Ortho- lower extremity Flashcards
Anterior Cruciate Ligament Injury- pathophysiology
ACL connects posterior aspect of femoral condyle to anterior aspect of tibia
- controls anterior tibia on femur and rotational stability
Bones twist in opposite directions under full body weight
Anterior Cruciate Ligament Injury- cause
Non-contact deceleration -> valgus twisting
Hyperextension
Marked internal rotation
Pure deceleration
Anterior Cruciate Ligament Injury- epidemiology
F>M
Common - soccer, basketball, football, skiing
Anterior Cruciate Ligament Injury- S/S & PE
S/S:
- pop
- immediate effusion
- Difficulty/Can’t weight bear
- Unstable
Exam:
- Lachmans
- anterior drawer
- Lever sigh
Anterior Cruciate Ligament Injury- diagnosis
MRI w/ out contrast
Anterior Cruciate Ligament Injury- labs & imaging
Xray - NOT diagnostic - will show effusion
Anterior Cruciate Ligament Injury- treatment
Young/active + complete tear - surgery
- autograft - own patellar or hamstring tendon
- allograph - cadaver
Older/sedentary OR partial tear - conservative
- PT to strengthen hamstrings
- bracing
Bracing? - debated - remain weight bearing if possible!!
- to protect other structures - inc risk of 2nd meniscus injury
- acute - knee immobilizer and crutches
- Subacute/chronic - hinged brace
Rice
Pain control
Refer Orther
Posterior Cruciate Ligament Injury- pathophysiology
PCL - strongest ligament in knee
Sprains or partial tears more common
Associated w/ injuries - ACL and MCL tears
Posterior Cruciate Ligament Injury- cause
Blow to knee while flexed
- striking knee against dashboard
- falling on a bent knee
Posterior Cruciate Ligament Injury- S/S & PE
S/S:
- swelling IMMEDIATE and PROFOUND
- Severe pain
- Limited ROM
- instable - unable to move
Posterior Cruciate Ligament Injury- diagnosis
Sag sign - tibia posteriorly set off
Posterior draw test - positive
MRI
Posterior Cruciate Ligament Injury- treatment
Refer Ortho
RICE, pain control, immobilization w/ crutches
Isolated PCL tear - treated non-op w/ PT
W/ other injuries - surgery
Medial Collateral Ligament injury- pathophysiology
Most commonly injured
w/ ACL
Extra-articular - joint effusion LESS COMMON
Medial Collateral Ligament injury- cause
Valgus stress on partially flexed knee
Medial Collateral Ligament injury- S/S & PE
S/S:
- Focal pain over ligament
- Minor swelling
- Limited ROM - improves w/in 2w
Medial Collateral Ligament injury- diagnosis
Valgus stress exam
MRI - doesn’t need to happen acutely
Medial Collateral Ligament injury- treatment
Graduated weight bearing Bracing - minor -hinged - sever -immobilizer PT 6-8 weeks of healing Isolated - Rarely need surgery
Meniscus injuries- pathophysiology
“Shock absorbers”
Very common injury
Acutely or degeneration
Meniscus injuries- cause
Internal rotation of femur on tibia w/ flexion knee
- posterior meniscus b/t femur and tibia
Sudden extension - external rotation
- lateral meniscus
Partial or complete tear
Posterior or anterior horn tear
Longitudinal or bucket handle tear
Meniscus injuries- S/S & PE
S/S: - catching, locking, clicking - Painful walking and squatting - Mild to mod joint swelling - JOINT LINE TENDERNESS - lock in extension - piece of menis obstructing joint Exam - McMurray
Meniscus injuries- diagnosis
MRI w/ out contrast
Meniscus injuries- labs & imaging
Xray - nl, but may show joint space narrowing or effusion
- more helpful if hx or OA
Meniscus injuries- treatment
“Degenerative tears - PT
Acute tears - arthroscopic meniscus repair or debridement “
Knee Dislocation- pathophysiology
Dislocation of tibiofemoral joint of knee
ORTHO EMERGENCY
Many present already reduced!
To dislocate - at least 3, if not 4, major knee ligaments are torn
Anterior - most common
Posterior, lateral, medial
Popliteal artery - partial or complete disruption in 40%
Peroneal nerve - 23% injured
Knee Dislocation- cause
Multi-trauma
High-energy trauma
- Hyperextension - anterior dislocation
- anterior blow - posterior desolation: dashboard
Knee Dislocation- S/S & PE
Gross deformity - if not reduced
LARGE effusion
SIGNIFCANT pain- can’t weight bear
MUST EVAL FOR NEUROVASC
- palpable distal pulses - DOES NOT exclude vascular injury
- MUST DO ABI
- assess sensation and strength
ABI - Systolic BP in LE - ankle - Systolic BP in UP - brachial - >.9 - monitor w/ serial exams -
Knee Dislocation- labs & imaging
Xray - AP and lateral
- obtain even if reduced - tibial plateu fracture
CT arteriogram - GOLD
Arterial duplex US
- both eval popliteal artery
- not always indicated -> if ABI
Knee Dislocation- treatment
IV pain control
Reduce - even if has vascular injury
- then reassess
Post reduction xray
Splint - long leg w/ 20–30-degree flexion
Admit for pain control - serial exams w/ortho consult
Knee Dislocation- prognosis
Require MRI after swelling reduced - will likely need surgery
Complications are frequent
Rarely go back to pre-injury state
Knee Dislocation- complications
Complications - limb ischemia, permanent nerve damage, compartment syndrome, arthrofibrosis (most common)
Knee Bursitis- pathophysiology
Bursa becomes irritated - produced too much fluid
-> swelling and puts pressure on adjacent parts
Pre-patellar - most common
- Housemaid’s knee
Knee Bursitis- S/S & PE
S/S:
- swelling and tenderness over bursa
- become infected -> erythema, warmth
Knee Bursitis- diagnosis
Clinical
Knee Bursitis- treatment
NSAIDs
RICE
No pressure over patella
Refractory - prepatellar bursa injections - corticosteroids
Knee Osteoarthritis- pathophysiology
3x more common than hip
Chronic progressive knee pain
- medial more affected
Knee Osteoarthritis- epidemiology
> 65
Knee Osteoarthritis- S/S & PE
S/S:
- Morning stiffness <30min
- Crepitus
- Mild effusion
- Pain relieved w/ rest
- Severe - Genu Valgum or Genu Varum
Knee Osteoarthritis- diagnosis
Xray - joint space narrowing, osteophytes
Knee Osteoarthritis- treatment
Conservative - weight loss, graded exercise
APAP and NSAIDs
Intra-articular Corticosteroid - short term relief
- doesn’t improve quality of life -> greater cartilage loss
Synvisc - intra-articular viscosupplementionation
- mixed date
Platetet-Rich plasma injections - mixed
Total or partial knee replacement
Patella Subluxation & Dislocation- pathophysiology
Very common
Medial or lateral - more common
Patella Subluxation & Dislocation- cause
Direct blow to side of knee
Patella Subluxation & Dislocation- S/S & PE
Pain, swelling, deformity
Limited ROM - locked in extension
Patella Subluxation & Dislocation- diagnosis
Xray - sunrise view
Patella Subluxation & Dislocation- treatment
Reduction - apply pressure while extending knee Immobilization short-term PT - quad strengthening 1st time - no surgery Recurrent - surgery
Patella Fracture- cause
Direct patellar impact
- dashboards
- fall onto flexed knee
Patella Fracture- S/S & PE
Significant swelling
Focal pain - will bruise
Patella Fracture- diagnosis
Xray - AP, Later, SUNRISE VIEW
- multiple fracture types
- important to examine and document - intact extensor mechanism
Patella Fracture- treatment
Refer Ortho
RICE
Pain Control
No surgery - extensor mechanism intact, nondisplaced fx, vertical fracture
- Extension bracing WITH WEIGHT BEARING
Surgery - extensormechanism failur, open fx, displaced fx, comminuted fx
- ORIF
Patella Fracture- Bipartite Patella
Bipartite Patella
- patella composed of 2 bones, seen bilaterally
- If separate while bending knee - pos for bipartite
Patellar Tendon Rupture- pathophysiology
Not common
Patellar Tendon Rupture- cause
Sudden quadriceps contraction with knee in a flexed position
- jumping
Patellar Tendon Rupture- S/S & PE
Pain, swelling
ELEVATION OF PATELLA
Patellar Tendon Rupture- diagnosis
Xray - patella displacement
MRI
Patellar Tendon Rupture- treatment
Refer Ortho
Complete tear - surgery
Partial - splint and watch
Chondromalacia/Patellofemoral syndrome- pathophysiology
Runnes Knee
Damage to undersurface cartilage of patella - sec to poor patellar tracking
Risk for lateral patella subluxation
Chondromalacia/Patellofemoral syndrome- epidemiology
W>M
adolescents/YA
Chondromalacia/Patellofemoral syndrome- S/S & PE
Chronic, anterior knee pain - inc when going upstairs and/or squatting No effusion Grand test Apprehension test
This causes knee to be unstable - will come in because of dislocation
Chondromalacia/Patellofemoral syndrome- diagnosis
Xray - AP, lateral, SUNRISE (bilateral)
- Patella alta/baja or lateral patella tilt
MRI - cartilage damage
Chondromalacia/Patellofemoral syndrome- treatment
NO surgery - 1st line
- NSAIDs
- PT
Surgery - persistent/progressive
- PT failed after 1y
- Arthroscopic debridement
- Patellar realignment surgery
Tibial Plateau fracture- pathophysiology
Fracture of proximal tibia - intra-articular
Tibial Plateau fracture- cause
Higher energy injury
- other ST injuries
Valgus or vaus twist with axial loading
Trauma
Tibial Plateau fracture- S/S & PE
Severe pain
Swelling
Tibial Plateau fracture- diagnosis
Xray - eval proximal and distal tibia
- can miss this fracture
CT - if high suspicion
Tibial Plateau fracture- treatment
Pain control
Consult ortho
No surgery - no to min displacement
- hing brace, crutches
Surgery - displaced, comminuted, open
- ORIF
Tibial Plateau fracture- prognosis
Complications
- Peroneal nerve injury - foot drop?
- MRI for ST injury - ACL and meniscal tear
- Compartment syndrome
Tibial Shaft fracture- pathophysiology
Common
Tibial Shaft fracture- cause
Torsional injury
Direct blow
Tibial Shaft fracture- diagnosis
Xray
Tibial Shaft fracture- treatment
No surgery - no to min displacement
- hing brace, crutches -> watlking cast
Surgery - displaced, comminuted, open
- splint w/ crutches -> ORIF
Fibula Shaft Fracture- pathophysiology
Fibula - no weight bearing bone
Fibula Shaft Fracture- diagnosis
Xray - visualize entire bone
Fibula Shaft Fracture- treatment
Splint -> cast
Weight bear just fine
Ankle Sprain- pathophysiology
Most common reason to miss athletics
Inversion - most common
High ankle sprain - <10%
- syndesmosis injury - tibiofibular and interosseous ligaments
Low ankle sprain - >90%
- anterior talofibular ligament (ATFL)
- Calcaneofibular ligament (CFL)
Ankle Sprain- S/S & PE
Anterior draw
Talar tilt
Ankle Sprain- diagnosis
Should you xray? - way over ordered Ottawa Ankle rules: - inablitiy to bear weight - medial, lateral malleolus point, bony tenderness - 5MT base tenderness - Navicular tenderness
MRI - ligamentous injury
Ankle Sprain- treatment
RICE
Immobilization - w/ weight bearing
Early ROM and reture - 2w low, several w high
Surgery - complete or recurrent sprain/instability
Malleoli Fracture- pathophysiology
Distal tibia fracture
- can be inconjunction w/ fibula
Bimalleolar - medial and lateral
Trimalleolar - medial, lateral, posterior
Malleoli Fracture- treatment
Isolated <3mm displacement - ortho refer, walking boot 6-8w
Displaced, comminuted, open - surgery
Achilles Tendon Rupture- pathophysiology
Largest tendon in body
Achilles Tendon Rupture- cause
Trauma
Abrupt
Weekend warrior
Achilles Tendon Rupture- epidemiology
M
30-40
Achilles Tendon Rupture- S/S & PE
Felt like shot in the foot, big pop
Thompson test
Achilles - feels soft
Achilles Tendon Rupture- diagnosis
Xray - eval for bony injury
MRI - TOC
Achilles Tendon Rupture- treatment
Refer ortho
Surgery - sooner the better
Splint, crutches, pain meds
- may need hosp to control pain
Phalangeal Fractures- pathophysiology
very common
Phalangeal Fractures- treatment
Rarely surgery
Buddy tape + hard soled shoe
5th Metatarsal Fracture- pathophysiology
Very common
Dancer’s fracture
5th Metatarsal Fracture- cause
Forced inversion during plantar flexion
5th Metatarsal Fracture- treatment
Stress fracture - distal - no weigth bearing Jones - middle - no weight bearing Avulsion (Pseudo Jones) - weight bearing ok
No surgery - stiff soled shoe
- 1-4
Surgery - open fractures, displacement of 1st or multiple fractures
Plantar Fasciitis- pathophysiology
Inflammation of aponeurosis at origin on the calcaneus
- chronic overuse -> microtears
Plantar Fasciitis- epidemiology
Obesity
Dec dorsiflexion in a non-athletic population
Weight bearing endurance activity
Plantar Fasciitis- S/S & PE
Sharp heel pain
- stepping out of bed - worse at end of day
- bilateral
Plantar Fasciitis- diagnosis
Clinical
- pinpoint tenderness
- dorsiflexion of toes - foot inc tenderness w/ palpation
Plantar Fasciitis- treatment
Stretching
NSAIDs
arch support
Hammer Toe- pathophysiology
Flexion deformity of PIP w/ extension of DIP
Hammer Toe- cause
High heals
Hammer Toe- diagnosis
Clinical
Hammer Toe- treatment
No surgery - wide shoes, padding/splinting
Refer Podiatry
Corns and Calluses- pathophysiology
Toughened area of skin - relatively thick and hard due to repeated friction, pressure, other irritation
Corns and Calluses- S/S & PE
Corn - painful, small, hard center
Callus - larger, non-painful
Corns and Calluses- treatment
File
Padding
Bunions- pathophysiology
Hallux valgus
Pressure on lateral MCP joint - causes metatarsal head displaced medially -> bone deformity
Bunions- epidemiology
Genetic
Bunions- S/S & PE
Slow onset
Can be painful
Bunions- treatment
Wide shoe
Pain control
Refer podiatry - surgery?
Ingrown Toenail- pathophysiology
Nail grows - cutting into one or both sides of paronychium or nail bed
Ingrown Toenail- S/S & PE
Painful
Infected?
Ingrown Toenail- treatment
Warm water soaks
Abx ointment
well-fitting shoes
Nail lifting or removal
