Clin Med: Msk 2 - Lower Body Flashcards
Hip Fractures Dx
x-ray
What type of hip fractures are commonly seen?
subcapital & intertrochanteric fractures
Hip Fractures Tx
Surgery almost always indicated, exceptt:
–> Severely debilitated, at end of life, medical illness that cannot be corrected for surgery
–> Surg w/n 48 hrs assoc. w/ decr mortality
Hip Dislocations Tx
- reduction under sedation
- if unable - OR
Pelvis Fractures Dx
x- ray
Pelvis Fractures Tx
Surg
Legg Calve Perthe Disease Dx
- x-ray,
- MRI more sensitive for severity & staging
Legg Calve Perthe Disease Tx
- Conservative tx (NSAIDS, PT)
- Depending on degree of necrosis, may req surgery
Slipped Capital Femoral Epiphysis Dx
x-ray
Slipped Capital Femoral Epiphysis Tx
Surgery (screw fixation)
Femoral Shaft Fractures Dx
X-rays
- Femur: AP & lateral views
- Hip: AP, lateral, frog leg lateral views
- Knee: AP & lateral views
Femoral Shaft Fractures Tx
- In line traction (EMS or ER)
- Intramedullary nailing
Distal Femur Fracture Dx
- x-ray
- CT to further describe the fracture, used for pre-op planning
Distal Femur Fracture Tx
- ORIF
- Intramedullary nail
MCL and LCL Injuries Dx
- x-ray
- MRI provides ligament injury
Describe Ottawa Knee Rules/criteria for MCL/PCL films
- pt >55yo
- tenderness at head of fibula
- isolated tenderness of patella
- can’t flex knee to 90 degrees
- can’t transfer weight for 4 steps immediately after & in the ED
MCL/LCL Injuries Conservative Tx
- NSAIDS
- Ice/elevation
- Early ROM
- Hinged knee brace (varus/valgus constrained) 3-4 weeks
- WBAT, crutches if needed 3-4wks
MCL/LCL Injuries Surgical Tx
- After 4 wks
- Surgery indicated for complete tears, tears w/ meniscus or ACL injury, knee instability
- Repair or reconstruction of MCL
ACL injury Dx
MRI
ACL injury acute stage Tx
- reduce pain, edema & hemarthrosis w/ NSAIDS
- aspiration of blood may be used to reduce symptoms
- delay of 2-4 wks b/t acute phase of injury & surgical correction is common
Who can be considered for PT for an ACL injury?
- older individuals
- pts w/ sedentary lifestyle
- pts who are willing to modify their sports activity & participate in swimming, running & cycling
ACL injury surgical Tx
Autograft or allograft replacement of the tendon
PCL Injury Dx
MRI
PCL Injury Tx
- RICE, NSAIDS, hinged knee brace, PT
- Surg rarely needed &often not very successful
Meniscus Tears Dx
MRI
Meniscus Tears Conservative Tx
- RICE
- knee sleeve or brace
- crutches as needed
- PT
Who can get conservative Tx for Meniscus Tears?
- Degenerative tear
- Poor surg candidate
- Acute tear (conservative tx for 6 wks)
Meniscus Tears Surg Tx if
- conservative tx fails - up to 6 wks
- symp &/or displaced meniscal body tears, in knees free from severe degenerative knee OA
- symp meniscal root tears w/ goal of preventing/slowing progression of OA
What is the surgery for Meniscal tears?
Knee arthroscopy w/ meniscal repair or meniscectomy
Patella Fracture Dx
- x-ray
- CT if x-ray (-) & high suspicion
Patella Fracture Tx
- immobilization if non displaced
- surgery if displaced
Patellar Tendon Rupture Dx
- X-ray
- MRI if suspicion of more injury
Patellar Tendon Rupture Tx
- Place in knee immobilizer
- Immediate operative repair (by 3 days)
Quadriceps Tendon Rupture Dx
- X-ray
- MRI if suspicion of more injury
Quadriceps Tendon Rupture Tx
- Place in knee immobilizer
- Immediate operative repair (by 3 days)
Patella Dislocation Dx
x-ray
Patella Dislocation Tx
- Closed reduction
- Knee immobilizer
- Crutches
- PT
- Some pts may develop chronic/recurrent patella subluxation & require surg
Knee Dislocation Dx
- X-ray
- ABI
- arteriography - if concern for vascular injury
Knee Dislocation Tx
- Closed reduction
- Emergent vascular surg consult if
–> Diminished pulses
–> ABI <0.9
–> Abnormality on angiography
Osgood Schlatter Disease Dx
- clinical
- X-ray can confirm
Osgood Schlatter Dz conservative Tx
- Activity modification
- NSAIDS
- PT
Osgood Schlatter Dz surgical Tx
if conservative tx fails (must wait for the growth plate to close)
Bakers Cyst Dx
clinical
Bakers Cyst Tx
- Conservative tx (RICE, NSAID)
- correction (poss. surgery) of underlying knee pathology
Knee Bursitis Dx
- clinical
- if sepsis concern: CBC, ESR/CRP
Non-septic prepatellar bursitis Tx
- supportive care & avoidance of recurrent injury
- Occasionally, steroid injection
Septic prepatellar bursitis Tx
- Abx
- May req repeat aspiration, if bursal effusion persists
- In severe or refractory cases, pts can be referred for surgical I&D or bursectomy
Pes Anserine Bursitis Tx
- RICE, PT
- Steroid Injection
- Rarely, surgery is req
Chondromalacia Dx
- clinical
- x-ray can help (lat view)
Chondromalacia Tx
- Acute care: RICE, refrain from high impact activities, NSAIDS
- PT
- Knee taping/foot orthotics (pronated feet)
- Surg rarely performed, but may be done if 6-12 mos of conservative tx fails (arthroscopy & removal of damaged cartilage)
Iliotibial Band Syndrome Dx
clinical
Iliotibial Band Syndrome Tx
- ice, NSAIDS, stretching, activity mod (bicycle modification, foot orthotics)
- Surgical release of ITB rarely needed
Tibial Plateau Fractures Dx
- X-ray
- CT: further info/surg planning
- MRI look for ligamentous injury
Tibial Plateau Fractures Tx that is stable & minimally displaced
- splint
- long leg cast
- cast brace for 8-12 wks
Tibial Plateau Fractures surg indicated for intra-articular fractures with…
- > 2 mm joint depression/separation
- open injuries
- fractures w/ vascular injury
- fractures w/ assoc. ligamentous injuries req stabilization
Tibial Plateau Fracture Surg Tx
Depending on fracture:
- external fixation
- ORIF
- screw fixation
Maisonneuve Fracture Dx
- x-ray
Maisonneuve Fracture Tx
- Immediate reduction of ankle w/ long leg splint, NWB & referral to ortho
- Definitive tx: surgery
–> Fixation of ankle w/ screws
–> Fibula fracture doesn’t req surgical fixation
Ankle Sprain Dx
- x-rays indicated if bony tenderness or if the pt is unable to bear weight
- MRI may also be used in pts w/ persistent symp or if suspected
–> high-grade ligament injuries
–> osteochondral defects
–> occult fracture
Ankle Sprain Grade 1 (minimal impairment) Tx
- weight bear as tolerated
- PT
Ankle Sprain Grade 1 (moderate impairment) Tx
- Immobilize w/ air splint
- PT
Ankle Sprain Grade 3 (severe impairment) Tx
- Immobilization
- PT
- Poss. surg reconstruction
Achilles Tendonitis Dx
- testing usually unnecessary, but consider imaging studies when hx & PE are not sufficient for dx
- imaging in pts w/ insertional tendinopathy
–> x-ray findings may include calcaneal spurs or calcific tendinosis at tendon insertion - magnetic resonance imaging
Achilles Tendonitis Tx
- Conservative tx: RICE, NSAIDS, activity mod
- PT
- Surg as a last resort (removal if inflamed tendon)
Achilles Tendon Rupture Dx
- x-raysmay be used to rule out concomitant fractures, calcific tendon changes, or other abnormalities
Achilles Tendon Rupture Tx
- Splint in slight plantar flexion, NWB
- Surg repair
Ankle Dislocation Dx
x-ray
Ankle Dislocation Tx
- reduced quickly to avoid neurovascular compromise w/ post reduction films
- Splint
- Likely req surg due to instability & concomitant injuries
Ankle Fracture Dx
- X-ray
- CT if complex fracture or suspicion of talus fracture
Ankle Fracture Tx
- Isolated lateral malleolus fracture: –> Boot or cast, NWB
- All others likely req surg
Stress Fractures Dx
- x-rayas the initial test; however, this test is often normal for ≥ 3 months from symptom onset
- MRI if not visible on x-ray
Stress Fractures Tx
- 6-8 wks of NWB w/ immobilization for incomplete fractures or complete fractures that are nondisplaced
- Displaced fractures or fractures at high risk of malunion (metatarsals) may req surg
Plantar Fasciitis Dx
- clinical
- x-ray may show calcaneal bone spur
Plantar Fasciitis Tx
- NSAIDS
- Ice
- Stretching
- Steroid injection
- If no relief after 6-12 mos, may consider plantar fascia release
Bunions Dx
- based on PE
- x-ray can help determine severity
Bunions Tx
accommodative shoes, orthoses, surgery if needed
Hammer Toes Tx
Initial tx goal:relieve pressureon deformity
–> shoe mod, padding, splinting, or orthotics
- Surgery as a last resort
Charcot Foot Dx
- Foot x-ray w/ weight bearing views
- MRI if x-ray inconclusive or if there is concern for osteomyelitis
- Bone biopsy if dx is unclear after imaging (can differentiate b/t neuropathic arthropathy & osteomyelitis)
Charcot Foot Tx
- Offloading (w/ total contact cast)- designed for NWB foot 6-8 wks, then…
- Orthosis or Charcot specific shoes
- Surgery indicated if:
–> Non healing ulcers
–> Un-braceable deformity
–> Osteomyelitis
–> Amputation sometimes unavoidable
Morton Neuroma
- clinical
- X-rays not helpful
- MRI can show inflammation, but usually not needed
Morton Neuroma Tx
- Avoid compressive shoes
- Steroid injection
- Last resort is surg removal
Jones Fracture
x-ray
Jones Fracture Tx
Operatively or non operatively
Non operative
- Short leg cast (NWB) for 6-8 wks
Operative tx (in active individuals)
- Screw fixation
Lisfranc Injury Dx
- X-ray
Widening of the space b/t the 1st & 2nd metatarsal base > 2mm - If dx unclear w/ x-ray–> CT
Lisfranc Injury Tx
Acute tx:
- Immobilization (short leg splint)
- NWB
- URGENT orthopedics consult
Req surgery (ORIF)
Phalanx Fracture Dx
x-ray
Phalanx Fracture Tx
- If stable & non-displaced, can be splinted (“buddy taped) & placed in a hard sole shoe
- If displaced, closed reduction & splinting- if unable to reduce will req operative fixation
Calcaneus Fracture Dx
- X-ray
- CT - characterize fracture & operative planning
Calcaneus Fracture Tx
- Most req operative tx, as they are intraarticular &/or displaced
- Non displaced, non intraarticular fractures–> immobilized for 6-8 wks
- Initial splinting should be very bulky to allow for swelling
