Lower Extremity Orthopedic Review WAPA Spring Conference April 25, 2016 Seattle, Washington Fred Huang, MD Proliance Orthopedic Associates A Division ...
Lower Extremity Orthopedic Review WAPA Spring Conference April 25, 2016 Seattle, Washington Fred Huang, MD Proliance 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)
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
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?
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)
Trimalleolar Ankle Fracture
Trimalleolar Fracture 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
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
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)
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
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 these 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
Femoral Rodding
Percutaneous Femoral Rodding
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
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
Diagnosis of Hip DJD
Internal rotation External rotation
PAIN !!!!
Hip DJD – Radiographic Findings
Hallmarks of DJD
1. 2. 3. 4. 5.
Loss of cartilage thickness Bony sclerosis Osteophytes (bone spurs) Bone cysts Femoral head deformity
Hip DJD – Treatment Options
Standard treatments:
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 (2-3%) More familiar anatomy
True anterior approach:
Much lower dislocation risk ( MRI (or bone scan) helps to make the diagnosis
Should be treated “semi-urgently”
Screw fixation usually adequate since fracture is non-displaced
