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Lower Limb Conditions By Zachary Emerton, 4 Year Medical Student *super long title of doctorates and achievements pending* What is Orthopaedic Surgery? Derives from the Greek words… Orthos - to straighten Paidion- children 1890s it expanded to how we know it Image source: d_general_practitioners__preliminary_considerations_and_diseases_of_the_spinWhy Ortho? Ortho Bro? Do you… • Enjoy building furniture? • Like hammers or power tools? • Bench two plates or more? • Hate ECGs? • Enjoy being hands-on? • Like positive outcomes? If you said yes to any of these, then ortho may be for you! ▪ Classifying Fractures ▪ Imaging ▪ X-Rays ▪ Ankle Fractures Todays ▪ NOF (Neck of Femur) Fractures Topics ▪ ACL Tear ▪ Achilles Tendon Rupture ▪ Osteoarthritis ▪ Post-Op Complications What’s the difference Classifying between a fracture Fractures and a break? There is none! Who is the coolest guy in the hospital? The Ultra-Sound Guy Who’s the coolest guy in the hospital when the ultrasound guy isn’t around? The Hip Replacement Guy! Image source: IHH Healthcare Singapore How To Diagnose? History Examination Imaging Investigations History Mechanism Trauma Instant Relate to Swelling Your Anatomy Orthobro? Image source: https://my.clevelandclinic.org/health/diagnostics/23500-foot-x-ray What Imaging Method Is This? A. X-Ray C. Ultrasound B. CT D. MRI Orthobro? Image source: https://my.clevelandclinic.org/health/diagnostics/23500-foot-x-ray What Imaging Method Is This? A. X-Ray C. Ultrasound B. CT D. MRI Orthobro? mage source: https://www.swslhd.health.nsw.gov.au/medicalImaging /serv_CT_Extremities_Foot.html What Imaging Method Is This? A. X-Ray C. Ultrasound B. CT D. MRI Orthobro? mage source: https://www.swslhd.health.nsw.gov.au/medicalImaging /serv_CT_Extremities_Foot.html What Imaging Method Is This? A. X-Ray C. Ultrasound B. CT D. MRI Orthobro? Image source: https://fitterfeet.co.uk/diagnostics/imaging/ What Imaging Method Is This? A. X-Ray C. Ultrasound B. CT D. MRI Orthobro? Image source: https://fitterfeet.co.uk/diagnostics/imaging/ What Imaging Method Is This? A. X-Ray C. Ultrasound B. CT D. MRI Orthobro? Image source:https://radiopaedia.org/images What Imaging Method Is This? A. X-Ray C. Ultrasound B. CT D. MRI Orthobro? Image source:https://radiopaedia.org/images What Imaging Method Is This? A. X-Ray C. Ultrasound B. CT D. MRIX-Rays A-E Assessment Check Past Records Abnormal vs Normal? Unsure? Checkout normal bones Lateral View!!!Principals of Surgery Function Union Good Post OpAnkle Fractures Symptomatic • Pain • Popping Sound Presentation Clinical • Swelling • Bruising • Pain on WBRisk Factors Age Obesity Trauma (sports) Orthobro? What Imaging Would We Use to Identify a Broken Ankle? A. X-Ray C. Ultrasound B. CT D. MRI Orthobro? What Imaging Would We Use to Identify a Broken Ankle? A. X-Ray C. Ultrasound B. CT D. MRIYou can’t X-Ray everyone!When Might We Not Use Ottawa? • Note: the Ottawa rules may be less applicable in certain clinical situations where clinical judgement should be used, for example in people who: • Are younger than 18 years of age. • Are confused, have a cognitive deficit, communication problems, or are intoxicated, as the person's expression or perception of pain can be altered. • Have polytrauma, head injury, or diminished sensation in the lower extremities (for example due to neurological deficit). • Have gross swelling making palpation of the area impossible. • Are pregnant.Weber ClassificationManagement Surgery for C Conservative or Operative for B Boot for A (remember A is OKAY)ORIF 1. Open 2. Reduce 3. Lag screw 4. Plate 5. CloseMini Case 1 Barbara Gordon is a 32F who presents to A&E with pain on weight bearing after ‘twisting her ankle’. You are paged to see her. How do you deal with this? History Examination ImagingRequest an X-ray! Orthobro? What Type of Weber’s is This? A. C. B. D. Orthobro? What Type of Weber’s is This? A. C. B. D. Orthobro? How Would You Manage This Fracture? A. ORIF (surgery) C. CAM Boot B. Cast D. Pain Killers (Reassure and Discharge) Orthobro? How Would You Manage This Fracture? A. ORIF (surgery) C. CAM Boot B. Cast D. Pain Killers (Reassure and Discharge)Neck of Femur Fractures Symptoms • Severe Pain • Difficulty Weight Bearing Presentation Clinical • Shortened Ext. Rotated • Bruising • Swelling Age Female Risk Factors Smoking Alcoholic Trauma (Falls Risk)Diagnosing X-Ray MRI (gold standard) CTManagement Intracapsular Extracapsular Undisplaced DHS (dynamic hip screw) Internal Fixation Intramedullary Nail Hemiarthroplasty Displaced Total Hip Replacement Hemiarthroplasty Hemiarthroplasty favoured for those with poor pre-op mobility and co-morbidities as recovery is shorterMini Case 2 Ethel Green is an 82F who comes in presenting with pain and inability to weight bear on her right leg after falling and tripping on a rug. You are paged to see her. She lives in an assisted living complex and uses a Zimmer frame to mobilise Her right leg appears shortened and externally rotated. How do you proceed? Orthobro? What Type of Hip Fracture is This? A. Right Intracapsular C. Right Extracapsular B. Right intertrochanteric D. Osteoarthrits (no fracture) Orthobro? What Type of Hip Fracture is This? A. Right Intracapsular C. Right Extracapsular B. Right intertrochanteric D. Osteoarthrits (no fracture) Orthobro? How Will You Manage This? A. Send her home. (she’s too old C. Hemiarthroplasty for surgery) B. Total Hip Replacement D. Dynamic Hip Screw Orthobro? How Will You Manage This? A. Send her home. (she’s too old C. Hemiarthroplasty for surgery) B. Total Hip Replacement D. Dynamic Hip ScrewMini Case 3 Richard Grayson is a 36M. He is a gymnast who falls from a trapeze landing on his side. After briefly losing consciousness, he wakes up unable to bear weight on his right leg. Clinical examination reveals a shortened and externally rotated right leg alongside bruising down his entire right side. You are paged to assess him, how do you proceed? What tests would you like to perform? Orthobro? What Type of Hip Fracture is This? A. Right Intracapsular C. Right Extracapsular B. Right intertrochanteric D. Osteoarthrits (no fracture) Orthobro? What Type of Hip Fracture is This? A. Right Intracapsular C. Right Extracapsular B. Right intertrochanteric D. Osteoarthrits (no fracture) Orthobro? How Would You Manage This? A. DHS (Dynamic Hip Screw) C. THR (Total Hip Replacement) B. IM (intermedullary) nail D. Hemiarthroplasty Orthobro? How Would You Manage This? A. DHS (Dynamic Hip Screw) C. THR (Total Hip Replacement) B. IM (intermedullary) nail D. HemiarthroplastyKnee SurgeryACL Tear ‘Career ending injury’ Mechanism – Sudden turning, stopping, landing Presentation – Rapid Swelling, reduced ROM, pain Investigations – MRI (gold standard), X-Ray to rule out other causesManagement Non-Surgical – Rest, Analgesia, Brace… Autograft - Hamstrings - Patellar Tendon (BPTB) - Quadriceps Can be a primary repair but far less successfulAchilles Tendon Rupture Symptoms • Sudden popping • Severe Pain • Weakness Presentation Clinical • Deformity (gap) • Loss of resting tone Age Male Tendinopathy Risk Drugs (Steroids) Factors Trauma Obesity SmokingDiagnosing Simmond's triad - Angle of declination, - Palpation for a gap - Calf squeeze Ultrasound Potential MRI for surgical planningManagement Options Non operative in boot with wedges gap <2cm age >35 less mobile Operative Percutaneous repair (2cm incision) Open repair (5-8cm incision) GraftsOsteoarthritis Age Female Risk Obesity Factors Previous Trauma OccupationPresentation A 68-year-old woman presents with worsening knee pain over the last few years, especially with stair climbing and prolonged walking. She experiences morning stiffness and occasional swelling. The pain worsens after activity. She has a history of knee injuries and is overweight. Osteoarthritic Hands:Diagnosing Clinical Diagnosis: • patient is > 45 years • has exercise-related pain • no morning stiffness or morning stiffness lasting < 30 minutes Otherwise Imaging and Investigations!X-ray changes of osteoarthritis - Loss of joint space - Osteophytes at joint margins - Subarticular sclerosis - Subchondral cysts Management Options WEIGHT LOSS MUSCLE TOPICAL/ORAL WALKING INTRA-ARTICULAR JOINT REPLACEMENT STRENGTHENING NSAIDS AIDS/BRACES STEROID INJECTIONS (2-10 WEEKS)Complications• A-E Assessment • History of Admission • Past Notes • InvestigationsCase 4 72-year-old female with osteoarthritis, underwent total hip replacement 3 weeks Examination Fever (38.5°C) increased pain around the hip joint. Redness, swelling, and warmth around the incision site. Discharge from the wound. Decreased mobility and increased difficulty weight-bearing Differentials: Postoperative infection Management: Blood cultures and wound swabs for organism identification. IV antibiotics (empiric until swabs return) Wound debridement or revision surgery if necessary. Joint aspiration to confirm infection. Ensure joint is still in placeCase 5 Patient: 58-year-old male, underwent knee arthroplasty 2 weeks ago. Examination Swelling and pain in the left calf Warmth and redness over the calf Tenderness to palpation in the affected leg Mild shortness of breath and tachycardia (worrying for pulmonary embolism). Differentials: DVT Management: Doppler ultrasound to confirm DVT. Anticoagulation therapy (e.g., heparin or warfarin). Compression stockings and early mobilisation to prevent further clots. Pulmonary embolism workup if respiratory symptoms are present.Case 6 45-year-old male with a history of open fibular fracture treated with ORIF 6 months ago. Examination Chronic pain at the fracture site. Swelling or slight movement at the fracture site on palpation. Inability to remobilise effectively (despite physio) Differentials: Malunion Non-union Management: X-ray to assess for fracture healing status. Revision surgery to promote healing, including bone grafting or re-fixation. Stimulation therapies (e.g., electrical bone stimulation) may be considered.Case 7 34-year-old male, 2 days post-ORIF for distal fibula fracture. Examination Severe pain in the lower leg unrelieved by analgesia. Swelling and tightness around the calf and ankle. Paresthesia and weakness in the foot (difficulty dorsiflexing). Firmness of the calf on palpation. Decreased pulses in the foot. Differentials: Compartment Syndrome Management: Release dressing and cast Fasciotomy to relieve pressure. Neurovascular monitoring post-op. Rehabilitation and physiotherapy.Thank You For Watching Questions? Feedback (pls) :