Lower Limb

Question 1

What are the risk factors for knee osteoarthritis?

Answer 1

Knee osteoarthritis is common and is due to progressive loss of articular cartilage.

• It is more common in females and older patients (>60 years).
• Risk factors include high BMI and trauma, including previous meniscal/ligament tears, abnormal alignment (varus/ valgus), and hereditary tendency.

Question 2

What are the clinical features of knee osteoarthritis?

Answer 2

Patients often report a gradual onset of pain. A focus on the history should include functional activity such as walking distance, pattern of arthritis involvement (e.g. PFJ often is exacerbated by climbing stairs and deep flexion), and severity of pain (pain at rest or at night).

Patients may develop a limp and, as the arthritis progresses, the range of motion may decrease.

Examination often reveals an effusion, malalignment (varus – medial compartment and valgus – lateral compartment), crepitations behind the patella, and tenderness at the tibiofemoral joint.

Question 3

Describe the management of knee osteoarthritis

Answer 3

Nonoperative:

• Nonsurgical treatments include weight loss, walking aids, and analgesia (i.e. paracetamol, NSAIDS or weak opioids).
• Physiotherapy and nonimpact exercises (cycling, cross trainer and swimming) are well tolerated even in late disease.
• Corticosteroid and hyaluronic acid injections have limited and short‐lived benefits.
• Local anaesthetics are used as a diagnostic tool or with steroids in patients in whom surgical intervention is not being considered.

Operative: In the later stages when conservative therapies have failed.

• Realignment osteotomy
• Joint replacement (unicondylar/unicompartmental or total) may be considered.

Question 4

What is the aetiology of meniscal tears?

Answer 4

The menisci commonly tear either acutely following significant injury in the younger active patient, or as part of a degenerative process in the elderly patient.

• The medial meniscus is more commonly injured than the lateral side, and both tear more commonly in anterior cruciate deficient knees.

Question 5

What are the clinical features of meniscal tears?

Answer 5

The main symptom is of pain localised to either the medial or lateral compartment.

Locking can occur due to the meniscus inter­ posing in the tibiofemoral joint in extension, and rarely fixed flexion deformities can occur in large flipped meniscal tears (bucket handle tears). Other causes of locking include loose bodies, ACL rupture, and patellofemoral pathology.

Question 6

Describe the management of meniscal tears

Answer 6

Question 7

What is the aetiology of an ACL tear?

Answer 7

An anterior cruciate ligament (ACL) tear is a common injury to the knee joint, with an incidence in the UK of around 30 cases per 100,000 each year.

• An ACL tear typically occurs in an athlete with a history of twisting the knee whilst weight-bearing.
• The majority of ACL injuries occur without contact and result from landing from a jump, with the athlete not be able to continue playing thereafter.

Question 8

What are the clinical features of an ACL tear?

Answer 8

An ACL tear will typically present with a rapid joint swelling - haemarthrosis (as the ligament is high vascularised) and significant pain.

If the presentation is delayed, instability may also be evident, in which the patient describes the leg ‘giving way’.

Question 9

What are the potential complications of an ACL tear?

Answer 9

The specific clinical tests that can identify potential ACL damage are the Lachman Test and Anterior Draw Test.

A plain film radiograph of the knee (AP and lateral) should be taken to exclude bony injuries, any joint effusion, or a lipohaemarthrosis present.

An MRI scan of the knee is gold-standard to confirm the diagnosis (>90% sensitivity), also picking up any associated meniscal tears*

Question 10

Describe the management of an ACL tear

Answer 10

Question 11

What is Osgood-Schlatter disease?

Answer 11

Osgood-Schlatter disease is the inflammation (osteochondritis) of the patellar ligament where it inserts on the tibial tuberosity.

Question 12

What are the clinical features of Osgood-Schlatter disease?

Answer 12

It usually presents around the ages of 9-15 years of age as the tibial tuberosity has not fully ossified yet. Children who play lots of sports / physically active repetitively pull on the patellar ligament which causes inflammation of the ligament. It is bilateral in 25-50% of cases. Usually presents as:

• Knee pain after exercise
• Local tenderness
• Sometimes swelling over the tibial tuberosity
• Often hamstring tightness

Question 15

How is Osgood-Schlatter disease investigated and treated?

Answer 15

Ultrasound will show soft-tissue swelling. X-ray may show fracture of the tuberosity.

It is self-resolving with rest from exercise and physiotherapy for quadriceps tightening.

Question 16

What is Chondromalacia Patellae?

Answer 16

Chondromalacia patellae is the softening of the articular surface of the patella. It more often affects adolescent females and is associated with hypermobility and flat feet suggesting a biomechanical component to the aetiology.

Question 17

What are the clinical features of chondromalacia patellae?

Answer 17

Pain is worse when the patella is apposed to the femoral condyle. Therefore presents as:

Pain when standing up from sitting

Or pain when walking up stairs

Question 18

How is chondromalacia patellae managed?

Answer 18

Treatment is with physiotherapy for quadriceps strengthening.

Question 19

What are the clinical features of subluxation/dislocation of the patella?

Answer 19

Subluxation is the partial dislocation and can occur in more commonly with patients who are generally hypermobile. Subluxation of the patella gives sensation of sudden instability or giving way of the knee.

Rarely there may be dislocation of the patella.

Question 20

How is subluxation/dislocation of the patella treated?

Answer 20

Treatment is with quadriceps exercises and sometimes surgery may be needed to realign the pull on the patella by the quadriceps.

Question 21

What are the types of hip fracture?

Answer 21

Question 22

Describe the garden classification

Answer 22

Question 23

What are the clinical features of a hip fracture?

Answer 23

Impacted and stress fractures:

• Patients may complain of light pain in the groin or pain referred along the medial side of the thigh and knee.
• May not be obvious clinical deformity on examination
• Minor discomfort with active or passive hip range of motion, muscle spasms at extremes of motion
• Pain with percussion over greater trochanter

Displaced fractures:

• Pain in the entire hip region
• Leg in external rotation and abduction, with shortening

Question 24

Describe the pre-surgical management of hip fractures

Answer 24

Initial management of a neck of femur fracture should consist of an A to E approach to stabilise the patient and treat any immediately life- or limb- threatening problems, as this cohort of patients will likely sustain concurrent injuries (even in low-impact cases).

Ensure adequate analgesia is provided, as hip fractures are very painful. This can be either as opioid analgesia and / or regional analgesia (such as a fascia-iliaca block)

Definitive management is surgical, however the specific procedures depending on the type of fracture sustained, amongst several other factors.

Question 25

Describe the surgical management of extracapsular hip fractures

Answer 25

Question 26

Describe the surgical management of intracapsular hip fractures

Answer 26

Question 27

What are the types of hip dislocation?

Answer 27

Types of hip dislocation

• Posterior dislocation: Accounts for 90% of hip dislocations. The affected leg is shortened, adducted, and internally rotated.
• Anterior dislocation: The affected leg is usually abducted and externally rotated. No leg shortening.
• Central dislocation

Question 28

Describe the management of hip dislocation

Answer 28

Management of hip dislocation:

• ABCDE approach.
• Analgesia
• A reduction under general anaesthetic within 4 hours to reduce the risk of avascular necrosis.
• Long-term management: Physiotherapy to strengthen the surrounding muscles.

Question 29

What are the potential complications of hip dislocation?

Answer 29

Complications

• Sciatic or femoral nerve injury
• Avascular necrosis
• Osteoarthritis: more common in older patients.
• Recurrent dislocation: due to damage of supporting ligaments

Prognosis

• It takes about 2 to 3 months for the hip to heal after a traumatic dislocation
• the prognosis is best when the hip is reduced less than 12 hours post-injury and when there is less damage to the joint.

Question 30

What are the clinical features of hip osteoarthritis?

Answer 30

Patients often report a gradual onset of pain affecting their groin or anterior thigh.

Often pain radiates to the knee, and can occasionally present as isolated knee pain. It may become worse after periods of activity and is commonly associated with hip stiffness.

As the disease progresses, the range of movement at the hip joint declines. Internal rotation is the usually the first movement to be affected. In later stages of the disease there may be shortening of the affected leg, due to bone loss from the femoral head.

On examination:

• They will have an antalgic gait and may walk with a mobility aid.
• Passive movement is painful, and in severe OA, the range of motion is reduced.
• Thomas’s test may reveal a fixed flexion deformity of the hip and the Trendelenburg test may be positive, indicating weak abductors or secondary to pain.

Question 31

Describe the management of hip osteoarthritis

Answer 31

Conservative:

• In early osteoarthritis, exercise should be a core treatment, including local muscle strengthening and improving general aerobic fitness. Physiotherapy improves self-management and slows disease progression.
• This may be complemented with simple analgesics such as paracetamol, NSAIDs, or weak opioids.
• Other lifestyle modifications include weight loss and smoking cessation.

Operative:

• In the latter stages of the condition, the combination of joint pain, loss of function, and impaired quality of life may lead to consideration for total hip replacement surgery. This can either be a hemiarthroplasty or a total hip replacement.