lower extremity orthopedic review wapa winter conference january 30, 2013 seattle, washington fred...
TRANSCRIPT
![Page 1: Lower Extremity Orthopedic Review WAPA Winter Conference January 30, 2013 Seattle, Washington Fred Huang, MD Valley Orthopedic Associates A Division of](https://reader036.vdocuments.net/reader036/viewer/2022070413/5697bfd31a28abf838cac240/html5/thumbnails/1.jpg)
Lower Extremity Lower Extremity Orthopedic ReviewOrthopedic Review
WAPA Winter Conference
January 30, 2013
Seattle, Washington
Fred Huang, MD
Valley Orthopedic Associates
A Division of Proliance Surgeons, Inc.
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What We Aren’t Covering
Lumbar spine and foot conditions Musculoskeletal infections & tumors Inflammatory arthritis (i.e. rheumatoid
arthritis)
Great reference: Miller’s Review of Orthopedics
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Ankle Sprains
Most often an inversion injury
Lateral ligaments most commonly injured: Anterior talo-fibular ligament Calcaneo-fibular ligament Posterior talo-fibular ligament
Grades 1, 2, and 3
Ottawa Rules for imaging
Source: www.intermountainhealthcare.org
Source: www.bodyflow.com.au
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Ankle Sprains
Grades 1 and 2 treated with RICE R = rest I = ice C = compression E = elevation
NSAID’s, taping/bracing, and PT
Grade 3 injuries sometimes immobilized for several weeks (walking boot vs. cast)
Some grade 3 injuries treated operatively
Source: www.bodyflow.com.au
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Achilles Tendon Ruptures
Usually occur in patients 35-50 years old “Somebody kicked me in the back of the leg” Tears are about 5 cm above the calcaneal attachment Diagnosed with a positive Thompson test
Squeezing the calf muscle produces no ankle plantar flexion
Cast treatment: reliable but slightly higher risk of subsequent re-rupture
Surgical treatment: reduces risk of re-rupture but introduces surgical risks
Non-operative with early motion/rehab best?
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Ankle Fractures
Lateral malleolus fracture
Bimalleolar fracture - unstable
Trimalleolar fracture - unstable
Syndesmosis injury i.e. disruption of ligaments that
stabilize the distal tibio-fibular joint
“High” ankle sprains
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Lateral Malleolus Fracture
If minimally displaced and no major ligament injury, cast treatment sufficient (stress view important)
If significantly displaced or unstable, treat with ORIF (open reduction and internal fixation)
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Maissoneuve Injury
Involves ligamentous injury at ankle with bony injury of proximal fibula
Ankle swelling medially (deltoid ligament injury) and in the distal leg (syndesmosis ligament injury)
Proximal fibula fracture not seen on ankle films – must order full length tibia/fibula films
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Maissoneuve Injury
Stress views helpful Surgical treatment always Syndesmosis stabilization
with 1 or 2 screws Screws will break or
loosen when full activities allowed due to motion at distal tibio-fibular joint
Screws often removed electively prior to resumption of full activities
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Other Ankle Conditions
Peroneal tendon tears – posterolateral pain/swelling Most often degenerative – longitudinal tears in the peroneus brevis Peroneal tendon subluxation – often associated w/ trauma (SURGERY)
Ankle arthritis Often post-traumatic. Can also be inflammatory or just primary DJD. Fusion (versus arthroplasty?)
Lateral process fractures of the talus Frequently occur in snowboarders Forceful ankle dorsiflexion with eversion and axial loading Treated with excision vs. ORIF (or cast if non-displaced)
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Common Knee InjuriesCommon Knee Injuries
Meniscal TearsACL TearsMulti-ligament InjuriesTibial Plateau Fractures
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Age Related Injury Patterns
Teenagers Ligament and meniscal tears Patellar dislocations Growth plate injuries
Adults Ligament and meniscal tears Some tibial plateau fractures
Elderly More tibial plateau fractures
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Patello-femoral Pain
Frequent cause for ANTERIOR knee pain Worsened by squatting, stair-climbing, and lunges Often associated with anterior knee crepitus
(chondromalacia patella) Usually no joint line tenderness & negative McMurray’s Effusions possible, but rare MRI’s often “normal” Treatment consists of activity modification, formal PT,
NSAID’s, weight loss, and occasional steroid injections Patellofemoral rehab should include hip strengthening
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Growth Plate Fractures
Growth plate injuries <15 for
females <18 for males
Not always readily apparent on initial x-rays
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Patellar Instability
Almost all patellar dislocations are lateral and in teenagers
Medial patellofemoral ligament fails
Surgical treatment for recurrent instability and/or loose bodies
Reduce by extending the knee +/- direct pressure at the lateral patella
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Meniscal Tears
Clinical Symptoms Swelling Catching +/- locking Difficulty with pivoting and squatting
Physical Exam Findings Effusion Joint line tenderness Positive McMurray’s maneuver
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Meniscal Tears
Arthroscopic surgery if mechanical symptoms present
Degenerative tears: associated with minimal or no trauma
Many degenerative tears associated with DJD & thus not operated on
Source: www.opsmart.com
Source: www.stoneclinic.com
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Types of Ligament Injuries
ACL very common
MCL most common with ski injuries Usually treated non-operatively with brace
Combination injuries (ACL w/ MCL most common, but any combo possible)
PCL involved frequently in multi-ligament injuries
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ACL Tears
Twisting on a planted foot
Unable to continue sporting activity
Effusion within 1-2 hours
Lachman testIncreased anterior tibial translation at 20 degrees of knee flexion
Source: Knee Ligament InjuriesThe Staywell Company, 2001
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ACL Tears - Treatment
Non-operative treatment (Brace?)
Surgical treatment Timing of surgery Graft options: autograft versus allograft Associated procedures: meniscal repair vs.
meniscectomy, cartilage procedures
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Multi-ligament Knee Injuries
Higher energy mechanism than ACL tears
Knee (tibio-femoral) dislocation?
Critical to assess neurovascular function: Motor/sensory function at the ankle/foot Palpable distal pulses? (Popliteal artery injury?) Consider further vascular testing (CT-angiogram
vs. arterial ultrasound or arteriogram)
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Multi-ligament Knee Injuries
More frequently treated operatively than isolated ligament injuries
Allograft tissue almost always used
Rehab more difficult, post-op stiffness common, and return to sports less likely
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Multi-ligament Knee Injuries
Don’t forget the “5th” knee ligament ACL, PCL, MCL, and LCL = “big 4” Postero-lateral corner PLC injuries PLC is a complex collection of soft tissue structures
between the lateral femur, proximal fibula, and proximal tibia
Most often injured in conjunction with the PCL and/or LCL (i.e. rarely an isolated injury)
PLC injuries result in rotational instability
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Tibial Plateau Fractures
Wide spectrum of injury patterns
Medial and/or lateral; tibial eminences (cruciate injury)
Split and/or depressed fragments
Increased cartilage injury means post-traumatic arthritis more likely
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Tibial Plateau Fractures
CT scans helpful in defining the fracture
Anticipate other injuries (meniscal tears, ligament tears, arterial or neurologic deficits)
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Tibial Shaft Fractures
If aligned well, often treated initially with a long leg cast
Open fracture, inability to maintain alignment, polytrauma, and patient preference are all reasons why operative treatment frequently utilized
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Tibial Shaft Fractures
Benefits of operative treatment: Shorter immobilization time No long leg cast = less atrophy &
stiffness Avoidance of multiple cast adjustments
and frequent X-rays
Surgical Treatment options: Medullary rodding Plating External fixation
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Tibial Rodding
Can be done in a “closed” fashion
Highly dependent on fluoroscopy
Potential for persistent anterior knee pain
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Diagnosis of Knee DJD
3 compartments of the knee: 1. Patello-femoral 2. Medial tibio-femoral 3. Lateral tibio-femoral
Physical Exam: Stiffness Deformity (varus = bow-legged,
valgus = knock-kneed) Effusions common
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Knee DJD – Radiographic Findings
Hallmarks of DJD 1. Loss of cartilage thickness 2. Bony sclerosis 3. Osteophytes (bone spurs) 4. Bone cysts 5. Joint subluxation
Weight-bearing radiographs a must 1. Compare with other side 2. Flexed view important
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Knee DJD – Treatment Options
Standard treatments: 1. NSAID’s and acetaminophen 2. Glucosamine/chondroitin 3. Activity modification & wt. loss 4. Intra-articular steroid injections 5. Visco-supplementation (Synvisc) 6. Unloader braces 7. Neoprene sleeves 8. Osteotomy surgery 9. Knee replacement –
unicompartmental versus total knee replacement
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Varus Knee DJD – Proximal Tibial Osteotomy
Intermediate solution that improves pain and function usually for < 10 years
Allows for continued impact activities
Associated with a longer recovery time (to allow for healing of osteotomy)
Does not “burn bridges”
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Knee DJD – Total Knee Replacement
Reliable solution that improves pain and function usually for >10 years
Does not allow for continued impact activities
Intensive therapy and exercises critical post-op to establish ROM
New interest in multi-modal pain management, smaller incisions, and accelerated rehab
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Total Knee Replacement Risks
DVT/PE Infection Post-operative stiffness Early component
loosening or failure
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Hip Fractures
Common in the elderly Low energy trauma Osteoporosis
Higher energy injuries in adults – MVA’s, fall from heights
Variety of fractures and treatment options
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Femoral Neck Fractures
If non-displaced or impacted in a stable position, screw fixation suitable
If displaced not likely to heal, thus usual treatment is an endoprosthesis
(i.e. hemi-arthroplasty)
Some patients are managed with total hip arthroplasty
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Intertrochanteric Hip Fractures
Occur distal to the femoral neck, where the blood supply is very good
Unlike femoral neck fractures, non-union is not usually a concern
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Intertrochanteric Fracture Fixation
Fixation usually stable enough to allow for early full weight-bearing
Some surgeons prefer rods for IT fractures in the elderly – protects the entire length of the femur
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Femoral Shaft Fractures
Most are treated with medullary rods with interlocking screws
Percutaneous technique reduces soft tissue trauma to gluteal muscles and facilitates recovery
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Subtrochanteric Femoral Stress Fractures Associated with Bisphosphonates
Fosamax, Boniva, Actonel, Zometa
Decrease osteoclast activity, but also impair osteoblast activity
Better bone density, but bone architecture is less “coordinated”
Osteonecrosis of the jaw and stress fractures of the proximal femoral shaft – ask about jaw and thigh pain
Stop drug if on it > 3-5 years
Alternatives: Forteo (PTH) or Prolia?
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Diagnosis of Hip DJD
Most commonly causes GROIN pain Can also cause lateral hip pain and/or buttock pain Some even get referred pain to the ipsilateral thigh/knee
Symptoms worse with weight-bearing and better with rest
Physical Exam: Reduction of motion, especially internal rotation Pain worsened with internal rotation of the hip when flexed Possible shortening of the affected extremity
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Hip DJD – Radiographic Findings
Hallmarks of DJD 1. Loss of cartilage thickness 2. Bony sclerosis 3. Osteophytes (bone spurs) 4. Bone cysts
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Hip DJD – Treatment Options
Standard treatments: 1. NSAID’s and acetaminophen 2. Glucosamine/chondroitin 3. Activity modification 4. Intra-articular steroid injections 5. Total hip replacement
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Hip DJD – Total Hip Replacement
Reliable solution that improves pain and function, but not designed for impact activities
Posterior approach: Higher dislocation risk More familiar anatomy
True anterior approach: Lower dislocation risk Learning curve, special equipment Quicker recovery (1st 6 months)
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Total Hip Replacement Risks
DVT/PE Infection Leg length discrepancy Dislocation Component loosening or failure Intra-operative fracture
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Miscellaneous Hip Conditions
Trochanteric bursitis Lateral hip pain, worsened with direct pressure (side-lying) PT (stretching), NSAID’s, and cortisone injections
Hip labral tears Often degenerative, an early sign of DJD Traumatic injury – role for arthroscopic surgery – probably the best
results
Femoro-acetabular impingement (FAI) Early stage of DJD as well Open versus arthroscopic debridement
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Occult Femoral Neck Fracture
If films negative but exam positive --> MRI (or bone scan) helps to make the diagnosis
Should be treated
“semi-urgently”
Screw fixation usually adequate since fracture is non-displaced