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Pelvis and Lower Limb (Knee (Meniscal tears (Presentation (Locking (Bucket…
Pelvis and Lower Limb
Knee
Arthritis
Usually osteoarthritis
Causes
Occupation
Previous injury
Meniscal tears
Ligament tears
Previous surgery
Malalignment
Knee replacement
Same indications/ complications as hip replacement
Load bearing must be considered
Total knee replacement
Resurfacing of all 3 surfaces
Partial knee replacement
Indicated in younger patients/ isolated osteoarthritis
Meniscal tears
Usually young sportspeople
Twisting injuries
MCL>LCL
Presentation
Localised pain to joint line
Delayed effusion
Locking
Bucket handle tear
Pop
ACL
Older patients
Degenerate meniscal tear
Early osteoarthritis
Untreatable by surgery
Only fresh tears of outer 1/3rd of meniscus suitable for repair
Usually self-limiting despite not actually healing
ACL rupture
Twisting injury
Positive anterior draw test/ Lachmann's test
Repair only viable in sportspeople
Intense physiotherapy required
Requires tendon graft
PCL rupture
Uncommon in isolation
Repair only indicated in cases with severe laxity
MCL rupture
More common
Self-limiting
Hinged knee brace/ ligament tightening
LCL rupture
Requires surgery
Commonly includes injury to common perineal nerve/ popliteal artery
Extensor mechanism rupture
Occurs after heavy lifting or fall from height onto feet
Risk factors
Previous tendonitis
Steroids
Quinolones
Diabetes
Palpable gap
Requires surgical tendon repair
Patellar instability
Always dislocates laterally
Usually immediately self-corrects
Can cause MCL rupture
More common in young females
Ankle
Osteoarthritis
Uncommon
Commoner in football players
Ankle fusion yields better results
Ankle replacements often unsuccessful
Hallux valgus
Deformity of the great toe due to medial deviation of the 1st metatarsal
Commoner in females
Caused by tight footwear and rheumatoid arthritis
Bunion formation from chronic bursitis
Conservative management/ orthotic footwear
Osteotomy usually for cosmetic purposes
Hallux rigidus
Osteoarthritis of 1st metotarsalphalangeal joint
Orthotic footwear
Arthrodesis is gold-standard
Achilles tendonitis
Caused by repetitive strain
Pain over tendon or calcaneus
Treatment
Rest
Physiotherapy
Splintage
Heel-raised footwear
Surgical compression
Achilles tendon rupture
Predisposed by tendonitis
Can occur in rheumatoid arthritis
Commonest in middle-aged men
Most commonly caused by trauma
Positive Simmond's test
Surgical repair controversial
8 weeks in equine position in cast
Hip
Hip pathology
Pain in groin
Referred pain from knee via obturator nerve
Loss of internal rotation usually first sign
Abductor weakness = positive Trendelenburg's test
Hip replacement
Indications
Osteoarthritis
Rheumatoid arthritis
Slipped upper femoral epiphysis
Perthe's disease
Trauma
Avascular necrosis
Failure of conservative treatment
Usually last 15-20 years
Complications
Dislocation
Nerve injury
Infection
Leg length discrepancy
Loosening of implant
Avascular necrosis
Causes
Idiopathic
Steroids
Alcohol/ drug abuse
Hyperlipidaemia
Thrombophilia
Patchy sclerosis/ granulation on MRI
Hanging rope sign on X-ray
Treatment
Drilling (decompression)
Total hip replacement
Trochanteric bursitis
Occurs alongside tendonitis of abductor muscles
Presents with pain over greater trochanter
Treatment
Analgesia
Physiotherapy
Steroid injection
Foot
Morton's neuroma
Inflammation of interdigital nerves from chronic trauma
Presents with burning pain and paraesthesia radiating to toes
Commoner in females who wear high-heeled shoes
Use of orthotics improves pain
Neuroma can be excised if pain not controlled by steroid injections
Metatarsal stress fractures
2nd metatarsal > 3rd metatarsal
Commonest in occupations involving prolonged walking
Usually diagnosed once fracture has begun to heal
Moon boot for 6-12 weeks
Plantar fasciitis
Self-limiting
Caused by repetitive strain
Commonest in obese/ diabetic patients
Helped by stretching/ corticosteroids