3 - Ortho: Hip/Knee/Ankle/Foot Flashcards
(153 cards)
1
Q
Describe the Trendelenberg sign?
A
Shows gluteal weakness
Stand on one leg and opposite hip falls
2
Q
Describe the galeazzi test
A
The bent knee supine test to delineate a leg length deformity
3
Q
Describe the thomas test. With a positive result what must you rule out before dx of the target pathology
A
Detects hip flexion contracture
Supine, Hold knee of one leg and drop other leg, tests
Must rule out pelvic tilt and lumbar lordosis
4
Q
Where can referred pain from the hip go? what nerves are responsible for the regions affected.
A
Suprapatellar Region (femoral nerve) Medial Thigh (obturator nerve) Buttock (sciatic nerve)
5
Q
What are the treatment options for DJD or OA at the hip joint?
A
Activitiy Modification
Weight Control
Surgery (total hip, osteotomy of acetabulum, hip resurfacing, last option arthrodesis)
6
Q
What is a possible complication of total hip replacements?
A
Metallosis - fragments of the metal on metal hip replacements enter the blood stream (increased serum nickel)
7
Q
What are the possible complications of total hip replacements?
A
Periprosthetic fracture
Periprosthetic infection
Periprosthetic dislocation
Osteolysis - could be from infection, loss of bone around implant (likely related to motion of stem)
Component loosening -
Component wear
post-op parameters are aimed at preventing it
8
Q
What is acetabular protrusio?
A
Head of the femur or surgical implant pushing through the acetabulum
9
Q
What is the most important avoidable complication of hip replacement
A
DVT!!!
Must use prophylactic anti-coagulents, coumadin, warfarin etc.
10
Q
What is the common presentation of hip fractures?
A
Groin pain after fall
Deformity may reveal itself
Passive/Active motion is painful
11
Q
What is the log roll test?
A
Rolling the whole leg manually, gently to look for hip pathology pain
12
Q
What is the best radiographic examination for suspected occult hip fracture?
A
MRI - shows edema which indicates fracture
Also order AP: Llateral Pelvis and Hip Fractures
13
Q
What should you suspect if you hear crescent sign?
A
AVN - TYPE III osteonecrosis
14
Q
What is Coxa Saltan’s? Be able to differentiate between internal and external forms
A
Snapping of the hip, can be caused by internal or external factors
15
Q
Describe the common causes of external coxa saltan’s (snapping hip)
A
Most Common Females on banked surfaces (IT Band) - classic Pain and snapping on passive flexion Snapping may occur with: - climbing stairs - rising from seated position
16
Q
Describe the common causes of internal coxa saltans (snapping hip)
A
Illiopsoas tendon subluxing over the iliopectineal eminence
Labral tear
Occurs with hip moving from flexion to extension
Groin pain
Much less common than external
17
Q
Describe meralgia paresthetica
A
Entrapment of the femoral cutaneous nerve between the sartorious and the inguinal ligament at the level of the ASIS
18
Q
Describe symptoms of Meralgia Paresthetica
A
Pain and dysesthesia that radiate to the lateral thigh
Decreased sensation in the distribution of the lateral femoral cutaneous nerve
Positive Tinel sign medial to the ASIS
19
Q
Describe treatment of Meralgia Paresthetica?
A
Avoidance of clothes or activities that compress teh nerve
Weight reduction
Steroid injections can be diagnostic and therapeutic?
Surgery for persistent/severe symptoms
20
Q
What are the ligaments of the joint capsule?
A
Review in BRS…/
21
Q
what is the most likely type of fracture to occur in the proximal femur?
A
Type 2 (garden classification)
22
Q
What is the preferred method of treatment for a type 2 garden classification fracture of the hip?
A
Percutaneous screws
Type 3&4 always require arthroplasty
23
Q
Describe the treatment options for intracapsular hip fractures depending on the class of fracture.
A
Conservative treatment is rarely indicated
Garden;
1+2 - percutaneous screws
3+4 w/o DJD - Hemiarthroplasty
3+4 w/ evident DJD - Total Hip Arthroplasty
Possibly resection arthroplasty if there is no hope for arthroplasty to work
24
Q
What direction of hip dislocation is the most common by far?
A
Posterior - axial force in line with femur, adducted hip
Commonly associated with posterior wall acetabular fracture
25
How will a patient present with a posteriorly dislocated hip?
Anterior?
Will be flexed at the hip, adducte, and internally rotated
Will be externally rotated with varying degrees of flexion and abduction
26
What is the proper course of treatment for a hip dislocation?
Emergent Reduction (immediately) - often done closed right in the ER, can be also done in the OR
OR is indicated if there is an associated hip or femoral neck fracture of the ipsilateral side
Some form of sedation or nerve block should be done prior to reduction attempt
27
What are some of the common risk factors for AVN of the hip?
```
Alcoholism
The bends
Marrow-replacing diseases (gaucher's)
Sickle Cell
Hypercoagulable states
Steroids
SLE
Inflammatory Bowel Disease
Viruses
Transplant Patients
Trauma
```
28
What is the common presentation of Hip ON/AVN?
Dull, activity-related pain in the groin/buttock
Decreased internal rotation and abduction (ROM)
Progressive in nature
29
What are the common radiographic findings for AVN?
Sclerosis early on
May look normal
CRESCENT SIGN****
30
What modality is used to define the extent of ON/AVN of the hip
MRI, can also be a source of early detection
31
What is the course of treatment for Hip ON/AVN
Precollapse: Bisphosphates
Surgery: Controversial - wont be asked
- vascularized fibular graft possible
32
What is the most common type of bursitis in the hip?
Greater Trochanteric - underneath the IT band
33
What are the common symptoms of Greater trochanteric bursitis?
Pain/Tenderness over the greater trochanter
May radiate over lateral thigh
Discomfort when lying on that side
Pain can be elicited with extremes of adduction and internal rotation
34
What is the proper course of treatment for greater trochanteric bursitis?
Activity Modification
NSAIDs
Injection of the bursa with corticosteroids
35
What are the extracapsular ligaments in the hip?
Anterior - Iliofemoral ligament
| Posterior - ischiofemoral ligament
36
Review Young-Burgess Classifications Somehow
High Energy Injuries usually
LC - Lateral Compression
APC - Anterior Posterior Compression
VS - Vertical Shear
37
If you hear crescent sign in a vignette, what should you suspect?
AVN
38
What is the first thing you always do when examining a patient with pain complaints/
Compare the injured side to the non-injured side, to gain an understanding of normal for that patient
39
Describe the tests that can be used in diagnosis of the meniscus via palpation?
McMurray - External Rotation and Extension
Apley's Compression/Distraction -
40
Describe the tests that can be used in diagnosis of the knee ligaments via palpation?
Lachman's
Drawer Dests
Pivot Shift
Varus/Valgus
41
Describe the tests that can be used in diagnosis of patella pathology via palpation?
Crepitus
Apprehension
Clark Test
Height
42
Describe thessaly's test and what it is used for.
Used to test for meniscal injuries
Patient Stands Flat Footed, provider assists with hands to help with balance. The patient then flexes the knee to 20deg then rotates the femur on the tibia
Test is positive if the patient experiences medial or lateral line pain with the movements
43
Describe the functioning of synovium cell types A, B, C and fluid portion.
Type A - phagocytosis
Type B - production and secretion, likely the source of glycoprotein and hyaluronic acid and synovial fluid
Type C - undifferentiated
44
What is the function/composition of synovial fluid?
Major Functions: Lubrication, Nourishment
Lubricin - Hyaluronic Acid, Proteinase, Collagenase, Prostaglandins (inflammation)
DOES NOT CONTAIN: RBCs, Clotting Factors, Hemoglobin
45
Describe the function of Hyaluronic Acid?
Increases the viscosity and elasticity of articular cartilages, lubricates teh joint space
46
Describe the function of Lubricin in synovial joints?
Glycoprotein that is key in lubrication
47
Describe the different types of knee effusion and the possible indications of these appearances.
Knee Swelling within 4-6 hours indicates hemarthrosis (bleeding into the joint caused by a variety of pathologies)
Fat Globules: fractures
Cloudy Aspiration: infection
Viscosity: infection (string sign)
48
Describe the condition using the following synovial fluid analysis:
Yellow, opaque, Variable viscosity, 15,000 - 200,000 WBCs per mm, >75% PMNs, Poor mucin clotting
Septic
49
Describe the condition using the following synovial fluid analysis:
Yellow to Green, opaque, Low Viscosity, 2,000 - 15,000 WBCs per mm, >50% PMNs, Good to poor mucin clotting
Inflammatory
50
Describe the condition using the following synovial fluid analysis:
Yellow, transparent, high viscosity, 200 - 2,000 WBCs per mm, <25% PMNs, Good mucin clotting
Non-Inflammatory
51
Describe the condition using the following synovial fluid analysis:
Clear, Transparent, High viscosity, <25% PMNs, Good mucin clotting
Normal Knee
52
Describe two discussed synovial tissue pathologies seen in children and adolescents.
Toxic Synovitis: low grade temp, pain, negative cultures, 7-10 d duration, usually in the hip and knee. (unknown etiology - possible viral infection as cause)
Synovial Cell Carcinoma: Rare, adolescents and young adults, very malignant, spindle sarcomatous cells or epithelial cells. Radical surgery and cancer treatment therapy needed immediately
53
Describe Synovial Chondromatosis aka Reichel Syndrome)
```
Osteochondromatosis (3 stages)
Rare,
Causes unknown
Benign
Looks like a bunch of goat cheese in the joint on radiographs
```
54
Describe the cc of a torn meniscus
Pain, Snapping, Swelling, Stiffness, Decereased ROM, Instability, Locking
55
Describe the common history seen in pt. with torn meniscus
Acute: Twisting injury of the knee with foot planted
Chronic: Older patient with minimal or no trauma, pt can usually continue to ambulate, work or even participate in sports (with the exception of locked knee caused by a floater getting wedged)
56
Describe the P.E. findings in a meniscal tear at the knee joint.
Pain at the joint line, swelling/stiffness 24-72 hrs post injury, Popping/catching/locking, McMurrays Positive
57
Describe the objective tests done for dx of a torn meniscus
X-Ray: AP/Lat/Oblique, Sunrise Patella
MRI
Arthrogram
CT Scan to rule out inra-articular fractures
58
Discuss the possible other etiologies in a meniscus tear differential?
```
Loose Bodies (Floaters)
ACL Tear
MCL Tear
Osteochondritis Desicans OCD
Discoid Meniscus
```
59
Discuss the courses of treatment for a torn meniscus
Arthroscopy (repair or partial meniscectomy) - Repair generally unsuccessful
PT
Meds
60
What pathology is commonly seen with a double PCL sign on MRI?
In 80% of cases it is associated with a medial meniscus tear
61
Describe the common CC with an ACL Rupture?
Post-Traumatic pain and swelling
Instability
Immediate effusion >70% are ACL Rupture
62
Describe the common histories associated with an ACL tear.
Hyperextension/Twisting injury
Deceleration Injury
Audible Pop
Immediate pain and effusion
May be present with chronic instability which would be old injury
Think ACL with posterior medial meniscal horn tear
63
How many bundles of ACL are present?
2
Anteromedial - tight in flexion
Posterolateral - tight in extension
64
Describe the common P.E. findings in an ACL Rupture.
```
Lachmans test (most sensitive)
Anterior Drawer
Pivot Shift
Effusion
COMPARE BOTH KNEES!!!!!!!!!!!!
```
65
Describe the common objective tests used in dx of an ACL rupture
X-Ray (Segond Fracture: avulsion of the lateral portion of the tibial plataeu)
MRI
Aspiration
66
List the other possible etiologies involved with an ACL differential.
Torn Meniscus - Acute = Lateral, Chronic = Posterior horn of medial meniscus
Torn PCL
Torn MCL
Combo of alll!!!!!!!! (refrer to history and mechanism of injury)
67
Describe the course of treatment for an ACL rupture?
Age dependent
Surgery very common
Conservative (generally in older population)
- Bracing or PT
68
What are the possible treatments for repair of an ACL?
Graft Procedures: Auto/Allograft, Hamstrings/Bone-tendon-bone
Radiofrequency heat - to shrink a stretched ACL
Simple Debridement - to clear the damaged tissue and prevent locking/popping
69
Describe the general information about PCL tears.
```
Rare
Usually due to high energy trauma
Knee Dislocations commonly associated
Dashboard Injuries
Can display as recurvatum when standing with legs fully extended
```
70
Describe some of the objective testing available for dx of a torn PCL.
Posterior Drawer Test
| Posterior Sag Sign
71
Describe the bundles of the PCL and their characteristics.
Runs from the lateral aspect of the medial femoral condyle to the posterior portion of the tibial plataeu
2 Bundles:
Anterolateral: tight in flexion
Posteromedial: tight in extension
72
Describe what is involved with a CC of a dislocated patella.
Over 90% occur with a lateral dislocation of the patella
Spontaneous or traumatic, injury with palpable deformity of the knee
Knee is usually in the flexed position
73
What types of objective assessments can be done in dx of the patella/ patellar dislocation?
Apprehension Test (displace patella laterally, and patient flexes quad as a guarding mechanism)
Assess Q angle: large Q angle predisposes pt. for patellar subluxation or dislocation
74
What are some anatomical considerations involved with assessing the stability of the patella?
```
Lateral Positioning (naturally)
Recurvatum
Patellar Facet Deformity
Shallow Patello-Femoral Groove
Tight lateral retinaculum
```
75
Discuss treatment options for a subluxed/dislocated patella.
```
Reduction
Immobilization
Braces
Arthroscopic procedures
Open procedures (reallignment)
```
76
Describe the common characteristics associated with a CC of chondromalacia aka petellofemoral syndrome.
Pain around the knee cap
Crepitance
Pain when doing the stairs
77
Discuss the grading system for chondromalacia.
Grade I
focal areas of hyperintensity with normal contour
arthroscopically : softening or swelling of cartilage
Grade II
blister-like swelling/ fraying of articular cartilage extending to surface
arthroscopically : fragmentation and fissuring within soft areas of articular cartilage
Grade III
partial thickness cartilage loss with focal ulceration
arthroscopically : partial thickness cartilage loss with fibrillation (crab-meat appearance)
Grade IV
full thickness cartilage loss with underlying bone reactive changes
arthroscopically : cartilage destruction with exposed subchondral bone
78
What P.E. testing can be done in dx of chonromalacia/
Pain around patella
Patello-femoral grind
Clark's Sign
Lateral J sign - lateral movement of the patella in extension above the tochlear groove
79
What objective tests can be done in dx of chondromalacia?
Sunrise Radiograph
MRI
Bone Scan
Arthroscopy
80
What common injuries are part of the differential of chondromalacia?
Patellar Malalignment
Osteoarthritis
Osteochondritis Desicans
Plica Syndrome
81
Describe the treatment options for a patient diagnosed with chondromalacia.
Conservative: Meds, Braces, PT
Surgical: Chondroplasty, Lateral Release, Open realignment, Patellectomy
82
Describe the symptoms associated with a CC of prepatellar bursitis.
```
CC - painful swollen prepatellar bursa
Increased temp of skin over knee
Pain in flexion
Usually a direct blow or overuse injury
May be spontaneous
```
83
Describe the various etiologies of prepatellar bursitis.
Sepsis, Trauma, Arthritic
84
What is the common course of treatment for prepatellar bursitis?
Conservative: aspiration, cortisone, antibiotics
Surgical: Excision
85
Differentiate between osgood schlatters/jumpers knee and Sindig-Larsen Johansen Disease.
Both seen in boys>girls ages 10-15
Osgood: partial avuslion of the tibial tuberosity - often seen in early teens near the end of the growth phase.
Sindig: Calcification and abnormal formation of the inferior pole of the patella (causing pain similar to osgoods)
86
What is the most common etiology associated with a bakers cyst?
usually secondary to internal derangement in the knee (arthritis (rheu/osteo), synovitis, etc..)
87
What should be ruled out in a differential of a bakers cyst?
Synovial cell sarcoma - aspiration can help with ruling
88
Describe the grading of knee ligament (collateral) sprains.
First Degree - Pain/Tenderness associated with trauma, but no joint laxity
Second - Detectable joint laxity with localized pain and tenderness
Third - Ligaments completely torn and joint grossly unstable
89
What is thje strongest portion of the MCL?
The superficial portion is the strongest, the deep portion attaches to the medial meniscus for stabilization
90
What types of objective testing can be done for dx of an MCL sprain?
```
X-ray + Stress xray
MRI
Arthrogram
Arthroscopic Exploration
Segond Fracture
Pellegrini Stieda Disease
```
91
What is pellegrini stieda disease?
(PS) lesions are ossified post-traumatic lesions at (or near) the medial femoral collateral ligament adjacent to the margin of the medial femoral condyle. One presumed mechanism of injury is a Stieda fracture (avulsion injury of the medial collateral ligament at the medial femoral condyle).
92
What is involved with the differential of a collateral ligament tear?
Torn Meniscus
Tibial Plateau Fractures
ACL Rupture
93
Discuss treatment options for a collateral ligament tear?
Bracing
Casting
Surgery is rare
94
What is osteochondritis desicans?
Necrosis of subchondral bone
CC - pain, swelling, popping, locking
History - Repetitive use or trauma, acute injury history, idiopathic, incidental finding on unrelated radiograph
95
What types of physical findings are associated with osteochondritis desicans?
Painful ROM
Effusions
Poppin/Locking
Painful weight bearing
96
What types of objective testing can be done in dx of osteochondritis desicans/
Xray Tunnel View - usually involves the lateral aspect of the medial femoral condyle
MRI - open or closed lesion will be seen
97
What else may be part of the differential for osteochondritis desicans.
Torn Meniscus
| Torn ACL
98
What is the most common cause of loose bodies int he knee joint?
Osteochondritis Desicans
99
What are the possible treatments for osteochondritis desicans?
Conservative - long leg cast
Surgical - debridement, pinning, in situ pinning, OATES, drilling/microfracture, removal of free fragment, autologous cartilage transfer
100
Describe knee arthritis
Pain with weight bearing ,Swelling, Decreased ROM, varus/valgus deformity, Crepitance and catching
Progressive development of symptoms, may be compartmentalized on physical exam
Varus Deformity with OA in the medial compartment
101
Which objective testing can be done in dx of OA at the knee joint?
Weight-bearing Radiograph
Bone Scan
Blood work
102
What could be part of the differential for OA of the knee joint?
Torn Meniscus
Chondromalacia
Hip Pathology
Chondrocalcinosis
103
What nerve is involved with referred pain from the hip to the medial border of the knee joint?
Obturator N.
Anterior Branch - supplies adductors, pectineus, gracillus, and cutaneous branches to medial thigh
Posterior Branch - supplies obturator externus and adductors
104
What types of treatment can be offered for OA of the knee joint?
Conservative: Oral meds, PT, Injection, Assistive devices.
Surgical: High tibial osteotomy, unicompartmental knee replacement, total knee replacement
105
What are some risk factors associated with increased ankle sprain incidence?
Individuals with varus mal-alignment
Tight Calf Muscles
Incompletely healed previous injuries to the ankle
106
Describe the ligaments involved with an inversion ankle sprain.
ATFL is the most commonly injured with this mechanism
CFL is next
Followed by PTFL
107
Describe objective tests used in dx of ankle sprains.
Hx and PE
Stress Radiographs
Anterior drawer test
MRi
108
Discuss the grading system for ankle sprains.
Grade 1 - ATFL only injured, minimal change on inversion stress, normal anterior drawer test
Grade 2 - Torn ATFL and stretched CFL, laxity with inversion stress, positive anterior drawer.
Grade 3 - Torn ATFL/CFL, possibl PTFL involvement, uncommon, can be associated with fractures
109
Describe the common treatment for mild/moderate ankle sprains?
```
RICE
NSAIDS
Crutches for a few days
Functional splint (air cast or swede-o-brace)
Early weight-bearing and ROM
```
110
Describe treatment for severe ankle sprains
Walking boot or cast
Non-weight bearing, followed by and as-tolerated basis
ROM as pain allows
PT
111
What is the common recovery time for a severe ankle sprain?
6 weeks or more
| Surgery may be necessary
112
What exercise has mounting evidence for greatly improving the prognosis of ankle sprains, and reducing the incidence of re-injury.
Proprioceptive Balance Training
113
Describe "high ankle" sprains and the mechanism of injury involved.
How is it commonly diagnosed?
Syndesmosis sprain (more significant than regular inversion)
Eversion stress radiograph
114
Describe the weber classifications of ankle fractures.
A: transverse fibular avulsion, occasionally with an oblique medial malleolus fracture (internal rotation and adduction/inversion)
B: oblique fracture of the lateral mallelous w/ or w/o rupture of the tib/fib syndesmosis and medial injury (external rotation/eversion)
C: high fibular fracture with rupture of the tib/fib ligament and transverse avulsion fracture of the medial malleolus. Syndesmotic injury is more extensive than in type B (eversion)
115
Describe teh Maisoneuve Fracture
Eversion fracture that typically involves medial malleolus and disruption of the tib/fib syndesmoses, resulting in fx of the proximal fibula**, and torn deltoid ligament
Can be missed with ankle exam
Proximal Fibular fx is key in this dx
116
Describe common treatment for bimalleolar fractures?
Likely requires surgery,
117
Describe the symptoms of achilles tendonitis
Usually associated with sig. increase in activity or change in activity type
Pain with push-off of gait
Tender upon palpation
Marked increase in size of posterior anatomy
118
Describe treatment options for achilles tendonitis
```
Heel Lift/Boot/Cast
Pt
Soaks
NSAIDs
Can be precursor to rupture, takes weeks/months to resolve
```
119
Why are steroid injections contraindicated for achilles tendonitis?
corticosteroids have been shown to resolve inflammation, however they are also known to weaken the achilles tendon and greatly increase the incidence of rupture
120
Describe achilles tendon ruptures
Common in young/middle-aged adults
Commonly see history of chronic disease
Contributing biomechanical factors of the foot (spurs, increased pronation, pes cavus (high arch), tight calves)
121
Describe the dx process for an achilles tendon rupture.
Local tenderness/swelling, Palpable defects, Ultrasound/MRI, Inability to plantar flex
122
What physical testing can be done in the dx of achilles tendon rupture?
Thompson Test - squeeze calf and foot should plantar flex (positive if no flexion observed)
123
Where is the most common site of achilles tendon rupture/
4-6cm proximal to insertion on the calcaneous, due to decreased blood supply to the area "known as the "watershed area" of the tendon.
124
Describe treatment of an achilles rupture?
Surgical - repair end-to-end or use a fascial graft
Non-surgical - less strength, high rate of re-rupture, less complications obviously...
125
Describe the signs and symptoms of a calcaneus fracture.
Severe heel pain, toe gait, localized tenderness, low back pain, swelling
Can involve an avulsion of achilles insertion
Treament - may need arthrodesis, very difficult to get to heal
126
Describe Calcaneal Apophysitis aka Sever Disease
M>F, usually around 10-14 yrs old
Repetitive heel strike during running or jumping, repetitive traction through achilles tendon
Can be with or without fragmentation of the apophysis
Will exhibit walking/running pain, swelling, tight ROM
Open calcaneal growth plate on radiograph
127
Describe treatment options for sever's disease.
```
Activity modification
ICE
Shoes support/orthotics
Stretching
NSAIDS
Non-weight-bearing cast if severe
*this disease is self-limiting, growth plate will fuse eventually
```
128
Describe retrocalcaneal bursitis
Caused by repetitive dorsi/plantar flexion with friction/traction exerted on achilles (eg. shoe rubbing)
May include "pump bump" aka haglund's deformity callous formation
Treated with NSAIDs, RICE, Ultrasound, PT, Injections, Surgical bursectomy is rarely indicated
129
What is the tendon involved with acquired flatfoot?
Posterior Tibial Tendon is insufficient
Treated with orthotics or possibly casting for 6-8 weeks
Severe cases treated with surgery
130
Describe tarsal tunnel syndrome.
Caused by indirect trauma, repetitive heel strike during running on hard surfaces, and poor fitting shoes
Compression of the posterior tibial nerve in the posteromedial compartment of the ankle
131
Describe the symptoms of tarsal tunnel syndrome.
Treatments?
Localized swelling, pain(tingling/burning) medial ankle and heel, May have EMG/NCV deficits
```
NSAIDs/Corticosteroid Injections
Ultrasound
Activity modifications
Orthotics
Decompression surgery if indicated
```
132
Describe osteochondritis dissecans
Distinct lesion +/- detachment of articular cartilage from subchondral bone forming a loose body
Secondary to trauma
Average age: 20-35 yrs
Male 70% : Female 30%
6% of patients with any hx of ankle sprains, have OCD of ankle
133
What are the signs and symptoms of OCD in the ankle.
```
Pain
Acute inversion injury
Chronic ankle pain
Catching/Grinding
Feelings of instability or give-way episodes
```
DX/ radiograph, MRI, CT scan is modailty of choice if lesions are known
Treated conservatively and can do surgery if conservative fails
134
Describe the hawkins classifications for Talar Neck Fractures.
Type 1 - nondisplaced
Type 2 - displaced, subluxed subtalar joint
Type 3 - displaced, dislocated subtalar and tibiotalar joints
Type 4 - displaced, dislocated talonavicular joint (high risk of AVN)
135
Describe the significance of hawkins sign in a healing talar neck fracture.
Sign of revascularization
Osteopenia seen beneath the subchondral surface of the talar dome
Occurs 6-8 weeks after the fracture
136
Describe the courses of treatment of a talar neck fracture (depending on the hawkins grade)
Hawkins 1 - nonoperative: NWB cast for at least 8 weeks
Hawkins 2/3/4 - usually require surgery.
137
Describe a lateral process fracture of the Talus.
aka snowboarders fracture
seen with forced dorsiflexion and external rotation of the foot
can be seen on plain xrays
treated with casting usually dont need surgery
138
Describe Plantar fasciits.
Repetitive stress during weight bearing or push off
Predisposing factors - pes cavus, shortened achilles tendon, activity level, weight
Morning pain/stiffness
Walking "toe out"
Point tender at calcaneal insertion
Tightness of achilles tendon on affected side
139
Describe the common course of treatment for plantar fasciiitis
NSAIDs, Stretching, Night splints, Ultrasound therapy, Orthotics, Activity modification (tolerance), Injection and/or surgical in severe cases
140
Describe a march fracture injury
Stress fracture of the neck or shaft of the metatarsals (usually 2nd, 3rd, or 4th)
Gradual Onset, Sharp Point Tenderness, Diffuse Swelling
Treat with RICE, alter activity, stiff soled shoe, non-weight bearing, may require casting
141
What do you call a fracture located w/in 1.5 cm distal to tuberosity of 5th metatarsal?
Jones fracture - high incidence of AVN and non-union
Treat w/ NWB cast for 6-8 weeks is necessary for healing
Surgical intervention in the case of non-union
142
Describe the Lisfranc Injury
Fracture-Dislocation injury of the tarsal/metatarsal joint
Complex injury that is often missed
(initial xrays show minimal displacement, but severe ligamentous injury may exist)
143
What are the mechanisms of lisfranc injury.
Direct: results from dorsally applied force (i.e. crush, drop tool box, etc..)
Indirect; axial load and twist on a plantar flexed foot
144
What will be evident on a radiograph of a patient with a lisfranc injury?
"Fleck Sign" - avulsion of the ligament off the 2nd metatarsal base
Gold standard test is the CT scan
145
Discuss treatment of a lisfranc injury.
Non-operative (conservative
Operative - reduction of metatarsal is key
ORIF required for >2mm gap
146
Describe Morton's neuroma
Fibrous enlargement of the plantar interdigital nerve with entrapment between metatarsal heads (usually 3rd and 4th)
Can result from direct trauma (stretching of plantar structures during hyperextension of the MP joint) e.g. sprint starts or recovery from a jump
Tight Shoes can also cause it
147
Describe treatment for Morton's Neuroma
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Relieve PRessure (orthotics, metatarsal neck pad)
Local Injections
Surgery for refractory cases
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148
Describe Hallux Valgus (Bunion)
Big Toe deviates toward the direction of the little toe
As big toe drifts into valgus, a bump starts to develop on the medial side of the toe over the metatarsal
Can be treated by simply changing shoes or via surgical change of the foot (cosmesis)
149
Describe Hammer Toe
plantar flexed PIP joint
pain over taht portion
6-12 months of non-operative treatment, if unsuccessful then a surgery can be done to fix it.
Flexible deformity = soft tissue procedure
Rigid deformity = bone and soft tissue procedure
150
Describe Mallet Toe
Pain/Deformity including plantar flexted DIP joint
| 2nd and 3rd toes most common
151
Describe corns
Callosity overlying a bony prominence - common in dorsolateral aspect of the 5th toe and interdigital space between 4th and 5th toe
Conservative: relieve pressure on toe, modalities (gauze, cut-out pads, toe crest)
Surgery - excision if pain continues despite conservative tx
152
Describe the Freiberg infraction
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AVN of the lesser metatarsal heads
More common in females
ages 11-17 = peak incidence
Decreased ROM at MTP
Initial radiographs could be unremarkable
Bone Scan helpful in dx
CT scan late
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153
Describe the management of a freiberg infraction
Rest
NWB cast in acute phase
Shoe Modifications: MT bars, Rigid shanks, Rocker Bottom, Avoid Heels,
Acitivity modification
Surgery reserved for failed conservative treatment options
