Lower extremities Flashcards
articular
in the joint
periarticular
around the joint, like trochanteric bursa
what signals a congenital pathology
-pain persistent from infancy or appearing before 40
what signals degenerative dz (arthitis)
pain after 60YO
pelvic fx
- MC MOA
- can cause?
- dx
- tx
- complications
- lab tests to monitor complications?
high impact injuries–like MVA
can cause a lot of bleeding–fluid resucitation is needed
dx=cray
tx=severity and location of fx
COMPS=dvt, scatic nerve damage and BLEEDING
BLEEDING**
LABS: cbc, blood type and screen to monitor bleeding
Hip dislocation -what is it -MCC MC type CM and complictions PE Tx
head of femur pops out of acetabulum
MCC=high impact injury–MVA aka truama mcc
MC type=POSTERIOR–>axial loading on an adducted femur
CM
*POSTERIOR: affected limb is ADDucted, internally rotated and shortened
*anterior: abducted, externally rotated and shortened
*severe pain on mobilization
COMPLICATION OF POSTERIOR: sciatic nerve injury
PE
*always check femoral artery and nerve—can be compressed with anterior dislocation
TX
-conservative=closed reduction under conscious sedation
OR
ORIF surgery
always think about these potential complications with hip dislocations—5
- avascular necrosis— risk reduced if hip reduced early (<6 hours)
- sciatic nerve injury (posterior)
- DVT
- bleeding
- if anterior—check femoral artery and nerve
Hip Fx
- MC in?
- MOAs
- where is pain felt
- what does limb look like when PT supine
- three types
- complications
MC in elderly, esp women who are prone to osteoporosis
MOA: minor or indirect trauma in eldery, high impact injuries in younger PT
Pain MC felt in groin
*when patient is supine—affected limb will lie ABducted, externally rotated with some shortening
TYPES
- femoral head fx—-HIGHER chance of AVASC necrosis*******
- intertrochanteric—b/w greater and less trochs
- subtrochanteric–distal (below) the trochs
COMPS
- avasc necrosis–esp with femoral head fx
- DVT—-high chance—>give patient prophylactic antithrombotic therapy if indicated
TX
Surgical ORIF
limb presentation for:
1. posterior hip dislocation
vs
2. hip fx
DISLOCATION=leg shortened, internally rotated and adducted
FX=shortened, abducted and externally rotated
Slipped Capital Femoral Epiphyis (SCFE)
- define
- RF
- CM + PE
- DX
*displacement of femoral head (epiphysis) from the femoral neck through growth plate–SALTER 1
RF:
- children 8-16YO
- obese
- AA
- males during growth spurt
- if seen in kids b4 puberty–suspect hormonal or systemic disorders –hypothyroidism or hypopituitarism
CM
- ipsilateral (same side) dull achy HIP/GROIN/THIGH/KNEE pain with a PAINFUL LIMP
- worse with activity
PE
- externally rotated leg on affected side
- altered gait
DX
*XRAY: posterior displacement of femoral epiphysis—-best seen on FROG LEG lateral pelvis or lateral hip view
“ice cream cone fell off the cone”
TX
*non-weight bearing with crutches followed by internal fixation
what direction does the femora head epiphysis slip in a SCFE
posterior and inferior
Legg-Calve-Perthes Disease -define -etiology -bilateral or unilateral -age group MC -RF -CM -dx: early and late tx
- idiopathic avascular osteonecrosis of femoral head in children
- due to ischemia of capital femoral epiphysis
- MC unilateral
- MC in 4-10YO
RF:
- age 4-10
- males—4x more likely
- obesity
- coagulation abnormalities (face V leiden)
DECR RF: low incidence in AAs
CM
- painless limping for weeks—worse with actiity esp at the end of day
- intermittent hip, thigh, knee or groin pain
- restricted ROM–loss of abduction and internal rotation
- +/- atrophy of thigh muscles
DX
- early: incr density of the femoral epiphysis–widening of cartilage space
- late: deformity, (+) crescent sign—microfracturs with collapse of bone
TX
- observation with activity restriction (non-weight bearing inititally)
- orthro f/u
- usually self limiting condition–revascularization within 2 years
- PT
- brace/cast
- surgical for advanced cases
Femoral Shaft FX
- MOA for healthy adult
- MC complication
- MC associated with?
MOA for healthy adult=high energy trauma
MC compliaciton= BLEEDING** very significant amount** can cause hemodynamic instability
MC associated with femoral neck fx–always look out for this bc it can lead to avasc necrosis
Tibial and Fibular fx
- MC open or closed?
- PE: what must you always check?
MC open fxs with soft tissue injury
PE: Always check for: (and compare everything to the other side)
1. dorsalis pedis and posterior tibial pulses!!!!
2. Check ROM in toes
3. nerve injury
TX
- nondisplaced and closed: tx with full leg cast for 4-6 weeks–>then below knee walking cast for another 4-6 weeks
- comminuted or displaced–>ORIF
role of menisci
“spacers”
absorb shock
role of ligaments
hold joint together (connect bone-bone)
blood supply to leg comes from?
tibial artery
where does tibial artery pass?
behind the knee— why it is highly susceptible to trauma
what nerve passed laterally below the fibular head
Peroneal nerve
*also high risk for injury
Valgum
- define
- etiology
“GUM” makes your knees stick together
- knock-knee*
- deformity where tibia is bent or twisted laterally
- occurs result of collapse of lateral compartment of knee and rupture of MCL
Varum
- define
- etiology
RUM makes your knees spread apart
- bow leged
- deformity which tibia is bent medially
- occur from collapse of the medial compartment and rupture of LCL
Valgus stress test
- describe it
- what does it test for
ABDUCTION
*pt supine–>knee flexed–>pushing medially against the knee and pull laterally at the ankle–opens knee joint on medial side
PAIN= (+) test and indicatede MCL injury
Varus stress test
- describe it
- (+) test means
ADDUCTION
*pt supine–>knee flexed–>push laterally against the knee and pull medially at the ankle–>opens the knee joint on the lateral side
(+) test=PAIN=LCL injury
McMurrary Test
- descr it
- what does it indicate
*knee bent–>then externally rotated and extended
CLICKING SOUND= (+) test and indicated medical and/or lateral meniscal tear
**MEDIAL 3x more common than lateral
Anterior Drawer Test
- describe it
- indicates?
- knees bent–>feet flat on table–>cup hands around the knee with the thumbs on medial and lateral joint line— fingers are wrapped around on hamstrings–>push tibia forward
- **look to see if it slides forward from under the femur
**(+) test= ACL injury
Posterior drawer test
same as anterior set up– but you are pushing the tibia posteriorly—
(+) test=PCL injury
***less common than ACL
Lachman Test
- describe
- (+) test=?
*knee is placed 15 degrees flexed and externally rotated–>grasp distal femur with one hand and proximal tibia with other hand–>simultaneously pull tibia forward and femur back
(+) test is when tibia is pulled forward—– ACL injury
(+) apley test =?
meniscal tear
Popliteal Cyst
- aka?
- what is it
- cm
- ruptured cyst CM
- dx
Bakers cyst
- degenerative or inflammatory joint dz (or injury)
- causes knee to produce too much synovial fluid—gets displaced–forms cyst in back of knee
*most are asympto but they can cause POSTERIOR knee pain and stiffness
RUPTURED cyst: tenderness, warmth and erythema of calf—- can look like a DVT
DX
*US doppler to r/o DVT and ID the cyst
TX
- conservatice: ice, NSAIDs
- intraarticular cortico injections help with knee pain + swelling
- neeedle drainage for very large cysts
- refractory cases=surgical excision
tibia is\_\_\_\_\_(medial or lateral) Fibula is\_\_\_
tibia=medial
fibula=lateral
MCL injuries
- MOA
- CM
- tx–grade 1, 2, 3,
MOA: lateral trauma to the knee—-aka valgus stress–pushes the knee inward
more common than LCL
CM *stiffness *localized knee pain *ecchymosis *swelling VALGUS STRESS--- causes pain and laxity
TX
- Grades 1=sprain and grade 2=incomplete tear–> conservative: pain control, PT, RICE, NSAIDs, immobilizer
- grade 3=complete tears=surgical if very bad
LCL injury
- moa
- CM
- tx
MOA: medial trauma to the knee– aka varus stress–less comon than MCL
CM
- localized knee pain
- stiffness
- swelling
- ecchymosis
- pain and laxity with VARGUS stress
TX:
- Grades 1=sprain and grade 2=incomplete tear–> conservative: pain control, PT, RICE, NSAIDs, immobilizer
- grade 3=complete tears=surgical if very bad
ACL injury
- MC etiology
- cm
- PE tests–which is most sensitive
- Dx
MC done via sports injury–noncontact pivoting injury *******
Others: deceleration, changing direction, hyperextension, internal rotation
CM
- pop and swelling
- hemarthrosis
- knee buckling
- inability to bear weight
PE
- LACHMAN TEST=most sensitive
- Pivot test
- anterior drawer test–least reliable of the three
DX
- xray to r/o fx
- MRI best to assess tear
TX—therapy vs surgical— depends on activity level of PT
- CONVERSATIVE: nsaids, ICE, compression and PT
- SURGICAL: mainly done in younger/atheltic PT
PCL injury
- MC MOA + other moa
- CM + PE tests
- dx
- tx
MOA MC=MVA + dashboard injuries**
OTHER MOA: direct blow or fall on flexed knee
CM
- posterior knee pain
- anterior bruising
- large effusion/swelling
PE
*posterior drawer test
DX=MRI
TX
- conservative if PCL ONLY: rest, ice, compression and elevation (RICE), NSAIDs, knee immobilizer
- surgical: if acute injury or assoc with multiple injuries
Meniscal tears
- etiologies
- which meniscus is MC to tear
- CM + PE tests
ETIOLOGIES:
- degenerative changes
- acute injury/trauma–>squatting, compression, twisting
MEDICAL 3x more common vs lateral
CM
- popping or giving way during ambulation or walking/climbing/descending stairs
- swelling after activity
- locking of knee–inability to fully extend
PE
- MCMurary test–pop/click *****
- apley test—joint line tenderness with effusion and swelling
DX: MRI
TX:
- conservative: RICE, ortho f/u, PT
- Surgical: arthroscopic repair or partial meniscectomy if severe or persistent
Patellofemoral syndrome aka
-define
Chondromalacia
*idiopathic softening or fissuring of the patellar articular cartilage from overuse
RF
- runners
- cyclists
- women
CM
- anterior knee pain behind or around the patella
- worsened with knee hyperflexion—-sitting, jumping or climbing
PE
* (+) apprehension sign–>anticipated pain when you compress the patella during knee extension
TX
- conservative: RICE, nsaids, rehab=initial tx
- elastic knee sleeve for patellar stabilization
Patellar Dislocation
- MOA
- MC way of dislocation
- MC in who
MOA=valgus stress after twisting injury, direct blow
**lateral dislocation MC
MC in females
DX
(+) apprehension sign—- only do this if the patella already reduced
*xrays show dislocation
TX
- Closed reduction–>push anteriomedially on patella while gently extending the leg
- post reduction films*******
- knee immobilizer
- quad strengthening
Patellar Fx
- what is helpful indicator of this fx?
- MC MOA
- MC in who
- Dx
*since its hard to see on xray—-> (+) hemarthrosis (joint effusion) in context of trauma=helpful indicator of fx
MC MOA= direct blow
- falling on flexed knee
- forceful quad contraction
MC in younger patients
CM
- pain
- swelling
- deformity
- limited knee extension with pain
DX
*xray: sunrise & cross table lateral views allow better visualization
TX
- non displaced=knee immobilizer + leg cast
- displaced=surgery
Femoral Condyle Fx
- MOA
- Cm
- comps
MOA=axial loading
- falling from ht
- direct blow to femur
CM
- pain
- swelling
- inability to bear weight
COMPLICATIONS
- Peroneal nerve injuries
* drop foot
* decr sensation to posterior first web space of foot - Popliteal artery injury
TX
- IMMEDIATE ortho consult
- ORIF
- usually heals poorly
Tibieal Plateau Fx
- MC seen in?
- other MOAs
- CM
- dx
- tx
- comps
MC seen in children in MVAs
- direct trauma
- axial loading
- rotation
CM
- pain
- swelling
- hemarthrosis
- if displaced: check for peroneal nerve injury****—- will see foot drop if injured
DX
- CT for pre-surgical planning
- Hard to see on xray
TX
- conservative: non-weight bearing initially with high hinged knee-brace + ortho f/u IF NOT DISPLACED
- Dispalced=surgery
COMPS
- often assoc with soft tissue injuries—-> meniscal and ligament tears (lateral meniscal tear MC)
- compartment sydrome
- post degenerative arthritis in over 50% cases—- loss of joint congruity
- ALWAYS CHECK DISTAL PULSES***
Knee (tibial/femoral) dislocations
- which direction is mc dislocation
- which direction has most incidence of artery injry
- MOA
- CM
- TX
- Complications
SEVERE LIMB THREATENING EMERGENCY** due to very likely damage to popliteal artery
- Anterior MC
- posterior has highest incidence of popliteal injry
MOA: high velocity trauma— assoc with multiple trauma
CM
- obvois gross deformity
- over 50% spontaneously reduce before ER arrival
TX: IMMEDIATE ORTHO CONSULT
- prompt reduction
- most cases require surgrical intervention
- CHECK PULSES*****
COMPS
- VASCULAR
* popliteal artery injury in 1/3 cases—– must perform angiography or arterial duplex if pulses are diminshed or absent (normal pulses do not r/o injury) - NEURO: peroneal or tibial nerve injuries— peroneal MC
Osgood-Schlatter Dz
- define
- MOA
- MC in who
- CM
- Dx
- Apophysitis of tibial tubersity (inflammation or stress injury to the areas around growth plates in kids or adolescents)
- inflamation of the patellar tendon at insertion of the tibial tubercle due to overuse or small avulsions from repetitive knee extension & quads contraction
MOA: overuse, repetitive knee extenion and quad contraction
MC in males 10-15 YO during growths spurts, young athletes
CM
- Activity related anterior knee pain & swelling— worse during activity and relieved with rest
- prominence swelling and tenderness to anterior tibial tubercle
DX—clinical
imaging not needed if classic presentation
TX
- conservative: RICE, NSAIDs, knee immobilization—– most s/s resolve w.in 12-24 MO
- surgical only if refractory and if so…. only done after growth plate closes
Ankle sprain
- define sprain vs strain
- location of sprains
- MC location and MOAs
- DX: how to tell b/w sprain and fx
- tx
SPRAIN= ligament— connect bone to bone
STRAIN=tendon— connect bone to tissue
*can be lateral or medial sprain
MC=LATERAL and MOA=inversion and anterio talofibular ligament MC affected
MOA=eversion and that causes medial sprain of deltoid ligaments
DX--> OTTAWA ANKLE RULE INABILITY TO WALK >4 STEPS AT TIME OF INJURY & IN ER PLUS THE FOLLOWING: 1. ankle films *pain along the lateral malleolus or *pain along the medical malleolus 2. Foot films *navicular (midfoot) pain or *5th metatarsal pain
TX
- RICE
- NSAIDs
- crutches first 2-3 days
- ACE wrap for support
Lateral Ankle sprain involves what ligaments and why one ligament MC
THREE LATERAL LIGAMENTS:
- Anterior Talofibular (ATFL) MC because this is the main stabilizer during inversion
- calcaneofibular (CFL)
3, Posterior talofibular ligaments (PTFL)
Medial ankle sprains invovles what ligament
Deltoid ligament sprains
MOA=eversion
Achilles Tendon Rupture
- MCC
- RF
- CM
- PE
- DX
- TX
MCC=mechanical overload from eccentric contraction of fastrocsoleus complex
aka—–>sports-related injury, episodic athletes “weekend warriors”
RF
- 75% from sport related injury/weekend warriors
- incr risk with fluoroquinolone use, corticosteroid injections
- 30-50YO
CM
- sudden heel pain after push-off movement
- Pop
- sudden, sharp calf pain
- inability to bear weight
PE
(+) Thompson test–>PT is prone and you squeeze the fastrocnemius— if weak or absent plantar flexion=pos test and means rupture
DX: MRI best test
xrays initial to r/o fx
TX
- nonoperative: splint initially then cast
- surgical repair
MC MOA for ankle fractures
-list four MC fx and what is MC
rotational injury
high impact collision
repetitive stress—-stress fx
- Lateral malleolus fx—MC
- bimalleolar fx– both lateral and medial malleous
- trimalleolar fx or cotton fracture— includes posterior malleolus
- Pilon fx–aka Plafond–>central portion of the tibia
* mc happens with high impact trauma like jumping from a window
for which type of ankle fx do we use the webber ankle fx classification?
lateral malleolus
Weber Ankle Fx Classification -defines what? A B C
*defines where the fibular/lateral malleulus fx occurs in relation to the Syndesmosis joint (where fibula touches tibia)
Weber A= below syndesmosis *tibiofibular syndesmosis intact *deltoid ligament intact *stable \+/- medial malleolar fx
B= level of syndesmosis
- tibifibular syndesmosis intact or mild tear
- deltoid ligament intact or may be torn
- can be stable or unstable
C=above
- syndesmosis torn–widening of talofibular joint
- deltoid ligmanet damaged
- +medial malleolar fx
- UNSTABLE— needs ORIF
what is syndesmosis joint
where fibula touches tibia
Maisonneuve Fracture
- define
- imaging
- spiral fx of the proximal third of the fibula assoc with a distal medial malleolar fx or rupture of deep deltoid ligament
- complete disruption of the ligamnts arund the ankle + fibula fx at level of KNEE
IMAGING
*The ANKLE x-ray may or may not show a fracture or instability since the actual bone fracture is well above the ankle and the ligament injuries can only be seen with other imaging, like an MRI
tx for ankle fx
*dep on aligment of bones and stability of the ankle joint
GOAL=have bones heal as closely to perfect as possible
—>misalignment as ilttle as 2cm can lead to arthritis
stable break w.o displacement= splint or cast w/ or w/o crutches
unstable or displaced= surgical repair
Single mallolar fx
either distal fibula or tibia
bimalleolar ankle fx
distal fibula + tibia
Trimalleolar ankle fx
distal fibula + tibia + posterior tibial involvement
Stress/March Fx
- etiology
- MC bones involved?
- F or M MC?
- CM
- DX
- high risk area?
- overuse or high impact activites– military, athletes
- F>M
- MC bones=third metatarsal**, tibia, fibula, navicular bones
CM
- insidious onset
- localized pain + swelling + tenderness that incrs with acitvity
- *LOCALIZED BONE TENDERNESS at fx site
DX
50% of xays= (-) findings— initially first two weeks
**so mainly clinical diagnosis
HIGH RISK AREA FOR FX— lots of nerves
- 4th or 5th metatarsal,
- navicular
- talus
- THESE GET MRIs**
- **also get MRI if s/s persist despite tx
TX
- rest
- avoid high impact activities
- ice
- split
- NSAIDs
- SURGERY only for the high risk areas like the 5th metasaral
Plantar Fasciitis
- define
- RF
- CM
- Dx
*inflam + microscopic tears of the plantar fascia due to overuse
RF
- flat feet
- high arches
- heel spurs
- females 40-60 YO
- obese
CM
- sharp inferior heel pain
- pain comes after first few steps after resting
- pain decrs througohut the day— returns at night
PE
- reproducible pain on palpation over the heel pad
- pain incrs with dorsiflexion of toes
DX
clinical
TX
- Rest
- ice
- NSAIDS
- heel/arch support in shoes (orthotics)
- PT
- steroid inj if no relief with conservative tx
- can take up to 1 yr to fully heal….. if not better post 1 yr– surgery
Tarsal Tunnel Syndrome
-define
- posterior tibial nerve compression as it travels thru tarsal tunnel
- compression etiology: overuse, restrictive footwear, edematous state
CM
- compression s/s: altering pain/numbness at medial malleous, heel and sole
- pain incrs during the day–worse at night–with dorsiflexion and pain does not improve with rest
PE
(+) Tinel test—tap at posterior medial malleolus reproduces s/s
DX
- clinical
- electromyography confirms dx
TX
- INITIAL= conservative–NSAIDS, rest, orthotics, properly fitted shoes
- corticos if refractory to initial tx
- surgery–tunnel release for severe cases
medical term for bunion
Hallux Valgus
Hallux Valgus
aka
aka BUNION
- deformity of the first metatarsophalangeal joint with lateral deviation of proximal phalanx
- assoc with hx of wearing tight poiinted shoes, flat feet, and RA
CM
*pain over the great toe at the MTP joint
TX
- 1st line: comfortable, wide-toed shoes
- surgical repair if refractory to conserv tx
Hammer Toe
- define
- assoc with/RF
- CM
*deformity of PIP joint–>flexion of PIP joint with hyperextension of MTP and DIP joint
Assoc with having a 2nd, 3rd, or 4th toe longer than the first, tight fitting shoes, OA, RA
CM= PIP joint pain due to contact with shoes + PIP deformity
Neuropathic (Charcot) Arthropathy
- define
- MC what part
- joint damage + destruction from periph neuropathy from DM, PVD or other dzs
- MC affects midfoot and ankle
- DM and tabes dorsalis (form of tertiary syphilis)
CM
*ACUTE: nontender, swollen, warm and erythematous joint
CHRONIC: joint or foot deformity , alteration in shape of foot, ulcer or skin changes
DX
- XRAY: obliteration of joint space, disorganization of the joint
- MRI
- LABS: sometimes elev ESR
TX
- conservative: rest, non-weight bearing. Accommodative footwear
- surgical rarely performed—- only indicated if severe deformity
Morton’s Neuroma
-define
- compressive neuropathy of interdigital nerve
- MC involves second or third interdigital nerve b/w metatarsal heads
- ETIOLOGY: repepitive microtrauma—degeneration and proliferation of nerve
MC: women 25-50… esp if they wear heels, tight fitting shoes or have flat feet
CM
- BURNING (lancinating) pain esp with weight bearing
- MC in third intermetatarsal space
- reproducible pain on palpation or squeezing foot
- can have paresthesias of toes or plantar aspect
PE
- palpable painful mass hear tarsal heads– sometimes
- MUDLER’S SIGN–>clicking sensation when palpating the invovled interspace while squeezing metatarsal joints
DX=clinical
- US
- MRI
TX
- conservative: metatarsal support or pad, broad-toed shoes with firm soles
- glucocoticoir inj if refractory
- surgical resection
Jones fx
- what is it
- can occur with?
- CM
- tx
- comps
transverse fx of the 5th metatarsal at the metaphyseal-diaphyseal junction
- can occur with ankle sprains
- 20% end up in malunion or non-union
CM
*pain over 5th metatarsal area and lateral border of midfoot
TX
*non weight bearing in short leg cast for 6-8 weeks
COMPS
*nonunion or malunion— which then needs surigcal repair
Lisfranc Injury -where is lisfranc joint? -what is the injury -MOA CM + PE DX
JOINT=base of the first 3 metatarsall heads
INJURY=one or more of the metatarsal bones are displaced from the tarsus
MOA=varied
- rotational (midfoot)
- severe axial load
CM
- severe pain
- inability to bear weight
PE
- swelling, bruising, tendrness over the tarsometatarsal joint
- instability
XRAYS
*most common=one metatarsal away from the others
(+) Fleck Sign: fx at the base of the second metatarsal pathognomonic for disruption of ligaments
TX
- ORIF
- then non weight bearing cast for 12 weeks
