Clinical Correlation: Lower Limb

Question 1

What is a Maissoneuve Fracture?

Answer 1

fibular head fracture

can be detected with a squeeze test

Question 2

What is a squeeze test?

Answer 2

A maneuver where the leg is squeezed, forcing the tibia and fibula closer together.

Evoking pain in the ankle is suspicious for high ankle fracture

Evoking pain in the knee is suspicious for Maissoneuve fracture (fibular head fracture)

Question 3

Define enthesopathy

Answer 3

disorder of muscular or tendinous bony attachment

Question 4

Define the following terms concerning joint stability:

1. Dislocation
2. Subluxation
3. Laxity

Answer 4

1. complete discplacement
2. transient, partial displacement
3. normal variant in “joint looseness”

Question 5

What disorder has the following characteristics?

• Hx: overweight early adolescent with history of groin or knee pain referred to anteromedial thigh
• vague symptoms, worse with activity (repetitive load)
• Occurs bilaterally, but generally not at the same time
• Exam: limited internal rotation at the hip

Answer 5

Slipped capital femoral epiphysis (SCFE)

Question 6

Identify/diagnose

What is the treatment?

Answer 6

SCFE (slipped capital femoral epiphysis)

Surgical fixation

Question 7

Transient synovitis of the hip:

1. Epi
2. Etio
3. Exam
4. Tests
5. Treatment

Answer 7

1. ages 3-10
2. viral, post-vaccine, drug-induced
3. patient holds hip slightly flexed and externally rotated. Positive leg roll, refuses to bear weight, otherwise looks OK
4. CBC, sed rate -> mildly elevated
5. NSAIDs for 1-3wks

Question 8

Septic joint

1. Etio
2. Exam
3. Treatment
4. Complications

Answer 8

1. Gonorrhea of skin flora
2. Swollen, painful knee. Pain on both passive and active ROM. Red, hot joint. Usually has systemic signs of inflammation, but may be masked by diabetes or immunocompromise
3. Surgical incision and drainage, IV Abx
4. articular surface destruction

Question 9

What is the most common direction for patellar displacement?

Answer 9

Lateral

Question 10

Patellar dislocation:

1. History
2. Exam
3. Treatment

Answer 10

1. Cutting motion with active quadriceps contraction, producing immediate pain and swelling.
2. Ecchymosis (bruising) and effusion with positive apprehension test of the patella
3. Treat with physical therapy, surgery if recurrent

Question 11

A positive Lachmann test indicates damage to what? How does this injury generally occur?

Answer 11

Sprain or tear of the ACL (anterior cruciate ligament)

Injury due to twisting non-contact deceleration or hyperextension injury. Acutely seen with a distinct ‘pop’ and effusion. Chronic shows significant joint instability.

Question 12

Meniscal tear:

1. Etio
2. Hx
3. Rx

Answer 12

1. twisting motion during loading. Degenerative tears are common in older adults.
2. Locking and effusion of the knee joint
3. Locked: reduce and refer to ortho; non-locked: physical therapy and relative rest

Question 13

Compartment syndrome:

1. Etio
2. Pathogenesis

Answer 13

1. Trauma (bleed or fx) or chronic exertional (hypertrophy of muscles/vessels). More common in legs than arms.
2. increased pressure in a muscular compartment interferes with perfusion.

Question 14

What are the cardinal signs of compartment syndrome?

Answer 14

The 6P’s of compartment syndrome presentation:

1. Pain out of proportion (early)
2. Parasthesia (early)
3. Poikilothermia (later)
4. paralysis (late)
5. pallor (late)
6. pulselessness (late, rare)

Question 15

In compartment syndrom, what pressure level is generally considered a surgical emergency?

Answer 15

>60mmHg

Question 16

Ankle sprain:

1. Caused by what action?
2. What is the most commonly injured ligament in ankle sprain?
3. Physical exam

Answer 16

1. forced excessive inversion of the foot
2. anterior fibulonavicular ligament (part of the lateral ligament group of the ankle)
3. (+) anterior drawer test, do squeeze test for fibular head fracture or high ankle sprain involvement

Question 17

A middle aged male presents with a 4-hour history of difficulty walking. He was playing basketball and said he heard a ‘pop’ followed by intense pain in his upper heal. Physical exam shows a pronounced defect above the posterior heel and marked weakness to plantarflexion.

What is the diagnosis? What is the treatment?

Answer 17

1. Achilles tendon rupture
2. Acute immobilization or surgery, depending on the extent of injury.

Question 18

A football player is tackled from the side, forcing his knee to bend medially. What structure might have been damaged? What is the name for this motion?

Answer 18

1. Tibial collateral ligament (TCL/MCL)
2. Valgus stress

Question 19

What is the classic O’Donoghue sign?

How is this different from the “unhappy triad”?

Answer 19

Formerly ‘unhappy triad’

• ACL rupture
• TCL (MCL) rupture
• medial meniscus tear

Classically, the unhappy triad included medial meniscus tear, but has since been redefined due to lateral meniscus tear being more common in athletes.

Question 20

What is the primary medial stabilizer of the knee in extension?

Answer 20

ACL

Question 21

What is Paget’s disease? Where is it commonly found?

Answer 21

Abnormal bony remodeling and metabolism. Commonly found in the pelvis, femur, skull, and lower lumbar vertebrae.

Question 22

Exertional compartment syndrom is most common in which compartment of the leg?

Answer 22

anterior (40-50%)

Question 23

Stress fracture: describe

Answer 23

• pain from overuse causing bony breakdown faster than repair
• pain worsens through activity
• common locations: tibia, metatarsals
• locations with slow healing - navicular, femoral neck, anterior tibia, tension side of femoral neck

Question 24

Osteochondritis dessicans: describe

Answer 24

• children and adolescents
• interruption of blood supply to a bone segment causes it to separate from the surrounding are
• symptoms: pain, swelling, locking (advaced)
• locations: knee, elbow, joints
• treatment: relative rest (young), surgery to remove fragments (adults)

Question 25

Identify: traumatic avulsion of flexor digitorum profundus from the distal phalanx, due to passive forced extension of DIP joint during active flexion of DIP. Results in loss of active flexion of DIP. How is it treated?

Answer 25

Jersey finger Rx: surgical repair

Question 26

What is mallet finger?

Answer 26

* Traumatic avulsion of terminal extensor tendon from distal phalanx from forced flexion of the DIP during active extension (ball jamming fingertip) * Loss of active extension at DIP * Treatment: immobilization. Large displacement may require surgery

Question 27

Central extensor tendon slip rupture results in what kind of deformity? What is the mechanism of injury?

Answer 27

* Boutonniere deformity - PIP flexure with DIP hyperextension * forced passive PIP flex against active extension, resulting in avulsion of the central slip.

Question 28

What exam findings might you expect on a central extensor slip rupture? What is the treatment?

Answer 28

* tenderness over central slip on dorsal MP base. PIP flexed over a table edge cannot extend. Decreased passive DIP flexion. * Splint in extension with active DIP exercised. Full laceration requires surgical repair

Question 29

What chronic inflammatory disease frequently features a swan-neck disruption? What does a swan-neck rupture look like? What is the mechanism of action for a traumatic swan-neck deformity?

Answer 29

* Rheumatoid arthritis * Features: hyperextension of the PIP joint with flexion of the DIP joint. * Volar plate disruption

Question 31

L4 lumbar radiculopathy: 1. classic lesion site 2. symptom distribution (cutaneous sensation deficit) 3. Weakness 4. Reflex affected

Answer 31

1. L3-L4 lateral disc 2. Proximal to medial malleolus (medial surface of leg) 3. ankle dorsiflexion (tibialis anterior) 4. patellar reflex

Question 32

L4 lumbar radiculopathy: 1. classic lesion site 2. symptom distribution (cutaneous sensation deficit) 3. Weakness 4. Reflex affected

Answer 32

1. L4-L5 lateral disc 2. Proximal to 1st web space 3. Toe extension (extensor halucis longus, extensor digitorum brevis) 4. "none" or tibialis posterior reflex, medial hamstring reflex

Question 33

S1 lumbar radiculopathy: 1. classic lesion site 2. symptom distribution (cutaneous sensation deficit) 3. Weakness 4. Reflex affected

Answer 33

1. L5-S1 lateral disc 2. Posterolateral heel 3. Plantarflexion (gastrocnemius, soleus), foot eversion (fibularis longus, fibularis brevis), hip extension (gluteus maximus) 4. Achilles reflex

Question 34

Why are the gastrocnemius, quadriceps femoris (rectus femoris specifically), and the hamstrings at greater risk of tear injuries?

Answer 34

Because they cross two joints.

Question 35

Plantar fasciitis: describe

Answer 35

* Pain and irritation of the plantar fascia * increased risk with pes planus * usually an overuse injury * pain with first steps, improves with more movement (warming up)

Question 36

What is Sever's Condition?

Answer 36

a.k.a. calcaneal apophysitis irritation of the apophysis of the calcaneal bone due to overuse/weakness of the growth plate compared to the action of the calcaneal ligament. Treat: activity as tolerated. Immobilization or casting if refractory.

Question 37

Name the following 5th metatarsal fractures: 1. stress fracture in the proximal 5MT diaphysis 2. Traumatic fracture to the 5MT metaphyseal-disphyseal junction 3. 5MT base at fibularis brevis insertion 4. spiral fracture in along 5MT diaphysis

Answer 37

1. Pseudo-Jones 2. Jones 3. Avulsion 4. Dancer's

Question 38

What is a Lisfranc sprain?

Answer 38

Tarsometatarsal sprain

Question 39

Lisfranc sprain: describe

Answer 39

* Acute: hard blow to foot or awkward landing * Chronic: mid-foot pain with weight bearing, worse on tip-toes * Exam: mid-foot swelling with palpation of adjacent metatarsals * get weight-bearing views on x-ray