Week 6- Lower Leg Common Clinical Presentations Flashcards
1
Q
PART 1: COMMON CLINICAL PRESENTATIONS AND FRACTURE SCREENING
A
PART 1: COMMON CLINICAL PRESENTATIONS AND FRACTURE SCREENING
2
Q
Lower Leg Common Clinical Presentations
A
- Lower Leg Fractures
- Structural Abnormalities
- Hallux Rigidus
- Ankle Sprains
- Chronic Ankle Instability (CAI)
- (Anterior) Ankle Impingement Syndrome
- Achilles Tendon Tear/ Rupture
- Plantar Fasciitis
- Metatarsalgia
- Interdigital Neuroma
3
Q
What are the Ottawa Ankle Rules? (3)
A
- Bony tenderness along distal 6 cm of posterior edge of fibula or tip of lateral malleolus
- Bony tenderness along distal 6 cm of posterior edge of tibia/tip of medial malleolus
- Inability to bear weight both immediately after injury and for 4 steps during initial evaluation
4
Q
What are the Ottawa Foot Rules? (3)
A
- Bony tenderness at the base of 5th metatarsal
- Bony tenderness at the navicular
- Inability to bear weight both immediately after injury and for 4 steps during initial evaluation
5
Q
What are 2 other ways to screen for fracture, but are less accurate and useful?
A
- Tuning Fork
- Ultrasound
6
Q
-Tuning fork is better for identification of ________ fractures and less accurate for _______ fractures.
A
- transverse
- stress
7
Q
Ways to describe fractures.
A
- Open vs. Closed
- Anatomic site & extent
- Type: complete vs. incomplete
- Alignment of fragments
- Direction of fracture lines
- Special features
- Associated abnormalities (dislocation, subluxation, soft tissue injury)
- Special types (stress fracture, pathological fractures, bone graft fractures)
8
Q
PART 2: FRACTURES
A
PART 2: FRACTURES
9
Q
What are the (3) traumatic fracture areas in the lower leg?
A
- Distal Tibia/Fibula
- Hindfoot
- Midfoot/Forefoot
10
Q
Distal Tib-Fib Fractures:
- What is a common MOI?
- What are the (6) types of distal tib-fib fractures?
A
-Axial or rotational loading
- Unimalleolar (medial OR lateral malleolus)
- Bimalleolar (medial AND lateral malleolus)
- Trimalleolar (Both malleoli AND posterior rim of tibia)
- Tibia/Fibula shaft fracture
- Comminuted fracture at distal tibia
- Intra-articular fractures
11
Q
Hindfoot Fractures:
-What are the (2) fractures of the hindfoot and their MOI?
A
Calcaneous Fx
-Common MOI: fall from height
Talus Fx (worse prognosis) -Common MOI: forced ankle DF
12
Q
Midfoot/Forefoot Fractures:
-What are the (3) common midfoot/forefoot fractures?
A
- Navicular
- Metatarsal
- Phalangeal
13
Q
Navicular Fractures:
- Dorsal avulsion at _______ attachment.
- Tuberosity/body fractures.
- ______ fractures are common with insidious onset in WB athletes.
A
- deltoid attachment
- Stress fractures
14
Q
Metatarsal Fractures:
- Common MOI?
- What type of fracture is common at 2nd-4th mets?
- What type of fracture is common at 5th met?
A
- Common MOI: direct trauma
- Spiral common at 2nd-4th
- Avulsion at 5th (some stress)
15
Q
Phalangeal Fractures:
-Common MOI?
A
-stubbing and direct trauma
16
Q
List these fracture sites in order from most recommended time of immobilization to least:
- Fibula
- Toes
- Metatarsal
A
- Fibula (7-8 weeks)
- Metatarsal (4-6 weeks)
- Toes (3-4 weeks)
17
Q
Pediatric Physeal Fractures:
List the first 5 types of pediatric physeal fractures and a way to remember them.
A
- Type 1 (physis) = S (straight)
- Type 2 (metaphysis/physis) = A (above)
- Type 3 (epiphysis/physis) = L (lower)
- Type 4 (epiphysis/metaphysis/physis) = T (through)
- Type 5 (crush injury of physis) = R (rammed)
SALTR
18
Q
Pediatric Physeal Fractures: Type VI (Rang’s): involves \_\_\_\_\_\_\_\_\_\_\_/\_\_\_\_\_\_\_\_\_\_ of physis Types VII-IX (Ogden’s): do not directly involve physis, though may disrupt \_\_\_\_\_\_\_\_\_\_\_\_\_\_
A
- perichondral ring/periosteum
- blood supply
19
Q
ORIF is common for types ___ and ___ physeal ankle fractures.
A
-Types 3 and 4
20
Q
What are the prognostic factors for pediatric physeal fractures? (5)
A
- Worse prognosis if >1 week prior to reduction.
- Larger gap
- Gap >/=3mm for type 1 and 2
- Younger patients
- Higher risk of physis arrest in types 3-5.
21
Q
- Types __ and __ physeal fractures are typically casted 4-6 weeks following reduction
- Type __ and __ are in a long leg NWB cast weeks 1-4, and a boot from week 5-8.They are NWB first 2 weeks.
- Type __ if recognized early, may be managed with removal of affected physis f/b fat graft.
A
- Types 1 and 2
- Types 3 and 4
- Type 5
22
Q
PART 3: STRUCTURAL ABNORMALITIES
A
PART 3: STRUCTURAL ABNORMALITIES
23
Q
What are the lower leg structural abnormalities?
A
- Talipes Equinovarus
- Rearfoot varus
- Rearfoot valgus
- Forefoot varus
- Forefoot valgus
- Pes planus
- Pes cavus
- Hallux Valgus
24
Q
Talipes Equinovarus:
- “_________”
- Does it affect males or females more?
- What is it characterized by?
A
- “clubfoot”
- males > females
- Characterized by plantarflexed heel, inversion STJ/varus rearfoot, metatarsal adduction/varus forefoot
25
Rearfoot Varus/Valgus:
- Rearfoot varus: ________ of the calcaneus with the subtalar in neutral (limited ________)
- Rearfoot valgus: ________ of the calcaneus with the subtalar in neutral (excessive _______ and limited ________)
- Varus: Inversion of the calcaneus with neutral subtalar (limited pronation)
- Valgus: Eversion of the calcaneus with neutral subtalar (excessive pronation and limited supination)
26
Forefoot Varus/Valgus:
-Forefoot varus: ________ of the forefoot on the hindfoot with the subtalar joint in a neutral position
Forefoot valgus: ________ of the forefoot on the hindfoot with the subtalar joint in a neutral position
- -Varus: Inversion of the forefoot on the hindfoot with neutral subtalar
- Valgus: Eversion of the forefoot on the hindfoot with neutral subtalar
27
Pes Planus/Cavus:
- Pes planus: ______
- Pes cavus: longitudinal arches accentuated
-flat foot
28
Hallux Valgus:
- ______ deviation of 1st metatarsal and lateral deviation of great toe.
- What are the gait implications of hallux valgus?
- medial
| - Collapse of the medial arch, navicular drop, position of pronation during push-off = less rigid foot
29
PART 4: HALLUX RIGIDUS
PART 4: HALLUX RIGIDUS
30
What is Hallux Rigidus?
-Arthropathy of the great toe characterized by pain, swelling, and abnormal bone growth at the dorsal aspect of the 1st MTP.
31
What is seen during Hx of someone with Hallux Rigidus?
- Arthropathy
- Trauma/injury to articular surface of distal metatarsal
- Repetitive great toe extension
32
Hallux Rigidus Symptomology:
- _________ onset, __________
- 1st MTP pain, especially with what activities?
- Insidious onset, progressive
| - Great toe extension (walking up hill, stair ambulation, terminal stance
33
Hallux Rigidus Physical Examination:
- Limited great toe ______ ROM at the MTP.
- _______/_______/_______ to the dorsal 1st MTP.
- extension
| - Abrasion/swelling/tenderness
34
PART 5: ANKLE SPRAINS
PART 5: ANKLE SPRAINS
35
Ankle Sprains:
- Make up __% of ligament sprains.
- ______ involved in 60-70% of ankle sprains.
- 85%
| - ATFL
36
Ankle Inversion Sprain Hx:
- Most common ___ decade.
- Common ______ injury.
- __x more likely to sustain a lateral ankle sprain after initial.
- What is the MOI?
- 3rd decade
- running injury
- 5x
- MOI: forced ankle inversion
37
Ankle Inversion Sprain Symptomology:
- ______ ankle pain/swelling/warmth/redness.
- Painful with activities that place the foot in ________.
- lateral
| - supination
38
```
Ankle Inversion Sprain Physical Exam:
-Antalgic gait
-Increased figure-8 measurement
-Local warmth/tenderness
-Pain with _______ ROM
What tests are positive with inversion ankle sprains?
```
- inversion
| - + Anterior Drawer (ATFL), Reverse Anteriolateral Drawer, Medial Talar Tilt Stress Test
39
Medial Ankle Sprain:
- Involves _______ ligament.
- What is the MOI?
- deltoid
| - MOI: Forced ankle eversion
40
Medial Ankle Sprain Symptomology:
- _______ ankle pain/swelling/warmth/redness.
- Painful with activities that place the foot in ________.
- medial
| - pronation
41
```
Medial Ankle Sprain Physical Exam:
--Antalgic gait
-Increased figure-8 measurement
-Local warmth/tenderness
-Pain with _______/________ ROM
What tests are positive with inversion ankle sprains?
```
- pronation/eversion
| - + Lateral Talar Tilt Stress Test
42
Syndesmotic Ankle Sprain:
- "___________"
- Concern for _______ _______ and ________ ________.
- "high ankle sprain"
| - chronic instability and degenerative arthropathy
43
Syndesmotic Ankle Sprain Hx:
| -What are the common MOIs?
- Forced DF
- Forced eversion of talus
- Forced ER of talus
44
Syndesmotic Ankle Sprain Symptomology:
- Pain in ______ lower leg
- Aggravated with stair descent, walking up hill, and squatting.
-distal lower leg
45
Syndesmotic Ankle Sprain Physical Exam:
- Early ______ in stance phase.
- Swelling/tenderness at ________ ______ joint.
- Pain at end-range ___ ROM.
- What tests are positive with syndesmotic ankle sprain?
- heel-off
- anterior tibiofibular joint
- DF ROM
- + Fibular Translation, External Rotation, Syndesmotic Squeeze
46
PART 6: CHRONIC (lateral) ANKLE INSTABILITY (CAI)
PART 6: CHRONIC (lateral) ANKLE INSTABILITY (CAI)
47
CAI Hx:
- Recurrent _______ sprains.
- _______ muscle weakness.
- Impaired _________.
- Recurrent inversion sprains
- Fibular muscle weakness
- Impaired propioception
48
CAI Symptomology:
- Often ________ between sprains.
- Feelings of ankle _________.
- Ankle weakness
- Difficulty/inability to run
- asymptomatic
| - "giving way"
49
CAI Physical Examination:
| -Diminished ________ function of ankle.
-proprioceptive function
50
PART 7: (ANTERIOR) ANKLE IMPINGEMENT
PART 7: (ANTERIOR) ANKLE IMPINGEMENT
51
What is anterior ankle impingement?
-Soft tissue or bony spur formation at the anterior talocrural joint.
52
Anterior Ankle Impingement Hx:
| -________/__________ ankle sprains
-recurrent/high trauma ankle sprains
53
Anterior Ankle Impingement Symptomology:
- _________ ankle pain/swelling/warmth/redness.
- Painful with ____ ROM.
- anterior
| - DF ROM
54
Anterior Ankle Impingement Physical Exam:
- Antalgic gait/early heel-off
- Tenderness/palpable mass anterior tibiotalar joint
- Pain/limitation with end-range _____ ROM
- What test is positive with anterior ankle impingement?
- DF ROM
| - + Forced DF Test
55
PART 8: TENDINOPATHY
PART 8: TENDINOPATHY
56
What are the 3 common muscles we see tendinopathy in at the ankle?
- Fibular Longus/Brevis
- Tibialis Posterior
- Achilles
57
Fib Longus/Brevis Tendinopathy Hx:
- Repeated _________ injuries.
- Anatomic abnormalities/anomalies.
-inversion injuries
58
Fib Longus/Brevis Tendinopathy Symptomology:
- Pain posterior to _____________.
- __________ of fibularis tendons.
- lateral malleolus
| - Subluxation
59
Fib Longus/Brevis Tendinopathy Physical Exam:
- Swelling/bruising/tenerness _______ ankle.
- Pain with resistive > AROM testing ankle _______.
- Pain with end-range ______/_________.
- lateral
- eversion
- inversion/supination
60
Post Tib Tendinopathy Hx:
- Insidious onset, progressive, typically _________.
- Concomitant ________ ligament injury.
- Participation in sports that require ____________.
- unilateral
- deltoid
- quick directional change
61
Post Tib Tendinopathy Symptomology:
- Pain near area of insertion at ________.
- Pain proximal to ___________.
- navicular
| - medal malleolus
62
Post Tib Tendinopathy Physical Exam:
- Pes ________ with ________ dropping.
- Tenderness/swelling navicular and proximal to medial malleolus.
- Painful with resisted _________/________.
- Painful ________/_______ ROM.
- Pes planus with navicular dropping
- inversion/PF
- eversion/DF
63
Achilles Tendinopathy Hx:
- Common MOI?
- 5-18% of _______ injuries.
- Common MOI: intense eccentric loading on triceps surae
| - running injuries
64
Achilles Tendinopathy Symptomology:
- Pain near insertion of achilles tendon.
- _______ stiffness.
-morning stiffness
65
Achilles Tendinopathy Physical Exam:
- Tenderness/ swelling/ hypertrophy/ palpable defect at achilles tendon.
- Pain with _______ ROM
- Pain with resisted > AROM ________
DF ROM
| -resisted > AROM PF
66
Achilles Tendon Rupture Hx:
- Common MOI?
- Sudden/acute onset with known mechanism, commonly audible "____" with subsequent difficulty walking and WB.
- 2 things that put people at risk for rupture?
- Sudden push off with extended knee, Sudden/forced DF
- "pop"
- achilles tendinopathy, middle-aged adult
67
Achilles Tendon Rupture Symptomology:
| -Pain near _________ of achilles tendon.
-insertion
68
Achilles Tendon Rupture Physical Exam:
- Tenderness/ swelling/ hypertrophy/ palpable defect Achilles tendon/ posterior calf.
- Pain with ________ ROM.
- Weak/ absent active/ resisted _____.
- What test is positive with achilles rupture?
- DF ROM
- weak/absent PF
- + Thompson Test
69
PART 9: PLANTAR FASCIITIS
PART 9: PLANTAR FASCIITIS
70
Plantar Fasciitis lifetime prevalence = ___%.
-10%
71
Plantar Fasciitis Hx:
| -Risk factors include _______ and high _____ in non-athletic populations.
-limited DF ROM and high BMI
72
Plantar Fasciitis Symptomology:
- _____ ______ heel pain (worse with what?)
- Pain with ___________.
- Plantar medial heel pain (worse with first few steps after inactivity/prolonged WB.
- Pain with terminal stance
73
Plantar Fasciitis Physical Examination:
- Early ____-___ in stance phase.
- Guarding of ___________.
- Sweling/tenderness origin of plantar fascia with potential ____ _____.
- Pain with passive _____ of ankle and toes (windlass test).
- heel-off
- triceps-surae
- potential heel spur
- passive DF
74
PART 10: METATARSALGIA
PART 10: METATARSALGIA
75
What is metatarsalgia?
Pain in the distal forefoot, area of the met heads.
76
Metatarsalgia Hx:
| -Health conditions that increase stress on the ____ ______.
-met head
77
Metatarsalgia Symptomology:
| -Aggravated during prolonged ______ activities, _____ and _______ stance phases of gait.
-prolonged WB activities, mid and terminal stance phases of gait
78
Metatarsalgia Physical Examination:
- Findings for concomitant health conditions.
- Antalgic gait/diminished push-off.
- Observable ______ on plantar foot superficial to involved met heads.
- Tender plantar met heads.
-calluses
79
PART 11: INTERDIGITAL NEUROMA
PART 11: INTERDIGITAL NEUROMA
80
What is interdigital neuroma?
Thickening of soft tissue surrounding interdigital nerve.
81
Interdigital Neuroma Hx:
| -________ vs ______ onset
-insidious vs sudden
82
Interdigital Neuroma Symptomology:
| -Pain in area of met heads and corresponding ___ space.
-corresponding web space
83
Interdigital Neuroma Physical Exam:
- _______
- What test is positive with interdigital neuroma?
- Tenderness
| - + Foot Squeeze
