bone fractures mechanism & examination
mechanism of injury= trauma
examination = palpation, observation and function tasks eg. gait, active rom
bone fractures
- Pott’s Fracture (bimalleolar)
fracture affecting one or both malleoli which can occur in combination with an inversion injury and can sometimes be difficult to distinguish clinically between a fracture and moderate to severe ligament sprain. Mechanism usually landing from jump or sudden change of direction e.g. in football or rugby. - Metatarsals-March fracture 2nd/3rd, Fracture 5th in distance running. Tibia, fibula, navicular (Brukner et al. 1996)
Avulsion Fracture - Base 5th MT (peroneus brevis and tertius)
- PMH – Osteoporosis, relative energy deficiency (REDS), long-term steriod use, Cancer
- Localised Pain worse on weight-bearing relieved when weight taken off. Limp.
Bone- severs disease calcaneal apophysitis
Apophysitis - Apophyses are the sites of attachment of tendons at long bones. The epiphyseal plate is two to five times weaker than the surrounding fibrous structures (ligaments, tendons, and joint capsule) in children and adolescents.
**interview **
- Age – Childhood
Sporty children who complain of pain after sport locally over the heal
Localised Pain and swelling
examination
Observation and Palpation
Pain on isometric plantarflexion
Bone anterior impingement syndrome
Interview
PMH- Ankle sprains- reduced proprioception
SH- Sports that require full dorsiflexion, e.g. footballers, dancers, athletes.
examination
Palpation- pain at joint line
Passive movement- symptomatic in full DF
Active movement- symptomatic in full DF
Osteoarthirtis interview
4 most common sites
population
Location of symptoms:
- Most common 1st MTPJ (7.8%*)
- Then 2nd cuneometatarsal (3.9%*)
- Then Talonavicular (5.8%*)
- Then navicularcuniform (5.2*)
Talocrural OA post fracture. - Population prevalence of symptomatic radiographic OA (Roddy and Menz 2018)
- Gradual onset or post trauma
- > 45-years or over
- Joint pain related to activity and weightbearing
- Mild swelling
- No early morning stiffness (EMS) or morning stiffness that lasts no longer than 30-minutes
osteoarthiritis examination
- Passive/ Accessory motion – Non-contractile structures
- Observation – mild effusion, hallux valgus
- Calluses or blisters over bony changes (osteophytes)
- Active range.
Rheumatoid arthritis interview
- Up to 90% of those with RA will report foot problems
- (National Rheumatoid Arthritis Society)
- Location: Metatarsalphalangeal joints, subtalar, talocrural and mid-tarsal.
- Early morning stiffness (EMS) for longer than 30minutes.
- Swelling and heat
- General health: may have malaise (feeling unwell), fatigue and low grade fever as systemic.
- Extra-articular- rheumatoid nodules, vasculitis, pulmonary fibrosis, carditis, ocular disease
reumatoid arthiritis examination
Palpation – swelling and temperature
Observation- Swelling
Passive/ Accessory range of motion – non-contractile structures.
Achilles tendinopathy
- Retrocalcaneal bursitis
- Achilles tendonitis
Enthesitis- (Enthesis- where a tendon or ligament attaches to bone)- pathological feature of spondylarthritis.
- Achilles tendonitis
Muscle injuries and tendonitis
interview
examination
interview
Rupture- Achilles tendon rupture
Strains – Gastrocnemius
Tendonitis
- Achilles tendonitis
- Peroneal tendons
- Tibialis Posterior
- FHL – ballet dancers
Mechanism of injury – sudden (strain/ rupture) versus gradual onset (tendonitis).
examination
Muscle testing – contractile tissue
Palpation – show me where you pain is?
Pain on passive movement in opposite direction.
Shin splints/ medial tibial stress syndrome
**Interview **
* Pain (“ache”) increasing during exercise or after exercise, reduces with rest. Worse running on hard, non-compliant surfaces (concreate, treadmills)
* Pain located in lower 2/3 of tibia
* High BMI
* SH- athletes who run and jump e.g. netball, tennis, gymnastics
* Training overload
**examination **
* Palpation- pain on palpation along the posteromedial border of tibia >5cm
- Tibialis posterior, flexor digitorum longus and soleus muscles are overloaded. Can associated with:
- Pronation as arch has an important role to absorb shock
- Increased ankle plantar flexion
- Increased hip external rotation
Plantar fascitis - despite its itiis in the name pathophysiology, it is due to degeneration not trauma
**interview **
* Location of pain: medial heel and midfoot pain
* Worse on standing in the morning and when bare foot.
* Female>male
* PMH: obesity
* SH: Prolonged standing/walking e.g hairdresser
examination
* Palpation
* Passive DF and toe extension (PF on stretch)
* Associated with reduced dorsiflexion
*
ligament injurys
interview, exam, common ankle sprains
**interview **
* Mechanism of injury - excessive inversion. “twisted ankle”
* Swelling and bruising
* Difficulty weight-bearing
* X-ray- no fracture
examination
* Passive movements – inversion reproduces symptoms
* Accessory movements – Anterior draw to test instability anteriorly (ATFL)
* Palpation
ATFL most common, followed by CFL. Injury to PTFL is only in severe ankle sprains often accompanied by fractures, dislocations or both.
Associated with Potts Fracture
hindfoot
- talus
- calcaneus
midfoot
5 tarsal bones
* medial cuneiform
* intermediate cuneiform
* lateral cuniform
* cuboid
* navicular
forefoot
5 metatarsals and phalanges
pes cavus
- a foot with an abnormally high plantar longitudinal arch.
- People who have this condition will place too much weight and stress on the ball and heel of the foot while standing and/or walking.
pes planus
flatfoot
* the loss of the medial longitudinal arch of the foot
* heel valgus deformity
* medial talar prominence.
* This is often observed with the medial arch of the foot coming closer (than typically expected) to the ground or making contact with the ground (overpronated).
observation
- calluses, blisters, swelling, clawing of toes
- wear of shoes
standing
- pronation & supination (ask to actively move into full pr and sup)
- shape of achilles tendon posteriorly
- hallux valgus
- weight bearing
- muscle bulk
- up through kinetic chain knee, hip, spine
walking
hind, mid
hindfoot
* enough DF to heel strike?
* is there active PF in toe off?
* is there 0 degrees DF in midstance, or early heel lift
* step length- is it shortened due to range of DF or pain (antalgic)
midfoot/forefoot
* moving to toe off, does the mid-foot slightly invert and adduct?
* is there toe off?
functional tasks
perform the activity that reproduces symptoms regarding SIN
- standing on toes/heels
- double leg heel raise, single leg
- hopping
- single elg stand eyes open and closed
- line walk forwards/back
- single leg squat
PROM
- dorsiflexion- with/without knee flexion
- plantarflexion
- eversion, inversion- localising movement to forefoot, midfoot and rear foot
with overpressure - combining PF/INV,PF/EV,DF/INV,DF/EV
- toe flexion and extension
- toe abd
isometrics
DF
PF
IN
EV
muscle length
gastroc
soleus
may want to assess in wb and non-wb
hamstrings
