MSK V - Hip and Lower Extremity Flashcards
1
Q
most common etiology of hip fractures? age?
A
after a fall from standing position in person >50 y/o
2
Q
what are the greatest risk factors of hip fracture?
A
osteoporosis, female gender
3
Q
what is important to determine about the pt if hip fracture?
A
their baseline ambulatory status
4
Q
common sx’s of hip fractures?
A
pain in anterior hip/groin after fall
non-ambulatory
non-weight bearing
external rotation of leg on affected side
5
Q
what is the most sensitive test to identify a hip fracture?
A
internal rotation - pt will have pain
6
Q
physical exam for hip fracture?
A
pain on palpation over fracture area and pain with active/passive ROM
pain on internal rotation
assess neuro status
7
Q
what x-rays for hip fracture?
A
AP pelvis (all the time)
Frog lateral - if pt can tolerate it
8
Q
when would you order an MRI for hip fracture?
A
if suspected fx not seen on x-ray
9
Q
when should pt with hip fracture have surgery?
A
recommended to have surgery within first 24hrs
10
Q
why should you NOT delay surgery past 24hrs for hip fractures?
A
b/c pts will then have 2x the rate of major/minor complications like pneumonia, pressure ulcers, DVT, and death
11
Q
tx for femoral neck fracture?
A
cannulated screws or hemiarthroplasty
12
Q
what pts with femoral neck fx get cannulated screws as tx?
A
if younger pt like 55 y/o or older pt that is bad surgical candidate (won’t survive hemiarthroplasty)
13
Q
what is the reason to do hemiarthoplasty for femoral neck fx?
A
b/c femoral neck fx’s interrupt blood supply to femoral head
14
Q
tx for intertrochanteric femoral fx’s?
A
IM nailing (M/C) - force is inside the bone here and device is load sharing
DHS Compression Screw (not as good b/c force is on the outside of the bone)
15
Q
difference b/w intertrochanteric femoral fx’s and femoral neck fx’s?
A
intertrochanteric fx’s don’t interrupt the blood supply
femoral neck fx’s do interrupt the blood supply
16
Q
tx for subtrochanteric fx?
A
IM nailing
17
Q
when do you do a hemiarthroplasty?
A
displaced femoral neck, sub capital hip fx
18
Q
when do you use cannulated screws for hip fx?
A
nondisplaced femoral neck
19
Q
what do patients and family need to understand about hip fractures?
A
that the surgery is a major surgery and it carries inherent risks
20
Q
what happens to the people that do survive their hip fx?
A
return to one level below their baseline ambulatory/ADL status
21
Q
avascular necrosis risk factors?
A
chronic steroid use, post-trauma, post-infection
22
Q
sx’s of hip arthritis?
A
insidious onset of achy type pain in hip and/or groin
c/o stiffness in morning or after prolonged sitting with “loosening up” after approx. 30 min of activity (“Gelling”)
23
Q
pain in hip arthritis increased after prolonged what and relieved with what?
A
Pain increased after prolonged activity, relieved with rest
24
Q
pain in hip arthritis affects what and causes decreased what?
A
ADLs and causes decreased ROM
25
hip arthritis PE?
Assess gait - painful gait, Trendelenburg gait
TTP over anterior hip and groin
Active ROM limited by pain and/or structural deformity
Assess NV status in bilat LEs
26
active ROM in hip arthritis is limited by?
pain and/or structural deformity
27
if no structural deformity in hip arthritis, what should NOT be interrupted?
passive ROM
28
what should you check for in hip arthritis? what does it suggest?
pelvic obliquity - suggests leg-length discrepancy
29
x-rays for hip arthritis?
Standard AP pelvis
Frog lateral or lateral of affected hip
30
assess what on x-ray for hip arthritis?
joint space, congruity of femoral head/acetabular surface
assess for loose bodies, subchondral cysts
assess for evidence of avascular necrosis (may need MRI)
31
joint space narrowing and sclerosis suggest what?
early OA
32
osteophytes near the femoral head or acetabulum and subchondral bone cysts suggest what?
advanced OA
33
if suspect inflammatory arthritis of hip, run what labs?
CBC w/ diff, ESR, CRP, Rheum Factor, ANA, Lyme Titer
34
if joint pain, always think of what?
Lyme disease
35
when does the patient need surgery for arthritis?
when they can't live their life anymore
-surgery not dependent on the x-rays
36
1st line tx for hip arthritis?
APAP
37
tx for hip arthritis?
***Tylenol 1st line - NSAIDs as adjunct
Activity modification
Physical Therapy - strengthening/ROM
Ambulatory assistive devices (cane, brace) - cane helps a lot
Intra-articular cortisone injection (done under fluoroscopy)
Total hip arthroplasty (definitive)
38
what is the definitive tx of hip arthritis?
total hip arthroplasty
39
greater trochanteric bursitis triggered by?
minor direct trauma over greater trochanter
40
what does inflammation of the bursa and soft tissue in greater trochanteric bursitis lead to?
pain located in lateral hip
41
what muscles attach to the grater trochanter of the femur?
abductors
42
sx's of greater trochanteric bursitis?
Pts c/o aching, intense lateral-sided hip pain
-Worsened with direct pressure like sitting, laying on affected side
Pain radiates down lateral thigh
Painful ambulation on affected side
43
pts lateral hip pain in greater trochanteric bursitis is worsened with what?
Worsened with direct pressure like sitting, laying on affected side
44
greater trochanteric bursitis PE?
Pain over lateral hip with pain to palpation over greater trochanter
***Pain with passive hip rotation, adduction -> KEY!!!
Increased pain with resisted hip abduction
45
what is KEY to the PE of greater trochanteric bursitis? what is it doing?
Pain with passive hip rotation, adduction
| -stretching the IT band over the bursa -> PAIN!!!
46
tx for greater trochanteric bursitis?
CONSERVATIVE TX
- Ice
- NSAIDs
- PT
- Corticosteroid injection
47
who is femoral acetabular impingement seen in?
younger people
48
what is femoral acetabular impingement?
Condition where femoral neck is abnormally shaped during childhood growth
-Thus, causes impingement sx's in Femoroacetabular joint
49
what are the 2 types of femoral acetabular impingement?
Cam bone spur and Pincer bone spur
50
what is Cam bone spur?
type of femoral acetabular impingement
Abnormal Femoral Head/Neck junction with increased radius at the waist (bony overgrowth that is hitting the bone)
51
when does impingement occur in Cam bone spur?
during flexion, adduction, internal rotation
52
what is Pincer bone spur?
type of femoral acetabular impingement
- Excessive Acetabular Coverage
- Linear contact b/w the labrum and femoral head/neck junction
-Impinges on femoral neck
53
sx's of femoral acetabular impingement?
dull ache which waxes/wanes with activity/rest
pain in groin area
sharp stabbing pain may occur with turning, twisting, and squatting
54
improvement of sx's with femoral acetabular impingement with what?
with PT, but sx's return after PT stopped
55
what test is done to assess for femoral acetabular impingement?
Impingement Test (FAIR test) -> will produce PAIN!!!
- Hip flexion to 90
- Adduct to 20
- Internal Rotation
56
when do you do an MRI for femoral acetabular impingement?
pre-op if think there is a labrum tear
use MRI to assess labrum and articular cartilage
57
surgical tx for femoral acetabular impingement?
Arthroscopy for labral repair and/or debridement
Femoral head/neck resection to correct deformity
58
what tx is necessary for femoral acetabular impingement if pt wants to keep active?
surgery
59
what is the non-surgical tx for femoral acetabular impingement?
activity modification, NSAIDs, PT
60
causes of femur fractures?
high-energy/velocity injuries
| -MVA, fall from height, or metastatic lesions
61
complication for femur fractures?
severe blood loss and loss of limb/life if femoral artery injured/severed
62
sx's of femur fractures?
presents after trauma, non-weight bearing
may have other complants/injuries from high-energy injury
63
femur fractures are what type of injury?
a DISTRACTING INJURY -> need to make sure nothing else is broken b/c this fracture is caused by high energy
64
what else must you check for if pt has femur fracture?
other injuries: pelvis, knee, spine
65
what will affected leg for femur fracture look like?
rotated and shortened
66
x-rays for femur fracture?
AP, lateral of femur
67
tx of femur fracture
IM nailing (definitive tx)
Analgesics and anticoagulation afterward (MUST DO!!!)
-aspirin 325mg daily or Lovenox (LMWH)
PT
Follow healing thru serial x-rays to avoid non-or malunion
68
what is definitive tx for femur fractures?
IM nailing
69
what is so good about IM nailing as tx for femur fractures?
Pts can be mobilized sooner and reduce post-op sequelae (Ex: pneumonia, atelectasis, DVT, etc.)
70
what must be addressed first for femur fracture? may need what?
life-threatening injuries -> may need Ex-Fix
71
what is something that you MUST do after surgery for femur fx?
anticoagulation - aspirin 325mg daily or Lovenox (LMWH)
72
tibial plateau fx is caused by what injury?
high-energy deceleration injury
73
what is the mechanism of tibial plateau fx?
femoral condyles push down onto tibial pleather causing fx
74
tibial plateau fx seen with?
falls
75
high incidence of what after tibial plateau fx?
post-traumatic arthritis
76
sx's for tibial plateau fx?
mod-severe pain
non-weight bearing
tender to palpation and will resist active/passive ROM
77
what else should be assessed for with tibial plateau fx's?
other injuries
78
dx of tibial plateau fx's?
Standard Trauma series of knee
CT scan to be ordered if unstable fracture requiring ORIF (surgery)
If no fx seen on plain film, but patient symptomatic, order MRI to assess joint line
79
CT scan is the test to get if looking for what in tibial plateau fx's?
articular surface depression
80
tx for stable tibial plateau fx's?
Hinged-knee brace, crutches
Pt non-weight bearing but can do active ROM exercises from seated/lying position
Some may use long-leg cast for initial immobilization
81
what is a stable tibial plateau fx?
no depression of articular surface
82
tx for unstable tibial plateau fx's?
ORIF with side plate and screws
83
what is a Segond fx?
Avulsion fracture involving lateral aspect of tibial plateau
84
Segond fx associated with what?
disruption of ACL
85
Segond fx occurs as a result of?
internal rotation and varus stress
86
Segond fx seen in what 2 settings?
falls and sports (skiing, basketball, baseball)
87
sx's for Segond fx?
knee pain/swelling after trauma
Will hold knee in approx. 20 degrees flexed position for comfort (also common presentation for torn ACL)
Non-weight bearing
Moderate to large effusion with pain over lateral aspect of knee
Pt will resist full extension and may not be able to flex past 90 degrees secondary to hemarthrosis
88
is the knee stable or unstable in Segond fx?
knee stable unless other injury
89
imaging for Segond fx?
standard trauma knee series
MRI
90
MRI is essential to identify what for Segond fx?
to identify internal derangement and to assess the ACL to see if torn
91
tx for Segond fx if no extensive ligamentous injury?
cancellous screw (b/c small fx)
92
tx for Segond fx if have extensive ligamentous injury?
surgical intervention to correct anterior rotational instability
93
prognosis of Segond fx?
good if pt compliant with rehab program of protected weight-bearing and gentle ROM until healed
94
how is a patella fracture caused?
Direct trauma to anterior patella, i.e. dashboard injury
Sudden forceful contraction of quad muscles in context of sport injury
Direct blow to patella
95
sx's of patella fx?
a lot of swelling/large joint effusion
Absent extensor mechanism - can't extend leg
pain
96
what is something that must be checked if suspect patella fx?
extensor mechanism of leg -> will be ABSENT
97
imaging for patella fx?
standard trauma knee series - sunrise view (best view)
CT if severely comminuted
98
tx for patella fx?
ORIF with tension band wiring
NWB in hinged knee brace in LOCKED EXTENSION
99
when can pt with patella fx "open up brace" to 20 degrees? when can they do active ROM in brace under PT direction?
around 2 weeks to open up brace
after 4 weeks for active ROM
100
mechanism of quad tendon rupture? example?
forced flexion against resistance/extension
Ex: person jumping down onto deck of boat as it is coming up toward him from water
101
quad tendon rupture seen in who?
heavy-set males in 40s-50s
102
sx's of quad tendon rupture?
pts can describe exact moment the tendon "popped"
ABSENT EXTENSOR MECHANISM
a lot of swelling
defect in distal quad tendon
103
in complete quad tendon rupture, what will the pt be and what will they have?
pt will be NWB with large effusion to affected knee
104
what is the pain from in quad tendon rupture?
from the tear and from the effusion
105
tx for quad tendon rupture?
surgery (suture the tendon and tie it off)
pt held out to -20 degrees extension and NWB in locked hinged knee brace until healing allows for gentle AROM
106
pt with quad tendon rupture may transition to partial WB after how many weeks?
may transition to partial WB after 6 weeks as tissue heals
107
once ROM is restored in quad tendon rupture, pt works on...
strengthening
108
patellar tendon rupture at what age?
< 40 y/o
109
complete patella tendon rupture rare in young athlete unless associated with...
steroids
110
risk factors for patella tendon rupture?
RA, long-term DM, long-term steroid use, fluoroquinolones
111
sx's of patella tendon rupture
palpable defect in patellar ligament - defect below the knee
ABSENT EXTENSOR MECHANISM
112
imaging for patella tendon rupture?
standard trauma series of knee
113
conservative tx for patellar tendon rupture for what? what is the tx?
partial patellar ligament disruption
tx is immobilization in hinged knee brace for 4-6 weeks
114
surgical tx for patellar tendon rupture for what?
complete tears
115
what 3 injuries of the knee have ABSENT EXTENSOR MECHANISM?
quad tendon rupture, patellar fracture, and patellar tendon rupture
116
what is a Maisonneuve fracture?
Combination of spiral fracture of proximal fibula with ankle injury of one or more:
- Widening of ankle joint d/t rupture of distal tibiofibular syndesmosis
- Deltoid ligament disruption
- Fracture of the medial malleolus
117
sx's of knee arthritis?
Insidious onset of achy type pain in hip and/or groin
***C/o stiffness in morning or after prolonged sitting with "loosening up" after approx. 30 min of activity ("GELLING")
Pain increased after prolonged activity, relieved with rest
118
strongest predictor of knee OA progression? medial progression? lateral progression?
knee malalignment (valgus or virus)
medial progression of knee OA 4x more likely in varus
lateral progression of knee OA 5x more likely in valgus
119
imaging for knee arthritis?
arthritis series (with 30 degrees PA flexed view)
STANDING VIEW
120
varus knee does what?
meets medially and widens laterally
121
valgus knee does what?
meets laterally and widens medially
122
1st line tx for knee arthritis?
APAP (same for all types of arthritis)
123
last line/definitive tx for knee arthritis?
total knee arthroplasty
124
what does ACL tear result from?
valgus stress to knee or distal thigh with ipsilateral foot planted
non-contact pivoting injury
125
what does the ACL connect?
ACL connects the posterior aspect of the lateral femoral condyl to the anterior aspect of the tibia
126
what does ACL prevent the movement of?
ACL prevents anterior motion of the tibia
127
sx's of ACL tear
"pop" the moment the injury occurred
effusion to knee w/in 2 hours
instability with side-to-side movement
128
if knee swells up in 2 hours, what is it until proven otherwise?
If knee swells up in 2 hours = ACL tear until proven otherwise
129
definitive test for dx of ACL tear? when can you do it?
Lachman's test
| -can do it if there is NO swelling (swelling prevents the pulling forward)
130
x-rays for ACL tear to rule out?
Segond fracture
131
MRI for ACL tear to assess?
joint integrity
132
where do ACL tears occur in the ligament?
usually in the middle portion of the ligament
133
will see ACL tear with what type of MRI?
T2 - fluid shows up white
134
diagnostics for ACL tear?
Lachman's test
X-rays
MRI
135
reconstruction for ACL tear recommended if want to what?
if want to return to sports/occupation
136
when may pt use brace instead of surgery for ACL tear?
if low physical demand occupation/lifestyle
137
ACL tear puts pt at higher risk for what?
for post-traumatic DJD (arthritis) in affected knee
138
what lesions occur in most ACL tear pts? what do they suggest?
occult osteochondral lesions
Suggests articular cartilage sustains considerable mechanical impact at time of injury
139
MCL tear caused by what force?
valgus-type force directed to lateral knee
140
MCL tear common in what sports?
football, hockey, skiing, and soccer
141
MCL can occur with any trauma to what side of knee and with what force?
to lateral side of knee with valgus force
142
is MCL surgical or non-surgical?
almost always NON-SURGICAL
143
what does the MCL prevent the movement of?
MCL prevents lateral movement of tibia on the femur when valgus stress is placed on the knee
144
sx's of MCL tear?
acute onset of pain in medial aspect (b/c MCL stabilizes medial knee)
instability when changing direction or stairs
swelling of knee if ACL also involved
145
swelling of knee in MCL if what is also involved?
if ACL is also involved
146
PE for MCL tear
pt has antalgic gait
TTP over tract of MCL medially (femoral condyle to proximal tibia)
ROM preserved (if no effusion)
pain with valgus stress at 0 and 30 degrees
147
what stress test do you perform for MCL tear?
valgus stress test
148
tx of MCL tear?
RICE, gentle, NWB ROM exercised 3-5 days
Hinged knee brace to protect medial/lateral ambulation (prevents lat and medial movement)
PT
149
what is patella femoral syndrome aka?
chondromalacia patella
150
patella femoral syndrome is a common cause of?
anterior knee pain
151
what is a common cause of anterior knee pain?
patella femoral syndrome
152
what is patella femoral syndrome caused by?
lateral mal-tracking of patella during flexion/extension activity
-patella moves side to side -> get pain
153
what is muscle weak and what muscle is tight in patella femoral syndrome? what needs to be strengthened and why?
vastus medialis obliques is weak and IT band is tight
IT band is trying to pull the patella laterally so need to strengthen VMO to counteract it
154
in what activities does pain occur with patella femoral syndrome?
deep flexion of knee, stairs (descending), and prolonged sitting
155
patella femoral syndrome usually seen in who?
young, athletic women
156
patella femoral syndrome sx's
normal WB and minimal effect on ADLs
diffuse pain around knee
pt might localize to medial joint line
pt has stiff feeling when getting up from prolonged sitting
pain free during activities but achy afterwards
157
patella apprehension will be what in patella femoral syndrome? what will the pt have?
positive and pt will have tenderness with medial/lateral subluxation of the patella
158
what are the IT band and VMO like in patella femoral syndrome?
IT band tenderness/tightness
VMO atrophied compared to rest of quad
159
do pts with patella femoral syndrome have pain during activities?
NO!!! - they are pain free during activities, but achy afterwards
160
imaging for patella femoral syndrome? may see what?
Sunrise (Merchant) view most important
may see lateral subluxation of patella to confirm dx
161
tx for patella femoral syndrome
Activity modification
-***Pts can continue in their sport/activity as tolerated, but they must attend PT to work on strengthening VMO and adductor muscles
- NSAIDs on regular basis initially, then wean off
- Patella brace prn - keeps the patella in place
162
most important part of tx for patella femoral syndrome?
PT
163
when does patella femoral syndrome usually resolve?
in 4-6 weeks if pt compliant with PT and strengthening/stretching
164
intractable cases of patella femoral syndrome need what?
referral for surgical lateral release of knee capsule
165
what muscles need to be strengthened in patella femoral syndrome?
VMO and adductor muscles
166
what meniscus tears are most common?
medial meniscus tears
167
when do meniscus tears occur in life?
2nd-4th decades
168
meniscus tears result from?
a "twisting" or rotational movement of a flexed knee during sports
in older pts, these tears are degenerative in nature
169
sx's of meniscus tears?
medial/lateral sided pain "inside the knee over the joint line
***LOCKING is key finding (piece of meniscus gets stuck)
pain worse with activity/improves with rest
170
what is a key finding of meniscus tears?
LOCKING (piece of meniscus gets stuck)
171
PE for meniscus tears
TTP over affected joint line (medial > lateral)
+McMurray test (do bilaterally) (won't be pos if older pts but will have TTP over joint line)
can't squat deeply
172
imaging for meniscus tear?
standard x-rays to r/o fx
173
MRI for meniscus tear?
to assess surgical need
174
what test/sign is key to meniscus tear?
McMurray test/sign (will be positive in young, but negative in older)
175
tx for meniscus tear?
arthroscopy (highly successful)
176
meniscal repair in younger pts requires?
requires protected WB with gentle ROM x6 weeks (on crutches for 6 weeks)
177
meniscal repair in older and non-active pts?
menisectomy
178
tibia fracture caused by?
high-energy deceleration (ex: falls)
direct impact to tibia
179
tibia fractures occur in conjunction with?
other LE fx due to mechanism of injury
180
sx's of tibia fractures?
NWB or protected WB
moderate-severe pain
may have obvious deformity
swelling
CONCOMITANT INJURIES
181
PE of tibia fractures
TTP over fracture site
assess knee and ankle ROM
182
imaging for tibia fractures?
X-rays: AP, lateral views
183
tx for mid shaft tibia fractures?
they are unstable fx's so need IM nail fixation
184
ankle fractures occur when?
when foot is planted on ground/surface and body sustains rotation force
185
external rotation force will cause what with ankle fractures?
External Rotation causes spiral fx of fibula and greater force will also lead to medial malleolus fx
186
abduction force will cause what with ankle fractures?
Abduction force leads to transverse fx of fibula and avulsion fx of medial malleolus
187
sx's of ankle fx?
NWB or protected
lateral swelling
reduced ROM in dorsiflexion; eversion also affected
188
what is it important to assess with ankle fx?
proximal fibula
189
imaging for ankle fx?
X-rays: AP, Mortise, Lateral
May need stress views to determine stable vs unstable
190
tx for stable ankle fx?
cast or walking boot
191
tx for unstable ankle fx?
ORIF
192
what do you fix first in ankle fx?
the fibula - brings the whole ankle out to length
193
what is the most common sports injury seen in outpt clinics?
ankle sprain
194
what do pts report with ankle sprains?
"turning the ankle" during a fall or after landing on an irregular surface
195
what is the most common mechanism of injury for ankle sprain?
inversion and plantar flexion sprain -> injures anterior talofibular ligament
196
what ligament eversion cause injury to in ankle sprain?
injury to deltoid ligament
197
sx's of lateral ankle sprain
pain/swelling
TTP over anterior talofibular ligament, calcenofibular, and PTF ligaments
antalgic WB
ecchymosis after 24-48 hrs
198
sx's of medial ankle sprain
TTP over deltoid ligament also posterior tibial tendon
Swelling medially
Antalgic WB
Ecchymosis after 24-48 hrs
199
what is the most commonly torn/sprained ligament of the ankle? then which 2?
anterior talofibular ligament (first)
then PTF, then the calcaneofibular
200
tx for ankle sprain?
RICE, NSAIDs, early ROM
PT (but not right away)
air cast for mild sprain
201
calcaneus fracture results from?
high-energy deceleration injuries
| -MVC, fall from height (ex: jump from the 3rd floor)
202
what may pts complain of in addition to their calcaneus fx?
low back pain secondary to associated lumbar compression fx
203
sx's of calcaneus fx?
very swollen, NWB
204
what must be checked for calcaneus fx?
smoking status - if smoke, then heal fractures slowly
205
PE of calcaneus fx?
assess NV status and ROM
assess for associated injuries (back injuries)
calcaneus x-rays
206
CT for calcaneus fx done to assess?
articular surface and fx displacement for surgical staging
207
calcaneus fx's classified as/
intra-, extra-articular
208
tx of calcaneus fx?
well-padded posterior splint to LE
protected WB, with crutches (or wheelchair)
ANALGESICS
ORIF (7-10 days after to allow for swelling to resolve)
209
pts often have what even if have ORIF for calcaneus fx?
chronic heel pain
210
what are the 2 patterns of 5th metatarsal fractures?
Avulsion fx
Jontes fx
211
what is a 5th metatarsal avulsion fx?
fx of base of 5th metatarsal from pull of peroneus brevis
212
how does 5th metatarsal avulsion fx occur?
Forcible inversion of foot in plantar flexion (same mechanism as an ankle sprain), as may occur while stepping on a curb or climbing steps
Force pulls at insertion of peroneus brevis
213
tx of 5th metatarsal avulsion fx?
treated conservative and heal well
for large or very displaced fragment with intra-articular extension may need surgery
214
mechanism of 5th metatarsal fx?
fall, inversion injury resulting from mis-steps
215
what is a jones fracture?
this is a BAD fracture
transverse fx at base of 5th metatarsal, 1.5-3cm distal to the proximal tuberosity at the metadiaphyseal junction
216
what is a jones fracture so bad?
can interrupt the blood supply so almost always fixed with surgery
217
the 5th metatarsal base is the insertion of what muscle?
peroneus tertius
218
how does jones fx occur?
as a result of significant adduction force to the forefoot with the ankle in plantar flexion
219
jones fx's are prone to what that avulsion fx's aren't?
non-union (takes longer than 2 months to heal)
220
tx of jones fx
immobilization with a non-weight bearing cast for 6-8 weeks
internal fixation/bone grafting in cases of non-union or if fx significantly displaced
221
what is plantar fasciitis?
inflammation of a the plantar fascia (thick band of tissue) that connects the calcaneus to the toes
222
plantar fasciitis risk factors?
obesity
pes planovalgus orientation (flat feet)
reduced dorsiflexion (tight heel cords)
223
plantar fasciitis commonly seen in?
runners (or people that stand a long time)
224
sx's of plantar fasciitis
Sharp volar sided heel pain of moderate to severe intensity
Normal gait but may limp as pain worsens
***Will report that pain is worse "first thing in the morning when I get out of bed" -> KEY!!!
Pain reduces as pt. ambulates around for a bit
225
what is a key sx of plantar fasciitis?
pt reporting that pain is worse "first thing in the morning when I get out of bed"
226
PE of plantar fasciitis
TTP at origin of plantar fascia on the calcaneus
Pes planovalgus orientation (flat feet) seen on exam of stance
Tight Achilles' with active/passive dorsiflexion of ankle
227
imaging for plantar fasciitis
weight bearing studies of foot to assess for spurs, loss of arch, and to r/o stress fx
228
tx of plantar fasciitis
night splint, ice, NSAIDs, PT
corticosteroids injection used with caution (may cause fascial rupture)
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what must you warn pts with plantar fasciitis about with corticosteroid injection tx?
that it may cause fascial rupture
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risk factors for Achilles' tendon rupture?
"weekend warrior"
***Fluoroquinolone use
Steroid injections
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what is the mechanism of Achilles' tendon rupture?
usually traumatic injury during sporting event
- sudden forced plantar flexion
- violent dorsiflexion in a plantar flexed foot
-occurs 4-6 cm above the calcanea insertion in hypo vascular region
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what will pt report for Achilles' tendon rupture?
a "pop"
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sx's of Achilles' tendon rupture?
weakness and difficulty walking
pain in heel
can't get up on heel of affected foot
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PE of Achilles' tendon rupture
Palpable defect -> can feel it
+Thompson test -> weak/no ankle plantar flexion
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U/S for Achilles' tendon rupture?
to determine partial vs. complete year
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when use MRI for Achilles' tendon rupture?
if exam equivocal or if chronic rupture
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what test is used to evaluate the integrity of the Achilles' tendon?
Thompson's test
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positive findings of Thompon's test?
no plantar movement occurs at the foot -> indicates Achilles' tendon rupture
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non-operative tx of Achilles' tendon rupture
- Patient/surgeon preference
- Sedentary/Frail patient
- Put in boot with elevated/padded heel to take stress off the tendon
- Decreased plantar flexion strength results
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operative tx of Achilles' tendon rupture
- "end to end" Achilles' repair
- For acute ruptures
- New Level 1 evidence has suggested no difference in re-rupture rates
- Increased plantar flexion strength compared to non-operative management
