Week 4 Flashcards
What type of joint does the sacroiliac joint have
Fibrous and Synovial: fibrous capsule filled with synovial fluid
What movements can the sacroiliac joint perform
Not much movement because it is fibrous
What is the function of pubic symphysis
- Absorbs some upper body weight before it travels to the lower body
- Separates the pelvic bone for vaginal birth
What is the acetabulum
Where the head of femur inserts into = socket of the ball and socket joint
What type of joint does the hip joint have
ball and socket joint
What types of movements can the hip joint perform
Flexion, extension
abduction, adduction
lateral and medial rotation
Circumduction
What is a comminuted fracture
The bone is broken into more than 2 pieces
What are the 3 components that stabilize the joints
Congruency
Muscle tone
Ligaments
What does congruency of the joint mean
How well the bones in a joint fit into each other
What are the ligaments in hip joint
iliofemoral
pubofemoral
ischiofemoral (seen at posterior view)
What is a acetabular labrum
fibrocartilaginous rim along the acetabulum
What would the leg appearance be if there was a posterior hip dislocation
Internally rotated
Adducted
Shortened
What type of hip dislocation is the most common
Posterior hip dislocation
Why is posterior hip dislocation most common
Because the iliofemoral ligament is the strongest which prevents hyperextension of the hip hence anterior dislocation
What would the leg appearance be if there was an anterior hip dislocation
Externally rotated
abducted
Origin of sciatic nerve
L4-S3, sacral plexus
Where is the sciatic nerve located at
Runs inferiorly to piriformis and posterior to the acetabulum
From which foramen did the sciatic nerve leave from to exit the pelvis
Greater sciatic foramen
Which branch of the sciatic nerve is the most commonly damaged and why
Common fibular nerve (peroneal nerve) because it runs more laterally than tibial nerve
What is the consequence if the common fibular nerve is damaged
Foot drop - inability to lift front of the feet because of muscle paralysis caused by neurological damage
What is Trendelenburg’s gait
Dropping of the contralateral hip when standing on one leg
What causes the Trendelenburg’s gait
Weakness/paralysis of gluteus medius and or gluteus minimus
In Trendelenburg’s gait, if the hip dips on the right, which side has the affected muscles
Left
Which nerve innervates the gluteus medius and minimus muscles
Superior gluteal nerve
Origin of the superior gluteal nerve
L4 - S1
Location of the superior gluteal nerve
runs superiorly to the piriformis and passes between the gluteus medius and minimus muscles
From which foramen in the pelvis did the superior gluteal nerve exit from
Greater sciatic foramen
What arteries supply the head of femur
Medial and lateral circumflex arteries
Retinacular arteries
The medial and lateral circumflex arteries are branches of
Deep femoral artery
Which part of the femur is the weakest
Neck
What can muscle contractions do to femoral shaft fractures
Dislocate the fractured parts, potentially damaging surrounding arteries and nerves
What are the menisci
Cartilage at the knee joint that acts as shock absorbers between the tibia and femur
What are the ligaments at the middle of the knee joint
Anterior / Posterior Cruciate ligaments
What are the ligaments at the sides of the knee joint
Medial / Lateral collateral ligaments
Describe the load bearing axis in normal knee joints
In normal knee joints, there is a load bearing axis down the middle of the leg
Prevents stress on either side of leg
What is a varus knee
When the knees don’t touch each other even if feet are together
What causes varus knee
The load-bearing axis shifted to the medial side, increasing stress on the medial compartments of the knee and damage cartilage and medial meniscus
What is a valgus knee
When the knees are touching each other while feet are apart
What causes valgus knee
The load-bearing axis shifted to the lateral side, increasing stress on the lateral compartment of the knee and damage cartilage and lateral meniscus
Valgus and Varus knee can increase the risk of
Osteoarthritis
What is the drawer test for
To examine the function of anterior and posterior cruciate ligaments
Describe the drawer test
Ask the patient to flex their knee
Sit on patient’s feet to stabilize the leg
Grasp the leg and move it anteriorly / posteriorly
Observe any pain/asymmetrical movements/dysfunction
What are the ligaments around the inner ankle
Deltoid ligaments
- anterior tibiotalar ligament
- tibionavicular ligament
- tibiocalcaneal ligament
- posterior tibiotalar ligament
What are the ligaments around the outer ankle
anterior talofibular ligament
posterior talofibular ligament
calcaneofibular ligament
Which ligament is the most commonly damaged when you sprain your ankle
Anterior talofibular ligament
What is a Maisonneuve fracture
Fracture of proximal fibula and tear of anterior tibiofibular ligament at distal tibia and fibula
Can be associated with fracture at medial malleolus
Tibiofibular ligament is an example of syndesmosis. What is a syndesmosis
Fibrous joint between 2 bones connected by ligaments
What nerves innervate the dorsal surface of the foot
Mostly superficial branch of common fibular nerve (superficial peroneal nerve)
Sural nerve
Deep branch of common fibular nerve (deep peroneal nerve)
Saphenous nerve
What nerves innervate the plantar surface of the foot
Medial plantar nerve
Lateral plantar nerve
Saphenous nerve
Sural nerve
Calcaneal branch of tibial nerve
What is Simmond’s test used for and what is a positive result
To test for achilles tendon rupture; positive = ruptured
Positive result = No foot plantarflexion while calf compression
\what is anterior drawer test for ankle used for
To see if there is any damage to anterior talofibular ligament
How do you perform anterior drawer test for the ankle
- Patient is supine, with their feet hanging off the bed
- Foot is flexed, hold the heel
- Put pressure on the leg to stabilize it then move the heel upwards
What is the talar tilt test used for
To see if there is any damage to calcaneofibular ligament
How do you perform talar tilt
- Patient is seated with foot and ankle unsupported
- Foot is flexed
- Hold the leg to stabilize it then use the other hand to invert the foot
\what is the grind test used for
To test the metatarsophalangeal joints in the foot (can be used in thumb too)
Which ankle disorder will cause pain in grind test
hallux rigidus
What is hallux valgus
A progressive foot disorder affecting the 1st MTP, causing the MTP to be deviated and the 1st metatarsal to be abducted
What may form in hallux valgus overtime
bunion - a bony prominence on the medial side
What is the main risk factor for hallux valgus
Genetic predisposition; 70% of the patients have family history of hallux valgus
What are the risk factors for hallux valgus
Wearing high heels
Narrow toe box of shoe
Genetic predisposition
Pes planus
Cerebral palsy 2nd toe amputation
What can happen if hallux valgus is left untreated for a long time
Pain / discomfort / abnormal gait / soreness
What can hallux valgus cause if left untreated
Osteoarthritis
Tightness of gastrocnemius muscles
Defunctioned 1st ray
What is 1st ray
1st metatarsal bone + 1st cuneiform
Management of hallux valgus
Wear soft, wide toe box shoes
Analgesia
bunion pads / toe spacers / orthotics
Osteotomies if non-surgical options are not working or tolerated
What is osteotomy
Surgery that removes a part of a bone to realign the bones
What are the lesser toe deformities
Claw toes
Hammer toes
Mallet toes
What causes the lesser toe deformities and why do they cause lesser toe deformities
improper shoe wear
trauma
genetics
inflammatory arthritis
neuromuscular
metabolic diseases
These can cause lesser toe deformities due to imbalance of flexor and extensor muscles, tendons and ligaments that are supposed to hold the joint in place
What is hallux rigidus
Osteoarthritis of the 1st metatarsophalengeal in the first metatasal
Most common cause of hallux rigidus
Old age - wear and tear; overuse of the joint
Past trauma
Management of hallux rigidus
Analgesia
Orthotics
activity modification
Surgical - fusion / replacement
What is rheumatoid foot
Rheumatoid arthritis normally affects the joints of hands and toes first, causing inflammation of the synovium
As disease progresses, the ankle joint, midfoot, hindfoot, forefoot can be involved
What can happen if rheumatoid foot is left untreated for a long time
Lesser toe deformities
Flat foot
Calluses
Ulcers
Bunions
Difference between rheumatoid arthritis and osteoarthritis in clinical presentation
Rheumatoid arthritis - symmetrical , polyarticular
Osteoarthritis - asymmetrical, monoarticular
What is a sign of early ankle involvement in rheumatoid foot
difficulty in inclines and stairs
What is a sign of early hindfoot involvement in rheumatoid foot
difficulty in walking on uneven grounds such as grass
How does rheumatoid foot cause flat foot
As it damages the ligaments that support the medial arch hence the medial arch collapses
Which structures support the medial arch of the foot
Posterior tibial tendon
Plantar ligaments - long, short, calcaneonavicular
Plantar apopneurosis
What is pes planus
flat foot
What are the causes of pes planus
Congenital or acquired
What are the acquired causes of pes planus
Arthritis
Tibialis posterior dysfunction
Trauma that causes rupture of ligaments / tendon
After a long period of inactivity due to injury / coma -> causes muscle weakness when you resume to walking
What type of pes planus is normal during early childhood development and how does it present
Flexible pes planus
Flat feet on ground but arched when tip toeing
Why does pes planus occur in babies / young children
ligamentous laxity
immature neuromuscular control
adipose tissue underneath the arch giving it a flat look
What is the most common cause of adult-acquired flat foot
Tibialis posterior dysfunction
When does tendon degeneration begin in tibialis posterior dysfunction
Years before clinical presentations
Risk factors for tibialis posterior dysfunction
Females
young atheletes
elderly
Trauma
Diabetes
Obesity
Hypertension
Long term use of steroids
What causes tibialis posterior dysfunction
repetitive microtrauma and tenosynovitis
What can tibialis posterior dysfunction cause
Collapse of the arch of foot. Collapse of the arch can put more stress on surrounding ligaments and soft tissues
Clinical signs of tibialis posterior dysfunction
Pain and swelling around medial malleolus
Pain worsened with activity
Unable to tip toe
Difficulty in walking on uneven surfaces/stairs
Abnormal wear of shoes
Pain may move to lateral aspect
Why may pain in tibialis posterior dysfunction move from the medial aspect to the lateral aspect
In severe deformity, distal fibula becomes in contact with calcaneus
What is the difference between stage 2 and 3 tibialis posterior dysfunction
Both includes flat foot deformity
But in stage II, the deformity is passively correctable whereas stage III is not
What does stage III tibialis posterior dysfunction consist of
flat foot
hindfoot deformities
rigid forefoot
What is a sign that can be seen in flat foot deformity
too many toes sign
What is a positive too many toes sign
Look at the heel from the back of the patient
More toes can be seen
What is a negative too many toes sign
when only the fifth and a bit of fourth toe can be seen from behind
Examinations for TPD
Too many toes
Single and double leg heel raise
Plantarflexion and inversion of the foot against resistance
management of TPD
Orthotic devices to support the arch / maintain foot shape
Surgery
What is pes cavus
An abnormally high plantar arch
What can pes cavus lead to
People putting too much stress and weight on the ball and heel of foot
What are the deformities associated with pes cavus
Claw toes
hindfoot varus
forefoot adduction
What is plantar fasciitis
Inflammation of the plantar fascia (aponeurosis)
Causes of plantar fasciitis
excessive exercise
excessive weight
abnormal foot shape
arthropathies
Symptoms of plantar fasciitis
Pain with first few steps after rest but subsides
Pain worse after exercise
Tenderness / swelling at plantar aspect of heel
Management of plantar fasciitis
NSAID
Steroid injections
Rest
Orthotics
Night splints
Management of plantar fasciitis
NSAID
Steroid injections
Rest
Orthotics
Night splints
Surgery - for acute onset / those that don’t respond to therapy
What is Morton’s neuroma
Degenerative fibrosis of digital nerve near its bifurcation
Symptoms of Morton’s neuroma
Pain in forefoot
Burning, tingling sensation in toes
numbness
Sensation of having pebbles/marbles under their forefoot while walking
Do you need to remove Morton’s neuroma
Only if non-surgical treatments didn’t work or the symptoms recurred
What is tendo-achilles tendinosis
degenerative process of the achilles tendon due to repetitive microtrauma and failure to repair it
Symptoms of achilles tendinosis
pain behind the ankle
Pain eases with heat or walking
Morning stiffness
Which foot disorders does not allow you to inject steroids
Achilles tendinosis
Tibialis posterior dysfunction
Which is more common, primary or secondary bone cancer
Secondary (metastasised from another cancer
Risk factors for bone cancer
Previous radiotherapy
Predisposing conditions
Genetics
What are the predisposing conditions for bone cancer
Paget’s
Multiple Enchondromas
Fibrous dysplasia
What is Paget’s disease and why is it a risk factor for bone cancer
Disorder that increases the rate of bone renewal.
It is a risk factor because it increases the rate of cell turnover meaning malignant mutations has a higher chance of occurring, causing malignancy
What genetics are associated with bone cancer
p53 (Li Fraumeni syndrome)
RBI (retinoblastoma)
Red flag symptoms that may indicate bone cancer
Persistent pain
Pain at night
Swelling over joint
Palpable mass
Pathological fractures
What can tumours cause pathological fractures
Weakens the bone, causing the bone to fracture even due to a minor trauma
What are the imaging tests for bone cancer
Xrays
CT
MRI
bone scan
Why are xrays not always reliable
because it will only show when at least 50% of the bone is gone
so may not detect early stages
Which type of bone cancer is the most common
Osteosarcoma
Which age group is most commonly affected by osteosarcoma
Children and young adults
Where does the osteosarcoma usually affect
Distal femur / proximal tibia (long bones)
Which cells are affected by osteosarcoma
Mutation in Osteoblasts causing abnormal bone formation
Difference between Ewing’s sarcoma and osteosarcoma
Malignant cells in Ewing’s sarcoma look different
Ewing’s sarcoma most likely occur in shafts of bones whereas osteosarcoma usually occurs in metaphysis
Ewing’s sarcoma is more likely to respond to radiation therapy
What are the 4 most common bone cancers
osteosarcoma
Ewing’s sarcoma
chondrosarcoma
Osteoid Osteoma
Which bones do ewing’s sarcoma most commonly affect
distal femur and proximal tibia
What is chondrosarcoma
malignancy of chondrocytes; mutations in chondroblasts cause them to abnormally produce cartilage
Which age group does chondrosarcoma usually affect
Older people; 40-75 years olds
Which bones are most commonly affected by chondrosarcoma
pelvis
proximal femur
distal femur
What is osteoid osteoma
a painful benign tumour on the long bones
Which age group is most likely to be affected by osteoid osteoma
Young people 5-25 years old
What does osteoid osteoma look like on xrays
o shaped; well demarcated central nodule with sclerotic rim (white on xrays)
Symptoms of osteoid osteoma
Pain
Pain at night
Swelling
limping
Can pain caused by osteoid osteoma be alleviated
ye pain can be alleviated the NSAIDs
what is osteochondroma
Abnormal formation of bones and cartilage
can osteochondroma develop into malignancy
yes but <1%
What are enchondromas
Benign intramedullary cartilage lesion (inside the bone)
Where do enchondromas usually affect
small bones of the hand
can enchondroma develop into maligancy
rarely
Which tumours are most likely to metastasize to bones (BLT with a Kosher Pickle)
Breast
Lungs
Thyroid
with a
Kidney
Prostate
Sites that are most commonly affected y bone cancer
pelvis
ribs
vertebra
femurs
skull
What is MIREL’s score for
to predict the likelihood of pathological fractures in patients with long bone metastasis
What supplies the hyaline cartilage of joints
Synovial fluid
Subchondral bone
What is the hyaline cartilage made of
proteoglycan
water
collagen
Risk factors of knee OA
Old age
Obesity
Heavy physical workload
Sports
Genetics
ACL injury / meniscal tear / fractures
malalignment of the knee joint
Name the 2 articulations of the knee joint
Tibiofemoral joints x2
Patellofemoral joint
Describe the tibiofemoral articulations of the knee joint
Medial and lateral femoral condyles articulating with the medial and lateral tibial condyles, with menisci in between each
Which articulation in the knee joint is usually affected first in osteoarthritis
Patellofemoral joint
Pathology of osteoarthritis
- imbalance between wear and repair of articular cartilage leading to progressive loss; articular cartilage has poor healing potential
- increased pressure and rubbing on the bony surfaces
- inflammation
- subchondral bone sclerosis and hypertrophy
- the bone tries to remodel itself, causing formation of osteophytes
- microfractures on the subchondral bone causes synovial fluid to enter the bone and form cysts
- eventually, surrounding tissues, nerves and muscles can become inflamed
Symptoms of knee osteoarthritis
Joint pain
Joint swelling
Joint stiffness in the morning, but resolves within 30 minutes
Joint pain worse with activity
Locked knee - unable to bend or straighten the knee
Will every patient with knee OA have the same symptoms
No
Some people may have mild symptoms but advanced OA
Patients can have flare ups as well while feeling normal on other days
Non surgical management of knee OA
NSAID
Weight loss
Low intensity activity
Physiotherapy
What is given to treat flare ups of knee OA
steroid injections
How many steroid injections can be given in a year for flare ups of knee OA and why
3 a year
too much can damage the knee and accelerate OA
Total knee replacement surgery for OA is reserved for
Patients who are
- older
- medically fit
- with end stage OA
- frequent flare ups
- sleep disturbance
- severe pain affecting physical activities such as walking
Cons of total knee replacement
doesn’t last forever
can get infected
not suitable for young patients
doesn’t improve stiffness
some patients still experience pain
Why are knee replacement surgeries not indicated for young patients
Because the knee replacements do not last forever and with higher level of activity in young patients, it can loosen up more quickly
this means that a young patient will need revision surgeries in the future
Long term use of knee replacements can damage the patient’s own bones (scratches it)
High risk of complications in revision surgeries
Function of the medial collateral ligament in knee joint
resists valgus stress
Function of the lateral collateral ligament in knee joint
resists varus stress
Function of the anterior cruciate ligament in knee joint
Prevents anterior subluxation of the tibia
Prevents internal rotation of the tibia during extension
Function of the posterior cruciate ligament in knee joint
Prevents anterior subluxation of the femur
Prevents hyperextension of the knee
When can ACL be torn
During exercises that require sudden change in directions
Result of torn PCL
recurrent hyperextension of the knee
Result of torn ACL
Difficulty in turning on the spot
Why can’t the ACL and LCL repair itself when torn
Because it does not have a blood supply
Why can the MCL and PCL repair itself when torn
Because it has a good blood supply
Non surgical management of torn ACL
Rest
brace to protect the knee from instability
physiotherapy to strengthen surrounding ligaments for greater stability
Surgical management of torn ACL
autograft
allograft
Difference between autograft and allograft
Autograft - from patient’s own tissue whereas allograft is from another person
What examination test can be done to identify torn ACL
Anterior drawer test
Lachman’s test
Which knee ligament is the least commonly injured and doesn’t usually occur on its own
Lateral collateral ligament
What examination can be done to test LCL function
Straight leg raise
Varus stress test
Which direction does a high energy blow needs to be to damage LCL
Anteromedial
E.g. a person needs to tackle another person at their anteromedial part of their knee
Which direction does a high energy blow needs to be to damage the PCL
Anterior tibia
What happens if your PCL is torn
Recurrent hyperextension / feeling unstable when going down stairs
Which ligament injury is often associated with meniscal tear
ACL
Which type of meniscal tear is more common
medial meniscal tear
How can meniscal tears occur
Sport injury
Getting up from squatting position
Degenerate tear
Why do the menisci only have limited healing potential
Only peripheral 1/3 has blood supply
What to do if the patient with meniscal tear has locked knee / the tear is irreparable by itself
Arthroscopic menisectomy
What is a bucket handle tear
Full thickness tear of the meniscus, common in medial meniscus
Harder to treat
What is a key symptom of a bucket handle tear
Locked knee
What is degenerative meniscal tear
Spontaneous meniscal tear due to meniscus weakening with age
What are the complications of knee dislocation
Popliteal artery injury
Nerve injury
Compartment syndrome
Which nerve may be damaged by a knee dislocation
Common fibular nerve
How does compartment syndrome occur
Swelling or bleeding occurs in a muscle compartment. Because the deep fascia cannot be stretched, it will cause an increase in pressure on the arteries, veins, nerves and muscles in the compartment. This causes damage to blood flow / nerve injury
What is patellofemoral pain syndrome
Idiopathic adolescent anterior knee pain
What causes patellofemoral pain syndrome
Muscle imbalance
Tightness of lateral tissues
Bony malalignment
Flat feet
What is extensor mechanism rupture
Patellar tendon injuries and/or quad tendon injuries
What examination can be used to test for extensor mechanism rupture
Straight leg raise
What is osteochondritis dissecans
An area of the surface of the knee loses its blood supply so cartilage and bone can fragment off
Which age group does osteochondritis dissecans most commonly affect
children / young adults
Can fragmented pieces from osteochondritis dissecans heal itself
Yes, especially in developing children or young adults
What can happen if there are loose bodies in a joint
The fragments can grow by getting nutrients from the synovial fluid and cause locking/catching of the joint
Stick to synovium or fat pad
What is Baker’s cyst
Fluid filled sac located at the posterior of the knee joint
What causes Baker’s cyst
Synovial fluid escaped through a communication (connection) to a bursa under the medial gastrocnemius or semimembranosis
What conditions can cause Baker’s cyst in adults
OA
RA
meniscal tear
