Lower limb disorders part 1.pdf

Lower limb disorders Part 1 Prof Dr/ Anwar Ebid A) Isolated fractures(stable with no disruption of the pelvic ring ) Fracture of superior ischiopubic ramus Fracture of inferior ischiopubic ramus Fracture entering wall of acetabulum Fracture of wing of ilium Avulsion fractures of anterior inferior il...

Lower limb disorders Part 1 Prof Dr/ Anwar Ebid A) Isolated fractures(stable with no disruption of the pelvic ring ) Fracture of superior ischiopubic ramus Fracture of inferior ischiopubic ramus Fracture entering wall of acetabulum Fracture of wing of ilium Avulsion fractures of anterior inferior iliac spine, anterior superior iliac spine, or ischial tuberosity. B) Fractures with disruption of the pelvic ring (unstable) Combination of anterior and posterior fractures of the pelvic ring Disruption of pubic symphysis and posterior sacro-iliac joint DISLOCATIONS AND FRACTURE-DISLOCATIONS OF THE HIP Only three types of dislocation and fracturedislocation of the hip need be considered: 1. Posterior dislocation or fracture-dislocation 2.Anterior dislocation 3.Central fracture-dislocation. All these injuries are uncommon when compared, for example, with dislocation of the shoulder. Of the three types, the posterior dislocation is the most common. Diagnosis 1-POSTERIOR DISLOCATION AND FRACTURE-DISLOCATION The femoral head is forced out of the back of the acetabulum by violence applied along the shaft of the femur while the hip is flexed or semi flexed (Fig. 14.4A). The injury often occurs because of a motor accident in which the occupant of a car involved in a collision is thrown forwards and strikes the front of the flexed knee against a part of the bodywork. Another common cause is a motor cycle crash. In about half the cases of posterior dislocation of the hip, the head of the femur carries with it a small or large fragment of bone from the rim of the acetabulum (fracture dislocation) It should be noted that the sciatic nerve is almost directly in the path of displacement and may easily be damaged. Clinical features To remember the clinical deformity, it is easiest to think of the greater trochanter as being held in its normal position by the attached muscles as if by guy ropes and forming the center of a new vertical axis about which the femoral head may swing forwards or backwards (Fig. 14.5). Thus, in a posterior dislocation the femur and with it the whole lower limb is rotated medially as well as being displaced upwards (Fig. 14,5). There will be true shortening of the limb, perhaps by 2 or 3 cm. Radiographs will confirm the dislocation (Fig. 14.6) and show whether there is an associated fracture. Careful examination should always be made for signs of injury to the sciatic nerve. Treatment The dislocation should be reduced under general anesthesia as soon as possible (Reduction under general anesthesia) How: Reduction is usually affected without difficulty by pulling longitudinally upon the femur while the hip is flexed to a right angle and rotated laterally. Technique. The patient is placed supine, preferably on the floor or on a low table, and an assistant grasps the pelvis firmly through the iliac crests. The surgeon flexes the hip and knee to a right angle so that the line of the femur points vertically upwards, and then pulls the thigh steadily upwards, at the same time gradually rotating the femur laterally. ✓ After the dislocation has been reduced the limb is supported by traction, for 3-6 weeks. ✓ Mean while mobilizing exercises for the hip and knee are begun after a few days and are gradually intensified. Fig. 14.5 The position of the limb in anterior dislocation and posterior dislocation of the hip Anterior dislocation: -limb rotated laterally New axis of rotation Posterior dislocation:-limb rotated medially Complications (1) Injury to the sciatic nerve, (2) Damage to the femoral head, (3) Avascular necrosis of the femoral head, (4) Post-traumatic ossification and (5) Osteoarthritis. 2) ANTERIOR DISLOCATION Anterior dislocation of the hip is much less common than posterior dislocation. Indeed, it is a very uncommon injury. It is caused by forced abduction and lateral rotation of the limb, usually in a violent injury such as a motor accident or aircraft crash. There is not usually an associated fracture of the acetabular margin. Clinically, the limb rests in marked lateral rotation (Fig. 14.5). Treatment: Reduction under anesthesia is affected by strong traction upon the limb combined with medial rotation. Thereafter, treatment is the same as for posterior dislocation Complications : There is not the same risk of damage to the sciatic nerve as there is in posterior dislocations, but the femoral nerve and artery may be compressed, and the risk of osteoarthritis from avascular necrosis is the same 3) CENTRAL FRACTURE-DISLOCATION In central fracture— dislocation of the hip the femoral head is driven through the medial wall, or 'floor', of the acetabulum towards the pelvic cavity. It differs from anterior and posterior dislocations in that the capsule remains intact, but there is inevitably a fracture of the acetabulum, usually with much comminution. Central fracturedislocation is caused by a heavy lateral blow upon the femur, as in a fell from a height onto the side or a crushing injury, or it may be caused by a longitudinal force acting upon the femur (as from a blow upon the flexed knee) while the hip is abducted. The degree of displacement varies with the severity of the violence Treatment of central dislocation ✓ Severe shock may demand energetic resuscitation, and the possibility of major internal bleeding should be borne in mind. ✓ Treatment of the skeletal injury depends largely upon the degree of comminution and displacement of the acetabular fragments, and upon whether it is possible to restore the articular surface to its normal shape. ✓ In practice the cases thus fall into two groups: (1) Those in which the main part of the weight bearing surface of the acetabulum can be restored to its normal position, congruous with the femoral head; and (2) Those in which this is impossible on account of severe comminution of the weight-bearing surface. ✓ Where restoration of the articular surface is possible, non-surgical treatment by skeletal traction through a femoral Steinmann pin will sometimes pull down the displaced fragment of the acetabulum, which should then remain congruent with the femoral head when traction is removed. Treatment of central dislocation ✓ Traction should, however, be maintained for 4-6 weeks until bony stability has developed. ✓ Surgical treatment is indicated when an anterior or posterior fracture dislocation cannot be reduced by traction. Traction may be continued for symptomatic relief for 2 or 3 days while the fracture is fully evaluated, and the most appropriate surgical treatment planned. Ideally patients with these difficult fractures should be transferred to a unit that specializes in their treatment, but this should not be delayed for more than 7-10 days. The incision chosen for treatment depends on the location of the fracture and may require an Anterior ilio-inguinal approach Extended iliofemoral approach Combined anterior and posterior approach. Following open reduction, fixation of the fragments may be achieved by a combination of multiple screws and contoured plates. ✓ In many instances it is necessary to use additional bone grafts to reconstitute skeletal defects resulting from fracture impaction. ✓ Surgical complications are frequent, particularly infection and thromboembolism and appropriate prophylactic treatment is required. ✓ Following surgery. light traction should be continued until wound healing has occurred and weightbearing is deferred for at least 6 weeks. It should be borne in mind that many patients with central dislocation of the hip will eventually need total replacement arthroplasty on account of secondary degenerative changes, and one of the objectives of the primary treatment should be to: Restore the hip sufficiently closely to its normal position to ensure that conditions are favorable for arthroplasty, should it be required. Complications Severe hemorrhage from damage to a major blood vessel, Degenerative arthritis from damage to the articular surface of the acetabulum. This may develop early (within a few months) or after a period of years. If the disability from arthritis becomes severe the only effective treatment is by operation. The choice usually lies between arthrodesis and total replacement arthroplasty. FRACTURES OF THE PROXIMAL FEMUR Classification Fracture of the neck of the femur Fracture of the trochanteric region Fracture neck of femur Fracture of the neck of the femur is common in persons over the age of 60 years and is one of the so-called “fatigue fractures “ Women are especially at risk, because of a tendency for their bone to become increasingly fragile after the menopause in consequence of generalized osteoporosis. The causative injury is often slight usually a fall or stumble. In most cases the fracture is probably caused by a rotational force. In about 95% of cases, there is marked displacement, the shaft fragment being rotated laterally and displaced upwards, often with comminution of the posterior cortex. Clinical features A-Displaced fracture. A typical history is that the patient usually an elderly woman tripped and fell. 1-Unable to get up again unaided. 2-Unable to take weight on the injured limb. On examination the most striking feature is 3-Marked lateral rotation of the limb. This is often as much as 90°, so that the patella and the foot point laterally. 4-The limb is shortened by about 2-3 cm. 5-Any movement of the hip causes severe pain. B-Impacted abduction fracture In the exceptional case in which the fracture is impacted, the history and signs are different. 1-The patient may have been able to pick herself up after falling, and she may even have walked a few steps afterwards, perhaps with assistance. 2-Some patients have remained mobile despite pain and have not sought medical advice immediately. On examination 3-No detectable shortening and no rotational deformity. 4-The patient can move the hip through a moderate range without severe pain. Treatment Displaced fractures and impacted abduction fractures must be considered separately. Displaced fractures. A displaced fracture of the neck of the femur is one of the few fractures that needs rigid immobilization if it is to have any chance of uniting. The alternative treatment, in which the femoral head is excised and replaced by a metal prosthesis, is more commonly used, especially when there is comminution of either fragment, severe displacement, and when the patient is elderly or debilitated. Compression screw-plate (dynamic hip screw) used for some fractures of the femoral neck and for trochanteric fractures. The lag screw(s) gripping the head fragment is drawn into the barrel by tightening the end screw, thus compressing the fragments together. B) Same fracture fixed with parallel long screws. Displaced fractures After operation: ✓ The patient is nursed free in bed and active hip movements are encouraged. ✓ Most surgeons encourage early walking with the aid of crutches or a frame within the first week after the operation on the grounds that in these elderly patients the advantages to the general health of being up and about far outweigh the theoretical advantages to the fracture of rest. ✓ Alternative methods for selected fractures in the elderly. ✓ Because of the uncertain results of fixing these fractures by internal devices, especially in the elderly, most surgeons now advise immediate excision of the femoral head and its replacement by a metal prosthesis (Replacement arthroplasty) Treatment in children. ✓ Femoral neck fracture is uncommon in children, but when it occurs most surgeons advise operative fixation, usually by two or three threaded pins, because bone healing is more reliable and complications fewer. Impacted abduction fractures ✓ It must be emphasized that a diagnosis of impacted abduction fracture should not be made unless both the clinical and radiological criteria of impaction are satisfied. ✓ In the absence of such strict criteria, firm impaction of the fracture cannot be assumed, and there is a serious risk that the fragments will fall apart. ✓ Despite the feasibility of conservative treatment, there is an increasing trend towards routine internal fixation of impacted abduction fractures, because of a fear that displacement may occur. Complications Fractures of the neck of the femur are more prone to serious complications than is any other fracture. The important complications are Avascular necrosis Nonunion Osteoarthritis All these complications affect fractures with displacement rather than impacted abduction fractures. Comminuted trochanteric fracture with subtrochanteric extension. (U Trochanteric fracture after fixation with Gamma nail. INJURY POTENTIAL OF THE PELVIC AND HIP COMPLEX Injuries to the pelvis and hip joint are a small percentage of injuries in the lower extremity. Injuries to the pelvis primarily occur in response to abnormal function that excessively loads areas of the pelvis. In fact, overuse injuries to this area account for only 5% of the total for the whole body. This may be attributable to the strong ligamentous support, significant muscular support, and solid structural characteristics of the region. This can result in an irritation at the site of muscular attachment, and in adolescents, a more common type of injury might be an avulsion fracture at the apophysis, or bony outgrowth. Injury 1- Iliac apophysitis pain and swelling (inflammation) of the growth plate along the side of the hip (iliac crest). The growth plate is an area of weakness, and injury to it occurs because of repeated stress or forceful exercise. Example of such an injury, in which excessive arm swing in gait causes excessive rotation of the pelvis, creating stress on the attachment site of the gluteus medius and tensor fascia latae on the iliac crest. This can also occur at the iliac crest as a result of direct blow or because of a sudden, violent contraction of the abdominals. Growing Pains around the Hip & Pelvis: Apophysitis and Avulsion Fracture Apophysitis Apophysitis is due to long bones such as the femur (thigh bone) growing more quickly than the muscles of the thigh or hip. This is why it is sometimes referred to as “growing pains.” The relatively tight muscles then tug on the growth zones in the immature pelvis and femur, which is why the condition is often referred to as ‘traction apophysitis’. Avulsion Fracture An avulsion fracture almost always occurs in response to a large, rapid force where the muscle is in a position of stretch and contracting very hard, pulling on the growth center. Growing Pains around the Hip & Pelvis: Apophysitis and Avulsion Fracture The bones of the hip and pelvis, viewed from the front. Growth centers (apophyses) are delineated by the dotted red lines. These are the sites of apophysitis and avulsion fracture where a small piece of bone may dislodge with the muscle that attaches there. Most common sites are depicted on the right and less common sites on the left of the picture. ASIS: Anterior Superior Iliac Spine; AIIS: Anterior Inferior Iliac Spine. A position of hip flexion (thigh towards chest) and knee extension (knee straight). This position places the hamstring muscles on high stretch and places high loads on the bony growth centers at the muscle attachment to the ischial tuberosity (sitting bone). A position of hip extension (thigh moving backwards) and knee flexion (knee bent). This position places the hip flexor muscles, and particularly the rectus femoris, on high stretch. High loads are placed on the bony growth centers at the muscle attachments to the front of the pelvis and the lesser trochanter of the femur (thigh bone). 2- Apophysitis Inflammation of an apophysis, can also develop into a stress fracture. Pain usually gets worse with activity and there may be some mild swelling This is an area of growth on a bone that also acts as a point for muscles to attach to. It is common in young athletes because their bones are still growing and have not yet fully matured and hardened There will be tenderness at a specific point on the front of the hip. Apophysitis of the Ilium typically results in dull pain at the front of the hip. 1-Muscle tightness – for example, shortened hamstring muscles in the back of the thigh will place greater loads on the apophysis at the ischial tuberosity (sitting bone). 2-Rapid growth spurts – this problem often comes and goes during adolescence, with symptoms recurring during or just after a growth spurt. This is a period where the muscles are relatively short compared to the newly lengthened bones. 3-Being male – apophysitis is more common in males, generally because males tend to grow in more rapid spurts. 4-High activity levels – being very active places repetitive loads on the growth plates, which if combined with the other factors above, may contribute to the development of pain. 5-Type of activity – sports that involve rapid acceleration and deceleration, and large ranges of hip movement, such as soccer and gymnastics, place greater load across the hip and pelvic growth centers Factors related to the development of apophysitis Other apophysitis injuries which commonly occur in children are: Osgood Schlatter’s disease occurs at the top of the shin bone, at the front and just below the knee. Sinding-Larsen-Johansson (jumper's knee) causes pain at the bottom of the patella (kneecap), like Patellar tendonitis. Affect the proximal end of patellar tendon Sever’s disease – causes pain at the back of the heel, where the Achilles tendon inserts. Is inflammation of the patellar ligament at the tibial tuberosity (apophysitis). It is characterized by a painful bump just below the knee that is worse with activity and better with rest. Episodes of pain typically last a few weeks to months. One or both knees may be affected, and flares may recur. Risk factors include overuse, especially sports which involve frequent running or jumping. The underlying mechanism is repeated tension on the growth plate of the upper tibia Pain typically resolves with time. Applying cold to the affected area, rest, stretching, and strengthening exercises may help. Prevention One of the main ways to prevent OSD is to check the flexibility of quadriceps and hamstrings. Lack of flexibility in these muscles can be direct risk indicator for OSD Osgood– Schlatter disease (OSD) Physiotherapy & Rehabilitation Physiotherapy Recommended efforts include exercises to improve the strength of the gluteus, quadriceps, hamstring and gastrocnemius muscles. Bracing or use of an orthopedic cast to enforce joint immobilization is rarely required and does not necessarily encourage a quicker resolution. However, bracing may give comfort and help reduce pain as it reduces strain on the tibial tubercle. Rehabilitation Rehabilitation focuses on muscle strengthening, gait training, and pain control to restore knee function Exercises for strength, stretches to increase range of motion, ice packs, knee tape, knee braces, anti-inflammatory agents, and electrical stimulation to control inflammation and pain. Quadriceps and hamstring exercises are commonly prescribed by rehabilitation experts restore flexibility and muscle strength Isometric exercises, such as isometric leg extensions, have been shown to strengthen the knee Other exercises can include leg raises, squats, and wall stretches to increase quadriceps and hamstring strength Education and knowledge on stretches and exercises are important Jumper’s Knee Jumper's knee, more scientifically known as patellar tendonitis, is another relatively common source of pain located on the front side of the knee, just below the kneecap. This condition takes its name from the activity that is often associated with the injury. More specifically, patellar tendonitis results from the patellar tendon being overused and overstressed, causing painful inflammation, crepitus, and stiffness if the condition is left untreated. There are a few braces and patella straps designed for easing the pain and swelling associated with jumper’s knee / patellar tendonitis 3- Sacroiliitis Is due to excessive mobility, large forces are transferred to the sacroiliac joint, producing an inflammation of the joint Sacroiliitis can cause pain in the buttocks or lower back and can extend down one or both legs. Prolonged standing or stair climbing, running can worsen the pain. If one assumes a round shouldered, forward-head posture, the center of gravity of the body moves forward, This increase in the curvature of the lumbar spine produces a ligamentous laxity in the dorsal sacroiliac ligaments and stress on the anterior ligaments. Also, any skeletal asymmetry, such as a short leg, produces a ligament laxity in the sacroiliac joint. The sacroiliac joint also becomes very mobile in pregnant women, making them more susceptible to sacroiliac sprain Causes 1-Traumatic injury 4-Infection 2-Arthritis 3-Pregnancy 5-Poor posture 4- Anterior , posterior and central hip dislocation 5- Legg–Calvé–Perthes disease : In children 3 to 12 years old, In this condition, also called coxa plana, the femoral head degenerates, and the proximal femoral epiphysis is damaged. *This disorder strikes boys five times more frequently than girls and usually occurs to only one limb. **It is caused by trauma to the joint, synovitis or inflammation to the capsule, or some vascular condition that limits blood supply to the area. 6- Slipped capital femoral apophysitis is another disorder that can affect children aged 10 to 17 years. It is usually caused by some traumatic event that forces the femoral neck into external rotation, or it can be caused by failure of the cartilaginous growth plates. 7- Congenital hip dislocation A disorder that affects girls more often than boys. Legg–Calvé–Perthes disease Congenital hip dislocation Slipped capital femoral epiphysitis 8- Age-related disorder of the hip joint seen commonly in elderly individuals is osteoarthritis 9- Greater trochanteric bursitis Greater trochanteric bursitis, caused by hyperadduction of the thigh. This is a common cause of hip pain This can be produced by *Running with too much leg crossover in each stride *Imbalance between the abductors and adductors *Running on banked surfaces *Leg length difference, or *Remaining on the outside of the foot during the support phase of a walk or run. It is especially prevalent in *runners with a wide pelvis, * large Q-angle, and an *imbalance between the abductors and adductors N.B More than 60% of injuries to the hip occur in the soft tissue. Of these injuries, 62% occur in running, 62% are associated with a varum alignment in the lower extremity, and 30% are associated with a leg length discrepancy. These types of injuries are usually muscle strains, tendinitis of the muscle insertions, or bursitis. 10- Iliotibial band syndrome Iliotibial band syndrome (lateral hip pain) It is due to excess adduction and internal rotation movements, also due to excess tension in the tensor fascia latae in abducting the hip in singlestance weight bearing which seen in dancers and distance runners. Examples of athletes who are most prone to ITBS : Basketball players, Cyclists, Hockey players, Runners, Skiers, Soccer players. Causes of ITBS: 1-Excessive foot pronation 2-Hip abductor weakness 3-Internal tibial torsion 4-Medial compartment arthritis leading to genu varum 5-Preexisting iliotibial band tightness (congenital) Symptoms of iliotibial band syndrome (ITBS)? ✓ Hip pain: the iliotibial band repeatedly rubs against the greater trochanteric in the hip. The friction causes inflammation in the tendon and pain in the hip. There is might hear a snapping sound. ✓ Clicking sensations: might feel a snap, pop or click on the outside of your knee. ✓ Knee pain: the lateral epicondyle is on the outside of the knee near the bottom of your femur, where the bone widens. iliotibial band repeatedly rubs against the lateral epicondyle when the patients flex and extend knee. The friction causes inflammation in the tendon and pain in the knee. ✓ Warmth and redness: The outside of the knee might look discolored and feel warm to the touch Injury (Cont.) 11- Snapping hip syndrome also commonly produces a click as the hip capsule moves or the iliopsoas tendon snaps over a bony surface. which seen in dancers and distance runners. 12-The abductors can create an avulsion fracture on the greater trochanter, and the iliopsoas can pull hard enough to produce an avulsion fracture at the lesser trochanter, also Stress fractures can appear in the femoral neck 13-Piriformis syndrome Piriformis syndrome usually starts with pain, tingling, or numbness in the buttocks. Pain can be severe and extend down the length of the sciatic nerve (called sciatica). The pain is due to the piriformis muscle compressing the sciatic nerve, such as while sitting on a car seat or running. Pain may also be triggered while climbing stairs, applying firm pressure directly over the piriformis muscle, or sitting for long periods of time. Anterior knee pain 1- Overuse (vigorous physical activities that put repeated stress on the knee, such as jogging, squatting, and climbing stairs. 2-Patellar Malalignment (abnormal tracking of the kneecap in the trochlear groove) 3- Iliotibial band tightness 4- Muscle imbalance 5- Hip problems 6- Tight quadriceps and hamstring muscles 7-Problems with alignment of the legs between the hips and the ankles 8- Pes Planus (Flat Feet)