Lower limb

Congenital deformities

Talipes Equinovarus (Idiopathic clubfoot) talus= L anke bone, pes= L footEquinus= heal tilted backwardvarus= heel deviated medially
Incidence: 1-2/thousand births. Male/female = 2/1. Bilateral in 1/3rd of cases.

Etiology

Idiopathic in most of cases, but may be associated with tight uterus as in primegravida uterus. Associated with myelomeningocele, congenital tibial deficiency and arthrogriposis.

Clinical features

Components: Equinus of heel. Varus of hind foot. Adduction and supination of forefoot. Small heel and calf muscle. Exam for associated: DDH. Spina bifida. Arthrogriposis (absent creases in legs).

Spina bifida with club foot

Treatment Conservative
Begin in the first few days of life. Ponseti Method: Weakly manipulation and POP casting. If conservative treatment fails ; then Operative treatment is considered.

Adhesive strapping

Pes Planus (flat-foot)
The medial border (arch of the foot) is in contact with the ground. Common among children. Types: Flexible flat-foot: normal variation usually disappears spontaneously. Rigid flat-foot: cannot be corrected passively. Compensatory flat-foot e g. short tendo achillis, or external rotation of lower limbs (Charlie Chaplin look) .

Rigid club foot

High Arched feet (Pes Cavus)
Caused by muscle imbalance usually due to neuromuscular disorder eg. Poliomyelitis. Associated with claw toes. Both feet affected. Often NO treatment required apart from well moulded shoes.

Halux Valgus

Lateral angulation of the big toe due to varus angulation of the first metatarsal. Prominent head of first metatarsal (Bunion). In people who wear shoes. Loss of muscle tone in forefoot in elderly. In rheumatoid arthritis. Family history is common.

Clinical features

In elderly women 50-70 years or adolescents with positive family history. Usually bilateral. Painless deformity. Pain on inflammed buninion or OA of 1st MPJ. Difficulty in purchasing comfortable shoes.

Treatment

Asymptomatic, mild and non-progressive deformity; conservative treatment: comfortable footwear with low heels. Severe, progressive and painful deformity requires surgical treatment.

Claw Toes

Interphalangeal joints are flexed and metatarsophalangeal joint is extended. Seen in poliomyelitis, Rheumatoid arthritis but usually idiopathic. Associated with pes cavus.

Hammer Toes

Proximal IPJ flexed, distal IPJ and MPJ extended. Cause is obscure. Shoe pressure produce painful corns and callosities.

Rupture of Tendo Achillis

Age >40.After running or jumping feels a struck above the heel.Cannot tip toe.Gap is felt 5cm above heel.Simmond’s test: squeezing the calf causes planterflexion of foot normally. Absent planterflexion means rupture of the tendon.

Ruptured tendo achillis

Treatment
Operative repair then POP in equinus for 8 weeks.


Traction apophysitis(Sever’s disease) Pain and tenderness over Achillis tendon insertion. In boys around 10years old. Treat by raising the heel and abandon strenuous exercise.

Severs disease

Plantar FasciitisPainful Heel
Common in Males 30-60yrs. Pain with first steps after inactivity (rising from bed). Obesity, prolonged standing, and stiff shoe soles are predisposing factors. Local tenderness. X-ray: boney spur. Treatment: NSAID, pad under heel, local C/S injection.

Calcaneal spur

Kцhler’s diseaseOsteochondritis of the navicular Painful limp and tenderness in midfoot in children <5yrs. X-ray: dense, fragmented navicular bone. Usually resolve spontanuously.

Freiberb’s disease Crushing type of osteochondritis. Affects head of 2nd metatarsal. Usually seen in young adult women.


Rare, resulted from high energy trauma (fall from height or road traffic accident). The fractures might occur in head, neck, body, or lateral process. Might associated with dislocations of midtarsal, subtalar, ankle joints, or complete talar dislocation. There are pain, sever swelling, deformity and skin tenting which may lead to skin sloughing, and skin laceration sometimes. Imaging: X ray shows the type and severity of fractures and associated injuries , CT scan is of important value, MRI and radioactive isotope might be used.

Fracture talus and fixation

Treatment: Undisplaced fractures treated by below knee P.O.P in planter flexion for 8-12 weeks Displaced fractures: closed reduction , if failed open reduction and internal fixation followed by POP for 8-12 weeks. Non weight bearing continue for other 8-10 weeks. Complications: 1- Skin damage. 2- Avascular necrosis of the body of the talus. 3- Nonunion. 4- Osteoarthritis.


Fractures of calcaneum
In most cases the patient falls from a height, often from a ladder, onto one or both heels. Over 20 per cent of these patients suffer associated injuries of the spine, pelvis or hip. The fractures might be extra-articular fractures or intra-articular fractures (runs into superior articular surface involving subtalar joint. Clinical features: There is usually a history of a fall from height or road traffic accident . The foot is painful and swollen and a large bruise appears on the lateral aspect of the heel, after1-2 days ecchymosis spreads into the sole of the foot . The heel may look broad and squat. Always check for signs of a compartment syndrome of the foot (intense pain, very extensive bruising and diminished sensation, with pain on passive toe movement).

Fracture calcaneum

Fracture calcaneum and associated wedge fracture body of the vertebra


X- ray in lateral and axial view may shows chip, split, or crush fractures, CT sometimes used to assess the fracture details. Treatment:Elevation and ice packing till the swelling subsides.Displaced avulsion or intra-articular fractures needs open reduction and internal fixation followed by elevation and non-weight bearing mobilization for 8 weeks.Undisplaced fractures need p.o.p immobilization for 4 – 6 weeks followed by pressure bandage with analgesic .Comolications: 1- Stiffness of subtalar joint and midtarsal joint causing difficulty in walking especially on uneven surfaces. 2- Osteoarthritis. 3- Broadening of the heel: problems in shoe fitting.

Fracture base of 5th metatarsal

This injury is very common, caused by foot torsion. It is nearly always caused by a twisting injury in which the foot is forced into inversion and equines (planter flexion), the styloid process at the base of the 5th metatarsal being pulled off by the tendon of the peroneus brevis muscle, which is inserted into it . There is pain and tenderness over lateral side of foot. It regarded as muscle injury. Treated by pressure bandage and analgesia, if pain sever a below-knee walking plaster for 3 weeks.

Fracture base of 5th metatarsal

Metatarsal stress fracture ( March fracture)
Young adult (a military recruit or a nurse) or osteoporotic women affected usually, the foot may become painful and slightly swollen after overuse. A tender lump is palpable just distal to the midshaft of a metatarsal bone (usually the second metatarsal) . X-ray appearance may at first be normal but a radioisotope scan will show an area of intense activity in the bone. Later a hairline crack may be visible and later on a callus. No displacement occurs and neither reduction nor splintage is necessary. The forefoot may be supported with an elastic bandage and normal walking is encouraged.

March fracture