lower extremity injuries Flashcards
who do hip fx usually occur in?
- elderly female with osteoporosis
- generally fx happens first then they fall
clinical presentation for femoral head fx
- hip/groin pain s/p fall
- non-ambulatory or need assistance
- internal or external rotation of leg on affected side
- TTP over fx area
- pain with AROM and PROM
- pain with IR very sensitive for fx*
imaging to order for hip fx
- AP pelvis, frog lateral
- if suspect fx but it is not visible on x-ray then order MRI
treatment for femoral head fx
- almost always surgical
- cannulated screws
- hemiarthroplasty
garden classification
- for femoral neck fx
- predicts dev of AVN
- stages I- IV
garden stage I
- nondisplaced incomplete fx
- possible greenstick fx
- valgus impaction fx
- stable fx
- can be treated with internal fixation
garden stage II
- nondisplaced complete fx
- stable fx
- can be treated with internal fixation
garden stage III
- complete fx, incompletely displaced
- femoral head tilts into varus position
- unstable
- requires arthroplasty
garden stage IV
- complete fx completely displaced
- unstable
- requires arthroplasty
intertrochanteric fx
- hip fx that happens between greater and lesser troch
- extracapsular
- fx through cancellous bone with good blood supply so heals well
treatment for intertrochanteric fx
- IM nailing
- DHS compression screw
subtrochanteric hip fx
- fx below greater and lesser troch
- requires IM nailing
which hip fx get a hemiarthroplasty
- displaced femoral neck
- supcapital hip fx
which hip fx get cannulated screws
- nondisplaced femoral neck fx
which hip fx get nailing/ compression screws
- intertrochanteric fx
- subtrochanteric fx
prognosis of hip fx
- 25% of pts do not survive past 1 year
- of those who do survive, often return one level below baseline ambulatory/ ADL status
greater trochanteric bursitis
- usually women, more common in 40s and 50s
- triggered by minor direct trauma over greater troch
- pain in lateral hip
clinical presentation of greater troch bursitis
- aching, intense lateral hip pain
- worsened with direct pressure
- pain radiates down lateral thigh
- painful ambulation
- TTP over greater troch
- pain with resisted hip abduction and passive hip rotation
treatment for greater troch bursitis
- ice
- NSAIDs
- PT
- steroid injection
- surgery rare
femoral acetabular impingement
- femoral neck abnorm shaped during childhood growth
- active people may experience pain sooner
- cam bone spur vs. pincer bone spur
cam bone spur
- abnormal femoral head/ neck junction
- increased radius at waist
- impingement occurs during flexion, adduction, IR
pincer bone spur
- excessive acetabular coverage
- linear contact between labrum and femoral head/ neck junction
clinical presentation of femoral acetabular impingement
- pain in groin, may radiate to lateral hip
- dull ache which waxes/ wanes with activity and rest
- improves withPT but sx will return
- sharp stabbing pain with turning, twisting, squatting
diagnosis of femoral acetabular impingement
- impingement test- hip flexion to 90, adduct to 20 degrees the IR, will prod pain
- x-ray for bone morphology
- MRI for labrum and articular cartilage assessment
treatment for femoral acetabular impingement
- surgery- arthroscopic labral repair/ debridement, femoral neck/head resection
- activity modification
- NSAIDs
- PT
femur fx
- usually d/t high velocity injuries
- common site for metastatic lesions
- potential for severe blood loss and loss of life/limb
clinical presentation of femur fx
- NWB usually
- distracting injury
- mod- severe pain if pt is conscious
- affected leg shortened and rotated
diagnosis of femur fx
- assess NV status
- assess for other injuries
- xrays- AP, lateral of femur
treatment for femur fx
- address life threatening injuries first
- IM nailing best sx option
- analgesics and anticoags
- PT
- follow healing through serial x-rays
tibial plateau fx
- high energy deceleration injury
- femoral condyles piston down onto tibial plateau
- often occurs in conjunction with other LE injuries
clinical manifestations of tibial plateau fx
- mod-severe pain
- NWB
- very TTP
- resist AROM and PROM
- distracting injury- assess for other injuries
diagnosis of tibial plateau fx
- trauma series of knee
- CT if unstable and need ORIF
- if no fx seen on plain film but pt has sx order MRI
- assess if open vs closed and NV status
treatment of tibial plateau fx
- stable- hinged knee brace and crutches
- unstable- ORIF with side plate and screws
segond fx
- avulsion fx involving lateral aspect of tibial plateau
- 75% also have ACL inj
- usually seen in falls or sports
clinical presentation of segond fx
- knee pain/ swelling after trauma
- hold knee at 20 degree flexion
- NWB but stable
- mod- large effusion
- resist full ext and may not be able to flex past 90 d/t hemarthrosis
diagnosis of segond fx
- standard knee trauma series
- may show curvilinear fx
treatment of segond fx
- if small fx can use cancellous screw
- if extensive ligamentous injury requires surgery
- good prognosis
patella fx
- often d/t direct injury to anterior patella
- can be d/t sudden forceful contraction of quad
- can occur after ACL reconstruction or TKR
clinical presentation of patella fx
- NWB or protected WB
- mod-severe pain
- large area of swelling or large joint effusion
- absent extensor mechanism
- may have defect in distal quad tendon
- assess NV status
diagnosis of patella fx
- knee trauma series
- CT if severely comminuted
treatment of patella fx
- ORIF with tension band wiring
- NWB in hinged knee brace locked into exxt
- can unlock brace to 20 degrees for swing leg while walking
- active ROM in brace under PT supervision X 4 weeks
quad tendon rupture
- forced flexion against resistance/ ext
- i.e. person jumping down onto deck of boat as it is coming up at him
- usually heavy set males in 40s or 50s
- rupture at musculotendinous junction
clinical presentation of quad tendon rupture
- hears pop
- if complete rupture will be NWB with large effusion
- absent extensor mechanism
- lg area of swelling
likely defect in distal quad tendon - assess NV status
treatment for quad tendon rupture
- sx
- pt held to - 20 degrees extension and NWB in locked hinge knee brace
- may transition to PWB after 6 weeks
- once ROM restored then strengthen
- may take up to 1 year
patella tendon rupture
- palpable defect in patellar ligament
- patella alta
- absent extensor mechanism
- risk factors- RA, long term DM, long term steroids
- rupture rare in young athletes unless steroid use
treatment for patella tendon rupture
- standard knee trauma xrays
- conservative tx for partial tear- immobilization in hinged knee brace for 4-6 weeks
- surgery if complete tear
maisonneuve fx
- combo of spiral fx of proximal fibula with an ankle injury
- widened ankle joint d/t rupture of distal tibiofibular syndesmosis
- deltoid ligament disruption
- +/- fx of medial malleolus
ACL tear
- valgus stress to knee or distal thigh with ipsilateral foot planted
- young women
ACL tear clinical presentation
- hears “pop”
- mild- mod pain
- massive effusion
- instability
diagnosis of ACL tear
- lachman test- most sensitive
- anterior drawer sign
- xray to r/o segond fx
- MRI
treatment of ACL tear
- reconstruction to return to sports/ occupation
- joint instability puts pt at higher risk post traumatic OA
- occult osteochondral lesions in majority of pts
MCL tear
- common sports injury
- d/t valgus force to lateral knee
clinical presentation of MCL tear
- acute onset pain in medial aspect of knee
- instability when changing directions or stairs
- +/- swelling
- antalgic gait
- TTP over MCL
- ROM preserved if no effusion
- pain with valgus stress 0-30 degrees
diagnosis of MCL tear
- standard xray series
- no MRI required unless ACL tear suspected
treatment of MCL tear
- RICE
- gentle NWB ROM 3-5 days
- hinged knee brace
- PT
- most treated conservatively with good prognosis
patella femoral syndrome
- aka chondromalacia patella
- common cause of anterior knee pain
- lateral mal-tracking of patella during flex/ ext
- weakness of VMO and tightness of ITB
- pain during knee flexion, descending stairs, prolonged sitting
clinical presentation of patella femoral syndrome
- normal WB and minimal impact on ADLs
- diffuse pain around knee
- pain may be localized to medial joint line
- stiff feeling after prolonged sitting
- achey during activities
- inflammation but no effusion
- VMO atrophied
- ITB tenderness
- patella aprehension
- ROM not usually impacted
diagnosis of patella femoral syndrome
- xrays- sunrise (merchant) view most important
- lateral subulxation of patella
- usually xrays are normal
treatment of patella femoral syndrome
- activity modification
- strengthen VMO
- NSAIDs
- Patella brace PRN
- good prognosis if compliant with PT
- some require sx- lateral release
meniscus tear
- medial more common than lateral
- acute injury- twisting or rotational mvmt of flexed knee while foot planted
- if older adult d/t degeneration
clinical presentation of meniscus tear
- hear “pop”
- medial/lat sided pain “inside” knee over joint line
- +/- swelling
- pain worse with activities, improves with rest
- locking** or inability to fully ext/flex knee
diagnosis of meniscus tear
- TTP over affected joint line
- pos McMurray test
- unable to squat deeply
- in older pts may not have pos McMurray but will be TTP
- standard xray to r/o fx
- MRI for surgical assessment
treatment of meniscus tear
- meniscus repair for younger pts -> portected WB with gentle ROM X 6 weeks
- meniscetomy in older less active pts -> return to activity quickly
tibia fx
- high energy deceleration injury
- often occurs in conjunction with other LE fx
clinical presentation of tibia fx
- NWB or protected WB
- mod- severe pain
- may have obvious skin deformity
- swelling
diagnosis of tibia fx
- det if open vs closed (often open)
- TTP over fx site
- assess ankle and knee ROM
- xrays- AP and lateral views
treatment of tibia fx
- midshaft tibia fx often unstable
- IM nail fixation
- if multi-trauma may need ex- fx
ankle fx
- from foot being planted and body sustains rotational force
- ext rotation -> spiral fx of fibula +/- medial malleolus fx
- abduction force -> transverse fx of fibula and avulsion of medial malleolus
clinical presentation of ankle fx
- NWB or protected
- swelling
- reduced ROM
- crepitus
- assess prox fibula
diagnosis of ankle fx
- xray 3 views- AP, mortise, lateral
- may need stress views to det if stable vs unstable
treatment for ankle fx
- stable- tall walking boot or cast
- unstable- ORIF
ankle sprain
- “turned the ankle” during fall or landing
- most common mechanism is inversion and plantarflexion causing damage to ATF ligament
- eversion can cause high ankle sprain d/t damge to deltoid ligament
clinical presentation of ankle sprain
- pain/ swelling
- TTP
- antalgic WB
- ecchymosis 24-48 hours later
- exam finidngs similar to fx, need an xray
treatment of ankle sprain
- RICE
- tall boot
- NSAIDs
- early ROM
- PT
- good prognosis if compliant
calcaneus fx
- high energy deceleration injury, esp fall from height
- may complain of LBP secondary to associated lumbar compression fx
clinical presentation of calcaneus fx
- NWB
- severe pain
- +/- NV injury
- assess back*
- check smoking status
- often results in chronic heel pain
diagnosis of calcaneul fx
- well padded posterior splint
- crutches or wheelchairs
- analgesics
- ORIF delayed 7-10 days d/t swelling
5th metatarsal avulsion fx
- d/t inversion of foot and plantarflexion
- pulls at insertion of peroneus brevis
- must include 5th metatarsal base in lateral ankle xray
- usually treated conserv and heal well
jones fx
- transverse fx at base of 5th metatarsal
- d/t significant adduction force to forefoot with ankle in plantar flexion
- prone to non-union and take long to heal
- increased risk fx displacement with WB
treatment for Jones fx
- NWB for 6-8 weeks
- internal fixation and bone grafting may be required
plantar fasciitis clinical presentation
- shape volar sided heel pain
- usually normal gait but may limp
- pain worst in AM
- pain decreases as pt ambulates
diagnosis of plantar fasciitis
- TTP at origin of plantar fascia on calcaneus
- pes planovalgus orientation on exam common
- tight achilles
- xrays
treatment for plantar fasciitis
- night splint
- ice
- NSAIDs
- PT
- steroid injection and sx rare
achilles tendon rupture risk
- fluoroquinolone use
- steroid injections
- usually traumatic injury
achilles tendon rupture cause
- sudden forced plantar flexion
- violent dorsiflexion in plantar flexed foot
clinical presentation of achilles tendon rupture
- hears pop
- weakness and difficulty walking
- pain in heel
- palpable defect
- weak plantarflexion
diagnosis of achilles tendon rupture
- thomson test
- xray to r/o other pathology
- US
- MRI not usually needed
Thompson test
- used to dx achilles tendon rupture
- pt in prone with knee flexed at 90
- squeeze calf at widest girth
- pos if calf doesnt plantar flex when squeezed
treatment of achilles tendon rupture
- almost alway surgical
- non operative based on pt preference or if pt is frail
