Orthopedic Conditions of the Lower Extremity Flashcards
a. 55 yo female comes in with c/o R sided hip pain x 3 months.
i. What could this possibly be? (Differential?)
Best way to start is think about the anatomy and start asking your history questions.
What do you want to know? Duration, location, radiation, severity, onset, trauma
Trochanteric bursitis
Pain and tenderness over the greater trochanteric bursa.
Pain often worse when first rising from a seated position and may feel better after taking a few steps.
iii. Patients often cannot lie on the affected side due to pain.
what would you see on PE of trachanteric bursitis
Point tenderness over lateral greater trochanter. May have some discomfort with external rotation of hip
dx test for trochanteric bursitis
Xray (why?) (What do you order? AP and lateral)
need to rule out AVN AP lateral (frog leg) needed
TX trochanteric bursitis
NSAIDS
Physical therapy (what should they stretch - IT band, quads, hamstrings), Injection of local anesthetic and corticosteroid
if NSAIDS and physical therapy fail with tranchteric bursitis
Usually mix approx 1-2 ml of corticosteroid with 8-9 ml of local anesthetic (I personally like Kenalog 40/0.5 Marcaine/1% Lidocaine)
Target area where patient is most point tender
have pt of lateral decubitus position
Might be worth repositioning needle and working it around the area to find other “hot spots” using technique described above
when would we see therapeutic effect of corticosteroids
Takes about 2-3 weeks for cortisone’s full therapeutic effect
Snapping Hip Syndrome
MC area
Snapping sensation that occurs as tendons move over bony prominences (NOT as common)
w/ rotation of the hip or walking
- Most common IT band snapping over greater trochanter
IT band is inflamed
Pt’s can hear an audible snap as they are walking and flexing their hip
PE for snapping hip syndrome
Palpate the snapping sensation over lateral aspect of hip as patient adducts and rotates the hip
dx and treatment of snapping band
XR Treatment NSAIDS Physical Therapy- stregthen and lengthen those areas Possible Injection
e. Osteoarthritis of the hip pathophysiology and causes
i. Loss of articular cartilage in the hip joint
genetic
infection
trauma- fxs in the joint surface that affects the cartilage or your blood supply is compromised
classic presentation of hip arthritis
groin pain
mostly at night but this is pretty common
can have limitations in the motion sof the hip
PE of osteoarthritis of the hip
Loss of internal rotation (early sign) can progress to loss of flexion and extension
o Antalgic gait
o Do they use any ambulatory device? Walker or cane. Really hard for pt’s to put on socks or shoes if hip issues
dx tests for osteoarthritis of the hip
Xray look for joint space narrowing, osteophytes, cyst formation or sclerosis of bone (bone starts to lay out more bone so it will look highlighted)
AP and Lateral
these are super common and you are looking for that compromise of the joint space
Osteonecrosis (AVN)
Death of trabecular bone in femoral head
Tx for OA of the hip
NSAIDs
Therapeutic Arthrogram (cortisone injection guided by fluoroscopy - not beneficial for severe arthritis)
Total Hip Replacement (10-15 yr lifespan)
when would you not do Therapeutic Arthrogram for OA
moderate to severe because it’s not beneficial have to really push with Kaiser
at what stages of life do we typically see AVN
iii. Occurs with greater frequency in third through fifth decade.
common associated history with AVN
Associated with history of trauma, alcohol abuse, corticosteroid use, rheumatoid arthritis or lupus (systemic lupus erythematosus)
ETOH
CORTICO
TRAUMA
Most common .
PE with AVN
Pain with either internal/external rotation and/or abduction of hip
Typically gradual onset but can be acute onset
DX of AVN
Xray findings include sclerosis of femoral head í “mothy” appearance, the head is not smooth
DEFINITIVE TEST: MRI of bilateral hips to confirm diagnosis if unclear from Xray findings –>the head just looks black
TX for AVN
” Typically Total Hip Replacement
Very often confused with “hip pain”
low back pain
classic presentation whit low back pain
Pain that radiates down the leg and starts in the low back and/or gluteal area often d/t sciatic nerve irritation
TX for low back pain
NSAIDs and Physical Therapy often initial advice for treatment.
New Knee pain patient - thought process:
i. Mechanism of Injury
ii. Age of patient
iii. Length of symptoms
iv. Previous trauma
v. Previous conservative treatments
vi. Previous surgery
categories of knee pain
i. Osteoarthritic picture
ii. Soft tissue injury: ligament, cartilage, muscle
iii. Other category: dislocation, fracture, etc.
iv. History questions will get you started to your ultimate diagnosis…
i. Most common form of knee arthritis
d. Osteoarthritis
ii. Wear and tear of cartilage, often cumulative over time.
1. “ Bone on bone”
iii. Most common condition I see in clinic for patients over age of approx 40 years old.
HX of pt with knee OA
v. History may include symptoms of joint line pain, feeling of instability, pain @ nighttime and swelling.
vi. Patients may also present with swelling in knee and lower extremity.
vii. Often no single incident can be related back to the start of symptoms.
PE with knee OA
” Tenderness to palpation along joint line
“ Pain with extremes of motion- often can be limited d/t swelling.
“ Varus or valgus deformity to the knee
“ Crepitus with extension of knee may indicate patellofemoral compartment involvement.
DX test of knee OA
Xrays
o Standing AP, sunrise (merchant) views and lateral of affected side
o 3 compartments to knee: medial, lateral and patellofemoral
Findings: Joint space narrowing in one or more of the 3 compartments
medial joint narrow more common than lateral becuase of weight bearing
o Also have associated osteophytic changes (bone spur), sclerotic areas or cyst formation
when would we get an MRI for OA of knee
o Not usually necessary unless suspect soft tissue involvement ie: meniscal or ligament
what do we need to check beofre giving injection for knee OA
how often
A1C!
i. Injection of liquid anti-inflammatory into knee joint
ii. Can give months of pain relief
iii. Space injections out every 3-4 months
iv. Strict sterile technique
c. Hyaluronic Acid Injections CI
cannot give to pt’s allergic to eggs or sulfa (viscosupplementation)
Oral supplementation for OA
Glucosamine: found naturally in the body. Stimulates the formation and repair of articular cartilage. remember this is grade A for knee OA
Chondroitin sulfate: also found naturally in the body. It prevents other body enzymes from degrading the building blocks of joint cartilage.
Studies not conclusive, but patients often thinks it helps. Surgeons seem to like it.
Will not prevent osteoarthritis.
tx for knee OA
NSAIDS Injection brace phys therapy active modification
Bracing for OA
best for medial comaprtment arthritis unloading braces: mechanically create more space in joint where cartilage has worn away.
a. C-shaped fibrocartilagenous disks between tibia and femur
i. Meniscus
which miniscus has less mobility
why is this important
Medial meniscus less mobility than lateral meniscus
why is this important? b/c more likely tear since less mobile
when do we see the development of meniscus tears
ii. Rare in childhood, typically occur in late teens to third and fourth decade.
after 50 meniscal tears more often are d/t
iii. After age of 50, meniscal tears more often d/t arthritis than trauma.
common symptoms for meniscus tear
Common symptoms: joint line pain, sensation of catching in joint, popping or locking.
Patients will often have swelling or pain after activity.
Lockman’s is the most effect test for
ACLv.
typically mechanism of injury with meniscus tear
Mechanism of injury often a twisting type incident- although with degenerative tears not always the case.
PE for meniscus test
” Often tenderness to palpation along the joint line.
“ McMurray’s test: pain and popping with maneuver considered “positive” test
“ Deep squatting may also illicit pain.
“ May have pain at end ranges of motion on exam
diagnositc for mensicus tear
” Xray
o Knee series including obliques to r/o fracture if hx of trauma
o For patients over age of 40, I like to get AP standing and sunrise or merchant views of the knee (show joint space)
“ MRI
o Most useful diagnostic test to confirm diagnosis
ix. Treatment for meniscus tear
- Wide anatomical range of meniscal tears (don’t need to know)
a. Bucket handle tear, flap tear, radial tear, complex tear, degenerative tear - Pain often occurs when meniscal tissue becomes caught or stuck in the joint.
- Can have a locked knee from meniscal tear: often receive same day or same week surgery.
operative treatment for meniscus
a. Arthroscopy with meniscal tissue debridement
b. One of the most common operations that I consent patients for @ Kaiser
operative tx for meniscus
a. Small stable asymptomatic tears not always necessary to treat with arthroscopy (example: degenerative tears)
b. Rest, NSAIDs, and Physical Therapy
i. Corticosteroid injection often used w/ NSAIDs
anatomy of knee ligaments
- Collateral Ligaments: medial and lateral
a. MCL, LCL - Cruciate Ligaments: anterior and posterior
a. ACL, PCL
valgus stress is the mechanism of injury for what tear
iii. MCL injury
LCL mechanism of injury
varus stress
ACL tear mechanism of injury
see commonly in what decade of life
foot planted solidly with twisting mechanism
- Increased incident in third decade of life
- Acute hemarthrosis
not commonly seen PCL but what mechanism of injury is common
car accidne
Posterior drawer
“ Losee’s Test or Pivot Shift best for assessing
pcl
Anterior drawer and Lachmans best for
ACL
lachmans is absolute best
varus and valgus stress help evaluate
collateral ligaments
” Losee’s Test or Pivot Shift
demonstrates instability associated with ACL tear
diagnostic for ligament tears
Xray: always order one
o If history of trauma need at least oblique views as well as AP and lateral (typically NWB) to r/o fracture
o If patient is over 40 years old I often like standing AP and sunrise (merchant) view- why?
“ MRI: most useful for confirming soft tissue injuries such as ligaments or meniscus
“ Arthroscopy: MRI not always correct, if there is still pain in the knee despite conservative treatment the surgeon may recommend diagnostic arthroscopy
- Isolated Collateral Ligament Injuries tx
a. Typically non operative: gentle ROM, physical therapy, bracing
b. For combined injuries (ACL and LCL) operative repair
c. Partial tears usually heal on their own
Patellofemoral Syndrome tx
” NSAIDs, Physical Therapy, Bracing, Orthotics
QUAD strengthening
vastus medialis
inner most quad aspect
lengthen out hip flexers so everything functions
patellofemoral syndrome seen as
- Anterior knee pain worse after prolonged sitting, climbing stairs, jumping or squatting.
- May have associated grinding or clicking sounds with knee extension (crepitus)
what population do we see Patellofemoral Syndrome in
- Seen this in young adults to early 20’s (esp females) to older adults.
- Pain is often d/t tracking of patella within the femoral groove
dx for patellofemoral syndrome
” Xray- sunrise view of patella (merchants).
“ Often see lateral tilting to patella on Xray and/or lack of joint space in patellofemoral compartment
- ACL tear (rupture) Tx
a. Operative treatment: ACL reconstruction with either autograft or allograft
b. Non operative treatment: gentle ROM, physical therapy, bracing
- PCL tear (rupture) TX
a. Typically non operative since in a risky area (all the vasculature and nerves run there)
ii. Patellar Dislocation
reduce
get an XRAyY
strict immobilization via cylinder cast or knee brace
c. Discontinue cast after appropriate time and move to a hinge-type brace that allows limitation in motion and start gradually ROM work with Physical Therapy
PE with patellar dislocation
a. Tenderness over medial retinaculum
b. Pain and apprehension when patella is pushed laterally on exam
i. Apprehension test
associated injury with patellar dislocation
- May be associated with avulsion fracture along medial aspect of patella- get an X-ray!
Pes Anserine
a. Medial aspect of the tibia, where hamstring tendons insert.
seen with bursitis of the knee
tx with Bursitis of the Knee
i. Typically conservative
1. Injection of corticosteroid into affected area
2. NSAIDs
3. Rest
4. Compression
causes and repercussions of Bursitis of the Knee
b. Overuse activities such as running can cause inflammation of bursa
c. Osteoarthritis associated with inflamed and tender bursa
a. Lies between patella and skin
Prepatellar (Housemaid’s Knee)
b. Dome shaped swelling over patellac. Treatment
c. Treatment Prepatellar
i. Typically conservative
1. NSAIDs
2. Rest
3. Compression
4. May consider aspirating pre patellar bursitis if swelling is impeding ROM and causing a lot of pain (using strict sterile technique)
5. Typically inject corticosteroid after aspiration to assist with swelling/inflammation
- Quadriceps rupture seen most frequently in
occur more frequently in patients over 40.
- Quadriceps rupture will be seen with what PE finding
a. Inability to extend knee on physical exam
i. If your quadriceps tendon ruptures, your knee cap will flow down
b. Patella may be sitting low
c. Surgical repair often indicated
Tx FOR quad rupture
Surgical repair often indicated
Patellar Tendon Rupture seen most commonly in
occur more frequently in patients under 40
Patellar Tendon Rupture
a. Inability to extend knee on physical exam
i. If your patellar tendon ruptures, your knee cap will float up since nothing present to tether it down
High riding patella, palpable defect beneath patella
Cannot extend the knee from flexed position
Cannot do a straight leg raise
