Ankle

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Ankle Foot
Done By Rawan Jaradat
Medical ppt
http//hastaneciyiz.blogspot.com
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Anatomy

• There are 26 bones in the foot
• 7 tarsals , 5 metatarsals, 14 phalanges
• The tarsals are
• Calcaneum ,talus,cuboid ,naviculum and the three
  cuniforms (medial,
• intermediate,lateral)

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Anatomy ankle joint

• The ankle joint is a synovial hinge joint .
• Articulation The lateral malleolus of the
  fibula and the medial malleolus of the tibia
  along with the inferior surface of the distal
  tibia articulate with three facets of the talus.
  These surfaces are covered by cartilage.

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• Movements at the ankle joint are mainly
  dorsiflexion and plantarflexion
• The anterior talus is wider than the posterior
  talus. When the foot is dorsiflexed, the wider
  part of the superior talus moves into the
  articulating surfaces of the tibia and fibula,
  creating a more stable joint than when the foot
  is plantar flexed.
• The foot externaly rotates with dorsiflexion and
  internally rotates with plantarflexion

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Anatomy

• Other joints in the foot
• 1- the sub-talar joint.This joint lies between
  the calcaneum and the talus .
• 2-the mid-tarsal joint.This joint is really two
  joints - the joint between the talus and the
  navicular bone as well as the joint between the
  calcaneum and the cuboid bone.

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Anatomy muscles

• There is only one muscle on the dorsum of the
  foot ( digitorum brevis).
• The muscles on the planter aspect of the foot are
  divided into four layers
• ?first layerabductor hallucis,flexor digitorum
  brevis,abductor digiti minimi.
• ?second layerquadratus plantae,lumbricalis,flexor
  digitorum longus tendon,flexor hallucis longus
  tendon.
• ?third layer flexor hallucis brevis,adductor
  hallucis,flexor digiti minimi brevis.
• ? Forth layer interossei , peroneus longus
  tendon,tibialis posterior tendon

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Anatomy
The planter fascia is a very important structure
that takes its origin from the heel (calcaneum)
and inserts into the bases of the proximal
phalanges of the toes.

• Blood supply of the foot is from
• 1-anterior tibial artery which gives dorsalis
  pedis artery.
• 2-posterior tibial which gives the medial and
  lateral plantar arteries.
• 3- peroneal arteries.
• Nerve supply of the foot is from( saphenous,
  sural, superficial deep peroneal)

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Blood supply
Nerve supply
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Pathologies in the foot

• 1- Club foot
• 2- Flat foot

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Congenital Talipes Equinovarus (Idiopathic
Club-Foot)

• ?A true clubfoot is a malformation. The bones,
  joints, muscles, and blood vessels of the limb
  are abnormal. The medical term for this is
  talipes equinovarus -- relating the shape of
  the foot to a horses hoof.
• - Relatively common the incidence is 1 or 2
  /1000 births
• -Boys are affected twice as often as girls.
• -The condition is bilateral in one-third of
  cases.
• - Similar deformities are seen in neurological
  disorders, e.g. myelomeningocele, and in
  arthrogryposis.

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Causes

• -Its mostly a problem passed from parents to
  children (genetic), and it may run in families
• If you have one baby with clubfoot, the chance
  of having a second child with the condition are
  about one in 40.
• -Clubfoot does not have anything to do with the
  babys position during pregnancy.

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Clinical Features

• Clubfoot can be recognized in the infant by
  examination. The foot is inturned (twisted
  inward), stiff with the soles face
  posteromedially
• The heel is usually small and high retracted to
  the leg , and deep creases appear posteriorly and
  medially.
• it cannot be brought to a normal position(
  plantigrade position, meaning flat on the floor.)
• The infant must always be examined for
  associated disorders such as congenital hip
  dislocation and spina bifida

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Diagnosis

• In fact, doctors can see it on ultrasound images
  taken after about four months of pregnancy

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Diagnosis

• X- rays the tarsal bones are incompletely
  ossified at this age. However, the shape and
  position of the tarsal ossific centers are
  helpful in assessing progress after treatment

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Club-Foot (X-ray)
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Treatment

• If the condition is not corrected early,
  secondary growth changes occur in the bones and
  these are permanent.
• Relapse is common, specially in babies with
  associated neuromuscular disorders.
• 1-Conservative treatment
• Should begin early, preferably within a day or
  two of birth.
• It consists of repeated manipulation and adhesive
  strapping or application of plaster of Paris
  casts, which will maintain the correction.

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• 2- Operative treatment
• The objectives are
• A-The complete release of joint tethers (capsular
  and ligamentous contractures and fibrotic bands)
• B-Lengthening of tendons, so that the foot can be
  positioned normally without undue tension.
• After operative correction, the foot is
  immobilized in its corrected position in a
  plaster cast.
• Kirschner wires are sometimes inserted across the
  intertarsal and ankle joints to augment the hold.
  The wires and cast are removed at 6-8 weeks.
• After that, hobble boots (Dennis Browne) or
  customized orthosis are used to maintain the
  correction.

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Treatment
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Flat foot

• Infantile Flat Foot (Congenital Vertical Talus)
• Flat Foot in Children and Adolescents
• Flat Foot in adults

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Infantile flat foot (congenital vertical talus)

• Its a rare neonatal condition usually affects
  both feet.
• In appearance it is the very opposite of a
  club-foot the foot is turned outwards (valgus)
  and the medial arch is not only flat, it actually
  curves the opposite way from the normal,
  producing the appearance of a rocker-bottom
  foot.
• Passive correction is impossible
• The only effective treatment is by operation,
  ideally before the age of 2 years.

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Infantile flat foot (congenital vertical talus)
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X-ray

• X-ray features are characteristic
• The calcaneum is in equinus and the talus points
  into the sole of the foot, with the navicular
  dislocated dorsally onto the neck of the talus.

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Flat-Foot in Children and Adolescents

• When weight-bearing, the foot is turned outwards
  and the medial border of the foot is in contact
  with the ground the heel becomes valgus.
• Two forms of the condition are recognized
• 1- Flexible flat-foot
• 2-Stiff (rigid) flat-foot

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Flexible flat-foot

• Which appears in toddlers as a normal stage in
  development.
• It usually disappears after a few years when
  medial arch development is complete. The arch can
  be restored by simply dorsiflexing the great toe.
• Many of the children with flexible flat-foot have
  ligamentous laxity and there may be a family
  history of both flat-feet, and joint
  hypermobility.

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Stiff (rigid) flat-foot

• Occur in older children and adolescents
• cannot be corrected passively, and should alter
  the examiner to an underlying abnormality.
• conditions to be considered are
• 1-Tarsal coalition (often a bar of bone
  connecting the calcaneum to the talus or the
  naviculum)
• 2-Inflammatory joint condition
• 3-Neurological disorder.

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Flat foot
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Clinical Assessment

• 1-flexible flat-foot no symptoms, but the
  parents notice that the feet are flat or the
  shoes wear badly, the deformity becomes
  noticeable when the child stands.
• On examination ask the patient to go up on
  tiptoes if the heels invert, it is a flexible
  deformity.
• Then examine the foot with the child sitting or
  lying. Feel for localized tenderness and test the
  range of movement in the ankle, the subtalar and
  midtarsal joints.
• ?A tight Achilles tendon may induce a
  compensatory flat-foot deformity.

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• 2-rigid flat-foot Teenagers and young adults
  sometimes present with pain.
• On examination, the peroneal and extensor tendons
  appear to be in spasm,sometimes its called
  Spasmodic flat-foot.
• The spine, hips, and knees should always be
  examined as well as, joint hypermobility and
  neuromuscular abnormalities.
• ?In some cases a definite cause may be found, but
  in many no specific cause is identified.

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Imaging

• - X-rays are unnecessary for asymptomatic,
  flexible flat-feet.
• -For Pathological flat-feet (usually painful,
  and stiff) standing AP, lateral and oblique views
  may help to identify underlying disorders.
• -CT scanning is the most reliable way of
  demonstrating tarsal coalitions.

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Treatment

• flexible flat-feet require no treatment. Parents
  need to be reassured.
• If the condition is obviously due to an
  underlying disorder such as poliomyelitis
  .Splintage or operative correction and muscle
  rebalancing may be needed.
• Spasmodic flat-foot is relieved by rest in a cast
  or a splint. If there is an abnormal tarsal bar
  or other bony irregularity, this may have to be
  removed.
• In late cases, if pain is intolerable, a triple
  arthrodesis may be necessary.

Triple arthrodesis is a surgical procedure whose
purpose is to relieve pain in the rear part of
the foot, improve stability of the foot, and in
some cases correct deformity of the foot, by
fusing of the three main joints of the hindfoot
the subtalar joint, calcaneocuboid joint and the
talonavicular joint
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Flat Foot in Adults

• When adults present with symptomatic flat-feet
  the first thing to ask is whether they always had
  flat-feet or whether it is of recent onset.
• More recent deformities may be due to an
  underlying disorder such as rheumatoid arthritis
  or generalized muscular weakness
• Unilateral flat-foot should make one think of
  tibialis posterior synovitis or rupture.
• Treatment
• -Patients with painful rigid flat-feet may
  require more robust splintage.
• -Those with tibialis posterior rupture can be
  helped by operative repair or replacement of the
  defective tendon

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Medical ppt
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