Overuse during sports can injure the tendon attachment on the tibial tuberosity .
In adolescents this produces Osgood-Schlatters Disease.
Central core degeneration may occur in the patellar tendon in middle age as it does in the achilles tendon.
This may leave it vulnerable to complete rupture.
Patella Tendon Rupture
Most frequently in patient <40 y/o
Patient cannot actively extend knee
Palpable defect inferior to patella
+ patella alta
Weight bear as tolerated (wbat) with knee in extension
Patella tendon rupture
Notice superior appearing patella
Patella Femoral Syndrome/ Chondromalacia Patella
“ Runner’s Knee”
Degeneration of cartilage under the surface of the patella
Pain with ascending or descending stairs, running downhill, or sitting knees bent for prolonged periods
Lateral tilt of patella on sunrise/ skyline/ merchant’s view
Physical therapy focusing on quadriceps (vastus medialis) strengthening
Knee sleeve may be helpful
" Housemaid's Knee“
Brought on by unaccustomed kneeling on hard surfaces.
The bursa lies between the front of the patella and the overlying skin
Examination reveals a tender inflamed lump.
Needs to be differentiated from infection and Gout.
Trauma to the knee may cause internal bleeding into the joint (haemarthrosis), with rapid onset swelling, and an extremely painful, warm and tender joint.
The joint is usually held in a degree of flexion (partially bent).
Bleeding can occur after an injury to the joint capsule, ligament sprains , and meniscal tears .
Non-traumatic bleeding into the joint can occur with
haemophilia and other blood disorders,
anticoagulant treatment with warfarin and heparin,
and secondary cancer spread.
Other conditions which can cause sudden swelling (effusion) of the joint without a haemarthrosis include
crystal deposition disease (gout),
inflammatory arthritis (rheumatoid arthritis),
and septic arthritis (infected joint)
Patella Dislocation/ Subluxation
Lateral displacement of patella
Acute vs. recurrent
Reduction occurs with knee in extension
+ patella apprehension test
Immediate mobilization and strengthening exercises & patella sleeve
Immobilization in cylinder cast x 6 wks
Baker cyst, also termed popliteal cyst, is the most common mass in the popliteal fossa and results from fluid distension of the gastrocnemio-semimembranosus bursa.
Baker cysts are not uncommon and can be caused by virtually any cause of joint swelling ( arthritis ). The most common form of arthritis associated with Baker cysts is osteoarthritis , also called degenerative arthritis . Baker cysts also can result from cartilage tears (such as a torn meniscus ), rheumatoid arthritis , and other knee problems.
Popliteal Artery Aneurysm
Popliteal artery aneurysms are the most common peripheral artery aneurysms, comprising 70% to 85% of the total aneurysms in the periphery
Shin splints is the general name given to pain at the front of the lower leg.
Shin splints is not a diagnosis in itself but a description of symptoms of which there could be a number of causes.
The most common cause is inflammation of the periostium of the tibia (sheath surrounding the bone).
Traction forces occur from the muscles of the lower leg on the periostium.
Shin splints is an overuse injury and can be caused by running on hard surfaces or running on tip toes.
It is also common in sports where a lot of jumping is involved.
If you over pronate then you are also more susceptible to this injury.
Increased intracompartmental pressures that compromise the bloodflow to the compartment musculature
Muscles will develop ischemic necrosis if not treated properly
Skin becomes erythematous, shiny, warm, TENSE, tender to palpation
+ pain with passive plantar flexion of foot
+ paresthesias or foot drop
Check compartment pressures
MC affected is Anterior Tibial Compartment
Ice packs, elevation
If no response: fasciotomy <12 hrs after onset of symptoms
The muscles of the leg are wrapped with dense leathery tissue called fascia that divides them into groups called compartments.
This dense, inelastic cover prevents muscles from bulging during normal walking.
Unfortunately, this fascial envelope is unable to stretch to accommodate swollen muscles.
Severe fractures, trauma, vascular injuries and electrical injuries can all produce muscle damage.
As the injured muscle swells the pressure rises within the constricting compartment.
Eventually, the internal pressure rises so high that local circulation is cut off and the affected muscle dies.
The local increased pressure can also damage associated nerves resulting in a loss of both power and sensation.
Vericose Veins (Tortuous)
Usually, varicose veins and telangiectasia (spider veins) are normal veins that have dilated under the influence of increased venous pressure.
They are the visible surface manifestation of an underlying syndrome of venous insufficiency.
Venous insufficiency syndromes allow venous blood to escape from its normal flow path and flow in a retrograde direction down into an already congested leg.
Superficial vein thrombophlebitis may occur spontaneously or as a complication of medical or surgical interventions.
Sterile thrombophlebitis limited to the superficial veins rarely is life threatening, but a thorough diagnostic evaluation is mandatory because many patients with superficial phlebitis also have occult deep vein thrombosis (DVT), which carries very high rates of morbidity and mortality.
Phlebitis should be assumed to involve the deep veins until proven otherwise, because superficial vein thrombophlebitis and deep vein thrombophlebitis share the same pathophysiology, pathogenesis, and risk factors.
Deep vein thrombosis (DVT)
Deep venous thrombosis (DVT) and its sequela, pulmonary embolism, are the leading causes of preventable in-hospital mortality in the United States
The bedside diagnosis of venous thrombosis is insensitive and inaccurate.
Many thrombi do not produce significant obstruction to venous flow; venous collaterals may develop rapidly, and venous wall inflammation may be minimal.
Conversely, many nonthrombotic conditions produce signs and symptoms suggestive of DVT
A clinical suspicion of DVT or PE often stimulates efforts to identify known risk factors for venous thrombosis.
All recognized risk factors for DVT (and thus for PE) arise from the 3 underlying components of the
vessel intimal injury
Deep Venous Thrombosis (DVT)
Edema, principally unilateral , is the most specific symptom. Massive edema with cyanosis and ischemia (phlegmasia cerulea dolens) is rare.
Leg pain occurs in 50%, but this is entirely nonspecific. Pain can occur on dorsiflexion of the foot (Homans sign).
Tenderness occurs in 75% of patients but is also found in 50% of patients without objectively confirmed DVT
Homan’s sign : Discomfort in the calf muscles on forced dorsiflexion of the foot with the knee straight has been a time-honored sign of DVT. However, this sign is present in less than one third of patients with confirmed DVT
Clinical signs and symptoms of pulmonary embolism as the primary manifestation occur in 10% of patients with confirmed DVT.
The pain and tenderness associated with DVT does not usually correlate with the size, location, or extent of the thrombus.
Warmth or erythema of skin can be present over the area of thrombosis
Wells Clinical Score for DVT* Clinical Parameter Score Score Active 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
The D-dimer assays have low specificity for DVT; therefore, they should only be used to rule out DVT in low probability cases, not to confirm the diagnosis of DVT
Sensitivity of duplex ultrasonography for proximal vein DVT is 97%, but only 73% for calf vein DVT.
Fibula Shaft Fractures
Treated symptomatically & usually heal without complication
Tibial Shaft Fractures
Mechanisms of injury
1. direct trauma: MVA, skiing, (boot top)
2. indirect trauma: assoc with rotary & compressive forces as from skiing or a fall
Slightly displaced 0-50% & non-comminuted, 90% chance of union
>50% displacement, but continued bony contact, may be slightly comminuted, may be open or closed
Complete displacement with comminution, may be open or closed, 70% chance of union
Tibial Shaft Fractures
Pain, swelling, deformity
AP/lateral tibia fibula
initial- splint, ice, elevation, monitor for compartment syndrome
Definitive- LLC vs intramedullary (IM) nailing
Irrigation, IV antibiotics, open vs closed reduction, external fixation, monitor for compartment syndrome
Tibial shaft Fracture types
Tibial Plateau Fractures
Involve proximal articular surface of tibia
Pain localized to proximal tibia, +/- swelling
AP, lateral knee
Non-displaced fractures are treated with LLC
ORIF, External fixation, or combination of both
Tibial Plateau Fracture Classification
Obtain AP/lat/obliq to r/o fracture
Ottowa Ankle rules
MCC ankle injury is sprain
Mild sprain, mild pain, little swelling, and joint stiffness may be apparent
Stretch and/or minor tear of the ligament without laxity (loosening)
Usually affects the anterior talofibular ligament
Minimum or no loss of function
Can return to activity within a few days of the injury (with a brace or taping)
Moderate to severe pain, swelling, and joint stiffness are present
Partial tear of the lateral ligament(s)
Moderate loss of function with difficulty on toe raises and walking
Takes up to 2-3 months before regaining close to full strength and stability in the joint
Severe pain may be present initially, followed by little or no pain due to total disruption of the nerve fibers
Swelling may be profuse and joint becomes stiff some hours after the injury
Complete rupture of the ligaments of the lateral complex (severe laxity)
Usually requires some form of immobilization lasting several weeks
Complete loss of function (functional disability) and necessity for crutches
Usually managed conservatively with rehabilitation exercises, but a small percentage may require surgery
Recovery can be as long as 4 months
Inversion injury= injures lateral structures of ankle
MC mechanism of injury
MC ligament sprained=
1. Anterior talofibular ligament (front) - tears first
2. Posterior talofibular ligament (back) - tears second
3. Calcaneofibular ligament (middle) - tears last
Ice x 20min several x/day
WBAT c crutches prn
Eversion injury: sequence of structures ruptured
1. avulsion of medial malleolus or deltoid ligament rupture
2. anterior inferior tibiofibular ligament
3. Interosseous membrane
Tx: Depending on extent of injury
May be tx’d conservatively as c inversion
May require internal fixation
Medial Malleolar fracture
Medial Malleolar inversion fracture:
Must be accompanied by a lateral fracture or ligamentous rupture
Medial Malleolar eversion fracture:
Usually accompanied by a lateral malleolar fracture or tibiofibular ligament rupture
Depends on extent of injury
Lateral Malleolar Fracture
Most common of the ankle fractures
Fracture distal to the joint line
Tx: SLWC vs aircast vs running sneakers
Fracture @ joint line
Tx: SLC vs LLC vs internal fixation
Fracture above the joint line
Tx: internal fixation, SLC NWB x 6wks
Both medial and lateral disruption
Generally requires surgical intervention to restore normal joint kinematics
When deltoid ligament is ruptured in the setting of a lateral malleolar fracture, the ankle is exposed to the mechanical equivalent of a bimalleolar ankle fracture & should be operated on
Occurs when posterior injury to ankle includes avulsion of the tibial insertion of the posterior tibiofibular ligament
Usually surgical intervention
Fracture of the proximal fibula with syndesmosis rupture and associated medial malleolus fracture or deltoid ligament rupture
For all medial malleolar fx’s do additional xrays of knee to check for proximal fibular fx
Distal metatarsal osteotomy +/- internal fixation for mild deformity
1 st tarsal metatarsal arthodesis (fusion) for hypermobile 1 st ray
There is no ligament b/t the base of the 1 st & 2 nd metatarsal.
The 2 nd metatarsal is attached obliquely to the medial cuneiform by an interosseous ligament termed Lisfranc’s ligament
+ tenderness at lisfranc joint
+ swelling dorsally
AP/ lateral/ oblique foot (weight bearing when possible):
May reveal widening at joint
Reduced & treated with screw fixation
NWB x 6-8 wks
Dorsal dislocation of the proximal base of the second metatarsal ( small arrow ) when the foot is placed in extreme plantar flexion with an axial load ( large arrow ). This dislocation occurs because the base of the second metatarsal extends beyond the horizontal axis.
Transverse fracture of the 5 th metatarsal at the junction of the proximal metaphysis & diaphysis
+ tenderness lateral aspect of foot
AP/ lat/ obliq
Short leg cast (SLC)
Non-wt bearing (NWB) x 6wks
Frequently fail to heal when treated non-operatively, especially in smokers
Avulsion Fracture of the base of the 5 th Metatarsal
Pseudo-Jones fx/ dancer fx/ tennis fx
Occurs when the insertion of the peroneus brevis is avulsed during forced inversion of the forefoot
Neoplasia: leukemia, primary bone tumor, metastatic disease.
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