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LOWER EXTREMITY DISORDERS Flashcards

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1
Q

sciatic nerve = runs from

A

L4 - S3

  • articular & muscular
  • sensation
  • external rotation & posterior thigh, foot
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2
Q

femoral nerve =

A

L2 - L4

anterior thigh compartment

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3
Q

lateral femoral cutaneous nerve =

A

L3 - L4

sensory

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4
Q

blood supply of the hip

A

Femoral Artery
⦁ Profunda femoris
⦁ Circumflex

Artery of the ligamentum teres
⦁ Posterior division of the obturator artery
⦁ Femoral head

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5
Q

AVN = AVASCULAR NECROSIS

A
  • Interruption of vascular supply to the femoral head
  • Causes
    ⦁ fracture
    ⦁ dislocation
    ⦁ SCFE
    ⦁ steroids
    ⦁ ETOH
    ⦁ Perthes
    ⦁ Coagulopathy
    ⦁ Sickle cell
  • AVN = commonly bilateral
  • Prognosis: 70-80% of cases collapse - femoral head dies - by 3 years
  • TREATMENT
    ⦁ early - anticoags, bisphosphonates, decompression, treat the cause
    ⦁ later = surgery - decompression vs total hip vs arthrodesis

xray, then do MRI and bone scan for AVN

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6
Q

HIP BURSAE

A
  • between bone and surrounding soft tissue

o Trochanteric - between greater trochanter & IT band

o Ischial - between ischial tuberosity & gluteus muscles

o Iliopsoas - between lesser trochanter and iliopsoas tendon

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7
Q
  • pain & snapping in groin and anterior hip with hip flexion and crunches

PT is a runner and was a dancer

A

ILIOPSOAS BURSITIS / TENDINOSIS

  • inflammation of the bursa or inflammation of the tendon
  • HX & PE
  • consider XRAY or MRI to rule out other diagnoses
  • TX = relative rest, stretch, consider NSAIDS. PT
    consider injection or surgical referral if not improving with conservative treatment
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8
Q

FAdAxl

A

acetabular labrum tear

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9
Q
  • hip pain with deep click
  • catching sensation; feels stiff
  • worse with deep flexion & rising from seated position
  • decreased ROM
A

ACETABULAR LABRAL TEAR

HX & PE

  • Pain with FAdAxL = hip flexion, adduction, and axial load
  • imaging: (xrays negative) = MRI arthrogram (inject dye into joint

TREATMENT = PT to maximize ROM and strength
- can do steroid injection or surgery if needed

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10
Q

DIAGNOSIS OF ACETABULAR LABRAL TEAR

A

MRI ARTHROGRAM - see dye spill through with tear

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11
Q

-Ober Test

A

tightness of the IT band

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12
Q
  • left lateral hip pain
  • gradual onset
  • no trauma or previous hx
  • painful to lay on left side
A

TROCHANTERIC BURSITIS

HX & PE

  • point tender over lateral thigh
  • pain with Ober test (determines any tightness of the IT band)
  • **Hx Key = de-conditioned; significant increase in activity

Treatment = Ice, NSAIDS, PT (stretch IT band & strengthen hip muscles); steroid injection

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13
Q
  • progressive right hip & groin pain
  • associated decreased ROM
  • no trauma, no other joint complaints
A

OSTEOARTHRITIS OF THE HIP

HX & PE
- xrays - weight bearing

TREATMENT = PT, APAP > NSAIDS, hip injection (US guided) - steroid. Surgical referral if disabling. Can use APAP & NSAIDS together as long as no CI

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14
Q
  • 13 y/o female gymnast with increasing groin pain over last 2 months
  • hurts to jump, run, stretch and land
  • increased pain with increased activity
  • no acute trauma
A

PUBIC RAMUS STRESS FRACTURE

  • *Point tender left superior pubic ramus
  • non-tender adductors, normal hip exam
  • Xray (negative) - so do bone scan or MRI

Treatment = relative rest, non-painful activity, slow increase

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15
Q

STRESS FRACTURES

A
  • stress fractures can occur anywhere
  • commonly occur in feet, ankles, tibia, fibula, patella, femur, and/or others (ribs)
  • can be a sign of an underlying problem in addition to overuse (ie: estrogen deficiency, hormonal abnormalities, nutritional deficiencies, or metabolic disorders)

won’t see on xray - need MRI or bone scan

  • have gradual onset of pain with activity

HISTORY

  • increased intensity / duration of activity
  • change in footwear
  • change in surface

initial xrays often negative; negative studies = bone scan, MRI
key to treatment = pain free ambulation / activity

initial xrays often negative; negative studies = bone scan, MRI

key to treatment = pain free ambulation / activity

  • if fracture is on the inferior side = continue with non-painful activity, gradual return
  • if fracture is on superior side = ortho referral!!! - high risk for complete fracture
  • address causation - diet, activity level, maturity
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16
Q
  • chronic right groin pain after increased training in past month
  • worse with right footed kicking and resisted adduction
  • pain & stiffness gradually loosen up
  • pain with resisted adduction**
A

ADDUCTOR TENDINOPATHY

  • TTP medial groin at tendon insertion

TREATMENT = relative rest, ice strengthening - PT

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17
Q

hockey = think of

A

athletic pubalgia - sport’s hernia

dilated superficial ring of inguinal canal

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18
Q

hockey player with left groin pain; worse with skating & hip motion. no specific trauma

A

ATHLETIC PUBALGIA / SPORTS HERNIA

  • not a true hernia
  • pain in hernia region without palpable hernia
  • injury to conjoined tendon, internal oblique, external oblique, transversalis fascia, inguinal ligament, etc.
  • SURGICAL REFERRAL
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19
Q

PIRIFORMIS STRAIN VS SYNDROME

A

STRAIN = NO SCIATICA

SYNDROME = SCIATICA

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20
Q

PIRIFORMIS STRAIN / SYNDROME

A

Piriformis muscle lies over sciatic nerve
buttock & lower back pain -

  • left buttock pain; retired professional soccer player
  • insidious onset
  • painful to sit, pain increases after running
  • previous back aches, but no specific trauma
  • points to left lower back & buttocks
  • some radiation to hamstrings
  • no numbness, no red flags

PE = normal gait & appearance. TTP left upper/outer buttocks. painful resisted external rotation and painful passive internal rotation. normal sensory and strength

Piriformis strain = no sciatica
Piriformis syndrome = sciatica

TREATMENT = rule out other things. NSAIDS, stretch/strengthen. PT

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21
Q

femur fractures = think _______

if young = think ________

A

think DVT

if young = think AVN

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22
Q

femur fractures

A
  • head / neck
  • Etiology: fall (arrhythmia, osteoporosis, pathologic, seizures, stroke)
  • functional status
  • exam = rule out other injuries
    ⦁ shortened external rotation
    ⦁ internal rotation = pain in hip and groin

Treatment = Pins, ORIF (open reduction, internal fixation)

  • think DVT
  • if young = think AVN

Treatment of femur fractures - head / trochanter
⦁ internal fixation (screws) - in head / trochanter
⦁ hip compression screw - in head / trochanter & femur
⦁ Hemi-arthroplasty - hip replacement without replacing the acetabulum
⦁ Total hip replacement

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23
Q

femur fracture - shaft = worried about

Study These Flashcards
A

compartment syndrome

24
Q

shaft femur fracture

Study These Flashcards
A
  • high forces involved
  • lots of bleeding - vascular injury
  • treatment = SURGICAL REFERRAL
  • worried about compartment syndrome
25
75% of compartment syndrome cases are caused by
fractures
26
COMPARTMENT SYNDROME
- 75% caused by FRACTURES*** - other causes = crush, envenomation, immobilization, constrictive dressing, infection, burns, tourniquets - CECS (chronic exertion compartment syndrome) get compression of soft tissues first, then vessels, nerves - compression of veins before arteries due to pressure inside them TREATMENT = release pressure
27
most common hip dislocation
posterior
28
HIP DISLOCATION
- high energy trauma - MVA - younger patients o Anterior - 10-15% - dashboard with thigh abducted - leg is externally rotated o Posterior dislocation = most common - leg is internally rotated TREATMENT = reduction ASAP (concerned about AVN, and sciatic injury) - also keep in mind that there may be a concomitant injury - another fracture / dislocation
29
if leg is externally rotated
anterior hip dislocation
30
if leg is internally rotated
posterior hip dislocation
31
hip dislocation = worried about
AVN & sciatic injury may also be concomitant injuries - fx/dislocations
32
KNEE INJURY HISTORICAL CLUES
⦁ noncontact injury with a "pop" = ACL tear ⦁ contact injury with a "pop" = MCL, LCL tear, meniscus tear, or fracture ⦁ acute swelling = ACL tear, PCL tear, fracture, knee dislocation, patellar dislocation ⦁ lateral blow to the knee = MCL tear ⦁ medial blow to the knee = LCL tear ⦁ knee "gave out" or "buckled" = ACL tear, patellar dislocation ⦁ Fall onto a flexed knee or dashboard injury = PCL
33
flat feet
pes planus
34
genu varus vs genu valgus
genu varus = knees apart, feet together (bow legged) genus valgus = knees together, feet apart (knock knees)
35
popliteal fossa bulges
- popliteal artery aneurysm - Baker's cyst - popliteal thrombophlebitis
36
knee exam MUST include
hip ROM
37
PATELLOFEMORAL SYNDROME (PFS)
- idiopathic softening / fissuring of patellar articular cartillage - MC seen in runners** * *have anterior knee pain "behind" or around the patella - worse with knee hyperflexion (prolonged sitting), jumping or climbing DIAGNOSIS = APPREHENSION SIGN - apply pressure to medial & lateral patella - painful! TREATMENT = NSAIDS, rest, rehab ex: 12 y/o - nonspecific anterior knee pain; worse with activities such as running/squatting/jumping. May have some swelling. No injury. Occasional popping ⦁ Patellofemoral Grind = put pressure on superior patella as patient fires quads ⦁ Patellar Apprehension test - apply medial forces to patella - forcing it laterally Diagnosis = look for muscle imbalance, flexibility issues, feet and alignment TX = NICER = NSAIDS, ice, compression, elevation, rest - patellar stabilizing brace - PT
38
TEST FOR PFS
APPREHENSION TEST
39
MC knee ligament injury
ACL
40
ACL TEAR
***MC knee ligament injury; 70% sports related MOA = non-contact pivoting injury (deceleration, hyperextension, internal rotation) "pop" & swelling --> hemarthrosis knee buckling MC in women - inability to bear weight PE = Lachman's test (have ACL laxity) = most sensitive test TX = therapy vs surgery (depends on patient) ex: 18 y/o female BB player - preparing for layup, ends up on floor holding her knee, screaming in pain. felt a "pop" - unable to continue. Instability & increased stiffness PE = Valgus for MCL, Varus for LCL = Bohler Test TX = NICER, brace, pain free activity, time (2-8 weeks, take 1 year for full maturation of scar in a complete tear)
41
PCL TEAR
- MC associated with dashboard injuries - anterior force to proximal tibia with knees flexed - or direct blow injury or fall on a flexed knee - usually associated with other ligamentous injuries Anterior bruising Large effusion ``` PE = Pivot Shift test, Posterior drawer test TX = PT, bracing, occasionally surgery ``` **Sag sign = same position as anterior drawer - thumb slides medial to patella into tibial condyle. if lacking condyle = positive sag sign Posterior drawer = posterior pressure on tibia; positive if posterior translation of tibia
42
tests for meniscal injuries
McMurray test Apley test
43
MENISCAL TEAR
- MOI = degenerative (squatting, twisting, compression, or trauma with femur rotation) - Medial = 3x more common than lateral - because of bony attachments Locking Popping Giving way Effusion after activities ***MCMURRAY'S SIGN - pop or click when tibia is externally and internally rotated Apley Compression Test = pt prone - knee bent up in air, compress down and rotate TREATMENT = NSAIDS, partial weight bearing until ortho follow up; arthroscopy ex: steps off ladder onto uneven ground; knee twisted - immediate medial pain. Swelling. Now has trouble squatting, kneeling, climbing TESTS = full flexion, joint line tenderness, McMurray, Apley's compression test, Bounce test, Duck walk
44
CHRONIC PATELLAR TENDINOPATHY
NOT an inflammatory condition. not due to inflammation - so NSAIDS only help with pain. Steroid injections can decrease pain short term. - may be a red flag to other associated factors: nutrition, malalignments, muscle problems, training errors, medications (fluoroquinolones, doxy, steroids), systemic dz (psoriasis, SLE, hyperthyroid, DM) - TREATMENT = rest, d/c painful activities. avoid immobilization if possible, as too much rest is bad (results in poorly aligned collagen & healing) - progress through passive & active ROM
45
PATELLAR TENDONITIS / TENDINOSIS / TENDINOPATHY
- Jumper’s Knee - Affects participants in “explosive” sports involving quick movements ⦁ Basketball players are most commonly affected ⦁ Commonly in hikers/ backpackers on hills and unpredictable terrain Causes ⦁ Excessive activity - Especially a rapid increase in frequency/intensity of training ⦁ Improper mechanics of training ⦁ Excessive weight on person with a weight bearing exercise lifestyle TREATMENT = ice, NSAIDS, PT, orthotics
46
SEPTIC ARTHRITIS VS SEPTIC BURSITIS
- bursitis = red & angry looking. Area of fluctuance. Knee moves pretty well. DON'T aspirate the joint through the cellulitis - septic joint doesn't look red, just swollen. Very tender, and any motion causes severe pain
47
knee injections
THERAPEUTIC INJECTIONS - steroid delivery for OA and other non-infectious inflammatory arthritides (gout) - delivery of viscosupplementation GLUCOSAMINE & HYALURONATE INJECTIONS - studies show a weak benefit in pain relief with glucosamine +/- chondroitin, but no harm except $ - studies have not supported the benefit of multiple hyaluronate injections over a single steroid injection, however, they have shown pain relief
48
best approach for steroid injections (knee)
SUPERIOR ANTEROLATERAL
49
FIBULAR SHAFT FRACTURE
- treatment is based on patient's comfort (splint, cast, walking boot). complete healing - 6-8 wks ``` - referral ⦁ comminuted ⦁ significantly displaced ⦁ associated tibial fracture ⦁ neurovascular injury ``` - be sure to evaluate syndesmosis appropriately***
50
MC tibial plateau fracture
lateral
51
knee pain imaging
- if arthritis or fracture or you are going to refer = ⦁ standing AP of both knees, both laterals, and Merchant / sunrise view ⦁ for arthritis = get standing 30 degree AP too
52
HIP FLEXION MUSCLES
``` ⦁ anterior muscles ⦁ iliopsoas ⦁ rectus femoris ⦁ sartorius ⦁ pectineus ```
53
HIP EXTENSION MUSCLES
⦁ posterior muscles ⦁ gluteus maximus ⦁ hamstrings ⦁ adductor magnus
54
FAdAxL test
labral injury flexion adduction axial load
55
FAbER
SI joint Flexion Abduction External Rotation
56
FAIR
Piriformis Flexion Adduction Internal Rotation
57
FAdIR
FAI flexion Adduction internal rotation

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