Lower extremity Disorders Flashcards
1
Q
strain
A
stretching or partial tear in muscle or muscle-tendon unit
UE, LE, back
2
Q
Sprain
A
Stretching or tearing of ligament (bone-bone) or joint capsule
ankle, knee, wrist
3
Q
Contusion
A
injury to soft tissue from direct trauma and result of body part against sm hard
4
Q
SUbluxation
A
partial dislocation
(partial ligaments may be torn)
5
Q
Dislocation
A
acute or chronic ligamentous laxity/tearing fx
6
Q
Avulsion fracture
A
small portion of bone that was broken
sometimes may disrupt portion of ligament
7
Q
Pelvis (female)
A
larger and more broad
8
Q
Pelvis (male)
A
taller, higher iliac crest, more narrow ant compact
distance b/w ischium smaller
9
Q
Hamstring strains
A
1-3 muscles involved (semitendinosus, semimembranosus, biceps femoris)
excessive stretching or forceful contraction - can cause avulsion fx
10
Q
Hamstring strains found in
A
sprinters, dancers, runner, “ball sports”, adolescents
11
Q
Hamstring strains causes
A
inadequ. muscle strength or endurance
lack of flexibility
Insuff. warm up
12
Q
Hamstring strains s/s
A
sudden (pain)
swelling
bruising in back of thigh
13
Q
Hamstring strains PE
A
pain in HS or actions that cause contraction of HS
x-ray only if exam warrants (sore area or attachment to bony sturctures)
14
Q
Hamstring strains Tx
A
NSAIDs
crutches? severe
Compression
early ROM and eventual strength/flexibility exercises
15
Q
Adductor Strains “pulled groin”
Anatomy
A
Hip Joint adductor complex =
- adductor longus (MC injured)
- adductor magnus
- adductor brevis
- gracilis
- obturator brevis
- pectineus
16
Q
Adductor strains “pulled groin”
Causes
A
forceful hip extension
external rotation of abducted leg
17
Q
Adductor strains “pulled groin”
found in
A
soccer
hockey players
18
Q
Adductor strains “pulled groin”
S/S
A
immediate pain in groin area
19
Q
Adductor strains “pulled groin” PE
A
tender at injury site and subQ border of pubic ramus
pain and/or decreased strength w/ resisted leg adduction
20
Q
Adductor strains “pulled groin” - Dx
A
xray of hip
MRI for professionals
21
Q
Adductor strains “pulled groin” - TX
A
Rest, Ice, protected weight bearing/ NSAIDs
crutches - severe
early ROM - strength/flex exercises
22
Q
Avascular necrosis
A
w/o blood supply - bone dies and collapses
23
Q
Avascular necrosis - etiology
A
long term steriods
alcohol use
trauma, lupus, Gout, Sickle cell dz
24
Q
Avascular necrosis - S/S
A
PAIN- groin, thigh, buttock (increased with motion/weightbearing)
? eventual LIMITED ROM (internal rotation and abduction)
+/- LIMP
25
Avascular necrosis - DX
X-ray (positions and buzzword)
Hip A/P, frog-leg lateral
CRESCENT SIGN (curved subchondral radiolucent)
MRI?
26
Avascular necrosis - Tx
supportive care (rest, PT, analgesics, assistive walking devices)
surgery (joint preserve or total replacement)
27
Greater Trochanteric Pain Syndrome
(Trochanteric Bursitis)
gluteus medius or minimis tendinopathy
overuse
28
Greater Trochanteric Pain Syndrome
(Trochanteric Bursitis)
risk factors
females
obesity
knee pain
low back pain
29
Greater Trochanteric Pain Syndrome
(Trochanteric Bursitis)
S/S
lateral hip pain near greater trochanter
exacerated by = ambulation, prolonged standing, rising from chair, climbing stairs, direct pressure)
sleep disturbance
30
Greater Trochanteric Pain Syndrome
(Trochanteric Bursitis)
PE
TTP of greater trochanter
FABER TEST (Flexion, ABduction, External Rotation)
31
Greater Trochanteric Pain Syndrome
(Trochanteric Bursitis)
Dx
clinical
x-ray for other path
MRI if refractory s/s
32
Greater Trochanteric Pain Syndrome
(Trochanteric Bursitis)
Treatment
exercise/activity modification
pain control - steriod injection or NSAIDs
PT
surgery if refractory
33
Eval of Knee
location
injury/trauma?
what makes better/worse?
F/C/warmth/redness?
hx of tick bite = lyme?
rash w/ plaques = psoriasis arthritis?
34
Eval of Knee - common sayings may suggest
meniscus
"locking"
pain at joint line
recurrent knee effusion after activity
35
Eval of Knee - common sayings may suggest
ligamentous injury
"popping"
36
varus means
pushing away from center of body
37
valgus means
pushing in toward center of body
38
Imaging for the knee
X-rays
A/P, lateral, Sunrise (115 degrees flex) (sometimes)
standing if possible
39
Imaging for the knee
MRI
if suspected meniscus, ligamentus injury, occult fx
40
Ottawa Knee rules
must have 1 or more, 99% sensitive, 49% specific
age 55 +
isolated tenderness of patella
tenderness at head of fibula
inability to flex knee 90 degress
inability to bear weight immed after injury or while being eval for more than 4 steps
41
Pittsburgh Knee rules
99% sensitive, significantly more specific in adults
blunt trauma or fall + one of following:
age <12 or >50
inability to walk 4 weight bearing steps immed after or in ED, regardless of age
42
Other test for the knee
aspiration of effusion -> pain relief and valuable dx
Always consider if you think a joint is septic!!
43
aspiration findings of knee and what is may mean
frank blood =
rupture of ACL
44
aspiration findings of knee and what is may mean
turbid =
infxn
45
aspiration findings of knee and what is may mean
straw colored
meniscus tear or arthritis
46
genu Varus
bow- legged
pushing out on femur
47
Genu Valgus
"knock-knee"
pushing in on femur
48
Anterior Cruciate Ligament Injury
CLASSIC sound heard with this
AUDIBLE "POP" WHEN KNEE BUCKLES
49
Anterior Cruciate Ligament Injury
commonly occurs in sports activities w/ ..
jumping and pivoting
contact- plated foot, lateral force (valgus force)
noncontact - pivoting, jumping, deceleration
50
Anterior Cruciate Ligament Injury
patients complain of..
instability or knee "giving way"
51
Anterior Cruciate Ligament Injury
s/s
instability - esp w/ lateral mvmt or down stairs
pain, swelling
75% hemarthrosis
25% associated meniscal tear
52
ACL injuries PE
ANTERIOR DRAWER
LACHMAN (greater sensitivity and specifity)
PIVOT SHIFT TEST
53
Anterior Cruciate Ligament Injury - DX
X-rays rule out fx
- SEGOND FX = small avulsion injury seen over lateral compartment
MRI = diagnostic
54
Anterior Cruciate Ligament Injury
Tx
refer - ortho
RICE
Brace - knee immobilizer
Surgery! - esp in young, atheltes
PT
55
Posterior Cruciate Ligament injury
uncommon = b/c strongest ligament in the knee
56
Posterior Cruciate Ligament injury
MC mechanism
direct blow to ant tibia w/ knee flexion -> drives tibia posteriorly
often w/ MVA = knee hits dash
57
Posterior Cruciate Ligament injury
associated injuries..
70-90% assoc MCL or ACL injuries
1/3 neurovascular injuries
- torn popliteal artery = EMERGENCY SURGERY
58
Posterior Cruciate Ligament injury
s/s
difficulty walking
laxity of joint
pain, swelling
59
Posterior Cruciate Ligament injury
PE
posterior drawer
sag sign
60
Posterior Cruciate Ligament injury
Dx
x-rays r/o fx
MRI = diagnostic
61
Posterior Cruciate Ligament injury
Tx
RICE
Bracing - locked knee in full extension
PT
Ortho refer/surg
62
Collateral ligaments - Medial
HX
valgus stress on partially flexed knee
63
Collateral ligaments - Medial and Lateral
Exam
pain along ligament ; min. swelling
limited ROM from pain
64
Collateral ligaments - Medial
special tests
valgus stress
65
Collateral ligaments - Medial and Lateral
imaging
X-rays = A/P and lateral r/o fx
MRI = only is sus for cruciate ligament injury
66
Collateral ligaments - Medial and Lateral
Treatment
protected weight-bearing
Brace
PT
rarely surg - only if assoc injuries
67
Collateral ligaments - Lateral
Hx
varus stress
68
Meniscal injuries causes
traumatic vs degenerative (rep. squatting or osteoarthritis)
young - acute
old - chronic
69
Collateral ligaments - Lateral
special test
varus stress
70
Meniscal injuries - which is higher incidence of injury
medial > lateral
71
Meniscal injuries
S/S
audible clicking
locking sensation
pain, diff. walking
72
Meniscal injuries - pts may or may not..
report specific injury
(rotational injury to flexed knee w/ audible "pop"
73
Meniscal injuries
PE
MCMURRAY TEST
APLEY GRID TEST
74
Meniscal injuries
presentation
antalgic gut
joint line tenderness
swelling?, pain or diff. squatting
75
Meniscal injuries
DX
x-rays r/o fx
MRI = GOLD STANDARD
76
Meniscal injuries
TX
rest
pain control
PT
intra-articular corticosteriods
surgery?
77
Apley Distraction test
traction applied w/ rotation, pain occurs if damage to ligaments
no pain if it is meniscal
78
Apley compression/grinding test
hard downward pressure w/ rotation
pain = meniscal injury
79
Chondromalacia patella
aka PATELLOFEMORAL SYNDROME
80
Chondromalacia patella
what is it
ant. knee pain from softening and degeneration of articular cartilage of patella
81
Chondromalacia patella
"runner's knee"
worse w/ deep flexion, stair climbing, hill ascent/descent
82
Chondromalacia patella
causes and MC in
overuse
weakness of vastus medialis (quadricep)
young females
83
Chondromalacia patella
s/s
anterior knee pain
swelling?
84
Chondromalacia patella
PE
INCREASED Q ANGLE
patellar crepitus (audible, crunchy knee)
lateral deviation of patella
patellar hypermotility
apprehension sign
Patellar femoral grinding test
85
Chondromalacia patella
DX
x-ray : AP, Lateral, SUNRISE VIEW (r/o narrowing or osteophytes)
86
Chondromalacia patella
Rx
RICE
NSAIDs
bracing
PT
patellar taping/bracing
strengthening quad
87
Patellar grind test
pt supine; involved knee extended
webbed space of hand superior to patella and apply pressure
pt contracts gently quads
+ = pain in patellofemoral joint
88
Prepatellar bursitis
HOUSEMAID'S KNEE
NUN'S KNEE
CARPET'LAYER'S KNEE
89
Prepatellar bursitis
what is it
inflamm., swelling of prepatellar bursa (rep. kneeling on hard surfaces)
OR
acute trauma (can develop into infxn bursitis = cover for S. aureus and strep)
90
Prepatellar bursitis
s/s
tenderness to palpation
swelling
91
Prepatellar bursitis
PE
restricted ROM
palpable swollen bursa (margins palpable)
92
Prepatellar bursitis
DX
clinical
if trauma causes - xray
consider aspiration for infxn
93
Prepatellar bursitis
TX
RICE
NSAIDs
avoid causative mechanism
recurrent = surgery to remove bursa
94
Pes Anserinus Bursitis
medial side of knee at proximal tibia - medial knee pain
95
Pes Anserinus Bursitis
onset
insiduous - usually not w/ injury
96
Pes Anserinus Bursitis
common in who?
swimmers/ kickers
97
Pes Anserinus Bursitis
PE
point tenderness
98
Pes Anserinus Bursitis
DX
no x-ray findings
99
Pes Anserinus Bursitis
tx
RICE
NSAIDs
steriod injections? - hypopigmentation and atrophy in superficial location
100
Baker's Cyst
(Popliteal Cyst)
accumulation of joint fluid in posterior aspect of knee
pushes on weakest point of posterior capsule
discrete bulging in popliteal fossa
usually from arthiritis or meniscus tear
101
Baker's Cyst
(Popliteal Cyst)
s/s
cyst rupture = may have severe swelling and tightness in calf (order ultrasound if so to r/o DVT!)
pain, swelling
102
Baker's Cyst
(Popliteal Cyst)
Dx
MRI r/o mass, esp kids
103
Baker's Cyst
(Popliteal Cyst)
Tx
RICE
NSAIDs
brace (compression)
Aspiration - large or painful
surgery (rare)
104
Patellar tendinitis
inflammation, swelling of patellar tendon
105
Patellar tendinitis
Mechanism
basketball
volleyball players
(Jumper's knee)
106
Patellar tendinitis
s/s
pain at base of patella w/ exercise
107
Patellar tendinitis
PE
tenderness along tendon
increased pain w/ squatting or kneeling
108
Patellar tendinitis
DX
MRI if concerned about needing surg/debridement
109
Patellar tendinitis
Tx
RICE
NSAIDs
brace - compression
avoid kneeling - knee pads
steroid injection - could increase tendon rupture risk
110
Ankle Sprains
peak age
and in what sports
15-19
basketball, football, soccer
111
Ankle Sprains
3 diff types
lateral (MC)
medial
syndesmotic (high ankle)
112
Ankle Sprains
grading sytem - Grade 1
intra-ligamentous tears w/ pain
113
Ankle Sprains
grading sytem - Grade 2
incomplete tears w/ pain and mild-mod instability
114
Ankle Sprains
grading sytem - Grade 3
severe and disabling, complete ligament rupture
cannot tolerate weight bearing, gross instability, pain, assoc. w/ "pop"
115
Ottawa Ankle Rules
x- rays indicated for ..
Bony tenderness - post edge or tip of lateral or medial malleolus
OR
inability to bear weight at presentation (4 steps)
OR
bony tenderness - base of 5th metatarsal
116
Ottawa Ankle Rules
where to palpate?
what is considered weight bearing?
if pt transfers weight twice to each foot - considered bearing weight if even limping
palpate distal 6 cm posterior edge of fibula
117
Ankle Sprain - Lateral
Anterior Talofibular ligament (ATFL)
- WEAKEST and MC
- restricts internal rot of talus
Calcaneofibular ligament (CFL)
- resists adduction of talus
Posterior talofibular ligament (PTFL)
- STRONGEST
- resists posterior and rotatory instability
118
Ankle Sprain - Lateral
s/s
pain
swelling (lateral ankle)
bruising
diff bearing weight
limping
119
Ankle Sprain - Lateral
PE
ALWAYS PALPATE PROXIMAL FIBULA
ANTERIOR DRAWER
SUBTALAR TILT
120
Ankle Sprain - Lateral
DX
x-rays based on Ottawa ankle rules, r/o fx
(AP, lateral, mortise views)
MRI - if need degree of tear
121
Ankle Sprain - Lateral
Tx
RICE
brace - ankle stabilizer
crutches
122
Ankle sprain - medial
injury to deltoid ligament
superficial vs deep
almost never isolated - commonly w/ lateral malleolus fx
123
Ankle sprain - medial
mechanism
foot turned out, externally rotated and everted
124
Ankle sprain - medial
s/s
severe pain not improved w/ conservative measures
worse w/ weight bearing
125
Ankle sprain - medial
PE
any medial tenderness = palpate proximal fibula r/o Maisonneuve fx
External rotation stress test
126
Ankle sprain - medial
Dx
X-rays = Ottawa ankle rules
MRI?
127
Ankle sprain - medial
Tx
RICE
cast/walking boot
Rehab exercises
Referral?
128
Syndesmotic injuries - HIgh ankle sprains
highly complex group of ligaments that stabilze the mortise and keep the fibula articulating w/ distal tibia
129
Syndesmotic injuries - HIgh ankle sprains
Syndesmosis
Anterioinferior and posterioinferior tibiofibular ligament
interosseous ligament
inferior transverse ligament
130
Syndesmotic injuries - HIgh ankle sprains
S/S, dx, tx
same as other ankle sprains
131
Fibula Fx - Nondisplaced
MC fx treated by ortho surgeons
MC ankle fracture
132
Fibula Fx - Nondisplaced
Mechanism
rotational - usually
above, below, or at the level of the ankle OR avulsion
133
Fibula Fx - Nondisplaced
S/S
pain
swelling
limited ROM
134
Fibula Fx - Nondisplaced
DX
X-rays
135
Fibula Fx - Nondisplaced
Tx
RICE
brace, boot, crutches
136
Achilles tendinopathy
swelling/pain over achilles tendon
137
Achilles tendinopathy
Causes: younger
overuse
not stretching before activity
sudden trauma
138
Achilles tendinopathy
Causes: Older
scondary to arthritis - bone spur may irritate tendon
139
Achilles tendinopathy
S/S
"feels like I got hit by a rock in the back of my foot/heel"
pain in heel along tendon when walking/running; w/ standing on tiptoes
more painful/ stiff in morning
140
Achilles tendinopathy
PE
THOMPSON TEST -r/o ACHILLES TEST
point tenderness; limited dorsiflexion; palpable defect (bone spur)
141
Achilles tendinopathy
DX
x-rays = calcifications, spurs, avulsion
MRI
142
Achilles tendinopathy
Tx
long, healing process
RICE
boot/brace
PT
143
Achilles tendon rupture
MC what...
peak incidence.. (age and in who)
MC tendinous route in the LE
Peak incidence: 30-50 y/o
males > females
middle-aged athletes "weekend warriors"
144
Achilles tendon rupture
S/S
swelling, pain, bruising
sudden pain, w/ a pop in back of heel
(may describe feeling like they have been hit)
145
Achilles tendon rupture
PE
THOMPSON TEST - POS
point tenderness
palpable defect
inability to push off or toe walk (inability to plantarflex)
146
Achilles tendon rupture
DX
MRI
147
Achilles tendon rupture
Tx
ortho referral - surgical repair or cast immobilization
148
Ankle Fx
lateral/medial malleolus, posterior tip of fibula or any combo
2 or more fx sites = unstable
149
Ankle Fx
Dx
x-rays
150
Ankle Fx
TX
RICE
Pain control
Depends on displacement or stability of joint
(cast, surgery)
151
Retrocalcaneal Bursitis
inflamm of tissue w/i space in front of achilles
bursa- inflamm, hypertrophied, adherent to achilles -> degen. changes w/i achilles
152
Retrocalcaneal Bursitis
S/S
dull, aching pain in retrocal area
aggravated during startup activity
153
Retrocalcaneal Bursitis
PE
Haglund deformity
tenderness w/ applying pressure medial/laterally, squeezing anterior to achilles insertion
pain w/ dorsiflexion
154
Retrocalcaneal Bursitis
Dx
x-rays
MRI
155
Retrocalcaneal Bursitis
Tx
rest
orthoses
heel lifts
PT
surgery
156
Interdigital neuritis - Morton Neuroma
inflamm changes of interdigital nerve (intermetatarsal lig compresses nerve)
157
Interdigital neuritis - Morton Neuroma
MC where in foot?
MC in who?
2nd or 3rd webspace
middle-aged women - narrow or high heel shoes
158
Interdigital neuritis - Morton Neuroma
S/S
burning pain b/w toes, esp w/ shoes on
159
Interdigital neuritis - Morton Neuroma
PE
reproducible tenderness - 2nd/3rd interspace
160
Interdigital neuritis - Morton Neuroma
Dx
clinical
161
Interdigital neuritis - Morton Neuroma
Tx
NSAIDs
Proper footwear, orthotics
RICE
Injections
Surgery?
162
Plantar Fasciitis
fibrous tissue from plantar calcaneal tuberosity to flexor tendon in forefoot
163
Plantar Fasciitis
MC in what population?
older pts (40-60)
younger - runners, dancers
164
Plantar Fasciitis
Risk factors
obesity,
pes planus
Pes cavus
Prolonged standing
Walking/running on hard surfaces
Improper/ill-fitting shoes
165
Plantar Fasciitis
S/S
PAIN FIRST THING IN THE MORNING OR FOLLOWING PERIODS OF INACTIVITY
severe pain- bottom of foot/heel ; improves w/ weight bearing activity thru day; increased when walking
166
Plantar Fasciitis
Dx
Clinical
X-rays (heel spur? - in flexor digitorum brevis NOT plantar fascia- remova DOES NOT help)
MRI
167
Plantar Fasciitis
Tx
PATIENCE 80% RESOLVE W/I 12 MOS
RICE, massage, stretching/PT; night time splints; Heel cups/pads; Surgery - w/ no improvment 6-12 mos)
168
Pes Planus means
flat foot
169
Pes cavus means
high arch
170
Posterior tibial tendon injuries
from posterior, upper 2/3 fibula and lateral post. tibia to plantar navicular, cuneiform, cuboid, metatarsal bases
171
Posterior tibial tendon injuries
Function
adducts forefoot, inverts the heel
chronic - tendinitis
acute - rupture
172
Posterior tibial tendon injuries
PE
"TOO MANY TOES" sign
swelling, bruising, tenderness
rupture = palpable defect?
inability to toe walk or heel raise
weakness w/ inversion against resistance
173
Posterior tibial tendon injuries
Dx
X-rays
MRI
174
Posterior tibial tendon injuries
Treatment
RICE
Analgesics
NSAIDs
PT
Brace/boot
175
Stress Fx - Foot
stress rxn usually overuse (athletes)
rep. loading on bone -> microfx unable to heal from imbalance b/w bone resorption and formation
Pain (progressive onset) - worse w/ activity and relieved w/ rest
POINT TENDERNESS
176
Stress Fx - Foot
Dx
X-rays
CT
MRI
177
Stress Fx - Foot
TX
prevention
Activity restriction 1-6wks
Taping, bracing, boots, orthotics
178
5th Metatarsal fx
vertical or medial/lateral force when foot inverted w/ heel raised
179
Jones Fx
Proximal 5th metatarsal
Minimal blood supply and prone to poor healing after fx
