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MSK > Lecture 7: LE Injuries Part 2 > Flashcards

Lecture 7: LE Injuries Part 2 Flashcards

1
Q

What are the Ottawa Knee Rules? (5)

A
  1. Pt older than 55
  2. Tenderness at head of fibula
  3. Isolated patellar tenderness
  4. Inability to flex knee to 90deg
  5. Inability to bear weight for 4 steps both immediately after injury & in the ED

If any are met, order XR

Mainly used to rule out knee fx.

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2
Q

What are the typical views for a knee series?

A

AP & Lateral

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3
Q

MOI for an ACL tear

A

Sudden deceleration with rotational trauma/hyperextension force applied to knee

Usually a full tear.

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4
Q

When an ACL is torn, what is typically also torn?

A

Meniscal tear

Very rare to injure the other ligaments.

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5
Q

How does an ACL tear present? (4)

A
  • Sudden pain and collapse of knee
  • Audible pop
  • Joint effusion within hours => pain
  • Limited ROM
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6
Q

What 3 special tests check for ACL tear?

A
  1. Lachman test (most reliable)
  2. Anterior drawer
  3. Pivot shift test
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7
Q

What XRs do we order for an ACL tear and expected finding?

A
  • AP, lateral, tunnel views
  • Most commonly shows an effusion
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8
Q

What avulsion fracture may appear with ACL tears?

A

Segond fractures, which are the lateral capsular margin of the tibia

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9
Q

Who are tibial eminence fractures MC in?

A

People with open growth plates

aka the children

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10
Q

How is dx of an ACL tear confirmed?

A

MRI

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11
Q

Image of a tunnel knee XR

A
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12
Q

How does a knee joint effusion appear on XR?

A

Well-defined rounded homogeneous soft tissue density within suprapatellar recess on lateral view

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13
Q

What is the initial management for an ACL tear? (4)

A
  1. RICE with knee immobilizer
  2. Tylenol before NSAIDs
  3. Aspiration for large effusion
  4. ROM as pain allows
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14
Q

How does management with ortho for an ACL tear vary depending on age?

A
  • Young = reconstruction via graft
  • Old = PT to improve the surrounding muscles to compensate

Patella, hamstring, quad, or cadaver grafts

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15
Q

What are the MOIs associated with a PCL tear? (2)

A
  • Direct blow to tibia (knee striking dashboard in MVA or falling onto knee)
  • Extreme hyperextension (usually ACL rupture also)
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16
Q

When does a PCL tear typically occur?

A

Alongside a collateral ligament tear or ACL rupture.

Not very common to just completely rupture PCL alone

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17
Q

How does a PCL tear present? (5)

A
  • Same as ACL, but the special tests will be negative (lachman & pivot shift)
  • Sudden pain and collapse of knee
  • Audible pop
  • Joint effusion within hours => pain
  • Limited ROM
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18
Q

What special test is usually positive for a PCL tear specifically?

A

Posterior drawer test

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19
Q

When is NV status assessed for a PCL tear and how?

A

If we suspect multiligament injury, we should do an ABI, which should be greater than 0.9 to rule out.

If lower, order arterial imaging to check for an intimal tear

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20
Q

Initial management of a PCL tear (2)

A
  • RICE + knee immobilizer
  • ROM within 1-5 days
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21
Q

When is reconstruction indicated for a PCL tear? (2)

A
  1. PT fails to restore stability
  2. Multi-ligamentous injury
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22
Q

Main sequelae associated with a PCL tear (1)

A

OA

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23
Q

Main sequelae associated with an ACL tear (2)

A
  • Medial meniscus injury
  • Secondary degenerative joint disease
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24
Q

What is the MOI for an MCL tear?

A

Lateral/valgus blow to the knee (typically football)

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25
Q

What is the MOI for an LCL tear?

A

Associated with other traumatic knee injuries

Rarer than an MCL tear

Pretty hard to get hit from the inside of your knee

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26
Q

Clinical presentation of a collateral ligament tear (3)

A
  • Localized pain/tenderness/swelling/stiffness that worsens over 6-8 hrs
  • Usually able to bear weight after
  • Ecchymosis + effusion along ligament 1-2 days after
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27
Q

What testing should we do for a suspected collateral ligament tear?

A
  • Varus/valgus testing in both extension and 30deg flexion
  • Laxity in extension is more significant
  • Instability can be masked by pain and involuntary muscle contraction

Do their uninjured leg first

Extended legs stretch collateral ligaments, so laxity is concerning

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28
Q

How do we confirm a collateral ligament tear?

A

MRI

XR is for checking for avulsion fx

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29
Q

Management for a grade 1-2 collateral ligament tear (sprain-partial tear) (3)

A
  • RICE, hinged knee brace, NSAIDs
  • Early ROM exercises
  • Crutches with wt-bearing as tolerated
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30
Q

Management for grade 3/ruptured collateral ligament (1)

A

Ortho to decide brace vs repair

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31
Q

MOIs for meniscal injury

A
  • Rotational force with a planted foot
  • Older pts (degenerative tears)
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32
Q

Clinical presentation of a meniscal injury (5)

A
  1. Pain and stiffness following MOI that worsens over the next few days
  2. Sometimes able to ambulate
  3. Locking/catching/popping after effusion resolves
  4. Tenderness along joint line
  5. Effusion (MC in lateral tears)
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33
Q

What special test is positive for a meniscal injury?

A

McMurray test (painful click)

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34
Q

What position should a knee be in when you’re palpating?

A

90deg flexion

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35
Q

If a patient is over 40y and has a suspected meniscus tear, what modification should be done to XR?

A

Weight bearing in 45 deg flexion

Checking for OA

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36
Q

Initial management for meniscal injury

A

RICE + NSAIDs

PT after if no surgery

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37
Q

When is a referral to ortho indicated for meniscal injury? (4)

A
  • Young pt with traumatic tear
  • Failure of conservative (aka joint line stays tender)
  • Mechanical symptoms
  • Evidence of instability
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38
Q

Who is knee dislocation MC in?

A

Young males

But overall, not a very common MSK condition

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39
Q

How do we characterize knee dislocations and the MC type?

A

Direction of the tibia relative to the femur

MC is anterior

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40
Q

Clinical presentation of a knee dislocation (3)

A
  • Obvious deformity with severe pain and limited ROM
  • 50% spontaneously reduce
  • Ecchymosis and swelling
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41
Q

What indicates gross instability of the ligaments in a knee dislocation?

A

Hyperextension > 30deg when leg is lifted by the foot

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42
Q

Why is NV status checking essential in a knee dislocation?

A

Vascular injuries can occur even with normal pulses.

Make sure you check popliteal!

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43
Q

What does a CT check for in knee dislocations? MRI?

A
  • CT checks for occult fx post reduction
  • MRI checks for internal derangement post reduction
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44
Q

How is a knee reduced? (2)

A
  • Sedation => Longitudinal traction
  • Immobilize in 20deg flexion to check serial NV status later
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45
Q

After a knee is reduced, what should we do? (2)

A
  • Consult ortho and vascular
  • Admit for serial NV checks

Not a same-day discharge usually

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46
Q

What is found in between the tibia and fibula?

A

Interosseous membrane

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47
Q

What is the MC MOI to cause a tibial plateau fx?

A
  • High energy valgus trauma in young pt
  • Low-energy trauma in old pt (twisting/fall)
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48
Q

Which tibial plateau is MC fxd?

A

Lateral plateau

Valgus stress

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49
Q

Clinical presentation of a tibial plateau fx (4)

A
  • Massive pain
  • Non-weight bearing
  • Swelling/joint effusion
  • Limited ROM
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50
Q

Besides NV status, what else we concerned about in a tibial plateau fx?

A

Compartment syndrome

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51
Q

When are oblique views good for tibial plateau fx?

A

If AP/lateral were inconclusive

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52
Q

Initial managment of a tibial plateau fx (4)

A
  • Compression
  • Ice
  • Analgesia
  • Splint in full extension
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53
Q

When is urgent consult indicated for tibial plateau fx? (2)

A
  • Displacement or depression
  • Nearly all require ORIF
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54
Q

How do we manage a non-displaced tibial plateau fx? (3)

A
  • Long-leg posterior/knee immobilizer
  • NWB
  • Ortho in 1 week
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55
Q

MOI for a tibial tubercle fx

A

Sudden force to flexed knee during a contracted quad

Usually when jumping or landing

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56
Q

Who is a tibial tubercle fx MC in?

A

Children

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57
Q

How does a tibial tubercle fx present?

A
  • Pain/tenderness/swelling over tibial tuberosity
  • Displacement of patella superiorly (it has lost its inferior anchor point)
  • Loss of ROM
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58
Q

Management of tibial tubercle fx with incomplete/small avulsion (4)

A
  • RICE
  • Knee immobilizer/long-leg posterior
  • NWB
  • Ortho in 1 week
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59
Q

Management of tibial tubercle fx with complete avulsion (4)

A
  • RICE
  • Knee immobilizer/long-leg posterior
  • NWB
  • Urgent ortho for ORIF (24-48h)
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60
Q

What is the MC long bone fx overall?

A

Tibial shaft fx

Often with a fibular fx also

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61
Q

How do adults typically fx their tibial shaft? Children?

A
  • Adults: High energy blow directly
  • Children: Twisting
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62
Q

How does a tibial shaft fx present? (2)

A
  • Inability to bear weight
  • Pain/swelling/deformity
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63
Q

How would you diagnose/workup a tibial fx?

A
  1. AP & Lateral tib/fib XR (Can add on knee/ankle)
  2. Oblique XR/CT for complexity
  3. Bone scan if occult fx is suspected
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64
Q

Initial management for tibial shaft fx? (3)

A
  1. RICE
  2. Analgesics
  3. Long-leg posterior splint
65
Q

When is an emergent consult indicated for a tibial shaft fx? (4)

A
  • Open fx
  • Tib/fib
  • NV compromise
  • Compartment syndrome
66
Q

If you have a displaced tibial shaft fx, what are the 2 steps to manage it?

A
  1. Closed reduction
  2. Long leg splint via posterior & stirrup

Stirrups prevent ankle inversion/eversion

67
Q

If a tibial shaft fx is non-displaced, how do you manage it? (4)

A
  1. Long-leg posterior splint
  2. Crutches
  3. NWB
  4. Call ortho for 1 week f/u
68
Q

If a fibula fx presents isolated, what is the MC etiology? (2)

A
  • Direct blow to fibula
  • Rotational force
69
Q

What is unique about the fibula among the leg bones?

A

It is non-weight bearing, so an isolated fx is still weight bearing!

70
Q

How does a fibula fx present? (3)

A
  • Point tenderness and localized pain with swelling
  • Deformity if displaced
  • Maisonneuve fx may be present
71
Q

What is a Maisonneuve fracture?

A

Proximal fibula fx + medial malleolus fx/ligament disruption of the ankle w/o fx

72
Q

When is urgent consult indicated for fibular fx? (2)

A
  • Displaced
  • Maisonneuve fx
73
Q

What kind of fibula fx requires a stirrup splint/air-cast splint rather than a long-leg posterior?

A

Distal fibula fx

Assuming because distal fibula is related to ankle

Air-cast splint
74
Q

What kind of fibular fx can use a knee immobilizer splint?

A

Fibular head/neck fx

75
Q

For a simple fibular fx, do we want to start weight bearing sooner or later?

A

Sooner

76
Q

What are the 4 main ligaments of the ankle?

A
  • Anterior talofibular ligament (ATFL)
  • Calcaneofibular ligament (CFL)
  • Posterior talofibular ligament (PTFL)
  • Deltoid ligament (4 parts)

First 3 are the typical ligaments in an ankle sprain

77
Q

What are you noting for anterior standing & supine ankle/foot inspection? (3)

A
  1. Alignment of toes
  2. Position of foot relative to limb
  3. Medial curvature of forefoot
78
Q

What are you palpating for in the anterior foot/ankle exam? (3)

A
  1. Plantar fascia
  2. MTP joints
  3. Head of metatarsal for sesamoid bone tenderness
79
Q

What are you assessing and palpating in the posterior foot/ankle exam? (2)

A
  1. Assess heel alignment when standing
  2. Palpate achilles tendon insertion

Normal heel alignment is a neutral or slight valgus with no more than 2 lateral toes visible from behind.

80
Q

What are you inspecting and palpating for the medial foot/ankle exam? (3)

A
  1. Inspect arch (symmetric)
  2. Prominence of the medial midfoot
  3. Palpate for perimalleolar tenderness
Accessory navicular bone
81
Q

What are you inspecting/palpating for in the lateral foot/ankle exam when standing? (4)

A
  1. Calluses
  2. Ankle swelling
  3. Prominence of the posterior calcaneus
  4. Palpate for perimalleolar tenderness
82
Q

Can you invert or evert your ankle more?

A

Invert more

83
Q

What are the 5 specific muscles that test foot/ankle motions?

A
  1. Posterior tibialis: inversion and plantar flexion
  2. Anterior tibialis: Inversion and dorsiflexion
  3. Peroneus longus/brevis: Eversion
  4. Extensor hallucis longus: Dorsiflexion of great toe
  5. Flexor hallucis longus: Plantar flexion of great toe
84
Q

What does an anterior drawer test of the foot test?

A

ATFL instability

85
Q

What does a talar tilt test check for?

A

Integrity of CFL, deltoid, ATFL, and PTFL

86
Q

How do you perform thompson’s test and what does it check for?

A
  • Place patient prone and squeeze their calf
  • Plantar flexion should occur normally.
  • Absence of plantar flexion = achilles tendon rupture

Not to be confused with thomas test

87
Q

What XR view is good for viewing the ankle?

A

Mortise view

88
Q

What are the Ottawa Ankle Rules? (3)

A
  1. Pain at malleoli
  2. Inability to bear wt 4 steps
  3. Tenderness posteriorly or inferiorly at the malleoli

Any positive = order XR

89
Q

What are the Ottawa Foot Rules? (3)

A
  1. Inability to bear wt for 4 steps
  2. Tenderness at base of 5th metatarsal
  3. Tenderness over navicular bone
90
Q

Where does an achilles tendon rupture typically occur and how?

A
  • Occurs 5-7cm from the distal insertion site on calcaneus
  • MOI: Direct blow or forced dorsiflexion (Stop & Go)
91
Q

Where does an achilles tendon tear typically occur and how?

Not the same as a complete rupture!

Can be microtears

A
  • Typically occurs at the insertion site
  • MOI: Indirect (Forced dorsiflexion)
92
Q

How does an achilles tendon rupture present? (5)

A
  • Pop with severe pain
  • Difficulty bearing wt
  • Palpable defect
  • Weak plantar flexion
  • (+) thompson test
93
Q

How does an achilles tear typically present?

A
  • Less acute/severe pain
  • Localized tenderness overlying insertion
  • No palpable defect
94
Q

What confirms the dx of an achilles tendon injury?

A

MRI or US

95
Q

How do you manage an achilles tendon rupture? (3)

A
  • Short leg posterior splint in slight plantar flexion
  • NWB
  • Surgical vs non-surgical
96
Q

How do you manage an achilles tendon tear? (2)

A
  • Controlled ankle motion (CAM) boot
  • PT
97
Q

What is achilles tendonitis MOI?

A

Microtrauma from repetitive stress or increased load.

98
Q

How does achilles tendonitis present? (4)

A
  • Burning pain/stiffness 2-6cm above posterior calcaneus
  • (-) thompson
  • ROM and MS normal
  • Long-standing may cause palpable calcaneal spur

Worse with activity, better with rest

99
Q

How do you dx and manage achilles tendonitis? (3)

A
  • Clinical dx
  • Rest, ice, NSAIDs
  • PT if chronic
100
Q

What is the MC type of ankle sprain?

A

Lateral ankle sprain due to inversion injury?

101
Q

What ligaments can be damaged in a lateral ankle sprain?

A
  • ATFL
  • CFL
102
Q

Damage to what makes a high ankle sprain?

A

Tibiofibular syndesmosis due to severe inversion

103
Q

What does a squeeze test with pain suggest for ankle sprain?

A

Pain over distal tib/fib = damage to tibiofibular syndesmosis

104
Q

When is instability typically seen with talar tilts?

A

Grade 3 sprains

Pain is dependent on ligament injured

105
Q

What does a positive anterior drawer test of the foot/ankle suggest?

A

ATFL injury

106
Q

When you have an ankle sprain, what bones must you assess?

A
  • Malleoli
  • 5th metatarsal base

Checking for the ottawa rules

107
Q

When is an ankle sprain typically seen on ankle XR?

A

High ankle sprains

108
Q

What is phase 1 of ankle sprain management? (3)

A
  • RICE with NSAIDs
  • Air-cast splint or ankle brace
  • Wt bearing as tolerated

Casting is only for high-grade

109
Q

What is phase 2 of ankle sprain management? (3)

A
  • Start once weight bearing without pain
  • Continue splint
  • Start strengthening and stretching
110
Q

When can you start phase 3 of ankle sprain management and what is in it?

A
  • Once fulll ROM and 80% strength
  • Wean ankle brace
  • Increased strength exercise intensity
  • PT for limited ROM or pain
111
Q

After how long do you consider ortho for non-improvement of ankle sprain?

A

6 weeks of failure to improve

112
Q

What are the 3 types of ankle fx?

A
  • Unilateral fx w/o ligament disruption = stable
  • Bimaleolar = unstable
  • Trimaleolar = unstable
113
Q

What are the two types of bimaleolar ankle fx?

A
  1. Both medial and lateral malleoli fx
  2. Unilateral malleoli fx with ligament disruption
114
Q

What are the two types of trimaleolar ankle fx?

A
  1. Both malleoli + posterior lip of tibia
  2. Both malleoli + ligament disruption
115
Q

How do all ankle fx present? (3)

A
  • Pain & swelling
  • Point tenderness and limited ROM
  • Palpate proximal fibula for tenderness (Maisonneuve fx)
116
Q

What is the primary difference between management of an unstable, displaced ankle fx vs a stable ankle fx? (2)

A
  • Unstable means you need to make it NWB and call ortho in a week
  • Stable is just WB splint/cast for 4-6weeks
117
Q

How do we manage a suspected occult ankle fx? (2)

A
  • Short leg splint + repeat XR in 10-14d
  • Repeat XR should show a bony callus around the occult fx
118
Q

MC MOI for a calcaneal fx?

A

Axial loading

Make sure to check vertebral fx also

119
Q

What is the MC tarsal bone fx?

A

Calcaneal

120
Q

How does a calcaneal fx present and what should you remember to check? (4)

A
  • NWB
  • Pain/swelling/ecchymosis
  • Check NV status and cap refill
  • Assess lumbar spine for tenderness

MC MOI is axial loading

121
Q

How do we manage a calcaneal fx? (4)

A
  1. RICE
  2. Posterior short leg splint with lots of padding
  3. NWB
  4. Ortho in 24h

Gotta make sure it does not displace

122
Q

What is the 2nd MC tarsal bone fx?

A

Talar fx

123
Q

What are the MOIs for a talar fx?

A

High force plantar/dorsi/inversion

124
Q

What is the big issue with a talar fx?

A

Extensive blood supply, so be wary of AVN

125
Q

MC type of ankle dislocation?

A

Posterior displacement of talus from tibia

126
Q

Why are ankle dislocations concerning?

A

Highly unstable

Ankles are very compact

127
Q

What is the MOI for a posterior ankle dislocation?

A

Posterior force on a plantar flexed foot

128
Q

How does an ankle dislocation present? (2)

A
  • Grossly deformed
  • Posterior will be locked in plantar flexion and anterior tibia is easily palpable
129
Q

First step to manage an ankle dislocation after imaging?

A

Reduction via downward traction

Splint with posterior leg after

130
Q

What are the two MOIs for a metatarsal fx?

A
  1. Twisting/rotational force
  2. Blunt trauma (dropping something on your foot)
131
Q

How does a metatarsal fx present? (2)

A
  • Pain with wt bearing
  • Swelling/ecchymyosis/tenderness (Only tenderness on exam if stress fx)
132
Q

What is a Jones fx?

A

Fracture at the base of the 5th metatarsal

133
Q

For a single, nondisplaced metatarsal fx, what do we do for management? (2)

A
  • Short leg posterior/fx brace
  • Weight bearing as tolerable
134
Q

For multiple metatarsal fxs or displaced/angulated ones, what is the management?

A

Consult ortho

135
Q

What is a tarsometatarsal injury?

A

Lisfranc joint/injury, aka disruption of the tarsometatarsal joint.

136
Q

What is the MOI for a lisfranc injury/tarsometatarsal injury?

A

Axial loading on a plantar flexed foot, follow by forcible rotation, bending/compression

MVA, crush injuries, Horseriding

137
Q

How does a lisfranc joint injury present? (3)

A
  • Midfoot pain/tenderness
  • Inability to bear weight
  • (+) deformity, swelling, ecchymosis
138
Q

How do you dx a lisfranc injury?

A

WEIGHT BEARING foot series bilaterally

139
Q

How do we manage a non-displaced lisfranc injury? (2)

A
  • NWB short-leg posterior for 6-8wks
  • Rigid arch support for 3 months

If displaced, call ortho after splint

140
Q

What phalanx is MC injured?

A

5th phalanx

141
Q

Which joint is MC dislocated in the foot?

A

MTP of the 1st joint

142
Q

Management of phalangeal injuries?

A
  1. Non-displaced = buddy tape
  2. Displaced/angulated = reduce then buddy tape
  3. Dislocation = digital block then reduce
143
Q

What is Hallux Valgus?

A

Bunions, which are lateral deviations of great toe at MTP joint

144
Q

Who is hallux valgus MC in?

A

Females

10x

145
Q

Top 2 causes of hallux valgus?

A
  • Tight-fitting shoes
  • OA
146
Q

How does hallux valgus present?

A

Pain and swelling

147
Q

What is considered normal valgus angulation at the MTP joint?

A

< 15%

148
Q

Management of Hallux Valgus

A
  • Shoe wear modification
  • Avoid high heels
  • Call ortho for persistent symptoms
149
Q

What is Morton’s Neuroma?

A

Perineural fibrosis of the common digital nerves between the metatarsal heads

150
Q

Who and where is Morton’s neuroma MC in?

A
  • Base of the 3rd/5th toes in the 3rd web space
  • Females due to tight shoes
151
Q

Where is pain MC in Morton’s neuroma?

A

Burning plantar pain in forefoot

152
Q

How does Morton’s neuroma present? (3)

A
  • Burning plantar pain in mid foot
  • Dysesthesias in affected toes
  • Walking on a marble
153
Q

How do we perform an interdigital neuroma test? (3)

A
  1. Apply direct plantar pressure to interspace
  2. Squeeze metatarsals together
  3. (+) = increased tenderness and pain radiating into the toes
154
Q

Management of Morton’s Neuroma? (3)

A
  • Pt education on low-heeled, well-cushioned shoes & pads
  • Corticoidsteroid injections
  • Surgical last resort
155
Q

What kind of pain does plantar fasciitis cause?

A

Heel pain, esp in adults 40-60

156
Q

MC RFs for plantar fasciitis?

A
  1. Obesity
  2. Flat feet
  3. Prolonged jumping/standing
157
Q

How does plantar fasciitis present? (4)

A
  • Insidious onset
  • Heel pain that is worse during their 1st steps
  • Tenderness over medial calcaneal tuberosity and 1-2cm along plantar fascia
  • Passive dorsiflexion may cause pain
158
Q

Management of plantar fasciitis? (4)

A
  1. Initial: OTC orthotic heel pad + home stretching
  2. Avoid barefoot walking/flat shoes
  3. Ice and NSAIDs
  4. 6-12 months to resolve :(
159
Q

What are the options for plantar fasciitis after you fail conservative therapy?

A
  1. Corticosteroids into heel
  2. Custom orthotics
  3. Surgical release

MSK (17 decks)

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