Disorders of the LE Flashcards
What are other names for AVN
bone infarction, osteonecrosis, ischemic necrosis, aspetic necrosis
What are risk factors for AVN
ETOH, Steriod use (most common), sickle cell, lupus, infection, HIV/AIDs, prior joint with AVN
What is the ASEPTIC acronym for
AVN
Alcohol/Aids/HIV
SLE/Sickle cell
Exogenous steroids
Pancreatitis
Trauma
Infection/irratation
Caisson disease (decompression sickness)
How does AVN of the hip present
groin pain
How is AVN diagnosed
imaging - may not be detected early on x-ray
MRI more sensitive for diagnosis
what is the treatment of AVN without bony collapse
osteoporosis drugs (bishosphates - aldendrate)
surgical procedures to induce revascularization
what is the treatment for AVN with collapse or in older patients
arthroplasty
What is SCFE
Slipped Capital Femoral Epiphysis
when does SCFE occur most often
adolescents 10-16 with more common in overweight and obese males
What is the common presentation of SCFE
hip pain (groin and thigh)
associated with limp or ER of the leg
reduced ROM - loss of IR, reduced flexion and ABDuction
What is the most common treatment for SCFE
percutaneous fixation (pinning)
what is the goal of percutaneous pinning for SCFE patients
stabilize and prevent further slippage , NOT full reduction
What is the most common orthopedic disorder in newborns
Developmental Dysplasia of the hip (DDH)
What newborns are at higher risk for DDH
firstborn breech newborns
what other deformities are often associated with DDH
metatarsus adductus and torticollis
what is DDH
essentially abnormal hip development (acetabulum)
define dysplasia
shallow, underdeveloped acetabulum
What is the mainstay diagnostic tests for DDH
Barlow and Ortolani maneuvers
all infants routinely screened (until walking)
Barlow Maneuver
dislocates a dislocatable hip; “click” on exit
Ortolani maneuvers
reduces a dislocated hip; “clunk” on entry
when is imaging started for DDH
4 to 6 months when ossification of the femoral head begins
what is the treatment for DDH
Pavlik harness first line
Spica casting for 6-18 months or failure of harness
when is open reduction with a spica recommended for DDH
older than 18 months with failure of the spica
when is open reduction with osteotomy recommended for DDH
older than 2 years with persistent dysplasia
What is trochanteric Bursitis
inflammation of the trocanteric bursa between greater trochanter and IT band
What is the treatment for trochanteric bursitis
Rest, ice
NSAIDs
PT/stretching
Intra-bursal injection
bursectomy last resort
when are hip dislocations more common
s/p THA with less force in comparison to native joint
what is the treatment for hip dislocations
closed reduction with sedation or open reduction
what rates are higher after hip fractures
high mortality and morbidity rates
what are risk factors for hip fractures
advancing age
osteoporosis
history of falls
smokers
prior trauma
what views of x-rays are needed to assess for hip fractures
AP, lateral and traction views
when is a CT needed for a hip fracture
Delineation of displacement and determine fracture pattern
when is an MRI indicated for a hip fracture
if there is concern for occult fracture
When is ORIF used for hip fractures
non-displaced or young patients
when is an arthroplasty indicated for a hip fracture
when the fracture is displaced or older patients
when is observation or non-operative management indicated for hip fractures
if a patient has multiple comorbidities, poor pre-injury functional status or high operative risk
What are complications in regards to hip fractures
high readmission rate
high mortality rate
high revision/conversion rate
high risk for functional impairment
risk for osteonecrosis
risk of non-union
How much blood can be ‘stored’ in the thigh
one liter of blood
what do you have to use caution with for femur fractures
hemodynamic instability
When are femoral shaft fractures common
young males 15-24yo (trauma) vs Females >75 (fragility fx)
When is CT indicated for femoral shaft fractures
to delineate fracture pattern
what is varus in the knee
bow leg
what is valgus in the knee
knock kneed
What athletes are at an increase risk for IT band syndrome
Runners and cyclists
what knee alignment increases your risk for IT band syndrome
knees with Varus alignment
what special test is positive with IT band syndrome
Obers test (inability to adduct in extension)
what is Osgood Schlatters disease
apophysitis of the tibial tubercle - inflammation at or near the growth plate
what is key on the exam of Osgood Schlatters
pain with knee extension against resistance
what type of injury is the leading indication for knee arthroscopy
meniscal tears
what is the most common type of meniscal tear
medial is more common than lateral
What location is common for degenerative tears of the meniscus
posterior horn
what are the mechanical symptoms for meniscal tears
clicking, locking especially with flap and bucket handle tears
what special tests are used for meniscal tears
apleys compression and McMurrarys test
when is surgical intervention indicated for meniscal tears
younger patients and traumatic injury
what determines partial meniscectomy vs repair for meniscal tear
location of the tear is important
What does the ACL prevent
anterior tibial translation
what is the MOI for ACL injuries
sudden stopping and pivoting or direct lateral blow to the knee
what special tests are used for ACL injuries/tears
Lachmans/anterior drawer
+ for both is laxity and the ability to pull the tibia towards examiner
what imaging modalities are recommended for ACL injuries
MRI
what is the most common treatment for ACL tear
ACL reconstruction
Autograft vs allograft
What does the PCL do
prevent posterior translation of the tibia
What ligament is stronger the ACL or PCL
PCL is stronger
What is the MOI for PCL tears
MVC - knee hitting the dashboard
fall directly onto bent knee
hyperextension injury
what special tests are used for PCL tears/ injury
posterior drawer and Sag sign
what is the treatment options for PCL tears
if not associated with other injuries - non-operative management
if associated with other injuries - PCL repair/reconstruction
what other injuries are associated with MCL injuries
ACL and meniscus injuries
what makes up the unhappy triad
ACL + MCL _ meniscus tear
what is the MOI for MCL injuries
Excessive valgus force (blow from lateral knee)
What special test is used for MCL injuries
Valgus stress test
when is surgery indicated for patients with MCL injuries
multi-ligament or severe complete tear of the MCL - repair vs reconstruction
What is the MOI for LCL injuries
varus blow to the knee, direct blow to medial knee
What special test is used for LCL injuries
Varus stress test
what treatments are used for LCL injuries
activity restriction, RICE, NSAIDs
if complete tear - repair vs reconstruction
what age group is most common for Quad tendon rupture
> 40 yo
what age group is most common for Patellar tendon rupture
< 40 yo
what increases the risk of quad/patella tendon rupture
hx of tendonitis or corticosteroid injections
what is the MOI for quad and patella tendon rupture
forceful quad contraction or fall on flexed knee
what is the treatment for quad/patella tendon rupture
urgent surgical repair
what is patellar tendonitis also known as
jumpers knee
what is shown on an MRI with a patient with patellar tendonitis
tendon thickening
what is the standard treatment for patellar tendonitis
RICE, NSAIDs, activity modification, Pt and Chopat strap
what is the common cause of a knee dislocation
MVC - high energy trauma
what are knee dislocation patients at higher risk for
vascular injury
assess neurovascular post reduction
what is the most common population with patellar dislocations
females due to increased Q angle and increased laxity baseline
what is the MOI for patellar dislocation
blow to the lateral knee or twisting with a foot planted in ER
what is long-term treatment for patellar dislocation
first time: brace, ice, NSAIDS, activity restriction
repeated: consider operative treatment
what is the MOI for distal femur fractures
axial load with rotational force
what are distal femur fracture at high risk for
neurovascular injury - must check on exam
what is the first line imaging for a distal femur fracture
x-rays
when is CT indicated for distal femur fracture
complex or intra-articular fractures and pre-operative planning
what is the treatment for distal femur fracture
splinting until surgical fixation
what is the primary population for patellar fractures
males between 20-50yo
what is the MOI for patellar fractions
direct trauma or forceful quads contraction with flexed knee
what is the key sign for patellar fractures
unable to lift leg straight up with extended knee
what are the treatments for patellar fractures
non-operative (immobilizing) vs ORIF for more severe fractures
what are the two main groups for tibial plateau fractures
young from high energy trauma and elderly with osteopenia and minor falls
what is the MOI for tibial plateau fractures
axial load with varus or valgus stress
what are tibial plateau fractures at high risk for
neurovascular injury, compartment syndrome and soft tissue injury
What are the treatment options for tibial plateau fractures
nonop (brace/immobilization) or ORIF
what is a large concern with tibial/fibular shaft fractures
compartment syndrome
what test is used to assess for vascular injury in tibial/fibular shaft fracture patients
angiography if there is a concern for vascular injury
what is compartment syndrome
limb threatening problem caused by bleeding/swelling in a given compartment compressing of nerves, vasculature
what are the most common locations for compartment syndrome
lower leg, thigh, forearm, hand, foot, buttock, shoulder, paraspinals
what are the “6 P’s”
diagnosis of compartment syndrome
Pain (first with passive stretch, then out of proportion to exam)
pallor
Pulselessness
Parasthesia
Paralysis
Pressure (<30)
what is used to check pressure in compartment syndrome patients
Manometer
what is necessary for treatment with a pressure over 30
emergent fasciotomy
what is pes planus
flat foot and primarily due to ligamentous laxity
when does pes planus become symptomatic
increase weight bearing on hindfoot
valgus deformity of hindfoot with weightbearing
lack of arch support
what is hallux valgus
aka bunions
progressive deformity of the first MTP joint
valgus devision of the phalanx
increasing prominence of the medial head of the 1st MTP
what population is hallux valgus often seen in
women are 10x more common and increased risk with FH
what increases your risk for hallux valgus
wearing high heel shoes with narrow toes
anatomic variations and joint laxity
deformity/amputation of the second toe
pes planus
RA
CP
what are you assessing with xrays for hallux valgus
the angle between the first phalanx and first MT
what is the treatment for hallux valgus
changes in footwear, padding symptomatic areas and surgical for symptom management
define iatrogenic
relating to illness caused by medical examination or treatment
what is the primary causes of hallux varus
iatrogenic - over correction of hallux valgus
Inflammatory arthropathies, neurologic disorders or congenital
what is the treatment for hallux varus
bracing or taping if early post op
footwear alterations
surgical realignment
what is compressed with mortons neuroma
compression of interdigital nerve
what is the most common location for mortons neuroma
3rd webspace
what are the theories for MOI for mortons neuroma
friction from 3rd and 4th MT heads, traction from intermetatarsal ligament and compression from poor footwear
what is the treatment for mortons neuroma
footwear changes, padding over metatarsals, steroid injections and surgical removal for definitive treatment
what can happen after surgical removal of mortons neuroma
post-op sensory deficits
What is the importance of plantar aponeurosis
muscle attachments, protection of underlying structures, structural support (arches)
what increases your risk for plantar fasciitis
obesity, lack of dorsiflexion, pes planus or cavus, prolonged standing, standing/walking/running on hard surfaces, poor footwear
what is the treatment for plantar fasciitis
primarily considervative: Rest, NSAIDs, stretching, ice - tennis ball/water-bottle, splinting or orthosis
if failure >9 mo - surgery for plantar fasciotomy
where does achilles tendonitis occur
the insertion site of the achilles
what is the treatment for achilles tendonitis
primarily conservative: activity modification, RICE, NSAIDs, footwear modification, stretching and heel sleeves/padding
AFO
tendon debridement or osteophytectomy
what is retrocalcaneal bursitis associated with
achilles tendonitis
what treatment do you avoid for retrocalcaneal bursitis
avoid intra-bursal coticosteroids due to increase risk of tendon rupture
what is a drug risk factor for achilles tendon rupture
fluoroquinolone antibiotic use or steroid injections
what is the MOI for achilles tendon rupture
sudden forcible DF/PF
landing from jump, sudden direction change during PF
when you have an audible ‘pop’ with sudden heal pain what are you thinking
achilles tendon rupture
a positive thompson test is indicative of what?
Achilles tendon rupture
what is the treatment options for achilles tendon rupture
immobilization and non-weight bearing vs surgical repair
What is the common MOI for ankle sprain
inversion “rolled” ankle
what ligaments are damaged with a plantar flexion inversion injury
ATFL and CFL
what ligaments are damaged with a dorsiflexed inversion injury
CFL
What defines Grade 3 ankle sprain
severe functional loss, inability to bear weight, diffuse swelling, diffuse ankle tenderness
What does a patient with a grade one ankle sprain present with
minimal functional loss, no lump, no to minimal swelling, mild point-tenderness; pain with ankle inversion
a patient presents with moderate functional loss, positive limp, localized swelling and moderate point tenderness of the ankle, what grade ankle sprain do they have
Grade two
What are the grades of ankle sprains
1-3
Anterior drawer and Talar tilt special tests are used for
ankle sprains to assess integrity of ATFL and CFL
What are the Ottowa ankle rules
to determine if x-rays are necessary for ankle sprain patients
specific vs diffuse tenderness
when can Ottowa ankle rules be overridden
patient is intoxicated/uncooperative, other distracting injuries, decreased sensation of the LEs, significant edema that limits ability to palpate
what is a high ankle sprain
syndesmotic injury
what is the MOI for high ankle sprain
everseion of the ankle
patient presents with a high ankle sprain, what test are you going to perform to determine a syndesmotic injury
Hopkins test
what is a positive Hopkins test indicative of
syndesmotic injury
what is the most likely MOA for ankle dislocations
plantar flexion and inversion
what way is the most common location for ankle dislocation
posteromedial dislocation
what is usually present with a ankle dislocation
fracture-dislocation
what are ankle dislocations at high risk for
neurovascular injury
what x-rays do you get when concerned for ankle dislocation
AP, lateral and mortise (IR of the ankle)
What are the three most common patterns for ankle fractures
Isolate malleolar, bimalleolar and trimalleolar
what is a Pilon fracutre
distal tibia fracture +/- fibula that interrupts the cartilaginous surface
if a patient has an adduction force to a supinated foot what is their most likely injury
Ankle fracture
what is the treatment for stable ankle fractures that are non-displaced or with good reduction
cast for usually 4-6 weeks
what type of ankle fractures require ORIF
unstable and inability to maintain reduction - open fractures
What is the typically age range and gender for calcaneal fractures
Males 20-30 years of age
What is a secondary response to a calcaneal fracture that you have to be aware of
compartment syndrome in 10% of calcaneal fractures
a patient presents with moderate to severe heel pain, hindfoot edema, widening or shortening of the heel (deformity) , ecchymosis about the heel (extends to the arch) what is their likely diagnosis
calcaneal fracture
A patient presents with calcaneal fracture - what images would you order for the patient
AP, Lateral, and Oblique/axial views
what types of calcaneal fractures require operative treatment
displaced, intra-articular, fracture-dislocations, and open fractures
what is a bulky jones splint used to treat
non-operative treatment for calcaneal fracture
what metatarsal is the least likely to fracture in the foot
first metatarsal
what are the common MOI for metatarsal fracture
Direct Trauma (drop something on the foot)
Twisting (toes get caught and continue ambulation)
Avulsion fractures
Stress
Fractures
What imaging views are recommended for patients with concern for metatarsal fracutres
AP, Lateral +/- oblique views
when is an MRI indicated for metatarsal fractures
to rule out stress fractures with negative x-rays
a patient is placed into a hard sole shoe s/p metatarsal fracture - what bones are likely broken
second to fourth MT
what are the zones that make up with 5th MT bone
Avulsion fracture (zone 1) - Pseudo-jones
Jones fracture (zone 2)
Stress fracture (zone 3)
Other
What zones of 5th MT fractures have a high rate of non-union
Jones Fractures (Zone 2)
What is a Lisfranc injury
fracture dislocation of TMT joint
