Lecture 1 Flashcards
Foot progression angle
- Evaluates limb position during gait
- Angular difference between foot axis (line through heel and 2nd metatarsal) and progression of gait
Interaction of neuromuscular and skeletal systems during gait
- Dysfunction in either/both results in gait deviation
- Can involve single or multiple segments and/or joints
- Treatment ranges from conservative to surgical
Gait analysis identifies
- Gait deviation and causes of abnormalities
- Track neuromuscular disease progression, surgical/conservative treatment planning and postoperative outcomes
Potential surgical/conservative treatment planning and postoperative outcomes
- Muscle weakness
- Abnormal muscle tone and contracture
- Abnormal joint motion and range
Joints do not function in isolation
- Movements are affected by movements and positions of other joints
- Adaptation may occur at other joints
Common causes of rotational abnormalities
- 2⁰ to trauma
- Congenital
- Prior surgery
- Metabolic and neurological conditions
Rotational deformities may cause
- In-toed gait (“pigeon-toed”)
- Out-toe gait
In-toeing gait (“pigeon-toed”)
- Femoral anteversion
- Internal tibial torsion
- Metatarsus adductus
Out-toeing gait
- Femoral retroversion
- External tibial torsion
- Pes planovalgus
- Tight hip external rotators
Angular deformities (coronal/frontal plane)
- Genu varum
- Genu valgum
Bowing deformities
- Excessive curve of a bone with respect to proximal and distal ends
In-toeing and out-toeing gait indicates
- Potential torsional deformity
- Noticed in young children
- Most resolve over time as a part of development
- Compensations can develop that can mask abnormality
Tibial/femoral rotation at birth
- Tibia is more internally rotated
- Femoral head/neck is anteverted
Angle of femoral torsion (angle of declination)
- Angle between long axis of femur head/neck and coronal plane of condyles (bicondylar plane, transcondylar axis)
- View from transverse plane
Typical values of angle of femoral torsion/declination
- ~40⁰ at birth, then decreases with age
- Normal range is between 8-15(20)⁰
Anteversion
- Increased angle of femoral torsion (> 15⁰)
- Increased hip IR
- Decreased hip ER
Retroversion
- Decreased angle of femoral torsion (<8⁰)
Femoral anteversion
- Increased medial hip rotation/decreased lateral hip rotation
Characteristics of femoral anteversion
- Sits in W position (hips flexed, internally rotated)
- Squinting patella: faces medially
- “Eggbeater” running pattern
Craig Test (trochanteric prominence angle test)
- Determines the amount of anteversion (8-15⁰ is normal)
Performing the Craig Test
- Patient prone, knee at 90⁰ flexion
- Hip rotated medially & laterally while palpating the greater trochanter
- Stop when greater trochanter is most prominent laterally (parallel to table)
- Measure the hip angle using the long axis of the tibia
Internal tibial torsion (“pigeon-toed”)
- Normally internally rotated at birth, external rotates as one ages
- Normal (depends on age): wide range of values
- Evaluate transmalleolar axis or or thigh/foot angle
Metatarsus adductus
- Adduction of the forefoot in the transverse plane at the tarsometatarsal joint (Lisfranc’s)
- “Bean-shaped” sole
Foot borders in metatarsus adductus
- Convex lateral border
- Prominent tuberosity of 5th metatarsal
- Concave medial border
- Vertical skin crease at 1st metatarsocuneiform joint in more severe cases
Blecks classification (metatarsus adductus)
- Abnormal heel bisector line
- Should pass through 2nd/3rd web space
Determination of treatment in metatarsus adductus
- Flexible vs. rigid
- The more flexible, the more conservative treatment
- Most (85-90%) resolve on their own
Metatarsus angle
- Angle between longitudinal axis of 2nd met and longitudinal axis of tarsal
Congenital MA foot deformity
- Attributed to intrauterine position
- Some evidence of family history
- Can be seen with other foot deformities
Treatment of MA depends on severity and age
- Stretching
- Corrective casting
- Surgery
- Tarsometatarsal Capsule Release
- Osteotomy
Uncorrected MA can result in other functional, anatomical problems
- 5th metatarsal frx
- Lateral foot pain
- Hallux valgus
- Development of skewfoot
Dislocation
- Displacement of bone from its natural position
- 2 bones that form a joint are not congruent
- Subluxation is partial dislocation
Traumatic (acute)
posterior dislocation
- Axial load on femur with a flexed, adducted internally rotated hip
Traumatic (acute)
anterior dislocation
- Occurs with hip abducted and externally rotated
- Anterior superior (pubic)
- Anterior inferior (obturator)
Dislocation can be associated with
- Acetabular wall and femoral head fracture
- Ligament disruption
Non-traumatic (non-acute) dislocation
- Repetitive microtrauma
- Connective tissue disorders
- Dysplasia of bony surfaces
Joint capsule is stronger anteriorly due to
- Ligament support
Posterior dislocation (clinical)
- Dashboard injury during MVA is a more common cause
- 10-20% can have a sciatic nerve injury
- Affected limb is shortened, adducted, internally rotated, flexed
Anterior dislocation (clinical)
- Hyperextension injury against an abducted leg
- Affected limb is abducted and externally rotated
Anterior dislocation (imaging)
- Femoral head is located medial or inferior to acetabulum
Posterior dislocation (imaging)
- Femoral head superimposes on acetabular roof
- Lesser trochanter less visible
Developmental Dysplasia of the Hip (DDH)
- Abnormality in the size, shape, orientation of the femoral head, acetabulum or both
- Can cause congenital hip dislocation (or subluxation)
- Left hip affected more than right, but can be bilateral
Factors contributing to DDH
- Intra-uterine position
- Breech presentation
- Left occiput anterior positions left limb against moms spine
- More common in Female, Family history, Firstborn
Evaluation of DDH
- Asymmetric skinfolds
- Unequal leg length/femoral shortening (Galeazzi sign/Allis sign)
- Affected side lower than normal
- Limited hip abduction
- May see Trendelenburg gait
- Ortolani and Barlo maneuvers
Ortolani and Barlow maneuvers
- Only useful up to 3rd month
- Infant supine, hips flexed to 90⁰
- Index and middle finger placed over greater trochanter
Ortolani maneuver
- Gently abduct hip while exerting upward force through trochanter
- Palpable clunk is positive, dislocated hip is reduced
Barlow maneuver
- Infants hips are adducted and a gentle downward force is exerted
- Attempting to produce dislocation
Ultrasound vs. radiograph
- Ultrasound can be used in infants under 6 months
- Radiographs are useful after 6 months
Hilgenreiner line
- Horizontal line through triradiate cartilages
Perkin line
- Line perpendicular to Hilgenreiner line
- Intersecting lateral most aspect of acetabular roof
Shenton line
- Curved line along inferior border of superior pubic ramus and along the inferomedial border of femur neck
Acetabular index
- Angle between Hilgenreiner line and line passing through triradiate cartilage and lateral acetabular margin
- Can show acetabular dysplasia or overcoverage
Femoral head should lie within
- Inferomedial quadrant formed by Hilgenreiner and Perkin lines
- Shenton line should be uninterrupted
Acetabular index angel depends on
- Age
