Lower extremity disorders Flashcards
What is Avascular Necrosis (AVN)
Bone infarction, aseptic necrosis, osteonecrosis
What gender is effect by AVN most
Male
Which bones are primarily effected by AVN
Hip (Femoral head)
Knee (Condyles)
Shoulders (Humeral head)
What causes AVN
Interruption of blood supply
-trauma
-idiopathic
What causes AVN of the jaw
bisphosphonate use
What are the risk factors for AVN
Alcohol/AIDS
Sickle cell/SLE
Exogenous steroids
Pancreatitis
Trauma
Infection
Caisson disease
What is Caisson disease
Decompression sickness
An acute neuralogical emergency from a release of a nitrogen gas bubble that impinges the vessels and spinal cord
How does true hip pain manifest
groin pain
What are some symptoms of AVN
Insidious onset of joint pain
Six similar to OA
How do you diagnose AVN
Imaging
-> MRI is most sensitive
How do you treat AVN when there is no bone collapse
Osteoporosis drugs (Bisphosphonates)
Surgery to induce revascularization
How would you treat AVN when there is bone collapse or if the patient is older
Arthroplasty
What does SCFE stand for
Slipped Capital Femoral Epiphysis
What is a SCFE
Slippage of the epiphysis off the metaphysis
What is the most common adolescent hip disorder
SCFE
Which hip are SCFE most often seen in
Left
What is the most common presentation of a SCFE
Hip pain (groin and thigh)
Limp or external rotation of leg
primary knee pain
Reduced ROM on exam
What is the test of choice to diagnose SCFE
Xray
How are SCFE treated
Percutaneous fixation (pinning)
ORIF if severe
What is the most common orthopedic disorder in newborns
Developmental hip Dysplasia
Which gender is more effected by developmental hip dysplasia and which side is more effected
Females
Left (in utero positioning)
How does ethnicity contribute to developmental hip dysplasia
Because of how they swaddle
Native Americans do cradle boarding
What causes developmental hip dysplasia
Predisposed hip laxity
Intra-uterine or post natal malpositioning
Which newborns are at higher risk for having developmental hip dysplasia
First born
Breech
+ family history
Macrosomia
Oligohydramnios
If a newborn presents with developmental hip dysplasia, what else are you going to look for
Metatarsus adductus
Torticollis
A mother brings her newborn in who you suspect has developmental hip dysplasia, what are you going to do to test them?
Barlow and ortolani maneuvers
What does the Barlow test for
It will dislocate a dislocatable hip (Click on exit)
What does the ortolani test for
Reduces a dislocated hip (Clunk on entry)
What type of imaging would be done for developmental hip dysplasia on a baby 0-4 months
US
After 4 months of age, why do you switch to xray for developmental hip dysplasia
Ossification of the femoral head begins
What is the first line treatment for newborns <4months with a +ortolani
Pavlik harness
*keeps femoral head in acetabulum
How would a baby who has a failed pavlik harness or is 6-8 months of age be treated for developmental hip dysplasia
Spica cast
What is trochanteric bursitis
Inflammation of trochanteric bursa
Where is the great trochanteric bursa located
Between the greater troch and the IT band
A patient comes in with hip pain and point tenderness over their greater trochanter, what is their likely diagnosis
Trochanteric bursitis
What is the treatment for trochanteric bursitis
Rest / Ice
NSAIDs
PT
Intra-bursal corticosteroid
Bursectomy is last resort
What would be a likely cause for a native joint hip dislocation
High energy trauma
-MVC
What is the normal presentation of a hip dislocation
Acute pain
Deformity
inability to bear weight
Shortening and internal rotation of foot
What is the study of choice to diagnose a hip dislocation
Xray
What are the risk factors for a femoral neck fracture
Old age
Osteoporosis
Hx of falls
Smokers
Prior trauma
What are the complications associated with hip fractures
High readmission rate
High mortality rate
High revision / conversion rate
Risk of functional impairment
Risk for osteonecrosis
Risk for non-union
How much blood can be stored in the thigh
About 1 liter
Why can patients become hemodynamically unstable with a femur fx
Due to the amount of blood in the thigh and great vessels
How are most femur fractures treated
Surgically with an intramedullary nail
What is the usual cause of IT band syndrome
Overuse -> causes friction between IT band and lateral condyle
What type of athletes typically get IT band syndrome
Runners
Cyclists
(repetitive knee flexion/extension)
What anatomically can cause IT band syndrome
Knees with varus alignment (bow legs)
A patient comes in who is training for a marathon and complain of lateral knee pain that gets worse with activity, what is their likely diagnosis
IT band syndrome
You diagnose a patient with IT band syndrome, how do you treat them
Rest/ice
NSAIDs
PT
When is surgery done for IT band syndrome
refractory cases
What is osgood schlatters disease
Apophysitis of the tibial tubercle
What type of patients are most susceptible to having osgood schlatters disease
Males and athletes (jumpers, runners)
A patient come is complaining of anterior knee pain, enlargement of tibial tubercle with point tenderness over the tibial tubercle with pain on extension with resistance… What is their probably diagnosis
Osgood Schlatters
What is the #1 indication for knee arthroscopy
Meniscal tears
What type of meniscal tear is most common
Medial
What is the presentation of a meniscal tear
Pain along the respective joint line, clicking and locking, +/- joint effusion
Where is the effusion seen with meniscal tears
Intraarticular
What tests can you do to check for meniscal tears
Apley’s
McMurray’s
What is the imaging modality of choice for meniscal tears
MRI
How do you treat a degenerative meniscal tear
rest
ice
NSAIDs
PT
When is surgery done with meniscal tears
Younger patients
traumatic injury
partial meniscectomy vs repair (location of tear important)
What makes up 50% of all knee injuries
ACL tears
Which gender is more likely to suffer from an ACL tear
Females
Which gender is more likely to suffer from an ACL tear
Females
What is the MOI for an ACL tear
Sudden stopping and pivoting
Direct lateral blow to knee
A patient comes in with complaints of acute knee pain, difficulty bearing weight, complaining of knee instability and claims they heard a “pop” while playing volleyball. What is their most likely diagnosis?
ACL tear
What are the special tests that can help determine an ACL tear
Lachmans
Anterior drawer
*if positive= laxity
What is the treatment for most ACL tears?
Reconstruction
Which ligament in the knee is stronger than the ACL
PCL
What is a PCL tear often associated with
Other knee injuries
What is the rarest of all knee ligament injuries
PCL
What is the MOI for a PCL tear
Knee hitting dashboard in MVC
Fall directly on bent knee
Hyperextension
A patient presents with posterior knee pain with a feeling of instability. They have a positive posterior drawer test and a positive sag sign. What is their likely diagnosis
PCL tear
What does a positive posterior drawer test indicate
Laxity-> tibia moves away from examiner
What is a positive sag sign indicative of
Tibia sinks towards patient/table
How would you treat an ACL tear that does not have significant deformity
Restricted weight bearing +/- immobilization
non-operative
How would you treat a PCL tear that is associated with other injuries
PCL repair/reconstruction
What does the MCL do in the knee
Stabilizes valgus stress
If a patient comes in with an ACL and meniscus injury, what other injury are you going to look for
MCL
What is the MOI for an MCL injury
Blow to lateral knee with planted foot
-Excessive valgus force
A patient comes in with complaints of medial knee pain, feeling unstable, having trouble bearing weight, and recalls a popping sound when tackled in football the day prior. What is their likely diagnosis
MCL injury
What might you see on an exam for an MCL injury
Ecchymosis
Effusion
Medial tenderness
+valgus stress test
What is the diagnostic test of choice to diagnose an MCL injury
MRI
How would you treat a partial tear or stable complete tear of an MCL
Rest, Ice, NSAIDS, PT, bracing
How would you treat a multilligament knee injury or a severe complete tear of the MCL
Surgical repair or reconstruction
What does the LCL do in the knee
Stabilizes varus movement
What is the MOI for an LCL injury
Direct blow to the medial knee
What is the imaging test of choice for LCL injury diagnosis
MRI
What will you find on exam for a positive LCL injury
Lateral knee pain
Instability with stairs
Joint effusion / ecchymosis
Tenderness on lateral joint line
Laxity with varus stress test
What mechanism are the quad and patellar tendon apart of
Extensor mechanism
What age group is at high risk for a quad tendon rupture
> 40
What is the MOI for a quad/patellar tendon rupture
Forceful quad contraction or fall on flexed knee
What is the diagnostic test of choice for a quad or tendon rupture
MRI
What may be seen in an xray when there is a patellar tendon rupture
Patella alta
What is the treatment for a quad or patellar tendon rupture
urgent surgical repair
What is patellar tendonitis known as
jumpers knee
A patient comes in with complaint of insidious onset knee pain, pain while at high jump practice and had tenderness to palpation just inferior to the patella. What is their likely diagnosis and what test will you order to confirm your suspicion?
Patellar tendonitis
MRI
What is the MOI for a knee injury
high energy traum-> knee hitting dashboard in MVC
What is important to do before getting any imaging in knee dislocations
Reduction
What is important to assess post reduction
Neuromuscular status of the leg
If there is vascular injury that occurs with a knee dislocation, what imaging should be ordered
CT angio
Once the knee is reduced, what are you looking for on Xray
Avulsion fx
other associated fx
Joint space irregularities
Which gender is at higher risk of a patellar dislocation
Women
Why are women more susceptible to patellar dislocations
Q-angle
higher baseline laxity
Which direction does the patella most often dislocate
Laterally
What is the MOI for a patellar dislocation
Blow to the lateral knee
Twisting w/ foot planted in external rotation
What is the first line imaging for a patellar fx
Xray
What is the MOI for distal femur fx
Axial load with rotational force
What is the treatment for a distal femur fx
Splint until ORIF
When is ORIF used in a patellar fx
Severely comminuted
Extensor mechanism defect
Open fx
Displaced fx
What is the MOI for a tibial plateau fx
Axial load with varus or valgus stress
If a patient has a tibial plateau fx, what are they at high risk for
Neuromuscular injury
compartment syndrome
What are the most common long bone fractures
Tibia/fibula
If a patient has a tibial shaft fracture, what are you also concerned about
Compartment syndrome
What is the likely MOI for a transverse, comminuted, or displaced tibial/fibular fx
MVC, GSW
What is the MOI for an oblique or transverse fx of the tibia/fibula
Bending
What type of tibial/fibular fx are seen in ballet dancers/military
Stress fx
What is compartment syndrome
Bleeding/swelling in a given compartment -> compression of nerves, vasculature and the fascia does not stress in response to swelling
Where are the most common locations for compartment syndrome
Lower leg
thigh
forearm
hand
foot
buttocks
shoulder
paraspinals
What is the traditional diagnosis for compartment syndrome
The 6P’s
*If most are present, damage has already occurred
What are the 6Ps
Pain
Pallor
Pulselessness
Paresthesia
paralysis
pressure (<30)
What is pes planus
flat foot
What is hallux valgus
Bunions
*Progressive deformity of the 1st MTP joint
Which gender is more likely to have bunions and why
women because of high heels with narrow toes
What is the cause of hallux varus
Overcorrection of hallux valgus
What is Mortons neuroma
Compressive neuropathy inter digitally
Where is Mortons neuroma most common and in which gender
females
3rd interwed space
MOI for Mortons neuroma
Friction from 3rd/4th MT head
traction from inter metatarsal ligament
A patient complains of feeling like there’s a pebble in their shoe whenever they are walking, specifically around the 3rd interweb space. What is their likely diagnosis
Mortons neuroma
What is the definitive treatment for Mortons neuroma
Surgical removal
What is plantar fasciitis
Inflammation of the plantar fascia
When is the pain from plantar fasciitis worse
In the AM
Walking barefoot
Walking up stares
Where does achilles tendonitis generally occur
At the insertion site
What is the MOI for achilles tendonitis
Repetitive ankle motion (common in runners)
What kind of deformity will be seen on xray with achilles tendonitis
Haglund deformity
What is often associated with achilles tendonitis
Retrocalcaneal bursitis
What do you want to avoid with treating retrocalcaneal bursitis
Intra-bursal corticosteroids because of the risk of tendon rupture
What will you see on a physical exam in someone with an achilles tendon rupture
positive thompson test
What is one of the most common ankle injuries
Ankle sprain
What is the MOI for an ankle sprain
Ankle inversion
What is seen with a grade 1 ankle sprain
minimal functional loss
No limp
Minimal / no swelling
Mild point tenderness
What is seen with a grade 2 ankle sprain
Moderate functional loss
limp
localized swelling
moderate point tenderness
What is a grade 3 ankle sprain
Severe function loss
inability to bear weight
diffuse swelling
diffuse ankle tenderness
What are the special tests you can do to test for an ankle sprain
Anterior drawer test: tests integrity of talofibular ligament
Talar tilt: tests integrity of calcaneofibular joint
What is a syndesmotic injury
High ankle sprain
What is the MOI for a high ankle sprain
Eversion of the ankle
What might you see on an xray with a high ankle sprain
Widening of the syndesmosis
Who are ankle fractures most commonly seen in
elderly women
What are the three most common ankle fracture patterns
Isolated malleolar (66%)
bimalleolar
trimalleolar
What is a pilot fx
An ankle fx that involves both the distal tibia and fibula
What is the most commonly fractured tarsal bone
Calcaneous
A patient comes in with tenderness to palpation on the calcaneous, widening or shortening of the heel, and ecchymosis about the heel that extends into the arch, what is their likely diagnosis
Calcaneal fx
What type of splint would you place on a simple calcanea fx
Bulky jones
What is a jones fx
FX of the proximal 5th MT (high rate of non-union)
*Different from psuedojones which is just the tip
What is the most common forefoot injury
Phalangeal fx
-5th phalanx in particular
What is the MOI for phalangeal fx
Dropping something on foot or stubbing toe
