507Lower Limb Conditions
Chapter 14
Lower Limb
Conditions
Aetiological classification
Anatomical classification
Hip and femur
Knee and tibia
Ankle and hindfoot
Forefoot and toes
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Orthopaedic Conditions of the Lower Limb: A Comprehensive Guide, Lecture notes of Holism
An overview of various orthopaedic conditions affecting the lower limb, including their causes, symptoms, and diagnostic methods. Conditions covered include trauma, infection, neoplasia, arthritis, developmental disorders, and miscellaneous conditions. The document also includes X-ray appearances and references to Huckstep 1999.
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Lower Limb Conditions 507
Chapter 14
Lower Limb
Conditions
Aetiological classification
Anatomical classification
Hip and femur
Knee and tibia
Ankle and hindfoot
Forefoot and toes
508 A Simple Guide to Orthopaedics
Classification
Aetiological
Classification
Congenital abnormalities
Dwarfism - achondroplasia
cretinism
gargoylism
Amelia and phocomelia
CDH and protrusio acetabuli
Coxa vara and valga
Genu varum, valgum and recurvatum
Talipes
Congenital vertical talus
Talocalcaneal - navicular bar
Pes planus and cavus
Metatarsus primus varus
Macrodactyly
Syndactyly and webbing
Neoplasia
Benign - bony
cartilaginous
soft tissue
Malignant - primary - bony
cartilaginous
soft tissue
secondary
Trauma
Soft tissue injuries - t e n d o n s a n d
ligaments
nerves
vessels
Subluxation and dislocation
Fractures
510 A Simple Guide to Orthopaedics
Aetiological
Classification
Most conditions of the lower limb are dis-
cussed in detail in the relevant sections of
this book. It is the purpose of this chapter
to discuss other conditions which do not
fall into any of the other categories. Con-
ditions discussed in other chapters are given
below.
Congenital abnormalities
Developmental abnormalities include limb
defects, such as overgrowth and fusion, as
well as congenital dislocation of the hip
and bilateral coxa and genu vara and valga.
They also include ankle and foot condi-
tions such as talipes equino varus, congenital
vertical talus, metatarsus primus varus and
other foot deformities.
Generalised developmental conditions
include achondroplasia and polyostotic
fibrous dysplasia.
Neoplasia
Developmental tumours include multiple os-
teochondroma (diaphyseal aclasis) and be-
nign bone cysts as well as multiple
neurofibroma. Most tumours, however, are of
unknown origin and develop in childhood or
adult life. They range from benign tumours
such as aneurysmal bone cysts, eosinophilic
granuloma and non-ossifying fibromata, to
malignant tumours such as osteogenic
Lower Limb Conditions 511
Genu valgum Osteogenic sarcoma
Aetiological Classification
Trauma (^) Infection
Neoplasia
X-ray appearance
of osteomyelitis
Deformity due to
tibial trauma
Congenital
abnormalities
© Huckstep 1999 Huckstep 1999©
Huckstep 1999© Huckstep 1999©
Lower Limb Conditions 513
Aetiological Classification
Poliomyelitis Hallux valgus
X-ray appearance of
osteoarthritis
Rheumatoid arthritis
Miscellaneous conditions
Paralysis
Arthritis
Huckstep 1999©
©Huckstep 1999
Huckstep 1999© ©Huckstep 1999
514 A Simple Guide to Orthopaedics
Anatomical Classification
Hip and femoral conditions
Paget’s disease
Paget’s disease affecting the femur is fairly
common and may cause overgrowth, bowing,
pathological fractures and, rarely, osteogenic
sarcoma.
Infection
Secondary osteomyelitis is more common than
primary osteomyelitis and usually follows
operative internal fixa-tion of hip or femur
or open femoral fractures. Pyogenic arthritis
of the hip is still fairly common, particu-
larly in children and is usually due to blood
borne spread.
Snapping hip
This is a fairly common condition resulting
from the ilio-tibial band catching over the
greater trochanter. It may be due to unac-
customed exercise and can cause inflamma-
tion of the bursa over the greater trochan-
ter.
This condition will usually respond to
rest and anti-inflammatory drugs. It
occasionally requires division of the ilio-
tibial band in the mid thigh.
Tom Smith’s disease and Girdlestone’s
arthroplasty
Tom Smith’s disease is a septic arthritis of
a major joint occurring in the first year of
516 A Simple Guide to Orthopaedics
life and leading to complete destruction of
the joint. It is now uncommon except in
developing countries.
A similar, but more common situation, occurs
following Girdlestone’s procedure. This is
an excision arthroplasty of the hip which is
performed following an unresolved infection
complicating total hip arthroplasty.
Both arthroplasties may present as a
telescoping unstable hip requiring later hip
replacement.
Avascular hip conditions
Perthes’ disease is due to avascular changes
in the head of the femur. It occurs most
commonly between the ages of 5 and 10 years.
It is discussed in more detail in Chapter 7.
Avascular changes of the head of the femur
also occur in sickle cell disease and in
slipped epiphyses in children. In adults,
avascular changes may follow hip disloca-
tion or subcapital fractures of the femur.
These changes also occur in chronic alco-
h o l i s m a n d f o l l o w i n g p r o l o n g e d
glucocorticosteroid therapy, espec-ially in
patients who have undergone renal or other
organ transplantation.
Slipped capital femoral epiphysis
Slipped epiphysis is discussed in more detail
in chapter 7 and occurs most commonly between
the ages of 10 and 15 years. Although trauma
plays a part in some cases, in many children
an imbalance of sex and growth hormones is
thought to be responsible.
Lower Limb Conditions 517
Hip and Femoral Conditions
X-ray appearance of Tom
Smith’s disease and
Girdlestone’s
arthroplasty
X-ray appearance of
slipped capital femoral
epiphysis
X-ray appearance of
Perthes’ disease
X-ray appearance of
avascular necrosis
© Huckstep 1999
©Huckstep 1999
Huckstep 1999©
Lower Limb Conditions 519
X-ray arthrogram of
a Baker’s cyst
Enlarged prepatellar
bursa
Knee and Tibial Conditions
Genu varum Paget’s disease
Osgood–Schlatter’s
disease
Lateral meniscal
cyst
© Huckstep 1999 ©Huckstep 1999
Huckstep 1999© ©Huckstep 1999
Huckstep 1999© ©Huckstep 1999
520 A Simple Guide to Orthopaedics
Cyst of the lateral meniscus
This is probably a degeneration of the lateral
meniscus following trauma rather than a
congenital cyst. There is a tender cystic
swelling, usually situated over the middle
of the lateral meniscus.
Treatment used to be a total meniscectomy
but local excision of the cyst alone is
adequate.
Deformities of the knee
Premature fusion of the medial femoral or
tibial epiphysis will produce a genu varus
while early fusion of the lateral femoral or
tibial epiphysis will lead to a genu valgum
(Chapter 7). Unbalanced paralysis of the knee
extensors or flexors may lead to flexion
deformity or genu recurvatum.
Degenerative changes in the medial and
lateral joint of the knee may lead to narrowing
of the joint and a small degree of genu
varum or valgum. Swelling of the knee in
arthritis of any cause will lead to limita-
tion of full extension and often flexion as
well.
Paget’s disease of the tibia
Paget’s disease is discussed in further detail
in Chapter 11. There is usually bowing and
thickening of the tibia and pathological
fractures may occur. Osteogenic sarcoma is
a rare complication. High-output cardiac
failure may occur in extensive Paget’s
disease, as the affected bone is highly
vascular.
522 A Simple Guide to Orthopaedics
Ankle and hind foot conditions
Tendonitis Tendonitis on the medial side of the ankle is usually due to inflammation of the tibialis posterior tendon sheath and on the lateral side to inflammation of the sheaths of the peroneal tendons. Posteriorly the sheath of the tendo calcaneus may become inflamed by overuse of the tendon, by rubbing on the back of a shoe or by minor tears of the fibres of the tendon itself. Partial or complete rupture of the tendon may also occur. Clinically there is tenderness and often swelling over the sheath of the relevant tendon and usually pain on stressing the tendon. Treatment includes ‘resting the tendon’ with an elevated heel on both shoes, the application of ice packs and elevation of the leg in the acute stage.In chronic tendon- itis deep heat, massage and sometimes injec- tions of hydrocortisone and local anaesthetic into the tendon sheath (not the tendon) may be necessary. Occasionally incision of the tendon sheath may be required. Rupture of the plantaris tendon may also occur and lead to a sudden sharp pain in the mid calf. The treatment is the same as for a tendonitis of the tendo Achillis.
Painful heel Pain under the heel is usually due to a plantar fasciitis, possibly following bruising of the heel. It may be associated with a calcaneal spur seen on X-ray but this is often unrelated to the pain. The heel sometimes becomes painful in chronic infec- tions, in rheumatoid arthritis and in other
inflammatory diseases.
Lower Limb Conditions 523
X-ray appearance
of a calcaneal
Tendinitis spur
Ankle and Hind Foot
Conditions
X-ray appearance of
osteoarthritis
X-ray appearance of
rheumatoid arthritis
© Huckstep 1999 Huckstep 1999©
Huckstep 1999©
Huckstep 1999©
Lower Limb Conditions 525
Ankle and Hind Foot
Conditions
Pes planus Arch support
Pes cavus and
clawed toes
Paralysed foot
Huckstep 1999© Huckstep 1999©
©Huckstep 1999 ©Huckstep 1999
526 A Simple Guide to Orthopaedics
Spastic paralysis from an upper motor neurone lesion may also require a below knee caliper, again sometimes preceded by elon- gation of the tendo Achillis.
Forefoot and toe conditions Classification of forefoot conditions can be divided into those affecting the plantar surface, the dorsum and the sides of the feet. Deformities of the toes are often as- sociated with these conditions.
Plantar surface of foot
A n t e r i o r m e t a t a r s a l g i a This is a painful area under the metatarsal heads, commonly the 2nd, 3rd, and 4th. It is usually due to weakening of the dynamic muscular structure of the foot. It is often associated with obesity, poor muscle tone, clawing of the toes and sometimes various n e u r o l o g i c a l c o n d i t i o n s s u c h a s poliomyelitis, leading to weakness of the intrinsic muscles.
Morton’s metatarsalgia (plantar n e u r o m a ) This is due to irritation followed by enlargement of a plantar digital nerve, usually between the 2nd and 3rd or 3rd and 4th metatarsal heads. The patient complains of pain in the forefoot, often at night when the feet are warm, and also while walking. The condition is often associated with an anterior metatarsalgia. During exam-ination the main tender area can usually be pinpo- inted to lie between the metatarsal heads rather than under them as is the case in anterior metatarsalgia. The pain is usually worse on lateral compression of the forefoot which compresses an enlarged neuroma between the metatarsal heads. There may also be numb- ness between the toes supplied by the relevant
cutaneous nerve.