thickening of the trabeculae in all the bones making them more susceptible to shear forces and may fracture more easily
6. Increased fluorine ingestion leads to laying down of new bone inside the medullary cavity
7. Epiphyseal, metaphyseal and diaphyseal dysplasias which can cause increased bone density

Front 193

What is Albers-Schonberg disease (marble bone disease)?

Back 193

It is a rare hereditary disorder causing thickening of the trabeculae in all the bones

Front 194

What four appendages can undergo calcification?

Back 194

1. Small arteries due to diabetes, hyperparathyroidism and ateriosclerosis
2. Muscles and tendons due to injury
3. Bursa
4. Sinus tracts

Front 195

What causes gout?

Back 195

Crystalline sodium urate monohydrate deposits usually close to a joint

Front 196

What causes pseudogout?

Back 196

Deposits of pyrophosphate crystals

Front 197

What is calcinosis cutis?

Back 197

Where calcium deposits form in the skin

Front 198

What is the condition called when calcium deposits form in the skin?

Back 198

Calcinosis cutis

Front 199

How long would evidence of infection take to show up on an X-ray?

Back 199

10 days or more

Front 200

What is the process of bone infection?

Back 200

1. The infection firstly spreads into the medullary bone
2. Infection will not cross the epiphyseal line
3. It then passes through the cortex and the pus produced elevates and strips the periosteum
4. This gives a fuzzy outline to the bone
5. The bone will lose density appear hazy
6. In time a loose body or sequestrum may be formed
7. This can be passed to the surface by sinus formation or it may eventually be reabsorbed or remodelled
8. In some cases a remodelling of the cortex may produce a sclerotic osseous shell called an involucrum which encapsulates the sequestrum
9. If treatment is inefficient a chronic walled-off abscess containing debris and sometimes a sequestrum may form and persist for years
10. This is known as Brodie's abscess

Front 201

What are the 7 causes of bone infections?

Back 201

1. Blood-borne
2. Secondary to a direct entry wound such as surgery or a compound fracture
3. Tuberculosis
4. Leprosy
5. Syphilis
6. Viral agents such as smallpox
7. Acute bacterial infections caused by Staph aureus, Staph pyogenes, Salmonella or Haemophilus influenzae

Front 202

What is the disease process of OA?

Back 202

1. Irregularity and narrowing of the cartilaginous space which may or may not be accompanied by deformity
2. The cartilage will degenerate and become calcified (chondrocalcinosis) and the joint space slowly disappears
3. There will be increased sclerosis and there may be the formation of subchondral cysts
4. At the periphery of the joint there will be clearly visible spiky outgrowths of bone (osteophytes) which tend to grow at right angles to the long bone axis and can attain considerable size
5. Osteophytes severely limit joint motion and will also cause pain and pressure problems for the patient.
6. In later stages of the disease the joint will become partially or fully ankylosed and the osteophytes may fracture causing loose bodies within the joint capsule

Front 203

What are three autoimmune diseases that attack the joints?

Back 203

1. RA
2. Scleroderma
3. Disseminated lupus erythematosus

Front 204

What is the disease process in joints in autoimmune disease?

Back 204

1. Early changes are effusion into the joint capsule as the synovial linings are attached with an intracapsular increase in density
2. The epiphyses of the long bones become demineralised and as the synovial pannus invades the bone there is a progression towards erosions at the chondral margins, loss of cortex and punched out periarticular erosions.
3. There is a progressive loss of normal trabecular patterns and generalised osteoporosis.
4. Articular and bony changes are associated with progressive deformity and characteristic abduction deformities of digits
5. Gross subluxations and dislocations will be evident in severe cases
6. There is usually midtarsal and rearfoot involvement in long-standing cases
7. Radiographic signs of severe pronation may often be seen.

Front 205

What is avuscular necrosis of the femoral epiphysis called?

Back 205

Legg-Calve-Perthes disease

Front 206

What is Legg-Calve-Perthes disease?

Back 206

Avuscular necrosis of the femoral epiphysis

Front 207

What is avuscular necrosis of the vertebral epiphysis?

Back 207

Scheuermann's disease

Front 208

What is Scheuermann's disease?

Back 208

Avuscular necrosis of the vertebral epiphysis

Front 209

What is avuscular necrosis of the tibial tubercle?

Back 209

Osgood-Schlatter's disease

Front 210

What is Osgood-Schlatter's disease?

Back 210

Avuscular necrosis of the tibial tubercle

Front 211

What is the disease process of avuscular necrosis of the epiphysis or apophysis?

Back 211

1. There is a transient increase in sclerosis caused by the failure of the blood supply to remove calcium salts followed by osteoporosis, crumbling and degeneration of the epiphysis
2. Revascularisation slowly occurs over a period of months and the epiphysis remodels sometimes with residual deformity
3. The conditions are self-limiting and the clinical importance relates to the functional importance of the joint involved

Front 212

What are the five osteochondroses of the foot and what are they?

Back 212

1. Freiberg's infraction
2. Sever's disease
3. Kohler's disease
4. Iselin's disease
5. Buschke's disease

Front 213

What is the disease process for Freiberg's infraction?

Back 213

1. It affects the lesser metatarsal heads, usually the second or third at the age of about 12-14 years
2. An increase in the joint space may be noted due to the eggshell crush degeneration that occurs in the metatarsal head
3. The finally remodelled head may be flattened or saucer-shaped
4. In later life it may produce secondary hypertrophic osteoarthritic degeneration

Front 214

What is the disease process for Sever's disease?

Back 214

1. Sever's disease of the calcaneal apophysis usually occurs in the age range 8-12 years
2. An irregularity and sclerosis may be exhibited along the apophyseal line on the posterior aspect of the calcaneum. However it should be noted that the apophyseal line is frequently irregular in any case
3. Some authorities believe that a diagnosis of Sever's disease cannot be made with any certainty on radiographic evidence alone

Front 215

What is the disease process of Kohler's disease?

Back 215

1. Kohler's disease of the navicular occurs in children aged 2-10 years.
2. Most are male and it can be familial
3. The navicular becomes dense initially, followed by porosis and collapse into a disc shape
4. If untreated, the bone may not regain proper form and may remain a lifelong problem

Front 216

What is Iselin's disease?

Back 216

Osteochondritis of the 5th metatarsal base

Front 217

What is osteochondritis of the 5th metatarsal base?

Back 217

Iselin's disease

Front 218

What is Buschke's disease?

Back 218

Osteochondritis of the cuneiforms

Front 219

What is osteochondritis of the cuneiforms?

Back 219

Buschke's disease

Front 220

How many types of fracture are there and what are they?

Back 220

1. Simple fractures
2. Stress fractures
3. Compound fractures
4. Complicated fractures
5. Greenstick fractures
6. Comminuted fractures
7. Impacted fractures
8. Avulsion fractures
9. Pathological fractures

Front 221

What is a simple fracture?

Back 221

Where there may or may not be displacement of the bone ends but there is no penetration through the skin

Front 222

What are stress fractures?

Back 222

Extremely fine simple fractures more usually seen on the lesser metatarsals although the tibia and fibula are also recognised sites particularly in runners. The fracture may be so fine as to be missed until a later stage when bony callus can be seen around the site. Suspected stress fractures can sometimes only be confirmed using isotope scanning methods

Front 223

What are compound fractures?

Back 223

Where the skin has been breached by bone

Front 224

What are complicated fractures?

Back 224

Where there is associated trauma or infection involving muscles, tendons and blood vessels

Front 225

What are greenstick fractures?

Back 225

These occur when the bone is bent but only one of the cortex breaks (frequently seen in children)

Front 226

What are comminuted fractures?

Back 226

Where there is splintering or fragmentation

Front 227

What are impacted fractures?

Back 227

Where one bone is forcibly driven into the other

Front 228

What are avulsion fractures?

Back 228

Where a chip of bone is ripped away by fibrous attachment such as muscle or ligament. Such fractures can occur in similar sites to accessory ossicles. The 5th metatarsal base is a common site for a fracture and for os vesalianum and care must be taken to differentiate between them

Front 229

What are pathological fractures?

Back 229

These may occur due to osteoporosis or in cases of primary or secondary neoplastic bone disease

Front 230

What is the fracture called where there may or may not be displacement of the bone ends but there is no penetration through the skin?

Back 230

A simple fracture

Front 231

What is the fracture called which is an extremely fine simple fracture usually seen on the lesser metatarsals and tibia and fibular in runners?

Back 231

A stress fracture

Front 232

What is the fracture called where the skin has been breached by bone?

Back 232

A compound fracture

Front 233

What is the fracture called where there is associated trauma or infection involving muscles, tendons and blood vessels?

Back 233

A complicated fracture

Front 234

What is the fracture called which occurs when the bone is bent but only one side of the cortex breaks (frequently seen in children)?

Back 234

Greenstick fracture

Front 235

What is a fracture called where there is splintering or fragmentation?

Back 235

Comminuted fracture

Front 236

What is a fracture called where one bone is driven forcibly into the other?

Back 236

An impacted fracture

Front 237

What is a fracture called where a chip of bone is ripped away by fibrous attachment such as muscle or ligament?

Back 237

An avulsion fracture

Front 238

What is a fracture called which may occur due to osteoporosis or in cases of secondary neoplastic bone disease?

Back 238

Pathological fractures

Front 239

What are the four certain parts of the foot prone to specific types of fracture?

Back 239

1. Ankle - Potts fracture
2. Calcaneum
3. The talar neck
4. Metatarsal and phalangeal fractures

Front 240

What is a Pott's fracture?

Back 240

This fracture occurs following a forceful direct injury or twist to the ankle and causes a spiral fracture to the fibula c 5-8cm above the malleolus and also fractures the medial malleolus. There is considerable disruption of the ankle mortise and the articular surfaces between the trochlear surface of the talus and the tibia may be damaged

Front 241

What sorts of fractures may occur at the calcaneum?

Back 241

Comminuted or stress fractures following a fall from a height or due to disease processes. A comminuted fracture will show as a line of increased density

Front 242

How can the talar neck be fractured?

Back 242

The talar neck can be fractured by forced ankle dorsiflexion

Front 243

What is the normal timetable for fracture healing?

Back 243

Week 1-2 Extravasation of blood takes place between the broken ends. X-rays show sharp bone edges with or without displacement and effusion into the soft tissues
Week 2-3 A fibrosis occurs in the initial blood clot and calcification forms between the broken ends and may be visualised as a fuzzy plug of tissue. The bone edges will be more blurred. If the fracture is immobilised there will be little or no extra callus formation. A fracture that remains mobile will produce an increased amount of calcified tissue in the area which can be seen clearly on X-ray
Week 3-8 Calcification in an immobilised fracture should be completed. The fracture line will disappear and remodelling of any excess bone will eventually over a period of months restore nearly normal but slightly thickened contours in the bone. A fracture which has not been immobilised or in which the bone ends are not opposed or in a patient with poor circulation or disease processes may continue to delayed or non-union and exhibit osteoporotic changes with extra bone callus continuing to form. The fracture line will remain evident

Front 244

What are six benign bone tumours of the lower limb?

Back 244

1. Osteochondroma (osteocartilaginous exostosis)
2. Enchondroma
3. Solitary (simple) bone cyst
4. Aneurysmal bone cyst
5. Osteoid osteoma

Front 245

What is an osteochondroma?

Back 245

It may occur as a solitary lesion developing from the periosteum. They may be asymptomatic but can cause pain due to pressure on nerves. A subungual exostosis is a good example but they can be found on the femur or tibia

Front 246

What are the three factors for an enchondroma?

Back 246

1. These are benign but can become malignant
2. The tumour is expansile and produces an area of osteoporosis, loss of trabeculation and thin cortices giving a soap bubble appearance
3. Pathological fractures can occur

Front 247

What are four factors for solitary bone cyst?

Back 247

1. It contains clear or serosanguinous fluid
2. It generally occurs in the age range 4-15 years
3. It occurs mainly in the femur but it can occur in the long bones of the foot and calcaneum
4. It may cause cortical thinning with lucent areas in the medulla but does not always expand the bone

Front 248

What are four factors for an aneurysmal bone cyst?

Back 248

1. It is a sponge-like cyst with blood-filled spaces and fibrous septa.
2. It occurs in the age range 20-30 years
3. It occurs mainly in the long bone metaphyses
4. There is a rarefied central area with a thin cortical shell and the cyst will rapidly expand and destroy bone tissue

Front 249

What are the five factors for an osteoid osteoma?

Back 249

1. A most painful lesion which occurs most often in the long bones in the extremities affecting mainly the femur, tibia and feet
2. Found mainly in 5-20 year old males
3. Radiologically it shows as an ovoid translucent nidus up to 2cm in diameter surrounded by an area of sclerosis
4. The patient complains of severe pain at night
5. DDX should include Brodie's abscess

Front 250

What are two factors for synovial chondromatosis?

Back 250

1. This condition occurs mainly in young or middle-aged males
2. Multiple metaplastic cartilaginous bodies form within the synovial membranes around a joint, usually the knee or shoulder but occasionally in the digits. Sometimes they will become true loose bodies within the joint

Front 251

How many types of malignant bone tumours are there and what are they?

Back 251

1. Osteosarcoma
2. Chondrosarcomas
3. Fibrosarcomas
4. Giant cell tumours
5. Ewing's tumours
6. Secondary metastases

Front 252

What are 4 factors for osteosarcoma?

Back 252

1. Commonest primary malignant bone neoplasm.
2. It is not common in the foot but is in the tibia and femur
3. It can occur secondary to Paget's disease
4. X-rays reveal radiating "sunray" spicules of bone raising the periosteum and a mixture of lysis and sclerosis within the shaft of the bone. A wedge of ossified tissue can form under the periosteum and is called Codman's triangle

Front 253

What is Codman's triangle?

Back 253

A wedge of ossified tissue that forms under the periosteum in osteosarcoma

Front 254

What are three factors for chondrosarcomas?

Back 254

1. These tumours arise from cartilaginous tissue
2. They are rare in the foot (but are noted in the calcaneus) and occur mainly in the long bones
3. They produce "grape-like" lesions with a calcified periphery and multiple calcified central foci

Front 255

What are two factors for fibrosarcomas?

Back 255

1. These tumours occur mainly in the 40-60 age range
2. They are highly destructive, producing expansile 'motheaten' lesions with slightly periosteal reaction in the major long bones and kee joint

Front 256

What are five factors for giant cell tumours?

Back 256

1. 15% are malignant
2. Affect 16-45 year age range
3. They mainly affect the knee but are found in feet
4. They are vascular tumours
5. DDX should include an aneurysmal bone cyst

Front 257

What are three factors for Ewing's tumour?

Back 257

1. Affects mainly 10-20 year olds
2. Initially there may only be minor porotic changes with early periosteal changes and delicate spiculisation suggestive of osteomyelitis. Later changes cause considerable tissue destruction including pathological fractures
3. It has frequently metastasised by the time the patient is first seen

Front 258

Where do secondary metastases come from that cause malignant bone tumours?

Back 258

The breast, kidney, prostate or bowel

Front 259

What are the 7 ways that gait can be analysed?

Back 259

1. Temporal and spatial parameters
2. Kinetics
3. Accelerometers
4. Kinematics
5. Electromyography
6. Energy expenditure
7. Multisystems

Front 260

What is the shorthand form of notation used for recording during gait analysis?

Back 260

GHORT (Gait Homunculus Observed Relational Tabular)

Front 261

What is GHORT?

Back 261

Gait Homunculus Observed Relational Tabular. It is a shorthand form of notation for recording gait

Front 262

What are nine practical observations to be made during gait?

Back 262

1. Observe for amounts and timing of events
2. Look for assymetry
3. Concentrate on one aspect at a time
4. Bisection of calcaneus and posterior aspect of leg is often helpful
5. A mark on the medial side of the navicular is also helpful
6. Be aware that many individuals may consciously or subconsciously alter gait while being observed
7. At least an 8-10 metre walkway is desirable with provision for watching subjects from behind/in front (frontal plane) as well as from the side (sagittal plane)
8. Patient should be wearing shorts
9. Observe with and without shoes and with and without orthoses

Front 263

What are 18 frontal plane observations during gait analysis?

Back 263

Upper body
1. Head/eyes level or tilted?
2. Shoulders level?
3. Height of finger tips
4. Symmetrical arm swing
5. Pelvis level or tilted?
Lower limb
6. Position of knee
7. Q angle/patellar position
8. Timing of knee motion
9. Position of tibia
10. Timing of tibial rotation
Foot
11. Timing/amount of rearfoot motion
12. Timing/amount of heel contact/off
13. Timing/amount of midfoot motion
14. Transfer from low gear to high gear during propulsion
15. Angle and base of gait
16. Abductory twist?
17. Prominent extensor tendons (extensor substitution)
18. Clawing of digits ( flexor stabilisation)

Front 264

What 8 observations can be made of the gait in the sagittal plane?

Back 264

Upper body
1. Forward or backward tilt
2. Symmetrical arm swing
Lower limb
3. Position/timing of hip joint motion
4. Position/timing of knee joint motion
5. Position/timing of ankle joint motion
Foot
1. Timing/amount of heel lift
2. Timing/amount of midtarsal joint motion
3. Timing/amount of 1st MTPJ motion

Front 265

What is step length?

Back 265

The distance from inital heel strike of one foot to the heel strike of the opposite foot

Front 266

What is cadence?

Back 266

The number of steps taken per unit time usually minute

Front 267

What is stride length?

Back 267

The distance between two successive placements of the same foot. Stride length = two step lengths

Front 268

What is the walking base?

Back 268

The distance between the feet usually measured at the midpoint of the heel

Front 269

What is kinetics?

Back 269

The study and measurement of forces and moments exerted on the body that influence movement

Front 270

What is the study and measurement of forces and moments exerted on the body that influence movement

Back 270

Kinetics

Front 271

What is force?

Back 271

Force = mass x acceleration

Front 272

What is mass x acceleration?

Back 272

Force

Front 273

What is pressure?

Back 273

Pressure = force/area

Front 274

What is force/area?

Back 274

Pressure

Front 275

What are 5 systems designed to study the way in which load is distributed over the plantar surface of the foot?

Back 275

1. Harris & Beath mat
2. Pedobarograph
3. Force plates
4. Musgrave footprint
5. In-shoe force measurement

Front 276

What are xx factors for Tricophyton rubrum?

Back 276

1. Affects skin and nails
2. 85% of cases of onychomycosis thought to be due to T. rubrum
3. Diffuse dry scaling tinea on the soles is usually due to T rubrum

Front 277

What are three factors for Tricophyton mentagrophytes?

Back 277

1. Affects skin and nails
2. Especially associated with vesicle eruption
3. 12% of onychomycosis due to T mentagrophytes

Front 278

What are three factors for Epidermophyton floccosum?

Back 278

1. Affects skin in a variety of ways
2. Responsible for vesicle eruption
3. Rarely involved in onychomycosis

Front 279

What are two factors for candida?

Back 279

1. Affects skin and naiils
2. In nails it is often responsible for paronychia

Front 280

What are the three principal functions of blood?

Back 280

1. The transportation of heat, hormones and metabolites (such as oxygen) around the body
2. To help in the regulation of pH and temperature
3. To protect the body through clotting mechanisms, the action of white blood cells and antibodies

Front 281

What are seven indications for blood analysis?

Back 281

1. Anaemias eg from an altered erythrocyte count
2. Infections eg from a raised leucocyte count
3. Systemic inflammation eg from a raised erythrocyte sedimentation rate (ESR)
4. Metabolic disorders eg raised serum glucose and ketone levels
5. Clotting disorders eg from an abnormal platelet count
6. Hormonal disorders eg from a high level of serum thyroxine
7. Immunology-related disorders eg in seropositive arthritides

Front 282

What are three blood tests used to detect inflammation?

Back 282

1. ESR (erythrocyte sedimentation rate) is the rate of fall of red blood cells in a column of blood. The ESR increases with age and is higher in females than in males. A raised ESR reflects an increase in the plasma concentration of proteins and is indicative of diseases associated with malignancy, infections and inflammations
2. Plasma viscosity is used sometimes instead of ESR. As with ESR the level of viscosity is dependent on the concentration of proteins but is the same in males and females and increases only slightly with age
3. C-reactive protein (CRP) is synthesised in the liver and can be detected in the blood within 6 hours of an inflammatory response. This test is also replacing ESR.

Front 283

What is prothrombin time?

Back 283

The prothrombin time determines the amount of prothrombin in the blood. It is commonly used to monitor patients taking warfarin

Front 284

What are the tests for rheumatoid arthritis and what is tested?

Back 284

The latex or Rose-Waaler test. Rheumatoid factors are autoantibodies found in the serum usually of the immunoglobulin IgM class which are directed against human IgG

Front 285

What are rheumatoid factors?

Back 285

Rheumatoid factors are autoantibodies found in the serum usually of the IgM class which are directed against human IgG. It detects RA in 80% of cases.

Front 286

What are the milestones for early walking and posture in a young child?

Back 286

6-7 months - most babies will sit unassisted and attempt to crawl
9-12 months - sitting alone. They will start to pull themselves up into a standing position and stand holding on to furniture (cruising) at 9-12 months but they frequently fall backwards into a sitting position
12 months - the child should be able to stand alone briefly and may possibly walk alone.
97% of children walk between 9 and 18 months.

Front 287

Describe the walking posture of a young child

Back 287

The child will have a wide base of gait for stability with the arms flexed and held high for balance and no arm swing.
The base of gait will become narrower as the child gains confidence, developing a heel to toe gait from 3 years of age

Front 288

What are the eight development stages of childhood?

Back 288

1-4 weeks Neonatal
4 weeks to 1 year Infant
1-6 years Early childhood
6-10 years Late childhood
10-12 years Prepubertal
12-14 years Puberty
14-17 years Adolescence
18 years + Adulthood

Front 289

Describe the gait of a child just beginning to walk

Back 289

The initial stages of walking involve a 'stomping gait' with the entire limb being lifted, circumducted over the ground and then plunged down again. There is little frontal or sagittal plane movement at the pelvis. The leg is usually maintained in an externally rotated position with little transverse plane motion and the knees are in a varus position. The foot neither supinates nor pronates and there is little demand on the ankle to either dorsiflex or plantarflex. Gait is apropulsive, shock absorption minimal and velocity control poor. The child thrusts its head, the heaviest single component of the body, downwards to increase speed and up and backwards to reduce velocity.

Front 290

Describe the gait of a child at two years of age.

Back 290

The child's gait will have refined considerably. The foot is still not capable of supinating at toe off. However, the pelvis is beginning to rotate in all three body planes and the leg demonstrates signs of internal rotation at heel contact. The frontal plane position of the knees is valgus. The net result is a much smoother gait. Although velocity control is improved, the arms still do not swing in coordination with the legs.

Front 291

Describe the gait of a child at four years of age

Back 291

Gait is no longer apropulsive. Heel lift and the associated subtalar joint supination are apparent for the first time. Leg and pelvic rotations are now completely developed, although arm swing is still not coordinated with leg movement

Front 292

Describe the gait of a child at five to six years of age

Back 292

Pronation-supination at the contact and propulsive phases of gait is fully developed. Stride length is increased and foot-to-ground contact time is greatly reduced compared with 12 months previously

Front 293

Describe the growth and development phases of a child's foot

Back 293

At birth many of the bones of the foot are still cartilaginous. The calcaneus and talus are clearly visible on X-ray. The navicular and cuneiforms are rather imprecise (the lateral cuneiform appears at 3-6 months) and can take 2-3 years to have a functional calcific appearance. The sesamoids of the first metatarsal appear at around 8-10 years. The first metatarsal base is the site of the epiphysis whereas the epiphysis of the other metatarsals is located at the metatarsal head. Metatarsals ossify around 14-16 years for females and 16-18 years for males. The lower limb continues to grow in length and girth until the age of 19-20 years in males and growth ceases for females at around 15-17 years.

Front 294

What 5 cognitive aspects about children should be considered during an interview?

Back 294

1. Limited attention span
2. Influenced by immediate events
3. Limited experience (black and white)
4. Egocentric
5. Non-conceptual

Front 295

What six areas should be paid particular attention to when taking a history of a child?

Back 295

1. Perinatal history (pregnancy and childbirth)
2. Neonatal history
3. Post-neonatal history
4. Developmental milestones
5. Family history
6. Previous consultations

Front 296

What questions would you ask a mother about her pregnancy when taking a history of a child?

Back 296

It is important to ascertain whether the pregnancy was normal
Did the mother take any medication during her pregnancy? Some drugs eg phenytoin used to control epilepsy or high doses of Vitamin A are known to be teratogenic during the first trimester of pregnancy
Did the mother smoke or drink during the pregnancy?
Smoking can retard growth in some cases and excessive alcohol intake can delay intellectual development
Did the mother sustain any maternal trauma or complications (threatened miscarriage, antepartum haemorrhage or toxaemia) during pregnancy?
Did she come into contact with any infections likely to cause abnormality in the child eg measles, chicken pox?

Front 297

What are some of the questions that should be asked about a delivery when taking a child's history?

Back 297

The mother should be asked about the nature and duration of labour.
Was the delivery uneventful, full term (40 weeks) or premature (gestational age less than 37 weeks). Muscle tone is diminished in premature babies compared to those who reach full term and an increased predisposition to developmental dislocation of the hip (DDH) and internal position of one leg is seen. Incidence of hip dislocation is higher when the fetus is malpositioned in utero (frank breech) or when there are twins. Caeserean section is often indicated in cases of frank breech, transverse lie, large size or fetal stress. Long deliveries especially if there was fetal distress could be significant if there is evidence of poor posture, coordination or motor function. Forceps delivery can sometimes result in temporary facial or brachial palsy.

Front 298

What is the APGAR score?

Back 298

At birth the baby undergoes several tests to determine their Apgar score. This routine procedure is performed at the first and fifth minute after birth. It is used to evaluate the cardiovascular, respiratory and neurological status of the neonate
A = appearance - colour
P = pulse - indication of heart rate
G = grimace - plantar aspect of the foot is stimulated to provoke the child to cry
A = activity - muscle tone
R = respiratory effort
The child's response to each test is rated on a scale of 0-2. 2 is the maximum score. A score of 10 is the maximum and is rarely achieved. A low score below 6 is indicative of problems.

Front 299

What should be asked about in the post-neonatal history?

Back 299

Feeding problems in the early months which can influence normal growth and development

Front 300

What questions are asked about developmental milestones (8) in the child's history?

Back 300

1. Head control
2. Ability to sit alone
3. Ability to crawl
4. Ability to stand, walk, run
5. Ability to hop on one foot, tandem walk
6. Ability to walk up and down stairs
7. Result of 8 month hearing test
8. Ability to comprehend and obey simple commands

Front 301

What questions should be asked about the family during a history taking session with a child?

Back 301

Are there any other siblings with a similar problem?
In genetically determined conditions eg immune deficiency states, neurodegenerative disease or muscular dystrophy, enquiries about second and third-degree relatives may be considered

Front 302

What are eight points that an examination of a child should cover?

Back 302

1. Observation of gait and posture
2. General walking capability
3. Symmetry of body
4. Obvious deformity
5. Muscle bulk and wasting
6. Joint motion
7. Vascular and skin quality
8. Footwear

Front 303

What are the seven reflexes present in the first twelve months of life?

Back 303

1. Oral reflex - a baby will suck a finger placed in its mouth. Failure to do this may indicate a cerebral problem later leading to motor dysfunction in the lower limb
2. Moro reflex - startle reflex when dropped suddenly. It disappears by 5 months. Failure to respond suggests weakness. Asymmetry may indicate lower spinal lesion if one leg affected. Hyperactivity suggests CNS infection and reverse Moro indicates basal ganglia disease
3. Grasp reflex - up to 9 months. An object is placed in the hand and fingers grasp it. Failure to respond suggest CNS weakness depending upon symmetry of reflex
4. Plantar reflex - in a child under a year the response is extensor. An abnormal response indicates dysfunction of the upper motor neurones
5. Placing and stepping/walking reflex - when a surface is placed against the anterior tibia the baby will lift the limb to place the foot on the surface. This response goes after 4 weeks of age. If the baby is held gently above a surface with soles touching the surface this will elicit a stepping/walking action. This goes after 8 weeks. Absence may indicate brain damage
6. Tonic neck reflex - when baby is supine and not crying the head will be turned to one side and the arm on the same side will be extended. This reflex is present up until 3 months
7. Patellar and ankle reflex - results should be similar to normal adults

Front 304

What is lordosis of the spine?

Back 304

Lordosis is increased forward curvature in the sagittal plane which commonly affects the lumbar vertebrae

Front 305

What is increased forward curvature in the sagittal plane which commonly affects the lumbar vertebrae?

Back 305

Lordosis

Front 306

What does the Trendelenberg test measure?

Back 306

It measures normal muscle action between the pelvis and greater trochanter (gluteus medius).

Front 307

What test measures normal muscle action between the pelvis and greater trochanter (gluteus medius)?

Back 307

The Trendelenberg test

Front 308

When examining the hips of a child, what is it important to remember?

Back 308

It is important to avoid damaging the blood supply to the femoral head. At birth the head of the femur lies superficially in the acetabulum which makes it easier to dislocate or restrict blood flow causing avuscular necrosis

Front 309

What happens to the knees during childhood?

Back 309

Genu varum (bow legs)happens between birth and 2 years
Genu valgum (knock knees) happens between 3 and 5 years
Another episode of genu valgum may occur between 12 and 14 years which is mainly seen in girls due to the pubertal effects of growth.

Front 310

How long does the subtalar undergo valgus rotation in a child?

Back 310

Up to 6 years

Front 311

In a newborn what is the number of degrees dorsiflexion and plantarflexion?

Back 311

50 degrees dorsiflexion, 30 degrees plantarflexion

Front 312

In the neonate what is the neutral position of the calcaneus?

Back 312

8 - 10 degrees varus

Front 313

In the newborn what is the forefoot/rearfoot relationship?

Back 313

The forefoot is inverted 10-15 degrees on the rearfoot

Front 314

What test is used to assess ligamentous laxity?

Back 314

The Beighton scale

Front 315

What are the nine points on the Beighton scale?

Back 315

The Beighton scale assesses the degree of
1. Elbow hyperextension
2. Thumb hyperextension
3. Fifth finger hyperextension
4. Knee hyperextension
5. Spine - ability to bend and touch hands flat on the floor
One point is awarded to each side except for 5 where only one point is awarded = 9
A score of 5 or more is considered ligamentously lax. In addition a child with ligamentous laxity presents with excessive eversion of the calcaneus in stance

Front 316

How many tests are there to test DDH (developmental dislocation of the hip) and what are they?

Back 316

1. Barlow's test
2. Palmen's sign
3. Ortolani's manoeuvre
4. Limitation of hip abduction
5. Galleazi's sign
6. Telescope (piston) sign

Front 317

What are four factors for DDH (developmental dislocation of the hip)?

Back 317

1. It is usually detected shortly after birth but it is possible for the condition to be missed and not picked up until later in the child's development
2. DDH may have serious repercussions leading to osteoarthritis, limb shortening and hip pain
3. Various tests are used to establish the presence of DDH but feeling for displacement of the femoral head may be all that is required
4. It should be noted that clinical examination may produce false negatives. X-ray and ultrasound imaging can confirm a diagnosis

Front 318

What is Barlow's test?

Back 318

The baby is placed supine with hip and knees flexed. Thumb pressure is applied over the lesser trochanter with the middle finger of each hand over the greater trochanter. The femoral head is gently dislocated by moving the pressure on the hand backwards. Consequent release of pressure allows the head to slip back into position. A positive result indicates that the hips are unstable due to ligamentous laxity. The test becomes less useful as the child becomes older. This is a questionable manoeuvre as the potential for avascular necrosis or neurological damage is increased by intentionally dislocating the hip joint

Front 319

What is Palmen's sign?

Back 319

This is similar to Barlow's test and performed in the same manner. It is a provocative test for a subluxable (but not dislocatable) hip. If the hip is subluxable, the examiner feels a give (but not a clunk) as the femoral head is displaced partially out of the acetabulum

Front 320

What is Ortolani's manoeuvre?

Back 320

This is performed by flexing the hips to 90 degrees. The middle fingers are again placed over the greater trochanter and the thigh is lifted and abducted. The hip can be relocated with a palpable (rather than audible) click. This test is reliable up to 6-8 weeks of age but clicking can arise from ligaments moving, giving false positives

Front 321

What is the limitation of hip abduction test?

Back 321

This test is used when the infant's dislocated hips no longer reduce with Ortolani's manoeuvre (after 2 months). Abducting the hip with the thigh and knee flexed will be resisted on the dislocated side. This is due to contracted adductors. The anchor sign is abnormal

Front 322

What is the anchor sign?

Back 322

Altered function of the gluteal muscles due to hip dysplasia will cause a change in the shape of the buttocks. As a result the gluteal fat folds will not appear level ('anchor sign'). The central crease forms the central anchor with the two base lines along the buttocks as the bottom of the anchor. If the base lines are not level this implies asymmetry.

Front 323

What is Galleazi's sign?

Back 323

The infant is observed supine with hips and knees flexed and with the feet placed flat on the couch. In normal limbs the level of the knees should be equal. If one knee is lower than the other this may indicate hip pathology on the low side. This is similar to the skyline test for checking the length of the femur and tibia

Front 324

What is the telescope (piston) sign?

Back 324

The hip may be out of the acetabulum but still mobile along the ala of the ilium. With the infant supine, the thigh in the sagittal plane and at right angles to the trunk, longitudinal traction may cause the head to slide up and down along the lateral side of the ala.

Front 325

How many tests are used to test for knee pain in the child and what are they?

Back 325

1. Patella compression test
2. Medial facet tenderness test
3. Quadriceps muscle bulk evaluation
4. Muscle function
5. Squatting test

Front 326

What is the medial facet tenderness test?

Back 326

The patella is displaced medially and the practitioner palpates the posterior medial surface. Performing this test also determines whether there is any tightness of the lateral capsule tending to pull the patella laterally, increasing shearing forces on the posterior facets which may damage the articular cartilage

Front 327

What is the quadriceps muscle bulk evaluation?

Back 327

The patient is asked to contract the quadriceps muscle group. The bulk of the vastus medialis is assessed. Loss of muscle can occur with chronic pain or poor mechanical function of the knee

Front 328

What is the squatting test?

Back 328

The patient is asked to stand on both feet and then crouch down. Patients with severe pain will express discomfort. As the knee flexes the posterior surface of the patella is compressed against the femur. The degree to which squatting is restricted will indicate the severity of this condition

Front 329

What are four factors for anterior knee pain?

Back 329

1. Anterior knee pain can occur during adolescence
2. More common in females
3. The pain will be most intense during or after vigorous activity although kneeling or sitting with a flexed knee for long periods ('cinema seat' sign) may also incite discomfort.
4. A high Q angle has been implicated as a precipitating factor

Front 330

What are three causes of a high Q angle?

Back 330

1. Internal femoral rotation
2. External tibial rotation
3. Genu valgum

Front 331

What angle should the Q angle reduce to at what age?

Back 331

The Q angle should reduce to 15 degrees by 6 years of age

Front 332

What is a cause of pain over the lateral side of the medial femoral condyle?

Back 332

Intra-articular knee pain due to osteochondritis dissecans characterised by primary necrosis of subchondral bone will cause pain over the lateral side of the medial femoral condyle

Front 333

What is Osgood-Schlatter's disease?

Back 333

1. It is a traction apophysitis affecting the tibial tubercle and is associated with patellar tendon strain
2. It predominantly affects males between 10 and 14 years of age.
3. Pain is anterior and below the knee
4. Examination demonstrates the presence of a prominent and tender tibial tubercle and quadriceps wasting may be visible.
5. Extending the leg against resistance exacerbates the symptoms.
6. Radiographs may show fragmentation of the tibial tuberosity

Front 334

What is the age that a child presents with genu vara which should be further investigated?

Back 334

3-4 years of age

Front 335

What distance between the knees at any age in genu vara should be investigated?

Back 335

5 cm

Front 336

What are two conditions predisposing to genu vara with tibial vara?

Back 336

1. Rickets
2. Blount's disease

Front 337

What are five factors for rickets?

Back 337

1. Rickets will present as genu varum as well as anterior bowing at the junction of the middle and lower one-third of the tibia
2. Swelling of the wrists and ankles and bossing of the cranium is also seen in rickets
3. Radiological investigation will show the epiphyses to be widened and irregular, whereas the metaphyses will appear "cupped"
4. Dietary deficiency, malabsorption, renal disease or hypophosphatasia may reduce levels of Vitamin D, calcium and phosphate
5. If biochemical tests are normal then Blount's disease must be considered

Front 338

What are nine factors for Blount's disease?

Back 338

1. This is a condition affecting the growth of the medial upper tibial epiphysis.
2. Cessation of the growth plate causes the tibia to develop a lateral varus tilt.
3. It is due to the lateral side of the growth plate expanding faster than the medial side.
4. Blount's disease is thought to be a combination of obesity and marked physiological bowing. This will have the effect of compressing the medial side of the growth plate which causes further bowing of the tibia. The lateral epiphysis continues to expand as pressure is released. The medial epiphysis will appear fragmented on X-ray.
5. Blount's disease may appear at any time between the ages of 18 months and 4 years
6. Referral for treatment should be initiated as the condition will invariably progress without treatment.
7. In the infant, Blount's disease is often severe with both knees affected.
8. Arrest of the medial growth plate may also affect older children aged between 6 and 13 in whom the deformity is usually unilateral and less severe than the infantile variety though no less certain to progress without treatment
9. Unilateral tibia vara can contribute to limb length discrepancy

Front 339

What three other conditions can also result in marked genicular bowing?

Back 339

1. Trauma
2. Infection
3. Fluorosis

Front 340

What is fluorosis?

Back 340

Fluorosis is when a child receives too much fluoride in the developmental period

Front 341

When is genu valgum normally present?

Back 341

Between 3-5 years and 12-14 years of age

Front 342

What is a cause of unremitting cases of genu valgum?

Back 342

Metabolic abnormalities of the epiphyses

Front 343

What are four causes of unilateral genu valgum?

Back 343

1. Trauma
2. Osteomyelitis
3. Tumour
4. Developmental bone disturbance

Front 344

What excessive triplanar motion has been associated with genu valgum?

Back 344

Excessive subtalar joint pronation of the foot has been associated with genu valgum as it throws body weight medial to the central axis of the foot and hence tends to force the foot into pronation

Front 345

What deformity of the forefoot can be a cause of genu valgum?

Back 345

Excessive varus deformity of the forefoot may create frontal plane movement of the knee in order to bring the entire forefoot into ground contact. Genu valgum will result.

Front 346

What is the popliteal angle in children?

Back 346

The popliteal angle is defined as the angle of the tibia to the femur when the hip is flexed and knee extended

Front 347

What two things does evaluation of the popliteal angle reveal?

Back 347

1. It is used to assess hamstring tightness in healthy children and hamstring contracture in cerebral palsy.
2. It is also used as an indicator of gestational age in infants. The mean angle in newborns is reported to be 27 degrees and reduces to zero by age 11 months

Front 348

What is a common cause of asymmetrical hip motion and subsequent in-toeing?

Back 348

Hamstring and more specifically medial hamstring shortening

Front 349

What % extension should children under 10 years be getting in the 90:90 test?

Back 349

Less than 70% extension is unsatisfactory. If the hamstrings resist the final 30 degrees of motion this indicates an abnormal tightness

Front 350

How are medial hamstrings tested?

Back 350

The medial hamstrings can be tested by internally rotating the flexed upper thigh while gradually extending the knee

Front 351

How can tight hamstrings affect a child's gait?

Back 351

1. Children with tight hamstrings can assume a normal angle and base of stance.
2. During gait as the knee extends just prior to heel contact the tight medial hamstring will abruptly rotate the leg internally
3. Children will demonstrate a windmilling style of running, the lower leg being circumducted during the late swing phase of running in order to short-cut around the extended knee position
4. This can cause in-toeing

Front 352

What should be tested in any child complaining of persistent nocturnal leg pains?

Back 352

Hamstrings

Front 353

At what age does in-toeing commonly resolve itself?

Back 353

Between the ages of 4 and 11

Front 354

What four factors should be assessed in in-toeing?

Back 354

1. Gait analysis - the position of the patella. In the in-toeing child the patella will either point in the direction of progression or it will be internally rotated or 'squinting'. A squinting patella indicates that the cause of the gait defect is proximal to the knee joint. Severely adducted feet in the presence of a forward-looking patella occur in cases of internal genicular position (knee), internal tibial torsion (leg) and metatarsus adductus (forefoot).
2. Ranges of motion at the hip and knee joint and the position of the transmalleolar axis and forefoot should be assessed. The range of hip rotation is assessed with the knee and hip extended. The leg is brought to the neutral position where the patella is facing directly upwards. The leg is internally rotated and then externally rotated. In children of less than 4 years an excessive internal range of hip motion is considered abnormal and will often explain an in-toeing gait. In children older than 4 asymmetry of motion may be significant. Most children who present with internal femoral position grow out of the condition. While internal rotation falls from about 60 degrees at age 4 to under 40 degrees in the adult, decreasing 2-3 degrees per year, external rotation remains at a constant 40 degrees from 4 years of age to adulthood
3. Measuring internal tibial torsion by the transmalleolar axis
4. Metatarsus adductus

Front 355

How is internal tibial torsion diagnosed?

Back 355

By measuring the transmalleolar axis which is formed between the midpoints of the medial and lateral malleoli. There should be one thumb's thickness between the medial and lateral malleoli. The transmalleolar axis increases during the first few years of life from 2-4 degrees at birth to 10-20 degrees in the adult

Front 356

What is another name for internal tibial position?

Back 356

Internal genicular position

Front 357

What is another name for internal genicular position?

Back 357

Internal tibial position

Front 358

How is internal genicular position measured?

Back 358

If the transmalleolar axis is normal then the thigh is stabilised, the foot grasped, rotating the tibia internally then externally. Normally a small but symmetrical range of motion of 10-20 degrees will be evident. In cases of internal genicular position 45 degrees or more of internal rotation may be present. External rotation usually remains no more than 10-20 degrees although in some cases it is completely absent

Front 359

Should internal genicular position be treated?

Back 359

The prognosis without treatment is good. It tends to resolve spontaneously around 5-6 years of age. Its significance lies in the fact that it can cause frequent tripping. There is also evidence to suggest that it may be a factor associated with the development of osteoarthrosis of the knee. For that reason it is worthwhile monitoring the child to ensure that resolution does occur. The patient should be seen every 6 months, gait analysis performed and the range of motion at the knee and the transmalleolar axis measured. If tripping and clumsiness is severe, treatment may be considered.

Front 360

What is metatarsus adductus?

Back 360

It is a transverse plane deformity arising at the tarsometatarsal (Lisfranc's joint).

Front 361

What is the hallmark of metatarsus adductus and what four other clinical signs confirm this condition?

Back 361

A C-shaped curvature of the lateral border of the foot is the hallmark. Other clinical signs are:
1. Wrinkling of the skin in the medial longitudinal arch as a consequence of bunching of the metatarsal bases
2. A dorsal plantar crease medial to the first metatarsal cuneiform joint
3. A high arch profile created by adduction of the forefoot on the rearfoot
4. A marked tendency to lateral weightbearing during gait
Internal tibial torsion and abnormal knee position may also occur in combination with metatarsus adductus

Front 362

What is the hallmark of metatarsus adductus and what four other clinical signs confirm this condition?

Back 362

A C-shaped curvature of the lateral border of the foot is the hallmark. Other clinical signs are:
1. Wrinkling of the skin in the medial longitudinal arch as a consequence of bunching of the metatarsal bases
2. A dorsal plantar crease medial to the first metatarsal cuneiform joint
3. A high arch profile created by adduction of the forefoot on the rearfoot
4. A marked tendency to lateral weightbearing during gait
Internal tibial torsion and abnormal knee position may also occur in combination with metatarsus adductus

Front 363

What are two signs that a metatarsus adductus foot will spontaneously resolve?

Back 363

The foot can be corrected by manipulation
The adductus position is mild

Front 364

What are three clinical signs that indicate a metatarsus adductus is unlikely to spontaneously correct?

Back 364

1. Calcaneal eversion
2. Medial talonavicular joint bulging
3. Humping of the dorsolateral midfoot

Front 365

What does an uncompensated metatarsus adductus foot look like?

Back 365

A high-arched supinated foot and may have skin lesions under the 5th MTPJ. In more severe cases there will be the presence of a vertical crease overlying the medial cuneiform

Front 366

What are four causes of adducted gait that should be ruled out before a diagnosis of metatarsus adductus?

Back 366

1. Internal femoral rotation
2. Internal tibial torsion
3. Genicular position
4. Compensation for a forefoot valgus and hallux varus

Front 367

Where does the adductus of the forefoot occur in congenital talipes equinovarus (CTEV) compared to metatarsus adductus?

Back 367

The adductus of the forefoot occurs at the midtarsal joint and not at the tarsometarsal joint as in metatarsus adductus

Front 368

What are the four components of congenital talipes equinovarus (CTEV)?

Back 368

1. Equinus
2 Inversion of the rearfoot
3. Adductus
4. Pronation of the forefoot

Front 369

Where are the most severe deformities in congenital talipes equinovarus?

Back 369

They occur in the rearfoot. The talus is abducted and the calcaneus is in equinus and inverted. The navicular is displaced medial to the head of the talus. The posterior and medial soft tissues including tibialis posterior, flexor digitorum longus and triceps surae are also shortened and atrophied forming a 'pipe stem' shape to the leg.

Front 370

When is it easier to correct a clubfoot deformity?

Back 370

Within the first few days of life rather than waiting a few weeks.

Front 371

What are the five problems that will always reoccur in congenital talipes equinovarus (CTEV)?

Back 371

1. Shortening of the foot
2. Reduced calf muscle circumference
3. Reduced ankle and subtalar joint motion
4. Medial displacement of the navicular
5. Abduction of the talus on the calcaneus

Front 372

Why does a child under 5 years look like it has flat feet?

Back 372

They have a depressed medial longitudinal arch because the low calcaneal inclination angle and the underdeveloped sustentaculum tali. It is only with external torsion of the tibia in the first five years of life that the calcaneus begins to assume 20 degree angle of inclination and the medial longitudinal arch becomes apparent.

Front 373

What are the five clinical signs of a flat foot?

Back 373

1. calcaneal eversion
2. bulging of the talus (talonavicular joint subluxation)
3. abduction of the forefoot
4. "too many toes sign" - when a normal foot is observed from the rear it is possible to see the fifth and sometimes the fourth toe. In a pronated foot the third toe may be seen as well.
5. C-shaped lateral border - the concavity of the C will be over the calcaneocuboid joint.
Helbing's sign is not always reliable because in some cases of excessive pronation it is not seen. This is so when the foot maximally pronates from a supinated position associated with rearfoot varus. Pronation can occur using the available range of subtalar joint motion but the calcaneus may still remain in a relatively inverted position. This is commonly referred to as partially compensated rearfoot varus

Front 374

What are seven risk factors that may affect the foot in its overall development?

Back 374

1. Obesity
2. Ligamentous laxity
3. Hypotonia (Down's syndrome)
4. Rotational deformities
5. Frontal plane tibial deformities
6. Equinus
7. Tarsal coalitions

Front 375

What four places will the child who has excessive pronation experience discomfort?

Back 375

1. Medial longitudinal arch
2. Talonavicular area
3. Leg muscles
4. Tibialis anterior because the excessive pronatory movement of the foot causes the muscle to work aphasically leading to overuse. Excessive pronation is very responsive to conservative orthotic treatment

Front 376

What four tests are used to test whether there is a flexible flatfoot?

Back 376

1. Hallux dorsiflexion (Jack's test) - this invokes the windlass mechanism associated with the plantar aponeurosis which a gives a rise in arch height if the foot is flexible
2. Tip toe standing test - testing rearfoot inversion
3. The swivel test where the child is asked to turn their upper body in stance and look over one shoulder while the foot on that side is observed. If the foot demonstrates a supination movement with arch rise this signifies a flexible foot
4. The supination resistance test - with the child weightbearing the examiner places two fingers on the plantar aspect of the navicular and pushes up. If arch rise is observed a flexible foot is indicated.

Front 377

What two conditions are associated with a rigid pronated foot?

Back 377

1. Tarsal coalition
2. Peroneal spastic flatfoot

Front 378

What are xx factors for tarsal coalition?

Back 378

1. Tarsal coalition is a fibrous, cartilaginous or osseous union of two or more tarsal bones and is congenital in origin
2. Coalition between the calcaneus and the navicular and the middle facet of the subtalar joint is the most common presentation and is conclusively linked with the syndrome of peroneal spastic flat foot which is a painful rigid pronation of the foot with tonic spasm of the peroneal muscles
3. Tarsal coalitions usually become painful during the second decade of life when the coalition starts to ossify and may be associated in the rearfoot with a sudden injury.
4. The child will present with mild deep pain in the subtalar joint and limitation of subtalar joint movement. Generally the more severe the limitation of movement, the more severe the pain. Talocalcaneal coalition tends to produce the most severe pronation of the foot
5. If the tarsal coalition has ossified it can be confirmed by X-ray. The calcaneonavicular coalition is best demonstrated by X-ray. The talocalcaneal coalition is less easily seen on X-ray
6. The peroneal muscle spasm which may be continuous or occasional is probably the response of the peroneal muscles to effusion into the subtalar joint. It can be reduced by a local anaesthetic into the peroneal nerve at the fibular head

Front 379

How can you test whether the subtalar joint is at its end of ROM which is useful in rigid flat feet?

Back 379

The child is asked to look over one shoulder while the practitioner observes the calcaneus of the foot on the opposite side. If the foot fails to pronate more, then the STJ is considered to be functioning at its end of ROM

Front 380

What are the three criteria used to diagnose hallux valgus

Back 380

1. A first MTPJ angle in excess of 15 degrees which can be measured by an X-ray. An angle in excess of 9 degrees between the 1st and 2nd metatarsal is significant for hallux valgus
2. Osteophytic thickening of the first MTPJ. Visible thickening of the joint indicates hypertrophy of the metatarsal head caused by loss of congruency of the joint and subsequent early degeneration of the joint surface
3. A strong family history of hallux valgus

Front 381

What other factor is also associated with hallux valgus?

Back 381

Hypermobility

Front 382

What six factors can an X-ray pick up in hallux valgus?

Back 382

1. !st MTPJ space
2. Hallux valgus angle
3. 1st-2nd intermetatarsal angle
4. Medial eminence
5. Osteophytic development
6. Sesamoid position

Front 383

What four lesser toe deformities are cause for parental concern?

Back 383

1. Adductovarus third, fourth and fifth toes
2. Dorsiflexed 2nd toe
3. Overriding 5th toe
4. Underriding 3rd and 4th toes

Front 384

What four criteria should be applied before treating lesser toe deformities?

Back 384

1. Is weightbearing on the apex of the toe rather than the soft plantar pulp? Apical weightbearing may lead to development of painful corns and callus
2. Is the malposition of one toe likely to influence the position of an adjacent otherwise normal toe eg a dorsiflexed second toe will lead to loss of buttress effect on the hallux which will predispose to hallux valgus
3. Is the malpositioned toe likely to be irritated by footwear or cause footwear-fitting problems?
4. Is the type of toe deformity likely to respond to conservative or surgical treatment?

Front 385

Which plane deformities best respond to conservative treatment and which plane deformities best respond to surgical treatment?

Back 385

Transverse and frontal plane deformities are resistant to conservative treatment whereas sagittal plane deformities and even the sagittal plane component of complex digital deformities respond more favourably to conservative treatment

Front 386

What age does conservative treatment become progressively less effective?

Back 386

In children older than 9

Front 387

What five conditions are specific to age of the child?

Back 387

1. Developmental dislocation of the hip in the young child
2. Perthe's disease or toxic synovitis of the hip in 5-7 year olds (more common in males)
3. Kohlers osteochondritis of the navicular (5-12 year olds)
4. heel pain (Sever's traction apophysitis) in 9-12 year olds
5. SCFE (slipped capita femoris epiphysis) or anterior knee pain in young adolescents (12-15 years of age)

Front 388

What age would a child get developmental dislocation of the hip?

Back 388

A young child would get this condition

Front 389

At what age would a child get Perthe's disease or toxic synovitis of the hip and would it be male or female?

Back 389

5-7 years old

Front 390

At what age would a child get Kohler's osteochondritis of the navicular?

Back 390

5-12 years old

Front 391

At what age would a child get heel pain (Sever's traction apophysitis)?

Back 391

9-12 years old

Front 392

At what age would a child get a slipped capita femoris epiphysis?

Back 392

12-15 years of age

Front 393

What four possible causes could cause a limp in a child in the CNS?

Back 393

1. Cerebral tumour
2. Cerebral palsy
3. Spina bifida
4. Spinal muscular atrophy

Front 394

What four possible causes could cause a limp in a child associated with the peripheral nervous system?

Back 394

1. Poliomyelitis
2. Friedrich's ataxia
3. Muscular dystrophy
4. Charcot-Marie-Tooth disease

Front 395

What five possible causes could cause a limp in a child associated with the back?

Back 395

1. Trauma
2. Acute appendicitis
3. Herniated nucleus pulposus (slipped disc)
4. Schuermann's disease of the spine (osteochondritis of the spine)
5. Spondylolisthesis (forward displacement of vertebra on one distal to it)

Front 396

What seven possible causes could cause a limp in a child associated with the hip?

Back 396

1. Developmental dislocation of the hip (DDH)
2. Slipped capita femoral epiphysis (SCFE)
3. Transient synovitis of the hip
4. Legg-Calve-Perthes disease
5. Trauma
6. Coxa vara (provokes waddling gait)
7. Trochanteric bursitis

Front 397

What three possible causes could cause a limp in a child associated with the femur/tibia?

Back 397

1. Fracture (fractured femur may present as hip or knee pain)
2. Blount's disease
3. Limb-length inequality (short femur or tibia)

Front 398

What eight possible causes could cause a limp in a child associated with the knee?

Back 398

1. Osgood-Schlatter's disease (traction apophysitis)
2. Osteochondritis dissecans
3. Chondromalacia
4. Haemophilia
5. Sickle cell anaemia
6. Rickets
7. Baker's cyst
8. Referred pain from the hip

Front 399

What fourteen possible causes could cause a limp in a child associated with the ankle/foot?

Back 399

1. Fracture/sprain
2. Rickets (ankle)
3. Osteomyelitis (calcaneus)
4. Unicameral bone cyst (calcaneus)
5. Sever's disease (traction apophysitis)
6. Osteochondroses - Mouchet's or Diaz/Kohler's/Buschke's/Freiberg's/Treve's disease
7. Haglund's disease
8. Iselin's disease (traction apophysitis of the 5th metatarsal tuberosity)
9. Accessory navicular - Type II
10. Tarsal coalition
11. Embedded foreign body in foot
12. Verruca
13. Onychocryptosis
14. Subungual exostosis

Front 400

What five conditions could cause a child to limp?

Back 400

1. Septic arthritis (juvenile idiopathic arthritis)
2. Angioleiomyoma
3. Leukaemia
4. Attention seeking device
5. Child abuse

Front 401

What is Mouchet's disease?

Back 401

Osteochondritis of the talus

Front 402

What is osteochondritis of the talus called?

Back 402

Mouchet's disease or Diaz's disease

Front 403

What is Buschke's disease?

Back 403

Osteochondritis of the cuneiforms

Front 404

What is osteochondritis of the cuneiforms known as?

Back 404

Buschke's disease

Front 405

What is Treve's disease?

Back 405

Osteochondritis of the sesamoids

Front 406

What is osteochondritis of the sesamoids known as?

Back 406

Treve's disease

Front 407

What is angioleimyoma?

Back 407

It is a benign tumour arising from the smooth muscle of a blood vessel

Front 408

What is a benign tumour arising from the smooth muscle of a blood vessel?

Back 408

An angioleimyoma

Front 409

What are five questions a practioner should ask when assessing a child with a limp?

Back 409

1. Is the limp constant or intermittent
2. Is the limp only present in the morning, at the end of the day when the child is fatigued or it it present throughout the day?
3. What is the posture of the lower extremity when the child is limping?
4. What is the effect of climbing stairs or running?
5. Did the limp start following vigorous activity?

Front 410

What three conditions does the ESR show up as normal and what four conditions does it show as abnormal?

Back 410

It shows up as normal in
1. Trauma
2. The osteochondroses
3. Slipped capita femoral epiphysis (SCFE)
It shows up as abnormal in
1. Osteomyelitis
2. Septic arthritis
3. Juvenile idiopathic arthritis
4. Malignancy

Front 411

What is juvenile plantar dermatitis?

Back 411

It is also known as forefoot eczema and it is seasonal. A rash appears on the weightbearing area of the foot. A pink, shiny or glazed appearance is noted with scaling. The skin thins and is inflexible with resultant fissure forming. Differential diagnosis includes tinea pedis.

Front 412

What is the most common form of psoriasis in the young?

Back 412

Acute guttate psoriasis

Front 413

What are three factors for acute guttate psoriasis in the young?

Back 413

1. Often related to a minor infection such as a streptococcal sore throat
2. The rash either subsides in about 6 weeks or progresses to plaque psoriasis
3. Plaque psoriasis mainly affects the extensor surfaces but occasionally the flexures and may involve the interdigital web spaces and nail folds

Front 414

What are the five factors for juvenile idiopathic arthritis (JIA)?

Back 414

1. Previously known as juvenile chronic arthritis
2. One of the most common chronic illnesses of childhood
3. It is a major cause of functional disability
4. The child with JIA may present with lower limb pain including forefoot and rearfoot deformities
5. Treatment is based upon maintaining a good lower limb position with splints/orthoses, maximum muscle strength, a full range of joint motion and appropriate footwear. It is important to use a team approach in the management of this condition

Front 415

What is the commonest acute injury in sport?

Back 415

The ankle sprain

Front 416

What is the commonest tendon injury in sport?

Back 416

Achilles tendon injury

Front 417

What is the most frequently seen joint pathology in sport?

Back 417

Patellofemoral syndrome

Front 418

What are nine intrinsic risk factors associated with sports injuries?

Back 418

1. Age
2. Gender
3. Previous injury
4. Structural alignment
5. Flexibility
6. Physical fitness
7. Physical build
8. Psychological factors
9. Systemic disease

Front 419

What are seven extrinsic risk factors associated with sports injuries?

Back 419

1. Sporting equipment
2. Exercise surface
3. Sporting activity
4. Sport position
5. Training errors
6. Warm up and stretching
7. Environmental factors

Front 420

What six reasons are given for younger athletes being more injury prone?

Back 420

1. There is generally less muscle mass and muscle strength
2. There is less protective sports equipment available for children
3. The quality of coaches in children's teams is often lower
4. Fractures are more common in children - adolescents have fractures in the physeal areas whereas preadolescents have more fractures in the diaphysis
5. The osteochondritides only occur in the younger athlete as does traction apophysitis of the calcaneus (Sever's disease), of the 5th metatarsal ttuberosity (Iselin's) and the tibial tubercle (Osgood-Schlatters)
6. Younger athletes have reduced flexibility

Front 421

What four reasons are given for older athletes being prone to injuries?

Back 421

1. There is generally less muscle mass and muscle strength
2. Less flexibility
3. Musculotendinous injuries are the commonest injury in the older athlete due to a number of cellular changes which occur with increasing age
4. Overuse injuries are also common due to a delayed physiological response to exercise

Front 422

What three changes in muscles that occur with age can result in sports injury?

Back 422

1. Changes in collagen cross-linking cause in increase in tendon stiffness and reduce the elasticity of the tendon. This can result in a muscle being subject to earlier and prolonged loading in a movement cycle and being unable to undergo normal stretching resulting in damage to the musculotendinous unit. 2. The diameter, density and cellularity of the collagen fibrils are also diminished with advancing age which results in reduced muscle mass and strength.
3. Finally, the blood supply to tendons reduces with age resulting in an increased risk of tendonitis, tendonosis or rupture

Front 423

What are the three factors of the female athlete triad?

Back 423

1. Amenorrhoea or menstrual irregularities (less than five menses per year)
2. Osteoporosis (due to menstrual abnormalities, hormonal imbalance, calcium deficiency or malnutrition)
3. Eating disorders (anorexia nervosa, bulimia nervosa, binge-eating disorders, anorexia athletica)

Front 424

Chronic or overuse injuries are usually due to the presence of one or both of the following factors. What are they?

Back 424

1. Normal structure and function but inadequate preparation or excessive demands placed on the tissues
2. Abnormal structure and function with relatively normal demands placed on the tissues

Front 425

What six factors should be looked at in a structural assessment of an athlete?

Back 425

1. Muscle inflexibility (hamstrings, iliotibial band, quadriceps, lateral retinacula of the knee and calf muscles)
2. Muscle weakness (vastus medialis, gluteus medius, medial retinacula of the knee)
3. Patella malalignment or hypermobility (in frontal, transverse or sagittal plane)
4. Patella maltracking (during flexion and extension)
5. Excessive subtalar joint pronation
6. Frontal plane malalignment of the knee or tibia

Front 426

What bony injuries are limb length inequalities associated with?

Back 426

Stress fractures which tend to occur in the longer limb

Front 427

What four reasons are given for stress fractures occuring in limb length discrepancies?

Back 427

1. Longer stance phase
2. Skeletal realignment
3. Greater osseous torsion
4. Increased muscle activity of the longer limb

Front 428

What sort of soft tissue injury is hypermobility associated with?

Back 428

Ligamentous injury

Front 429

What soft tissue injury is associated with inflexibility?

Back 429

Musculotendinous injury

Front 430

What two sports injuries can be caused by cardiovascular changes?

Back 430

1. Acute and chronic compartment syndromes of the lower leg
2. Popliteal artery entrapment syndrome

Front 431

What two cardiovascular pathologies can exercise cause?

Back 431

1. Effort-induced deep vein thrombosis
2. External artery endofibrosis

Front 432

What is external artery endofibrosis?

Back 432

It is continuous repetitive flexing of the artery while under pressure such as when cycling or running

Front 433

What nine factors should an athlete be looking for in a sports shoe?

Back 433

1. Comfortable
2. Correct fit in length and width
3. Appropriate for the patient's sport
4. Does not show signs of excessive wear
5. Has appropriate tread, stud, spikes, cleats for the sport and exercise surface
6. Provides sufficient shock absorption, especially in the midsole
7. Provides appropriate motion control for the patient
8. Firm fastening
9. Lightweight

Front 434

What is footballer's ankle?

Back 434

Anterior ankle impingement

Front 435

What is anterior ankle impingement injury commonly known as?

Back 435

Footballer's ankle

Front 436

What is tennis leg?

Back 436

A rupture/tear of the medial head of gastrocnemius

Front 437

What is a rupture/tear of the medial head of gastrocnemius commonly called?

Back 437

Tennis leg

Front 438

What is fresher's leg?

Back 438

Exercise-induced shin pain

Front 439

What is exercise-induced shin pain commonly known as?

Back 439

Fresher's leg

Front 440

What is a March fracture?

Back 440

Metatarsal stress fracture

Front 441

What is a metatarsal stress fracture commonly known as?

Back 441

A March fracture

Front 442

What is jumper's knee?

Back 442

Patella tendonitis

Front 443

What is patella tendonitis commonly known as?

Back 443

Jumper's knee

Front 444

What is runner's knee?

Back 444

Patellofemoral syndrome

Front 445

What is patellofemoral syndrome commonly known as?

Back 445

Runner's knee

Front 446

What are five ways for the athlete to avoid training injuries?

Back 446

1. Participating in more than one sport
2. Combination of strength, flexibility and endurance training
3. Incorporation of rest days in the weekly training schedule
4. Periods during the year of greater training/sport levels ie seasons
5. Variation in training methods to help maintain interest

Front 447

What four questions should be asked about injury history in a sports patient?

Back 447

1. Have you broken any bones within the lower limb?
2. Have you ruptured or torn any ligaments or tendons in the lower limb?
3. Is there a history of prolonged or intermittent swelling of any joints in the lower limb
4. Have you had any injuries which have resulted in missing more than 2 weeks from sport?

Front 448

What are four characteristics of medial tibial stress syndrome pain?

Back 448

1. Location is tenoperiosteal junction
2. Diffuse
3. Dull ache
4. Post-exercise, lasts < 2 days

Front 449

What could the following condition be
1. Location - tenoperiosteal junction
2. Diffuse pain
3. Dull ache
4. Pain continues post-exercise for more than 2 days?

Back 449

Medial tibial stress syndrome

Front 450

What are the four characteristics of a tibial stress fracture

Back 450

1. Location - bone
2. Focal pain
3. Intense ache
4. Pain is constant, made worse by exercise

Front 451

What could the following condition be?
1. Location - bone
2. Focal pain
3. Intense ache
4. Pain is constant, made worse by exercise

Back 451

Tibial stress fracture

Front 452

What are the four characteristics of chronic compartment syndrome?

Back 452

1. Location - muscle compartment
2. Diffuse pain
3. Tightness, fullness, cramping
4. Induced by exercise, immediate relief with rest

Front 453

What could the following condition be?
. Location - muscle compartment
2. Diffuse pain
3. Tightness, fullness, cramping
4. Induced by exercise, immediate relief with rest

Back 453

Chronic compartment syndrome

Front 454

What are the main uses of X-ray?

Back 454

Articular and osseous pathology

Front 455

What are the main uses of computed tomography (CT)?

Back 455

Ossesous, especially cortical pathology

Front 456

What are the main uses of magnetic resonance imaging (MRI)?

Back 456

Tendon, ligament, muscle, cartilage, bone marrow pathology

Front 457

What are the main uses of nuclear bone scanning?

Back 457

Abnormal bone activity

Front 458

What are the main uses of ultrasound?

Back 458

Tendon, ligament, muscle fascial pathologies

Front 459

What are the main uses of intracompartmental pressure studies?

Back 459

Muscle/fascial pathology

Front 460

What are the main uses of nerve conduction studies?

Back 460

Nerve pathology

Front 461

What are the main uses of arteriography/venography?

Back 461

Arterial and venous pathology

Front 462

What four sports pathologies would X-ray be used for?

Back 462

1. Fractures
2. Ligament ruptures or laxity
3. Osteochondral defects
4. Osteochondritides

Front 463

What three sports pathologies would computed tomography (CT) be used to diagnose?

Back 463

1. Stress fractures
2. Cartilage tears
3. Osteochondral defects

Front 464

What six sports pathologies would magnetic resonance imaging (MRI) be used to diagnose?

Back 464

1. Tendonopathies
2. Ligament injuries
3. Muscle tears
4. Cartilage tears
5. Stress fractures
6. Osteochondral defects

Front 465

What three sports pathologies would nucear bone scanning diagnose?

Back 465

1. Stress fractures
2. Medial tibial stress syndrome
3. Osteochondritides

Front 466

What two sports pathologies would ultrasound be used to diagnose?

Back 466

1. Tendonopathies
2. Plantar fasciitis

Front 467

What sports pathology would intracompartmental pressure studies be used to diagnose?

Back 467

Compartment syndromes

Front 468

What sports pathology would nerve conduction studies diagnose?

Back 468

Exercise-related nerve entrapments

Front 469

What sports pathologies would arteriography/venography be used to diagnose?

Back 469

1. Effort-induced deep vein thrombosis
2. Arterial entrapment syndromes

Front 470

What are the three grades for ligament injuries?

Back 470

Grade 1 = stretching of the ligament without macroscopic tears
Grade 2 = partial macroscopic tear
Grade 3 = Complete rupture

Front 471

What are the four grades for tendonitis?

Back 471

Grade 1 = pain after exercise
Grade 2 = Pain pre- and post-exercise, pain reduced during exercise
Grade 3 = Pain before, during and after exercise
Grade 4 = Constant pain and volume of exercise reducing

Front 472

What are the grades for a muscle tear?

Back 472

Grade 1 = minimal tear with no loss of strength
Grade 2 = macroscopic tear with loss of strength
Grade 3 = complete tear with no function

Front 473

What five questions would you ask a patient to assess the pain of their condition?

Back 473

1. What eases or aggravates the pain?
2. At what time of the day is it worse?
3. Is the pain constant or intermittent?
4. What type of medication is the patient taking?
5. What is the previous medical history and history of injury?

Front 474

What four factors should be considered when looking at general health?

Back 474

1. Does the patient look well?
2. Is the patient well nourished (obese or thin and wasted)?
3. Colour (pale and anaemic, jaundiced)?
4. Look at the hands, are they misshapen (rheumatoid arthritis)?

Front 475

What is the aetiology of osteoarthritis?

Back 475

General degeneration

Front 476

What is the aetiology of footballer's ankle?

Back 476

Chronic injury

Front 477

What is the aetiology of osteochondritis dissecans?

Back 477

Chronic injury

Front 478

What is the aetiology of hallux rigidus?

Back 478

General degeneration

Front 479

What is the aetiology of toe deformities?

Back 479

Congenital and acquired

Front 480

What is the aetiology of accessory ossicles?

Back 480

Congenital/injury

Front 481

What is the aetiology of stress fractures?

Back 481

Repetitive injury

Front 482

What is the aetiology of subungual exostosis?

Back 482

Repetitive injury

Front 483

What is the aetiology of exostoses?

Back 483

Injury/dislocation/biomechanical

Front 484

What is the aetiology of tarsal coalition?

Back 484

Congenital

Front 485

What are four aetiologies of metatarsalgia?

Back 485

1. General degeneration
2. Referred
3. Multifactorial
4. Rheumatoid

Front 486

What is the aetiology of sesamoiditis?

Back 486

Repetitive injury/degenerative

Front 487

What is the aetiology of bony or cartilaginous tumours?

Back 487

Neoplastic metastasis/primary or secondary

Front 488

What are four aetiologies of periosteal/joint pain?

Back 488

1. Infective
2. Neoplastic
3. Metabolic
4. Autoimmune reactive

Front 489

What is usually the aetiology of tendonitis, subluxing peroneal tendons, chronic ankle sprain and compartment syndrome?

Back 489

Most of these are associated with injury

Front 490

What is the aetiology of sinus tarsi syndrome?

Back 490

Degenerative/trauma or rheumatoid manifestation

Front 491

What is the aetiology of nodules?

Back 491

Dermatological/rheumatoid/ganglia/cysts

Front 492

What is the aetiology of tarsal tunnel syndrome?

Back 492

Degenerative/biomechanical

Front 493

What are four aetiologies of peripheral neuropathies?

Back 493

1. Metabolic
2. Endocrine
3. Proximal entrapment
4. trauma

Front 494

What is the aetiology of interdigital neuromata?

Back 494

Repetitive injury and (Morton's) degeneration

Front 495

What is the aetiology of hereditary and motor sensory neuropathies (HMSN)?

Back 495

Congenital with hereditary predisposition

Front 496

What is the aetiology of radicular pain?

Back 496

Lumbar referred pain

Front 497

What is the aetiology of peripheral vascular disease?

Back 497

Socioenvironmental/endocrine and metabolic

Front 498

What is the aetiology of acute embolism?

Back 498

Secondary to other factors eg atherosclerosis

Front 499

What is the aetiology of Buerger's disease?

Back 499

Ethnic and social factors predispose to manifestation

Front 500

What is Buerger's disease?

Back 500

Buergers's disease is an acute inflammation and thrombosis (clotting) of arteries and veins of the hands and feet.

Front 501

What is the aetiology of retrocalcaneal bursitis?

Back 501

Repetitive injury/mechanical/rheumatoid

Front 502

What is the aetiology of heel pad pain?

Back 502

Obesity/occupational referred from back

Front 503

What is the aetiology of plantar fasciitis?

Back 503

Repetitive injury, biomechanical

Front 504

What is the aetiology of onychocryptosis?

Back 504

Iatrogenic/congenital

Front 505

What is the aetiology of plantar warts?

Back 505

Infective

Front 506

What are four aetiologies of callosity/corns?

Back 506

1. Biomechanical
2. Deformity
3. Endocrine
4. Footwear design

Front 507

What are five aetiologies of ulcers?

Back 507

1. Vascular
2. Infective
3. Traumatic
4. Dermatological
5. Neoplastic

Front 508

What are the three main aspects of pain that should be considered when assessing a patient?

Back 508

1. Physical pain - intensity, location or physical symptoms
2. Functional - walking distance, activity levels
3. Behavioural - protecting affected painful area, abnormal gait

Front 509

What are eight tools for scoring pain?

Back 509

1. Visual analogue scales
2. Verbal scales - pain is grouped into categories
3. Questionnaires
4. Observational techniques - recording observed patient pain levels eg sleep patterns, medication
5. Physiological measures - not useful as unreliable
6. Quality of life status
7. Health status
8. Foot specific pain questionnaires

Front 510

What six joints of the foot are most commonly affected by osteoarthritis?

Back 510

1. Ankle
2. Subtalar
3. Calcaneocuboid
4. Talonavicular
5. 1st tarsometatarsal
6. 1st MTPJ

Front 511

What ten aetiologies can cause osteoarthritis?

Back 511

1. OA can be secondary to a fracture extending into the joint eg fracture of the neck of the talus may lead to OA of the ankle
2. Dislocation
3. Repeated minor traume
4. Infection in the joint - septic arthritis unless diagnosed and treated early will lead to lysis of cartilage and secondary OA
5. Inflammatory arthropathies such as RA and the seronegative arthropathies eg psoriatic arthritis, Reiter's disease and ankylosing spondylitis
6. Metabolic disorders such as gout and pseudogout
7. Systemic diseases such as diabetes mellitus which can lead to Charcot foot or ankle
8. Proximal malalignment - following a malunited fractured tibia has frequently been stated to lead to arthritis by imposing abnormal stresses on distal joints
9. Haemophilia
10. Avascular necrosis eg Freiberg's infraction affecting the 2nd metatarsal head

Front 512

What are the 7 symptoms of OA?

Back 512

1. Generally pain and stiffness in the area of the affected joint
2. With time and progression the distance the patient can walk without pain gradually reduces
3. Pain may become constant and also present at night, disturbing sleep
4. With time the ROM in the affected joint will decrease
5. Dorsiflexion is usually the first movement to be lost so a heel raise could be helpful
6. In severe OA the joint may completely lose movement and become virtually ankylosed.
7. Patients may complain of a limp, swelling or joint deformity

Front 513

What are the 7 signs of OA?

Back 513

1. The joint may appear swollen or deformed or be held in an abnormal position
2. The joint may feel warm if the underlying cause is infection or an inflammatory arthropathy but otherwise not
3. An effusion may be present in ankle OA but is not usually clinically detectable in OA of other foot joints
4. Osteophytes may be felt in superficial joints as hardy bony swellings and represent new bone formation around the periphery of affected joints.
5. Localised tenderness may also be found
6. The ROM will be reduced, the degree depending on how advanced the arthritis is and movement will be painful, more so at the extremes
7. Often movement may feel 'dry', rather than smooth and easy. In advanced OA grating or crunching may be felt by the examiner as the joint is moved.

Front 514

What are the two factors in the aetiology of footballer's ankle (anterior impingement of the ankle)?

Back 514

1. It occurs in soccer players as a result of repeated kicking of the ball with the foot held in equinus
2. In this position the anterior capsule largely takes the strain as the extensor tendons are mechanically disadvantaged and bony traction spurs develop

Front 515

What are the two presenting symptoms of footballer's ankle (anterior ankle impingement)?

Back 515

1. There will be pain, often on kicking a stationary ball but also on dorsiflexion of the ankle
2. The patient may complain of some restriction of dorsiflexion

Front 516

What are two signs of footballer's ankle (anterior ankle impingement syndrome)?

Back 516

1. Local tenderness over the neck of the talus and anterior tibial margin
2. Pain on dorsiflexion of the ankle and perhaps some restriction of this movement

Front 517

What will X-rays reveal in footballer's ankle (anterior ankle impingement)?

Back 517

Plain X-rays will demonstrate a dorsal talar spur and also a spur on the anterior lip of the tibia. The spur on the anterior lip of the tibia can be subtle, appearing as a convex margin rather than the normal concave one. Both these spurs are intracapsular although this may be difficult to appreciate on a plain X-ray

Front 518

What is the aetiology of osteochondritis dissecans (ankle/talocrural joint)?

Back 518

An osteochondral fragment becomes separated from the talar dome, usually posteromedially or mid-laterally. It is now thought that all of the lateral and most of the medial lesions originate from trauma, probably associated with inversion injuries of the ankle

Front 519

What are three presenting symptoms of osteochondritis dissecans (ankle/talocrural joint)?

Back 519

Because of the aetiology the diagnosis may be missed acutely and the patient treated for a simple sprain or malleolar fracture. If, however, symptoms persist after adequate treatment of the recognised injury, an osteochondral fracture should be suspected. Acute symptoms will be those of a sprained ankle with the patient complaining of:
1. Pain, swelling and difficulty walking.
2. Chronic symptoms are more general with patients complaining of discomfort, pain and perhaps stiffness during or after exercise.
3. If an osteochondral fragment has become detached from the talar dome then there may be locking and giving way in the ankle, suggestive of a loose body

Front 520

What is an osteochondral fracture?

Back 520

The cartilage covering the end of a bone in a joint (articular cartilage) is torn.

Front 521

What are two signs of osteochondritis dissecans (ankle/talocrural joint)?

Back 521

Acute signs will include:
1. Swelling and tenderness over the lateral ligament complex with pain on inversion of the ankle
2. It may be possible to locate tenderness over the talar dome midlaterally or behind the medial malleolus

Front 522

What will diagnostic investigations show?

Back 522

Lateral lesions classically are shallow, horizontal and often detached or elevated. Medial lesions are frequently cup-shaped and deeper. In the acute stage X-rays may appear normal, especially if the lesion is stage 1 ie only the articular cartilage is damaged. Even in a chronic lesion it may be difficult to detect any changes on plain X-ray. A bone scan is extremely useful as it will usually be positive. MRI is the most sensitive as well as the most expensive of demonstrating osteochondral fractures

Front 523

What three differential diagnoses should be included when diagnosing osteochondritis dissecans (ankle/talocrural joint)?

Back 523

1. Anterolateral impingement syndrome
2. Tendonitis of any of the tendons crossing the ankle joint
3. Early OA
3.

Front 524

What is the aetiology of hallux rigidus?

Back 524

Hallux rigidus is a condition in which dorsiflexion of the 1st MTPJ is restricted and painful on movement. Plantarflexion may also be limited but dorsiflexion is the functional movement affected by the pathology. It may occur secondary to an osteochondritis dissecans of the 1st metatarsal head in adolescents, usually females. In adults, males tend to predominate and it can be secondary to a systemic disease such as RA or gout but most commonly is primarily due to a local arthritic degeneration. Various theories have been advanced for the primary cause such as a long first metatarsal and hallux and repeated trauma; patients tend to have pronated, narrow, long feet with a flat longitudinal arch

Front 525

What are the presenting symptoms of hallux rigidus?

Back 525

Intermittent pain in adolescents who may experience episodes of acute pain made worse by walking. Adults present with pain on walking, stiffness and pain over the dorsal exostosis in more advanced cases although lateral joint pain may be observed as well.

Front 526

What are the signs of hallux rigidus?

Back 526

The hallux is commonly straight and a dorsal bony prominence with perhaps a bunion (soft bursa swelling) may be found. Locally there may be some tenderness over the exostosis and around the 1st MTPJ. The ROM should be assessed with the foot in a plantigrade position but also in a plantarflexed position. A grind test, in which the hallux is compressed longitudinally with rotation, may be painful where the joint is not stiff. In advanced cases compensatory secondary hyperextension of the IPJ may be found and commonly there is a callosity on the medial plantar aspect of the head of the proximal phalanx or base of the distal phalanx

Front 527

What will X-rays reveal in hallux rigidus?

Back 527

X-rays of the 1st MTPJ may be normal or show a dorsal exostosis with a normal-looking joint. In more advance cases degenerative changes will be apparent with progressive OA. If hallux rigidus is due to gout or RA then periarticular erosions may be present with osteoporosis.

Front 528

What differential diagnosis should be considered when diagnosing hallux rigidus?

Back 528

In flexor hallucis longus tenosynovitis, dorsiflexion of the hallux may be restricted and painful. Resisted plantarflexion of the hallux will be painful and local tenderness may be felt posterior to the medial malleolus

Front 529

What are the aetiology of os trigonum and the accessory navicular?

Back 529

There are at least 15 accessory ossicles around the foot and ankle. Most are anatomical variants in origin. Only two are likely to cause symptoms. Around the hindfoot there is os trigonum, on the posterior aspect of the talus close to the lateral tubercle and the accessory navicular. The type II accessory navicular is roughly 1cm in size and united to the main body of the navicular by a synchondrosis of about 12mm

Front 530

What are the presenting symptoms of os trigonum and accessory navicular?

Back 530

The os trigonum causes symptoms with activities in repeated plantarflexion, affecting football players and dancers standing en pointe. Patients complain of posterolateral ankle pain when the ankle is plantarflexed and impingement occurs. An accessory navicular may cause rubbing in a shoe, because of local pressure, or may become symptomatic following a twisting injury to the foot.

Front 531

What are the signs of os trigonum and accessory navicular?

Back 531

With a symptomatic os trigonum tenderness may be felt behind the lateral malleolus and peroneal tendons and forced passive plantarflexion of the ankle will be painful. When an accessory navicular is present there will be local tenderness in association with a prominent navicular and perhaps pain on resisted inversion.

Front 532

What differential diagnoses should be considered when diagnosing os trigonum and accessory navicular?

Back 532

A symptomatic os trigonum may be mistaken for peroneal tendonitis, flexor hallucis longus tendonitis or a fracture of the lateral process of the posterior talar tubercle. A symptomatic accessory navicular is usually obvious because of local tenderness but should not be confused with tibialis posterior tendonitis.

Front 533

What is the aetiology of stress fractures?

Back 533

Stress fractures occur due to overuse in unadapted feet or when surgery in the foot leads to high stresses elsewhere. Fractures have been reported in groups such as runners, army recruits and dancers. They may also occur though rarely after first ray surgery eg Keller's excisional arthroplasty operation which increases stresses on the lesser metatarsals. From whatever cause the most common site is a metatarsal shaft. Stress fractures have also been reported in the calcaneus, navicular, cuboid and proximal phalanx of the hallux.

Front 534

What are the presenting symptoms of stress fractures?

Back 534

Pain occurs in relation to activity. Initially it may be vague and difficut to localise but settles on rest. With time the patient may complain of a limp.

Front 535

What are the signs of a stress fracture?

Back 535

In the early stages there may be little to find on clinical examination but if activity continues then local tenderness and swelling will develop. A limp may be present.

Front 536

What should X-rays reveal in stress fractures?

Back 536

Plain X-rays may often be normal in the early stages and it can be 2-3 weeks before changes become apparent for metatarsal stress fractures and up to 5 weeks for calcaneal ones. In the metatarsal shafts early changes may be a fine line of bone resorption followed either by sclerosis of periosteal callus, depending on whether the cortex has been breached. In the calcaneum the fractures tend to occur in the posterior part and appear as endosteal callus with an intact cortex on X-ray. Because of the delay in X-ray a bone scan may be helpful if there is doubt about the diagnosis. CT or MRI scans may be helpful to show stress fractures which are difficult to depict on X-ray.

Front 537

What are the differential diagnoses that should be considered when diagnosing stress fractures?

Back 537

The clinical picture, relation to activity and local tenderness should point towards the correct diagnosis. One should beware of metatarsal stress fractures in the diabetic as they may be the precursor of a Charcot foot.

Front 538

What is the aetiology of a subungual exostosis?

Back 538

This is a bony spur usually arising from the dorsomedial aspect of the distal phalanx of the hallux. Rarely it may arise from the lesser toes. It is generally a benign osteochondroma, congenital in origin, and may be noticed from adolescence up to early middle age. There is some suggestion that those occurring in young adult athletes may be the result of repetitive minor trauma inside the shoe.

Front 539

What is Starling's law of the capillary?

Back 539

There are a number of forces acting to force fluid through the endothelial cell of the capillary. The forces that are acting on the flow into the capillary are:
1. Blood pressure (hydrostatic)
2. Gravity pressure (if below heart)
3. Interstitial protein (osmotic pressure)
The forces that are acting on the flow out of the capillary are:
1. Plasma protein (osmotic pressure)
2. Gravity pressure (if above heart)
3. Tissue elasticity

Front 540

What is Starling's law of the heart?

Back 540

The Law of the Heart states that the normal heart will maintain a blood pressure of 0 at the sinus venosus no matter how much blood is returned to the heart. In other words, the heart adjusts its pumping rate to the rate of blood return. It adjusts to the amount of returning blood in the following ways:


1. More blood returning stretches the atria and ventricles more.
2. Stretching heart SA node muscle causes faster rhythmicity.
3. Stretching heart muscle causes faster conduction.
4. Stretching heart muscle causes stronger, more complete contraction.
The amount of blood a heart pumps per minute is called the minute volume or cardiac output. The amount pumped per beat is the stroke volume. The amount of blood that returns to the heart is called the venous return.

Front 541

What are the presenting symptoms of subungual exostosis?

Back 541

Patients may notice a swelling under the nail or may complain of pain on walking or running with shoes on

Front 542

What are the signs of subungual exostosis?

Back 542

The nail may be elevated and there may be a darkish discolouration, resembling a haematoma, apparent under the nail. The distal nail edge may be elevated, suggesting an enlarged distal tuft.

Front 543

What differential diagnoses should be considered when diagnosing subungual exostosis?

Back 543

A subungual exostosis may be confused with other conditions such as a glomus tumour or subungual wart

Front 544

What is the aetiology of a tarsal coalition?

Back 544

This is a congenital condition in which adjacent tarsal bones have a fibrous, cartilage or bone connection or bridge which progressively restricts normal movement. This may be termed syndesmosis, synchondrosis or synostosis. Generally it begins as a fibrous union in infancy and progresses to cartilaginous and then bony union; however it may remain fibrous. The most common coalition is probably talocalcaneal followed by calcaneonavicular.

Front 545

What is the aetiology of a tarsal coalition?

Back 545

This is a congenital condition in which adjacent tarsal bones have a fibrous, cartilage or bone connection or bridge which progressively restricts normal movement. This may be termed syndesmosis, synchondrosis or synostosis. Generally it begins as a fibrous union in infancy and progresses to cartilaginous and then bony union; however it may remain fibrous. The most common coalition is probably talocalcaneal followed by calcaneonavicular.

Front 546

What are the presenting symptoms of a tarsal coalition?

Back 546

Although these coalitions usually ossify between 8 and 16, symptoms may not develop until late childhood or into adulthood. Sometimes patients never develop symptoms and the diagnosis is made incidentally. When they do present, patients may complain of stiffness and ankle pain when playing sport. They may also complain of recurrent ankle sprains

Front 547

What are the signs of tarsal coalition?

Back 547

Stiffness in the subtalar or midtarsal joint movements is usually the predominant sign. Patients may also have a valgus flatfoot with subtalar irritability, characterised by pain on forced plantarflexion of the ankle joint and some peroneal spasm. In childhood, presentation like this is known as peroneal spastic flatfoot.

Front 548

What diagnostic investigations would be done for diagnosing tarsal coalitions?

Back 548

X-rays may demonstrate a coalition. A CT scan may confirm the diagnosis.

Front 549

What other differential diagnoses should be considered when diagnosing tarsal coalition?

Back 549

Other conditions leading to stiff subtalar or midtarsal joints such as degenerative or inflammatory arthritis

Front 550

What are five aetiologies of metatarsalgia?

Back 550

Metatarsalgia is characterised by pain felt under one or more metatarsal heads when weightbearing. It may be due to a number of causes:
1. Atrophy of the plantar fat with age. This results in a generalised metatarsalgia because of loss of the cushioning effect of the fat pad.
2. Increased pressure under the lesser metatarsals following 1st MTPJ surgery eg for hallux valgus of Keller's operation
3. MTPJ problems. Subluxation or dislocation of the proximal phalanx may lead to a pistoning effect which depresses the metatarsal head increasing its load. This may occur in inflammatory arthropathies or in a cavus foot with claw toes. Claw toes that dorsiflex on the metatarsal head pull the fat pad forward, exposing the metatarsal head to greater loading during stance.
4. A prominent fibular (lateral) condyle on a metatarsal head may cause a very local plantar callosity with pain on weightbearing
5. Proximal stiffness of malalignment eg a pes cavus foot may lead to an excessive loading on one side of the foot.

Front 551

What are the presenting symptoms of metatarsalgia?

Back 551

Patients complain of pain under the ball of the foot on walking, made worse by walking barefoot. Well-padded shoes such as trainers can reduce symptoms effectively. Patients may also complain of hard skin continually building up under the foot, which adds to the general discomfort.

Front 552

What are the signs of metatarsalgia?

Back 552

The main sign is tenderness under the metatarsal heads on palpation; callosities may be present under the symptomatic heads, indicating the increased load. With a prominent fibular condyle the callosity is small and well-defined and has a central keratotic core. This may be described as a local intractable plantar keratoma. The other type of callosity observed will be a diffuse lesion without a central keratotic core. Prominent metatarsal heads may be palpated and their degree of rigidity should be assessed, as should the mobility of the toes. It is important to access the mobility of the proximal joints to ensure they are supple.

Front 553

What diagnostic investigations would be done in metatarsalgia?

Back 553

X-rays will demonstrate evidence of any inflammatory arthropathy and any changes in an MTPJ. If available, dynamic pressure studies will show the distribution of pressure under the metatarsal heads.

Front 554

What differential diagnoses would be considered in the diagnosis of metatarsalgia?

Back 554

This lies between the various causes of metatarsalgia. A wart may cause a plantar callosity but does not normally occur under a metatarsal head. A Morton's neuroma is commonly referred to as Morton's metatarsalgia although the pain and tenderness is actually between metatarsals, radiating into toes (digital neuritis)

Front 555

What is the aetiology of sesamoiditis?

Back 555

Flexor hallucis brevis inserts into the base of the proximal phalanx of the hallux and within its tendons two sesamoid bones lie under the first metatarsal head. These may give rise to pain if they become arthritic. This can occur secondary to hallux rigidus or inflammatory arthropathies such as RA. Chondromalacia type changes have also been reported. Rarely, sesamoids may fracture following trauma and stress fractures have been reported. Hypertrophy of a sesamoid can lead to a painful plantar callosity

Front 556

What are the presenting symptoms of sesamoiditis?

Back 556

Pain under the first metatarsal head on weight-bearing is the main symptom. Patients may notice this particularly on toe-off

Front 557

What are the signs of sesamoiditis?

Back 557

Tenderness may be localised to one or both sesamoids. Extension at the first MTPJ may be limited and painful and a painful callosity may be present.

Front 558

What diagnostic investigations would be used to diagnose sesamoiditis?

Back 558

X-rays and bone scans

Front 559

What are the differential diagnosis for sesamoiditis?

Back 559

Other causes of pain around the 1st MTPJ such as hallux rigidus. The high incidence of bipartite sesamoids may lead to a false diagnosis of a fracture

Front 560

What is the aetiology of tumours in the foot?

Back 560

Bony or cartilaginous tumours are fortunately rare in the foot. Nevertheless, a number have been reported, both benign and malignant. Among the most common benign ones are osteoid osteoma, enchondroma and osteochondroma. Osteoid osteomas may occur in the tarsus in the foot, enchondromas in metatarsals or phalanges and osteochondromas normally only occur as subungual exostoses. Malignant tumours reported include osteosarcoma, chondrosarcoma and Ewing's tumour. Osteosarcomas and chondrosarcomas have been reported in the tarsus and metatarsals, Ewing's in the tarsus. Although a secondary deposit is the most common bony tumour in the body as a whole, secondaries are rare in the foot but may occur: if they do, the most likely primary cause is a bronchial carcinoma.

Front 561

What are presenting symptoms of tumours in the foot?

Back 561

This will depend on the individual tumour. Osteoid osteomas tend to occur in young adults and classically give rise to night pain relieved by aspirin. Enchondromas may cause cortical thinning of a metatarsal and therefore present with acute pain from a pathological fracture. Malignant tumours may present with pain and/or swelling.

Front 562

What are signs of a tumour in the foot?

Back 562

These depend on the diagnosis and may vary from nil to tenderness and swelling from a pathological fracture

Front 563

What diagnostic investigations would be carried out in tumours of the foot?

Back 563

X-rays will demonstrate most of these lesions, showing areas of bone destruction, expansion or new bone formation. An osteoid osteoma may be seen as a central nidus with surrounding sclerosis, but can be very difficult to see and a bone scan may help by showing it as a concentrated hot spot. MRI is extremely helpful both in diagnosis and delineating the extent of a malignant tumour. Before any definitive treatment is planned a biopsy of the tumour is usually necessary. As well as imaging bony tumours, a full blood screen will usually be performed, along with a chest X-ray and bone scan, unless the tumour is simple and benign.

Front 564

What is the differential diagnosis of a tumour of the foot?

Back 564

The first consideration with any lesion suspected of being a tumour is whether it is benign or malignant. Infection should always be considered as it may sometimes be difficult to differentiate. Although it should not cause any confusion in diagnosis, an old fracture may sometimes look suspicious to the untutored eye.

Front 565

What is the aetiology of tendinitis?

Back 565

Peritendonitis (inflammation of the tendon sheath) may affect any of the tendons crossing the ankle into the foot but most commonly involves the Achilles tendon and tibialis posterior. Achilles tendonitis occurs usually in young adults who are joggers or athletes. Tibialis posterior tenosynovitis (inflammation of its tendon sheath) normally occurs in late middle age. Less common, tenosynovitis of a peroneal tendon may occur and in dancers tenosynovitis of the flexor hallucis longus tendon can occur where it passes in a groove behind the talus.

Front 566

What are the presenting symptoms of tendonitis?

Back 566

Patients with peritendonitis will present with pain on exercise, usually along the course of the tendon. They may also notice some swelling. It is worth enquiring whether they have recently changed running shoes.

Front 567

What are the signs of tendonitis?

Back 567

In Achilles tendonitis the tendon will be painful to palpation about 5cm proximal to its distal insertion; with time, swelling and crepitus may be found. In tibialist posterior tenosynovitis there will be tenderness behind the medial malleolus with pain on resisted inversion and perhaps passive eversion. It is important to rule out ruptured tibialis posterior tendon. In this case the patient may present with vague pain on the medial aspect and a spontaneous flat foot. The hindfoot will be in valgus and the heel will not invert if the patient stands on tiptoe. When looked at from behind, the forefoot is abducted, producing the 'too many toes sign'.
For the peroneal tendons, tenderness will be felt distal to the lateral malleolus, along the course of the tendons, with pain on inversion and plantarflexion. Differentiating between brevis and longus may be difficult; tenderness on the sole of the foot between the cuboid and base of the first metatarsal will suggest problems with peroneus longus. Evert the hindfoot actively against resistance to clarify such involvement.
In tenosynovitis of flexor hallucis longus there will be tenderness posterior to the medial malleolus with pain on passive extension of the hallux. Occasionally tenderness can be found at the level of the sesamoids and may cause limitation of movement at the first MTPJ.

Front 568

What investigations are carried when tendonitis is suspected?

Back 568

Peritendonitis is largely a clinical diagnosis; if doubt exists then MRI may be helpful in showing fluid in the tendon sheath. Abolition of the patient's symptoms by injection of local anaesthetic may also be diagnostic

Front 569

What are the differential diagnoses to be considered in tendonitis?

Back 569

In Achilles tendonitis it is important not to miss rupture. Up to 25% of acute ruptures are missed. Similarly with tibialis posterior tenosynovitis, rupture should be look for. Tenderness at the insertion may be due to an accessory navicular.

Front 570

What is the aetiology of subluxing peroneal tendons?

Back 570

The peroneal tendons are held behind the lateral malleolus by the retinaculum and this may be ruptured in an acute injury. Following that the tendons are free to sublux

Front 571

What are the presenting symptoms of subluxing peroneal tendons?

Back 571

A painful snapping sensation at the ankle on certain movements

Front 572

What are the signs of subluxing peroneal tendons?

Back 572

There will be tenderness along the peroneal tendons behind the lateral malleolus and the tendons may sublux anteriorly with resisted eversion and dorsiflexion

Front 573

What investigations would be carried out if subluxing peroneal tendons were suspected?

Back 573

This is mainly a clinical diagnosis but if doubt exists then a peroneal tenogram may show dye leakage indicating a torn retinaculum

Front 574

What differential diagnoses would be considered when diagnosing subluxing peroneal tendons?

Back 574

Acutely with a sprained ankle and more chronically with peroneal tenosynovitis

Front 575

What is the aetiology of chronic ankle sprain?

Back 575

Chronic lateral pain following an acute inversion injury of the ankle is common, being reported in up to 50% of some patient groups. This may be due to residual instability, causing recurrent sprains, but most commonly is due to soft tissue impingement in the lateral gutter. The initial sprain leads to inflammation, synovitis and then scar tissue and fibrosis

Front 576

What are the presenting symptoms of chronic ankle sprain?

Back 576

Patients complain of pain over the anterolateral aspect of the ankle on walking and often weakness and a feeling of giving way

Front 577

What are the signs of chronic ankle sprain?

Back 577

Tenderness is present over the anterolateral gutter of the ankle. Ankle and subtalar joint movement is usually normal. Instability should be carefully looked for. Clinically this is done by comparing inversion between the two ankles and doing an anterior drawer test. In this test the patient lies supine with the knee flexed and the examiner sits on the patient's foot to stabilise it. The tibia is then pushed back on the talus. Instability is shown by excessive movement by comparison to the other ankle. A clunking sensation may be elicited sometimes. This may be a difficult test to do without the patient fully relaxed under a general anaesthetic.

Front 578

What investigations would be carried out when diagnosing chronic ankle sprain?

Back 578

X-rays are usually normal but may show small bony spurs or calcification. Stress X-rays for instability will be normal. A bone scan may show mildly increased uptake and is only useful in excluding other causes of pain. MRI is the only tool which can show increased soft tissue in the lateral gutter

Front 579

What differential diagnoses should be considered when diagnosing chronic ankle sprain?

Back 579

Other local causes of pain should be excluded, such as an osteochondral fracture, peroneal tendon problems and arthritis of the ankle joint.

Front 580

What is the aetiology of sinus tarsi syndrome?

Back 580

It follows a sprained ankle which does not resolve in the normal time and may be due to degeneration of the fatty soft tissue in the sinus tarsi. Some practitioners consider that the condition represents a mild form of subtalar instability

Front 581

What are the presenting symptoms of sinus tarsi syndrome?

Back 581

The patient will complain of chronic pain, situated laterally following a sprained ankle

Front 582

What are the signs of sinus tarsi?

Back 582

Apart from tenderness over the sinus tarsi there is little to find.

Front 583

What investigations should be carried out when diagnosing sinus tarsi?

Back 583

X-rays will be normal. An injection of local anaesthetic into the sinus tarsi should provide some temporary relief and is diagnostically useful

Front 584

What differential diagnoses should be considered when diagnosing sinus tarsi?

Back 584

Other causes of continued pain following a sprained ankle

Front 585

What is the aetiology of compartment syndrome?

Back 585

The muscles and nerves in the leg are contained within four compartments, each of which has fascial or fascial and osseous boundaries. The foot also has four compartments. A compartment syndrome results from ischaemia to muscles and may involve nerves, secondary to raised pressure within that compartment. It may occur acutely following a fracture or soft-tissue trauma or chronically with symptoms after a certain level of exercise. Mild compartment syndromes are not infrequently missed following a fractured tibia and present with residual sequelae such as claw toes.

Front 586

What are the presenting symptoms of compartment syndrome?

Back 586

Chronic compartment syndromes of the leg will present with pain in the involved compartment after a degree of exercise, usually running. The pain settles on rest but symptoms may become worse with time. If the anterior compartment is involved, then pain and paraesthesia may radiate into the dorsum of the foot and ankle from involvement of the superficial peroneal nerve. If the deep posterior compartment is involved, then pain and paraesthesia over the sole of the foot, in the distribution of the posterior tibial nerve may be felt.

Front 587

What are the signs of compartment syndrome?

Back 587

At rest physical examination may be normal, although there may be some tenderness over the distal tibia. This may become more marked if the patient exercises on a treadmill to produce symptoms

Front 588

What investigations should be undertaken when diagnosing compartment syndrome?

Back 588

X-rays should be taken to exclude a stress fracture or other osseous causes of leg pain. Measuring compartment pressures with a catheter introduced under local anaesthetic is the most useful way to confirm the diagnosis. Pressures are measured before and after exercise. There is some debate as to the correct abnormal compartment pressures. Generally, intracompartmental pressures at rest should be less than 15mmHg and 5-10 min following exercise should have returned to 15mmHg or less.

Front 589

What differential diagnoses should be considered when diagnosing compartment syndrome?

Back 589

Shin splints or stress fractures of the tibia will be the main differential diagnosis for leg pains. For neurological symptoms in the foot an entrapment neuropathy should be excluded

Front 590

What is the aetiology of tarsal tunnel syndrome?

Back 590

The posterior tibial nerve, a branch of the sciatic nerve, may become compressed as it passes under the flexor retinaculum behind the medial malleolus. The compression may cause direct pressure leading to motor and sensory symptoms or may compress the vascular supply, the vasa nervorum, causing sensory symptoms only. Aetiology of tarsal tunnel syndrome is idiopathic, trauma or associated with bony alignment. Other cases may be related to problems such as RA or compression within the tunnel associated with a ganglion, lipoma or venous varicosities

Front 591

What are the presenting symptoms of tarsal tunnel syndrome?

Back 591

The patient is likely to complain of a diffuse burning type of pain on the sole of the foot. With time symptoms may become localised. Often pain is worse on activity and better at rest. A proportion of patients get night-time pain and some 30% have proximal radiation of pain to the midcalf region known as the Valleix phenomenon

Front 592

What is Valleix phenomenon?

Back 592

Proximal radiation of pain into the calf region

Front 593

What is proximal radiation of pain into the calf region known as?

Back 593

Valleix phenomenon

Front 594

What are the signs of tarsal tunnel syndrome?

Back 594

Sensory or motor weakness is rare to find but should be carefully looked for. Most useful is a positive Tinel sign obtained by starting proximally and percussing along the course of the nerve. At the site of entrapment percussion will cause radiation of the pain along the course of the nerve

Front 595

What investigations would be carried out to assist diagnosis of tarsal tunnel syndrome?

Back 595

X-rays may demonstrate any post-traumatic bony spurs causing compression but do not in themselves make a diagnosis. Electro-diagnostic tests are necessary for this. Nerve conductionn studies looking at sensory conduction velocities and the amplitude and duration of motor-evoked potentials. Tests should be performed bilaterally and a peripheral neuropathy should be excluded. If an extrinsic compression in the tunnel is suspected then an MRI may be helpful

Front 596

What is the differential diagnosis of tarsal tunnel syndrome?

Back 596

Because of the diffuse nature of the symptoms the differential diagnosis is quite wide but two possibilities should be particularly looked for. A peripheral neuropathy eg from diabetes may cause burning pains in the foot but is usually bilateral. Sciatica with nerve root irritation causing distal pain also needs to be excluded. Straight leg raising will be restricted and painful.

Front 597

What is the aetiology of nerve entrapments?

Back 597

Other nerve entrapments include the deep peroneal nerve under the inferior extensor retinaculum and the superficial peroneal nerve as it exits the deep fascia about 11.5cm above the lateral malleolus, the medial plantar nerve at the master knot of Henry and first branch of the lateral plantar nerve between abductor hallucis and quadratus plantae muscles. Most of these entrapments occur in runners or athletes.

Front 598

What is the master knot of Henry?

Back 598

The crossing of the Flexor Digitorum Longus and Flexor Hallucis Longus tendons, on the medial side of the foot.

Front 599

What is the crossing of the Flexor Digitorum Longus and Flexor Hallucis Longus tendons, on the medial side of the foot called?

Back 599

The master knot of Henry

Front 600

Where does the calcaneonavicular (spring) ligament start and end?

Back 600

It runs from the sustenaculum tali to plantarmedial aspect of navicular

Front 601

Which ligament runs from the sustenaculum tali to the plantarmedial aspect of the navicular?

Back 601

Calcaneocuboid (spring) ligament

Front 602

What are symptoms and signs of deep peroneal nerve entrapment?

Back 602

Patients complain of pain over the dorsum of the foot and sometimes numbness and paraesthesia in the first web space. There may be altered sensation in the first web space and a positive Tinel sign

Front 603

What are signs and symptoms of superficial peroneal nerve entrapment?

Back 603

Symptoms include pain over the dorsum of the foot and ankle and inferior lateral border of the calf. As a sensory nerve there are no motor signs but there may be a positive Tinel sign. A fascial defect or muscle herniation where the nerve exits the deep fascia should be looked for.

Front 604

What are the signs and symptoms of medial plantar nerve entrapment?

Back 604

Patients complain of an aching pain over the medial aspect of the arch, often radiating into the medial three toes, becoming worse on running. A positive Tinel sign may be found and also tenderness under the medial arch.

Front 605

What are the signs and symptoms of first branch of lateral plantar nerve?

Back 605

Patients complain of chronic pain, often increased on running but sometimes present when walking. On examination there will be tenderness over the nerve deep to abductor hallucis and pressure reproduces the patient's symptoms.

Front 606

What investigations would be carried out when diagnosing nerve entrapments?

Back 606

Nerve conduction studies may help with the diagnosis of deep peroneal nerve entrapment but are less useful in diagnosing the others. More recently, abnormalities of nerve conduction and electromyography have demonstrated plantar nerve abnormalities. Injection of local anaesthetic at the site of entrapment may act as a diagnostic test if it abolishes symptoms.

Front 607

What would the differential diagnosis be for nerve entrapments?

Back 607

The same as for tarsal tunnel syndrome ie peripheral neuropathy eg from diabetes may cause burning pains in the foot but is usually bilateral. Sciatica with nerve root irritation causing distal pain also needs to be excluded. Straight leg raising will be restricted and painful.

Front 608

What is the aetiology of peripheral neuropathy?

Back 608

Peripheral neuropathies may be due to a variety of causes. In the West the leading cause is diabetes and in the Third World it is leprosy. Other causes include spina bifida, pernicious anaemia, drugs and alcoholism. The different patterns of peripheral neuropathy may vary but in diabetics the most common is a symmetrical distal polyneuropathy, encompassing motor, sensory and autonomic components

Front 609

What are the presenting symptoms of peripheral neuropathy?

Back 609

Patients may notice no symptoms at all if the neuropathy presents as a painless one. The first inkling of a problem may be when a patient presents with a complication such as ulceration or infection. In a diabetic who normally has a painless foot with no sensation the presence of pain is important and may indicate deep infection, such as an abscess or osteomyelitis. If the presentation is of a painful neuropathy the patient may complain of a burning sensation in the legs and feet, commonly worse at night.

Front 610

What are the signs of peripheral neuropathy?

Back 610

In a diabetic the foot may adopt a cavus appearance with clawed toes. In the absence of vascular disease the foot will feel warm and there may be distended veins. Sensation to light touch and pinprick will be reduced and joint position sense may be impaired. The toes may be clawed with wasting of the intrinsic foot muscles and the ankle jerk absent. Callosities may be present under the metatarsal heads and heel.

Front 611

What investigations would be carried out for peripheral neuropathy?

Back 611

In evaluating a peripheral neuropathy it is important to look for an underlying cause. The urine should be tested for sugar and a random blood glucose test performed to look for the most common cause. A careful history and examination should uncover evidence of other causes. Nerve conduction studies may be helpful to rule out an entrapment neuropathy.

Front 612

What is the aetiology of Morton's metatarsalgia (neuroma)?

Back 612

This condition is a type of entrapment neuropathy affecting a plantar digital nerve. It most commonly affects the common digital nerve to the 3/4 interspace but may also occur in the 2/3 interspace. The diagnosis probably does not exist in the first or fourth webspaces, although there has been much debate over this. The incidence of a second neuroma in the same foot is 4%. Women are affected at least four times more often than men and the condition can affect adults of any age. The nerve develops a fusiform swelling, just proximal to its bifurcation, at the level of the intermetatarsal bursa. Although frequently termed a neuroma, technically it is not as the histology shows a degenerative process rather than a proliferative one.

Front 613

What are the presenting symptoms of Morton's metatarsalgia (neuroma)?

Back 613

The patient complains of a burning pain on the sole of the foot, at the level of the metatarsal heads and commonly radiating into one or two toes. It may feel to the patient like walking on a sharp pebble. Occasionally, pain will radiate proximally. Pain is often worse on walking and may be particularly exacerbated by tight-fitting shoes, as these will compress the metatarsal heads together, thus "trapping" the nerve. Resting or removing the tight shoes may settle the pain. Less than half the patients complain of numbness in the toes.

Front 614

What are signs of Morton's metatarsalagia (neuroma)?

Back 614

On palpation of the relevant interspace the patient's pain will be reproduced, sometimes with radiation into a toe. However, it may be difficult to elicit conclusive evidence on examination. If pressure is maintained in the interspace with one hand, while the other alternately squeezes the forefoot from side to side to compress the metatarsal heads together, then a painful click may be obtained. This is known as Mulder's click and is only helpful if it reproduces pain. It is important to ensure that any tenderness is not over the metatarsal heads, rather than intermetatarsal, although in rare cases nerves may become trapped under a metatarsal head. Sensation in the toes is usually normal but may vary.

Front 615

What investigations should be undertaken when diagnosing Morton's metatarsalgia (neuroma)?

Back 615

X-rays should be taken to rule out other pathology. Although ultrasound and MRI have been used to look for the swelling in the nerve they have not generally proved reliable enough to be used as diagnostic tools. Ultrasound has been reported as useful if the neuroma is 5mm in diameter. Nerve conduction studies are not helpful. A diagnostic injection of local anaesthetic may be helpful if it abolishes the patient's pain.

Front 616

What differential diagnoses should be considered when diagnosing Morton's metatarsalgia (neuroma)?

Back 616

Problems affecting the metatarsal head such as synovitis, intermetatarsal bursa and Freiberg's disease should be considered. It is important to be careful about whether the tenderness is under a metatarsal head or intermetatarsal. Pain from a neurological cause such as tarsal tunnel syndrome, peripheral neuropathy or referred pain from the back should be excluded.

Front 617

What is the aetiology of retrocalcaneal bursitis?

Back 617

There are two bursae at the heel. One is deep to the Achilles tendon and the other lies superficial to its insertion. The deep bursa is infrequently affected but as it has a synovial lining, symptoms may be early indicators of an inflammatory arthropathy such as RA. Men are affected more often than women. Symptoms in the subcutaneous bursa affect adolescent females most frequently

Front 618

What are the presenting symptoms of retrocalcaneal bursitis?

Back 618

For the subcutaneous bursa the symptoms are 'pump or heel bumps'. The patient complains of a tender prominence at the heel when wearing shoes.

Front 619

What are the signs of retrocalcaneal bursitis?

Back 619

Inflammation of the deep bursa will produce tenderness deep to the Achilles tendon. In heel bumps there is variable tenderness over a thickened bursa situated just lateral to the Achilles tendon attachment.

Front 620

What investigations should be undertaken when diagnosing retrocalcaneal bursitis?

Back 620

A plain lateral X-ray should be taken. With deep bursitis calcaneal erosions should be looked for. In heel bumps the X-ray is usually normal with no evidence of any posterosuperior prominence to the calcaneus.

Front 621

What differential diagnoses should be considered when diagnosing retrocalcaneal bursitis?

Back 621

This is mainly with other causes of heel pain and with Achilles tendonitis

Front 622

What is the aetiology of heel pad syndrome?

Back 622

This is a chronic inflammatory process within the heel fat pad. The heel is subject to repetitive impact loading on walking which can exceed body weight. With running these forces can rise to 3-8 times body weight. Predisposing symptoms may be running on hard surfaces eg roads, obesity and increasing age.

Front 623

What are the presenting symptoms of heel pad syndrome?

Back 623

Patients complain of heel pain, worse in the early morning and on weightbearing. They may have a limp

Front 624

What are the signs of heel pad syndrome?

Back 624

There is localised central tenderness under the heel.

Front 625

What investigations should be carried out when diagnosing heel pad syndrome?

Back 625

This is essentially a clinical diagnosis. X-rays or ultrasonography are not helpful

Front 626

What differential diagnoses should be considered when diagnosing heel pad syndrome?

Back 626

This will include plantar fasciitis and entrapment neuropathies, particularly of the nerve to the abductor digiti quinti

Front 627

What is the aetiology of plantar fasciitis?

Back 627

This is a chronic inflammation at the site of the attachment of the plantar fascia to the medial tubercle of the calcaneum. It possibly represents a traction periostitis and may be precipitated by overuse and occurs in middle-aged people and with a male predominance

Front 628

What are the presenting symptoms of plantar fasciitis?

Back 628

Patients complain of pain under the heel on weightbearing. This may be particularly acute on getting up in the morning

Front 629

What are the signs of plantar fasciitis?

Back 629

There is tenderness along the anteromedial border of the calcaneum which may be increased by passive dorsiflexion of the toes.

Front 630

What investigations could be carried out for plantar fasciitis?

Back 630

The diagnosis is clinical although a bone scan may show increased uptake locally. X-rays may show a spur on the inferior border of the calcaneum but this is equally found in asymptomatic people

Front 631

What differential diagnoses would be considered when diagnosing plantar fasciitis?

Back 631

Heel pad syndrome. Entrapment neuropathies particularly of the nerve to abductor digiti quinti.

Front 632

What is the aetiology of soft tissue masses or tumours?

Back 632

Some benign soft-tissue masses such as ganglions are common in the foot. A ganglion is a mucoid cyst which usually arises from an underlying joint. In the foot they most commonly occur over the dorsum of the ankle. Plantar fibromatosis is analogous to Dupuytren's contracture in the hand and is a proliferation of the plantar aponeurosis to form discrete nodules, usually in the instep. A glomus tumour is a benign bright red vascular tumour, the size of a small pea, and is usually located subungually or in a web space.

Front 633

What are the presenting symptoms of a ganglion, plantar fibromatosis and a glomus tumour?

Back 633

A ganglion presents as a painful lump inside footwear. Plantar fibromatosis may present with painful nodules although often the patient only notices some mild discomfort or simply a swelling. A glomus tumour however may present with marked pain.

Front 634

What are the signs of a ganglion, plantar fibromatosis and a glomus tumour?

Back 634

A ganglion will appear as a mobile subcutaneous lump of variable size. Small ones may appear quite firm, whereas larger ones often have a more spongy feel. The nodules of plantar fibromatosis are felt as firm, fairly immobile nodules, often along the edge of the plantar fascia and under the instep. A glomus tumour will appear as a subungual mass or may be palpated as a small nodule in a web space.

Front 635

What investigations could be carried out to diagnose a glomus tumour?

Back 635

X-rays may distinguish a glomus tumour from a subungual exostosis, otherwise the diagnosis is made from clinical information

Front 636

What differential diagnoses should be considered when diagnosing a ganglion?

Back 636

Multiple ganglions around the extensor tendons on the dorsum of the ankle should arouse suspicion of RA. A lipoma may be mistaken for a ganglion and is commonly located on the dorsolateral aspect of the ankle.

Front 637

What is the aetiology of crystal arthritis?

Back 637

Arthritic changes may be caused by the deposition of crystals within a joint. This may be sodium urate crystals in gout or calcium pyrophosphate dihidrate crystals in pseudogout. Gout is a disease characterised by a disorder of purine metabolism and is associated with hyperuciaemia. It may be primary with a strong hereditary factor or be secondary to other problems such as renal failure. Pseudogout is sometimes associated with other metabolic conditions such as hyperparathyroidism but otherwise it is idiopathic

Front 638

What are the presenting symptoms of crystal arthritis?

Back 638

Up to 75% of inital attacks of gout affect the big toe. The patient complains of acute onset of a swollen, very painful 1st MTPJ. Pseudogout may present with gout-like attacks but these are usually less severe. About 50% of patients however will present with progressive degeneration of joints. In the foot the ankle, subtalar and talonavicular joints are most commonly affected.

Front 639

What are the signs of crystal arthritis?

Back 639

In the acute stage of gout the great toe will be swollen and very tender. In chronic cases the signs of osteoarthritis will be present. Gouty tophi (deposits of sodium urate) may be found in the cartilages of the ears and in bursae, tendons and soft tissues generally.

Front 640

What investigations could be carried out to diagnose crystal arthritis?

Back 640

Acutely, the serum uric acid may be raised but acute attacks can occur with a normal uric acid level. Aspiration of joint fluid and examination under a polarising lens will show brightly birefringent needle-like crystals in gout and more pleomorphic rectangular crystals in pseudogout. Chronically, X-rays will show degenerative changes in joints affected. Gout gives a characteristic appearance of sharp, punched-out juxta-articular lesions (Martel's sign) with little reactive sclerosis and no general osteoporosis.

Front 641

What differential diagnoses should be considered when diagnosing crystal arthritis?

Back 641

Acutely, this will be with acute infection and septic arthritis. Chronic forms will be associated with other causes of degenerative joint disease.

Front 642

What is the aetiology of hereditary and motor sensory neuropathy?

Back 642

This condition is also known as peroneal muscular atrophy and was first described by Charcot, Marie and Tooth in 1886. It is an inherited neuropathy with a predominantly motor component affecting the lower limbs. Motor weakness begins in the peronei, then the dorsiflexors and may involve all the muscles below the knee. There may also be sensory changes and involvement of the upper limb. The initial symptoms are usually in childhood but the neuropathy then slowly progresses. The adult may then present with a cavus foot, claw toes and pain and callosities over the metatarsal heads. Fixed deformities may develop with equinus of the forefoot and varus of the hindfoot.

Front 643

What are the presenting symptoms of hereditary and motor sensory neuropathy?

Back 643

This will depend on how far the disease has progressed. Initially the patient may present with just a clumsy gait and perhaps a history of recurrent ankle sprains. With time the weakness and changes in the shape of the foot become more apparent. The patient may then complain of footwear problems and pain along the lateral border of the foot because of the varus heel.

Front 644

What are the signs of hereditary and motor sensory neuropathy?

Back 644

In the established case there will be a cavus foot with a high arch, a plantarflexed first ray, clawing of the toes and peroneal and intrinsic muscle weakness. Weakness of other muscle groups should be looked for and the hands examined. Sensory changes, if present, are usually mild

Front 645

What investigations could be carried out to diagnose hereditary and motor sensory neuropathy?

Back 645

A careful clinical examination is important because of the differential diagnosis. X-rays will show the cavus and demonstrate any degenerative changes when fixed deformities are present. Nerve conduction studies and electromyography are important for accurate diagnosis and to rule out other causes of pes cavus.

Front 646

What differential diagnoses should be considered when diagnosing hereditary sensory and motor neuropathy?

Back 646

This is from other causes of pes cavus, which will include idiopathic, muscular diseases such as muscular dystrophy, neurological problems such as cerebral palsy, Friedrich's ataxia, poliomyelitis and spinal cord problems. In addition, pes cavus may be due to residual clubfoot or compartment syndrome.

Front 647

What is the aetiology of infection?

Back 647

Infection may occur in the soft tissues, as osteomyelitis in the bone or as septic arthritis in a joint. The cause may be direct innoculation following an open wound, either traumatic or surgically created or via haematogenous spread. Traumatic or surgical infection may occur at any time but septic arthritis is more likely to occur in the very young or the elderly or immunocompromised. Bony infections are most commonly due to Staphylococcus aureus but streptococci may also be associated with soft-tissue infections.

Front 648

What are presenting symptoms of infection?

Back 648

These will vary according to the tissue involved and degree of infection. Cellulitis will present with pain, swelling and erythema of the involved area. Because the bones are very superficial in the foot, osteomyelitis should always be suspected under any area of cellulitis. Septic arthritis is likely to present with exquisite pain on moving a joint, usually the ankle, and with overlying swelling and erythema. However, in the elderly or immunocompromised, symptoms may be strikingly muted, reducing suspicion of an underlying joint infection. In acute septic arthritis or osteomyelitis the patient is likely to have systemic signs of being unwell.

Front 649

What are signs of infection?

Back 649

Swelling, tenderness and erythema of the soft tissues will be noted. In septic arthritis there is likely to be marked pain on very limited movement of the joint. If marked local tenderness is elicited over a bony area this should alert you to the possibility of underlying osteomyelitis. If infection spreads to a tendon sheath, causing a tenosynovitis then passive movement of the tendon will be limited and very painful and tenderness may be present along the length of the tendon.

Front 650

What investigations could be undertaken to diagnose infection?

Back 650

X-rays are necessary to exclude or demonstrate osteomyelitis. However it may take 10 days to show any changes. A bone scan will be positive well before X-rays and may help. In septic arthritis a diminution in joint space or adjacent osteomyelitis may be seen. Aspiration of fluid from a joint and gram stain and culture can provide a diagnosis. Blood cultures should also be done. A full blood count will show a raised white cell count and the erythrocyte sedimentation rate (ESR) or C-reactive protein will be high. Obviously, if there is an open discharge with pus then swabs should be taken

Front 651

What differential diagnosis should be considered when diagnosing infection?

Back 651

Infection is a clinical diagnosis. Usually the question to be decided is whether there is underlying bony or joint infection.

Front 652

What is the aetiology of reflex sympathetic dystrophy (RSD)?

Back 652

This is an interesting condition which is poorly understood but results from a dysfunction of the sympathetic nervous system. It can follow trauma, sometimes minor in nature, after a fracture or following surgery. Pain can become so unremitting that the patient wishes amputation and may also develop depression and personality changes

Front 653

What are the presenting symptoms of reflex sympathetic dystrophy (RSD)?

Back 653

Patients complain of a burning pain, often out of proportion to the injury. Initially this will be due to the trauma of surgery but instead of settling the pain increases and becomes the dominant complaint. Pain can occur at rest with movement and may well trouble the patient at night. The weight of blankets on the bed or even a sheet may be intolerable. As well as affecting the injured area the patient may experience pain over the whole foot in a global distribution

Front 654

What are the signs of reflex sympathetic dystrophy (RSD)?

Back 654

These may vary according to the stage of the condition. The limb may be swollen and may have a shiny dry appearance. There may be hair and nail changes, with dry skin or excessive sweating. The affected area may become very sensitive and even light touch may evoke considerable and prolonged pain. Because of muscular spasm, patients may develop fixed equinus at the ankle or claw toes.

Front 655

What investigations could be carried out when diagnosing reflex sympathetic dystrophy (RSD)?

Back 655

X-rays may show osteopenia within a few weeks and subperiosteal bone resorption. A bone scan is very helpful as it will show generalised increased uptake in the affected area. Patients have a characteristic delayed bone scan pattern of diffuse increased tracer throughout the foot, with juxta-articular uptake accentuation. Temporary pain relief from a lumbar sympathetic block is also a useful test, although a negative test does not exclude RSD. Both psychological and organic problems can arise, making the problems intractable.

Front 656

What differential diagnosis should be considered when diagnosing reflex sympathetic dystrophy (RSD)?

Back 656

It can be difficult sometimes to decide if mild RSD is present or if the patient simply has a very painful injury or one is missing a component of that injury.

Front 657

What is the aetiology of referred pain?

Back 657

Referred pain has been mentioned in connection with compartment syndrome involving the deep peroneal and posterior tibial nerve. The main source of referred pain is sciatica due to nerve root compression in the back. Most commonly this is due to a prolapsed intervertebral disc and over 90% of these occur at the L4/5 or L5/S1 levels

Front 658

What are the presenting symptoms of referred pain?

Back 658

Patients will usually complain of low back pain radiating into a buttock and down the leg. They may have little back pain and mainly leg pain. A careful history may indicate the nerve root involved. Pain radiating down the back of the leg into the sole of the foot is generally S1 in origin and down the lateral border of the leg and into the hallux is generally L5 in origin

Front 659

What are the signs of an acute disc prolapse?

Back 659

In an acute disc prolapse the patient experiences considerable pain and is unable to move easily. He may have a scoliotic tilt to the spine when viewed from behind, paraspinal muscle spasm and tenderness in the buttock. Straight leg raising will be restricted and causes pain in the distribution of the nerve root. Sensory changes and muscle weakness appropriate to that nerve root may be found but not invariably. Reflexes may be diminished; the knee jerk is L3/L4 and ankle jerk is L5/S1.

Front 660

What investigations should be considered in referred pain?

Back 660

X-rays should be taken of the lumbosacral spine. If surgery is contemplated or the diagnosis is unclear then an MRI scan or CT scan is necessary.

Front 661

What differential diagnoses should be considered when diagnosing referred pain?

Back 661

The symptomatology is usually clear but back pain is very common and a more distal problem co-existing with long-standing back pain and sciatica should always be considered.

Front 662

What is the "at risk" foot mean?

Back 662

It means that there is a risk of loss of tissue viability

Front 663

What are the ten functions of the skin?

Back 663

1. Prevents dehydration
2. Contains other tissue of the body
3. Communication
4. Sensation (touch, heat, cold, pain, etc)
5. Immunological (direct barrier, cellular)
6. Protects body from UV light
7. Thermoregulation
8. Shock absorption
9. Vitamin D production
10. Protection from irritants (chemicals, etc)

Front 664

What 8 ischaemic vascular conditions are responsible for an at-risk foot?

Back 664

1. Peripheral vascular disease
2. Critical limb ischaemia
3. Occlusion eg tourniquet
4. Severe anaemia
5. Deep vein thrombosis
6. Compartment syndrome
7. Buerger's disease - acute inflammation and thrombosis of arteries and veins of the hands and feet
8. Microangiopathy

Front 665

What 7 venous stasis conditions are responsible for an at-risk foot?

Back 665

1. Incompetent lower limb valves
2. Congestive heart failure (right-sided)
3. Obesity
4. Failure of respiratory/abdominal pump
5. Calf muscle pump failure
6. Pericapillary fibrin deposition
7. Oedema - pitting/non-pitting

Front 666

What 11 neurological conditions are responsible for an at-risk foot?

Back 666

1. Distal symmetrical polyneuropathy
2. Mononeuropathies
3. Radiculopathies
4. UMNs
5. LMNs
6. Diabetes mellitus
7. Tabes dorsalis
8. Leprosy
9. Alcoholism
10. Vitamin B12 deficiency (pernicious anaemia)
11. HIV/AIDS

Front 667

What 4 neoplastic conditions are responsible for an at-risk foot?

Back 667

1. Malignant melanoma
2. Basal cell carcinoma
3. Squamous cell carcinoma
4. Malignant transformation of wounds

Front 668

What 10 infections are responsible for an at-risk foot?

Back 668

1. Erysipelas - an acute streptococcus bacterial infection of the dermis, resulting in inflammation and characteristically extending into underlying fat tissue.
2. Osteomyelitis
3. Cellulitis
4. Lymphangitis
5. Lympadenitis
6. Bactaraemia
7. Septicaemia
8. Dermatophyte infection
9. Yeast infection
10. Herpes infection

Front 669

What is erysipelas?

Back 669

An acute streptococcus bacterial infection of the dermis, resulting in inflammation and characteristically extending into underlying fat tissue.

Front 670

What 10 immune system dysfunctions are responsible for an at-risk foot?

Back 670

1. DiGeorge syndrome - an inherited condition where several different genes are lost. This can result in health problems such as the immune system of varying degrees.
2. HIV/AIDS
3. Malnutrition
4. Diabetes mellitus
5. Long-term steroid use
6. Immunosuppressive drugs
7. Radiation
8. Effects of aging
9. Leukaemia
10. Lymphoma

Front 671

What 5 traumatic conditions are responsible for an at-risk foot?

Back 671

1. Heat
2. Cold
3. Radiation
4. Chemicals (acids and alkalis)
5. Mechanical (pressure, shear and friction)

Front 672

What is DiGeorge syndrome?

Back 672

An inherited condition where several different genes are lost. This can result in health problems of varying degrees.

Front 673

What 7 musculoskeletal conditions are responsible for an at-risk foot?

Back 673

1. RA
2. Gout
3. OA
4. Psoriatic arthropathy
5. Reiter's syndrome
6. Neuroarthropathy (Charcot foot)
7. Ankylosing spondylitis

Front 674

What are 3 examples of seronegative arthropathies?

Back 674

1. psoriatic arthritis,
2. ankylosing spondylitis
3. inflammatory bowel syndrome arthritis

Front 675

What is a more sensitive test for RA than CRP or ESR?

Back 675

Anticyclic Citrullinated Peptide Antibodies (Anti-CCP)

Front 676

What are 8 factors responsible for an at-risk foot?

Back 676

1. Vascular - ischaemia
2. Vascular - venous stasis
3. Neurological
4. Neoplasia
5. Infections
6. Immune system dysfunction
7. Trauma
8. Musculoskeletal

Front 677

What six significant pathologies is an at-risk foot more likely to develop?

Back 677

1. Ulceration
2. Infection
3. Necrosis
4. Amputation
5. Malignant lesions
6. Severe deformity

Front 678

What is the definition of viable tissue?

Back 678

That tissue which is able to withstand normal environmental stresses without loss of structure or function

Front 679

For tissue viability to be maintained what are the 10 factors which are essential?

Back 679

1. Adequate oxygen supply - good quality and quantity of blood
2. Adequate nutrient supply - sufficient nutrients to meet the respiratory need of cells
3. Adequate removal of respiratory metabolites - removal of carbon dioxide, lactate, etc
4. Adequate sensory, motor and autonomic nerve supply
5. Adequate immune function - local and systemic immune mechanisms are effective
6. Freedom from infection - local or systemic
7. Freedom from major environmental stresses - heat, cold, radiation, mechanical trauma, chemical trauma
8. Freedom from malignant disease - skin, soft-tissue, vascular or bone malignancy
9. Freedom from intrinsic (systemic or local) disease
10. Ability to compensate for minor changes to the environment
- production of melanin in response to UV radiation
- production of hyperkeratosis in response to mechanical trauma
- ability to regulate constant pH, temperature

Front 680

What are four factors which can result in loss of tissue viability?

Back 680

1. A large full thickness wound can cause a patient to lose significant volumes of body fluids, body heat and to place the person at high risk of infection
2. The affected area of skin will be unable to withstand normal weightbearing traumas and will be susceptible to damage from UV light
3. Any pharmacological (or other) product placed on the affected area eg steroid or iodine ointments is liable to systemic absorption
4. Any wound provides a portal of entry for micro-organisms. In a susceptible or immunocompromised patient this may lead to serious and potentially limb or life threatening infection

Front 681

What are 12 examples of conditions or treatments which may delay healing?

Back 681

1. Cardiovascular - PVD, venous insufficiency, lymphatic obstruction
2. Endocrine/metabolic - Diabetes mellitus, malnutrition, deficiency syndromes, obesity
3. Immunological - DiGeorge syndrome, hypogammaglobulinaemia, HIV, RA, hypersensitivity
4. Immunosuppressive agents - long-term steroids, immunosuppressive drugs, radiation, cytotoxic drugs
5. Infectious - cytomegalovirus, infectious mononucleosis, severe bacterial, mycobacterial or fungal disease
6. Haematological - leukaemia, anaemias, haemophilia, sickle-cell anaemia
7. Musculoskeletal - deformities, hypermobility
8. Neoplasia - Carcinomas, lymphomas, sarcomas
9. Respiratory - chronic obstructive airways disease
10. Renal - chronic nephropathy
11. Traumatic - burns, foreign bodies, repeated minor trauma, tight clothing (tourniquet effect)
12. Exogenous factors - inappropriate dressings, antiseptics, environmental conditions, caustics and irritants

Front 682

What is cytomegalovirus?

Back 682

It is a herpes virus frequently associated with salivary glands. They are life threatening for immunosuppressed patients

Front 683

What is mononucleosis?

Back 683

Glandular fever

Front 684

What is the medical term for glandular fever?

Back 684

Mononucleosis

Front 685

What are 8 skin conditions which increase the at-risk status of a patient?

Back 685

1. Dry fissures
2. Wet fissures
3. Callus and corns
4. Blisters
5. Pruritic lesions
6. Malignant lesion
7. Trauma
8. Infection

Front 686

What are 5 causes of dry fissures?

Back 686

1. Sun
2. Wind
3. Ageing
4. Hypothyroidism
5. Chemotherapy

Front 687

What are four causes of wet fissures?

Back 687

1. Occlusive dressings and footwear
2. Poor hygiene
3. Hyperhidrosis
4. Certain occupations eg baker, cook

Front 688

What are four causes of callus and corns?

Back 688

1. Foot deformities
2. Abnormal foot function
3. Ill-fitting footwear
4. Ichthyosis

Front 689

What is ichthyosis?

Back 689

All types of ichthyosis have dry, thickened, scaly or flaky skin.

Front 690

What seven skin conditions cause blisters?

Back 690

1. Epidermolysis bullosa
2. Pompholyx
3. Pemphigus
4. Urticaria
5. Pustular psoriasis
6. Juvenile plantar dermatitis
7. Ill-fitting footwear

Front 691

What five skin conditions cause pruritic lesions?

Back 691

1. tinea pedis
2. atopic eczema
3. venous stasis eczema
4. contact dermatitis
5. asteatotic dermatitis

Front 692

What four skin conditions cause malignant lesions?

Back 692

1. Melanoma
2. Squamous cell carcinoma
3. Basal cell carcinoma
4. Kaposi's sarcoma

Front 693

What four conditions cause trauma in the skin?

Back 693

1. Cuts
2. Bruises
3. Ingrown toenail
4. Insect bites

Front 694

What four conditions cause skin infection which increases the risk of the at-risk patient?

Back 694

1. Paronychia
2. Onychia
3. Erysipelas
4. Necrotising fasciitis

Front 695

What is onychia?

Back 695

Inflammation of the nail matrix

Front 696

What is inflammation of the nail matrix?

Back 696

Onychia

Front 697

What is necrotising fasciitis?

Back 697

Necrotizing fasciitis is a rare bacterial infection that can destroy skin and the soft tissues beneath it, including fat and the tissue covering the muscles (fascia)

Front 698

What causes acromegaly/gigantism?

Back 698

Excess pituitary growth hormone

Front 699

What three effects do acromegaly /gigantism have on the lower limb?

Back 699

1. Enlargement of feet
2. Erosion of articular surfaces leading to joint problems
3. Thickened sweaty skin

Front 700

What is Addison's disease caused by?

Back 700

Adrenocorticol insufficiency

Front 701

What disease is caused by excess pituitary growth hormone?

Back 701

Acromegaly/gigantism

Front 702

What disease is cause by adrenocortical insufficiency?

Back 702

Addison's disease

Front 703

What six effects does Addison's disease have on the lower limb?

Back 703

1. Increased pigmentation over bony prominences and extensor surfaces
2. Generalised effects of dehydration
3. Weight loss
4. Weakness
5. Fatigue
6. Orthostatic hypotension (postural hypotension)

Front 704

What is Cushing's syndrome caused by?

Back 704

Excess cortisol which may be due to excess pituitary adrenocorticotropic hormone (ACTH) or exogenous ACTH such as steroids

Front 705

What is the disease caused by excess cortisol which may be due to excess pituitary adrenocorticotropic hormone (ACTH) or exogenous ACTH such as steroids?

Back 705

Cushing's syndrome

Front 706

What seven effects does Cushing's syndrome have on the lower limb?

Back 706

1. Muscle wasting and weakness
2. Thin, atrophic skin
3. Poor wound healing
4. Reduced inflammatory response
5. Tendency to bruising
6. Osteoporosis
7. Generalised effects of hypertension and glucose intolerance

Front 707

What causes diabetes mellitus?

Back 707

A relative or absolute lack of insulin secretion leading to elevated blood glucose levels and alterations in lipid metabolism

Front 708

What is the disease caused by a relative or absolute lack of insulin secretion leading to elevated blood glucose levels and alterations in lipid metabolism

Back 708

Diabetes mellitus

Front 709

What four effects does diabetes mellitus have on the lower limb?

Back 709

1. Arteriosclerosis leading to calcification of arteries
2. Atherosclerosis
3. Peripheral vascular disease
4. Neuropathy can appear in various forms. The most common form is bilateral, symmetrical, peripheral sensorimotor polyneuropathy but wasting of hip and thigh muscles (diabetic amyotrophy) predominantly affects elderly males and single nerves can also be affected

Front 710

What causes hypocalcaemia?

Back 710

The most common causes are deficiency of parathyroid hormone, Vitamin D or kidney disease

Front 711

What disease does deficiency of parathyroid hormone, Vitamin D or kidney disease cause?

Back 711

Hypocalcaemia

Front 712

What two effects does hypocalcaemia have on the lower limb?

Back 712

1. Tetany (paraesthesia of lips, tongue, fingers, feet, muscle spasm)
2. Lack of Vitamin D will lead to
- reduced calcium absorption n the gut compensated for by parathyroid hypersecretion leading to bone resorption, rickets or osteomalacia with a tendency for bowed legs and fractures

Front 713

What causes hypercalcaemia?

Back 713

Idiopathic hypersecretion of parathyroid hormone

Front 714

What disease is caused by Idiopathic hypersecretion of parathyroid hormone?

Back 714

Hypercalcaemia

Front 715

What four effects does hypercalcaemia have on the lower limb?

Back 715

1. Muscle weakness
2. Bone resorption of phalanges
3. Soft tissue calcification
4. Osteitis fibrosa cystica (rare caused by excess parathyroid hormone)

Front 716

What is the most common form of hyperthyroidism?

Back 716

An autoimmune condition called Grave's disease

Front 717

What is Grave's disease?

Back 717

An autoimmune hyperthyroid condition

Front 718

What three effects does hyperthyroidism (Grave's disease) have on the lower limb?

Back 718

1. Moist warm skin
2. Pretibial myxoedema - swollen and lumpy appearance over the shins and feet (infiltrative dermopathy)
3. Muscle weakness
4. Muscle wasting

Front 719

What is the most common form of hypothyroidism?

Back 719

Hashimoto's disease, an autoimmune condition

Front 720

What is Hashimoto's disease?

Back 720

An autoimmune hypothyroid disease

Front 721

What two effects does hypothyroidism (Hashimoto's disease) have on the lower limb?

Back 721

1. Dry, scaly, coarse, thickened skin
2. A tendency to tarsal tunnel syndrome

Front 722

What causes postmenopausal syndrome?

Back 722

A fall in oestrogens leads to bone resorption

Front 723

What effect does postmenopausal syndrome have on the lower limb?

Back 723

Osteoporosis leading to crush fractures of the spine and fractures of the wrist (Colles fracture) and of the neck of femur (Perthes fracture)

Front 724

What are the six characteristic features of ischaemic ulcers?

Back 724

1. Usually very painful which is alleviated by limb dependency
2. Small, shallow, punched-out appearance
3. Dry or small amount of exudate
4. Pale, grey or yellow base
5. On dorsum or apices of toes, under nails, borders of feet
6. Thin surrounding skin, often a halo of erythema

Front 725

What are the six characteristics of neuropathic ulcers?

Back 725

1. Often painless
2. Often very deep
3. Often copious exudate, may be bloody
4. Red or yellow (infected) base
5. Under metatarsal heads, apices of clawed toes, heels
6. Thick border of callus surround

Front 726

What six characteristics do venous ulcers have?

Back 726

1. Associated with an aching or bursting pain, alleviated by limb elevation
2. Shallow, spreading, with irregular borders
3. Copious, often smelly exudate
4. Red or yellow (infected) base
5. Distal third of leg
6. Often associated with skin scoriation or eczema, telangiectases and haemosiderosis. Varicose veins may be visible.

Front 727

What three effects does sickle-cell anaemia have on the lower limb?

Back 727

1. Chronic punched out ulcers around the ankle
2. Aseptic necrosis of the femoral head
3. Peripheral vascular disease

Front 728

What affect do thalassaemias have on the lower leg?

Back 728

Leg ulcers

Front 729

What three effects does Vitamin B12 deficiency (pernicious anaemia) have on the lower limb?

Back 729

1. Glove and stocking anaesthesia
2. Loss of vibration and position sense
3. Muscle weakness

Front 730

What two effects does polycythaemia have on the lower limb?

Back 730

1. Increased risk of thrombosis
2. Haemorrhage

Front 731

What two effects does haemophilia have on the lower limb?

Back 731

1. Risk of haemorrhage
2. Bleeding into joints with eventual destruction

Front 732

What are the five factors for RA?

Back 732

This is an inflammatory joint condition characterised by 1.Rapid subluxation and deformation of joints especially of hands and feet giving rise to HAV
2. It is characterised by formation of soft tissue nodules over subluxed joints
3. Atrophic skin
4. Muscle wasting
5. Vasculitis

Front 733

What is rheumatoid factor?

Back 733

It is an antibody produced in response to the altered IgM which acts as the trigger for autoimmune destruction of joint structure

Front 734

What four factors can compromise tissue viability in RA?

Back 734

1. Nodules are likely to break down due to pressure and form deeply perforating ulcers
2. Muscle weakness leads to vascular stasis and this combined with thin skin increases the likelihood of ulceration
3. Vascular involvement in RA may be limited to discrete digital arteritis, forming small lesions in the skin of digits around nail folds or may involve a generalised vasculitis leading to thrombotic lesions of larger vessels leading to dry gangrene.
4. Vasculitis may also affect the vasa nervorum leading to peripheral sensorimotor neuropathy with subsequent deformities such as foot drop and with the tissues being at risk of unnoticed trauma

Front 735

What are three factors for the sero-negative arthritides?

Back 735

1. Examples are psoriatic arthritis, Reiter's disease, ankylosing spondylitis, enteropathic arthritis, Behcet's disease
2. They are inflammatory processes which all test negative for the rheumatoid factor but show a marked correlation with the presence of the HLA B-27 antigen
3. They all show a tendency to involve the sacroiliac joints as well as peripheral arthritis

Front 736

What is psoriatic arthritis?

Back 736

This condition is seronegative and tends to involve terminal interphalangeal joints which may precede skin and nail lesions by months or years. Although slowly progressive, the condition can be extremely destructive, causing absorption of the phalanges. Deformities and skin lesions all compromise tissue viability

Front 737

What is Reiter's disease?

Back 737

This is a seronegative arthritis and is usually sexually transmitted and almost entirely confined to males. The inflammatory arthritis involves toes, ankles and knees and painful heel is a common symptom. Skin and nail lesions (keratodermia blennorrhagica) closely resemble those of psoriasis. Both the joint deformities and skin lesions compromise tissue viability.

Front 738

What is keratodermia blennorrhagica?

Back 738

Conical hyperkeratotic lesions usually on the soles of the feet

Front 739

What is ankylosing spondylitis?

Back 739

This is a seronegative arthritis and affects males far more than females but here the spine, hips and shoulders are usually affected. The feet are rarely involved and the condition has little effect on tissue viability of the lower limb

Front 740

What is enteropathic arthritis?

Back 740

This is a seronegative arthritis linked to Crohn's disease. It shows a flitting peripheral arthritis of lower limb joints which remits as the bowel disease improves. Effects on tissue viability of the lower limb are transitory

Front 741

What is Behcet's disease?

Back 741

This is a rare seronegative arthritis which in addition to peripheral arthritis exhibits vasculitis, venous thrombosis and neurological defects. The patient is therefore at increased risk of gangrene and amputation

Front 742

What is gout?

Back 742

Gout is an inflammatory condition produced by the presence of high levels of uric acid which crystallises out in joints, provoking an inflammatory response. The most common site is the 1st MTPJ producing symptoms of acute pain, swelling and inflammation. Even if untreated, the symptoms subside after 2-3 weeks and tissue viability returns to normal, but if repeated attacks occur, crystalline deposits eventually cause destructive changes in articular cartilage and underlying bone with permanent deformities. In severe cases, tophaceous ulcers may arise especially over bony prominences.

Front 743

What is infectious (septic/pyogenic) arthritis?

Back 743

This is a rapidly evolving inflammatory condition that can destroy a joint very quickly if not arrested. The condition is usually extremely painful and a portal of entry can usually be detected. Patients particularly at risk of this condition include those on long-term steroid therapy or on immunosuppressive drugs

Front 744

What are degenerative joint conditions?

Back 744

Conditions such as OA also result in deformities but are usually slow to develop. The MTPJ of the first digit is the most commonly affected joint giving rise to a hallux limitus/rigidus or hallux valgus deformity. They are often the result of injury or the wear and tear of ageing

Front 745

What are connective tissue disorders?

Back 745

These disorders have many features in common especially vasculitis and fibrosis of ground substance. Each is a multisystem disease with variable characteristics. Several, including systemic lupus erythematosus, polyarteritis nodosa, polymyositis and dermatamyositis exhibit muscle and joint pains. The vasculitis can lead to partial or total obstruction of small vessels in resulting in tissue necrosis

Front 746

What peripheral neuropathic effect does alcoholism have on the lower limb?

Back 746

Sensorimotor neuropathy

Front 747

What peripheral neuropathic effect does Charcot-Marie-Tooth disease (peroneal atrophy) have on the lower limb?

Back 747

Predominantly motor neuropathy

Front 748

What peripheral neuropathic effect does connective tissue diseases eg RA, SLE, polyarteritis nodosa, sarcoidosis have on the lower limb?

Back 748

Sensory or mixed neuropathy, mononeuritis multiplex

Front 749

What peripheral neuropathic effect do drugs and/or toxins have on the lower limb?

Back 749

Generalised neuropathy

Front 750

What peripheral neuropathic effect does Guillain-Barre syndrome have on the lower limb?

Back 750

Predominantly motor neuropathy

Front 751

What peripheral neuropathic effect does Hansen's disease have on the lower limb?

Back 751

Sensory neuropathy

Front 752

What peripheral neuropathic effect does HIV/AIDS have on the lower limb?

Back 752

Distal symmetrical polyneuropathy

Front 753

What peripheral neuropathic effect do malignancies have on the lower limb?

Back 753

Predominantly sensory

Front 754

What peripheral neuropathic effect does poliomyelitis have on the lower limb?

Back 754

Motor neuropathy

Front 755

What peripheral neuropathic effect does trauma have on the lower limb?

Back 755

Sensorimotor neuropathy

Front 756

What is mononeuritis complex?

Back 756

Mononeuritis multiplex is the clinical picture that arises from problems with multiple individual nerves serially or almost simultaneously

Front 757

What neuropathic affect does syringomelia have?

Back 757

Sensorimotor neuropathy

Front 758

What neuropathic effect does motor neurone disease have

Back 758

Motor neuropathy

Front 759

What neuropathic effect does tabes dorsalis (tertiary syphillis) have?

Back 759

Sensory only

Front 760

What neuropathic effect does subacute combined degeneration (Vitamin B12 deficiency) have?

Back 760

Sensorimotor

Front 761

How can Parkinson's disease affect tissue viability?

Back 761

Postural stability renders the person liable to falls.

Front 762

How do motor neuropathies threaten tissue viability?

Back 762

By creating deformities leading to high pressure points which make the tissue vulnerable during everyday ambulation

Front 763

What are the five regulatory roles of the kidney?

Back 763

1. Water balance
2. Electrolyte balance
3. Acid-base balance
4. Production of active vitamin D3
5. Production of haemopoietins

Front 764

What three conditions happen when the functions of the kidney are disturbed?

Back 764

1. Hypertension which increases the risk of atherosclerosis or occasionally lead to peripheral neuropathy. Chronic glomerulonephritis which is characterised by diffuse sclerosis of the glomeruli is usually also accompanied by hypertension
2. If the calcium:phospate balance is disturbed, hypocalcaemia and hyperphosphataemia occur leading to an increase in parathyroid hormone and bone resorption with rickets or osteomalacia as a consequence. A familial disease of the kidney which results in rickets is characterised by impaired renal absorption of phosphate and reduced intestinal absorption of calcium. This in turn leads to resorption of bone to raise plasma calcium levels resulting in rickets or osteomalacia. It is called Vitamin D-resistant rickets to distinguish it from the deficiency disease
3. Anaemia can result from a lack of erythropoietin

Front 765

When there is severe ischaemia characterised by a deteriorating wound, extensive necrosis and risk of infection who should this patient be referred to and what would the potential outcome be?

Back 765

Vascular surgeon, orthopaedic surgeon and the outcome would be reconstructive surgery and/or amputation

Front 766

If there were spreading infection such as cellulitis, pyrexia, osteomyelitis who would the patient be referred to and what would the potential outcome be?

Back 766

GP, consultant physician, surgeon and the outcome would be systemic antibiotics, intravenous antibiotics and surgical debridement or amputation

Front 767

If there was a worsening medical/physical state characterised by sudden loss of weight, malaise, fatigue or change in conscious level who would this patient be referred to and what would the potential outcome be?

Back 767

GP, consultant physician and the outcome would be medical review or hospitalisation

Front 768

If there was failure to prevent weightbearing who would the patient be referred to and what would the potential outcome be?

Back 768

GP or hospital consultant and the outcome would be hospitalisation for total bed rest

Front 769

If the patient were experiencing pain which cannot be managed by over the counter remedies who would the patient be referred to and what would the outcome be?

Back 769

GP for an analgesic prescription

Front 770

If there were unusual/suspicious changes in a lesion who would the patient be referred to and what would the outcome be?

Back 770

GP or dermatologist and the outcome would be a biopsy or excision

Front 771

If the patient were experiencing extreme anxiety, depression or stress who would the patient be referred to and what would the potential outcome be?

Back 771

GP or psychiatrist for a psychiatric evaluation

Front 772

If the patient were experiencing onset of confusion and/or dementia who would the patient be referred to and what would the potential outcome be?

Back 772

GP or psychiatrist for a psychiatric evaluation

Front 773

What are eleven age-related structural changes to skin tissue of the foot?

Back 773

1. Skin moisture content reduces
2. Skin becomes drier
3. Skin more prone to fissuring
4. Skin is less flexible/elastic
5. Skin becomes weaker, more likely to tear or split
6. Atrophy or displacement of subcutaneous fat may occur
7. Weightbearing forces on skin increases as foot function worsens
8. Hyperkeratotic lesions become more likely
9. Number of pigmented lesions is likely to increase
10. Extravasation of blood into skin is more likely
11. Loss of skin viability is more likely as a result of deterioration in circulation

Front 774

What are seven age-related structural changes in the nails of the foot?

Back 774

1. Rate of nail growth reduces
2. Nail plate becomes drier
3. Nail plate becomes thicker
4. Increased likelihood of debris/callus in nail sulci or beneath nail plate
5. Increased incidence of subungual lesions
6. Involution of nail plate more likely
7. Nail plate becomes more brittle and liable to split/crack

Front 775

What are five age-related structural changes to joints in the foot?

Back 775

1. Increased likelihood of degenerative arthropathy in weightbearing joints
2. Long-term compensation for functional foot abnormalities likely to contribute to joint pathology eg hallux valgus, hallux limitus
3. Thickening of joint margins with resultant decreased range of motion is likely
4. Overall mobility of foot joints reduced
5. Increased likelihood of joint deformity

Front 776

What are ten exogenous factors associated with age-related changes to the foot?

Back 776

1. UV light
2. Diet
3. Smoking
4. Alcohol consumption
5. Chemicals/drugs
6. Occupation
7. Sports, hobbies and activities
8. Trauma
9. Footwear
10. Cosmetics

Front 777

What are eight skin conditions seen in elderly people with lifelong exposure to sunlight?

Back 777

1. Wrinkles
2. Hyperpigmentation
3. Hypopigmentation
4. Solar keratoses
5. Basal cell carcinoma
6. Squamous cell carcinoma
7. Malignant melanoma
8. Dry, inelastic skin

Front 778

What are twelve reasons why pathologies in the elderly are likely to deteriorate faster?

Back 778

1. Less effective immune system
2. Poor peripheral circulation
3. Diminished peripheral sensory perception
4. Motor weakness
5. Confusion
6. Loss of tissue resilience
7. Combined systemic pathology
8. Effects of drugs
9. Inability to self-care
10. Poor nutrition
11. Poor hygiene
12. Inadequate footwear

Front 779

What is one of the most important factors contributing to the pathology of arterial disease in the elderly?

Back 779

Elevation of blood pressure

Front 780

What are three significant changes to the arteries in the aging process?

Back 780

1. Calcification of the tunica media (arteriosclerosis)
2. Fibro-fatty occlusion of the vessels (atherosclerosis)
3. Arterial complications of the above such as aneurysms, thrombosis, embolism

Front 781

What four problems can side effects of antihypertensives (especially diuretics) lead to in the elderly?

Back 781

1. Postural hypotension
2. Falls
3. Dehydration
4. Gout

Front 782

What are seven causes of venous hypertension in the elderly?

Back 782

1. Right-sided congestive heart failure
2. Lack of exercise (inactive skeletal muscle pumps)
3. valvular dysfunction
4. DVT
5. Venous occlusion
6. Respiratory disease (poor respiratory pump mechanism)
7. Abdominal masses eg tumours
3.

Front 783

What are five consequences of venous hypertension in the elderly?

Back 783

1. Venous stasis eczema
2. Venous ulceration
3. Oedema
4. Hyperpigmentation (especially haemosiderosis)
5. Malignant (fungating) wounds

Front 784

What are five signs of age-related changes to the peripheral nervous system?

Back 784

1. Defects of sensory perception
2. Muscle weakness
3. Deformity
4. Dry skin
5. Vasodilation

Front 785

What are eleven causes of pruritis in the elderly?

Back 785

1. Excessive dryness of the skin
2. Haematological disorder eg polycythaemia rubra vera where excess blood cells are produced as a result of an abnormality of the blood marrow)
3. Hepatic disease
4. Renal disease
5. Malignant disease
6. Drugs
7. Infestations eg scabies, lice, fleas
8. Inflammatory skin diseases eg eczema, psoriasis
9. Incontinence
10. Autonomic dysfunction
11. Hypersensitivity

Front 786

What are eight features of anaemia

Back 786

1. Lethargy
2. General malaise
3. Intermittent claudication
4. Pallor
5. Headache
6. Breathlessness
7. Angina
8. Skin atrophy

Front 787

What are the three commonest types of anaemia to affect the elderly?

Back 787

1. Iron deficiency anaemia
2. Pernicious anaemia
3. Folate deficiency anaemia

Front 788

How does iron deficiency anaemia arise?

Back 788

It arises from haemorrhagic disorders including those caused by gastric bleeding following long-term use of NSAIDs

Front 789

What are two symptoms of iron-deficiency anaemia?

Back 789

1. Koilonychia (spoon-shaped nails)
2. Brittle nails

Front 790

What are 7 symptoms of pernicious anaemia (Vitamin B12 deficiency)?

Back 790

1. General symptoms of anaemia
2. Weight loss
3. Peripheral neuropathy
4. Progressive muscle weakness may result in digital deformity and ataxia
5. Sore red tongue (glossitis)
6. Purpura
7. Mild fever

Front 791

What is glossitis?

Back 791

Sore red tongue

Front 792

What is a sore red tongue called?

Back 792

Glossitis

Front 793

What is folate-deficiency anaemia associated with?

Back 793

Malnutrition

Front 794

What is acidosis?

Back 794

An accumulation of waste gases

Front 795

What is an accumulation of waste gases?

Back 795

Acidosis

Front 796

What is a festinating gait?

Back 796

Where the person appears to chase their centre of gravity forwards, shuffling and stooping

Front 797

What is the gait type where the person appears to chase their centre of gravity forwards, shuffling and stooping?

Back 797

Festinating gait

Front 798

What 14 factors constitute a high risk elderly patient?

Back 798

1. Patients with systemic pathology presenting a risk to foot health eg diabetes mellitus, Cushing's disease, leukaemia, anaemia, etc)
2. Patients with existing foot ulceration or other loss of lower limb tissue viability
3. Patients who have a history of falls
4. Patients with peripheral vascular disease
5. Patients with peripheral neuropathy
6. Patients with hip joint pathology or prosthesis
7. Patients who are bed ridden
8. Malnourished patients
9. Patients taking certain medications (steroids, anticoagulants, anticancer drugs, etc)
10. Patients with severe cognitive impairment
11. Patients unable to self-care with poor carer support
12. Infirm or frail people living alone
13. Poor patients
14. Socially isolated patients

Front 799

What are seven factors for medium-risk elderly patients?

Back 799

1. Patients with poor skin quality or skin disease
2. Patients with thickened nails
3. Patients with calluses or corns
4. Patients with toe deformities
5. Immobile patients
6. Patients with superficial fungal infections of skin or nail
7. Patients unable to self-care with adequate carer support

Front 800

What are7 factors for low risk elderly patients?

Back 800

1. Patients with mild foot pathology
2. Patients with good circulatory status
3. Patients with good neurological status
4. Independent patients or those receiving good levels of home care
5. Mobile patients
6. Patients with good personal care/hygiene

Front 801

What is the surgical recommendation for patients with (myocardial infarction) MI?

Back 801

Surgery should be avoided in patients who have had an MI within the previous 6 months

Front 802

What is the surgical recommendation for the patient who has angina?

Back 802

In stable angina where there is no history of an MI or other risk factors, the perioperative risk of an MI is low. In unstable angina, surgery is contraindicated until the angina has been controlled by medical or surgical means

Front 803

What is the surgical recommendation of a coronary artery bypass graft (CABG)?

Back 803

A history of a CABG should be considered a low perioperative risk

Front 804

What is the surgical recommendation of patients who have congestive heart failure (CHF)?

Back 804

Patients with CHF represent a high risk of adverse cardiac events from the stress of surgery

Front 805

What is the surgical recommendation for a patient with conduction disturbances?

Back 805

Conduction defects represent a low perioperative risk

Front 806

What is the surgical recommendation of a patient with arrhythmia?

Back 806

Any patient with a history suggestive of arrhythmia should have an ECG performed

Front 807

What is the surgical recommendation for a patient with valvular heart disease?

Back 807

Prophylactic antibiosis is not required in clean podiatric surgery to prevent bacterial endocarditis. It is, however required in nail surgery

Front 808

What is the surgical recommendation of a patient with hypertension?

Back 808

Elective surgery is contraindicated in uncontrolled hypertension

Front 809

What two complications are obese patients at risk of perioperatively?

Back 809

1. Increased risk of DVT
2. Wound complications such as infection and dehiscence

Front 810

What problem can Vitamin C and serum zinc deficiencies cause after surgery?

Back 810

Impaired wound healing

Front 811

What three main effects can steroids such as prednisolone have during the perioperative period?

Back 811

1, Suppression of the hypothalamus/pituitary adrenal (HPA) axis - controls reaction to stress
2. Poor wound healing
3. A predisposition to infection

Front 812

What are four drugs that alter platelet function?

Back 812

1. Aspirin
2. NSAIDs
3. Steroids
4. Antihistamines

Front 813

What increased postoperative risk is there when a woman takes the contraceptive pill?

Back 813

Postoperative DVT formation

Front 814

What two problems can smoking cause for surgery?

Back 814

1. Vasoconstrictive effect of nicotine
2. Increased platelet adhesiveness

Front 815

What eight effects can heavy alcohol consumption have on surgery?

Back 815

1. Impaired immune response
2. Postoperative healing
3. Metabolism of LAs
4. Implications for treatment compliance
5. Osteoporosis
6. Increased bleeding risk
7. Diminish adrenocortical responses
8. They often have nutritional imbalances

Front 816

What two problems do sickle cells cause?

Back 816

1. Increase blood viscosity
2. Obstruct microvascular blood flow leading to thrombosis and infarction

Front 817

What is recommended to smokers before surgery?

Back 817

They should discontinue at least 1 week prior to surgery

Front 818

What two things are done for people with sickle cell anaemia (trait and disease) during surgery?

Back 818

1. They are given LA without adrenalin
2. They have surgery without a tourniquet

Front 819

What can 3 problems can kidney disease cause during the perioperative period?

Back 819

1. Lower limb circulation
2. Oedema
3. Delay wound healing

Front 820

What 5 symptoms of kidney disease should be investigated before surgery?

Back 820

1. Haematuria
2. Dysuria
3. Polyuria
4. Oliguria
5. Flank pain

Front 821

What 8 abnormal findings in urinalysis would be enough to postpone surgery?

Back 821

1. Presence of glucose
2. Presence of protein
3. Presence of ketones
4. Presence of bilirubin
5. More than four red or white blood cells per field
6. Bacteria
7. Casts
8. Crystals

Front 822

What is ketosis?

Back 822

It is associated with chronic starvation and indicates a lack of carbohydrates

Front 823

What five problems can hyperglycaemia cause in post-surgical wound healing?

Back 823

1. Impairs wound healing by retarding wound closure
2. Delaying wound contracture
3. Slowing collagen synthesis
4. Impairing granulocytes
5. Reducing red blood cell viscosity

Front 824

How does surgical stress cause hyperglycaemia?

Back 824

Surgical stress causes a catabolic reaction resulting in glucagon, adrenaline and cortisol secretion. Blood glucose levels rise and other fuel pathways are mobilised.

Front 825

What four problems does general anaesthesia cause for the diabetic patient?

Back 825

1. Increased insulin demands
2. The risk of silent MI
3. Nausea and vomiting
4. Delays in food and oral medication intake. Early morning surgery allows the optimal equilibrium between insulin dose and caloric intake with immediate oral nutrition postoperatively

Front 826

What two problems can RA patients have with surgery?

Back 826

1. Many patients coming to surgery have been on long-term steroids. These drugs suppress the HPA axis and patients may require corticosteroid coverage during the perioperative period
2. Disease-remittive drugs eg methotrexate suppress the bone marrow and can cause leucopenia and thrombocytopenia increasing the likelihood of infection

Front 827

What is thrombocytopenia?

Back 827

Reduced platelet count

Front 828

What is a reduced platelet count called?

Back 828

Thrombocytopenia

Front 829

What autoimmune arthritis is Raynaud's associated with?

Back 829

Systemic lupus erythematosus

Front 830

What is contraindicated in surgery when the patient has Raynaud's?

Back 830

Adrenalin in the LA

Front 831

What is a patient who has a history of gout at risk of?

Back 831

There is a substantial risk of a postoperative gouty attack which may be due to local surgical trauma, dehydration and the temporary interruption of uricosuric medication

Front 832

What are four contraindications to LA?

Back 832

1. Unstable epilepsy - high blood levels of LA are known to cause convulsions in some epileptic patients
2. Methaemoglobinaemia - prilocaine can cause problems with this condition
3. Pregnancy and breastfeeding - prilocaine should be avoided as it can cross the placental barrier. Lidocaine and bupivacaine are considered safe for use with breastfeeding mothers
4. Porphyrias - LA can precipitate an attack in some patients

Front 833

What are three blood clotting abnormalities?

Back 833

1. von Willebrand's disease
2. Haemophilia
3. Vitamin K deficiency

Front 834

When are sutures removed?

Back 834

10-14 days postoperatively

Front 835

What four things does the surgeon expect to see in a wound postoperatively?

Back 835

1. An intact wound that shows no signs of dehiscence
2. a 'normal' amount of inflammation
3. no sign of excessive bleeding, oedema or haematoma formation
4. the position maintained if any reconstructive technique has been performed.

Front 836

What is dehiscence?

Back 836

Wound dehiscence is a previously closed wound reopening.

Front 837

Question

Back 837

Answer

Front 838

Name 2 classes of drugs used to treat hypertension in patients over 55yrs old

Back 838

"1) calcium channel blockers

Front 839

2) thiazide diuretics (thiazides)"

Front 840

Name two drugs used to treat hypertension in pts >55yrs old, and the class of drug

Back 840

"1) calcium channel blockers (e.g. Nefidipine, Verapamil)

Front 841

2) thiazide diuretics (bendroflumethiazide)"

Front 842

What are the 2 first line drugs for the Tx of hypertension in pts. less than 55yrs old and caucasian?

Back 842

"1) ACE inhibitors (Ramipril)

Front 843

2) Angiotensin II Receptor antagonist (Losartil)"

Front 844

How do loop and thiazide diuretics differ?

Back 844

"Thiazide diuretics

Front 845

- used for heart failure"

Front 846

What is the action of a diuretic?

Back 846

Diuretics work on the kidneys to increase urine volume by reducing salt and water reabsorption from the tubules.

Front 847

Name three causes of oedema

Back 847

-

Front 848

How do loop diuretics work?

Back 848

"- increase excreted Sodium%

Front 849

- have venodilation action"

Front 850

What is the action of thiazide diuretics?

Back 850

"Thiazide diuretics:

Front 851

4. increase renin release"

Front 852

What different types of drug exist for Tx of hypertension?

Back 852

"1- thiazide diuretics

Front 853

5- Beta-adrenoceptor antagonists"

Front 854

What system do antihypertensive drugs work on?

Back 854

The renin-angiotensin system

Front 855

What does the renin-angiotensin-aldosterone system do?

Back 855

The renin-angiotensin system regulates blood pressure and systemic vascular resistance. This influences cardiac output and arterial pressure.

Front 856

What is the end product of the renin-angiotensin-aldosterone (RAAS) system?

Back 856

The final end product of the renin-angiotensin-aldosterone system is aldosterone, produced in the Adrenal glands and acts on the kidneys

Front 857

What action does Aldosterone have and on which organ?

Back 857

Aldosterone acts on the distal kidney tubules to increase sodium absorption.

Front 858

What is NATURESIS?

Back 858

Naturesis is the excretion of sodium in the urine, esp. in greater than normal amounts.

Front 859

All diuretics increase _________ by increasing urine production and excretion of ______.

Back 859

All diuretics increase NATURESIS by increasing urine production and SODIUM excretion.

Front 860

Why might thiazide diuretics be used in preference to loop diuretics?

Back 860

"1) less potent than loops

Front 861

4) reduce calcium excretion (hence = bone preserving)"

Front 862

Name 3 indications for use of thiazide diuretics

Back 862

"thiazide diuretics are indicated for:

Front 863

3) resistant oedema + loop"

Front 864

Name two examples of thiazide diuretics

Back 864

"examples of thiazide diuretics

Front 865

2. Hydrochlorothiazide"

Front 866

What is the mechanism of action of thiazide diuretics?

Back 866

"Thiazide diuretics MOA:

Front 867

d) decreased plasma volume & decreased peripheral resistance"

Front 868

Name 4 main adverse effects of thiazide diuretics

Back 868

1. impair glucose tolerance
2. hyponatraemia
3. hypokalaemia
4. uric acid retention
5. allergy (rare)

Front 869

5. allergy (rare)"

Front 870

Why would loop diuretics be used in Tx of hypertension?

Back 870

"Loop diuretics might be used where:

Front 871

- where heart failure is present"

Front 872

What are the main indications of loop diuretic use?

Back 872

"Loop diuretic indications:

Front 873

4) if thiazides don't work for HTN"

Front 874

Name a loop diuretic

Back 874

Furosemide = loop diuretic

Front 875

What is the mechanism of action of loop diuretics?

Back 875

"Loop diuretics MOA:

Front 876

3. chloride and sodium ions are lost & water follows"

Front 877

Can thiazide diuretics be used in renal failure?

Back 877

No, but loop diuretics can be used where there is renal failure.

Front 878

Name three contraindications for thiazide diuretic use, and explain why:

Back 878

"thiazide contraindications:

Front 879

3. gout (decrease uric acid excretion)"

Front 880

How much sodium is normally excreted by the kidneys?

Back 880

normally about 1% of filtered sodium is excreted in the urine

Front 881

Describe the main sites of action of the loop and thiazide diuretics

Back 881

"Loop diuretics act on the thick segment of the ascending loop.

Front 882

Thiazides act on the beginning of the distal convoluted tubule."

Front 883

What is a "symport system"?

Back 883

A symport system is one in which the transport of one substance across a membrane is coupled to that of another. Both travel in the same direction.

Front 884

What is a NEPHRON?

Back 884

A nephron is made up of a glomerulus and its associated tubules.

Front 885

Name four substances not normally present in urine.

Back 885

Blood, glucose, acetone and proteins are not normally present in urine.

Front 886

Name four substances that are excreted by the kidneys.

Back 886

"the kidneys excrete:

Front 887

4. drugs and toxins"

Front 888

Name some classes of salts excreted by the kidneys.

Back 888

"Salts excreted by the kidneys include:

Front 889

- sulphates of Na/K/Ca"

Front 890

What is the osmotic diuretic effect?

Back 890

Osmotic diuresis - is the diuretic effect caused by a high osmotic gradient between kidney filtrate and the surrounding medulla/capillaries.Osmosis is the movement of water from an area of high concentration to an area of lower concentration.

Front 891

Examples of an osmotic diuretic effect?

Back 891

hyperglycemia and excess salt intake both cause dehydration

Front 892

Sympathetic nerves ______ the heart rate.

Back 892

Sympathetic nerves INCREASE the heart rate.

Front 893

Parasympathetic nerves _______ the heart rate.

Back 893

Parasympathetic nerves DECREASE heart rate.

Front 894

What role do the arterioles play in blood pressure?

Back 894

"Arterioles:

Front 895

2. regulate relative blood flow through particular organs."

Front 896

What things might cause vasodilatation?

Back 896

"Vasodilatation is caused by:

Front 897

- inflammatory mediators"

Front 898

What might cause vasoconstriction?

Back 898

"Vasoconstriction is caused by:

Front 899

- noradrenaline acting on Alpha1 adrenoceptors"

Front 900

Name three causes of hypertension.

Back 900

"Hypertension can be caused by:

Front 901

4. tumour"

Front 902

If hypertension is untreated, what conditions may ensue?

Back 902

"Untreated hypertension can lead to:

Front 903

3. kidney failure"

Front 904

What is the effect of taking thiazides alongside other drugs for hypertension?

Back 904

Thiazides potentiate the effect of other antihypertensive drugs.

Front 905

Where is renin synthesized and what is its action?

Back 905

"Renin is synthesized in the kidney.

Front 906

It is a proteolytic enzyme that cleaves Angiotensinogen into Angiotensin I."

Front 907

Where is ACE synthesized and what is its action?

Back 907

"ACE is a membrane-bound enzyme found in vascular (and other) endothelium.

Front 908

It cleaves Angiotensin I into Angiotensin II."

Front 909

Name some actions of Angiotensin II.

Back 909

"Angiotensin II causes:

Front 910

3. Vascular growth"

Front 911

What does Angiotensin I do increase blood pressure?

Back 911

Angiotensin I is a weak vasoconstrictor, which increases blood pressure by inhibiting bradykinin (a vasodilator). This increases peripheral resistance.

Front 912

Where is the ACE located?

Back 912

"The ACE is located on the vascular endothelium of the lungs.

Front 913

Since all blood must return to the right heart and be sent through the lungs, ACE located in the lungs will affect all the Angiotensin I."

Front 914

What effect does Angiotensin II have on other organs?

Back 914

Angiotensin II is a powerful vasoconstrictor which reduces blood flow to all other rgans.

Front 915

Name an ACE inhibitor and state its action?

Back 915

"ACE inhibitors:

Front 916

5. vasodilation & reduced periph"

Front 917

Name an Angiotensin II Receptor Antagonist and state its action?

Back 917

"Angiotensin II receptor antagonists:

Front 918

3. vasodilatation & reduced peripheral resistance"

Front 919

Compare and contrast ACE inhibition and Angiotensin II receptor inhibition?

Back 919

"ACE inhibition:

Front 920

-"

Front 921

What is the mechanism of action of aldosterone? Which organ secretes it and on what organ does it act?

Back 921

"Aldosterone is secreted by the adrenal gland.

Front 922

It switches on Na+/K+ ATPase in the kidneys. Blood reabsorbs Na+ and secretes K+. Water follows Na+ into blood, blood volume and BP increase."

Front 923

What effect does ACE have on bradykinin?

Back 923

In the normal Renin-Angiotensin pathway, ACE inhibits bradykinin.

Front 924

What is the action of bradykinin?

Back 924

Bradykinin is a hormone vasodilator that decreases peripheral resistance.

Front 925

What effect does ACE inhibition have on bradykinin levels?

Back 925

ACE inhibition means that bradykinin remains active, and able to cause vasodilation. Peripheral resistance is decreased.

Front 926

Name some contraindications for the SARtAn drugs

Back 926

"Angiotensin II receptor antagonists should not be used:

Front 927

2. caution in renal artery stenosis"

Front 928

What does SARTAN stand for?

Back 928

"Second generation

Front 929

What does SARTAN stand for?

Back 929

"Second generation
Angiotensin II
RecepTor
ANtagonistS"

Front 930

Adverse effects of the SARTANS?

Back 930

"Sartan adverse effects?

Front 931

6) insomnia"

Front 932

Adverse effects of ACE inhibitors?

Back 932

"ACE inhibitors adverse effects?

Front 933

6) muscle cramps"

Front 934

Name some calcium channel blocker drugs used in hypertension.

Back 934

"Calcium Channel Blockers:

Front 935

e.g. Verapamil, Nifedipine"

Front 936

What is the action of calcium channel blockers and how do they work?

Back 936

"calcium channel blockers

Front 937

3) this has a vasodilato"

Front 938

What are the side effects of calcium channel blockers?

Back 938

"Calcium channel blockers:

Front 939

2) cause flushing"

Front 940

Name some contraindications for the SARtAn drugs

Back 940

"Angiotensin II receptor antagonists should not be used:

Front 941

2. caution in renal artery stenosis"

Front 942

What does SARTAN stand for?

Back 942

"Second generation

Front 943

ANtagonistS"

Front 944

Adverse effects of the SARTANS?

Back 944

"Sartan adverse effects?

Front 945

6) insomnia"

Front 946

Adverse effects of ACE inhibitors?

Back 946

"ACE inhibitors adverse effects?

Front 947

6) muscle cramps"

Front 948

Name some calcium channel blocker drugs used for hypertension

Back 948

"Calcium channel blockers:

Front 949

Nifedipine, Amlodipine, Verapamil"

Front 950

What adverse effects do calcium channel blockers hve?

Back 950

"Calcium channel blockers can cause:

Front 951

3) reflex tachycardia"

Front 952

What is the action of calcium channel blockers and how do they work?

Back 952

"calcium channel blockers:

Front 953

2) inhibit depolarisation-induced calcium entry into cardiac and/or vascular smooth m"

Front 954

Name two classes of calcium channel blocker and give an example of each.

Back 954

"Phenylakylamines (Verapamil)

Front 955

Dihydropyridines (Nifedipine, Amlodipine)"

Front 956

Explain how Phenylakylamines and Dihydropyridines differ (compare and contrast)

Back 956

"Phenylakylamines (Nifedipine, Amlodipine) act on both arteriolar and cardiac smooth muscle.

Front 957

Dihydropyridines (Verapamil) act only on cardiac smooth muscle."

Front 958

Do calcium channel blockers have a negative or positive inotropic effect?

Back 958

Calcium channel blockers have a negative inotropic effect. Inhibition of calcium entry into smooth muscle reduces its contractility.

Front 959

Which calcium channel blockers may be used if a patient has cardiac failure?

Back 959

None. Calcium channel blockers have a negative inotropic effect which can exacerbate heart failure.

Front 960

What are Beta-blockers?

Back 960

Beta blockers are Beta adrenoceptor antagonist agents.

Front 961

What is the action of a Beta-blocker?

Back 961

"Beta adrenoceptor antagonists:

Front 962

- block B1 and/or B2 receptors in cardiac, vascular and pulmonary smooth muscle."

Front 963

How do Beta-blockers work?

Back 963

"Beta adrenoceptor antagonists work by:

Front 964

5. reduce sympathetic activity"

Front 965

Name the two types of Beta blocker agent and give an example of each.

Back 965

"Beta blockers may be selective or non-selective.

Front 966

Propanalol is non-selective and acts on both B1 & B2 receptors."

Front 967

What is the advantage of a B1 selective Beta blocker drug?

Back 967

A selective B1 selective beta-blocker drug will only act on the heart (having a negative inotropic effect). It will not relax vascular smooth muscle.

Front 968

Name a drug that has affinity for B1 adrenoceptors, and state its action.

Back 968

"- Atenolol

Front 969

i.e. reduces cardiac contractility, oxygen demand and BP"

Front 970

Name a drug that can act on both Beta 1 and 2 adrenoceptors, and say where these receptors are found.

Back 970

"Propanalol is a Beta adrenoceptor antagonist.

Front 971

B2 - found in vascular smooth muscle and lungs"

Front 972

What conditions might be treated using beta-blockers?

Back 972

"Beta blockers used to treat:

Front 973

- anxiety"

Front 974

When should you not give a Beta-blocker?

Back 974

"Beta-blockers not to be used:

Front 975

(conditions where the heart is slowed)"

Front 976

Adverse effects of Beta-blockers?

Back 976

"Beta blockers adverse effects:

Front 977

- hallucinations/nightmares"

Front 978

What is the action of Alpha 1 adrenoceptor antagonists?

Back 978

"Alpha 1 receptor blockers:

Front 979

- this causes vasodilation and reduction in peripheral resistance"

Front 980

What is the Alpha 1 adrenoceptor agonists mode of action?

Back 980

Alpha 1 adrenoceptor agonists act to cause vasoconstriction. Positive inotropic effect, increased BP

Front 981

What other useful cardiovascular side effect do Alpha 1 adrenoceptor antagonists agents have?

Back 981

Alpha 1 adrenoceptor antagonists also lower plasma LDL and increase HDL

Front 982

Alpha 1 adrenoceptor antagnonist adverse effects?

Back 982

"Alpha 1 adrenoceptor antagonist adverse effects:

Front 983

- impotence"

Front 984

Why is a thiazide diuretic helpful in treating hypertension?

Back 984

-

Front 985

Explain the action of the first generation antihypertensive drugs.

Back 985

"First generation antihypertensive drugs.

Front 986

= decrease al"

Front 987

Explain the action of the second generation antihypertensive drugs.

Back 987

"Second generation antihypertensive drugs.

Front 988

= Angiotensin II antagonists"

Front 989

Name two antihypertensive drugs where cough is a side effect.

Back 989

Cough is a side effect of ACE inhibitors (Ramipril, Lisinopril) and Angiotensin II receptor antagonists (Losartan, Valsartan)

Front 990

State one absolute contraindication for ACE inhibitors.

Back 990

"ACE inhibitor contraindication = pregnancy

Front 991

= Renovascular disease"

Front 992

State one absolute contraindication for Angiotensin II receptor antagonists.

Back 992

"Angiotensin II receptor blocker contraindication

Front 993

= Renal artery stenosis"

Front 994

Name an Alpha 1 adrenoceptor antagonist agent, and state its MOA.

Back 994

"Alpha 1 adrenoceptor antagonist

Front 995

= also lowers LDL and raises HDL"

Front 996

Outline the NICE (2006) guildelines for the management of hypertension.

Back 996

#NAME?

Front 997

Explain the action of drugs that act on the ACE system, including first ad second generation drugs. Include their side effects

Back 997

(long answer)

Front 998

Describe the action of one positive inotropic agent and one negative inoptropic agent in the management of cardiovascular conditions.

Back 998

Calcium channel blockers are negatively inotropic. Inhibition of calcium entry into smooth muscle reduces its contractility.
Alpha 1 adrenoceptor agonists act to cause vasoconstriction. Positive inotropic effect, increased BP

Front 999

What is the relevance of genetic variation when considering intervention with ACE inhibitors?

Back 999

"ACE inhibitors reduce BP and slow progression of renal disease.

Front 1000

Alt agents include"

Front 1001

List the main modes of action by which antihypertensive drugs reduce blood pressure.

Back 1001

"Various agents availablem main MOAs are:

Front 1002

3. reducing peripheral resistance (CCBs, ACE inhibition, SARTANs, Alpha adrenoceptor blockers"

Front 1003

What are the potential problems of using diuretic therapy?

Back 1003

"Problems of diuretic therapy inc:

Front 1004

e) rare allergy"

Front 1005

Is propanalol safe to use in patients with congestive heart failure?

Back 1005

-

Front 1006

Atenolol does not precipitate asthma."

Back 1006

-

Front 1007

Down-regulation of adrenoceptors may occur in long-term propanalol use."

Back 1007

-

Front 1008

Plasma concentrations are closely related to clinical activity."

Back 1008

-

Front 1009

Calcium channel blockers are negatively inotropic"

Back 1009

"True

Front 1010

Calcium channel blockers are negatively inotropic"

Front 1011

Calcium channel blockers are all highly selective for vascular smooth muscle"

Back 1011

FALSE

Front 1012

Nifedipine may sometimes cause angina"

Back 1012

-

Front 1013

Nifedipine can be used in hypertensive crisis"

Back 1013

-

Front 1014

Verapamil is an effective antiarrhthmic for ventricular arrhthmias"

Back 1014

-

Front 1015

Question

Back 1015

Answer

Front 1016

What is the purpose of the Arachidonic Acid pathway?

Back 1016

The AA pathway produces inflammatory mediators (including Eicosanoids) using Arachidonic Acid as the substrate.

Front 1017

Name the main products of the arachidonic acid pathway.

Back 1017

"The arachidonic acid pathway produces:

Front 1018

4. Prostaglandins"

Front 1019

By the action of which enzyme is Arachidonic Acid liberated from membrane phospholipids?

Back 1019

Phospholipase-A enzyme liberates arachidonic acid from membrane phospholipids.

Front 1020

What two enzymatic pathways exist in respect of Arachidonic Acid?

Back 1020

"Arachidonic Acid may either be acted on by:

Front 1021

- cyclo-oxygenase enzymes"

Front 1022

The 5-lipoxygenase pathway produces mediators called ___________

Back 1022

Leukotrienes

Front 1023

The cyclooxygenase (COX) pathway produces which three inflammatory mediators?

Back 1023

"The cycloxygenase pathway produces:

Front 1024

3) Prostaglandins"

Front 1025

When arachidonic acid is acted upon by COX enzymes, what is produced?

Back 1025

COX enzymes act on arachidonic acid and intermediate compounds called cycloendoperoxides result.

Front 1026

Thromboxanes are produced where?

Back 1026

Thromboxanes are produced by platelets.

Front 1027

Prostacyclin is produced where?

Back 1027

Prostacyclin is produced in the endothelium.

Front 1028

Where are prostaglandins produced?

Back 1028

Prostaglandins are produced in smooth muscle.

Front 1029

Which cycloxygenase enzyme is found in most cells?

Back 1029

COX 1 is found in most cells. It is "constitutive".

Front 1030

What is necessary to stimulate expression of COX2 ?

Back 1030

An inflammatory stimulus is necessary to induce expression of COX 2.

Front 1031

COX 1 is particularly abundantly expressed by platelets."

Back 1031

"True.

Front 1032

COX 1 is particularly abundantly expressed by platelets."

Front 1033

At a site of inflammation, which type of COX enzyme would you expect to encounter?

Back 1033

Both types. COX 1 is present in most cells, and COX 2 is induced by inflammatory stimuli.

Front 1034

What is kwn about COX 3?

Back 1034

Not a great deal, but it is thought to be the site of action for paracetamol.

Front 1035

Define cyclozygenase (COX).

Back 1035

Cycloxygenase is an enzyme that coverts Arachidonic Acid into various eicosanoids (inflammatory mediators).

Front 1036

How do the inflammatory mediators produced in the arachidonic acid pathway exert their effects?

Back 1036

The inflammatory mediators from the AA pathway act on receptors present in body tissues.

Front 1037

What are the main functions of the eicosanoids?

Back 1037

-

Front 1038

List the cardinal signs of inflammation.

Back 1038

"Inflammation cardinal signs:

Front 1039

State the three main events in inflammation.

Back 1039

"Inflammation involves:

Front 1040

What is the action of thromboxane?

Back 1040

ThromboXane causes platelet aggregation and is an vasoconstrictor.

Front 1041

What is the action of Prostacyclin?

Back 1041

ProstacyclIN INhibits platelet aggregation and is a vasodilator.

Front 1042

What do the Prostaglandins do?

Back 1042

"Prostaglandins:

Front 1043

Name some substances that control the inflammatory response.

Back 1043

"Inflammatory response controlled by:

Front 1044

What is inflammation?

Back 1044

The inflammatory response represents the vascular and cellular changes that occur in response to tissue insult or injury.

Front 1045

Name some substances that control the inflammatory response.

Back 1045

"Inflammatory response controlled by:

Front 1046

Inflammation is...?

Back 1046

The inflammatory response represents the vascular and cellular changes that occur in response to tissue insult or injury.

Front 1047

Most anti-inflammatory therapy is based on what?

Back 1047

....manipulation of eicosanoid synthesis

Front 1048

State the main types of anti-inflamm drugs.

Back 1048

"Main anti inflamm drugs are:

Front 1049

Name a common feature of NSAIDs and Glucocorticoid drugs.

Back 1049

Both NSAIDs and glucocorticoids inhibit synthesis of eicosanoids.

Front 1050

What causes most adverse effects of NSAIDs and why?

Back 1050

"Most adverse NSAID effects are caused by COX-1 inhibition.

Front 1051

What accounts for the analgesic and anti-inflammatory effects of NSAIDs and why?

Back 1051

"The analgesic and anti-inflammatory effects of NSAIDs are due to COX-2 inhibition.

Front 1052

Compare and contrast 2 different NSAIDs

Back 1052

-

Front 1053

Name one mild and one potent NSAID.

Back 1053

"Mild NSAID = Ibuprofen

Front 1054

Give 3 licensed indications for use of diclofenac sodium.

Back 1054

"Indications for diclofenac sodium:

Front 1055

Outline the pharmacodynamics of aspirin

Back 1055

-

Front 1056

Give three reasons why and NSAID and Warfarin should not ideally be used together.

Back 1056

"NSAIDs and Warfarin should not be used together because:

Front 1057

When would you use a COX-2 inhibitor?

Back 1057

"Selective inhibition of COX-2 improves GI tolerance.

Front 1058

What is the BNF's advice about approach to NSAID selection?

Back 1058

"An NSAID should be chosen on the basis of the incidence of GI and other side effects". (p.505)

Front 1059

Name the main endogenous glucocorticoid.

Back 1059

Cortisol is the main endogenous GC.

Front 1060

What is the main endogenous mineralocorticoid?

Back 1060

The main endogenous mineralocorticoid is Aldosterone.

Front 1061

What is the name of the most common synthetic analogue of cortisol?

Back 1061

Hydrocortisone is the most common synthetic analogue of cortisol.

Front 1062

What is the normal action of endogenous glucocorticoids?

Back 1062

"e.g. Cortisol

Front 1063

How do glucocorticoids interfere with the arachidonic acid pathway?

Back 1063

Glucocorticoids inhibit synthesis of phospholipase A2, thus inhibiting arachidonic acid synthesis.

Front 1064

What other anti-inflammatory effects do glucocorticoids have?

Back 1064

As well as directly inhibiting arachidonic acid production, they indirectly reduce liopxygenase and cyclooxygenase, thus reducing inflammation.

Front 1065

How do glucocorticoids suppress the immune system?

Back 1065

-

Front 1066

Name 4 features of Cushing's Syndrome.

Back 1066

"Cushing's Syndrome features:

Front 1067

Define Cushing's Syndrome.

Back 1067

Cushing's Syndrome is a persistent and continuous state of cortisol overproduction, not in line with normal circadian rhythm patterns.

Front 1068

What causes Cushing's Syndrome?

Back 1068

"Cushing's Syndrome can be caused by:

Front 1069

Why must oral steroid therapy always be withdrawn slowly?

Back 1069

-

Front 1070

When would a corticosteroid injection into a joint be contraindicated, and why?

Back 1070

-

Front 1071

Name 4 indicated uses for methotrexate.

Back 1071

"Methotrexate indicated uses:

Front 1072

Outline methotrexate's mechanism of action.

Back 1072

"Methotrexate MOA =

Front 1073

What is often take 24hrs post-methotrexate, and why?

Back 1073

Folic acid is often given after methotrexate, to "save" cells. Methotrexate is a powerful folic acid antagonist. FOlic acid is essential for DNA synthesis and if not administered cell death occurs.

Front 1074

What monitoring precautions are taken with methotrexate therapy?

Back 1074

System toxicity possible. Blood counts should be monitored.

Front 1075

Name 2 DMARDs (not methotrexate) and state their MOA.

Back 1075

-

Front 1076

State the category, MOA, indications, contrainds, interactions and SEs of methotrexate.

Back 1076

-

Front 1077

State the category, MOA, indications, contrainds, interactions and SEs of Prednisolone.

Back 1077

-

Front 1078

State the category, MOA, indications, contrainds, interactions and SEs of Ibuprofen.

Back 1078

-

Front 1079

State the category, MOA, indications, contrainds, interactions and SEs of voltarol.

Back 1079

-

Front 1080

Name four side effects of methotrexate.

Back 1080

"Methotrexate side effects:

Front 1081

When should DMARDs be given?

Back 1081

DMARDs do not have immediate onset, so should ideally be given immediately post-diagnosis.

Front 1082

Name the different classes of DMARDs.

Back 1082

"Classes of DMARDs:

Front 1083

What classes of drugs are suitable for Tx of RA?

Back 1083

"Drugs suitable for Tx of RA:

Front 1084

DMARDs have no anti-inflammatory or analgesic action."

Back 1084

"True.

Front 1085

What is the main difference between NSAIDs and DMARDs in relation to RA?

Back 1085

NSAIDs do not stop the progression of RA, unlike DMARDs.

Front 1086

How slow is DMARD onset of action?

Back 1086

DMARDs usually take between 8-12 weeks to take effect.

Front 1087

Name one reason why methotrextate is cytotoxic?

Back 1087

Methotrexate is cytotoxic because it is potent folate antagonist. Folate is necessary for synthesis of purines and pyramidines, without which DNA synthesis is possible. Without folic acid, cell death occurs.

Front 1088

Why is long term steroid therapy harmful?

Back 1088

Steroid therapy has many and serious SEs. Long term use is not advised because:

Front 1089

NSAIDs inhibit synthesis of all inflammatory mediators."

Back 1089

"False.

Front 1090

Name one reversible and one non-reversible COX inhibting drug.

Back 1090

"Reversible COX inhibitor = ibuprofen

Front 1091

What 2 main actions do NSAIDs chare with Paracetamol?

Back 1091

"Both NSAIDs and Paracetamol are:

Front 1092

Why is a patient's Prothrombin Time important if NSAIDs are being considered?

Back 1092

All NSAIDs may induce life-threatening bleeds in patients with prolongd prothrombin times.

Front 1093

What is the main drug interaction with Aspirin?

Back 1093

Aspirin should never be given with Warfarin. Aspirin has an antiplatelet action and increases the bleeding time.

Front 1094

Is Aspirin safe for asthmatics?

Back 1094

No. Aspirin may induce asthma in some patients.

Front 1095

Is Aspirin excreted from the body unchanged?

Back 1095

No. Aspirin is hydrolysed and conjugated before excretion.

Front 1096

Is Indomethacin a weak or potent NSAID?

Back 1096

Indomethacin is a potent NSAID.

Front 1097

Name 2 unwanted side effects of Indomethacin.

Back 1097

"Indomethacin can:

Front 1098

Indomethacin and Aspirin interact to the same extent with Warfarin."

Back 1098

"False.

Front 1099

Why might simultaneous prescription of thiazide diuretics and Allopurinol not be a good idea?

Back 1099

Thiazide diuretics elevate plasma urate, so are contraindicated in gout.

Front 1100

Give the MOA of corticosteroid drugs.

Back 1100

-

Front 1101

Give 2 examples of corticosteroid drug preparations and state their uses.

Back 1101

-

Front 1102

What side effects can corticosteroids have?

Back 1102

-

Front 1103

Explain the actions and role of cotricosteroids in managing RA (10).

Back 1103

-

Front 1104

Outline the options for intervention with DMARDs for RA, using examples (15)

Back 1104

-

Front 1105

Short notes on methylprednisolone acetate (injectable agent)

Back 1105

-

Front 1106

Short notes on prednisolone.

Back 1106

-

Front 1107

What are the problems of using Aspirin and Ibuprofen together?

Back 1107

-

Front 1108

What are the side effects of oral steroid use?

Back 1108

-

Front 1109

Actions and indications for synthetic glucocorticoid use (15)?

Back 1109

-

Front 1110

Example of COX-2 selective inhibitor drug.

Back 1110

Celecoxib

Front 1111

Short notes on Celecoxib.

Back 1111

"Class - COX2 selective NSAID

Front 1112

Name a topically applied NSAID

Back 1112

topical NSAID = ibuprofen

Front 1113

Tx options for gout?

Back 1113

"Gout Tx:

Front 1114

What is gout?

Back 1114

Gout is due to overproduction of purines. Sodium urate crystals form in the joints and evoke an inflammatory response.

Front 1115

Example of a glucocorticoid drug.

Back 1115

Prednisolone

Front 1116

Cause of Cushing's syndrome?

Back 1116

Cushing's syndrome caused by chronic, excessive corticosteroid levels.

Front 1117

Cause of Addison's Disease?

Back 1117

Addison's Disease represents adrenocortical hormone deficiency.

Front 1118

Generally, how do glucocorticoids work?

Back 1118

"GCs induce lipocortin, which inhibits phospholipase A2, reducing the availability of arachidonic acid, and depressing prostaglandin synthesis (reducing inflammation).

Front 1119

Name the two main therapeutic goals of corticosteroid use.

Back 1119

"Corticosteroid use:

Front 1120

Name some indications for Prednisolone.

Back 1120

"Prednisolone indications:

Front 1121

Prednisolone contraindications?

Back 1121

"Prednisolone contraindications:

Front 1122

Name some adverse effects of topical corticosteroids.

Back 1122

"Side effects of topical corticosteroids include:

Front 1123

Why should systemic steroid therapy never be withdrawn quickly?

Back 1123

Sudden withdrawl of systemic steroid therapy causes acute adrenal insufficiency ("crisis")

Front 1124

Name some general adverse effects of corticosteroids.

Back 1124

"Corticosteroids, general adverse effects:

Front 1125

Corticosteroids - main indications

Back 1125

"- Rheumatic disorders

Front 1126

Corticosteroids - name some common modes of drug delivery.

Back 1126

"Corticosteroids delivery modes:

Front 1127

Name an agent that can be used as an intra-articular steroidal anti-inflammatory agent.

Back 1127

Hydrocortisone Acetate can be given as an intra-articular injection.

Front 1128

Name a topical corticosteroid agent.

Back 1128

Betamethasone valerate - potent topical steroid agent.

Front 1129

How does corticosteroid therapy damage the immune system?

Back 1129

-

Front 1130

What is the cellular process by which corticosteroids affect physiology?

Back 1130

Cellular level - steroids are lipophilic and can pass through cell membranes. On entering cell, steroid binds to receptor incytosol. Drug/receptor complex enters the nucleus where gene expression is altered. Increases number of receptors sensitive to that corticosteroid.

Front 1131

What intra-articular steroidal agent are podiatrists licensed to administer?

Back 1131

Podiatrists may administer Methylprednisolone Acetate as an intra-articular injection.

Front 1132

Why might you give an injection into a joint?

Back 1132

"Joint injections are given for

Front 1133

Contraindications for joint injections?

Back 1133

"Joint injections contras:

Front 1134

Question

Back 1134

Answer

Front 1135

Define diabetes mellitus

Back 1135

Diabetes mellitus is a multisystem disease, characterised by hyperglycemia, caused by absolute or relative lack of insulin production or action.

Front 1136

Name the different types of diabetes

Back 1136

"Diabetes mellitus types 1 & 2

Front 1137

diabetes insipidus"

Front 1138

Common signs and symptoms of diabetes?

Back 1138

"Acute signs:

Front 1139

fatigue/lethargy"

Front 1140

What is polydipsia?

Back 1140

Abnormally intense thirst

Front 1141

What is polyuria?

Back 1141

Production of large volumes of dilute, pale urine

Front 1142

What is the criteria for diagnosis of diabetes mellitus?

Back 1142

"Fasting venous plasma glucose of equal to or greater than 7mmol/L. (WHO)

Front 1143

NB Random glucose tests are unreliable."

Front 1144

What is an HbA1c test and what does it represent?

Back 1144

HbA1c

Front 1145

What is the action of insulin?

Back 1145

"Insulin is a potent hypoglycemic hormone, produced by Beta cells.

Front 1146

Action= reduces circulating glucose by enhancing membrane transport of glucose into certain cells"

Front 1147

What is the action of glucagon?

Back 1147

"Glucagon is a potent hyperglycemic hormone, produced by Alpha cells.

Front 1148

Action= release glucose into bloodstream"

Front 1149

Three cardinal signs of diabetes mellitus?

Back 1149

"1. polyuria (copious wee)

Front 1150

3. polydypsia (intense thirst)"

Front 1151

What is the range of blood glucose levels that drug therapy aims at in DM?

Back 1151

"DM blood glucose ranges:

Front 1152

not more than 9 mmol/L after meals"

Front 1153

What is HbA1c?

Back 1153

"A test of glycosylated haemoglobin.

Front 1154

HbA1c should be 6.5-7.5%"

Front 1155

What is the current prevalence of diabetes in the UK?

Back 1155

Current UK diabetes prevalence is 5%.

Front 1156

How does excess blood sugar lead to diabetic complications?

Back 1156

Excess blood glucose reacts with proteins in body tissue to form advanced glycation end-products (AGE)s. These cause inflammation in the vasculature which causes heart disease and organ damage.

Front 1157

Outline the process of insulin secetion by a Beta cell.

Back 1157

"Increase in blood glucose.

Front 1158

Glucose enters B-cell via Glut2 channel. Glucose is metabolised in cell, producing ATP. ATP blocks K+/ATP channels and depolarises membrane. This causes Ca2+ channels in membrane to open, allowing influx of Ca2+. This signal induces insulin granules to be secreted from B-cell."

Front 1159

Standard Tx for T1D?

Back 1159

"T1D treated by:

Front 1160

Tx for type 2 diabetes?

Back 1160

"Tx algorithm for T2D=

Front 1161

Categories of oral antidiabetic agents?

Back 1161

"Oral antidiabetic agents:

Front 1162

Example of a biguanide

Back 1162

biguanide=metformin

Front 1163

example of a sulphonylurea

Back 1163

"sulphonylureas

Front 1164

Give two examples of the thiazolidinediones

Back 1164

"Thiazolidinediones=

Front 1165

Name one intestinal alpha-glucosidase inhibitor

Back 1165

Acarbose is an intestinal alpha-glucosidase inhibitor

Front 1166

When are Repaglinide and Nateglinide indicated?

Back 1166

"Repaglinide and Nateglinide are indicated:

Front 1167

Which antidiabetic agents are insulin secretagogues?

Back 1167

"Insulin secretagogues

Front 1168

What is the action of a thiozolildinedione? Give an example of the drug.

Back 1168

"Thozolidinedione drugs

Front 1169

Give advantages and disadvantages of this class."

Back 1169

"Sulphonylureas

Front 1170

State the indications and contraindications for Metformin.

Back 1170

"Metformin

Front 1171

If a patient cannot tolerate metformin or other drugs and their diabetes cannot be controlled by diet, what drug may be used?

Back 1171

"Acarbose - an intestinal Alpha-glucosidase inhibitor.

Front 1172

Side effects of Thiazolidonediones?

Back 1172

"Thiazolidonedione side effects?

Front 1173

Side effects of Sulphonylureas?

Back 1173

"Sulphonylureas side effects?

Front 1174

Side effects of intestinal Alpha-glucosidase inhibitors?

Back 1174

"Intestinal Alpha-glucosidase inhibitors side effects:

Front 1175

Side effects of Metformin

Back 1175

"Metformin side effects:

Front 1176

Side effects of Meglitinides?

Back 1176

"Meglitinides side effects:

Front 1177

State the NICE algorithm for treatment of T2D.

Back 1177

Diet
Metformin
Metformin + Sulphonylureas
Metformin + Sulphonylureas + TDZ
Metformin + Sulphonylureas + Insulin

Front 1178

What HbA1c level means that diet control is not working?

Back 1178

HbA1c of >6.5% with diet control means that diet control not working

Front 1179

If a patient is on Metformin and Sulphonylurea, at what HbA1c should their medication be altered?

Back 1179

If a patient is on Metformin and a Sulphonylurea and their HbA1c rises above 7.5%, then Insulin or TZD should be added.

Front 1180

Which antidiabetic drug is a black triangle drug? Why?

Back 1180

"Rosiglitazone is a Black Triangle drug.

Front 1181

What are the symptoms of a hypoglycemic attack?

Back 1181

-

Front 1182

What should you go in the event of a pt having a hypoglycemic attack in clinic?

Back 1182

"-stop procedure

Front 1183

How might Tx differ between T1 and T2D?

Back 1183

"T1D = always insulin

Front 1184

What are the types of insulin used?

Back 1184

"Insulin:

Front 1185

Name the drug categories for Tx of T2D

Back 1185

"T2D:

Front 1186

List the actions of the drugs for Tx of T2D?

Back 1186

"1-insulin secretagogues (stimulate insulin production)

Front 1187

The cyclooxygenase (COX) pathway produces which three inflammatory mediators?

Back 1187

"The cycloxygenase pathway produces:
1) Thromboxanes
2) Prostacyclin
3) Prostaglandins"

Front 1188

Name some contraindications for the SARtAn drugs

Back 1188

"Angiotensin II receptor antagonists should not be used:
1. in pregnancy or breastfeeding
2. caution in renal artery stenosis"

Front 1189

What is pseudo equinus?

Back 1189

A cavus foot with limited ankle ROM is a pseudo equinus because there was contact of the neck of the talus with the anterior inferior part of the tibia. It was pseudo equinus because the Achilles tendon was not the cause of limited ankle motion.

Front 1190

What is ankle equinus?

Back 1190

A sagittal plane deformity in which there is less than 10° of available dorsiflexion at the ankle joint, when the subtalar joint is in its neutral position and the midtarsal joint is fully locked

Front 1191

What are the major classifications of ankle equinus?

Back 1191

1. Osseus
- due to congenital morphology of ankle joint
2. Muscular
- congenital shortage
- acquired shortening of posterior leg muscles (various mechanisms)
- secondary to:
spastic paralysis
cerebral palsy
CVA
onic spasm: 'guarding' mechanism to immobilize painful joints / structures
excessive pronation
decreased tension in posterior leg muscles leads to subsequent contracture
weak dorsiflexor musculature
tight hamstrings
limb length discrepancy
prolonged bed rest / high heels

Front 1192

What is the DDx of ankle equinus?

Back 1192

Differential Dx of limited ankle joint dorsiflexion

- test AJ dorsiflexion with knee flexed and extended
- knee extended - gastrocnemius taut
- knee flexed - gastrocnemius lax

Therefore,
- insufficient dorsiflexion when knee extended and flexed: osseus or soleal equinus
- insufficient dorsiflexion when knee extended, but sufficient when flexed: gastrocnemius equinus
- only way to DDx between soleal and osseus equinus is the feel of the end ROM
abrupt block - osseus
spongy - soleal

Front 1193

What are the pathomechanics of ankle equinus?

Back 1193

Pathomechanics

- inadequate AJ dorsiflexion during stance phase
- needs dorsiflexion
- STJ pronation unlocks distal structures and allows DF of forefoot on the rearfoot

uncompensated

- insufficient STJ pronation
- heel cannot contact the ground, resulting in bouncy gait
- XS WB on forefoot: HK lesions and clawing of lesser digits
- achilles tendinitis


- secondary hamstring contracture
- GRFs cannot resist effect of supinator muscles, so supination contracture may occur
- more proximal joints may attempt to compensate via genu recurvatum, abducted angle of gait, excessive knee flexion, hip flexion

EQUIN proximal compensation mechanisms

fully compensated
- STJ pronation provides required 10 degrees of DF
- excessive STJ pronation to achieve DF
- unlocking of distal structures
- sagittal plane PF of calcaneus and midtarsal joint collapse / break
- very destructive compensation
- leads to gross excessive pronation, and associated with all pronation-induced pathologies

NB: if there is insufficient STJ ROM to bring heel to ground, a bouncy gait with early heel lift may be observed (partial compensation)

Front 1194

What is the treatment of ankle equinus?

Back 1194

- orthoses to control XS pronation
- gastrocnemius stretching program
- heel lifts to reduce strain from achilles tendon
- surgery: achilles tendon lengthening, gastrocnemius recession