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MSK > Clinical conditions of the lower limb > Flashcards

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
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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
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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
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4
Q

What tends to cause a pulled hamstring?

A
  • Sudden muscular exertion e.g. jumping, sprinting and lunging
  • Common in footballers and athletes
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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)
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6
Q

What is osteoarthritis?

A
  • Degenerative disorder
  • Breakdown of articular hyaline cartilage
  • Joint pain
  • Functional limitation
  • Reduced quality of life
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7
Q

What are the risk factors for primary osteoarthritis?

A
  • Age
  • Female
  • Ethnicity
  • Genetics
  • Nutrition
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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
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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
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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
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11
Q

What causes a loss of joint space in OA?

A
  • Cartilage becomes eroded down to the subchondral bone
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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
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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
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14
Q

What causes osteophytes in OA?

A
  • Osseous metaplasia of connective tissue
  • Irregular outgrowth of new bone
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15
Q

What are the four cardinal signs of OA on an X-ray?

A
  • Reduced joint space
  • Subchondral sclerosis
  • Bone cysts
  • Osteophytes
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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
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17
Q

How do we diagnose hip OA?

A
  • Clinical presentation
  • Supported by X-ray changes
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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)
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19
Q

What are the classifications of neck of femur fractures?

A
  • Intracapsular
  • Extracapsular (which are further divided into intertrochanteric and subtrochanteric)
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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
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21
Q

Who tends to be affected by intracapsular fractures?

A
  • Elderly
  • Post-menopausal women with osteoporotic bone
  • Often occur after a minor fall
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22
Q

Who tends to be affected by extracapsular fractures?

A
  • Young and middle-aged population
  • Usually result of significant traumatic force
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23
Q

How is a displaced intracapsular fracture treated?

A
  • Surgical replacement of the femoral head
  • Either hemiarthroplasty or total hip replacement
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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
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25
Q

How does the leg appear in a neck of femur fracture?

A
  • Affected leg is shortened, abducted, and externally rotated
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26
Q

Why is the hip externally rotated in a displaced #NOF?

A
  • Due to short lateral rotators of hip:
    1. piriformis
    2. obturator internus
    3. superior and inferior gemelli
    4. quadratus femoris
    (also iliopsoas)
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27
Q

Why is the hip abducted in a displaced #NOF?

A
  • Due to strong abductors that attach to the greater trochanter:
    1. Gluteus medius
    2. Gluteus minimus
    (also externally rotate femur)
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28
Q

Why is the lower limb shortened in a displaced #NOF?

A
  • Strong muscles of thigh pull distal fragment of femur upwards:
    1. Rectus femoris
    2. Adductor magnus
    3. Hamstring muscles
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29
Q

Define dislocation of the hip

A
  • Head of femur is fully displaced out of the cup-shaped acetabulum of the pelvis
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30
Q

What is the common cause of hip dislocation?

A
  • High-speed road traffic collisions
  • Requires a massive amount of force
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31
Q

What is the most common type of hip dislocation?

A
  • 90% are posterior
  • Most commonly due to knee impacting on dashboard during a road traffic collision
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32
Q

What are the signs of a posterior hip dislocation?

A
  • 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
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33
Q

Why does shortening occur in a posterior hip dislocation?

A
  • Head of femur is pulled upwards by the strong extensors and adductors:
    1. Gluteus maximus
    2. Hamstrings
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34
Q

Why does internal rotation occur after a posterior hip dislocation?

A
  • Anterior fibres of the gluteus medius and minimus pull on the posteriorly displaced greater trochanter
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35
Q

What are the signs of anterior hip dislocation?

A
  • Limb is held in a position of external rotation and abduction with slight flexion
  • Femoral nerve palsies can be present but are uncommon
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36
Q

Describe central dislocation?

A
  • 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
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37
Q

What are the different kinds of knee X-rays?

A
  • AP
  • Lateral
  • Patella axial (‘Skyline’)
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38
Q

What are the causes of femoral shaft fractures in the young?

A
  • High velocity trauma e.g. falls from a height or road traffic collisions
  • Should also consider abuse in children
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39
Q

What are the causes of femoral shaft fractures in the elderly?

A
  • 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
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40
Q

What signs indicate a femoral shaft fracture?

A
  • Proximal fragment is often abducted and flexed
  • Distal segment is adducted into a varus deformity and extended
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41
Q

Why is the proximal fragment of the femur abducted and flexed following a femoral shaft fracture?

A
  • Abducted due to pull of gluteus minimus and medius on greater trochanter
  • Flexed due to action of iliopsoas on lesser trochanter
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42
Q

Why is the distal fragment of the femur adducted and extended following a femoral shaft fracture?

A
  • Adducted due to action of adductor magnus and gracilis
  • Extended due to pull of gastrocnemius on posterior femur
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43
Q

What is a serious complication of a femoral shaft fracture?

A
  • 1000-1500ml blood lost in a closed fracture
  • Patient may develop hypovolaemic shock
  • Blood loss may be double if fracture is open
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44
Q

How do we treat femoral shaft fractures?

A
  • Surgical fixation
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45
Q

What causes distal femoral fractures?

A
  • High-energy sporting injuries in the young
  • Fall from standing in the elderly
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46
Q

Why is reduction of a distal femoral fracture essential?

A
  • Popliteal artery may become involved if there is significant displacement of the fracture
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47
Q

What is the usual mechanism of tibial plateau fractures?

A
  • High-energy
  • Axial loading with varus or valgus angulation of the knee
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48
Q

Which part of the bone is affected in a tibial plateau fracture?

A
  • Articulating surface of the tibia with the knee joint
  • Can be unicondylar or bicondylar
  • Lateral condyle is most commonly affected
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49
Q

What do most patients develop after a tibial plateau fracture?

A
  • Articular cartilage is always damaged
  • Most patients will develop post-traumatic OA
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50
Q

What causes patella fractures?

A
  • Direct impact injury e.g. knee against dashboard
  • Eccentric contraction of quadriceps
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51
Q

What indicates a patella fracture on examination?

A
  • Palpable defect in patella
  • Haemarthrosis
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52
Q

What happens if the patella fracture is displaced?

A
  • Extensor mechanism is destructed
  • Patient is unable to perform a straight leg raise
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53
Q

How do we treat patella fractures?

A
  • Displaced fractures require reduction and surgical fixation
  • Undisplaced fractures can be protected through splinting and crutches
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54
Q

What else can present as a patella fracture?

A
  • Bipartite patella
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55
Q

What is meant by patella dislocation?

A
  • Patella is completely displaced out of its normal alignment
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56
Q

Which direction does the patella usually dislocate in and why?

A
  • Laterally
  • Due to the Q angle between the line of pull of the quadriceps tendon and the patellar ligament
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57
Q

What normally holds the patella in the right place?

A
  • 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
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58
Q

What are the common causes of patella dislocation?

A
  • Trauma
  • Often a twisting injury in slight flexion
  • Or a direct blow to the knee
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59
Q

Who is most commonly affected by a patella dislocation?

A
  • Athletic teenagers
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60
Q

What is the usual mechanism of a patella dislocation?

A
  • Internal rotation of the femur on a planted foot whilst flexing the knee (e.g. a sudden change of direction during sports)
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61
Q

What factors can predispose someone to patella dislocation?

A
  • Generalised ligament laxity
  • Weakness of the quadriceps muscle
  • Shallow trochlear groove
  • Long patellar ligament
  • Previous dislocations
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62
Q

How do we treat a patellar dislocation?

A
  • Extend knee and manually reduce patella
  • Immobilise while healing takes place
  • Followed by physio to strengthen VMO
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63
Q

What are meniscal injuries?

A
  • Most common type of knee injury
  • Typically occur during a sudden twisting motion of a weight-bearing knee in a high degree of flexion
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64
Q

What are the symptoms of meniscal injury?

A
  • Intermittent pain
  • Localised to joint line
  • Knee catches, clicks or locks
  • Sensation of giving way
  • Swelling occurs as a delayed symptom
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65
Q

Why is acute haemarthrosis not common in meniscal injury?

A
  • 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
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66
Q

How does a patient suffering from meniscal injury present on examination?

A
  • Joint line tenderness
  • Restricted motion due to pain or swelling
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67
Q

How do we treat acute traumatic meniscal tears?

A
  • Surgical meniscectomy or meniscal repair
  • Conservative treatment is recommended for chronic degeneration of the menisci
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68
Q

What can cause collateral ligament injuries?

A
  • Common sporting injury (especially direct contact sports)
  • Usually result from acute varus or valgus angulation of the knee
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69
Q

What usually controls the movement of the knee joint?

A
  • 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
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70
Q

Which ligament is is at risk in acute valgus sprain?

A
  • Medial collateral ligament
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71
Q

Which ligament is at risk in acute varus sprain?

A
  • Lateral collateral ligament
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72
Q

Which collateral ligament is more at risk of injury?

A
  • MCL is more commonly injured
  • Torn LCL has a higher chance of causing knee instability
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73
Q

Why does torn LCL have a higher chance of causing knee instability?

A
  • Medial tibial plateau forms a deeper and more stable socket for the femoral condyle
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74
Q

How does a patient with collateral ligament injury present?

A
  • Immediately after the injury, patient will experience pain and swelling of the knee
  • As pain and stiffness subside, joint may feel unstable/give way
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75
Q

What is the unhappy triad?

A
  • Injury to ACL, MCL, and medial meniscus
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76
Q

What causes an unhappy triad?

A
  • Strong force applied to the lateral aspect of the knee
  • Medial meniscus is firmly attached to MCL, which is why it is also injured
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77
Q

Which cruciate ligament is more commonly injured?

A
  • ACL is weaker and is more commonly injured
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78
Q

What usually causes a tear of the ACL?

A
  • 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
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79
Q

What are the symptoms of a torn ACL?

A
  • 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
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80
Q

What is the function of the ACL?

A
  • Prevents medial rotation of the tibia when the knee is extended
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81
Q

What usually causes PCL injury?

A
  • 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
Q

How do we treat PCL injuries?

A
  • Conservative management with bracing and rehabilitation
83
Q

How do we detect ACL and PCL injuries?

A
  • Anterior and posterior drawer tests
  • Lachman’s test
84
Q

What causes dislocation of the knee joint?

A
  • Uncommon injury
  • Always results from high energy trauma
  • At least 3 of the 4 ligaments have to be ruptured
85
Q

What injury is associated with a knee dislocation?

A
  • Arterial injury
  • Because the popliteal artery is immobile
  • May tear and cause haematoma
  • Or may be crushed or suffer a traction injury
86
Q

What needs to happen after a dislocated knee is reduced?

A
  • Fully assess the vascularity of the leg with MRA
87
Q

What can cause swellings around the knee?

A
  • 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
Q

Describe effusions of the knee

A
  • 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
Q

What causes delayed swelling of the knee joint?

A
  • Reactive synovitis
  • Inflammation of the synovium following injury results in increased production of synovial fluid
90
Q

Which bursae of the knee are most commonly inflamed?

A
  • Prepatellar bursa
  • Infrapatellar bursa
  • Pes anserinus bursa
  • Suprapatellar bursa
91
Q

Where is the pre-patellar bursa found?

A
  • Superficial bursa with a thin synovial lining
  • Located between the skin and patella
  • Contains a minimal amount of fluid
92
Q

How does pre-patellar bursitis present?

A
  • Knee pain and swelling
  • Erythema overlying inflamed bursa
  • Difficulty working and kneeling on affected side
93
Q

What is the history of a patient with pre-patellar bursitis?

A
  • Repetitive trauma to the bursa
  • Housemaid’s knee
  • Leaning forwards on the knee
94
Q

Where is the infra-patellar bursa found?

A
  • 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
Q

What is the history of a patient with infra-patellar bursitis?

A
  • Repeated microtrauma caused by activities involving kneeling
  • Clergyman’s knee
96
Q

Which condition tends to cause supra-patellar bursitis?

A
  • Knee effusion
  • Because suprapatellar bursa is an extension of the synovial cavity of the knee joint
97
Q

What are some causes of a knee effusion?

A
  • 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
Q

What causes semimembranosus bursitis?

A
  • 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
Q

What is Osgood-Schlatter’s disease?

A
  • OSD is inflammation of the apophysis of the patellar ligament into the tibial tuberosity
100
Q

Who is commonly affected by OSD?

A
  • Teenagers who play sport (running and jumping)
  • Causes localised pain and swelling
101
Q

What are the symptoms of OSD?

A
  • Intense knee pain during running, jumping, squatting, ascending and descending stairs and during kneeling
102
Q

How does OSD resolve?

A
  • Usually resolves with rest and ice
  • When apophyses fuse, pain and swelling resolve
103
Q

What are the symptoms of OA of the knee?

A
  • 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
Q

How is OA of the knee treated?

A
  • Initially patients are taught exercises to strengthen the vastus medialis muscle
  • Analgesia, weight loss, activity modification
  • Surgery in form of total knee replacement
105
Q

Define septic arthritis?

A
  • Invasion of the knee joint space by microorganisms, usually bacteria.
106
Q

Which joints can be affected by septic arthritis?

A
  • Knee (most commonly affected)
  • Hip
  • Shoulder
  • Ankle
  • Wrists
107
Q

Which pathogens can cause septic arthritis?

A
  • Staphylococcus aureus
  • Staph. epidermis
  • Neisseria gonorrhoeae
  • Strep. viridans
  • Strep. pneumoniae
108
Q

What are the risk factors for septic arthritis?

A
  • Extremes of age
  • Diabetes mellitus
  • Rheumatoid arthritis
  • Immunosuppression
  • IV drug abuse
  • Prosthetic joints
  • Delayed wound healing
109
Q

Why are prosthetic joints at increased risk of septic arthritis?

A
  • Due to intra-operative contamination or haematogenous spread from a distant infective focus
  • Biofilms can easily form
110
Q

What are the consequences of bacterial infection of joints?

A
  • 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
Q

What is the triad of symptoms of septic arthritis?

A
  • Fever
  • Pain
  • Reduced range of motion
  • May evolve over a few days to a few weeks
112
Q

What should a septic joint be examined for?

A
  • Erythema
  • Swelling
  • Warmth
  • Tenderness
  • Limitation of active and passive range of motion
113
Q

How do we treat septic arthritis?

A
  • Aspiration of the joint needs to be carried out immediately
  • Aspirate should be sent for urgent microscopy, culture and sensitivities
114
Q

What are the clinical signs of compartment syndromes?

A
  • 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
Q

What should we do if we suspect compartment syndrome?

A
  • Fasciotomy (surgical decompression) of call affected compartments
116
Q

What are the short term consequences of compartment syndrome?

A
  • 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
Q

Why does compartment syndrome result in neurovascular signs?

A
  • 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
Q

What are the long-term consequences of compartment syndrome?

A
  • Rhabdomyolysis can result in AKI which may become chronic
  • Necrotic muscle may also undergo fibrosis leading to Volkmann’s ischaemic contracture
119
Q

What is the usual mechanism of injury of an ankle fracture?

A
  • Inversion or eversion injury
120
Q

What do we need to consider when seeing a patient with an ankle fracture?

A
  • 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
Q

What are the complications associated with fracture blisters?

A
  • 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
Q

What are the complications associated with open fractures?

A
  • Require urgent surgery with extensive irrigation and debridement to reduce the risk of osteomyelitis (infection of the bone)
123
Q

What is the ankle joint normally like?

A
  • 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
Q

Why is it important to recognise that the ankle joint is organised in a ring shape?

A
  • 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
Q

What is talar shift?

A
  • 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
Q

How are stable ankle fractures treated?

A
  • Non-operatively with an aircast boot or a fibreglass cast
  • Patients can weight-bear safely
  • Low rate of complications such as secondary osteoarthritis
127
Q

How are unstable ankle fractures treated?

A
  • Need surgical stabilisation
  • Can be high risk surgery in patients with diabetes or peripheral vascular disease
128
Q

What is an ankle sprain?

A
  • A partial or complete tear of one or more ligaments of the ankle joint
129
Q

What are the following factors that put a patient at increased risk of ankle sprain?

A
  • 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
Q

What usually causes ankle sprains?

A
  • Excessive strain on the ligaments of the ankle
  • Can be caused by excessive external rotation, inversion or eversion of the foot
131
Q

What is the most common mechanism of injury of ankle sprain?

A
  • Inversion injury affecting a plantar-flexed and weightbearing foot
  • Anterior talofibular ligament is most at risk of sprain
132
Q

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?

A
  • 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
Q

Who is commonly affected by rupture of the Achilles tendon?

A
  • Most commonly occurs in men aged 30-50 years during recreational sports
  • E.g. jumping, pivoting and running
134
Q

What are the mechanisms of injury of Achilles tendon rupture?

A
  • 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
Q

Which area of the Achilles tendon is the common site of rupture?

A
  • Vascular watershed area
  • Area of decreased vascularity and thickness of the tendon
136
Q

What are the symptoms and signs of Achilles tendon rupture?

A
  • 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
Q

What test is used to test for a ruptured Achilles tendon?

A
  • Thompson’s test
138
Q

How is Achilles tendon rupture diagnosed?

A
  • MRI and USS
139
Q

How is rupture of the Achilles tendon treated?

A
  • 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
Q

What is hallux valgus?

A
  • Varus deviation of the first metatarsal
  • Valgus deviation of the hallux
  • Prominence of the first metatarsal head, with or without an overlying callus
141
Q

Who is commonly affected by hallux valgus?

A
  • Middle-aged females
142
Q

What are the signs and symptoms of hallux valgus?

A
  • Leads to painful movement of the first MTPJ and difficulty with footwear
  • Most common cause of bunion
143
Q

What can cause hallux valgus?

A
  • 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
Q

How do we treat hallux valgus?

A
  • Surgery should not be carried out for cosmetic reasons alone
  • Involves metatarsal osteotomy and realigning the fragments
145
Q

What is hallux rigidus?

A
  • OA of the first metatarsophalangeal joint
  • Resulting in stiffness of the joint
146
Q

Why is the first metatarsophalangeal joint prone to OA?

A
  • Joint is normally under tremendous stress during walking
  • Can also develop due to gout and previous septic arthritis
147
Q

What is the commonest symptom of hallux rigidus?

A
  • 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
Q

What happens to the range of motion of the big toe in hallux rigidus?

A
  • Range of dorsiflexion of the toe becomes severely restricted due to the arthritis
  • Plantarflexion is usually retained
149
Q

How do we treat hallux rigidus?

A
  • Activity modification
  • Analgesia
  • Orthotics or aids
  • Intra-articular steroid injections
  • Surgery - arthrodesis (fusion) of 1st MTPJ
150
Q

What is different about ankle OA?

A

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
Q

What is the gold standard treatment of ankle OA?

A
  • Gold standard treatment is arthrodesis (allows patient to walk very well)
  • Ankle arthroplasty may be considered (more risks)
152
Q

What are the different types of toe deformity?

A
  • Claw toe
  • Mallet toe
  • Hammer toe
  • Curly toe
153
Q

What is claw toe?

A
  • Often affect all four of the small toes at the same time
  • Toes are hyperextended at the MTPJ
  • Flexed at the PIP joint
154
Q

List some causes of claw toe

A
  • 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
Q

What is hammer toe?

A
  • Toe is flexed at the PIPJ
  • Deformity is most common in the second toe
156
Q

What are some causes of hammer toe?

A
  • Ill-fitting pointed shoes
  • Pressure on the second toe from an adjacent hallux valgus
157
Q

What is mallet toe?

A
  • Toe is flexed at the DIPJ
  • Deformity is most common in the second toe
158
Q

What are curly toes?

A
  • Congenital
  • Usually involve 3rd to 5th digits
  • Usually bilateral
159
Q

Why do curly toes develop?

A
  • Tendons of the flexor digitorum longus or flexor digitorum brevis are too tight
160
Q

How do we treat curly toes?

A
  • 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
Q

What is Achilles tendinopathy?

A
  • A degenerative, not an inflammatory process
  • Can be insertional or non-insertional
162
Q

What can cause Achilles tendinopathy?

A
  • Follows many years of overuse
  • Especially in athletes whose training regimens are poor
  • Other risk factors include obesity and diabetes
163
Q

What are the symptoms and signs of Achilles tendinopathy?

A
  • 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
Q

How do we treat Achilles tendinopathy?

A
  • Physiotherapy
  • Especially eccentric stretching exercises
  • Try to improve the vascularity of the tendon and promote healing
165
Q

What is pes planovalgus?

A
  • Flat foot
  • Medial arch of the foot has collapsed
  • Medial border of the foot almost touches the ground
  • Valgus angulation of the hindfoot
166
Q

Why do most young children appear flat footed?

A
  • Their arches have not yet developed
  • There is a large amount of subcutaneous adipose tissue in the sole of the foot
167
Q

What is meant by flexible flat foot?

A
  • 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
Q

What is meant by rigid flat feet?

A
  • Always abnormal
  • Result of tarsal coalition
  • When patient stands on tiptoe, no arches appear and hindfoot remains in valgus
169
Q

What causes adult acquired flat foot?

A
  • Dysfunction of the tibialis posterior tendon, which usually supports the medial longitudinal arch of the foot
170
Q

Who is usually affected by adult acquired flat foot?

A
  • Middle-aged females
  • Obesity
  • Hypertension
  • Diabetes
  • Pregnancy
171
Q

Why does adult acquired flat foot cause lateral deviation of the hindfoot?

A
  • Spring ligament is stretched
  • Causes talar head to be displaced inferomedially
  • Flattens medial longitudinal arch
172
Q

How do we treat adult acquired flat foot?

A
  • Orthotics used to support medial arch
  • Physiotherapy to improve muscle strength
  • Some patients require surgical reconstruction/arthrodesis
173
Q

What is foot disease?

A
  • A common and serious complication of diabetes and includes infection, ulceration or destruction of the tissues of the foot
174
Q

What foot diseases do diabetics suffer from?

A
  • 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
175
Q

How do diabetic patients make their foot disease worse?

A
  • Patients often continue to weight bear on very significant soft tissue abnormalities
  • This exacerbates the problem
176
Q

How do we reduce the risk of foot disease in diabetic patients?

A
  • 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
177
Q

What is Charcot arthropathy?

A
  • Progressive destruction of the bones, joints and soft tissues
  • Most commonly involves ankle and foot
178
Q

What causes Charcot arthropathy?

A
  • Combination of neuropathy, abnormal loading of the foot, repeated microtrauma
  • Metabolic abnormalities leads to inflammation causing osteolysis, fractures, dislocation and deformity
179
Q

What else can diabetic neuropathy lead to?

A
  • Muscle spasticity (e.g. tight Achilles tendon)
  • Exacerbates deformity
  • Rocker-bottom foot may develop
180
Q

How is Charcot arthropathy treated?

A
  • Optimisation of glycaemic control
  • Reduction of the load placed on the affected joints
181
Q

What is Piriformis syndrome?

A
  • 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
182
Q

What are the symptoms of Piriformis syndrome?

A
  • 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
183
Q

What is the most common cause of sciatic nerve entrapment?

A
  • Spasm of the piriformis muscle, usually due to overuse or to direct trauma
  • Anatomical variations in the relationship between nerve and muscle
184
Q

What is treatment of Piriformis syndrome?

A
  • Activity modification
  • Non-steroidal anti-inflammatory drugs
  • Physiotherapy
185
Q

If the sciatic nerve were completely transected in the buttock, what effect would this have on the movement of the lower limb?

A
  • 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
Q

What shows that the superior gluteal nerve has been injured?

A
  • Pelvis on contralateral side will drop (positive Trendelenburg sign) and the foot will catch on the ground on walking
187
Q

What is meralgia paraesthetica?

A
  • Compression of the lateral cutaneous nerve of the thigh as it pierces the fascia lata in the thigh
188
Q

What causes meralgia paraesthetica?

A
  • Obesity
  • Pregnancy
  • Tight clothing
  • Wearing a tool belt
189
Q

What are the symptoms of meralgia paraesthetica?

A
  • 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
Q

How do we diagnose meralgia paraesthetica?

A
  • Absence of motor signs
  • Excluding pelvic and intra-abdominal causes of nerve irritation such as a tumour
191
Q

What causes femoral nerve lesions?

A
  • May result from penetrating wounds to the groin
  • Rarely injured during surgery
192
Q

What are the signs and symptoms of femoral nerve lesions?

A
  • 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
Q

What happens when the tibial nerve is damaged in the proximal popliteal fossa?

A
  • 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
Q

Where is the common peroneal nerve most commonly injured?

A
  • Where the nerve winds around the neck of the fibula
195
Q

What are some causes of common peroneal nerve injury?

A
  • Prolonged bed rest
  • Pressure from a tight plaster cast
  • Poorly placed stirrups in the operating theatre
  • Fractures in the neck of the fibula
196
Q

How do patients with common peroneal nerve injuries present?

A
  • 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
Q

What can cause injury to the superficial peroneal nerve?

A
  • Fractures of the proximal fibula
  • Penetrating injuries to the lateral leg
  • Ankle arthroscopy
  • Lateral approach to surgery on the ankle joint
198
Q

What do patients whose superficial peroneal nerve is damaged by injury present with?

A
  • 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
Q

What do patients whose superficial peroneal nerve is damaged through ankle surgery present with?

A
  • 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
Q

What affects the deep peroneal nerve?

A
  • Most common site of mononeuropathy
  • Due to motor neurone disease, diabetes, ischaemia and vasculitis
  • Can also be injured during a total knee replacement
201
Q

What are the symptoms of damage to the peroneal nerve?

A
  • Foot drop
  • Inability to actively extend toes
  • Small patch of numbness in the first dorsal webspace

MSK (5 decks)

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