CMS II Ortho: E2

What Special Test:

Assesses for TFL or ITB tightness, Position the pt in sidelying position on the unaffected side with hip and knee flexed. On the affected side flex the knee to 90° and Abduct and Hyperextend the ipsilateral hip while stabilizing the hip. Allow the leg to be lowered. Inability to keep leg lowered= tight TFL or ITB.

Ober Test

What Special Test:

Assesses for a torn Achilles’ Tendon. With the pt in prone position, squeeze the calf mms and observe for plantar flexion. Test is (+) if the ankle does not plantar flex.

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Thompsons Test

What Special Test:

Assesses for a deep vein thrombosis. Squeeze the calf or dorsiflex and squeeze the calf and observe the patient’s face for signs of pain. (+) = possible DVT

Homan's Test

Elevation of intracompartmental pressure to a degree that compromises blood flow to involved muscles and nerves

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Compartment syndrome

Compartment syndrome most commonly occurs after a _____ fracture

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Tibia

What is the most common involved compartment in compartment syndrome?

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Anterior compartment

Pressures > _____ mmHg in 1/4 compartments is dangerous

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40 mmHg

6Ps of Compartment Syndrome

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- Pain

- Paresthesia

- Pallor

- Paralysis

- Pulselessness

- Poikilothermia

Where does the paresthesia radiate to with anterior/lateral compartment syndrome?

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Dorsal aspect of foot

Where does the paresthesia radiate to with posterior compartment syndrome?

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Plantar aspect of foot

True or False: Compartment syndrome can be due to prolonged running/walking and symptoms resolve after 30 minutes of stopped activity

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True (exertional compartment syndrome)

What do you use to test for compartment syndrome?

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Indwelling catheter or needle with a pressure monitor

Clinically significant pressure in compartment syndrome

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> 30 mmHg

Dangerous pressure in compartment syndrome

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> 40 mmHg

Tx for acute compartment syndrome

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Fasciotomy

Is chronic/exertional compartment syndrome an emergency?

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No

Is acute compartment syndrome an emergency?

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Yes

38 y/o pt presents with diffuse swelling and tenderness of the left calf. On PE, they have left lower leg ecchymosis and difficulty with dorsiflexion and plantar flexion of the left calf. What is the most likely dx?

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Gastrocnemius tear

Gradual onset of pain in the anteromedial aspect of the distal 1/3 of leg

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Shin splints

Pt presents with pain on the anteromedial aspect of their leg after increasing their running activity. States that they have been running on hard, uneven surfaces. Most likely dx?

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Shin splints

Shin splints AKA ______

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Medial tibia stress syndrome (MTSS)

Tx for shin splints

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Rest, ice, NSAIDs, PT

28 year old athlete presents with pain in the anteromedial distal 1/3 of their right leg. On PE, there is pain to palpation on the posterior tibialis. What imaging should you order? What do you expect it to show?

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Shin splints (medial tibial stress syndrome) → MRI shows associated stress fractures

plain films would be normal

What testing is done to confirm the diagnosis of a stress fracture?

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MRI

Hairline/microscopic break in bone caused by microtraumatic, cumulative overload on bone such as overtraining, incorrect biomechanics, fatigue, poor nutrition and osteoporosis

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Stress fracture

Which stress fracture has the worst prognosis and may need surgery?

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Anterior tibial

_____ AKA below knee amputation

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Transtibial amputation

70% of amputations are due to ____

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DM, Infections, PVD

20% of amputations are due to _____

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Trauma

Amputation at the transmetatarsal or tarsometatarsal level

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Midfoot amputation

What amputation:

Poor funx and difficult prosthetic management. The retained talus and calcaneus frequently are pulled into equinus and WB place excessive pressure on the amputation site.

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Hindfoot amputation

What leg amputation is the better one to have due to increased knee function?

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Below Knee Amputations

Which amputation has the greatest patient outcome?

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Below the knee (BKA) with prosthetic

What are common causes of amputations?

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- diabetes

- severe infection

- PVD

- trauma

What test is good for diagnosing proximal DVT/clot formation?

Duplex US

What is the gold standard to confirm DVT?

Venography

+ Homan's sign = _____

DVT

Patient presents with unilateral left calf erythema and swelling. on PE, their left calf is significantly warmer than the right. Homan's sign is positive on the left. What is the gold standard study to confirm diagnosis?

DVT → venography

Which drug should be given as prophylaxis for DVT?

Enoxaparin (lovenox)

Know anatomy... fine I guess

What special test:

Assess for cartilage degeneration under the patella with the pt supine and knee extended.

Patellar Grind Test (Clarke Sign)

What special test:

Examiner applies force in the lateral direction to the ankle from the medial aspect and force in the medial direction of the knee from the lateral aspect. Positive test shows medial instability of the knee. MCL Injury

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Valgus stress test

What special test:

Examiner applies force in the medial direction to the ankle from the lateral aspect and force in the lateral direction of the knee from the medial aspect. Positive test shows lateral instability of the knee. LCL Injury

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Varus stress test

58-year-old male presents with complaints of swelling, pain, and locking of his left knee. He reports he was playing basketball and felt pain after pivoting his left leg quickly. What special test would help to confirm this dx?

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meniscal tear → McMurray or Apley's compression

MOI is pivoting/rotating

+ McMurray test = ____

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Meniscal tear

If the examiner internally rotates during the McMurray's test, what are they testing for?

Lateral meniscus

If the examiner externally rotates during the McMurray's test, what are they testing for?

Medial meniscus

+ Apprehensive test

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Patellar dislocation

What is the test:

Pt supine, legs flat on table, quadriceps relaxed

Try to dislocate the patella laterally Positive apprehensive test if pt becomes apprehensive about you testing the knee, asks you to stop or face grimaces

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Patellar Apprehension

What special test:

Patient supine, with knee flexed at 30 degrees. Femur stabilized with one hand and tibia is pulled anterior with the other hand. Tests for ACL tears/injuries.

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Lachman test

What special test:

Patient supine, hip flexed, knee flexed at 90 degrees. Patient foot stabilized by examiner sitting on foot. Examiner "pulls" tibia forward/anterior

Anterior drawer test

+ Posterior drawer test

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PCL injury

What special test:

Pt supine, hip flexed, knee flexed at 90 degrees. Patient's foot stabilized by examiner sitting on foot Examiner “pushes” tibia backward/posterior Positive = torn PCL

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Posterior drawer test

Hallmark symptom of patellar/quadriceps tendinitis

Anterior knee pain

What is the gold standard to confirm PE?

Pulmonary angiography

"Knocked knee"

Valgus

"Bowed leg"

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Varus

Valgus or Varus: pushing on knees laterally

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Valgus

Valgus or Varus: pushing on knees medially

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Varus

+ Valgus stress test = (MCL/LCL) injury

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MCL

+ Varus stress test = (MCL/LCL) injury

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LCL

+ Anterior drawer test = ______

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Torn ACL

What diagnostic study is used to diagnose meniscal injuries?

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MRI

+ McMurray and + Apley's Compression test

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Meniscal tear

Tx for meniscal tear

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Menisectomy/Arthroscopy

______ AKA "Jumper's knee"

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Patellar tendinitis

17 year old volleyball player presents with tenderness along the patellar tendon. What is the dx?

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patellar tendonitis -- key word volleyball bc its called "jumper's knee"

What is the most sensitive physical exam test for an ACL injury?

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Lachman test

What diagnostic study is used for ACL/PCL/MCL/LCL injuries?

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MRI

+ Lachman test and + Anterior drawer test

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ACL injury

The "Terrible"/"Unhappy" triad

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- ACL tear

- MCL tear

- Meniscal tear

What are the causes of Tibial Plateau fractures?

falls from heights, MVA accidents and

MVA/pedestrian accident

What diagnostic study would you order for a patellar fracture?

Plain film: AP, Lateral, & Sunrise view

What is the most common patellar dislocation?

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Lateral dislocation

Are patellar dislocations more common in females or males? Why?

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Females due to excessive Q angle

XR shows + patella alta (superior appearing) think _____

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Patella tendon rupture

On exam patient cannot actively extend their knee and there is a palpable defect inferior to the patella. Possible dx?

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Patella tendon rupture

What is a "true" knee dislocation?

Tibiofemoral dislocation

What should you check in a tibiofemoral dislocation?

Pulses for vascular compromise

Which is a medical emergency & requires STAT ortho consult and reduction: Patellar dislocation or Tibiofemoral dislocation

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Tibiofemoral dislocation

Pain and swelling in the anterior knee over the tibial tuberosity commonly seen in adolescent athletes. Possible dx?

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Osgood-Schlatter disease

Which population is Osgood-Schlatter disease MC in?

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adolescent male athletes

15 y/o male athlete presents with pain and swelling in his anterior left knee over the tibial tuberosity. how should you treat?

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Osgood Schlatter → RICE, NSAIDS, ortho consult

but r/o fx on plain film XR

If you see a prominent area over the tibial tubercle on XR from an adolescent pt complaining of pain, what dx should you suspect?

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Osgood Schlatter

What is the most common form of knee arthritis?

Osteoarthritis

Know this

75 y/o patient with a history of knee trauma 20 years ago presents with gradual onset of knee pain x months. Patient states that the pain wakes them up at night. Patient is obese. Most likely dx?

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Osteoarthritis

______ AKA Runner's knee

Patellofemoral syndrome

What is the most commonly injured ligament in an ankle sprain?

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Anterior talofibular ligament

What is a common cause of ankle sprain?

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inversion injury (90%)!

+ Thompson's test = _____

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Achille's tendon rupture

Absence of plantar flexion when calf is squeezed

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+ Thompson's test (Achille's tendon rupture)

The medial clear space of the ankle should not exceed _____ mm on XR

4 mm

90% of all ankle injuries are due to ______ injuries- sprains

Inversion

A trimalleolar ankle fracture involves the _____

Medial, lateral, and posterior malleolus

A bimalleolar ankle fracture involves the _____

Medial and lateral malleolus

Flat foot arch

Pes planus

Elevated longitudinal arch of foot

Pes cavus

Pain in the morning with 1st step, think ______

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Plantar fascitis

56 year old female presents with complaints of heel pain. she reports the pain is worse in the AM, especially with her first steps out of bed. On PE, she has tenderness to palpation. how should you treat?

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plantar fasciitis → NSAIDs, ice, stretching (PT), steroid injections