Lower Extremity Disorders part 1 Flashcards
how to perform PE of the hip and thigh
- Anterior and posterior views - Noting deformities, muscular atrophy, swelling, discoloration, etc.
-
Palpate
- Iliac crests, posterior iliac spine, and the greater trochanter
- The anterior region for masses, adenopathy, or tenderness in the region of the anterior superior iliac spine - Note the patient’s gait
-
ROM
- Flexion
- extension
- abduction/adduction
- internal and external rotation
patient lying supine with lumbar spine flat on the table (knees slightly flexed)
what position is this?
zero starting position for flexion
Maximum flexion is the point at which ?
Normal degree of flexion?
the pelvis begins to rotate
Normal is 0 - 110° to 130°
how to examine extension of hip/thigh?
normal degrees?
- Perform standing, with leg hanging off side of table, or prone
- Normal 20°-30°
normal degree range for abduction/adduction
Abduction – normal is 35°- 50°
Adduction – normal is 25°- 35°
normal degree range for internal and external rotation in flexion of hip/thigh
Assess with knee and hip flexed
Normal is 25°- 35°
Evaluation for hip flexor contracture or tight psoas
Patient lies supine with legs hanging off end of table. The patient pulls one hip into maximum flexion while you observe the contralateral hip to see if it flexes off the surface of the table.
what test is this
thomas test
what is the trendelenburg test?
- Patient stands on one leg
- With normal hip abductor strength, the pelvis will stay level
- If hip abductor strength is inadequate, the pelvis will dip toward the opposite side; positive Trendelenburg test
- The muscle weakness is on the STANCE side
What is the FABER test for?
- AKA: Figure-of-4 test
- Stress maneuver to detect hip and sacroiliac pathology
- If painful, the hip or sacroiliac region may be affected
- Pain on ipsilateral side anteriorly = hip problem
- Pain in contralateral SI joint = SI dysfunction
how to perform and interpret Leg Length measurement
- Measured from the anterior iliac crest to the medial malleolus of the tibia of the same leg
- >3 cm difference can lead to significant back and hip problems
how to perform and interpret Log Roll Test
- Internally and externally rotate the relaxed lower extremity in a supine position
- Pain in the anterior hip or groin, particularly in internal rotation is indicative of OA or femoral head osteonecrosis
how to perform and interpret piriformis test
- Patient lies supine or on unaffected side, with hip and knee flexed to approximately 90 degrees
- Stabilize the pelvis with one hand and apply flexion, adduction, and internal rotation pressure at the knee
- Pain in the buttock or down the leg = (+) → piriformis is impinging on the sciatic nerve
how to perform and interpret Scouring test
- Flex the hip and knee at 90°, apply posterolateral force through the hip as the femur is rotated in the acetabulum
- Passively adduct and internally rotate the hip followed by abduction and external rotation
- Pain or grating sound = labral pathology, a loose body, or internal derangement
imaging options for the hip and femur
- Hip Series - AP; Lateral
- Specialty Hip Views - Frog Leg view; Obturator/Oblique view
- AP Pelvis - For comparison if needed
4 structures seen in obturator/oblique hip view
- iliopectineal line
- posterior acetabular wall
- acetabular roof
- obturator foramen
how does a hip dislocation occur most often?
Often occurs as part of a high grade, multi-trauma presentation
2 types of hip dislocation?
which is MC?
- Posterior: MC (90%)
- Anterior
posterior force applied to a flexed knee
Ex. MVA “knee-to-dashboard” injury, pedestrian vs vehicle, high energy impact athletes (football, rugby, gymnastics, skiing)
which type of hip dislocation
posterior
hyperextension force against an abducted leg or an anterior force on a posterior femoral head
which type of hip dislocation
anterior
Complicated injuries - most likely with which type of hip dislocation
posterior
4 complicated injuries from hip dislocation
- Acetabular or femoral head/neck fx
- Sciatic nerve damage - Sciatic and peroneal nerve MC
- Ligamentous injuries or fractures of the knee
- Avascular necrosis of femoral head
- Severe pain
- Inability to move affected leg
- Numbness, tingling, muscle weakness with nerve injury
- drop foot and sensory changes along lateral lower leg and dorsal foot
dx?
drop foot + sensory changes are indicative of what?
hip dislocation
peroneal damage
Leg is shortened, adducted and internally rotated
what type of hip dislocation?
posterior
Abduction with external rotation and flexion of the hip
which type of hip dislocation
anterior
The direction of anterior dislocation is determined by the ? at the time of injury
degree of hip flexion
diagnostics for hip dislocation
- X-ray hip series STAT
- CT hip W/O contrast - after reduction to assess for fracture and trapped intra-articular loose bodies
management for posterior hip dislocation
- Urgent closed reduction (w/in 6 hours!)
- Allis maneuver - MC performed technique
management for anterior hip dislocation
May require open reduction
all hip reductions require ?
- procedural sedation and post reduction films
-
Post reduction immobilization with a triangular “abduction pillow” or knee immobilizer
- Flexion and adduction positioning could cause recurrent posterior dislocation - ortho consult / referral
other reductions maneuvers for hip dislocation
- stimson gravity
- bigelow maneuver
- captain morgan
Emergent orthopedic consultation for hip dislocation is indicated if: (3)
- Anterior dislocation (usually requires open reduction)
- Posterior reduction is unsuccessful
- NV compromise
disposition for hip dislocations
- Most require hospital admission - Non-weight bearing, +/- traction and parenteral pain control
- Uncomplicated dislocations: Crutch assisted weight bearing followed by physical therapy until ambulation without pain
- followed and monitored for AVN x 2-3 years
2 MOI of hip fractures?
which is MC?
- Fall - MC
- Posterior force to flexed knee
classifications for hip fx
-
Intracapsular
- Femoral head
- Femoral neck -
Extracapsular
- Intertrochanteric
- Subtrochanteric
RF for hip fx
- Elderly age
- Caucasian
- Female
- Sedentary lifestyle
- Smoking
- Chronic alcohol use
- Psychotropic medication
- Dementia
- Osteoporosis
- Pain in groin, hip, buttock radiating to the knee
- Inability to ambulate
- Externally rotated, abducted, shortened leg
- Pain with minimal ROM or SLR
dx?
w/u?
- hip fx
- Standard hip XR series with pelvis; Additional images of back, femur and/or knee if needed; MRI/CT if negative XR
management for hip fx
- Urgent ortho consult (< 24 hrs)
-
Surgical intervention (w/in 48h)
- ORIF - young patients
- Arthroplasty in older patients - Allows for immediate ambulation - Additional immobilization is not necessary - maintain position of comfort
CI to surgery for hip fx (3)
- Medically unstable
- Patients who were previously non-ambulatory
- Dementia patients with minimal pain during transfers
complications with hip fx
- Infection
- DVT/PE
- Pneumonia
- Decubitus ulcer
- UTI
- Nonunion and avascular necrosis
- Implant failure is more common with extracapsular fractures
All hip fx patients should be evaluated post-operatively for ____
osteoporosis
2 MOI of greater trochanteric bursitis
- Repetitive trauma (running, walking)
- Blunt trauma
-
Lateral hip pain
- Radiates down lateral aspect of thigh and past the knee or up into the buttock
- Worse when rising from seated or recumbent position, night time when lying on affected side
- Improves after the first few steps but worsens again after prolonged walking (>30 min) - Point tenderness over greater trochanter
- Pain with active abduction and adduction + internal rotation
dx?
w/u?
tx?
- Greater Trochanteric Bursitis
- Hip series - r/oother ddx (hx of trauma etc.)
- NSAIDs, activity modification, ice; Short term use of cane if needed; home stretching, heat 15 min before and ice 20 min after; bursal injection w/ local anesthetic & corticosteroid
how to use cane for greater trochanteric bursitis
Hold the cane in the hand that’s opposite the side that needs support
cause of AVN
Bone infarction due to lack of adequate blood supply
Traumatic or systemic in nature (ex. microvascular thrombosis)
MC sites for AVN
- proximal and distal femoral heads resulting in hip and knee pain respectively
- Other sites: ankle, shoulder, elbow, wrist (scaphoid fx), jaw (rare)
RF for AVN
- MC 20-50 years of age
- Trauma, alcohol/tobacco use, radiation therapy, long-term steroid use, bisphosphonates, hx of tissue/organ transplant, chronic medical conditions
- Pain is severe initially
- Later becomes dull aching and throbbing
- Painful/loss of ROM
- Painful weight bearing - Femur: antalgic gait
dx?
w/u + findings?
AVN
- Hip+pelvis XR
- Early: normal
- Later: patchy areas of sclerosis and lucency
- Late: “crescent sign” a well-defined sclerotic area beneath articular surface = subchondral fracture - MRI, CT and/or bone scan are needed if clinical suspicion and XR negative
initial management for AVN
- Avoid weight bearing
- Adequate pain management - NSAIDs with break-through opiates
- Refer to ortho
what management option is required in most d/t younge age of AVN occurance
surgical intervention
Based upon staging ranging from core decompression with bone grafting to arthroplasty
non-surgical management for AVN
doesn’t halt dz progression
- Bedrest, partial weight bearing with crutches, progressing as tolerated, and pain management
- PT - can restore ROM and improve gait
complications with AVN
Collapse of femoral head = secondary degenerative arthritis
- Chronic pain
- Loss of ROM
- Decreased ambulatory capacity
- Abnormal gait
2 MOI of femoral shaft fx
- High energy trauma - MVA
- Less common pathologic fractures - Osteopenia, tumor
Pain, localized tenderness, swelling, shortening and deformity of the leg
Assess NV status
Look for evidence of open fx
Assess for complications: extensive blood loss, compartment syndrome, multi-ssytem injuries
dx?
w/u?
mgmt?
Femoral Shaft Fractures
- Femur (AP + lateral); Hip, knee and pelvis (R/o associated injuries)
- pain management; fluids; temp. stabilization (Long leg, posterior and stirrup splint w/ traction device); ortho consult
anatomic structures of the knee part of medial surface
- Adductor tubercle
- Medial epicondyle
- Medial condyle
anatomical structures of the anterior knee
- Patella
- Patellar tendon
- Tibial tuberosity
anatomical structures of the lateral knee
- Lateral epicondyle
- Lateral condyle
- Head of fibula
joints of the knee
- Tibiofemoral joint
- Patellofemoral joint – (Trochlear groove)
additional structures of the knee
- Medial meniscus
- Lateral meniscus
- MCL, LCL
- ACL, PCL
- Bursae
PE inspection for valgus/varus deformity graphic
abnml gaits to watch for when inspecting in PE knee
- Antalgic gait (limp)
- wide-stance gait
- waddling
- Trendelenburg gait
Patient should be able to flex both knees symmetrically into a squat
Pain with squatting may indicate ?
meniscal injury
how to assess joint line of the knee?
focal an generalized tenderness indicates ?
- Perform while knee is flexed at 90 and relaxed
- Palpate medial & lateral joint lines
- Focal tenderness = torn meniscus
- Generalized tenderness = arthritis
how to perform an interpret Bulge sign?
- Direct fluid superiorly over medial recess then inferiorly from the suprapatellar pouch inferiorly
- + test: fluid wave over medial knee
how to perform and interpret Ballottement
- Push down on the patella and rapidly release
- + test: rapid rebound, indicating increased fluid pressure
2 primary knee motions?
normal findings?
flexion and extension
- Zero starting point is full extension of the knee (0°)
- Normal flexion is 0° to 135-145°
- Active flexion may be assessed by having pt squat or while lying supine or prone - Knee hyperextension (past 0) MC seen in children or patients with joint instability
how to assess infrapatellar bursa?
Inferior and lateral to the patella
how to assess strength of quadriceps
While sitting, have the patient extend the knee against resistance
how to assess hamstring strength
- pt prone, place the knee in approximately 90° flexion and ask the patient to flex the knee further against resistance
- Flex knee against resistance in a sitting position
how to perform and interpret patellar tracking
- Have pt flex and extend the knee and observe movement of patella BL
- Normal: Patella lies slightly lateral in extension and moves centrally with flexion
- Abnormal: A more exaggerated arc of movement either laterally or medially = patellar instability
how to perform and interpret patellar apprehnesion sign
- Pt lies supine with knee relaxed in approx 30° flexion - May put roller under knee to support it; Displace patella laterally by applying medial pressure
- (+) test: contracts quadriceps or become apprehensive due to pain
indications for patellar apprehension sign
- Patellofemoral syndrome
- Patellar subluxation
- Patellar dislocation
Assesses for cartilage degeneration under the patella = Patellofemoral syndrome (Chondromalacia)
what test?
Patellar Grind Test (Clarke Sign)
how to perform and interpret Patellar Grind Test (Clarke Sign)
- Pt supine and the knee is fully extended; one hand superior to patella and gently push patella inferiorly as you instruct pt to contract the quadricep
- Pain, grinding, or clicking is a (+) test
valgus stress test
assesses for?
technique?
- medial collateral ligament (MCL)
- Abduct and flex knee to 30°; Examiner applies a valgus (lateral) pressure
varus stress test
assesses for?
technique?
- lateral collateral ligament (LCL)
- Performed same way as valgus but a varus (medial) pressure is applied to the knee
technique for McMurray Test?
Interpretation?
indications?
- Pt supine with examiner at side of pt; One hand on heel while other is palpating joint line
- test: pain, popping, or clicking is noted
- Assess for meniscal injuries
how to assess medial meniscus (MEG) using McMurray test?
External rotation, valgus stress and slowing extending the leg
how to assess lateral meniscus (LIR) using McMurray test?
Internal rotation, varus stress and slowing extending knee
MOST SENSITIVE TEST FOR ACL!
Lachman Test
technique and interpretation of Lachman Test
- pt is supine with knee flexed 25-30 degrees, relaxed quadriceps muscle
- Place one hand on distal femur and one on proximal tibia
- Pull anteriorly on tibia
+ test: anterior translation a partial or complete tear of the ACL
This exam is negative in approx. 50% of acute ACL tears
Anterior drawer test
Technique and interpretation of Anterior Draw test?
what does it assess for?
- supine with hamstrings and quads relaxed and knee flexed to approx 90 degrees; Sit on pt’s foot to help stabilize; Grasp proximal tibia with both hands and slide tibia anteriorly
- test: significant laxity compared to opposite side
- Assess ACL stability
- Used to assess dysfunction of the ACL - Positive in severe grade II or grade III tears
- Generally performed under anesthesia
which knee test?
Pivot Shift Test
technique and interpretation of Pivot Shift Test
- Place the knee in full extension and slowly flexing knee while examiner applies a valgus stress and internal rotation
- test: subluxation will occur at 20-40° flexion
Posterior drawer test
assesses for what?
technique?
interpretation?
- Assess the posterior cruciate ligament (PCL)
- Perform the same way as the anterior drawer, but slide the tibia posteriorly
- +test: tibia falls back posterior to the femur
Noble’s test
assesses for what?
technique?
interpretation?
- Assesses the iliotibial band (IT Band)
- Pt supine with knee flexed to 90°; Apply pressure to lateral femoral condyle or 1-2 cm proximal to it as pt’s knee is passively extended
- Test: Patient complains of tenderness over the lateral femoral condyle at 30 degrees of flexion
Ober’s test assesses for?
tensor fascia lata and iliotibial band tightness
technique for Ober’s test
interpretation?
- Patient lies on unaffected side with the unaffected knee and hip flexed
- Places the affected knee in 90 degrees of flexion
- Abduct and extend the ipsilateral hip while stabilizing the pelvis then slowly lower the thigh as far as possible
+ test: Inability of extremity to drop below horizontal to level of table = tightness in the fascia and IT band
a dense, fibrous band of tissue that originates from the ASIS region, extends down the lateral portion of the thigh, and inserts on the lateral tibia
Iliotibial Band (ITB)
In knee extension the ITB sits ___ to the lateral femoral condyle
anterior
In knee flexion (>30°) the ITB moves ____ to the lateral femoral condyle
posterior
cause of ITB syndrome
- Repetitive flexion-extension leads to inflammation
- Runners/cyclers
-
Pain in anterolateral aspect of knee
- Worse repetitive activity (running/cycling)
- Most intense at heel-strike
- Resolves at rest - (+) audible popping with walking/running
- Tenderness over lateral femoral epicondyle
- (+) Ober’s + Noble’s test
- Lateral knee pain when patient hops with a flexed knee
dx?
w/u?
management?
ITB syndrome
- clinical dx; knee series to r/o
- conservative (NSAIDS, ice, rest, stretch&strengthening, modify exercises), refer to ortho if no improvement (LCI, surgical ITB lengthening (last resort))
2 MOI of distal femur fx
- Low-energy trauma in osteoporotic geriatric patient
- High-energy trauma in young patient
classifications of distal femur fx
- Supracondylar
- Intercondylar - Right, left, or both condyles may be affected
- Sudden onset of pain after trauma with the inability to bear weight
- Swelling, deformity, rotation
- Limited ROM
- Assess NV status
- Look for evidence of open fx
- Assess for associated injuries
dx?
Distal Femur Fractures
diagnostics for Distal Femur Fractures
- Knee series - AP, lateral
- Oblique view or CT - Often needed to determine amount of dispacent prior to surgical repair
- MRI - Further assess non-displaced fractures and soft tissue injuries
- CTA - If vascular compromise
mangement for Non-displaced or minimally displaced distal femur fx
Long leg splint (posterior and stirrup) → cast
Non-weight bearing
Ortho referral
management for Displaced or intra-articular distal femur fx
- Temporary long leg splint for protection and stabilization
- Urgent ortho consult for ORIF (w/in 24 hours)
management for Open fracture, vascular compromise, or compartment syndrome in distal femur fx
Emergent ortho consult
MOI of patellar fractures
- Direct force - Fall, direct blow
- Indirect force - Powerful contraction of the quadriceps
May be associated with a patella dislocation
- Localized tenderness and swelling
- Patellar defect may be palpable if significant displacement
- Assess for intact extensor mechanism - Active extension of the knee or SLR
- Joint effusion may be present
dx?
w/u?
patellar fx
Knee series (AP, Lat, sunrise); CT to r/o occult fx; MRI to assess internal derangement
management for Non-displaced with intact extensor mechanism patellar fx
Knee immobilizer or posterior long-leg splint with knee in extension
Refer to ortho for outpatient f/u
management for Displaced, complex, open fractures or loss of extensor function patellar fx
Consult ortho for surgical intervention
Emergent if open otherwise it’s an urgent consult
3 MOI of patellar dislocation
- Direct trauma
- Landing on hyperextended knee
- Quadricep contraction during knee flexion
- Patella is lateral (MC)
- Pain, tenderness, and deformity
- Hemarthrosis may be present
- (+) Patellar apprehension test in spontaneously reduced dislocations
Dx?
w/u?
management?
patella dislocation (dislocates laterally MC)
- Knee XR - AP, Lateral, Sunrise
- Reduction, Post-reduction films, Knee/patella immobilizer in full extension x 4-6 wks, Ortho f/u within 1 wk
An overuse syndrome involving the patellofemoral region
aka: Runner’s Knee
dx?
Patellofemoral Syndrome
Anterior knee pain with excessive use resulting from:
- Abnormal patellar tracking
- Ligamentous hyperlaxity causing the patella to subluxation
- Hip/knee muscle weakness, flexibility imbalance
- Abnormal hip-knee biomechanics - Increased Q-angle (valgus knee deformity)
- Diffuse aching pain over the anterior knee, “behind the knee cap,” with activities that increase the load of the patellofemoral joint
- Pain worse after prolonged sitting
- Gait shows patellar “squinting” - Patella point toward each other during ambulation
- Tenderness along articular surface of patella when leg is extended and relaxed
- Apprehension sign = associated instability
- Patellar grind test = associated chondromalacia
- One leg squat → assess for quad and hip strength
- + Trendelenburg sign
dx?
Patellofemoral Syndrome
patellofemoral syndrome
w/u?
- Clinical dx
-
X-ray: knee AP, lateral, and axial view
- May show lateral deviation or tilting of the patella
- R/o other causes of pain - MRI - Indicated only if surgery is considered
management for patellofemoral syndrome
- Rest, Ice, NSAIDs
- Patellar stabilizer brace or taping techniques (McConnell taping)
- Weight loss if applicable
- PT is hallmark of treatment: Quad strengthening & stretching, Hamstring stretching
- Refer to ortho if no improvement with conservative therapy
- Patellar alignment
- Patellar resurfacing
- Patellofemoral arthroplasty
Inflammatory or infectious swelling of the prepatellar bursa
dx?
Prepatellar Bursitis
causes of Prepatellar Bursitis
-
Inflammatory
- Direct blow
- Chronic compression: Wrestling, Praying, Carpet installation - Bacterial - Direct penetration
- Early on pain only with activity or direct pressure which progresses to constant pain
-
Localized swelling over knee
- Unable to differentiate patella from surrounding joint
- Differentiate this from joint effusion - Septic: Erythema, warmth, increased pain
- Inflammatory: Less painful, minimal warmth
dx?
Prepatellar Bursitis
w/u for Prepatellar Bursitis
- Knee x-ray: R/o bony conditions; Will show diffuse anterior soft tissue swelling
- Bursal aspiration: If septic bursitis is suspected; Synovial fluid analysis, gram stain, cx, cell count, crystal analysis
management for inflammatory prepatellar bursitis
- NSAIDs, Ice, Activity modification
- Corticosteroid injection - Only if septic bursitis is ruled out in those who fail conservative tx
management for infectious prepatellar bursitis
- mild - PO Keflex (MSSA); Bactrim/Clinda (MRSA if hx is suggestive)
- severe - IV ceftriaxone / cefazolin - MSSA; IV vancomycin - MRSA
