DISSICANS AND FOOT DEFORMITY AND KNEE

Osteochondritis dissecans

A small well demarcated avascular fragment of bone and overlying cartilage sometimes separated from one of the femoral condyle and appears as a loose body in the joint

A etiology:

Either single impact trauma Or repeated micro trauma

Clinical features:

Male patient usually 15-20 years Presented with intermittent ach or swelling. Later attacks of giving way ,locking may occur.


Waisted quadriceps muscle Joint effusion Soon after the attack there are two signs almost diagnostic

1.tenderness localizes to one femoral condyle. 2.wilsons sign positive (the knee is flexed to 90 degree rotated medially and then gradually straightened pain is felt). repeating the test with the knee rotated laterally is painless.



XR show aline of demarcation or an empty hollow. Loose body in the joint

Radioactive isotopes increase activity around the lesion.

M R I

Arthroscopy.

Treatment:
In the earliest stage (stable lesion) activity curtailed for 6-12 months.

If the fragment unstable

If small removed. Large >1 cm fixed in situ.

If the fragment is completely detached in one piece

Refixation

If fragment in pieces

(discarded and drilling bed).


Recently
articular cartilage transplantation.

Loose bodies

 A etiology:
Injury. Osteochondritis dissecans. OA. Charcots' disease. Synovial chondromatosis.

Clinical features

May be symptom less. Usually complaint is attack of sudden locking without injury. Patient may be aware of some thing popping in and out of the joint. Loose body may be felt during palpation.

XR can detect the loose body There might be underlying factors

Treatment:
Loose body causing symptom should remove by arthroscopy



The ankle and foot congenital deformitiesTalipes equinovarus
idiopathic club foot

Talipes is derived from talusPes foot

The heel is in equines . hind foot in Varus mid foot . forefoot adducted and supinated. It is common 1-2 \1000 births Male 2:1 female 1\3 is bilateral

A etiology:

Genetic. arrested development. neuromuscular disorder.


Clinical features: At birth obvious deformity in which the foot is both turned and twisted so the sole faces posteriomedial Heel inverted Forefoot adducted and supinated

Talus protrude on posteriolateral surface. Heel small and high. Deep creases appear medially. Calf abnormal thin.

On examining foot movement dorsiflexion and eversion were resisted to varying degree. The infant must examined for other associated anomalies e.g. hip and spine disorder.



XR AP Lateral


Rx:
conservative 1.1-2 day after delivery repeated manipulation and adhesive strapping by the relative or physiotherapist.


2. Or pop 3. Conservative continue for 8-12 weeks (PONSENTI ) METHOD OF POP. Either to continue or shift TO SURGERY

to surgery Better until the child is near walking age Soft tissue release.

Flat foot:
The apex of the arch has collapsed and medial border if the foot is in contact or nearly contact with the ground.The heel become valgus and the foot pronated at subtalar –mid tarsal complex.


Flat foot may be flexible (the arch simply restored by sampling dorsiflexion of the great toe, OR STANDING ON THE TOES Or might be rigid flat foot (deformity cannot corrected passively. as in RA. (subtalar joint).

Rx : either conservative Rx :Under lying cause. Or Surgery.

High –arched feet (pes cavus) The arch is higher than normal and often there is also clawing of the toes.

Causes:

Neurological disorder Congenital causes. Acquired neuromuscular disorder Miscellaneous (trauma, burn, compartment syndrome)

Clinical features

8-10 years at school there might be family history a spinal disorder. Pain at metatarsal head Callosities.

examination

deformity obvious Over flexion at IP joint. Hyperextension at MP joint. Drop metatarsal head

High arch mid foot Neurological examinations important XR different measurements.

treatment
Often no rx If symptom present surgery is recommended (bony soft tissue or tendon transfer ).

Hallux valgus

H V is the commonest of the foot deformities and probably of the musculoskeletal deformities ,in which the Angulation of the big toe is excessive .



A etiology:
Metatarsus primus. Elderly people with loss of the muscle tone. RA Positive family history in 60 %

Clinical features:

Most common in women 50-70 Bilateral In those appear in adolescence has strong familial tendency No symptom apart from deformity.


Some time pain due to either pressure shoe Metatarsalgia. deformity lesser toes. OA 1st metatarsal joint.

Deformity obvious, bunion swollen. Forefoot is too wide Great toe valgus position. 2nd toe is crowded and hammer toe deformities are common


old shoes will show the traces of long standing pressure. Good range of joint movement XR to measure the degree between the first and 2nd metatarsals.

Treatment:

Adolescents (conservative by proper shoe). If failure with frank deformity surgery is indicated. By different osteotomy.

Adult:

Surgery by different osteotomy Exscion arthroplasty.

Painful feet

My feet are killing me This is common complaintPain due to

mechanical pressure (deformed foot) joint inflammation a localized bone lesion

peripheral ischemia. Muscular strain May be part of general disorder (diabetes).

Posterior heel pain

Sever's disease Calcaneal bursitis Plantar fascitis Painful fat pad Nerve entrapment.

Sever's disease

Harmless condition ocur in children ,during active period of growth. Now it is consider as strain at the attachment of the posterior apophysis of calcaneum.from pull of achilles tendon

Clinical features

Age 8-13 years. Pain behind the heal, slight limping. O/E tenderness over the lower part of the tuberosity.

Radiographs

Usually fail to show any alteration. Sometimes show fragmentation of the calcaneal apophysis.

Treatment

Most cases not required.It is gardually subside.If in pain few weeks below –knee walking plaster

Plantar fasciitis

believed to be inflammatory, there is pain in the anterior part of the calcaneus.

Clinical features.

The complaint is of pain beneath the heel on or walking; the pain extends medially and into the sole

On examination

tenderness over the site of attachment of the plantar fascia to the calcaneus

Radiographs

usually do not show any abnormality. A sharp spur projecting forwards from the tuberosity of the calcaneus is sometimes found.

Treatment.

Conservative treatment : message

Rolling pin excercise

The heel should be protected by a resilient cushion on an insole.

Anti inflamatory drugs

If fail go to

Local injection corticosteriod

Pain over mid foot
Kohler disease.

Pain in the forefoot

Metatarsalgia (flattening metatarsal arch). RA in MP joint Sesamoiditis. Freiberg's disease (crushing type of Osteochondritis of 2nd metatarsal head)


Stress fracture (2nd 3rd metatarsal ) Interdigital nerve compression Tarsal tunnel syndrome.

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