Ganglion Cyst of the Foot

ganglion

A ganglion cyst is a mass or lump that forms below the surface of the skin. It is a benign cyst that is filled with a jelly-like fluid. The term ganglion means “knot”. It is not a malignant tumor, but a soft tissue benign mass. Ganglion cysts can occur anywhere; however, they usually occur at the wrist area and may occur at the foot (usually on top). This mass can change in size, vary in size, and may grow slowly.

wrist and footPresentation

The mass is usually asymptomatic and typically, the patient will find the mass at the top of the foot. The patient may have a burning sensation due to nerve irritation or compression of the nerve. Sometimes, a ganglion cyst mass occurs in the tarsal tunnel area, causing tarsal tunnel syndrome. If this is the case and the pain and burning sensation is not resolved with in tarsal tunnelconservative treatment, excision of the mass is probably the best option. The patient may have skin irritation, as well as difficulty in walking and wearing shoes. If the ganglion is pushing on a nerve and causing irritation, something surgical needs to be done, such as aspiration or removal. Usually, the patient’s symptoms become better after these treatments.

The physician will need to differentiate a ganglion cyst from plantar fibromatosis. Remember, ganglion cysts tend to occur at the top of the foot. Plantar fibromatosis occurs at the bottom of the foot. A ganglion cyst will transilluminate, while plantar fibromatosis will not.

tansilluminateTreatment

Treatment typically consists of observation, shoe modification, and aspiration/injection of steroids. Surgery is performed as the last resort.

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Common Foot Conditions and Injections

 

Conditions which cause pain and inflammation are treatable with the use of diagnostic and therapeutic injections. The purpose of this article is to shed some light on common ankle and foot conditions that may require injections and where the proper sites to perform these injections are located.

anklejoint

Ankle Joint

The ankle joint is formed by articulation of the tibia and talus. Injections are performed here to alleviate pain occurring from trauma, arthritis, gout, or other ankleeeeinflammatory conditions. Anterolateral Ankle Impingement can occur due to the build-up of scar tissue in the ankle joint or from the presence of bony spurs. When executing an injection here, the ankle will need to be in a neutral position. The physician will mark the injection site just above the talus and medial to the tibialis anterior tendon. The injection site should be disinfected with betadine. Then, the needle is inserted into the identified site and directed posterolaterally. The solution is injected into the joint space and should flow smoothly without resistance. It may be helpful to pull on the foot in order to distract the ankle joint.

First Metatarsophalangeal Joint

The MTP joint is a common injection site frequently affected by gout and firstmetaosteoarthritis. The injection site is first disinfected with betadine and then the needle is inserted on the dorsomedial or dorsolateral surface. The needle is angled at 60-70° of the plane to match the slope of the joint. The solution is injected into the joint space and should flow smoothly without resistance. Pulling on the big toe is sometimes helpful in distracting the joint.

 

Peroneal Tendonitis

Peroneal Tendonitis is an irritation to the tendons that run on the outside area of the ankle, the peroneus longus and peroneus brevis. First, the injection site is disinfected with betadine. Then, the needle should be carefully inserted in a proximal direction when injecting the peroneus brevis and longus tendon sheath. The needle will need to advance distally to inject the peroneus brevis alone at its bony insertion.

peroneal

Achilles Tendonitis

Achilles Tendonitis is an irritation and inflammation of the large tendon in the back of the ankle. Achilles tendonitis is a common overuse injury that occurs in athletes. needlingInjections of steroids should be given around the tendon, not through the tendon. The injections inserted directly into the tendon is not recommended due to the increased risk of tendon rupture. A platelet injection can be done through the tendon with needling and fenestration.

 

Tarsal Tunnel Syndrome

Tarsal Tunnel Syndrome is a condition of pain and paresthesia caused by irritation to the posterior tibial nerve. When performing an injection for this condition, the tarsal tunnelphysician will want to feel the pulse of the posterior tibial artery. The nerve is posterior and the physician will want to find the area of maximum tenderness. The injection site should be 1-2cm above the tender area, which is marked on the medial side of the foot and disinfected with betadine. The solution is injected at a 30° angle and directed distally. It is important to inform the patient that the foot may become numb and that care should be taken when walking and driving. Injections for Tarsal Tunnel Syndrome are usually performed after a treatment program which can include rest stretching and the use of shoe inserts.

 

Plantar Fasciitis

The plantar fascia is a band of connective tissue deep to the fat pad on the plantar aspect of the foot. Patients with plantar fasciitis complain of chronic pain symptoms that are often worse in the morning with walking. The injection site is identified and marked on the medial side of the foot and betadine is used as a disinfectant. The physician will need to avoid injecting through the fat pad at the bottom of the foot to avoid fat atrophy. The needle is inserted in a medial to lateral direction one finger breath above the sole of the foot, in a line that corresponds to the posterior aspect of the tibia. The solution is injected past the midline of the width of the foot.plantar

 

Unbelievable Bacteria- Part II

Why do open fractures have increased risk for infection?

The presence of bacteria within an open wound increases the risk of colonization when hardware is used. Once the hardware is colonized, the bacteria grows rapidly. During the rapid growth phase, the bacteria secretes a polysaccharide sugar layer, called a “biofilm”, or slime layer that encases the bacteria. This biofilm provides protection to the bacteria against the body’s defenses and antibiotics.

biooo

Within the biofilm, there are channels that allow the bacteria to pass nutrients, messaging signals, and even DNA to each other. The bacteria pass on their DNA by:

passDNA

  1. Transformation
  2. Transduction
  3. Conjugation

Transformation is when a bacterial cell ruptures, releasing its DNA, which is then taken in by another bacteria. Transduction occurs when DNA is transferred from one bacterium to another by a virus. Phage DNA and proteins are made and bacterial chromosomes are broken up, completing the gene transfer. The phage release themselves from the host, carrying either bacterial or phage DNA. Conjugation occurs when two bacteria attach themselves together with a sex pilus and exchange their DNA.

How does the bacteria become resistant to antibiotics?

beta

The bacteria can alter the genes they express by as much as 50-60%. By doing this, the bacteria can produce enzymes such as beta-lactamases, which destroy certain antibiotics before they can reach their target site. They can also make Efflux pumps which expel antibacterial agents from the cell before it can reach its target site. Finally, by expressing different genes, the bacterial cell wall can be altered to no longer contain the binding site of the antibiotic agent. Because the antibiotics cannot break through the biofilm and access the bacteria, the bacterium in the biofilm can become up to a thousand times more resistant to the antibiotics by the different mechanisms previously discussed.

If there is biofilm on the hardware, what can the physician do?

xfix

The only proven treatment, is to remove the hardware and wash the wound. However, removal of the hardware is a problem if the fracture is not healed and the fixation is needed. The physician may decide to suppress the infection, leaving the hardware until the fracture has improved. Or, the physician may decide the remove the hardware and seek an alternative method for stabilizing the fracture, such as an external fixator, and then using a biological material to help heal the fracture.

These are the issues that make infection with hardware so complex!

Galeazzi Fracture

Galeazzi Fractures are a type of fracture of the radial shaft which is associated with dislocation of the distal radio-ulnar joint (DRUJ). This particular fracture is name after Ricardo Galeazzi who was an Italian surgeon in Milan. This injury is uncommon and only accounts for about 7% of all forearm fractures in adults.

 

A radius fracture may be short, oblique, or transverse and involves a fractures at the junction of the middle third and distal third of the radius with associated injury to the distal-ulnar joint. The closer the fracture is to the DRUJ, the more likely that it will be unstable. Dislocation of the DRUJ is usually dorsal. It may be associated with either a ligamentous injury or fracture of the styloid process of the ulna.

styloid fx

A fracture is usually located above the proximal border of the pronator quadratus muscle. The distal fragment usually moves towards the ulna. Galeazzi fractures are best treated with open reduction and internal fixation of the radius and assessment of the distal radio-ulnar joint.

unstable

Surgery is necessary. Nonsurgical treatment in adults usually results in recurrent dislocations of the distal ulna and a bad outcome. Surgery is done by a volar plate fixation. Followed by assessment of the Distal Radio Ulnar Joint (DRUJ), if stable, the forearm will be splinted in supination for six weeks. If the joint is unstable, reduce and pin the distal radio-ulnar joint in supination for about four weeks. If the joint is not reducible, open and explore the joint. Check for entrapment of the ECU.

reduction