Ortho Path - Lecture 12

Front 1

What are five disorders that cause forefoot pain?

Back 1

(1)Degenerative Joint Disease, (2)Hallux Valgus, (3)Stress Fracture, (4)Gout—1st MTP, (5)Morton’s Neuroma

Front 2

What are two disorders that cause midfoot pain?

Back 2

(1)Avascular Necrosis (Navicular), (2)Tendonitis (Tibialis Posterior, FHL, FDL)

Front 3

What is one disorder that causes heal pain at the bottom of the heal?

Back 3

Plantar Fasciitis

Front 4

What are two disorders that cause heal pain at the back of the heal?

Back 4

(1)Retrocalcaneal Bursitis, (2)Achilles Rupture or Tendonitis

Front 5

What is another name for degenerative joint disease in the forefoot?

Back 5

Hallux Rigidus because it often occurs at the 1st MTP joint

Front 6

Are men or women more affected by DJD in the forefoot?

Back 6

Men

Front 7

*Is Hallux Rigidus bilateral or unilateral?

Back 7

Bilateral

Front 8

How will Hallux Rigidus present?

Back 8

Pain and tenderness over MTP joint. Decreased ROM (extension) which affects walking.

Front 9

What are four treatment options for Hallux Rigidus?

Back 9

(1)Mobilizations to 1st MTP joint, (2)Metatarsal bar in shoes (Rocker bar), (3)Correct other biomechanical factors above the MTP joint, (4)Surgery indicated rarely

Front 10

What is hallux valgus?

Back 10

Medial deviation of the first metatarsal bone

Front 11

What is the progression of symptoms of hallux valgus?

Back 11

(1)Initially a callus develops over the medial side of the head of the metatarsal bone, (2)As the condition progresses, the bursa becomes thickened and inflamed, (3)The chronic inflammation results in excessive bone growth (exostosis), (4)Results in a bunion

Front 12

What is a common cause of hallux valgus?

Back 12

Shoes with a narrow toe box

Front 13

What are four treatment options for hallux valgus?

Back 13

(1)Education and advice regarding footwear (no high heels and adequate toe box room), (2)Exercises to strengthen muscles, (3)Toe spacer, (4)Surgery is very common and quite successful

Front 14

What is another name for a stress fracture in the forefoot?

Back 14

March fracture (often seen in soldiers)

Front 15

Where does a forefoot stress fracture occur?

Back 15

Occurs at metatarsals (Mainly 2nd and3rd)

Front 16

What can cause a forefoot stress fracture?

Back 16

Prolonged stress on bone leads to small cracks in the bone. Weight-bearing activities painful and if left undiagnosed--Disruption of fracture

Front 17

What is the treatment for a forefoot stress fracture?

Back 17

Treatment is normally to decrease weight-bearing activities until healed. Metatarsal support in orthotic, taping, exercises (ROM & rotation - 8 sets, 40 reps), boot cast.

Front 18

What is the clinical name for Morton's Neuroma?

Back 18

Metatarsalgia

Front 19

What is Morton's Neuroma/Metatarsalgia?

Back 19

A fibrous tissue formation around the digital nerve. Usually between 2-3rd and 3-4th MT space.

Front 20

Is Morton's Neuroma/Metatarsalgia more common at the 2-3rd MT or 3-4th MT?

Back 20

3-4th MT

Front 21

Is Morton's Neuroma/Metatarsalgia more common in men or women?

Back 21

Women

Front 22

How does Morton's Neuroma/Metatarsalgia present?

Back 22

Walking is very painful. Pain at outer border of forefoot to tip of toe (intermittent pain), paresthesia is possible.

Front 23

How is Morton's Neuroma/Metatarsalgia treated?

Back 23

Orthotics, coritosteroid injection, alcohol injection, neuroectomy, cryogenic, neuroblasi

Front 24

What is another name for avascular necrosis of the navicular?

Back 24

Kohler’sDisease

Front 25

*Who is the most common patient of avascular necrosis of the navicular?

Back 25

More common in boys (3-8 years)

Front 26

What is a cause of avascular necrosis of the navicular?

Back 26

Abnormal strain on an un-ossified navicular

Front 27

How does avascular necrosis of the navicular present?

Back 27

Foot pain with weight-bearing is main symptom. Mild swelling. Pain may persist for 6-9 months.

Front 28

What is a treatment for avascular necrosis of the navicular and how long can it take to heal?

Back 28

May require a walking cast or orthotics while healing. Resolves in approximately 2 years.

Front 29

What is a common misdiagnosis for Tibialis Posterior/FHL/FDLTendonitis?

Back 29

Plantar fasciitis

Front 30

How would you determine if a patient had tendonitis?

Back 30

Differentiate each muscle with specific muscle testing and localization of tenderness. Check joints above and below.

Front 31

What is the treatment for tendonitis?

Back 31

May require orthotics to control supination or pronation. RICE, education and progressive return to activity.

Front 32

What are four functions of the plantar fascia?

Back 32

(1)Supports longitudinal arch of foot (with gait), (2)Creates a more rigid foot for propulsion/push-off, (3)Originates off the medial process of calcaneal tuberosity, (4)Divides into five bands and inserts into plantar aspects of the bases of the proximal phalanges

Front 33

What is plantar fasciitis?

Back 33

Inflammation of the plantar fascia at its origin on medial calcaneal tuberosity. Chronic inflammation may progress to global thickening of fascia with nodule formation or traction spurring of calcaneus (heel spur).

Front 34

*What are five causes of plantar fasciitis?

Back 34

(1)increased standing, (2)walking, (3)running, (4)hill climbing, (5)improper or worn-out footwear

Front 35

How should normal heal wear present?

Back 35

Equal, bilateral, lateral

Front 36

What are five abnormal lower extremity biomechanics associated with plantar fasciitis?

Back 36

(1)Pes planus (over pronation), (2)Internal tibial torsion (over pronation), (3)Tight Achilles tendon (over pronation), (4)Pes cavus (lack of pronation), (5)External tibial tibial torsion (lack of pronation)

Front 37

How does the pain of plantar fasciitis typically present?

Back 37

(1)Usually unilateral, (2)Worse when initially getting out of bed in morning, (3)Pain typically on bottom of heel, (4)Pain may subside with activity only to return with time

Front 38

What are eight treatments for plantar fasciitis?

Back 38

(1)Correct biomechanical dysfunction, (2)RICE, (3)NSAID’s, (4)Taping, (5)Footwear modifications, (6)Orthotics-common and helpful, (7)Surgery-rarely, (8)Foot core exercises

Front 39

What can a chronic retrocalcaneal bursitis result in?

Back 39

Chronic conditions can cause increased bone growth in area--Bony Spur or “Pump Bump”

Front 40

What is the treatment for retrocalcaneal bursitis?

Back 40

Treatment includes RICE, footwear modifications (padding) and NSAID’s

Front 41

Describe achilles tendonitis.

Back 41

Inflammation of the AT or its insertion. May progress to thickening, nodule formation or partial rupture.

Front 42

Where does achilles tendonitis commonly occur?

Back 42

Occurs commonly 2-6 cm proximal to tendon insertion (least vascularity)

Front 43

What are four causes of achilles tendonitis?

Back 43

(1)Frequent overuse syndrome, (2)External irritation from shoe, (3)Common in runners or sports involving repetitive jumping, (4)Abnormal biomechanics in L/E

Front 44

How does achilles tendonitis present?

Back 44

(1)Local tenderness on palpation +/- palpable thickening, nodule or gap, (2)+/- swelling/redness, (3)Pain on resisted PF, (4)Pain on stretch

Front 45

How is achilles tendonitis treated?

Back 45

RICE, frictions, heel lift, gentle stretching, progress to strength

Front 46

What do patients report when they experience an achilles rupture?

Back 46

Client may report hearing a pop or snap after landing on foot or pushing off of foot.

Front 47

How would a patient with an achilles rupture present?

Back 47

May have increased passive dorsiflexionon examination. Weak and painless plantarflexion (grade 3 strain). Positive Thompson Test.

Front 48

Which ankle sprain is more common: inversion or eversion?

Back 48

Inversion sprains are much more common

Front 49

*Which ligaments are injured in ankle inversion sprains?

Back 49

Lateral ligaments are injured with inversion sprains (anterior talofibular ligament most common). Calcaneal fibular ligament is affected in 20-40% of cases.

Front 50

How is an ankle sprain treated?

Back 50

RICE, Frictions, Rehabilitation program (ROM, strength, balance, functional retraining)

Front 51

Why are ankle sprains slow to heal?

Back 51

Ligaments have low blood supply

Front 52

What can happen to ligaments with a more severe sprain?

Back 52

Chronic laxity can occur with more severe sprains. May require ankle brace or taping for activities. Surgery indicated in rare situations (Evan’s Repair {(Peroneus Brevis})

Front 53

What is a high ankle sprain?

Back 53

A tear of the IOM between the tibia and fibula

Front 54

What are three conditions that can be referred to as shin splints?

Back 54

(1)Medial tibial stress syndrome (tib ant), (2)Stress fractures, (3)Compartment syndromes

Front 55

What are four conditions classified as medial tibial stress syndrome?

Back 55

(1)Musculotendinous strains, (2)Tendinitis, (3)Interosseous membrane pain, (4)Periostitis

Front 56

What is another name for compartment syndrome?

Back 56

Exercise-induced ischemia

Front 57

What is compartment syndrome?

Back 57

Increased intramuscular pressure impedes blood flow and function of the tissues within that compartment.

Front 58

What is the cause of compartment syndrome?

Back 58

Exact cause is not known. Most common factor is a high level of physical activity with repetitive DF/PF. Frequently found in runners and cyclists.

Front 59

*What are four ways that the pain of compartment syndrome present?

Back 59

(1)Pain induced only by activity (differentiates from vascular claudication), (2)Pain located along specific muscular group, (3)Numbness or tingling may occur (deep peroneal or tibial nerve , (4)Symptoms normally disappear quickly with stopping activity.

Front 60

Which leg compartments frequently suffer from compartment syndrome?

Back 60

Anterior and Deep posterior compartments most frequently involved.

Front 61

How would the leg pulses present with compartment syndrome?

Back 61

The pulses will be normal.

Front 62

What five muscles, nerve, and artery are in the anterior compartment?

Back 62

(1)Tibialis anterior, (2)Extensor digitorum longus, (3)Extensor hallucis, (4)Deep peroneal nerve, (5)Anterior tibial artery & vein

Front 63

What two muscles and nerve are in the lateral compartment?

Back 63

(1)Peroneus longus, (2)Peroneus brevis, (3)Superficial peroneal nerve

Front 64

What three muscles, two arteries, and one nerve are in the deep posterior compartment?

Back 64

(1)Tibialis posterior, (2)Flexor digitorum longus, (3)Flexor hallucis longus, (4)Tibial nerve, (5)Peroneal artery & vein, (6)Posterior tibial artery & vein

Front 65

What three muscles are in the superficial posterior compartment?

Back 65

(1)Soleus, (2)Gastrocnemius, (3)Plantaris

Front 66

*What is Charcot-Marie-Tooth disease?

Back 66

Hereditary peripheral motor and sensory neuropathy. The most common inherited neuro disorder (1 in 3000).

Front 67

When does Charcot-Marie-Tooth disease usually present?

Back 67

Usually manifests late childhood-early adulthood in lower extremity.

Front 68

*How does Charcot-Marie-Tooth disease usually present?

Back 68

Muscle atrophy, loss of touch, vibration, proprioception senses; *pain is intact. ”stork leg”: peroneal and calf muscle atrophy; B/L pes cavus, hammer toes.

Front 69

What are two early signs of Charcot-Marie-Tooth disease?

Back 69

(1)Painful muscle spasm or affected muscles, (2)Distal muscle weakness (falls often)

Front 70

What are three treatments for Charcot-Marie-Tooth disease?

Back 70

(1)PT and moderate exercise, (2)bracing for foot deformities and to control foot-drop, (3)surgery: straightening and pinning toes, fuse arch bones

Front 71

What were the nine pediatric orthopaedic conditions discussed?

Back 71

(1)Fractures—Salter-Harris, (2)Osgood-Schlatters, (3)Congenital Hip Dysplasia, (4)Legg-Perthes’ Disease, (5)Slipped Capital Femoral Epiphysis(SCFE), (6)Severs Disease, (7)Volkmann’s Ischemic Contracture, (8)Pulled Elbow, (9)Sprengel’s Deformity

Front 72

*What fracture is unique to childhood?

Back 72

Fracture of the *growth plate* is an injury unique to childhood

Front 73

How do Salter-Harris fractures heal?

Back 73

Most such fractures heal without permanent deformity. A small percentage, however, are complicated by growth arrest and subsequent deformity.

Front 74

What is the Salter-Harris classification system?

Back 74

The Salter-Harris classification of growth plate injuries aids in estimating both the prognosis and the potential for “growth arrest".

Front 75

What is the acronym for the Salter-Harris classification system?

Back 75

SALTR

Front 76

What is a type I Salter-Harris fracture and what percentage of incidence?

Back 76

Straight across (separated); 5%

Front 77

What is a type II Salter-Harris fracture and what percentage of incidence?

Back 77

Above (proximal); 75%

Front 78

What is a type III Salter-Harris fracture and what percentage of incidence?

Back 78

Lower; 10%

Front 79

What is a type IV Salter-Harris fracture and what percentage of incidence?

Back 79

Through (growth plate & above and below); 10%

Front 80

What is a type V Salter-Harris fracture and what percentage of incidence?

Back 80

Rammed (compression); 1%

Front 81

Which Salter-Harris types are the most severe fractures?

Back 81

Types IV and V. The often result in a shortened limb.

Front 82

Describe a Salter-Harris Type I fracture.

Back 82

Displaced, or widened at the growth(epiphyseal) plate. These injuries are associated with a favourable prognosis regardless of region.

Front 83

What would lead a practitioner to suspect a Salter-Harris Type I fracture?

Back 83

Point tenderness at the growth plate should lead the practitioner to suspect Type I Salter-Harris fracture even if radiographs are normal.

Front 84

Describe a Salter-Harris Type II fracture.

Back 84

Fracture through growth plate and metaphysis. Rarely do these injuries result in functional limitations, except at the knee and ankle

Front 85

Does a Salter-Harris Type II fracture result in limb shortening?

Back 85

These injuries may produce minimal shortening.

Front 86

Describe a Salter-Harris Type III fracture.

Back 86

Fracture through the growth plate and the epiphysis.

Front 87

Do Salter-Harris Type III fractures result in longterm disabilities?

Back 87

Yes, this type of fracture is prone to chronic disability because it typically involves the articular surface of the joint.

Front 88

Describe a Salter-Harris Type IV fracture.

Back 88

Fracture through the metaphysis, growth plate and epiphysis.

Front 89

Do Salter-Harris Type IV fractures result in longterm disabilities?

Back 89

Yes, like the type III fracture the articular cartilage can be damage in this type of fracture resulting in chronic disability. These injuries can produce joint deformity with angulation more likely at the knee and ankle.

Front 90

Describe a Salter-Harris Type V fracture.

Back 90

Compression or crush injury of the epiphyseal plate with no associated epiphyseal or metaphyseal fracture. Most occur in the lower extremities and are associated with a diaphyseal fracture.

Front 91

How are Salter-Harris Type V fractures diagnosed and what is the prognosis?

Back 91

In type V injuries, initial plain film x-rays are normal. The diagnosis is more often made in retrospect as premature closing is observed. These injuries have a poor prognosis because angulation and/or shortening are 100%.

Front 92

What is congenital hip dysplasia?

Back 92

Femoral head and acetabulum are not formed properly.

Front 93

What is the incidence of congenital hip dysplasia?

Back 93

Incidence is 1.5 in 1000 births. Abnormality is bilateral in > 50%. Girls 8 times more than boys.

Front 94

How is congenital hip dysplasia diagnosed and treated?

Back 94

Barlow maneuver (dislocate hip), Ortolani click test (reset hip). Treated with brace for 23-24 hours/day for 6-8 weeks.

Front 95

What is Slipped Capital Femoral Epiphysis (SCFE)?

Back 95

A Type I Salter-Harris epiphyseal injury. Most common adolescent hip disorder.

Front 96

What is the etiology of Slipped Capital Femoral Epiphysis (SCFE)?

Back 96

Genetic (African American > Caucasians). Mechanical (growth spurt, overweight).

Front 97

*Who is Slipped Capital Femoral Epiphysis (SCFE) more common in?

Back 97

More common in obese males (tends to be preteens - teens)

Front 98

*What are three symptoms a patient with Slipped Capital Femoral Epiphysis (SCFE) may present with?

Back 98

(1)Present with a limp, (2)hip laterally rotated and reports of knee, (3)hip or anterior thigh pain

Front 99

How is Slipped Capital Femoral Epiphysis (SCFE) misdiagnosed?

Back 99

(1)Suspected hip referral pain, (2)20 - 50% report knee pain only and are written off as growing pains

Front 100

Upon physical examination of a patient with Slipped Capital Femoral Epiphysis (SCFE) what two findings would you expect?

Back 100

(1)Loss of internal rotation, abduction, flexion (metaphysis moves anterior and externally rotates), (2)Increased hip extension

Front 101

What is the treatment for Slipped Capital Femoral Epiphysis (SCFE)?

Back 101

Gently reduce with traction, ORIF with pins to avoid necrosis

Front 102

*What are three potential complications of Slipped Capital Femoral Epiphysis (SCFE)?

Back 102

(1)Avascular Necrosis, (2)Chondrolysis, (3)Premature OA

Front 103

What is Legg-Perthe's disease?

Back 103

Avascular necrosis of femoral head. Cause is unknown.

Front 104

*What is the incidence of Legg-Perthe's disease?

Back 104

Occurs between ages 3-11. 5 times more common in boys (particularly active boys).

Front 105

Is Legg-Perthe's disease bilateral or unilateral?

Back 105

Bilateral in 15% of affected children

Front 106

What is the prognosis if Legg-Perthe's disease is diagnosed before 6 years of age? After 10 years of age?

Back 106

6yo: Good prognosis

10yo: High risk for early OA

Front 107

*Where can the pain of Legg-Perthe's disease present?

Back 107

Pain may be in the hip or knee.

Front 108

What three symptoms will a patient with Legg-Perthe's disease present with?

Back 108

(1)Loss of abduction and internal rotation, (2)Atrophy of the upper thigh muscles, (3)Ambulates with a limp

Front 109

What is the treatment for Legg-Perthe's disease and how is it diagnosed?

Back 109

Treatment: Traction, leg braces (~8 months)

Diagnosis: Confirmed with x-ray

Front 110

What is Osgood-Schlatter disease?

Back 110

Osteochondritis of the tibial tubercle. Is thought to be due to continuous traction of the immature epiphyseal insertion by the patellar tendon. Athletic activity +/- a recent growth spurt may lead to cartilage detachment.

Front 111

What are the signs and symptoms of Osgood-Schlatter disease?

Back 111

Pain, swelling and tenderness occur at the site of the patellar tendon insertion. Self-limiting disease.

Front 112

How is Osgood-Schlatter disease diagnosed?

Back 112

X-ray may show fragmentation of the tibial tubercle. Localizing the maximal point of tenderness over the tibial tuberosity.

Front 113

What are two treatments of Osgood-Schlatter disease?

Back 113

(1)Avoid excessive activity (particularly deep knee bends), (2)Excision of the ossicle may eventually be required

Front 114

When is Osgood-Schlatter disease "healed"?

Back 114

Complete remission when there is fusion of the tibial tubercle to the diaphysis. Resolution occurs over a period of several weeks to months.

Front 115

What is Sever's disease?

Back 115

Achilles tendon pulls on the epiphysis of the calcaneus. This can disrupt the plate and cause pain and swelling. Self-limiting disease. X-rays are often normal.

Front 116

What is the incidence of Sever's disease?

Back 116

Boys 8-15 most commonly affected

Front 117

How is Sever's disease treated?

Back 117

Rest, support, education

Front 118

What is osteochondritis dissecans?

Back 118

Condition characterized by subchondral bone necrosis and sometimes by complete or partial separation of the articular fragments. Articular cartilage remains intact until subchondral bone breaks down. Unlikely cause of knee locking.

Front 119

*What is the most common site for osteochondritis dissecans?

Back 119

Lateral aspect of the Medial femoral condyle of the femur

Front 120

What is the incidence of osteochondritis dissecans?

Back 120

Males, 10 - 30yo, athletes, result of shearing forces with low blood supply.

Front 121

What are three treatments for osteochondritis dissecans?

Back 121

In most cases the treatment is conservative. (1)Limitation of activities, (2)Isometric quadriceps exercises, (3)Open arthrotomy or arthroscopic surgery is only indicated when the fragments are greater than 1 cm in diameter

Front 122

What is Sprengel's deformity?

Back 122

Scapula does not descend. Often associated with abnormalities of the cervical spine (Klippel-feil & cervical rib). Can have a ligamentous connection between the medial border of the scapula and the lower cervical spinous processes. Scapula is not only high and small but also rotated downward.

Front 123

What ROM is decreased with Sprengel's deformity?

Back 123

Shoulder abduction

Front 124

What is the treatment for Sprengel's deformity?

Back 124

Surgery but function is seldom improved

Front 125

What is Volkmann’s Ischemic Contracture?

Back 125

Associated with supracondylar fractures of the distal humerus. The brachial artery may be caught and kinked in the fracture site. Similar to a compartment syndrome affecting nerves within the compartment. Not specific to children.

Front 126

What are symptoms of Volkmann’s Ischemic Contracture?

Back 126

Numbness, swelling, discoloration of the fingers with increasing arm pain. If left alone, can result in contractures of the muscles of the forearm.

Front 127

What is another name for a pulled elbow?

Back 127

Nursemaids elbow

Front 128

What structures are affected with a pulled elbow?

Back 128

Radial head is pulled through the annular ligament as the ligament is still thin and weak.

Front 129

Which age group is most susceptible to a pulled elbow?

Back 129

Preschool age children vulnerable to a sudden longitudinal pull or jerk on their arms

Front 130

What are the symptoms of a pulled elbow?

Back 130

Decreased supination and ++pain are the only significant findings.

Front 131

Do x-rays show any significant results for a pulled elbow?

Back 131

X-rays are usually negative