Regional Adult Orthopaedics: Pelvis and Lower Limb Master Deck Flashcards
Presentation of pathology pain?
Typically, produces pain in the groin which may radiate to the knee (both supplied by the obturator nerve)
May also cause buttock pain (this must be differentiated from lumar spine and SI joint pathologies)
May present purely as knee pain, part. SUFE
Other causes of groin pain?
Hernia (inguinal or femoral)
Tendonitis (esp. adductor tendonitis)
Pubis symphisis dysfunction
High lumbar disc prolapse (with L1/2 radiculopathy) - rare
Examination findings with hip pathology?
Reduced ROM with LOSS OF INTERNAL ROTATION (often the 1ST SIGN)
+ve Trendellenburg test (weakness of the abductors, gluteus medius and minimus, due to altered hip mechanics or weakness from chronic disuse)
Shortened lower limb (seen in severe OA, Perthes disease, SUFE or AVN/fracture)
Difference between total hip arthroplasty and total hip replacement?
Almost synonymous, except THA is a broader term that inc. hip resurfacing
How long do hip replacements last?
Loosening of one/more of the prosthetic components
In a low-demand elderly patient, the cup can last 15 years and the stem 20 years
How does THR loosening occur?
Wear particles from the bearing surface cause an inflammatory response at the interface; macrophages release inflammatory mediators that stimulate osteoclasts to resorb bone
Conservative measures for hip arthritis?
- Simple analgesics and physio
- Stick use (reduces force on the joint)
- Weight reduction
- Modified activities
If these fail to work, THA can be considered
Early local complications of hip surgery?
Infection
Dislocation
Sciatic nerve injury
Leg length discrepancy
Early general complications of hip surgery?
Medical comps. from surgery (MI, chest infection, UTI, hypovolaemia)
DVT and PE
Late local complications of hip surgery?
Early loosening
Late infection (haematogeneous spread from a distant site)
Late dislocation
Why is THR avoided in young patients?
More likely to require revision surgery as higher demand
Subsequent surgeries are more complex, have higher complication rates and poorer functional outcomes
Types of AVN?
Primary (idiopathic)
Secondary due to: • Alcohol abuse • Steroid use • Hyperlipidaemia • Thrombophilia
Presentation of AVN of the hip joint?
Groin pain
Ix for AVN of the hip joint?
Early stages may only be seen on MRI
Later stages show PATCHY SCLEROSIS of the weight-bearing area of the femoral head, with a lytic zone underneath formed by granulation tissue from attempted repair; the lytic zone forms the classic “HANGING ROPE sign” on X-ray
Femoral head may then collapse with irregularity of the articular surface and secondary OA
Treatment options for AVN of the hip joint?
If detected early (pre-collapse) - drill holes made in femoral neck and into the abnormal area of the head can relieve P, promote healing and prevent collapse
If collapse has occurred, the only surgical option is THR
Describe trochanteric bursitis
AKA greater trochanteric pain syndrome (similar to rotator cuff problems)
Broad tendinous insertion of the abductor muscles is under considerable strain and can suffer from tendonitis and degeneration, leading to tendon tears
Trochanteric bursa can also become inflamed
Symptoms and signs of trochanteric bursitis?
Pain and tenderness in the region of the greater trochanter
Pain on resisted abduction
Treatment of trochanteric bursitis?
Analgesia, anti-inflammatories and physio (to strengthen other muscles and avoid abductor weakness)
Steroid injections
No surgical treatment has a proven benefit
Joints of the knee?
Medial and lateral compartments of the tibiofemoral joint AND the patellofemoral joint (fibula DOES NOT participate in the knee joint)
These communicate with each other as one synovial knee joint
What are the menisci?
Fibrocartilaginous menisci are within the tibiofemoral joint and these ensure congruence between the concave femoral condyles and the flat tibial plateau
Important “shock absorbers” that distribute load evenly
4 main ligaments of the knee and their functions?
Anterior cruciate (ACL) - prevent abnormal internal rotation of the tibia
Posterior crucitate (PCL) - prevents hyperextension and anterior translation of the femur
Medial collateral (MCL) - resists valgus force
Lateral collateral (LCL) - resists varus force and abnormal external rotation of the tibia
Types of arthritis of the knee?
Seropositive and seronegative inflammatory arthritides
OA:
• Primary - no obvious causative factors but it may have genetic influences and hobbies/occupation
• Secondary
Causes of early OA?
Previous meniscal tears
Ligament injuries, esp. ACL deficiency
Malalignment:
• Genu varum - medial compartment OA
• Genu valgum - lateral compartment OA
Patellofemoral dysfunction and instability predisposes to patellofemoral OA
Treatment of knee arthritis?
Knee replacement - patient with substantial pain and disability where conservative Mx is not helping:
• Total knee replacement
• Partial knee replacement
Younger patients OR heavy manual workers with isolated medial compartment OA due to varus knees:
• Consider osteotomy of the proximal tibia - shifts load to the lateral compartment
Complications of knee arthritis surgery?
Infection, thrombosis and medical comps
Unexplained pain
Low risk of joint dislocation
Context of meniscal tears?
Classically with a twisting force on a loaded knee, e.g: turning at football and squatting
Presentation of a meniscal tears?
Pain localised to the medial (mostly) OR lateral joint line; effusion develops the following day
Pain and mechanical symptoms (catching sensation or locking with difficulty straightening the knee)
Knee may feels as though it will give way if a loose meniscal fragment is caught in the knee while walking
Definition of true knee locking?
Mechanical block to full extension caused by a torn meniscus flipping and becoming stuck in the intercondylar notch
Describe locking in meniscal tears
Locking may not always occur if the torn area if unable to flip and become caught
What is pseudo-locking?
NOT A SIGN OF MENISCAL INJURY but may be due to arthritis; tends to occur after rising from sitting
Knee becomes “stuck” with temp. difficulty in straightening the joint; this either spontaneously resolves OR the patient has a trick manoeuvre that relieves it
Examination findings of a meniscal tear?
Effusion
Joint line tenderness
Pain on tibial rotation localising to the affected compartment (STEINMANN’S TEST - +ve for an ACUTE meniscal tear)
A locked knee with a displaced bucket handle meniscal tear will have a 15 degree springy block to full extension
Ix for meniscal tears?
MRI
Why are medial meniscus tears more common than lateral?
Medial meniscus is more fixed and less mobile
The force for pivoting movements if centred on the medial compartment
Patterns of meniscal tears?
Longitudinal
Radial (poor blood supply)
Oblique
Horizontal
Large longitudinal tears may cause a “BUCKET HANDLE TEAR”, where a large meniscal fragment can flip up and become stuck in the intercondylar notch - causes LOCKING and inability fully extend the knee
Describe degenerative meniscal tears
Meniscus weakens with age and may tear spontaneously or with an innocuous injury
Likely the 1st stage in many cases of knee OA
How can degenerative meniscal tears be distinguished from acute tears?
Degenerative tears are Steinmann’s -ve; likely to have assoc. signs of OA
Treatment of degenerative meniscal tears?
Symptoms do not improve with resection so cannot be treated with arthroscopy
Why do the menisci have limiting healing potential?
Only have an arterial supply on the OUTER THIRD
Also decreases with age (poor over 25-30 years old) and with increased time from the injury
Which mensical tears can be considered for repair?
Only reasonably new longitudinal tears inv. the outer 1/3rd in a younger patient
Repair inv. suturing the meniscus to its bed
Treatment of meniscal tears that are not eligible for repair?
Pain and inflammation settles with time
Steroid injections can help in the early period
If pain/mechanical symptoms do not settle in 3 months - athroscopic partial menisectomy (however knees with signs of OA on X-ray or MRI are unlikely to benefit as menisectomy can increase stress on damaged surfaces)
Context and presentation of ACL ruptures?
Usually occur with a high rotational force, like turning upper body laterally on a planter foot (leads to internal rotaiton on the tibia), e.g: in sports
POP is heard and patient develops haemarthrosis WITHIN AN HOUR and deep pain in knee
Chronically, patient has ROTATORY INSTABILITY with their knee GIVING WAY when turning on a planted foot
Examination findings with ACL rupture?
Knee swelling (haemarthrosis or effusion)
Excessive anterior translation of the tibia on the anterior drawer test and Lachman test
Variable presentation of ACL ruptures?
1/3 of patients compensate well and can continue sports
1/3 manage by avoiding certain movements but may not be able to do high impact sports
1/3 do poorly with frequent giving way even with normal daily activities
OLDER PATIENTS ARE MORE LIKELY TO COMPENSATE/COPE
Treatment of ACL ruptures?
Physio (helps compensation)
Primary repair for the torn ACL is ineffective
Most have reconstruction + rehabilitation:
• Sports players
• Those who have a desire to do sport again + no help with physio
Context and presentation of PCL ruptures?
Can be due to a direct blow to the anterior tibia with the knee flexed or hyperextended, e.g: motorcycle crash
PCL RUPTURES ARE UNCOMMON IN ISOLATION
Treatment of PCL ruptures?
In a multi-ligament injured knee - reconstruction
If an isolated PCL rupture surgical reconstruction only for those:
• With severe laxity and recurrent instability with frequent hyperextension
• Feeling unable to descend stairs (with anterior subluxation of the femur)
Context of MCL ruptures?
Usually due to valgus stress injuries, e.g: rugby tackle from the side; higher forces can also damage the ACL and risk lateral tibial plateau fracture
FAIRLY COMMON
Symptoms and signs of MCL rupture?
Laxity and pain on valgus stress with tenderness over the origin/insertion of the MCL
Treatment of MCL ruptures?
Acute tears - hinged knee brace
Chronic MCL instability - MCL tightening or reconstruction with tendon graft
Context of LCL ruptures?
Varus stress injury that may/may not damage the PCL; often part of multi-ligament injuries
High incidence of common peroneal/fibular nerve injury from excessive stretch AND a high incidence of popliteal artery intimal/complete tear
Treatment of LCL ruptures?
Usually surgical:
• Early repair
• Late reconstruction with tendon graft
Treatment of multi-ligament knee injuries?
Surgical reconstruction due to the degree of instability
Describe complete knee dislocations
Result in rupture of all 4 of the knee ligaments
High incidence of neurovascular injury
Treatment of complete knee dislocations?
Reduced as an EMERGENCY; may require external fixation for temporary stabilisation
Regularly check foot circulation, as intimal tears can occur that later thrombose (if required, vascular stenting or bypass)
Reperfusion may cause compartment syndrome, esp. after prolonged ischaemia and a fasciotomy may be required
Patients usually need multi-ligament reconstruction
Context of osteochondral and chrondral injuries?
Impaction or shear of the articular surfaces OR due to a direct blow; ongoing pain and effusion after a knee injury warrants further Ix
Defect in the surface of the knee may fill with fibrocartilage, which is not as good as hyaline but is better than nothing
Treatment of osteochondral and chondral injuries?
Acute injuries inv. large osteochondral fragments with a substantial proportion of bone - fix with pins
If from a non-weight bearing area OR have little bone attached - remove arthroscopically
Microfracture- if a defect has bare bone at its base, holes can be made to induce bleeding and promote fibrocartilage formation from stem cells differentiating into chondroblasts
Mosaicplasty - osteochondral plugs (from non‐weight bearing areas) are plugged into the defect
Culturing chondrocytes from a sample of hyaline cartilage on a biological membrane and suturing this onto the defect
Constituents of the extensor mechanism of the knee?
Tibial tuberosity, the patellar tendon, quadriceps tendon and quadriceps muscles
Cause of extensor mechanism ruptures?
Patellar OR quadriceps tendon can rupture with rapid contractile force, e.g: lifting a heavy weight, after a fall OR spontaneously (with a severely degenerate tendon)
Occurrence of extensor mechanism ruptures?
Patellar tendon ruptures tend to occur in younger age group (<40 years)
Quadriceps tendon ruptures tend to occur in older patients (>40 years)
Predisposing factors to extensor mechanism ruptures?
Hx of tendonitis, chronic steroid use/abuse, diabetes, RA and chronic renal failure
Quinolone antibiotics (CIPROFLOXACIN) can cause tendonitis and risk tendon ruptures
Examination findings of extensor mechanism ruptures?
Assessment of ANY ACUTE KNEE INJURY should inc. STRAIGHT LEG RAISE
Usually have a palpable gap in the extensor mechanism (this may not be obvious in obese patients)
Ix for extensor mechanisms ruptures?
X-ray - high (PT rupture) or low (quads rupture) lying patella
US can confirm extent of injury
Treatment of extensor mechanism ruptures?
Steroid injections for tendonitis of the extensor mechanism of the knee should be avoided (high risk of tendon rupture)
Treatment of complete and substantial partial tears is surgical:
• Tendon-to-tendon repair
• Reattachment of the tendon to the patella
What is patellofemoral dysfunction?
Disorders of the patellofemoral articular resulting in anterior knee pain :
• Chondromalacia patellae (softening of the hyaline cartilage)
• Adolescent anterior knee pain
• Lateral patellar compression syndrome
Describe the cause of patellofemoral dysfunction
Quadriceps muscle tends to pull the patella in a slight lateral direction; in some people, excessive lateral force produces anterior knee pain and the lateral facet of the patella is compressed against the lateral wall of the distal femoral trochlea
Occurrence of patellofemoral dysfunction?
More common in women (wider hips so more lateral pull of the quadriceps, part. during adolescence, due to a greater degree of ligamentous laxity)
Other pre-disposing factors inc:
• Joint hypermobility
• Genu valgum
• Femoral neck anteversion
Symptoms of patellofemoral dysfunction?
Anterior knee pain, worse going downhill
Grinding/clicking sensation at the front of the knee after prolonged sitting, causing PSEUDO-LOCKING where the knee acutely stiffens in a flexed position (in contrast to the true locking in a bucket handle meniscal tear)
Treatment of patellofemoral dysfunction?
Most improve with physiotherapy (rebalances quad muscles)
Taping can alleviate symptoms
Surgery is a last resort
Context of patellar instability/dislocation?
Can occur with a direct blow or sudden twist of the knee
Patella almost always displaced laterally and may spontaneously reduce when the knee is straightened; rarely, may have to be manually manipulated into position
Ix findings in patellar instability?
When the patella dislocates, medial patellofemoral ligament tears and osteochondral fracture may occur as the medial facet of the patella strikes the lateral femoral condyle:
• Small opacification on X-ray.
Lipohaemarthrosis occurs with characteristic X-ray appearance
Predisposing factors to patellar instability?
Ligamentous laxity
Female gender
Shallow trochlear groove
Genu valgum
Femoral neck anteversion
High-riding patella (patella alta)
Treatment of patellar instability?
If recurrent dislocation is frequent, tibial tubercle transfer or medial patellofemoral ligament (MPFL) reconstruction with tendon autograft may help.
Occurrence of patellar instability?
Risk of recurrent instability decreases with age and physio
Risk of recurrent dislocation after 1st time is 10%
Types of ankle OA?
Primary (idiopathic)
Secondary, e.g: due to previous injury, part. in football players
Describe ankle OA
Repeated dorsiflexion may cause anterior damage with osteophyte formation; anterior osteophytes can cause pain on dorsiflexion, resulting in impingement
Pain on dorsiflexion may be improves with removal of osteophytes (AKA cheilectomy)
What is hallux valgus?
Deformity of the great toe due to:
• Medial deviation of the 1st metatarsal
• Lateral deviation of the toe itself
Unclear aetiology
Occurrence of hallux valgus?
More common in FEMALES (4:1) and there is often a FAMILIAL TENDENCY
Incidence increases with age although it may occur in adolescence
Wearing of shoes has been implicated but no evidence
More common in RA patients, other inflammatory arthropaties and some neuromuscular diseases, e.g: MS, cerebral palsy
Symptoms and signs of hallux valgus?
May be painful due to joint incongruence
Widened forefoot may rub the foot against shoes, causing an inflamed bursa over the medial 1st metatarsal head (BUNION)
Great and second toes may rub - ulceration and skin breakdown
In severe cases, hallux may override the second toe
Treatment of hallux valgus?
Conservative:
• Wear wider and deeper shoes to prevent painful bunions
• Use a spacer in the 1st web space to stop rubbing between the great and second toes
Surgical Mx (tends to disappoint cosmetically):
• Osteotomy - realign bones
• Soft tissue procedures - tighten slack tissues and release tight tissues
Complications of hallux valgus surgery?
Dissatisfaction
Pain in the metatarsal heads (metatarsalgia)
What is hallux rigidus?
OA of the 1st MTPJ that may be:
• Primary (degenerative)
• Secondary to osteochondral injury
Treatment of hallux rigidus?
Conservative:
• Wear stiff-soled shoes to limit motion at MTPJ
• Insert metal bar into the sole of the shoe
• If osteophytes impinge during dorsiflexion in early cases, cheilectomy may help
Surgery - GOLD STANDARD IS ARTHRODESIS (using total joint replacement or metal hemi-arthroplasties); successful fusion should alleviate pain with a sacrifice of no motion and no wearing heels
Complications of 1st MTPJ arthrodesis?
Metal hemi-arthroplasties have high failure rates and, once failure occurs, salvage surgery is difficult with disappointing results
Describe Morton’s neuroma
Plantar interdigital nerves (from the medial and lateral plantar nerves), overlying the intermetatarsal ligaments, can be subjected to repeated trauma, becoming inflamed and swollen (forms a neuroma)
Symptoms of Morton’s neuroma?
Burning pain and tingling radiating into the affected areas
3rd interspace nerve is most commonly involved, followed by the 2nd
Occurrence of Morton’s neuroma?
Women affected 4x more (high heels are implicated)
Examination finding with Morton’s neuroma?
Loss of sensation in affected web space
Medio-lateral compression of the metatarsal heads may reproduce symptoms OR produce a characteristic “click” (MULDER’S CLICK TEST)
Ix for Morton’s neuroma?
US can demonstrate swollen nerve
Treatment of Morton’s neuroma?
Conservative:
• Use of a metatarsal pad or offloading insole
• Steroid and local anaesthetic injections can relieve symptoms and aid diagnosis
Excision of the neuroma (but some patients continue to have pain and there is a small risk of recurrence)
Describe metatarsal stress fracture
Usually in the 2nd metatarsal, followed by the 3rd
May occur in runners, in soldiers (prolonged marches), dancers or during distance walking in people who are not used to it
Ix for metatarsal stress fractures?
X-ray may not demonstrate a fracture for ~3 weeks, until resorping at the fracture ends occurs OR callus begins to appear
Bone scan can confirm diagnosis
Treatment of metatarsal stress fractures?
Prolonged rest for 6-12 weeks in a rigid soled boot is required to allow healing and resolution of symptoms
Causes of tendonitis of the Achilles tendon?
Can occur due to:
• Repetitive strain (from sports), which leads to peritendonitis
• Degenerative process with intra-substance microtears
• Quinolone antibiotics, e.g: Ciprofloxacin
• RA, other inflammatory arthropathies
• Gout
Symptoms of achilles tendonitis?
Pain may be in the main substance of the Achilles tendon OR at its insertion into the calcaneus
Treatment of Achilles tendonitis?
Rest, physio, use of a heel raise to offload the tendon and splints/boot
Resistant cases may benefit from tendon decompression and resection of paratenon but scars in this area can be problematic and the conditions tend to be self-limiting
Why should steroid injections not be used for Achilles tendonitis?
RISK OF TENDON RUPTURE, as tendonitis already predisposes to rupture
Occurrence of Achilles tendon rupture?
Tends to occur in middle-aged or older groups and is usually due to degenerative changes within the tendon OR recent tendonitis
Symptoms of Achilles tendon rupture?
Sudden deceleration with resisted calf muscle contraction, e.g: lunging at squash, leads to SUDDEN PAIN (akin to being kicked in the back of the leg) and difficulty weight-bearing
Examination findings of Achilles tendon rupture?
No plantarflexion of the foot when squeezing the calf (Simmond’s test)
Treatment of Achilles tendon rupture?
Controversial
Non-operative Mx (good functional outcome and avoids wound problems):
• Series of casts in the equinous position (ankle plantarflexed with the toes pointing down, as this closes the gap in the torn tendon) over ~8 weeks
Operative repair (restores tension of the tendon and may have lower re-rupture rate): • Followed with a series of casts for ~8 weeks
What is plantar fasciitis?
Self-limiting repetitive stress/overload/degenerative conditions of the foot
Symptoms of plantar fasciitis?
Pain with walking on the instep of the foot (at the origin of the plantar aponeurosis on the distal plantar aspect of the calcaneal tuberosity) with localized tenderness on palpation of this site
Risk factors for plantar fasciitis?
DIABETES, obesity
Frequent walking on hard floors with poor cushioning in shoes
Cushioning heel pad atrophies with age
Treatment of plantar fasciitis?
Symptoms can take UP TO 2 YEARS to resolve:
- Rest, Achilles and plantar fascia stretching exercises and a gel filled heel pad may help
- Corticosteroid injection may also alleviate symptoms
- Surgical release of the plantar fascia may have little value risks injury to the plantar nerves
What is pes planus?
Can be a normal variation affecting up to 20% of the population, where the medial arch does not develop in childhood (developmental flat feet)
Acquired flat feet may be due to tibialis posterior tendon stretch/rupture, RA or diabetes with Charcot foot (neuropathic joint destruction).
Risk factors for pes planus?
Familial tendency
Patients with generalized ligamentous laxity are more likely to have flat feet
Complications of flat feet?
May be at higher risk of tendonitis of the tibialis posterior tendon
Treatment of flat feet?
Developmental flat feet do not usually result in any problems and do not require any specific treatment
Describe tibialis posterior tendon dysfunction
Inserts predominantly onto the medial navicular and supports the medial arch of the foot (as well as being a plantarflexor and invertor of the foot)
It is under repeated stress and, part. with degeneration, can develop tendonitis, elongation and eventually rupture
Synovitis (RA) can also result in tendon rupture
Treatment of tibialis posterior tendon dysfunction?
Splint with a medial arch support to avoid rupture; if this fails, surgical decompression and tenosynovectomy may prevent rupture
If the foot remains supple with no OA present, a tendon transfer may be performed to try to prevent secondary OA, with a calcaneal osteotomy, to reduce stress often performed
Once OA ensues, the most appropriate surgical treatment, if symptoms are severe, is arthrodesis
Signs of elongation/rupture of the tibialis posterior tendon?
Loss of the medial arch with resulting valgus of the heel and flattening of the medial arch of the foot
Complications of tibialis posterior tendon dysfunction?
Degenerative OA of the hindfoot and midfoot
What is pes cavus?
Abnormally high arch of the foot; may be idiopathic but is often related to NM conditions inc:
• Hereditary Senory and Motor Neuropathy
• Cerebral palsy
• Polio (unilateral)
• Spinal cord tethering from spina bifida occulta
Claw toes often accompany pes cavus
Treatment of pes cavus?
Pain from pes cavus may be treated with soft tissue releases and tendon transfer (lateral transfer of tibialis anterior) if supple
OR
Calcaneal osteotomy if more rigid
Severe cases may require arthrodesis
Why do claw and hammer toes occur?
ACQUIRED imbalance between the flexor and extensor tendons
Describe claw toes
Hyperextension at MTPJ with hyperflexion at PIPs and DIPs
Describe hammer toes
Similar to claw toes but hyperextension at the DIPs
Other symptoms of claw and hammer toes?
Can be painful
Rubbing on footwear can cause corns and skin breakdown
Treatment of claw and hammer toes?
Toe “sleeves” and corn plasters can prevent skin problems
Surgical solutions inc. tenotomy (division of an overactive tendon), tendon transfer, arthrodesis (PIPJ) or toe amputation
