Lecture 6: LE Injuries Part 1 Flashcards
What is the zero starting position for hip flexion? How do we test hip flexion?
- Patient lying supine with lumbar spine flat on table, knees slightly flexed
- Can be tested seated or standing.
How do we test hip extension?
What needs to be done when testing rotation of the hip?
Holding the kneecap to prevent its use.
What is the thomas test?
- Hip flexor contracture test or tight psoas
- Supine
- One hip: max flexion
- Contralateral hip: observe to see if it flexes off the surface
What does the trendelenburg test show?
- Test of hip ABductors
- A weak hip ABductor causes a DIP towards the OPPOSITE SIDE.
- Muscles weakness is on the STANCE SIDE.
The leg that is straight is the weak one
What does the FABER test check?
- Flexion-ABduction-External Rotation Test
- Figure-of-4 test
- Checks hip and sacroiliac pathology
- Ipsilateral pain = HIP PATHOLOGY
- Contralateral pain = SI dysfunction
Where do we measure leg length from?
- anterior iliac crest to medial malleolus
- > 3cm diff is significant
Send to podiatry
What does the leg roll test check for?
- Simle internal and external rotation of hip while supine and relaxed.
- Pain, esp anterior hip= OA or femoral head osteonecrosis
What does the piriformis test check for?
- Supine/unaffected side, then contralateral hip and knee flexed to 90deg
- Stabilize pelvis, apply flexion adduction and internal rotation at knee
- Pain in butt/leg = **piriformis is impinging on sciatic nerve
What is the scouring test?
- Flex hip and knee 90
- Apply posterolateral force through hip as femur rotates
- Passively adduct and internally rotate hip followed by abduction and external rotation
- Pain/grating sound = labral pathology, loose body, or internal derangement
What are the specialty hip views?
- Frog leg view
- Obturator/Oblique view
MC type of hip dislocation and MOI
- Posterior (90%)
- Posterior force applied to a flexed knee
What kind of hip joint can dislocate much easier?
A prosthetic hip joint
It is generally not as deep as a normal hip joint
Complications seen in posterior hip dislocation
- Acetabular/femoral head/neck fx
- Sciatic nerve damage
- Ligament damage
- Avascular necrosis
How does a posterior hip dislocation present?
- Severe pain
- INability to move leg
- Peroneal damage: drop foot + sensory changes on lateral lower leg/dorsum
Describe an posterior hip dislocation on physical presentation
Shortened, adducted, and internally rotated
How does an anterior hip dislocation present physically?
- Abduction and external rotation and flexion
What determines the direction of anterior hip dislocation?
Degree of hip flexion at injury
Diagnostics for a hip dislocation
- Hip XR
- CT hip w/o contrast (assess fx & trapped intra-articular loose bodies)
How do we manage hip dislocations due to acute, traumatic events?
- Posterior: Allis maneveur to do a closed reduction within 6 hours ideally
- Anterior: Open reduction
- All reduction require procedural sedation and post reduction films
- Post reduction immobilization via triangular pillow
What do we monitor after hip reduction for 2-3 years?
Avascular necrosis
MC MOI for a hip fx
Fall
4 possible locations for a hip fx
- Intracapsular: femoral head/neck
- Extracapsular: intertrochanteric/subtrochanteric
How does a hip fx present?
- Pain in groin, hip, butt radiating to knee
- INability to ambulate
- External rotation, ABduction, shortened leg
- Pain with minimal ROM or SLR
Stress fx will not have a deformity
How soon do we intervene for a hip fx and how?
- 48 hrs!!!!
- ORIF for young
- Arthroplasty for old
Contraindications to hip fx surgery
- Medically unstable
- Previously non-ambulatory to begin with
- Dementia patients with minimal pain during transfers
In what kind of hip fx are implant failures MC?
Extracapsular fx
Clinical presentation of greater trochanteric bursitis
- Lateral hip pain radiating down past knee or up butt
- Worse when rising, Worse when lying on it
- Improves for a few steps then worsens
- Tenderness
- Pain with active abduction and adduction + internal rotation
Management of greater trochanteric bursitis
- NSAIDs, ice
- Short term use of cane on opposite side of affected leg
- Home stretching
- Bursal injections
MC sites for avascular necrosis
- Proximal and distal femoral heads (hip and knee pain)
MC demographic for avascular necrosis + RFs
20-50
How does AVN present?
- Severe pain initially
- Later: dull aching and throbbing
- Painful/loss of ROM
- Antalgic gait if femur has AVN
Diagnostic signs for AVN of the femur
- Early: normal
- Later: Patchy sclerosis and lucency
- Crescent sign indicates subchrondral facture
Initial management for AVN
- Avoid weight-bearing
- NSAIDs
- Ortho
When is surgery typically indicated for AVN?
Almost all patients due to the young age it occurs in
What is important regarding AVN management?
Non-surgical management DOES NOT HALT PROGRESSION
Improvement of QOL and gait
MOI of femoral shaft fracture
High-energy trauma (skiing, MVA)
How does a femoral shaft fx present?
- Pain/tenderness/swelling
- Shortening/deformity of the leg
- Check for compartment or blood loss
Management of a femoral shaft fx
- Pain management
- Fluids
- Temporary stabilization
- Ortho
Knee joint anatomy
What position do we palpate knee joint lines in and findings?
- Knee must be flexed at 90deg
- Focal tenderness = suggests torn meniscus
- Generalized tenderness = arthritis
Describe a bulge sign and ballottement
- Bulge sign: Direct fluid over medial recess and then inferiorly from suprapatellar patch inferiorly: **(+) Fluid wave over medial knee **
- Ballottement: Push down on patella and rapidly release:** (+) rapid rebound **
How do we do varus and valgus stress tests?
- Valgus: apply a valgus force to check MCL
- Varus: apply a varus force to check LCL
Abduct and flex knee to 30deg when doing these.
What is abnormal patellar tracking?
Exaggerated arc of movement = patellar instability
How do you test for the patellar apprehension sign?
- Supine with knee at 30deg flexion
- Displace patella laterally via medial pressure
- (+) pt will contract quads or become apprehensive d/t pain
How do we do the patellar grind test/clarke sign and what for?
- Supine + knee fully extended
- One hand superior to patella and gently push patella inferiorly as pt contracts quad.
- (+) pain, grinding or clicking
- Checks for patellofemoral syndrome/chondromalacia
What is the McMurray test and what is it for?
- Supine
- One hand on heel, one on joint line
- Medial meniscus checked via MEG (ext rotation + valgus + extension)
- Lateral mensiscus checked via LIR (Interal rotation + varus + extension
- (+) pain, popping, clicking
Meniscus test
What is the most sensitive test for an ACL tear?
Lachman test
How do you perform a lachman test?
- Supine with knee at 30deg flexion
- One hand on distal femur + proximal tibia
- Pull anteriorly on tibia
- (+) anterior translation with ACL tear
How do we perform an anterior drawer test?
- Supine with hamstrings and quads relaxed
- Knees flexed to 90deg
- Sit on pts foots
- Grasp proximal tibia and slide tibia anteriorly
- (+) significant laxity compared to contralateral
ACL stability
How do we do a pivot shift test?
- Do under anesthesia
- Full extension and slowly flexing the knee
- Examiner applies valgus stress and internal rotation
- (+): subluxation occurring at 20-40deg flexion
ACL dysfunction check, pos in grade 2 or 3 tears
Describe Noble’s test
- Supine with knee flexed to 90deg
- Apply pressure to lateral femoral condyle for 1-2cm as knee is passively extended
- (+) pt complains of tenderness over lateral femoral condyle at approx 30deg of flexion
IT Band test
Describe Ober’s test
- Lay on unaffected side, flex unaffected knee and hip
- Abduct and extend ipsilateral hip while stabilizing pelvis and lowering thigh
- (+) Inability of extremity to drop below horizontal to the level of the table
Tensor fascia lata and IT band tightness
Where does the IT band originate from and where does it insert to?
- Origin: ASIS
- Insertion: Lateral tibia
When is the ITB anterior to the lateral femoral condyle? Posterior?
- In knee extension, it is anterior
- Past 30deg flexion, it is posterior
How does ITB syndrome present?
- Pain in anterolateral aspect of knee, esp at heel strike
- Audible popping
- Tenderness over lateral femoral epicondyle
- (+) Ober’s and Noble’s
- Lateral knee pain with hopping on flexed knee
How do we manage ITB syndrome?
- Conservative
- Ortho for steroid injection or surgical ITB lengthening if ^ fails
How does a distal femur fx present?
- MOI: low energy in osteoporotic geriatrics
- MOI: High energy in young
- Supracondylar vs intercondylar
Describe the clinical presentation of a distal femur fx
- Sudden onset of pain post trauma with inability to bear weight
- Limited ROM
- Normal fx presentation
When is an oblique view or CT used for distal femur fx?
- Determine extent of injury
- Surgical planning
Management of distal femur fx
- Non-displaced/minimal: long leg splint + rest + non-weight bearing
- Displaced/intra-articular: Long leg splint + ORIF in 24h
- Open: Emergent ortho
What should we assess in a patellar fx
Intact extensor mechanism: active extension of knee or SLR
Management of a patellar fx
- Pain
- Non-displaced: Knee immobilizer so knee is extended
- Displaced: call ortho for surgery
MOIs for a patellar dislocation
- DIrect trauma
- Landing on hyper extended knee
- Quad contraction during knee flexion
Clinical presentation of a patellar dislocation
- Usually a lateral dislocation
- Hemarthrosis may occur
- (+) patellar apprehension test in spontaneously reduced dislocations
Management for a patellar dislocation
- Reduction
- Flex hip, extend knee, medial force on patella directly
- Immobilizer with full extension for 4-6 weeks
- F/u with ortho in 1 week
MOI for patellofemoral syndrome
Runner’s knee, aka overuse
Etiologies for anterior knee pain
- Abnormal patellar tracking
- Ligamentous hyperlaxity causing patellar subluxation
- Hip/kneemuscle weakness + imbalance
- Abnormal hip-knee biomechanics (Q-angle: valgus knee)
How does patellofemoral syndrome present?
- “pain behind the kneecap” with any activities that load the joint
- Patellar squinting in gait (pointing towards each other)
- Tenderness along articular surface in extended and relaxed leg
- Apprehension sign = associated instability
- Patellar grind test = associated chondromalacia
- One leg squat = assess quad/hip strength
How is patellofemoral syndrome Dx?
- Clinically
- XR for r/o DDx
- MRI for surgery planning if indicated
Management of patellofemoral syndrome
- Consevative
- McConnell taping
- PT IS HALLMARK
Two main causes of prepatellar bursitis
- Inflammatory
- Bacterial infection
Presentation of prepatellar bursitis
- Early on pain only with activity or direct pressure, progressing to constant pain
- Localized swelling that you need to diff from joint effusion.
- Septic bursitis
- Inflammatory
When is bursal aspiration indicated for prepatellar bursitis?
Suspicion of septic bursitis
Management of inflammatory burisits
- Conservative
- Corticosteroid injection if you have r/o septic
Management for infectious bursitis
- Oral keflex for MSSA
- Bactrim/clinda for MRSA
- IV rocephin (MSSA) and/or vanco (MRSA)
