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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.

Typology: Lecture notes

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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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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.