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
