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2MBChB Musculoskeletal > Lower Limb Ortho > Flashcards

Lower Limb Ortho Flashcards

1
Q

What makes up the ankle mortise?

A

Lateral and medial malleoli.

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2
Q

What sits in the ankle mortise?

A

Trochlea tali and the upper surface of the talus.

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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.

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4
Q

What is the surgical treatment for an extracapsular fracture of the hip?

A

Bone is fixed.

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5
Q

What is the surgical treatment for an intracapsular fracture of the hip?

A

Total hip replacement.

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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.

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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.

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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.

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9
Q

Which muscles are the hip flexors?

A

Iliacus.

Psoas major.

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10
Q

Which muscles are the secondary hip flexors?

A

Rectus femoris.

Sartorius.

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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.

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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.

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13
Q

Which muscles are the hip adductors?

A

Adductor brevis.

Adductor longus.

Adductor magnus.

Pectineus.

Gracilis.

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14
Q

What is the origin and insertion of the gracilis muscle?

A

Common origin: inferior pubic rami.

Insertion: linea aspera; pectineal line; tibia.

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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.

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16
Q

Which muscles are the hip abductors?

A

Gluteus minimus.

Gluteus medius.

Tensor fascia lata.

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17
Q

What is the origin and insertion of the gluteus minimus and medius?

A

Origin: iliac wing.

Insertion: greater trochanter of the femur.

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18
Q

What are the clinical issues associated with the hip abductor muscles?

A

Weakness which leads to a Trendelenburg gait and Trendelenburg lurch.

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19
Q

What is the origin and insertion of the tensor fascia lata?

A

Origin: iliac crest.

Insertion: lateral tibia via the iliotibial tract.

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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.

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21
Q

Which muscles are the hip extensors?

A

Gluteus maximus.

Hamstrings (biceps femoris, semimembranosus, semitendinosus).

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22
Q

Which muscles are the hip extensors and knee flexors?

A

Hamstrings (biceps femoris, semimembranosus, semitendinosus).

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23
Q

What is the origin and insertion of gluteus maximus?

A

Origin: posterior aspect of ilium/sacrum.

Insertion: iliotibial tract.

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24
Q

What is the origin and insertion of biceps femoris?

A

Origin: long head - ischial tuberosity; short head - linea aspea.

Insertion: fibula head.

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25
Q

What is the origin and insertion of semimembranosus?

A

Origin: ischial tuberosity.

Insertion: posterior tibia.

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26
Q

What is the origin and insertion of semitendinosus?

A

Origin: ischial tuberosity.

Insertion: medial tibia.

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27
Q

Where is hip joint pain felt?

A

In the groin.

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28
Q

Where does lateral hip pain originate from?

A

The bursa (bursitis).

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29
Q

What are the main movements in the knee?

A

Flexion.

Extension.

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30
Q

What is the main function of the medial and lateral collateral ligaments?

A

Resist varus/valgus stresses at the knee joint.

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31
Q

What are the functions of the anterior cruciate ligaments?

A

Resists anterior translation and external rotation of the tibia on the femur.

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32
Q

What are the functions of the posterior cruciate ligaments?

A

Resists posterior translation of the tibia on the femur.

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33
Q

What are the important functions of the meniscus?

A

Load transfer (‘shock absorbers’).

Increase femero-tibial conformity.

Stabilise the knee during movement.

Lubricate the knee.

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34
Q

Which muscles are the knee extensors?

A

Quadriceps (rectus femoris, vastus intermedius, vastus medialis, vastus lateralis).

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35
Q

From proximal to distal, what is the extensor mechanism of the knee?

A

Quadriceps muscle.

Quadriceps tendon.

Patella.

Patellar tendon.

Tibial tubercle.

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36
Q

What factors may predispose to patellar instability/dysfunction?

A

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.

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37
Q

Which muscles are the hip extensors and knee flexors?

A

Hamstring muscles (biceps femoris, semimembranosus, semitendinosus).

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38
Q

What nerve supplies the anterior compartment of the leg?

A

Deep peroneal nerve.

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39
Q

What nerve supplies the lateral compartment of the leg?

A

Superficial peroneal nerve.

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40
Q

What nerve innervates the deep posterior compartment of the leg?

A

Tibial nerve.

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41
Q

What nerve innervates the superficial posterior compartment of the leg?

A

Medial sural cutaneous nerve.

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42
Q

What vessels supply the anterior compartment of the leg?

A

Anterior tibial vessels.

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43
Q

What vessels supply the deep posterior compartment of the leg?

A

Posterior tibial vessels.

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44
Q

What are the muscles of the anterior compartment of the leg?

A

Tibialis anterior.

Extensor hallicus longus.

Extensor digitorum longus.

Peroneus tertius.

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45
Q

What are the muscles of the lateral compartment of the leg?

A

Fibularis longus.

Fibularis brevis.

Peroneus longus.

Peroneus brevis.

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46
Q

What are the muscles of the deep posterior compartment of the leg?

A

Tibialis posterior.

Flexor hallicus longus.

Flexor digitorum longus.

Popliteus.

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47
Q

Gastrocnemius.

Soleus.

Plantaris.

A
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48
Q

Draw the smiley pirate!!

A

The smiley pirate is a schematic way to draw out how the muscles of the leg are organised.

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49
Q

What is the nerve supply to these areas?

A
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50
Q

What are the ankle plantar flexors and what is their common insertion?

A

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.

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51
Q

Which muscle is the ankle dorsiflexor?

A

Tibialis anterior (origin: lateral surface proximal tibia; insertion: medial cuneiform and base of first metatarsal).

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52
Q

What joint is responsible for side-to-side movement (inversion/eversion) in the foot?

A

Talo-calcaneal joint.

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53
Q

What ligaments are found medially and laterally in the ankle?

A

Medially - deltoid ligament.

Laterally - lateral ligament.

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54
Q

What are the bones of the hindfoot?

A

Calcaneus.

Talus.

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55
Q

What are the bones of the midfoot?

A

Cuboid.

Navicular.

Cuneiforms.

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56
Q

What are the bones of the forefoot?

A

Metatarsals.

Phalanges.

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57
Q

What are the supporting structures of the medial arch of the foot?

A

Tibialis posterior tendon.

Spring (calcaneonavicular) ligament.

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58
Q

What is the origin and insertion of the plantar fascia?

A

Origin: tuberosity of calcaneus.

Insertion: heads of metatarsals.

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59
Q

How does the acetabulum develop?

A

Triradiate cartilage of the ilium, pubis and ischium come together and ossify to form the acetabulum.

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60
Q

What is the purpose of Hilgenriner’s line?

A

Checks if the pelvis is square.

H for Hilgenriner’s and horizontal.

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61
Q

What is the purpose of Perkin’s line?

A

Checks that the upper femoral epiphysis is in the medial inferior quadrant (90% of joint should be in that quadrant to be normal).

P for Perkin’s and perpendicular to the H line.

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62
Q

What is developmental dysplasia of the hip?

A

Disorder of abnormal development resulting in dysplasia and possible subluxation or dislocation of the hip secondary to capsular laxity and mechanical factors.

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63
Q

Which population is developmental dysplasia of the hip most common in?

A

Lef hips of females.

More commonly seen in Native Americans and Laplanders; rarely seen in African patients.

64
Q
A
65
Q

What is the safety hip position?

A

Flexion and adduction.

Femoral head sits in the acetabulum which stimulates growth of the acetabulum.

66
Q

Immobility through lower limb injury may lead to what?

A

Dehydration and starvation.

DVT or PE.

Pneumonia.

67
Q

What are the common places in the lower limb for impacted fractures?

A

Femoral neck.

Tibial plateau.

Calcaneus.

68
Q

What are intra-capsular fractures of the femur?

A

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
Q

What are extra-capsular fractures of the femur?

A

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
Q

What factors affect when to refer a patient with hip pain onto orthopaedics?

A

Pain (especially night pain).

Loss of function.

Physical fitness.

Mental fitness.

Support at home.

Patient expectations.

Age of patient.

Uncertain about diagnosis.

71
Q

What are the common causes of hip pain?

A

Osteoarthritis.

Rheumatoid arthritis and other arthritides.

Fracture.

Referred from back.

Malignancy.

72
Q

What are the common problems causing knee pain?

A

Ligament strain (often medial collateral).

Bursitis.

Osgood-Schlatter’s (inflammation of patellar tendon around the attachment onto the tibial tuberosity).

Osteoarthritis.

73
Q

What is the role of imaging in arthritis?

A

Make a diagnosis.

Monitor disease activity and response to treatment.

74
Q

What is the disease distribution of osteoarthritis?

A

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
Q

What are the radiographic findings of osteoarthritis?

A

Loss of joint space.

Osteophytes.

Subchondral cysts.

Sclerosis.

76
Q

What is the disease distribution of rheumatoid arthritis?

A

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
Q

What are the radiograph features of rheumatoid arthritis?

A

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
Q

What is the disease distribution of psoriatic arthritis?

A

Small joints of hands and feet.

DIP joints.

IP joint of big toe.

79
Q

What is the disease distribution of ankylosing spondylitis?

A

Scattered lower limb large joints.

80
Q

What is the disease distribution of Reiters syndrome?

A

Scattered lower limb large joints.

Lower limb entheses.

81
Q

What are early imaging findings for the arthritides?

A

Increased joint vascularity.

Inflamed synovium.

Bone marrow oedema.

Subtle early bone erosion.

82
Q

What do normal ligaments look like on MRI scans?

A

Black.

83
Q

What do damaged ligaments look like on MRI scans?

A

Light.

84
Q

What are the early MRI findings that indicate bony tumours in the spine?

A

Bone marrow infiltration.

85
Q

What are the late MRI findings that indicate bony tumours in the spine?

A

Extradural mass and spinal cord compression.

86
Q

What are the causes of spinal cord disease?

A

Trauma.

Demyelination.

Tumour.

Ischaemia.

87
Q

What conditions can put you at an increased risk for an extensor mechanism rupture in the lower limb?

A

Previous tendonitis of the extensor mechanism.

Steriods injected into the extensor mechanism tendon.

Chronic renal failure, ciprofloxacin.

88
Q

What clinical features will be apparent if there is an extensor mechanism rupture?

A

Unable to straight leg raise.

Palpable gap.

89
Q

What injuries can an extensor mechanism rupture consist of?

A

Rectus femoris tear.

Quadriceps tendon rupture.

Patellar fracture.

Patellar tendon rupture.

90
Q

Which menisci is more mobile?

A

Lateral because it is under less shear stress than the medial menisci.

91
Q

Tear of which menisci is more common?

A

Medial menisci tears.

92
Q

Why is there limited healing potential of meniscal tears?

A

Only peripheral 1/3 has a blood supply, therefore, radial tears won’t heal.

93
Q

What is the treatment for acute meniscal tears?

A

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
Q

Onset: 1 week ago, twisting injury.

Symptoms/Signs: Locked Knee.

Imaging: Bucket handle meniscal tear.

What would the recommendation be?

A

Urgent arthroscopic meniscal surgery.

95
Q

Onset: 6 months ago, no injury.

Symptoms/Signs: Arthritic.

Imaging: Advanced structure OA +/- Meniscal tear.

What would the recommendation be?

A

No arthroscopic meniscal surgery.

96
Q

Onset: 1 week ago, twisting injury.

Symptoms/Signs: Meniscal.

Imaging: Longitudinal tear in repairable zone of meniscus.

What would the recommendation be?

A

Consider arthroscopic meniscal repair (if suitable candidate).

97
Q

Onset: 1 month ago.

Symptoms/Signs: Meniscal.

Imaging: Displaced parrot beak tear. Moderate OA.

What would the recommendation be?

A

Optimal non-operative treatment and re-assess.

98
Q

Onset: 4 months ago.

Symptoms/Signs: Meniscal.

Imaging: Displaced parrot beak tear. Moderate OA.

What would the recommendation be?

A

Consider non-urgent arthroscopic partial meniscectomy.

99
Q

Onset: 6 months ago.

Symptoms/Signs: Possibly meniscal.

Imaging: Complex posterior horn tear.

What would the recommendation be?

A

Optimal non-operative treatment and re-assess.

100
Q

What is the purpose of the MCL?

A

Resist valgus stress.

101
Q

What is the purpose of the LCL?

A

Resist varus stress.

102
Q

What is the purpose of the ACL?

A

Resist anterior subluxation of the tibia and internal rotation of the tibia in extension.

103
Q

What is the purpose of the PCL?

A

Resist posterior subluxation of the tibia, i.e. anterior subluxation of the femur, and hyperextension of the knee.

104
Q

What could a MCL rupture lead to?

A

Valgus instability.

105
Q

What could an ACL rupture lead to?

A

Rotatory instability.

106
Q

What could a PCL rupture lead to?

A

Recurrent hyperextension or instability descending stairs.

107
Q

What could a posterolateral corner rupture lead to?

A

Varus and rotatory instability.

108
Q

What makes up the posterolateral corner of the knee and what’s its purpose?

A

PCL and LDL with the popliteus and other small ligaments.

Resist external rotation of the tibia in flexion.

109
Q

What is the treatment for an MCL injury?

A

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
Q

What is the treatment for an ACL rupture?

A

ACL repair doesn’t work -> reconstruction only using hamstring or patellar tendon (autograft) or Achilles tendon (allograft).

111
Q

What is the rule of thirds relating to ACL rupture?

A

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
Q

What is the treatment for LCL injury?

A

Complete rupture needs urgent repair if caught early (within 2-3 weeks).

Later requires reconstruction using hamstring or another tendon.

113
Q

What is the treatment for a knee dislocation?

A

Emergency reduction, recheck neurovascular status (if any concerns then vascular surgery).

May nee external fix for temporary stabilisation.

114
Q

What is the treatment for patellar dislocation?

A

Some may benefit from surgical stabilisation - bony or soft tissue procedures.

115
Q

What is injured if the mechanism of injury was a valgus force?

A

MCL injury.

116
Q

What is injured if the mechanism of injury was a twisting force?

A

ACL or meniscal injury.

117
Q

What is injured if the mechanism of injury was a varus force?

A

LCL injury.

118
Q

What is injured if the mechanism of injury was from hitting a dashboard or hyperextension?

A

PCL rupture.

119
Q

What is injured if the mechanism of injury was from getting up from squatting?

A

Meniscal tear.

120
Q

What attaches to the calcaneus?

A

Achilles tendon (strongest tendon in the body).

121
Q

What should be done in a foot and ankle examination?

A

Exposure.

Look.

Gait.

Feel.

Move.

Neurological.

Vascular.
Special tests.

122
Q

How do you distinguish between fixed and flexible pes planus?

A

Flexible flat feet form an arch when patient is on their tip-toes.

123
Q

Who is most likely to develop tibialis posterior dysfunction?

A

Obese middle-aged female.

Increases with age.

Flat foot.

Hypertension.

Diabetes.

Steroid injection.

Seronegative arthropathies.

Idiopathic tendonosis.

124
Q

What is the treatment for tibialis posterior dysfunction?

A

Physiotherapy.

Insole to support medial longitudinal arch.

NO steroid injections.

Orthoses to accommodate foot shape.

Bespoke footwear.

Surgery.

125
Q

What are the causes of plantar fasciitis?

A

Physical overload - excessive exercise or weight.

Seronegative arthropathy.

Diabetes.

Abnormal foot shape - planovalgus or carovarus.

126
Q

What is the treatment for plantar fasciitis?

A

Usually self-limiting 18-24 months.

NSAIDs.

Night splints.

Taping.

Heel cups or medial arch supporters.

Physio.

Steroid injection (rare).

Surgery (50% success).

127
Q

What are the causes of pain in hallux valgus?

A

Medial nerve, bursa or intrinsic pain within the joint.

128
Q

What is hallux rigidus?

A

Osteoarthritis of the first MTP joint.

129
Q

What makes up the knee extensor mechanism?

A

Quadriceps muscle.

Quadriceps tendon.

Patella.

Patellar tendon.

130
Q

What clinical finding is indicative of a knee extensor mechanism rupture?

A

Patient unable to perform a straight leg raise.

Palpable gap.

May be a high or low patella seen on xray.

131
Q

What is the management for a extensor mechanism rupture of the knee?

A

Surgical repair for larger tears or complete rupture.

132
Q

What is Osgood-Schlatter’s disease?

A

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
Q

What are the clinical findings of an Achilles tendon rupture?

A

Palpable gap.

Unable to tiptoe stand.

Simmond’s test positive (squeeze the calf and there is no plantarflexion of the foot).

134
Q

What is the treatment for Achilles tendon rupture?

A

Conservative as surgical intervention provides no greater benefit.

Conservative - serial casting or moon boot and heel raise.

135
Q

What is femeroacetabular impingement syndrome?

A

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
Q

What is a CAM type impingement in femeroacetabular impingement syndrome?

A

Femoral deformity.

Usually young athletic males.

Asymmetric femoral head with decreased head:neck ratio; can be related to previous SUFE.

137
Q

What is a pincer type impingement in femeroacetabular impingement syndrome?

A

Acetabular deformity.

Usually seen in females.

Acetabular overhang.

138
Q

What are the consequences of femeroacetabular impingement syndrome?

A

Damage to the labrum and tears.
Damage to cartilage.

Osteoarthritis in later life.

139
Q

What would be the presentation of femeroacetabular impingement syndrome?

A

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
Q

What is the management of femeroacetabular impingement syndrome?

A

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
Q

What are the idiopathic causes of avascular necrosis?

A

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
Q

Which part of the femoral blood supply is affected in avascular necrosis associated with injury?

A

Medial femoral circumflex artery.

143
Q

What are the risk factors of avascular necrosis?

A

Irradiation.

Trauma.

Haematologic diseases (leukaemia, lymphoma, sickle cell or hypercoagulable states).

Dysbaric disorders (decompression sickness [the bends]).

Alcoholism.

Steroid use.

144
Q

What is the presentation of avascular necrosis?

A

Insidious onset of groin pain.

Exacerbated by stairs or impact.

Examination is usually normal unless disease has advanced to collapse/osteoarthritis.

145
Q

What radiographic feature is indicative of avascular necrosis?

A

Hanging rope sign = sclerotic line.

146
Q

When is avascular necrosis reversible?

A

If there are no subchondral plaques visible on xray.

147
Q

When is avascular necrosis irreversible?

A

When there are subchondral plaques visible on xray.

148
Q

What is the management of avascular necrosis?

A

Bisphosphonates.

Core decompression +/- bone grafting.

Curettage and bone grafting.

Vascularise fibular bone graft.

Rotational osteotomy.

Total hip replacement.

149
Q

What is idiopathic transient osteonecrosis of the hip?

A

Local hyperaemia and impaired venous return with marrow oedema and increased intramedullary pressure.

150
Q

What is the presentation of idiopathic transient osteonecrosis of the hip?

A

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
Q

How is idiopathic transient osteonecrosis of the hip diagnosed?

A

Elevated ESR.

Radiographs show osteopenia of the head and neck, thinning of the cortices and preserved joint space.

152
Q

What is the management of idiopathic transient osteonecrosis of the hip?

A

Self-limiting condition that resolves in 6-9 months.

Analgesia.

Protected weight-bearing to avoid stress fracture.

153
Q

What is trochanteric bursitis?

A

Repetitive trauma caused by iliotibial band tracking over the trochanteric bursa causing inflammation.

154
Q

What is the presentation of trochanteric bursitis?

A

Pain on the lateral aspect of the hip.

Pain on palpation of the greater trochanter.

155
Q

What is the management of trochanteric bursitis?

A

Analgesia.

NSAIDs.

Physiotherapy.

Steroid injection.

No proven benefit from surgery.

2MBChB Musculoskeletal (17 decks)

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