Ortho - Lower limb Flashcards
48 year old ex-athlete has 2 years of bilateral knee pain/ Pain at rest, tried analgesics and CS injections but no benefit. Unable to perform ADLs.
a) Give 4 possible XR findings
b) Management
a) LOSS: loss of joint space, osteophytes, subchondral sclerosis, subchondral cysts
b) Bilateral knee replacement. (due to failure of conservative management, severe symptoms and severe impact on QoL)
30 year old ultra marathon runner presents with pain in the lateral knee.
a) What is the most likely diagnosis?
b) What is the mechanism of injury?
c) What examination findings would support this diagnosis?
d) Management
a) Iliotibial band syndrome (ITBS)
b) Repetitive friction of the distal part of the IT band over the lateral femoral condyle, causing inflammation. Especially associated with running, cycling and hiking
c) Lateral femoral condyle tenderness. Pain on squatting (impingement on knee flexion).
Note: normal on imaging
d) Management: NSAIDs, RICE, physiotherapy, activity modification
c)
Meniscal tears.
a) Causes
b) What is the unhappy triad?
c) Test for meniscal damage
d) Presentation
e) Management (rehabilitate, removal and repair)
f) How many menisci are in the knee and what is their function?
a) Twisting/pivoting injury when fully weight bearing e.g. while squatting (usually acute).
b) ACL, MCL and medial meniscal tear. May be due to valgus stress to extended knee (e.g. rugby tackle)
c) McMurray test: flex knee, internally rotate and extend gradually. Then repeat for external rotation. Positive: pain response
d) Acute pain, popping, catching, locking (especially in flexion - could be loose floating meniscal cartilage), joint line tenderness.
- May be swelling due to effusion (note: if large effusion, may also be ACL tear)
e) - MRI
- Referral to acute knee clinic
- Conservative: PRICER - protect, rest, ice, compression, elevation, rehabilitation (physio)
- Surgery - if locking / acute severe/ failure of conservative management/ severe functional limitation
f) Two - lateral and medial meniscus (both crescent/semilunar shaped). Cartilaginous structures that reduce friction and act as shock absorbers by spreading the load through the knee during flexion and rotation.
NOF: classification
Intracapsular: further classified by Garden staging
1/2 - non displaced (1 = partial fracture and 2 = complete fracture)
3/4 - displaced (3 = partial displacement and 4 = complete displacement)
Extracapsular: either intertrochanteric or subtrochanteric
NOF: presentation
a) History/ symptoms
b) Signs o/e
a) Fall (usually elderly, low impact) or trauma. Pain, unable to weight bear
b) Shortened and externally rotated leg. Unable to weight bear or SLR. Pain on rolling and any other movement
NOF: Management
a) Immediate
b) Surgical (Fix or replace)
a) - A-E, full neurovascular examination (usually normal in NOF), analgesia
- AP and lateral pelvic XR (if unclear, MRI)
- Bloods: FBC, UEs, group and save, coagulation, créatine kinase (if long lie time)
- Other Ix: ECG, urine dip, CXR (as required)
- Treat comorbidities: nutrition, delirium, infection, CV disease, VTE prevention, etc.
b) - Intracapsular, non-displaced (Garden 1-2): ORIF with cannulated screws (if young and fit) or hemiarthroplasty if old and poor morbidity
- Intracapsular, displaced (Garden 3-4): THR (if otherwise pretty fit and well), hemi if poor morbidity, possibly ORIF with cannulated screws in young and fit
- Intertrochanteric - DHS
- Subtrochanteric: IM nail
THR vs hemiarthoplasty
a) Explain the difference
b) What is the guidance currently
a) THR - replace femoral head (ball) and acetabulum (socket). Hemiarthroplasty: just replace femoral head
b) THR for patients with a displaced intracapsular fracture who (if non-displaced, fix it):
- Are able to walk independently out of doors with no more than the use of a stick; and
Are not cognitively impaired; and
Are medically fit for anaesthesia and the operation
(otherwise, hemiarthroplasty)
Internal and external fixation.
ORIF - open reduction and internal fixation
ExFix - eternal fixation via frame (eg Ilizarov frame) - useful for open or complex fractures (e.g. tib-fib) where infection risk is high
NOF: complications
- Intracapsular fracture: may lead to rupture of medial circumflex femoral artery, which can lead to AVN of femoral head
- Immobility leading to frailty, infection, VTE, pressure sores
NOF: risk factors
Risk of falls:
- Increasing age
- Comorbidities
- Cognitive and sensory impairment
- Lack of strength
- Movement disorder, gait instability (eg. Parkinson’s)
- Postural hypotension
- Medications (diuretics, antihypertensives, sedatives)
- Alcohol and drugs
Risk of fracture on falling:
- Increasing age.
- Osteoporosis.
- Osteomalacia and vitamin D deficiency.
NOF: mortality score
Nottingham hip fracture score
Knee trauma: Ottawa knee rules for XR
- any one of the following… (WAIT)
WAIT, get an X-ray of knee if:
- Weight bearing for 4 steps not possible – immediately and in ER
- Age ≥55 years (possible osteoporotic fracture)
- Inability to flex knee to 90 degrees
- Tenderness isolated to patella or head of fibula
What are the simple 6 fractures? (Donny ED)
- 5th metacarpal neck #
- Base of 5th metatarsal #
- Buckle # wrist
- Paediatric clavicle #
- Proximal radius #
- Toe # or dislocation
Acute knee pain: Indications for assessment at acute knee clinic/fracture clinic/ED
(Any of 6 features)
- A sensation of a ‘pop’ or ‘snap’.
- Rapid swelling (suggestive of ligament injury [esp ACL], fracture or dislocation).
- Inability to complete the activity.
- Instability.
- Locking.
- Giving way.
Ligaments of the knee.
a) ACL - function? Mechanism of injury?
b) PCL - function? Mechanism of injury?
c) MCL - function? Mechanism of injury?
d) LCL - function? Mechanism of injury?
a) Prevents forward movement of the tibia/ over-rotation.
- Injured in rotational /pivoting injuries on standing leg, usually non-contact (often land and sudden change of direction; football, basketball and skiing)
b) Prevents forward movement of the femur.
- Injured in dashboard injury or fall on flexed knee
c) Prevents lateral movement of the tibia when valgus stress is applied (away from midline).
- Injured in lateral stress or rotational injuries (often in combination with ACL and medial meniscus)
d) Prevents medial movement of the tibia when varus stress is applied (towards the midline)
- Injured in medial stress (rare) or runner twisting on side of planted foot
