Lower Extremity
Orthopedic Review
WAPA Winter Conference
January 30, 2013
Seattle, Washington
Fred Huang, MD
Valley Orthopedic Associates
A Division of Proliance Surgeons, Inc.
What We Aren’t Covering
Lumbar spine and foot conditions
 Musculoskeletal infections & tumors
 Inflammatory arthritis (i.e. rheumatoid
arthritis)
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Great reference:

Miller’s Review of Orthopedics
Ankle Sprains

Most often an inversion injury

Lateral ligaments most
commonly injured:
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Anterior talo-fibular ligament
Calcaneo-fibular ligament
Posterior talo-fibular ligament

Grades 1, 2, and 3

Ottawa Rules for imaging
Source: www.bodyflow.com.au
Source: www.intermountainhealthcare.org
Ankle Sprains

Grades 1 and 2 treated with RICE
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
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
Achilles Tendon Ruptures
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
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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
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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?
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
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)
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
Maissoneuve Injury



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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
Other Ankle Conditions

Peroneal tendon tears – posterolateral pain/swelling



Ankle arthritis



Most often degenerative – longitudinal tears in the peroneus brevis
Peroneal tendon subluxation – often associated w/ trauma (SURGERY)
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)
Common Knee Injuries
Meniscal
Tears
ACL Tears
Multi-ligament Injuries
Tibial Plateau Fractures
Age Related Injury Patterns

Teenagers
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
Adults
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Ligament and meniscal tears
Patellar dislocations
Growth plate injuries
Ligament and meniscal tears
Some tibial plateau fractures
Elderly

More tibial plateau fractures
Patello-femoral Pain
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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
Growth Plate Fractures

Growth plate
injuries
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

<15 for
females
<18 for males
Not always
readily
apparent on
initial x-rays
Patellar Instability



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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
Meniscal Tears

Clinical Symptoms
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
Swelling
Catching +/- locking
Difficulty with pivoting and squatting
Physical Exam Findings
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Effusion
Joint line tenderness
Positive McMurray’s maneuver
Meniscal Tears

Arthroscopic surgery if
mechanical symptoms
present
Source: www.stoneclinic.com

Degenerative tears:
associated with
minimal or no trauma

Many degenerative
tears associated with
DJD & thus not
operated on
Source: www.opsmart.com
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
ACL Tears
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Twisting on a
planted foot
Unable to continue
sporting activity
Effusion within 1-2
hours
Lachman test
Increased anterior tibial
translation at 20 degrees of
knee flexion
Source: Knee Ligament Injuries
The Staywell Company, 2001
ACL Tears - Treatment

Non-operative treatment (Brace?)

Surgical treatment
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Timing of surgery
Graft options: autograft versus allograft
Associated procedures: meniscal repair vs.
meniscectomy, cartilage procedures
Multi-ligament Knee Injuries

Higher energy mechanism than ACL tears

Knee (tibio-femoral) dislocation?

Critical to assess neurovascular function:
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Motor/sensory function at the ankle/foot
Palpable distal pulses? (Popliteal artery injury?)
Consider further vascular testing (CT-angiogram
vs. arterial ultrasound or arteriogram)
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
Multi-ligament Knee Injuries

Don’t forget the “5th” knee ligament
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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
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
Tibial Plateau Fractures

CT scans helpful in
defining the fracture

Anticipate other injuries
(meniscal tears, ligament
tears, arterial or
neurologic deficits)
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
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
Tibial Rodding

Can be done in a
“closed” fashion

Highly dependent on
fluoroscopy

Potential for persistent
anterior knee pain
Diagnosis of Knee DJD

3 compartments of the knee:
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1. Patello-femoral
2. Medial tibio-femoral
3. Lateral tibio-femoral
Physical Exam:
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Stiffness
Deformity (varus = bow-legged,
valgus = knock-kneed)
Effusions common
Knee DJD – Radiographic Findings

Hallmarks of DJD
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1.
2.
3.
4.
5.
Loss of cartilage thickness
Bony sclerosis
Osteophytes (bone spurs)
Bone cysts
Joint subluxation
Weight-bearing
radiographs a must
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1. Compare with other side
2. Flexed view important
Knee DJD – Treatment Options

Standard treatments:

1. NSAID’s and acetaminophen
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2. Glucosamine/chondroitin
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3. Activity modification & wt. loss
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4. Intra-articular steroid injections
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5. Visco-supplementation (Synvisc)
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6. Unloader braces
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7. Neoprene sleeves
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8. Osteotomy surgery
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9. Knee replacement –
unicompartmental versus total knee
replacement
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”
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
Total Knee Replacement Risks
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DVT/PE
Infection
Post-operative stiffness
Early component
loosening or failure
Hip Fractures

Common in the elderly
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Low energy trauma
Osteoporosis

Higher energy injuries
in adults – MVA’s, fall
from heights

Variety of fractures
and treatment options
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
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
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
Femoral Shaft Fractures

Most are treated with
medullary rods with
interlocking screws

Percutaneous
technique reduces soft
tissue trauma to
gluteal muscles and
facilitates recovery
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?
Diagnosis of Hip DJD
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Most commonly causes GROIN pain

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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
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Physical Exam:
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Reduction of motion, especially internal rotation
Pain worsened with internal rotation of the hip when flexed
Possible shortening of the affected extremity
Hip DJD – Radiographic Findings
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Hallmarks of DJD
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1.
2.
3.
4.
Loss of cartilage thickness
Bony sclerosis
Osteophytes (bone spurs)
Bone cysts
Hip DJD – Treatment Options

Standard treatments:
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
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1.
2.
3.
4.
5.
NSAID’s and acetaminophen
Glucosamine/chondroitin
Activity modification
Intra-articular steroid injections
Total hip replacement
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:

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Lower dislocation risk
Learning curve, special equipment
Quicker recovery (1st 6 months)
Total Hip Replacement Risks
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DVT/PE
Infection
Leg length discrepancy
Dislocation
Component loosening or failure
Intra-operative fracture
Miscellaneous Hip Conditions

Trochanteric bursitis
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Hip labral tears
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Lateral hip pain, worsened with direct pressure (side-lying)
PT (stretching), NSAID’s, and cortisone injections
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
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