minimi. 2nd layer: quadratus plantae, tendons of FDL, tendon of FHL, lumbricals)
Lateral Plantar Nerve
– smaller than medial
– innervates abductor digiti minimi and quadratus plantae, flexor digit minimi, and sometimes the plantar and dorsal interossei of the 4th interosseous space
– the deep branch then innervates the adductor hallucis, the lateral 3 lumbricals, and the remaining interosseous spaces
Medial Plantar Nerve
– the larger of the two plantar nerves
– innervates the abductor hallucis, flexor hallucis brevis, flexor digitorum brevis, and the most medial lumbrical
– a laborer with hallux rigidis should probably get a fusion; an athlete with hallux rigidis should probably have a cheilectomy
– the poorest prognosis in Symes amputation is vascular disease – these get heel ulcers which are basically a contraindication to a Symes.
– best thing to predict healing in amputation – transcutaneous oxygen pressure TcPO2; also, toe pressures, and Doppler indices of 0.45
– coronal CT of the calcaneus will miss the calcaneocuboid joint
– in the 60 year old stroke patient with flexible clawtoes – initial management, especially in diabetics and vasculopaths, is nonoperative – crest pads to lift toes off ground, high toe box shoe that doesn’t rub on the dorsal aspects of the toes, and a metatarsal bar or pad to relieve the pressure on the heads. Failing this, if flexible, try some form of soft tissue release such as a Girdlestone-Taylor flexor to extensor transfer. Failing this, do proximal phalangeal resections (DuVries) or IP fusions with dorsal hood resections. (???)
– for a patient with tib post dysfunction: if they are still able to do single leg raises and have some inversion strength although fatigue early, and they have pain with passive dorsiflexion/eversion, and local tenderness, they probably still have a tib post in continuity, but it is inflamed and somewhat attenuated (maybe partially torn). Options include further nonop with bracing, etc, or try synovectomy and FDL transfer if the foot is otherwise normal.
– trimalleolar fracture dislocations are eversion/pronation, external rotation injuries with the posterior tibiofibular ligament remaining INTACT and pulling off the posterior part of the tibia.
– the chevron procedure does not result in MTP ankylosis; its most common complications are recurrence or undercorrection and offers a limited correction of the deformity. Therefore, it is recommended only for mild and some moderate deformities. AVN is the most dreaded complication, and is increased if you do a lateral soft tissue release.
It does not significantly shorten the bone, and does not lead to joint stiffness or pain.
– Lisfranc injuries invariably require ORIF. The ultimate result is probably most likely related to how anatomic the reduction is obtained and maintained. Some feel that the initial injury energy is the most important factor, but more seem to believe that how well you treat it is the most important. It is agreed upon that initial energy of injury does have some prognostic importance (just how much is debatable)
– an avulsion off the medial malleolus with a comminuted fibular fracture is often caused by the pronation-abduction mechanism.
– position of tibio-talar (ankle) arthrodesis: neutral plantarflexion/dorsiflexion, 0-5 of valgus, 5-10 of external rotation. Also, translate the talus about a centimeter posterior to diminish the lever arm of the rest of the foot. The only time you might fuse in a bit of equinus is in the polio patient, where the equinus is helpful in stabilizing the knee in midstance.
– posteromedial ankle dislocation – commonly associated with neurologic injury
– ball and socket ankle is associated with: tarsal coalition, fibular hemimelia, hypoplastic lateral femoral condyle, femoral deficiency, absent rays on lateral aspect of foot. It is not associated with cavovarus.
– rates of AVN for talar neck fractures: Hawkins I – 0-13%, Hawkins II – 20-50%, Hawkins III – 90-100%
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