Lower Limb Pathology Flashcards
What is ususally the first clinical sign of hip pathology?
reduced range of motion with loss of internal rotation usually the first sign
What conditions may give shortening of the limb?
SUFE Perthes Severe OA AVN Fracture
Give some early local complications of a replaced joint?
infection dislocation nerve injury leg/arm length discrepancy medical complications - MI, chest ifection, UTI, blood loss, hypovolaemia, DVT, PE
Give examples of late local complications of a replaced joint?
early loosening late infection (haematogenous spread from a distant site) late dislocation (due to complonent wear)
What can cause AVN of th hip joint?
primary/idiopathic 2y to: - alcohol abuse - steroids - hyperlipidaemia - thrombophilia
What are the radiographic chnages of AVN?
Early cases may only be seen on MRI
Later cases may show patchy sclerosis of the weight bearing are of the femoral head with a lytic zone underneath formed by granulatio tissue from attempted repair
What are the treatment options for AVN of the head of the femur?
Detected early enough - holes drilled to alleviate pressure, promote healing and prevent collapse
Late detection - surgery of THR
What is trochanteric bursitis?
the broad tendinous insertion of the abductor muscles is under considerable strain which can lead to tendonitis and degradation, tendon tears.
The trochanteric bursa can also become inflammed.
How does throchanteric brursitis present? What treatment is used?
pain and tenderness in the region of the greater trochanter with pain on resisted abduction.
Analgesia, anti-inflams, physio and steroid injections
Is there a use of surgery in trochanteric bursitis?
No - no surgical tretament has a proven benefit
What is a Morton’s neuroma?
Plantar interdigital nerves are subjected to repeated trauma, become inflammed and swollen creating a neuroma.
What kind of pain is associated with a Morton’s neuroma and how is this treated?
Burning pain and tingling radiating into the affected toes.
Metatarsal pad or offloading insoles can be used. Steroid and local anaesthetic injections. Excision (may continue to have pain and there is a risk of recurrence)
Where do metatarsal stress fractures most commonly occur?
In the 2nd metatarsal followed by the 3rd.
What can predispose to tendonitis?
Quinolone antibiotics
RA
Other inflam arthropathies
Gout
What is the treatment for tendinitis of the achilles tendon?
rest
physiotherapy conditioning
use of a heel raise
use of a splint or boot
What des tendonitis predispose to and what does this have to do with steroids?
Tendonitis predisposes to tendon rupture.
Steroid injection should not be administered around the achilles tendon due to risk of rupture.
What is tendon rupture usually due to?
degenerative changes within the tendon or
recent tendinitis
Describe plantar fasciitis.
A self-limiting repetitive stress/overload or degenerative condition of the foot.
What could be causitive factors for plantar fasciitis?
Diabetes
obesity
frequent walking on hard floors with poor cushioning in shoes
What can be used to treat plantar fasciitis?
rest
achilles and plantar fascia stretchig exercises
gel filled heel pad
corticosteroid injections
What are people with pes planus at higher risk of?
tendonitis of the tibialis posterior tendon
What can cause acquired flat foot?
tibialis posterior tendon stretch o rupture
RA
Diabetes with Charcot foot (neuropathic joint destruction)
What is pes cavus?
Abnormally high arch of the foot
What can cause pes cavus?
Idiopathics
often related to neuromuscular conditions - hereditary sensory and motor europathy, CP, polio (unilateral) and spinal cord tethering from spina bifida occulta
What kind of toes usualy accompany pes cavus?
Claw toes
What kind of alignment do most arthritic knees give?
Varus alignment
What may predispose a patient to early OA of the knee?
Previous meniscal tears
Ligament injuries
Malalignment
What are the mechanisms of injury for MCL, ACL, LCL, PCL and meniscal tears?
Valgus - MCL Twisting - ACL or meniscal injury Varus - LCL Dashboard/ hyperextension - PCL Getting up from squatting - Meniscal tear
If the ACL ruptures what is commonly heard?
Pop
What are onlay devices?
Plates and screws
What are inlay devices?
IM nails
How do patellar dislocations occur? What direction?
Sudden quaricepts contraction with a flexed knee
Always lateral
On examination what would you expect in a patellar dislocation?
Medial pain
effusion
Positive patellar apprehension test
Can’t SLR
In a soft tissue knee injury, pain along either joint line suggests what pathology?
Meniscal tear
If the pt has damaged their extensor mechanism, what will they not be able to do?
Straight leg raise
What is the test for an MCL injury?
Valgus stress with knee at 30degrees flexion
What is the test for an LCL injury?
Varus stress at 30degrees
What is the test for an ACL injury?
Anterior drawer test at 90degrees
Lachmanns test at 30degrees
What is the test for a PCL injury?
Posterior sag at 90degrees and posterior drawer at 90degrees
How do meniscal tears usually occur?
Sporting injuries in young patients or atraumatic spontaneous degenerate tears in older patients (>40)
What imaging modality is used for a suspected meniscal tear?
MRI
What part of the meniscus has a blood supply? What does this mean?
Only peripheral 1/3rd has a blood supply meaning radial tears won’t heal
What does an acute locked knee suggest? What is required?
Displaced bucket handle meniscal tear
Urgent surgery is required
What are the 3 grades of knee ligament injury?
1 - sprain
2 - partial tear
3 - complete tear
If a pt has sustained a ACL and MCL rutures, what should be considered?
Early ACL reconstruction and MCL repair
ACL is the main stabiliser against what?
ACL is the main stabiliser against internal rotation of the tibia
What treatment is required for ACL rupture?
1/3rd of pts can compensate
1/3rd of patients can avoid instability by avoiding certain manoeuvres
reconstruction with auto- or allograft
What is the failure rate of ACL reconstruction?
10%
Is LCL rupture common?
No
What is a complication of LCL rutpure?
Common peroneal (femoral) nerve palsy
When a LCL rupture does occur, what does it usualy occur with?
PCL or ACL injury
What causes a PCL rupture?
Direct blow to the anterior tibia (dashboard/motorbike) or hyperextension injury
PCL instability can make the patient feel what?
Recurrent hyperextension or feeling of unstable when going down stairs
Is dislocating a knee common?
No
Give the complications of knee dislocation.
Popliteal artery injury
commpn peroneal nerve injury
compartment syndrome
Arthrofibrosis and stiffness
How does a patellar dislocation occur?
Sudden quads contraction with a flexed knee
Rapid turn or direct blow
What are the risk factors for a patellar dislocation?
Female adolescent ligamentous laxity/ hypermobility valgus knee Increased femoral neck anteversion torsional abnormalities underdeveloped (hypoplastic) lateral femoral condyle
Extensor mechanism rupture occurs in those with what?
previous tendonitis
on steroids
chronic renal failure
on ciprofloxacin
What is the treatment for extensor mechanism rupture?
Surgical repair
What imaging modality is used to confirm an extensor mechanism rupture?
USS
What imaging modality is used to confirm a ligament tear?
MRI
What imaging modality is used to confirm damage to the hyaline cartilage?
MRI
What imaging modality is used to confirm an undisplaced fracture of the knee?
MRI
Ankle injury is usually caused by what movements?
Inversion or eversion
A non-uniform joint space in an ankle injury indicates what?
Instability
A tri-malleolar fracture involves what? These fractures have a tendency to what?
Medial malleolus
Lateral malleolus
Posteroinferior tibia (posterior malleolus)
These fractures have a tendency to instability
Fractures of the 5th metatarsal base are always in what direction and should not be confused with what?
Always transverse and should not be confused with normal longitudinal adolescent ossification centre
How does a calcaneal fracture usually occur?
Following axial compression (e.g. fall from height onto heel)
What xray vies are required to assess a midfoot injury completely?
AP - 1&2 TMT joint
Oblique - 3&4 TMT joint
Lisfranc injuries usuall involve what?
Several TMT joints with multiple ligamentous avulsion fractures
Seen best on CT
What should not be given to extensor mechanism knee rupture or achilles tendonitis/rupture?
Steroid injection! - risks tendon rupture
Management of a patella dislocation?
Reduce with knee extension
Aspiration
Brace
Physiotherapy
What urgent management is required for a knee dislocation?
Reduction under sedation
Stabilise in splint or externa-fixator
Definitive surgery - sequential ligamentous repair
Dislocating a hip is common. True or false.
False - occur in high velocity injuries - RTA dashboard injury, fall from height
What direction do hips most commonly dislocate?
Posterior
If a hip is dislocated how does the pateints leg look?
Flexed
Internally rotated
Adducted knee
Complications of hip dislocation.
Scaitic nerve palsy
Avascular necrosis of the head of the femur
Secndary OA of the hip
Myositis ossificans
