T&O (Lower) Flashcards
Describe the three stages of Degenerative Disc Disease
Dysfunction - outer annular tears, cartilage destruction
Instabiity - Sublaxation & Spondylolisthesis
Restabilisation - Osteophytes and canal stenosis
State the three types of intracapsular fracture
Subcapital
Transcervical
Basocervical
State the two types of extracapsular fracture
Intertrochanteric
Subtrochanteric
Describe the blood supply of the Neck of Femur
Retrograde flow primarily through medial circumflex
branch of femoral artery
Very minor supply through ligamentum arteriosum (running through ligamentum teres in head of femur)
Minor supply through intramedullary vessels
Describe the Garden Classification of Intracapsular #NOF
I - Incomplete Fracture
II - Complete Fracture
III - Partial Displacement
IV - Complete Displacement
Give 3 clinical features of #NOF
Pain
Inability to weight bear
Shortened and Externally Rotated
What X-Ray planes are needed for suspected #NOF?
AP and Lateral of Hip
AP of Pelvis
How would you surgically manage a non displaced intracapsular #NOF
IE Garden Classification I or II
Dynamic Hip Screw
Very dependent on blood supply interruption
How would you surgically manage a displaced intracapsular #NOF
Low Activity level pre fracture - HemiArthroplasty (ideally cemented)
Active Individual - Total Hip Replacement
How would you surgically manage an extracapsular #NOF
Intertrochanteric - Dynamic Hip Screw
Subtrochanteric - IM Femoral Nail
Describe how OA of the Hip would present on examination
- Passive movement is painful
- If severe ROM is reduced
- At end stage the patient may have a fixed flxeion deformity and may walk with a Trendelenberg Gait
How is OA of the Hip classified?
WOMAC classification (based on pain stiffness and function)
The definitive management for OA of the Hip is a hip replacement. Describe the three approaches.
- Posterior Approach (most common, quick recovery as abductors intact, may damage sciatic nerve)
- Anterolateral Approach (Abductor mechanisms are detached, allowing excess abduction and exposure of acetablum, risk of superior gluteal nerve damage)
- Anterior Approach
Describe the blood supply of the femur
Highly vascularised due to it’s role in Haemopoiesis
Supplied by penetrating branches of profunda femoris
How might a Femoral Shaft fracture present
Pain and Inability to weight bear
May have obvious deformity (proximal segment flexed and externally rotated)
Give three risk factors for Femoral Shaft Fractures
Bisphosphonate
Metastatic Deposits
High Energy Trauma
How are Femoral Shaft Fractures classified?
Winquist and Hansen Classification (0-4 with increasing communition)
What two managements would you carry out for an OPen Fracture
Antibiotic Prophylaxis
Tetanus Injection
How would you immobolise a Femoral Shaft Fracture?
Potentially traction splinting is required if it is an isolated fracture due to strong force of the quads
Describe the surgical management of a Femoral Shaft Fracture
IM Nail (usually anterograde although if other lower limb fractures may use retrograde) Ex-Fix (if open fracture or polytrauma)
Describe the aetiology of an ACL tear
Aims to prevent anterior movement of tibia on fibula
Caused by sudden twisting on weight bearing knee
Give three presenting features of an ACL tear
Rapid Joint Swelling (as ligament is highly vascular)
Significant Pain
Leg may feel like it’s giving way
Give 3 investigations of a suspected ACL tear
MRI
X-Ray (rule out bony injuries)
Lachmans Test (pulling tibia forward when leg is bent at a 30 degree angle)
Describe the management of an ACL tear
RICE
Rehab and Strength training
Surgical (uses tendon as a graft)
Describe two mechanisms of PCL tear
- Direct blow to proximal tibia
- Fall with hyperflexion of the knee and plantar flexed foot
How does a PCL tear present?
Immediate pain and joint instability
MCL tears are the most commonly injured ligament of the knee. What is its normal role?
Acts as a valgus stabiliser of the knee
How is the MCL normally torn?
When external force is applied to the lateral knee
How does an MCL tear present clinically?
Pain at joint line following trauma to lateral knee
Swelling may occur a few hours later
May be able to weight bear
Can be graded I-III
Give two investigations for MCL tear
MRI
Valgus Stress Test (Grade II - lax in 30 degree flexion but not in extension, Grade III - Lax in flexion and extension)
How would you manage MCL tears?
Grade I - RICE and Strength Training
Grade II - Knee Brace and Strength Training
Grade III - Knee brace and consider of surgical repair
The Menisci of the Knee are two C shaped fibrocartilages resting on the tibial plateau. State two of their roles
- Shock absorbers
- Increasing articular surface area
Meniscal Tears are often caused by twisting on a weight bearing knee. State the four types of tear.
- Bucket Handle (longitudinal where medial becomes separated from lateral)
- Vertical (longitudinal with no separation)
- Transverse (Parrot Beak)
- Degenerative
Give three clinical features of Meniscal Tears
- Tearing sensation associated with sudden pain
- Swelling over 6-12 hrs
- Part of it may be trapped in the joint giving the feature of knee locking
Surgery is generally only required for Meniscal Tears greater than 1cm. Describe the two arthroscopic managements
If outer 1/3 - rich vascular supply allows for healing via sutures
If inner 1/3 - trimmed
Give three risks of Arthroscopic Meniscal Repairs
DVT
Saphenous Nerve/Vein Damage
Peroneal Nerve Damage
What region of the Tibial Plateau is more damaged in a Tibial Plateau fracture?
Normally the lateral Tibial Plateau resulting in a varus deformity
What would an X-Ray of a Tibial Plateau fracture show?
Lipohaemarthroses
How are Tibial Plaeau Fractures classified?
Schatzker Classification (from I-VI)
How are Tibial Plateau Fractures managed?
Conservative - Hinged knee brace, minimal weight bearing, physio
Surgical - ORIF or Ex-Fix
What is the IT band?
Longitudinal fibres from shared aponeuroses of TFL and Gluteus Maximus
Iliac Tubercle to the Anterolateral Tibial Tubercle
What is IT Band Syndrome?
The most common cause of lateral knee pain in athletes
Inflammation from repeated flexion and extension of the knee causing impringement against lateral femoral condyle
Give three risk factors for IT Band Syndrome
Athletic
Genu Varum/Bow Legged
Weak Abductors
How does IT Band Syndrome Present?
Lateral knee pain (worse downhill or on a camber)
IT Band Syndrome is a clinical diagnosis, explain a clinical test.
Nobles Test - Patient lays supine, palpate lateral femoral condyle as patient bends leg. Pain should be felt at 30 degrees as the IT band slides over condyle.
How would you manage IT Band Syndrome?
Modify Activity Simple Analgesia Steroid Injections Physio Surgery - release of IT band at its insertion
What forms the ankle joint?
Talus and Mortise (formed of lateral malleolus/medial malleolus/tibial plafond)
Describe the Syndesmosis bonding the tibia and fibula together
Interosseous Membrane
Anteroinferior Tibiofibular Ligament
Posteroinferior Tibiofibular Ligament
What is an ankle fracture?
Any fracture to the malleoli (medial, lateral or posterior) with or without syndesmosis disruption
Name four anatomical classifications of Ankle Fractures
Isolated Medial Malleolus Fracture
Isolated Lateral Malleolus Fracture
Bimalleolar
Trimalleolar
Describe the Weber Classification of Ankle Fractures (for lateral malleoli)
A - Below level of syndesmosis
B - At level of Syndesmosis
C- Above level of Syndesmosis
How would you investigate Ankle Fractures?
XRay - AP and Lateral
What are the Ottawa Rules?
The concept that if the diagnosis is unclear, pain/tenderness over one of the malleoli and inability to weight bear for >4 steps indicates an Ankle Fracture
How would you manage an Ankle Fracture?
Reduce
Below knee back slab
Surgery - If displaced B, or class C, or Open, requires ORIF
How can you classify Ankle Sprains?
High Ankle - Injuries to Syndesmosis
Low Ankle - Injuries to Anterior Talofibular/Calcaneofibular
What mechanism is likely to cause an Ankle Sprain?
Inversion on a plantarflexed ankle
What is the Achilles Tendon?
Unites the tendons of Gastrocnemius, Soleus and Plantaris and inserts into Calcaneous
Describe the pathophysiology of Achilles Tendonitis
Repetitive action causes microtears and subsequently inflammation
Over time the tendon becomes thickened/fibrotic/loses its elasticity
Give three risk factors for Achilles Tendonitis
Poor Footwear Choice
Unfit Individual with sudden increase in exercise
Fluoroquinolone use
How would Achilles Tendonitis present?
Gradual onset of pain and stiffness in posterior ankle (often worsened by movement and improved by heat)
Tenderness over palpation
How would Achilles Rupture present?
Sudden onset severe pain following audible popping sound
Loss of power of plantar flexion
How would you diagnose an Achilles Rupture?
Simmons Test - squeeze patients calf while they are knelt, normally the reaction should be plantarflexion
USS
How would you manage Achilles Tendonitis?
RICE
NSAIDs
May require physio
How would you manage Achilles Rupture?
- Immobilisation (Full equinus for two weeks, semi equinus for four weeks, then neutral for four weeks)
- If you give the patient a moonboot over the plaster they can weight bear
- Any delayed presentation will require surgical repair
What is a Talar Fracture?
Typically occurs in high energy trauma where ankle is forced into dorsiflexion
50% through Talar Neck
Why is the Talus at risk of avascular necrosis in a fracture?
The talus relies on extra-osseous blood supply which is likely to be interuppted
How would a Talar Fracture present?
Immediate pain and swelling
Unable to dorsiflex/plantarflex
Describe the Hawkins Classification of Talar Neck Fractures
I - Undisplaced
II - Subtalar Dislocation
III - Subtalar and Tibiotalar Dislocation
IV - Subtalar, Tibiotalar and Talonavicular Dislocation
Increasing risk of AVN
How should you image a suspected Talar Fracture?
X-Ray (AP and Lateral)
Taken in dorsiflexion as plantarflexion reduces any sublaxation
How would you manage a Talar Fracture?
I - Conservatively in plaster for 3 months, non weight bearing
II-IV - Closed reduction and temporary cast, definitive surgical fixation
What is Hallux Valgus (AKA Bunion)
Deformity of the first metatarsalphalangeal joint
Medial deviation of first metatarsal and lateral deviation of hallux
Once the metatarsal head escapes intrinsic control, tendons become a deforming force
Give three risk factors for Hallux Valgus
Female
High Heel use
Hypermobility disorders
How does Hallux Valgus present?
Painful Medial Prominence (aggravated by walking/weight bearing)
What investigation could you use to diagnose Hallux Valgus?
X-Ray - looking at the angle between the first metatarsal and the proximal phalanx (diagnosed if greater than 30 degrees
Describe two surgical managements of Hallux Valgus
Chevron Procedure - V Shaped Osteotomy of distal metatarsal
Lapidus Procedure - fuses first metatarsal and medial cuneiform
Plantar Fasciitis accounts for 80% of heel pain complaints. Describe the pathophysiology
Thick fibrous tissue from calcaneal tuberosity to proximal phalanx
Microtears cause a chronic breakdown
Give 3 risk factors for Plantar Fasciitis
Obesity
Prolonged Standing
Pes Cavus
How does Plantar Fasciitis present?
Sharp heel pain worse in the morning, before easing off after the first few steps
How would you manage Plantar Fasciitis?
Activity Modification
NSAIDs
Steroid Injections
Plantar Fasciotomy
What is a complication of Plantar Fasciotomy?
Medial Foot Instability
Give 5 medical managements of Hip Fractures
- Establish cause of fall
- Analgesia (Nerve Block)/Antiemetics/Laxatives
- Discuss rescucitation
- Prevent AKI
- Bone protection assessment
What X-Ray feature are you looking for on lateral view of Hip Fracture?
‘Head off the back’
Describe three possible X-Ray features of a #Hip
Obvious fracture
More proximal lesser trochanter (Also may be more prominent due to external rotation)
Disruption of Shenton’s Line
Increased density due to overlapping bone
Why do total hip replacements last well?
The femoral head is replaced with metal, whereas the acetabulum is replaced with plastic. This wears well
Describe a Dynamic Hip Screw
One screw into femoral shaft, and four more to keep that in place
Screw can shorten and lengthen with weight bearing (compression is good for healing)
What is a Cephalomedullary Nail and when is it used?
One nail from femoral head to knee, kept in place by two more
Used if reverse oblique displacement as they are generally more unstable and not appropriate for DHS fixation
How does a Bisphosphonate Fracture present?
Normally after 8-10 years of taking Bisphosphonates
Generally subtrochanteric stress fracture
Pre fracture changes include cortical expansion and black line developing on XRAY
What is SCFE?
Slipped Capital Femoral Epiphyses
Perichondrial ring that normally resists shearing forces pre ossification becomes weak, allowing the femoral neck to slide from the head/epiphyses
Name two risk factors of SCFE
Hyperthyroidism, Obesity
How does SCFE present?
Groin or Thigh Pain
Limp
How is SCFE imaged?
Frog leg XRay
How is SCFE managed?
Surgical screw connecting diaphysis through the femoral neck and epiphyses to femoral head
May do prophylactic screwing of contralateral leg
When should you weight bear after IM nail?
Immediately
How would you manage an undisplaced patella fracture?
Aspirate any Haemarthroses
4-6 weeks leg immobilised in extension
How would you manage a displaced patella fracture?
ORIF with tension banding
How do tension bands work?
Convert tensile to compressive forces by shifting the centre of rotation
How does a Patella Dislocation normally occur?
Sudden severe contraction of the Quads, normally in external rotation
How is a patella dislocation managed?
Back slab with knee in extension
How does a Knee Dislocation occur and what are the associated injuries?
Occurs in high velocity trauma
Cruciate ligaments and at least one collateral ligaments are torn
How are Knee Dislocations managed?
Backslab for one week at 15 degree flexion (to allow swelling reduction)
12 week cast (with Quad exercises and weight bearing as soon as they can lift the leg)
Name the three main ligaments of the lateral ankle
Anterior Talofibular, Posterior Talofibular, Calcaneofibular
What ligament is commonly damaged in ankle fractures?
Deltoid
