KEY FACTS Clubfeet can be idiopathic or syndromic. Initial treatment in almost all cases should be Ponseti casting, even if the patient presents outside of infancy, as casting can be quite effective. Surgery is reserved for those cases in whom casting is ineffective. Flatfeet are often not pathologic. The Jack toe sign, or Jack test, can be used to show if the patient can form an…

KEY FACTS General Amputation and disarticulation should be viewed as reconstructive procedures and not a failure of treatment. In this manner, one realizes that it is the initial step in getting patients back to their previous functional status. Indications for amputation include ischemia, trauma, infection, tumor, and painful dysfunction of the foot and ankle not amenable to further conservative management. The goal is to create a…

KEY FACTS Foot and ankle tumors are relatively rare entities but must be kept in the differential diagnosis of musculoskeletal complaints in that area. The overwhelming majority of bone and soft tissue tumors in the foot and ankle are benign, but occasionally, a primary sarcoma will be present. Acral metastases (i.e., below the knee) are uncommon, although they can occur most commonly from breast, lung, thyroid,…

KEY FACTS Toe and metatarsal fractures are the most common fractures of the foot with an incidence of 140 per 100,000 per year. The 5th metatarsal is the most frequently fractured metatarsal (23%). The metatarsals are affected by stress fractures more commonly than all other sites in the body. A majority of metatarsal fractures are low-energy injuries suitable for closed treatment. The intact soft tissues splint…

KEY FACTS The midfoot includes 5 tarsal bones: Navicular, cuboid, and 3 cuneiforms (medial, 1st; middle, 2nd; and lateral, 3rd). Mobile or "essential" midfoot joints include: Talonavicular Calcaneocuboid Cuboid: 4th and 5th metatarsals Nonmobile or "nonessential" midfoot joints include: Naviculocuneiform Metatarsocuneiform Navicular fracture outcome is dependent on fracture pattern and restoration of normal anatomy. Restoration of normal anatomical alignment leads to better outcomes in displaced fractures.…

KEY FACTS Navicular Fractures Three types of navicular fractures generally occur: Avulsion fractures, high-energy fractures with other associated injuries, and stress fractures. Avulsion fractures can generally be treated nonoperatively, except in those cases in which the fragment is large enough to warrant open reduction and internal fixation. These injuries are by far the least severe of the 3. High-energy injuries will require a plan that takes…

KEY FACTS The talus is the 2nd most commonly fractured tarsal bone (after the calcaneus). The blood supply of the talus can be tenuous, as there are limited spaces at which vessels can enter the bone, given its morphology and participation in multiple joints. The blood supply of the talar body is retrograde through the talar neck. Although there is great concern for osteonecrosis after talar…

KEY FACTS Calcaneus fractures account for ~ 2% of all fractures. The calcaneus is the most frequently fractured tarsal (hindfoot) bone. It represents 60% of all tarsal fractures. Minor avulsion fractures off anterior process are common and usually benign. Most intraarticular calcaneus fractures are the result of an axial load applied directly to the heel. A high-energy calcaneus fracture is often a life-altering event for the…

KEY FACTS The tibial pilon fracture is a rare, yet devastating injury. Despite the best treatment, patients sustaining high-energy pilon fractures generally do not return to their previous state of general health or function. After recovery from pilon fractures, many patients continue to have debilitating pain and ankle stiffness. Pilon fractures can occur from both low- and high-energy mechanisms. The pilon fracture usually has an anterolateral…

KEY FACTS The treatment of ankle fractures is chiefly concerned with mitigating and minimizing the risk of posttraumatic arthritis. The relative stability of an ankle fracture will ultimately determine whether surgical intervention is warranted. Supination-external rotation ankle fractures are the most common rotational injuries. Syndesmotic stability must be assessed in all operative ankle fractures; sagittal plane instability is often a more sensitive indicator of the presence…

KEY FACTS The natural history of osteochondral lesions of the talus appears to be fairly benign, especially as it relates to the risk of the development of arthritis. Treatment is thus most appropriately based on the patient's symptoms, a very relevant fact given that many osteochondral lesions are incidental findings. There are a host of classifications for osteochondral lesions, although no 1 classification is used universally,…

KEY FACTS Ankle Instability Ankle sprains are among the most common injuries seen by orthopaedic surgeons. A variety of pathologies can result from an ankle sprain mechanism. These individual pathologies should be actively sought, as the treatment is not the same for all of these different pathologies. The lateral ankle ligaments, as well as the syndesmotic ligaments, can be injured. Medial ankle injuries are less common,…

KEY FACTS Tendon pathology is most commonly related to the degenerative process of tendinosis, as is seen in the Achilles and posterior tibial tendons. While tendonitis is a more common term colloquially, tendinosis is a much more common problem clinically. Predisposing factors should be sought, most notably a cavovarus foot in those patients with peroneal tendon pathology. Predisposing factors for less common tendon pathologies are less…

KEY FACTS Achilles Tendinosis Achilles tendinosis can be noninsertional or insertional, although it is the same pathology, i.e., degenerative tendinopathy. Insertional tendinopathy can be associated with a Haglund deformity, insertional ossification, or both. A heel lift and physical therapy are the mainstays of treatment and are often effective, although it tends to be more effective in noninsertional tendinopathy. Operative treatment consists of tendon debridement and repair with…

KEY FACTS Heel pain results in 1 million medical visits per year and comprises 1% of all visits to orthopaedic surgeons. The majority of patients with heel pain will be treated successfully nonoperatively. Heel pain can be plantar (subcalcaneal) or posterior. Posterior pain is often due to insertional Achilles tendinopathy &/or retrocalcaneal bursitis. Etiologies of heel pain include: Plantar fasciitis, most common by far Plantar nerve…

KEY FACTS The most common etiology of ankle arthritis is posttraumatic. The ankle bears the highest load per surface area of any joint in the body, yet has a small surface contact area of only 350 mm². The cartilage in the ankle is thinner than in the hip and knee. The ankle joint is highly congruent, and its cartilage is uniform and stiff, allowing it to…

KEY FACTS An interdependent system of dynamic, static, and bony restraints is responsible for the maintenance of normal toe alignment and stability. Given the relatively small size of the lesser toes in proportion to the relatively large repetitive stresses they experience during normal gait, failure of 1 of these restraints can lead to a domino-like failure of the others, leading to deformity and dysfunction. Optimal treatment…

KEY FACTS Hallux Rigidus Hallux rigidus is the most common arthritic condition in the foot. Hallux rigidus tends to be bilateral, although it is often not synchronous. The 1st metatarsophalangeal (MTP) joint generally becomes stiffer and more painful as the arthritis progresses, although progression is inconsistent. Some patients will progress linearly, while others' symptoms will remain consistent over time. Nonoperative treatment is similar to nonoperative treatment…