ortho block 3

commonly it is a valgus force without rotation (ie football clipping injury)

the MCL is best palpated with the knee in a slight flexion, apply a varus and then a valgus stress with the knee in full extension and then at 25° of flexion

the injury is a result of pure varus (adduction) force to the knee

it is best examined with the leg in a figure of 4 position and apply a varus then valgus stress

injury results from a rotational (twisting) or hyperextension force applied to the knee joint that overcomes the strength of the ligament

the most sensitive test is the Lachman test, in which the knee is flexed to 25° and the tibia is gently pulled forward while the femur is stabilized

anterior drawer test is performed with the knee flexed 90° is also helpful for tears

• there are 4 injury patterns:
• a dashboard injury
• fall onto a flexed knee with foot in plantar flexion
• pure hyperflexion injury
• hyperextension to the knee (ACL ruptures first then PCL, most commonly occurs in contact sports)

most sensitive test is the posterior drawer test

• direct trauma
• indirect MOI (page 541/542 of book)

• apprehension sign when patella is translated laterally
• ROM is limited in extension and flexion because of pain or fluid
• if retinaculum is torn there will be tenderness along the medial edge of the patella
• if medial patellafemoral ligament is torn at its origin, there will be tenderness just proximal to the medial femoral epicondyle

the MOI is multifactorial and in many situations is related to overuse and overloading of the patellofemoral joint

the patellar apprehension sign may be performed to evaluate the possibility of patellar instability. Palpate the patella as the pt places the knee thru ROM to determine whether crepitus occurs and also check for hamstring and quad tightness

it usually results from a combination of trauma and mechanical malalignment and may occur at any age, the medial plica is the plica that most often become pathologic

place the knee in 90° of flexion and then extend the knee, with a pathologic plica, a pop may occur at about 60° of flexion

pts with traumatic tears report a significant twisting injury to the knee

mcmurray test will be positive when the flexion circumduction maneuver is associated with a painful click

these typically occur with a fall on the knee that is partially flexed. when the quads muscle forcibly contracts to break the impact of the fall, the quad or patellar tendon may be overwhelmed

pt will have the inability to extend the knee against gravity or perform a straight-leg raising test

• ACL: only pos for effusion and possibly an avulsion fx of the lateral capsular margin of the tibia
• PCL: can help identify bony pathology, aid in diagnosis and help in planning surgical management
• MCL/LCL: may reveal an avulsion from the femoral origin of the MCL or the fibular insertion of the LCL, but usually negative
• Meniscus: weight bearing AP view with knees flexed at 45° is sensitive for early osteoarthritis

failure of an ossification center of the patella to fuse, most commonly the superior lateral corner

• treatment: rest or immobilization (5-7 days), or use of a brace with a lateral pad combined with a decrease in flexion-extension activities followed by quad strengthening.
• if the unusual case of persistent pain over the fibrous junction of the ossicle with the patella, surgery to remove the unfused ossicle may be required

it usually lies under the insertion site of the Sartorius, gracilis and semitendinosus muscles on the medial flare of the tibia just below the tibial plateau

may result from overuse, it occurs more commonly in pts with early osteoarthritis in the medial compartment of the knee

it lies between the anterior surface of the lower part of the femur and the deep surface of the quadriceps femoris

overuse

lateral aspect of the knee and may become irritated with repetitive movement over the lateral femoral condyle as the knee is flexed and extended

more common in long-distance runners and cyclists

it is located on the anterior aspect of the knee, it is superficial and lies between the skin and bony patella

occurs secondary to chronic kneeling (housemaids knee), also people installing carpets or tile floors

describes the symptom complex associated with compression neuropathy of the tibial nerve or its branches posterior to the medial malleolus

pts report diffuse, poorly localized pain along the medial ankle, paresthesias or dysthesias along the medial ankle and into the arch are a common component of the symptom complex

a charcot foot elevated above the heart for 1 minute will lose its redness, whereas a foot affected by cellulitis will not

neurogenic claudication is associated with spinal stenosis, ischemia to the cauda equine is the underlying pathology, induced by postures that mechanically compress the nerve roots with resultant paresthesias and dysesthesias

vascular claudication is secondary to peripheral vascular disease and compromised blood flow with walking activities

ganglia and plantar fibromas

common site for ganglia lateral aspect of the foot or ankle arising from the subtalar or ankle joint

plantar fibroma- benign thickening of the plantar fascia, it is a firm mass on the bottom of the foot that may be painful and is more likely to interfere with shoe wear

Thompson test by placing the pt prone with the knee and ankle at 90°, squeezing the calf normally results in plantar flexion of the ankle, a positive test is the absence of plantar flexion. MOST RELIABLE WITHIN 48 hours of the rupture

non-surgical: casting or bracing with the foot in plantar flexion

surgical: cast immobilization ~8 weeks followed by 8-12 weeks with a tapered heel lift

the lisfranc fx involves the second tarsometatarsal joint

Tx: nondisplaced are treated by 6-8 weeks of non weight beaing cast immobilization, followed by a rigid arch support for 3 months. Displaced = surgical stabilization

5th metatarsal fx is a fx of the proximal diaphysis

Tx: immobilization with an air stirrup, wooden-soled shoe, or fracture brace is continued until sxs subside (avulsion fxs for zone 1, 2). Acute fx in zone 2 non-weight bearing ambulation in a short leg cast for 6-8 weeks. Zone 3 needs surgical intervention

plantar pain in the forefoot (most common), dysesthesias into the affected two toes or burning plantar pain that is aggravated by activity. Pts state they feel like they are walking on a marble or that there is a wrinkle in my sock

• tx: pts should wear low-heeled, well cushioned shoe with a wide toe box, also can use a well cushioned sandal.
• can use metatarsal pads to spread the metatarsal heads and to take the pressure off of the nerve
• can use a mixture of lidocaine without epi and corticosteroid injection just proximal to the metatarsal heads

if sxs persist or recur surgical excision of the neuroma or division of the transverse metatarsal ligament is indicated

• accommodative shoes, a metatarsal pad, or an orthotic device is the key to treatemtn
• surgery to realign the toes and/or metatarsal head may be considered in non-surgical tx fails

• buddy taping the fractured toe to an adjacent toe
• a closed reduction under a digital block or open reduction and pinning should be considered for markedly angulated fractures or for fractures involving the articular surface of the MTP joints of all toes or the interphalangeal joint of the great toe

• if shear forces are minimalized, new bone formation can replace the osteonecrotic bone
• nonsurgical tx is appropriate when the overlying articular cartilage is intact, activity modifications, avoid running and jumping and possible a period of crutch ambulation
• Immobilization is reserved for refractory sxs or noncompliant pts

• surgical treatment is necessary after skeletal maturity and in children in whom the lesion has progressed to the stage that the articular cartilage has partially or totally separated
• if lesion is intact, it is drilled to promote vascularity
• unstable lesions require temporary internal fixation to promote healing

corns: usually occur from inappropriate tight footwear, with subsequent development of toe deformities. Hard corns occur over exposed bony prominences, soft corns develop between the toes in the web space as well as over bony prominences

callus: hyperkeratotic lesion of the skin that forms in response to excessive pressure over a bony prominence. It usually occurs beneath the metatarsal heads and is associated with metatarsalgia

warts: hyperkeratotic lesions on the soles of the foot caused by HPV

early radiographs (less than 2 weeks from onset of sxs) may be normal, but after 3-4 weeks, radiographs show a healing callus at the fx site

a bone scan is more sensitive than an XRAY and may be positive by 5 days postinjury

• increased pain with passive stretching of the muscles of the involved compartment
• anterior: passive stretch of the extensor halluces longus (flexing the great toe) causes marked pain
• lateral: inversion of the foot will passively stretch the peroneus longus and brevis

the recommended tx for an acute sesamoid fx is a removable short leg fx brace or a stiff-soled shoe with a rocker bottom, usually at 4 wks the sxs improve. once healed a felt pad to suspend the metatarsal head is recommended for 6 months