Post on 03-Jan-2016
transcript
Lower limb injuries
Richard Hardern
Content
• Knee, ankle, foot• Anatomy• History and examination• Treatment of limb threatening
problems
Not a case for the Emergency Nurse Practitioner!
Knee anatomy
• Bones• Ligaments: cruciate and collateral• Menisci
Ankle anatomy
• Bones• Ligaments: medial & lateral• Tendons
Peroneus brevis
Gastrocnemius
Foot anatomy
• Bones
History & examination
• Mechanism of injury• Mechanism of injury• Mechanism of injury
General Considerations
•Always inquire about the mechanism of injury. •Always inquire about the effect on function. •Always do the following in this order:
•Inspection •Palpation •Range of Motion (active before passive)
Knee: look
•Skin- scars, redness •Muscle- wasting of quads (compare diameter of thigh if quads wasted) •Bone/joint- Effusion, Varus Valgus deformity( measure intermalleolar distance if valgus), •Watch them walking too at some point (even if only from WR into examination cubicle)
Knee: feel
•Skin - Temperature, back of hand •Muscle- Ask patient to contract quads •Bone/joint- Effusion fluid displacement test, patellar tap test (may be negative if tense effusion) •Joint line tenderness (with knee bent) •Patellar tendon •MCL,LCL •Popliteal swellings
Knee: move
•Active then passive- •Flexion (135 degrees normal) •Extension (put hand behind knee)•Feel for crepitus
Knee: special tests - collaterals
Knee: special tests - cruciates
ACL
PCL
Knee: special tests - menisci
Knees: active resisted extension
Ankle/foot examination
• Look –Knee distally–Walking too (at some point)
Ankle/foot examination
• Feel– Knee distally– Medial & lateral (include base 5th
MT)– Leave tender area until last
Ankle / foot examination
• Move – Ankle– Midtarsal– Stability test: anterior drawer
Anterior draw test
Emergency problems
– Dislocation (not patellar)– Compartment syndrome
• Skin medially is at risk.• If skin becomes broken/necrotic, #
becomes an open one.• Risks of complications much
greater (especially infection).• Needs emergent reduction (with
analgesia).• Damage to popliteal artery if
dislocated knee
Compartment syndrome• The pain may be intensely out of proportion to
the injury, especially if no bone is broken. • There may also be a tingling or burning sensation
(paresthesias) in the muscle. • The muscle may feel tight or full. • If the area becomes numb or paralysis sets in,
cell death has begun and efforts to lower the pressure in the compartment may not be successful in restoring function.
• Pain worse if affected muscle passively stretched.• Pulses not lost (until very late).