Hip, Thigh, Ankle and Foot Flashcards
Likely cause of anterior thigh pain
Lateral cutaneous nerve syndrome
Likely cause of lateral hip pain
Greater trochanter bursitis or snapping Hip Syndrome
Likely cause of inquinal pain
Oestearthritis and avascular necrosis
Likely cause of medial thigh pain
Fractured femur
What special test do you do if no suspicion of hip/thigh fracture
Internal and external rotation starting at neutral and with flexion to 90 degrees
Describe the Faber test
stress with flexed and internally rotated hip, increased pain with Sacro-Iliac joint pathology or non-organic pain
Is an orthopaedic emergency and should be reduced ASAP in order to decrease the risk of osteonecrosis (NV status before and after reduction).
hip dislocation
Complications of a hip dislocation
- early OA
- Osteonecrosis
* secondary to cartilage damage of the femoral head and acetabulum - avascular necrosis
What type of dislocations are most common
posterior
Risk factors for AVN
- secondary to trauma
- stress fractures
- chronic steroid use (RA, COPD, organ transplant)
- alcohol
- ***Hip fracture (/any bone)
causes of fracture of the pelvis
- low-energy trauma (elderly)
2. high energy trauma (multisystem trauma)
With a fracture of the pelvis you must assess neuro-vascular status (STAT), because of
common injuries to peripheral nerves and sometimes damage to spinal nerve roots.
W/ a fracture of the pelvis, it is important to get
stat x-rays and CT scan
Tx of pelvic fractur
Usually in need for immediate surgery if stable or possible external fixation, depending on severity and instability.
- Major bleeds are common w/ pelvic fx
- Morbidity and mortality decreases when they are fixed early within 48 hrs!
morbidity and mortality associated w/ pelvic fxs are decreased when fixed within __
48hrs
Xray view points for pelvic fxs
- Judet (oblique) view- posterior wall or sacro iliac joint/ fx through acetabulum
- inlet/outlet view– look for fx in front or a shift in the front or back
- AP Pelvis
What should you do with an open-book pelvis fracture
- Open-Book Pelvic Fracture: this will bleed and the patient will die if you do not slow down the bleed! (CLOSE THE SI JOINT)
- Slow down the bleed w/ a pelvic binder (pressure) or clamp (iliac crest)
- the faster you can close the pelvis the better outcome for the patient
-External fixation (rods on the legs) to slow down the bleeding
What is an open book pelvic fracture
This causes disruption of pubic symphysis and the pelvis opens like a book
Most common fracture in elderly pts
hip fracture
who most commonly gets hip fractures
elderly with the incident of hip fractures doubling past age 50 and with women > men.
___ in ___ with a hip fracture die between one year after fracture and 50% of them never return to previous level of ambulation and independence.
1 in 4 pts
Intra-capsular (femoral neck) fx are usually associated with
a high risk for non-union secondary to AVN
Extra-capsular (intertrochanteric or above the lesser trochanter): requires
a stronger fixation** and has better chance of healing
With a displaced prox. femur fracture, the injured limp is ___
externally rotated, abducted and shortened
Non-displaced prox. femur fracture presents with
- increased pain with gentle rotation and extension and
- unable to do Straight Leg Raise (SLR).
tx of prox. femur fx
Most cases require surgical fixation depending on the location of the fracture.
__ fractures often disrupts the blood supply to the head of the femur
femoral neck fractures
Describe the Garden classification of femoral neck fractures
Type 1: stable fracture with impaction in valgus.
Type 2: complete but non-displaced.
Type 3: displaced (often rotated and angulated) with varus displacement but still has some contact between the two fragments.
Type 4: completely displaced and there is no contact between the fracture fragments.
Tx of femoral neck fractures
All require surgery but the fixation depends on the type
*best for surgery in 24-48 hrs
- hip pining with cannulated screws
- bipolar hemiarthroplasty (no acetabular component)
- Dynamic compression hip screw (DHS)– wt. baring helps compress fx
Tx of intertrochanteric fx
- compression hip screw
- Intra-medullary nail w/ cannulated screws
*If you have anything outside the capsule you need stronger fixation!!
Gamma Locking Nail system is for what type of fx
Subtrochanteric hip fx
Describe a runners story if they present with a femoral neck stress fracture
Story: Runners block off the pain so if they present w/ pain
Workup and Tx of femoral neck stress fx
- stop running
- non-wt. baring on crutches
- get Xray and MRI
Femoral neck stress fracture WILL stop you from running- painful, needs fixation, and needs surgery!!!
With a fracture of the femoral shaft it is important to assess for
- multi-system injuries
- bleeding
- compartment syndrome
- assess NV status
- assess ipsilateral knee
what is the tx for a fracture of the femoral shaft
- splint for comfort and transport,
- followed by skeletal traction (Harry splint- extends leg) until surgery
Presents as severe pain as a result of high-energy trauma with possible multi-system injuries, bleeding and compartment syndrome.
fracture of femur shaft
Sx of OA of the hip
- Restricted range of motion (ROM),
- antalgic gait,
- inquinal pain and stiffness (initially with activity) that may lead to
- decreased ambulation and functional independence (AODLs)
Tx of OA of the hip
- Total Hip Arthroplasty (THA) for pts with persistent pain after failure of conservative therapy, including
- medications,
- cortisone injection,
- activity modifications and
- use of assistive devices (cane or walker).
Who is a poor surgical candidate for total hip arthroplasty secondary to OA
- morbid obese (BMI 33 or higher)
- Poorly controlled DM (A1C of 7 or higher– A1c is >8 they are at risk for complications (infection, AVN)
- Unstable co-morbidities
Hip replacement indications
- Pain #1
- Quality of life is impaired
**do not tx Xrays tx symptoms
Describe a total hip arthroplasty vs re-surfacing
head of femur and a layer of the hip are removed and replaced w/ a ceramic head (metal breakdown over time and causes toxic poisoning)
Re-surfacing: done in younger patients that need just a resurfacing (ie. hx of AVN), they articulate w/ own acetabulum and cartilage
Sx of Trochanteric bursitis
- Inflammation** and
- hypertrophy of the Greater Trochanter (GT) bursa
- with direct trauma or sometimes with no apparent reason.
- Pain and tenderness over the GT area that could radiate to the knee, but not to the foot.
- Pain worse when first rising from a sitting position
Treatment of trochanteric bursitis
- NSAIDS***
- activity modifications
- short term use of walking cane
- local cortisone injections (inject at point of max. tension)
- Long term PT***
- Stretch ITB
Walking one mile generates __ of stress on each foot.
> 60 tons
__% of musculoskeletal problems affect the foot and ankle
20%
*Most problems can be handle at the office.
Unilateral pain is common, if bilateral pain think ___ or __ etiology
systemic or spinal etiology.
- DM
- PVD
- Neuropathies
- OA
with foot and ankle complaints gets _
Get standing (weight bearing) x-rays.
When examining gait and standing eval of foot and ankle look for:
- foot drop,
- flat foot and
- equinous deformity
- Standing exam from posterior and lateral angle, looking for asymmetry and for the “too many toes sign” (Posterior Tibial tendon deficiency).
Describe the tests for foot and ankle
- Talar tilt and anterior drawers for lateral ankle ligaments instability.
- Squeeze test for foot neuroma.
- Motor and sensory test for neuropathies w/ microfilament
- Strength against resistance for nerve function deficit.
Forefoot (metatarsal) pain is more symptomatic in ______
females 9x more than males
“Da shoes”
Causes of forefoot (metatarsal) pain
- Bunions
- Hammer toe
- Claw toe
- Ingrown toe nail
- Metatarsalgia
- Neuromas
- Stress fx
- mallet toe
What is Haglund deformity
prominent superior process of Calcaneus with common atrophy of Achilles tendon at the insertion point into Calcaneus and with Achilles bursitis.
*causes hindfoot pain
tx by lengthen the gastroc.
Causes of hindfoot pain
- Haglund deformity
2. plantar fascitis
Tx of plantar facscitis
- More than 95% of cases can be managed with NON-surgical treatment.
- **PT And stretch!
- Night splint
- roll out bottom of foot
- It commonly takes 6 to 12 months for symptoms to resolve.
Describe the medial ankle anatomy
- “Tom Dick and a very nervous Harry.”
- Tibialis Posterior tendon,
- Flexor Digitorium tendon,
- Tibial nerve/artery and
- Flexor Hallucis Longus tendons
*inject a foot block btwn the digitorum and hallucis longus
Too many toe signs shows problem w/
posterior tibial tendon dysfunction
*Tendon that is ruptured our popped out of the tunnel (sublaxated) other tendons take over and the lateral tendons take over and toes flare laterally
Symptomatic Pes Planus aka __
flat foot
*hyperpronation and tight heel cord–> can cause bunion
Most common site for OA
dorsal osteophytes
causes of midfoot pain
- OA
- plantar fasciaitis
- fibromas (hard nodules/rocks, very tender)
Presentation of pes planus
hyperpronation and tight heel cord
What is a Dancer’s fx
aka avulsion fx
- the most common fx of the base of the 5th metatarsal.
tx of avulsion/dancer’s fx
Usually non-surgical and tend to heal well with SLC-NWB
short-leg cast non-weight bearing
Named after Sir Robert Jones, who first described this fracture pattern in 1902.
Jone’s fx
- fx of 5th metatarsal
- *cannot weightbare for 6-8 weeks
where do stress fx commonly occur on the 5th metatarsal
these occur distal to the ligaments which firmly bind the 4th and 5th metatarsals together.
- Fractures in Zone I are typically __ type fractures
- Zone II fractures involve an area of the bone a little more distal (or toward the toes), and most typically appear as ___ fractures.
- Zone III fractures usually occur___ of the metatarsal bone.
I- avulsion fxs
II- horizontal or transverse fxs
III- in the shaft
What is a Lisfranc fracture dislocation
lateral shift of the second metatarsal w/ WB xrays
*when in doubt MRI
tx of Lisfranc fracture dislocation
- if stable 6-8 weeks NWB cast
2. unstable: ORIF and 6-8 weeks of NWB
what is a Hallux Valgus Deformity
- bunion
- Lateral deviation of great toe at first MT joint
- 10:1 female to male ratio
how do you dx a Hallux Valgus Deformity
Diagnostic x-ray is WB with normal hallux valgus angle <15 degrees and <10 degrees at the Intermetatarsal joint
where are morton’s neuroms most common
btwn 3rd and 4th metatarsals
how do you dx Morton’s neuroma
- Squeeze test (provocative test).
- “Walking on a marble”
- Use double marking (lipstick) for placement of padding.
TX of Morton’s neuroma
Treatment: cortisone injection or surgery.
Causes of ankle pain
- peroneal tendon dysfunction
- Talus OCD lesion
- Subtalar joint OA
- Tarsal tunnel syndrome
Ligaments of ankle sprains
- Anterior Tibio-fibular
- Anterior talo-fibular
- Calcaneo-fibular
- Posterior Talo-fibular
- Deltoid ligament
When do you xray ankle sprains
- Can’t weight bear
- Marked swelling and ecchymosis
- Positive Instability tests
- When in doubt or thinking of referral…x-ray it !
TX of ankle sprains
- R.I.C.E. rest, ice, compression and elevation.
- Ankle brace or air cast or even a SLC (walking or NWB)
- Contrast bath
- Crutches
- PT consult
Adverse outcomes of ankle sprains
- chronic instability
2. probable early OA
Most of the blood supply of the talus enters through the __
neck via the sinus tarsi.
What is Tarsal tunnel syndrome
is a compression, or squeezing on the Posterior Tibial Nerve that produces symptoms anywhere along the path of the nerve.
Patients with tarsal tunnel syndrome experience one or more of the following symptoms:
- Numbness or tingling, burning, or a sensation similar to an electrical shock.
- Pain, including shooting pain
Usually related to a neuropathy that progress to a Charcot’s foot, or osteomyelitis.
diabetic foot
tx of diabetic foot
- Education
- Better control of DM (A1C blood test).
- Wt. control
- Worse case: I and D and later amputation.
What is the usual location of an achilles tendon rupture/tear
of tear at 5-7 cm proximal to insertion into Calcaneus.
presentation/PE of an achilles tendon rupture
- HX of “hit with a bat” or “loud snap sound”
- Difficulty with weight bearing.
- Step off deformity with injured foot at 90 degrees of dorsi-flexion in rest position.
- (+) Thompson test: squeeze of calf with no plantar flexion noted, most reliable within 48 hours of injury.
What imaging should you get for an ankle fx
- AP,
- Lateral and
- mortise views, with especial attention to the medial clear space on the mortise view and tenderness over Deltoid ligament and proximal Tibia (Maisonneuve Fx).
\_\_\_ ankle fracture: location usually determines need for ORIF. \_\_\_ Fracture (very unstable)
Lateral malleolus
Pilon
With calcaneus fractures always look at ___
the L-spine (primarily L1) for a compression fracture related to the mechanism of injury.
Talus fractures are commonly involved w/
- Charcot’s foot and often collpased
- watch out for compartment syndrome
- AVN waiting to happen
What is an equinous deformity
ankle in dorsiflexion walk and looks like a horse (related to flat feet)
w/ foot injuries get
weight baring xrays
*shows flat foot or other arc deformities
claw toe can cause an ulcer
ulcer at metatarsal, hyperextended at plantar side MTPJ and dorsal side of PIP?
SX: pain and tightness most commonly with the 1st step in the morning
plantar fasciitis
