Lower limb pathologies Flashcards
What hip pathologies do we need to know?
Arthritis
AVN
Trochanteric bursitis/gluteal cuff syndrome
What arthritises can affect the hip?
OA- primary or secondary to AVN, dysplasia, SUFE, Perthes
RA
Seronegative inflammatory
What is conservative treatment for hip arthritis?
Simple analgesia, physio, walking aids and weight reduction
When is surgery indicated for hip arthritis?
Hip replacement depending on pain levels
How long do hip replacements tend to last?
10-20 years
What can cause AVN in the hip?
Idiopathic
Trauma
Alcohol abuse
Steroids
How do you treat AVN in the hip?
MRI early on- Release pressure
Late on- damage done therefore replace.
WHat is trochanteric bursitis/gluteal cuff syndrome?
Tendonitis/tendon tears of gluteus medius insertion or trochanter bursa inflammation
How does trochanteric bursitis/gluteal cuff syndrome present?
Pain and tenderness over greater trochanter and pain on resisted abduction.
How is trochanteric bursitis/gluteal cuff syndrome treated?
Analgesia, anti-inflammatory, physio and steroids
No surgery!
Where does hip pain usually localise?
Groin but can radiate to knee
How does hip pain often present?
Decreased range of movement and increased pain on rotation.
What are the forms of arthritis found in the knee?
Primary OA
OA secondary to: Meniscal tears, ligament injury and malalignment.
Seropositive and negative arthritis
How do you treat arthritis in the knee?
Conservative- Analgesia and physio
Surgery- Partial or full knee replacement if in substantial pain
What are the complications of a knee replacement?
SImilar to hip but decreased chance of dislocation but increased chance of pain
What are the five soft tissue injuries of the knee we need to know?
Meniscal tears ACL rupture PCL rupture MCL tear LCL tear Combined ligament injury
What is a meniscal tear?
Tear in the meniscus usually due to twisting a loaded knee. Often occurs with ACL rupture
How does a meniscal tear present?
Pain on medial (commonly) or lateral joint line
Catching sensation
Locking- can’t fully extend
Effusion
Pain on tibial rotation (+ive Steinmann’s test)
What meniscal tear is most likely to produce locking?
Bucket handle tear
How do you treat a meniscal tear?
Limited healing due to poor blood supply
What is an ACL rupture?
Rupture of the ACL due to high rotation force turning body laterally.
How does an ACL rupture present?
Feel a ‘pop’ and develop haemarthrosis within an hour. Deep pain and knee gives way on walking.
+ive anterior draw test and Lachman test
How do you treat an ACL rupture?
Primary repair not effective so manage with physio.
If sports person reconstruct (tendon graft).
What is a PCL rupture?
Rupture of PCL due to direct blow to anterior tibia with knee flexed or hyperextended.
How to you treat a PCL rupture?
Reconstruct but not common
What causes a MCL tear?
Valgus stress injury- tackle from side
Get laxity and pain on valgus stressing
How do you treat a MCL tear?
Heals by itself but brace while doing so.
What causes a LCL tear?
Varus stress injury
How do you treat a LCL tear?
SUrgical repair or reconstruction but get lots of instability
What is a combined ligament injury?
Damage to 2+ knee ligaments. Often requires surgery.
WHat is the most important combined ligament tear?
Complete knee dislocation. This is an emergency due to potential for neurovascular injury!!!!!
What is an emergency knee situation?
Complete knee dislocation
What is an osteochondral injury of the knee?
Damage to the articular surface of the knee due to a direct blow.
How does osteochondral damage to the knee present?
Ongoing pain and effusion after injury
How do you treat osteochondral injury of the knee?
Replace with fibrocartilage
What makes up the extensor mechanism?
Tibial tuberosity, patellar tendon, patella, quads tendon and quads muscle
What is an extensor mechanism rupture?
Rupture of the patella or quads tendon due to rapid contraction or spontaneous in degraded tendon
What predisposes you to extensor mechanism rupture?
Tendonitis Steroid use Diabetes RA CRF
How do you diagnose extensor mechanism rupture?
Straight leg raise and obvious gap in extensor mechanism
How do you treat an extensor mechanism rupture?
Tendon to tendon or tendon to patella repair
What is patellofemoral dysfunction?
DIsorders of patellofemoral articulation causing anterior knee pain.
What things can cause patellofemoral dysfunction?
Chondromalacia, lateral patellar compression syndrome and adolescent anterior knee pain
How does patellofemoral dysfunction present?
ANterior knee pain worse going down hill
Grind or click at front of knee
Stiffness after sitting
How do you treat patellofemoral dysfunction?
Physio and tape up
What is patellar instability?
Patella dislocation- nearly always lateral
What causes patellar instability?
DIrect blow or sudden twist of knee
Lax ligaments
What happens when you dislocate your patella laterally?
Tear medial patellofemoral ligament making future dislocation likely
How do you treat patellar instability?
Chance of future dislocation decreases with age and give physio
What are the common sites for OA in the foot?
Dorsum of foot- Remove osteophytes
Ankle- Arthrodesis or replace
What is hallux rigidus?
OA of the first MTP joint
Can be primary or secondary
How do you treat hallux rigidus?
Stiff soled shoes
Remove osteophytes
Arthrodesis
What is hallux valgus?
Deformation of great toe due to medial deviation of 1st metatarsal and lateral movement of toe
What makes hallux valgus more common?
Woman, shoes and RA
What are some of the complications of hallux valgus?
Painful
RUbbing leading to bursitis and ulcers
How do you treat hallux valgus?
Conservative: Wider shoes and spacer between toes
Surgery to realign but not the best
What is morton’s neuroma?
Inflammation and swelling of plantar interdigital nerves
How does morton’s neuroma present?
Burning pain and tingling radiating to toes.
Loss of sensation in webbing
+ive Muller’s click test- mediolateral compression of tarsal heads.
How do you treat morton’s neuroma?
Conservative: Metatarsal pad or insole. Steroid + analgesia
Neuroma excision
Where are metatarsal stress fractures most common?
2nd followed by 3rd metatarsal
WHat causes metatarsal stress fractures?
Exercise
What makes metatarsal stress fractures hard to diagnose?
Take up to 3 weeks to show on XR
How do you treat metatarsal stress fractures?
Rest and rigid shoe
What causes Achilles tendonitis?
RSI or degeneration
What can predispose you to Achilles tendonitis?
Quinalone AB, RA and gout
How do you treat Achilles tendonitis?
Rest
Physio
Heel risers
Splint
How do you treat a ruptured Achilles tendon?
Repair and cast for 8 weeks or non-op in equine boot
What is plantar fasciitis?
Inflammation of plantar fascia due to RSI or degeneration
How does plantar fasciitis present?
Pain in instep when walking
How do you treat plantar fasciitis?
Self-limiting. Rest Plantar and Achilles stretches Gel soles Steroids Surgery rare
What is pes planus?
Flat feet- medial arch does not develop or is lost
What causes pes planus?
Lax ligaments
Lose arch due to: RA, tendon stretch or diabetes
How do you treat pes planus?
No problems therefore treatment normally but can predispose to posterior tibial tendonitis
What is pes cavus?
Abnormally high arch to foot
What causes pes cavus?
Idiopathic or neuromuscular conditions such as CP
What complications can pes cavus cause?
Claw toe
Pain
How do you treat pes cavus?
Soft tissue release
Tendon transfer
Arthrodesis
What is tibialis posterior tendon dysfunction?
Tendonitis, elongation or rupture of TPT which supports medial arch
How do you treat tibialis posterior tendonitis?
Splint and decompression
How do you treat an elongated/ruptured tibialis posterior tendon?
Tendon transfer if no OA
Arthrodesis if got OA
What are claw and hammer toes?
Claw = Hyperextension of MTP and flexion of PIP = DIP Hammer = Hyperextension of MTP + DIP and flex of PIP
What causes claw and hammer toes?
Flexor and extensor tendon imbalance
What are some of the complications of claw and hammer toes?
Rubbing, pain and ulcers
How do you treat claw and hammer toes?
Protect skin Divide tendons Tendon transfer Arthrodesis Amputation
What is primus varus?
Where the 1st metatarsal points away from the second widening the feet.
What can primus varus cause?
Pain, shoes to feel tight and rubbing to form bursitis (bunion)
How do you treat primus varus?
Reposition 1st metatarsal
