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y2 msk > Lower limb problems II > Flashcards

Lower limb problems II Flashcards

1
Q

Femoral shaft fracture is often due to

A

High energy injuries

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2
Q

Investigations for femoral shaft fractures

A

Xray

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3
Q

What can happen in displaced femoral shaft fracture

A

Substantial blood loss
Fat entering venous system causing embolism
-> resp distress / hypoxia / confusion

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4
Q

Management of femoral shaft fractures

A
  1. Thomas splint for temporary stabilisation
  2. closed reduction + IM nail / plate fixation
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5
Q

Subtrochanteric (proximal femur) fracture often occurs in

A

Osteoporotic bone in elderly

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6
Q

What are the issues with subtrochanteric fractures

A

It takes a long time to heal and Non-union often occurs due to poor blood supply to the area

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7
Q

Management of subtrochanteric fracture

A
  1. Thomas splint for initial stabilisation
  2. IM nail
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8
Q

What type of joint is the knee joint

A

Hinge type of synovial joint

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9
Q

Movements of the knee joint

A

Flexion
Extension
Small degree of internal and external rotation

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10
Q

Articulating surfaces of the knee joint

A

2 between femur and tibia
1 between femur and patella

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11
Q

What type of bone is patella

A

Sesamoid bone - bone embedded in tendon / muscle

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12
Q

The patella is embedded in which tendon

A

Quadriceps tendon

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13
Q

The joint capsule of the knee is supported by ligaments. What are the ligaments of the knee

A

Patellar ligament
Lateral collateral ligament
Medial collateral ligament
Anterior cruciate ligament
Posterior cruciate ligament

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14
Q

Which ligaments of the knee joints are intracapsular

A

Anterior and posterior cruciate ligaments

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15
Q

Name A-D

A

A- Lateral collateral ligament
B- Anterior cruciate ligament
C- Posterior cruciate ligament
D- Medial collateral ligament

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16
Q

Name A-H

A

A- iliotibial band
B- Anterior cruciate ligament
C- Menisci
D- Fibula
E- Quadricep muscles
F- Patella
G- Patellar ligament
H- Tibia

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17
Q

Apart from ligaments, what else helps support the knee

A

Iliotibial band

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18
Q

Attachment of anterior cruciate ligament

A

From the intercondylar region of tibia, blends with medial epicondyle of tibia
Ascends posteriorly and attaches to the lateral femoral epicondyle

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19
Q

Attachment of posterior cruciate ligament

A

From the posterior intercondylar region of the tibia
Ascends anteriorly and attach to the medial femoral condyle

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20
Q

Function of MCL

A

resists valgus stress (force from lateral side)

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21
Q

Function of LCL

A

Resist varus stress (force from medial side)
Resist posterior-lateral rotation of the knee

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22
Q

Function of ACL

A

Resists internal rotation of the tibia in extension (bones of the knee joint twist in opposite directions)
Prevent anterior subluxation of tibia (so tibia won’t move forward)

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23
Q

Function of PCL

A

Resists posterior subluxation of the tibia
Prevents hyperextension of the knee

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24
Q

Function of menisci

A

Shock absorbers
Distribute the load of weight evenly across the knee joint

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25
Q

What is special about medial menisci

A

It is attached to medial collateral ligament which makes it more likely to be damaged (damage to MCL often causes damage to medial meniscus)

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26
Q

Name A-D

A

A- Suprapatellar bursa
B- Prepatellar bursa
C- Infrapatellar bursa
D- Semimembranous bursa

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27
Q

Clinical significance of suprapatellar bursa

A

Abnormal fluid within the knee joint can fill in here causing visible swelling

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28
Q

The extensor mechanism of the knee describes

A

Quadricep muscles and tendon
Patella
Patellar ligament

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29
Q

The extensor mechanism of the knee is responsible for

A

leg extension at the knee

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30
Q

Distal femur fracture often occurs in

A

Osteoporotic bone

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31
Q

Injury mechanism of distal femur fracture

A

Fall onto flexed knee in osteoporotic bone

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32
Q

The knee of the patient with distal femur fracture is often

A

Flexed (cannot extend it)

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33
Q

Investigation of distal femur fracture

A

Xray - AP and lateral

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34
Q

Management of distal femur fracture

A

Fixed with plate and screws

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35
Q

Why is true knee dislocation a medical emergency

A

Due to its high chance of neurovascular injuries and compartment syndrome

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36
Q

True knee dislocation management

A

Multi‐ligament reconstruction (because in order for the knee to dislocate, all the ligaments must be broken)

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37
Q

Most common presentation of patellar dislocation

A

Lateral dislocation

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38
Q

Patellar dislocation is most common in

A

Teenagers ,female

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39
Q

Risk factors for patellar dislocation

A

Ligamentous laxity
Valgus alignment of the knee
Shallow trochlear groove

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40
Q

Symptoms of patellar dislocation

A

Pain and tenderness medially where the patellar ligament is torn

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41
Q

Clinical signs of patellar dislocation

A

Haemarthrosis (swelling)
Positive patellar apprehension test

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42
Q

What is haemarthrosis

A

Bleeding into synovial membrane

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43
Q

Describe the patellar apprehension test

A
  1. patient in supine / sitting up with knee flexed 30 degrees
  2. try to displace the patella laterally
    Pain = positive
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44
Q

Investigations for patellar dislocations

A

Patellar apprehension test
Xray

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45
Q

What may be seen on xray for patellar dislocation

A

Lipohaemarthrosis
Associated osteochondral fracture

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46
Q

Management for patellar dislocation

A

Most spontaneously reduce when the knee is straightened
Splint
Physiotherapy

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47
Q

How likely are patients going to experience another patellar dislocation after one

A

10% experience another recurrent dislocation

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48
Q

How to prevent further recurrent dislocations of the patella

A

Physio to strengthen quadriceps
Risk decreases with as they grow older
Surgery

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49
Q

What can cause tibial plateau fractures to occur

A

High energy injury in young
Low energy injury in old osteoporotic bone

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50
Q

Tibial plateau fracture is classified by

A

Schatzker system

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51
Q

Tibial plateau fracture is an intra/extra-articular fracture

A

Intra-articular

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52
Q

Different presentations of tibial plateau fractures

A

split in the bone
a depression of the articular surface
a combination of both

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53
Q

Injury mechanism of tibial plateau fracture

A

valgus force to the knee with foot planted

54
Q

Investigations for tibial plateau fracture

A

Xray - AP and lateral
CT

55
Q

What may be seen on xray for tibial plateau fracture

A

lipohaemarthrosis; fat floating on top of blood which bled into the joint

56
Q

Lipohaemarthrosis is a specific sign for

A

Intra-articular fractures

57
Q

Complications of tibial plateau fracture

A

Blow to lateral aspect of knee -> damage the common fibular nerve
High risk of compartment syndrome
Damage to soft tissue

58
Q

Sign of common fibular nerve damage

A

Foot drop

59
Q

Why does common fibular nerve damage cause foot drop

A

Because the deep branch of common fibular nerve provides motor innervation to muscles in the anterior compartment of leg
Those muscles are required to dorsiflex the foot

60
Q

Management of tibial plateau fracture

A

ORIF
Bone grafting for depressed fractures
TKR (most still require TKR despite other management)

61
Q

Tibial plateau fracture is associated with soft tissue injury. How can this be a problem in management

A

Substantial soft tissue swelling -> requires temporary external fixation -> ORIF

62
Q

Injury mechanisms of tibial shaft fractures

A

Torsional injury
Bending
Compressive force from deceleration
Direct force

63
Q

Torsional injury can cause which fracture configuration of the tibial shaft

A

Spiral fracture

64
Q

Compressive force from deceleration can cause which fracture configuration of the tibial shaft

A

Oblique fracture

65
Q

High energy direct force can cause which fracture configuration of the tibial shaft

A

Comminuted fracture

66
Q

Tibial shaft fracture is at a high risk of

A

compartment syndrome of the anterior compartment of leg

67
Q

Investigation for tibial shaft fracture

A

Xray - AP and lateral

68
Q

Management for tibial shaft fracture

A

above knee cast
ORIF with IM nails

69
Q

What is valgus knee

A

When the bone at the knee joint is angled out and away from the body’s midline

70
Q

Describe the image

A

Valgus knee

71
Q

What is varus knee

A

When the bone of the knee joint is angled inwards towards the body’s midline

72
Q

Describe the image

A

Varus knee

73
Q

What factors increases the risk for knee osteoarthritis

A

Valgus / varus knee
Ligament injuries - esp ACL
Previous meniscal tears
Active occupation and hobbies

74
Q

Which type of OA can valgus knee cause

A

Lateral OA

75
Q

Which type of OA can varus knee cause

A

Medial OA

76
Q

Injury mechanism of meniscal tears

A

Twisting force on loaded knee (weightbearingon knee) e.g. turning at football / squatting

77
Q

How do most older patients get meniscal tear

A

Atraumatic, spontaneous tears due to weakened meniscus

78
Q

Degenerative meniscal tear is an early sign of

A

knee oA

79
Q

Rupture of which ligament is often associated with meniscal tear

A

ACL

80
Q

Which type of meniscal tear is more common

A

Medial meniscal tear

81
Q

Symptoms of meniscal tear

A

Pain and tenderness localised to medial/lateral joint line (depending on which type of tear)

Unable to fully straighten knee (true locking)

Knee about to collapse during walking

82
Q

Why would patients with meniscal tears describe the feeling that their knee is going to collapse during walking

A

Because the meniscal fragment may be caught in the knee joint during movement

83
Q

Patients with knee arthritis sometimes describe that their knee is stuck as well. Is this the same as locked knee in meniscal tears

A

No, meniscal tears cause true locked knee whereas arthritis causes pseudo-locking which can resolve spontaneously

84
Q

Pseudo-locking vs true locked knee

A

Pseudo-locking can be resolved spontaneously whereas true locking cannot
True locking is due to a fragment trapped in knee joint whereas pseudo-locking is due to too much pain

85
Q

Acute locked knee in a patient with meniscal tear suggests

A

Large bucket handle meniscal tear

86
Q

Does true-locking occur in all patients with meniscal tear

A

No, only if the meniscal tear is severe and unstable enough to be flipped and trapped in knee

87
Q

Clinical signs of meniscal tear

A

Swelling
Positive McMurray’s test (but may not be accurate)
Positive Steinman test (but may not be accurate)

88
Q

Describe McMurray’s test for meniscal tear

A
  1. Patient supine
  2. Manually flex the hip and knee by grasping the patient’s feet
  3. Extend the knee with internal rotation of the tibia + varus (inwards) stress
  4. Then return to flexion of the knee and extend the knee again but with external rotation + valgus stress
89
Q

Describe specifically what each step of Mcmurray’s test is testing for

A
  1. Flex -> extend knee with internal rotation + varus stress = tests for lateral meniscal tear
  2. Flex -> extend knee with external rotation + valgus stress = tests for medial meniscal tear
90
Q

Describe Steinman’s test

A
  1. Patient supine
  2. Stabilise the knee in flexed position
  3. Hold the ankle of the leg
  4. Rotate the leg medially and laterally
    Pain = positive
91
Q

Pain during external rotation in Steinman test suggests

A

Medial meniscal tear

92
Q

investigations for meniscal tear

A

Steinman’s
McMurray’s
MRI

93
Q

How to differentiate between degenerative and acute meniscal tear

A

Degenerative tear is Steinman’s negative and likely to be associated with signs of OA

94
Q

Why is it important to differentiate between degenerative and acute meniscal tear

A

Because management is different - degenerative tears are unlikely to benefit from arthroscopic meniscectomy whereas acute tears can

95
Q

Management for acute meniscal tear

A

Meniscal repair (only indicated in some)

Arthroscopic meniscectomy (If meniscal repair fails / meniscal repair not indicated and pain does not settle after 3 months)

96
Q

When is meniscal repair indicated

A

In young patients with fresh meniscal tears

97
Q

Describe the healing of meniscal tears

A

Slow due to blood supply only on its outer 1/3
Healing potential decreases with increasing age

98
Q

What are bucket handle tears

A

Large longitudinal meniscal tear, where the fragment can flip out and cause knee locks

99
Q

Why may it be useful to see patients with suspected soft tissue injuries of the knee a few days later if not significant

A

Due to pain and instability limiting examination findings

100
Q

What imaging technique is used to identify soft tissue injuries of the knee

A

MRI

101
Q

If you suspect large soft tissue injury of the knee, what should you do

A

early MRI instead of seeing the patient again few days later

102
Q

Which knee ligament is the most commonly injured

A

ACL

103
Q

Mechanism of injury of ACL

A

Sudden pivoting with foot planted

104
Q

Symptoms of ACL tear

A

Audible pop followed by pain and swelling
Pain settles but leaves rotatory instability

105
Q

What is the main complaint that patients with ACL injury will present

A

Rotatory instability (ACL is responsible to resist the internal rotation of tibia)

106
Q

Clinical signs of ACL injury

A

Excessive anterior movement of the tibia on anterior drawer test and Lachman test (ACL is responsible to prevent anterior subluxation of tibia)

107
Q

Describe Anterior drawer test

A
  1. Patient supine, knee flexed
  2. Sit on the patient’s foot to immobilise the foot
  3. Grab the tibial head with both hands and pull it anteriorly
    Positive = abnormal anterior movement of tibia
108
Q

Describe the Lachman test

A
  1. Patient supine, knee slightly flexed
  2. tibia is slightly externally rotated
  3. Hold the knee with one hand and the tibial head with another hand
  4. Pull the tibial head anteriorly (like in anterior drawer test)
    Positive = anterior movement of tibia
109
Q

Investigations for ACL injury

A

Joint aspiration - may show haemarthrosis
MRI

110
Q

Management of ACL injury

A

Some may compensate well (not heal)
Physiotherapy
ACL reconstruction if indicated
Rehab after ACL reconstruction

111
Q

Why can’t ACL repair itself

A

Because there is no blood supply

112
Q

When is ACL reconstruction indicated

A

No improvement from physio
Multiligament reconstruction
For professional athletes

113
Q

Mechanism of injury of PCL injury

A

Direct blow to anterior tibia

114
Q

Symptoms of PCL injury

A

Popliteal knee pain and bruising
Positive posterior drawer test
Positive sag test

115
Q

Describe the sag test (Godfrey sign)

A
  1. Patient supine, knee flexed to 90 degrees
  2. Inspect the tibial tuberosities
    Positive = tibia sags posterior compared to other knee
116
Q

Investigations for PCL injury

A

Xray - PCL injury is often associated w other injuries
MRI
Sag test
Posterior drawer test

117
Q

Management for PCL injury

A

Most don’t require reconstruction surgery
Reconstruction surgery for those that develop instability

118
Q

What instability can PCL injury cause

A

Recurrent hyperextension
Feeling unstable when going down stairs

119
Q

Mechanism of injury of MCL

A

Valgus stress - rugby tackling from the side

120
Q

Symptoms of MCL

A

Knee swelling
Valgus instability
Medial joint line tenderness
Pain on valgus

121
Q

Investigations for MCL injury

A

Clinical - valgus stress test
Xray / MRI if needed

122
Q

Describe the valgus stress test

A
  1. Patient supine with knee in extension and slight external rotation
  2. Hold the ankle with one hand and the other hand hold the lateral condyle of the femur
  3. Push against the knee medially and laterally against the ankle
    Positive = abnormal movement / pain
123
Q

Management of MCL injury

A

Usually heals well
Hinged knee brace
MCL tightening / reconstruction for chronic MCL instability

124
Q

Why does MCL injury heal well whereas ACL injury doesn’t

A

Because there is blood supply to MCL whereas there isn’t to ACL

125
Q

LCL injury often occurs with

A

PCL or ACL injury
Uncommon on its own

126
Q

Mechanism of injury of LCL

A

Varus stress
Hyperextension

127
Q

Symptoms of LCL injury

A

Knee swelling
Varus instability
Lateral joint line tenderness
Positive varus stress test

128
Q

Describe the varus stress test

A
  1. Patient supine, knee fully extended
  2. Hold the ankle with one hand and the medial epicondyle of knee with another
  3. Push against the knee laterally and medially against the ankle
    Positive = abnormal movement / pain
129
Q

Investigations for LCL injury

A

Clinical - Varus stress test
Xray / MRI if needed

130
Q

Management of LCL injury

A

Early urgent repair
Late reconstruction for those that are later diagnosed

131
Q

LCL injury is often associated with

A

Common fibular nerve damage
Multiligament injuries
Vascular injury - popliteal artery

y2 msk (19 decks)

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