Lecture 6: LE Injuries Part 1 Flashcards
(76 cards)
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
- Simle 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
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
17
Q
How does an anterior hip dislocation present physically?
A
- Abduction and external rotation and flexion
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
- 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
27
In what kind of hip fx are implant failures MC?
Extracapsular fx
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 mensiscus checked via LIR (Interal 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
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
* Consevative
* 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 burisits
* Conservative
* Corticosteroid injection **if you have r/o septic**
76
Management for infectious bursitis
* Oral keflex for MSSA
* Bactrim/clinda for MRSA
* IV rocephin (MSSA) and/or vanco (MRSA)
