Lower Limb Conditions

Question 1

what is avascular necrosis

Answer 1

loss of blood supply, most commonly to the femoral head

Question 2

how is avascular necrosis of the hip managed

Answer 2

pre-collapse of femoral relieve pressure by air holes

once collapsed the only option is THR

Question 3

what is trochanteric bursitis

Answer 3

inflammation of the bursa surrounding the greater trochanter as the tendons around the abductor muscles are under great stress

Question 4

pain around the greater trochanter and pain on resisted abduction is suggestive of what

Answer 4

trochanteric bursitis

Question 5

describe the management of trochanteric bursitis

Answer 5

analgesics
steroid injection
physiotherapy

Question 6

list some pre-disposing factors to knee arthritis

Answer 6

previous meniscal or ligamentous injury

malalignment eg valgus or varus

Question 7

what is the function of the menisci

Answer 7

to act as shock absorbers and distribute load from fmeoral condyles to flat tibial articular surfaces

Question 8

the medial meniscus is fixed/mobile and under lots/little stress

Answer 8

fixed and under a lots of stress

Question 9

describe the mechanism of injury that occurs with meniscal tears

Answer 9

occurs with twisting force on a loaded knee - playing sport

Question 10

describe the presentation of a meniscal tear

Answer 10

pain localised to medial/lateral joint line
sense of knee locking
cannot fully extend the knee 15 degree block
steinmanns test positive

Question 11

describe the blood supply to the meniscus

Answer 11

only peripheral third of the meniscus has blood supply therefore tears dont always heal well

Question 12

what investigation is carried out for suspected meniscal tear

Answer 12

MRI - showing the location and degree of the tear

Question 13

describe a bucket handle tear

Answer 13

large longitudinal tear causing fragment to come out of normal position and displacing anteriorly

Question 14

what is the treatment for a meniscal tear

Answer 14

vascular ones can be treated by suturing the meniscus to the bed
if no blood supply the tears must be removed altogether predisposing to OA

Question 15

describe a grade 1, 2 and 3 ligament injury

Answer 15

1 - sprain with some torn fibres but macroscopically intact
2 - partial tear with fascicles disrupted
3 - complete tear

Question 16

describe the presentation of ACL rupture

Answer 16

occurs on rotating body laterally with foot planted, internal rotation on the tibia
hear a pop when injury occurs
development of haemarthrosis
long term feeling of instability

Question 17

what is a haemarthrosis

Answer 17

effusion due to bleeding within the joint

Question 18

what is the management for ACL rupture

Answer 18

rest and physio best option in elderly etc

if young and active attempt reconstruction of ligament with tendon graft from patella

Question 19

what mechanism causes an MCL rupture

Answer 19

valgus stress - usually contact sports

Question 20

what is the management for MCL rupture

Answer 20

rarely surgery - usually knee brace if no other ligament injuries

Question 21

what causes a PCL rupture

Answer 21

direct blow to anterior tibia eg motor cycle crash

Question 22

the PCL is more or less common to rupture than the ACL and why

Answer 22

less common as is a thicket ligament

Question 23

list the structures in the extensor mechanism from proximal to distal

Answer 23

quadriceps 
quadriceps tendon 
patella 
patella tendon
tibial tuberosity

Question 24

list some of the risk factors for developing extensor mechanism ruptures

Answer 24

chronic steroid use 
diabetes 
chronic renal disease 
previous tendonitis 
quinolone antibiotics - increases tendonitis risk

Question 25

patella rupture commonly occurs in which age group

Answer 25

<40s

Question 26

quadriceps rupture commonly occurs in which age group

Answer 26

>40s

Question 27

straight leg raise is positive in which condition

Answer 27

extensor mechanism rupture - cannot lift leg on extension

Question 28

describe the management of extensor mechanism rupture

Answer 28

surgical tendon to tendon repair or reattach tendon to patella

Question 29

what is hallux valgus

Answer 29

lateral deviation of the great toe with medial deviation of the first metatarsal head

Question 30

list the risk factors for developing hallux valgus

Answer 30

female > male wearing shoes familial history inflammatory arthritis and MS

Question 31

describe the presentation of hallux valgus

Answer 31

pain around first MTP development of bunion - shoes rubbing to cause inflamed bursa rubbing of great toe against second toe causing skin break and ulceration

Question 32

describe the management of hallux valgus

Answer 32

conservative - wear accomodating shoes, use of spacer between first and second toe surgical - osteotomies to realign bones and soft tissue procedures to release tight tissues

Question 33

what is hallux rigidus

Answer 33

osteoarthritis of the first MTP

Question 34

describe both the conservative and surgical management for hallux rigidus

Answer 34

conservative - wearing of stiff soled shoes to prevent movement surgical - arthrodesis to prevent motion and alleviate pain or MTP ceramic joint replacement

Question 35

which nerves are affected in mortons neuroma

Answer 35

plantar interdigital nerves overlying the intermetatarsal ligaments

Question 36

how does mortons neuroma present

Answer 36

burning pain and tingling commonly in the third toe loss of sensation of webbed space positive mulders test

Question 37

describe mulders test

Answer 37

click heard when compressing MTPs medio-laterally means mortons neuroma

Question 38

what is used to diagnose mortons neuroma

Answer 38

ultrasound showing swollen nerve

Question 39

what is the treatment for mortons neuroma

Answer 39

conservative - steroid or local anaesthetic in injections to relieve pain surgical - excision of neuroma but high rates of recurrence

Question 40

where are metatarsal stress fractures most likely to occur

Answer 40

second and third MTPs

Question 41

how is a stress fracture diagnosed

Answer 41

x-ray may not show fracture until 3 weeks after injury when calluses are formed - must re-do then

Question 42

what is the management of metatarsal stress fracture

Answer 42

prolonged rest for 6-12 weeks in a rigid soled boot

Question 43

what increases risk of developing achilles tendonitis

Answer 43

quinolone antibiotics RA and gout repetitive strains from sports

Question 44

tendonitis can be treated with steroid injection true/false

Answer 44

false as increases risk of ruptures

Question 45

describe simmonds test when assessing for achilles tendon rupture

Answer 45

loss of plantarflexion when squeezing the calf

Question 46

plantar fasciitis is a self-limiting condition true/false

Answer 46

true - caused by repetitive stress and overload on the foot

Question 47

what are the risk factors for developing plantar fasciitis

Answer 47

obesity excessive walking diabetes

Question 48

how does plantar fasciitis present

Answer 48

pain felt walking on the instep of the foot localised tenderness on palpation pain is worst in the morning taking first steps

Question 49

how is plantar fasciitis managed

Answer 49

rest and achilles stretching, corticosteroids can also improve pain

Question 50

what is pes cavus

Answer 50

abnormally high arched feet

Question 51

how is pes cavus managed

Answer 51

soft tissue releases and tendon transfers if supple | osteotomies if more rigid

Question 52

describe claw toes appearance

Answer 52

hyperextension at MTP | hyperflexion at PIP and DIP

Question 53

describe hammer toes appearance

Answer 53

hyperextension at MTP hyperflexion at PIP hyperextension at DIP

Question 54

describe mallet toes appearance

Answer 54

fixed flexion deformity of the DIP, manage with flexor tenotomy and joint arthrodesis at DIP