AnatomyAnatomyLecture 8Lecture 8

Lower ExtremitiesLower Extremities

Physician Assistant Physician Assistant ProgramProgram

Miami Dade CollegeMiami Dade College

"Whatever your mind "Whatever your mind can conceive and can conceive and believe it can achieve." believe it can achieve."

Napoleon Napoleon HillHill

Pelvis & HipsPelvis & Hips

Hip Hip dislocationdislocation

90% are 90% are posterior posterior dislocationsdislocations

Hip DislocationHip Dislocation

Femur FxFemur Fx

Iliotibial Band Friction Iliotibial Band Friction SyndromeSyndrome

Occurs in runners and cyclistsOccurs in runners and cyclists Result of abrasion b/t iliotibial band and Result of abrasion b/t iliotibial band and

lateral femoral condylelateral femoral condyle + tenderness over lateral epicondyle @ 30 + tenderness over lateral epicondyle @ 30

degrees of flexion degrees of flexion tenderness may be present throughout length tenderness may be present throughout length

of ITBof ITB Tx:Tx:

Decrease activityDecrease activity Ice massageIce massage Stretching of ITBStretching of ITB

Hamstring injuryHamstring injury Hamstring injuries are one of the most Hamstring injuries are one of the most

common among runners. common among runners. The hamstring muscles run down the back The hamstring muscles run down the back

of the leg from the pelvis to the lower leg of the leg from the pelvis to the lower leg bones, and an injury can range from minor bones, and an injury can range from minor strains to total rupture of the muscle. strains to total rupture of the muscle.

A sudden, sharp pain in the back of the A sudden, sharp pain in the back of the thigh that stops you in mid-stride, is thigh that stops you in mid-stride, is probably a hamstring injury, probably a hamstring injury,

After such an injury, the knee may not After such an injury, the knee may not extend more than 30 to 40 degrees short of extend more than 30 to 40 degrees short of straight without intense pain. straight without intense pain.

KneeKnee

The KneeThe Knee Ligaments:Ligaments:

Anterior Cruciate Ligament (ACL)Anterior Cruciate Ligament (ACL) Posterior Cruciate Ligament (PCL)Posterior Cruciate Ligament (PCL) Medial Collateral Ligament (MCL)Medial Collateral Ligament (MCL) Lateral Collateral Ligament (LCL)Lateral Collateral Ligament (LCL)

Anterior Cruciate Ligament Anterior Cruciate Ligament (ACL) (ACL)

originates in front of the intercondylar originates in front of the intercondylar eminance of the tibia and inserts on the eminance of the tibia and inserts on the posteromedial aspect of the lateral posteromedial aspect of the lateral femoral condyle.femoral condyle. LatLat med med

It is composed of two “bundles”.It is composed of two “bundles”. The anteromedial bundle is tight in flexionThe anteromedial bundle is tight in flexion The posterior bundle is tight in extension.The posterior bundle is tight in extension.

The ACL prevents anterior translation of The ACL prevents anterior translation of the tibiathe tibia

Posterior Cruciate Posterior Cruciate Ligaments (PCL)Ligaments (PCL)

Originates on the medial femoral Originates on the medial femoral condyle and inserts on the tibia.condyle and inserts on the tibia. MedMedlatlat

It is also composed of two bundlesIt is also composed of two bundles An anteriolateral bundle that is tight An anteriolateral bundle that is tight

in flexion in flexion And an posteromedial bundle that is And an posteromedial bundle that is

tight in extensiontight in extension The PCL prevents posterior The PCL prevents posterior

translation of the tibiatranslation of the tibia

Medial Collateral LigamentMedial Collateral Ligament(MCL)(MCL)

Originates on the medial femoral Originates on the medial femoral epicondyle and inserts on the epicondyle and inserts on the proximal tibiaproximal tibia

The deep portion of the ligament is The deep portion of the ligament is intimately associated with the intimately associated with the medial meniscusmedial meniscus

The MCL prevents valgus angulation The MCL prevents valgus angulation of the kneeof the knee

Lateral Collateral LigamentLateral Collateral Ligament(LCL)(LCL)

Originates on the lateral femoral Originates on the lateral femoral epicondyle and inserts on the lateral epicondyle and inserts on the lateral aspect of the fibular head.aspect of the fibular head.

It prevents varus angulation of the It prevents varus angulation of the kneeknee

Medial Supporting Medial Supporting StructuresStructures

(From superficial to deep layers)(From superficial to deep layers) Sartorus and fasciaSartorus and fascia Superficial MCL, posterior oblique Superficial MCL, posterior oblique

ligament, semimembranousligament, semimembranous Deep MCL, capsuleDeep MCL, capsule

Lateral Supporting Lateral Supporting StructuresStructures

Iliotibial tract, biceps, fasciaIliotibial tract, biceps, fascia Patella retinaculum, patellofemoral Patella retinaculum, patellofemoral

ligamentligament LCL, arcuate ligament, fabellofibular LCL, arcuate ligament, fabellofibular

ligament, capsuleligament, capsule

MenisciMenisci Crescent shaped fibrocartilagenous Crescent shaped fibrocartilagenous

structures that are triangular in cross structures that are triangular in cross section.section.

Only the peripheral 20-30% of the menisci Only the peripheral 20-30% of the menisci are vascularized are vascularized

These structures deepen the articular These structures deepen the articular surface of the tibial plateau surface of the tibial plateau

Also play a role in stability, lubrication, Also play a role in stability, lubrication, and nutritionand nutrition

Joint RelationshipsJoint Relationships The height of the lateral femoral The height of the lateral femoral

condyle is greater than that of the condyle is greater than that of the medial femoral condylemedial femoral condyle

The lateral condyle is relatively straight, The lateral condyle is relatively straight, but the medial condyle is curved, but the medial condyle is curved, allowing the medial tibial plateau to allowing the medial tibial plateau to externally rotate in full extensionexternally rotate in full extension (The screw home mechanism)(The screw home mechanism)

The patellofemoral joint is composed of The patellofemoral joint is composed of the patella and the femoral trochleathe patella and the femoral trochlea

Meniscal TearMeniscal Tear MC injury to the knee requiring MC injury to the knee requiring

surgerysurgery Medial meniscal tears occur 3x more Medial meniscal tears occur 3x more

frequently than lateral meniscal tearsfrequently than lateral meniscal tears May be caused by acute trauma or May be caused by acute trauma or

long term wear and tearlong term wear and tear Locked knee requires urgent Locked knee requires urgent

interventionintervention

Meniscal TearMeniscal Tear Diagnosis:Diagnosis:

History: History: lockinglocking catching episodescatching episodes giving way episodesgiving way episodes pain with squattingpain with squatting SwellingSwelling

Physical Exam:Physical Exam: + effusion+ effusion + joint line tenderness+ joint line tenderness + McMurray+ McMurray

MRI= >90% accurateMRI= >90% accurate

Meniscal TearMeniscal Tear Treatment:Treatment:

Meniscal repair may be achieved Meniscal repair may be achieved arthroscopically by suturing the torn arthroscopically by suturing the torn meniscusmeniscus This may be an option if tear occurs in an area This may be an option if tear occurs in an area

with blood supplywith blood supply Partial meniscectomyPartial meniscectomy

Arthroscopic removal of the torn meniscusArthroscopic removal of the torn meniscus

MenisciMenisci Meniscal CystsMeniscal Cysts

Most commonly involve lateral meniscus in Most commonly involve lateral meniscus in conjunction with horizontal cleavage tearsconjunction with horizontal cleavage tears

Discoid Meniscus (Popping Knee Discoid Meniscus (Popping Knee Syndrome)Syndrome) Congenitally round (discoid) lateral Congenitally round (discoid) lateral

meniscus that does not acquire its normal meniscus that does not acquire its normal semilunar shapesemilunar shape

Patients develop popping with knee Patients develop popping with knee extensionextension

Ligament SprainsLigament Sprains

Ligament sprainsLigament sprains

Medial Collateral Ligament Medial Collateral Ligament (MCL) Sprain(MCL) Sprain

Caused by valgus force to kneeCaused by valgus force to knee Diagnosis:Diagnosis:

+ tenderness along MCL (Grade I-III)+ tenderness along MCL (Grade I-III) + opening of medial joint line with valgus stress + opening of medial joint line with valgus stress

when knee is @ 30 degrees of flexion (Grades II-III)when knee is @ 30 degrees of flexion (Grades II-III) (Posterior Cruciate Ligament is most responsible for (Posterior Cruciate Ligament is most responsible for

medial-lateral stability when knee is fully extended)medial-lateral stability when knee is fully extended) Tx:Tx:

IceIce NSAIDSNSAIDS Physical TherapyPhysical Therapy Grade III sprains may require surgical repairGrade III sprains may require surgical repair

Lateral Collateral Ligament Lateral Collateral Ligament (LCL) Sprain(LCL) Sprain

Caused by varus force to knee Caused by varus force to knee UncommonUncommon Dx:Dx:

+ tenderness along LCL (Grade I-III)+ tenderness along LCL (Grade I-III) + opening of lateral joint line with varus + opening of lateral joint line with varus

stress when knee is @ 30 degrees of stress when knee is @ 30 degrees of flexionflexion

Tx:Tx: Non-operative:Non-operative:

IceIce NSAIDSNSAIDS Physical therapyPhysical therapy

Anterior Cruciate Ligament Anterior Cruciate Ligament (ACL) Sprains(ACL) Sprains

Caused by twisting of knee Caused by twisting of knee while foot is firmly planted on while foot is firmly planted on groundground

Hx:Hx: Patient hears a “pop” feels a tear Patient hears a “pop” feels a tear

and acute pain in kneeand acute pain in knee Knee may feel unstable with Knee may feel unstable with

weight bearingweight bearing Acute swelling at time of injuryAcute swelling at time of injury

Anterior Cruciate Ligament Anterior Cruciate Ligament (ACL) Sprains(ACL) Sprains

Dx:Dx: + Lachman (20-30 degrees flexion, pull tibia + Lachman (20-30 degrees flexion, pull tibia

anteriorly)anteriorly) + anterior drawer (90 degrees)+ anterior drawer (90 degrees) + pivot shift with anterolateral instability+ pivot shift with anterolateral instability Arthrocentesis reveals hemarthrosisArthrocentesis reveals hemarthrosis MRI >90% accurateMRI >90% accurate

Tx:Tx: Physical therapy (pre/post op)Physical therapy (pre/post op) Open vs. Arthroscopic surgical reconstruction with Open vs. Arthroscopic surgical reconstruction with

patella tendon or hamstring tendon autograft; patella tendon or hamstring tendon autograft; allograft (cadaver); xenograft (another animal)allograft (cadaver); xenograft (another animal)

CPM (continuous passive motion machine) and CPM (continuous passive motion machine) and hinged knee brace post-ophinged knee brace post-op

If stable = no surgery nec. If stable = no surgery nec.

ACL tearACL tear

Posterior Cruciate Ligament Posterior Cruciate Ligament (PCL) Sprain(PCL) Sprain

Caused by hyperextension of knee or Caused by hyperextension of knee or direct blow to anterior aspect of direct blow to anterior aspect of flexed knee (Dashboard)flexed knee (Dashboard)

Dx:Dx: + posterior drawer+ posterior drawer + posterior sag sign+ posterior sag sign MRI >90% accurateMRI >90% accurate

Tx:Tx: Physical therapyPhysical therapy Surgical reconstruction in patients who Surgical reconstruction in patients who

have high demand knees (athletes) and have high demand knees (athletes) and severe instabilitysevere instability

Unhappy TriadUnhappy Triad This is the term given to an injury where This is the term given to an injury where

the ACL, MCL and Medial Meniscus are the ACL, MCL and Medial Meniscus are all three torn.  all three torn. 

The mechanism for this injury is usually The mechanism for this injury is usually a lateral blow to the knee with the foot a lateral blow to the knee with the foot fixed.  fixed. 

1. ACL tear1. ACL tear 2. MCL tear2. MCL tear 3. Medial meniscus tear3. Medial meniscus tear

History & significanceHistory & significance Pain after sitting/stair climbing= Pain after sitting/stair climbing=

patellofemoral etiologypatellofemoral etiology

Dashboard injury= PCL tear/ dislocationDashboard injury= PCL tear/ dislocation

Locking/ pain after squatting= Meniscal tearLocking/ pain after squatting= Meniscal tear

Non-contact injury with “pop”= ACL tearNon-contact injury with “pop”= ACL tear

Contact injury with “pop”= Collateral ligament, Contact injury with “pop”= Collateral ligament, meniscus, patellar dislocationmeniscus, patellar dislocation

History & significanceHistory & significance Acute swelling= ACL, peripheral meniscus Acute swelling= ACL, peripheral meniscus

tear, osteochondral fx, +/- capsule teartear, osteochondral fx, +/- capsule tear

Knee “gives way”= Ligamentous laxity, Knee “gives way”= Ligamentous laxity, patella subluxation or dislocation, meniscal patella subluxation or dislocation, meniscal tear, chondromalacia patellatear, chondromalacia patella

Anterior force- dorsiflexed foot= patella Anterior force- dorsiflexed foot= patella injuryinjury

Anterior force- plantarflexed foot= PCL Anterior force- plantarflexed foot= PCL injuryinjury

Examination & Examination & SignificanceSignificance

+ Effusion= Ligamentous/ meniscus injury (acute) + Effusion= Ligamentous/ meniscus injury (acute) or Arthritis (chronic)or Arthritis (chronic)

ROM= Block-meniscus tear loose body, ACL tear ROM= Block-meniscus tear loose body, ACL tear impingingimpinging

+ patella crepitus with PROM= patellofemoral + patella crepitus with PROM= patellofemoral pathologypathology

+ patella grind= patellofemoral pathology+ patella grind= patellofemoral pathology

+ McMurray= meniscal pathology or + McMurray= meniscal pathology or chondromalacia of articular surfacechondromalacia of articular surface

Examination & Examination & SignificanceSignificance

Varus/valgus @ 30 degrees= LCL/MCL laxityVarus/valgus @ 30 degrees= LCL/MCL laxity

Varus/ valgus @ 0 degrees= LCL/MCL & Varus/ valgus @ 0 degrees= LCL/MCL & PCL/posterior capsulePCL/posterior capsule

+ Lachman= ACL tear+ Lachman= ACL tear

+ Anterior drawer= ACL tear+ Anterior drawer= ACL tear

+ Pivot shift= Anterolateral rotational instability+ Pivot shift= Anterolateral rotational instability

+ Tibia sag= PCL tear+ Tibia sag= PCL tear

Patella TendinitisPatella Tendinitis ““Jumper’s Knee”Jumper’s Knee” Seen mostly in basketball & volleyball playersSeen mostly in basketball & volleyball players + tenderness along patella tendon+ tenderness along patella tendon Tx:Tx:

Ice Ice NSAIDSNSAIDS Refrain from jumping activities Refrain from jumping activities Physical therapyPhysical therapy Rarely surgeryRarely surgery

Patellar TendinitisPatellar Tendinitis Overuse during sports can injure the Overuse during sports can injure the

tendon attachment on the tendon attachment on the tibial tibial tuberositytuberosity. . In adolescents this produces In adolescents this produces Osgood-Osgood-

Schlatters Disease.Schlatters Disease. Central core degeneration may occur in Central core degeneration may occur in

the patellar tendon in middle age as it the patellar tendon in middle age as it does in the achilles tendon. does in the achilles tendon.

This may leave it vulnerable to complete This may leave it vulnerable to complete rupture. rupture.

Patella Tendon RupturePatella Tendon Rupture Most frequently in patient <40 y/oMost frequently in patient <40 y/o Exam:Exam:

Patient cannot actively extend kneePatient cannot actively extend knee Palpable defect inferior to patellaPalpable defect inferior to patella

Xray:Xray: + patella alta+ patella alta

Tx:Tx: Surgical repairSurgical repair Weight bear as tolerated (wbat) with knee in Weight bear as tolerated (wbat) with knee in

extensionextension

Patella tendon Patella tendon rupturerupture Notice superior Notice superior

appearing patellaappearing patella

Normal Knee

Patella Femoral Syndrome/Patella Femoral Syndrome/Chondromalacia PatellaChondromalacia Patella

““Runner’s Knee”Runner’s Knee” Degeneration of cartilage under the surface Degeneration of cartilage under the surface

of the patellaof the patella Hx:Hx:

Pain with ascending or descending stairs, Pain with ascending or descending stairs, running downhill, or sitting knees bent for running downhill, or sitting knees bent for prolonged periodsprolonged periods

Xray:Xray: Lateral tilt of patella on sunrise/ skyline/ Lateral tilt of patella on sunrise/ skyline/

merchant’s viewmerchant’s view Tx:Tx:

Physical therapy focusing on quadriceps (vastus Physical therapy focusing on quadriceps (vastus medialis) strengtheningmedialis) strengthening

NSAIDSNSAIDS IceIce Knee sleeve may be helpfulKnee sleeve may be helpful

Prepatellar Bursitis Prepatellar Bursitis ""Housemaid's Knee“Housemaid's Knee“ Brought on by unaccustomed Brought on by unaccustomed

kneeling on hard surfaces. kneeling on hard surfaces. The bursa lies between the front of The bursa lies between the front of

the patella and the overlying skin the patella and the overlying skin Examination reveals a tender Examination reveals a tender

inflamed lump. inflamed lump. Tx:Tx:

Local anestheticsLocal anesthetics Steroid injectionSteroid injection avoiding kneeling. avoiding kneeling.

Needs to be differentiated from Needs to be differentiated from infection and Gout. infection and Gout.

HaemarthrosisHaemarthrosis Trauma to the knee may cause internal bleeding into Trauma to the knee may cause internal bleeding into

the joint (haemarthrosis), with rapid onset swelling, the joint (haemarthrosis), with rapid onset swelling, and an extremely painful, warm and tender joint. and an extremely painful, warm and tender joint.

The joint is usually held in a degree of flexion (partially The joint is usually held in a degree of flexion (partially bent). bent).

Bleeding can occur after an injury to the joint capsule, Bleeding can occur after an injury to the joint capsule, ligament sprains, and meniscal tears. ligament sprains, and meniscal tears.

Non-traumatic bleeding into the joint can occur with Non-traumatic bleeding into the joint can occur with haemophilia and other blood disorders, haemophilia and other blood disorders, anticoagulant treatment with warfarin and heparin, anticoagulant treatment with warfarin and heparin, and secondary cancer spread. and secondary cancer spread.

Other conditions which can cause sudden swelling Other conditions which can cause sudden swelling (effusion) of the joint without a haemarthrosis include (effusion) of the joint without a haemarthrosis include crystal deposition disease (gout), crystal deposition disease (gout), inflammatory arthritis (rheumatoid arthritis), inflammatory arthritis (rheumatoid arthritis), and septic arthritis (infected joint)and septic arthritis (infected joint)

Patella Dislocation/ Patella Dislocation/ SubluxationSubluxation

Lateral displacement of patellaLateral displacement of patella Acute vs. recurrentAcute vs. recurrent Reduction occurs with knee in Reduction occurs with knee in

extensionextension + patella apprehension test+ patella apprehension test Tx:Tx:

Immediate mobilization and strengthening Immediate mobilization and strengthening exercises & patella sleeveexercises & patella sleeve

Vs. Vs. Immobilization in cylinder cast x 6 wks Immobilization in cylinder cast x 6 wks Vs.Vs. Surgical repairSurgical repair

Patellar fracturePatellar fracture

Condylar fracturesCondylar fractures

Popliteal MassPopliteal Mass Popliteal AbscessPopliteal Abscess TumorTumor Baker’s cystBaker’s cyst Popliteal aneurysmPopliteal aneurysm

Baker’s CystBaker’s Cyst Baker cyst, also termed popliteal cyst, is the most Baker cyst, also termed popliteal cyst, is the most

common mass in the popliteal fossa and results from common mass in the popliteal fossa and results from fluid distension of the gastrocnemio-semimembranosus fluid distension of the gastrocnemio-semimembranosus bursa. bursa.

Baker cysts are not uncommon and can be caused by Baker cysts are not uncommon and can be caused by virtually any cause of joint swelling (arthritis). The virtually any cause of joint swelling (arthritis). The most common form of arthritis associated with Baker most common form of arthritis associated with Baker cysts is osteoarthritis, also called degenerative cysts is osteoarthritis, also called degenerative arthritis. Baker cysts also can result from cartilage arthritis. Baker cysts also can result from cartilage tears (such as a torn meniscus), rheumatoid arthritis, tears (such as a torn meniscus), rheumatoid arthritis, and other knee problems. and other knee problems.

Popliteal Artery Popliteal Artery AneurysmAneurysm

Popliteal artery aneurysms Popliteal artery aneurysms are the most common are the most common peripheral artery peripheral artery aneurysms, comprising 70% aneurysms, comprising 70% to 85% of the total to 85% of the total aneurysms in the periphery aneurysms in the periphery

Shin splintsShin splints Shin splints is the general name given to pain at Shin splints is the general name given to pain at

the front of the lower leg. the front of the lower leg. Shin splints is not a diagnosis in itself but a Shin splints is not a diagnosis in itself but a

description of symptoms of which there could be a description of symptoms of which there could be a number of causes. number of causes.

The most common cause is inflammation of the The most common cause is inflammation of the periostium of the tibia (sheath surrounding the periostium of the tibia (sheath surrounding the bone). bone).

Traction forces occur from the muscles of the Traction forces occur from the muscles of the lower leg on the periostium.lower leg on the periostium.

Shin splints is an overuse injury and can be caused Shin splints is an overuse injury and can be caused by running on hard surfaces or running on tip toes. by running on hard surfaces or running on tip toes.

It is also common in sports where a lot of jumping It is also common in sports where a lot of jumping is involved. is involved.

If you over pronate then you are also more If you over pronate then you are also more susceptible to this injury. susceptible to this injury.

Compartment SyndromeCompartment Syndrome Increased intracompartmental pressures that compromise Increased intracompartmental pressures that compromise

the bloodflow to the compartment musculaturethe bloodflow to the compartment musculature Muscles will develop ischemic necrosis if not treated properlyMuscles will develop ischemic necrosis if not treated properly Dx:Dx:

Skin becomes erythematous, shiny, warm, TENSE, tender Skin becomes erythematous, shiny, warm, TENSE, tender to palpationto palpation

+ pain with passive plantar flexion of foot+ pain with passive plantar flexion of foot + paresthesias or foot drop+ paresthesias or foot drop Severe painSevere pain

Check compartment pressuresCheck compartment pressures MC affected is Anterior Tibial CompartmentMC affected is Anterior Tibial Compartment Tx:Tx:

Ice packs, elevationIce packs, elevation If no response: fasciotomy <12 hrs after onset of If no response: fasciotomy <12 hrs after onset of

symptomssymptoms

Compartment SyndromeCompartment Syndrome The muscles of the leg are wrapped with dense The muscles of the leg are wrapped with dense

leathery tissue called fascia that divides them into leathery tissue called fascia that divides them into groups called compartments. groups called compartments.

This dense, inelastic cover prevents muscles from This dense, inelastic cover prevents muscles from bulging during normal walking. bulging during normal walking.

Unfortunately, this fascial envelope is unable to Unfortunately, this fascial envelope is unable to stretch to accommodate swollen muscles. stretch to accommodate swollen muscles.

Severe fractures, trauma, vascular injuries and Severe fractures, trauma, vascular injuries and electrical injuries can all produce muscle damage. electrical injuries can all produce muscle damage.

As the injured muscle swells the pressure rises As the injured muscle swells the pressure rises within the constricting compartment. within the constricting compartment.

Eventually, the internal pressure rises so high that Eventually, the internal pressure rises so high that local circulation is cut off and the affected muscle local circulation is cut off and the affected muscle dies. dies.

The local increased pressure can also damage The local increased pressure can also damage associated nerves resulting in a loss of both power associated nerves resulting in a loss of both power and sensation.and sensation.

Vericose Veins (Tortuous)Vericose Veins (Tortuous) Usually, varicose veins and Usually, varicose veins and

telangiectasia (spider veins) are normal telangiectasia (spider veins) are normal veins that have dilated under the veins that have dilated under the influence of increased venous pressure. influence of increased venous pressure.

They are the visible surface They are the visible surface manifestation of an underlying syndrome manifestation of an underlying syndrome of venous insufficiency. of venous insufficiency.

Venous insufficiency syndromes allow Venous insufficiency syndromes allow venous blood to escape from its normal venous blood to escape from its normal flow path and flow in a retrograde flow path and flow in a retrograde direction down into an already congested direction down into an already congested leg. leg.

ThrombophlebitisThrombophlebitis Superficial vein thrombophlebitis may occur Superficial vein thrombophlebitis may occur

spontaneously or as a complication of medical or spontaneously or as a complication of medical or surgical interventions. surgical interventions.

Sterile thrombophlebitis limited to the superficial Sterile thrombophlebitis limited to the superficial veins rarely is life threatening, but a thorough veins rarely is life threatening, but a thorough diagnostic evaluation is mandatory because many diagnostic evaluation is mandatory because many patients with superficial phlebitis also have occult patients with superficial phlebitis also have occult deep vein thrombosis (DVT), which carries very high deep vein thrombosis (DVT), which carries very high rates of morbidity and mortality. rates of morbidity and mortality.

Phlebitis should be assumed to involve the deep Phlebitis should be assumed to involve the deep veins until proven otherwise, because superficial veins until proven otherwise, because superficial vein thrombophlebitis and deep vein vein thrombophlebitis and deep vein thrombophlebitis share the same pathophysiology, thrombophlebitis share the same pathophysiology, pathogenesis, and risk factors. pathogenesis, and risk factors.

Deep vein thrombosis Deep vein thrombosis (DVT)(DVT) Deep venous thrombosis (DVT) and its Deep venous thrombosis (DVT) and its

sequela, pulmonary embolism, are the sequela, pulmonary embolism, are the leading causes of preventable in-hospital leading causes of preventable in-hospital mortality in the United States mortality in the United States

The bedside diagnosis of venous thrombosis The bedside diagnosis of venous thrombosis is insensitive and inaccurate. is insensitive and inaccurate.

Many thrombi do not produce significant Many thrombi do not produce significant obstruction to venous flow; venous obstruction to venous flow; venous collaterals may develop rapidly, and venous collaterals may develop rapidly, and venous wall inflammation may be minimal. wall inflammation may be minimal.

Conversely, many nonthrombotic conditions Conversely, many nonthrombotic conditions produce signs and symptoms suggestive of produce signs and symptoms suggestive of DVT DVT

DVTDVT A clinical suspicion of DVT or PE often A clinical suspicion of DVT or PE often

stimulates efforts to identify known risk stimulates efforts to identify known risk factors for venous thrombosis. factors for venous thrombosis.

All recognized risk factors for DVT (and All recognized risk factors for DVT (and thus for PE) arise from the 3 underlying thus for PE) arise from the 3 underlying components of the components of the

Virchow triad:Virchow triad: venous stasis, venous stasis, hypercoagulability, and hypercoagulability, and vessel intimal injury vessel intimal injury

Deep Venous Thrombosis Deep Venous Thrombosis (DVT)(DVT) Edema, principally unilateralEdema, principally unilateral, is the most specific symptom. , is the most specific symptom.

Massive edema with cyanosis and ischemia (phlegmasia Massive edema with cyanosis and ischemia (phlegmasia cerulea dolens) is rare.cerulea dolens) is rare.

Leg painLeg pain occurs in 50%, but this is entirely nonspecific. Pain occurs in 50%, but this is entirely nonspecific. Pain can occur on dorsiflexion of the foot (Homans sign).can occur on dorsiflexion of the foot (Homans sign).

Tenderness occurs in 75% of patients but is also found in Tenderness occurs in 75% of patients but is also found in 50% of patients without objectively confirmed DVT50% of patients without objectively confirmed DVT

Homan’s signHoman’s sign: Discomfort in the calf muscles on forced : Discomfort in the calf muscles on forced dorsiflexion of the foot with the knee straight has been a dorsiflexion of the foot with the knee straight has been a time-honored sign of DVT. However, this sign is present in time-honored sign of DVT. However, this sign is present in less than one third of patients with confirmed DVT less than one third of patients with confirmed DVT

Clinical signs and symptoms of pulmonary embolism as the Clinical signs and symptoms of pulmonary embolism as the primary manifestation occur in 10% of patients with primary manifestation occur in 10% of patients with confirmed DVT.confirmed DVT.

The pain and tenderness associated with DVT does not The pain and tenderness associated with DVT does not usually correlate with the size, location, or extent of the usually correlate with the size, location, or extent of the thrombus.thrombus.

Warmth or erythemaWarmth or erythema of skin can be present over the area of of skin can be present over the area of thrombosisthrombosis

Well’s CriteriaWell’s CriteriaClinical Parameter Score ScoreActive cancer (treatment ongoing, or within 6 months or palliative) +1

Paralysis or recent plaster immobilization of the lower extremities +1

Recently bedridden for >3 d or major surgery <4 wk +1

Localized tenderness along the distribution of the deep venous system +1

Entire leg swelling +1

Calf swelling >3 cm compared to the asymptomatic leg +1

Pitting edema (greater in the symptomatic leg) +1

Previous DVT documented +1

Collateral superficial veins (nonvaricose) +1

Alternative diagnosis (as likely or > that of DVT) -2

Total of Above Score High probability >3

Moderate probability 1 or 2

Low probability <0

DVTDVT The The D-dimer assaysD-dimer assays have low specificity have low specificity

for DVT; therefore, they should only be for DVT; therefore, they should only be used to rule out DVT in low probability used to rule out DVT in low probability cases, not to confirm the diagnosis of cases, not to confirm the diagnosis of DVTDVT

Sensitivity of Sensitivity of duplex ultrasonographyduplex ultrasonography for proximal vein DVT is 97%, but only for proximal vein DVT is 97%, but only 73% for calf vein DVT. 73% for calf vein DVT.

Fibula Shaft FracturesFibula Shaft Fractures Treated symptomatically & usually Treated symptomatically & usually

heal without complicationheal without complication

Tibial Shaft FracturesTibial Shaft Fractures Mechanisms of injuryMechanisms of injury

1. direct trauma: MVA, skiing, (boot top)1. direct trauma: MVA, skiing, (boot top) 2. indirect trauma: assoc with rotary & compressive 2. indirect trauma: assoc with rotary & compressive

forces as from skiing or a fallforces as from skiing or a fall Type IType I

Slightly displaced 0-50% & non-comminuted, 90% Slightly displaced 0-50% & non-comminuted, 90% chance of unionchance of union

Type IIType II >50% displacement, but continued bony contact, >50% displacement, but continued bony contact,

may be slightly comminuted, may be open or closedmay be slightly comminuted, may be open or closed Type IIIType III

Complete displacement with comminution, may be Complete displacement with comminution, may be open or closed, 70% chance of unionopen or closed, 70% chance of union

Tibial Shaft FracturesTibial Shaft Fractures Exam:Exam:

Pain, swelling, deformityPain, swelling, deformity XR:XR:

AP/lateral tibia fibulaAP/lateral tibia fibula Tx:Tx:

closed fx: closed fx: initial- splint, ice, elevation, monitor for compartment initial- splint, ice, elevation, monitor for compartment

syndromesyndrome Definitive- LLC vs intramedullary (IM) nailingDefinitive- LLC vs intramedullary (IM) nailing

Open fx:Open fx: Irrigation, IV antibiotics, open vs closed reduction, external Irrigation, IV antibiotics, open vs closed reduction, external

fixation, monitor for compartment syndromefixation, monitor for compartment syndrome

Tibial shaft Fracture Tibial shaft Fracture typestypes

Tibial Plateau FracturesTibial Plateau Fractures Involve proximal articular surface of tibiaInvolve proximal articular surface of tibia Exam:Exam:

Pain localized to proximal tibia, +/- swellingPain localized to proximal tibia, +/- swelling Imaging:Imaging:

AP, lateral kneeAP, lateral knee CT scanCT scan

Initial Tx:Initial Tx: Ice, SplintingIce, Splinting Non-displaced fractures are treated with LLCNon-displaced fractures are treated with LLC Surgical Tx Surgical Tx

ORIF, External fixation, or combination of bothORIF, External fixation, or combination of both

Tibial Plateau Fracture Tibial Plateau Fracture ClassificationClassification

The AnkleThe Ankle

BonesBones TibiaTibia FibulaFibula TalusTalus

Obtain Obtain AP/lat/obliq to AP/lat/obliq to r/o fracturer/o fracture

Ottowa Ankle Ottowa Ankle rulesrules

AnkleAnkle

Ankle SprainsAnkle Sprains MCC ankle injury is sprain

Grade IGrade I Mild sprain, mild pain, little swelling, and joint Mild sprain, mild pain, little swelling, and joint

stiffness may be apparent stiffness may be apparent Stretch and/or minor tear of the ligament Stretch and/or minor tear of the ligament

without laxity (loosening) without laxity (loosening) Usually affects the Usually affects the anterior talofibular ligamentanterior talofibular ligament Minimum or no loss of function Minimum or no loss of function Can return to activity within a few days of the Can return to activity within a few days of the

injury (with a brace or taping) injury (with a brace or taping)

Ankle SprainsAnkle Sprains Grade IIGrade II Moderate to severe pain, swelling, Moderate to severe pain, swelling,

and joint stiffness are present and joint stiffness are present Partial tear of the lateral ligament(s) Partial tear of the lateral ligament(s) Moderate loss of function with Moderate loss of function with

difficulty on toe raises and walking difficulty on toe raises and walking Takes up to 2-3 months before Takes up to 2-3 months before

regaining close to full strength and regaining close to full strength and stability in the joint stability in the joint

Ankle SprainsAnkle Sprains Grade IIIGrade III Severe pain may be present initially, followed by Severe pain may be present initially, followed by

little or no pain due to total disruption of the nerve little or no pain due to total disruption of the nerve fibers fibers

Swelling may be profuse and joint becomes stiff Swelling may be profuse and joint becomes stiff some hours after the injury some hours after the injury

Complete rupture of the ligaments of the lateral Complete rupture of the ligaments of the lateral complex (severe laxity) complex (severe laxity)

Usually requires some form of immobilization lasting Usually requires some form of immobilization lasting several weeks several weeks

Complete loss of function (functional disability) and Complete loss of function (functional disability) and necessity for crutches necessity for crutches

Usually managed conservatively with rehabilitation Usually managed conservatively with rehabilitation exercises, but a small percentage may require exercises, but a small percentage may require surgery surgery

Recovery can be as long as 4 monthsRecovery can be as long as 4 months

Ankle SprainsAnkle Sprains Inversion injury= injures lateral structures of Inversion injury= injures lateral structures of

ankleankle MC mechanism of injuryMC mechanism of injury MC ligament sprained= MC ligament sprained=

1. Anterior talofibular ligament (front) - tears first1. Anterior talofibular ligament (front) - tears first 2. Posterior talofibular ligament (back) - tears second 2. Posterior talofibular ligament (back) - tears second 3. Calcaneofibular ligament (middle) - tears last 3. Calcaneofibular ligament (middle) - tears last

Tx:Tx: Ice x 20min several x/dayIce x 20min several x/day ElevationElevation NSAIDSNSAIDS WBAT c crutches prnWBAT c crutches prn Early ROMEarly ROM strengtheningstrengthening

Ankle SprainsAnkle Sprains Eversion injury: sequence of Eversion injury: sequence of

structures rupturedstructures ruptured 1. avulsion of medial malleolus or deltoid 1. avulsion of medial malleolus or deltoid

ligament ruptureligament rupture 2. anterior inferior tibiofibular ligament2. anterior inferior tibiofibular ligament 3. Interosseous membrane3. Interosseous membrane

Tx: Depending on extent of injuryTx: Depending on extent of injury May be tx’d conservatively as c inversionMay be tx’d conservatively as c inversion May require internal fixationMay require internal fixation

Medial Malleolar Medial Malleolar fracturefracture

Medial Malleolar inversion fracture:Medial Malleolar inversion fracture: Must be accompanied by a lateral Must be accompanied by a lateral

fracture or ligamentous rupturefracture or ligamentous rupture Medial Malleolar eversion fracture:Medial Malleolar eversion fracture:

Usually accompanied by a lateral Usually accompanied by a lateral malleolar fracture or tibiofibular malleolar fracture or tibiofibular ligament ruptureligament rupture

Tx:Tx: Depends on extent of injuryDepends on extent of injury

Lateral Malleolar Lateral Malleolar FractureFracture

Most common of the ankle fracturesMost common of the ankle fractures Weber A:Weber A:

Fracture distal to the joint lineFracture distal to the joint line Tx: SLWC vs aircast vs running sneakersTx: SLWC vs aircast vs running sneakers

Weber B:Weber B: Fracture @ joint lineFracture @ joint line Tx: SLC vs LLC vs internal fixationTx: SLC vs LLC vs internal fixation

Weber C:Weber C: Fracture above the joint lineFracture above the joint line Tx: internal fixation, SLC NWB x 6wksTx: internal fixation, SLC NWB x 6wks

Bimalleolar FractureBimalleolar Fracture Both medial and lateral disruptionBoth medial and lateral disruption Unstable fractureUnstable fracture Generally requires surgical intervention Generally requires surgical intervention

to restore normal joint kinematicsto restore normal joint kinematics When deltoid ligament is ruptured in the When deltoid ligament is ruptured in the

setting of a lateral malleolar fracture, the setting of a lateral malleolar fracture, the ankle is exposed to the mechanical ankle is exposed to the mechanical equivalent of a bimalleolar ankle fracture equivalent of a bimalleolar ankle fracture & should be operated on& should be operated on

Bimalleolar fractureBimalleolar fracture

Trimalleolar FractureTrimalleolar Fracture Occurs when posterior injury to Occurs when posterior injury to

ankle includes avulsion of the tibial ankle includes avulsion of the tibial insertion of the posterior tibiofibular insertion of the posterior tibiofibular ligamentligament

Tx:Tx: Usually surgical interventionUsually surgical intervention

Trimalleolar fxTrimalleolar fx

Maisonneuve FractureMaisonneuve Fracture Fracture of the Fracture of the proximal fibulaproximal fibula with with

syndesmosis rupturesyndesmosis rupture and associated and associated medial medial malleolus fracturemalleolus fracture or deltoid ligament rupture or deltoid ligament rupture

For all medial malleolar fx’s do additional xrays For all medial malleolar fx’s do additional xrays of knee to check for proximal fibular fxof knee to check for proximal fibular fx

Exam:Exam: + tenderness medial ankle, proximal fibula, & + tenderness medial ankle, proximal fibula, &

interosseous membraneinterosseous membrane Xray:Xray:

AP/lat/obliq ankleAP/lat/obliq ankle AP/lat tibia fibulaAP/lat tibia fibula

Tx:Tx: Syndesmotic screw fixationSyndesmotic screw fixation

Maisonneuve FractureMaisonneuve Fracture

Tibial Pilon FractureTibial Pilon Fracture Mechanism of injury:Mechanism of injury:

Produced primarily by rotational forceProduced primarily by rotational force ““explosion fracture” produced by axial loadingexplosion fracture” produced by axial loading

Type I: Type I: intraarticular through the tibial plafond without intraarticular through the tibial plafond without

significant displacement of articular surfacesignificant displacement of articular surface Type II: Type II:

incongruity of articular surface without a great deal incongruity of articular surface without a great deal of comminutionof comminution

Type III: Type III: demonstrates incongruity as well as displacement of demonstrates incongruity as well as displacement of

multiple small fracture fragments involving the multiple small fracture fragments involving the metaphysis of the distal tibiametaphysis of the distal tibia

Tibial Pilon FracturesTibial Pilon Fractures XR: XR:

AP/lat/obliq distal tibia (ankle)AP/lat/obliq distal tibia (ankle) Accurate classification requires CT scanAccurate classification requires CT scan Complications range as high as 54% in Complications range as high as 54% in

some seriessome series Most complications, such as infections & Most complications, such as infections &

wound breakdown, relate to soft tissueswound breakdown, relate to soft tissues Tx:Tx:

ORIFORIF External fixation or a combination of bothExternal fixation or a combination of both

Achilles TendinitisAchilles Tendinitis Pain at achilles tendon, increased by running Pain at achilles tendon, increased by running

decreased by restdecreased by rest Pain is often worse following activity, rather Pain is often worse following activity, rather

than duringthan during Often palpable thickening over tendon or Often palpable thickening over tendon or

peritendinous tissuesperitendinous tissues Tx:Tx:

1. decrease running activities, small heel lift, 1. decrease running activities, small heel lift, NSAIDS, ice after activity, achilles tendon stretchingNSAIDS, ice after activity, achilles tendon stretching

2. SLWC x 10 days, then repeat above tx2. SLWC x 10 days, then repeat above tx 3. occasionally surgical debridement or achilles 3. occasionally surgical debridement or achilles

tendon lengtheningtendon lengthening

Achilles Tendon RuptureAchilles Tendon Rupture Occurs most commonly at narrowest Occurs most commonly at narrowest

portion of tendon approx. 2 inches portion of tendon approx. 2 inches superior to point of attachment to superior to point of attachment to calcaneuscalcaneus

Mechanisms of injury:Mechanisms of injury: 1. extra stretch applied to taut tendon1. extra stretch applied to taut tendon 2. forceful dorsiflexion with ankle in 2. forceful dorsiflexion with ankle in

relaxed staterelaxed state 3. direct trauma to taut tendon3. direct trauma to taut tendon

Achilles Tendon RuptureAchilles Tendon Rupture C/O acute pain in lower calf & difficulty C/O acute pain in lower calf & difficulty

ambulatingambulating +/- palpable defect or mass in post. calf +/- palpable defect or mass in post. calf + Thompson test+ Thompson test

squeeze calf, foot should plantarflex, if no squeeze calf, foot should plantarflex, if no plantarflexion then achilles tendon is outplantarflexion then achilles tendon is out

Tx:Tx: 1. surgical repair1. surgical repair 2. equinus walking boot x 8 wks followed by 2. equinus walking boot x 8 wks followed by

2.5 cm heel for another 4 weeks2.5 cm heel for another 4 weeks

FootFoot Bones of the foot:Bones of the foot: 7 tarsals7 tarsals

TalusTalus CalcaneusCalcaneus NavicularNavicular Medial CuneiformMedial Cuneiform Intermediate CuneiformIntermediate Cuneiform Lateral CuneiformLateral Cuneiform CuboidCuboid

5 metatarsals5 metatarsals ““rays of the foot”rays of the foot”

14 phalanges14 phalanges

Plantar FasciitisPlantar Fasciitis Plantar fasciitis is the #1 most common Plantar fasciitis is the #1 most common

foot problem. foot problem. It is caused by activity, overuse and aging. It is caused by activity, overuse and aging. Plantar fasciitis is an inflammation due to Plantar fasciitis is an inflammation due to

repeated overstretching of the plantar repeated overstretching of the plantar fascia ligament (fat pad of the foot), fascia ligament (fat pad of the foot), usually at the point where the fascia is usually at the point where the fascia is attached to the calcaneus. attached to the calcaneus.

Pain is most severe in the morning and Pain is most severe in the morning and stepping down onto foot, decreases as day stepping down onto foot, decreases as day goes ongoes on

Plantar FasciitisPlantar Fasciitis Contributing factors are: Contributing factors are:

flat (pronated feet) flat (pronated feet) high arches (supinated feet) high arches (supinated feet) increasing age increasing age sudden weight increase sudden weight increase sudden increase in activity level sudden increase in activity level running in sand running in sand hereditary factors hereditary factors

Xray: May reveal bony spur at same siteXray: May reveal bony spur at same site Tx:Tx:

Achilles stretchingAchilles stretching Ice massageIce massage Rest from activitiesRest from activities NSAIDSNSAIDS Shock absorbing heel cupsShock absorbing heel cups Ankle orthosis (AFO) for recalcitrant casesAnkle orthosis (AFO) for recalcitrant cases Avoid cortisone injectionsAvoid cortisone injections

Hammer Toe DeformityHammer Toe Deformity Plantar flexion deformity of the PIP joint Plantar flexion deformity of the PIP joint

which is either flexible or rigidwhich is either flexible or rigid The deformity is usually accompanied by a The deformity is usually accompanied by a

flexion deformity of the DIP joint, but an flexion deformity of the DIP joint, but an extension deformity is occasionally observedextension deformity is occasionally observed

Tx:Tx: Shoewear with wide toe box, toe trainersShoewear with wide toe box, toe trainers

Surgery:Surgery: A. flexor tendon transfer from plantar aspect of A. flexor tendon transfer from plantar aspect of

toe to extensor hoodtoe to extensor hood B. resection of head of proximal phalanx, K-wire B. resection of head of proximal phalanx, K-wire

fixationfixation

Hallux ValgusHallux Valgus Most common deformity of the footMost common deformity of the foot Results in excessive valgus angulation of the Results in excessive valgus angulation of the

big toe big toe Splaying of the forefoot with varus angulation Splaying of the forefoot with varus angulation

of the first metatarsal predisposes of the first metatarsal predisposes The anatomical deformity consists of: The anatomical deformity consists of:

Increased forefoot width Increased forefoot width Lateral deviation of the hallux Lateral deviation of the hallux Prominence of the first metatarsal headProminence of the first metatarsal head

Clinical featuresClinical features More common in women More common in women Often bilateral Often bilateral

Symptoms result from Symptoms result from A bursa over metatarsal head = A bursa over metatarsal head = bunion bunion Osteoarthritis of the first MTPJOsteoarthritis of the first MTPJ

Hallux ValgusHallux Valgus Xray:Xray:

Bilateral weight bearing AP/ lateral/ oblique Bilateral weight bearing AP/ lateral/ oblique footfoot

Initial Tx:Initial Tx: Shoewear education/ modification (sneakers)Shoewear education/ modification (sneakers)

Surgical Tx:Surgical Tx: Distal metatarsal osteotomy +/- internal Distal metatarsal osteotomy +/- internal

fixation for mild deformityfixation for mild deformity 11stst tarsal metatarsal arthodesis (fusion) for tarsal metatarsal arthodesis (fusion) for

hypermobile 1hypermobile 1stst ray ray

Lisfranc InjuryLisfranc Injury There is no ligament b/t the base of the 1There is no ligament b/t the base of the 1stst & &

22ndnd metatarsal. metatarsal. The 2The 2ndnd metatarsal is attached obliquely to the metatarsal is attached obliquely to the

medial cuneiform by an interosseous ligament medial cuneiform by an interosseous ligament termed Lisfranc’s ligament termed Lisfranc’s ligament

Exam:Exam: + tenderness at lisfranc joint + tenderness at lisfranc joint + swelling dorsally+ swelling dorsally

Xray:Xray: AP/ lateral/ oblique foot (weight bearing when AP/ lateral/ oblique foot (weight bearing when

possible): possible): May reveal widening at jointMay reveal widening at joint

Tx:Tx: Reduced & treated with screw fixationReduced & treated with screw fixation NWB x 6-8 wksNWB x 6-8 wks

Dorsal dislocation of the proximal base of the second metatarsal (Dorsal dislocation of the proximal base of the second metatarsal (small small arrowarrow) when the foot is placed in extreme plantar flexion with an axial ) when the foot is placed in extreme plantar flexion with an axial load (load (large arrowlarge arrow). This dislocation occurs because the base of the ). This dislocation occurs because the base of the second metatarsal extends beyond the horizontal axis. second metatarsal extends beyond the horizontal axis.

LisfrancLisfranc

Jones FractureJones Fracture Transverse fracture of the 5Transverse fracture of the 5thth metatarsal at metatarsal at

the junction of the proximal metaphysis & the junction of the proximal metaphysis & diaphysisdiaphysis

PE:PE: + tenderness lateral aspect of foot+ tenderness lateral aspect of foot + swelling + swelling +/- ecchymosis+/- ecchymosis

Xray:Xray: AP/ lat/ obliqAP/ lat/ obliq

Tx:Tx: Short leg cast (SLC) Short leg cast (SLC) Non-wt bearing (NWB) x 6wksNon-wt bearing (NWB) x 6wks

Frequently fail to heal when treated non-operatively, Frequently fail to heal when treated non-operatively, especially in smokersespecially in smokers

Surg:Surg: ORIFORIF

Jones fxJones fx

Avulsion Fracture of the Avulsion Fracture of the base of the 5base of the 5thth Metatarsal Metatarsal

Pseudo-Jones fx/ dancer fx/ tennis fxPseudo-Jones fx/ dancer fx/ tennis fx Occurs when the insertion of the peroneus brevis Occurs when the insertion of the peroneus brevis

is avulsed during forced inversion of the forefootis avulsed during forced inversion of the forefoot Exam:Exam:

+ tenderness+ tenderness + swelling at base of 5+ swelling at base of 5thth metatarsal metatarsal +/- ecchymosis+/- ecchymosis

Xray:Xray: AP/lat/obliqAP/lat/obliq

Tx:Tx: Short leg walking cast (SLWC) x 6 wksShort leg walking cast (SLWC) x 6 wks

Pseudo-Jones FracturePseudo-Jones FractureDancer FractureDancer FractureTennis FractureTennis Fracture

Avulsion FractureAvulsion Fracture

Pseudo-Jones FracturePseudo-Jones Fracture

Comminuted Fracture of Comminuted Fracture of proximal and/ or distal proximal and/ or distal

phalanx of great toephalanx of great toe Xray:Xray:

AP/lat/obliqAP/lat/obliq Tx:Tx:

SplintSplint Hard sole shoeHard sole shoe IceIce

Fractures of phalanges of Fractures of phalanges of lesser toeslesser toes

Xray:Xray: AP/lat/obliqAP/lat/obliq

Tx:Tx: Buddy tapeBuddy tape Ice Ice NSAIDSNSAIDS

March FractureMarch Fracture Stress fracture usually of the middle of the Stress fracture usually of the middle of the

shaft of the 3shaft of the 3rdrd metatarsal (or 4 metatarsal (or 4thth)) History of having gone on long walk/march History of having gone on long walk/march

with no clear h/o traumawith no clear h/o trauma Also seen in females with eating/exercising Also seen in females with eating/exercising

disordersdisorders Exam:Exam:

+ tenderness midshaft of the involved metatarsal+ tenderness midshaft of the involved metatarsal Pain with increased flexion or extension of toesPain with increased flexion or extension of toes Pain subsides with restPain subsides with rest

March FractureMarch Fracture Initial Xray:Initial Xray:

AP/lat/obliq weight bearing foot will be AP/lat/obliq weight bearing foot will be negativenegative

Follow up Xray:Follow up Xray: In 2 wks will show callus formationIn 2 wks will show callus formation

Tx:Tx: Symptomatically with crutches or if Symptomatically with crutches or if

patient’s occupation requires prolonged patient’s occupation requires prolonged standing or ambulationstanding or ambulation

SLWC x 3-4 wksSLWC x 3-4 wks

Stress Stress fxfx

Metatarsal FractureMetatarsal Fracture Class A:Class A:

Neck Fractures---Neck Fractures---

Class B:Class B: Shaft fractures---------------------Shaft fractures---------------------

Class C:Class C: Proximal 5Proximal 5thth metatarsal fracture (Jones) metatarsal fracture (Jones)

Calcaneus FracturesCalcaneus Fractures May be intraarticular or extraarticularMay be intraarticular or extraarticular h/o fall or twisting injury & pain localized to h/o fall or twisting injury & pain localized to

hindfoothindfoot Xray:Xray:

AP/lat/obliq/ axial heel/ Broden’s view (lateral xray AP/lat/obliq/ axial heel/ Broden’s view (lateral xray with foot passively dorsiflexed/ supinated & internally with foot passively dorsiflexed/ supinated & internally rotated)rotated)

Also should have CT scan of heel to see extent of injury Also should have CT scan of heel to see extent of injury Include L/S spine due to associated injuriesInclude L/S spine due to associated injuries

Initial management:Initial management: SplintSplint IceIce ElevationElevation

Calcaneus FractureCalcaneus Fracture Tx:Tx:

Non-displaced intraarticular fx= NWB 4-6 wksNon-displaced intraarticular fx= NWB 4-6 wks Displaced intraarticular fx= ORIF, NWB x 6-8 wks, Displaced intraarticular fx= ORIF, NWB x 6-8 wks,

early motionearly motion Minimally displaced tuberosity fracture= NWB 3-6 Minimally displaced tuberosity fracture= NWB 3-6

wkswks Displaced tuberosity fx= internal fixation, NWB 4-Displaced tuberosity fx= internal fixation, NWB 4-

6wks6wks Sustentaculum tali= SLWC x 4-6 wksSustentaculum tali= SLWC x 4-6 wks Non-displaced anterior process fx= SLWC x 4-6 Non-displaced anterior process fx= SLWC x 4-6

wkswks Displaced anterior process fx = ORIFDisplaced anterior process fx = ORIF

ClubfootClubfoot High arched foot that may have a High arched foot that may have a

crease across the sole of the foot. crease across the sole of the foot. The heel inversion (varus) c internal The heel inversion (varus) c internal

rotation rotation Forefoot inverted and adducted Forefoot inverted and adducted

(soles face each other)(soles face each other) Plantar flexion c inabiliity to Plantar flexion c inabiliity to

dorsiflexdorsiflex Leg internal rotationLeg internal rotation

Angular limb deformitiesAngular limb deformities Bowlegs (Genu Varum) and Knock Bowlegs (Genu Varum) and Knock

knees (Genu Valgum)knees (Genu Valgum) are a common are a common cause of orthopedic consultation. cause of orthopedic consultation.

For most children, these conditions For most children, these conditions represent the spectrum of normal represent the spectrum of normal development.development.

Pathologic cases of bowlegs and knock Pathologic cases of bowlegs and knock knees are uncommon (Rickets).knees are uncommon (Rickets).

Flat feet (pes planus)Flat feet (pes planus) another common skeletal variation. another common skeletal variation.

The most common type is the hyper-mobile or The most common type is the hyper-mobile or flexible flat foot.flexible flat foot. The longitudinal arch of the foot is absent or The longitudinal arch of the foot is absent or

flat in stance, but reconstitutes when the foot flat in stance, but reconstitutes when the foot is non-weight bearing.is non-weight bearing.

Most flat feet are asymptomatic. Most flat feet are asymptomatic. A flat foot associated with a tight heel cord A flat foot associated with a tight heel cord

may be caused by muscular dystrophy or may be caused by muscular dystrophy or cerebral palsy.cerebral palsy.

LimpLimp Common etiologies across the age Common etiologies across the age

spectrum are spectrum are Limb length inequalitiesLimb length inequalities Infections: septic arthritis, osteomyelitis.Infections: septic arthritis, osteomyelitis. Non-infectious causes: transient Non-infectious causes: transient

synovitis,JRA, trauma, child abuse, DDH, synovitis,JRA, trauma, child abuse, DDH, LCPD, SCFE.LCPD, SCFE.

Neoplasia: leukemia, primary bone Neoplasia: leukemia, primary bone tumor, metastatic disease. tumor, metastatic disease.

'Excellence is an art won by training and habituation. We do not act 'Excellence is an art won by training and habituation. We do not act rightly becauserightly because

we have virtue or excellence, but rather we have those because we we have virtue or excellence, but rather we have those because we have acted rightly. have acted rightly.

We are what we repeatedly do. Excellence, then, is not an act but a We are what we repeatedly do. Excellence, then, is not an act but a habit.'habit.'

AristotelesAristotelesA journey of a thousand miles begins with a single step. Lao Tsu

“I find that the harder I work, the more luck I seem to have”.  Thomas

Jefferson

Self conquest is the greatest of victories.Self conquest is the greatest of victories. PlatoPlato

““Imagination is everything. It is the preview Imagination is everything. It is the preview of life’s coming attractions.”of life’s coming attractions.”

Albert EinsteinAlbert Einstein

Nothing great was ever achieved without enthusiasm.

Ralph Waldo Emerson

““If a man empties his purse into his If a man empties his purse into his head, no man can take it away from head, no man can take it away from him. An investment in knowledge him. An investment in knowledge always pays the best interest” always pays the best interest” Benjamin Benjamin FranklinFranklin

““I will persist until I succeed”.I will persist until I succeed”. Og Mandino Og Mandino

"Whatever your mind can conceive "Whatever your mind can conceive and believe it can achieve." and believe it can achieve."

Napoleon HillNapoleon Hill

GOOD LUCK IN THE GOOD LUCK IN THE EXAMEN !!!EXAMEN !!!

ENJOY YOUR VACATION TIME ENJOY YOUR VACATION TIME WISELY WISELY AND AND SAFETLYSAFETLY

Ciao, ci Ciao, ci vediamo!!!vediamo!!!