This document provides an overview of pes planus (flat foot). It discusses the anatomy and supporting structures of the longitudinal arches. There are several types of pes planus described, including flexible pes planovalgus and tarsal coalition. Flexible pes planovalgus is the most common type and involves collapse of the arch with weight bearing along with hindfoot valgus and forefoot abduction. Tarsal coalition is a congenital anomaly involving fusion of the tarsal bones that results in a rigid flatfoot. Imaging can be used to assess the degree of arch collapse and deformity. Treatment depends on the type and severity but may include orthotics, stretching, or surgery.
Hip dysplasia in adults, types, radiographs and management!
Useful for Orthopaedic residents and Surgeons.
Include most of the basics from reliable sources, pardon for any mistakes. Contact at singh_prabhjeet@yahoo.com for any corrections.
Hip dysplasia in adults, types, radiographs and management!
Useful for Orthopaedic residents and Surgeons.
Include most of the basics from reliable sources, pardon for any mistakes. Contact at singh_prabhjeet@yahoo.com for any corrections.
Basic principle of Knee Joint arthroscopy and techniques for beginners. Basic Steps of Knee Joint Diagnostic arthroscopy and common complication following knee joint arthroscopy.
Basic principle of Knee Joint arthroscopy and techniques for beginners. Basic Steps of Knee Joint Diagnostic arthroscopy and common complication following knee joint arthroscopy.
Anatomy of ankle and foot is described briefly with clinical importance and photos.
Dr Junaid Ahmad Consultant Plastic Surgeon is best in Lahore. He offers Foot and Hand Trauma management. Call 03104037071
A Coding Guide to Magnetic resonance cholangiopancreatography (MRCP). Remember to document 3-D MIP imaging for your 3-D cholangiographic post processing images.
MRCP is an MRI exam of the biliary system and pancreas. The exam is typically performed without contrast and includes 3D cholangiographic post processing such as MIPS. Since there is no specific CPT code that describes MRCP, the AMA and ACR have published information regarding the appropriate CPT code selection.
According to the coding resources, an MRCP includes a standard MRI of the abdomen along with MIP images to better delineate the bile duct anatomy. Therefore, it is appropriate to report MRCP with codes for MRI of the abdomen as well as coding separately for the 3-D rendering codes assuming documentation supports the 3-D imaging.
If documentation lacks information addressing the 3-D MIP imaging on a radiology report, the coder cannot assign the additional CPT code for these images. By just documenting MRCP in the title of the exam, or using verbiage stating “MRCP Protocol” without specifying the 3-D imaging will not support the additional code for these images in the event of an audit.
Anatomy of the ankle and joints of footAkram Jaffar
Objectives:
After completion of this presentation, it is expected that the students will be able to
Musculoskeletal Anatomy
Describe the distal end of the tibia and be able to identify:
• the shaft
• the sharp anterior border
• the subcutaneous anteromedial surface or “shin”
• the interosseous border
• the medial malleolus
• articular surfaces
Describe the distal end of the fibula and be able to identify:
• the shaft
• the interosseous border
• the lateral malleolus with grooves for peroneal tendons
• articular surface
Identify the key features of the seven tarsal bones:
• the calcaneus
calcaneal tuberosity
medial, lateral and anterior tubercles
the sustentaculum tali
peroneal trochlea
• the talus:
head
neck
body
dome
posterior tubercle with groove for flexor hallucis longus
• the cuboid with groove for peroneus longus on the plantar surface
• the navicular with tuberosity for the insertion of tibialis posterior
• the five metatarsals with fifth tuberosity for peroneus brevis
• the phalanges with 2 on big toe, 3 on others
• sesamoid bones at base of 1st metatarsals
Describe the structure, function and maintenance (bones, muscles, tendons, ligaments) of the arches of the foot:
medial longitudinal
lateral longitudinal
transverse
Identify the attachments and understand the functions of the deep fascia:
• plantar aponeurosis
• fibrous septa of the sole
• extensor, flexor and peroneal retinaculae
Describe the components & function of the foot & ankle joints:
• ankle joint:
articular surfaces
fibrous capsule
synovial membrane
Ligaments (medial/deltoid, lateral/tri-fascicular)
Movements (plantar/dorsi flexion)
• subtalar joints:
• distal tibiofibular joint
• talo-calcaneo-navicular (mid-tarsal) joint
• tarso-metatarsal joints
• metatarsophalangeal
• interphalangeal
Recognise the shape, size and attachments of:
• the long plantar ligament
• the short plantar (plantar calcaneocuboid) ligament
Clinical Anatomy
Explain the relevant anatomy of:
• the differences between the superior and inferior tibiofibular joints
• fracture of the second & fifth metatarsals
• ankle sprain with fractured shaft of fibula
• the three degrees of ankle sprain
• the ratio of lateral to medial ankle ligament sprains
• plantar fasciitis and calcaneal spur
• pes planus
• hallux valgus and its predominance in females
• the ankle jerk and plantar reflex
Radiological Anatomy
Identify:
• the antero-posterior and lateral views of the distal tibia, fibula and foot bones
• the ankle joint space
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
CDSCO and Phamacovigilance {Regulatory body in India}NEHA GUPTA
The Central Drugs Standard Control Organization (CDSCO) is India's national regulatory body for pharmaceuticals and medical devices. Operating under the Directorate General of Health Services, Ministry of Health & Family Welfare, Government of India, the CDSCO is responsible for approving new drugs, conducting clinical trials, setting standards for drugs, controlling the quality of imported drugs, and coordinating the activities of State Drug Control Organizations by providing expert advice.
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In India, pharmacovigilance activities are monitored by the Pharmacovigilance Programme of India (PvPI), which works closely with CDSCO to collect, analyze, and act upon data regarding adverse drug reactions (ADRs). Together, they play a critical role in ensuring that the benefits of drugs outweigh their risks, maintaining high standards of patient safety, and promoting the rational use of medicines.
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- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
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Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
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ASA GUIDELINE
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20. Maintenance of the longitudinal
arches
The longitudinal arches are supported and stabilised
by:
The muscles whose tendons run into the apex of the
arches and tend to increase their height (e.g. tibialis
anterior)
The muscles whose tendons run into the sole of the
foot (e.g. peroneus longus tibialis post. and
smallintrinsic muscles which also run longitudinally
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22. shape of the bones which allows them to interlock
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23. A variety of longitudinally
arranged ligaments which
prevent the extremities
separating, for example the
long and short plantar
ligaments and by the plantar
calcaneonavicular ("spring")
ligament.
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24. The plantar aponeurosis links
the extremities of the arches, and
acts as the equivalent of a tie
beam in an architectural arch.
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29. PES PLANUS AND PES VALGUS
(‘FLAT-FOOT’)
The term ‘flatfoot’ applies when the apex of the arch
has collapsed
and the medial border of the foot is in contact (or
nearly in contact) with the ground;
the heel becomes valgus
and the foot pronates at the subtalar-midtarsal
complex.
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30. 3 components that are involved in producing the
alignment abnormalities of symptomatic adult
flatfoot:
collapse of the longitudinal arch
hindfoot valgus
forefoot abduction
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31. Assesment of these components
Each of these components
can be assessed on either
the lateral or AP view of
the foot.
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32. Assesment of these components
COLLAPSE OF LONGITUDINAL ARCH
Lateral: 1st metatarsal talar angle < 4
Lateral: Calcaneal pitch 18 to 20°
FOREFOOT ABDUCTION
AP: Talonavicular coverage angle
AP: 1st metatarsal talar angle
HINDFOOT VALGUS
Lateral: Talo-calcaneal angle
AP: Talo-calcaneal angle
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33. OTHER SIGNS
AP & Lateral: CYMA line
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37. Lateral talar - 1st metatarsal angle
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38. MILD :greater than 4° convex downward is considered
pes planus
with an angle of 15° - 30° considered moderate , and
greater than 30° severe
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46. CYMA line
A cyma line is an architectural term designating the
union of two curve lines.
A normal midtarsal joint should create a smooth cyma
between the talonavicular joint and calcaneocuboid
joint on both the AP and lateral views (Figures a).
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49. Flexible Pes Planovalgus (Flexible
Flatfoot)
Physiologic variant consisting of a decrease in the medial
longitudinal arch and a valgus hindfoot and forefoot
abduction with weightbearing
Epidemiology
incidence
unknown in pediatric population
20% to 25% in adults
Pathoanatomy
generalized ligamentous laxity is common
25% are associated with gastrocnemius-soleus contracture
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50. NATURAL HISTORY
The arch is usually obscured in an infant's foot because
of subcutaneous fat.
Both footprint[26,39] and radiographic[42] studies of the
child's foot demonstrate that the longitudinal arch
develops during the first decade of life
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51. This observation also leads to the overwhelming
conclusion that prophylactic treatment of a typical
flatfoot is unnecessary, with profound implications for
the corrective shoe and insert–orthosis .
Development of the arch is independent of the use of
such external orthoses or the wearing of corrective
shoes.
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52. Presentation
Symptoms
usually asmptomatic in children
may have arch pain or pretibial pain
Physical exam
inspection
foot is only flat with standing and
reconstitutes with toe walking, hallux
dorsiflexion, or foot hanging
valgus hindfoot deformity
forefoot abduction
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53. recommended viewsrequired
weightbearing AP foot
evaluate for talar head coverage and talocalcaneal angle
weightbearing lateral foot
evaluate Meary's angle
weightbearing oblique foot
rule out tarsal coalition
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The arch can often be restored
by simply dorsiflexing the great toe
(Jack’s test), and
during this manoeuvre the tibia
rotates externally
(Rose et al., 1985).
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58. Treatment:
Nonoperative
observation, stretching, shoewear modification,
orthotics
indications
asymptomatic patients, as it almost always resolves
spontaneously
counsel parents that arch will redevelop with age
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59. Techniques
athletic heels with soft arch support or stiff soles may be
helpful for symptoms
UCBL heel cups may be indicated for symptomatic relief of
advanced cases
rigid material can lead to poor tolerance
stretching for symptomatic patients with a tight heel cord
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63. Operative
continued refractory pain despite use of extensive
conservative managemen.
Achilles tendon or gastrocnemius fascia
lengthening
If flexible flatfoot with a tight heelcord with painful
symptoms
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65. sliding calcaneal osteotomy
corrects the hindfoot valgus
plantar base closing wedge osteotomy of the first
cuneiform
corrects the supination deformity
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67. Tarsal Coalition & Peroneal Spastic
Flatfoot
Congenital anomaly that leads to fusion of tarsal
bonesand a rigid flatfoot results in syndrome peroneal
spastic flatfoot
most common coalitions are
calcaneonavicular Slide 13
most common
talocalcaneal
talonavicular
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69. The true incidence of tarsal coalition is greater than
the
1% usually quoted.
Tarsal coalition appears to be inherited, probably as a
unifactorial disorder of autosomal dominant .
The specific type of coalition probably represents a
genetic mutation that is responsible for failure of the
primitive mesenchyme to segment
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70. age of onset
calcaneonavicular
8-12 years old
talocalcaneal
12-15 years old
Pathophysiology
mesenchymal segmentation leading to coalition of tarsal
bones
coalition may be
fibrous
cartilagenous
osseous
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71. Associated conditions
multiple coalitions are associated with
fibular deficiency
Apert syndrome
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72. Presentation
Symptoms
pain worsened by activity
onset of symptoms correlates with age of ossification of
coalition
calf pain
secondary to peroneal spasticity
recurrent ankle sprains
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73. Physical exam
inspection & palpationpes planus
collapse of the medial longitudinal arch
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74. The medial border of the foot from just
behind the first metatarsal head to a point about 2 cm
distal to the calcaneal tuberosity
should be elevated from the floor when the subject is
standing.
The apex of this arch is usually about 1 cm.
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75. system for grading
Jack described a general system for grading the morphology
of the medial longitudinal arch.
grade I arch is subjectively slightly depressed
on weightbearing.
grade II arch, the entire medial
border of the foot touches the floor but its edge is
straight.
grade III arch, the entire medial border of
the foot not only touches the floor but also bulges toward
the examiner in a convex manner
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76. Physical exam
inspection
hindfoot valgus
forefoot abduction
range of motion
limited subtalar motion
heel cord contractures
arch of foot does not
reconstitute upon toe-standing
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79. Peroneal spastic pes planus.
Tarsal coalition, rigid pes planus, and peroneal muscle
spasm together as essential components of
Peroneal spasm actually is an acquired or adaptive
shortening of the muscle-tendon units
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80. Stretch reflex of a
shortened muscle-tendon unit
Inversion stress by the examiner, producing an
unsustained three-four-beat clonus of the peroneal
muscles,.
That peroneal muscle tight-ness is the frequent
resultof tarsal coalition and not the cause
must be emphasized
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81. Peroneal muscle tightness is seen in
rheumatoid arthritis, osteochondral fracture,
and infection in the subtalar joint (tuberculous, mycotic, or
pyogenic), or neo-plasm (osteoid osteoma, osteochondroma,
fibrosarcoma) adjacent to the subtalar joint in the talus or
calcaneus.
The relaxed position of the subtalar joint is valgus,
which places the least strain on the talocalcaneal
interosseous
ligament according to Lapidus.
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82. Imaging
Radiographs recommended views
Required
anteroposterior view
standing lateral foot view
45-degree oblique view
most useful for calcaneonavicular coalition
Slide 30
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83. calcaneonavicular coalition
"anteater" sign
elongated anterior
process of calcaneus
talocalcaneal coalition
talar beaking on lateral
radiograph
occurs as a result of
limited motion of the
subtalar joint
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87. CT scan
necessary to
rule-out additional coalitions
determine size and extent of coalition
MRI
may be helpful to visualize a fibrous or cartilagenous
coalition
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89. Treatment
Nonoperative
observation
asymptomatic cases
immobilization with casting or orthotics
initial treatment for symptomatic cases
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90. Operative
surgical resection of coalition with interposition of
fat graft or extensor digitorum brevis
resistant cases when nonoperative management fails to relieve
symptoms
subtalar arthrodesis
triple arthrodesis (subtalar, calcaneocuboid, and
talonavicular)
advanced coalitions that fail resection
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98. What s this shows??
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99. pes planus
Zahid H Malik
ve a nice day
Thanks for your participation
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Editor's Notes
From architecheral point of view … these thing need for a high arch bridge .. Nature as used all these principles.
18 to 20°
CRANIOFACIAL DYSPLASIA The best-known of these conditions is Apert’s syndrome
(acrocephalosyndactyly). The head is somewhat
egg-shaped: flat at the back, narrow anteroposteriorly,
with a broad, towering forehead, depressed face,
bulging eyes and prominent jaw