Disease Profiles: Lower Limb Conditions Flashcards
Describe the usual mechanism of injury of a hip fracture in a younger patient
High energy trauma
Describe the surgery available for patients with recurrent patella dislocation
Lateral release, MPFL reconstruction
Describe the management of ankle instability due to ligament injury
Physiotherapy, consider arthroscopy for pain
Reconstruction if needed (75% will not need reconstruction)
Why is a CT useful in a calcaneus fracture?
Calcaneal fractures are often comminuted, anatomy can be clarified by CT
Rupture of which ligament may lead to rotatory instability?
ACL
Name two potential complications of an LCL rupture
Common fibular nerve palsy, early OA of the knee
What is the usual mechanism of injury for an ankle fracture?
Inversion injury with a rotational force applied to the foot
Name the surgical procedure used to treat a displaced intracapsular fracture in a patient who was previously high functioning
Total hip replacement
Which patient group is most likely to develop hallux valgus?
Higher incidence in females, familial tendency, incidence increases in age
Commoner in rheumatoid arthritis and other inflammatory arthropathies as well as some neuromuscular diseases (multiple sclerosis, cerebral palsy)
What can causes a metatarsal stress fracture?
Repeated injury or stress e.g. runners, soldiers on long marches, dancers
What is type II tibialis posterior tendon dysfunction?
Planovalgus, midfoot abduction, passively correctable
Which investigations would you perform in suspected Morton’s neuroma?
X-ray (AP/LAT/oblique WB) to rule out MSK pathology
Diagnostic US - swollen nerve
Describe the clinical presentation of an ACL injury
Audible pop followed by deep knee pain and swelling (haemarthrosis) within an hour of the injury
Pain settles but leaves rotatory instability
What does joint pain in hallux valgus indicate?
OA
Which patient group is most likely to fracture their hip?
60+ years, association with osteoporosis, majority are female
Which type of extracapsular hip fracture is represented by the red line in the diagram?
Basicervical
What causes a loose body in a joint?
Trauma, osteochondritis dissecans and joint degeneration can cause a fragment of cartilage +/- bone to detach
Which patient group is most likely to rupture their Achilles tendon?
>40 years, associated with diabetes, RA and steroid use
Describe the management of a ruptured LCL diagnosed early (within 2-3 weeks)
Urgent repair
Describe the usual management of a knee extensor mechanism rupture
Urgent surgical repair with follow up physio to gradually increase ROM
Which tendon can cause an avulsion fracture of the 5th metatarsal?
Peroneus brevis tendon
Describe the x-ray findings of a tibial plateau fracture
Variable - from obvious fracture line to subtle subchondral sclerosis
Horizontal beam lateral shows lipohaemarthrosis
Small avulsed bone fragments can indicate significant soft tissue injury
How would you manage a PCL injury which is part of a multilligament knee injury?
Usually requires reconstruction
Which patient group is most likely to dislocate their patella?
Most common in teenagers, higher incidence in females
Describe the clinical presentation of a PCL injury
Popliteal knee pain and bruising
How would you diagnose an LCL injury?
Isolated LCL tear is a clinical diagnosis but x-rays and MRI can be used to rule out associated injuries
Describe the management of a bucket handle meniscal tear
If picked up early - can be repaired If irreparable - partial meniscectomy
When might a theatre reduction be indicated for a complete knee dislocation?
If medial femoral condyle button-holed through the medial capsule
How can a patella dislocation cause an osteochondral fracture?
Medial patellofemoral ligament will tear and the medial facet of the patella strikes the lateral femoral condyle
What does a loss of contour of Shenton’s line in pelvic x-ray indicate?
Hip fracture
Describe the management of patellofemoral dysfunction
Physio to strengthen quadriceps (particularly vastus medialis obliqus)
Taping may help alleviate symptoms
Which investigation would you perform in suspected bone marrow oedema (bone bruising)?
MRI
Which classification system is used to categorise intracapsular hip fractures?
Garden classification - predicts union and risk of AVN, which influences treatment
What is type I tibialis posterior tendon dysfunction?
Swelling, tenderness, slightly weak muscle power
Which type of antibiotics can cause tendonitis?
Quinolone antibiotics (ciprofloxin)
Which part of the knee extensor mechanism tends to rupture in the younger age group (<40 years)?
Patellar tendon
Name the classification mechanism for tibial plateau fractures
Schatzer
When might an arthroscopic meniscectomy be indicated in a meniscal tear?
Irreparable tears with recurrent pain, effusion or mechanical symptoms (catching, clicking, locking) which fails to settle within 3 months
Describe the management of a Lisfranc injury
Requires fixation - ORIF
Describe the examination findings in ACL injury
Excessive anterior translation of the tibia on the anterior drawer test and Lachman test
What is the usual mechanism of injury for a calcaneus fracture?
Axial compression e.g. falling from height onto the heel
Describe the clinical presentation of a Baker’s cyst
Can appear as general fullness of the popliteal fossa
Soft and non-tender
Describe the clinical presentation of hallux valgus
Usually bilateral, joint incongruence can cause pain
May be unable to wear closed shoes due to bursa (bunion) and/or nerve damage
The great toe and second toe may rub causing ulceration and skin breakdown
Transfer metatarsalgia or poor balance indicates defunctioned 1st ray
How would you manage an isolated PCL injury?
Conservative - generally don’t require reconstruction
What is trochanteric bursitis?
Repetitive trauma caused by iliotibial band tracking over trochanteric bursa which causes inflammation of the bursa
Describe the surgical management of Achilles tendonitis
Tendon decompression and resection of paratenon (rarely used as condition is usually self-limiting)
Describe the clinical presentation of a loose body in a joint
History of mobile lump or sharp occasional pain and locking/catching suggestive of loose body
They should not cause constant, generalised or severe pain
Describe the management of a patella dislocation
Manually reduce if not already spontaneously reduced, brace, physio
Rupture of which ligament may lead to valgus instability?
MCL
When would surgical management of hallux valgus be indicated?
Failure of conservative management, lesser toe deformities, lifestyle limitation, overlapping, functional limitation (NOT cosmetic reasons alone)
What is plantar fasciitis?
Degenerative condition of the plantar fascia that causes sharp pain on the bottom of the foot pain
Why is there a risk of AVN in a talus fracture?
Talus has a reversed blood supply
Describe the examination findings in Morton’s neuroma
Loss of sensation in the affected webspace, Mulder’s click test
Which investigations would you perform if you suspect a loose body?
X-ray (commonly overdiagnosed), MRI can confirm
Describe the pathophysiology of Achilles tendon rupture
May follow a single high energy event, but is often the culmination of recurrent minor tears or following recent tendonitis
Describe the x-ray findings of a calcaneus fracture
Calcaneal compression causes loss of the central peak seen in a normal calcaneaus (measured using Bohler’s angle), and bone density will increase
Describe the clinical presentation of a hip fracture
Hip/groin pain, may be swelling, unable to weightbear
Which patient groups are most likely to develop trochanteric bursitis?
Females, young runners and older patients
Which other fracture clinically resembles a 5th metatarsal fracture?
Lateral malleolar fracture
Describe the usual mechanism of injury for a complete knee dislocation
Serious high energy injury (usually - can be low energy in elderly)
How would you investigate a low energy pelvic fracture?
MRI most sensitive, CT more sensitive than x-ray especially once fractures start to heal
Describe the clinical presentation of tibialis posterior tendon dysfunction
Pain and/or swelling posterior to medial malleolus, change in foot shape, diminished walking ability/balance, mid foot and ankle pain
Describe the examination findings in hallux rigidus
Dorsal exostosis (bone spur), IPJ hyperextension
Describe the examination findings of a patella dislocation
Pain medially, haemarthrosis (effusion), positive patella apprehension test
When might an arthroscopic meniscal repair be indicated in a meniscal tear?
Acute traumatic peripheral meniscal tears in younger patients
Which investigation would you perform in a suspected tibial shaft fracture?
X-ray - AP and lateral
What is lipohaemarthrosis?
Escape of fat and blood from the bone marrow into the joint due to an intra-articular fracture, most commonly seen in the knee
Describe the mechanism of injury of a ‘bumper injury’
Tibial plateau fracture affecting the lateral condyle which is caused by valgus force with foot planted
Which investigations would you perform in a suspected ankle fracture?
X-ray - AP and lateral views
CT can help clarify fracture anatomy, especially complex fractures
US and MRI may be needed to define soft tissue injury
What is gluteal cuff syndrome?
The broad tendinous insertion of the abductor muscles (predominantly the gluteus medius) is under considerable strain and is subject to tendonitis and degeneration leading to tendon tears
A stress fracture most commonly occurs in which metatarsals?
Most commonly 2nd metatarsal, followed by 3rd
Describe the management of a metatarsal stress fracture
Rest for 6‐12 weeks in a rigid soled boot
What are hammer toes?
PIPJ flexion, DIPJ extension and neutral MTPJ
Which nerve is at risk of damage in an LCL rupture?
Common fibular nerve
Which nerve is at risk of damage due to a hip dislocation?
Sciatic nerve
What is the usual mechanism of injury for a meniscal tear in an older patient?
Atraumatic spontaneous degenerate tears, probably represents 1st stage of knee OA
Describe the management of bone marrow oedema (bone bruising)
Will settle with time - no treatment know to speed up resolution (3 months-over a year)
Name the components of the extensor mechanism of the knee
Tibial tuberosity, the patellar tendon, the patellar, the quadriceps tendon and the quadriceps muscles
Describe the management of a degenerative meniscal tear
Corticosteriod injection may help with symptoms in the early period, pain and inflammation may settle but healing rates decrease with age
Arthroscopic menisectomy not indicated as only suitable for unstable tears and not pain only
What is the usual mechanism of injury for LCL injury?
Varus stress and hyperextension
Often occurs in combination with PCL or ACL injury
Which classification system is used to categorise pelvic ring fractures?
Young-Burgess classification
What is the usual mechanism of injury for a meniscal tear in a younger patient?
Usually a sporting injury, classically a twisting force on a loaded knee
What is the primary investigation for a pelvic fracture?
X-ray - pelvis and lateral hip
Describe the surgical management of an ankle fracture
ORIF
Which patient factor is inversely proportional to the risk of recurrent patella instability?
Age
Which investigation would you perform in suspected PCL injury?
X-ray, MRI
What is the mechanism of injury for a 5th metatarsal fracture?
Inversion injury
Why are knees with degenerative changes on imaging unlikely to benefit from an arthroscopic menisectomy to treat a meniscal tear?
Removal of meniscal tissue may increase the stress on already worn/damaged surfaces
Describe the management of tibialis posterior tendon rupture
If no secondary OA present - tendon transfer
If secondary OA present - arthrodesis
Describe the mechanism of injury of a tibial plateau fracture in a older patient
Low energy injury
What is the usual mechanism of injury for an MCL injury?
Valgus stress with possible external rotation (e.g. rugby tackling from the side)
What is the gold standard investigation for pelvic soft tissue injury?
MRI - provides a more complete assessment of all soft tissues and bones
What is the usual mechanism of injury for a PCL injury?
Tend to occur following a direct blow to anterior tibia (e.g. dashboard, motorbike)
Isolated PCL rupture rare (usually occurs with other injury)
Why is a Jones fracture of the 5th metatarsal at risk of non-union?
Poor blood supply
Describe the clinical presentation of a patella dislocation
Clear history of patella dislocating laterally, often self-relocating
Describe the conservative management of a tibial plateau fracture
Above knee cast
Why are intracapsular hip fractures prone to femoral head AVN and non-union?
Can damage the medial femoral circumflex artery
What is a bucket handle meniscal tear?
Large meniscal fragment is able to flip out of its normal position and displace anteriorly or into the intercondylar notch where the knee locks and is unable to fully extend due to mechanical obstruction from the trapped meniscal fragment
Which deformity can develop following a bucket handle meniscal tear which remains locked?
Fixed flexion deformity
Which type of hip fracture occurs distal to the intertrochanteric line?
Extracapsular fracture
Why would a repeat x-ray or MRI be indicated in a patient with suspected hip fracture?
Some undisplaced fractures are subtle/invisible on x-ray, so if clinical suspicion persists further investigation is needed
What is a Lisfranc injury?
Fracture and/or dislocation of the midfoot that disrupts one or more tarsometatarsal joints
Describe the clinical presentation of a meniscal tear
Pain and tenderness localised to joint line, patient may feel knee is about to give way if a loose meniscal fragment is caught in the knee when walking, catching or locking sensation
Name the two categories of intracapsular hip fracture
Subcapital and transcervical
Which artery is at risk in a complete knee dislocation?
Popliteal artery
Describe the management of plantar fasciitis
Rest, NSAIDs, physiotherapy
Night splinting, taping, heel cups or medial arch supports
Corticosteriod injections may alleviate symptoms
Describe the prognosis of a ruptured LCL
Tends not to heal and can cause varus and rotatory instability
Which investigations would you perform in a calcaneus fracture?
X-ray, CT
Describe the mechanism of injury of a tibial plateau fracture in a younger patient
High energy injury
Which classification system is used to categorise ankle fractures?
Weber classification
Which investigations would you perform in suspected ACL injury?
Joint aspiration - haemarthrosis
MRI to confirm
Describe the clinical presentation of pes cavus
Pain in the arch of the foot, often accompanied by claw toes
Describe the definitive management of a complete knee dislocation
Sequential ligamentous repair
Name two possible complications of a femoral shaft fracture
Significant blood loss, risk of fat embolus
Why are tibia/fibula fractures commonly found with a talus fracture?
The fibia and fibula are paired bones forming an elongated ring with the talus - bony ring injuries usually involve disruption at >1 site
When would vascular stenting or by‐pass be indicated in a complete knee dislocation?
If there is associated neurovascular injury
Describe the management of an acute MCL injury
Hinged knee brace
Which investigation would you perform in suspected hallux rigidus?
WB X-ray - AP/LAT and oblique
What is Mulder’s click test?
Medio‐lateral compression of the metatarsal heads (exerted by squeezing the forefoot with your hand) may reproduce symptoms or produce a characteristic ‘click’
Used to examine causes of metatarsalgia associated with Morton’s neuroma
What is hallux rigidus?
OA of the first MTP joint
Describe the pathophysiology of tibialis posterior tendon dysfunction
The tendon is under repeated stress and particularly with degeneration can develop tendonitis, elongation and eventually rupture
Describe the x-ray findings in a quadriceps tendon rupture
Effusion, patella sitting low
Describe the management of chronic MCL instability
MCL tightening (advancement) or reconstruction with tendon graft (rare)
Which investigation would you perform in a suspected patella fracture?
X-ray - AP and lateral
Which investigations would you perform for a complete knee dislocation where there is no concern over neurovascular status?
X-ray, MRI
Which part of the knee extensor mechanism tends to rupture in the older age group (>40 years)?
Quadriceps tendon
Which type of hip fracture occurs proximal to the intertrochanteric line and involves the femoral head and neck?
Intracapsular fracture
Describe the clinical presentation of Morton’s neuroma
Burning pain and a tingling that radiates to the affected toes
Pain exacerbated by footwear, and relieved by removal of shoe, massaging foot and changing footwear
What typically causes acute pelvic soft tissue injury?
Muscle tear or tendon avulsion
What is pes cavus?
Abnormally high arch of the foot
What is a Baker’s cyst?
Inflammation and swelling of the semimembranosus bursa that usually arises in conjunction with OA of the knee
Name the surgical procedure used to treat an subtrochanteric extracapsular fracture
IM nail
Describe the examination findings of a patient with a hip fracture
Lower limb on affected side may be shortened and externally rotated
Which investigations can be used to distinguish between complete and partial tears of the Achilles tendon?
US or MRI
What typically causes chronic pelvic soft tissue injury?
Chronic overuse which causes bone or soft tissue pain at the site of tendon/ligament attachment
Describe the surgical management of a ruptured Achilles tendon
Suture repair of tendon
Describe the clinical presentation of an LCL injury
Knee swelling with ecchymosis, pain, deformity and instability
What is Morton’s neuroma?
Benign fibrotic thickening of a plantar digital nerve due to repeated trauma (irritation)
What might a small opacification suggest in a patella dislocation?
Osteochondral fracture
Describe the management of a calcaneus fracture
Cast immobilisation with nonweightbearing for 6-12 weeks
Describe the conservative management of a pelvic fracture
Analgesia, weight bearing as tolerated
Which nerve is at risk in a complete knee dislocation?
Common fibular nerve
Describe the definitive management of a hip dislocation
Fixation of associated pelvic fractures, fixation of other injuries in poly-trauma patients
What is the usual mechanism of injury of a femoral shaft fracture?
High energy injuries, occur in major trauma patients and is often associated with other injuries
Describe the conservative management of hallux valgus
Wearing wider and deeper shoes to prevent bunions, the use of a spacer in the first web space to stop rubbing between the great and second toes
Why should steroid injections for tendonitis of the extensor mechanism of the knee be avoided?
High risk of tendon rupture
Describe the clinical presentation of patellofemoral dysfunction
Anterior knee pain, worse going downhill
Grinding or clicking sensation at the front of the knee and stiffness after prolonged sitting causing ‘pseudolocking’ where the knee acutely stiffens in a flexed position
How would you manage an isolated PCL injury in which the patient has recurrent instability?
Consider reconstruction
Describe the clinical presentation of plantar fasciitis
Start up pain after rest on the instep of the foot (at the origin of the plantar aponeurosis on the distal plantar aspect of the calcaneal tuberosity)
Pain can be worse after exercise
Which investigation would you perform in a suspected metatarsal stress fracture?
X-ray - AP and oblique views
Bone scan may be needed to confirm as fracture may not be visible for 3 weeks on x-ray
How can a loose body grow over time?
Gets nutrition from the synovial fluid
Describe the indications for surgical excision of Morton’s neuromas
Symptoms persist after 2-3 months of footwear modification and metatarsal pads/metatarsal dome, inadequate response to corticosteriod injection
What is bone marrow oedema (bone bruising)?
Impaction to articular surface leads to microscopic fracture of trabecular bone with bleeding and inflammation
What is the most commonly injured knee ligament?
ACL
Describe the examination findings of a meniscal tear
May be inflammatory effusion present, positive meniscal provocation tests e.g. Steinman’s
Acute locked knee signifies displaced bucket handle meniscal tear
Describe the operative management of a patella fracture
ORIF, partial/total patellectomy
How does tibialis posterior tendon dysfunction lead to flat feet?
Elongation or rupture leads to loss of the medial arch with resulting valgus of the heel and flattening of the medial arch of the foot
Name a complication of bone marrow oedema (bone bruising)
Hyaline cartilage over area may deteriorate over time leaving a full thickness chondral defect
What is hallux valgus?
Deformity of the great toe due to medial deviation of the 1st metatarsal and lateral deviation of the toe itself
Describe the clinical presentation of a calcaneus fracture
Pain, inability to bear weight, significant swelling
Look for other injuries especially spinal
Name the surgical procedure used to treat an intertrochanteric extracapsular fracture
Dynamic hip screw
Describe the conservative management of a tibial shaft fracture
Above knee cast
Patient may need closed reduction in theatre before cast is fitted
A meniscal tear occurs in 50% of injuries to which other knee ligament?
ACL
Which ankle ligament is most commonly injured?
AFTL - weakest ligament
Describe the examination findings of a patella fracture
Palpable patella defect, significant haemarthrosis, unable to perform straight leg raise
How can you distinguish between a 5th MT base fracture in an adolescent and the normal adolescent ossification centre?
5th MT base fracture will be transverse, ossification centre is longitudinal
When might an US be indicated in a pelvic soft tissue injury?
Can show acute injuries affecting superficial structures
Describe the clinical presentation of a patella fracture
Severe pain in/around kneecap
What is the usual mechanism of injury for an ACL injury?
Usually twisting sports injury - higher rotational force, turning the upper body laterally on a planted foot (football, rugby, skiing)
Why is the risk of AVN and non-union low in extracapsular hip fractures?
Blood supply to the head of femur is intact
Name two fractures associated with a hip dislocation
Posterior acetabular wall, femoral
What is a Thomas splint used for?
Initial management of a femoral shaft fracture for temporary stabilisation
Why is it unusual to have a single pelvic fracture?
Bony disruption usually affects more than one site
Describe the conservative management of a patella fracture
Knee immobilised in extension, full weight bearing
Describe the management of a femoral shaft fracture
Nearly always operative - IM nail, plate fixation (ORIF/MIPPO)
What causes pes cavus?
Can be idiopathic but is often related to neuromuscular conditions
Describe the conservative management of claw and hammer toes
Toe ‘sleeves’ and corn plasters to prevent toes rubbing on footwear
Describe the USS/MRI findings in a knee extensor mechanism rupture
May show partial/complete tear
Which type of extracapsular hip fracture represented by the green line in the diagram?
Reverse oblique
What is a grade 3 ligament injury?
Complete tear
Why should steroid injection not be administered around the Achilles tendon?
Risk of rupture
Which type of extracapsular hip fracture is represented by the blue line in the diagram?
Subtrochanteric
What causes the medial patella pain in a patella dislocation?
Torn medial patella retinaculum tendon
Which patient group is most likely to develop Morton’s neuroma?
Mean age 45-50, obese, female (possible link to high heels)
Describe the prognosis of plantar fasciitis
Symptoms can take up to two years to resolve
Which meniscus tears most commonly?
Medial meniscus
Describe the surgical management of claw and hammer toes
Tenotomy, tendon transfer, arthrodesis (PIPJ) or toe amputation
Describe the clinical presentation of an knee extensor mechanism rupture
Knee pain and weakness
Describe the management of trochanteric bursitis
Analgesia (NSAIDs), physio, steroid injection
What is the usual mechanism of injury for a talar dome margin fracture?
Excessive inversion/eversion
Define a chronic ankle sprain
Recurrent sprains or giving way, persisting for more than 6 months
What is type III tibialis posterior tendon dysfunction?
Fixity and mortise signs
Which direction does the hip most commonly dislocate in?
Posteriorly
Describe the management of a loose body
Arthroscopic removal can help troublesome symptoms but won’t help degenerative joint pain
Name the directions for a complete knee dislocation
Posterior, anterior, medial, lateral, rotatory
What is a grade 2 ligament injury?
Partial tear - some fascicles disrupted
Describe the examination findings in trochanteric bursitis
Pain on palpation of the greater trochanter and on restricted abduction
Which region of the 5th metatarsal is a common site for a stress fracture?
Proximal shaft
Describe the clinical presentation of a tibial shaft fracture
Pain, inability to bear weight, deformity
Why are patients with hip fractures mobilised early?
To avoid complications of prolonged bed rest
Describe the usual mechanism of injury of a hip fracture
Low impact fall in the elderly (92% of patients are over 60)
Which investigations would you perform for a complete knee dislocation where there is concern over neurovascular status?
X-ray, CT angiogram
Describe the conservative management of ACL injury
Can stabilize with time and physiotherapy
Which syndrome may trochanteric bursitis be linked to?
Gluteal cuff syndrome
When would a pelvic binder for a pelvic fracture be indicated?
Initial management for high energy mechanisms to control circulatory loss
Which investigation would you perform in a suspected tibial shaft fracture?
X-ray - AP and lateral
Name the surgical procedure used to treat an undisplaced intracapsular fracture in a patient who was previously high functioning
Compression hip screw
Describe the x-ray findings in a patella tendon rupture
Effusion, patella sitting high
Describe the clinical presentation of Achilles tendon rupture
Sudden deceleration with resisted calf muscle contraction (e.g. lunging at squash) leads to sudden pain (like being kicked in the back of the leg) and difficulty weight bearing
Which investigation would you perform in a suspected meniscal tear?
MRI
Describe the immediate management of a hip dislocation
Urgent reduction, stabilise in tractions if required
What is the usual mechanism injury for a hip dislocation?
Impact during RTA or contact sports with the hip flexed
Which type of intracapsular hip fracture is shown in the diagram?
Transcervical neck fracture
Describe the usual mechanism of injury for a pelvic fracture in an older patient
Frailty fractures of older osteoporotic bone
Rupture of which ligaments leads to varus and rotatory instability?
Posterolateral corner - PCL, LCL, popliteus and other smaller ligaments
Describe the clinical presentation of Achilles tendonitis
Pain of the Achilles tendon or at its insertion in the calcaneus
Morning stiffness
Pain and stiffness eases with walking
What is the mechanism of injury for ankle ligament damage?
Initial contact on a plantarflexed inverted foot, excessive supintion of the rearfoot about an externally rotated leg
Why should surgical management of hallux valgus be carefully considered in adolescents?
Carries a risk of recurrence of the deformity later in life
Why is a CT useful in a Lisfranc injury?
Lisfranc fractures usually involve several TMT joints, with multiple ligamentous avulsion fractures
Rupture of which ligament may lead to recurrent hyperextension or instability descending stairs?
PCL
Describe the clinical presentation of trochanteric bursitis
Pain on the lateral aspect of the hip
Which investigations would you perform in a suspected Lisfranc injury?
X-ray - AP and oblique views, CT
Describe the clinical presentation of a hip dislocation
Flexed, internally rotated and adducted knee
Name a fracture associated with a patella dislocation
Osteochondral fracture
What is a grade 1 ligament injury?
Sprain - some fibres torn but macroscopic structure intact
Describe the surgical management of hallux valgus
Osteotomies to realign the bones and soft tissue procedures to tighten slack tissues and release tight tissues
What is the most common cause of acquired flat foot in adults?
Tibialis posterior tendon dysfunction
Describe the examination findings in plantar fasciitis
Fullness or swelling on plantarmedial aspect of heel
Localised tenderness on palpation of the plantar aspect of heel and/or plantarmedial aspect of heel
Tinel’s test positive for Baxter’s nerve
Describe the operative management of a pelvic fracture
ORIF, external fixators, internal fixators
What is a CT used for in a tibial plateau fracture?
Shows area of condylar involvement/depth of depression which guides treatment
Name the surgical procedure used to treat an intracapsular fracture in a patient who was previously low functioning
Hemi-arthroplasty
Which direction does the patella always dislocate in?
Laterally
What is the usual mechanism of injury for a knee extensor mechanism rupture?
The patellar tendon or quadriceps tendon can rupture with rapid contractile force which can occur after lifting a heavy weight, after a fall or spontaneously in a severely degenerate tendon
Can be associated with blunt or penetrating trauma
Describe the management of pes cavus
Soft tissue releases and tendon transfer if supple, or calcaneal osteotomy if more rigid
Arthrodesis for severe cases
Describe the clinical presentation of bone marrow oedema (bone bruising)
A major source of pain after meniscal tear and ligament injuries
What is a Pilon fracture?
High energy fractures which occur at the bottom of the tibia and involves the ankle joint
Describe the conservative management of Achilles tendonitis
Activity modification, analgesia, NSAIDs, physiotherapy
Heel raise to offload the tendon and use of a splint or boot
Describe the prognosis of ACL injury
May cause little or no problems in some, whilst in others they can give substantial problems with function
Most have radiographic evidence of arthritis within 10 years (even those who have surgery)
Which type of hip fracture is prone to femoral head AVN and non-union?
Intracapsular fracture
Describe the conservative management of hallux rigidus
Weight loss if needed
Analgesia, NSAIDs, activity modification
May involve the wearing of stiff soled shoe to limit motion at the MTPJ
How might you choose to conservatively treat a small partial tear of the quadriceps?
Immobilisation and physio
Which patient group is more likely to injure their ACL?
Higher incidence in females
Describe the examination findings in a knee extensor mechanism rupture
Unable to straight leg raise, palpable gap in the extensor mechanism
Partial tears can also occur which may have some extensor mechanism function but reduced power
What are claw toes?
Hyperextension at the MTPJ with flexion at the PIPJ and DIPJ
Describe the examination findings of a PCL injury
Positive posterior drawer test, positive sag sign
When might you aspirate a knee with a patella dislocation?
If intractable pain and very swollen
What is the usual mechanism of injury for a patella dislocation?
Can occur with a direct blow or sudden quadriceps contraction with a flexing knee
Describe the examination findings of a bucket handle meniscal tear
Acutely locked knee, 15° springy block to extension, heel height asymmetry indicating fixed flexion deformity
Describe the examination findings in Achilles tendon rupture
Weakness of plantar flexion and a palpable gap, unable to tiptoe stand, positive calf squeeze (Simmonds) test
Which type of intracapsular hip fracture is shown in the diagram?
Subcapital neck fracture
Describe the examination findings of an LCL injury
Lateral joint line tenderness, lateral joint laxity on varus stress test
Which investigations would you perform in a hip dislocation?
NV assessment, X-ray, CT after reduction if further injury suspected
Describe the management of a ruptured LCL diagnosed later (after 3 weeks)
Reconstruction with tendon graft
Which patient group is most likely to rupture their extensor mechanism?
More common in the middle age population who play running or jumping sports
Describe the conservative management of Morton’s neuroma
Involves RICE, stretching calf muscles, the use of a metatarsal pad or offloading insole, weight loss if appropriate and activity modification
Steroid and local anaesthetic injections may relieve symptoms
What causes a loose body in a joint?
Trauma, osteochondritis dissecans and joint degeneration can cause a fragment of cartilage +/- bone to detatch
Describe the conservative management of an ankle fracture
Cast or moonboot
Describe the immediate management for a complete knee dislocation
Emergency reduction under sedation, may need emergency fix for temporary stabilisation
Why are x-rays not very sensitive in low energy pelvic fractures?
The fractures are often undisplaced so the x-ray appears normal
Describe the management of tibialis posterior tendon tendonitis
Medial arch support to avoid rupture, orthosis/bespoke footwear
If fails to settle - surgical decompression and tenosynovectomy may prevent rupture
Why does a multiligament knee injury usually require surgical reconstruction?
Causes gross instability
Which investigations would you perform in a suspected tibial plateau fracture?
X-ray - AP and horizontal beam lateral
CT
What causes Achilles tendonitis?
Can occur due to repetitive strain (from sports) which leads to a peritendonitis or due to degenerative process with intrasubstance microtears
Why doe the meniscus have a limited healing potential?
Only has an arterial blood supply in its outer third - radial tears won’t settle
Name the 4 categories of extracapsular hip fracture
Basicervical, intertrochanteric, reverse oblique and subtrochanteric fractures
Describe the x-ray findings in a patella dislocation
Lipo‐haemarthrosis occurs with characteristic x-ray appearance
Describe the mechanism of action of a patella fracture
Traumatic injury - direct trauma or rapid contracture of the quadriceps with a flexed knee
How would you investigate a high energy pelvic fracture in a polytraumatic patient?
CT
Describe the surgical management of a tibial plateau fracture
ORIF, external fixator, delayed TKR
How would you investigate a high energy pelvic fracture where the pelvis is the only site of injury?
X-ray first, CT if needed to show fracture detail
When would ACL reconstruction be indicated?
Rotatory instability not responding to physio, as part of multiligament reconstruction or in professional athletes
Which investigations would you perform in a suspected knee extensor mechanism rupture?
X-ray
USS or MRI
Name three potential complications of a hip dislocation
Sciatic nerve palsy, ANV femoral head, secondary OA of hip
How can hallux valgus lead to the formation of a bunion?
A widened forefoot may cause rubbing of the foot with shoes resulting in an inflamed bursa over the medial 1st metatarsal head
What is the usual mechanism of injury for a talus fracture?
Forced dorsiflexion/rapid deceleration
How would you diagnose trochanteric bursitis?
Clinical diagnosis, visible on MRI but not usually needed
Describe the usual mechanism of injury for a pelvic fracture in a younger patient
High energy injury, typically RTA or fall from height
Which patient group is most likely to develop tibialis posterior tendon dysfunction?
Obese middle aged female
Why does an injury to the ACL cause rotatory instability?
Gives way on turning on a planted foot due to excessive internal rotation of the tibia
Reperfusion of the knee following neurovascular injury due to complete dislocation can result in what complication?
Compartment syndrome
Describe the clinical presentation of hallux rigidus
Painful 1st MTP joint, stiffness
Pain increases with activity/aggrevated by shoes
Which type of extracapsular hip fracture is represented by the yellow line in the diagram?
Intertrochanteric
What is patellofemoral dysfunction?
Describes disorders of the patellofemoral articulation resulting in anterior knee pain - includes chondromalacia patellae, adolescent anterior knee pain and lateral patellar compression syndrome
Describe the conservative management of a ruptured Achilles tendon
Series of casts in the equinous position - avoids potential for wound problems
In patients with recurrent patella dislocation, physiotherapy to strengthen which muscle can help?
Quadriceps
What is a fabella?
Acessory ossicle in the lateral head of gastrocnemius (usually) commonly misdiagnosed as a loose body
Describe the surgical management of hallux rigidus
In early cases where dorsal osteophytes impinge during dorsiflexion, removal of osteophytes (cheilectomy) may help
Gold standard surgical treatment is arthrodesis
