Transcript Lower limb injuries - Wilderness Medicine

Lower limb injuries
Richard Hardern
Content
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Knee, ankle, foot
Anatomy
History and examination
Treatment of limb threatening problems
Not a case for the
Emergency Nurse
Practitioner!
Knee anatomy
• Bones
• Ligaments: cruciate and collateral
• Menisci
Ankle anatomy
• Bones
• Ligaments: medial & lateral
• Tendons
Peroneus brevis
Gastrocnemius
Foot anatomy
• Bones
History & examination
• Mechanism of injury
• Mechanism of injury
• Mechanism of injury
General Considerations
•Always inquire about the mechanism of
injury.
•Always inquire about the effect on function.
•Always do the following in this order:
•Inspection
•Palpation
•Range of Motion (active before passive)
Knee: look
•Skin- scars, redness
•Muscle- wasting of quads (compare diameter
of thigh if quads wasted)
•Bone/joint- Effusion, Varus Valgus deformity(
measure intermalleolar distance if valgus),
•Watch them walking too at some point (even if
only from WR into examination cubicle)
Knee: feel
•Skin - Temperature, back of hand
•Muscle- Ask patient to contract quads
•Bone/joint- Effusion fluid displacement test,
patellar tap test (may be negative if tense
effusion)
•Joint line tenderness (with knee bent)
•Patellar tendon
•MCL,LCL
•Popliteal swellings
Knee: move
•Active then passive•Flexion (135 degrees normal)
•Extension (put hand behind knee)
•Feel for crepitus
Knee: special tests collaterals
Knee: special tests - cruciates
ACL
PCL
Knee: special tests - menisci
Knees: active resisted
extension
Ankle/foot examination
• Look
– Knee distally
– Walking too (at some point)
Ankle/foot examination
• Feel
– Knee distally
– Medial & lateral (include base 5th MT)
– Leave tender area until last
Ankle / foot examination
• Move
– Ankle
– Midtarsal
– Stability test: anterior drawer
Anterior draw test
Emergency problems
– Dislocation (not patellar)
– Compartment syndrome
• Skin medially is at risk.
• If skin becomes broken/necrotic, #
becomes an open one.
• Risks of complications much greater
(especially infection).
• Needs emergent reduction (with
analgesia).
• Damage to popliteal artery if dislocated
knee
Compartment syndrome
• The pain may be intensely out of proportion
to the injury, especially if no bone is broken.
• There may also be a tingling or burning
sensation (paresthesias) in the muscle.
• The muscle may feel tight or full.
• If the area becomes numb or paralysis sets
in, cell death has begun and efforts to lower
the pressure in the compartment may not be
successful in restoring function.
• Pain worse if affected muscle passively
stretched.
• Pulses not lost (until very late).