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Name:
Acquired Flat Foot for Orthopaedic Exams
Description:
Acquired Flat Foot for Orthopaedic Exams
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T00H18M54S
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https://cadmoreoriginalmedia.blob.core.windows.net/9b932800-c4d3-4741-91a2-4e330c255dea/Acquired Flat Foot for Orthopaedic Exams.mp4?sv=2019-02-02&sr=c&sig=CO9Aizf7atbCL0QowWucwIWTc52hlW8NcVd6RzCl%2Bn8%3D&st=2024-11-21T16%3A50%3A00Z&se=2024-11-21T18%3A55%3A00Z&sp=r
Upload Date:
2024-05-31T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
Yeah Hello. Good morning again, I'm going to restart again this session about acquired flatfoot, which is a very common topic. In other exams, and that's why I'm just going to go through it. Most of the things which here are found in orthopedics, there's nothing much more I can add apart from the uploads.
Listen, when I take the questions at the end of the session. This session will be a presentation, which I'm going to do first, then I'm going to tell you about the approach to the exams, and then there's some few cases in which it can be presented and that we'll discuss at the end of the presentation. As with everything the first time we start, we need to know the anatomy of the people standing.
Uh, in the acquired foot to just to make it very clear, acquired slap for the most common cause the least. The tip was dysfunctional, and that's why we're going to talk about the post identity first. The tibia is pushed to the tendon, arises from the posture part of the fibula and the tibia and the incautious membrane, and inserts into the wide area in the area of the foot, mainly all the molecular, but also has the insertion into the hole of the foot into most of the metatarsal and torso bones, except the fifth metatarsal.
And because of this wide area where it's inserted. As you can see from the picture, it lies on the posterior aspect and medial to the tibiotalar joint and also medial to this the joint. And this is why it acts as a dynamic support and all these. In water for the hind foot and attacks and submerge the forefoot wide attachment and antagonistic to the erroneous breeds, so all functions are opposite of that.
And this motion was also very important because it can dissolve the transverse joints creating the pigeon river, which is effective in giving the total fish out of the gait. Um, and the important thing in the tenotomy is it is supplied by the opposite branches of our tree. And there's a small area. About centimeters from the region, up to 6 centimeters, which is not a watershed area.
It is supposed to have poor intrinsic supply, and most of the issues usually start in this area. This is commonly known. So this is important because when you are examining, you need to know where to look for the standard and what you're looking for. Usually, the presentation is quite straightforward. You can see a flat foot like this. The latter's symmetrical, and it's usually these heavy insertions occur more in women, and most of them have other metabolic disorders.
It is history of steroid use should be looked into, and most of them are seronegative. Some of them have selective symmetry disorders. Etiology not really clear. Some say post-traumatic tendonitis. Sometimes because of inflammatory reactions, surround it, in which there is some damage to the tendon and because it occurs in the older people, there is, say, probably an element of micro degeneration, micro-cap and degeneration acting together.
So overall, it's more like a degenerative picture, but for a period of time of micro trauma. So it's quite not very clear. But what we know is over a period of time, because this inflammation, pain, discomfort, this progresses if you don't look into it and start treating them as soon as you diagnose them. Uh, in the early pathology, usually this 10% of it is severe pain, discomfort.
Which leads to the lengthening of this tendon and therefore making it insufficient. In a sense, the continuity is maintained, but it's no longer functional. So initially, the first thing which goes is obviously the pain, and once this insufficiency sets in, then the dynamic is lost. And if there's no if it's not treated, it continues to cause attrition of the static stabilizers of the hind foot and eventually the collapse of the whole foot in the later stages, leading to a fixed deformity of which is a typical deformity, which you can see.
You just saw the picture previously suppressed as time two brothers who be abducted and worse and worse. The differential diagnosis. It could be post-traumatic. So could I have a straightforward injury? But most of them, although can present a traumatic there's some inflammatory. Or micro deaths, which are degenerative procedure in internet.
And if you see a similar fat protein, what a patient should be mostly thinking about the tarsal coalition, not more than not in terms of. Uh, positive signs of the symptoms. It depends on the stage again, in the initial stages, it's usually pain on the medial aspect of ankle sinusitis, which can lead to weakness. And then, of course, as it progresses more because of the continued attrition, it leads to progressive loss of parts and in very advanced stages.
What can happen is he can go to such an extent, develop the deficiency of the deltoid can actually cause tubular impingement. So you can get pain on that aspect in the later stages of the. So when we are actually looking at the symptoms and talking about them, we should be continuously be thinking about depending on where the pain is, what kind of progress you need has been happening.
Yes, probably a lot of side pain and probably quite advanced. So whenever we are taking any history from the patient as well, we need to be looking at all these things in this thing because all the symptoms are in sequence and we should be able to pick that up right from the history. Up usually the main thing what to look at is ask them to do a single limb is race. If they're able to perform, it's probably stage one of which the stages are going to the future next.
And if they are unable to perform, then it's stage two, 3 and four. Of course, you need to test for the response to attend Tibetans to the. Tendon and the power will be reduced initially, it will be flexible and greater as time progresses is going to be rigid. Are this how typically it looks and.
And when you look at it, the main thing what we're looking at is, of course. Best plainness hind foot, Vargas and the forefoot. Four-foot abducted and various. OK, so this is a classification which you have to keep in mind. I mean, these are available in various forms in different.
So when you go in different books, but this is the simplest one, which I found, which I found it very useful tenotomy three sites which are useful. This one, the previous picture and the treatment slide, as long as you're thorough with this, the rest of the thing. Once you start practicing, it should be easier. When there's a d-generation or tear, there's no deformity. Stage one.
Stage two is when the it's the degeneration has quite a flexible deformity, initially egawa. With moderate arching and then the whole of the arches. Collapsed collapsed. Stage three. It deformity, not pursue the correctable. And stage 4 is whether there's a vulgar state of the tail in the English masters, mainly because of the deltoid insufficiency.
So the first thing is when you are actually taking the history and when you're talking to them, you most of the time as soon as you see a patient, a 60 year old, usually both the times have seen it's been female patient, but it doesn't matter. You look at them and when you take a history, you're automatically looking at it and thinking, is it in stage one, stage two stage or stage four?
And if. The in one of my cases, which I got the first patient, which I thought was the patient was in extreme pain and I couldn't actually examine the examiners at all. The only thing I could find is 10 minutes on the. On on the medial aspect and straightaway. The patient was uncomfortable, and the examiner asked me to stop, and then we start discussing the fact, theoretically about the man to examine the patient.
So in those cases, the best thing would be, of course, to immobilize the patient in a working class, to book for three or four months to get the pain under control. The main thing is also to make sure you give up support. It's not collapsed and you also use a medium and also use a medium high which support to adjust to it.
Ankle foot is this an option, which you always have to keep in mind? Sometimes you may get patients who are in very low demand or very high risk for surgery, in which case you need. You can put this forward as one of the options. Uh, so the next part of it is, of course, the operating procedure, which you talk about once you have investigated and found out what it is.
So I go do that next. So if there's no deformity, but there's an insufficiency in the sense, you can't see the flight that is flexible, but Uh, together's posture is no longer as functional as it should be, then this is the time to think about how we want to deal with this. Initially, we want to have the kinds of measures. And of course, if you see this no improvement or you think there's a progression, the best thing is to think about a tendon transfer and possible checking on osteotomy if anyone is fully capable of.
If there's a mild to moderate, flexible deformity as into it, then you definitely need a slide in your. And it's a severe, flexible deformity, then it's going to be a tendon transfer with medial side calkin osteotomy and possible lateral column that. Up after that, it's probably going to be a double or triple tenodesis, depending on what you find clinically and also.
The you need to get further investigation is a CT scan to see if there's any degeneration or then find out the joints, which are involved and possibly even need to pull out of this internal fusion. And stage 4 is a very difficult to treat because. In the long term, all of them are not very good options. So our aim would be to try to catch them as early as possible.
The main thing is to recognize it and tailor the treatment according to what the patient needs. So the examination approach, I think this is quite easy. You know, straight away that it's a post because most of them do have significant deformities. You could either get a picture or you get a picture of one of those investigations. They just put it in front of you and say, this is what you need to do.
History, you need to take the relevant history unless the classification, which I told you. There you are basically trying to from the history, trying to put this patient into one of those categories and then decide your plan for your treatment even before you examine the patient. And, of course, examination nothing goes forward with the examination as important as the history.
So that again, a systemic approach. Which we go through now. Then what a few cases which we can discuss, I think with. Applause for the FARC is more than the bit of it, which we can go on each of that. We can keep on talking a lot. I think we need to take the cases discussed. Then the interaction will be much better. So the here is history.
Obviously, the age is the typical slightly older age people, and they'll give you a typical history. Usually there'll be most of them. You will see a history of trauma, but it's probably a bit of tendonitis. Scott was back and then the and most of the time to be able to tell you the progression. Past medical history is very important. This is apart from deciding whether we're going to intervene or not.
We also need to know if there are other reasons why it would be causing problems like probably this ranks injuries when you can get a complete slap slap foot is patient enough to undergo any intervention at all. And of course, you need to know anything has been done in the past as well. So we can start. Start the next part of it. And of course, we need to look into the expectations of patients if it is a long case, which is we need to be going through all these things.
Most of them are short cases. You might be asked to say, ask one or two questions and then carry on. Basically, you try to cut short as much as possible and plan accordingly. Uh, the inspection this has to be done very, very quickly as soon as you see from front and you see it's a flat feet. Ask them to turn around and ask them to walk.
Gate is important. And then you observe from behind and ask them to do a race to find with the. You know, not. And then looking to the deformities, whether it's fixed or flexible, you can test for the BDD tendon and areas of tenderness. You can actually ask for them before trying to test the areas of tenderness because it can be very, very uncomfortable.
Of course, we can look into the investigations, the radiographs, Yes. I'll just go to the. These are the radiographs. So when is it usually a standard API that'll weight bearing radiographs? And here you can see the tails. And the first metatarsal in different lines, and also when you look at this one, you can see the tiles is not in the same line as the first metatarsal, which is an indication that there's a.
Hello, this divorce institutions and also the Kirchner pitch is low. So the there's a picture of where this insurgency leading to impeachment. And in the initial stages, the MRI does help, but you can be given any of these to start off with. The point to make you go for the exams and acquired foot is there could be a variety of courses of acquired flatfoot, but tempo's is one of the causes.
So don't think it's always going to be a deposit insufficiency. You're going to have other causes of flatfoot, for example, and for different causes of flatfoot, which came to the exams and don't get caught out. It's always going to be a deposit. It's one thing which I probably want to highlight the other guys. Yeah, OK. OK very good point.
Yeah, yeah, I agree entirely. I mean, in the first exam, one of the main key, keep your options open. And when you're thinking or even examining the patient, you are always thinking, would it be that this thing? I mean, most of the time, it's deep dysfunction. What I meant to say is because when you take it through the history, basically you're trying to rule out other causes side.
To make a provisional diagnosis, I would take relevant history.
Segment:0 .
Yeah Hello. Good morning again, I'm going to restart again this session about acquired flatfoot, which is a very common topic. In other exams, and that's why I'm just going to go through it. Most of the things which here are found in orthopedics, there's nothing much more I can add apart from the uploads.
Listen, when I take the questions at the end of the session. This session will be a presentation, which I'm going to do first, then I'm going to tell you about the approach to the exams, and then there's some few cases in which it can be presented and that we'll discuss at the end of the presentation. As with everything the first time we start, we need to know the anatomy of the people standing.
Uh, in the acquired foot to just to make it very clear, acquired slap for the most common cause the least. The tip was dysfunctional, and that's why we're going to talk about the post identity first. The tibia is pushed to the tendon, arises from the posture part of the fibula and the tibia and the incautious membrane, and inserts into the wide area in the area of the foot, mainly all the molecular, but also has the insertion into the hole of the foot into most of the metatarsal and torso bones, except the fifth metatarsal.
And because of this wide area where it's inserted. As you can see from the picture, it lies on the posterior aspect and medial to the tibiotalar joint and also medial to this the joint. And this is why it acts as a dynamic support and all these. In water for the hind foot and attacks and submerge the forefoot wide attachment and antagonistic to the erroneous breeds, so all functions are opposite of that.
And this motion was also very important because it can dissolve the transverse joints creating the pigeon river, which is effective in giving the total fish out of the gait. Um, and the important thing in the tenotomy is it is supplied by the opposite branches of our tree. And there's a small area. About centimeters from the region, up to 6 centimeters, which is not a watershed area.
It is supposed to have poor intrinsic supply, and most of the issues usually start in this area. This is commonly known. So this is important because when you are examining, you need to know where to look for the standard and what you're looking for. Usually, the presentation is quite straightforward. You can see a flat foot like this. The latter's symmetrical, and it's usually these heavy insertions occur more in women, and most of them have other metabolic disorders.
It is history of steroid use should be looked into, and most of them are seronegative. Some of them have selective symmetry disorders. Etiology not really clear. Some say post-traumatic tendonitis. Sometimes because of inflammatory reactions, surround it, in which there is some damage to the tendon and because it occurs in the older people, there is, say, probably an element of micro degeneration, micro-cap and degeneration acting together.
So overall, it's more like a degenerative picture, but for a period of time of micro trauma. So it's quite not very clear. But what we know is over a period of time, because this inflammation, pain, discomfort, this progresses if you don't look into it and start treating them as soon as you diagnose them. Uh, in the early pathology, usually this 10% of it is severe pain, discomfort.
Which leads to the lengthening of this tendon and therefore making it insufficient. In a sense, the continuity is maintained, but it's no longer functional. So initially, the first thing which goes is obviously the pain, and once this insufficiency sets in, then the dynamic is lost. And if there's no if it's not treated, it continues to cause attrition of the static stabilizers of the hind foot and eventually the collapse of the whole foot in the later stages, leading to a fixed deformity of which is a typical deformity, which you can see.
You just saw the picture previously suppressed as time two brothers who be abducted and worse and worse. The differential diagnosis. It could be post-traumatic. So could I have a straightforward injury? But most of them, although can present a traumatic there's some inflammatory. Or micro deaths, which are degenerative procedure in internet.
And if you see a similar fat protein, what a patient should be mostly thinking about the tarsal coalition, not more than not in terms of. Uh, positive signs of the symptoms. It depends on the stage again, in the initial stages, it's usually pain on the medial aspect of ankle sinusitis, which can lead to weakness. And then, of course, as it progresses more because of the continued attrition, it leads to progressive loss of parts and in very advanced stages.
What can happen is he can go to such an extent, develop the deficiency of the deltoid can actually cause tubular impingement. So you can get pain on that aspect in the later stages of the. So when we are actually looking at the symptoms and talking about them, we should be continuously be thinking about depending on where the pain is, what kind of progress you need has been happening.
Yes, probably a lot of side pain and probably quite advanced. So whenever we are taking any history from the patient as well, we need to be looking at all these things in this thing because all the symptoms are in sequence and we should be able to pick that up right from the history. Up usually the main thing what to look at is ask them to do a single limb is race. If they're able to perform, it's probably stage one of which the stages are going to the future next.
And if they are unable to perform, then it's stage two, 3 and four. Of course, you need to test for the response to attend Tibetans to the. Tendon and the power will be reduced initially, it will be flexible and greater as time progresses is going to be rigid. Are this how typically it looks and.
And when you look at it, the main thing what we're looking at is, of course. Best plainness hind foot, Vargas and the forefoot. Four-foot abducted and various. OK, so this is a classification which you have to keep in mind. I mean, these are available in various forms in different.
So when you go in different books, but this is the simplest one, which I found, which I found it very useful tenotomy three sites which are useful. This one, the previous picture and the treatment slide, as long as you're thorough with this, the rest of the thing. Once you start practicing, it should be easier. When there's a d-generation or tear, there's no deformity. Stage one.
Stage two is when the it's the degeneration has quite a flexible deformity, initially egawa. With moderate arching and then the whole of the arches. Collapsed collapsed. Stage three. It deformity, not pursue the correctable. And stage 4 is whether there's a vulgar state of the tail in the English masters, mainly because of the deltoid insufficiency.
So the first thing is when you are actually taking the history and when you're talking to them, you most of the time as soon as you see a patient, a 60 year old, usually both the times have seen it's been female patient, but it doesn't matter. You look at them and when you take a history, you're automatically looking at it and thinking, is it in stage one, stage two stage or stage four?
And if. The in one of my cases, which I got the first patient, which I thought was the patient was in extreme pain and I couldn't actually examine the examiners at all. The only thing I could find is 10 minutes on the. On on the medial aspect and straightaway. The patient was uncomfortable, and the examiner asked me to stop, and then we start discussing the fact, theoretically about the man to examine the patient.
So in those cases, the best thing would be, of course, to immobilize the patient in a working class, to book for three or four months to get the pain under control. The main thing is also to make sure you give up support. It's not collapsed and you also use a medium and also use a medium high which support to adjust to it.
Ankle foot is this an option, which you always have to keep in mind? Sometimes you may get patients who are in very low demand or very high risk for surgery, in which case you need. You can put this forward as one of the options. Uh, so the next part of it is, of course, the operating procedure, which you talk about once you have investigated and found out what it is.
So I go do that next. So if there's no deformity, but there's an insufficiency in the sense, you can't see the flight that is flexible, but Uh, together's posture is no longer as functional as it should be, then this is the time to think about how we want to deal with this. Initially, we want to have the kinds of measures. And of course, if you see this no improvement or you think there's a progression, the best thing is to think about a tendon transfer and possible checking on osteotomy if anyone is fully capable of.
If there's a mild to moderate, flexible deformity as into it, then you definitely need a slide in your. And it's a severe, flexible deformity, then it's going to be a tendon transfer with medial side calkin osteotomy and possible lateral column that. Up after that, it's probably going to be a double or triple tenodesis, depending on what you find clinically and also.
The you need to get further investigation is a CT scan to see if there's any degeneration or then find out the joints, which are involved and possibly even need to pull out of this internal fusion. And stage 4 is a very difficult to treat because. In the long term, all of them are not very good options. So our aim would be to try to catch them as early as possible.
The main thing is to recognize it and tailor the treatment according to what the patient needs. So the examination approach, I think this is quite easy. You know, straight away that it's a post because most of them do have significant deformities. You could either get a picture or you get a picture of one of those investigations. They just put it in front of you and say, this is what you need to do.
History, you need to take the relevant history unless the classification, which I told you. There you are basically trying to from the history, trying to put this patient into one of those categories and then decide your plan for your treatment even before you examine the patient. And, of course, examination nothing goes forward with the examination as important as the history.
So that again, a systemic approach. Which we go through now. Then what a few cases which we can discuss, I think with. Applause for the FARC is more than the bit of it, which we can go on each of that. We can keep on talking a lot. I think we need to take the cases discussed. Then the interaction will be much better. So the here is history.
Obviously, the age is the typical slightly older age people, and they'll give you a typical history. Usually there'll be most of them. You will see a history of trauma, but it's probably a bit of tendonitis. Scott was back and then the and most of the time to be able to tell you the progression. Past medical history is very important. This is apart from deciding whether we're going to intervene or not.
We also need to know if there are other reasons why it would be causing problems like probably this ranks injuries when you can get a complete slap slap foot is patient enough to undergo any intervention at all. And of course, you need to know anything has been done in the past as well. So we can start. Start the next part of it. And of course, we need to look into the expectations of patients if it is a long case, which is we need to be going through all these things.
Most of them are short cases. You might be asked to say, ask one or two questions and then carry on. Basically, you try to cut short as much as possible and plan accordingly. Uh, the inspection this has to be done very, very quickly as soon as you see from front and you see it's a flat feet. Ask them to turn around and ask them to walk.
Gate is important. And then you observe from behind and ask them to do a race to find with the. You know, not. And then looking to the deformities, whether it's fixed or flexible, you can test for the BDD tendon and areas of tenderness. You can actually ask for them before trying to test the areas of tenderness because it can be very, very uncomfortable.
Of course, we can look into the investigations, the radiographs, Yes. I'll just go to the. These are the radiographs. So when is it usually a standard API that'll weight bearing radiographs? And here you can see the tails. And the first metatarsal in different lines, and also when you look at this one, you can see the tiles is not in the same line as the first metatarsal, which is an indication that there's a.
Hello, this divorce institutions and also the Kirchner pitch is low. So the there's a picture of where this insurgency leading to impeachment. And in the initial stages, the MRI does help, but you can be given any of these to start off with. The point to make you go for the exams and acquired foot is there could be a variety of courses of acquired flatfoot, but tempo's is one of the causes.
So don't think it's always going to be a deposit insufficiency. You're going to have other causes of flatfoot, for example, and for different causes of flatfoot, which came to the exams and don't get caught out. It's always going to be a deposit. It's one thing which I probably want to highlight the other guys. Yeah, OK. OK very good point.
Yeah, yeah, I agree entirely. I mean, in the first exam, one of the main key, keep your options open. And when you're thinking or even examining the patient, you are always thinking, would it be that this thing? I mean, most of the time, it's deep dysfunction. What I meant to say is because when you take it through the history, basically you're trying to rule out other causes side.
To make a provisional diagnosis, I would take relevant history.
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