Lower Limb Ortho Flashcards
1
Q
What makes up the ankle mortise?
A
Lateral and medial malleoli.
2
Q
What sits in the ankle mortise?
A
Trochlea tali and the upper surface of the talus.
3
Q
What is the function of the labrum that sits on the acetabulum?
A
Increases the conformity and the amount of femoral head that is captured within the acetabulum.
Important stabiliser of the hip joint.
4
Q
What is the surgical treatment for an extracapsular fracture of the hip?
A
Bone is fixed.
5
Q
What is the surgical treatment for an intracapsular fracture of the hip?
A
Total hip replacement.
6
Q
When would a psoas abscess be considered in the different diagnosis?
A
If a patient is looking unwell, they have a high CRP, hip is flexed and they don’t like to extend the leg.
7
Q
What is the origin and insertion of the iliacus muscle?
A
Origin: Iliac crest/inner aspect of ilium.
Insertion: Lesser trochanter of femur.
8
Q
What is the origin and insertion of the psoas major muscle?
A
Origin: transverse processes L1-L5.
Insertion: Lesser trochanter of the femur.
9
Q
Which muscles are the hip flexors?
A
Iliacus.
Psoas major.
10
Q
Which muscles are the secondary hip flexors?
A
Rectus femoris.
Sartorius.
11
Q
What is the origin and insertion of the rectus femoris muscle?
A
Origin: anterior inferior iliac spine.
Insertion: tibia via the patellar tendon.
One of the 4 heads of the quadriceps.
12
Q
What is the origin and insertion of the sartorius muscle?
A
Origin: anterior superior iliac spine.
Insertion: tibia.
Also externally rotates the hip.
13
Q
Which muscles are the hip adductors?
A
Adductor brevis.
Adductor longus.
Adductor magnus.
Pectineus.
Gracilis.
14
Q
What is the origin and insertion of the gracilis muscle?
A
Common origin: inferior pubic rami.
Insertion: linea aspera; pectineal line; tibia.
15
Q
What clinical issues are associated with the hip adductor muscles?
A
Adductor tendinopathy.
Osteitis pubis.
Spasticity in neuromuscular conditions e.g. cerebral palsy.
16
Q
Which muscles are the hip abductors?
A
Gluteus minimus.
Gluteus medius.
Tensor fascia lata.
17
Q
What is the origin and insertion of the gluteus minimus and medius?
A
Origin: iliac wing.
Insertion: greater trochanter of the femur.
18
Q
What are the clinical issues associated with the hip abductor muscles?
A
Weakness which leads to a Trendelenburg gait and Trendelenburg lurch.
19
Q
What is the origin and insertion of the tensor fascia lata?
A
Origin: iliac crest.
Insertion: lateral tibia via the iliotibial tract.
20
Q
What is a Trendelenburg gait?
A
The Trendelenburg gait is an abnormal gait caused by weakness of the abductor muscles of the lower limb. A Trendelenburg lurch is a compensatory mechanism for the weakness in these muscles.
21
Q
Which muscles are the hip extensors?
A
Gluteus maximus.
Hamstrings (biceps femoris, semimembranosus, semitendinosus).
22
Q
Which muscles are the hip extensors and knee flexors?
A
Hamstrings (biceps femoris, semimembranosus, semitendinosus).
23
Q
What is the origin and insertion of gluteus maximus?
A
Origin: posterior aspect of ilium/sacrum.
Insertion: iliotibial tract.
24
Q
What is the origin and insertion of biceps femoris?
A
Origin: long head - ischial tuberosity; short head - linea aspea.
Insertion: fibula head.
25
What is the origin and insertion of semimembranosus?
Origin: ischial tuberosity.
Insertion: posterior tibia.
26
What is the origin and insertion of semitendinosus?
Origin: ischial tuberosity.
Insertion: medial tibia.
27
Where is hip joint pain felt?
In the groin.
28
Where does lateral hip pain originate from?
The bursa (bursitis).
29
What are the main movements in the knee?
Flexion.
Extension.
30
What is the main function of the medial and lateral collateral ligaments?
Resist varus/valgus stresses at the knee joint.
31
What are the functions of the anterior cruciate ligaments?
Resists anterior translation and external rotation of the tibia on the femur.
32
What are the functions of the posterior cruciate ligaments?
Resists posterior translation of the tibia on the femur.
33
What are the important functions of the meniscus?
Load transfer ('shock absorbers').
Increase femero-tibial conformity.
Stabilise the knee during movement.
Lubricate the knee.
34
Which muscles are the knee extensors?
Quadriceps (rectus femoris, vastus intermedius, vastus medialis, vastus lateralis).
35
From proximal to distal, what is the extensor mechanism of the knee?
Quadriceps muscle.
Quadriceps tendon.
Patella.
Patellar tendon.
Tibial tubercle.
36
What factors may predispose to patellar instability/dysfunction?
**Genu valgum**.
**Femoral head anteversion**.
**Weak quadriceps** (vastus medialis) which could be due to a larger Q angle as the quads then have to work more to pull the quads into neutral alignment.
**Ligamentous laxity**.
37
Which muscles are the hip extensors and knee flexors?
Hamstring muscles (biceps femoris, semimembranosus, semitendinosus).
38
What nerve supplies the anterior compartment of the leg?
Deep peroneal nerve.
39
What nerve supplies the lateral compartment of the leg?
Superficial peroneal nerve.
40
What nerve innervates the deep posterior compartment of the leg?
Tibial nerve.
41
What nerve innervates the superficial posterior compartment of the leg?
Medial sural cutaneous nerve.
42
What vessels supply the anterior compartment of the leg?
Anterior tibial vessels.
43
What vessels supply the deep posterior compartment of the leg?
Posterior tibial vessels.
44
What are the muscles of the anterior compartment of the leg?
Tibialis anterior.
Extensor hallicus longus.
Extensor digitorum longus.
Peroneus tertius.
45
What are the muscles of the lateral compartment of the leg?
Fibularis longus.
Fibularis brevis.
Peroneus longus.
Peroneus brevis.
46
What are the muscles of the deep posterior compartment of the leg?
Tibialis posterior.
Flexor hallicus longus.
Flexor digitorum longus.
Popliteus.
47
Gastrocnemius.
Soleus.
Plantaris.
48
Draw the smiley pirate!!
The smiley pirate is a schematic way to draw out how the muscles of the leg are organised.
49
What is the nerve supply to these areas?
50
What are the ankle plantar flexors and what is their common insertion?
Gastrocnemius (medial and lateral head) - origin: femoral condyles.
Soleus - origin: broad area on posterior tibia/fibula.
Plantaris - origin: lateral femoral condyle.
*Calcaneus via the Achilles tendon.*
51
Which muscle is the ankle dorsiflexor?
Tibialis anterior (origin: lateral surface proximal tibia; insertion: medial cuneiform and base of first metatarsal).
52
What joint is responsible for side-to-side movement (inversion/eversion) in the foot?
Talo-calcaneal joint.
53
What ligaments are found medially and laterally in the ankle?
Medially - deltoid ligament.
Laterally - lateral ligament.
54
What are the bones of the hindfoot?
Calcaneus.
Talus.
55
What are the bones of the midfoot?
Cuboid.
Navicular.
Cuneiforms.
56
What are the bones of the forefoot?
Metatarsals.
Phalanges.
57
What are the supporting structures of the medial arch of the foot?
Tibialis posterior tendon.
Spring (calcaneonavicular) ligament.
58
What is the origin and insertion of the plantar fascia?
Origin: tuberosity of calcaneus.
Insertion: heads of metatarsals.
59
How does the acetabulum develop?
Triradiate cartilage of the ilium, pubis and ischium come together and ossify to form the acetabulum.
60
What is the purpose of Hilgenriner's line?
Checks if the pelvis is square.
## Footnote
*H for Hilgenriner's and horizontal.*
61
What is the purpose of Perkin's line?
Checks that the upper femoral epiphysis is in the medial inferior quadrant (90% of joint should be in that quadrant to be normal).
## Footnote
*P for Perkin's and perpendicular to the H line.*
62
What is developmental dysplasia of the hip?
Disorder of abnormal development resulting in dysplasia and possible subluxation or dislocation of the hip secondary to capsular laxity and mechanical factors.
63
Which population is developmental dysplasia of the hip most common in?
Lef hips of females.
More commonly seen in Native Americans and Laplanders; rarely seen in African patients.
64
65
What is the safety hip position?
Flexion and adduction.
## Footnote
*Femoral head sits in the acetabulum which stimulates growth of the acetabulum.*
66
Immobility through lower limb injury may lead to what?
Dehydration and starvation.
DVT or PE.
Pneumonia.
67
What are the common places in the lower limb for impacted fractures?
Femoral neck.
Tibial plateau.
Calcaneus.
68
What are intra-capsular fractures of the femur?
Interfere with blood supply to femoral head.
Prone to femoral head avascular necrosis or non-union.
Treated by hemiarthroplasty, unless undisplaced or young patient when reduction and screw fixation may be tried.
69
What are extra-capsular fractures of the femur?
Don’t affect blood supply to femoral head.
Don’t get femoral head avascular necrosis or non-union.
Treated by internal fixation using dynamic hip screws.
70
What factors affect when to refer a patient with hip pain onto orthopaedics?
Pain (especially night pain).
Loss of function.
Physical fitness.
Mental fitness.
Support at home.
Patient expectations.
Age of patient.
Uncertain about diagnosis.
71
What are the common causes of hip pain?
Osteoarthritis.
Rheumatoid arthritis and other arthritides.
Fracture.
Referred from back.
Malignancy.
72
What are the common problems causing knee pain?
Ligament strain (often medial collateral).
Bursitis.
Osgood-Schlatter's (inflammation of patellar tendon around the attachment onto the tibial tuberosity).
Osteoarthritis.
73
What is the role of imaging in arthritis?
Make a diagnosis.
Monitor disease activity and response to treatment.
74
What is the disease distribution of osteoarthritis?
Joint involvement = asymmetrical.
Affects weight-bearing joints or active joints (e.g. spine, hip, knee, thumb base, DIP).
Sometimes affects other joints where there is overuse, previous injury or previous arthritis.
75
What are the radiographic findings of osteoarthritis?
Loss of joint space.
Osteophytes.
Subchondral cysts.
Sclerosis.
76
What is the disease distribution of rheumatoid arthritis?
Joint involvement = symmetrical.
Affects the synovial lining of synovial joints.
Can affect any synovial joint but commonly affects MCP, MTP, PIP (not DIP), wrists, hips, knees, shoulders, atlantoaxial joint (C1/2).
77
What are the radiograph features of rheumatoid arthritis?
Synovial proliferation and reactive joint effusion cause soft tissue swelling.
Hyperaemia causes bone demineralisation -\> **periarticular osteoporosis**.
Inflammatory pannus (inflamed, thickened synovium) **destroys bone initially at the joint margins**.
**Joint subluxation and deformity** due to capsular and ligamentous softening.
78
What is the disease distribution of psoriatic arthritis?
Small joints of hands and feet.
DIP joints.
IP joint of big toe.
79
What is the disease distribution of ankylosing spondylitis?
Scattered lower limb large joints.
80
What is the disease distribution of Reiters syndrome?
Scattered lower limb large joints.
Lower limb entheses.
81
What are early imaging findings for the arthritides?
Increased joint vascularity.
Inflamed synovium.
Bone marrow oedema.
Subtle early bone erosion.
82
What do normal ligaments look like on MRI scans?
Black.
83
What do damaged ligaments look like on MRI scans?
Light.
84
What are the early MRI findings that indicate bony tumours in the spine?
Bone marrow infiltration.
85
What are the late MRI findings that indicate bony tumours in the spine?
Extradural mass and spinal cord compression.
86
What are the causes of spinal cord disease?
Trauma.
Demyelination.
Tumour.
Ischaemia.
87
What conditions can put you at an increased risk for an extensor mechanism rupture in the lower limb?
Previous tendonitis of the extensor mechanism.
Steriods injected into the extensor mechanism tendon.
Chronic renal failure, ciprofloxacin.
88
What clinical features will be apparent if there is an extensor mechanism rupture?
Unable to straight leg raise.
Palpable gap.
89
What injuries can an extensor mechanism rupture consist of?
Rectus femoris tear.
Quadriceps tendon rupture.
Patellar fracture.
Patellar tendon rupture.
90
Which menisci is more mobile?
Lateral because it is under less shear stress than the medial menisci.
91
Tear of which menisci is more common?
Medial menisci tears.
92
Why is there limited healing potential of meniscal tears?
Only peripheral 1/3 has a blood supply, therefore, radial tears won't heal.
93
What is the treatment for acute meniscal tears?
Arthroscopic repair in acute peripheral tears in younger patients with extensive rehab.
Consider arthroscopic meniscectomy for mechanical symptoms (painful catching or locking) for irreparable tears of failed meniscal repairs.
94
Onset: 1 week ago, twisting injury.
Symptoms/Signs: Locked Knee.
Imaging: Bucket handle meniscal tear.
What would the recommendation be?
Urgent arthroscopic meniscal surgery.
95
Onset: 6 months ago, no injury.
Symptoms/Signs: Arthritic.
Imaging: Advanced structure OA +/- Meniscal tear.
What would the recommendation be?
No arthroscopic meniscal surgery.
96
Onset: 1 week ago, twisting injury.
Symptoms/Signs: Meniscal.
Imaging: Longitudinal tear in repairable zone of meniscus.
What would the recommendation be?
Consider arthroscopic meniscal repair (if suitable candidate).
97
Onset: 1 month ago.
Symptoms/Signs: Meniscal.
Imaging: Displaced parrot beak tear. Moderate OA.
What would the recommendation be?
Optimal non-operative treatment and re-assess.
98
Onset: 4 months ago.
Symptoms/Signs: Meniscal.
Imaging: Displaced parrot beak tear. Moderate OA.
What would the recommendation be?
Consider non-urgent arthroscopic partial meniscectomy.
99
Onset: 6 months ago.
Symptoms/Signs: Possibly meniscal.
Imaging: Complex posterior horn tear.
What would the recommendation be?
Optimal non-operative treatment and re-assess.
100
What is the purpose of the MCL?
Resist valgus stress.
101
What is the purpose of the LCL?
Resist varus stress.
102
What is the purpose of the ACL?
Resist anterior subluxation of the tibia and internal rotation of the tibia in extension.
103
What is the purpose of the PCL?
Resist posterior subluxation of the tibia, i.e. anterior subluxation of the femur, and hyperextension of the knee.
104
What could a MCL rupture lead to?
Valgus instability.
105
What could an ACL rupture lead to?
Rotatory instability.
106
What could a PCL rupture lead to?
Recurrent hyperextension or instability descending stairs.
107
What could a posterolateral corner rupture lead to?
Varus and rotatory instability.
108
What makes up the posterolateral corner of the knee and what's its purpose?
PCL and LDL with the popliteus and other small ligaments.
Resist external rotation of the tibia in flexion.
109
What is the treatment for an MCL injury?
Usually heals well, even a complete tear, unless combined with ACL or PCL rupture.
Treatment is brace, early motion and physio.
Rarely requires surgery (advancement or reconstruction with tendon graft).
110
What is the treatment for an ACL rupture?
ACL repair doesn't work -\> reconstruction only using hamstring or patellar tendon (autograft) or Achilles tendon (allograft).
111
What is the rule of thirds relating to ACL rupture?
1/3 compensate and are able to function well.
1/3 can avoid instability by avoiding certain activities.
1/3 do not compensate and have frequent instability or can't get back to high impact sport.
112
What is the treatment for LCL injury?
Complete rupture needs urgent repair if caught early (within 2-3 weeks).
Later requires reconstruction using hamstring or another tendon.
113
What is the treatment for a knee dislocation?
Emergency reduction, recheck neurovascular status (if any concerns then vascular surgery).
May nee external fix for temporary stabilisation.
114
What is the treatment for patellar dislocation?
Some may benefit from surgical stabilisation - bony or soft tissue procedures.
115
What is injured if the mechanism of injury was a valgus force?
MCL injury.
116
What is injured if the mechanism of injury was a twisting force?
ACL or meniscal injury.
117
What is injured if the mechanism of injury was a varus force?
LCL injury.
118
What is injured if the mechanism of injury was from hitting a dashboard or hyperextension?
PCL rupture.
119
What is injured if the mechanism of injury was from getting up from squatting?
Meniscal tear.
120
What attaches to the calcaneus?
Achilles tendon (strongest tendon in the body).
121
What should be done in a foot and ankle examination?
Exposure.
Look.
Gait.
Feel.
Move.
Neurological.
Vascular.
Special tests.
122
How do you distinguish between fixed and flexible pes planus?
Flexible flat feet form an arch when patient is on their tip-toes.
123
Who is most likely to develop tibialis posterior dysfunction?
Obese middle-aged female.
Increases with age.
Flat foot.
Hypertension.
Diabetes.
Steroid injection.
Seronegative arthropathies.
Idiopathic tendonosis.
124
What is the treatment for tibialis posterior dysfunction?
Physiotherapy.
Insole to support medial longitudinal arch.
NO steroid injections.
Orthoses to accommodate foot shape.
Bespoke footwear.
Surgery.
125
What are the causes of plantar fasciitis?
Physical overload - excessive exercise or weight.
Seronegative arthropathy.
Diabetes.
Abnormal foot shape - planovalgus or carovarus.
126
What is the treatment for plantar fasciitis?
Usually self-limiting 18-24 months.
NSAIDs.
Night splints.
Taping.
Heel cups or medial arch supporters.
Physio.
Steroid injection (rare).
Surgery (50% success).
127
What are the causes of pain in hallux valgus?
Medial nerve, bursa or intrinsic pain within the joint.
128
What is hallux rigidus?
Osteoarthritis of the first MTP joint.
129
What makes up the knee extensor mechanism?
Quadriceps muscle.
Quadriceps tendon.
Patella.
Patellar tendon.
130
What clinical finding is indicative of a knee extensor mechanism rupture?
Patient unable to perform a straight leg raise.
Palpable gap.
May be a high or low patella seen on xray.
131
What is the management for a extensor mechanism rupture of the knee?
Surgical repair for larger tears or complete rupture.
132
What is Osgood-Schlatter's disease?
Inflammation of patellar tendon into tibial tuberosity which leaves a prominent bony lump - known as a tibial apophysitis.
Can also occur at the patella and Achilles.
133
What are the clinical findings of an Achilles tendon rupture?
Palpable gap.
Unable to tiptoe stand.
Simmond's test positive (squeeze the calf and there is no plantarflexion of the foot).
134
What is the treatment for Achilles tendon rupture?
Conservative as surgical intervention provides no greater benefit.
Conservative - serial casting or moon boot and heel raise.
135
What is femeroacetabular impingement syndrome?
Altered morphology of the femoral neck and/or acetabulum causing abutment of the femoral neck on the edge of the acetabulum during movement (usually flexion, adduction and internal rotation).
136
What is a CAM type impingement in femeroacetabular impingement syndrome?
Femoral deformity.
Usually young athletic males.
Asymmetric femoral head with decreased head:neck ratio; can be related to previous SUFE.
137
What is a pincer type impingement in femeroacetabular impingement syndrome?
Acetabular deformity.
Usually seen in females.
Acetabular overhang.
138
What are the consequences of femeroacetabular impingement syndrome?
Damage to the labrum and tears.
Damage to cartilage.
Osteoarthritis in later life.
139
What would be the presentation of femeroacetabular impingement syndrome?
Activity related pain in the groin, particularly in flexion and rotation.
Difficulty sitting.
C-sign positive (when asked to show the pain make a C shape with thumb and index finger and put that to thigh).
FADIR (flexion, adduction, internal rotation) provocation test positive.
140
What is the management of femeroacetabular impingement syndrome?
Observation in asymptomatic patients.
Arthroscopic or open surgery to remove CAM/debride labral tears.
Peri-acetabular osteotomy/debride labral tears in pincer impingement.
Arthroplasty in older patients with secondary osteoarthritis.
141
What are the idiopathic causes of avascular necrosis?
Coagulation of the intraosseous microcirculation.
Venous thrombosis causes retrograde arterial occlusion.
Intraosseous hypertension.
Decreased blood flow to femoral head.
Necrosis of the femoral head.
Chondral fracture and collapse.
142
Which part of the femoral blood supply is affected in avascular necrosis associated with injury?
Medial femoral circumflex artery.
143
What are the risk factors of avascular necrosis?
Irradiation.
Trauma.
Haematologic diseases (leukaemia, lymphoma, sickle cell or hypercoagulable states).
Dysbaric disorders (decompression sickness [the bends]).
Alcoholism.
Steroid use.
144
What is the presentation of avascular necrosis?
Insidious onset of groin pain.
Exacerbated by stairs or impact.
Examination is usually normal unless disease has advanced to collapse/osteoarthritis.
145
What radiographic feature is indicative of avascular necrosis?
Hanging rope sign = sclerotic line.
146
When is avascular necrosis reversible?
If there are no subchondral plaques visible on xray.
147
When is avascular necrosis irreversible?
When there are subchondral plaques visible on xray.
148
What is the management of avascular necrosis?
Bisphosphonates.
Core decompression +/- bone grafting.
Curettage and bone grafting.
Vascularise fibular bone graft.
Rotational osteotomy.
Total hip replacement.
149
What is idiopathic transient osteonecrosis of the hip?
Local hyperaemia and impaired venous return with marrow oedema and increased intramedullary pressure.
150
What is the presentation of idiopathic transient osteonecrosis of the hip?
Progressive groin pain over several weeks.
Difficulty weight-bearing.
Usually unilateral.
* Commoner in men than women.*
* Likely to get it are middle-aged men and pregnant women in* *third* *trimester.*
151
How is idiopathic transient osteonecrosis of the hip diagnosed?
Elevated ESR.
Radiographs show osteopenia of the head and neck, thinning of the cortices and preserved joint space.
152
What is the management of idiopathic transient osteonecrosis of the hip?
Self-limiting condition that resolves in 6-9 months.
Analgesia.
Protected weight-bearing to avoid stress fracture.
153
What is trochanteric bursitis?
Repetitive trauma caused by iliotibial band tracking over the trochanteric bursa causing inflammation.
154
What is the presentation of trochanteric bursitis?
Pain on the lateral aspect of the hip.
Pain on palpation of the greater trochanter.
155
What is the management of trochanteric bursitis?
Analgesia.
NSAIDs.
Physiotherapy.
Steroid injection.
*No proven benefit from surgery.*
