Lower limb injuries

Richard Hardern

Content

• 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).