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MSK 2 > Lower Leg Clinical Presentations > Flashcards

Lower Leg Clinical Presentations Flashcards

1
Q

List Common Clinical Presentations at the Lower Leg

A
  1. Lower leg fractures
  2. Structural abnormalities
  3. Hallux rigidus
  4. Ankle sprains
  5. CAI
  6. Anterior ankle impingement syndrome
  7. Tendinopathies
    • Achilles Tendon tear/rupture
    • Plantar fascitis
  8. Metatarsalgia
  9. Interdigital Neuroma
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2
Q

using a tuning fork to test for lower leg fractures

A
  1. Test types
    • provocation of pain
    • sound conduction
  2. 128 Hz (256 and 512 Hz also described)
  3. Vibratory irritation at damaged periosteum
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3
Q

Clinical value of tuning fork test

A
  1. sensitivity questionable → poses a problem with use of tests for screening purposes
  2. may not aid in ID of fracture with mineralized callus
  3. better ID of transverse fractures than other fracture types
  4. less accurate for stress fractures
    • bone shell more intact in earlier stages
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4
Q

Ultrasound

A
  1. Methodology
    • provocation of pain
    • heat absorbed at damaged periosteum
  2. Clinical Value
    • negative LR and sensitivity questionable → poses a problem with use of tests for screening purposes
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5
Q

common MOI for distal tib/fib fractures

A

axial or rotational loading

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6
Q

Types of traumatic fractures of the distal tib/fib

A
  1. Unimalleolar fracture
    • M or L malleolus
  2. Bimalleolar fracture
    • M and L malleolus
  3. Trimalleolar fracture
    • both malleoli and posterior rim of tibia
  4. Tibia and fibula shaft fracture
  5. Comminuted fracture of distal tibia
  6. intra-articular fractures
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7
Q

Types of hindfoot traumatic fractures

A
  1. calcaneus fractures
    • common MOI → fall from a height
    • intra-articular vs extra-articular
  2. talus fractures
    • common MOI → forced ankle DF
    • most intra-articular
    • involving the head, neck or body
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8
Q

Common fractures of the midfoot and forefoot

A
  1. Navicular fractures
  2. Metatarsal fractures
  3. Phalangeal fractures
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9
Q

Navicular fractures

A
  1. dorsal avulsion at deltoid attachment
  2. tuberosity fractures
  3. body fractures
  4. stress fractures → common with insidious onset in w/b athlete
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10
Q

metatarsal fracture

A
  1. Common MOI → direct trauma
  2. 1st met vs mets
  3. 2nd-4th met → spiral common
  4. 5th met → avulsion fracture common, stress fracture
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11
Q

Phalangeal fractures

A
  1. Common MOIs → stubbing and direct trauma
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12
Q

recommended length for immobilization for fractures of the lower leg

A
  1. fibula → 7-8 weeks
  2. Metatarsal → 4-6 weeks
  3. Toes → 3-4 weeks
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13
Q

Pediatric Physeal Fractures

A
  1. Type I → growth plate only
  2. Type II → physis and metaphysis
  3. Type III → physis and epiphysis
  4. Type IV → epiphysis, physis, and metaphysis
  5. Type V → crush injury of physis
  6. Type VI (Rang’s)
  7. Type VII-IX (Ogden’s)
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14
Q

Type VI (Rang’s) physeal fracture

A
  1. involves perichondral ring or associated periosteum of physis
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15
Q

Types VII-IX (Ogden’s) physeal fractures

A

do not directly invovle physis, though may disrupt blood supply

  • VII → osteochondral fracture of epiphysis
  • VIII → fracture of metaphysis
  • IX → avulsion of periosteum
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16
Q

Surgery for Pediatric Ankle Fractures

A
  1. reduction of displaced fracture (closed vs open)
  2. fixation vs no fixation
    • ORIF common Types III and IV (articular surface concern)
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17
Q

prognosis for Pediatric Ankle Fractures

A
  1. Worse prognosis if >1 week prior to reduction
  2. Larger gap
  3. Gap >/= 3 mm for Types I and II
  4. Younger patients (amount of growth to come)
  5. Higher risk of physis arrest in types III, IV and V
    • 2-40% with Type I and II
    • 8-50% with Types III and IV
    • F/U assessment 2 years s/p fracture
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18
Q

management of Types I and II physeal fractures

A
  1. typically casted 4-6 weeks following reduction
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19
Q

management of type III and IV physeal fractures

A
  1. long leg NWB cast weeks 1-4
  2. boot from week 5-8
    • NWB first 2 weeks
    • typically may remove for ROM
  3. If ORIF with type III (>2mm displacement), common hardware removal once healed
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20
Q

management of Type V physeal fractures

A
  1. if recognized early, may be managed with removal of affected physis area f/b fat graft
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21
Q

structural abnormalities at lower leg

A
  1. Talipes equinovarus
  2. Rearfoot varus
  3. Rearfoot valgus
  4. Forefoot varus
  5. Forefoot valgus
  6. Pes planus
  7. Pes cavus
  8. Hallux valgus
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22
Q

describe Talipes Equinovarus (clubfoot)

A
  • commonly bilateral
  • 1/800 births
  • males > females
  • characterized by:
    • plantarflexed heel
    • inversion STJ/varus rearfoot
    • metatarsal adduction/varus forefoot
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23
Q

describe rearfoot abnormalities

A
  1. rearfoot varus
    • inversion of the calcaneus with the subtalar in neutral (limited pronation)
  2. rearfoot valgus
    • eversion of the calcaneus with the subtalar in neutral (excessive pronation and limited supination)
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24
Q

describe forefoot abnormalities

A
  1. forefoot varus
    • inversion of the forefoot on the hindfoot with the subtalar joint in a neutal position
  2. forefoot valgus
    • eversion of the forefoot on the hindfoot with the subtalar joint in a neutral position
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25
Q

describe pes planus

A
  1. rigid/congenital
    • calcaneus in varus, midtarsal region in pronation, talus faces medially and downward, navicular displaced dorsal and lateral on talus
  2. acquired/flexible
    • like rigid, but the foot is mobile
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26
Q

describe pes cavus

A

longitudinal arches accentuated

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27
Q

describe hallux valgus

A
  1. medial deviation of 1st metatarsal and lateral deviation of great toe
  2. gait implications
    • collapse of the medial arch, especially as it relates to instability of the first metatarsal
    • navicular drop
    • position of pronation during push-off = less rigid foot
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28
Q

what is hallux rigidus

A

arthropathy of the great toe characterized by pain, swelling, and abnormal bone growth at the dorsal aspect of the 1st MTP

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29
Q

Hx for hallux rigidus

A
  1. arthropathy
    • RA, gout, spondyloarthropathy
  2. trauma/injury to the articular surface of the distal metatarsal
  3. repetitive great toe extension
30
Q

symptomology of hallux rigidus

A
  1. insidious onset, progressive
  2. 1st MTP pain, especially walking up hill, stair ambulation, and terminal stance
31
Q

Hallux rigidus physical exam findings

A
  1. limited great toe extension ROM at the MTP
    2.
32
Q

Inversion Ankle Sprain general info

A
  1. 85% of ankle ligament sprains
  2. ATFL involved in 60-70% of ankle sprains
  3. Include in differential
    • avulsion fracture 5th met styloid process
    • osteochondral lesion
    • malleolar fracture
33
Q

inversion ankle sprain history

A
  1. most common 3rd decade of life
  2. common running injury
  3. athletes reported to be 5x more likely to sustain a lateral ankle sprain after initial sprain has occured
  4. MOI → forced ankle inversion
34
Q

symptomology of inversion ankle sprain

A
  1. lateral ankle pain
  2. lateral ankle swelling/warmth/redness
  3. painful with activities that place foot in supinated position
35
Q

physical exam findings for inversion ankle sprain

A
  1. antalgic gait
  2. increased figure 8 measurement
  3. local warmth/tenderness (most common ATFL area)
  4. pain with inversion ROM
  5. (+) anterior drawer test (ATFL)
  6. (+) medial talar tilt stress test
  7. (+) reverse anteriolateral drawer test
36
Q

Medial Ankle Sprain Hx

A
  1. involves deltoid ligament
  2. Hx
    • MOI → forced ankle eversion
37
Q

symptomology of medial ankle sprain

A
  1. medial ankle pain
  2. medial ankle swelling/warmth/redness
  3. painful with activities that place foot in pronated position
38
Q

physical exam findings for medial ankle sprains

A
  1. antalgic gait
  2. increased figure-8 measurement
  3. warmth/tenderness area distal to medial malleolus
  4. pain with pronation/eversion ROM
  5. (+) lateral talar tilt stress test
39
Q

Syndesmotic sprains Hx

A
  1. “high ankle sprain”
  2. concern for chronic instability/degenerative arthropathy
  3. Hx
    • Common MOIs
      • forced DF
      • forced eversion of talus
      • forced ER of talus
40
Q

symptomology of syndesmotic sprains

A
  1. pain distal lower leg
  2. aggravated with stair descent/walking up hill/squatting
41
Q

physical exam findings for syndesmotic sprains

A
  1. early heel-off in stance phase
  2. swelling/tenderness anterior tibiofibular joint
  3. pain at end-range DF ROM
  4. (+) fibular translation test
  5. (+) external rotation test
  6. (+) syndesmosis squeeze test
42
Q

Hx of CAI

A
  1. recurrent inversion sprain
  2. fibular muscle weakness
  3. impaired proprioception
43
Q

symptomology of CAI

A
  1. often asymptomatic between sprains
  2. feelings of ankle “giving way”
  3. ankle weakness
  4. difficulty/inability to run (worse on un-even surfaces)
44
Q

physcial exam findings of CAI

A
  1. diminished proprioceptive function of ankle
45
Q

(Anterior) Ankle Impingement Hx

A
  1. Soft tissue or bony spur formation at the anterior talocrural joint
  2. Hx
    • recurrent/high trauma ankle sprain(s)
46
Q

symptomology of anterior ankle impingement

A
  1. anterior ankle pain
  2. anterior ankle swelling/warmth/redness
  3. painful with activities that place foot in DF position
47
Q

physical exam findings of anterior ankle impingement

A
  1. antalgic gait/early heel-off
  2. tenderness/palpable mass anterior tibiotalar joint
  3. pain/limitation with end-range DF ROM
  4. (+) forced DF test
48
Q

Fibularis Longus/Brevis Tendinopathy Hx

A
  1. repeated inversion injuries
  2. anatomic abnormalities/anomalies
49
Q

Fibularis Longus/Brevis Tendinopathy symptomology

A
  1. pain posterior to lateral malleolus
  2. subluxation of fibularis tendons
50
Q

Fibularis Longus/brevis Tendinopathy physical exam findings

A
  1. swelling/bruising lateral ankle
  2. pain with AROM < resistive testing ankle eversion
  3. pain with end-range inversion/supination
  4. tenderness fibularis longus/brevis tendons
51
Q

Tibialis Posterior Tendinopathy Hx

A
  1. insidious onset, progressive, typically unilateral
  2. concomitant deltoid ligament injury
  3. participation in sports that require quick directional change
52
Q

Tibialis Posterior Tendinopathy symptomology

A
  1. pain near area of insertion at navicular
  2. pain proximal to medial malleolus
53
Q

Tibialis Posterior Tendinopathy physical exam findings

A
  1. foot posture → pronated foot/pes planus
  2. Navicular drop in standing
  3. Tenderness/swelling navicular/proximal to medial malleolus
  4. Painful with resisted inversion and PF
  5. Painful eversion/DF ROM
54
Q

Achilles Tendinopathy Hx

A
  1. Common MOI
    • intense eccentric loading on triceps surae
  2. 5-18% of running injuries
55
Q

Achilles Tendinopathy Symptomology

A
  1. pain near insertion of achilles tendon
  2. morning stiffness
56
Q

Achilles Tendinopathy Physical Exam Findings

A
  1. Tenderness/swelling/hypertrophy/palpable defect at achilles tendon
  2. pain with DF ROM
  3. pain with AROM < resisted PF
57
Q

Hx of Achilles Rupture

A
  1. Common MOI
    • sudden push off extended knee
    • sudden forced DF
  2. sudden/acute onset with known mechanism commonly audible “pop”, subsequently difficulty walking/weight-bearing
  3. Achilles tendinopathy
  4. middle-aged adult
58
Q

Achilles tendon tear/rupture symptomology

A

pain near insertion of achilles tendon

59
Q

Achilles tendon tear/rupture physical exam findings

A
  1. tenderness/swelling/hypertrophy/palpable defect achilles tendon/posterior calf
  2. pain with DF ROM
  3. weak/absent active/resisted PF
  4. (+) Thompson Test (rupture)
60
Q

diagnosis/classification of Achilles tendon/rupture

A

in addition to the arc sign and Royal London Hospital test, clinicians can use a subjective report of pain located 2 to 6 cm proximal to the Achilles tendon insertion that began gradually and pain with palpation of the midportion of the tendon to diagnose midportion Achilles tendinopathy

61
Q

Plantar Fascitis Hx

A
  1. lifetime prevalence → 10%
  2. Hx
    • risk factors
      • limited DF ROM
      • high BMI in non-athletic populations
62
Q

Plantar Fascitis symptomology

A
  1. Plantar medial heel pain
    • worse with first few steps following period of inactivity and with prolonged w/b activity
  2. Pain with terminal stance
63
Q

Plantar Fascitis physical exam findings

A
  1. early heel-off in stance phase
  2. guarding of triceps surae
  3. swelling/tenderness origin of plantar fascitis
    • potentially heel spur
  4. Pain with passive DF of ankle and toes (windlass test)
64
Q

History and Physical Exam findings for Plantar Fascitis diagnosis/classification

A
  1. plantar medial heel pain → most noticeable with initial steps after a period of inactivity but also worse following prolonged w/b
  2. heel pain precipitated by a recent increase in w/b activity
  3. pain with palpation of the proximal insertion of the plantar fascia
  4. (+) windlass test
  5. (-) tarsal tunnel tests
  6. limited active and passive talocrural joint DF ROM
  7. abnormal foot posture index score
  8. high BMI in nonathletic individuals
65
Q

Metatarsalgia Hx

A
  1. pain in the distal forefoot, area of the met heads
  2. Hx
    • health conditions that increase stress on the met head
66
Q

symptomology of metatarsalgia

A
  1. aggravated during prolonged w/b activities, mid and terminal stance phases of gait
67
Q

Metatarsalgia physical exam findings

A
  1. findings for concomitant health conditions
  2. antalgic gait/diminished push-off
  3. observable calluses on plantar foot superficial to involved met heads
  4. tender plantar med heads
68
Q

interdigital neuroma Hx

A
  1. thickening of soft tissue surrounding interdigital nerve
  2. Hx
    • insidious onset vs sudden onset (DF injury of toes)
69
Q

symptomology of interdigital neuroma

A

pain in area of met heads and corresponding web space

70
Q

physical exam findings of interdigital neuroma

A
  1. tenderness
  2. (+) foot squeeze test

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