Lower Limb Pathologies Flashcards
What is osteoarthritis of the hip?
A degenerative disease of the synovial joint which results in the progressive loss of cartilage
Give 4 risk factors for hip osteoarthritis
Trauma Muscle weakness Manual job High impact sports player Paediatric hip conditions Family history
Describe the pathophysiology of osteoarthritis
Over time there is less water and fewer proteoglycans in collagen
In the synovium this causes inflammation to occur
The synovium becomes more thick and vascularised over time
The bone tries to remodel and forms lytic lesions with sclerotic edges
In late disease, bone cysts can form around the joint
Give 3 symptoms of hip osteoarthritis
Limiting hip pain
Pain at night and at rest
Hip stiffness
Hip locking and instability
What will be found on examination of the hip joint in hip osteoarthritis?
Altered gait
Leg length discrepancy
Unable to fully flex and extend
Limited internal rotation
What is seen on x-rays in osteoarthritis?
Joint space narrowing
Osteophytes
Sclerosis
Bone cysts
Give 4 non-operative ways hip osteoarthritis can be managed
NSAIDs Walking aids Weight loss Activity modification Physiotherapy Steroid injections
Give 4 ways hip osteoarthritis can be managed operatively
Debridement of the joint Osteotomy Femoral head resection Hip resurfacing Total hip arthroscopy
When do neck of femur fractures occur?
Low energy falls in the elderly
High energy trauma in young patients
Why do NOF# take a long time to heal?
Surrounded by a capsule
Bathed in synovial fluid
No periosteal layer –> limits callus formation
Why is the mortality for NOF# so high?
Patients have long stays in hospital where they are immobilized and at risk of infections
Give the main symptom of a NOF#
Pain in the groin referred to medial thigh and knee
What finding will be present in a patient with a NOF#?
Leg shortened and externally rotated and abducted
How are intracapsular NOF# classified?
Garden Classification
What is a Garden stage 1 NOF#?
Fracture is nondisplaced and incomplete
What is a Garden stage 2 NOF#?
Undisplaced but complete fracture
What is a Garden stage 3 NOF#?
Complete fracture but incompletely displaced
What is a Garden stage 4 NOF#?
Complete fracture which is completely displaced
What may be seen on x-ray of a NOF#?
Can see fracture line
Break in Shenton’s line
How is an undisplaced intracapsular NOF# treated?
Internal fixation with screws
How is a displaced intracapsular NOF# treated?
Arthroplasty (either hemi or THR)
How is an extracapsular peritrochanteric NOF# treated?
Dynamic hip screw or intramedullary nail
How is an extracapsular subtrochanteric NOF# treated?
IM nail
Give 2 potential complications of a NOF#
Avascular necrosis
Nonunion
Dislocation
Failure of surgery
What is the Nottingham Hip Score?
A score which predicts mortality following a hip fracture
What elements are included in the Nottingham Hip Score?
Age (66-85 +3, >86 +4) Sex (if male +1) Admission haemoglobin (if <10g/dL, +1) Mini-mental test score (if <6/10, +1) Living in an institution (+1) Number of comorbidities (if >2 +1) Malignancy (+1)
A score of above 6 puts patients at high risk of mortality from hip fracture
Why are hip dislocations rare?
Hip joint is very stable and supported by soft tissue constraints
In which direction do 90% of hips dislocate?
Posteriorly
Usually due to hitting a flexed knee on a dashboard in a car crash
How will a posterior hip dislocation present?
Hip and leg in flexion
Adduction and internal rotation
May be sciatic nerve injury
How will an anterior hip dislocation present?
Hip and leg in flexion
Abduction
External rotation
Give 4 possible complications after a hip dislocation
Post-traumatic hip arthritis
Femoral head osteonecrosis
Sciatic nerve injury
Recurrent dislocations
What is sciatica?
Sciatica is the term used to describe discomfort from compression of the sciatic nerve
Give 3 symptoms of sciatica
Pain in buttocks and back of leg Pain worse when sitting for long periods of time Weakness in the calf muscles Back pain Tingling in legs
Which test can be done to assess sciatic pain?
Straight leg raise (sciatic stretch test)
Give 3 potential causes of sciatica
Spinal stenosis Spondylolisthesis Spinal injury Spinal tumour Cauda equina Bone spurs Piriformis syndrome
How is sciatica managed?
NSAIDs, stay active, heat/cold packs, physiotherapy, steroid injections, amitriptyline, gabapentin, diazepam
If a spinal cause is found, lumbar decompression surgery can be done
Give 4 risk factors for knee osteoarthritis
Articular trauma Repetitive knee bending Muscle weakness Obesity Metabolic syndrome Female Elderly Family history
Give 4 symptoms of knee osteoarthritis
Limiting knee pain Pain at night or at rest Activity induced swelling Instability Locking Catching sensation
How is knee osteoarthritis managed?
Nonoperatively –> NSAIDs, rehabilitation, education, weight loss
Operatively –> High tibial osteotomy, unicompartmental arthroplasty, total knee arthroscopy
What movement may cause a ruptured ACL?
High twisting force to the bent knee
What are the symptoms of a ruptured ACL?
Load crack heard
Pain
Rapid joint swelling
Poor healing
What movement may cause a ruptured PCL?
Hyperextension of the knee
What movement may cause a ruptured MCL?
Leg forced into valgus from a blow to the lateral knee
What are the symptoms of a meniscal tear?
Delayed knee swelling
Joint locking
Recurrent episodes of pain and effusions after minor injury
What will be seen on examination of a patella fracture?
Palpable patella defect
Unable to raise leg
Give 4 complications of a patella fracture
Weakness and anterior knee pain Loss of reduction Nonunion Osteonecrosis Infection Stiffness
What nerve can be damaged in a dislocated patella?
Common peroneal nerve
Give 2 common mechanisms for dislocating the patella
Dashboard injury in RTA
Fall from a height
What is dimple sign in a patella dislocation?
Buttonholing of the medial femoral condyle through the medial capsule
Give 4 complications of a patella dislocation?
Stiffness Laxity Instability Peroneal nerve injury Vascular compromise
What is prepatellar bursitis?
Inflammation of the prepatellar bursa in the knee (Housemaid’s Knee)
How is prepatellar bursitis managed?
Compression wrap
NSAIDs
Immobilisation
Can be aspirated
What is Osgood-Schlatters disease?
Also known as tibial tubercle traction apophysitis. Inflammation and swelling at the distal attachment area of the patellar tendon
How does Osgood-Schlatter disease present?
Pain on anterior knee worse on kneeling
Common in children and athletes who jump (basketball players)
What is Sinding-Larsen-Johansson Syndrome?
Overuse injury causing pain at the inferior pole of the patella at the proximal attachment point of the patella tendon.
What kind of fracture pattern are common in tibial fractures?
Spiral
What classification system is used for tibial shaft fractures?
Tscherne Classification
What is a grade 0 closed tibial fracture?
Minimal soft tissue injury, indirect injury, simple fracture pattern
What is a grade 1 closed tibial fracture?
Superficial abrasion or contusion, mild fracture pattern
What is a grade 2 closed tibial fracture?
Deep abrasion, skin or muscle contusion, severe fracture pattern, direct trauma
What is a grade 3 closed tibial fracture?
Extensive skin contusion or crush injury, severe damage to underlying muscle, compartment syndrome, subcutaneous avulsion
What is a grade I open tibial fracture?
Open fracture with a small puncture wound without skin contusion, negligible bacterial contamination, low-energy fracture pattern
What is a grade II open tibial fracture?
Open injuries with small skin and soft tissue contusions, moderate contamination, variable fracture patterns
What is a grade III open tibial fracture?
Open fractures with heavy contamination, extensive soft tissue damage, arterial or neural injuries
What is a grade IV open tibial fracture?
Open fractures with incomplete or complete amputations
What are the Ottawa ankle rules?
Rules for determining which patients with foot or ankle problems require an x-ray
When does a patient with traumatic ankle pain qualify for an x-ray?
Point tenderness on lateral malleolus
Point tenderness on medial malleolus
Inability to weight bear for 4 continuous steps immediately after injury
When does a patient with traumatic foot pain qualify for an x-ray?
Point tenderness on the base of the 5th metatarsal
Point tenderness on the navicular
Inability to weight bear for 4 continuous steps immediately after the injury
How is a medial malleolus fracture treated?
Short leg walking cast or boot
ORIF
How is a lateral malleolus fracture treated?
Short leg walking cast or boot
ORIF
How are bilateral malleolus fractures treated?
Total contact casting
ORIF
How is a posterior malleolus fracture treated?
Short leg walking cast or boot
ORIF
How is an open malleolus fracture treated?
Emergency operative debridement
ORIF
External fixation
What is a Webers A ankle fracture?
Fracture is below the ankle syndesmosis
What is a Webers B ankle fracture?
Fracture at the level of the syndesmosis
What is a Webers C ankle fracture?
Fracture above the ankle syndesmosis
What is the most common direction for an ankle to dislocate?
Medial (80%)
How will a medial ankle dislocation present?
Locked in supination
How will a lateral ankle dislocation present?
Locked in pronation
What is a high ankle sprain?
Syndesmosis injury to the soft tissue around the ankle. Commonly from external rotation injuries
What signs will be found on examination of a high sprain injury?
Positive Hopkins test –> compression of tibia and fibula at the mid-calf causes pain at the syndesmosis
Pain over syndesmosis is elicited with external rotation of the foot with the knee and hip flexed at 90 degrees
What is a low ankle sprain?
Injury to the anterior tibiofibular ligament and calcaneofibular ligament.
How is a low ankle sprain managed?
RICE, Elastic bandage, 1 week of immobilisation
Describe the phases of gait
Stance phase –> foot is on the floor
Swing phase –> foot is moving forward
In gait what is the difference between a stride and a step?
Stride –> distance between consecutive ground contact of the same foot
Step –> distance between consecutive ground contact of alternating feet
What is a hallux valgus?
Valgus deviation of the phalanx which promotes varus positioning of the metatarsal. Metatarsal head displaces medially and the sesamoid complex is laterally translated. This causes pain due to a shift in weight bearing.
Give 2 symptoms of hallux valgus?
Difficulty wearing shoes
Obvious foot deformity
Pain
How is hallux valgus managed?
Shoe modification
Pads
Spacers
Can have surgical correction
What is achilles tendonitis?
Gradual onset of posterior heel pain worse following activity
Give 2 risk factors for achilles tendon rupture
Quinolone antibiotics
Hypercholesterolaemia
Steroid injections
Athletes who do not train regularly
How will an achilles tendon rupture present?
Hear a pop Weakness Difficulty walking Pain in heel Sudden onset
What test is done to assess for an achilles tendon rupture?
Thompson/Simmonds test
Lack of plantar flexion when the calf is squezed
How is an achilles tendon rupture managed?
Functional bracing
Surgical repair of the achilles tendon
What is plantar fasciitis?
Inflammation of the plantar fascia aponeurosis at its attachment point on the calcaneus
What patients are more at risk of plantar fasciitis?
Runners
Dancers
Obese people
Inactive patients
What is the pathophysiology of plantar fasciitis?
Microtears in the plantar fascia from overuse lead to inflammation and chronic inflammation.
Give 3 risk factors for plantar fasciitis
Excessive pronation High arches Tight gastrocnemius and soleus Prolonged standing Leg length discrepancy Unsupportive footwear
What are the symptoms of plantar fasciitis?
Sharp pain in the heel
Worse in the morning and evening
Pain relieved when walking on heels and on ambulation
How is plantar fasciitis managed?
Pain control Splinting Good footwear Steroid injection Gastrocnemius recession Plantar fasciotomy
What is claw toe?
MTP hyperextension and PIP and DIP flexion
What is a hammer toe?
PIP flexion, DIP extension, MTP neutral
What is a mallet toe?
Hyperflexion of the DIP joint
What is morton’s neuroma?
Compressive neuropathy of the interdigital nerve. Thickening of tissue around the nerve.
Give 3 causes of morton’s neuroma?
Wearing tight, pointed shoes Being active Flat feet High arches Bunion Hammer toes
