Ortho- Lower Extremities Jaynstein Flashcards
(114 cards)
1
Q
Valgus vs varus
A
Valgus is when the knees come together (gum) and varus is when the knees go out
2
Q
_______ connects the posterior aspect of the femoral condyle to the anterior aspect of the tibia
A
ACL
3
Q
ACL injury typically tears in a non-contact deceleration, producing _______ twisting
A
valgus
Pivot sports where you plant foot and femur comes toward and tear ACL
4
Q
What are symptoms of a torn ACL?
A
“pop,” tenative approach to walking, difficulty bearing weight, knee feels “unstable”
5
Q
Should you test ACL with the lachmann’s and anterior drawer and lever sign when they have an ACL tear?
A
usually don’t test when unstable and wait until the swelling goes down
6
Q
If there is direct trauma to an ACL what imaging should you get? If there is indirect trauma, what imaging would you be less likely to get?
A
xray, less likely to get xray for pivot trauma
7
Q
An exam of this type of injury shows:
- Knee xrays often show a large effusion
- Can demonstrate a Segond fracture –> avulsion fx of the lateral tibial plateau
A
ACL
8
Q
TOC for ACL
A
MRI without contrast but effusions can obscure imaging
9
Q
Treatment for ACL for young/active with complete tear?
A
Surgical repair (allograft or autograft)
10
Q
Treatment for ACL for older/sedentary or partial tear?
A
Conservative- PT to strengthen the hamstrings
*Typically you will wait 6 months to operate on an ACL tear
11
Q
What type of bracing should you use for ACL injuries?
A
• Bracing (debated) to protect other structures – pt at increased risk of secondary
meniscus injury
• Acute: knee immobilizer and crutches (if unstable)
• Subacute/chronic: hinged brace (if stable) because more mobile
12
Q
This type of injury is mc due to a blow to the knee while it’s flexed and is commonly done in “dashboard accidents” or running and falling up the stairs and hitting knee on the stairs
A
PCL
13
Q
What are signs and symptoms of a PCL injury?
A
Swelling is immediate and typically profound with severe PAIN and limited ROM
14
Q
This exam finding is typical of what type of injury?
• “sag sign” – obvious set-off of the tibia posterior
A
PCL
15
Q
What is the preferred imaging in a patient with a PCL injury and why is it important?
A
MRI with contrast because this is a severe injury and you want to check that the popliteal artery is intact
16
Q
What is treatment for a PCL tear?
A
Ortho referral and often admitted because pain so severe, RICE, surgery
17
Q
This type of tear is the mc injured ligament in the knee and is often associated with concurrent ACL tear?
A
MCL
18
Q
The MCL (and LCL) are extra-articular and, therefore, joint ______ is less common with these injuries
A
effusion
19
Q
MOI for this injury is typically plant and get hit on the outside of the leg so it goes in. There is also very localized tender pain on the medial side
- Valgus stress on a partially flexed knee
- Lateral to medial impact
A
MCL
20
Q
What test do you do to test the MCL?
A
Valgus stress exam- causes pain and laxity
Don’t typically need an MRI- watch and wait
21
Q
Treatment for MCL?
A
Weight bearing as tolerated, bracing, PT, allow for 6-8 weeks for healing
*isolated MCL tears rarely need surgery
22
Q
A patient planted and got hit from the inside, this is rare but what type of injury might the person have?
A
LCL
23
Q
Mode of injury of this ligament?
- Varus stress on a partially flexed knee
- Medial impact
A
LCL
24
Q
What are signs of an LCL tear?
A
- Focal pain over ligament
- Minor swelling
- Limited ROM acutely – improves 2 wks
25
What is the test of choice for LCL tear?
Varus test, testing pain and laxity
26
Treatment for LCL tear?
Ortho referral- often surgical, & brace
27
This type of injury mc happens from multiple, usually twisting related non-blunt force injury
meniscus
28
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What type of injury are these symptoms of?
• “catching,” “locking,” “clicking”
• Painful walking and squatting
• Mild to moderate joint swelling
• *** Joint line tenderness
```
Meniscus tear
29
*** Joint line tenderness should make you think of
Meniscus tear
30
Pts with this injury may experience “locking in extension” – piece/flap of meniscus obstruction joint
Meniscus tear
31
What imaging would you do for meniscus and what would it show?
Xrays usually normal but may show joint space narrowing or effusion
32
What is the imaging of choice for a meniscus tear?
MRI
33
Treatment for meniscus? Degenerative and acute?
* Degenerative tears – non-op, PT
| * Acute tears – arthroscopic meniscus repair or debridement
34
This type of injury is considered an orthopedic emergency?
Knee dislocation (complete dislocation of the tibiofemoral joint which is behind the knee)
35
How many ligaments do you have to tear in your knee for a complete dislocation and which type of dislocation is mc?
3 out of 4 and anterior
36
What nerve and artery are behind the knee that you really need to be aware of in knee dislocations?
popliteal artery and peronal nerve
37
This type of injury is most common with high-energy trauma such as hyperextension or anterior blow to knee
knee dislocation
38
What are some signs of knee dislocation?
PAIN, gross deformity, large effusion, significant pain
39
What is so important to check in people with knee dislocations?
* MUST evaluate for neurovascular injuries!
* Palpable distal pulses – does NOT exclude the possibility of a vascular injury!
* Obtain Ankle-Brachial Index
* Popliteal vasculature
40
An ABI measures the ________ BP of the ______ and ______ artery
systolic, ankle and brachial
41
An ABI < _______ is a sign for concern
0.9
42
What is the gold standard imaging for a knee dislocation?
CT arteriogram (gold standard) or arterial duplex ultrasound
- Evaluates for popliteal artery injury
* once you make sure vasculature is intact, you can do which imaging? MRI
43
What is the treatment for a knee dislocation?
• IV pain control – often admitted for this alone!
• Reduce–even if pt has a vascular injury–reduce than reassess and obtain
ortho/vascular consult and advanced imaging (*longer something is out, harder it is to get back in)
• Post-reduction xray
• Splint in a long leg splint with 20-30 degree flexion
• Admit for pain control and serial exams with ortho consult
44
Bursa becomes irritated and produces too much fluid, which causes it to swell and puts pressure on the adjacent parts of the knee
Knee bursitis
45
"housemaids knee or gardeners knee"
Knee bursitis
46
What are signs and symptoms of knee bursisits?
Swelling and tenderness over the bursa could have overlying erythema and warmth
47
How do you diagnose bursitis?
The diagnosis is clinical and the bursa in front of the patella will move around
48
What is the treatment for bursitis?
* NSAIDs
* RICE
* Eliminate pressure over the patella
* Refractory – prepatellar bursa injections
49
These are symptoms of what?
* Morning stiffness lasting < 30 minutes
* Crepitus
* Mild effusion
* Pain relieved with rest
* Severe - Genu Valgum (knock knee) or Genu Varum (bow leg
Knee osteoarthritis
50
How do you diagnose osteoarthritis?
Xray
51
What would an xray show for a patient with osteoarthritis?
joint space narrowing, osteophytes- (bony projections) that form along joint margins
52
What is the treatment for someone with knee osteoarthritis?
* Conservative: Weight loss (for those with BMI >25), graded exercise (quad strengthening)
* APAP and NSAIDs
* Intra-articular Corticosteroid - Offers short-term relief, but does not improve quality of life, and may result in greater cartilage loss
* Can try other types of injections and knee replacement if BAD
53
Patient had a direct blow to the knee and now has severe pain, swelling and deformity of the front of the knee. Patients knee is also locked in extension. What is this a sign of?
Patella dislocation & subluxation
54
How do you diagnose a patella dislocation & subluxation?
xray
55
What is the treatment for a patella dislocation & subluxation?
* Reduction – apply pressure while extending the knee
* Immobilization short-term
* PT – quad strengthening
* Non-op after first, op if recurrent
56
This patient fell onto her flexed knee and now has significant swelling and focal pain. What injury type is mc?
Patella fracture
57
How do you diagnose a patellar fracture?
Xray – AP, lateral, and sunrise views!
*Important to document that the patellar tendon is intact
58
What is the treatment for a patellar fracture?
* Ortho referral, RICE, pain control
* Non-operative: extensor mechanism intact, non-displaced fx, vertical fracture
* **Extension bracing WITH weight bearing
59
A patient comes in for a knee sprain and you notice on xray that the patella is composed of two bones. The patient is not in pain and has no significant complaints. Is this normal? What could this be?
Bipartite patella (patella is composed of two bones)
60
A patient presents with pain and swelling of the knee with elevation of the patella after trying to jump high on a box. What should you be suspicious of and what imaging should you get?
patellar tendon rupture and you should get an xray
61
How do you diagnose a patella tendon rupture?
Xray shows patella displacement --> MRI
62
Treatment for a patella tendon rupture?
Ortho referral
63
“runners knee”
Chondromalacia/patellofemoral syndrome
64
These are signs and symptoms of what?
* Progressive pain that is increased with going up stairs and/or squatting
* No effusion
* Grind test and apprehension sign
Chondromalacia/patellofemoral syndrome
65
How do you diagnose Chondromalacia/patellofemoral syndrome?
* Xrays – AP, lateral, and sunrise (bilateral)
* Patella alta/baja, or lateral patella tilt
* MRI – assess cartilage damage
66
How do you treat Chondromalacia/patellofemoral syndrome?
* Non-operative is mainstay
* NSAIDs, PT (quad strengthening)
* Operative if persistent/progressive > 1 yr and PT failed
* Arthroscopic debridement
* Patellar realignment surgery
67
A patient presents with severe pain and swelling of the lower leg after landing and twisting his leg from jumping out of a tree. What is the most likely diagnosis?
Tibial plateau fracture
68
What is the test of choice imaging for a person with a tibial plateau fracture?
Xray
69
You suspect a patient has a tibial plateau fracture but you see nothing on xray... what should you do?
Get a CT
70
What is a do not miss diagnosis that can be caused by a tibial plateau fracture?
Compartment syndrome and peronal nerve injury (test foot drop)
71
Treatment for tibial plateau fracture?
* Pain control
* Consult ortho on all
* Non-op – no to min displacement
* Hinged brace, crutches
* Operative – displaced, comminuted, open
* ORIF
72
Patient had a direct blow to the lower leg with twisting. What is the mc injury?
Tibial shaft fracture
73
Dx for Tibial shaft fracture
xray
74
Tx for Tibial shaft fracture
- No to minimal displacement -> splint with crutches, then walking cast
- Displaced or comminuted -> splint with crutches, ORIF
75
This is a type of fracture in a non-weight bearing bone of the lower leg?
Fibula shaft fracture
76
Imaging for fibula shaft fracture?
xray (make sure you can visualize entire bone)
77
Tx for fibula shaft fracture?
splint -> cast, weight bearing fine
78
What is the order of ligaments injured in an ankle sprain?
ATFL -> CFL -> lateral mallelous fracture
79
MOI for this ligament tear: Inversion injury Pain at base of fibula
CFL (calcaneofibular ligament)
80
MOI for this ligament tear: Inversion injury
| Pain across tib/fib syndesmosis
ATFL (anterior tibiofibular ligament)
81
Is a low ankle sprain or high ankle sprain more common?
Low ~ 90%
82
What test checks for movement of ATFL?
Anterior drawer test
83
What test checks for movement of ATFL & CFL?
Talar tilt
84
When do you apply the Ottawa Ankle Rule?
To determine whether or not you should do imaging for an ankle sprain
85
When should you get an xray for an ankle sprain?
* Inability to bear weight
* Medial or lateral malleolus point, bony tenderness
* 5MT base tenderness
* Navicular tenderness
(ottawa rule)
86
this is a _______ degree ankle sprain...
- stretching of the fibers
- Walkable, min swelling
First degree sprain
87
How do you treat a first degree ankle sprain?
Tx: RICE, ace bandage, keep moving and weight bearing
not always bad advice to "walk to off"
88
this is a _______ degree ankle sprain...
- partial tear
- (+/-) walking, moderate swelling
second degree
89
How do you treat a second degree ankle sprain?
Tx: RICE, might need 2-3 days NWB, airsplint
90
this is a _______ degree ankle sprain...
-complete tear
• No walking, “egg-shaped” swelling within 2 hours, can be less painful than 2nd deg
3rd degree
91
Treatment for 3rd degree tear?
Tx: RICE, NWB 3-7 days with re-exam in 5-7 days.
+/- surg vs PT
92
Treatment for a lateral malleoli fracture?
Since the lateral malleoli is on the same side as the fibula, and the fibula is weight bearing, people can walk on this.
* Isolated lateral malleolus fracture with < 3mm displacement
* Ortho referral, likely walking boot 6-8 weeks
* Displaced, comminuted, open à surgical repair
93
Treatment for a medial malleoli fracture?
* Tx: More likely to be surgical because tibia is the weight bearing bone of the body
* Splint, crutches, ortho referral
94
These types of malleoli fractures should be fixed immediately
BIMALLEOLAR FRACTURE
• Fxr of medial and lat malleoli
TRIMALLEOLAR FRACTURE
•broken 2 bones in 3 areas
95
This type of injury is common in "weekend warrior" and you hear a "pop" or like they cot shot in the foot patients OR patients who are asymptomatic but are on FLUOROQUINOLONES
Achilles tendon rupture
96
What is the TOC for an achilles tendon rupture?
MRI
97
Tx for achilles tendon rupture?
Ortho referral -> surgical repair
98
A phalangeal (toe) fracture is pretty common. WHat is the treatment?
Buddy tape and hard (cast) shoe
99
A metatarsal fracture does not need to be operated on if it is a non-displaced fracture of toes ______
1-4
1=big toe
100
If you have to operate on a toe what is the best surgical option?
Pinning
101
"dancers fracture"
5th metatarsal fracture (pinky)
102
Avulsion fracutre= _______. is weight bearing ok or not?
pseudo jones
Weight bearing is ok
103
____ and stress fractures require weight bearing or non-weight bearing
Jones and stress fractures require non-weight bearing
104
This is a symptom of what?
• Sharp heel pain – insidious upon stepping out of bed, worse at end of the day, may be bilateral
PLANTAR FASCIITIS
105
How do you dx plantar fasciitis and what is treatment of plantar fasciitis?
Diagnose: Clinical – pinpoint tenderness, dorsiflexion of the toes and foot increases tenderness with
palpation
Tx: Stretching, NSAIDs, arch support
106
This condition is common in high heel wearers and causes Flexion deformity of the PIP joint with extension of DIP (toes2-5)
Hammer toe
107
What is the treatment for hammer toe?
* Non-op to start – “wide” shoes, padding/splinting
| * Podiatry referral for chronic pain
108
Corn or callus?
-painful, small with very hard center
corn
109
Corn or callus?
-larger, non-painful
callus
110
What is the treatment for a corn and callus?
Tx: file/remove, padding
111
AKA: hallux valgus
| • Pressure on the lateral MCP joint causes the metatarsal head displaces medially – bony deformity
Bunions
112
What is the tx for bunions?
* Wide shoes, padding
* Pain control
* Podiatry referral
* Surgery
113
Painful condition in which the nail grows so that it cuts into one or both sides of the paronychium or nail bed
Ingrown toe nails
114
Treatment for ingrown toe nails?
Tx: warm water soaks, antibacterial ointment, well fitting shoes (open toe shoes best), nail lifting or removal
