Ankle & Foot

1. Ankle & Foot Done By: RawanJaradat Medical ppt http://hastaneciyiz.blogspot.com

2. 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)

4. 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.

5. 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

6. 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.

7. Anatomy – muscles • There is only one muscle on the dorsum of the foot ( digitorumbrevis). • The muscles on the planter aspect of the foot are divided into four layers: first layer:abductorhallucis,flexordigitorumbrevis,abductordigitiminimi. second layer:quadratusplantae,lumbricalis,flexordigitorumlongustendon,flexorhallucislongus tendon. third layer: flexor hallucisbrevis,adductorhallucis,flexordigitiminimibrevis.  Forth layer: interossei , peroneuslongustendon,tibialis posterior tendon

9. 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 dorsalispedis 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)

10. Blood supply Nerve supply

11. Pathologies in the foot 1- Club foot 2- Flat foot

12. 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.

13. Causes : -It’s 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 baby’s position during pregnancy.

14. 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

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

17. 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

18. Club-Foot (X-ray)

19. 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.

20. 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.

21. Treatment

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

23. Infantile flat foot (congenital vertical talus) • It’s 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.

24. Infantile flat foot (congenital vertical talus)

25. 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.

26. 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

27. 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.

28. 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.

29. Flat foot

30. 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.

31. 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.

32. 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.

33. 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

34. 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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