ECOS 1 Midterm Clinical Flashcards
Developmental Dysplasia of the Hip “Hip Dysplasia”
Newborns
Infants with DDH, whether treated or untreated, have a higher incidence of early-onset hip osteoarthritis in adulthood.
Hip clunk -Distinct and pronounced palpable (and at times audible) shift of femoral head, felt as the femoral head is dislocated or reduced on examination with the Ortolani (abducting legs) and Barlow (going back to midline) maneuvers
another sign: uneven height of knees when baby is lying down with legs flexed
Legg Calve Perthe’s disease (Perthes Disease)
Very rare, 3-12y/o, More in boys
Blood supply to the head of femur interrupted, necroses, weak bone → fractures. Bone reforms, return of blood supply however new bone shape can lead to degenerative joint disease (osteoarthritis) later in life.
Symptoms: limping, limited ROM of hip joint, pain worse with activity, better with rest
Risks/causes: hereditary, skeletal immaturity, obesity and lower socioeconomic status
Diagnosis: History and Exam (Problems rotating the leg, muscle atrophy of the LE, affected leg may be shorter than the normal leg), X-ray, MRI
Slipped Capital Femoral Epiphysis (SCFE)
more common than Perthe’s disease
8-15 y/o, more in boys
the growth plate is damaged and the femoral head moves (“slips”) from the rest of the femur. Head of the femur stays in the cup of the hip joint while the rest of the femur is shifted. This can happen slowly, over time, or it can happen immediately from trauma.
Risks/causes: obesity, growth spurt, endocrine disorder (hypothyroidism & osteodystrophy), or genetic predisposition
Symptoms: Leg rotated outward (impaired internal rotation). Hip pain (onset gradual or sudden) with limping.
Avascular necrosis (AVN)
Temporary or permanent loss of blood supply to the bone, the bone tissue dies and the bone collapses. If avascular necrosis happens near a joint, the joint surface may collapse.
Anyone but MC is 30-50 y/o (Like Perthes but in Adults (no growth plate))
ROM, joint pain, pain with activity & rest
Risks/Causes: Injury, Blood disorders, Long-term use of medicines, such as corticosteroids, Autoimmune disease, Chemotherapy and/or Radiation treatments, Pancreatitis, Alcoholism, Hyperlipidemia
Diagnosis: History, Exam, X-ray, CT, MRI, Radionuclide bone scan, Biopsy, Functional evaluation of bone. Abnormal head of femur, no growth plate
Trochanteric Bursitis
inflammation of bursa
More common in women, middle-aged, and older people. (>50 yo at onset, female > males)
Risks/Causes: injury (MCC), overuse (MCC), spinal/postural abnormalities, arthritis, or surgery, obesity, knee pain, IT band tenderness, low back pain
Symptoms: pain outside hip & thigh, or in butt, hurts sleeping, going up stairs (activity), getting out of a chair.
Diagnosis: Xray not indicative. MRI shows bursitis. Blood test to see if infection is the source.
Osteoarthritis (OA) of the Hip
one of the most common conditions
Primary (no cause) or Secondary (other disease, injury, etc,)
OA causes breakdown of cartilage in joint, bony spurs (growth, bone ends thickened), bits of bone and cartilage in joint space, limiting joint movement
Develops around 20-30 y/o, but most people over 60 yrs have OA
Risks/Causes: Heredity,excess weight, injury or overuse; often an underlying reason, such as joint injury or repetitive joint stress from overuse
Symptoms: pain & stiffness after overuse or inactivity (during sleep) of a joint. Develop slowly over years, less movement in the joint over time. A grinding feeling of the joint when moved, as the cartilage wears away (in more advanced stages).
Degeneration of joint, thinning of cartilage around femur head, weak labrum
Meralgia Paresthetica
Tingling, numbness, burning pain in outer thigh
Compression of lateral femoral cutaneous nerve (pinched by inguinal L.), which supplies sensation to your upper leg
Symptoms: occur on side of your body & might intensify after walking or standing
Risks/Causes: Tight clothing or belts, obesity or weight gain, and pregnancy. Local trauma or a disease, such as diabetes.
Diagnosis: imaging, EMG, Nerve conduction studies and nerve blockade can be used to rule out other conditions.
Femoroacetabular Impingement (FAI)
aka Hip impingement
common cause of hip pain in Adolescents, adults, and athletes of all ages.
Hip impingement, is a condition where the hip joint is not shaped normally. This causes the bones to painfully rub together
Symptoms: Limping, Pain & stiffness in the hip that worsens during physical activity or long periods of sitting
Labral Tear
Hip impingement when the ball of the hip pinches against the socket. This can cause damage to the labrum, the cartilage that surrounds the hip socket, and lead to stiffness, pain and/or arthritis in the hip.
Symptoms: Locking, clicking or catching sensation in hip joint
Risks/Causes: Trauma, Injury or dislocation, born with structural abnormalities, and repetitive motions.
Hip Fracture
Partial or complete break of femur where it meets pelvic bone
- Most common cause of hip fractures in elderly are falls*; young people from trauma
- The most serious fall related injury is hip fracture*
- Women > 85 y/o more at risk than women 60-69 y/o*, white women more at risk than black women
Risks/Causes: family hx, osteoporosis, tobacco & alcohol use, physical inactivity, chronic medications
Symptoms: Shorter leg on affected side, cannot get up or put weight on affected side leg, bruising and swelling in hip, outward turned leg
Diagnosis: Any older person with hip pain after a fall should be treated as a hip fracture until proven otherwise.
Pelvic Fractures/Crush Injuries
Causes: Significant trauma
Symptoms: bone tenderness, difficulty walking, loss of nerve function, injuries to organs within the pelvic ring such as the intestines, kidneys, bladder or genitals.
Compartment Syndrome: acute or chronic, BVs & Nerves in the girdle compressed by the pressure from muscles and bleeding. Pressure can decrease blood flow which can stop nerve and muscle cells from being nourished/oxygenated.
- 5 P’s: Pain, Paresthesia, Pallor, Paralysis, Pulselessness
- 3 A’s: Increased Analgesic requirement, Anxiety, Agitation
Septic Arthritis
Painful infection of a joint (germs through bloodstream or directly onto joint from injury)
Infants & Older Adults most likely to have septic arthritis
Risks: Age >80, DM, RA, Prosthetic joint, recent joint surgery, skin infection, IV drug abuse, previous intra-articular corticosteroid injection
Mechanism of infection: hematogenous spread to joint, bite, trauma, exposure during joint surgery, etc.
Healthy patients (staph aureus and streptococcal), sexually active, young patient (N gonorrhea), Immunocompromised
Symptoms: Discomfort, hard to use joint, swollen, red, warm, patient may have a fever (fever distinguishes Septic arthritis from just arthritis)
Septic Arthritis Diagnostic:
Synovial Fluid from Joint Aspiration (Arthrocentesis), blood test
Piriformis Syndrome
The piriformis muscle, located in the butt region, spasms and causes butt pain. Irritates the sciatic nerve and causes pain, numbness and tingling along the back of the leg and into the foot (similar to sciatic pain)
Risks/Causes: Anatomical variation, history of direct trauma to buttock
Symptoms: Pain after sitting for a while, rising from seated position. Pain improves with ambulation. Radiates to posterior thigh.
Signs and symptoms: Positive log roll with sciatic notch tenderness, Unlike sciatica from disk herniation, piriformis syndrome is exacerbated by active external hip rotation
Diagnosis: MRI excluding disc herniation. +sciatic nerve edema.
Sprain
small ligamentous tears, blood loss, bruising, hear or feel “pop”
Strain
muscle is stretching and contracting simultaneously, athletes who switch directions, carry something heavy, “grabbing sensation”
Osgood-Schlatter Disease/Syndrome
8-15 y/o, during growth spurt, growth plate injury
Bilateral (30% cases)
microtrauma to the patellar ligament insertion onto the tibial tuberosity via sports/Rapid changes of movement/anything that pulls patellar L.
Pain with climbing stairs or squatting
Diagnosis: Point tenderness over the tibial tubercle, All other ligament and structural testing is negative, X-rays not needed
Osteoarthritis
Anterior Or Generalized Knee Pain
Boney enlargement or deformity at the joint margins, genu varum deformity, and stiffness lasting ≤ 30 minutes. Crepitus.
Chronic inflammatory disease, Loss of articular cartilage, Osteophytes (boney spurs) at insertion sites of tendons or ligaments. Soft tissue thickening of joint capsule.
Patella moves laterally, Osteophytes around, Asymmetric joint space, Lipping along margins of bone (spurs)
Risk factors: Age, trauma, obesity, Varus/valgus deformities
Bursitis: Housemaid’s knee
Anterior Or Generalized Knee Pain
Chronic microtrauma from repetitive activity or pressure
Local swelling, tenderness, warmth, erythema, pain with AROM or compression (prepatellar bursa)
PE: Redness (erythema) and swelling at the site of the bursa. Tenderness and warmth. Remaining exam: Ligaments intact
Evaluation: aspiration of bursa for cell count, C & S, assess for crystals
Patello femoral Pain Syndrome Chondromalacia Patella
Anterior Or Generalized Knee Pain
< 60 y/o, gradual onset
Uni or bi lateral, worse with climbing stairs squatting for sitting for a long time.
–Crepitus with those activities
PE: Joint symmetry, rarely with effusion, patella position within the femoral groove as well as tracking with active ROM, Crepitus under the patella w/AROM & PROM, +Patellar grind test, Quadriceps weakness may be identified.
Iliotibial Band Syndrome
Anterior Or Generalized Knee Pain
Pain over the lateral aspect of the knee (above the joint line)
May occur with increase in activity (i.e. change in distance or intensity)
no imaging necessary; RICE, IT band stretches.
PE: Appear symmetric, No warmth or erythema, Pain with palpation over the lateral femoral condyle, Normal ligamentous testing, Positive OBER’s test on affected side. Assess Fibular head for dysfunction
Patellar Subluxation
Anterior Or Generalized Knee Pain
Foot planted, leg rotating and downward pressure from femur which pulls the patella laterally
Dislocation: complete lack of contact between two articular surfaces
Apprehension Test: Stretching of patella L, if too much dislocation, patient won’t want you to move the patella
Anterior Cruciate Ligament (ACL) Injury
Anterior Or Generalized Knee Pain
MC injured knee L.
Causes:
- -Contact injury (30% of ACL injuries). Fixed lower leg (i.e. planted) with direct blow causing hyperextension or valgus deformation
- -Non-contact injury (70% of ACL injuries) Sudden deceleration with a change in direction
Symptoms: Large effusion, popping sensation, knee instability (giving out), associated to other injuries
Can lead to osteoarthritis 10-20 years after the initial injury
Diagnosis: Anterior drawer test or Lachman’s test, Knee MRI or knee arthroscopy
Meniscal Injuries
Anterior Or Generalized Knee Pain
Common knee injury from either medial or lateral meniscus
Causes:
- -Acute meniscal tear (Results from a sudden change of direction in which the knee is twisted or rotated while the corresponding foot is planted)
- -Chronic meniscal tear (Often from degenerative changes seen in older patients with minimal twisting injury history)
Symptoms: Locking or Catching of knee during extension, “popping” or “giving out” sensation or vague sense knee is not moving properly
Meniscal tears can occur by themselves or along with ligamentous knee injuries
Large meniscal tears can impair the motion of the knee, cause effusions, and lead to premature osteoarthritis
Diagnosis:
- -Medial or lateral joint line tenderness, loss of smooth passive motion of knee, inability to fully extend knee or squat
- -Positive McMurray’s test, Apley grind & distraction, possibly + Bounce Home
- -Knee MRI (or knee arthroscopy)
Unhappy Triad
Anterior Or Generalized Knee Pain
Injury of the ACL, MCL and Medial meniscus
Foot planted, valgus deformity, rapid deceleration injury, and rotation
Lateral Ankle Sprain
Most common sprain!
Mechanism of injury: Foot inversion and/or plantar flexion
- Anterior talofibular ligament*** or Calcaneofibular Ligament
- Positive Talar Tilt* test (aka Inversion test) & Anterior drawer
Medial Ankle Sprain
MOI: Forced eversion
Deltoid Ligament
Positive Eversion Test
Likely have fracture somewhere else because this L. is very strong so something serious must have happened
Grading Sprains:
Grade 1: No laxity in the joint = minimal ligament damage (Manage conservatively–NSAIDs, R.I.C.E., PT)
Grade 2: Mild to moderate laxity in the joint (Manage conservatively)
Grade 3: Complete disruption of the ligament (Conservative management with immobilization x 3 weeks –If unstable, surgery likely needed)
Syndesmotic/High Ankle Sprain
MOI: Forced external rotation of a dorsiflexed ankle
Ligament: Tibiofibular syndesmosis
Positive Squeeze test
Injury to interosseous membrane
Achilles Tendonitis
Repetitive motions create micro tears in the tendon resulting in inflammation
Athletes
Pain/stiffness at tendon insertion (posterior calcaneus)
Pain is worse with activity and goes away with rest
NEGATIVE Thompson test
Achilles Tendon Rupture
A tear of the Achilles Tendon. Rupture = Complete Tear
Athletes
Signs and symptoms: 80% occur during high impact recreational sports
Patients report a popping sensation at their heel, may or may not have pain
POSITIVE Thompson test
Sever’s Disease (Calcaneal apophysitis)
Apophysitis: an inflammation or stress injury to the areas on and around an apophysis (growth plate)
Active children going through growth spurts (growth phase)
Signs and Symptoms: Chronic heel pain in growing children, Pain is related to increased activity, Pain is reproduced with direct palpation over the apophysis
Tibiotalar Effusion
Joint Effusion: An abnormal accumulation of fluid in or around a joint
Tibiotalar Joint
Joint effusions can be caused by a number of things: Injury, Arthritis, Infection, Hemarthrosis
Arch Deformities
Pes Planus: A loss of the longitudinal arch of the foot & “flat feet”
Pes Cavus: Exaggerated longitudinal arch
Hammer Toe vs Claw Toe
Hammer Toe: Hammers have one head, so only one joint flexed. PIP joint flexed
Claw toe: PIP and DIP joints flexed
Hallux Valgus (aka Bunion)
Very common foot malformation
Lateral deviation of the great toe (1st digit)
Leads to bunion (prominence) on the medial aspect of 1st digit MP joint
Hallux valgus (bunion) leads to inflammation and irritation at 1st MP joint
Plantar Fasciitis
An inflammation of the plantar fascia
Repetitive biomechanical use → micro tears of the fascia
Signs and symptoms: Sharp stabbing plantar/heel pain, Pain is worse with first few steps in the morning and improves, Pain with prolonged standing & forced dorsiflexion
Morton’s Neuroma
Inflammation and thickening of tissue that surrounds the nerve between toes
Patient reports feeling like they are walking on a marble
Palpable in web space, which will replicate burning pain (push between 3rd & 4th toes)
Can have radiation of pain and numbness of toes
Mulder’s Sign –A palpable clicking sensation between the third web space as the transverse arch is compressed (As you crunch toes together you will feel clicking)
Precursors are loss of transverse metatarsal arch and stretching of the injury
Fibular Nerve Compression (aka Peroneal Nerve)
When the fibular nerve gets compressed leading to dysfunction of the distal nerve
nerve most commonly gets compressed at the point it wraps around the lateral aspect of the fibular head
Prolonged lying, crossing legs, ankle sprains, prolonged immobilization in a cast
Signs and Symptoms: Foot drop, Weakness of dorsiflexion and eversion, “Steppage” gate, Sensory loss over dorsal foot/lateral shin
Charcot Foot
A consequence of chronic foot inflammation that leads to mid foot deformities and a collapse of the longitudinal arch
Always associated with neuropathy of the foot –Diabetic neuropathy
Signs and symptoms: Visible collapse of the longitudinal arch, Warmth, redness and edema over the joint, History of minor trauma, Long term history of peripheral neuropathy
Diabetic neuropathy: Peripheral nerves damaged from prolonged high BGL, loss of sensation (MC in feet). Loss of sensation prevents patients from realizing foot injuries.
Gout
An inflammatory arthropathy caused by the deposition of MONOSODIUM URATE crystals in joints
Signs and Symptoms:
- -Most commonly occurs in the first MTP joint
- -Diet high in purines (meat, shellfish and alcohol)–Uric acid is a breakdown product of purines
- -Patients frequently have past exacerbations
- -Joint aspiration reveals NEGATIVELY BIREFRINGENT NEEDLE SHAPED CRYSTALS
Ligaments of the ankle/foot
The distal fibula is attached to the talus and calcaneus, motion of the ankle will cause motion of the fibula (linked motion)
Anterior Talofibular L.
Posterior Talofibular L.
Calcaneofibular L.
Distal and proximal fibula are like see-saw, go opposite
Minor Motions of Tibiotalar Joint
Glide named for direction Talus moves
Anterior glide is the minor motion with Plantar flexion (55-65 d). Ankle less stable
Anteromedial glide of the talus is the minor motion with Eversion (10-20 d)
Posterolateral glide of the talus is the minor motion with Inversion (20 d)
Talocalcaneal (subtalar) Joint Motions
Eversion/Anteromedial Glide (5-10 d): As the calcaneus moves into eversion, the talus will glide anteriorly and medially
Inversion/Posterolateral Glide (5-10 d): As the calcaneus moves into inversion, the talus will glide posteriorly and laterally
Tarsal Bones (Motion of the Cuboid, Navicular, and Cuneiforms)
Plantar Glide: Bones go down
- -Cuboid & Navicular coupled rotation about A&P axis (Heel to toe axis)
- —>Cuboid moves out laterally, eversion
- —>Navicular rotates medially to inversion
- -Cuneiforms (plantar glide only - plantar fasciitis)
Dorsal Glide: Bones go up (dorsum)
Metatarsals: Motion is named for the direction of the head (dorsal or plantar glide)
MTP’s, PIPs and DIP’s Motions
All three joint types will have the same motions
Dorsal/plantar glide
–>Flexion/extension
Rotatory Glide
–>Internal/external rotation
Abduction/Adduction
–>Medial/lateral glide
