Knee
(Varus/Valgus) stress with a twisting motion on a planted foot is usually the largest factor in ACL injuries
Which ligaments are intra-articular and which are extra-articular?
MCL
PCL
LCL
ACL
Intra: ACL/PCL
Exra: LCL, MCL
what is the most commonly ruptured ligament in ankle injuries?
ATFL (anterior talofibular ligament)
you have a 9 year old boy in your clinic complaining of right heel pain. He denies any injury, and says this has been happening during the last few weeks, worse when he plays soccer. Physical exam is largely negative except for bony tenderness over the heel and pain with dorsiflexion. What would be your treatment?
Calcaneal apophysitis: heel bone grows faster than muscles and tendons, adding extra tension (risks include sudden growth, inflexibility, playing sports)
Tx: rest, ice, ibuprofen, heel inserts, should get better in about 3-6 months (when growth slows a bit)
Periosteal thickening/reaction.
What are 2 other structures that can often be associated with ACL tears? (unhappy triad)
MCL tear, medial meniscus tear
Which of these special tests would be positive in the case of an acute ACL tear?
Lachmann's test
Posterior drawer test
Anterior Drawer test
McMurray's test?
Anterior drawer, lachmann's
What tests can assess risk of potential ACL rupture?
a high ankle sprain is what??
injury/disruption of the distal tibiofibular syndesmosis.
Foot drop is secondary to injury to what? Fractures of what bone are commonly associated?
Secondary to common peroneal (fibular) nerve injury -->fibula fractures
Microtears/injury at the insertion site of either tibialis anterior (more common, pain at anterior shin) or tibialis posterior (medial lower leg)
tibial stress fracture. when the tibial muscles aren't able to stabilize and absorb shock from impacts to the tibia causing increased risk of stress fx.
When a patient reports catching/locking in the knee, what particular structure are you concerned about?
Meniscus.
What is an anatomical anomaly that makes one more predisposed to a meniscus tear?
Patients with tibial tubercle avulsion fractures often have a history of what? What action would be lost in this injury?
Osgood-Schlatter Disease.
Loss of knee extension
A 46-year-old male presents to the ER with a limp and pain in the back of his right lower leg. He recounts an unusual incident during his game earlier today. While attempting to make a rapid move to outpace an opponent, he experienced a sudden, sharp pain in the back of his right lower leg. He describes it as feeling as if he'd been kicked, but he is sure there were no players behind him at that moment. There is no significant swelling, but he complains of difficulty putting weight on the affected leg. What is the most likely diagnosis?
Achilles Tendon Rupture
What is common presentation of a lisfranc injury? diagnostic signs on XR?
presentation: pain swelling over midfoot, plantar mid foot bruising, pain/instability with rotation/movement of mid foot while holding calcaneus.
-XR (more sensitive with weight bearing if pt tolerates):
-Shift of at least 2mm of joint space between 1st/2nd metatarsal (sign that ligament is ruptured)
-Fracture/Avulsion fx of base of 2nd metatarsal is diagnostic for lisfranc injury.
What is the most common serious complication of a tibial shaft fracture?
DVT (10-25%)
Second is Compartment syndrome
What is the preferred way of reducing a patellar dislocation? How is this treated?
Don't pull/push on it, have patient extend knee and the quad tendon and try to pull it back in. Tx: knee immobilizer/locked in extension, NWB/Partial WB. PT, ortho consult
Which compartment of the knee is often the first affected by osteoarthritis?
Patellofemoral compartment
Medial Compartment
Lateral Compartment
Medial Compartment (most of weightbearing is through medial compartment)
Which ankle injury is most likely to cause long term disability and post-traumatic OA?
High ankle sprain
Lateral Malleolus Fracture
Medial Malleolus Fracture
Pilon Fracture
Pilon fractures are often involving fractures of distal tibia and fibula, and are usually highly displaced, intra-articular and comminuted.
What are some concerns surrounding treatment of jones' fractures? (fx of the base of the 5th metatarsal)
1) watershed blood supply - if fracture cuts off blood flow, there is a high risk of necrosis. = risk of nonunion
2) there are a lot of tendons that attach to the base of the 5th metatarsal (fibularis brevis, fibularis tertius (FYI) ) that can pull fracture out of position = risk of malunion
Explain the weber classification of ankle fractures.
Weber A: fibular fracture distal to syndesmosis - stable and syndesmosis is intact.
Weber B: fibular fracture at the level of the syndesmosis , syndesmosis can be intact or partially torn. Mortise joint is not widened, variable stability
Weber C: Fibular fracture proximal to the syndesmosis ,syndesmosis is ruptured, mortise joint widened. Needs surgery.
What is the theory behind why ACL repair using the BEAR technique may be better than the standard ACL reconstruction?
Theory is that the native ACL has proprioceptive fibers that activate quad/hamstrings to stabilize knee with certain movements. Graft's dont, therefore, risk of re-rupture is higher than a native knee.
A 75 year-old female presents with medial knee pain that worsens with stair climbing. Physical examination reveals swelling and point tenderness inferior and medial to the patella and tenderness overlying the medial tibial plateau. Which of the following is the most likely diagnosis?
Pes Anserine Bursitis
Patellofemoral Syndrome
Patellar Tendinitis
ACL tear
Pes Anserine Bursitis
-bony tenderness at distal 6cm of fibula or tibia, or either malleolus.
-unable to bear weight (or take 4 steps after injury and in ED)
-pain at lateral aspect of 5th metatarsal, or navicular bone.
A 42 year-old female experiences pain on the plantar surface of her left foot in the area of the third metatarsal head. The pain is associated with wearing tight shoes and is relieved by removing shoes. Examination reveals a palpable mass and reproduction of pain with deep palpation of the third intermetatarsal space. The patient has tried wearing wider shoes with metatarsal cushions and taking NSAIDS but her symptoms persist. What is the best therapeutic option at this point?
Corticosteroid injection into morton's neuroma is the next step when conservative measures fail.
a patient presents to you with a 1 month history of near constant radicular symptoms and hip/buttock pain. Physical exam reveals +SLR, and shooting pain down his leg with abduction/flexion and external rotation. He reports that a few months ago, he had a small fracture "somewhere in my hip" after playing tennis, but he didn't follow up with treatment. Upon getting xrays, there is ossification noted in his gluteal region. What was the likely original fracture and source of this ossification?
Heterotopic ossification s/p ischial tuberosity avulsion fracture, if large enough, can compress the sciatic nerve and cause radicular symptoms.