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Surgery Block > Orthopaedics - Knee, Ankle + Foot > Flashcards

Orthopaedics - Knee, Ankle + Foot Flashcards

1
Q

Describe the mechanism of low energy fractures of the tibia

A

Invariable twisting, inversion or eversion injuries

Often occur following a fall from a standing height

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2
Q

Describe the mechanism of high energy tibial fractures

A

Direct blow to the tibia and fibula causing fracture comminution and soiling of the wound

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3
Q

What additional imaging is needed for tibial plateau fractures? Why?

A

CT scan - aids in operative planning

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4
Q

How are ankle fractures classified? Describe this briefly

A

Weber classification
A - Below syndesmosis
B - At level of syndesmosis
C - Above syndesmosis

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5
Q

What is a Pilon fracture?

A

Intra-articular fracture of the ankle joint

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6
Q

What classification is used for Pilon Fractures?

A

Ruedi and Allgower Classification

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7
Q

For which fractures is an above knee back slab indicated?

A
  • Tibial plateau

- Diaphyseal

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8
Q

For what sort of fractures is a below knee back slab indicated?

A
  • Pilon

- Ankle fracture

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9
Q

What classification is used for tibial and fibular fractures?

A

Schatzker

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10
Q

Define achilles tendonitis and describe its pathophysiology briefly

A

Inflammation of the calcaneal tendon – repetitive action of the tendon results in microtears –> localised inflammation –> thickening, fibrosis and loss of elasticity

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11
Q

What are the risk factors for achilles tendonitis?

A
  • Unfit individual suddenly increasing exercise frequency
  • Poor footwear
  • Male
  • Obesity
  • Fluroquinolone use (rupture)
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12
Q

What are the clinical features of achilles tendonitis?

A
  • Gradual onset of pain + stiffness
  • Pain often worse with movement
  • Can be relieved by mild exercise or heat
  • Tenderness over tendon (worst 2-6cm above insertion)
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13
Q

What are the clinical features of achilles tendon rupture?

A
  • Sudden onset severe pain in posterior calf
  • Audible popping sound + feeling
  • Loss of power in ankle plantar flexion
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14
Q

How is plantar flexion still maintained despite achilles tendon rupture?

A

Peroneal tendons also contribute to plantarflexion

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15
Q

What are the two most commonly used indicators of achilles tendon rupture?

A
  • Simmond’s test

- Palpable ‘step’ in the tendon

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16
Q

What is Simmond’s test?

A

Assesses potential achilles tendon rupture :

  • Patient kneels on a chair, affected ankle hanging off edge
  • Squeeze affected calf
  • -> plantar flexion absent if tendon is ruptured
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17
Q

What are the main DDx for achilles tendonitis?

A
  • Ankle sprain
  • Stress fractures of tibia or calcaneus
  • Osteoarthritis
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18
Q

What investigation can be used if you are not sure of a diagnosis of achilles tendonitis?

A

USS of ankle

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19
Q

What is the management for achilles tendonitis?

A

Supportive - stop precipitating exercise, ice the area and use anti-inflammatories

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20
Q

What is the management for an acute achilles tendon rupture (<2wks)?

A
  • Analgesia
  • Immobilisation
  • Ankle splinted in plaster in full equinus (max. pointed) for 2 weeks
  • Move ankle to semi equinus for 4 weeks
  • Move ankle to neutral for 4 weeks
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21
Q

What is the management for a delayed (>2wks) achilles tendon rupture?

A

Surgical fixation with end-to-end tendon repair

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22
Q

What is plantar fasciitis? Describe the physiology

A

Inflammation of the plantar fascia of the foot - microtears of the fascia

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23
Q

What are the risk factors for plantar fasciitis?

A
  • Anatomical eg. excessive pronation or pes cavus (high arch)
  • Weak plantarflexors
  • Tight gastrocnemius or soleus
  • Prolonged standing or excessive running
  • Leg length discrepancy
  • Obesity
  • Unsupportive footwear
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24
Q

What are the main clinical features in a history of plantar fasciitis?

A
  • Sharp pain across plantar aspect
  • Pain most severe in heel + can radiate distally
  • Worse after inactivity
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25
Q

What may be seen on examination of plantar fasciitis?

A
  • Tender palpation of infracalcaneal region
  • Palpation of medial calcaneal tubercle reproduces symptoms
  • Overpronation
  • High arches
  • Leg length discrepancy
  • Femoral anteversion
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26
Q

What are the main DDx to consider for plantar fasciitis?

A
  • Achilies tendonitis
  • Morton neuroma
  • Calcaneal stress #
  • Inflammatory arthropathy
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27
Q

What can be seen if an X ray is done in plantar fasciitis?

A

Plantar heel spur

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28
Q

What imaging modality can be used to visualise plantar fasciitis?

A

MRI scan - identify areas of thickening and any associated oedema

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29
Q

What is the main management for plantar fasciitis?

A
  • Activity moderation
  • Regular analgesics
  • Change of footwear
  • Physiotherapy
  • Corticosteroid injections
  • Plantar fasciotomy
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30
Q

What are the main functions of the menisci?

A
  • Shock absorbers of the knee joint

- Increase articulating surface

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31
Q

What are the different types of meniscal tears?

A
  • Vertical
  • Longitudinal (Bucket-Handle) ***
  • Transverse (Parrot-beak)
  • Degenerative
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32
Q

What are the most common causes for meniscal tears?

A
  • Trauma related injury

- Degenerative disease

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33
Q

What is the most common mechanism of injury in traumatic meniscal tears?

A

Twisted knee while flexed + weight bearing

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34
Q

What are the common clinical features on presentation of a meniscal tear?

A
  • Tearing sensation in the knee
  • Intense sudden-onset of pain
  • Slow swelling of knee (~6-12hrs)
  • May be locked in flexion/unable to extend
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35
Q

What may be seen on examination of a meniscal tear?

A
  • Joint line tenderness
  • Significant joint effusion
  • Limited knee flexion
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36
Q

What specific tests can be used for assessment of a meniscal tear?

A
  • McMurray’s test

- Apley’s grind test

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37
Q

What are the DDx to consider in an acutely swollen knee joint post trauma?

A
  • Fracture
  • Cruciate ligament tear
  • Meniscal tear
  • Colateral ligament tear
  • Osteochondritis dissecans
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38
Q

What is the gold standard investigation for confirmation of a meniscal tear?

A

MRI

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39
Q

What is done in arthroscopic surgery for meniscal tears of different regions?

A
  • Tear in outer 1/3 of meniscus - suture tear together
  • Tear in inner 1/3 - trim tear
  • Tear in middle 1/3 - either repair or trim
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40
Q

What is the main complication of a meniscal tear?

A

Increased risk of developing osteoarthritis later in life

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41
Q

What are the main risks associated with knee arthroscopy?

A
  • DVT

- Damage to local structures eg. saphenous N+V, Peroneal nerve + popliteal vessels

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42
Q

Why does an ACL tear often result in significant functional impairment of the knee joint?

A

ACL is an important stabiliser + is primary restraint to limit anterior translation of tibia

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43
Q

How does an ACL injury often occur?

A

Twisting injury whilst weight bearing eg. landing from a jump

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44
Q

What are common clinical features of ACL tears?

A
  • Rapid joint swelling
  • Significant pain
  • Instability (leg ‘gives way’)
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45
Q

Why is there joint swelling in an ACL tear?

A

Highly vascular ligament –> haemoarthrosis (within 15-30mins)

46
Q

What is Lachman’s test?

A

Used to assess ACL tear

  • Place knee in 30 degs flexion
  • Pull tibia forward whilst stabilising femur
47
Q

Which specific test on examination is best for assessing for an ACL tear?

A

Lachman’s test

48
Q

What DDx should be considered in an ACL tear?

A
  • Fracture
  • Meniscal tear
  • Collateral ligament tear
  • Quadriceps/patellar ligament tear
49
Q

Why should an X ray be done for a suspected ACL tear?

A

Exclude bony injuries, joint effusion or lipohaemoarthrosis

50
Q

What is the gold standard investigation to diagnose an ACL tear?

A

MRI of knee

51
Q

What conservative management is there for an ACL tear?

A
  • Strength training of the quadriceps - stabilises the knee

- Canvas knee splint

52
Q

What surgical management is there for ACL tears?

A

Tendon or artificial graft for the ACL

53
Q

What is the main complication of ACL tears?

A

Post-traumatic osteoarthritis

54
Q

How do PCL tears tend to occur?

A
  • High energy trauma eg. RTA

- Low energy trauma with hyeprflexion of knee on plantarflexed foot

55
Q

What are the main clinical features of a torn PCL?

A
  • Immediate posterior knee pain
  • Instability of joint
  • Positive posterior drawer test
  • Posterior sag
56
Q

What is the gold standard diagnostic test for a PCL tear?

A

MRI scan

57
Q

What is the conservative management for a PCL tear?

A

Knee brace and physio

58
Q

What injury is an ACL tear most commonly associated with?

A

Meniscal tear (lateral meniscus more common)

59
Q

Which is the most commonly injured ligament of the knee?

A

Medial collateral ligament

60
Q

How is the MCL often injured?

A

When external rotational forces are applied to the lateral knee

61
Q

What is the primary function of the MCL?

A

Valgus stabiliser

62
Q

How are MCL injuries graded?

A

Grade 1 - mild, minimal torn fibres + no loss of MCL integrity
Grade 2 - Moderate, incomplete tear and increased laxity of MCL
Grade 3 - severe, complete tear and gross laxity of MCL

63
Q

What are common clinical features of an MCL tear?

A
  • Immediate medial joint line tenderness
  • Swelling (after few hours)
  • Increased laxity
  • Hears a ‘pop’ at time of injury
64
Q

How can a grade 2 MCL tear be differentiated from a grade 3?

A

Grade 2 = lax on 30 degs of flexion but solid in full extension
Grade 3 = lax in both positions

65
Q

What is the gold standard investigation for a MCL tear?

A

MRI scan

66
Q

What is the management for an MCL tear (based on grade)?

A
  • Grade 1 –> RICE + strength training
  • Grade 2 –> Analgesia + knee brace with strength training
    Grade 3 –> Analgesia with knee brace + crutches
67
Q

When is surgery considered for a MCL tear?

A

Grade 3 tear with associated distal avulsion

68
Q

What are the timescales for full recovery of an MCL tear based on grade?

A

Grade 1 = 6wks
Grade 2 = 10wks
Grade 3 = 12wks

69
Q

What are the main complications following an MCL tear?

A
  • Instability in the joint

- Damage to saphenous nerve

70
Q

What is iliotibial band syndrome? How is it thought to be caused?

A

Inflammation of the IT band - repetitive flexion/extension of knee causing impingement of band against lateral femoral condyle

71
Q

What anatomical risk factors are there for IT band syndrome?

A
  • Genu varum
  • Excessive internal tibial torsion
  • Foot pronation
  • Hip abductor weakness
72
Q

What are the main clinical features of IT band syndrome?

A
  • Lateral knee pain
  • Exacerbated by exercise
  • Pain often worse running downhill
73
Q

What special tests are there for IT band syndrome?

A
  • Nobles test

- Renne test

74
Q

Describe Nobles test briefly

A
  • Patient supine
  • Examiner places finger on lateral femoral condyle
  • Knee slowly extended
    +ve if pain felt at 30degs (ITB passing over lateral femoral condyle)
75
Q

Describe Renne test briefly

A
  • Examiner places pressure on lateral epicondyle
  • Patient asked to squat
    +ve if pain felt at 30 degs of flexion
76
Q

What are the main DDx for ITB syndrome?

A
  • Degenerative joint disease
  • Fractures
  • Ligamentous injury
77
Q

How is ITB syndrome managed?

A
  • Modification of activity
  • Analgesia in periods of pain
  • Local steroid injections
  • Physiotherapy
78
Q

When is surgery indicated in ITB syndrome? What is involved?

A

Still symptomatic or functionally limited after 6months

–> Release of ITB from attachments

79
Q

What is the mechanism of injury in a tibial plateau fracture?

A

High energy trauma or axial loading - causes impaction of the femoral condyle onto the tibial plateau

80
Q

Why is the lateral tibial plateau more commonly fractured?

A

Usually a varus-deforming force

81
Q

What are commonly seen clinical features of a tibial plateau #?

A
  • Sudden onset pain
  • Unable to weight bear
  • Knee swelling –> lipohaemoarthrosis
  • Tenderness over medial or lateral aspects of proximal tibia
  • Potential ligament instability
82
Q

What is first line investigation for a tibial plateau #?

A

Anteroposterior and lateral X-ray

83
Q

What is the investigation used for assessment of severity in a tibial plateau #?

A

CT scan

84
Q

What classification is used for tibial plateau fractures?

A

Schatzker

85
Q

Briefly outline the Schatzker classification

A 
Used for tibial plateau #:
1 - Lateral split #
2 - Lateral split + depressed
3 - Lateral pure depression
4 - Medial plateau
5 - Bicondylar #
6 - Metaphyseal-diaphyseal disassociation
86
Q

When is conservative management indicated in a tibial plateau fracture?

A

Uncomplicated - no evidence of ligamentous damage, tibial sublaxation or articular step <2mm

87
Q

What conservative management is there for tibial plateau fractures?

A
  • Hinged Knee brace
  • Non/partial weight bearing for around 8-12wks
  • Physiotherapy
  • Suitable analgesia
88
Q

What is considered a complicated tibial plateau fracture?

A
  • Articular step >2mm
  • Angular deformity >10 degs
  • Metaphyseal-diaphyseal translation
  • Ligamentous injury
  • Associated tibial fractures
89
Q

What is the typical surgical management for a tibial plateau fracture? What is the purpose of this

A

ORIF - aim is to restore joint surface congruence and ensure stability
Fill metaphysical gaps with bone graft or bone substitute

90
Q

Why are tibial plateau fractures considered significant?

A

Disruption of the congruence of the articular surface - if left leads to rapid degenerative change

91
Q

What is the main complication post tibial plateau fracture?

A

Post-traumatic arthritis

92
Q

Where do talar fractures tend to most commonly occur?

A

Through the talar neck

93
Q

What is the risk in talar fractures?

A

High risk of avascular necrosis - talus relies predominantly on extraosseous arterial supply which is highly susceptible to interruption

94
Q

What are the clinical features of a talar fracture?

A
  • Hx of high impact trauma
  • Immediate pain and swelling around the ankle
  • Clear deformity if dislocation
  • Patient unable to dorsi/plantarflex ankle
95
Q

How are type 1 and 2 talar fractures differentiated on imaging?

A

Take an x-ray in both dorsiflexion and plantarflexion

–> Plantarflexion will reduce any sublaxation

96
Q

What classification is used for talar fractures? Outline this briefly

A 
Hawkin's Classification
1 - Undisplaced
2 - Subtalar dislocation
3 - Subtalar and tibiotalar disolcation
4 - Subtalar, tibiotalar and talonavicular dislocation
97
Q

How are type 1 talar fractures managed?

A

Conservatively in a plaster with non-weight bearing crutches for ~3months
–> assess for union + AVN in fracture clinic

98
Q

How are type 2-4 talar fractures managed?

A

Closed reduction
Once reduced place a cast + order repeat radiographs
THEN definitive surgical fixation when next available

99
Q

What are the main complications to be aware of in talar fractures?

A
  • AVN
  • Osteoarthritis
  • Arthodesis
100
Q

What is Hawkin’s sign?

A

Subchondral lucency of the talar dome - visible 6-8wks post injury –> indicates sufficient vascularity of talus and so low risk of AVN

101
Q

What is the medical term for a bunion? What is this?

A

Hallux valgus – Deformity at the first metatarsophalangeal joint

102
Q

Describe hallux valgus

A
  • Medial deviation of the first metatarsal
  • Lateral deviation +/- rotation of the hallux
  • Associated joint sublaxation
103
Q

Why do high heels/narrow fitting footwear cause increased risk of hallux valgus?

A

Keep the hallux in a values position (first metatarsal head drifts more medially)

104
Q

What are the main risk factors for hallux valgus?

A
  • Female
  • CT disorders
  • Hypermobility syndrome
  • Anatomical variants (eg. long 1st metatarsal, malalignment of the 1st MTP joint, flat feet)
105
Q

How does a hallux valgus typically present?

A
  • Painful medial prominence

- Aggravated by walking, weight bearing or narrow toe shoes

106
Q

What are the main DDx to consider in hallux valgus?

A
  • Gout
  • Septic arthritis
  • Hallux rigidus
  • Osteoarthritis
  • Rheumatoid arthritis
107
Q

What investigation is used for hallux valgus? What does it look at?

A

X ray

  • Degree of lateral deviation
  • Signs of joint sublaxation
108
Q

What measurement is said to be diagnostic of hallux valgus?

A

Angle between first metatarsal and first proximal phalanx >15 degs

109
Q

What is the conservative management for hallux valgus?

A
  • Sufficient analgesia
  • Adjustment of footwear
  • Orthosis (if flat foot)
  • Physiotherapy
110
Q

What surgical procedures are there for problematic hallux valgus?

A
  • Chevron procedure
  • Scarf procedure
  • Lapidus procedure
  • Keller procedure
111
Q

What surgical complications are there for hallux valgus?

A
  • Wound infection
  • Delayed healing
  • Nerve injury
  • Osteomyelitis
  • Recurrence
112
Q

What are the complications of hallux valgus?

A
  • AVN
  • Non-union
  • Displacement
  • Reduced ROM

Surgery Block (12 decks)

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