lower limb conditions Flashcards
what is most likely to be aspirated from a swollen joint post ACL rupture?
haemorarthrosis
what is most likely to be aspirated from a swollen joint post meniscal tear?
synovial fluid
what is most likely to be aspirated from a swollen joint post fracture?
lipohaemoarthrosis (blood + fat)
which type of hip fracture is at greater risk of avascular necrosis?
intracapsular
hip fracture presentation
shortened abducted + externally rotated leg
pain in groin/hip - may radiate to knee
not able to weight bear
older patient who has fallen (60+)
how would fractured neck of femur (NOF) appear on x-ray?
disruption to shenton’s line
hip fracture investigations
x-ray - AP + lateral
MRI or CT where x-ray neg but still suspicion
*venous thromboembolism assessment
mortality in hip fractures
30% in a year
5-10% at 30 days
aim to perform surgery within 48hrs due to mortality
management of a displaced intracapsular hip fracture in a low functioning (old) patient?
hemiarthroplasty = replacing head of femur but leaving acetabulum
management of a displaced intracapsular hip replacement in a young active patient?
total hip replacement
managment of a non-displaced intracapsular hip fracture
compression hip screw / internal fixation
(with screws) hold head in place while heals
management of an intertrochanteric hip fracture
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)
management of subtrochanteric hip fracture
intramedullary nail (IM nail)
= a metal pole inserted through the greater trochanter into the central cavity of the shaft of the femur
hip dislocation presentation
flexed, internally rotated + adducted knee
complications of hip dislocations
sciatica nerve palsy
AVN of femoral head
OA
management of hip dislocation
neurovascular assessment - sciatic
radiographs
urgent reduction + stabilise
-> fixation of associated pelvic fratures + other injuries
causes of avascular necrosis
idiopathic alcohol abuse steroids hyperlipidaemia thrombophilia hip fractures / dislocations
AVN investigations
early changes may only be seen on MRI
x-ray
- patchy sclerosis at weight bearing part of femoral head
- lytic zone - “hanging rope sign”`
managment of AVN
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
trochanteric bursitis presentation
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
treatment of trochanteric bursitis
analgesia, NSAIDs
physio - strengthen other muscles
steroid injections
causes of ACL rupture
higher rotational force - internal rotation of tibia
football, rugby, skiing, high impact sport
causes of meniscal tear
twisted force on a loaded knee
- turning at football
- squatting
degenerative
50% of ACL ruptures have meniscal tears
how can the MCL be torn?
rugby tackle from the side
higher forces can damage ACL too
causes of PCL rupture
direct blow to anterior tibia
- with knee flexed (motorbikes/dashboard injuries)
which meniscus is most commonly torn?
medial
medial = fixed lateral = more mobile
healing of meniscal tears
only peripheral tears can be expected to heal due to blood supply
meniscal tear presentation
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
meniscal tear investigation
MRI
arthroscopy
management of menical tears
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
is surgery the best pain management in knee ligament injuries?
surgery does NOT treat pain
pain comes from secondary effects - bone marrow oedema, synovitis
management of MCL rupture
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
healing process in MCL vs LCL
MCL - heals well, rarely surgery
LCL - doesn’t heal, urgent surgery within 2-3weeks
lateral collateral ligament (LCL) rupture
uncommon
usually from varus + hyperextension
doesn’t heal
can cause varus + rotatory instability
complete rupture needs urgent surgery (2-3weeks)
PCL rupture cause, presentation + managment
cause = direct blow to tibia presentation = popliteal knee pain / brusing
surgery only if instability - recurrent hyperextension, feeling unstable when going downstairs
ACL rupture investigations
anterior drawer test lachmans test (flexed 25 degrees)
MRI
arthroscopy
ACL rupture manangement
conservative = RICE, NSAIDs, physio, crutches
active, young, frequent instability = arthroscopic surgery (20% failure rate)
- new ligament formed using a graft of tendon
knee dislocation cause + complications
high energy injury - rupture all 4 ligaments
complications
- popliteal artery injury
- common peroneal nerve injury (foot drop)
- lateral collateral injury
- compartment syndrome
knee dislocation mangement
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
patellofemoral dysfunction presentation
anterior knee pain - worse going downhill
grinding/clicking sensation at front of knee + stiffness after prolonged sitting –> causing pseudolocking
mangement of patellofemoral dysfunction
90% improve with physio - rebalancing quadriceps muscle
taping may alleviate symptoms
risk factors of extensor mechanism rupture
previous tendonitis
steroids
chronic renal failure
ciprofloxacin
patellar tendon rupture <40yrs
quadriceps tendon rupture >40yrs
extensor mechanism rupture presentation, investigation + management
pres = unable to straighten leg + palpable gap
Ix = US or MRI
Mx = urgent surgical repair
Osgood-Schlatter presentation
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
Osgood-Schlatter pathophysio
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)
complication of Osgood-Schlatter
avulsion fracture
tibial tuberosity is separated from rest of tibia
–> surgical intervention required
Baker’s cyst
can be 2nd to degenerative changes - OA, meniscal tears
painful rupture - compartment syndrome risk
soft + non-tender synovial fluid filled sac in popliteal fossa
Baker’s cyst investigations
first line = US - rule out DVT
MRI - can show underlying knee pathology (meniscal tears)
managment of Baker’s cyst
conserv
- analgesia, physio
- US guided aspiration - likely to recur
- steroid injections
surgical = arthroscopic on underlying pathology
Hallux valgus (bunions)
metatarsal angled medially + big toe laterally - MTP becomes inflamed + enlarged
can lead to OA
cause unclear
more common in women
hallux valgus investigation + managment
Ix = weight bearing xray
conserv Mx = wide shoes, analgesia, bunion pads (protects from friction)
surgical = realign bones, 30% unhappy
Mortons neuroma
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
Morton’s neuroma presentation
pain at location of lesion
sensation of a lump in the shoe
burning, numbness, pins + needles in distal toe
Mortons neuroma investigations
deep pressure applied to affected area causes pain
metatardal squeeze test
Mulder’s sign - painful click is felt
Ix = US (swollen nerve), MRI
Mortons neuroma mangement
metatarsal pad, offloading insole
steroid + local anaesthetic injections - may relieve symptoms + aid diagnosis
neuroma can be excised - some still pain, risk of recurrence
achilles tendonopathy risk factors
sports that stress achilles - basketball, tennis, track
inflam conditions - rheumatoid, ankylosing
diabetes
raised cholesterol
fluoroquinolone antibiotics - ciprofloxacin, levofloxacin
management of achilles tendonopathy
rest, analgesia, physio
orthotics (insoles)
extracorporeal shock wave therapy (ESWT)
surgery to remove nodules, adhesions or alter tendon
** NO steroid injections - tendon rupture risk **
achilles rupture presentation
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
diagnosis of achilles rupture
US
management of Achilles tendon rupture
analgesia, rest + imobilisation - DVT risk
specialist boots - first in plantar flexion, gradually moved to neutral position (6-12 weeks)
surgical - reattaching then similar boots
adv vs disadv of surgical + non-surgical managment of achilles tendon rupture
surgical - anaesthetic risks, poor wound healing, infection
non-surgical (boots) - high risk of rerupture
plantar fasciitis causative factors
diabetes
obesity
frequent walking on hard floors with poor cushioning
degenerative - cushioning fat pad atrophies with age
management of plantar fasciitis
rest, physio/stretching
gel filled heel pad
steroid injections
symptoms can take 2 yrs to heal :/
causes of pes cavus
idiopathic
neuromuscular conditions
- cerebral palsy, polio, spina bifida occulta
treatment of pes cavus
flexible = soft tissure releases, tendon transfer
rigid = calcaneal osteotomy
severe cases = arthrodesis (bones fused)
which artery is most at risk in a paediatric supracondylar fracture?
brachial artery
which artery is most at risk in a shoulder dislocation?
axillary
complications of total joint athroplasty in the elective patient?
PE dislocation of prosthesis myocardial infarction joint infection pneumonia
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.
hallux rigidus
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?
plantar fasciitis
A quadricep tendon rupture is a relatively common injury in the patient over 40 and rarely requires surgical intervention.
FALSE
almost always surgically managed
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?
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.
