Lecture 7: LE Injuries Part 2 Flashcards
1
Q
What are the Ottawa Knee Rules? (5)
A
- Pt older than 55
- Tenderness at head of fibula
- Isolated patellar tenderness
- Inability to flex knee to 90deg
- Inability to bear weight for 4 steps both immediately after injury & in the ED
If any are met, order XR
Mainly used to rule out knee fx.
2
Q
What are the typical views for a knee series?
A
AP & Lateral
3
Q
MOI for an ACL tear
A
Sudden deceleration with rotational trauma/hyperextension force applied to knee
Usually a full tear.
4
Q
When an ACL is torn, what is typically also torn?
A
Meniscal tear
Very rare to injure the other ligaments.
5
Q
How does an ACL tear present? (4)
A
- Sudden pain and collapse of knee
- Audible pop
- Joint effusion within hours => pain
- Limited ROM
6
Q
What 3 special tests check for ACL tear?
A
- Lachman test (most reliable)
- Anterior drawer
- Pivot shift test
7
Q
What XRs do we order for an ACL tear and expected finding?
A
- AP, lateral, tunnel views
- Most commonly shows an effusion
8
Q
What avulsion fracture may appear with ACL tears?
A
Segond fractures, which are the lateral capsular margin of the tibia
9
Q
Who are tibial eminence fractures MC in?
A
People with open growth plates
aka the children
10
Q
How is dx of an ACL tear confirmed?
A
MRI
11
Q
Image of a tunnel knee XR
A
12
Q
How does a knee joint effusion appear on XR?
A
Well-defined rounded homogeneous soft tissue density within suprapatellar recess on lateral view
13
Q
What is the initial management for an ACL tear? (4)
A
- RICE with knee immobilizer
- Tylenol before NSAIDs
- Aspiration for large effusion
- ROM as pain allows
14
Q
How does management with ortho for an ACL tear vary depending on age?
A
- Young = reconstruction via graft
- Old = PT to improve the surrounding muscles to compensate
Patella, hamstring, quad, or cadaver grafts
15
Q
What are the MOIs associated with a PCL tear? (2)
A
- Direct blow to tibia (knee striking dashboard in MVA or falling onto knee)
- Extreme hyperextension (usually ACL rupture also)
16
Q
When does a PCL tear typically occur?
A
Alongside a collateral ligament tear or ACL rupture.
Not very common to just completely rupture PCL alone
17
Q
How does a PCL tear present? (5)
A
- Same as ACL, but the special tests will be negative (lachman & pivot shift)
- Sudden pain and collapse of knee
- Audible pop
- Joint effusion within hours => pain
- Limited ROM
18
Q
What special test is usually positive for a PCL tear specifically?
A
Posterior drawer test
19
Q
When is NV status assessed for a PCL tear and how?
A
If we suspect multiligament injury, we should do an ABI, which should be greater than 0.9 to rule out.
If lower, order arterial imaging to check for an intimal tear
20
Q
Initial management of a PCL tear (2)
A
- RICE + knee immobilizer
- ROM within 1-5 days
21
Q
When is reconstruction indicated for a PCL tear? (2)
A
- PT fails to restore stability
- Multi-ligamentous injury
22
Q
Main sequelae associated with a PCL tear (1)
A
OA
23
Q
Main sequelae associated with an ACL tear (2)
A
- Medial meniscus injury
- Secondary degenerative joint disease
24
Q
What is the MOI for an MCL tear?
A
Lateral/valgus blow to the knee (typically football)
25
What is the MOI for an LCL tear?
Associated with other traumatic knee injuries
| Rarer than an MCL tear
## Footnote
Pretty hard to get hit from the inside of your knee
26
Clinical presentation of a collateral ligament tear (3)
* Localized pain/tenderness/swelling/stiffness that worsens over 6-8 hrs
* **Usually able to bear weight after**
* Ecchymosis + effusion along ligament 1-2 days after
27
What testing should we do for a suspected collateral ligament tear?
* Varus/valgus testing in both extension and 30deg flexion
* **Laxity in extension is more significant**
* **Instability can be masked by pain and involuntary muscle contraction**
| Do their uninjured leg first
## Footnote
Extended legs stretch collateral ligaments, so laxity is concerning
28
How do we confirm a collateral ligament tear?
MRI
| XR is for checking for avulsion fx
29
Management for a grade 1-2 collateral ligament tear (sprain-partial tear) (3)
* RICE, **hinged knee brace**, NSAIDs
* Early ROM exercises
* Crutches with wt-bearing as tolerated
30
Management for grade 3/ruptured collateral ligament (1)
Ortho to decide brace vs repair
31
MOIs for meniscal injury
* Rotational force with a planted foot
* Older pts (degenerative tears)
32
Clinical presentation of a meniscal injury (5)
1. Pain and stiffness following MOI that worsens over the next few days
2. **Sometimes able to ambulate**
3. Locking/catching/popping after effusion resolves
4. **Tenderness along joint line**
5. Effusion (MC in lateral tears)
33
What special test is positive for a meniscal injury?
McMurray test (painful click)
34
What position should a knee be in when you're palpating?
90deg flexion
35
If a patient is over 40y and has a suspected meniscus tear, what modification should be done to XR?
Weight bearing in 45 deg flexion
| Checking for OA
36
Initial management for meniscal injury
RICE + NSAIDs
| PT after if no surgery
37
When is a referral to ortho indicated for meniscal injury? (4)
* Young pt with traumatic tear
* Failure of conservative (aka joint line stays tender)
* Mechanical symptoms
* Evidence of instability
38
Who is knee dislocation MC in?
Young males
| But overall, not a very common MSK condition
39
How do we characterize knee dislocations and the MC type?
Direction of the **tibia relative to the femur**
| MC is anterior
40
Clinical presentation of a knee dislocation (3)
* Obvious deformity with severe pain and limited ROM
* **50% spontaneously reduce**
* Ecchymosis and swelling
41
What indicates gross instability of the ligaments in a knee dislocation?
Hyperextension > 30deg when leg is lifted by the foot
42
Why is NV status checking essential in a knee dislocation?
Vascular injuries can occur even with normal pulses.
| Make sure you check popliteal!
43
What does a CT check for in knee dislocations? MRI?
* CT checks for occult fx post reduction
* MRI checks for internal derangement post reduction
44
How is a knee reduced? (2)
* Sedation => **Longitudinal traction**
* **Immobilize in 20deg flexion** to check serial NV status later
45
After a knee is reduced, what should we do? (2)
* Consult ortho and vascular
* Admit for serial NV checks
| Not a same-day discharge usually
46
What is found in between the tibia and fibula?
Interosseous membrane
47
What is the MC MOI to cause a tibial plateau fx?
* High energy valgus trauma in young pt
* Low-energy trauma in old pt (twisting/fall)
48
Which tibial plateau is MC fxd?
Lateral plateau
| Valgus stress
49
Clinical presentation of a tibial plateau fx (4)
* Massive pain
* **Non-weight bearing**
* Swelling/joint effusion
* Limited ROM
50
Besides NV status, what else we concerned about in a tibial plateau fx?
Compartment syndrome
51
When are oblique views good for tibial plateau fx?
If AP/lateral were inconclusive
52
Initial managment of a tibial plateau fx (4)
* Compression
* Ice
* Analgesia
* **Splint in full extension**
53
When is urgent consult indicated for tibial plateau fx? (2)
* Displacement or depression
* Nearly all require ORIF
54
How do we manage a non-displaced tibial plateau fx? (3)
* Long-leg posterior/knee immobilizer
* NWB
* **Ortho in 1 week**
55
MOI for a tibial tubercle fx
Sudden force to **flexed knee during a contracted quad**
| Usually when jumping or landing
56
Who is a tibial tubercle fx MC in?
Children
57
How does a tibial tubercle fx present?
* Pain/tenderness/swelling over tibial tuberosity
* **Displacement of patella superiorly** (it has lost its inferior anchor point)
* Loss of ROM
58
Management of tibial tubercle fx with incomplete/small avulsion (4)
* RICE
* **Knee immobilizer/long-leg posterior**
* NWB
* Ortho in 1 week
59
Management of tibial tubercle fx with complete avulsion (4)
* RICE
* Knee immobilizer/long-leg posterior
* NWB
* Urgent ortho for ORIF (24-48h)
60
What is the MC long bone fx overall?
Tibial shaft fx
| Often with a fibular fx also
61
How do adults typically fx their tibial shaft? Children?
* Adults: High energy blow directly
* Children: Twisting
62
How does a tibial shaft fx present? (2)
* Inability to bear weight
* Pain/swelling/deformity
63
How would you diagnose/workup a tibial fx?
1. AP & Lateral tib/fib XR (Can add on knee/ankle)
2. Oblique XR/CT for complexity
3. **Bone scan if occult fx is suspected**
64
Initial management for tibial shaft fx? (3)
1. RICE
2. Analgesics
3. Long-leg posterior splint
65
When is an emergent consult indicated for a tibial shaft fx? (4)
* Open fx
* Tib/fib
* NV compromise
* Compartment syndrome
66
If you have a displaced tibial shaft fx, what are the 2 steps to manage it?
1. Closed reduction
2. Long leg splint via posterior & stirrup
| Stirrups prevent ankle inversion/eversion
67
If a tibial shaft fx is non-displaced, how do you manage it? (4)
1. Long-leg posterior splint
2. Crutches
3. NWB
4. Call ortho for 1 week f/u
68
If a fibula fx presents isolated, what is the MC etiology? (2)
* Direct blow to fibula
* Rotational force
69
What is unique about the fibula among the leg bones?
It is non-weight bearing, so an isolated fx is still weight bearing!
70
How does a fibula fx present? (3)
* Point tenderness and localized pain with swelling
* Deformity if displaced
* **Maisonneuve fx may be present**
71
What is a Maisonneuve fracture?
Proximal fibula fx + medial malleolus fx/ligament disruption of the ankle w/o fx
72
When is urgent consult indicated for fibular fx? (2)
* Displaced
* Maisonneuve fx
73
What kind of fibula fx requires a stirrup splint/air-cast splint rather than a long-leg posterior?
Distal fibula fx
| Assuming because distal fibula is related to ankle
74
What kind of fibular fx can use a knee immobilizer splint?
Fibular head/neck fx
75
For a simple fibular fx, do we want to start weight bearing sooner or later?
Sooner
76
What are the 4 main ligaments of the ankle?
* Anterior talofibular ligament (ATFL)
* Calcaneofibular ligament (CFL)
* Posterior talofibular ligament (PTFL)
* Deltoid ligament (4 parts)
| First 3 are the typical ligaments in an ankle sprain
77
What are you noting for anterior standing & supine ankle/foot inspection? (3)
1. Alignment of toes
2. Position of foot relative to limb
3. Medial curvature of forefoot
78
What are you palpating for in the anterior foot/ankle exam? (3)
1. Plantar fascia
2. MTP joints
3. Head of metatarsal for sesamoid bone tenderness
79
What are you assessing and palpating in the posterior foot/ankle exam? (2)
1. Assess heel alignment when standing
2. Palpate achilles tendon insertion
## Footnote
Normal heel alignment is a neutral or slight valgus with no more than 2 lateral toes visible from behind.
80
What are you inspecting and palpating for the medial foot/ankle exam? (3)
1. Inspect arch (symmetric)
2. Prominence of the medial midfoot
3. Palpate for perimalleolar tenderness
81
What are you inspecting/palpating for in the lateral foot/ankle exam when standing? (4)
1. Calluses
2. Ankle swelling
3. Prominence of the posterior calcaneus
4. Palpate for perimalleolar tenderness
82
Can you invert or evert your ankle more?
Invert more
83
What are the 5 specific muscles that test foot/ankle motions?
1. Posterior tibialis: inversion and plantar flexion
2. Anterior tibialis: Inversion and dorsiflexion
3. Peroneus longus/brevis: Eversion
4. Extensor hallucis longus: Dorsiflexion of great toe
5. Flexor hallucis longus: Plantar flexion of great toe
84
What does an anterior drawer test of the foot test?
ATFL instability
85
What does a talar tilt test check for?
Integrity of CFL, deltoid, ATFL, and PTFL
86
How do you perform thompson's test and what does it check for?
* Place patient prone and squeeze their calf
* Plantar flexion should occur normally.
* **Absence of plantar flexion = achilles tendon rupture**
| Not to be confused with thomas test
87
What XR view is good for viewing the ankle?
Mortise view
88
What are the Ottawa Ankle Rules? (3)
1. Pain at malleoli
2. Inability to bear wt 4 steps
3. Tenderness posteriorly or inferiorly at the malleoli
| Any positive = order XR
89
What are the Ottawa Foot Rules? (3)
1. Inability to bear wt for 4 steps
2. Tenderness at base of 5th metatarsal
3. Tenderness over navicular bone
90
Where does an achilles tendon rupture typically occur and how?
* Occurs **5-7cm from the distal insertion site on calcaneus**
* MOI: Direct blow or forced dorsiflexion (Stop & Go)
91
Where does an achilles tendon tear typically occur and how?
| Not the same as a complete rupture!
## Footnote
Can be microtears
* Typically occurs at the insertion site
* MOI: Indirect (Forced dorsiflexion)
92
How does an achilles tendon rupture present? (5)
* Pop with severe pain
* Difficulty bearing wt
* Palpable defect
* Weak plantar flexion
* (+) thompson test
93
How does an achilles tear typically present?
* Less acute/severe pain
* Localized tenderness overlying insertion
* **No palpable defect**
94
What confirms the dx of an achilles tendon injury?
MRI or US
95
How do you manage an achilles tendon rupture? (3)
* Short leg posterior splint in slight plantar flexion
* NWB
* Surgical vs non-surgical
96
How do you manage an achilles tendon tear? (2)
* Controlled ankle motion (CAM) boot
* PT
97
What is achilles tendonitis MOI?
Microtrauma from repetitive stress or increased load.
98
How does achilles tendonitis present? (4)
* Burning pain/stiffness 2-6cm above posterior calcaneus
* (-) thompson
* ROM and MS normal
* **Long-standing may cause palpable calcaneal spur**
| Worse with activity, better with rest
99
How do you dx and manage achilles tendonitis? (3)
* Clinical dx
* Rest, ice, NSAIDs
* PT if chronic
100
What is the MC type of ankle sprain?
Lateral ankle sprain due to inversion injury?
101
What ligaments can be damaged in a lateral ankle sprain?
* ATFL
* CFL
102
Damage to what makes a high ankle sprain?
Tibiofibular syndesmosis due to severe inversion
103
What does a squeeze test with pain suggest for ankle sprain?
Pain over distal tib/fib = damage to tibiofibular syndesmosis
104
When is instability typically seen with talar tilts?
Grade 3 sprains
| Pain is dependent on ligament injured
105
What does a positive anterior drawer test of the foot/ankle suggest?
ATFL injury
106
When you have an ankle sprain, what bones must you assess?
* Malleoli
* 5th metatarsal base
| Checking for the ottawa rules
107
When is an ankle sprain typically seen on ankle XR?
High ankle sprains
108
What is phase 1 of ankle sprain management? (3)
* RICE with NSAIDs
* Air-cast splint or ankle brace
* Wt bearing as tolerated
| Casting is only for high-grade
109
What is phase 2 of ankle sprain management? (3)
* Start once weight bearing without pain
* Continue splint
* Start strengthening and stretching
110
When can you start phase 3 of ankle sprain management and what is in it?
* Once fulll ROM and 80% strength
* Wean ankle brace
* Increased strength exercise intensity
* PT for limited ROM or pain
111
After how long do you consider ortho for non-improvement of ankle sprain?
6 weeks of failure to improve
112
What are the 3 types of ankle fx?
* Unilateral fx w/o ligament disruption = stable
* Bimaleolar = unstable
* Trimaleolar = unstable
113
What are the two types of bimaleolar ankle fx?
1. Both medial and lateral malleoli fx
2. Unilateral malleoli fx with ligament disruption
114
What are the two types of trimaleolar ankle fx?
1. Both malleoli + posterior lip of tibia
2. Both malleoli + ligament disruption
115
How do all ankle fx present? (3)
* Pain & swelling
* **Point tenderness** and limited ROM
* **Palpate proximal fibula for tenderness (Maisonneuve fx)**
116
What is the primary difference between management of an unstable, displaced ankle fx vs a stable ankle fx? (2)
* Unstable means you need to make it NWB and call ortho in a week
* Stable is just WB splint/cast for 4-6weeks
117
How do we manage a suspected occult ankle fx? (2)
* Short leg splint + repeat XR in 10-14d
* Repeat XR should show a bony callus around the occult fx
118
MC MOI for a calcaneal fx?
Axial loading
| Make sure to check vertebral fx also
119
What is the MC tarsal bone fx?
Calcaneal
120
How does a calcaneal fx present and what should you remember to check? (4)
* NWB
* Pain/swelling/ecchymosis
* **Check NV status and cap refill**
* **Assess lumbar spine for tenderness**
| MC MOI is axial loading
121
How do we manage a calcaneal fx? (4)
1. RICE
2. Posterior short leg splint with **lots of padding**
3. NWB
4. Ortho in 24h
| Gotta make sure it does not displace
122
What is the 2nd MC tarsal bone fx?
Talar fx
123
What are the MOIs for a talar fx?
High force plantar/dorsi/inversion
124
What is the big issue with a talar fx?
Extensive blood supply, so be wary of AVN
125
MC type of ankle dislocation?
Posterior displacement of talus from tibia
126
Why are ankle dislocations concerning?
Highly unstable
| Ankles are very compact
127
What is the MOI for a posterior ankle dislocation?
Posterior force on a plantar flexed foot
128
How does an ankle dislocation present? (2)
* Grossly deformed
* Posterior will be **locked in plantar flexion and anterior tibia is easily palpable**
129
First step to manage an ankle dislocation after imaging?
Reduction via downward traction
| Splint with posterior leg after
130
What are the two MOIs for a metatarsal fx?
1. Twisting/rotational force
2. Blunt trauma (dropping something on your foot)
131
How does a metatarsal fx present? (2)
* Pain with wt bearing
* Swelling/ecchymyosis/tenderness (**Only tenderness on exam if stress fx**)
132
What is a Jones fx?
Fracture at the base of the 5th metatarsal
133
For a single, nondisplaced metatarsal fx, what do we do for management? (2)
* Short leg posterior/fx brace
* Weight bearing as tolerable
134
For multiple metatarsal fxs or displaced/angulated ones, what is the management?
Consult ortho
135
What is a tarsometatarsal injury?
Lisfranc joint/injury, aka disruption of the tarsometatarsal joint.
136
What is the MOI for a lisfranc injury/tarsometatarsal injury?
Axial loading on a plantar flexed foot, follow by forcible rotation, bending/compression
| MVA, crush injuries, Horseriding
137
How does a lisfranc joint injury present? (3)
* **Midfoot pain**/tenderness
* Inability to bear weight
* (+) deformity, swelling, ecchymosis
138
How do you dx a lisfranc injury?
**WEIGHT BEARING** foot series bilaterally
139
How do we manage a non-displaced lisfranc injury? (2)
* NWB short-leg posterior for 6-8wks
* Rigid arch support for 3 months
| If displaced, call ortho after splint
140
What phalanx is MC injured?
5th phalanx
141
Which joint is MC dislocated in the foot?
MTP of the 1st joint
142
Management of phalangeal injuries?
1. Non-displaced = buddy tape
2. Displaced/angulated = reduce then buddy tape
3. Dislocation = digital block then reduce
143
What is Hallux Valgus?
Bunions, which are lateral deviations of great toe at MTP joint
144
Who is hallux valgus MC in?
Females
| 10x
145
Top 2 causes of hallux valgus?
* Tight-fitting shoes
* OA
146
How does hallux valgus present?
Pain and swelling
147
What is considered normal valgus angulation at the MTP joint?
< 15%
148
Management of Hallux Valgus
* Shoe wear modification
* **Avoid high heels**
* **Call ortho for persistent symptoms**
149
What is Morton's Neuroma?
Perineural fibrosis of the common digital nerves between the metatarsal heads
150
Who and where is Morton's neuroma MC in?
* Base of the 3rd/5th toes in the 3rd web space
* Females due to tight shoes
151
Where is pain MC in Morton's neuroma?
**Burning plantar pain in forefoot**
152
How does Morton's neuroma present? (3)
* Burning plantar pain in mid foot
* Dysesthesias in affected toes
* **Walking on a marble**
153
How do we perform an interdigital neuroma test? (3)
1. Apply direct plantar pressure to interspace
2. Squeeze metatarsals together
3. (+) = increased tenderness and pain radiating into the toes
154
Management of Morton's Neuroma? (3)
* Pt education on low-heeled, well-cushioned shoes & pads
* Corticoidsteroid injections
* Surgical last resort
155
What kind of pain does plantar fasciitis cause?
Heel pain, esp in adults 40-60
156
MC RFs for plantar fasciitis?
1. Obesity
2. Flat feet
3. Prolonged jumping/standing
157
How does plantar fasciitis present? (4)
* Insidious onset
* Heel pain that is worse during their 1st steps
* Tenderness over medial calcaneal tuberosity and 1-2cm along plantar fascia
* Passive dorsiflexion may cause pain
158
Management of plantar fasciitis? (4)
1. Initial: OTC orthotic heel pad + home stretching
2. Avoid barefoot walking/flat shoes
3. Ice and NSAIDs
4. 6-12 months to resolve :(
159
What are the options for plantar fasciitis after you fail conservative therapy?
1. Corticosteroids into heel
2. Custom orthotics
3. Surgical release
