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lower limb conditions Flashcards

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1
Q

what is most likely to be aspirated from a swollen joint post ACL rupture?

A

haemorarthrosis

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2
Q

what is most likely to be aspirated from a swollen joint post meniscal tear?

A

synovial fluid

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3
Q

what is most likely to be aspirated from a swollen joint post fracture?

A

lipohaemoarthrosis (blood + fat)

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4
Q

which type of hip fracture is at greater risk of avascular necrosis?

A

intracapsular

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5
Q

hip fracture presentation

A

shortened abducted + externally rotated leg

pain in groin/hip - may radiate to knee
not able to weight bear
older patient who has fallen (60+)

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6
Q

how would fractured neck of femur (NOF) appear on x-ray?

A

disruption to shenton’s line

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7
Q

hip fracture investigations

A

x-ray - AP + lateral

MRI or CT where x-ray neg but still suspicion

*venous thromboembolism assessment

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8
Q

mortality in hip fractures

A

30% in a year
5-10% at 30 days

aim to perform surgery within 48hrs due to mortality

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9
Q

management of a displaced intracapsular hip fracture in a low functioning (old) patient?

A

hemiarthroplasty = replacing head of femur but leaving acetabulum

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10
Q

management of a displaced intracapsular hip replacement in a young active patient?

A

total hip replacement

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11
Q

managment of a non-displaced intracapsular hip fracture

A

compression hip screw / internal fixation

(with screws) hold head in place while heals

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12
Q

management of an intertrochanteric hip fracture

A

dynamic hip crew (DHS) = sliding hip screw, screw goes through neck + into femur, plate with a barrel that holds the screw is screwed to the outside of femoral shaft

(extracapsular)

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13
Q

management of subtrochanteric hip fracture

A

intramedullary nail (IM nail)

= a metal pole inserted through the greater trochanter into the central cavity of the shaft of the femur

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14
Q

hip dislocation presentation

A

flexed, internally rotated + adducted knee

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15
Q

complications of hip dislocations

A

sciatica nerve palsy
AVN of femoral head
OA

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16
Q

management of hip dislocation

A

neurovascular assessment - sciatic
radiographs
urgent reduction + stabilise

-> fixation of associated pelvic fratures + other injuries

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17
Q

causes of avascular necrosis

A 
idiopathic
alcohol abuse
steroids
hyperlipidaemia 
thrombophilia
hip fractures / dislocations
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18
Q

AVN investigations

A

early changes may only be seen on MRI

x-ray

  • patchy sclerosis at weight bearing part of femoral head
  • lytic zone - “hanging rope sign”`
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19
Q

managment of AVN

A

if detected early enough (pre-collapse) = drill holes can be made up the femoral neck into abnormal area in head - relieve pressure, promote healing, prevent collapse

post collapse = total hip replacement

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20
Q

trochanteric bursitis presentation

A

middle aged with gradual onset lateral hip pain
resisted abduction
pain + tenderness in region of greater trochanter
- pain = aching/burning
- worse with activity + sitting cross legged
- may disrupt sleep

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21
Q

treatment of trochanteric bursitis

A

analgesia, NSAIDs
physio - strengthen other muscles
steroid injections

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22
Q

causes of ACL rupture

A

higher rotational force - internal rotation of tibia

football, rugby, skiing, high impact sport

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23
Q

causes of meniscal tear

A

twisted force on a loaded knee

  • turning at football
  • squatting

degenerative
50% of ACL ruptures have meniscal tears

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24
Q

how can the MCL be torn?

A

rugby tackle from the side

higher forces can damage ACL too

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25
causes of PCL rupture
direct blow to anterior tibia | - with knee flexed (motorbikes/dashboard injuries)
26
which meniscus is most commonly torn?
medial ``` medial = fixed lateral = more mobile ```
27
healing of meniscal tears
only peripheral tears can be expected to heal due to blood supply
28
meniscal tear presentation
pop sound or sensation on injury pain,swelling,stiffness locking of knee (bucket handle) instbaility of knee "giving way" *pain may be referred to hip or lower back
29
meniscal tear investigation
MRI arthroscopy
30
management of menical tears
radial tears wont heal rest, ice, compression, elevation NSAIDS physio - after pain + swelling has settled acute peripheral tears in young = arthroscopic meniscal repair irreparable tears with recurrent pain, effusion or mechanical probs = arthroscopic resection
31
is surgery the best pain management in knee ligament injuries?
surgery does NOT treat pain pain comes from secondary effects - bone marrow oedema, synovitis
32
management of MCL rupture
usually heals well even if complete tear - brace, early motion, physio - pain can take several months to settle rarely requires surgery - reconstruction to tendon graft
33
healing process in MCL vs LCL
MCL - heals well, rarely surgery LCL - doesn't heal, urgent surgery within 2-3weeks
34
lateral collateral ligament (LCL) rupture
uncommon usually from varus + hyperextension doesn't heal can cause varus + rotatory instability complete rupture needs urgent surgery (2-3weeks)
35
PCL rupture cause, presentation + managment
``` cause = direct blow to tibia presentation = popliteal knee pain / brusing ``` surgery only if instability - recurrent hyperextension, feeling unstable when going downstairs
36
ACL rupture investigations
``` anterior drawer test lachmans test (flexed 25 degrees) ``` MRI arthroscopy
37
ACL rupture manangement
conservative = RICE, NSAIDs, physio, crutches active, young, frequent instability = arthroscopic surgery (20% failure rate) - new ligament formed using a graft of tendon
38
knee dislocation cause + complications
high energy injury - rupture all 4 ligaments complications - popliteal artery injury - common peroneal nerve injury (foot drop) - lateral collateral injury - compartment syndrome
39
knee dislocation mangement
emergency reduction recheck neurovascular status if normal exam = observe in hospital clinical concern = arteriogram, MRI may need ex-fix to stabilise, revascularisation + multi-ligament construction * prioritise revascularisation
40
patellofemoral dysfunction presentation
anterior knee pain - worse going downhill grinding/clicking sensation at front of knee + stiffness after prolonged sitting --> causing pseudolocking
41
mangement of patellofemoral dysfunction
90% improve with physio - rebalancing quadriceps muscle taping may alleviate symptoms
42
risk factors of extensor mechanism rupture
previous tendonitis steroids chronic renal failure ciprofloxacin patellar tendon rupture <40yrs quadriceps tendon rupture >40yrs
43
extensor mechanism rupture presentation, investigation + management
pres = unable to straighten leg + palpable gap Ix = US or MRI Mx = urgent surgical repair
44
Osgood-Schlatter presentation
boys aged 10-15 gradual onset of symptoms - visible or palpable hard + tender lump at tibial tuberosity - pain in anterior aspect of knee -> exacerbated by activity, kneeling + extension of knee
45
Osgood-Schlatter pathophysio
multiple minor avulsion fractures occur where the patella ligament pulls away tiny pieces of bone leads to growth of tibial tuberosity - causes visible lump below knee lump -- initally tender, as inflammation settles + heals becomes hard + non-tender (permanent lump)
46
complication of Osgood-Schlatter
avulsion fracture tibial tuberosity is separated from rest of tibia --> surgical intervention required
47
Baker's cyst
can be 2nd to degenerative changes - OA, meniscal tears painful rupture - compartment syndrome risk soft + non-tender synovial fluid filled sac in popliteal fossa
48
Baker's cyst investigations
first line = US - rule out DVT MRI - can show underlying knee pathology (meniscal tears)
49
managment of Baker's cyst
conserv - analgesia, physio - US guided aspiration - likely to recur - steroid injections surgical = arthroscopic on underlying pathology
50
Hallux valgus (bunions)
metatarsal angled medially + big toe laterally - MTP becomes inflamed + enlarged can lead to OA cause unclear more common in women
51
hallux valgus investigation + managment
Ix = weight bearing xray conserv Mx = wide shoes, analgesia, bunion pads (protects from friction) surgical = realign bones, 30% unhappy
52
Mortons neuroma
dysfunction of nerve in the intermetatarsal space towards top of foot (usu 3rd + 4th) caused by irriation of nerve ending relating to the biomechanics of the foot **heels may exacerbate
53
Morton's neuroma presentation
pain at location of lesion sensation of a lump in the shoe burning, numbness, pins + needles in distal toe
54
Mortons neuroma investigations
deep pressure applied to affected area causes pain metatardal squeeze test Mulder's sign - painful click is felt Ix = US (swollen nerve), MRI
55
Mortons neuroma mangement
metatarsal pad, offloading insole steroid + local anaesthetic injections - may relieve symptoms + aid diagnosis neuroma can be excised - some still pain, risk of recurrence
56
achilles tendonopathy risk factors
sports that stress achilles - basketball, tennis, track inflam conditions - rheumatoid, ankylosing diabetes raised cholesterol fluoroquinolone antibiotics - ciprofloxacin, levofloxacin
57
management of achilles tendonopathy
rest, analgesia, physio orthotics (insoles) extracorporeal shock wave therapy (ESWT) surgery to remove nodules, adhesions or alter tendon ** NO steroid injections - tendon rupture risk **
58
achilles rupture presentation
sudden onset pain in tendon or calf - feeling like something has hit them on the back of the leg positive simmonds test palpable gap in tendon unable to stand on tip toes
59
diagnosis of achilles rupture
US
60
management of Achilles tendon rupture
analgesia, rest + imobilisation - DVT risk specialist boots - first in plantar flexion, gradually moved to neutral position (6-12 weeks) surgical - reattaching then similar boots
61
adv vs disadv of surgical + non-surgical managment of achilles tendon rupture
surgical - anaesthetic risks, poor wound healing, infection non-surgical (boots) - high risk of rerupture
62
plantar fasciitis causative factors
diabetes obesity frequent walking on hard floors with poor cushioning degenerative - cushioning fat pad atrophies with age
63
management of plantar fasciitis
rest, physio/stretching gel filled heel pad steroid injections symptoms can take 2 yrs to heal :/
64
causes of pes cavus
idiopathic neuromuscular conditions - cerebral palsy, polio, spina bifida occulta
65
treatment of pes cavus
flexible = soft tissure releases, tendon transfer rigid = calcaneal osteotomy severe cases = arthrodesis (bones fused)
66
which artery is most at risk in a paediatric supracondylar fracture?
brachial artery
67
which artery is most at risk in a shoulder dislocation?
axillary
68
complications of total joint athroplasty in the elective patient?
``` PE dislocation of prosthesis myocardial infarction joint infection pneumonia ```
69
This 50 year old lady complains of left 1st MTPJ pain on walking, particularly when wearing thin, non-supportive shoes. She cannot wear high heels because of the pain and stiffness in the joint. On examination, active and passive range of movement of the joint is reduced (and quite tender at the end range of movement) and grind test is positive.
hallux rigidus
70
A 60 year old lady presents with a complaint of right foot pain. On closer questioning, she tells you she first noticed it a month ago and it's been getting worse since. She feels it on the instep of her foot (medial arch) and it's worse if she does a lot of walking. On examination, she is acutely tender over the calcaneal tuberosity at the posterior end of the medial arch. What is the most likely diagnosis?
plantar fasciitis
71
A quadricep tendon rupture is a relatively common injury in the patient over 40 and rarely requires surgical intervention.
FALSE almost always surgically managed
72
You are asked to review a 12 year old boy referred by his GP with a lump in his thigh. The boy is systemically well and has no significant past medical history. He reports that the lump started about 9 months ago after he fell off his bike and bruised his thigh. Initially it was soft but has hardened. He reports the size was increasing but it hasn't grown in some time now. On examination, the mass is very hard and is somewhat mobile in the anterior compartment of the thigh but it feels tethered within the muscle. It isn't tender. What is the likely diagnosis?
myositis ossificans where heterotopic ossification (bone forming outside the skeleton) occurs in muscles usually after an injury. The injury may be innocuous and it can form after muscle contusion (“dead leg”), fractures (especially around the elbow) and dislocations (especially traumatic hip dislocation). Heterotopic ossification can also occur in the muscles and soft tissues after surgery including hip replacement particularly if it is a revision (re‐do) procedure. Bony masses are seen in the soft tissues on xray. Stiffness may develop but aggressive physiotherapy may result in more ectopic bone formation making the situation worse. Once the new bone formation has settled, the abnormal bone can be excised to try to relieve stiffness with high strength NSAIDs (Indomethacin) or radiotherapy used to help prevent recurrence.

MSK (14 decks)

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