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
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