LE Part 1 Flashcards
What are the hip abductors?
- Gluteus medius
- Gluteus minimus
- Tensor fascia lata
What are the hip extensors?
- Gluteus maximus
- Adductor magnus
- Biceps femoris
- Semitendinosus
- Semimembranosus
What are the hip adductors?
- Pectineus
- Adductor brevis
- Adductor longus
- Gracilis
What are the hip flexors?
- Iliacus
- Psoas majro
- Pectineus
- Rectus femoris
- Sartorius
Anatomy of LE: Arteries
Anatomy of LE: Nerves
Inspection/palpation of the hip and thigh
- Inspect anterior and posterior noting deformities, muscle atrophy, swelling, discoloration, etc,
- Palpate iliac crests, posterior iliac spine, and greater trochanter
- Palpate anterior region for masses, adenopathy, or tenderness in the region of the anterior superior iliac spine
- Note gait
Flexion ROM of hip and thigh
- Zero starting position is with patient lying supine with lumbar spine flat on table
- Maximum flexion is point at which pelvis begins to rotate
- Normal is 0-110 to 130
Normal hip and thigh ROM: extension
- Perform standing, with leg hanging off side of table, or prone
- Normal 20-30 degrees
Normal hip and thigh abduction/adduction
- Abduction: normal is 35-50
- Adduction: normal is 25-35
Internal and external rotation in felxion of hip and thigh
- Assess with knee and hip flexed
- Normal is 25-35
What is the thomas test?
- Evaluate for hip flexor contracture or tight psoas
- Patient lies supine with legs hanging off end of table
- Patient pulls one hip into maximum flexion while you observe the contralateral hip to see if it flexes off the surface of the table
What is trendelenburg test?
- Patient stands on one leg
- With normal hip abductor strength, pelvis will stay level
- If hip abductor strength is inadequate pelvis will dip towards opposite side: positive trendelenburg test
- Muscle weakness is on stance side
What is FABER testing?
- Figure of 4 test
- Stress maneuver to detect hip and sacroiliac pathology
- If painful, hip or sacroiliac region may be affected
- Pain on ipsilateral side anteriorly - hip problem
- Pain in contralateral SI joint = SI dysfunction
How is leg length measurement performed and what is it for?
- Measure from anterior iliac crest to medial malleolus of tibia of same leg
- > 3 cm difference can lead to significant back and hip problems
What is the log roll test?
- Internally and externally rotate relaxed lower extremity in supine position
- Pain in anterior hip or groin, particularly in internal rotation is indicative of OA or femoral head osteonecrosis
What is piriformis test?
- Patient lies supine or on unaffected side with hip and knee flexed to approx 90 degrees
- Stabilize pelvis with one hand and apply flexion, adduction, and internal rotation pressure at the knee
- Pain in buttock or down the leg = + piriformis test –> piriformis is impinging on sciatic nerve
What is scouring test
- Flex hip and knee at 90 degrees, apply posterolateral force through the hip as the femur is rotated in the acetabulum
- Passively adduct and internally rotate the hip followed by abduction and external rotation
- Pain or grating sound = labral pathology, a loose body, or internal derangement
Imaging of the hip and femur
Hip series:
* AP
* Lateral
Specialty hip views:
* Frog leg view
* Obturator/oblique view
AP pelvis for comparison if needed
Disorders of the hip
- Hip dislocation
- Hip fracture
- Greater trochanteric bursitis
- Avascular necrosis of the hip
- Iliotibial band syndrome
What is usual MOI for hip dislocation
- High grade, multi-trauma presentation
- Posterior (MC90%) MOI: Posterior force applied to a flexed knee
- Anterior: hyperextension force against an abducted leg or an anterior force on posterior femoral head
- Prosthetic joints can dislocate under much less force
When are complicated injuries due to hip dislocation most likely?
Posterior dislocations
What can be complicated injuries in hip dislocation?
- Acetabular or femoral head/neck fracture
- Sciatic nerve damage: sciatic and peroneal nerve most often affected
- Ligamentous injuries or fractures of the knee
- Avascular necrosis of the femoral head
Clinical presentation of hip dislocation
- Severe pain
- Inability to move affected leg
- Numbness, tingling, muscle weakness with nerve injury
- Peroneal damage: drop foot and sensory changes along lateral lower leg and dorsal foot
Physical exam of hip dislocation
- Deformity based on direction of dislocation
- Must assess NV status
PE of posterior hip dislocation
Leg is shortened, adducted and internally rotated
PE of anterior hip dislocation
- Abduction iwth external rotation and flexion of the hip
- Can be anterior superior or inferior
- Direction determined by degree of hip flexion at time of injury
Diagnostics for hip dislocation
- Stat x-ray hip series: femur and knee may be needed to rule out associated injuries
- CT hip without contrast: utilized after reduction to asssess for fracture and trapped intra-articular loose bodies
Management of hip dislocation
- Acute traumatic hip dislocations are emergency
- Posterior dislocation: urgent closed reduction (w/i 6 hours), Allis maneuver most common
- Anterior dislocations; may require open reduction
- All require procedural sedation and post reduction films
- Post reduction immobilization with a triangular abduction pillow or knee immobilizer
- Ortho consult/referral
What are the hip reduction maneuvers
- Allis
- Stimson gravity
- Captain morgan
When would an ortho consult/referral be indicated emergent?
- Anterior dislocation
- POsterior reduction is unsuccessful
- NV comrpomise
Disposition of hip dislocation
- Most require hospital admission
- Non-weight bearing, +/- traction and parenteral pain control
- Uncomplicated: crutch assisted weight bearing followed by physical therapy until ambulation without pain
- Patient followed and monitored for avascular necrosis for 2-3 years
MOI of hip fracture
- Fall MC
- Posterior force to flexed knee
Classifications of hip fracture
- Intracapsular: femoral head or neck
- Extracapsular: intertrochanteric or subtrochanteric
Hip fracture risk factors
- Elderly age
- Caucasian
- Female
- Sedentary lifestyle
- Smoking
- Chronic alcohol use
- Psychotropic medication
- Dementia
- Osteoporosis
Hip fracture presentation
- Pain in groin, hip, buttock radiating to knee
- Inability to ambulate
- Externally rotated, abducted, shortened leg
- Stress fractures = no obvious deformity
- Pain with minimal ROM or SLR
- May have associated injuries ie pelvic fracture, NV compromise, knee injury
Diagnostics for hip fracture
- Standard hip XR series with pelvis
- Additional images of back, femur, and/or knee if needed
- MRI or CT if clinical presentation and negative x-ray
Management of hip fracture
- Urgent ortho consult
- Surgical interventions (w/i 48 h) most often required
- ORIF in young patients
- Arthroplasty in older patients to allow for immediate ambulation
- Additional immobilization not necessary - maintain position of comfort
Ccontraindications of hip fracture surgery
- Medically unstable
- Patients who were previously non-ambulatory
- Dementia patients with minimal pain during transfers
Complications of hip fracture
- Infection
- DVT/PE
- Pneumonia
- Decubitus ulcer
- UTI
- Nonunion and avascular necrosis
- Implant failure more common with extracapsular fractures
Prognosis and follow up of hip fracture
- All patients evaluated post-op for osteoporosis
- One year mortality rate 14-36% often due to complications
MOI of greater trochanteric bursitis
- Repetitive trauma
- Blunt trauma
Clinical presentation of greater trochanteric bursitis
- Lateral hip pain
- Radiates down lateral aspect of the thigh past the knee or up into the buttock
- Worse when rising from seated or recumbent position, night time when lying on affected side
- Improves after the first few steps but worsens again after prolonged walking (>30 minutes)
- Point tenderness over greater trochanter
- Pain with active abduction and adduction + internal rotation
Diagnostics for greater trochanteric bursitis
Hip series: only to rule out other ddx
Management of greater trochanteric bursitis
- NSAIDs
- Activity modification
- Ice
- Short term use of cane if needed: hold cane in hand that’s opposite to side that needs support
- Home stretching: heat 15 mins before and ice for 20 mins after
- Bursal injection with local anesthetic and corticosteroid
Other names for avascular necrosis
- Aseptic necrosis
- Ischemic necrosis
- Osteonecrosis
Pathology of avascular necrosis
- Bone infarction due to lack of adequate blood supply
- Traumatic or systemic in nature
- MC sites are the proximal and distal femoral heads resulting in hip and knee pain respectively
Epidemiology of avascular necrosis
MC 20-50 years of age
Risk factors for avascular necrosis
- Trauma
- Alcohol/tobacco use
- Radiation therapy
- Long term steroid use
- Bisphosphonates
- Hx of tissue/organ transplant
- Chronic medical conditions
Clinical presentation of avascular necrosis
- Initial severe pain during cell death
- Later becomes dull aching and throbbing
- Painful/loss of ROM
- Painful weight bearing
- Femur: antalgic gait
Diagnostics of avascular necrosis
- Hip and pelvic x-ray
- Early disease: x-ray normal
- Later: patchy areas of sclerosis and lucency
- Late: “crescent sign”
- MRI, CT, and/or bone scan needed if clinical suspicion and x-ray is negative
What is crescent sign?
- Present in late avascular necrosis
- Well-defined sclerotic area just beneath the articular surface indicative of a subchondral fracture
Initial management of avascular necrosis
- Avoid weight bearing
- Adequate pain management: NSAIDs with break-through opiates
- Refer to ortho
What is required in most patients due to young age of occurance of avascular necrosis
Surgery
What is non-surgical management of avascular necrosis
- Note: doesn’t halt disease progression
- Bedrest
- Partial weight bearing with crutches
- Progressing as tolerated
- Pain management
- PT- can restore ROM and improve gait
Complications of avascular necrosis
- Collapse of femoral head leading to secondary degenerative arthritis
- Chronic pain
- Loss of ROM
- Decreased ambulatory capacity
- Abnormal gait
MOI of femoral shaft fractures
- High energy trauma such as MVA
- Less common pathologic fractures: osteopenia, tumor
Clinical presentation of femoral shaft fractures
- Pain
- Localized tenderness
- Swelling
- Shortening and deformity of leg
What should be assessed in femoral shaft fractures?
- NV status
- Evidence of open fx
- Assess for complications: extensive blood loss, compartment syndrome, multi-system injuries
Diagnostics of femoral shaft fractures
- Femur (AP and lateral)
- Hip, knee and pelvis radiographs
Management of femoral shaft fractures
- Pain management
- Fluid resuscitation
- Temporary stabilization: long leg, posterior and stirrup splint with a traction device
- Ortho consultation
What is present on the medial surface of the knee
- Adductor tubercle
- Medial epicondyle
- Medial condyle
What is present on the anterior surface of the knee
- Patella
- Patellar tendon
- Tibial tuberosity
What is present on the lateral surface of the knee
- Lateral epicondyle
- Lateral condyle
- Head of fibula
Joints of the knee
- Tibiofemoral joint
- Patellofemoral joint
Knee flexors
Hamstring muscles: semimebranosus, gracilis, sartorius, semitendinosus
Knee extensors
Quadriceps: rectus femoris, vastus lateralis, vastus medialis, vastus intermedius
Additional structures of the knee
- Medial meniscus
- Lateral meniscus
- MCL, LCL
- ACL, PCL
- BUrsae
Anterior, lateral, and posterior views of physical exam of knee
- Assess for asymmetry, deformities, atrophy of muscles, swelling, erythema
- Valgus/varus deformity
What are you assessing with gait for knee
- Abnormal gait: antalgic gait (limp)
- Wide-stance gait
- Waddling
- Trendelenburg gait
What can pain with squatting indicate?
Meniscal injury
How is joint line palpation performed?
Knee flexed at 90 and relaxed
What does focal and generalized tenderness of medial/lateral joint line suggest?
- Focal: torn meniscus
- Generalized: arthritis
Where is the infrapatellar bursa located?
Inferior and lateral to the patella
What may be noted in knee effusion
- Fullness and loss of parapatellar dimpling in large effusions
- Bulge sign: + test fluid wave over medial knee
- Ballottement: + test rapid rebound, indicating increased fluid pressure
How is the bulge sign performed?
Direct fluid superiorly over medial recess then inferiorly from the suprapatellar pouch inferiorly
How is ballottement performed?
Push down patella and rapidly release
What should the joint be palpated for during passive ROM
?
Crepitus
What are the primary knee motions?
Flexion and extension
Zero starting point is full extension of the knee
Normal flexion is 0 degrees to 135-145 degress
How can active flexion of the knee be assessed?
Have patient squat or while lying supine or prone
Knee hyperextension is more often seen in which populations?
Children or patients with joint instability
How do you assess quadriceps muscle strength
While sitting, have the patient extend the knee against resistance
How do you assess hamstring muscle strenght
Patient prone, place knee in approx 90 degree flexion and ask patient to flex knee further against resistance
Flex knee against resistance in sitting position
What is patellar tracking
- Patient flex and extend knee and patella movement observed
- Normal: patella slightly lateral in extension and centrally in flexion
- Abnormal: exaggerated arc of movement either laterally or medially = patellar instability
How is patellar apprehension sign performed
- Patient lies supine with knee relaxed in 30 degree flexion
- Displace patella laterally by applying medial pressure
What does a + patellar apprehension sign look like? What does this mean?
- Patient contracts the quadriceps or becomes apprehensive due to pain
- Indicates patellofemoral syndrome, patellar subluxation, patellar dislocation
What is patellar grind sing?
Assesses for cartilage degeneration under the patella in patellofemoral syndrome (chondromalacia)
Technique for patellar grind sing
- Patient supine and knee fully extended
- One hand superior to patella gently push patella inferiorly as you instruct patient to contract quadricep
interpretation of patellar grind sing
Pain, grinding, or clicking is + test
What does valgus stress test assess?
Medial collateral ligament
Technique to perofrm valgus stress test
Abduct and flex knee to 30 degrees
Examiner applies a valgus pressure
Technique to perform varus stress test
Assesses the lateral collateral ligament
Medial pressure applied to knee
Tecnique to perform mcmurray test
- Patient uspine with examiner at side of patient
- One hand on the heel while other palpates joint line
- Medial meniscus: external rotation, valgus stress and slowly extending the leg (MEG)
- Lateral meniscus: (LIR) internal rotation, varus stress and slowly extending knee
What is the interpretation and indication for mcmurray test
+ test pain, popping, or clicking noted
-indications: assess for meniscal injuries
What is the most sensitive test for ACL?
Lachman test
Technique for Lachman test
- Patient supine with knee flexed approx 25-30 degrees and instructed to relax quadriceps muscle
- Place one hand on the distal femur and one on proximal tibia
- Pull anteriorly on the tibia
Interpretation of lachman test
+ test: anterior translation = partial or complete tear of ACL
What is anterior drawer test?
- Negative in 50% of ACL tears
- Assess ACL stability
- Patient supine with hamstrings and quads relaxed and knee flexed to 90 degrees, sit on foot to help stabilize
- Grasp proximal tibia with both hands and slide tibia anteriorly
Interpretation of anterior drawer
+ test: signficant laxity compared to opposite side
What is pivot shift test?
Used to assess dysfunction of the ACL: postiive in severe grade II or grade III tears
Generally performed under anesthesia
Technique for pivot shift test
Place the knee in full extension and then slowly flex the knee while examiner applies a valgus stress and internal rotation
Interpretation of pivot shift test
Subluxation occurs at 20-40 degree flexion if positive
What is posterior drawer test used to assess?
Posterior cruciate ligament
Technique to perform posterior drawer test
Perform same way as anterior drawer but slide tibia posteriorly
+ posterior drawer test
tibia falls back posterior to the femur
What is noble’s test used to assess?
Iliotibial band
Technique for noble’s test
Patient supine with knee flexed to 90 degrees
Apply pressure to lateral femoral condyle or 1-2 cm proximal to it as the knee is passively extended
What is a + noble’s test
tenderness over lateral femoral condyle at approx 30 degrees of flexion
What is ober’s test used to assess
tensor fascia lata and iliotibial band tightness
technique for ober’s test
lie on unaffected side with unaffected knee and hip flexed
place affected knee in 90 degree of flexion
abduct and extend the ipsilateral hip while stabilizing the pelvis then slowly lower the thigh as far as possible
interpretation of ober’s test
inability of the extremity to drop below horizontal to the level of the table indicates tightness in the fascia an IT band
imaging of the knee
x-ray: knee series standard 2 V
additional views ordered on a case by case basis
disorders of the thigh and knee
iliotibial band syndrome
distal femur fractures
patellar fracture
patellofemoral syndrome
prepatellar bursitis
what is the it band
dense, fibrous band of tissue
originates from asis region
extends down lateral portion of the thigh and inserts on lateral tibia
physiology of it band
in knee extension it band sits anterior to lateral femoral condyle
in knee felxion, it band moves posterior to the lateral femoral condyle
pathophysiology of it band syndrome
repetitive flexion-extension leads to inflammation, usually in runners/cyclers
presentation of it band syndrome
- pain in anterolateral aspect of the knee, worse with repetitive activity and most intense at heel-strike
- resolves with rest
- audible popping with walking/running
- tenderness over lateral femoral epicondyle
- ober’s and noble’s test
- Lateral knee pain when patient hops with a flexed knee
diagnosis of it band syndrome
clinical, knee series only to rule out other disorders
management of it band syndrome
conservative therapy: NSAIDs, ice, rest
PT focusing on stretching and strengthening of surrounding muscles, patient education on how to modify exercise
refer to ortho if no improvement with conservative therapy: local corticosteroid injection, surgical IT band lengthening
MOI of distal femur fractures
low energy trauma in osteoporotic geriatric patient
high-energy trauma in young patient
how is distal femur fracture classified
based on location: supracondylar, intercondylar (right, left, or both condyles may be affected)
presentation of distal femur fracture
- sudden onset of pain after trauma with the inability to bear weight
<swelling, deformity, rotation
- limited ROM
Assess NV status
Look for evidence of open fracture
Assess for associated injuries
Diagnostics for distal femur fractures
Knee series: AP, lateral
Oblique view or CT: often needed to determine amount of displacement prior to surgical repair
MRI: further assess non-displaced fractures and soft tissue injuries
CTA: if vascular compromise
Management of non-displaced distal femur fracture
Long leg splint –> cast
non-weight bearing
ortho referral
management of displaced or intra-articular distal femur fracture
temporary long leg splint for protection and stabilization
urgent ortho consult for ORIF (within 24 hours?
Management of open fracture, vascular compromise, or compartment syndrome for distal femur fracture
emergent ortho consult
MOI of patellar fracture
Direct force: fall, direct blow
Indirect force: powerful contraction of the quadriceps
Associated injury possible with patellar fracture
patella dislocation
presentation of patellar fracture
localized tenderness and swelling
patellar defect may be palpable if significant displacement
assess for intact extensor mechanism: active extension of the knee or SLR
joint effusion may be present
diagnostics for patellar fracture
knee series: ap, lateral, sunrise view
ct to rule out occult fracture
mri to assess for internal derangement
management of non-displaced with intact extensor mechanism patellar fracture
pain management
knee immobilizer or posterior long-leg splint with knee intextension
refer to ortho for outpatient f/u
management of displaced, complex, open, or loss of extensor function patellar fracture
consult ortho for surgical intervention
emergent if open otherwise urgent consult
moi of patellar dislocation
direct trauma
landing on hyperextended knee
quadricep contraction during knee flexion
clinical presentation of patellar dislocation
most often dislocates laterally
pain, tenderness, and deformity
hemarthrosis may be present
+ patellar apprehension test in spontaneously reduced dislocations
diagnostics for patellar dislocation
knee xr: ap, lateral, sunrise
management of patella dislocation
reduction: procedural sedation, gradually flex hip and extend knee while applying medial force to the patella
Post-reduction films
knee/patella immobilizer in full extension x 4-6 weeks
ortho f/u in 1 week
what is patellofemoral syndrome
overuse syndrome involving patellofemoral region
anterior knee pain with excessive use resulting from:
-abnormal patellar tracking
-ligamentous hyperlaxity causing the aptella to sublux
-hip/knee muscle weakness, flexibility imbalance
-abnormal hip-knee biomechanics: increased Q-angle (valgus knee deformity)
presentation of patellofemoral syndrome
diffuse aching pain over the anterior knee, behind the knee cap with activities that increase the load of the patellofemoral joint: running, walking, stairs, jumping, kneeling, squats
- pain worse after prolonged sitting
physical exam of patellofemoral syndrome
Gait with patellar squinting (patella pointing toward each other during ambulation)
tenderness along articular surface of patella when leg extended and relaxed
apprehension sign = associated instability
-patellar grind test = associated chondromalacia
-one-leg squat to assess for quad and hip strength
+ trendelenburg sign = weak hip abductor
diagnostics for patellofemoral syndrome
clinical diagnosis
x-ray: knee AP, lateral, and axial view may show lateral deviation or tilting of patella and rules out other pain causes
MRI only if surgery is considered
management of patellofemoral syndrome
rest, ice, nsaids
-patellar stabilizer brace or taping techniques –> mcconnell taping
-weight loss if applicable
- PT hallmark of treatment: quad strengthening and stretching, hamstring stretching
refer to ortho if no improvement with conservative therapy: patellar alignment, patellar resurfacing, patellofemoral arthroplasty
what is prepatellar bursitis
inflammatory or infectious swelling of the prepatellar bursa
mechanism of prepatellar bursitis
inflammatory: direct blow, chronic compression via wrestling, praying, carpet installation
bacterial infection: direct penetration
presentation of prepatellar bursitis
early on pain only with activity or direct pressure which progresses to constant pain
localized swelling over the knee: unable to differentiate patella from surrounding joint, differentiates this from joint effusion
septic bursitis: erythema, warmth, increased pain
Inflammatory: less painful, minimal warmth
diagnostics for prepatellar bursitis
knee x-ray to rule out bony conditions, will show diffuse anterior soft tissue swelling
bursal aspiration: if septic bursitis is suspected and synovial fluid analysis, gram stain, culture, cell count, crystal analysis
management of inflammatory bursitis
NSAIDs, ice, activity modification
corticosteroid injection only if septic bursitis is ruled out in those who fail conservative treatment
management of infectious bursitis
oral antibiotics for mild cases: oral keflex to cover MSSA, bactrim or clindamycin to cover MRSA if hx suggestive
IV abx for more severe cases: iv ceftriazone, cefazolin-MSSA; IV vanc for MRSA
