Lower Extremity Disorders Flashcards
Sciatic Nerve:
- branches from which nerve root?
- sensation where?
Femoral Nerve:
- branches from which nerve root?
- sensation where?
Lateral Femoral Cutaneous:
-branches from which nerve?
Sciatic:
- L4-S3
- sensation posterior thigh and foot
Femoral Nerve:
- L2-4
- sensation anterior thigh
Lateral Femoral Cutaneous:
-L3-4
Avascular Necrosis:
- what is this?
- causes
- prognosis
- tx
What: interruption of vascular supply of the femoral head. Commonly bilateral.
CauseS:
- fx
- dislocation
- SCFE (slipped capital femoral epiphysis)
- Steroids
- ETOH
- Perthes
- Coagulopathy
- Sickle Cell
Prognosis: 70-80% collapse by three years.
Tx:
- early: anticoagulation, bisphosphonates, decompression, tx cause
- late: surgery, decompresssion vs total arthrodesis (fusion)
What is the MC type of hip pain
What are common types of imaging techniques of the hip?
MC type of hip pain is musculotendinous
Imaging of hip:
- Xray: weight bearing AP and frog leg
- Bone scan
- CT
- MRI
- MRI arthrogram
General DDX of hip pain?
General tx of overuse/sports related hip pain?
What are some other areas to consider when pt presents with hip pain?
Bone, tendon, muscle, bursae, arthritis.
Tx:
- activity modification, PT, NSAIDS
- if bursae consider injection/surgery
- if tear in muscle consider intraarticular injection or referral to ortho.
Consider:
- low back pain
- knee pain
- pelvic pathology
- intrabdominal pathology
32YO female runner, previous dancer, gradual increase in distance and abdominal work outs, pain and snapping in the groin and anterior hip with hip flexion and crunches….
what does this pt have?
dx
Tx?
Iliopsoas bursitis/tendinosis
Dx:
- H&P
- consider Xray or MRI to r/o other dx
Tx:
- rest, stretch, NSAIDS
- PT
- Injection?
- Surgical referral if not responding to conventional therapy.
28YO male skier, hip pain with deep click that persists 2 mo after a fall. Catching sensation, worse with deep flexion and raising from seated position. Decreased ROM.
what does this pt have?
dx
Tx?
Acetabular Labrum Tear
Dx:
- H&P
- Xray (negative)
- MRI Arthrogram
Tx:
- PT to maximize ROM and strength
- Corticosteroid injection?
- surgical referral?
52YO women with left lateral hip pain after a vacation at the beach, gradual onset, no trauma or previous hx, painful laying on left side.
what does this pt have?
dx
Tx?
Trochanteric bursitis (lateral makes you think bursitis)
Dx:
- H&P
- -point tender over lateral thigh
- pain with Ober test (lateral decubitis, extension of the hip, decreased adduction)
Tx:
- Ice, NSAIDS
- PT***, stretch IT band, strengthening hips
- evaluate biomechanics, leg length and gain
- corticosteroid injection
Retired navey CPO with progressive right hip and groin pain, decreased ROM, bowling game suffering. No trauma and no other joint complaints.
what does this pt have?
dx
Tx?
Osteoarthritis HIp
Dx:
- H&P
- Weight bearing Xray
Tx:
- PT
- APAP (acetaminophen), NSAIDS
- Hip injection
- surgical referral if disabling
13YO female gymnast with increasing groin pain over the past 2 months. Pain to jump, run, stretch, and land. Increased pain with increased activity, no acute trauma.
what does this pt have?
dx
Tx?
Pubic Ramus Stress Fx
Dx:
- H&P
- point tenderness of left superior pubic ramus
- non-tender adductors
- normal hip exam
- Xray (neg)
- Bone scan or MRI
Tx:
-Rest
Stress fx:
- where do these occur?
- causes
- sx
- dx tests
- tx
Occur anywhere!
Cause:
- overuse
- estrogen deficiency
- hormonal abnormalities
- nutritional deficiency
- metabolic disorders
Sx:
- gradual onset of pain with activity
- increased intensity/duration of activity
- pt may report change in footwear or change in surface (such as going from running outdoors to running on treadmill)
Dx Tests:
- Xray (initially negative often)
- Bone scan and MRI
Tx:
- pain free ambulation/activity
- if fx is on inferior side: NON-painful acitivty
- if fx is on superior side: ortho referral, high risk for complete fx of femoral neck.
25YO male soccer player with chronic right groin pain for past sever weeks. Increased training in past month, worse pain with right footed kicking and resisted adduction.
what does this pt have?
dx
Tx?
Adductor Tendinopathy
Dx:
-H&P
Tx:
- rest
- ice
- isometric and eccentric strengthening
- PT
22YO college hockey player with left groin pain, progressive sx over past months, worse with skating and hip motion, no specific trauma.
what does this pt have?
clinical presentation
cause
Tx?
Athletic Pubalgia/Sports Hernia
Clinical presentation:
-pain in hernia region without palpable hernia, possible dilated superficial ring.
Cause:
-injury to conjoined tendon, internal oblique, external oblique, trasversalis fascia, inguinal ligament
Tx: surgical referral.
41YO female with left buttock pain, retired professional soccer player, insidious onset, pain to sit and increased pain after running.
what does this pt have?
Hx
PE
Not sure, could be muscular, bursitis, stress fx, etc.
Hx:
- previous back aches
- no specific trauma
- radiation of pain to hamstrings
- no numbness
PE:
- normal gait
- TTP left upper/outer buttocks
- painful resisted external rotation
- painful passive internal rotation.
- normal sensory and strength.
TTP = Tenderness to palpation.
Piriformis Strain vs Syndrome
- which one has sciatica?
- tx
Piriformis strain = no sciatica
Piriformis Syndrome: + sciatica
Tx:
- NSAIDS
- stretch/strengthen
- PT; core strength program.
**piriformis can pinch the sciatic nerve.
Femur Fractures- –Head/Neck
- causes
- Tx
- -Shaft
- cause
- tx
- what is one major concern you must think of.
Causes:
-fall (arrhythmia, osteoporosis, pathologic, seizure, stroke)
Tx:
-pins, ORIF, THA, hemi.
*think DVT or if young AVN.
Shaft fx:
cause: high force injury, bleeders.
Tx:
- traction
- surgical referral
Concern: compartment syndrome
Compartment Syndrome:
- causes
- tx
Causes:
- 75% are fx
- crush, envenomation, immobilization, constrictive dressing, infection, burns, tourniquets
- chronic exertional compartment syndrome = fascial envelopes that the muscles traverse though, they don’t allow for the muscle to engorge, can pinch off the vessels/nerves.
Tx:
-release pressure.
Hip Dislocation:
- cause
- tx
Cause: high energy trauma (MVA)
- anterior dislocation: dashboard w/ thigh abducted, external rotation
- posterior dislocation: internal rotation
Tx:
- reduction asap!
- -worry about AVN and sciatic injury
WHat are the MC causes of knee pain in each of the following age groups:
- teen (less than 20YO)
- Adult (20-48yrs)
- Older pts (greater than 48YO)
Teen:
- Patellofoemoral syndrome (95%)
- Tendinitis
- Osgood-Schlatters
- Osteochondritis Dissecans (OCD)
Adult:
- PFS (patellofemoral syndrome)
- Meniscus tear
- Ligament tear
- Bursitis
- Tendinitis (IT band friction)
Older Patients:
- meniscus tear
- arthritis
- bursitis
Which type of injuyr is associated with each of the following:
- noncontact injury with “pop”
- contact injury with “pop”
- acute swelling
- lateral blow to the knee
- medial blow to the knee
- knee “gave out” or buckled”
- fall onto a flexed knee
- noncontact injury with “pop”: ACL tear
- contact injury with “pop”: MCL or LCL tear, meniscus tear, fracture
- acute swelling: ACL tear, PCL tear, fx, knee dislocation, patellar dislocation
- lateral blow to the knee: MCL tear
- medial blow to the knee: LCL tear
- knee “gave out” or buckled”: ACL tear, patellar dislocation
- fall onto a flexed knee: PCL tear
12YO female presents with nonspecific anterior knee pain. Worse with activites like running, squatting, jumping. May have some swelling, No injury, occasional popping.
what does this pt have?
Dx
Tx
Patellafemoral syndrom/chondromalacia
Dx: look for muscle imbalance, flexibility issues, feet, and alignment
Tx: NICER (NSAIDS, ICE, COMPRESSION, ELEVATION, REST)
- stabilizing brace
- PT to correct deficits
Test of the patella?
Patellofemoral Grind:
-pressure on superior patella as pt fires quads, pain is positive exam.
patellar apprehension test:
-apply medial forces to patella forcing it laterally, apprehension is positive exam indicating previous subluxation or dislocation.
18YO female basketball player on breakaway layup goes down under the basket with no one around, ends up on the floor holding her knee and screaming in pain. Felt a pop, unable to continue, experienced instability and increased stiffness.
what does this pt have?
Tx
ACL tear, could also be patellar instability
Tx:
- surgical vs non-op
- -consider age, activity, concomitant injury
Special tests and Tx for Collateral ligament injuries of the knee
Test:
-Bohler test: valgus(MCL), varus (LCL)
Tx:
- NICEr
- brace
- pain free activity
- time: 2-8wkks based on grade.
Special test of ACL
Special test for PCL
Tx for PCL tear
ACL:
- Lachman
- Anterior drawer
PCL:
- Sag sign (thumb slides medial to patella into tibial condyle) Positive sign is lacking condyle
- posterior drawer
PCL Tear:
- PT = quad strengthening
- bracing
- surgery
54YO old male construction worker steps off ladder onto uneven ground and has his knee twist andd experiences immediate medial pain. develops some swelling, is now having trouble with squatting, kneeling, and climbing ladders.
what does this pt have?
Meniscus injury
SPecial test for meniscus injury
Is medial or lateral meniscus injury MC?
Tx of meniscus injury
Full flexion
Joint line tenderness
McMurray = medial meniscus is external rotation of tibia.
lateral meniscus is internal rotation of tibia.
–positive is a click.
Tx of meniscus injury:
-arthroscopy with meniscectomy vs repain
14YO male soccer player present to clinic with insidious onseet of anterior knee pain. localizes the pain to the patellar tendon. No swelling, no injury, progressive in nature.
what does this pt have?
cause
Tx
Patellar Tondonitis
aka Jumpers knee
Cause:
- explosive sports involving quick movements (basketball players, hikers)
- excessive activity (especially a rapid increase in frequency/intensity of training)
- improper training mechanics
- excessive weight on person with a weight bearing exercise lifestyle
Tx:
-acute: Ice, NSAIDS, PT (flexibility, eccentric exercises), treat mechanics (heel lift/orthotics), immobilize if necessary
- Chronic: not an inflammatory condition
- -d/c painful activities, avoid immobilization–too much rest is bad!
- -PT
Chronic Tendinopathy:
-causes
Causes:
- nutrition
- malalignments: hyperpronation/supination, pes cavus/planus, ankle instability
- Muscle problems: weakness/imbalance, inflexability
- Training errors; poor technique, excessive force
- Meds: FQ, doxy, steroids
- systemic dz: psoriasis, SLE, hyperthyroid, DM
WHen do you needle a knee?
Atraumatic swollen knee, we need to r/o what main conditions by tapping the knee?
What are we looking at in the joint fluid?
Where do you tap a knee joint?
Needle a knee as a diagnostic tool or as a therapeutic tool.
R/O infection(hematogenous/post-op, inflammation(RA, psoriasis), reactive(meniscus,DJD)
Joint fluid:
- cell count & diff
- crystals
- culture
- gram stain
Tap the joint on the anterolateral aspect of the knee.
Atraumatic Swollen Knee: what is the cell count, ESR and culture results in each of the following:
- REactive
- Inflamm
- Infection
Reactive:
- cell count: 0-20K
- culture: negative
- ESR: less than 30
Inflamm:
- Cells:20-50K
- Culture: negative
- ESR: less than 50
Infection:
- cell: greater than 50K
- Culture: positive
- ESR: greater than 100
Differentiate between septic bursitis and septic arthritis.
Septic Bursitis:
- red, angry looking
- area of fluctuance
- knee moves well
- DO NOT aspirate joint through cellulitis
Septic joint:
- not red
- swollen
- very tender
- motion causes severe pain
Fibular Shaft Fx:
-tx
Tx:
- splint, cast, walking boot for 3-4wks
- gradual return to activities
- may require referral if comminuted, significantly displaced, associated tibial fx, neurovascular injury
Tibial Plateau Fx:
- MC site
- Tx
MC site is lateral 60%
Tx:
- refer
- splint
- NICER
- non-weightbearing
WHat imaging is required for knee pain caused by arthritis, fx, or referral?
AP (standing) both knees, both laterals, and merchant/sunrise view
for arthritis: standing 30 degree AP
When do you follow up fx?
F/U fx at 1 week for repeat XR.
