Lower Limbs Flashcards
Most Common causes in-toeing (3) in children
Metatarsus adductus
Increased femoral anteversion
Increased internal tibial torsion
3 risk factors for developing dysplasia of the hip
5 Fs: Female Family history Frank Breech First born LeFt hip Syndromic child '
!!! Typical clinical picture of slipped upper femoral epiphysis (SUFE) (5)
Leg length discrepancy In flexion, hip goes into abduction and external rotation Knee pain Antalgic gait Decreased internal rotation
Clin tests for developmental dysplasia of the hip (DDH)
Ortolani test (safe) Barlow test (unsafe)
! Describe foot position of clubfoot:7
CAVE cavus (high arch) adduction of midfoot-kidney shaped Varus -hind foot rotated in Equinus - foot plantarflexed Also: Achilles tendon short, 1st metatarsal flexed, medial displacement of cuboid and navicular bones.
What is leg-calve-perthe’s disease?
Avascular osteonecrosis of femoral epiphysis. Idiopathic
What kind of patient Is most likely to present with Perthes disease?
5-10 year old boy
Clinical presentation of perthe’s disease (8)
Limping child Usually unilateral Pain hip/groin, may refer to knee Decreased abduction and internal rotation of hip Trendelenburg gait and sign Out-tœing, LLD, quad atrophy
Diagnosis Perthes disease
XR showing AVN of femoral epiphysis
Normal bloods
Treatment Perthes
Conservative.
Clin test to test for tarsal tunnel syndrome
Positive Tinel sign
Tap area of post tibial nerve behind lateral malleolus. Positive = pain
Describe normal position of legs at birth
Bowed legs
Describe normal position of legs by 2 years
Straight
Describe normal position of legs at 4 years
Maximal genu valgum (up to 15 degrees)
What is pes planus
Flat foot
3 features of pes planus
- Collapsed medial arch
- Heel valgus
- forefoot varying degrees of abduction
Most common cause pes planus
Tibialis posterior tendon degeneration
Inflammation or rupture
What is pes cavus
High arched foot
What is cavovarus
High arched foot
! Name 4 features pes cavus (3 extra bonus)
- high arched foot!
- Heel varus (inversion)!.
- Forefoot adduction
- Clawed toes
Other: plantar soft tissue and Achilles tight with callosities under metatarsal heads , first metatarsal drop
Causes pes cavus. 3 broad and 1 example each
Neuromm d/o: Charcot Mary tooth disease (weak/paralysed intrinsic foot muscles).
Congenital: arthrogryposis(rare)
Trauma: compartment syndrome (volkmann’s ischaemic contracture) and circumferential burns.
What is metatarsalgia
Pain over forefoot in region of metatarsal heads. Bottom of foot.
Define Morton’s neuroma
Interdigital neuroma mostly 3rd Webspace. Numbness/neuritic pain in distrib of common digital nerve (pathological enlarge of nerve)
First line rx Morton’s interdigital neuroma
Infiltration with lignocaine (steroid) - also a diagnostic test. If fail (doesn't last longer than 6weeks) - resect.
Features of claw toes (2)
Dorsiflexion metatarsophalangeal joint
Flexion proximal distal IP joint.
(Usually ass with pes cavus)
What is Achilles tendonosis
Chronic inflamm and degen
Subclassify Achilles tendinosis (2)
Insertional (degen of tendon as it inserts on calcaneus)
Non-insertional (degen of mid substance)
What is genu recurvatum
Bending backwards knees
What is patellar tracking
Patella shifts out of place as leg bends or straightens.
What is patella baja
Low riding patella
What is patella Alta
High riding patella
What is the q angle and what is the normal?
Quadriceps angle (between quads and patella tendon) Men 14° Women 17° (higher = knock knees and dislocation lateral, lower = bow-legged)
Name 8 complications skin traction
- Distal oedema
- vascular obstruction
- Peroneal nerve palsy - foot drop, path sensation top (dorsum) of foot and upper lateral + lower posterolateral leg and anterolateral leg, slapping gait
- skin necrosis over bony prominences
- compartment syndrome
- allergic reactions to adhesive
- excoriation of skin from slipping of adhesive strapping (abrasion of epidermis)
- pressure sores around malleoli and over tendo calcaneus
- complications of bed rest: thromboembolism, pneumonia, constipation, UTI, bed sores…
Describe the Danis Weber classification
Lateral malleolus fibula fractures (ankle)
• type A: below syndesmosis and oblique # medial malleolus
• type B: at level syndesmosis with # of medial malleolus with disruption medial ligament
• type c: above level syndesmosis, tibiafibular ligament torn, unstable # subluxation of ande joint
Major complication of tibia metaphysis fracture?
Extreme swelling and blisters
Which patellar dislocation is most common?
Lateral
Treatment ankle fractures?
All ORIF
except undisplaced lateral malleolus fracture without medial tenderness (tenderness= medial malleolus #or deltoid ligament injury)
Which structure is in danger in fibula neck fracture?
Common peroneal nerve
Thomas splint indication?
- femur #
* use with skin or skeletal traction
How determine size and weight of Thomas traction?
- Measure thigh circumference at groin, add 4 cm for ring
- measure true limb length (ASIS to medial malleolus), add 20cm for length splint
- Max weight 5 kg (more = skin sloughing) or 10% of patient’s body weight if <5kg
Name 3 indications skin traction
- femur #
- hip dislocation or #disloc
- Dunlop traction for supracondylar #
How measure apparent limb length?
Measure how patient walks -altered mechanisms of lower extremities, compensatory mechanisms
From umbilicus to medial malleolus
Most common tarsal fracture?
Calcaneal fracture
Mechanism of calcaneal fracture?
- high energy, axial loading, fall from height onto heels which drives talus downwards onto calcaneus
- 10% ass with compression fractures of thoracolumbar spine so NB to rule out spine injury
- 75% intra-articular
- 10% bilateral
Clinical features calcaneal fracture? (5)
- makes swelling and bruising on heel/sole
- wider, shorter, flatter heel when viewed from behind
- varus heel
- compartment syndrome of foot frequent
- hold heel in palm of hand and gently squeeze. Pain = calcaneal #
Treatment calcaneal fractures?
TREATMENT PRINCIPLES:
- soft tissue resuscitation
- restore articular congruity
- restore normal calcaneal width and height
- maximal functional recovery may take longer than 12 months
- conservative if undisplaced: non weight bearing cast for 3 months with early ROM and strengthening
- displaced = ORIF
Name and describe the classification used for neck of femur #
Garden classification (ap xray) • type 1: incomplete #, valgus impacted , trabeculae malaligned . Type 2: complete #, nondisplaced, neutral alignment. trabeculae aligned • type 3: complete, partially displaced , varus alignment, trabeculae malaligned . Type 4: complete, fully displaced, varus alignment, trabeculae aligned
Position of limb in displaced neck of Femur #?
External rotation and abduction with shortening
Name 4 complications neck of femur fracture
. Avn / osteonecrosis (disruption medial and lateral femoral circumflex arteries )
• nonunion
• dislocation
• DVT (nb to give clexane )
Name 6 causes AVN of femoral head
- Neck of femur #
- chronic systemic steroid use
- SUFE
- leg calve Perthes disease
- SLE
- ra
Treatment intertrochanteric #?
Closed reduction under fluoroscopy then dynamic hip screw or IM nail
Name 5 complications intertrochanteric # of the femur
- DVT
- varus displacement of proximal fragment
- malrotation
- non-union
- failure of fixation device
Subtrochanteric femur fracture treatment?
Closed reduction under fluoroscopy then plate fixation or IM nail
Name 3 complications subtrochanteric femur #
.Malalignment
• non-union
• wound infection
Treatment neck of femur #? (4)
• Garden 1: internal fixation to prevent displacement ( valgus impacted # )
. Garden 2: internal fixation to prevent displacement
• garden 3: young orif; elderly hemi-arthroplasty
. Garden 4: young orif; elderly hemi-arthroplasty
Treatment femoral diaphysis # adults?
Orif with IM nail
External fixator for unstable patients, open #, highly vascular areas
Mechanism of injury lisfranc #? (2)
- Fall onto plantarflexed foot
* direct crush injury
What is a lisfranc injury?
Tarsometatarsal fracture dislocation between 1st and 2nd mt
Clinical presentation lisfranc injury? (4)
- Shortened forefoot
- prominent base
- pain dorsal foot
- plantar medial bruising! (Unique)
Treatment lisfranc #?
Orif with K wires if displaced
Which 3 other fractures must be excluded when a calcaneal # is seen?
- Spine
- pelvis
- hip
When a pes cavus is diagnosed, what other pathologies must be examined for? (3)
- Spastic diplegia
- old poliomyelitis
- spina bifida occulta
Which foot bones fracture commonly in sports?
Metatarsals 2-5
Which foot bones fracture commonly in mva?
Talus
Identify picture 66 and its indication
Thomas splint with Balkan frame
Older children > 12,5 kg femoral shaft #
