CHAPTER 46. Podiatric Care
Lynda Marks
OBJECTIVES
At the conclusion of this chapter, the reader will be able to:
1. Identify the skeletal structure of the foot.
2. Describe specific physical and psychosocial assessment for podiatric patients.
3. Describe operative procedures of the foot.
4. Describe perianesthesia care to be provided to patients having surgical procedures on the foot.
I. ANATOMY AND PHYSIOLOGY
A. Bony structure—7 tarsal, 5 metatarsal, 14 phalanges (Figure 46-1)
1. Tarsals—seven bones of the ankle, hindfoot, and midfoot
a. Talus—irregularly shaped bone
(1) Located between bimalleolar fork and tarsus
(2) Ligament attachments, no tendons
b. Calcaneus—largest bone in foot
c. Cuboid—wedge shaped
d. Scaphoid (navicular)—bound with ligaments
e. Three cuneiforms
(1) Interposed between scaphoid, first three metatarsals, and cuboid
(2) Wedge shaped
2. Metatarsals—five
a. First toe (great toe)
b. Four lesser toes
c. Articulates with three cuneiforms
d. Form tarsometatarsal or Lisfranc’s joint
3. Phalanges
a. Great toe—proximal and distal
b. Lesser toes (2, 3, 4, 5)—proximal, middle, distal
4. Sesamoids
a. Small, round bones
b. Embedded (partially or totally) in substance of corresponding tendon
c. Pressure-absorbing mechanism
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| FIGURE 46-1 ▪ Bones of the right foot. (Redrawn from Jacob S, Francone C: Elements of anatomy and physiology, ed 2, Philadelphia, 1989, WB Saunders.) |
B. Arches
1. Formed by bony structure
2. Longitudinal (lengthwise) arches
a. Medial longitudinal arch—formed by calcaneus, talus, navicular, three cuneiforms, and first three metatarsals
b. Lateral longitudinal arch—formed by calcaneus, cuboid, and fourth and fifth metatarsals
3. Transverse—across the ball (top) of the foot
C. Muscles, ligaments, and tendons; nerves (multiple structures)
II. ASSESSMENT PARAMETERS (PROCEDURE SPECIFIC)
A. Structural disorders—causes
1. Weakness of muscles, ligaments, and tendons
2. Imbalance between bone support and supporting structure
3. Constant wear, rub
B. Identified disorders (Table 46-1 for podiatric definitions)
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1. Hallux valgus (also called bunion): deformity of the foot involving the first metatarsal and great toe (hallux)
a. Lateral angulation of great toe
b. Progresses, resulting in medial deviation of first metatarsal
c. Often accompanied by multiple disorders and symptoms; commonly affects lesser toes
d. Occurs in females nine times more often than males; may be congenital or as a result of rapid growth
e. Symptoms
(1) Adults—pain or dull ache over metatarsal head
(2) Adolescents—chief complaints are unrelenting pain, altered body image; may have family history.
f. Radiographs show exostosis with subluxation or dislocation of first metatarsal head.
2. Hallux varus
a. First metatarsal deviates medially, and the great toe deviates laterally.
b. Condition may start in late childhood or early adult life.
c. More common in females
d. May be agitated by improperly fitting footwear
3. Hallux rigidus—“stiff big toe”
a. Painful stiffness of first metatarsophalangeal joint of the toes when walking; toe becomes rigid.
b. Caused by arthritis
4. Corns—conical thickening of skin in areas of constant irritation
5. Bursal hypertrophy—inflammation of the joint
6. Digital deformity
a. Mallet toe—congenital abnormality of the distal interphalangeal joint, usually genetic
(1) Flexion posture of the distal interphalangeal joint
(2) Most commonly affects second toe
(3) Associated with a long digit
(4) Caused by pressure at tip of toes
(5) Occurs in persons with peripheral neuropathy; no known reason
b. Varus toes
(1) Curly or overlapping toes
(2) Flexion and varus rotation
(3) Commonly affects third, fourth, and fifth toes
c. Hammer toe deformity
(1) Affects one of the lesser four toes (commonly second toe)
(2) Hyperextension at metatarsophalangeal joint, flexion at proximal interphalangeal joint
(3) Etiology unknown
d. Clawtoe
(1) Hyperextension of metatarsophalangeal joint with flexion of the proximal interphalangeal joint
(2) Associated with cavus foot deformity and neuromuscular conditions
7. Interdigital deformity (Morton’s neuroma)
a. Benign enlargement of third common digital branch at site of bifurcation of interdigital nerves (medial plantar nerve)
b. Frequently between and distal to third and fourth metatarsal heads
c. Symptoms and common findings
(1) Pain in plantar forefoot area (sharp, dull, throbbing, or burning sensation)
(2) Swelling of plantar metatarsal
(3) Affects females more than males
(4) Overweight person
8. Pes planus (flatfoot)
a. Loss of normal medial longitudinal arch
b. Initial treatment is conservative therapy with shoes, arch supports.
c. Surgical treatment with onset of disabling pain
d. Correction procedures include Miller, Durham flatfoot plasty, triple arthrodesis, calcaneal displacement osteotomy.
9. Pes cavus (hollow foot, clawfoot)
a. Occurs with neuromuscular conditions such as spina bifida, cerebral palsy, muscular dystrophy, congenital clubfoot
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