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MSS Weeks 3-5 > Lower Extremity Injury: Clinical Correlations > Flashcards

Lower Extremity Injury: Clinical Correlations Flashcards

1
Q

LE Neuromuscular Anatomy:

  1. Psoas mjr,mnr br.:
  2. 6(5) External rotators br.:
  3. G max:
  4. **G med,G min,TFL: **
A
  1. Psoas mjr,mnr br.:
    • L1,2,3
  2. 6(5) External rotators br.:
    • L5,S1,2
  3. G max:
    • Inferior gluteal n.
  4. G med,G min,TFL:
    • Superior gluteal n.
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2
Q

Name the msucles the following nerves innervate:

  1. Femoral n.
  2. Obturator n.
A
  1. Femoral n. (IPSquad)
    • Iliacus
    • Pectineus
    • Sartorius
    • Quads
  2. Obturator n. (POAAAG)
    • Pectineus
    • Obt ext
    • 3 Add’s
    • Gracilis
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3
Q

Name the descending nerve braches of the leg, starting with the sciatic nerve:

A
  1. Sciatic n. ⇒ Tibial n. & Common fibular n.
  2. Common fibular n. ⇒ Superficial fibular n. & deep fibular n.
  3. Tibial n. ⇒ Med. plantar n. & Lat. plantar n.
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4
Q

What muscles does the sciatic nerve innervate?

A

BSASB

  1. Biceps long
  2. Semi T
  3. Add mag
  4. Semi M
  5. Biceps short
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5
Q

What muscles does the tibial n. innervate?

A

PGPS(TFF)

  1. Popliteus
  2. Gastrocnemius
  3. Plantaris
  4. Soleus
  5. Tib post
  6. FDL
  7. FHL
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6
Q

What muscles does the superficial fibular n. innnervate?

A

FF

  1. Fibularis long
  2. Fibularis brev
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7
Q

What muscles does the deep fibular n. innervate?

A

TEEP(F)EE

  1. Tib ant
  2. EDL
  3. EHL
  4. Fib tertius
  5. EDB
  6. EHB
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8
Q

How are the foot muscles innervated?

A

Tibial n. ⇒ Med. & Lat. Plantar nerves

  • Medial Plantar (3 1/4 mm.)
    1. Abductor hallucis
    2. Flexor digitorum brevis
    3. medial Lumbrical
      • 1 of 4 lumbricals
    4. Flexor hallucis brevis
  • Lateral Plantar
    • All other muscles
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9
Q

Slipped capital femoral epiphysis (SCFE):

  • History:
  • Etiology:
  • Presentation:
  • Exam:
  • Imaging:
  • Treatment:
A
  • History:
    • classically overweight early adolescent with history of groin or knee pain
      • may be referred to anteromedial thigh
      • may occur bilaterally (not simultaneous)
  • Etiology:
    • repetitive overload
  • Presentation:
    • Vague symptoms, worse with activity
  • Exam:
    • Limitation of hip internal rotation
  • Imaging:
    • plain X-rays
  • Treatment:
    • surgical fixation
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10
Q

**Transient synovitis of the hip **

  • **Epidemiology: **
  • **Etiology: **
  • **Examination: **
  • **Tests: **
  • **Treatment: **
A
  • **Epidemiology: **
    • Ages 3-10
  • Etiology:
    • viral, post-vaccine or drug-induced
  • Examination:
    • Holds hip slightly flexed & ER
    • Any motion causes pain (+) log roll
    • Refuses to bear weight; otherwise looks okay
  • **Tests: **
    • Sed rate 35-60mm/hr & CBC
      • mild leukocytosis
  • Treatment:
    • NSAIDs for 1-3 wks
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11
Q

**Septic joint **

  • Etiology:
  • **Examination: **
  • **Treatment: **
  • Complication
A
  • Etiology:
    • Gonorrhea or skin flora
  • **Examination: **
    • Swollen, extremely painful joint
    • Passive & active ROM very painful
    • Red, hot joint
    • Usually has systemic signs,
      • may be absent in diabetic patient or immunosuppressed patient
  • **Treatment: **
    • often requires surgical I&D followed by IV antibiotics
  • **Complication: **
    • ​articular surface destruction
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12
Q

Patellar dislocation

  1. Epidemiology
  2. History
  3. Examination
  4. Treatment
A
  1. Epidemiology - usually lateral dislocation
  2. History
    • cutting with active quadriceps contraction,
    • immediate pain & swelling
  3. Examination - ecchymosis, effusion
    • Positive apprehension test – feeling of instability with stressing of the joint
  4. Treatment – physical therapy
    • _​​_If recurrent may eventually need surgery
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13
Q

Definitions:

  1. effusions
  2. bursa ⇒ bursitis
  3. ganglions
A
  1. effusions
    • excessive fluid in joint
  2. bursa ⇒ bursitis
    • ​​synovial lined sac that contains fluid
    • acts to reduce friction between structures
    • Common locations: Achilles, olecranon, subacromial, prepatellar & other knee locations
      • inflammation can happen with repeated rubbing or pressure
  3. ganglions
    • fluid filled soft tissue mass filled with collection of synovial or peritendinous fluid that arises from a joint or tendon sheath
    • Common location: wrist
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14
Q

**Presentation: **Effusions vs Bursitis vs Ganglions

A
  1. Effusions
    • Uniform & diffuse around a joint
    • Does not move independently (non-mobile)
      • “attached” to joint
  2. Bursitis
    • Localized, mobile
    • Small or large
    • Located throughout body
    • Usually feel “squishable”
  3. Ganglion
    • Usually relatively small < 2 cm
    • Usually near joints
    • Usually fairly tense
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15
Q

Describe the different musculotendinous injuries:

  1. Enthesopathy
  2. Tendinitis
  3. Tendinosis
A
  1. Enthesopathy
    • disorder of muscular or tendinous bony attachment
  2. Tendinitis
    • technically acute inflammation of tendon
    • Traumatic – blow or pull
  3. **Tendinosis **
    • chronic degenerative condition of tendon
    • Chronic – submaximal repetitive irritation
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16
Q

What is a strain?

What are the associated symptoms?

A
  • Muscle fiber damage from overstretching
    • Eccentric loading (muscle lengthening during firing)
  • Symptoms
    1. Stiffness
    2. Bruising
    3. Swelling
    4. Soreness
17
Q

What is a sprain?

What are the associated symptoms?

A
  • Ligamentous damage from overloading
  • Symptoms
    1. Instability or laxity
    2. Swelling
18
Q

What are the articular surfaces of the knee joint?

A

See Netter Plate 496 & 499

  1. Femoral condyles
  2. Tibial plateau
  3. Patella
19
Q

What are the knee ligaments?

A
  1. Medial meniscus
    • C-shaped
  2. Lateral meniscus
    • o-shaped
  3. Cruciates
    • Anterior (ACL)
    • Posterior (PCL)
  4. Medial (tibial) collateral
  5. Lateral (fibular) collateral
20
Q

What is the “unhappy triad”?

A
  1. Anterior Cruciate Ligament (ACL) - (Tear)
  2. Medial Collateral Ligament (MCL) - (Tear)
  3. Lateral Meniscus - (Compression)
21
Q

Anterior cruciate ligament sprain or tear

  1. **Etiology **
  2. **History **
  3. Exam
A
  1. Etiology
    1. twisting non-contact, deceleration or hyperextension injury
  2. History
    1. Acute - pop and rapid effusion
    2. Chronic - instability
  3. Exam
    • (+) Lachmann
      1. knee at 20-30° flexion
      2. stabilize femur
      3. check anterior translation & endpoint of tibia
    • Postitive Anterior Drawer test (less commonly used)
22
Q

Describe the Lachmann test:

A

Lachmann Test:

  1. knee at 20-30° flexion
  2. stabilize femur
  3. check anterior translation & endpoint of tibia
23
Q

What are you looking for in an MRI of a knee (i.e. radiologic assessment)?

A
  • Associated ligament injuries
  • Menisci
  • Articular cartilage
  • “bone bruise”
24
Q

**Joint stability **

  1. Dislocation
  2. **Subluxation **
  3. Laxity
A
  • Dislocation – complete displacement
  • Subluxation – transient, partial displacement
  • Laxity – normal variant in “joint looseness”
25
**Meniscal tear** 1. **Etiology ** 2. **History ** 3. **Exam ** 4. **Treatment**
1. **Etiology** * usually occur with _twisting on a loaded_ (weight-bearing) _knee in athletes_; * _degenerative tears_ are common in _older_ _patients_ 2. **History** - _locking & effusion_ 3. **Exam** 1. pain _over joint line_ 2. pain with _circumduction tests_ (McMurray) 4. **Treatment** 1. **Locked** - _needs reduction_; referral to orthopaedic surgeon 2. **No locking** - _physical therapy and relative rest_
26
Compartments of the leg: **Anterior** 1. **Muscles** 2. **Major neurovascular structures** 3. **Exertional compartment syndrome (%)**
1. **Muscles** * **Extensors** * Tibialis anterior * Extensor hallucis longus * Extensor digitorum longus * Fibularis tertius 2. **Major neurovascular structures** * **Deep fibular n** (1st dorsal web space) * **Anterior tibial a & v** 3. **Exertional compartment syndrome (%)** * 40-50%
27
Compartments of the leg: **Lateral** 1. **Muscles** 2. **Major neurovascular structures** 3. **Exertional compartment syndrome (%)**
1. **Muscles** * **Fibularis longus & brevis** 2. **Major neurovascular structures** * **Superficial fibular n** (lateral leg & lateral dorsal foot) * **Fibular a & v** 3. **Exertional compartment syndrome (%)** * 20%
28
Compartments of the leg: **Superifical Posterior ** 1. **Muscles ** 2. **Major neurovascular structures ** 3. **Exertional compartment syndrome (%) **
1. **Muscles ** * **Superficial flexors** * gastrocnemius * soleus * plantaris 2. **Major neurovascular structures ** * **Tibial n** (motor) * **Sural n** (sensory, lateral foot & distal calf) 3. **Exertional compartment syndrome (%) ** * **rare**
29
Compartments of the leg: **Deep Posterior ** 1. **Muscles ** 2. **Major neurovascular structures ** 3. **Exertional compartment syndrome (%) **
1. **Muscles ** * **Deep flexors** * FDL * tibialis posterior * FHL * popliteus 2. **Major neurovascular structures ** * **Tibial n** (plantar foot) * **Posterior tibial a & v** 3. **Exertional compartment syndrome (%) ** * 30%
30
**Compartment syndromes** 1. **Pathology ** 2. **Etiology** 1. Acute 2. Chronic exertional 3. Common locations
1. **Pathology** * _elevation of pressures in a muscular compartment high enough to interfere with perfusion_ 2. **Etiology** 1. **Acute** – _severe bleed_ * usually caused by fracture 2. **Chronic exertional** – _from hypertrophied muscle in tight compartment with exercise_ * increases muscle bulk up to 20%) 3. **Common locations** – _leg \>\> forearm_
31
**Compartment Syndromes** 1. **Presentation (6P’s)** 2. Acute compartment syndrome injury pressures * ​What do different pressures indicate clinically?
* **Presentation** (6P’s) 1. **Pain** out of proportion (early sign) 2. **Paresthesia** (early sign) 3. **Poikilothermia** (coolness) 4. **Paralysis** (late) 5. **Pallor** (late) 6. **Pulselessness** (late & rare) * Acute compartment syndrome injury pressures 1. 0 - 10 mm Hg = _normal_ 2. 10-30 mm Hg = _elevated, not dangerous_ 3. 30-40 mm Hg = _in acute compartment syndrome potentially dangerous_ * Follow clinical picture and repeat measurements until resolves * 40-60 mm Hg = usually dangerous, usually requires compartment release * \> 60 mm Hg = consistently dangerous, requires urgent release
32
**Ankle sprains** 1. **Etiology ** 2. **Exam **
1. **Etiology** – _forced ankle inversion_ 2. **Exam** 1. **Anterior drawer test** – abnormal is 3-5 mm more than uninjured side * may also feel softer end point on injured side * **Squeeze test** 1. squeeze the tibia & fibular together mid-shaft 2. pain at ankle suspicious for high ankle sprain 3. pain at knee suspicious for **Maisonneuve fracture** – _fracture of the proximal fibula associated with ankle injury_ 2. External rotation test (+) suspicious for high ankle sprains
33
**Achilles tendon rupture** 1. **Typical patient ** 2. **History ** 3. **Exam** 4. **Treatment **
1. **Typical patient** * _middle aged male_ ruptures while playing basketball 2. **History** * heard _pop_ & felt like someone _hit them in back of ankle with golf club_ * _difficulty walking_ 3. **Exam** 1. _Defect_ in Achilles 2. _Pain & weakness with plantar flexion_ 4. **Treatment** – either _acute immobilization_ or _surgery_

MSS Weeks 3-5 (22 decks)

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