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Trauma and Orthopaedics - Lower Limb Conditions George WuWhat are we going to cover? 1. Acute Swollen Joint – Septic Arthritis, Gout, Pseudogout, Haemoarthrosis 2. Orthopaedic Emergencies – Compartment Syndrome, Open Fractures 3. Common Fractures – Hip fractures, Ankle Fractures 4. Knee Injuries – ACL, Meniscus Tears 5. Common conditions of the Foot – Achilles Tendonitis, Plantar Fasciitis, Hallux Valgus 6. Osteoarthritis (Hip and Knee)Acute Swollen Joint • An acutely swollen joint is a common presentation to the ED • It can be caused by many different conditions – is it septic arthritis, crystal arthropathy, blood?Approach • Take a good history • PMH • PSH – Any history of joint replacement • Any systemic symptoms – Fevers? • Investigations • If unwell à A-E Assessment • Joint Examination • Bloods, Imaging • Joint Aspiration!!!Septic Arthritis • It is infection of the joint • Cause • S. Aureus – most common in adults • N. Gonnorhoea – more common in younger, sexually active patients • Salmonella – more common in those with sickle cell disease • Features • Single, swollen joint – severe pain • Fever – if no fever, does not rule out • On Examination – red, swollen, warm and pain on active and passive movements • Investigations • Bloods + Blood Cultures • Joint Aspiration + Fluid Analysis – Before antibiotics • Management • Start IV Empirical Antibiotic Treatment ASAP • Flucloxacillin, if penicillin allergic à Clindamycin • Usually Long Course – after 2 weeks switch to Oral Antibiotics for a total of 4-6 weeks • Joint Wash Out – Orthopaedic Surgeons Gout • Crystal Arthropathy – collection of monosodium urate crystals in the joint usually caused by chronic hyperuricaemia • Disease of the Kings – overindulgence in food and alcohol • Risk Factors • Diet Rich in Purines – Shellfish, Red Mead, Alcohol • Decreased excretion of uric acid – CKD, Diuretics • Features • Classically affects Big Toe (1 MTP Joint) – But can affect other joints • Red, Painful, Swollen • Usually episodic – patient have flare ups lasting days or weeks • Investigations • Joint Aspiration + Microscopy – Shows needle shaped negatively birefringent monosodium urate crystals under polarised light • Imaging – severe cases can show punched out lesions of bone • Management • Acute Attacks – NSAIDs or Colchicine (can cause Diarrhoea) • Prevention • Lifestyle Modifications • Allopurinol + Colchicine CoverPseudogout • Crystal arthropathy – caused by deposits of calcium pyrophosphate crystals in the joint • Risk Factors – advanced age, hyperparathyroidism, Haemochromatosis • Features • More commonly affects proximal joints – knee and wrist • Mimics gout – red, hot, swollen joint • Investigations • Joint Aspiration and Microscopy – positively birefringent rhomboid-shaped crystals • X-Ray – Chondrocalcinosis • Management • NSAIDS + Treat Underlying CauseHaemoarthrosis • Bleeding into the Joint Cavity – usually after traumatic injury • Features • Investigations • ManagementOrthopaedic Emergencies Compartment Syndrome • Rise in pressure within a closed anatomical space – any fascial compartment can be affected • Usually occurs after high-energy trauma, crush injuries, fractures causing vascular injury • 2 common fractures – tibial shaft, supracondylar fracture • Pathophysiology – continuous increase in pressure within the compartment à compresses on nerves first leading to paraesthesia à pressure reaches diastolic pressure and compromises arterial flow à ischaemia • Features • Usually presents within hours • Severe pain – disproportionate to injury + made worse on passive movement + does not respond to analgesia • Paresthesia • Pulses may still be felt • If untreated à 6 P’sCompartment Syndrome • Iusedtigations/Examination – usually clinical diagnosis but intra-compartmental pressure monitor can be • Pressure above 20 mmHg is abnormal, Pressure above 40 is diagnostic • Management • Recognise early • Urgent Surgical Treatment – Fasciotomy +/- debridement • Monitor renal function - rhabdomyolysisTrigger Warning!! Graphic ContentOpen Fractures • Fracture + Break in the skin à open to the environment à Infection • Usually associated with soft tissue damage (nerves, vessels, muscles) • Classification - Gustillo-Anderson Classification • Initial Management • A-E Assessment + Resuscitation • Assess neurovascular status + Any contamination • Imaging • Urgent realignment/reduction + splinting --> reassess neurovascular status • Broad spectrum antibiotics +/- tetanus injection • Definitive Management • Debridement of wound – remove dead tissue • Wound wash out • If vascular compromise à vascular surgeons • Stabilize fracture – usually external fixationCommon Fractures of the Lower LimbHip Fractures – Common Exam T opic Types of Fractures – Intracapsular or Extracapsular? Blood supply – Femoral head has retrograde blood supply à if this is disrupted can cause avascular necrosisHip Fractures – NOF Fracture • Very common orthopaedic presentation – elderly, osteoporotic women • Very high mortality – 30% at one year • Cause – falls in frail patients (common), high energy injuries • Features • pain and inability to weight bear • O/E – classically shortened and externally rotated • Classification – Garden Classification • Investigations • Plain Pelvic X-Ray – Disruption to shenton’s line • Complications – if the fracture is displaced à disrupt blood supply and cause avascular necrosisManagement of NOF Fracture • A-E approach – stabilise patient • Give adequate analgesia – consider fascia-iliaca block • Surgery - goal is to allow immediate weight-bearing to minimize complications • Undisplaced NOF à internal fixation using screws • Displaced NOF à arthroplasty • If good pre-morbid status à Total hip replacement • Were able to walk independently • Are not cognitively impaired • Medically fit for procedure • If poor pre-morbid status à hemi-arthroplastyHip Fractures – Extra-Capsular Fractures • If stable inter-trochanteric fracture à dynamic hip screw • Requires weight bearing so that compression is achieved across the fractures site • If oblique, transverse or sub-trochanteric fractures à intramedullary nailAnkle Fractures • Very Common Injury – younger males, older females • Ankle Anatomy • Articulartion between end of tibia + fibula and the talus bone • Tibia and fibia are joined by syndesmosis • Ankle Fracture – fracture of any malleolus • Ankle Anatomy • Isolated lateral malleolus • Isolated medial malleolus • Bimalleolar • Trimalleolar fracutreAnkle Fractures – Ottawa Ankle Rules • If uncertain à To X-ray or not? • If presence of any of features below à take plain X- rays • Bone tenderness at posterior edge or tip of lateral malleolus • Bone tenderness at posterior edge or tip of medial malleolus • Inability to bear weight both immediately and in ED for four steps • Cannot be used if patient is intoxicated or uncooperative or have any other painful injuriesAnkle Fractures – Weber Classification • Classifies lateral malleolus fractures • Tmore unstable the fracturethe fracture à the • Type A – below the syndesmosis à conservative • Type B – at the level of the syndesmosis à conservative or surgical • Type C – below the level of syndesmosis --> always surgicalAnkle Fractures – Management • Assess neurovascular status • Immediate fracture reduction in ED à Below knee back slab à Post-reduction neurovascular examination • Conservative Management – CAM boot for 6 weeks and encourage weight bearing • Surgical Management – surgical fixation • Usually ORIF – usually using plates and screwsKnee InjuriesACL Rupture • Common injury to knee joint – 30 cases per 100,000 • ACL helps to stabilize knee joint – prevents anterior displacement of tibia • Mechanism – athlete with history twisting of the knee while weight-bearing – sudden change in direction twisting the flexed knee • Features – pain, rapid joint swelling (10-15 minutes), sudden “popping” sound • Ligament is very vascular à damage cuases haemarthrosis • Examination - Lachman Test and Anterior Draw Test • Investigations • Plain X-Ray – rule out bony injuries • MRI – gold standard + also pick up meniscal tears (50% have associated meniscal tears)ACL Rupture – Repair or Not Repair • Initial Management – All patients • ICE (Rest, Ice, Compression, Elevation) • Conservative or Surgical Management • Conservative – rehabilitation to increase strength of quadriceps to stabilise knee • Surgical Repair – use of hamstring tendon to reconstruct ACL • Complications – post-traumatic arthritis • Depends on patient and level of activity, extent of injuryMeniscus T ear • Menisci are C-shaped cartilage in the knee joint that help shock absorption • Medial menisci is larger and attached to the MCL • Lateral meniscus is smaller, more circular and not attached to LCL • Mechanism – twisting injuries whilst knee is flexed and weight bearing • Types – bucket-handle (longitudinal) is most common • Features – tearing sensation in knee, sudden onset of pain, knee swelling over 6-12 hours • If there is a free body within the knee à knee may be locked in flexion • Investigations • McMurray’s Test – any clicking, locking or pain à positive • MRI – Gold Standard • Management • Immediate – RICE • Smaller tears – usually heal by themselves • Larger tears – requires surgery • Outer third has good blood supply à repaired using suture • Inner third has poor blood supply à trimmed to reduce locking symptomsUnhappy TriadCommon Foot ConditionsHallux Valgus - Bunion • Very common foot problem – 35% of people aged > 65 years + more common in women • Deviation of great toe away from midline + associated MTPJ subluxation • Features – painful medial bony prominence – aggravated by walking, weight bearing activities and shoes • Can have inflammation or skin damage • Investigations – Clinical + X-ray to assess deviation and subluxation • Management • Conservative – analgesia, adjust footwear • Surgical - bunionectomy requires 2-6 wekks of healing – different procedures but usually involve osteotomiesAchilles T endonitis/T endon rupture • Common cause of posterior heel pain • Spectrum of Disease – tendinopathy à partial tear à rupture • Risk factors – jumping sports (basketball), fluoroquinolone antibiotics (ciprofloxacin), hypercholesterolaemia • Features • Tendinopathy – gradual onset of pain worse on activity, stiffness, tenderness • Tendon rupture – audible pop in ankle, sudden onset of pain and inability to walk (plnatarflex) • Investigations • Clinical Diagnosis • Simmonds calf squeeze test • Ultrasound • Management • Tendinopathy – supportive measures (rest, analgesia, physiotherapy), avoid steroid injections • Rupture • < 2 weeks – analgesia + immobilisation (splinted in plaster + crutches + no weight bearing) • > 2 weeks – surgical repairAchilles Tendon Rupture – Simmond’s T estPlantar Fasciitis • Most common cause of heel pain in adults – usually worse around media • Develops due to chronic overuse à microtears à recurrent inflammation • Risk Factors – weak plantarflexors (calf muscles), prolonged standing/running • Features • Heel pain – worse in the morning and gets better throughout the day • Usually on medial side of heel • Associated with tight achilles tendon • Management • Rest where possible • Regular NSAIDs • Footwear – good arch support and cushioned heels • Physiotherapy • Can trial corticosteroid injectionsOsteoarthritis (Knee and Hip) • Most common joint disease worldwide – degenerative joint disease - “wear” and “tear” • Usually affects large weight bearing joints – knee and hip – but can also affect the hands • Risk Factors – Obesity, Repetitive trauma (occupation or sports), Age, Female Gender • Pathophysiology – degradation of cartilage + remodelling of bone due to active response of chondrocytes and inflammatory cells • Features – pain and stiffness in joints, pain worsened with activity and relived by rest, reduced range of movement and deformities • Symptoms are usually unilateral • Stiffness usually lasts a few minutes • Investigations – diagnosis usually clinical but X-rays can be usedOsteoarthritis – X-Ray Features • LOSS Mnemonic • Loss of joint space • Osteophytes • Subchondral sclerosis – whitening of bone underneath cartilage • Subchondral cystsOA of the Knee • Most common affected joint is the knee • Risk Factors – genetics, age, female gender, obesity • Features – pain around knee that can radiate to thigh and hip – worsened by exercise and relieved by rest, stiffness • Often have bilateral disease à reduced function • If severe à reduced range of motion and crepitus • Investigations – X-Ray • Conservative Management • Lifestyle modifications – weight loss, exercise, smoking cessation • Analgesia (Paracetamol and Topical NSAIDs) – to ensure mobility • Physiotherapy • Steroid Injections • Surgical Management • Advanced Osteoarthritis à Total Knee Replacement – usually lasts for 10 years • If disease is localised to medial or lateral compartment à partial knee replacement – faster recovery timeOA of the hip nd • 2 most common affected joint • Risk Factors – age, obesity, female gender, genetic factors • Features • Pain in groin • Stiffness – improves with mobility • O/E – antalgic gait or walk with mobility, can reduce range of motion • End stage – fixed flexion deformity – Thomas test • Investigations – X-ray • Management • Conservative management • Surgical Management – Hip Replacement • Clooseningons of Surgery – VTE, bledeing, infection, dislocation, • Hip replacements last 15-20 years à may require revisionsThanks to our partners!See future sessions and watch recordings at: SUPTA.UK