Lower Extremity

Question 1

Osteoarthritis Hip

Causes?
Sx?
Hx?
Px?
Imaging?
Tx?

Answer 1

Breakdown and loss of articulate cartilage within the joint surfaces, leading to loss of congruency and decreased joint function.
** Trendelenberg gait!

Causes: Injury, age, obesity, & congenital disposition, female, repetitive use of joints, bone density, muscle weakness, joint laxity.

Sx: pain in the groin area, disability, difficulty walking and climbing stairs, decreased ROM with abduction, night pains

Hx: Gradual onset of pain that is relieved by rest, over age 50, increased pain with activity, morning stiffness

Px: TTP over joint and musculature, decreased ROM, pain with internal/external rotation, failure to walk more than a few blocks, abductor lurch

Imaging: X-ray (loss of joint space, osteophyte formation)

Tx: Activity modification, shoe wear, NSAIDS, weight loss, joint injection, joint replacement.

Question 2

Trochanteric Bursitis

Sx?
Imaging?
Tx?

Answer 2

Bursa-closed fluid filled sac between muscle/bone and muscle/muscle that occur where friction or impingement may occur.

Sx: Point tenderness, pain with walking/running especially up an incline, inability to sleep on side.

Imaging: X-ray to R/O other pathology

Tx: Ice/heat, gentle stretching, NSAIDS, activity modification, steroid injection, PT (gluteal stretch, IT band stretch, prone hip extension, wall squat with a ball, straight leg raise, side-lying leg lift.

Question 3

Developmental dysphasia of the hip (DDH)

PE?
Imaging?
Tx?

Answer 3

A patient born with a hip dislocation or instability of the hip which may then result in hip dysphasia or to abnormal growth of the hip.

Risk Factors: Breech position and Caesarian delivery, first born, female, and family history.

PE: Baby relaxed. Ortaloni (out/clunk) and Barlow (in) maneuvers to check for hip instability. Check for asymmetric abduction. Look for torticollis and MTA (packaging problem).

Imaging: Ultrasound, Graf classification system, children <6 months. Children >6 months do an x-ray.

Tx: Babies: Pavlik Harness (check US to make sure hips are reduced, check weekly for femoral nerve function, and once US shows normalization of hips, start to wean from pavlik)
Older child: Closed reduction and adductor tenotomy vs open reduction with or without pelvic osteotomy.

Question 4

Transient Synovitis

Signs? PE? DDX? IMAGING? LABS? Treatment?

Answer 4

Hip pain that is typically unilateral and limits internal rotation of the affected hip. (Usually boys 3-10 years)
DIAGNOSIS OF EXCLUSION.

Signs: limp, or refusal to walk for 1-2 days. Low grade fever or afebrile.

PE: Limited internal rotation of affected hip.

Ddx: Septic arthritis, femoral osteomyelitis, Jeuvenile rheumatoid arthritis, and acute rheumatic fever.

Imaging: X-ray (pelvis & hips)- normal, US (hips)- variable amount of fluid (yellowish).

Labs: WBC may be normal, ESR minimally elevated.

Treatment: Bed rest (3-5 days)

Question 5

Leg Calve Perthes (LCP or Perthes)

Sx? Labs? Imaging? Tx?

Answer 5

Lack of blood flow to the femoral head, so the bone dies and stops growing. Happens spontaneously between 5-10 yrs. More common in males.

Sx: Pain with hip movement, mild knee or thigh pain, limp, decreased hip ROM (internal rotation and abduction), + Trendelenberg sign and gait, antalgic gait.

Labs: Normal

Imaging: X-ray (AP and frog-leg lateral)- may be normal at first.

Tx: Restoration of ROM and containment of the femoral head. Total hip replacement (20s-30s).

Question 6

Slipped Capital Femoral Epiphysis (SCFE)

Severity? Sx? PE? Treatment?

Answer 6

Most common hip disorder in pre-adolescent and adolescent children. (80% obese or due to delay of secondary sex characteristics).

Severity: Mild 1/3 detached,0-30 degrees. Moderate 1/3-2/3 detached, 30-60 degrees. Severe 2/3-complete detached, 60-90 degrees.

Sx: Limping with thigh or knee pain. Foot externally rotated. Positive trendelenberg.

PE: Obligatory external rotation of hip when flexed. Little to no internal hip rotation on affected side.

Tx: In situ fixation

Question 7

Chondromalacia patella (Patella/femoral syndrome)

CC?
Hx?
Obs?
PE?
Imaging?
Tx?

Answer 7

Cartilage deterioration beneath the patella.

CC: Pain, grinding under the patella.

Hx: Increased pain with activity, difficulty with stairs and squats

Obs: Normal gait, +/- swelling

PE: Very TTP posterior surface of the patella (Test: Patellar apprehension/grind). ROM normal. Increased pain at extremes of flex/ex.

Imaging: X-RAY (sunrise view)/MRI

Tx: Rest. Ice. Knee sleeve with open patella, strap. PT (to strengthen quads). OTC anti-inflammatory.

Question 8

Patella Dislocation

CC? Hx? PE? Imaging? Tx?

Answer 8

CC: I felt my knee cap go out, and now it’s painful.

Hx: Blow to knee, vagus or twisting injury, + family history, hypermobile patella.

PE: APPREHENSION TEST! If still dislocated, pt will hold knee in flexion. TTP over lateral and medial knee. Effusion. Lateral tilt of patella.

Imaging: X-RAYS. +/- MRI

Tx: PT. Brace. If 2nd dislocation might need surgery.

Question 9

Meniscal tear

Types? CC? Hx? Px? Special tests? Imaging? Tx?

Answer 9

Types: Flap tear, Torn horn tear, Bucket handle tear, Transverse tear.

CC: Pain, swelling, acutely then intermittent episodes of locking, buckling, giving out. Difficulty with stairs. More sx with activity.

Hx: Twisting injury to knee with foot in WB position. Popping or tearing sensation followed by intense pain. Acute sx gets better in 10-14 days.

Px: +/1 horseshoe swelling pattern (on top of patella). TTP over corresponding joint line. ROM notably decreased. Pt may be able to obtain full extension but not full flexion. Quad strength/tone may be slightly decreased. Pt may present with locked knee.

Special Tests: McMurray and Appre Comprehension.

Imaging: X-RAYS/MRI. (X-RAY not helpful unless sig. deterioration. MRI diagnostic)

Tx: Ortho visit or crutches, compression, ICE, and PT.

Question 10

ACL Tear

CC? Hx? Special tests? Imaging? Tx?

Answer 10

CC: Painful, swollen knee with marked pain and instability since injury.

Hx: Foot planted and leg twisted in opposite direction secondary to tackle or weight shift. May hear a snap. Whole knee hurts.

Special tests: Lachman’s, Anterior drawer, and Pivot shift (high specificity for decking ACL)

Imaging: X-RAYS/MRI.

Tx: Until ortho is seen, RICE, crutches, straight leg brace, encourage ROM when pain allows, and OTC or Rx pain meds.

Question 11

Medial/Lateral Collateral Ligament Tear

Degrees? CC? Hx? Obs? PE? Special tests? Tx?

Answer 11

Degrees: 1st (stretched, irritated and inflamed, intact), 2nd (ligament partially torn), 3rd (complete disruption of the ligament).

CC: Pain and swelling over injured ligament.

Hx: Contact type injury, where the knee folds in. Pain over injury.

Obs: May be obvious swelling and ecchymosis. Hemarthrosis. Able to WB unless 2nd or 3rd degree.

PE: TTP over medial joint line and superior and inferior to joint line. ROM intact with increased pain with full flexion. Strength may be compromised.

Special tests: Valgus stress (lift leg and bend 30 degrees).

Tx: Straight leg immobilized and crutches x7 days. Rest. Ice. Anti-inflammatory. Restrict ADL and sports participation. PT at 7-10 days. Refer to ortho if 3rd degree.

Question 12

Osteoarthritis

Signs? Treatment/Management?

Answer 12

Medial compartment most susceptible to age related degenerative changes.

Signs: Knee pain + 3 additional symptoms (>50, crepitus, bony enlargement, morning stiffness more than 30 min, bony tenderness, no palpable warmth)

Management: Orthopedic surgeon (Total Knee Arthroplasty) or Manage pain (Tylenol, NSAIDS, Narcotics, Corticosteroid injection).

Question 13

Osgood Schlatter Disease

CC? PE? Tx?

Answer 13

Children: self-limited condition in active children.
Early pre-adolescent (11-14): Repetitive injury/microscopic avulsion from insertion of the patella at tibial tuberosity.

CC: Painful, tender tibial tuberosity. Increased pain with activity.

PE: TTP over tibial tuberosity. Extension hurts.

Tx: Rest, ice, immobilization, stretching.

Question 14

Osteochondral Defect

CC? Hx? PE? Imaging? Treatment?

Answer 14

Defect in the sub-chondral region with partial or complete separation of the bone fragment.

CC: Vague knee pain, ++ pain. +/- effusion with exercise.
+/- locking.

Hx: Repetitive overloading. More in men. Usually <18 yo.

PE: Pain with full flexion of knee, forcible compression of affected area of distal femur elicits pain during flex. If the fragment is loose and effusion may be present. Locking may be present if the fragment blocks the joint. May walk with foot externally rotated.

Imaging: X-RAYS/MRI

Tx: No WB. Surgery (arthroscopic debridement or fixation of lesion). Prognosis poor in patients with closed growth plates.

Question 15

Bount’s Disease (Tibia Vara)

Signs? PE? Imaging? Tx?

Answer 15

Seen in obese children that walk at an early age (9-10 months). A diseases of the medial proximal tibial growth plate.

Signs: Persistent unilateral or bilateral bowing after 2 yo.

PE: Excessive bowing uni or bilateral, tibial torsion. Lateral thrust with ambulation.

X-rays: Standing AP hip to ankle with patella pointing forward (older than 18 months old). Metaphyseal diaphyseal angle >16 degrees has a 95% chance of increasing.

Tx: <3- Bracing. >4- surgery. >20- MDA. (Proximal tibial osteotomy, guided growth)

Question 16

Achilles Rupture

CC? Hx? Obs? PE? Imaging? Special tests?

Answer 16

CC: Pain, swelling, bruising, no WB

Hx: Middle aged male. Feeling like being shot or kicked in cold. +/- pop.

Obs: Swelling, bruising, +/- visible defect

PE: TTP over achilles, palpable defect, entire ankle feels boggy. PROM wnl. AROM decreased. Strength in plantar flexion 0-1 out of 5.

Imaging: X-RAYS. MRI. Refer for surgery.

Special tests: Thompson test (squeezing gastrocnemius to make the foot plantar flex)

Question 17

Ankle Sprain

Degree? CC? Hx? Obs? PE? R/O? Special tests? Imaging? Tx?

Answer 17

Stretching or tearing of the ligaments that stabilize the ankle joint. (MC ATF ligament)

Degrees:
1- ligament stretched
2- ligament partially torn
3- complete tear of 1 or more ligaments

CC: Ankle pain, swelling, bruising, no WB.

Hx: “rolling out” (inversion), +/- pop.

Obs: Swelling and ecchymosis

PE: TTP over anterior/lateral joint line and distal tip of fibula. AROM and PROM decreased. Decreased strength in DF and eversion. May have decreased sensation over dorsum of foot.

R/O bony injury! Look at distal difula + base of 5th metatarsal.

Special tests:

1) Anterior drawer: Excessive anterior displacement suggest ligamentous injury.
2) Tilt test: Degree of inversion is observed and compared to uninsured side (assess calcaneofibular ligament)
3) Squeeze test: Pain in the region of the distal syndesmosis confirms distal syndesmotic injury when you squeeze the tibia and fibula above the ankle.

Imaging: Ottawa rules –> X-RAY
Ankle film if: Pain in malleolar zone, lateral malleolus, medial malleolus, or unable to WB.
Foot film if: Pain in mid-foot zone, base of 5th metatarsal, navicular, or unable to WB.

Tx: 1-2nd degree: RICE. Anti-inflammatory. Horseshoe pad. Air cast. Stirrup splint. No WB 3-7 days. Early ROM, alphabet. PT if appropriate. 3rd degree same as above + refer.

** Syndesmotic sprain: Dorsiflexion and eversion of the ankle with internal rotation of the tibia.

Question 18

Plantar Fasciitis

CC? Hx? PE? Imaging? Tx?

Answer 18

Inflammatory response at origin of the plantar fascia at the plantar medial aspect of the calcaneus.

CC: Pain in posterior portion of arch. Worse in AM.

Hx: Increasing pain over time. Bad in AM, better in day, bad at night. No hx of injury.

PE: TTP over plantar aponeurosis (medial insertion)

Imaging: None.

Tx: Roll over warm water bottle in the morning. Roll over frozen bottle at night. Cold stretching. Gentle massage. NSAIDS. Night splint. Refer if not responding.

Question 19

Hallux Valgus (Bunions)

CC? Obs? PE? Imaging? Tx?

Answer 19

Deformity of the 1st MTP joint, results from lateral deviation of the proximal phalanx and the resultant medial pressure against the metatarsal head.

CC: Deformity, difficulty with shoe wear, pain over medial eminence.

Obs: Deformity of 1st MTP joint.

PE: Obvious deformity, +/- TTP over medial eminence. Decreased ROM 1st MTPj.

Imaging: X-RAYS (evaluate joint incongruency or refer)

TX: Conservative first (bunion splint). Surgery if indicated.

Question 20

Pes Planus (Flat foot)

Sx? PE? Tx? Look out for?

Answer 20

Congenital. Flexible or rigid.

Sx: Flattening of the longitudinal arch when pt is standing. Flexible flat foot (ROM ok and no achilles contracture). Usually non-painful. If pain, rule out tarsal coalition, congenital vertical talus, and accessory navicular.

PE: Joint laxity. Resting arch in foot. Good hindfoot motion.

Tx: Reassurance. If pain, orthotics.

• • Rigid flat feet look out for:
    1) Tarsal coalition: Structural anomaly bw 2 or 3 tarsal bones causing a rigid flat foot. (Calcaneonavicular or talocalcaneal).
    2) Vertical talus: Foot deformity. Not painful. (Assoc. with spina bidida, arthrogryposis, and diastematomelia).
    3) Accessory navicular: Normal variant in 12% of population. Can be painful.

Question 21

Club Foot/ Congenital Talipes Equinovarus

Epid? Sx? PE? Tx?

Answer 21

Epid: Most common birth defect. MC males. Half of cases bilateral. 25% family occurrence.

Sx: Small foot and calf. Medial posterior foot skin creases.

PE: "CAVE"
Midfoot cavus 
Forefoot adductus 
Hindfoot varus
Hindfoot equinus 

Tx: Ponseti Method (serial manipulation and casting). Posterior achilles tenotomy. Mitchel Shoes and Bar for night and nap time until 5yo.

Question 22

Sever’s Disease

Sx? PE? Imaging? Tx?

Answer 22

Overuse injury of the calcaneal apophysis seen in immature athletes just before or during peak growth. Common cause of heel pain.

Sx: Pain in the area of the calcaneal apoptosis in an immature athlete. Pain increased with activity or impact. Stretch of the triceps surface exacerbates pain. Warmth, erythema, and swelling.

PE: Tight achilles. Positive squeeze test. Pain over the calcaneal apophysis.

Imaging: X-RAYS (to R/o osteomyelitis or bone cysts). MRI (to localize inflammation). Bone scan (may show increased uptake but usually not helpful).

Tx: Activity modification. NSAIDS. Ice before and after playing sports.Heel pads/cups. Short leg cast immobilization for persistent pain.