Hip, Thigh, Knee MDT Flashcards
Name the injury:
- Causative injury usually is high-energy trauma, such as a motor vehicle accident or a fall from a height
- Posterior dislocations account for more than 90% of hip dislocations
- Occurs when the femoral head is displaced from the acetabulum
Hip dislocation
Pt presents with:
- Severe pain
- Unable to move the lower extremity
- May experience numbness throughout the lower limb
- Most have multiple injuries and may be unconscious from associated head trauma
Hip dislocation
Pt PE:
- Leg is short, hip is fixed in adduction and internally rotated
Posterior hip dislocation
Pt PE:
- hip assumes a position of mild flexion, abduction, and external rotation
Anterior dislocation
What is the difference in neurovascular assessment of anterior and posterior hip dislocation
- Sciatic nerve injuries are common with posterior dislocations
- Femoral nerve palsy may be present with anterior dislocations
Rads for hip dislocation
- Plain films
- CT
Treatment of Hip dislocation
- MEDEVAC
-A reduction should be performed as soon as possible to decrease the risk of osteonecrosis - Neurovascular function should be evaluated both before and after reduction
- SIQ until evaluated by orthopedics
- Narcotic level analgesic
What is of concern after reduction of hip dislocation
Osteonecrosis
The following describes what injury:
- high-energy trauma such as a motor vehicle accident
- associated with potentially life-threatening pulmonary, vascular complications, intra-abdominal and head injuries
Fracture of the Femoral Shaft
Pt presents with:
- Severe pain in the thigh
- Unable to move or weight bear on affected extremity
- May have multi-systems involved
Fracture of the Femoral Shaft
How Fracture of the Femoral Shaft confirmed?
Plain film radiographs
Treatment of Fracture of the Femoral Shaft
- Immediate splinting AND traction
-MEDEVAC - Surgery required
- If open wound, apply dressing
The following describes what injury:
- Often misdiagnosed or missed
- Most commonly occur in military recruits, athletes and runners
- Result from dynamic, continuing process rather than single acute, traumatic event
Stress Fracture of the Femoral Neck
Pt presents with:
- Patient presents with vague pain in groin, anterior thigh or knee
- Associated with weight bearing activities and typically subside after cessation of activity
- Reports increase in exercise intensity or activity level In the few weeks preceding symptoms
Stress Fracture of the Femoral Neck
Pt PE:
- Antalgic gait
- Tenderness at proximal thigh or groin may be present
-Limited ROM, most significantly in internal rotation
- Pain to groin or thigh with straight leg raise
Stress Fracture of the Femoral Neck
How is Stress Fracture of the Femoral Neck diagnosed?
- Radiographs are not diagnostic in most patients
- Bone scan will detect fracture within 24-48 hours after injury
- MRI is sensitive for differentiating compression side or tension side stress fracture
Treatment of Stress Fracture of the Femoral Neck
- MEDEVAC
- Analgesics
- Orthopedic Evaluation
- Activity modification
- Crutches
- Non weight bearing status
The following describes what injury:
- fractures of the pelvic ring and acetabulum
- injuries range in severity from stable, low-energy fractures to severe, life-threatening
Pelvis fracture
Pt presents with:
- Patients typically complain of pain in groin area with attempted weight bearing and inability bear weight
- May describe a feeling of coming apart in the hip with attempted weight bearing
- Associated symptoms could be from head, chest and abdomen
- High-energy injuries can present in shock and often have associated musculoskeletal or multisystem injuries
Pelvis Fracture
Pt PE:
- Patients able to ambulate will have an antalgic gait
- may see hip and knee displacement
- Gentle compression of pelvis will localize the area of injury
Pelvis Fracture
What areas of the body need plain film x rays for pelvic fracture
- Pelvis
- Hip
- Head
- Cervical
- Chest
Why and what labs would be drawn for pelvic fracture
Urinalysis: hematuria is common
Hematocrit: evaluate blood loss
Treatment of Pelvis Fracture
- MEDEVAC
- Definitive treatment of unstable pelvic and acetabular fractures usually requires operative intervention
- Hemodynamic resuscitation
- No weight bearing
- Narcotic level pain management
- Treat other associated injuries
The following describes what injury:
-Strains to several muscles:
Iliopsoas
Sartorius
Rectus femoris
-Vigorous muscular contraction while the muscle is on stretch frequently causes the injury
- Results from acute or overuse injury
Hip Strain
Pt presents with:
Pain over hip that is exacerbated when that area continues to be used during strenuous activity
Hip strain
Pt PE:
- Hip adductors is identified by tenderness in the groin
- Iliopsoas typically causes pain in the deep groin or inner thigh
- Hip flexors is identified by tenderness to the tendons in the ASIS region
- Increased pain with motion to hip
- Hip Strain
What special test will be positive for hip strain
Positive Thomas test- for tight hip flexors
Why would you need rads for hip strain?
- Radiographs of pelvis and hip can rule out fracture or other bony lesion
- MRI may be needed if un-resolving chronic hip pain
Treatment of hip strain
- Light duty with a focus on activity modification
NSAIDS - Pain free hip stretching and strengthening
- Run-walk program for progressive run schedule
- Failed conservative therapy needs to be evaluated be orthopedics to rule out other pathology
The following describes what injury:
- Injury happens when actively contracted muscle is put on a stretch
- The posterior thigh muscles (hamstring muscles) are injured more often than the anterior thigh muscles (quadriceps)
- Strain/tear typically occurs at the musculotendinous junction
Thigh strain
Pt presents with:
- sudden onset of posterior or thigh pain that occurred while running, water skiing, or some other rapid movement
- A “pop” may have been perceived at the onset of pain
- direct blows during contact sports that results in a contusion
Thigh strain
Pt PE:
- Muscle injury and associated hemorrhage may be evident by ecchymosis located in the posterior thigh
- Local tenderness at the site of the injured muscle
- Hamstring- pain with hip flexion and knee extension
- Quadriceps- pain with hip extension and knee flexion
Thigh strain
What special test will be positive for thigh strain
Positive Thomas test with rectus femoris strain
What is more common, hamstring or quadricep strain?
Hamstring
What radiologic study should be used for thigh strain?
- Plain film
- MRI
- US
Plain film- not needed
MRI- can confirm but rarely indicated
US-cheapest and fastest for confirmation
Treatment of Thigh strain
-rest and elevate the limb while applying ice and compressive wraps as needed
- rehabilitation with pain free stretching and strengthening of the injured muscle
- NSAIDs
The following describes what injury:
- may develop without apparent cause
- Possibly associated with lumbar spine disease, intra-articular hip pathology, significant limb-length inequalities, inflammatory arthritis, or previous surgery around the hip
- Cause of lateral hip pain
Trochanteric Bursitis
Pt presents with:
- Patients usually have pain and tenderness over the lateral hip
- The pain may radiate distally to the knee or ankle (but not onto the foot) or proximally into the buttock
- Pain worse when going from sit to stand
- May decrease after warming up but return after 30 to 1 hours of walking
- Unable to lie on affected side
Trochanteric Bursitis
Pt PE:
- Point tenderness over the lateral greater trochanter
- Tenderness above the trochanter suggests tendinitis of the gluteus medius tendon
- Patients report increased discomfort with hip adduction or adduction with internal rotation
Trochanteric Bursitis
What special tests will be positive for Trochanteric Bursitis
Resisted hip abduction also causes pain
Trendelenburg test
Faber
Treatment of Trochanteric Bursitis
- NSAIDS
- Light Duty- Activity modification
- Hip strengthening(focus on abduction) and stretching
- Refer to Ortho if conservative management failed
The following describes what injury:
- results from a rotational (twisting) or hyperextension force
- About half the time, is accompanied by a significant meniscal tear
ACL tear
Which ligament is the primary stabilizer of the knee?
The anterior cruciate ligament (ACL) is a primary stabilizer of the knee
Pt presents with:
- usually report sudden pain and giving way of the knee from a twisting or hyperextension-type injury
- 1/3 report an audible “pop” as the ligament tears
- unable to continue participating in athletic activity because of pain and/or instability
ACL tear
Pt PE:
- Moderate to severe effusion
- Possibly hemarthrosis (bleeding in the joint)
- Generalized knee tenderness
- Limited by pain and effusion
- Locking/popping sensation
Knee ligament tear
How do you confirm ACL tear
MRI
Treatment of ACL tear
- RICE
- Light Duty to include running or cutting activities
Orthopedic Consult - Physical Therapy Consult
- A knee immobilizer or range-of-motion brace may be used for comfort when necessary until acute pain subsides
What is the strongest ligament in the knee?
PCL
The following describes what injury:
- Injury caused by stretch or complete rupture of the ligament
- Less common than other ligamentous/meniscal injury
PCL Tear
What are the 4 injury patterns that suggest PCL tear
- Dashboard injury—a posteriorly directed force to the anterior knee with the knee in flexion, as in a motor vehicle accident
- Fall onto a flexed knee with the foot in plantar flexion
- A pure hyperflexion injury to the knee
- A hyperextension injury to the knee-typically, the ACL ruptures first, and then with sufficient force, injury to the PCL follows
What special tests will be positive for PCL tear
Posterior Drawer
Sag test
What radiolgic studies can confirm PCL tear
- MRI
- Plain film to r/o other pathologies
Treatment of PCL tear
- RICE
- NSAIDs/Tylenol
- Light Duty to include running or cutting activities
- Orthopedic Consult
- Physical Therapy Consult
What ligaments of the knee resist valgus and varus force?
MCL= valgus
LCL= varus
What special tests are used for MCL and LCL
MCL= valgus stress test
LCL= varus stress test
Treatment of MCL tear
- Usually non operative and heal within 4-6 weeks
- Conservative treatment
- Physical therapy
- NSAIDS
- RICE
- Hinged brace
- Crutches, weight bearing as tolerated (WBAT)
- Ortho consult if conservative management fails
What grade of LCL tear requires surgical management?
Grade III
Conservative treatment of LCL tear
- Physical therapy
- NSAIDS
- RICE
- Hinged brace
- Crutches, weight bearing as tolerated (WBAT)
The following describes what injury:
- Chronic pressure or friction (overuse) causes thickening of this synovial lining and subsequent excessive fluid formation, thereby leading to localized swelling and pain
Knee bursitis
What injury Forms dome shaped swelling over anterior aspect of the knee
Prepatellar bursitis
What are common sites for bursitis of the knee
Prepatellar and pes anserine bursa
Pt presents with:
- Pain with activity and direct pressure
- The pain often is more severe after the patient has been sedentary for some time, and patients will notice a limp when first arising from a chair
- Possible localized swelling over the involved structure
- This is most marked with prepatellar bursitis
Knee bursitis
Pt PE:
- dome shaped swelling over the anterior aspect of the knee
- tenderness to fluid filled dome shape over patella
Prepatellar bursitis
Pt PE:
- mild swelling to medial aspect of the knee
- Tenderness focal medial flare of the tibia just below the tibial plateau
Pes anserine bursitis
How should you treat septic prepatellar bursitis
Aspiration
Treatment of knee bursitis
- RICE
- NSAIDS
- Light duty- activity modification
- Painfree LE stretching and strengthening exercises
- Antibiotic treatment for septic bursitis
The following describes what injury:
- occurs with repetitive flexion and extension of the knee
- up to 25% of physically active people
- This syndrome HAS NOT been reported in people that do not exercise
- Mostly seen in runners and cyclists
IT band syndrome
Pt presents with:
- Pain focal to the anterorlateral aspect of the knee that worsens with activity
- Worse with downhill running, mostly during heel strike
- Discomfort or complete resolution at rest
IT band syndrome
Pt PE:
- Tenderness to direct palpation over/near the lateral femoral condyle
- Tenderness may extend above or below the lateral femoral condyle
- genu varum(bow legs)
- pes planus
- tibial internal rotation
IT band syndrome
What special tests will be positive for IT band syndrome
Positive Obers
Positive pain when jumping on flexed knee
Treatment of IT band syndrome
- Foam rolling
- Light Duty
- Modifications to training regimen
- Proper running time/distance progression
- Hamstring and ITB stretching
- Hip abductor strengthening
The following describes what injury:
- Patients with traumatic tears typically report a significant twisting injury to the knee
- Older patients with a degenerative tear may have a history of minimal or no trauma, such as simply rising from a squatting position
- Patients usually can ambulate after an acute injury and frequently may be able to continue to participate in athletics
- May describe symptoms of mechanical locking, catching or popping
Meniscal tear
Pt presents with:
Mechanical symptoms such as locking, catching, and popping can then develop; patients usually experience pain with twisting or squatting
Menisal tear
Pt PE:
- moderate to severe effusion
- Tenderness over the medial or lateral joint lines
- Knee may feel as though it is “catching” thru range of motion
Meniscal tear
What special test will be positive for meniscal tear
McMurray
What study confirms meniscal tear
MRI
Treat of meniscal tear
- Locked knee (ie: bucket handle tear) should promptly be treated with urgent referral to ortho
- If absence of mechanical locking then treatments should start with RICE
- NSAIDS
- ROM and pain free strengthening exercises
- Consult to orthopedics
- Patient with traumatic effusion and mechanical symptoms need urgent orthopedic evaluation
The following describes what injury:
- “Jumpers knee”
- Associated with jumping sports
- Also seen in patients who increase physical training too quickly
- “too much, too fast, too soon”
Quadriceps/Patellar Tendonitis
Pt presents with:
-patients often point to a tender spot where symptoms concentrate
- Pain is exacerbated by exercise
Exacerbated by prolonged sitting, squatting, or kneeling in some cases
- Climbing or descending stairs, running, and, of course, jumping often increase the pain
Quadriceps/Patellar Tendonitis
What is the difference in location for quadricep and patellar tendonitis?
Superior pole of patella - quadricep tendonitis
Inferior pole of patella - patellar tendonitis
Pt PE:
- Mild infrapatellar bursa swelling
- Tenderness at tendon insertion/origination sites as discussed
- Crepitus
- Knee motion normal but pain with extension
Quadriceps/Patellar Tendonitis
Treatment of Quadriceps/Patellar Tendonitis
- NSAIDS
- Ice
- Light duty
- Pain free quadriceps and hamstring stretching and strengthening
- Patellar tendon strap-Chopats for comfort
The following describes what injury:
- Most common cause of knee pain in primary care setting
- Around 20% among adolescents
- Most common in third decade of life
- Runners total mileage correlates with development
Patellofemoral pain
What factors among military recruits put them at risk for patellofemoral pain
- Fitness level upon entry to service
- Prior exercise behavior
- BMI over 25
- Training load
Pt presents with:
- Diffuse aching anterior knee pain
- Exacerbated by prolonged sitting (theater sign), climbing stairs, jumping, or squatting
- Usually no preexisting trauma
- Some patients report a sense of instability or a retropatellar catching or grinding sensation
- Usually no history of swelling is reported
Patellofemoral pain
Pt PE:
- Femoral anteversion
- Genu valgum
- Foot over pronation
- Tenderness noted to medial and/or lateral subpatellar borders
- Crepitus maybe noted with patellar mobility (nonspecific finding)
Patellofemoral pain
What special test should be done for patellofemoral pain
Patellar apprehension
Hamstring flexibility
Treatment of Patellofemoral Pain
- NSAIDS
- Ice
- Light Duty-Active Rest
- Quadricep and hamstring flexibility and strengthening
- Weight loss is recommended when a patient is obese
- Support biomechanical limitations
- McConnel taping
- Patellar tracking brace
- Motion control shoe/Inserts
The following describes what injury:
- Also called Bakers cyst
- Common in both children and adults
- Associated with knee injury and chronic inflammation
- Fluctuate in size and symptoms
- Rupture can lead to severe pain and edema of the lower extremity
Popliteal cyst
Pt presents with:
- Swelling/fullness in the popliteal fossa
- Posterior knee pain
- Knee stiffness
- Small cysts may be asymptomatic
- Larger cysts can dissect down the posterior calf and/or rupture, resulting in severe calf pain and decreased motion at the ankle
Popliteal cyst
What must be r/o prior to dx of popliteal cyst
DVT
Pt PE:
- Edema to the popliteal fossa
- Palpate the area to determine the size, consistency, and amount of tenderness
- Flexion may be limited by pain and excessive joint fluid
Popliteal cyst
What radiologic study should be done for popliteal cyst
US
Treatment of Popliteal Cyst
- NSAIDS and or analgesics
- Ice
- Light duty-activity modification
- Return to activities pain free
- Orthopedic consultation if symptomatic
The following describes what injury:
- Typically seen between ages of 14-18, possibly later in males
- Much more common in active adolescents who participate in sports
- Characterized by pain and swelling at the tibial tubercle
- Overuse causes chronic avulsion of the ossification center of the tibial tubercle
Osgood Schlatter
Pt presents with:
- Anterior knee pain that increases gradually over time
- Exacerbated by direct trauma, kneeling, running ,jumping and other activity
- Relieved by rest
- Typically asymmetric, occasionally bilateral
Osgood Schlatter
Pt PE:
- slight swelling/bony prominence of tibial tubercle
- Tenderness to tibial tubercle
- Pain with resisted extension of knee
Osgood Schlatter
When should radiograph plain films be obtained for Osgood Schlatter
- Pain at night
- Pain not related to activity
- Acute onset of pain
- Associated systemic complaints such as fever, chills
Treatment of Osgood schlatter
- Usually benign and self limited
- Resolves when the growth plate reaches skeletal maturity (ie: stop growing)
- NSAIDS
-Protective pad over knee - Duty modification
- Avoid complete rest
- Home Exercise Program
- May consider physical therapy
