Lecture 6: LE Injuries Part 1 Flashcards
1
Q
What is the zero starting position for hip flexion? How do we test hip flexion?
A
- Patient lying supine with lumbar spine flat on table, knees slightly flexed
- Can be tested seated or standing.
2
Q
How do we test hip extension?
A
3
Q
What needs to be done when testing rotation of the hip?
A
Holding the kneecap to prevent its use.
4
Q
What is the thomas test?
A
- Hip flexor contracture test or tight psoas
- Supine
- One hip: max flexion
- Contralateral hip: observe to see if it flexes off the surface
5
Q
What does the trendelenburg test show?
A
- Test of hip ABductors
- A weak hip ABductor causes a DIP towards the OPPOSITE SIDE.
- Muscles weakness is on the STANCE SIDE.
The leg that is straight is the weak one
6
Q
What does the FABER test check?
A
- Flexion-ABduction-External Rotation Test
- Figure-of-4 test
- Checks hip and sacroiliac pathology
- Ipsilateral pain = HIP PATHOLOGY
- Contralateral pain = SI dysfunction
7
Q
Where do we measure leg length from?
A
- anterior iliac crest to medial malleolus
- > 3cm diff is significant
Send to podiatry
8
Q
What does the leg roll test check for?
A
- Simple internal and external rotation of hip while supine and relaxed.
- Pain, esp anterior hip= OA or femoral head osteonecrosis
9
Q
What does the piriformis test check for?
A
- Supine/unaffected side, then contralateral hip and knee flexed to 90deg
- Stabilize pelvis, apply flexion adduction and internal rotation at knee
- Pain in butt/leg = piriformis is impinging on sciatic nerve
10
Q
What is the scouring test?
A
- Flex hip and knee 90
- Apply posterolateral force through hip as femur rotates
- Passively adduct and internally rotate hip followed by abduction and external rotation
- Pain/grating sound = labral pathology, loose body, or internal derangement
highly sensitive test, terrible specificity
11
Q
What are the specialty hip views?
A
- Frog leg view
- Obturator/Oblique view
12
Q
MC type of hip dislocation and MOI
A
- Posterior (90%)
- Posterior force applied to a flexed knee
13
Q
What kind of hip joint can dislocate much easier?
A
A prosthetic hip joint
It is generally not as deep as a normal hip joint
14
Q
Complications seen in posterior hip dislocation
A
- Acetabular/femoral head/neck fx
- Sciatic nerve damage
- Ligament damage
- Avascular necrosis
15
Q
How does a posterior hip dislocation present?
A
- Severe pain
- INability to move leg
- Peroneal damage: drop foot + sensory changes on lateral lower leg/dorsum
16
Q
Describe an posterior hip dislocation on physical presentation
A
Shortened, adducted, and internally rotated
same orientation as a posterior shoulder
17
Q
How does an anterior hip dislocation present physically?
A
- Abduction and external rotation and flexion
out and about like anterior shoulder
18
Q
What determines the direction of anterior hip dislocation?
A
Degree of hip flexion at injury
19
Q
Diagnostics for a hip dislocation
A
- Hip XR
- CT hip w/o contrast (assess fx & trapped intra-articular loose bodies)
20
Q
How do we manage hip dislocations due to acute, traumatic events?
A
- Posterior: Allis maneveur to do a closed reduction within 6 hours ideally
- Anterior: Open reduction
- All reduction require procedural sedation and post reduction films
- Post reduction immobilization via triangular pillow
21
Q
What do we monitor after hip reduction for 2-3 years?
A
Avascular necrosis
22
Q
MC MOI for a hip fx
A
Fall
23
Q
4 possible locations for a hip fx
A
- Intracapsular: femoral head/neck
- Extracapsular: intertrochanteric/subtrochanteric
24
Q
How does a hip fx present?
A
- Pain in groin, hip, butt radiating to knee
- INability to ambulate
- External rotation, ABduction, shortened leg (also out and about)
- Pain with minimal ROM or SLR
Stress fx will not have a deformity
25
How soon do we intervene for a hip fx and how?
* 48 hrs!!!!
* ORIF for young
* Arthroplasty for old
26
Contraindications to hip fx surgery
* Medically unstable
* **Previously non-ambulatory to begin with**
* Dementia patients with minimal pain during transfers
| although i read surgery can be palliative
27
In what kind of hip fx are implant failures MC?
Extracapsular fx
| trochanteric
28
Clinical presentation of greater trochanteric bursitis
* Lateral hip pain radiating down past knee or up butt
* **Worse when rising**, **Worse when lying on it**
* **Improves for a few steps then worsens**
* Tenderness
* **Pain with active abduction and adduction + internal rotation**
29
Management of greater trochanteric bursitis
1. NSAIDs, ice
2. **Short term use of cane on opposite side of affected leg**
3. Home stretching
4. Bursal injections
30
MC sites for avascular necrosis
* Proximal and distal femoral heads (hip and knee pain)
31
MC demographic for avascular necrosis + RFs
20-50
32
How does AVN present?
* Severe pain initially
* **Later: dull aching and throbbing**
* **Painful/loss of ROM**
* Antalgic gait if femur has AVN
33
Diagnostic signs for AVN of the femur
* Early: normal
* Later: Patchy sclerosis and lucency
* **Crescent sign** indicates **subchrondral facture**
34
Initial management for AVN
* Avoid weight-bearing
* NSAIDs
* Ortho
35
When is surgery typically indicated for AVN?
**Almost all patients** due to the young age it occurs in
36
What is important regarding AVN management?
Non-surgical management **DOES NOT HALT PROGRESSION**
| Improvement of QOL and gait
37
MOI of femoral shaft fracture
High-energy trauma (skiing, MVA)
38
How does a femoral shaft fx present?
* Pain/tenderness/swelling
* Shortening/deformity of the leg
* **Check for compartment or blood loss**
39
Management of a femoral shaft fx
* Pain management
* Fluids
* Temporary stabilization
* Ortho
40
Knee joint anatomy
41
What position do we palpate knee joint lines in and findings?
* Knee must be flexed at 90deg
* Focal tenderness = suggests torn meniscus
* Generalized tenderness = arthritis
42
Describe a bulge sign and ballottement
* Bulge sign: Direct fluid over medial recess and then inferiorly from suprapatellar patch inferiorly: **(+) Fluid wave over medial knee**
* Ballottement: Push down on patella and rapidly release: **(+) rapid rebound**
43
How do we do varus and valgus stress tests?
* Valgus: apply a valgus force to check MCL
* Varus: apply a varus force to check LCL
| Abduct and flex knee to 30deg when doing these.
44
What is abnormal patellar tracking?
Exaggerated arc of movement = patellar instability
45
How do you test for the patellar apprehension sign?
* Supine with knee at 30deg flexion
* Displace patella laterally via medial pressure
* (+) pt will contract quads or become apprehensive d/t pain
46
How do we do the patellar grind test/clarke sign and what for?
* Supine + knee fully extended
* One hand superior to patella and gently push patella inferiorly as pt contracts quad.
* (+) pain, grinding or clicking
* Checks for **patellofemoral syndrome/chondromalacia**
47
What is the McMurray test and what is it for?
* Supine
* One hand on heel, one on joint line
* Medial meniscus checked via MEG (ext rotation + valgus + extension)
* Lateral meniscus checked via LIR (Internal rotation + varus + extension
* (+) pain, popping, clicking
| **Meniscus test**
48
What is the most sensitive test for an ACL tear?
Lachman test
49
How do you perform a lachman test?
1. Supine with knee at 30deg flexion
2. One hand on distal femur + proximal tibia
3. Pull anteriorly on tibia
4. (+) anterior translation with ACL tear
| Best test for ACL tear
50
How do we perform an anterior drawer test?
* Supine with hamstrings and quads relaxed
* Knees flexed to 90deg
* Sit on pts foots
* Grasp proximal tibia and slide tibia anteriorly
* (+) significant laxity compared to contralateral
| ACL stability
51
How do we do a pivot shift test?
1. Do under anesthesia
2. Full extension and slowly flexing the knee
3. Examiner applies valgus stress and internal rotation
4. (+): subluxation occurring at 20-40deg flexion
| ACL dysfunction check, pos in grade 2 or 3 tears
52
Describe Noble's test
* Supine with knee flexed to 90deg
* Apply pressure to lateral femoral condyle for 1-2cm as knee is passively extended
* (+) pt complains of tenderness over lateral femoral condyle at approx 30deg of flexion
| IT Band test
53
Describe Ober's test
1. Lay on unaffected side, flex unaffected knee and hip
2. Abduct and extend ipsilateral hip while stabilizing pelvis and lowering thigh
3. (+) **Inability of extremity to drop** below horizontal to the level of the table
| Tensor fascia lata and IT band tightness
54
Where does the IT band originate from and where does it insert to?
* Origin: ASIS
* Insertion: Lateral tibia
55
When is the ITB anterior to the lateral femoral condyle? Posterior?
* In knee extension, it is anterior
* Past **30deg flexion**, it is posterior
56
How does ITB syndrome present?
* Pain in anterolateral aspect of knee, esp at heel strike
* Audible popping
* Tenderness over lateral femoral epicondyle
* (+) Ober's and Noble's
* Lateral knee pain with hopping on flexed knee
57
How do we manage ITB syndrome?
* Conservative
* Ortho for steroid injection or surgical ITB lengthening if ^ fails
58
How does a distal femur fx present?
* MOI: low energy in osteoporotic geriatrics
* MOI: High energy in young
* Supracondylar vs intercondylar
59
Describe the clinical presentation of a distal femur fx
* Sudden onset of pain post trauma with **inability to bear weight**
* Limited ROM
* Normal fx presentation
60
When is an oblique view or CT used for distal femur fx?
* Determine extent of injury
* Surgical planning
61
Management of distal femur fx
* Non-displaced/minimal: long leg splint + rest + non-weight bearing
* Displaced/intra-articular: Long leg splint + ORIF in 24h
* Open: Emergent ortho
62
What should we assess in a patellar fx?
Intact extensor mechanism: active extension of knee or SLR
63
Management of a patellar fx
* Pain
* Non-displaced: Knee immobilizer so knee is extended
* Displaced: call ortho for surgery
64
MOIs for a patellar dislocation
* Direct trauma
* Landing on hyper extended knee
* Quad contraction during knee flexion
65
Clinical presentation of a patellar dislocation
* **Usually a lateral dislocation**
* Hemarthrosis may occur
* (+) patellar apprehension test in spontaneously reduced dislocations
66
Management for a patellar dislocation
* Reduction
* Flex hip, extend knee, medial force on patella directly
* Immobilizer with full extension for 4-6 weeks
* F/u with ortho in 1 week
67
MOI for patellofemoral syndrome
Runner's knee, aka overuse
68
Etiologies for anterior knee pain
* Abnormal patellar tracking
* Ligamentous hyperlaxity causing patellar subluxation
* Hip/kneemuscle weakness + imbalance
* Abnormal hip-knee biomechanics (Q-angle: valgus knee)
69
How does patellofemoral syndrome present?
* "pain behind the kneecap" with any activities that load the joint
* Patellar squinting in gait (pointing towards each other)
* Tenderness along articular surface in extended and relaxed leg
* Apprehension sign = associated instability
* Patellar grind test = associated chondromalacia
* One leg squat = assess quad/hip strength
70
How is patellofemoral syndrome Dx?
* **Clinically**
* XR for r/o DDx
* **MRI for surgery planning if indicated**
71
Management of patellofemoral syndrome
* Conservative
* McConnell taping
* **PT IS HALLMARK**
72
Two main causes of prepatellar bursitis
* Inflammatory
* Bacterial infection
73
Presentation of prepatellar bursitis
* Early on pain only with activity or direct pressure, progressing to constant pain
* Localized swelling that you **need to diff from joint effusion.**
* Septic bursitis
* Inflammatory
74
When is bursal aspiration indicated for prepatellar bursitis?
Suspicion of septic bursitis
75
Management of inflammatory bursitis
* Conservative
* Corticosteroid injection **if you have r/o sepsis alrdy**
76
Management for infectious patellar bursitis
* Oral keflex for MSSA
* Bactrim/clinda for MRSA
* IV rocephin (MSSA) and/or vanco (MRSA)
