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MSK > LE Part 2 > Flashcards

LE Part 2 Flashcards

1
Q

How do we decide when to get a knee x-ray?

A

Ottawa knee rules

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2
Q

What are the ottawa knee rules?

A
  • Radiograph if 1 criterion is met
  • Age >55
  • Tenderness at head of fibula
  • Isolated tenderness of the patella
  • Inability to flex knee to 90 degrees
  • Inability to bear weight for 4 steps both immediately after the injury and in ED
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3
Q

Knee anatomy: Ligaments and menisci

A
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4
Q

What are the borders of the knee joint capsule?

A
  • Superiorly: femur at margin of condyle
  • Posteriorly: encloses condyles and intercondylar fossa
  • Inferiorly: margin of tibial plateau except where tendon of popliteus crosses the bone
  • Anteriorly: quadriceps tendon, patella, and patellar ligament continuous with medial and lateral margins
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5
Q

Knee disorders/injuries

A
  • Ligamentous injuries
  • Meniscal injuries
  • Knee dislocations
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6
Q

What is the function of the ACL

A
  • Primary stabilizer of the knee
  • Prevents anterior translation of tibia in relation to femur
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7
Q

MOI of ACL tear

A
  • Sudden deceleration with rotational trauma or hyperextension force applied to knee
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8
Q

Pathology of ACL tear

A
  • Complete rupture of ligament most often occurs
  • Commonly associated with a meniscal tear: MCL, LCL, or PCL rarely damaged
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9
Q

Presentation of ACL tear

A
  • Twisting or hyperextension injury followed by sudden pain and giving way of the knee
  • Audible pop
  • Joint effusion within first few hours –> increased pain
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10
Q

Physical exam of ACL tear

A
  • Joint effusion
  • Limited ROM –> inability to bear full weight
  • +Lachman test (most reliable)
  • Anterior drawer test
    • pivot shift test (only done when sedated)
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11
Q

Diagnostics of ACL tear

A
  • X-ray knee series
  • AP, lateral, and tunnel views
  • Most often only shows effusion
  • May show avulsion fracture of the lateral capsular margin of the tibia –> Segond fracture
  • Tibial eminence fracture common in patients with open growth plates (avulsion)
  • MRI often ordered to confirm diagnosis
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12
Q

How does a joint effusion appear on knee imaging?

A

Well-defined rounded homogenous soft tissue density within the suprapatellar recess on a lateral radiograph

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13
Q

Management of ACL tear

A

Initial
* RICE with knee immobilizer brace +/- crutches
* Pain relief –> acetaminophen before NSAIDs
* Consider aspiration if effusion large
* Start early ROM exercises as pain allows

Refer to ortho
* Young patients –> reconstruction with graft from patients patellar, hamstring, or quad tendon or cadaver
* Older patients –> PT to strengthen surrounding muscles to improve stability

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14
Q

What is the function of the PCL?

A

Prevents posterior translation of the tibia in relation to the femur

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15
Q

MOI of PCL tear

A
  • Direct blow to the tibia ie knee strikes dashboard in MVA or fall onto knee
  • Extreme hyperextension (associated ACL rupture)
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16
Q

Pathology of PCL tear

A
  • Ranges from stretch injury to complete rupture
  • Often associated with other injuries: collateral ligaments, ACL ruptures
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17
Q

Physical exam for PCL tear

A
    • posterior drawer test
  • Assess NV status if multiligamentous injury suspected –> assess with ABI if <.9 order arterial imaging to r/o intimal tear that could lead to thrombosis
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18
Q

Clinical presentation of PCL tear

A
  • Sudden pain and giving way of knee
  • Joint effusion within first few hours –> increased pain
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19
Q

Diagnostics for PCL tear

A
  • Same as ACL
  • X-ray knee series: AP, lateral, and tunnel views
  • Often shows effusion
  • May show avulsion fracture
  • Tibial eminence fracture in patients with open growth plates
  • MRI to confirm
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20
Q

Management of PCL tear

A

Initial
* RICE
* Knee immobilizer
* Begin ROM after 1-5 days
* Isolated PCL injuries: PT to strengthen quads and hamstrings and restore ROM and if PT fails to restore stability, reconstruction
* Multi-ligamentous injuries: reconstruction

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21
Q

Sequelae of PCL tear

A

Osteoarthritis

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22
Q

What is the function of collateral ligaments?

A

Provide stability from varus (LCL) and valgus (MCL) stress

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23
Q

MOI of collateral ligament tear

A
  • Medial collateral ligament (MCL): lateral (valgus) blow to the knee
  • Lateral collateral ligament (LCL): usually in association with other traumatic knee injuries
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24
Q

Presentation of collateral ligament tear

A
  • Localized pain
  • Tenderness
  • Swelling and stiffness along ligament course
  • Worsens over 6-8 hours
  • Patient may be able to bear weight after injury
  • 1-2 days after injury ecchymosis along ligament course and small effusion
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25
Q

Physical exam of collateral ligament tear

A
  • Assess uninjured extremity first to gage normal laxity
  • Varus/valgus testing performed in extension and 30 degree flexion
  • Laxity noted in extension - more significant trauma
  • Instability may be masked by pain and involuntary muscle contraction
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26
Q

Diagnostics of collateral ligament tear

A
  • AP/lateral knee x-ray: assess for avulsion fracture
  • MRI to confirm
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27
Q

Management of collateral ligament tear

A

Sprains-partial tear (grade I and II)
* RICE, hinged knee brace, NSAIDs
* Early ROM exercises
* Crutches with weight bearing as tolerated

Complete rupture
* Refer to ortho
* Tx varies based upon location of rupture
* Conservative vs. repair or reconstruction

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28
Q

Function of meniscus

A
  • Gel like pads that sit between femur and tibia
  • Function as shock absorbers and provide smooth gliding surface during ambulation
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29
Q

MOI of meniscal injury

A
  • Rotational force of the knee while foot is planted
  • Older patients (degenerative tear): minimal (squatting down) to no trauma
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30
Q

Presentation of mensical injury

A
  • Pain and stiffness following MOI that progressively worsens over 2-3 days
  • Ambulation after injury is possible
  • Patient may report hearing a pop at time of injury
    • locking, catching, or popping noted more after effusion begins to resolve
  • Tenderness along joint line of affected meniscus with medial meniscus more commonly affected
  • Effusion (directly affects ROM): larger in more lateral tears, smaller with tears of avascular central body
  • +McMurray - painful click noted on exam
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31
Q

Diagnostics of meniscal injury

A
  • XRay: 2 view knee series to r/o other pathologies
  • Add a weight bearing AP with knee in 45 degree flexion if >40 y/o to provide info on amount of osteoarthritis
  • MRI knee to identify details of tear
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32
Q

Management of meniscal injury

A

Initial: RICE, NSAIDs
Referral to ortho for arthroscopic repair if indicated
* If no indications for surgery, initial management then PT

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33
Q

Indications for referral to ortho for arthroscopic repair of meniscal injury

A
  • Young patients with traumatic tear
  • Failure to conservative therapy
  • Mechanical symptoms
  • Evidence of ligamentous instability
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34
Q

Epidemiology of knee dislocation

A

MC in young males

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35
Q

MOI of knee dislocation

A
  • Severe ligamentous disruption
  • MVA
  • Fall from heights, trampoline falls
  • Martial arts
  • Spontaneous with walking in morbidly obese patients
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36
Q

How is knee dislocation characterized?

A
  • Direction of tibia relative to femur
  • Anterior
  • Posterior
  • Lateral
  • Medial
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37
Q

Presentation of knee dislocation

A
  • Obvious deformity with severe pain and limited ROM
  • 50% spontaneously reduce: inquire about mechanism and position of leg following injury and suspect if grossly unstable on exam
  • Ecchymosis and swelling often present
  • Can have popliteal artery, common peroneal and tibial nerve injuries; limb-threatening vascular injuries even with normal pulses
  • Attempt ligamentous assessment: may be limited due to large effusions; hyperextension >30 degrees when leg is lifted by the foot indicates gross instability
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38
Q

Diagnostics of knee dislocation

A
  • XR 2 view knee: initial assessment and post reduction
  • CT to assess for occult fracture after reduction and stabilization
  • MRI to assess soft tissue after reduction and stabilization and assess extent of internal derangement
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39
Q

Management of knee dislocation

A
  • Reduction
  • Ortho and vascular surgery consultation
  • Admit for serial NV checks
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40
Q

How is reduction of knee dislocation performed?

A
  • Procedural sedation
  • Immediate reduction by longitudinal traction
  • Followed by post-reduction NV check
  • If distal pulses intact, assess vascular integrity by ABI or angiography
  • Immobilize knee in 20 degree flexion and allow access to distal feet for serial NV assessment
  • Post reduction imaging
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41
Q

Compartments of the lower leg

A
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42
Q

Bones of the lower leg

A
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43
Q

What imaging can be performed for tibia/fibula?

A

Tib/fib series:
* AP
* Lateral

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44
Q

Disorders of the tibia and fibula

A

Tibia and fibula fractures

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45
Q

MOI of tibial plateau fracture

A
  • Valgus stress = lateral plateau fracture due to high-energy trauma in young patient
  • Low-energy trauma in osteoporotic geriatric patient during twisting or fall
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46
Q

Presentation of tibial plateau fracture

A
  • Sudden onset of pain after trauma with inability to bear weight
  • Swelling, joing effusion
  • +/- deformity
  • Limited ROM
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47
Q

Diagnostics for tibial plateau fractures

A
  • XR: AP and lateral knee; oblique views: beneficial if AP/lateral are inconclusive
  • CT/MRI: evaluate amount of displacement prior to surgical repair; assess for soft tissue injury
  • CTA: if vascular compromise
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48
Q

What can be present on lateral x-ray for tibial plateau fracture?

A

Lipohemarthrosis

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49
Q

Initial managmeent of tibial plateau fracture

A
  • Compression
  • Ice
  • Analgesics
  • Splinting in extension
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50
Q

When would you get emergent consultation for tibial plateau fracture

A
  • Open fracture
  • NV compromise
  • Compartment syndrome
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51
Q

When would you get urgent consultation for tibial plateau fracture

A
  • Fractures with any displacement or depression
  • Most all will require ORIF
  • Consult within 24-48 hours
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52
Q

Treatment of non-displaced tibial plateau fracture

A
  • Long-leg posterior splint or knee immobilizer
  • Crutches
  • Strict non-weight bearing
  • F/u with ortho within 1 week
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53
Q

MOI of tibial tubercle fracture

A
  • Sudden force to the flexed knee with quadriceps contracted
  • Ex: knee flexion at the beginning of a jump or an awkward landing
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54
Q

Presentation of tibial tubercle fracture

A
  • MC in children and bones with open grwoth plates
  • Pain, tenderness, and swelling over tibial tuberosity
  • Displacement of patella
  • Loss of ROM
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55
Q

Diagnostics for tibial tubercle fracture

A

XR knee- 2 view

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56
Q

Management of tibial tubercle fracture

A

Incomplete or small avulsion
* RICE
* Knee immobilizer, long leg posterior splint, no weight bearing
* Refer to ortho within 1 week

Complete avulsion
* RICE
* knee immobilizer, long leg posterior splint, no weight bearing
* Urgent ortho consult for ORIF (24-48 hrs)

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57
Q

What is the MC long bone frature

A

Tibial shaft fracture most often in association with fibular fracture

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58
Q

MOI of tibial shaft fracture

A
  • Adults: high-energy direct blow to the tibia
  • Children: twisting injury
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59
Q

presentation of tibial shaft fracture

A

inability to bear weight
pain, swelling
deformity

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60
Q

what complications should be assessed for in tibial shaft fracute

A

open fracture
nv compromise
compartment syndrome

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61
Q

diagnostics of tibial shaft fracture

A

AP and lateral tibia/fibula xray, add on knee and ankle if associated injury suspected
add oblique xray or CT to further evaluate complexity of fracture
bone scan if occult fracture is suspected

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62
Q

initial management of tibial shaft fracture

A

RICE
analgesics
long leg posterior splint

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63
Q

what conditions require emergent consultation in tibial shaft fracture

A

open fracture
tib/fib fracture
nv compromise
compartment syndrome

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64
Q

management of displaced tibial shaft fracture

A

closed reduction and long leg splinting (posterio +stirrup)
admit for observation and monitoring of complications
consult ortho

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65
Q

management of non-displaced tibial shaft fracture

A

long-leg posterior splint
crutches
strict non-weigth bearing
f/u with ortho within 1 week

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66
Q

what is a stirrup splint indicated for

A

ankle sprains
isolated fractures of the fibula or tibia
reduced ankle dislocations

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67
Q

position of foot for stirrup splint

A

ankle in 90 degree dorsiflexion, patient in prone position to prevent shortening the achilles

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68
Q

is fibula fracture often isolated?

A

no often associated with tibia fracture

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69
Q

moi of fibula fracture

A

direct blow to the lower leg
rotational force

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70
Q

clinical presentation of fibula fracture

A

may be able to bear weight if isolated
point tenderness and localized pain with swelling
defomity if fraction is displaced
assess for maisonneuve fracture

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71
Q

what is a maisonneuve fracture

A

proximal fibula fracture with associated medial malleolus fracture or ligament disruption of the ankle without fracture

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72
Q

diagnostics of fibula fracture

A

2 view tib/fib
isolated knee/ankle if needed

73
Q

initial management of fibula fracture

A

RICE
analgesics
long leg posterior splint

74
Q

when would emergent consultation be needed for fibula fracture

A

open fracture
tib/fib fracture
nv compromise
crush injuries
compartment syndrome

75
Q

management of displaced or maisonneuve fracture

A

posterior long leg splint
refer to ortho within 24-48 hours

76
Q

management of fibular head/neck fracture

A

knee immbolizer splint or long leg posterior
ortho consult within a wekk

77
Q

management of distal fibula fracture

A

stirrup splint or air case splint
ortho within a week

78
Q

look back at anatomy and such of the foot and ankle

A
79
Q

what should be noted on anterior view, standing and supine inspection and palpation of foot and ankle

A

alignment of the toes, position of the foot in relation to the limb and medial curvature of the forefoot
palpate plantar fascia, MTP joints, and head of metatarsal for sesamoid bone tenderness

80
Q

posterior view of foot and ankle inspection and palpation

A

heel alignment while standing- normal is neutral or slight valgus with no more than one or two lateral toes visible from behind
palpate achilles tendon insertion

81
Q

medial view of foot and ankle inspection and palpation

A

arch should be symmetric, high arch = pes cavus, flatfoot = pes planus
prominence of the medial midfoot = accessory navicular bone
palpate for perimalleolar tenderness

82
Q

lateral view of foot and ankle inspection and palpation

A

inspect while standing for calluses, ankle swelling or prominence of the posterior calaneus
palpate for perimalleolar tenderness

83
Q

inspection and palpation of foot and ankle while standing on toes

A

note symmetry
heels should move into a normal-slight varus postiion

84
Q

gait observing ankle and foot

A

analyze alignment of foot during different phases of gait: heel strike, mid stance, toe-off, swing phase
look for obvious limp, lurch, dragging of the feet, in-toeing out-toeing, and drop-foot gait

85
Q

normal range of motion of foot and ankle

A

starting position: foot perpendicular to tibia
plantar flexion: 0-50 degrees
dorsiflexion: 0-20 degrees
inversion: 0-35 degrees
eversion: 0-25 degrees
flexion of toes 0-30 degrees
extension of toes: 0-80 degrees

86
Q

muscle testing of posterior tibialis

A

resist as patient inverts and plantar flexes

87
Q

muscle testing of anterior tibialis

A

resist as patient inverts and dorsiflexes the foot

88
Q

muscle testing of peroneus longus and brevis

A

resist eversion

89
Q

muscle testing of extensor hallucis longus

A

resist dorsiflexion of the great toe

90
Q

muscle testing of flexor hallucis longus

A

resist plantar flexion of the great toe

91
Q

anterior drawer test of the foot

A

excessive anterior translocation of the foot is indicative of anterior talofibular ligament instability

92
Q

talar tilt test

A

test integrity of the calcaneofibular ligament, deltoid ligament, anterior and posterior talofibular ligaments
calcaneofibular: inversion from anatomical position
deltoid: eversion from anatomical position
anterior talofibular: plantarflexion and inversion
posterior talofibular: dorsiflexion with inversion and eversion

93
Q

thompson’s test

A

compression of the calf in a prone position should produce plantar flexion
absence of this finding indicates achilles tendon rupture

94
Q

imaging of the ankle

A

AP
lateral
mortise: better view of ankle joint

95
Q

ottawa ankle rules

A

radiograph if 1 is present
pain at malleoli
inability to bear weight 4 steps
tenderness posteriorly or inferiorly at the malleoli

96
Q

imaging of the foot

A

AP
oblique
lateral

97
Q

ottawa foot rules

A

radiograph if 1 is present
inability to bear weight for 4 steps
tenderness at base of 5th metatarsal
tenderness over navicular bone

98
Q

achilles tendon rupture

A

occurs 5-7 cm from insertion site on calcaneus
MOI = direct blow or indirect forced dorsiflexion in stop and go sports

99
Q

achilles tendon tear

A

occurs at insertion site
moi indirect forced dorsiflexion

100
Q

presentation of achilles tendon rupture

A

often pop sound with sudden severe pain
difficulty bearing weight
palpable defect
weak active plantar flexion
+ thompson test

101
Q

presentation of achilles tendon tear

A

less acute/severe pain
localized tenderness over insertion site
no palpable defect

102
Q

diagnostics for achilles tendon injury

A

ankle x-ray: rule out avulsion fracture or other injury
MRI or US confirms dx

103
Q

management of achilles tendon rupture

A

RICE
short leg posterior splint in slight plantar flexion
non weight bearing
surgical vs non-surgical management depending on comorbidities and goals
follow up with ortho in 1 week

104
Q

management of achilles tendon tear

A

controlled ankle motion )CAM) boot and PT
follow up with ortho in 1 week

105
Q

moi of achilles tendonitis

A

microtrauma from reptetitive stress
patient increased training program or rigor for a long period of time

106
Q

presentation of achilles tendonitis

A

burning pain and stiffness 2-6 cm above posterior calcaneus worse with activity and relieved with rest
- thompson test
no defect noted
ROM and MS normal
long-standing tendonitis may result in palpable calcaneal spur

107
Q

diagnostics for achilles tendonitis

A

clinical

108
Q

management of achilles tendonitis

A

Rest, ice, NSAIDs x 7-10 days
chronic tendonitis or no improvement with conservative therapy: refer to PT

109
Q

classifications of ankle sprain

A

lateral ankle sprain (MC)
medial ankle sprain
high ankle sprain

110
Q

what is a lateral ankle sprain

A

inversion injury
damage to anterior talofibular ligament or calcaneofibular ligament

111
Q

what is a medial ankle sprain

A

eversion injiry
damage to deltoid ligament

112
Q

what is a high ankle sprain

A

severe inversion
damage to the tibiofubular syndesmosis

113
Q

presentation of ankle sprain

A

history of fall or twisting injury
pain, swelling
ecchymosis
difficulty ambulating
localized point tenderness over involved ligament: assess both malleoli and 5th metatarsal base
decreased ROM
+ Squeeze test if damage to tibiofibular syndesmosis
+ talar tilt with pain with individualized tendon maneuver, instability with grade 3 sprains
+ anterior drawer with anterior talofibular injury

114
Q

what is squeeze test

A

squeeze tibia and fibula and mid calf
if pain over distal tib/fib, damage to tibiofibular syndesmosis

115
Q

diagnostics for ankle sprain

A

ankle series if ottawa ankle rules apply
normal unless high ankle sprain: tibiofibular syndesmosis widening

116
Q

management in phase 1 of ankle sprain

A

rice with nsaids
aircase splint or ankle brace (rarely a cast for high grade injuries)
weigth bearing as tolerated - crutches if severe pain

117
Q

management of phase 2 of ankle sprain

A

initiate once weight bearing without pain (appx 2-4 weeks after injury)
continue splint
start strengthening exercises and achilles stretching ie writing ABCs, ROM with elastic band, heel raise

118
Q

management of phase 3 of ankle sprain

A

start once full ROM has returned and strength up to 80% of normal approx4-6 weeks after injury
wean ankle bracing
increased strength exercise intensity: one leg balance, running figure eights
refer to PT if limited ROM and pain after 2-3 weeks of home therapy

119
Q

indications for referral to ortho for ankle sprain

A

nerve injury
hx of chronic instability
failure to improve after 6 weeks

120
Q

classification of ankle fracture

A

unilateral fracture without ligament disruption (stable)
bimaleolar (unstable): both medial and lateral malleoli fractured, unilateral malleoli with ligament disruption
trimaleolar (unstable): both malleoli with posterior lip of tibia, both malleoli with ligament disruption

121
Q

MOI of ankle fracture

A

twisting or fall
inversion: lateral joint
eversion: medial joint

122
Q

presentation of ankle fracture

A

pain and swelling
point tenderness and limited ROM
identify if point tenderness is only over the malleoli or if ligaments are affected
palpate proximal fibula for tenderness (maisonneuve fx)
assess NV status

123
Q

diagnostics of ankle fracture

A

ankle xr series: add tib/fib or foot if indicated based upon exam
ct ankle: to evaluate complex fractures prior to surgical repair

124
Q

when would emergent ortho evaluation be indicated for ankle fracture

A

open fracture
nv compromise
associated dislocation
unstable and displaced - ORIF

125
Q

management of unstable, nondisplaced ankle fracture

A

short or long leg splint/cast; non weight bearing
f/u with ortho within 7 days

126
Q

management of stable ankle fracture

A

weight-bearing splint/cast x4-6 weeks

127
Q

management of suspected occult fracture

A

short leg splint and repeat x-ray in 10-14 days
repeat x-ray in 10-14 days will reveal a bony callus around occult fracture as healing begins

128
Q

what is the mc tarsal bone fracture

A

calcaneal fracture

129
Q

moi of calcaneal fracture

A

axial loading, often associated with vertebral fracturec

130
Q

clinical presentation of calcaneal fracture and talar fracture

A

severe pain in heel with inability to bear weight
swelling, ecchymosis, and deformity may be present
assess NV status, cap refill preferred or doppler, distal pulses may be diminished due to swelling
assess lumbar spine for tenderness

131
Q

diagnostics for calcaneal fractures

A

xray: foot and ankle series
lumbar x-ray if + exam
ct scan ankle/foot for further evaluation of fracture may be needed for surgical planning

132
Q

management of calcaneal/talar fractures

A

RICE
well padded posterior short leg splint
non-weight bearing
ortho consult within 24 hours: displaced fractures require ORIF, non-displaced fractures may be treated conservatively with serial x-rays to ensure displacement doesn’t occur

133
Q

what is the 2nd MC tarsal fracture

A

talar fracture

134
Q

anatomic considerations for talar fracture

A

extensive blood supply
at risk for avascular necrosis

135
Q

moi of talar fracture

A

high force plantarflexion, dorsiflexion or inversion force

136
Q

diagnostics for talar fracture

A

foot and ankle series
CT scan ankle/foot for further evaluation of fracture if surgery is considered

137
Q

what is ankle dislocation

A

displacement of talus from the tibia

138
Q

types of ankle dislocation

A

posterior (MC)
lateral

139
Q

moi of posterior ankle dislocation

A

posterior force on a plantar flexed foot

140
Q

moi of lateral ankle dislocation

A

forced inversion, eversion, or external or internal rotation of the ankle

141
Q

ankle dislocations are highly _____

A

unstable. disruption of the lateral or medial ligaments and/or tibiofibular syndesmosis

142
Q

clinical presentation of ankle dislocation

A

grossly deformed
posterior dislocation: locked in plantar flexion with the anterior tibia easily palpable
assess nv status: if vascular compromise noted, reduction not delayed for imaging

143
Q

diagnostics of ankle dislocation

A

ankle/foot series
CT/MRI often needed to further assess associated fx or ligamentous damage

144
Q

management of ankle dislocation

A

reduction via procedural sedation, grasping heel and foot and downward traction and applying posterior leg splint
reassess NV status
obtain post reduction films
consult ortho immediately for repair of capsular or ligamentous tears

145
Q

moi of metatarsal fracture

A

twisting or rotational force
blunt trauma

146
Q

clinical presentation of metatarsal fracture

A

pain with weight bearing
swelling, ecchymosis, and tenderness over the fracture site
in stress fractures, may only demonstrate tenderness on exam
fracture at base of 5th metatarsal = Jones fracture

147
Q

diagnostics for metatarsal fracture

A

foot series: stress fracture may not be evident in early presentation, repeat in 2-3 weeks
consider CT or bone scan if still normal and a suspicion of stress fracture exists

148
Q

management of metatarsal fracture

A

single nondisplaced metatarsal neck and shaft fracture placed in short leg posterior cast or fracture brace to immobilize the fracture, weight-bearing is permitted as tolerated
Multiple metatarsal fractures or displaced/angulated fractures: consult ortho for open or closed reduction

149
Q

what is tarsometatarsal injury

A

AKA: lisfranc joint
disruption of the tarsometatarsal joint often associated with fx of the metatarsals and tarsalts

150
Q

MOI of tarsometatarsal injury

A

axial load placed on plantar-flexed foot followed by forcible rotation, bending or compression

Ex: crush injuries, high-impact accidents such as MVA, or high-impact sports

151
Q

clinical presentation of tarsometatarsal injury

A

midfoot pain/tenderness
inability to bear weight
+ deformity, swelling, ecchymosis
assess for compartment syndrome and NV injury

152
Q

diagnostics for tarsometatarsal injury

A

weight bearing foot series, often bilateral images for comparison
CT/MRI if clinical suspcion but normal x-rays

153
Q

management of non0displaced tarsometatarsal injury

A

non-weight bearing splint/cast (short-leg posterior) x 6-8 weeks
then rigid arch support x 3 months

154
Q

management of displaced fracture/tmt joint

A

splint with non-weight bearing short-leg posterior splint
refer to ortho for ORIF

155
Q

what is the most common fracture

A

5th phalanx

156
Q

what is the most common dislocation of the phalanges

A

MTP of 1st joint

157
Q

clinical presentation

A

pain/tenderness
swelling
ecchymosis
deformity
limited ROM

158
Q

diagnostics for phalangeal injury

A

foot series

159
Q

management of non-displaced phalangeal injury

A

buddy tape

160
Q

managemnt of displaced/angulated phalangeal injury

A

reduce under local anesthesia and buddy tape

161
Q

management of dislocation of phalnge

A

digital block with traction reduction and repeat post reduction films

162
Q

what is hallux valgus

A

lateral deviation of the great toe at the metatarsophalangeal joint

163
Q

who more commonly gets hallux valgus

A

10x more common in females
caused by tight fitting shoes and osteoarthritis

164
Q

clinical presentation of hallux valgus

A

pain and swelling of the 1st MTP joint aggravated by shoe wear
most patients have normal ROM

165
Q

diagnostics for hallux valgus

A

foot series
measure valgus angulation at the MTP joint: normal is <15 degrees

166
Q

non-surgical management of hallux valgus

A

patient education and shoe wear modifications
recommend shoes with adequate width at the forefoot, soft material and stitiching patterns over the bunion
avoid high heels
usually successful in mild to moderate cases

refer to ortho for surgical evaluation patients who remain symptomatic despite conservative therapy

167
Q

what is morton’s neuroma

A

perineural fibrosis of the common digital nerve as it passes between the metatarsal heads
most commonly at base of the 3rd and 4th toes
3rd web space

168
Q

who most commonly gets morton’s neuroma

A

5x more common in females
likely related to compression by tight shoes

169
Q

presentation of morton’s neuroma

A

plantar pain in the forefoot MC
burning in nature
aggravated by activity, wearing high heeled or tight shoes
relief with rest
dysesthesias into the affected two toes
many patients state they feel as though they are walking on a marble or there is a wrinkle in their sock
interdigital neuroma test +

170
Q

what is interdigital neuroma test

A

apply direct plantar pressure to the interspace with one hand and then squeeze the metatarsalts together with the other hand
+ if increased tenderness and pain radiating into the toes

171
Q

diagnosis of morton’s neuroma

A

clinical diagnosis
x-rays normal
MRI and US can detect neuroma but findings are inconsistent

172
Q

management of morton’s neuroma

A

most cases non-surgically managed
patient education: wear low-heeled, well-cushioned shoes with wide toe box, application of metatarsal pad in sole of shoe
corticosteroid injection if unresponsive to conservative therapy
surgical intervention if symptoms persist or recur: surgical excision of the neuroma or division of the transverse metatarsal ligament

173
Q

what is one of the most common causes of heel pain in adults

A

plantar fasciitis

174
Q

peak incidence of plantar fasciitis

A

40-60 yo

175
Q

risk factors for plantar fasciitis

A

obesity
flat feet
prolonged standing/jumping

176
Q

plantar fasciitis clinical presentation

A

insidious onset
heel pain worse when initiating waljing
typically most severe during 1st steps in morning
pain lessens with walking
worsens toward end of day due to prolonged weight bearing and relieved by sitting
tenderness directly over the medial calcaneal tuberosity and 1 to 2 cm along plantar fascia
passive dorsiflexion of toes may cause increased pain

177
Q

diagnosis of plantar fasciitis

A

x-rays may be used to rule out other conditions

178
Q

management of plantar fasciitis

A

non-surgical management for most patients
initial treatment: OTC orthotic heel pad and a home stretching program
avoid barefoot walking and flat shoes
avoid activities that may be causative (dancing, running)
Ic and NSAIDs may be helpful
may take 6-12 months of treatment to resolve

179
Q

management of plantar fasciitis if unresponsive to conservative therapy

A

corticosteroid into the heel
custom orthotic
surgical treatment with partial release of plantar fascia

MSK (11 decks)

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