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ORTHO > LOWER EXTREMITY DISORDERS > Flashcards

LOWER EXTREMITY DISORDERS Flashcards

1
Q

sciatic nerve = runs from

A

L4 - S3

  • articular & muscular
  • sensation
  • external rotation & posterior thigh, foot
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2
Q

femoral nerve =

A

L2 - L4

anterior thigh compartment

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3
Q

lateral femoral cutaneous nerve =

A

L3 - L4

sensory

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4
Q

blood supply of the hip

A

Femoral Artery
⦁ Profunda femoris
⦁ Circumflex

Artery of the ligamentum teres
⦁ Posterior division of the obturator artery
⦁ Femoral head

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5
Q

AVN = AVASCULAR NECROSIS

A
  • Interruption of vascular supply to the femoral head
  • Causes
    ⦁ fracture
    ⦁ dislocation
    ⦁ SCFE
    ⦁ steroids
    ⦁ ETOH
    ⦁ Perthes
    ⦁ Coagulopathy
    ⦁ Sickle cell
  • AVN = commonly bilateral
  • Prognosis: 70-80% of cases collapse - femoral head dies - by 3 years
  • TREATMENT
    ⦁ early - anticoags, bisphosphonates, decompression, treat the cause
    ⦁ later = surgery - decompression vs total hip vs arthrodesis

xray, then do MRI and bone scan for AVN

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6
Q

HIP BURSAE

A
  • between bone and surrounding soft tissue

o Trochanteric - between greater trochanter & IT band

o Ischial - between ischial tuberosity & gluteus muscles

o Iliopsoas - between lesser trochanter and iliopsoas tendon

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7
Q
  • pain & snapping in groin and anterior hip with hip flexion and crunches

PT is a runner and was a dancer

A

ILIOPSOAS BURSITIS / TENDINOSIS

  • inflammation of the bursa or inflammation of the tendon
  • HX & PE
  • consider XRAY or MRI to rule out other diagnoses
  • TX = relative rest, stretch, consider NSAIDS. PT
    consider injection or surgical referral if not improving with conservative treatment
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8
Q

FAdAxl

A

acetabular labrum tear

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9
Q
  • hip pain with deep click
  • catching sensation; feels stiff
  • worse with deep flexion & rising from seated position
  • decreased ROM
A

ACETABULAR LABRAL TEAR

HX & PE

  • Pain with FAdAxL = hip flexion, adduction, and axial load
  • imaging: (xrays negative) = MRI arthrogram (inject dye into joint

TREATMENT = PT to maximize ROM and strength
- can do steroid injection or surgery if needed

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10
Q

DIAGNOSIS OF ACETABULAR LABRAL TEAR

A

MRI ARTHROGRAM - see dye spill through with tear

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11
Q

-Ober Test

A

tightness of the IT band

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12
Q
  • left lateral hip pain
  • gradual onset
  • no trauma or previous hx
  • painful to lay on left side
A

TROCHANTERIC BURSITIS

HX & PE

  • point tender over lateral thigh
  • pain with Ober test (determines any tightness of the IT band)
  • **Hx Key = de-conditioned; significant increase in activity

Treatment = Ice, NSAIDS, PT (stretch IT band & strengthen hip muscles); steroid injection

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13
Q
  • progressive right hip & groin pain
  • associated decreased ROM
  • no trauma, no other joint complaints
A

OSTEOARTHRITIS OF THE HIP

HX & PE
- xrays - weight bearing

TREATMENT = PT, APAP > NSAIDS, hip injection (US guided) - steroid. Surgical referral if disabling. Can use APAP & NSAIDS together as long as no CI

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14
Q
  • 13 y/o female gymnast with increasing groin pain over last 2 months
  • hurts to jump, run, stretch and land
  • increased pain with increased activity
  • no acute trauma
A

PUBIC RAMUS STRESS FRACTURE

  • *Point tender left superior pubic ramus
  • non-tender adductors, normal hip exam
  • Xray (negative) - so do bone scan or MRI

Treatment = relative rest, non-painful activity, slow increase

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15
Q

STRESS FRACTURES

A
  • stress fractures can occur anywhere
  • commonly occur in feet, ankles, tibia, fibula, patella, femur, and/or others (ribs)
  • can be a sign of an underlying problem in addition to overuse (ie: estrogen deficiency, hormonal abnormalities, nutritional deficiencies, or metabolic disorders)

won’t see on xray - need MRI or bone scan

  • have gradual onset of pain with activity

HISTORY

  • increased intensity / duration of activity
  • change in footwear
  • change in surface

initial xrays often negative; negative studies = bone scan, MRI
key to treatment = pain free ambulation / activity

initial xrays often negative; negative studies = bone scan, MRI

key to treatment = pain free ambulation / activity

  • if fracture is on the inferior side = continue with non-painful activity, gradual return
  • if fracture is on superior side = ortho referral!!! - high risk for complete fracture
  • address causation - diet, activity level, maturity
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16
Q
  • chronic right groin pain after increased training in past month
  • worse with right footed kicking and resisted adduction
  • pain & stiffness gradually loosen up
  • pain with resisted adduction**
A

ADDUCTOR TENDINOPATHY

  • TTP medial groin at tendon insertion

TREATMENT = relative rest, ice strengthening - PT

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17
Q

hockey = think of

A

athletic pubalgia - sport’s hernia

dilated superficial ring of inguinal canal

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18
Q

hockey player with left groin pain; worse with skating & hip motion. no specific trauma

A

ATHLETIC PUBALGIA / SPORTS HERNIA

  • not a true hernia
  • pain in hernia region without palpable hernia
  • injury to conjoined tendon, internal oblique, external oblique, transversalis fascia, inguinal ligament, etc.
  • SURGICAL REFERRAL
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19
Q

PIRIFORMIS STRAIN VS SYNDROME

A

STRAIN = NO SCIATICA

SYNDROME = SCIATICA

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20
Q

PIRIFORMIS STRAIN / SYNDROME

A

Piriformis muscle lies over sciatic nerve
buttock & lower back pain -

  • left buttock pain; retired professional soccer player
  • insidious onset
  • painful to sit, pain increases after running
  • previous back aches, but no specific trauma
  • points to left lower back & buttocks
  • some radiation to hamstrings
  • no numbness, no red flags

PE = normal gait & appearance. TTP left upper/outer buttocks. painful resisted external rotation and painful passive internal rotation. normal sensory and strength

Piriformis strain = no sciatica
Piriformis syndrome = sciatica

TREATMENT = rule out other things. NSAIDS, stretch/strengthen. PT

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21
Q

femur fractures = think _______

if young = think ________

A

think DVT

if young = think AVN

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22
Q

femur fractures

A
  • head / neck
  • Etiology: fall (arrhythmia, osteoporosis, pathologic, seizures, stroke)
  • functional status
  • exam = rule out other injuries
    ⦁ shortened external rotation
    ⦁ internal rotation = pain in hip and groin

Treatment = Pins, ORIF (open reduction, internal fixation)

  • think DVT
  • if young = think AVN

Treatment of femur fractures - head / trochanter
⦁ internal fixation (screws) - in head / trochanter
⦁ hip compression screw - in head / trochanter & femur
⦁ Hemi-arthroplasty - hip replacement without replacing the acetabulum
⦁ Total hip replacement

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23
Q

femur fracture - shaft = worried about

A

compartment syndrome

24
Q

shaft femur fracture

A
  • high forces involved
  • lots of bleeding - vascular injury
  • treatment = SURGICAL REFERRAL
  • worried about compartment syndrome
25
Q

75% of compartment syndrome cases are caused by

A

fractures

26
Q

COMPARTMENT SYNDROME

A
  • 75% caused by FRACTURES***
  • other causes = crush, envenomation, immobilization, constrictive dressing, infection, burns, tourniquets
  • CECS (chronic exertion compartment syndrome)

get compression of soft tissues first, then vessels, nerves
- compression of veins before arteries due to pressure inside them

TREATMENT = release pressure

27
Q

most common hip dislocation

A

posterior

28
Q

HIP DISLOCATION

A
  • high energy trauma - MVA
  • younger patients

o Anterior

  • 10-15%
  • dashboard with thigh abducted
  • leg is externally rotated

o Posterior dislocation = most common
- leg is internally rotated

TREATMENT = reduction ASAP (concerned about AVN, and sciatic injury)
- also keep in mind that there may be a concomitant injury - another fracture / dislocation

29
Q

if leg is externally rotated

A

anterior hip dislocation

30
Q

if leg is internally rotated

A

posterior hip dislocation

31
Q

hip dislocation = worried about

A

AVN & sciatic injury

may also be concomitant injuries - fx/dislocations

32
Q

KNEE INJURY HISTORICAL CLUES

A

⦁ noncontact injury with a “pop” = ACL tear

⦁ contact injury with a “pop” = MCL, LCL tear, meniscus tear, or fracture

⦁ acute swelling = ACL tear, PCL tear, fracture, 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 or dashboard injury = PCL

33
Q

flat feet

A

pes planus

34
Q

genu varus vs genu valgus

A

genu varus = knees apart, feet together (bow legged)

genus valgus = knees together, feet apart (knock knees)

35
Q

popliteal fossa bulges

A
  • popliteal artery aneurysm
  • Baker’s cyst
  • popliteal thrombophlebitis
36
Q

knee exam MUST include

A

hip ROM

37
Q

PATELLOFEMORAL SYNDROME (PFS)

A
  • idiopathic softening / fissuring of patellar articular cartillage
  • MC seen in runners**
  • *have anterior knee pain “behind” or around the patella
  • worse with knee hyperflexion (prolonged sitting), jumping or climbing

DIAGNOSIS = APPREHENSION SIGN - apply pressure to medial & lateral patella - painful!

TREATMENT = NSAIDS, rest, rehab

ex: 12 y/o - nonspecific anterior knee pain; worse with activities such as running/squatting/jumping. May have some swelling. No injury. Occasional popping

⦁ Patellofemoral Grind = put pressure on superior patella as patient fires quads
⦁ Patellar Apprehension test - apply medial forces to patella - forcing it laterally

Diagnosis = look for muscle imbalance, flexibility issues, feet and alignment
TX = NICER = NSAIDS, ice, compression, elevation, rest
- patellar stabilizing brace
- PT

38
Q

TEST FOR PFS

A

APPREHENSION TEST

39
Q

MC knee ligament injury

A

ACL

40
Q

ACL TEAR

A

***MC knee ligament injury; 70% sports related
MOA = non-contact pivoting injury (deceleration, hyperextension, internal rotation)

“pop” & swelling –> hemarthrosis
knee buckling
MC in women
- inability to bear weight

PE = Lachman’s test (have ACL laxity) = most sensitive test

TX = therapy vs surgery (depends on patient)

ex: 18 y/o female BB player - preparing for layup, ends up on floor holding her knee, screaming in pain. felt a “pop” - unable to continue. Instability & increased stiffness

PE = Valgus for MCL, Varus for LCL = Bohler Test

TX = NICER, brace, pain free activity, time (2-8 weeks, take 1 year for full maturation of scar in a complete tear)

41
Q

PCL TEAR

A
  • MC associated with dashboard injuries - anterior force to proximal tibia with knees flexed
  • or direct blow injury or fall on a flexed knee
  • usually associated with other ligamentous injuries

Anterior bruising
Large effusion

PE = Pivot Shift test, Posterior drawer test
TX = PT, bracing, occasionally surgery

**Sag sign = same position as anterior drawer - thumb slides medial to patella into tibial condyle. if lacking condyle = positive sag sign

Posterior drawer = posterior pressure on tibia; positive if posterior translation of tibia

42
Q

tests for meniscal injuries

A

McMurray test

Apley test

43
Q

MENISCAL TEAR

A
  • MOI = degenerative (squatting, twisting, compression, or trauma with femur rotation)
  • Medial = 3x more common than lateral - because of bony attachments

Locking
Popping
Giving way
Effusion after activities

***MCMURRAY’S SIGN - pop or click when tibia is externally and internally rotated

Apley Compression Test = pt prone - knee bent up in air, compress down and rotate

TREATMENT = NSAIDS, partial weight bearing until ortho follow up; arthroscopy

ex: steps off ladder onto uneven ground; knee twisted - immediate medial pain. Swelling. Now has trouble squatting, kneeling, climbing

TESTS = full flexion, joint line tenderness, McMurray, Apley’s compression test, Bounce test, Duck walk

44
Q

CHRONIC PATELLAR TENDINOPATHY

A

NOT an inflammatory condition. not due to inflammation - so NSAIDS only help with pain. Steroid injections can decrease pain short term.

  • may be a red flag to other associated factors: nutrition, malalignments, muscle problems, training errors, medications (fluoroquinolones, doxy, steroids), systemic dz (psoriasis, SLE, hyperthyroid, DM)
  • TREATMENT = rest, d/c painful activities. avoid immobilization if possible, as too much rest is bad (results in poorly aligned collagen & healing)
  • progress through passive & active ROM
45
Q

PATELLAR TENDONITIS / TENDINOSIS / TENDINOPATHY

A
  • Jumper’s Knee
  • Affects participants in “explosive” sports involving quick movements
    ⦁ Basketball players are most commonly affected
    ⦁ Commonly in hikers/ backpackers on hills and unpredictable terrain

Causes
⦁ Excessive activity - Especially a rapid increase in frequency/intensity of training
⦁ Improper mechanics of training
⦁ Excessive weight on person with a weight bearing exercise lifestyle

TREATMENT = ice, NSAIDS, PT, orthotics

46
Q

SEPTIC ARTHRITIS VS SEPTIC BURSITIS

A
  • bursitis = red & angry looking. Area of fluctuance. Knee moves pretty well. DON’T aspirate the joint through the cellulitis
  • septic joint doesn’t look red, just swollen. Very tender, and any motion causes severe pain
47
Q

knee injections

A

THERAPEUTIC INJECTIONS

  • steroid delivery for OA and other non-infectious inflammatory arthritides (gout)
  • delivery of viscosupplementation

GLUCOSAMINE & HYALURONATE INJECTIONS

  • studies show a weak benefit in pain relief with glucosamine +/- chondroitin, but no harm except $
  • studies have not supported the benefit of multiple hyaluronate injections over a single steroid injection, however, they have shown pain relief
48
Q

best approach for steroid injections (knee)

A

SUPERIOR ANTEROLATERAL

49
Q

FIBULAR SHAFT FRACTURE

A
  • treatment is based on patient’s comfort (splint, cast, walking boot). complete healing - 6-8 wks
- referral
⦁	comminuted
⦁	significantly displaced
⦁	associated tibial fracture
⦁	neurovascular injury
  • be sure to evaluate syndesmosis appropriately***
50
Q

MC tibial plateau fracture

A

lateral

51
Q

knee pain imaging

A
  • if arthritis or fracture or you are going to refer =
    ⦁ standing AP of both knees, both laterals, and Merchant / sunrise view
    ⦁ for arthritis = get standing 30 degree AP too
52
Q

HIP FLEXION MUSCLES

A 
⦁	anterior muscles
⦁	iliopsoas
⦁	rectus femoris
⦁	sartorius
⦁	pectineus
53
Q

HIP EXTENSION MUSCLES

A

⦁ posterior muscles
⦁ gluteus maximus
⦁ hamstrings
⦁ adductor magnus

54
Q

FAdAxL test

A

labral injury

flexion
adduction
axial load

55
Q

FAbER

A

SI joint

Flexion
Abduction
External Rotation

56
Q

FAIR

A

Piriformis

Flexion
Adduction
Internal Rotation

57
Q

FAdIR

A

FAI

flexion
Adduction
internal rotation

ORTHO (15 decks)

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