Orthopedics: Lower Extremity

With damage to the hip what nerve and artery are we concerned about?

Medial circumflex femoral artery

Sciatic nerve

• Most commonly strained quadriceps muscle

• MOI: Kicking, esp. if foot hits an object mid-kick

• Symptoms: Acute anterior thigh pain, worsened with hip flexion/knee extension

Rectus Femoris Strain (Hip Flexor Strain)

Treatment:

• Strain: RICE, rehab

• Proximal rupture: consider surgery

Symptoms: Groin pain, ↓ ROM (especially with flexion + internal rotation)

Femoral head = NOT round

Femoroacetabular Impingement (FAI)

• Type:

  • CAM: Femoral head aspherical

Symptoms: Groin pain, ↓ ROM (especially with flexion + internal rotation)

Acetabular abnormality

Femoroacetabular Impingement (FAI)

• Type:

  • Pincer: Acetabular over-coverage

What is a MIXED Femoroacetabular Impingement (FAI)?

We see CAM (femoral head abnormality) and Pincer (acetabular abnormality)

• Direct blow to iliac crest or greater trochanter (contact sports)

• Symptoms: Bruising, tenderness

Hip Pointer (Iliac Crest Contusion)

Treatment: RICE, NSAIDs → early ROM & resistance exercises

Posterior (most common):

• Dashboard injury, hip flexed → posterior force

• Position: Shortened, flexed, internally rotated, adducted hip

Posterior Hip Dislocation

Management:

• Early reduction <6 hrs

• Closed reduction (pop back into place) or open reduction (surgery)

Anterior:

• Less common

• Position: Externally rotated, abducted, flexed hip

Anterior Hip Dislocation

Management:

• Early reduction <6 hrs

• Closed reduction (pop back into place) or open reduction (surgery)

What three major complications can arise from hip dislocations (posterior/anterior)?

• Posterior Complications: Sciatic nerve injury, AVN (medial circumflex artery), chondrolysis

• Anterior Complications: Femoral artery/nerve injury, AVN

How do you treat a femur fracture?

Intramedullary nail

• MOI:

  • Direct blow (fall, dashboard)

  • Indirect (eccentric quad contraction)

• Symptoms:

  • Inability to extend knee

  • Hemarthrosis, swelling

• Complication:

  • popliteal artery rupture

Patella Fracture

Treatment:

• Immobilization (extension cast/brace) if nondisplaced

• Patellectomy if severe

• Lateral = most common

• Causes: Shallow trochlea, ligamentous laxity, MPFL rupture

• Symptoms: Knee buckling, + patellar apprehension

Patellar Instability/Dislocation

• Treatment:

  • Reduction + conservative care (PT, NSAIDs)

  • MPFL repair/reconstruction if recurrent

Valgus force (blow to lateral knee), often with medial meniscus tear

Symptoms: Medial knee pain, instability, swelling

Tests:

• ↑ laxity with valgus stress

MCL Injury (Medial Collateral Ligament)

Treatment: Brace, surgery if complete tear

• Varus force (blow to medial knee), less common in isolation

• Symptoms: lateral knee pain, swelling, instability

• Tests:

  • ↑ laxity with varus stress

LCL Injury (Lateral Collateral Ligament)

Treatment: Brace, surgery if complete tear

• Traumatic (younger athletes) vs. Degenerative (elderly)

• Medial > lateral, except acute ACL → lateral

• Symptoms: Locking, popping, joint line tenderness

• Tests: +McMurray, +Apley

• Zones:

  • Red zone (outer third): vascular, heals well

  • White zone (inner): avascular, poor healing

Meniscal Tear

• Treatment:

  • Young: Repair or meniscectomy

  • Older: RICE, PT

Which meniscal tear is more common? (Medial vs lateral)

Medial meniscus more common UNLESS

ACL tear then lateral is more expected

• MOI: Non-contact pivot or hyperextension and severe force directed anteriorly with the knee “semi-flexed”

• Risk: Women more likely (↑ Q-angle)

• Symptoms: “Pop,” swelling, instability

• Tests: +Lachman (best), +Anterior drawer

ACL Tear (Anterior Cruciate Ligament)

Treatment:

• Low demand: PT

• High demand: Surgical reconstruction

What is O'Donoghue’s Triad (“Terrible Triad”)?

• ACL + MCL + medial meniscus

• Valgus force mechanism

  Note: WE NOW KNOW that the Lateral meniscus is often torn in acute ACL injury

• MOI: Dashboard injury (tibia pushed posteriorly)

• Symptoms: Instability, difficulty walking

• Test: +Posterior drawer

PCL Tear (Posterior Cruciate Ligament)

• Treatment: Conservative unless other ligaments injured

• Cause: repetitive trauma/pressure to knee; “Housemaids knee”

• Symptoms: pain with AROM, swelling anterior to patella, warmth

Prepatellar Bursitis (most common)

• Etiology: obesity and overuse in athletes

• Symptoms: sharp non-radiating pain on medial tibia just below knee

• Muscles affected: Semitendinosus, Gracilis, Sartorius

Anserine Bursitis

With Anserine Bursitis, what muscles are affected?

Sartorius, Gracilis, Semitendinosus (SGT.)

• MOI: Popliteal swelling from synovial fluid buildup

• Can mimic DVT if ruptured

• Generally asymptomatic but may cause posterior knee pain

Baker’s Cyst or Popliteal Cyst

What compartment is most commonly affected in Compartment Syndrome?

Anterior compartment (lower leg)

• Cause: Fracture, crush injury, reperfusion injury

• Anterior = most common

• 6 Ps: Pain out of proportion, paresthesia, pallor, pulselessness, paralysis, poikilothermia

• Dx: >30 mmHg compartment pressure

Acute Compartment Syndrome

• Treatment:

  • Emergency fasciotomy

What compartment?

Numbness: first web space (of toe)

Action causing pain: plantar flexion

Anterior compartment

What compartment?

Numbness: dorsum of foot

Action causing pain: inversion and dorsiflexion (of foot)

Lateral compartment

What compartment?

Numbness: lateral foot

Action causing pain: dorsiflexion

Superficial Posterior compartment

What compartment?

Numbness: plantar aspect of foot

Action causing pain: dorsiflexion

Deep Posterior compartment

• Causes: exercise with repetitive motions

• Symptoms: achy, crampy, squeezing pain or pressure, reproduceable by the patient

• Cessation of exercise usually decreases pain

Chronic (Exertional) Compartment Syndrome

• Risk factors: Virchow’s triad (stasis of blood flow, hypercoagulability, endothelial damage)

• Symptoms:

  • Unilateral swelling, pain, warmth

  • +Homan’s sign (pain on dorsiflexion)

• Dx: Duplex ultrasound, D-dimer

DVT / VTE (Deep Vein Thrombosis/ Venous Thromboembolism)

How do you treat DVT / VTE?

Anticoagulation with unfractionated heparin (warfarin) or LMWH

• Most common ankle sprain

• Ligaments: ATFL (most common)

• MOI: Foot rolls inward

• Symptoms: Lateral ankle pain, swelling, bruising

• Tests: + Anterior drawer test

• XRAY depending on “Ottawa” ankle rules

Low Ankle Sprain – Inversion

• Treatment: RICE, brace, PT; surgery rarely needed

• Ligament: Deltoid ligament (medial side)

• Less common, more severe

• MOI: Foot rolls outward

• Symptoms: Medial ankle pain/swelling; possible fibula or syndesmosis injury

• XRAY depending on “Ottawa” ankle rules

Low Ankle Sprain – Eversion

• Treatment

  • RICE, brace, longer rehab; consider imaging for fracture

• Injury to syndesmosis (AITFL) —> Anterior Inferior Tibiofibular Ligament

• MOI: External rotation + dorsiflexion

• Test: Squeeze test, external rotation test

High Ankle Sprain

• Treatment:

  • Longer rest, possible surgery

• Zone: ~6 cm above calcaneal insertion (hypovascular zone)

• MOI: Push-off during running/lateral movement

• Symptoms: Sudden “pop,” feels like “getting kicked in back of ankle,” inability to plantarflex

• Test: +Thompson test

Achilles Tendon Rupture

• Treatment:

  • Non-surgical: Plantarflexion cast

  • Surgical: Tendon repair

Get a ________ xray if:

• Pain in the malleolar zone AND:

  • Bone tenderness at the posterior edge or tip of the lateral malleolus (distal 6 cm), OR

  • Bone tenderness at the posterior edge or tip of the medial malleolus, OR

  • Inability to bear weight both immediately after injury and in the ER (4 steps)

Get an ankle x-ray

Get a _______X-ray if:

• Pain in the midfoot zone AND:

  • Bone tenderness at the base of the 5th metatarsal, OR

  • Bone tenderness at the navicular bone, OR

  • Inability to bear weight both immediately after injury and in the ER (4 steps)

Get a foot x-ray

What is the Ottawa rules mnemonic?

Mnemonic:

“In Ottawa, we drink Fine MALBEC”

• FI – Fifth Metatarsal

• N – Navicular

• MAL – Medial Malleolus

• L – Lateral Malleolus

• BE – Bear weight (4 steps)

• C – Clinical Judgment

• MOI: Sudden stretch at musculotendinous junction (sprinting)

• Severe: Complete avulsion from ischium

• Symptoms: Posterior thigh pain ± sciatic nerve symptoms (numbness/tingling from hematoma)

Proximal Hamstring Injury

Treatment:

• Strain: RICE

• Avulsion:

  • >3 cm retraction → early surgery

  • <3 cm → try non-operative