Clinical conditions of the lower limb Flashcards
1
Q
What can cause injury to the superior gluteal nerve?
A
- Hip surgery
- Injections to buttock
- Fractures of greater trochanter
- Dislocation of hip joint
2
Q
What indicates that a patient has a superior gluteal nerve palsy?
A
- Positive Trendelenburg sign
- Patient stands on injured lower limb
- Pelvis on unsupported side descends
3
Q
What normally prevents the pelvis from tilting towards the unsupported side when a person stands on one leg?
A
- Gluteus medius and minimus of the supporting lower limb usually contract
4
Q
What tends to cause a pulled hamstring?
A
- Sudden muscular exertion e.g. jumping, sprinting and lunging
- Common in footballers and athletes
5
Q
What can sudden tension on the hamstrings result in?
A
- Muscle sprain
- Partial tear
- Complete tear of the origin of the hamstring muscles from the ischial tuberosity (can be accompanied by avulsion fracture)
6
Q
What is osteoarthritis?
A
- Degenerative disorder
- Breakdown of articular hyaline cartilage
- Joint pain
- Functional limitation
- Reduced quality of life
7
Q
What are the risk factors for primary osteoarthritis?
A
- Age
- Female
- Ethnicity
- Genetics
- Nutrition
8
Q
What are the risk factors for secondary osteoarthritis?
A
- Obesity
- Trauma
- Infection e.g. septic arthritis, TB
- Inflammatory arthritis e.g. RA
- Metabolic disorders affecting the joints e.g. gout
9
Q
What are the symptoms of OA?
A
- A deep aching joint pain, exacerbated by use
- Reduced range of motion and crepitus
- Stiffness during rest
10
Q
What is the pathology of OA?
A
- Excessive or uneven loading of the joint
- Increased proteoglycan synthesis by chondrocytes
- Hyaline cartilage initially becomes swollen
- As disease progresses, proteoglycan content falls
- Cartilage softens and loses elasticity
- Microscopically, flaking and fibrillation develop
11
Q
What causes a loss of joint space in OA?
A
- Cartilage becomes eroded down to the subchondral bone
12
Q
What causes subchondral sclerosis in OA?
A
- Altered distribution of biomechanical forces
- Subchondral bone responds with vascular invasion and increased cellularity
- Becomes thicker and denser at areas of pressure
- Eburnation manifests as subchondral sclerosis
13
Q
What causes subchondral bone cysts in OA?
A
- Traumatised subchondral bone undergoes cyst degeneration
- Due to osseous necrosis or intrusion of synovial fluid
14
Q
What causes osteophytes in OA?
A
- Osseous metaplasia of connective tissue
- Irregular outgrowth of new bone
15
Q
What are the four cardinal signs of OA on an X-ray?
A
- Reduced joint space
- Subchondral sclerosis
- Bone cysts
- Osteophytes
16
Q
What are the symptoms of OA of the hip?
A
- Joint stiffness
- Pain in the hip, gluteal and groin regions radiating to the knee
- Mechanical pain
- Crepitus
- Reduced mobility
17
Q
How do we diagnose hip OA?
A
- Clinical presentation
- Supported by X-ray changes
18
Q
How do we treat hip OA?
A
- Weight reduction and activity modification
- Mobility aids
- Muscle-strengthening and orthotic footwear
- Analgesia and anti-inflammatories
- Steroid injections
- Hyaluronic acid injections
- Total hip replacement (only cure)
19
Q
What are the classifications of neck of femur fractures?
A
- Intracapsular
- Extracapsular (which are further divided into intertrochanteric and subtrochanteric)
20
Q
Why are intracapsular fractures more dangerous than extracapsular fractures?
A
- Intracapsular fractures are likely to disrupt the ascending cervical (retinacular) branches of the medial femoral circumflex artery
- Artery of ligamentum teres cannot sustain metabolic demand of the femoral head
- High risk of avascular necrosis
21
Q
Who tends to be affected by intracapsular fractures?
A
- Elderly
- Post-menopausal women with osteoporotic bone
- Often occur after a minor fall
22
Q
Who tends to be affected by extracapsular fractures?
A
- Young and middle-aged population
- Usually result of significant traumatic force
23
Q
How is a displaced intracapsular fracture treated?
A
- Surgical replacement of the femoral head
- Either hemiarthroplasty or total hip replacement
24
Q
What are the symptoms of a fractured neck of femur?
A
- Reduced mobility/sudden inability to bear weight on the limb
- Pain which may be felt in the hip, groin and/or knee
- Exacerbation of pain on palpation of greater trochanter and rotation of hip
25
How does the leg appear in a neck of femur fracture?
- Affected leg is shortened, abducted, and externally rotated
26
Why is the hip externally rotated in a displaced #NOF?
- Due to short lateral rotators of hip:
1. piriformis
2. obturator internus
3. superior and inferior gemelli
4. quadratus femoris
(also iliopsoas)
27
Why is the hip abducted in a displaced #NOF?
- Due to strong abductors that attach to the greater trochanter:
1. Gluteus medius
2. Gluteus minimus
(also externally rotate femur)
28
Why is the lower limb shortened in a displaced #NOF?
- Strong muscles of thigh pull distal fragment of femur upwards:
1. Rectus femoris
2. Adductor magnus
3. Hamstring muscles
29
Define dislocation of the hip
- Head of femur is fully displaced out of the cup-shaped acetabulum of the pelvis
30
What is the common cause of hip dislocation?
- High-speed road traffic collisions
- Requires a massive amount of force
31
What is the most common type of hip dislocation?
- 90% are posterior
- Most commonly due to knee impacting on dashboard during a road traffic collision
32
What are the signs of a posterior hip dislocation?
- Affected limb will be shortened and held in a position of flexion, adduction and internal rotation.
- Sciatic nerve palsy is present in 8-20% of cases
33
Why does shortening occur in a posterior hip dislocation?
- Head of femur is pulled upwards by the strong extensors and adductors:
1. Gluteus maximus
2. Hamstrings
34
Why does internal rotation occur after a posterior hip dislocation?
- Anterior fibres of the gluteus medius and minimus pull on the posteriorly displaced greater trochanter
35
What are the signs of anterior hip dislocation?
- Limb is held in a position of external rotation and abduction with slight flexion
- Femoral nerve palsies can be present but are uncommon
36
Describe central dislocation?
- Head of the femur is driven into the pelvis through the acetabulum
- It is always a fracture-dislocation
- Femoral head is palpable on rectal examination
- High risk of intrapelvic haemorrhage due to disruption of venous pelvic plexuses
- Life-threatening
37
What are the different kinds of knee X-rays?
- AP
- Lateral
- Patella axial ('Skyline')
38
What are the causes of femoral shaft fractures in the young?
- High velocity trauma e.g. falls from a height or road traffic collisions
- Should also consider abuse in children
39
What are the causes of femoral shaft fractures in the elderly?
- If patient has osteoporotic bones or bone lesions, femoral fractures can occur following a low-velocity injury e.g. falling over from the standing position
40
What signs indicate a femoral shaft fracture?
- Proximal fragment is often abducted and flexed
- Distal segment is adducted into a varus deformity and extended
41
Why is the proximal fragment of the femur abducted and flexed following a femoral shaft fracture?
- Abducted due to pull of gluteus minimus and medius on greater trochanter
- Flexed due to action of iliopsoas on lesser trochanter
42
Why is the distal fragment of the femur adducted and extended following a femoral shaft fracture?
- Adducted due to action of adductor magnus and gracilis
- Extended due to pull of gastrocnemius on posterior femur
43
What is a serious complication of a femoral shaft fracture?
- 1000-1500ml blood lost in a closed fracture
- Patient may develop hypovolaemic shock
- Blood loss may be double if fracture is open
44
How do we treat femoral shaft fractures?
- Surgical fixation
45
What causes distal femoral fractures?
- High-energy sporting injuries in the young
- Fall from standing in the elderly
46
Why is reduction of a distal femoral fracture essential?
- Popliteal artery may become involved if there is significant displacement of the fracture
47
What is the usual mechanism of tibial plateau fractures?
- High-energy
- Axial loading with varus or valgus angulation of the knee
48
Which part of the bone is affected in a tibial plateau fracture?
- Articulating surface of the tibia with the knee joint
- Can be unicondylar or bicondylar
- Lateral condyle is most commonly affected
49
What do most patients develop after a tibial plateau fracture?
- Articular cartilage is always damaged
- Most patients will develop post-traumatic OA
50
What causes patella fractures?
- Direct impact injury e.g. knee against dashboard
- Eccentric contraction of quadriceps
51
What indicates a patella fracture on examination?
- Palpable defect in patella
- Haemarthrosis
52
What happens if the patella fracture is displaced?
- Extensor mechanism is destructed
- Patient is unable to perform a straight leg raise
53
How do we treat patella fractures?
- Displaced fractures require reduction and surgical fixation
- Undisplaced fractures can be protected through splinting and crutches
54
What else can present as a patella fracture?
- Bipartite patella
55
What is meant by patella dislocation?
- Patella is completely displaced out of its normal alignment
56
Which direction does the patella usually dislocate in and why?
- Laterally
- Due to the Q angle between the line of pull of the quadriceps tendon and the patellar ligament
57
What normally holds the patella in the right place?
- Contraction of the vastus medialis obliquus
- VMO stabilises patella within the trochlear groove and controls tracking of the patella when the knee is flexed and extended
58
What are the common causes of patella dislocation?
- Trauma
- Often a twisting injury in slight flexion
- Or a direct blow to the knee
59
Who is most commonly affected by a patella dislocation?
- Athletic teenagers
60
What is the usual mechanism of a patella dislocation?
- Internal rotation of the femur on a planted foot whilst flexing the knee (e.g. a sudden change of direction during sports)
61
What factors can predispose someone to patella dislocation?
- Generalised ligament laxity
- Weakness of the quadriceps muscle
- Shallow trochlear groove
- Long patellar ligament
- Previous dislocations
62
How do we treat a patellar dislocation?
- Extend knee and manually reduce patella
- Immobilise while healing takes place
- Followed by physio to strengthen VMO
63
What are meniscal injuries?
- Most common type of knee injury
- Typically occur during a sudden twisting motion of a weight-bearing knee in a high degree of flexion
64
What are the symptoms of meniscal injury?
- Intermittent pain
- Localised to joint line
- Knee catches, clicks or locks
- Sensation of giving way
- Swelling occurs as a delayed symptom
65
Why is acute haemarthrosis not common in meniscal injury?
- Because menisci are avascular
- Presence of haemarthrosis indicates a tear in the peripheral vascular aspect of the meniscus or an associated injury to the ACL
66
How does a patient suffering from meniscal injury present on examination?
- Joint line tenderness
- Restricted motion due to pain or swelling
67
How do we treat acute traumatic meniscal tears?
- Surgical meniscectomy or meniscal repair
- Conservative treatment is recommended for chronic degeneration of the menisci
68
What can cause collateral ligament injuries?
- Common sporting injury (especially direct contact sports)
- Usually result from acute varus or valgus angulation of the knee
69
What usually controls the movement of the knee joint?
- Medial and lateral collateral ligaments brace knee against unusual varus or valgus deformation
- Collateral ligaments also work with PCL to prevent posterior motion of tibia on femur
70
Which ligament is is at risk in acute valgus sprain?
- Medial collateral ligament
71
Which ligament is at risk in acute varus sprain?
- Lateral collateral ligament
72
Which collateral ligament is more at risk of injury?
- MCL is more commonly injured
- Torn LCL has a higher chance of causing knee instability
73
Why does torn LCL have a higher chance of causing knee instability?
- Medial tibial plateau forms a deeper and more stable socket for the femoral condyle
74
How does a patient with collateral ligament injury present?
- Immediately after the injury, patient will experience pain and swelling of the knee
- As pain and stiffness subside, joint may feel unstable/give way
75
What is the unhappy triad?
- Injury to ACL, MCL, and medial meniscus
76
What causes an unhappy triad?
- Strong force applied to the lateral aspect of the knee
- Medial meniscus is firmly attached to MCL, which is why it is also injured
77
Which cruciate ligament is more commonly injured?
- ACL is weaker and is more commonly injured
78
What usually causes a tear of the ACL?
- Quick deceleration, hyperextension, rotational injury
- E.g. following a sudden change of direction during sport
- Or due to application of a large force to the back of the knee
79
What are the symptoms of a torn ACL?
- Patient reports feeling a popping sensation in their knee with immediate swelling
- When swelling has subsided, patient experiences instability of the knee
- Due to tibia sliding anteriorly under femur
- Antero-lateral rotatory instability
80
What is the function of the ACL?
- Prevents medial rotation of the tibia when the knee is extended
81
What usually causes PCL injury?
- Dashboard injury
- Fall on a flexed knee with the ankle plantarflexed
- Tackle with the knee flexed
- Severe hyperextension injury can avulse PCL from its insertion
82
How do we treat PCL injuries?
- Conservative management with bracing and rehabilitation
83
How do we detect ACL and PCL injuries?
- Anterior and posterior drawer tests
- Lachman's test
84
What causes dislocation of the knee joint?
- Uncommon injury
- Always results from high energy trauma
- At least 3 of the 4 ligaments have to be ruptured
85
What injury is associated with a knee dislocation?
- Arterial injury
- Because the popliteal artery is immobile
- May tear and cause haematoma
- Or may be crushed or suffer a traction injury
86
What needs to happen after a dislocated knee is reduced?
- Fully assess the vascularity of the leg with MRA
87
What can cause swellings around the knee?
- Bony e.g. Osgood-Schlatter's disease
- Soft tissue e.g. enlarged popliteal lymph node, popliteal artery aneurysm, lymphoedema of the lower limb
- Fluid - effusion or soft tissue haematoma
88
Describe effusions of the knee
- Haemarthrosis is blood in the joint. ACL rupture until proven otherwise
- Lipo-haemarthrosis is blood and fat in the joint. Fracture until proven otherwise because bone marrow releases fat.
89
What causes delayed swelling of the knee joint?
- Reactive synovitis
- Inflammation of the synovium following injury results in increased production of synovial fluid
90
Which bursae of the knee are most commonly inflamed?
- Prepatellar bursa
- Infrapatellar bursa
- Pes anserinus bursa
- Suprapatellar bursa
91
Where is the pre-patellar bursa found?
- Superficial bursa with a thin synovial lining
- Located between the skin and patella
- Contains a minimal amount of fluid
92
How does pre-patellar bursitis present?
- Knee pain and swelling
- Erythema overlying inflamed bursa
- Difficulty working and kneeling on affected side
93
What is the history of a patient with pre-patellar bursitis?
- Repetitive trauma to the bursa
- Housemaid's knee
- Leaning forwards on the knee
94
Where is the infra-patellar bursa found?
- Consists of two bursae
- One sits between the skin and the patellar tendon
- The other sits between the patellar tendon and the tibia bone
95
What is the history of a patient with infra-patellar bursitis?
- Repeated microtrauma caused by activities involving kneeling
- Clergyman's knee
96
Which condition tends to cause supra-patellar bursitis?
- Knee effusion
- Because suprapatellar bursa is an extension of the synovial cavity of the knee joint
97
What are some causes of a knee effusion?
- Osteoarthritis
- Rheumatoid arthritis
- Infection e.g. septic arthritis
- Gout and pseudogout
- Repetitive microtrauma to the joint (due to running on soft or uneven surfaces)
98
What causes semimembranosus bursitis?
- Indirect consequence of swelling within the knee joint
- Fluid can move from posterior capsule of knee joint into semimembranosus bursa
- Resulting swelling is seen in popliteal fossa
- Called Baker's cyst
99
What is Osgood-Schlatter's disease?
- OSD is inflammation of the apophysis of the patellar ligament into the tibial tuberosity
100
Who is commonly affected by OSD?
- Teenagers who play sport (running and jumping)
- Causes localised pain and swelling
101
What are the symptoms of OSD?
- Intense knee pain during running, jumping, squatting, ascending and descending stairs and during kneeling
102
How does OSD resolve?
- Usually resolves with rest and ice
- When apophyses fuse, pain and swelling resolve
103
What are the symptoms of OA of the knee?
- Knee pain, stiffness and swelling
- Worse after prolonged inactivity or rest
- Deformity at the knee joint is common (varus, valgus or fixed flexion)
- Crepitus
- Feeling that the knee is giving way
104
How is OA of the knee treated?
- Initially patients are taught exercises to strengthen the vastus medialis muscle
- Analgesia, weight loss, activity modification
- Surgery in form of total knee replacement
105
Define septic arthritis?
- Invasion of the knee joint space by microorganisms, usually bacteria.
106
Which joints can be affected by septic arthritis?
- Knee (most commonly affected)
- Hip
- Shoulder
- Ankle
- Wrists
107
Which pathogens can cause septic arthritis?
- Staphylococcus aureus
- Staph. epidermis
- Neisseria gonorrhoeae
- Strep. viridans
- Strep. pneumoniae
108
What are the risk factors for septic arthritis?
- Extremes of age
- Diabetes mellitus
- Rheumatoid arthritis
- Immunosuppression
- IV drug abuse
- Prosthetic joints
- Delayed wound healing
109
Why are prosthetic joints at increased risk of septic arthritis?
- Due to intra-operative contamination or haematogenous spread from a distant infective focus
- Biofilms can easily form
110
What are the consequences of bacterial infection of joints?
- Damage to articular cartilage
- Either due to the organism's pathologic properties or host's immune response
- Neutrophils stimulate the hydrolysis of collagen and proteoglycans
111
What is the triad of symptoms of septic arthritis?
- Fever
- Pain
- Reduced range of motion
- May evolve over a few days to a few weeks
112
What should a septic joint be examined for?
- Erythema
- Swelling
- Warmth
- Tenderness
- Limitation of active and passive range of motion
113
How do we treat septic arthritis?
- Aspiration of the joint needs to be carried out immediately
- Aspirate should be sent for urgent microscopy, culture and sensitivities
114
What are the clinical signs of compartment syndromes?
- Severe pain in the limb
- Which is excessive for the degree of injury
- Increasing
- Not relieved by analgesia
- Pain is exacerbated by passive stretch of the muscles
115
What should we do if we suspect compartment syndrome?
- Fasciotomy (surgical decompression) of call affected compartments
116
What are the short term consequences of compartment syndrome?
- Increase in intercompartmental pressure
- Leads to decreased perfusion of muscle
- Ischaemic muscle releases mediators
- Capillary permeability increases
- Exacerbates the rise in intracompartmental pressure
- In severe untreated cases, rhabdomyolysis and AKI can result
117
Why does compartment syndrome result in neurovascular signs?
- If compartment pressure exceeds the systolic arterial pressure, there will be loss of peripheral pulses and increased capillary refill time
- Nerve fibres are susceptible to ischaemia - thin cutaneous fibres are affected more quickly than motor fibres
- Distal paraesthesia precedes loss of motor function
118
What are the long-term consequences of compartment syndrome?
- Rhabdomyolysis can result in AKI which may become chronic
- Necrotic muscle may also undergo fibrosis leading to Volkmann's ischaemic contracture
119
What is the usual mechanism of injury of an ankle fracture?
- Inversion or eversion injury
120
What do we need to consider when seeing a patient with an ankle fracture?
- Co-morbidities e.g. diabetes, neuropathy, peripheral vascular disease, smoking
- These are likely to affect fracture healing
- Also assess integrity of overlying soft tissues
121
What are the complications associated with fracture blisters?
- Surgery needs to be delayed until after the blisters have healed
- Sometimes the skin over the blister can become necrotic so healing can take longer
122
What are the complications associated with open fractures?
- Require urgent surgery with extensive irrigation and debridement to reduce the risk of osteomyelitis (infection of the bone)
123
What is the ankle joint normally like?
- Talus is seated firmly in a mortise comprising the distal tibia and the medial and lateral malleoli
- Ankle joint and associated ligaments can be visualised as a ring in the coronal plane
124
Why is it important to recognise that the ankle joint is organised in a ring shape?
- When a ring is broken, it tends to break in two places
- Fractures of the ankle joint are likely to occur alongside ligament damage elsewhere in the ring
125
What is talar shift?
- Disruption of any two out of the syndesmosis, medial or lateral ligaments causes the ankle mortise to become unstable and widen
- Talus shifts medially or laterally within the ankle joint
126
How are stable ankle fractures treated?
- Non-operatively with an aircast boot or a fibreglass cast
- Patients can weight-bear safely
- Low rate of complications such as secondary osteoarthritis
127
How are unstable ankle fractures treated?
- Need surgical stabilisation
- Can be high risk surgery in patients with diabetes or peripheral vascular disease
128
What is an ankle sprain?
- A partial or complete tear of one or more ligaments of the ankle joint
129
What are the following factors that put a patient at increased risk of ankle sprain?
- Weak muscles/tendons that cross the ankle joint
- Weak or lax ankle ligaments (can be hereditary)
- Inadequate joint proprioception
- Slow neuromuscular response to an off-balance position
- Running on uneven surfaces
- High-heeled shoes
130
What usually causes ankle sprains?
- Excessive strain on the ligaments of the ankle
- Can be caused by excessive external rotation, inversion or eversion of the foot
131
What is the most common mechanism of injury of ankle sprain?
- Inversion injury affecting a plantar-flexed and weightbearing foot
- Anterior talofibular ligament is most at risk of sprain
132
In severe sprain of the ankle, why is it not uncommon to find that the patient has an avulsion fracture of their fifth metatarsal tuberosity?
- The peroneus (fibularis) brevis tendon is attached to a tubercle on the base of the 5th metatarsal
- In an inversion injury, it is under tension and can pull off a fragment of bone at its insertion site
133
Who is commonly affected by rupture of the Achilles tendon?
- Most commonly occurs in men aged 30-50 years during recreational sports
- E.g. jumping, pivoting and running
134
What are the mechanisms of injury of Achilles tendon rupture?
- Making a forceful push-off with extended knee
- A fall with the foot outstretched in front and the ankle dorsiflexed , forcibly overstretching the tendon
- Falling from a height/abruptly stepping into a hole/off a kerb
135
Which area of the Achilles tendon is the common site of rupture?
- Vascular watershed area
- Area of decreased vascularity and thickness of the tendon
136
What are the symptoms and signs of Achilles tendon rupture?
- A sudden and severe pain at the back of the ankle or in the calf
- The sound of a loud pop or snap
- A palpable gap or depression in the tendon
- Initial pain and swelling followed by bruising
- Inability to stand on tip toe or to push off whilst walking
137
What test is used to test for a ruptured Achilles tendon?
- Thompson's test
138
How is Achilles tendon rupture diagnosed?
- MRI and USS
139
How is rupture of the Achilles tendon treated?
- Surgical reconstruction is difficult because two ends of tendon are frayed following rupture
- Most tendon ruptures are treated conservatively
- Foot is held in the correct position in an aircast boot
140
What is hallux valgus?
- Varus deviation of the first metatarsal
- Valgus deviation of the hallux
- Prominence of the first metatarsal head, with or without an overlying callus
141
Who is commonly affected by hallux valgus?
- Middle-aged females
142
What are the signs and symptoms of hallux valgus?
- Leads to painful movement of the first MTPJ and difficulty with footwear
- Most common cause of bunion
143
What can cause hallux valgus?
- Can occur secondary to:
- Trauma
- Arthritic/metabolic conditions such as gout
- Rheumatoid arthritis
- Connective tissue disorders that cause ligamentous laxity e.g. Ehlers-Danlos syndrome
144
How do we treat hallux valgus?
- Surgery should not be carried out for cosmetic reasons alone
- Involves metatarsal osteotomy and realigning the fragments
145
What is hallux rigidus?
- OA of the first metatarsophalangeal joint
- Resulting in stiffness of the joint
146
Why is the first metatarsophalangeal joint prone to OA?
- Joint is normally under tremendous stress during walking
- Can also develop due to gout and previous septic arthritis
147
What is the commonest symptom of hallux rigidus?
- Pain in the MTPJ on walking and attempted dorsiflexion of the toe
- Patients tend to compensate for the pain by walking on the outside of their foot
148
What happens to the range of motion of the big toe in hallux rigidus?
- Range of dorsiflexion of the toe becomes severely restricted due to the arthritis
- Plantarflexion is usually retained
149
How do we treat hallux rigidus?
- Activity modification
- Analgesia
- Orthotics or aids
- Intra-articular steroid injections
- Surgery - arthrodesis (fusion) of 1st MTPJ
150
What is different about ankle OA?
Nearly all cases of ankle OA are secondary arthritis
- Either due to previous trauma or inflammation
- Other risk factors include joint stress and obesity
151
What is the gold standard treatment of ankle OA?
- Gold standard treatment is arthrodesis (allows patient to walk very well)
- Ankle arthroplasty may be considered (more risks)
152
What are the different types of toe deformity?
- Claw toe
- Mallet toe
- Hammer toe
- Curly toe
153
What is claw toe?
- Often affect all four of the small toes at the same time
- Toes are hyperextended at the MTPJ
- Flexed at the PIP joint
154
List some causes of claw toe
- Muscle imbalance causes ligaments and tendons to become unnaturally tight
- Usually due to neurological damage
- May be secondary to conditions such as cerebral palsy, stroke, diabetes, or alcohol dependence
- Trauma inflammation and RA
155
What is hammer toe?
- Toe is flexed at the PIPJ
- Deformity is most common in the second toe
156
What are some causes of hammer toe?
- Ill-fitting pointed shoes
- Pressure on the second toe from an adjacent hallux valgus
157
What is mallet toe?
- Toe is flexed at the DIPJ
- Deformity is most common in the second toe
158
What are curly toes?
- Congenital
- Usually involve 3rd to 5th digits
- Usually bilateral
159
Why do curly toes develop?
- Tendons of the flexor digitorum longus or flexor digitorum brevis are too tight
160
How do we treat curly toes?
- Conservatively with passive extension of toes and stretching of flexor tendons
- Surgery is rarely needed and is only considered in children >6 who are experiencing pain
161
What is Achilles tendinopathy?
- A degenerative, not an inflammatory process
- Can be insertional or non-insertional
162
What can cause Achilles tendinopathy?
- Follows many years of overuse
- Especially in athletes whose training regimens are poor
- Other risk factors include obesity and diabetes
163
What are the symptoms and signs of Achilles tendinopathy?
- Pain and stiffness along Achilles tendon in the morning
- Pain in the tendon or at the back of the heel that worsens with activity
- Severe pain 24 hours after exercising
- Thickening of the tendon
- Swelling that is present all of the time but worsens on activity
- A palpable bone spur
164
How do we treat Achilles tendinopathy?
- Physiotherapy
- Especially eccentric stretching exercises
- Try to improve the vascularity of the tendon and promote healing
165
What is pes planovalgus?
- Flat foot
- Medial arch of the foot has collapsed
- Medial border of the foot almost touches the ground
- Valgus angulation of the hindfoot
166
Why do most young children appear flat footed?
- Their arches have not yet developed
- There is a large amount of subcutaneous adipose tissue in the sole of the foot
167
What is meant by flexible flat foot?
- Patient has no medial arch whilst standing normally
- When standing on tiptoes, a normal medial arch appears
- Hindfoot returns from valgus deviation into normal alignment
168
What is meant by rigid flat feet?
- Always abnormal
- Result of tarsal coalition
- When patient stands on tiptoe, no arches appear and hindfoot remains in valgus
169
What causes adult acquired flat foot?
- Dysfunction of the tibialis posterior tendon, which usually supports the medial longitudinal arch of the foot
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Who is usually affected by adult acquired flat foot?
- Middle-aged females
- Obesity
- Hypertension
- Diabetes
- Pregnancy
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Why does adult acquired flat foot cause lateral deviation of the hindfoot?
- Spring ligament is stretched
- Causes talar head to be displaced inferomedially
- Flattens medial longitudinal arch
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How do we treat adult acquired flat foot?
- Orthotics used to support medial arch
- Physiotherapy to improve muscle strength
- Some patients require surgical reconstruction/arthrodesis
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What is foot disease?
- A common and serious complication of diabetes and includes infection, ulceration or destruction of the tissues of the foot
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What foot diseases do diabetics suffer from?
- Loss of sensation due to peripheral neuropathy
- Ischaemia due to peripheral arterial disease and microvascular disease
- Immunosuppression due to poor glycaemic control
- Can lead to foot ulcers, severe infections and other serious complications
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How do diabetic patients make their foot disease worse?
- Patients often continue to weight bear on very significant soft tissue abnormalities
- This exacerbates the problem
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How do we reduce the risk of foot disease in diabetic patients?
- Regular diabetic foot clinics for screening
- Feet will be checked for corns, calluses, cracks and dry skin
- Check sensation and perfusion of the feet are assessed
- Check shoes to make sure they protect against trauma and fit well
- Educate patients
- Tight glycaemic control
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What is Charcot arthropathy?
- Progressive destruction of the bones, joints and soft tissues
- Most commonly involves ankle and foot
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What causes Charcot arthropathy?
- Combination of neuropathy, abnormal loading of the foot, repeated microtrauma
- Metabolic abnormalities leads to inflammation causing osteolysis, fractures, dislocation and deformity
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What else can diabetic neuropathy lead to?
- Muscle spasticity (e.g. tight Achilles tendon)
- Exacerbates deformity
- Rocker-bottom foot may develop
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How is Charcot arthropathy treated?
- Optimisation of glycaemic control
- Reduction of the load placed on the affected joints
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What is Piriformis syndrome?
- Sciatica-like symptoms that do not originate from compression of the spinal nerve roots
- Due to compression of the sciatic nerve by the piriformis muscle
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What are the symptoms of Piriformis syndrome?
- A dull ache in the buttock
- Typical sciatica pain in the thigh, leg and foot
- Pain when walking up stairs or inclines
- Increased pain after prolonged sitting
- Reduced range of motion of the hip joint
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What is the most common cause of sciatic nerve entrapment?
- Spasm of the piriformis muscle, usually due to overuse or to direct trauma
- Anatomical variations in the relationship between nerve and muscle
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What is treatment of Piriformis syndrome?
- Activity modification
- Non-steroidal anti-inflammatory drugs
- Physiotherapy
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If the sciatic nerve were completely transected in the buttock, what effect would this have on the movement of the lower limb?
- Hamstrings paralysed but movement of hip is still normal
- Knee extension is unaffected
- Knee flexion absent
- Dorsiflexion and plantarflexion of the ankle paralysed
- Inversion and eversion of midfoot paralysed
- All movement of toes are paralysed
186
What shows that the superior gluteal nerve has been injured?
- Pelvis on contralateral side will drop (positive Trendelenburg sign) and the foot will catch on the ground on walking
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What is meralgia paraesthetica?
- Compression of the lateral cutaneous nerve of the thigh as it pierces the fascia lata in the thigh
188
What causes meralgia paraesthetica?
- Obesity
- Pregnancy
- Tight clothing
- Wearing a tool belt
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What are the symptoms of meralgia paraesthetica?
- Burning/stinging in distribution of nerve over the anterolateral aspect of the thigh
- Aggravated by walking or standing
- Relieved by lying down with the hip flexed
- Tenderness on palpation of the trapped nerve
- Reduced sensation in the distribution of the nerve
190
How do we diagnose meralgia paraesthetica?
- Absence of motor signs
- Excluding pelvic and intra-abdominal causes of nerve irritation such as a tumour
191
What causes femoral nerve lesions?
- May result from penetrating wounds to the groin
- Rarely injured during surgery
192
What are the signs and symptoms of femoral nerve lesions?
- Depends on the site of injury
- Weakness and wasting of the quadriceps femoris group of muscles, sartorius, iliacus and pectineus
- Hip flexion will be compromised
- Active extension of the knee will be lost and the knee jerk reflex will be absent
- Anaesthesia/paraesthesia on the anteromedial thigh and medial leg
193
What happens when the tibial nerve is damaged in the proximal popliteal fossa?
- Patient has paralysis of gastrocnemius and soleus
- Therefore cannot plantarflex their ankle
- Inability to stand on tiptoe
- Inversion of midfoot will be compromised
- Dorsiflexors and everters of the ankle and foot can act unopposed
194
Where is the common peroneal nerve most commonly injured?
- Where the nerve winds around the neck of the fibula
195
What are some causes of common peroneal nerve injury?
- Prolonged bed rest
- Pressure from a tight plaster cast
- Poorly placed stirrups in the operating theatre
- Fractures in the neck of the fibula
196
How do patients with common peroneal nerve injuries present?
- Foot drop due to paralysis of tibialis anterior muscle and long extensors of the toes
- Inversion of the ankle due to paralysis of the peroneus longus and brevis
- Loss of sensation on the lateral leg and dorsal aspect of the foot
197
What can cause injury to the superficial peroneal nerve?
- Fractures of the proximal fibula
- Penetrating injuries to the lateral leg
- Ankle arthroscopy
- Lateral approach to surgery on the ankle joint
198
What do patients whose superficial peroneal nerve is damaged by injury present with?
- Loss of active eversion of the midfoot
- Loss of sensation over the distal anterolateral leg and dorsum of the foot excluding the first webspace
199
What do patients whose superficial peroneal nerve is damaged through ankle surgery present with?
- Peroneal muscles will be unaffected as their supply is proximal to the injury
- Sensory loss will only affect the dorsum of the foot (distal to the nerve injury)
200
What affects the deep peroneal nerve?
- Most common site of mononeuropathy
- Due to motor neurone disease, diabetes, ischaemia and vasculitis
- Can also be injured during a total knee replacement
201
What are the symptoms of damage to the peroneal nerve?
- Foot drop
- Inability to actively extend toes
- Small patch of numbness in the first dorsal webspace
