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MSK > lower limb conditions > Flashcards

lower limb conditions Flashcards

1
Q

what is most likely to be aspirated from a swollen joint post ACL rupture?

A

haemorarthrosis

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2
Q

what is most likely to be aspirated from a swollen joint post meniscal tear?

A

synovial fluid

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3
Q

what is most likely to be aspirated from a swollen joint post fracture?

A

lipohaemoarthrosis (blood + fat)

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4
Q

which type of hip fracture is at greater risk of avascular necrosis?

A

intracapsular

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5
Q

hip fracture presentation

A

shortened abducted + externally rotated leg

pain in groin/hip - may radiate to knee
not able to weight bear
older patient who has fallen (60+)

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6
Q

how would fractured neck of femur (NOF) appear on x-ray?

A

disruption to shenton’s line

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7
Q

hip fracture investigations

A

x-ray - AP + lateral

MRI or CT where x-ray neg but still suspicion

*venous thromboembolism assessment

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8
Q

mortality in hip fractures

A

30% in a year
5-10% at 30 days

aim to perform surgery within 48hrs due to mortality

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9
Q

management of a displaced intracapsular hip fracture in a low functioning (old) patient?

A

hemiarthroplasty = replacing head of femur but leaving acetabulum

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10
Q

management of a displaced intracapsular hip replacement in a young active patient?

A

total hip replacement

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11
Q

managment of a non-displaced intracapsular hip fracture

A

compression hip screw / internal fixation

(with screws) hold head in place while heals

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12
Q

management of an intertrochanteric hip fracture

A

dynamic hip crew (DHS) = sliding hip screw, screw goes through neck + into femur, plate with a barrel that holds the screw is screwed to the outside of femoral shaft

(extracapsular)

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13
Q

management of subtrochanteric hip fracture

A

intramedullary nail (IM nail)

= a metal pole inserted through the greater trochanter into the central cavity of the shaft of the femur

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14
Q

hip dislocation presentation

A

flexed, internally rotated + adducted knee

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15
Q

complications of hip dislocations

A

sciatica nerve palsy
AVN of femoral head
OA

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16
Q

management of hip dislocation

A

neurovascular assessment - sciatic
radiographs
urgent reduction + stabilise

-> fixation of associated pelvic fratures + other injuries

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17
Q

causes of avascular necrosis

A 
idiopathic
alcohol abuse
steroids
hyperlipidaemia 
thrombophilia
hip fractures / dislocations
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18
Q

AVN investigations

A

early changes may only be seen on MRI

x-ray

  • patchy sclerosis at weight bearing part of femoral head
  • lytic zone - “hanging rope sign”`
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19
Q

managment of AVN

A

if detected early enough (pre-collapse) = drill holes can be made up the femoral neck into abnormal area in head - relieve pressure, promote healing, prevent collapse

post collapse = total hip replacement

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20
Q

trochanteric bursitis presentation

A

middle aged with gradual onset lateral hip pain
resisted abduction
pain + tenderness in region of greater trochanter
- pain = aching/burning
- worse with activity + sitting cross legged
- may disrupt sleep

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21
Q

treatment of trochanteric bursitis

A

analgesia, NSAIDs
physio - strengthen other muscles
steroid injections

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22
Q

causes of ACL rupture

A

higher rotational force - internal rotation of tibia

football, rugby, skiing, high impact sport

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23
Q

causes of meniscal tear

A

twisted force on a loaded knee

  • turning at football
  • squatting

degenerative
50% of ACL ruptures have meniscal tears

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24
Q

how can the MCL be torn?

A

rugby tackle from the side

higher forces can damage ACL too

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25
Q

causes of PCL rupture

A

direct blow to anterior tibia

- with knee flexed (motorbikes/dashboard injuries)

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26
Q

which meniscus is most commonly torn?

A

medial

medial = fixed
lateral = more mobile
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27
Q

healing of meniscal tears

A

only peripheral tears can be expected to heal due to blood supply

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28
Q

meniscal tear presentation

A

pop sound or sensation on injury
pain,swelling,stiffness
locking of knee (bucket handle)
instbaility of knee “giving way”

*pain may be referred to hip or lower back

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29
Q

meniscal tear investigation

A

MRI

arthroscopy

30
Q

management of menical tears

A

radial tears wont heal
rest, ice, compression, elevation
NSAIDS
physio - after pain + swelling has settled

acute peripheral tears in young = arthroscopic meniscal repair

irreparable tears with recurrent pain, effusion or mechanical probs = arthroscopic resection

31
Q

is surgery the best pain management in knee ligament injuries?

A

surgery does NOT treat pain

pain comes from secondary effects - bone marrow oedema, synovitis

32
Q

management of MCL rupture

A

usually heals well even if complete tear

  • brace, early motion, physio
  • pain can take several months to settle

rarely requires surgery - reconstruction to tendon graft

33
Q

healing process in MCL vs LCL

A

MCL - heals well, rarely surgery

LCL - doesn’t heal, urgent surgery within 2-3weeks

34
Q

lateral collateral ligament (LCL) rupture

A

uncommon
usually from varus + hyperextension

doesn’t heal
can cause varus + rotatory instability
complete rupture needs urgent surgery (2-3weeks)

35
Q

PCL rupture cause, presentation + managment

A 
cause = direct blow to tibia
presentation = popliteal knee pain / brusing

surgery only if instability - recurrent hyperextension, feeling unstable when going downstairs

36
Q

ACL rupture investigations

A 
anterior drawer test
lachmans test (flexed 25 degrees)

MRI
arthroscopy

37
Q

ACL rupture manangement

A

conservative = RICE, NSAIDs, physio, crutches

active, young, frequent instability = arthroscopic surgery (20% failure rate)
- new ligament formed using a graft of tendon

38
Q

knee dislocation cause + complications

A

high energy injury - rupture all 4 ligaments

complications

  • popliteal artery injury
  • common peroneal nerve injury (foot drop)
  • lateral collateral injury
  • compartment syndrome
39
Q

knee dislocation mangement

A

emergency reduction
recheck neurovascular status

if normal exam = observe in hospital
clinical concern = arteriogram, MRI

may need ex-fix to stabilise, revascularisation + multi-ligament construction
* prioritise revascularisation

40
Q

patellofemoral dysfunction presentation

A

anterior knee pain - worse going downhill

grinding/clicking sensation at front of knee + stiffness after prolonged sitting –> causing pseudolocking

41
Q

mangement of patellofemoral dysfunction

A

90% improve with physio - rebalancing quadriceps muscle

taping may alleviate symptoms

42
Q

risk factors of extensor mechanism rupture

A

previous tendonitis
steroids
chronic renal failure
ciprofloxacin

patellar tendon rupture <40yrs
quadriceps tendon rupture >40yrs

43
Q

extensor mechanism rupture presentation, investigation + management

A

pres = unable to straighten leg + palpable gap

Ix = US or MRI

Mx = urgent surgical repair

44
Q

Osgood-Schlatter presentation

A

boys aged 10-15

gradual onset of symptoms

  • visible or palpable hard + tender lump at tibial tuberosity
  • pain in anterior aspect of knee -> exacerbated by activity, kneeling + extension of knee
45
Q

Osgood-Schlatter pathophysio

A

multiple minor avulsion fractures occur where the patella ligament pulls away tiny pieces of bone

leads to growth of tibial tuberosity - causes visible lump below knee
lump – initally tender, as inflammation settles + heals becomes hard + non-tender (permanent lump)

46
Q

complication of Osgood-Schlatter

A

avulsion fracture

tibial tuberosity is separated from rest of tibia
–> surgical intervention required

47
Q

Baker’s cyst

A

can be 2nd to degenerative changes - OA, meniscal tears
painful rupture - compartment syndrome risk

soft + non-tender synovial fluid filled sac in popliteal fossa

48
Q

Baker’s cyst investigations

A

first line = US - rule out DVT

MRI - can show underlying knee pathology (meniscal tears)

49
Q

managment of Baker’s cyst

A

conserv

  • analgesia, physio
  • US guided aspiration - likely to recur
  • steroid injections

surgical = arthroscopic on underlying pathology

50
Q

Hallux valgus (bunions)

A

metatarsal angled medially + big toe laterally - MTP becomes inflamed + enlarged

can lead to OA
cause unclear
more common in women

51
Q

hallux valgus investigation + managment

A

Ix = weight bearing xray

conserv Mx = wide shoes, analgesia, bunion pads (protects from friction)

surgical = realign bones, 30% unhappy

52
Q

Mortons neuroma

A

dysfunction of nerve in the intermetatarsal space towards top of foot (usu 3rd + 4th)

caused by irriation of nerve ending relating to the biomechanics of the foot

**heels may exacerbate

53
Q

Morton’s neuroma presentation

A

pain at location of lesion
sensation of a lump in the shoe
burning, numbness, pins + needles in distal toe

54
Q

Mortons neuroma investigations

A

deep pressure applied to affected area causes pain
metatardal squeeze test
Mulder’s sign - painful click is felt

Ix = US (swollen nerve), MRI

55
Q

Mortons neuroma mangement

A

metatarsal pad, offloading insole
steroid + local anaesthetic injections - may relieve symptoms + aid diagnosis

neuroma can be excised - some still pain, risk of recurrence

56
Q

achilles tendonopathy risk factors

A

sports that stress achilles - basketball, tennis, track
inflam conditions - rheumatoid, ankylosing

diabetes
raised cholesterol
fluoroquinolone antibiotics - ciprofloxacin, levofloxacin

57
Q

management of achilles tendonopathy

A

rest, analgesia, physio
orthotics (insoles)
extracorporeal shock wave therapy (ESWT)
surgery to remove nodules, adhesions or alter tendon

** NO steroid injections - tendon rupture risk **

58
Q

achilles rupture presentation

A

sudden onset pain in tendon or calf - feeling like something has hit them on the back of the leg
positive simmonds test
palpable gap in tendon
unable to stand on tip toes

59
Q

diagnosis of achilles rupture

A

US

60
Q

management of Achilles tendon rupture

A

analgesia, rest + imobilisation - DVT risk

specialist boots - first in plantar flexion, gradually moved to neutral position (6-12 weeks)

surgical - reattaching then similar boots

61
Q

adv vs disadv of surgical + non-surgical managment of achilles tendon rupture

A

surgical - anaesthetic risks, poor wound healing, infection

non-surgical (boots) - high risk of rerupture

62
Q

plantar fasciitis causative factors

A

diabetes
obesity
frequent walking on hard floors with poor cushioning
degenerative - cushioning fat pad atrophies with age

63
Q

management of plantar fasciitis

A

rest, physio/stretching
gel filled heel pad
steroid injections

symptoms can take 2 yrs to heal :/

64
Q

causes of pes cavus

A

idiopathic
neuromuscular conditions
- cerebral palsy, polio, spina bifida occulta

65
Q

treatment of pes cavus

A

flexible = soft tissure releases, tendon transfer

rigid = calcaneal osteotomy

severe cases = arthrodesis (bones fused)

66
Q

which artery is most at risk in a paediatric supracondylar fracture?

A

brachial artery

67
Q

which artery is most at risk in a shoulder dislocation?

A

axillary

68
Q

complications of total joint athroplasty in the elective patient?

A 
PE
dislocation of prosthesis
myocardial infarction
joint infection
pneumonia
69
Q

This 50 year old lady complains of left 1st MTPJ pain on walking, particularly when wearing thin, non-supportive shoes. She cannot wear high heels because of the pain and stiffness in the joint. On examination, active and passive range of movement of the joint is reduced (and quite tender at the end range of movement) and grind test is positive.

A

hallux rigidus

70
Q

A 60 year old lady presents with a complaint of right foot pain. On closer questioning, she tells you she first noticed it a month ago and it’s been getting worse since. She feels it on the instep of her foot (medial arch) and it’s worse if she does a lot of walking. On examination, she is acutely tender over the calcaneal tuberosity at the posterior end of the medial arch.

What is the most likely diagnosis?

A

plantar fasciitis

71
Q

A quadricep tendon rupture is a relatively common injury in the patient over 40 and rarely requires surgical intervention.

A

FALSE

almost always surgically managed

72
Q

You are asked to review a 12 year old boy referred by his GP with a lump in his thigh.

The boy is systemically well and has no significant past medical history. He reports that the lump started about 9 months ago after he fell off his bike and bruised his thigh. Initially it was soft but has hardened. He reports the size was increasing but it hasn’t grown in some time now.

On examination, the mass is very hard and is somewhat mobile in the anterior compartment of the thigh but it feels tethered within the muscle. It isn’t tender.

What is the likely diagnosis?

A

myositis ossificans

where heterotopic ossification (bone forming outside the skeleton) occurs in muscles usually after an injury. The injury may be innocuous and it can form after muscle contusion (“dead leg”), fractures (especially around the elbow) and dislocations (especially traumatic hip dislocation). Heterotopic ossification can also occur in the muscles and soft tissues after surgery including hip replacement particularly if it is a revision (re‐do) procedure.

Bony masses are seen in the soft tissues on xray. Stiffness may develop but aggressive physiotherapy may result in more ectopic bone formation making the situation worse. Once the new bone formation has settled, the abnormal bone can be excised to try to relieve stiffness with high strength NSAIDs (Indomethacin) or radiotherapy used to help prevent recurrence.

MSK (14 decks)

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